eNotification: Adapting eReferral for Public Health Notifiable Disease Reporting in New Zealand.

OBJECTIVES: New Zealand is currently implementing a standard for the electronic referral of patients from primary care to District Health Board (DHB) provided specialist services (eReferral). Medical Officers of Health working within DHB public health services receive referrals through a legally mandated disease notification system. Although laboratories have reported notifiable diseases electronically since 2007 clinical and risk factor information are still reported by fax or telephone. This paper describes a project that aims to adapt eReferral for public health purposes. METHODS: A work group of Medical Officers of Health was convened to develop criteria for priority disease selection and to develop data and functional requirements. RESULTS: Eleven out of 52 notifiable diseases were selected based on potential to improve public health response and or make referral easier for medical practitioners. In addition to identifiers and demographics data requirements included: symptom onset date, occupation and place of work (or other day time location) and workplace name. The work group specified that most enteric disease eReferrals should be triggered by a positive laboratory test. Vaccine preventable disease eReferrals should occur at the time of relevant laboratory test order. CONCLUSIONS: The project is at an early stage and consultation with referrers has been limited. The next stage will require working closely with referring doctors to resolve practical issues with occupation coding, to minimize practice workflow change, and to maintain consistency with other eReferral processes.

Throat swabbing for the primary prevention of rheumatic fever following health information.

AIM: To determine whether health promotion activities in March-August 2009 increased sore throat swabbing rates among Flaxmere (Hawke's Bay, New Zealand) children aged 5-14 years, and in particular among Maori and Pacific children. METHOD: Monthly totals of Hawke's Bay bacterial throat swabs for the period March-October 2008 and March-October 2009 were obtained. Using Poisson regression, the 2008 and 2009 test rates for Flaxmere children residing in the target area during the intervention were compared with non-Flaxmere children. Flaxmere test rates were determined for Maori or Pacific children and non-Maori non-Pacific children separately. RESULTS: Flaxmere children had a higher pre-intervention bacterial throat swab rate, compared to non-Flaxmere children (6.0% vs 3.2%; p<0.001). The throat swab rate increased significantly for Flaxmere children during the intervention period, compared to both the previous year (1.6; 1.3-2.0) and compared to the increase observed among non-Flaxmere children (1.4; 1.1-1.8). Subanalysis among Flaxmere children found a significant increase in the throat swab rate of Maori and Pacific children (1.8; 1.4-2.4). CONCLUSIONS: A demonstrable increase in throat swabbing rates among high-risk Flaxmere children was observed following a combination of health promotion interventions. The increase in throat swabbing rates observed among Maori and Pacific children suggest that the intervention was effective for children with the highest risk.

Limited novel influenza A (H1N1) 09 infection in travelling high-school tour group.

BACKGROUND: A single case of novel influenza A (H1N1) 09 infection was identified by PCR among a New Zealand high-school group that toured California in April 2009. Close monitoring of the tour group and their New Zealand contacts identified 11 other tour members with respiratory symptoms who were investigated. In all nine instances where nasopharyngeal swabs were indicated, tests were negative for novel influenza A (H1N1) 09 by PCR. OBJECTIVE: To determine whether serology could identify any cases of novel influenza A (H1N1) 09 that had not been detected by PCR. METHODS: Acute and convalescent serological testing for antibodies against pandemic (H1N1) 2009 and seasonal A (H1N1) influenza viruses using haemagglutination inhibition assays and microneutralisation assays. RESULTS: Serological analysis of symptomatic tour members identified a further possible case of novel influenza A (H1N1) 09 infection. The possible case had not been tested by PCR because he or she had already received prophylaxis with oseltamivir. CONCLUSIONS: These findings suggest infection among tour group members was limited despite prolonged periods of close contact during travel. Furthermore, multiple public health interventions are likely to have effectively prevented an outbreak following the tour group's return.

A school and community outbreak of tuberculosis in Palmerston North, New Zealand.

AIM: To describe a secondary school outbreak of tuberculosis in Palmerston North, New Zealand in 2006. METHODS: Case and contact management was conducted by MidCentral District Health Board according to national guidelines. RESULTS: The index (and source) case was a school student. Delayed diagnosis led to extensive transmission. Contact investigation detected fifteen secondary cases, from six of whom Mycobacterium tuberculosis organism was cultured which was identical to that found in the index case. Latent tuberculosis infection was diagnosed in 235 of 1828 contacts. Following logistic regression, risk of infection was significantly associated with age, exposure setting (household and school vs other settings) and duration of exposure. Large numbers of contacts were infected who had no known contact with the index case, thus indicating probable tertiary transmission from the 7 infectious secondary cases. The secondary healthcare cost of the outbreak was estimated at $279,481. Findings from school tuberculosis (TB) outbreaks since 1990 are summarised. CONCLUSION: This was the largest tuberculosis outbreak described in New Zealand and one of the largest school outbreaks reported in the published literature.

Tuberculosis epidemiology in New Zealand: 1995-2004.

AIMS: To describe the epidemiology of tuberculosis (TB) in New Zealand (NZ) for the 10-year period 1995-2004, and to place this in the context of long-term incidence trends. METHODS: We calculated TB incidence rates since the early 1920s using published data. A more detailed analysis examined TB notification and laboratory data for the period 1995 to 2004 using population denominator data from the 1996 and 2001 Census. We calculated incidence rates by age, sex, ethnicity, place of residence, country of birth, and deprivation for the two 5-year periods: 1995 to 1999 and 2000 to 2004. We also calculated and compared TB case fatality and mortality rates for those periods. We described outbreaks by using TB outbreak reporting data. RESULTS: The long-term decline in TB incidence in NZ halted in the mid-1980s, and in the last two decades, annual rates have stabilised at around 10 cases per 100,000. The average rate for 1995-2004 period was 10.3 per 100,000. The TB incidence rate in NZ is higher than that in Australia, USA, and Canada, and slightly lower than that in the UK. Within NZ there are marked ethnic differences in rates, with age-standardised incidence rates 10.5, 22.3, and 36.5 times higher in Maori, Pacific peoples, and people of Other ethnicity respectively than the rate in Europeans. Rates generally increase with age. Approximately two-thirds (64.6%) of people with TB were born overseas. TB case fatality and mortality rates in NZ are declining and are comparable to those in Australia, Canada, USA, and the UK. Twenty-four TB outbreaks, including 221 cases, were reported between mid-1996 and 2004. CONCLUSIONS: TB is not declining in NZ. The burden of disease is very unevenly distributed across the population with marked ethnic inequalities.

Leptospirosis presenting to an intensive care unit in provincial New Zealand: a case series and review.

BACKGROUND: Leptospirosis is a disease associated with meat and agricultural workers which is endemic in New Zealand and Australia. During 2003-2005, it resulted in 207 hospitalisations in New Zealand. Hawke's Bay had the highest regional incidence in 2004 and 2005. While admission to intensive care units with leptospirosis is not infrequent, no such cases have been described in the literature from New Zealand, and only five from Australia. METHODS: A chart review of all patients admitted to the intensive care/high dependency unit of a regional hospital in New Zealand with a diagnosis of leptospirosis from June 1999 to May 2005. Admission features, progress and diagnostic tests were collated, and APACHE II score on admission and daily Sequential Organ Failure Assessment (SOFA) score were calculated. RESULTS: 15 cases were identified; median age was 44 years (range, 27-62), and 13 were men. Myalgia, headache, nausea and vomiting were common; nine had conjunctival suffusion. Ten had hypotension and 14 had renal failure before ICU admission. Eleven received vasoactive support, and three received renal replacement therapy. Median length of ICU stay was 4 days (range, 2- 11; mean, 4 days). Median hospital stay was 6 days (range, 2-13; mean, 7.6 days). All patients survived and were discharged free of dialysis. CONCLUSION: Leptospirosis presents to the ICU with a variety of signs and symptoms. Renal failure is the most common organ dysfunction requiring intensive care, and its severity is disproportionate to other signs of severe sepsis. Leptospirosis has a good prognosis with early management in an ICU.

The health status of asylum seekers screened by Auckland Public Health in 1999 and 2000.

AIM: Approximately 1500 to 1800 applications for refugee status are made to the New Zealand Immigration Service each year. Approximately one third of these asylum seekers receive health screening from Auckland Public Health. We report here key findings from this screening programme for the period 1999 to 2000. METHODS: The files of patients attending the Auckland Public Health Protection Asylum Seekers Screening Clinic at Green Lane Hospital were reviewed. Data on demographics, medical examination, diagnostic testing and referrals were analysed. RESULTS: Nine hundred people, mainly from Middle Eastern countries, received screening. Important findings were: symptoms of psychological illness (38.4%); Mantoux skin test positivity ( 36.4%); active tuberculosis (0.6%); TB infection requiring chemoprophylaxis (18%) or chest X-ray monitoring (15%); gut parasite infection; carrier state for alpha and beta thalassaemia and the heterozygous states for HbS and HbE; incomplete immunisation; and the need for referral to a secondary care service (32.6%). CONCLUSIONS: Immigrant communities in New Zealand have special healthcare needs, as well as experiencing language barriers, cultural differences and economic difficulties. Healthcare providers should be alert to these needs. Appropriate resources are required to address these issues in a timely fashion.

Could laboratory-based notification improve the control of foodborne illness in New Zealand?

AIMS: To estimate the completeness and timeliness of notifications of seven potentially foodborne diseases in Auckland. METHODS: The diseases audited were shigellosis, salmonellosis, campylobacteriosis, yersiniosis, listeriosis, hepatitis A and verocytotoxigenic (VTEC) E. coli infections. Hospital and community laboratory-confirmed cases for the calendar year 2000 were audited against those notified to the Auckland Regional Public Health Service. Cases were matched on disease, name, date of birth, gender and National Health Index number. RESULTS: There were 3182 laboratory-confirmed cases of the seven diseases identified of which 77% had been notified to the Auckland Regional Public Health Service. The proportion of laboratory-confirmed cases notified ranged from a 65% for hepatitis A to 100% for VTEC infection. The median delay between laboratory confirmation and practitioner notification was two days. Notification of all laboratory-confirmed cases would have resulted in an estimated 145 additional investigations in the year 2000. CONCLUSION: A change to laboratory-based notification could improve public health investigation and control of foodborne disease in New Zealand.