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AUSTRALIA AND NEW ZEALAND SOCIETY FOR EPIDEMIOLOGY AND RESEARCH IN COMMUNITY HEALTH

AUSTRALIA AND NEW ZEALAND SOCIETY FOR EPIDEMIOLOGY AND RESEARCH IN COMMUNITY HEALTH ('OMMUNITY HEALTH SWDIES VOLUME IV. NIJMBER .T, 1980 AUSTRALIA AND NEW ZEALAND SOCIETY FOR EPIDEMIOLOGY AND RESEARCH IN COMMUNITY HEALTH New Zealand Annual Conference, 1980. The following are abstracts of papers presented at the New Zealand Conference of the Society, held in Wellington 21-23 August, 1980. SCIENTIFIC PAPERS CHILDREN'S MEDICAL EMERGENCIES 45-54 years there has been a 16% and 18% VARIATIONS EXPLAINED decline in CHD mortality respectively between the years 1968 and 1977. In cqntrast in non- B. C. Allan and J. Reinken Maoris aged 65-74 there was a decline of 7% in both sexes in the same time period. The New Management Services and Research Unit, Zealand decline in CHD mortality lags behind that in other countries, notably the USA. The Department of Health, Wellington, New Zealand reasons for the decline are unknown. It may be Child utilisation of general practitioner and due to a reduction in the community of risk Accident and Emergency Department services factor levels leading to a reduced incidence of in the Wellington region over a ten week period CHD, or it may reflect alterations either in the is examined. The presentation rate at the medical management or in the natural history Accident and Emergency Department, and the itself. An examination of available data on proportion of all general practitioner consult- trends in risk factor levels in New Zealand is ations which occur out of surgery hours are inconclusive except for reported smoking habits used as measures of emergency medical care. in doctors and the need for periodic standard- Considerable variations among suburbs are ised measurement of risk factor levels in the found for both these measures. Areas where the population is clear. In 1974 an incidence study general practitioners give relatively few consult- of CHD was carried out in Auckland and a ations out of surgery hours have higher rates of repeat of this study is now under way so that presentation at the Accident and Emergency the important public health questions raised by Department out of hours. Other factors affect- the decline in CHD may be assessed. ing the presentation rates are also explored. LEGIONELLOSIS IN NEW ZEALAND: A Review. TRENDS IN CORONARY HEART DISEASE K. A. Bettelheim and R. V. Metcalfc IN NEW ZEALAND National Health Instiiute, Wellington Robert Beaglehole, David Hay and Frank Foster Legionellosis or Legionnaire's Disease was' first Community Health Auckland School of Med- described in USA in 1976. Since the beginning icine, National Heart Foundation of New of 1979 reagents sup lied by the Center for Zealand and National Centre for Health Disease Control (USA7 have been used at the statistics National Health Institute to test serum from patients suspected of suffering from this con- From 1950 until the mid-1960s there was a dition. definite increase in New Zealand in death rates It is proposed to discuss the results obtained from coronary heart disease (CHD) in both from studying these patients in relation to the men and women. Since 1968 the mortality rate clinical data supplied. from CHD has fallen, especially in younger non- Our experiences to date will be compared Maoris.In non-Maori men and women aged with those published overseas. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES 255 THE DISTRIBUTION OF LEPTOSPIRAL the handicapped - ordinary homes with ‘access’ arrangements added - run by multidisciplinary ANTIBODIES AMONG THE NEW ZEALAND teams, including those voluntary society rep- POPULATION resentatives relevant to the type of handi- caps; the staffiig and building funded by K. A. Bettelheim, R. V. Metcalfe and A.L. Thompson hospital boards. the usual invalid benefit funded by Social Welfare and a proportion paid National Health Institute, Department of back to the hospital boards for rent and other Health, Wellington, New Zealand services, the ‘workshop’ and social experiences provided by the relevant voluntary society. This To date only a small number of serovars of is what, in the case of the Nelson homes, has leptospirae have been shown to infect the naturally evolved. human or animal population of New Zealand. The results of studying over 5,000 healthy persons for the presence of antibodies to these leptospirae will be presented and compared GEOGRAPHICAL DISTRIBUTION OF ANTI- to clinical cases. The role of the environment BODIES TO TOXOPLASMA CONDII IN A and occupation in establishing whether anyone NEW ZEALAND POPULATION will come in contact with these organisms will be assessed. It will be shown that antibody levels are a useful indication of monitoring E. B. Densham and K.A. Bettelheim risk factors to leptospirosis in various popula- National Health Institute, Wellington, New tion groups. Zealand Sera from the National Serum Bank collection were tested for toxoplasma antibodies using the Indirect Fluorescent Antibody test. The MULTI-DISCIPLINARY HOMES FOR THE numbers of reactors from each area were com- HANDICAPPED pared to see if there was any significant geo- graphical variation. A similar comparison was Dr. K. A. Bradford made using the diagnostic serum speciments. It is of interest that approximately 40% of Braemm Psychopaedic Hospital, Nelson healthy New Zealanden have antibodies to Toxoplasma gondii. The paper will describe some small Group Homes for the Handicapped run by the Nelson Hospital Board, by multidisciplinary teams con- sisting of representatives from statutory bodies plus voluntary agencies. WHAT ARE COMMUNITY HEALTH It would be perfectly feasible for them to be PROJECTS DOING NOW AND WHAT run by an even wider multidisciplinary team RELATIONSHIPS WOULD THEY LIKE TO consisting of the present members plus any relevant voluntary society representatives and HAVE WITH THE CONVENTIONAL HEALTH SYSTEM? staffed and run in the same way as those des- cribed. For instance, most residents in the Jan Dowland and Anne de Lacey homes to be described attend the IHC Work- shop, and the IHC helps with social 1ife.Like- Management Services and Research Unit, wise, if the residents were physically rather Department of Health, Wellington than intellectually handicapped the CCS (Crippled Children Society) might be involved A joint presentation will be given on Saturday rather than the IHC. It happens that in the August 23 -- Community Health Project Day - Nelson homes described, three of the admin- outlining the authors’ experience and involve- istration team who run the homes are members ment in community health projects and raising of the executive of the IHC (Society €or the some of the issues they feel are important. It Intellectually Handicapped). will go on to review the relationships that Also of interest is the fact that one of the projects have with conventional health services, residents is very physically handicapped with a touching upon such concerns as autonomy, paralysis of one side, and nurses coming in accountability and co-ordination. It is hoped twice daily help her with her bathing etc. that this paper will act as a stimulus to the The paper will ask whether it would be poss- workshop discussions which will follow. ible for other districts to have small homes for COMMUNITY HEALTH STUDIES 256 VOLUME IV, NUMBER 3, 1980 rise which on occasions occurs within a few KAVA, ALCOHOL AND TOBACCO days and as such may indicate the ‘susceptible’ CONSUMPTION IN TWO TONGAN worker. POPULATIONS In conclusion it will be argued that within certain limits of exposure, whether or not Sitaleki A. Finau, John Stanhope and Ian Prior excessive absorption of lead occurs will depend primarily on the attitude and motivation of Epidemiology Unit, Wellington Hospital. management, nurse, doctor and workers. Wellington, New Zealand The prevalence of kava (Piper methysticum), alcohol and tobacco consumption in Nuku’alofa (urban) and Foa (rural) are des- ‘MY DAD’S BIGGER” YOURS’ - A STUDY cribed. Kava consumption is almost exclusive OF BODY HEIGHT OF THEIR PARENTS AS to males (48%) with significantly higher prev- ESTIMATED BY MEMBERS OF AN ENTIRE alence in the rural males. Only seven females COMMUNITY (0.9%) currently consume kava. Cunent alcohol consumption is almost exclusive to the urban F. A. de Hamel population and predominantly male. But 169 (84.0%) of the rural males are irregulady or Department of Preventive and Social Medicine, have ceased consuming alcohol. Only 2 (1%) University of Otago Medical Schoool, New rural males are current alcohol consumers. In Zealand tobacco consumption, there is a significant male predominance. There is a significantly Since the height of a person is partly genetic- higher total tobacco consumption in the urban ally determined an enquiry was made of all population. 1192 adult members of a community as to the In the urban population, there is no three way heights of both their parents. These estimates interaction between kava, alcohol and tobacco were compared with the subjects’ own measur- consumption. There is a significant ed height. After allowing for age the men were association between kava and tobacco only. found to estimate both their father and their The odds ratios are greater than three. This mother to be significantly taller than did the description reflects the degree of change of women. Since it would be factually imposs- life-style and may provide the basis for en- ible for the men of a community to have taller couraging traditional habits (kava), if proven parents than the women of the same commun- harmless, to replace tobacco and alcohol ity, it seems that there is a psychological consump tion. sex-related component inherent in the estim- ation of parent size. The data has been studied from a variety of aspects in an attempt to determine more precisely some of the factors which are important in determining parental LEAD ABSORPTION IN A BATTERY body image. FACTORY AND SMELTER Dr. Bill Glass Department of Community Health, Auckland School of Medicine SABIN LIVE ORAL POLIOVACCINE (SLOP) The health supervision of workers in this W. Hamilton, M. W. Wilson and N. S. Kuttner industry will be considered with reference to the different methods used over the past National Health Institute, Wellington, ‘ New twenty-one years. Zealand The limitations of lead in air levels as a means of controlling human risk will be compared Except in the Tropics, where results of enteric with the advantages of blood leads. infections, both viral and bacterial, interfere It will be shown that whereas lead in air with the growth of SLOP in the intestinal levels in the battery factory have not changed mucosa, the use of Sabin vaccine has stimulated over three years the blood lead levels of the a high degree of hard immunity to poliomyelitis. workers have fallen. Since October 1961 more than three million Results of blood lead tests carried out in the people in New Zealand have received SLOP. first two months of employment will show the It is likely that the spread of the virulent (i.e. rapid rise which occurs during this period, a paralvtouenic) wild type viruses have been sub- VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES stantially diminished in the NZ population- THE GOALS OF A HEALTH SERVICE: There is a cohort of individuals born since the ANALYSIS OF SOME CONCEPTS end of the mass campaign of pOfiOmYelitis immunization in November 1961 who are now R* wholly dependant on SLOP for their immunity. Serological studies elsewhere have indicated a Corporate Planning unit, Wellington Hospital slow decline in measurable poliovirus neutral- izing antibody after childhood vaccination. A serological study was Planned to deter- The statement of the goals of a health service mine the extent of this in New Zealand. is important for helping to describe the options There is a decline in antibody levels to all and implications of resource allocation and use. three types of PoliO~~ UP to 8 Ye= follow- Many previous goal statements of health sew- ing upon the Primary schedule of immunization ices have not been of much help because of the but thereafter the levels remain stationary at conceptual confusion of key terms such as least until age 21. health, disease, illness, sickness, handicap, &- ability. This presentation describes a number of ways in which terms such as these are used, and provides a framework in which they can be related. Using these distinctions, a number of goal options are presented and the practical implic- ations described for resource allocation and use. A SCIENTIFIC APPROACH TO THE CHIROPRACTIC DEBATE Laurence Malcolm and Pauline Bamett RESOURCES IN PRIMARY HEALTH CARE Health Planning and Research Unit, Christchurch, New Zealand C. S. Higgins The Report of the Commission of Inquiry on Chiropractic, with its strong support for the Health Planningand Research Unit, Christchurch recognition of Chiropractic in New Zealand, is leading to a re-evaluation by the medical This paper was pre'pared as an information profession of the place of manipulative resource for the Canterbury Primary Health therapy and chiropractic in the treatment of Care Advisory Group. It also represents some back pain. preliminary research into the interface between A community medicine research project in primary and secondary care in North Canter- Christchurch by medical students, supervised bury. by the authors, examined the problem of back An attempt is made to clarify the concept of pain as presenting to general practitioners, primary health care. This is followed by an inventory of services currently available in the manipulative physiotherapists and chiropractors. NCRB area which might be appropriately It also examined the attitudes of the medical allocated to the primary health care sector, profession and the public to the problem. together with the manpower resources within The research has revealed that back pain is a these services and the public costs of running common problem, that manipulative therapy is and providing the services. widely believed to be effective, that chiro- practic seems to offer little that is not now pro- While manpower is distributed relatively evenly among the various services, most of the vided by manipulative physiotherapy and that wider co-operation between all parties would costs are generated by general practitioners. This suggests the possibility of a significant seem to be acceptable. Given these findings an appropriate policy imbalance of resources within the primary would seem to be the payment of benefits to health care sector. chiropractors only on referral by doctors. The Discussion on what might constitute an apparent effectiveness of manipulative therapy appropriate balance of resources both within for back pain whether provided by physio- the primary care sector and between primary therapists or chiropractors should be tested care and hospital care is likely to be fruitless by controlled trials of referral by general in the absence of an adequate information base practitioners to both groups. which quantifies the present existing balance. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES THE DISTRIBUTION OF BRUCELLA ANTI- STREPTOCCAL SKIN INFECTION: A BODIES AMONG THE NEW ZEALAND COMMUNITY HEALTH PROBLEM POPULATION Gail E. Meekin W. J. Maskill, R. V. Metcalfe and K. A. Bettelheim. National Health Institute, Department of Health, Wellington, New Zealand National Health Institute, Department of Studies undertaken during the last few years Health, Wellington, New Zealand. have revealed a high rate of streptococcal involvement in skin infections of New Zealand The results of studying over 5,000 healthy persons for the presence of antibodies to school children. Serotyping of streptococcal Brucella abortus will be presented. These strains ( M and T) isolated from these studies has shown the existence of pyodermal sero- results will be compared with antibody levels obtained from clinical cases. The role of types of known nephritogenic potential. environmental factors will be assessed. The use- Measurement of streptococcal antibody levels fulness of monitoring populations for such in subjects with skin infection compared with those having upper respiratory tract infection antibody levels will be demonstrated. has demonstrated the superiority of the antiDNase B test over the antjstteptolysin 0 test when the skin is involved. Relationship of skin-associated. serotypes to cases of acute glomerulonephritis has been established. THE DESIGN AND EXECUTION OF A QUESTIONNAIRE SURVEY OF REPRODUCTIVE OUTCOMES OF AGRICULTURAL CHEMICAL APPLICATORS ANTIBODY LEVELS TO LEGIONELLA PNEUMOPHILA IN HEALTHY NEW Don Matheson and Allan H. Smith ZEALANDERS Department of Community Health, Wellington R. V. Metcalfe and H. Sillprs Clinical School of Medicine. Wellington Hospital, Wellington, New Zealand National Health Institute In response to the growing concern about the Since the description of Legionnaire’s disease health effects of agricultural chemicals, in part- in the USA in 1976 and the description of the icular 2,4,5-T, a postal survey has been con- aetiological agent, Legionella pneumophla, ducted of registered chemical applicators. All there has been great interest in the diagnosis of chemical applicators throughout New Zealand this disease. Currently the accepted basis of who were registered with the Agricultural diagnosis is serological. As interpretation of Chemicals Board for one or more years between these results is dependent on a baseline of 1973 and 1979 have been included giving a normal values, the antibody levels of healthy total of 650 workers in this group. In addition, New Zealand blood donors were examined. The the questionnaire has been sent to a group of standard indirect fluorescent antibody test was married contract workers. The objective of the used. study is to see if there is any difference in Sera with antibodies to L. pneumophila have reproductive outcomes, including miscarriages, been found suggesting that this agent has been still births and congenital defects, for concept- present in the New Zealand population. ions occurring during years in which the father was involved in spraying 2,4,5,-T and other chemicals. The questions asked concerning PRIMARY HEALTH CARE DEVELOPMENT exposure and reproductive outcomes are IN PACIFIC ISLAND COMMUNITIES presented and discussed. The methods used in the attempt to obtain a satisfactory response K. W. Newcll are described including communications through the news media, Contractors Federa- Department of Community Health, Wellington tion circulars, and direct mailings to the target Clinical School of Medicine population. Figures concerning the response rate will be presented and discussed. Primary Health care and Health for All by the Year 2000 are the stated top ranking health COMMUNITY HEALTH STUDIES VOLUME IV. NUMBER 3, 1980 259 objectives of WHO and all member states from a study of large bowel cancer which shows (including New Zealand) during the next 20 for example, that in 1976 New Zealand had the years. The conceptual model of how this could highest mortality in the world for the age- be achieved is given in WHO publications and range 35-64 and that mortality in the age- in the Alma Ata declaration. range 35-45 is currently more than one and a During 1978-1979 an appreciation (using half that of the next highest country. official data and field visits) has been made of The program has been designed for general most of the Pacific Island States, including the use in epidemiological studies requiring age- present position and their future plans. This adjustment techniques. Because the New shows that while some states, such as Fiji, have Zealand population census data has already an expanding system, most others have a low been assembled, New Zealand users can use the coverage of Primary Health Care and that program by supplying numerator mortality or change is difficult. This is partly because the incidence data only. WHO model has a number of inherent assumpt- ions which are difficult to apply in widely scattered populations. The Pacific is fortunate as there are few areas experiencing the gross health effects of poverty. However, the Pacific is at a disadvantage as the small size of most of the States means that the areas has few resources to develop the necessary unique solutions. These problems were discussed at a Commonwealth Secretariat Con- ference in London in 1980, and the recom- FACTORS PREDISPOSING THE ELDERLY mendations will be presented and discussed TO FALLS with especial emphasis upon possible New Zealand roles. J. Reinken and J. Campbell Management Services and Research Unit, Department of Health, Wellington and Otago Medical School, Dunedin, New Zealand A GENERALISED COMPUTER PROGRAM This paper examines the factors predisposing FOR ANALYSIS OF N.Z. MORTALITY (AND elderly people to falls. INCIDENCE) RATES The data are provided by Dr. Campbell’s Neil Pearce, Ah Smith study of elderly people in Gisborne. An age- stratified random sample of over 65’s in the Department of Community Health, Wellington Gisborne Urban Area was identified and visited Clinical School of Medicine, Wellington by a specially trained nurse and later by the Hospital, Wellington, New Zealand geriatric physician. Each elderly person was also invited to be examined by an opthalmologist. The results of these examinations yielded a The methods of age-adjustment of mortality number of variables possibly leading to falls: (or incidence) rates are of considerable import- Observed postural hypotension ance for epidemiological studies and have been Reported postural hypotension the subject of much debate, as different Regular medication known to cause hypo- methods of adjustment can lead to different tension results. An Algol computer program is Impaired mobility described which calculates age-specific and Reduced flexion of the neck crude overall mortality rates (per 100,000 of Visual impairment population) as well as calculating the age- Neurological problems adjusted rates using a number of different standard populations (including NZ, World, The relationships of these factors to the truncated World, African and European). In persons’ histories of falls, by the type of fall, each case the program also calculates the pattern and frequency have been explored using average rates for user-specified periods (e.g. the discriminant analysis technique to compute for each 5 years between 1948-1977). The use risk factors (cf. C. E. Salmond, et al). of the program is illustrated with examples COMMUNITY HEALTH STUDIES 260 VOLUME IV, NUMBER 3, 1980 Illustrative data are taken from two Welling- OCCuPATIoNAL AND HEALTH ton region surveys. The fint analysis invest- STATUS igates the motivation behind visiting a doctor. The second investigates factors involved in J. Reinken and C. E. Salmond accommodation changes among the elderly. Management Seruices and Research Unit, Department of Health, and Epidemiology Unit, Wellington Hospital, Wellington, New Zealand We present data taken from two health surveys, conducted in 1976, in Porirua and WHY EDIT? GARBAGE IN-GARBAGE OUT! Hamilton. We explore in this paper the relation- ship between occupational factors and current C. E. Salmond and S. McKenzic health status. Neither educational attainment nor occupational status significantly affected Epidemiology Unit, Wellington Hospital and current health status in either city. The diff- Management Services and Research Unit, erences in women’s health status between. Department of Health, Wellington, New Zealand Porirua and Hamilton were found to be insig- nificant when we controlled for hours of The well-known phrase ’garbage in-garbage work (shift work or long hours). out’ summarises the fact that random or We considered, as well, ‘work-related‘ current systematic errors in numerical data affect the or chronic disease. The prevalence of such dis- results of any statistical analysis of those data. ease was not affected by either educational This paper outlines methods of minimizingand level, occupational group or hours of work, detecting those errors of fact, of interpretation although blue-coliar female workers in Porirua or of transcription which can (and do) occur did report somewhat higher levels of ‘work- during the processing of questionnaire data. related’ illness than did white-collar workers. Single and double coding methods are The history of accidents in the past year, compared, and the superiority of double coding ‘work-rJated’ or not, was likewise not affected is quantified. The use of check digits is des- by the educational or occupational factors cribed and an efficient system of such digits is used, although blue-collar male workers in presented. Hamilton reported slightly more ‘work-related’ Computer assisted editing procedures for accidents than their white-collar counterparts. detecting both out-of-range and inconsistent data are described. COMMUNICATING THE RESULTS OF A DISCRIMINANT ANALYSIS C. E. Salmond, B. C. Allan, J. Reinkcn, B. B. Taylor DOCTOR DISTRIBUTION AND MEDICAL MANPOWER POLICY Epidemiology Unit, Wellington Hospital, Management Seruices and Research Unit, I. G. Sheerin Department of Health; Department of Geriatrics, Wellington Hospital, Wellington, Department of Geopaphy, University of New Zealand Canterbury The geographic distribution of general prac- Discriminant analysis is a multivariate stat- titioners in New Zealandis uneven in relation istical tool. It can be used to define a minimum to population. The high output of medical set of variables which collectively distinguish to schools has raised the prospect of a doctor which of two groups an individual belongs. The surplus, and has not solved problems of un- discriminating variables can be used later to equal distribution. Some preliminary results predict the group membership of further indiv- of a research programme examining changes in iduals. the distribution of doctors between 1969 - Presentation of the detailed statistical results 1979 are described. The methodology, involv- of a discriminant analysis used in this way can ing monitoring claims made on the GMS be unintelligible to a non-statistical audience. schedule in order to measure manpower avail- However, this paper describes a simple method ability, is described. Some trends in the com- of presentation based on the readily understood position of the general practitioner workforce concept of a risk ratio. VOLUME IV, NUMBER 3. 1980 26 1 COMMUNITY HEALTH STUDIES are discussed. The areas of relative doctor THE MAAKA CLINIC: WHAT HAS IT scarcity and abundance are revealed, and the ACHIEVED THUS FAR? CAN ITS areas which have benefited most from the in- PRINCIPALS BE APPLIED ELSEWHERE? creased numbers of GPs are highlighted. Multiple correlation and regression analysis are D. Short and M. Shaw utilised to identify the important variables which appear to be influencing patterns of dis- Whakatane Hospital Board and Department of tribution. The implications of the results for Community Health, Wellington Clinical School medical manpower policy formulation are dis- of Medicine. cussed, and some research priorities for the future are proposed. This paper discusses the Maaka Clinic - a pilot primary health care service established three years ago in the small rural Maori community of Ruatoki. The Clinic was designed to over- come the community’s prior problems of un- acceptability and poor access to medical services. The Clinic principally provides General Practitioner services two half days a week and a middle ear disease clinic for diagnosis, treat- ment and follow-up. Emphasis is placed on the PRIMARY HEALTH CARE FOR HOSPITAL importance of careful consultation with the EMPLOYEES - AN ANALYSIS WITH COMMENTS OF ONE YEAR’S community’s leaders and the use of a Health Status study in establishing the Clinic’s ATTENDANCES priorities for resource allocation. The paper goes on to examine the findings of Mrs. Kath Shepherd - Registered Nurse a study of the Clinic’s impact on Ruatoki con- ducted after one year of service. The principal Occupational Health Service, Auckland points made are; what the community views as Hospital, New Zealand the essential criteria for an acceptable accessible service; the remarkable success of the treatment The Auckland Hospital Occupational Health and follow-up service for middle ear disease; Service, which was established in 1977, differs the relatively low capital and running costs from others in New Zealand in that it provides required by the Clinic. a health service for all staff, with emphasis on Finally, the implications of the Maaka Clinic education and prevention. The many activities in which the team was for provision of primary health care in comm- involved in 19 7 7 are briefly described. unities similar to Ruatoki is discussed. The economic climate of the ’80s dictates that cost-effectiveness must be evident, and this can FUTURE OVER-SUPPLY OF GENERAL be accurately demonstrated. Time is saved, as PRACTITIONERS - MYTH OR MISERY? personnel need not leave the hospital to obtain health care, kd the fact that they receive Julie Simpson, Member of Research Committee immediate attention results in little time being lost from work. Primary and preventative care, Research Committee, Canterbury Faculty, RNZCGP including education reduces sickness and accidents. The need for an information base about The contribution the service makes to the general practice for planning and educational well-being of the hospital community is in- purposes has been recognised by the Research valuable. Health surveillance of people who Committee of the Canterbury Faculty, of the may be at risk in their workplace lifts morale College of General Practitioners. as the staff find the presence of the Occupa- One of the committee’s recent activities has tional Health Service in the background re- been the exploration of North Canterbury assuring, as a watchdog for any problem which general practitioners’ opinions and attitudes may arise in the working environment. towards current issues in general practice. Occupational IHealth demands multidisciplinary This paper focuses on the range of responses active participation by management, nurses, of fifty-five general practitioners to the issue doctors and clerical staff who must become a of increased medical manpower and its inherent cohesive unit if the service is to fulfil its potent- implications for general practice. ial. It is imperative that the personnel who con- The majority of general practitioners are con- tribute to the service be adequately trained, cerned about the impending over-supply and flexible and able to use, in the broadest sense, favour a planning approach to minimise itst all of their skills. effect. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES countries. However, there appears to he excessiw CANCER OF THE LARYNX AND OTHER reliance on standard anticonvuhant doses given iIt HAZARDS OF MUSTARD GAS WORKERS frequent intervals regardless of the rate of metaholisni of the drug. 22 per cent of patients showed significant D. C. G. Skegg, K. P. Manning and P. M. Stell failure of compliance. as assessed by the time intervals between collection of drugs from the pharmacy. .Department of Preventive and Social Medicine, Prescription data offers a useful method tor University of Otago Medical School, Dunedin. examining drug utilization. Computerization could cxtend the rangc of information obtained by simplify- An attempt was made to trace 511 men and ing the collection of data. women who manufactured mustard gas in Britain during the 1939-45 war. Despite limit- ations in the identifying data available, 428 (84%) were traced to the end of 1974. The numbers of deaths from all neoplasms combined (45) and from all other causes (136) were slightly greater than those expected from national death rates, but not significantly so. Two deaths were attributed to carcinoma of the larynx and one to carcinoma of the trachea, compared with an expected number of 0.40 (KO.02). Carcinoma of the larynx was also mentioned on the death certificate of another man. Altogether seven subjects are known to have developed cancer of the larynx, compared with 0.75 expected (P<O.OOl). The laryngeal tumours were squamous cell carcinomas, and all but one were diagnosed more than 20 years after the end of the war. NUTRITIONAL ASSESSMENT OF Excess mortality was also observed from cancer KAMPUCHEAN REFUGEES ot the lung, pneumonia, and accidents, but the excesses were small and difficult to interpret. Dr. J. M. Stanhope Epidemiology Unit, Wellington Hospital, Wellington, New Zealand The organisation of a disaster relief program requires urgent attention to feeding, sanitation and the care of the sick and injured. In a short period spent in two refugee camps in Thailand, mortality was found to be much higher in Sa Kaeo camp, where 31,000 refugees arrived en muse severely malnourished, than in Khao I-Dang camp where the arrival of 82,000 PRESCRIBING FOR EPILEPSY IN THE WElr refugees, not so malnourished, was spread over LINGTON COMMUNITY six weeks. I,. Stunaway, D. G. Lambie, R. H. Johnson Rapid nutritional assessment was made by Wellington Clinic*crl Schurd qf Mcdit.inu clinical inspection, weights and height observ- All prescriptions for anticonvulsant mcdication ation and arm circumference measurement. The written over a four month period for patients in thc initial lack of laboratory facilities, though Wellington area were identified, with the aini of remedied later, required haemoglobinometry by examining patterns of anticonvulsant prescribing and a paper blot method. assessing the value of prescriptions as a source of The choice of food therapy was predicated bv information for drug utilization review. the culture of the refugees and the availability of 1479 patients received anticonvulsant medica- supplies. A small outbreak of poisoning tion. of which 139 were suspected of receiving occurred when some refugees collected and ate unfamiliar vegetables. medication for other than epilepsy. The incidencc of The impact of infectious disease, particularly treated epilepsy in the Wellington community is 4. I malaria, compounded the effects of malnutri- per lOtM1 population. 62 per cent or' patients werc on a singlc. tion. A pervading air of depression was allev- un!iconvulsant. which coiiipurcs Vivourahly with iated once nutritional rehabilitation was achieved. reports of excessive polypharniacy from European VOLUME IV, NUMBER 3; 1980 COMMUNITY HEALTH STUDIES 3 The varying periods of exposure to lead of DECISION CRITERIA FOR HOME OR those working with it. HOSPITAL CARE FOR MYOCARDIAL 4 The assessment of available evidence INFARCTION relating to the biological effects of lead. 5 The views of representatives of employers Anne Stephenson and Laurence Malcolm and employees. 6 The bias of those representatives. Health Planning and Research Unit, 7 The acceptability of risk by employees. Christchurch, New Zealand 8 The practicality of proposed standards. 9 The cost benefit of such standards. Admission rates to hospitals for coronary 10 The means of implementation and heart disease have been steadily increasing probable results of such standards. for all age groups over the past twenty years. Coronary heart disease is now the commonest The New Zealand standards are among the cause of admission to medical wards. most advanced in the world with flexibility pro- Recent randomised controlled trials have viding a balance between practicality and shown that myocardial infarction may be as perfection. effectively treated at home as in coronary care Units: A preliminary study of one hundred con- INAPPROPRIATE ADMISSION TO HOMES secutive admissions to the Princess Margaret FOR THE AGED Hospital coronary care unit, Christchurch, reveals that, of 72 males and 28 females, 46 B. B. Taylor and J. M. Neale have a primary diagnosis of myocardial infarction, 11 of myocwdial ischaemia, and 15 Department of Geriatric Medicine, Wellington of arrhythmia. The other 28 did not appear to Hospital, Wellington, New Zealand require the specialist care of the coronary care unit. An investigation of the health and social cir- Research over the next three years in collab- cumstances of recent admissions to church and oration with cardiologists and general practit- voluntary homes for the aged was undertaken ioners is proposed in order to develop more in order to determine the appropriateness of prescriptive criteria for pre-hospital assess- the move. The characteristics of these subjects ment of those with suspected myocardial is compared with those of a random sample of infarction. It is expected that thiswill lead the population aged 75 years and over living in to improved decision making and hence quality the community at large. It is found that in- of care and a reduction in admissions. appropriate admissions, as judged by health and disability criteria, account for a third of all admissions. Reasons for the move in these sub- jects include social deprivation, inappropriate PROTECTING THE HEALTH OF LEAD responses to crisis situations including bereave- WORKERS - THE DILEMMA OF ment, pressure from family and professional PRACTICALITY OR PERFECTION IN advisors, prolonged periods of hospital treat- SETTING STANDARDS ment, and the existence of long waiting lists. Better counselling and social work with the John Stoke aged, a more optimistic medical management of acute illness and accidents, a more appropriate Department of Health, Wellington, New use of waiting lists and readily available special Zealand housing for the elderly would lead to a reduct- ion in the demand for residential home care. Throughout the world, the relevant occupat- ional health authorities establish guidelines for the medical supervision of lead workers in order THE CHANGING PATTERN OF INFANT to ensure that their health is adequately safe- MORTALITY IN AUCKLAND, NEW guarded. ZEALAND In New Zealand these guidelines have recently been reviewed and revised by the Department S. L. Tonkin of Health. In this or similar processes the following 10 points require careful consider- Department of Health, Auckland, New Zealand ation. 1 The objective of establishing guidelines. A study of Post Neonatal infant mortality in 2 The different types of lead work to which the Auckland Hospital Board area in 1972 by they will be applied. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES personal interview of parents of dead children CHILDHOOD CANCER MORTALITY revealed that deaths could be assigned to three DURING 1955-74: ANALYSIS OF WHO main groups. These groups were birth defects, DATA FOR 29 COUNTRIES infections and cot deaths. The infection group was comprised of pneumonia, gastroenteritis Robert West, M.A, Ph.D. , and meningitis. Deaths from pneumonia could be attributed Department of Community Medicine, Welsh largely to parental non-recognition of the National School of Medicine, Cardiff. severity of the illness and non-seeking of medical advice, as could those from meningitis. All childhood deaths in 20 European and nine However, most of the babies who died from non European countries that were reported to gastroenteritis were under medical treatment at the WHO mortality data bank in Geneva have home when they died. A high proportion of been analysed. Death rates were compared for dead infants had not had regular ‘well baby’ all malignant neoplasma (ICD 8th edition 140- care. 209) with the lending causes of death in Education of parents, general practitioners infancy and in childhood. Death rates for sel- and nurses was undertaken. In five years, the ected malignant neoplasms and for lymphoma preventable deaths from infections have fallen and leukaemia were calculated by age and sex. to a quarter of the previous level. Mortality rates and time trends of the rates were studied within countries and were com- pared between countries. Total infant and childhood mortality from neoplastic diseases varies far less between countries than does ASSOCIATED HEALTH PROBLEMS OF mortality from other causes. During the quin- REDUNDANCY quennium 1970-74 in countries with low infant and childhood mortality approximately 11,000 C. M. Turner (Mrs.) R.G.N., R.F.N., R.M. of every million births dies as infants (in their and approximately 6,000 died as Occupational Health Centre, Relieving Nurse in children yea? under age 15) : of the 17,000 that Industry died before age 15 fewer than 1,000 died of malignant neoplasms. In several countries the New Zealand lacks statistical knowledge of possible under-diagnosis of malignancy as the adverse effects on health caused by cause of death is difficult to estimate since industrial redundancy. malignancy death rates were frequently missed Health services do not include this inform- by very high death rates from other causes. ation as part of a patient’s medical history, Leukaemia was the principal cause of death leaving a gap in any knowledge of these effects. among the neoplastic diseases and there are Limited research has shown that many of the clear signs that peak death rates from leukaemia health problems so caused are common to all have passed in most countries. Mortality from levels of the work force, whether it is the malignant neoplasms of kidney (mostly Wilm’s person making the redundancy decision, the tumours) and of brain and central nervous one implementing that decision or the victim. system (the most common solid tumours of We now know that stress lowers the body’s childhood - medulloblastoma, glioma and immunity to disease and leads to illness. astrocytoma) are decreasing also in several This decade will see more changes than any countries. previous decade in industry. Robots and the silicone chip will accelerate this process, creating more redundancy. It is essential that medical services consider this when planning future health programmes. VOLUME IV, NUMBER 3, 1980 265 COMMUNITY HEALTH STUDIES http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

AUSTRALIA AND NEW ZEALAND SOCIETY FOR EPIDEMIOLOGY AND RESEARCH IN COMMUNITY HEALTH

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"Copyright © 1980 Wiley Subscription Services, Inc., A Wiley Company"
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Abstract

('OMMUNITY HEALTH SWDIES VOLUME IV. NIJMBER .T, 1980 AUSTRALIA AND NEW ZEALAND SOCIETY FOR EPIDEMIOLOGY AND RESEARCH IN COMMUNITY HEALTH New Zealand Annual Conference, 1980. The following are abstracts of papers presented at the New Zealand Conference of the Society, held in Wellington 21-23 August, 1980. SCIENTIFIC PAPERS CHILDREN'S MEDICAL EMERGENCIES 45-54 years there has been a 16% and 18% VARIATIONS EXPLAINED decline in CHD mortality respectively between the years 1968 and 1977. In cqntrast in non- B. C. Allan and J. Reinken Maoris aged 65-74 there was a decline of 7% in both sexes in the same time period. The New Management Services and Research Unit, Zealand decline in CHD mortality lags behind that in other countries, notably the USA. The Department of Health, Wellington, New Zealand reasons for the decline are unknown. It may be Child utilisation of general practitioner and due to a reduction in the community of risk Accident and Emergency Department services factor levels leading to a reduced incidence of in the Wellington region over a ten week period CHD, or it may reflect alterations either in the is examined. The presentation rate at the medical management or in the natural history Accident and Emergency Department, and the itself. An examination of available data on proportion of all general practitioner consult- trends in risk factor levels in New Zealand is ations which occur out of surgery hours are inconclusive except for reported smoking habits used as measures of emergency medical care. in doctors and the need for periodic standard- Considerable variations among suburbs are ised measurement of risk factor levels in the found for both these measures. Areas where the population is clear. In 1974 an incidence study general practitioners give relatively few consult- of CHD was carried out in Auckland and a ations out of surgery hours have higher rates of repeat of this study is now under way so that presentation at the Accident and Emergency the important public health questions raised by Department out of hours. Other factors affect- the decline in CHD may be assessed. ing the presentation rates are also explored. LEGIONELLOSIS IN NEW ZEALAND: A Review. TRENDS IN CORONARY HEART DISEASE K. A. Bettelheim and R. V. Metcalfc IN NEW ZEALAND National Health Instiiute, Wellington Robert Beaglehole, David Hay and Frank Foster Legionellosis or Legionnaire's Disease was' first Community Health Auckland School of Med- described in USA in 1976. Since the beginning icine, National Heart Foundation of New of 1979 reagents sup lied by the Center for Zealand and National Centre for Health Disease Control (USA7 have been used at the statistics National Health Institute to test serum from patients suspected of suffering from this con- From 1950 until the mid-1960s there was a dition. definite increase in New Zealand in death rates It is proposed to discuss the results obtained from coronary heart disease (CHD) in both from studying these patients in relation to the men and women. Since 1968 the mortality rate clinical data supplied. from CHD has fallen, especially in younger non- Our experiences to date will be compared Maoris.In non-Maori men and women aged with those published overseas. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES 255 THE DISTRIBUTION OF LEPTOSPIRAL the handicapped - ordinary homes with ‘access’ arrangements added - run by multidisciplinary ANTIBODIES AMONG THE NEW ZEALAND teams, including those voluntary society rep- POPULATION resentatives relevant to the type of handi- caps; the staffiig and building funded by K. A. Bettelheim, R. V. Metcalfe and A.L. Thompson hospital boards. the usual invalid benefit funded by Social Welfare and a proportion paid National Health Institute, Department of back to the hospital boards for rent and other Health, Wellington, New Zealand services, the ‘workshop’ and social experiences provided by the relevant voluntary society. This To date only a small number of serovars of is what, in the case of the Nelson homes, has leptospirae have been shown to infect the naturally evolved. human or animal population of New Zealand. The results of studying over 5,000 healthy persons for the presence of antibodies to these leptospirae will be presented and compared GEOGRAPHICAL DISTRIBUTION OF ANTI- to clinical cases. The role of the environment BODIES TO TOXOPLASMA CONDII IN A and occupation in establishing whether anyone NEW ZEALAND POPULATION will come in contact with these organisms will be assessed. It will be shown that antibody levels are a useful indication of monitoring E. B. Densham and K.A. Bettelheim risk factors to leptospirosis in various popula- National Health Institute, Wellington, New tion groups. Zealand Sera from the National Serum Bank collection were tested for toxoplasma antibodies using the Indirect Fluorescent Antibody test. The MULTI-DISCIPLINARY HOMES FOR THE numbers of reactors from each area were com- HANDICAPPED pared to see if there was any significant geo- graphical variation. A similar comparison was Dr. K. A. Bradford made using the diagnostic serum speciments. It is of interest that approximately 40% of Braemm Psychopaedic Hospital, Nelson healthy New Zealanden have antibodies to Toxoplasma gondii. The paper will describe some small Group Homes for the Handicapped run by the Nelson Hospital Board, by multidisciplinary teams con- sisting of representatives from statutory bodies plus voluntary agencies. WHAT ARE COMMUNITY HEALTH It would be perfectly feasible for them to be PROJECTS DOING NOW AND WHAT run by an even wider multidisciplinary team RELATIONSHIPS WOULD THEY LIKE TO consisting of the present members plus any relevant voluntary society representatives and HAVE WITH THE CONVENTIONAL HEALTH SYSTEM? staffed and run in the same way as those des- cribed. For instance, most residents in the Jan Dowland and Anne de Lacey homes to be described attend the IHC Work- shop, and the IHC helps with social 1ife.Like- Management Services and Research Unit, wise, if the residents were physically rather Department of Health, Wellington than intellectually handicapped the CCS (Crippled Children Society) might be involved A joint presentation will be given on Saturday rather than the IHC. It happens that in the August 23 -- Community Health Project Day - Nelson homes described, three of the admin- outlining the authors’ experience and involve- istration team who run the homes are members ment in community health projects and raising of the executive of the IHC (Society €or the some of the issues they feel are important. It Intellectually Handicapped). will go on to review the relationships that Also of interest is the fact that one of the projects have with conventional health services, residents is very physically handicapped with a touching upon such concerns as autonomy, paralysis of one side, and nurses coming in accountability and co-ordination. It is hoped twice daily help her with her bathing etc. that this paper will act as a stimulus to the The paper will ask whether it would be poss- workshop discussions which will follow. ible for other districts to have small homes for COMMUNITY HEALTH STUDIES 256 VOLUME IV, NUMBER 3, 1980 rise which on occasions occurs within a few KAVA, ALCOHOL AND TOBACCO days and as such may indicate the ‘susceptible’ CONSUMPTION IN TWO TONGAN worker. POPULATIONS In conclusion it will be argued that within certain limits of exposure, whether or not Sitaleki A. Finau, John Stanhope and Ian Prior excessive absorption of lead occurs will depend primarily on the attitude and motivation of Epidemiology Unit, Wellington Hospital. management, nurse, doctor and workers. Wellington, New Zealand The prevalence of kava (Piper methysticum), alcohol and tobacco consumption in Nuku’alofa (urban) and Foa (rural) are des- ‘MY DAD’S BIGGER” YOURS’ - A STUDY cribed. Kava consumption is almost exclusive OF BODY HEIGHT OF THEIR PARENTS AS to males (48%) with significantly higher prev- ESTIMATED BY MEMBERS OF AN ENTIRE alence in the rural males. Only seven females COMMUNITY (0.9%) currently consume kava. Cunent alcohol consumption is almost exclusive to the urban F. A. de Hamel population and predominantly male. But 169 (84.0%) of the rural males are irregulady or Department of Preventive and Social Medicine, have ceased consuming alcohol. Only 2 (1%) University of Otago Medical Schoool, New rural males are current alcohol consumers. In Zealand tobacco consumption, there is a significant male predominance. There is a significantly Since the height of a person is partly genetic- higher total tobacco consumption in the urban ally determined an enquiry was made of all population. 1192 adult members of a community as to the In the urban population, there is no three way heights of both their parents. These estimates interaction between kava, alcohol and tobacco were compared with the subjects’ own measur- consumption. There is a significant ed height. After allowing for age the men were association between kava and tobacco only. found to estimate both their father and their The odds ratios are greater than three. This mother to be significantly taller than did the description reflects the degree of change of women. Since it would be factually imposs- life-style and may provide the basis for en- ible for the men of a community to have taller couraging traditional habits (kava), if proven parents than the women of the same commun- harmless, to replace tobacco and alcohol ity, it seems that there is a psychological consump tion. sex-related component inherent in the estim- ation of parent size. The data has been studied from a variety of aspects in an attempt to determine more precisely some of the factors which are important in determining parental LEAD ABSORPTION IN A BATTERY body image. FACTORY AND SMELTER Dr. Bill Glass Department of Community Health, Auckland School of Medicine SABIN LIVE ORAL POLIOVACCINE (SLOP) The health supervision of workers in this W. Hamilton, M. W. Wilson and N. S. Kuttner industry will be considered with reference to the different methods used over the past National Health Institute, Wellington, ‘ New twenty-one years. Zealand The limitations of lead in air levels as a means of controlling human risk will be compared Except in the Tropics, where results of enteric with the advantages of blood leads. infections, both viral and bacterial, interfere It will be shown that whereas lead in air with the growth of SLOP in the intestinal levels in the battery factory have not changed mucosa, the use of Sabin vaccine has stimulated over three years the blood lead levels of the a high degree of hard immunity to poliomyelitis. workers have fallen. Since October 1961 more than three million Results of blood lead tests carried out in the people in New Zealand have received SLOP. first two months of employment will show the It is likely that the spread of the virulent (i.e. rapid rise which occurs during this period, a paralvtouenic) wild type viruses have been sub- VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES stantially diminished in the NZ population- THE GOALS OF A HEALTH SERVICE: There is a cohort of individuals born since the ANALYSIS OF SOME CONCEPTS end of the mass campaign of pOfiOmYelitis immunization in November 1961 who are now R* wholly dependant on SLOP for their immunity. Serological studies elsewhere have indicated a Corporate Planning unit, Wellington Hospital slow decline in measurable poliovirus neutral- izing antibody after childhood vaccination. A serological study was Planned to deter- The statement of the goals of a health service mine the extent of this in New Zealand. is important for helping to describe the options There is a decline in antibody levels to all and implications of resource allocation and use. three types of PoliO~~ UP to 8 Ye= follow- Many previous goal statements of health sew- ing upon the Primary schedule of immunization ices have not been of much help because of the but thereafter the levels remain stationary at conceptual confusion of key terms such as least until age 21. health, disease, illness, sickness, handicap, &- ability. This presentation describes a number of ways in which terms such as these are used, and provides a framework in which they can be related. Using these distinctions, a number of goal options are presented and the practical implic- ations described for resource allocation and use. A SCIENTIFIC APPROACH TO THE CHIROPRACTIC DEBATE Laurence Malcolm and Pauline Bamett RESOURCES IN PRIMARY HEALTH CARE Health Planning and Research Unit, Christchurch, New Zealand C. S. Higgins The Report of the Commission of Inquiry on Chiropractic, with its strong support for the Health Planningand Research Unit, Christchurch recognition of Chiropractic in New Zealand, is leading to a re-evaluation by the medical This paper was pre'pared as an information profession of the place of manipulative resource for the Canterbury Primary Health therapy and chiropractic in the treatment of Care Advisory Group. It also represents some back pain. preliminary research into the interface between A community medicine research project in primary and secondary care in North Canter- Christchurch by medical students, supervised bury. by the authors, examined the problem of back An attempt is made to clarify the concept of pain as presenting to general practitioners, primary health care. This is followed by an inventory of services currently available in the manipulative physiotherapists and chiropractors. NCRB area which might be appropriately It also examined the attitudes of the medical allocated to the primary health care sector, profession and the public to the problem. together with the manpower resources within The research has revealed that back pain is a these services and the public costs of running common problem, that manipulative therapy is and providing the services. widely believed to be effective, that chiro- practic seems to offer little that is not now pro- While manpower is distributed relatively evenly among the various services, most of the vided by manipulative physiotherapy and that wider co-operation between all parties would costs are generated by general practitioners. This suggests the possibility of a significant seem to be acceptable. Given these findings an appropriate policy imbalance of resources within the primary would seem to be the payment of benefits to health care sector. chiropractors only on referral by doctors. The Discussion on what might constitute an apparent effectiveness of manipulative therapy appropriate balance of resources both within for back pain whether provided by physio- the primary care sector and between primary therapists or chiropractors should be tested care and hospital care is likely to be fruitless by controlled trials of referral by general in the absence of an adequate information base practitioners to both groups. which quantifies the present existing balance. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES THE DISTRIBUTION OF BRUCELLA ANTI- STREPTOCCAL SKIN INFECTION: A BODIES AMONG THE NEW ZEALAND COMMUNITY HEALTH PROBLEM POPULATION Gail E. Meekin W. J. Maskill, R. V. Metcalfe and K. A. Bettelheim. National Health Institute, Department of Health, Wellington, New Zealand National Health Institute, Department of Studies undertaken during the last few years Health, Wellington, New Zealand. have revealed a high rate of streptococcal involvement in skin infections of New Zealand The results of studying over 5,000 healthy persons for the presence of antibodies to school children. Serotyping of streptococcal Brucella abortus will be presented. These strains ( M and T) isolated from these studies has shown the existence of pyodermal sero- results will be compared with antibody levels obtained from clinical cases. The role of types of known nephritogenic potential. environmental factors will be assessed. The use- Measurement of streptococcal antibody levels fulness of monitoring populations for such in subjects with skin infection compared with those having upper respiratory tract infection antibody levels will be demonstrated. has demonstrated the superiority of the antiDNase B test over the antjstteptolysin 0 test when the skin is involved. Relationship of skin-associated. serotypes to cases of acute glomerulonephritis has been established. THE DESIGN AND EXECUTION OF A QUESTIONNAIRE SURVEY OF REPRODUCTIVE OUTCOMES OF AGRICULTURAL CHEMICAL APPLICATORS ANTIBODY LEVELS TO LEGIONELLA PNEUMOPHILA IN HEALTHY NEW Don Matheson and Allan H. Smith ZEALANDERS Department of Community Health, Wellington R. V. Metcalfe and H. Sillprs Clinical School of Medicine. Wellington Hospital, Wellington, New Zealand National Health Institute In response to the growing concern about the Since the description of Legionnaire’s disease health effects of agricultural chemicals, in part- in the USA in 1976 and the description of the icular 2,4,5-T, a postal survey has been con- aetiological agent, Legionella pneumophla, ducted of registered chemical applicators. All there has been great interest in the diagnosis of chemical applicators throughout New Zealand this disease. Currently the accepted basis of who were registered with the Agricultural diagnosis is serological. As interpretation of Chemicals Board for one or more years between these results is dependent on a baseline of 1973 and 1979 have been included giving a normal values, the antibody levels of healthy total of 650 workers in this group. In addition, New Zealand blood donors were examined. The the questionnaire has been sent to a group of standard indirect fluorescent antibody test was married contract workers. The objective of the used. study is to see if there is any difference in Sera with antibodies to L. pneumophila have reproductive outcomes, including miscarriages, been found suggesting that this agent has been still births and congenital defects, for concept- present in the New Zealand population. ions occurring during years in which the father was involved in spraying 2,4,5,-T and other chemicals. The questions asked concerning PRIMARY HEALTH CARE DEVELOPMENT exposure and reproductive outcomes are IN PACIFIC ISLAND COMMUNITIES presented and discussed. The methods used in the attempt to obtain a satisfactory response K. W. Newcll are described including communications through the news media, Contractors Federa- Department of Community Health, Wellington tion circulars, and direct mailings to the target Clinical School of Medicine population. Figures concerning the response rate will be presented and discussed. Primary Health care and Health for All by the Year 2000 are the stated top ranking health COMMUNITY HEALTH STUDIES VOLUME IV. NUMBER 3, 1980 259 objectives of WHO and all member states from a study of large bowel cancer which shows (including New Zealand) during the next 20 for example, that in 1976 New Zealand had the years. The conceptual model of how this could highest mortality in the world for the age- be achieved is given in WHO publications and range 35-64 and that mortality in the age- in the Alma Ata declaration. range 35-45 is currently more than one and a During 1978-1979 an appreciation (using half that of the next highest country. official data and field visits) has been made of The program has been designed for general most of the Pacific Island States, including the use in epidemiological studies requiring age- present position and their future plans. This adjustment techniques. Because the New shows that while some states, such as Fiji, have Zealand population census data has already an expanding system, most others have a low been assembled, New Zealand users can use the coverage of Primary Health Care and that program by supplying numerator mortality or change is difficult. This is partly because the incidence data only. WHO model has a number of inherent assumpt- ions which are difficult to apply in widely scattered populations. The Pacific is fortunate as there are few areas experiencing the gross health effects of poverty. However, the Pacific is at a disadvantage as the small size of most of the States means that the areas has few resources to develop the necessary unique solutions. These problems were discussed at a Commonwealth Secretariat Con- ference in London in 1980, and the recom- FACTORS PREDISPOSING THE ELDERLY mendations will be presented and discussed TO FALLS with especial emphasis upon possible New Zealand roles. J. Reinken and J. Campbell Management Services and Research Unit, Department of Health, Wellington and Otago Medical School, Dunedin, New Zealand A GENERALISED COMPUTER PROGRAM This paper examines the factors predisposing FOR ANALYSIS OF N.Z. MORTALITY (AND elderly people to falls. INCIDENCE) RATES The data are provided by Dr. Campbell’s Neil Pearce, Ah Smith study of elderly people in Gisborne. An age- stratified random sample of over 65’s in the Department of Community Health, Wellington Gisborne Urban Area was identified and visited Clinical School of Medicine, Wellington by a specially trained nurse and later by the Hospital, Wellington, New Zealand geriatric physician. Each elderly person was also invited to be examined by an opthalmologist. The results of these examinations yielded a The methods of age-adjustment of mortality number of variables possibly leading to falls: (or incidence) rates are of considerable import- Observed postural hypotension ance for epidemiological studies and have been Reported postural hypotension the subject of much debate, as different Regular medication known to cause hypo- methods of adjustment can lead to different tension results. An Algol computer program is Impaired mobility described which calculates age-specific and Reduced flexion of the neck crude overall mortality rates (per 100,000 of Visual impairment population) as well as calculating the age- Neurological problems adjusted rates using a number of different standard populations (including NZ, World, The relationships of these factors to the truncated World, African and European). In persons’ histories of falls, by the type of fall, each case the program also calculates the pattern and frequency have been explored using average rates for user-specified periods (e.g. the discriminant analysis technique to compute for each 5 years between 1948-1977). The use risk factors (cf. C. E. Salmond, et al). of the program is illustrated with examples COMMUNITY HEALTH STUDIES 260 VOLUME IV, NUMBER 3, 1980 Illustrative data are taken from two Welling- OCCuPATIoNAL AND HEALTH ton region surveys. The fint analysis invest- STATUS igates the motivation behind visiting a doctor. The second investigates factors involved in J. Reinken and C. E. Salmond accommodation changes among the elderly. Management Seruices and Research Unit, Department of Health, and Epidemiology Unit, Wellington Hospital, Wellington, New Zealand We present data taken from two health surveys, conducted in 1976, in Porirua and WHY EDIT? GARBAGE IN-GARBAGE OUT! Hamilton. We explore in this paper the relation- ship between occupational factors and current C. E. Salmond and S. McKenzic health status. Neither educational attainment nor occupational status significantly affected Epidemiology Unit, Wellington Hospital and current health status in either city. The diff- Management Services and Research Unit, erences in women’s health status between. Department of Health, Wellington, New Zealand Porirua and Hamilton were found to be insig- nificant when we controlled for hours of The well-known phrase ’garbage in-garbage work (shift work or long hours). out’ summarises the fact that random or We considered, as well, ‘work-related‘ current systematic errors in numerical data affect the or chronic disease. The prevalence of such dis- results of any statistical analysis of those data. ease was not affected by either educational This paper outlines methods of minimizingand level, occupational group or hours of work, detecting those errors of fact, of interpretation although blue-coliar female workers in Porirua or of transcription which can (and do) occur did report somewhat higher levels of ‘work- during the processing of questionnaire data. related’ illness than did white-collar workers. Single and double coding methods are The history of accidents in the past year, compared, and the superiority of double coding ‘work-rJated’ or not, was likewise not affected is quantified. The use of check digits is des- by the educational or occupational factors cribed and an efficient system of such digits is used, although blue-collar male workers in presented. Hamilton reported slightly more ‘work-related’ Computer assisted editing procedures for accidents than their white-collar counterparts. detecting both out-of-range and inconsistent data are described. COMMUNICATING THE RESULTS OF A DISCRIMINANT ANALYSIS C. E. Salmond, B. C. Allan, J. Reinkcn, B. B. Taylor DOCTOR DISTRIBUTION AND MEDICAL MANPOWER POLICY Epidemiology Unit, Wellington Hospital, Management Seruices and Research Unit, I. G. Sheerin Department of Health; Department of Geriatrics, Wellington Hospital, Wellington, Department of Geopaphy, University of New Zealand Canterbury The geographic distribution of general prac- Discriminant analysis is a multivariate stat- titioners in New Zealandis uneven in relation istical tool. It can be used to define a minimum to population. The high output of medical set of variables which collectively distinguish to schools has raised the prospect of a doctor which of two groups an individual belongs. The surplus, and has not solved problems of un- discriminating variables can be used later to equal distribution. Some preliminary results predict the group membership of further indiv- of a research programme examining changes in iduals. the distribution of doctors between 1969 - Presentation of the detailed statistical results 1979 are described. The methodology, involv- of a discriminant analysis used in this way can ing monitoring claims made on the GMS be unintelligible to a non-statistical audience. schedule in order to measure manpower avail- However, this paper describes a simple method ability, is described. Some trends in the com- of presentation based on the readily understood position of the general practitioner workforce concept of a risk ratio. VOLUME IV, NUMBER 3. 1980 26 1 COMMUNITY HEALTH STUDIES are discussed. The areas of relative doctor THE MAAKA CLINIC: WHAT HAS IT scarcity and abundance are revealed, and the ACHIEVED THUS FAR? CAN ITS areas which have benefited most from the in- PRINCIPALS BE APPLIED ELSEWHERE? creased numbers of GPs are highlighted. Multiple correlation and regression analysis are D. Short and M. Shaw utilised to identify the important variables which appear to be influencing patterns of dis- Whakatane Hospital Board and Department of tribution. The implications of the results for Community Health, Wellington Clinical School medical manpower policy formulation are dis- of Medicine. cussed, and some research priorities for the future are proposed. This paper discusses the Maaka Clinic - a pilot primary health care service established three years ago in the small rural Maori community of Ruatoki. The Clinic was designed to over- come the community’s prior problems of un- acceptability and poor access to medical services. The Clinic principally provides General Practitioner services two half days a week and a middle ear disease clinic for diagnosis, treat- ment and follow-up. Emphasis is placed on the PRIMARY HEALTH CARE FOR HOSPITAL importance of careful consultation with the EMPLOYEES - AN ANALYSIS WITH COMMENTS OF ONE YEAR’S community’s leaders and the use of a Health Status study in establishing the Clinic’s ATTENDANCES priorities for resource allocation. The paper goes on to examine the findings of Mrs. Kath Shepherd - Registered Nurse a study of the Clinic’s impact on Ruatoki con- ducted after one year of service. The principal Occupational Health Service, Auckland points made are; what the community views as Hospital, New Zealand the essential criteria for an acceptable accessible service; the remarkable success of the treatment The Auckland Hospital Occupational Health and follow-up service for middle ear disease; Service, which was established in 1977, differs the relatively low capital and running costs from others in New Zealand in that it provides required by the Clinic. a health service for all staff, with emphasis on Finally, the implications of the Maaka Clinic education and prevention. The many activities in which the team was for provision of primary health care in comm- involved in 19 7 7 are briefly described. unities similar to Ruatoki is discussed. The economic climate of the ’80s dictates that cost-effectiveness must be evident, and this can FUTURE OVER-SUPPLY OF GENERAL be accurately demonstrated. Time is saved, as PRACTITIONERS - MYTH OR MISERY? personnel need not leave the hospital to obtain health care, kd the fact that they receive Julie Simpson, Member of Research Committee immediate attention results in little time being lost from work. Primary and preventative care, Research Committee, Canterbury Faculty, RNZCGP including education reduces sickness and accidents. The need for an information base about The contribution the service makes to the general practice for planning and educational well-being of the hospital community is in- purposes has been recognised by the Research valuable. Health surveillance of people who Committee of the Canterbury Faculty, of the may be at risk in their workplace lifts morale College of General Practitioners. as the staff find the presence of the Occupa- One of the committee’s recent activities has tional Health Service in the background re- been the exploration of North Canterbury assuring, as a watchdog for any problem which general practitioners’ opinions and attitudes may arise in the working environment. towards current issues in general practice. Occupational IHealth demands multidisciplinary This paper focuses on the range of responses active participation by management, nurses, of fifty-five general practitioners to the issue doctors and clerical staff who must become a of increased medical manpower and its inherent cohesive unit if the service is to fulfil its potent- implications for general practice. ial. It is imperative that the personnel who con- The majority of general practitioners are con- tribute to the service be adequately trained, cerned about the impending over-supply and flexible and able to use, in the broadest sense, favour a planning approach to minimise itst all of their skills. effect. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES countries. However, there appears to he excessiw CANCER OF THE LARYNX AND OTHER reliance on standard anticonvuhant doses given iIt HAZARDS OF MUSTARD GAS WORKERS frequent intervals regardless of the rate of metaholisni of the drug. 22 per cent of patients showed significant D. C. G. Skegg, K. P. Manning and P. M. Stell failure of compliance. as assessed by the time intervals between collection of drugs from the pharmacy. .Department of Preventive and Social Medicine, Prescription data offers a useful method tor University of Otago Medical School, Dunedin. examining drug utilization. Computerization could cxtend the rangc of information obtained by simplify- An attempt was made to trace 511 men and ing the collection of data. women who manufactured mustard gas in Britain during the 1939-45 war. Despite limit- ations in the identifying data available, 428 (84%) were traced to the end of 1974. The numbers of deaths from all neoplasms combined (45) and from all other causes (136) were slightly greater than those expected from national death rates, but not significantly so. Two deaths were attributed to carcinoma of the larynx and one to carcinoma of the trachea, compared with an expected number of 0.40 (KO.02). Carcinoma of the larynx was also mentioned on the death certificate of another man. Altogether seven subjects are known to have developed cancer of the larynx, compared with 0.75 expected (P<O.OOl). The laryngeal tumours were squamous cell carcinomas, and all but one were diagnosed more than 20 years after the end of the war. NUTRITIONAL ASSESSMENT OF Excess mortality was also observed from cancer KAMPUCHEAN REFUGEES ot the lung, pneumonia, and accidents, but the excesses were small and difficult to interpret. Dr. J. M. Stanhope Epidemiology Unit, Wellington Hospital, Wellington, New Zealand The organisation of a disaster relief program requires urgent attention to feeding, sanitation and the care of the sick and injured. In a short period spent in two refugee camps in Thailand, mortality was found to be much higher in Sa Kaeo camp, where 31,000 refugees arrived en muse severely malnourished, than in Khao I-Dang camp where the arrival of 82,000 PRESCRIBING FOR EPILEPSY IN THE WElr refugees, not so malnourished, was spread over LINGTON COMMUNITY six weeks. I,. Stunaway, D. G. Lambie, R. H. Johnson Rapid nutritional assessment was made by Wellington Clinic*crl Schurd qf Mcdit.inu clinical inspection, weights and height observ- All prescriptions for anticonvulsant mcdication ation and arm circumference measurement. The written over a four month period for patients in thc initial lack of laboratory facilities, though Wellington area were identified, with the aini of remedied later, required haemoglobinometry by examining patterns of anticonvulsant prescribing and a paper blot method. assessing the value of prescriptions as a source of The choice of food therapy was predicated bv information for drug utilization review. the culture of the refugees and the availability of 1479 patients received anticonvulsant medica- supplies. A small outbreak of poisoning tion. of which 139 were suspected of receiving occurred when some refugees collected and ate unfamiliar vegetables. medication for other than epilepsy. The incidencc of The impact of infectious disease, particularly treated epilepsy in the Wellington community is 4. I malaria, compounded the effects of malnutri- per lOtM1 population. 62 per cent or' patients werc on a singlc. tion. A pervading air of depression was allev- un!iconvulsant. which coiiipurcs Vivourahly with iated once nutritional rehabilitation was achieved. reports of excessive polypharniacy from European VOLUME IV, NUMBER 3; 1980 COMMUNITY HEALTH STUDIES 3 The varying periods of exposure to lead of DECISION CRITERIA FOR HOME OR those working with it. HOSPITAL CARE FOR MYOCARDIAL 4 The assessment of available evidence INFARCTION relating to the biological effects of lead. 5 The views of representatives of employers Anne Stephenson and Laurence Malcolm and employees. 6 The bias of those representatives. Health Planning and Research Unit, 7 The acceptability of risk by employees. Christchurch, New Zealand 8 The practicality of proposed standards. 9 The cost benefit of such standards. Admission rates to hospitals for coronary 10 The means of implementation and heart disease have been steadily increasing probable results of such standards. for all age groups over the past twenty years. Coronary heart disease is now the commonest The New Zealand standards are among the cause of admission to medical wards. most advanced in the world with flexibility pro- Recent randomised controlled trials have viding a balance between practicality and shown that myocardial infarction may be as perfection. effectively treated at home as in coronary care Units: A preliminary study of one hundred con- INAPPROPRIATE ADMISSION TO HOMES secutive admissions to the Princess Margaret FOR THE AGED Hospital coronary care unit, Christchurch, reveals that, of 72 males and 28 females, 46 B. B. Taylor and J. M. Neale have a primary diagnosis of myocardial infarction, 11 of myocwdial ischaemia, and 15 Department of Geriatric Medicine, Wellington of arrhythmia. The other 28 did not appear to Hospital, Wellington, New Zealand require the specialist care of the coronary care unit. An investigation of the health and social cir- Research over the next three years in collab- cumstances of recent admissions to church and oration with cardiologists and general practit- voluntary homes for the aged was undertaken ioners is proposed in order to develop more in order to determine the appropriateness of prescriptive criteria for pre-hospital assess- the move. The characteristics of these subjects ment of those with suspected myocardial is compared with those of a random sample of infarction. It is expected that thiswill lead the population aged 75 years and over living in to improved decision making and hence quality the community at large. It is found that in- of care and a reduction in admissions. appropriate admissions, as judged by health and disability criteria, account for a third of all admissions. Reasons for the move in these sub- jects include social deprivation, inappropriate PROTECTING THE HEALTH OF LEAD responses to crisis situations including bereave- WORKERS - THE DILEMMA OF ment, pressure from family and professional PRACTICALITY OR PERFECTION IN advisors, prolonged periods of hospital treat- SETTING STANDARDS ment, and the existence of long waiting lists. Better counselling and social work with the John Stoke aged, a more optimistic medical management of acute illness and accidents, a more appropriate Department of Health, Wellington, New use of waiting lists and readily available special Zealand housing for the elderly would lead to a reduct- ion in the demand for residential home care. Throughout the world, the relevant occupat- ional health authorities establish guidelines for the medical supervision of lead workers in order THE CHANGING PATTERN OF INFANT to ensure that their health is adequately safe- MORTALITY IN AUCKLAND, NEW guarded. ZEALAND In New Zealand these guidelines have recently been reviewed and revised by the Department S. L. Tonkin of Health. In this or similar processes the following 10 points require careful consider- Department of Health, Auckland, New Zealand ation. 1 The objective of establishing guidelines. A study of Post Neonatal infant mortality in 2 The different types of lead work to which the Auckland Hospital Board area in 1972 by they will be applied. VOLUME IV, NUMBER 3, 1980 COMMUNITY HEALTH STUDIES personal interview of parents of dead children CHILDHOOD CANCER MORTALITY revealed that deaths could be assigned to three DURING 1955-74: ANALYSIS OF WHO main groups. These groups were birth defects, DATA FOR 29 COUNTRIES infections and cot deaths. The infection group was comprised of pneumonia, gastroenteritis Robert West, M.A, Ph.D. , and meningitis. Deaths from pneumonia could be attributed Department of Community Medicine, Welsh largely to parental non-recognition of the National School of Medicine, Cardiff. severity of the illness and non-seeking of medical advice, as could those from meningitis. All childhood deaths in 20 European and nine However, most of the babies who died from non European countries that were reported to gastroenteritis were under medical treatment at the WHO mortality data bank in Geneva have home when they died. A high proportion of been analysed. Death rates were compared for dead infants had not had regular ‘well baby’ all malignant neoplasma (ICD 8th edition 140- care. 209) with the lending causes of death in Education of parents, general practitioners infancy and in childhood. Death rates for sel- and nurses was undertaken. In five years, the ected malignant neoplasms and for lymphoma preventable deaths from infections have fallen and leukaemia were calculated by age and sex. to a quarter of the previous level. Mortality rates and time trends of the rates were studied within countries and were com- pared between countries. Total infant and childhood mortality from neoplastic diseases varies far less between countries than does ASSOCIATED HEALTH PROBLEMS OF mortality from other causes. During the quin- REDUNDANCY quennium 1970-74 in countries with low infant and childhood mortality approximately 11,000 C. M. Turner (Mrs.) R.G.N., R.F.N., R.M. of every million births dies as infants (in their and approximately 6,000 died as Occupational Health Centre, Relieving Nurse in children yea? under age 15) : of the 17,000 that Industry died before age 15 fewer than 1,000 died of malignant neoplasms. In several countries the New Zealand lacks statistical knowledge of possible under-diagnosis of malignancy as the adverse effects on health caused by cause of death is difficult to estimate since industrial redundancy. malignancy death rates were frequently missed Health services do not include this inform- by very high death rates from other causes. ation as part of a patient’s medical history, Leukaemia was the principal cause of death leaving a gap in any knowledge of these effects. among the neoplastic diseases and there are Limited research has shown that many of the clear signs that peak death rates from leukaemia health problems so caused are common to all have passed in most countries. Mortality from levels of the work force, whether it is the malignant neoplasms of kidney (mostly Wilm’s person making the redundancy decision, the tumours) and of brain and central nervous one implementing that decision or the victim. system (the most common solid tumours of We now know that stress lowers the body’s childhood - medulloblastoma, glioma and immunity to disease and leads to illness. astrocytoma) are decreasing also in several This decade will see more changes than any countries. previous decade in industry. Robots and the silicone chip will accelerate this process, creating more redundancy. It is essential that medical services consider this when planning future health programmes. VOLUME IV, NUMBER 3, 1980 265 COMMUNITY HEALTH STUDIES

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Oct 1, 1980

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