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Background Although the harm to health from electronic nicotine delivery systems (ENDS) compared to smoked tobacco remains highly uncertain, society and governments still need to know the likely range of the relative harm to inform regulatory policies for ENDS and smoking. Methods We identified biomarkers with specificity of association with different disease groupings e.g., volatile organic compound (VOCs) for chronic obstructive pulmonary disease; and tobacco-specific N´-nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) for all cancers. We conducted a review of recent studies (post January 2017) that compared these biomarkers between people exclusively using ENDS and those exclusively smoking tobacco. The percentage differences in these biomarkers, weighted by study size and adjusted for acrolein from other sources, were used as a proxy for the assumed percentage difference in disease harm between ENDS and smoking. These relative differences were applied to previously modelled estimates of smoking-related health loss (in health-adjusted life-years; HALYs). Results The respective relative biomarker levels (ENDS vs smoking) were: 28% for respiratory diseases (five results, three studies); 42% for cancers (five results, four studies); and 35% for cardiovascular (seven results, four studies). When integrated with the HALY impacts by disease, the overall harm to health from ENDS was estimated to be 33% that of smoking. Conclusions This analysis, suggests that the use of modern ENDS devices (vaping) could be a third as harmful to health as smoking in a high-income country setting. But this estimate is based on a limited number of biomarker studies and is best be considered a likely upper level of ENDS risk given potential biases in our method (i.e., the biomarkers used being correlated with more unaccounted for toxicants in smoking compared to with using ENDS).

Objective: To systematically characterise sugar‐sweetened beverage (SSB) tax policy changes in Pacific Island countries and territories (PICTs) from 2000 to 2019. Methods: Medline, Google Scholar, Pacific Islands Legal Information Institute database, Factiva and news and government websites were systematically searched up to October 2019. Information was extracted on the date and SSB tax level change, tax type, included beverages, and earmarking; and checked for consistency with local experts. Results: Three‐quarters of PICTs had an SSB tax (n=16/21) and 11 of these were excise taxes that included both imported and locally produced beverages. The level of tax was over 20% in 14 jurisdictions. SSB tax was increased by more than 20 percentage points in eight PICTs. Most taxes were ad valorem or volumetric, three were earmarked and only two taxes targeted sugar‐sweetened fruit juices. The majority of countries (14/21) had different tax rates for imported and locally produced beverages. Conclusions: More than three‐quarters of PICTs have SSB taxes. More than one‐third increased these taxes since 2000 at an amount that is expected to reduce soft drink consumption. Implications for public health: Despite high‐quality tax design elements in some PICTs, SSB control policies could generally be strengthened to improve health benefits, e.g. by targeting all SSBs and earmarking revenue for health.

BackgroundTo prioritise tobacco control interventions, simulating their health impacts is valuable. We undertook a systematic review of tobacco intervention simulation models to assess model structure and input variations that may render model outputs non-comparable.MethodsWe applied a Medline search with keywords intersecting modelling and tobacco. Papers were limited to those modelling health outputs (eg, mortality, health-adjusted life years), and at least two of cancer, cardiovascular and respiratory diseases. Data were extracted for each simulation model with ≥3 arising papers, including: model type, untimed or with time steps and trends in business-as-usual (BAU) tobacco prevalence and epidemiology.ResultsOf 1911 papers, 186 met the inclusion criteria, including 13 eligible simulation models. The SimSmoke model had the largest number of publications (n=46), followed by Benefits of Smoking Cessation on Outcomes (n=12) and Tobacco Policy Model (n=10). Two of 13 models only estimated deaths averted, 1 had no time steps, 5 had no future trends in BAU tobacco prevalence, 9 had no future trends in BAU disease epidemiology and 7 had no time lags from quitting tobacco to reversal of health harm.ConclusionsConsiderable heterogeneity exists in simulation models, making outputs substantively non-comparable between models. Ranking of interventions by one model may be valid. However, this may not be true if, for example, interventions that differentially affect age groups (eg, a tobacco-free generation policy vs increased cessation among adults) do not account for plausible future trends. Greater standardisation of model structures and outputs will allow comparison across models and countries, and for comparisons of the impact of tobacco control interventions with other preventive interventions.

Elimination and eradication of disease are among the ultimate goals of public health1 (for definitions see box 1). Vaccination has globally eradicated smallpox, rinderpest (a cattle disease that caused famines2) and two of the three serotypes of poliovirus.3 Three other vaccine-preventable diseases are eradicable globally with current technology,4 with measles the leading contender and with MMR vaccination potentially eradicating mumps and rubella at the same time. Some other diseases are close to being eradicated but without use of vaccines such as with the Guinea Worm Eradication Programme.5 Similarly, China has recently eliminated malaria with a range of non-vaccination tools, to become the 40th country to be certified malaria-free.6 Box 1 Definitions of key disease control terms from the Dahlem Workshop19 Control: The reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction. Example: diarrhoeal diseases. Elimination of disease: Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Example: neonatal tetanus. Elimination of infections: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent re-establishment of transmission are required. Example: measles, poliomyelitis. Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: smallpox. Extinction: The specific infectious agent no longer exists in nature or in the laboratory. Example: none. Is COVID-19 also potentially eradicable? Or is it inevitably endemic having established itself across the world? Commentators have focused on the challenges of reaching population (herd) immunity,7 yet population immunity is not essential and was not achieved for smallpox, which was eradicated through ring vaccination. As proof of concept for COVID-19 eradication, several countries and jurisdictions have achieved elimination without vaccination, using new and established public health and social measures (PHSMs) (eg, border control, physical distancing, mask wearing, testing and contact tracing supported by genome sequencing).8 Successful jurisdictions have included those with vast land borders such as China, high population densities such as Hong Kong,9 but also island nations such as Iceland and New Zealand, although with occasional outbreaks from border control failures that have been brought under control.10

This economic evaluation determines the optimal policy response to the COVID-19 pandemic in Victoria, Australia, using a net monetary benefit approach for policies ranging from aggressive elimination and moderate elimination to tight suppression and loose suppression., Key Points Question What has the least health losses and is the most cost-effective of 4 policy responses to the COVID-19 pandemic (aggressive elimination, moderate elimination, tight suppression, and loose suppression) in the state of Victoria, Australia? Findings In this simulation modeling economic evaluation of health losses and costs from COVID-19 policy responses, aggressive elimination was the most cost-effective from a health system perspective in 64% of simulations above a willingness to pay of $15 000 per health-adjusted life-years, followed by moderate elimination in 35% of simulations. Moderate elimination was most cost-effective from a gross domestic product (GDP) perspective (ie, including GDP losses in addition to health expenditure) in half of the simulations, followed by aggressive elimination in a quarter. Meaning While there is considerable uncertainty in outcomes for all 4 policy responses, the 2 elimination options appear to be the most optimal from both health system and health plus GDP perspectives., Importance Countries have varied enormously in how they have responded to the COVID-19 pandemic, ranging from elimination strategies (eg, Australia, New Zealand, Taiwan) to tight suppression (not aiming for elimination but rather to keep infection rates low [eg, South Korea]) to loose suppression (eg, Europe, United States) to virtually unmitigated (eg, Brazil, India). Weighing the best option, based on health and economic consequences due to lockdowns, is necessary. Objective To determine the optimal policy response, using a net monetary benefit (NMB) approach, for policies ranging from aggressive elimination and moderate elimination to tight suppression (aiming for 1-5 cases per million per day) and loose suppression (5-25 cases per million per day). Design, Setting, and Participants Using governmental data from the state of Victoria, Australia, and other collected data, 2 simulation models in series were conducted of all residents (population, 6.4 million) for SARS-CoV-2 infections for 1 year from September 1, 2020. An agent-based model (ABM) was used to estimate daily SARS-CoV-2 infection rates and time in 5 stages of social restrictions (stages 1, 1b, 2, 3, and 4) for 4 policy response settings (aggressive elimination, moderate elimination, tight suppression, and loose suppression), and a proportional multistate life table (PMSLT) model was used to estimate health-adjusted life-years (HALYs) associated with COVID-19 and costs (health systems and health system plus gross domestic product [GDP]). The ABM is a generic COVID-19 model of 2500 agents, or simulants, that was scaled up to the population of interest. Models were specified with data from 2019 (eg, epidemiological data in the PMSLT model) and 2020 (eg, epidemiological and cost consequences of COVID-19). The NMB of each policy option at varying willingness to pay (WTP) per HALY was calculated: NMB = HALYs × WTP − cost. The estimated most cost-effective (optimal) policy response was that with the highest NMB. Main Outcome and Measures Estimated SARS-CoV-2 infection rates, time under 5 stages of restrictions, HALYs, health expenditure, and GDP losses. Results In 100 runs of both the ABM and PMSLT models for each of the 4 policy responses, 31.0% of SARS-CoV-2 infections, 56.5% of hospitalizations, and 84.6% of deaths occurred among those 60 years and older. Aggressive elimination was associated with the highest percentage of days with the lowest level of restrictions (median, 31.7%; 90% simulation interval [SI], 6.6%-64.4%). However, days in hard lockdown were similar across all 4 strategies. The HALY losses (compared with a scenario without COVID-19) were similar for aggressive elimination (median, 286 HALYs; 90% SI, 219-389 HALYs) and moderate elimination (median, 314 HALYs; 90% SI, 228-413 HALYs), and nearly 8 and 40 times higher for tight suppression and loose suppression, respectively. The median GDP loss was least for moderate elimination (median, $41.7 billion; 90% SI, $29.0-$63.6 billion), but there was substantial overlap in simulation intervals between the 4 strategies. From a health system perspective, aggressive elimination was optimal in 64% of simulations above a WTP of $15 000 per HALY, followed by moderate elimination in 35% of simulations. Moderate elimination was optimal from a GDP perspective in half of the simulations, followed by aggressive elimination in a quarter. Conclusions and Relevance In this simulation modeling economic evaluation of estimated SARS-CoV-infection rates, time under 5 stages of restrictions, HALYs, health expenditure, and GDP losses in Victoria, Australia, an elimination strategy was associated with the least health losses and usually the fewest GDP losses.

AimTo estimate the health gain, health system costs and cost-effectiveness of cataract surgery when expedited as a falls prevention strategy (reducing the waiting time for surgery by 12 months) and as a routine procedure.MethodsAn established injurious falls model designed for the New Zealand (NZ) population (aged 65+ years) was adapted. Key parameters relating to cataracts were sourced from the literature and the NZ Ministry of Health. A health system perspective with discounting at 3% was used.ResultsExpedited cataract surgery for 1 year of incident cases was found to generate a total 240 quality-adjusted life years (QALYs) (95% uncertainty interval (UI) 161 to 360) at net health system costs of NZ$2.43 million (95% UI 2.02 to 2.82 million) over the remaining lifetimes of the surgery group. This intervention was cost-effective by widely accepted standards with an incremental cost-effectiveness ratio (ICER) of NZ$10 600 (US$7540) (95% UI NZ$6030 to NZ$15 700) per QALY gained. The level of cost-effectiveness did not vary greatly by sex, ethnicity and previous fall history, but was higher for the 65–69 age group compared with the oldest age group of 85–89 years (NZ$7000 vs NZ$14 200 per QALY gained). Comparing cataract surgery with no surgery, the ICER was even more favourable at NZ$4380 (95% UI 2410 to 7210) per QALY. Considering only the benefits for vision improvement and excluding the benefits of falls prevention, it was still favourable at NZ$9870 per QALY.ConclusionsExpedited cataract surgery appears very cost-effective. Routine cataract surgery is itself very cost-effective, and its value appears largely driven by the falls prevention benefits.

Objectives: To identify COVID-19 outbreaks and border control failures associated with quarantine systems in Australia and New Zealand and to estimate the failure risks. Design, setting, participants: Observational epidemiological study of travellers transiting quarantine in Australia and New Zealand up to 15 June 2021. Main outcome measures: The incidence of COVID-19 related failures arising from quarantine, and the failure risk for those transiting quarantine, estimated both per 100,000 travellers and per 1000 SARS-CoV-2 positive cases. Results: Australia and New Zealand had 32 COVID-19 related failures arising from quarantine systems up to 15 June 2021 (22 and 10, respectively). One resultant outbreak involved an estimated 800 deaths and quarantine failures instigated nine lockdowns. The failure risk for those transiting quarantine was estimated at 5.0 failures per 100,000 travellers and 6.1 failures (95%CI: 4.0 to 8.3) per 1000 SARS-CoV-2 positive cases. The latter risk was two-fold higher in New Zealand compared with Australia. The full vaccination of frontline border workers could likely have prevented a number of quarantine system failures. Conclusions: Quarantine system failures can be costly in terms of lives and economic impacts such as lockdowns. Ongoing improvements or alternatives to hotel-based quarantine are required.

Objectives We aimed to describe the epidemiology of statue attacks along with statue representativeness relative to modern day demographics in one case study country: New Zealand. Methods We performed Internet searches for the existence of outdoor statues of named individuals and historical attacks in New Zealand (NZ), combined a national survey with field visits to all identified statues to examine for injuries and repairs. Results Of the 123 statues identified, nearly a quarter (n = 28, 23%) had been attacked at least once (total of 45 separate attack events), with the number of attacks increasing from the 1990s. Attacks involved paint/graffiti (14% of all statues at least once), nose removal/damage (7%), decapitation (5%), and total destruction (2%). The risk of attack was relatively higher for statues of royalty (50%), military personnel (33%), explorers (29%), and politicians (25%), compared to other reasons for fame (eg, 0% for sports players). Statue subjects involved in colonialism or direct harm to Māori (Indigenous population), had 6.61 (95%CI: 2.30 to 19.9) greater odds (adjusted odds ratio) of being attacked than other subjects. Most of the statue subjects were of men (87%) and Europeans (93%). Other ethnicities were 6% Māori (comprising 15% of the population) and 1% each for Asian and Pacific peoples, who comprise 12% and 7% of the population respectively. Conclusions This national survey found an association between statue attacks and the role of statue subjects in colonialism or direct harm to the Indigenous population. Furthermore, the demography of the statue subjects may represent historical and current social power relationships—with under-representation of women and non-European ethnic groups.

New Zealand has a long-running campylobacter infection (campylobacteriosis) epidemic with contaminated fresh chicken meat as the major source. This is both the highest impact zoonosis and the largest food safety problem in the country. Adding to this burden is the recent rapid emergence of antibiotic resistance in these campylobacter infections acquired from locally-produced chicken. Campylobacteriosis rates halved in 2008, as compared with the previous 5 years, following the introduction of regulatory limits on allowable contamination levels in fresh chicken meat, with large health and economic benefits resulting. In the following decade, disease rates do not appear to have declined further. The cumulative impact would equate to an estimated 539 000 cases, 5480 hospitalisations, 284 deaths and economic costs of approximately US$380 million during the last 10 years (2009–2018). Additional regulatory interventions, that build on previously successful regulations in this country, are urgently needed to control the source of this epidemic.

Guidelines and governments must acknowledge the evidence and take steps to protect the public

Summary: Approaches to preventing or mitigating the impact of the COVID-19 pandemic have varied markedly between nations. We examined the approach up to August 2020 taken by two jurisdictions which had successfully eliminated COVID-19 by this time: Taiwan and New Zealand. Taiwan reported a lower COVID-19 incidence rate (20.7 cases per million) compared with NZ (278.0 per million). Extensive public health infrastructure established in Taiwan pre-COVID-19 enabled a fast coordinated response, particularly in the domains of early screening, effective methods for isolation/quarantine, digital technologies for identifying potential cases and mass mask use. This timely and vigorous response allowed Taiwan to avoid the national lockdown used by New Zealand. Many of Taiwan's pandemic control components could potentially be adopted by other jurisdictions.

This article takes a public health perspective on New Zealand’s pandemic preparations, its pandemic response, and the successful outcome (as of June 2020) of its Covid-19 elimination strategy. The health outcome appears to be the best in the OECD, but some other countries made better use of certain control strategies. In the postpandemic era there are many emerging opportunities for society to be gained by embedding better plans for controlling future emerging diseases, strengthening public health infrastructure and consolidating the evident benefits of reduced pollution during the lockdown.

Burden of Disease studies—such as the Global Burden of Disease (GBD) Study—quantify health loss in disability-adjusted life-years. However, these studies stop short of quantifying the future impact of interventions that shift risk factor distributions, allowing for trends and time lags. This methodology paper explains how proportional multistate lifetable (PMSLT) modelling quantifies intervention impacts, using comparisons between three tobacco control case studies [eradication of tobacco, tobacco-free generation i.e. the age at which tobacco can be legally purchased is lifted by 1 year of age for each calendar year) and tobacco tax]. We also illustrate the importance of epidemiological specification of business-as-usual in the comparator arm that the intervention acts on, by demonstrating variations in simulated health gains when incorrectly: (i) assuming no decreasing trend in tobacco prevalence; and (ii) not including time lags from quitting tobacco to changing disease incidence. In conjunction with increasing availability of baseline and forecast demographic and epidemiological data, PMSLT modelling is well suited to future multiple country comparisons to better inform national, regional and global prioritization of preventive interventions. To facilitate use of PMSLT, we introduce a Python-based modelling framework and associated tools that facilitate the construction, calibration and analysis of PMSLT models.

There is large uncertainty around the case fatality risk (CFR) for COVID-19 in China. Therefore, we considered symptomatic cases outside of China (countries/settings with 20+ cases) and the proportion who are in intensive care units (4.0%, 14/349 on 13 February 2020). Given what is known about CFRs for ICU patients with severe respiratory conditions from a meta-analysis, we estimated a CFR of 1.37% (95%CI: 0.57% to 3.22%) for COVID- 19 cases outside of China.

BackgroundInterventions that reduce morbidity, in addition to mortality, warrant prioritisation. It is important to understand the magnitude of potential morbidity and health gains from changing risk factor distributions. We quantified the impact of tobacco compared with overweight/obesity eradication on future morbidity and health-adjusted life expectancy (HALE) for the New Zealand population alive in 2011.MethodsBusiness-as-usual (BAU) future smoking rates were set based on past falling rates, but we assumed no future change in Body Mass Index (BMI) distribution, given historic trends. Population impact fractions and the percentage reduction in incidence rates for 16 tobacco-related and 14 overweight/obesity-related diseases (allowing for time lags) were calculated using the difference between BAU and eradication risk factor scenarios combined with tobacco and BMI incidence rate ratios. We used two multistate lifetable models to estimate HALE changes over the remaining lifespan and morbidity rate changes 30 years hence.ResultsHALE gains always exceeded life expectancy (LE) gains for overweight/obesity eradication (ie, absolute compression of morbidity), but for eradication of tobacco, the pattern was mixed. For example, among 32-year-olds in 2011, overweight/obesity eradication increased HALE by 2.06 years and LE by 1.21 years, compared with 0.54 and 0.50 years for tobacco eradication.Morbidity rate reductions 30 years into the future were considerably greater for overweight/obesity eradication (eg, a 15.8% reduction for 72-year-olds in 2041, or the cohort that was aged 42 years in 2011) than for tobacco eradication (2.7%). The same rate of morbidity experienced at age 65 years under BAU was deferred by 5 years with overweight/obesity eradication.ConclusionsPreventive programmes that reduce overweight and obesity have strong potential to reduce or compress morbidity, improving the average health status of ageing populations. This paper simulated eradication of tobacco and overweight/obesity; actual interventions will have lesser health impacts, but the relativities of morbidity to mortality gains should be similar.

Background: For countries with strong border control and an epidemic that is not yet advanced, there is an opportunity to eliminate SARS-CoV-2 that is causing the COVID-19 pandemic. We show how public health policies and their effects can be modelled to estimate the probability of elimination of SARS-COV-2 under i) strict physical distancing policies implemented in New Zealand and Australia on the 26th and 28th March, respectively, continuing until such time that elimination is achieved; and ii) the same policy, but with physical distancing decaying over 60 days to 26th and 28th of May. Methods: We developed an agent-based SEIR model that simulated key aspects of both country’s populations, disease, spatial and behavioural dynamics, as well as the mechanism and effect of public health policy responses on the transmission of SARS-CoV-2. Findings: Under maintained strong physical distancing, we estimated a median elimination date of July 12th for Australia (95% SI: June 5th to August 28th) and June 3rd for New Zealand (95% SI May 4th to June 27th). A 90% probability of elimination is achievable in Australia on August 17th (95% SI: August 8th – August 30th) and on June 14th (95% SI: June 17th – June 29th) in New Zealand. However, under our scenario of decaying adherence to physical distancing from implementation to 60 days post restrictions, a rebound in SARS-CoV-2 infections (i.e., a second wave) was likely in Australia and possibly in New Zealand. At 100 days, the probability of elimination was reduced to 10% in Australia and 68% in New Zealand. Interpretation: The findings suggest that with the effective implementation and maintenance of public health policies limiting physical interaction, it was possible to estimate a pattern the elimination of SARS-CoV-2 transmission in both countries. It seems highly likely NZ will have successfully eliminated as of 8 June, but not in Australia; the latter is consistent with our lower probabilities that modelled less stringent restrictions applied in Australia.

Approaches to preventing or mitigating the impact of the COVID-19 pandemic have varied markedly between nations. We examined the approach up to July 2020 taken by two countries which had successfully eliminated COVID-19: Taiwan and New Zealand (NZ). Both jurisdictions experienced the COVID-19 pandemic in the first half of 2020. Taiwan reported a lower COVID-19 incidence rate (19.0 cases per million) compared with NZ (235.5 per million). Extensive public health infrastructure established in Taiwan pre-COVID-19 enabled a fast coordinated response, particularly in the domains of early screening, effective methods for isolation/quarantine, and digital technologies for identifying potential cases. This timely and vigorous response allowed Taiwan to avoid the national lockdown used by NZ and the majority of high-income countries. Many of Taiwan’s pandemic control components could potentially be adopted by other high-income jurisdictions.

Background: For countries with strong border control and an epidemic that is not yet advanced, there is an opportunity to eliminate community transmission of SARS-CoV-2. We show how public health policies and their effects can be modelled to estimate the likely progression of SARS-COV-2 under i) strict physical distancing policies implemented in New Zealand and Australia on the 26 th and 28 th March, 2020 respectively, and ii) from September 1st, 2020 in Victoria, Australia as this state planned its exit from a significant second wave of infections. Methods: We developed a dynamic, public health policy model using an agent-based framework that simulated key aspects of both country’s populations, disease, spatial and behavioural dynamics, as well as the mechanism and effect of public health policy responses on the transmission of SARS-CoV-2. We demonstrate the model’s development and application through the first wave of infections in New Zealand, and first and second wave of infections experienced in Australia. Findings: Under maintained strong physical distancing, we originally estimated a median elimination date of July 12th for Australia (95% SI: June 5th to August 28th) and June 3rd for New Zealand (95% SI May 4th to June 27th). We estimated a 90% probability of elimination was achievable in Australia on August 17th (95% SI: August 8th – August 30th) and on June 14th (95% SI: June 17th – June 29th) in New Zealand. However, under our scenario of decaying adherence to physical distancing from implementation to 60 days post restrictions, we predicted a resurgence in SARS-CoV-2 infections (i.e., a second wave) was likely in Australia and possibly in New Zealand. At 100 days, the probability of elimination was reduced to 10% in Australia and 68% in New Zealand. Having demonstrated the utility of our model above, the subsequent adaptation of the model in Victoria, Australia estimated that a threshold of less than 5 new cases per day over 14 days (from a peak of ~500 in August) could be achieved on or around the 17th of October. This would enable Victoria to move to, and sustain, lower levels of restrictions to movement and trade than had been possible under its strict lockdown policy. Interpretation: The findings suggest that during Australia and NZ’s first wave of infections, elimination of community transmission of SARS-CoV-2 in both countries through effective implementation and maintenance of public health interventions was possible. Subsequently, the structure and function of the agent-based policy model developed to analyse the effect of policies during wave 1 has been instrumental in supporting decision-making among public health authorities during Australia’s current second wave of infections. Funding Statement: MS is funded by a NHMRC Fellowship (APP1136250), JT is funded by an ARC DECRA Fellowship (DE180101411). Declaration of Interests: None to declare.

The eradication of some introduced pests such as rats, stoats and possums in New Zealand seems increasingly feasible with successful action to date in various cities (e.g. Wellington City) and with the government’s national 2050 predator-free goal. Here we specifically detail the potential benefits of urban rat eradication and find these cover a wide range of topics including a potentially reduced risk of infection from at least seven zoonotic diseases (e.g. leptospirosis, toxoplasmosis, trichinellosis, murine typhus; and three enteric diseases). Other potential benefits include: psychological benefits from increased native bird life in cities; reduced damage to food supplies; reduced rat damage to building insulation and to building walls and roofing; and reduced fires in buildings associated with rat damage. However, there is considerable uncertainty on the size of such impacts and so we outline a tentative research agenda as a first step towards quantification of the likely key public health be...

Objective: To describe the basic epidemiology of sudden mass fatality events for the 1900 to 2015 period in New Zealand (NZ). Methods: Official lists and internet searches were used to identify the events. Events were categorised, rates calculated and time trends analysed. Results: A total of 56 sudden mass fatality events with 10 or more fatalities between 1900 and 2015 in NZ were identified. There were 1,896 deaths in total, with the worst event being the Hawke's Bay earthquake (258 deaths). Events were classified as transportation-related (64%), natural causes (11%), industrial (9%), war (9%) and infrastructure (5%). There were marked declines in the rate of events per person-years of exposure and the associated mortality rate (both p

Background Internationally, ethnic inequalities in mortality within countries are increasingly recognized as a public health concern. But few countries have data to monitor such inequalities. We aimed to provide a detailed description of ethnic inequalities (Māori [indigenous], Pacific, and European/Other) in mortality for a country with high quality ethnicity data, using both standard and novel visualization methods. Methods Cohort studies of the entire New Zealand population were conducted, using probabilistically-linked Census and mortality data from 1981 to 2011 (68.9 million person years). Absolute (standardized rate difference) and relative (standardized rate ratio) inequalities were calculated, in 1–74-year-olds, for Māori and Pacific peoples in comparison to European/Other. Results All-cause mortality rates were highest for Māori, followed by Pacific peoples then European/Other, and declined in all three ethnic groups over time. Pacific peoples experienced the slowest annual percentage fall in mortality rates, then Māori, with European/Other having the highest percentage falls – resulting in widening relative inequalities. Absolute inequalities, however, for both Māori and Pacific males compared to European/Other have been falling since 1996. But for females, only Māori absolute inequalities (compared with European/Other) have been falling. Regarding cause of death, cancer is becoming a more important contributor than cardiovascular disease (CVD) to absolute inequalities, especially for Māori females. Conclusions We found declines in all-cause mortality rates, over time, for each ethnic group of interest. Ethnic mortality inequalities are generally stable or even falling in absolute terms, but have increased on a relative scale. The drivers of these inequalities in mortality are transitioning over time, away from CVD to cancer and diabetes; such transitions are likely in other countries, and warrant further research. To address these inequalities, policymakers need to enhance prevention activities and health care delivery, but also support wider improvements in educational achievement and socioeconomic position for highest need populations.

Cancer is increasingly responsible for the mortality gap between high and low socioeconomic position groups in high-income countries. This study investigates which cancers are contributing more to socioeconomic gaps in mortality and how this changes over time.New Zealand census data from 1981, 1986, 1991, 1996, 2001 and 2006, were linked to three to five years of subsequent mortality and cancer registrations, resulting in 54 and 42 million years of follow-up cancer incidence and mortality, respectively. Age- and ethnicity-standardised cancer mortality rates and the slope index of inequality (SII) by income were calculated.The contribution of cancer to absolute inequalities (SII) in mortality increased from 16 to 27% for men and from 12 to 31% for women from 1981-84 to 2006-11, peaking in 1991-94 for men and in 1996-99 for women and then levelling off, parallel to peaks in lung cancer inequalities. Lung cancer was the largest driver of cancer inequality trends (49% of the cancer mortality gap in 1981-84 to 33% in 2006-11 for men and 32 to 33% for women) followed by colorectal cancer in men (2 to 11%) and breast cancer in women (declining from 44 to 13%). Women in the lowest income quintile experienced no decline in cancer mortality.The contribution of cancer to income inequalities in all-cause mortality has expanded in this high-income country. Action to address socioeconomic inequalities should prioritise equitable tobacco control, obesity control and improved access to cancer screening, early diagnosis and high quality treatment for those with the lowest incomes.

Cardiovascular disease (CVD) is the leading cause of death internationally. We aimed to model the impact of CVD preventive double therapy (a statin and anti-hypertensive) by clinician-assessed absolute risk level. An established and validated multi-state life-table model for the national New Zealand (NZ) population was adapted. The new version of the model specifically considered the 60–64-year-old male population which was stratified by risk using a published NZ-specific CVD risk equation. The intervention period of treatment was for five years, but a lifetime horizon was used for measuring benefits and costs (a five-year horizon was also implemented). We found that for this group offering double therapy was highly cost-effective in all absolute risk categories (eg, NZ$1580 per QALY gained in the >20% in 5 years risk stratum; 95%UI: Dominant to NZ$3990). Even in the lowest risk stratum (≤5% risk in 5 years), the cost per QALY was only NZ$25,500 (NZ$28,200 and US$19,100 in 2018). At an individual level, the gain for those who responded to the screening offer and commenced preventive treatment ranged from 0.6 to 4.9 months of quality-adjusted life gained (or less than a month gain with a five-year horizon). Nevertheless, at the individual level, patient considerations are critical as some people may decide that this amount of average health gain does not justify taking daily medication.

Background Doubts exist around the value of compiling league tables for cost-effectiveness results for health interventions, primarily due to methods differences. We aimed to determine if a reasonably coherent league table could be compiled using published studies for one high-income country: New Zealand (NZ). Methods Literature searches were conducted to identify NZ-relevant studies published in the peer-reviewed journal literature between 1 January 2010 and 8 October 2017. Only studies with the following metrics were included: cost per quality-adjusted life-year or disability-adjusted life-year or life-year (QALY/DALY/LY). Key study features were abstracted and a summary league table produced which classified the studies in terms of cost-effectiveness. Results A total of 21 cost-effectiveness studies which met the inclusion criteria were identified. There were some large methodological differences between the studies, particularly in the time horizon (1 year to lifetime) but also discount rates (range 0 to 10%). Nevertheless, we were able to group the incremental cost-effectiveness ratios (ICERs) into general categories of being reported as cost-saving (19%), cost-effective (71%), and not cost-effective (10%). The median ICER (adjusted to 2017 NZ$) was ~ $5000 per QALY/DALY/LY (~US$3500). However, for some interventions, there is high uncertainty around the intervention effectiveness and declining adherence over time. Conclusions It seemed possible to produce a reasonably coherent league table for the ICER values from different studies (within broad groupings) in this high-income country. Most interventions were cost-effective and a fifth were cost-saving. Nevertheless, study methodologies did vary widely and researchers need to pay more attention to using standardised methods that allow their results to be included in future league tables. Electronic supplementary material The online version of this article (10.1186/s12963-019-0192-x) contains supplementary material, which is available to authorized users.

Background Smartphones are increasingly available and some high quality apps are available for smoking cessation. However, the cost-effectiveness of promoting such apps has never been studied. We therefore aimed to estimate the health gain, inequality impacts and cost-utility from a five-year promotion campaign of a smoking cessation smartphone app compared to business-as-usual (no app use for quitting). Methods A well-established Markov macro-simulation model utilising a multi-state life-table was adapted to the intervention (lifetime horizon, 3% discount rate). The setting was the New Zealand (NZ) population (N = 4.4 million). The intervention effect size was from a multi-country randomised trial: relative risk for quitting at 6 months = 2.23 (95%CI: 1.08 to 4.77), albeit subsequently adjusted to consider long-term relapse. Intervention costs were based on NZ mass media promotion data and the NZ cost of attracting a smoker to smoking cessation services (NZ$64 per person). Results The five-year intervention was estimated to generate 6760 QALYs (95%UI: 5420 to 8420) over the remaining lifetime of the population. For Māori (Indigenous population) there was 2.8 times the per capita age-standardised QALY gain relative to non-Māori. The intervention was also estimated to be cost-saving to the health system (saving NZ$115 million [m], 95%UI: 72.5m to 171m; US$81.8m). The cost-saving aspect of the intervention was maintained in scenario and sensitivity analyses where the discount rate was doubled to 6%, the effect size halved, and the intervention run for just 1 year. Conclusions This study provides modelling-level evidence that mass-media promotion of a smartphone app for smoking cessation could generate health gain, reduce ethnic inequalities in health and save health system costs. Nevertheless, there are other tobacco control measures which generate considerably larger health gains and cost-savings such as raising tobacco taxes. Electronic supplementary material The online version of this article (10.1186/s12889-019-6605-8) contains supplementary material, which is available to authorized users.

In this study we aimed to produce the first detailed analysis of the epidemiology of the severe injury and mortality impacts of the 1931 Hawke’s Bay earthquake in New Zealand (NZ). This involved the compilation and analysis of archival data (hospitalisations and deaths) including the examination of 324 death certificates. We found that there were 662 people for whom some hospitalisation data were available at four weeks post-earthquake: 54% were still in hospital, 4% were still classified as “serious”, and 5% had died (n = 28). Our classification of death certificate data indicated 256 earthquake-attributable deaths and for another five deaths the earthquake was estimated to have played an indirect role. There were 15 buildings associated with three or more deaths each (accounting for 58% of deaths with a known location). Many of these buildings were multi-storey and involved unreinforced masonry – with some of this falling into the street and killing people there (19% of deaths). In contrast, deaths in homes, which were typically of wood construction and single stories, comprised only 3% of deaths. In conclusion, this earthquake had a relatively high injury impact that appears partly related to the lack of regulations for building construction that would mitigate earthquake-related risk. Such regulations continue to be of relevance for New Zealand and for other countries in earthquake zones.

Sugar-sweetened beverage (SSB) intake is associated with tooth decay, obesity and diabetes. We aimed to model the health and cost impact of reducing the serving size of all single serve SSB to a maximum of 250 ml in New Zealand. A 250 ml serving size cap was modeled for all instances of single serves (

Background Cardiovascular disease (CVD) is a leading cause of health loss and health sector economic burdens in high-income countries. Unemployment is associated with increased risk of CVD, and so there is concern that the economic downturn associated with the COVID-19 pandemic will increase the CVD burden. Aims This modeling study aimed to quantify potential health loss, health cost burden and health inequities among people with CVD due to additional unemployment caused by COVID-19 pandemic-related economic disruption in one high-income country: New Zealand (NZ). Methods We adapted an established and validated multi-state life-table model for CVD in the national NZ population. We modeled indirect effects (ie, higher CVD incidence due to high unemployment rates) for various scenarios of pandemic-related unemployment projections from the NZ Treasury. Results We estimated the potential CVD-related heath loss in NZ to range from 23,300 to 36,900 health-adjusted life years (HALYs) for the different unemployment scenarios. Health inequities would be increased with the per capita health loss for Māori (Indigenous population) estimated to be 3.7 times greater than for non-Māori (49.9 vs 13.5 HALYs lost per 1000 people). The estimated additional health system costs ranged between (NZ$303 million [m] to 503m in 2019 values; or US$209m to 346m). Conclusions and policy implications Unemployment due to the COVID-19 pandemic could cause significant health loss, increase health inequities from CVD, and impose additional health system costs in this high-income country. Prevention measures should be considered by governments to reduce this risk, including additional job creation programs and measures directed towards the primary prevention of CVD.

Leukocytoclastic vasculitis (LCV) is a rare small-vessel vasculitis characterised by neutrophilic inflammation of post-capillary venules. Incidence varies from 3 to 4.5 per 100 000 people per year. Patients typically present with painful, itchy purpura and erythema, although clinical manifestations can vary making diagnosis a challenge. We report the case of a 75-year-old man with a history of a previously completely excised and grafted squamous cell carcinoma (SCC) on the dorsum of his hand, who presented with an acutely swollen, erythematous and ulcerated lesion adjacent to the graft site. A shave biopsy failed to definitively exclude SCC recurrence. He was referred to the Plastics team who initially suspected Sweet's syndrome but could not rule out SCC recurrence. The patient underwent formal mapping incisional biopsies that later diagnosed LCV. He was managed conservatively and made an excellent recovery. We present clinical photographs and histology to illustrate disease progression. LCV is typically self-limiting with a good overall prognosis, but a minority of patients follow a protracted course, which may require treatment in the form of systemic corticosteroids or colchicine. LCV can only be confirmed histologically. We present this case in order to highlight the importance of adequate tissue biopsy when there is diagnostic uncertainty with an acute dermatosis, particularly in the context of previous skin malignancy.

Many of the arguments made by Thornley and colleagues against taking an elimination approach to covid-19 are misleading and incorrect1—in particular, their assertion that the infection fatality risk (IFR) for covid-19 is “similar to that for seasonal flu.” Research conducted in New Zealand and internationally suggests that the IFR for covid-19 is typically …

The research described in this paper sought to review the public health issues arising from the presence of feral deer, goats and pigs in New Zealand. Key findings were that while recreational hunting of these animals is likely to provide physical and mental health benefits, and contribute to food security, likely health-related harms from these animals include (i) injury risks from the associated firearms used in hunting; (ii) as reservoirs for zoonotic diseases; (iii) reduced mental health benefits of wilderness experience and natural ecosystems; and (iv) likely contribution to flooding risk via forest damage. Further research could better quantify these issues.

Objective: To perform a comprehensive economic evaluation of border closure for an island nation in the face of severe pandemic scenarios. Methods: The costing tool developed by the New Zealand (NZ) Treasury (CBAx) was used for the analyses. Pandemic scenarios were as per previous work;1 epidemiological data were from past New Zealand influenza pandemics. Results: The net present value of successful border closure was NZ$7.86 billion for Scenario A (half the mortality rate of the 1918 influenza pandemic) and $144 billion for preventing a more severe pandemic (10 times the mortality of scenario A). Cost–utility analyses found border closure was relatively cost‐effective, at $14,400 per QALY gained in Scenario A, and cost‐saving for Scenario B (taking the societal perspective). Conclusions: This work quantifies the economic benefits and costs from border closure for New Zealand under specific assumptions in a generic but severe pandemic threat (e.g. influenza, synthetic bioweapon). Preparing for such a pandemic response seems wise for an island nation, although successful border closure may only be feasible if planned well ahead. Implications for public health: Policy makers responsible for generic pandemic planning should explore how border closure could be implemented, including practical and legal frameworks.

The Department of Health’s ‘High Impact Intervention (HII) – Peripheral intravenous cannula care bundle’ lists six actions to be performed at the time of peripheral intravenous cannulation. Audit of compliance to these requires documentation. We assessed documentation on the anaesthetic charts of 50 surgical patients. Purpose-made stickers were then placed on all anaesthetic charts. Re-assessment of a further 50 patients’ charts demonstrated a significant improvement in documentation of the bundle post intervention (Fisher’s exact test P < 0.0001). This is an example of how a low-tech intervention can produce a high impact improvement in documentation.

Objective: As relatively little is known about how socioeconomic position might have affected health prior to the Second World War, we aimed to study lifespan by occupational class in two cohorts in New Zealand. Methods: The first study included men on the electoral rolls in Dunedin in the period 1893 to 1902. The second study used an established cohort of male military personnel who were recruited for the First World War. Linear regression was used to estimate lifespan by occupational class. Results: The first study of 259 men on the electoral rolls found no substantive lifespan differences between the high and low occupational class groups. But the second study of 2,406 military personnel found that men in the three highest occupational classes lived 3.5 years longer (95%CI: 0.3–6.8 years) than the three lowest classes (in the multivariable analysis adjusting for age in 1918 and rurality of occupation). Conclusions: We found no significant lifespan differences in one cohort, but a second cohort is the earliest demonstration to our knowledge of substantial differences in mortality by socioeconomic position in this country prior to the 1960s. Implications for public health: This study provides historical context to the long‐term efforts to address health inequalities in society.

We aimed to examine smoking-related content in all 24 James Bond movies in the Eon Productions series from 1962 to 2015. There were favourable downward trends for any smoking by James Bond (p=0.015 for trend), and for tobacco-related spy-gadgetry (p=0.009). Around 20% of Bond's 60 sexual partners smoked in each decade, and most recently in 2012. There were regular mentions of smoking risks to health (starting from 1967) and product placement of branded packs was present in two movies. Overall, the persisting smoking content remains problematic from a public health perspective, especially given the popularity of this movie series.

Background There is some evidence that home safety assessment and modification (HSAM) is effective in reducing falls in older people. But there are various knowledge gaps, including around cost-effectiveness and also the impacts at a health district-level. Methods and findings A previously established Markov macro-simulation model built for the whole New Zealand (NZ) population (Pega et al 2016, Injury Prevention) was enhanced and adapted to a health district level. This district was Counties Manukau District Health Board, which hosts 42,000 people aged 65+ years. A health system perspective was taken and a discount rate of 3% was used for both health gain and costs. Intervention effectiveness estimates came from a systematic review, and NZ-specific intervention costs were extracted from a randomized controlled trial. In the 65+ age-group in this health district, the HSAM program was estimated to achieve health gains of 2800 quality-adjusted life-years (QALYs; 95% uncertainty interval [UI]: 547 to 5280). The net health system cost was estimated at NZ$8.44 million (95% UI: $663 to $14.3 million). The incremental cost-effectiveness ratio (ICER) was estimated at NZ$5480 suggesting HSAM is cost-effective (95%UI: cost saving to NZ$15,300 [equivalent to US$10,300]). Targeting HSAM only to people age 65+ or 75+ with previous injurious falls was estimated to be particularly cost-effective (ICERs: $700 and $832, respectively) with the latter intervention being cost-saving. There was no evidence for differential cost-effectiveness by sex or by ethnicity: Māori (Indigenous population) vs non-Māori. Conclusions This modeling study suggests that a HSAM program could produce considerable health gain and be cost-effective for older people at a health district level. Nevertheless, comparisons may be desirable with other falls prevention interventions such as group exercise programs, which also provide social contact and may prevent various chronic diseases.

The aim was to determine the uptake of seasonal influenza vaccination and risk reduction behaviours among a health professional group with close patient contact, namely, optometrists. This group can have close facial proximity to patients during eye examinations.National telephone survey of optometrists in New Zealand.Seventy per cent of registered optometrists participated (n = 450 responses). Less than one-third (29.7 per cent, 95% CI: 27.4 to 32.0) of optometrists reported having had the seasonal influenza vaccination in 2012. The major reason given for not being vaccinated was that the vaccination was considered unnecessary (47 per cent) followed by 'time constraints' (28 per cent). During their last respiratory illness, 82 per cent reported working with symptoms and only 16 per cent reported the use of a face mask.There is major scope for increasing uptake of influenza vaccination and other protective behaviour for such health professional groups, especially those characterised by relatively close patient contact. Possible options include educational campaigns and government-funded vaccinators visiting the workplaces of all health-care workers.

Objective: We aimed to systematically compile a list of 10 movies to facilitate self-directed learning in psychiatry by medical students. Method: The selected areas were those of the top five mental health conditions from the Global Burden of Disease 2010 study. The search strategy for movies covered an extensive range of sources (published literature and websites), followed by closer examination and critical viewing of a sample. Results: Out of a total of 503 potential movies that were identified, 23 were selected for viewing and more detailed critique. The final top 10 were: for depressive and anxiety disorders: Ordinary People (1980), Silver Linings Playbook (2012); for illicit drug use: Trainspotting (1996), Winter’s Bone (2010), Rachel Getting Married (2008), Half Nelson (2006); for alcohol use disorders: Another Year (2010), Passion Fish (1992); and for schizophrenia: The Devil and Daniel Johnston (2006), and An Angel at My Table (1990). Conclusions: The final selection of 10 movies all appeared to have relatively high entertainment value together with rich content in terms of psychiatric themes. Further research could evaluate the extent to which medical students actually watch such movies, by assessing the level of withdrawals from a medical school library and surveying student responses.

Summary Background The undergraduate medical curriculum has earned a reputation for being overcrowded. The dilemma for educationalists is to determine what, if anything, can be jettisoned from a congested curriculum to accommodate new ideas or material. Context We report on a small study that demonstrated that when movies are used innovatively, they enhance students' understanding of medicine and also have a minimal impact on the ‘crowded’ curriculum. Innovation During a 5–week-long Public Health module students could borrow from the medical school library, free of charge, one or more movies, each with a public health message. In the final week of the module a 1.5–hour-long class was allocated when each student offered a brief synopsis of a movie that they had watched, and then identified key public health issues discussed in the movie. Implications Our study supports the view that the creative use of classroom time not only allows for better use of the timetable, but also proves to be an integrative, stimulating, and fun way for medical students to learn.

Pricing policies such as taxes and subsidies are important tools in preventing and controlling a range of threats to public health. This is particularly so in tobacco and alcohol control efforts and efforts to change dietary patterns and physical activity levels as a means of addressing increases in noncommunicable diseases. To understand the potential impact of pricing policies, it is critical to understand the nature of price elasticities for consumer products. For example, price elasticities are key parameters in models of any food tax or subsidy that aims to quantify health impacts and cost-effectiveness. We detail relevant terms and discuss key issues surrounding price elasticities to inform public health research and intervention studies.

Objective: To estimate the potential impact on cardiovascular health of modifying dietary intake of saturated fat across the New Zealand population, and whether this would be appropriate and feasible. Methods: First, a literature review of meta-analyses was conducted to estimate the magnitude of reduction in risk for cardiovascular events in response to a reduction in dietary saturated fat intake (with or without substitution with other macronutrients). Second, data from the New Zealand Adult Nutrition Survey 2008/09 were used to determine whether a change to the population's dietary fat intake would be warranted and feasible. Results: Five relevant meta-analyses were identified. No significant association between saturated fat intake alone and cardiovascular disease was found. However, the incidence of cardiovascular disease events was less when dietary saturated fats were replaced with polyunsaturated fats, reducing the risk of cardiovascular events by about 10%. Compared with nutritional guidelines, New Zealanders’ current saturated fat intake is excessive while polyunsaturated fat intake is inadequate; both would be corrected by a substitution of 5% of daily energy intake. Conclusions: Replacing 5% of daily energy consumed as saturated fat with polyunsaturated fats would be expected to reduce cardiovascular events by about 10%. Implications: In order to achieve the population-wide dietary fat modifications needed to improve cardiovascular health for New Zealanders, a public health strategy (e.g. fiscal, regulatory and/or educational interventions) must be implemented. Further work is needed to establish the cost-effectiveness of the various strategies.

The New Zealand Parole (Extended Supervision) Amendment Act (2004) legislated that individuals with specified sexual offences, principally child sex offenders, could be subject to an extended supervision order (ESO) based, in part, on completion of a “psychological health assessment” (PHA). However, after several years of these assessments, fewer than half of PHAs have resulted in ESOs, suggesting that the PHA referral threshold may be set too low, resulting in a large number of false positives. This research therefore aimed to explore whether there were more efficient means to determine appropriate PHA referral guidelines. Participants were 182 offenders who had been assessed for an ESO between 2004 and 2008. The method included reviewing participants’ PHA reports, static risk scores and criminal conviction histories. Discriminant function analysis revealed that the factors most predictive of an ESO being recommended were: the presence of a higher number of dynamic risk factors related to sexual offendin...

Introduction To advance the design and implementation of outdoor smokefree area policies, we aimed to develop simple, low-cost methods for measuring smoking in a variety of public places. Methods Two methods were developed and were used by solo observers during March 2011–February 2012 to measure the proportion of people smoking at a variety of sites. Results Both methods performed well (n=5553 people observed); the first at 58 sites in the UK and New Zealand (n=3191 observed); the second at 33 sites in New Zealand (n=2362 observed), with significant differences found between the smoking at types of sites and between countries. For the two countries combined, the proportions of people smoking (amongst those over 12 years) in children’s play areas was significantly lower compared to all the other sites combined (risk ratio=0.39; 95%CI: 0.20 to 0.76; p=0.002). Conclusions Solo observers can establish the proportion of people smoking in a range of outdoor sites. Such methods can inform outdoor smokefree area policymaking by providing baseline and post-policy data to enable location targeting and policy evaluation.

Background We have developed manual methods to gather data on the point prevalence of observed smoking in road vehicles. To enable the widespread international collection of such data, we aimed to develop a smartphone application (app) for this work. Methods We developed specifications for an app that described the: (1) variables that could be collected; (2) transfer of data to an online repository; (3) user interface (including visual schematics) and (4) processes to ensure the data authenticity from distant observers. The app functionality was trialled in roadside situations and the app was made publicly available. Results The smartphone app and its accompanying website were developed, tested and released over a period of 6 months. Users (n=18) who have registered themselves (and who met authentication criteria), have reported no significant problems with this application to date (observing 20 535 vehicles as of 5 July 2012). The framework, methodology and source code for this project are now freely available online and can be easily adapted for other research purposes. The prevalence of smoking in vehicles was observed in: Poland 2.7% (95% CI 2.3% to 3.1%); Australia 1.0% (95% CI 0.7% to 1.3%); New Zealand 2.9% (95% CI 2.6% to 3.2%)—similar to results using preapp methods in 2011 (3.2%, 95% CI 3.1% to 3.3%). Conclusions This project indicates that it can be practical and feasible for health researchers to work together with information science researchers and software developers to create smartphone apps for field research in public health. Such apps may be used to collect observational data more widely, effectively and easily than through traditional (non-electronic) methods.

Background and objectivesOur aimwas to use a national electronicAKI alert to define the incidence and outcome\ud of all episodes of community– and hospital–acquired adult AKI.\ud Design, setting, participants, & measurements A prospective national cohort study was undertaken in a\ud population of 3.06 million.Datawere collected betweenMarch of 2015 andAugust of 2015. All patients with adult\ud ($18 years of age) AKI were identified to define the incidence and outcome of all episodes of community- and\ud hospital-acquired AKI in adults. Mortality and renal outcomes were assessed at 90 days.\ud Results There was a total of 31,601 alerts representing 17,689 incident episodes, giving an incidence of AKI of 577\ud per 100,000 population. Community-acquired AKI accounted for 49.3% of all incident episodes, and 42%\ud occurred in the context of preexisting CKD (Chronic Kidney Disease Epidemiology Collaboration eGFR); 90-day\ud mortality rate was 25.6%, and 23.7% of episodes progressed to a higher AKI stage than the stage associated with\ud the alert. AKI electronic alert stage and peak AKI stage were associated with mortality, and mortality was\ud significantly higher for hospital-acquired AKI compared with alerts generated in a community setting. Among\ud patients who survived to 90 days after the AKI electronic alert, those who were not hospitalized had a lower rate\ud of renal recovery and a greater likelihood of developing an eGFR,60 ml/min per 1.73m2 for the first time,which\ud may be indicative of development of de novo CKD.\ud Conclusions The reported incidence of AKI is far greater than the previously reported incidence in studies reliant\ud on clinical identification of adult AKI or hospital coding data. Although an electronic alert systemis Information\ud Technology driven and therefore, lacks intelligence and clinical context, these data can be used to identify deficiencies\ud in care, guide the development of appropriate intervention strategies, and provide a baseline against\ud which the effectiveness of these interventions may be measured.

Background Alcohol-related harm is a major global health issue, and controls on alcohol marketing are one intervention utilized by governments. This study investigated the use of Google Street View (GSV) as a novel research method for collecting alcohol-related data in the urban environment. Methods The efficacy of GSV and on-street observation by observer teams was compared by surveying 400 m stretches of 12 streets in Wellington, the capital city of New Zealand. Data on alcohol sale, alcohol-related advertising, health promotion materials, regulatory information and visible alcohol consumption were collected. Results A total of 403 retailers with evidence of alcohol sales and 1161 items of alcohol-related communication were identified in on-street observation. Of the latter, 1028 items (89 %) were for alcohol marketing and 133 (11 %) were for alcohol-related health promotion and alcohol regulation. GSV was found to be a less sensitive tool than on-street observation with only 50 % of the alcohol venues identified and 52 % of the venue-associated brand marketing identified. A high degree of inter-observer reliability was generally found between pairs of observers e.g., for the detection of alcohol retail venues the intra-class correlation coefficient (ICC) was 0.93 (95 % CI: 0.78 to 0.98) for on-street observation and 0.85 (95 % CI: 0.49 to 0.96) for using GSV. Conclusions GSV does not seem suitable for the comprehensive study of the influences on alcohol consumption in the urban streetscape. However, it may still have value for large, static objects in the environment and be more time efficient than traditional on-street observation measures, especially when used to collect data across a wide geographical area. Furthermore, GSV might become a more useful research tool in settings with better image quality (such as more ‘footpath views’) and with more regularly updated GSV imagery.

Background Housing improvements have considerable potential for improving health. So does the provision of insecticide-treated bednets for malaria prevention. Therefore we aimed to conduct updated systematic reviews of health economic analyses in both these intervention domains. Methods and findings The search strategy included economic analyses of housing improvement interventions and use of insecticide-treated bednets for community-dwelling, healthy populations (published between 1 January 2000 and 15 April 2014). We searched the Cochrane Database of Systematic Reviews, MEDLINE, PubMed, EMBASE, and three health economics databases. Thirty-five economic analyses of seven types of intervention fulfilled the inclusion criteria. Most included studies adopted a health sector perspective and were cost-effectiveness analyses using decision analytic modeling or conducted alongside trials. The overall quality of the studies was generally likely to be adequate for informing policy-making (albeit with limitations in some areas). There was fairly consistent evidence for the cost-effectiveness/favorable cost-benefit of removing indoor lead to prevent lead poisoning and sequelae, and retrofitting insulation to prevent lung disease. But the value of assessing and improving home safety and providing smoke alarms to prevent injuries was more mixed and the economic evidence was inconclusive or insufficient for: home ventilation to prevent lung disease, installing heaters to prevent lung disease and regulating tap water temperatures to prevent scalding. Few studies (n = 4) considered health equity. The 12 studies of providing insecticide-treated bednets or hammocks to prevent malaria found these interventions to be moderately to highly cost-effective. Conclusions This systematic review provides updated evidence that several housing improvement interventions (such as removing indoor lead and retrofitting insulation) and also the provision of insecticide-treated bednets are cost-effective interventions. Nevertheless, for some interventions additional analyses are required to better clarify their health economic and health equity value.

Background There is evidence that smoking is associated with poorer mental health. However, the underlying mechanisms for this remain unclear. We used longitudinal data to assess whether smoking uptake, or failed quit attempts, are associated with increased psychological distress. Methods Data were used from Waves 3 (2004/05), 5 (2006/07) and 7 (2008/09) of the longitudinal New Zealand Survey of Family, Income and Employment. Fixed-effects linear regression analyses were performed to model the impact of changes in smoking status and quit status (exposure variables) on changes in psychological distress (Kessler 10 (K10)). Results After adjusting for time-varying demographic and socioeconomic covariates, smoking uptake was associated with an increase in psychological distress (K10: 0.22, 95% CI 0.01 to 0.43). The associations around quitting and distress were in the expected directions, but were not statistically significant. That is, smokers who successfully quit between waves had no meaningful change in psychological distress (K10: −0.05, 95% CI −0.34 to 0.23), whereas those who tried but failed to quit, experienced an increase in psychological distress (K10: 0.18, 95% CI −0.05 to 0.40). Conclusions The findings provide some support for a modest association between smoking uptake and a subsequent increase in psychological distress, but more research is needed before such information is considered for inclusion in public health messages.