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Public health risks associated with the intensification of dairy farming are an emerging concern. Dairy cattle are a reservoir for a number of pathogens that can cause human illness. This study examined the spatial distribution of dairy cattle density and explored temporal patterns of human campylobacteriosis and cryptosporidiosis notifications in New Zealand from 1997 to 2015. Maps of dairy cattle density were produced, and temporal patterns of disease rates were assessed for urban versus rural areas and for areas with different dairy cattle densities using descriptive temporal analyses. Campylobacteriosis and cryptosporidiosis rates displayed strong seasonal patterns, with highest rates in spring in rural areas and, for campylobacteriosis, summer in urban areas. Increases in rural cases often preceded increases in urban cases. Furthermore, disease rates in areas with higher dairy cattle densities tended to peak before areas with low densities or no dairy cattle. Infected dairy calves may be a direct or indirect source of campylobacteriosis or cryptosporidiosis infection in humans through environmental or occupational exposure routes, including contact with animals or feces, recreational contact with contaminated waterways, and consumption of untreated drinking water. These results have public health implications for populations living, working, or recreating in proximity to dairy farms.

A 2016 drinking water-related campylobacteriosis outbreak in Aotearoa New Zealand made much of an entire town sick leading to reforms colloquially called "Three Waters", which aims to improve the management and delivery of waste, storm and drinking water systems. Public discourse on the Three Waters reforms has been dominated by anti-co-governance rhetoric, concerns around privatisation and loss of local control and alternative less comprehensive reform models. This debate has drowned out the fundamental problem statement justifying the reforms, that is, the management of drinking water resources is currently: 1) demonstrably inadequate to protect public health and promote health equity; and 2) economically inefficient. We discuss four areas where the proposed Three Waters reforms are likely to address current and future challenges and improve public health. We conclude by outlining four areas of remaining contention.

Summary Background As with many Indigenous populations internationally, Māori in New Zealand suffer health inequity. We aimed to assess the rate of fall injuries at home with and without home modifications in houses with Māori occupants. Methods We did a single-blind randomised controlled trial in the Wellington and Taranaki regions of New Zealand and enrolled owner-occupied households with at least one Māori occupant. Only households who stated they intended to live at that address for the subsequent 3 years were eligible for participation. We randomly assigned (1:1) households to either the intervention group, who received home modifications (handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, repairs to window catches, high-visibility and slip-resistant edging for outside steps, fixing of lifted edges of carpets and mats, non-slip bath mats, and slip-resistant surfacing for outside areas such as decks) immediately, or the control group, who received the modifications 3 years later. Data on home injuries were obtained from the Accident Compensation Corporation and coded by study team members, who were masked to study group allocation. The primary outcome was the rate of medically treated fall injuries at home per household per year, analysed according to intention to treat. This Māori Home Injury Prevention Intervention (MHIPI) trial is now completed, and is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000148774. Findings Between Sept 3, 2013, and Oct 1, 2014, 824 households were assessed for eligibility and 254 were enrolled, of which 126 (50%) were assigned to the intervention group and 128 (50%) were assigned to the control group. After adjustment for previous falls and geographical region, there was an estimated 31% reduction in the rate of fall injuries at home per year exposed to the intervention compared with households in the control group (adjusted relative rate 0·69 [95% CI 0·47–1·00]). Interpretation Low-cost home modifications and repairs can be an effective means to reduce injury disparities. The high prevalence of modifiable safety issues in Māori homes merits considerable policy and community effort. Funding Health Research Council of New Zealand.

Objectives To identify COVID‐19 quarantine system failures in Australia and New Zealand. Design, setting, participants Observational epidemiological study of travellers in managed quarantine in Australia and New Zealand, to 15 June 2021. Main outcome measures Number of quarantine system failures, and failure with respect to numbers of travellers and SARS‐CoV‐2‐positive travellers. Results We identified 22 quarantine system failures in Australia and ten in New Zealand to 15 June 2021. One failure initiated a COVID‐19 outbreak that caused more than 800 deaths (the Victorian “second wave”); nine lockdowns were linked with quarantine system failures. The failure risk was estimated to be 5.0 failures per 100 000 travellers passing through quarantine and 6.1 (95% CI, 4.0–8.3) failures per 1000 SARS‐CoV‐2‐positive travellers. The risk per 1000 SARS‐CoV‐2‐positive travellers was higher in New Zealand than Australia (relative risk, 2.0; 95% CI, 1.0–4.2). Conclusions Quarantine system failures can be costly in terms of lives and economic impact, including lockdowns. Our findings indicate that infection control in quarantine systems in Australia and New Zealand should be improved, including vaccination of quarantine workers and incoming travellers, or that alternatives to hotel‐based quarantine should be developed.

The 2021 Global Health Security (GHS) Index Report was published on 8 December 2021. With an average country score of 38.9 out of a possible 100 points, global scores are essentially unchanged from 2019. Despite experience with the COVID-19 pandemic, no country is adequately prepared for future biological threats. No country scored above 75.9 and the scores of the bottom 11 States have all fallen since 2019. Aotearoa New Zealand, however, has substantially improved its country score, rising to 13th in the world at 62.5/100. This gain is partly driven by consolidation of capabilities developed and deployed in response to COVID-19. This is promising progress, but a lot more can be done to ensure legacy benefits from the pandemic response, notably through the proposed restructuring of the health system (Pae Ora (Healthy Futures) Bill). In this viewpoint article, we discuss this recent further development of the GHS Index, highlight the global results for 2021, delve into New Zealand's progress, and discuss what more is needed.

In August 2016, a large waterborne campylobacteriosis outbreak occurred in Havelock North, New Zealand. This analysis describes the clinical complications of cases admitted to hospital as a result of acute infection, identifies risk factors for hospitalisation and compares deaths between hospitalised and non-hospitalised cases. Hospital admissions with post-infectious sequelae were excluded as they are the subject of a separate analysis.A case series analysis was undertaken by reviewing the electronic medical records of 933 residents of Hawke's Bay District Health Board with probable and confirmed campylobacteriosis linked to the Havelock North Campylobacter outbreak.A total of 67 hospital admissions, among 58 individuals, are described. Pre-existing comorbidity and advanced age were significant risk factors for hospital admission in univariate analysis. Dehydration (74.1%), electrolyte imbalance (35.8%) and acute kidney injury (27.6%) were common among hospitalised cases. The proportion of hospitalised cases that died within one year was significantly higher when compared to deaths among non-hospitalised cases (OR 5.0, 95% CI: 2.3-10.7), although this trend was not statistically significant after adjusting for age and comorbidity (OR 2.3, 95% CI: 0.96-5.3).This study highlights the serious health impacts that occurred from a campylobacteriosis outbreak of this magnitude.

ObjectivesIn August 2016, Campylobacter spp contaminated an untreated reticulated water supply resulting in a large-scale gastroenteritis outbreak affecting an estimated 8320 people. We aimed to determine the incidence of probable reactive arthritis (ReA) cases in individuals with culture-confirmed campylobacteriosis (CC), self-reported probable campylobacteriosis (PC) and those reporting no diarrhoea (ND).DesignWe conducted a retrospective cohort study to identify incidence of probable ReA cases. We identified cases with new ReA symptoms using an adapted acute ReA (AReA) telephone questionnaire. Those reporting ≥1 symptom underwent a telephone interview with the study rheumatologist. Probable ReA was defined as spontaneous onset of pain suggestive of inflammatory arthritis in ≥1 previously asymptomatic joint for ≥3 days occurring ≤12 weeks after outbreak onset.SettingPopulation-based epidemiological study in Havelock North, New Zealand.ParticipantsWe enrolled notified CC cases with gastroenteritis symptom onsets 5 August 2016–6 September 2016 and conducted a telephone survey of households supplied by the contaminated water source to enrol PC and ND cases.ResultsOne hundred and six (47.3%) CC, 47 (32.6%) PC and 113 (34.3%) ND cases completed the AReA telephone questionnaire. Of those reporting ≥1 new ReA symptom, 45 (75.0%) CC, 13 (68.4%) PC and 14 (82.4%) ND cases completed the rheumatologist telephone interview. Nineteen CC, 4 PC and 2 ND cases developed probable ReA, resulting in minimum incidences of 8.5%, 2.8% and 0.6% and maximum incidences of 23.9%, 12.4% and 2.15%.DiscussionWe describe high probable ReA incidences among gastroenteritis case types during a very large Campylobacter gastroenteritis outbreak using a resource-efficient method that is feasible to employ in future outbreaks.

These conditions disproportionately affect Māori and Pacific Islanders, particularly those living in high socioeconomic deprivation., We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000–2018 and RHD mortality rates during 2000–2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0–14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9–27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9–3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2–5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3–14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1–13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.

Background Six thousand children are hospitalized each year in New Zealand with housing sensitive conditions, and 86.2% of these children are rehospitalized during childhood. The Healthy Homes Initiative, set up by the Ministry of Health, and implemented in Wellington through Well Homes, carries out housing assessments and delivers a range of housing interventions. Method Housing assessments were carried out by trained community workers. Philanthropic funding was received for the interventions through a local charitable trust. Results Well Homes saw 895 families. Mold in the home was the most commonly recorded area of poor housing quality, in 836 homes (93%). Partial or complete lack of insulation was also common, with 452 records (51%) having a documented need for further assessment and either an upgrade or full installation. Eighty-three percent of homes had insufficient sources of heating. A total of 5,537 interventions were delivered. Bedding, heaters, and draft stopping were delivered over 90% of the time. In contrast, insulation and carpets were only delivered 40% of the time. Interventions were least likely to be delivered in private rental housing. Discussion Targeted interventions using social partnerships can deliver housing improvements for relatively little health spending. Well Homes provides immediate and practical interventions, education, connection with social agencies, and advocacy for more substantial structural home improvements to help families keep their home warmer, drier, and healthier. This approach will be strengthened when combined with a new regulatory framework to raise the standards of private rental housing.

Group A Streptococcus (GAS) pharyngitis is a key initiator of acute rheumatic fever (ARF). In New Zealand, ARF cases occur more frequently among persons of certain ethnic and socioeconomic groups. We compared GAS pharyngitis estimates (1,257,058 throat swab samples) with ARF incidence (792 hospitalizations) in Auckland during 2010–2016. Among children 5–14 years of age in primary healthcare clinics, GAS pharyngitis was detected in similar proportions across ethnic groups (≈19%). Relative risk for GAS pharyngitis was moderately elevated among children of Pacific Islander and Māori ethnicities compared with those of European/other ethnicities, but risk for ARF was highly elevated for children of Pacific Islander and Māori ethnicity compared with those of European/other ethnicity. That ethnic disparities are much higher among children with ARF than among those with GAS pharyngitis implies that ARF is driven by factors other than rate of GAS pharyngitis alone.

ABSTRACT INTRODUCTIONMass masking is emerging as a key non-pharmaceutical intervention for reducing community spread of COVID-19. However, although hand washing, social distancing and bubble living have been widely adopted by the ‘team of 5 million’, mass masking has not been socialised to the general population. AIMTo identify factors associated with face masking in New Zealand during COVID-19 Alert Level 4 lockdown to inform strategies to socialise and support mass masking. METHODSA quantitative online survey conducted in New Zealand during April 2020 invited residents aged ≥18 years to complete a questionnaire. Questions about face masking were included in the survey. The sample was drawn from a commissioned research panel survey, with boosted sampling for Māori and Pacific participants. Responses were weighted to reflect the New Zealand population for all analyses. RESULTSA total of 1015 individuals participated. Self-reported beliefs were strongly related to behaviours, with respondents viewing face masking measures as ‘somewhat’ or ‘very’ effective in preventing them from contracting COVID-19 more likely to report having worn a face mask than respondents who viewed them as ‘not at all’ effective. The strongest barriers to face mask use included beliefs that there was a mask shortage and that the needs of others were greater than their own. DISCUSSIONHighlighting the efficacy of and dispelling myths about the relative efficacy of mask types and socialising people to the purpose of mass masking will contribute to community protective actions of mask wearing in the New Zealand response to COVID-19.

In 2020, we developed a public health decision-support model for mitigating the spread of SARS-CoV-2 infections in Australia and New Zealand. Having demonstrated its capacity to describe disease progression patterns during both countries' first waves of infections, we describe its utilisation in Victoria in underpinning the State Government's then 'RoadMap to Reopening'.Key aspects of population demographics, disease, spatial and behavioural dynamics, as well as the mechanism, timing, and effect of non-pharmaceutical public health policies responses on the transmission of SARS-CoV-2 in both countries were represented in an agent-based model. We considered scenarios related to the imposition and removal of non-pharmaceutical interventions on the estimated progression of SARS-CoV-2 infections.Wave 1 results suggested elimination of community transmission of SARS-CoV-2 was possible in both countries given sustained public adherence to social restrictions beyond 60 days' duration. However, under scenarios of decaying adherence to restrictions, a second wave of infections (Wave 2) was predicted in Australia. In Victoria's second wave, we estimated in early September 2020 that a rolling 14-day average of5 new cases per day was achievable on or around 26 October. Victoria recorded a 14-day rolling average of 4.6 cases per day on 25 October.Elimination of SARS-CoV-2 transmission represented in faithfully constructed agent-based models can be replicated in the real world.Agent-based public health policy models can be helpful to support decision-making in novel and complex unfolding public health crises.

BackgroundAcute rheumatic fever (ARF) is a serious sequela of Group A Streptococcus (GAS) infection associated with significant global mortality. Pathogenesis remains poorly understood, with the current prevailing hypothesis based on molecular mimicry and the notion that antibodies generated in response to GAS infection cross-react with cardiac proteins such as myosin. Contemporary investigations of the broader autoantibody response in ARF are needed to both inform pathogenesis models and identify new biomarkers for the disease.MethodsThis study has utilised a multi-platform approach to profile circulating autoantibodies in ARF. Sera from patients with ARF, matched healthy controls and patients with uncomplicated GAS pharyngitis were initially analysed for autoreactivity using high content protein arrays (Protoarray, 9000 autoantigens), and further explored using a second protein array platform (HuProt Array, 16,000 autoantigens) and 2-D gel electrophoresis of heart tissue combined with mass spectrometry. Selected autoantigens were orthogonally validated using conventional immunoassays with sera from an ARF case-control study (n=79 cases and n=89 matched healthy controls) and a related study of GAS pharyngitis (n=39) conducted in New Zealand.ResultsGlobal analysis of the protein array data showed an increase in total autoantigen reactivity in ARF patients compared with controls, as well as marked heterogeneity in the autoantibody profiles between ARF patients. Autoantigens previously implicated in ARF pathogenesis, such as myosin and collagens were detected, as were novel candidates. Disease pathway analysis revealed several autoantigens within pathways linked to arthritic and myocardial disease. Orthogonal validation of three novel autoantigens (PTPN2, DMD and ANXA6) showed significant elevation of serum antibodies in ARF (p < 0.05), and further highlighted heterogeneity with patients reactive to different combinations of the three antigens.ConclusionsThe broad yet heterogenous elevation of autoantibodies observed suggests epitope spreading, and an expansion of the autoantibody repertoire, likely plays a key role in ARF pathogenesis and disease progression. Multiple autoantigens may be needed as diagnostic biomarkers to capture this heterogeneity.

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear 'elimination strategy', which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the New Zealand Medical Journal has 14 new pandemic-related articles. Some of this work can help inform vaccination prioritisation decisions and inform preparations of primary and secondary care services and social services for any future raising of levels in the pandemic Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Background Severe influenza illness is presumed more common in adults with chronic medical conditions (CMCs), but evidence is sparse and often combined into broad CMC categories. Methods Residents (aged 18–80 years) of Central and South Auckland hospitalized for World Health Organization-defined severe acute respiratory illness (SARI) (2012–2015) underwent influenza virus polymerase chain reaction testing. The CMC statuses for Auckland residents were modeled using hospitalization International Classification of Diseases, Tenth Revision codes, pharmaceutical claims, and laboratory results. Population-level influenza rates in adults with congestive heart failure (CHF), coronary artery disease (CAD), cerebrovascular accidents (CVA), chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus (DM), and end-stage renal disease (ESRD) were calculated by Poisson regression stratified by age and adjusted for ethnicity. Results Among 891 276 adults, 2435 influenza-associated SARI hospitalizations occurred. Rates were significantly higher in those with CMCs compared with those without the respective CMC, except for older adults with DM or those aged Conclusions Our findings support the increased risk of severe, laboratory-confirmed influenza disease among adults with specific CMCs compared with those without these conditions.

Background Group A Streptococcal (GAS) infections cause the autoimmune disease acute rheumatic fever (ARF), which can progress to chronic rheumatic heart disease (RHD). Treating pharyngitis caused by GAS with antibiotics is important in preventing ARF. However, it is difficult to distinguish these infections from GAS carriers. There is growing evidence for GAS skin infections as a cause of ARF. This study will identify the incidence of true GAS pharyngitis and serological responses to GAS skin infections. The effectiveness of antibiotics for these conditions will be explored, and modifiable risk factors. Serum antibody titres indicating the upper limits of normal (ULN for ASO/ADB antibodies) will be established alongside carriage rates in asymptomatic children. Methods This is a prospective disease incidence study, with an associated case-control study. The study population includes 1000 children (5–14 years) from Auckland, New Zealand, 800 of whom have visited their healthcare professional, resulting in a throat or skin swab for GAS, and 200 who are asymptomatic. The conditions of interest are GAS throat swab positive pharyngitis (n = 200); GAS carriage (n = 200); GAS negative throat swab (n = 200); GAS skin infections (n = 200); and asymptomatic controls (n = 200). All participants, except asymptomatic controls, will have acute and convalescent serological testing for ASO/ADB titres (collected

New Zealand has a strategy of eliminating SARS-CoV-2 that has resulted in a low incidence of reported coronavirus-19 disease (COVID-19). The aim of this study was to describe the spread of SARS-CoV-2 in New Zealand via a nationwide serosurvey of blood donors. Samples (n = 9806) were collected over a month-long period (3 December 2020–6 January 2021) from donors aged 16–88 years. The sample population was geographically spread, covering 16 of 20 district health board regions. A series of Spike-based immunoassays were utilised, and the serological testing algorithm was optimised for specificity given New Zealand is a low prevalence setting. Eighteen samples were seropositive for SARS-CoV-2 antibodies, six of which were retrospectively matched to previously confirmed COVID-19 cases. A further four were from donors that travelled to settings with a high risk of SARS-CoV-2 exposure, suggesting likely infection outside New Zealand. The remaining eight seropositive samples were from seven different district health regions for a true seroprevalence estimate, adjusted for test sensitivity and specificity, of 0.103% (95% confidence interval, 0.09–0.12%). The very low seroprevalence is consistent with limited undetected community transmission and provides robust, serological evidence to support New Zealand's successful elimination strategy for COVID-19.

Rheumatic heart disease (RHD) is a large, preventable, global public health burden. In New Zealand (NZ), acute rheumatic fever (ARF) and RHD rates are highest for Māori and Pacific children. This structured review explores the evidence for primary prevention interventions to diagnose and effectively treat group A Streptococcus (GAS) pharyngitis and skin infections to reduce rates of ARF and RHD. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 50 publications from 1980 onwards. This review has identified that there is little available evidence for effective primary prevention strategies to reduce ARF rates in NZ. However, two primary intervention strategies that should be considered by communities at high-risk of ARF are: the use of school-based clinics to identify and treat GAS pharyngitis and GAS skin infections; and intramuscular benzathine penicillin G with lignocaine analgesia in children who present with a GAS positive throat.

We aimed to estimate the risk of COVID-19 outbreaks in a COVID-19-free destination country (New Zealand) associated with shore leave by merchant ship crews who were infected prior to their departure or on their ship.We used a stochastic version of the SEIR model CovidSIM v1.1 designed specifically for COVID-19. It was populated with parameters for SARS-CoV-2 transmission, shipping characteristics and plausible control measures.When no control interventions were in place, we estimated that an outbreak of COVID-19 in New Zealand would occur after a median time of 23 days (assuming a global average for source country incidence of 2.66 new infections per 1,000 population per week, crews of 20 with a voyage length of 10 days and 1 day of shore leave per crew member both in New Zealand and abroad, and 108 port visits by international merchant ships per week). For this example, the uncertainty around when outbreaks occur is wide (an outbreak occurs with 95% probability between 1 and 124 days). The combination of PCR testing on arrival, self-reporting of symptoms with contact tracing and mask use during shore leave increased this median time to 1.0 year (14 days to 5.4 years, or a 49% probability within a year). Scenario analyses found that onboard infection chains could persist for well over 4 weeks, even with crews of only 5 members.This modelling work suggests that the introduction of SARS-CoV-2 through shore leave from international shipping crews is likely, even after long voyages. But the risk can be substantially mitigated by control measures such as PCR testing and mask use.

Background Epidemiological evidence in multiple jurisdictions has shown an association between nitrate exposure in drinking water and an increased risk of colorectal cancer (CRC). Objective We aimed to review the extent of nitrate contamination in New Zealand drinking water and estimate the health and financial burden of nitrate-attributable CRC. Methods We collated data on nitrate concentrations in drinking water for an estimated 85% of the New Zealand population (∼4 million people) who were on registered supplies. We estimated nitrate levels for the remaining population (∼600,000 people) based on samples from 371 unregistered (private) supplies. We used the effective rate ratio from previous epidemiological studies to estimate CRC cases and deaths attributable to nitrate in drinking water. Results Three-quarters of New Zealanders are on water supplies with less than 1 mg/L NO3-N. The population weighted average for nitrate exposure for people on registered supplies was 0.49 mg/L NO3-N with 1.91% (95%CI 0.49, 3.30) of CRC cases attributable to nitrates. This correlates to 49.7 cases per year (95%CI 14.9, 101.5) at a cost of 21.3 million USD (95% 6.4, 43.5 million USD). When combining registered and unregistered supplies, we estimated 3.26% (95%CI 0.84, 5.57) of CRC cases were attributable to nitrates, resulting in 100 cases (95%CI 25.7, 171.3) and 41 deaths (95%CI 10.5, 69.7) at a cost of 43.2 million USD (95%CI 10.9, 73.4). Conclusion A substantial minority of New Zealanders are exposed to high or unknown levels of nitrates in their drinking water. Given the international epidemiological studies showing an association between cancer and nitrate ingestion from drinking water, this exposure may cause an important burden of preventable CRC cases, deaths, and economic costs. We consider there is sufficient evidence to justify a review of drinking water standards. Protecting public health adds to the strong environmental arguments to improve water management in New Zealand.

ObjectivesThe aims of this study are to describe area deprivation levels and changes that occur during residential moves involving New Zealand children from birth to their fourth birthday, and to assess whether these changes vary by ethnicity.DesignLongitudinal administrative data.SettingChildren born in New Zealand from 2004 to 2018.ParticipantsAll (565 689) children born in New Zealand with at least one recorded residential move.Outcome measuresA longitudinal data set was created containing lifetime address histories for our cohort. This was linked to the New Zealand Deprivation Index, a measure of small area deprivation. Counts of moves from each deprivation level to each other deprivation level were used to construct transition matrices.ResultsChildren most commonly moved to an area with the same level of deprivation. This was especially pronounced in the most and least deprived areas. The number of moves observed also increased with deprivation. Māori and Pasifika children were less likely to move to, or remain in low-deprivation areas, and more likely to move to high-deprivation areas. They also had disproportionately high numbers of moves.ConclusionWhile there was evidence of mobility between deprivation levels, the most common outcome of a move was no change in area deprivation. The most deprived areas had the highest number of moves. Māori and Pasifika children were over-represented in high-deprivation areas and under-represented in low-deprivation areas. They also moved more frequently than the overall population of 0 to 3 year olds.

Between August and November 2020, Aotearoa New Zealand experienced eight known failures of the COVID-19 border control system. Multiple introductions of this highly transmissible virus into New Zealand's almost completely susceptible population present a high risk of uncontrollable spread, threatening New Zealand's elimination strategy. In this editorial, we propose that, although steps are being taken reactively in response to these known breaches, systematic underestimation of risk across the pandemic response makes future failures inevitable. We present an epidemiological framework for identifying and addressing risk, giving examples of actions that can be taken to reduce the probability of further outbreaks and enable New Zealand to benefit from sustained elimination of COVID-19.

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.

New Zealand, a geographically remote Pacific island with easily sealable borders, implemented a nationwide ‘lockdown’ of all non-essential services to curb the spread of COVID-19. Here, we generate 649 SARS-CoV-2 genome sequences from infected patients in New Zealand with samples collected during the ‘first wave’, representing 56% of all confirmed cases in this time period. Despite its remoteness, the viruses imported into New Zealand represented nearly all of the genomic diversity sequenced from the global virus population. These data helped to quantify the effectiveness of public health interventions. For example, the effective reproductive number, Re of New Zealand’s largest cluster decreased from 7 to 0.2 within the first week of lockdown. Similarly, only 19% of virus introductions into New Zealand resulted in ongoing transmission of more than one additional case. Overall, these results demonstrate the utility of genomic pathogen surveillance to inform public health and disease mitigation., New Zealand implemented stringent COVID-19 control measures early after identification of its first case. Here, the authors perform whole genome sequencing of samples taken until 22 May 2020 and find high viral diversity indicative of multiple separate introductions and limited community transmission.

Enterobacteriaceae that produce extended-spectrum beta-lactamases (ESBLs) and AmpC beta-lactamases (ACBLs) are important pathogens and can cause community-acquired illnesses, such as urinary tract infections (UTIs). Fecal carriage of these resistant bacteria by companion animals may pose a risk for transmission to humans. Our work evaluated the sharing of ESBL- and ACBL-producing E. coli isolates between humans and companion animals. We found that in some households, dogs carried the same strain of ESBL-producing E. coli as the household member with a UTI. This suggests that transmission events between humans and animals (or vice versa) are likely occurring within the home environment and, therefore, the community as a whole. This is significant from a health perspective, when considering measures to minimize community transmission, and highlights that in order to manage community spread, we need to consider interventions at the household level., Extended-spectrum-beta-lactamase (ESBL)- or AmpC beta-lactamase (ACBL)-producing Escherichia coli bacteria are the most common cause of community-acquired multidrug-resistant urinary tract infections (UTIs) in New Zealand. The carriage of antimicrobial-resistant bacteria has been found in both people and pets from the same household; thus, the home environment may be a place where antimicrobial-resistant bacteria are shared between humans and pets. In this study, we sought to determine whether members (pets and people) of the households of human index cases with a UTI caused by an ESBL- or ACBL-producing E. coli strain also carried an ESBL- or ACBL-producing Enterobacteriaceae strain and, if so, whether it was a clonal match to the index case clinical strain. Index cases with a community-acquired UTI were recruited based on antimicrobial susceptibility testing of urine isolates. Fecal samples were collected from 18 non-index case people and 36 pets across 27 households. Eleven of the 27 households screened had non-index case household members (8/18 people and 5/36 animals) positive for ESBL- and/or ACBL-producing E. coli strains. Whole-genome sequence analysis of 125 E. coli isolates (including the clinical urine isolates) from these 11 households showed that within seven households, the same strain of ESBL-/ACBL-producing E. coli was cultured from both the index case and another person (5/11 households) or pet dog (2/11 households). These results suggest that transmission within the household may contribute to the community spread of ESBL- or ACBL-producing E. coli. IMPORTANCE Enterobacteriaceae that produce extended-spectrum beta-lactamases (ESBLs) and AmpC beta-lactamases (ACBLs) are important pathogens and can cause community-acquired illnesses, such as urinary tract infections (UTIs). Fecal carriage of these resistant bacteria by companion animals may pose a risk for transmission to humans. Our work evaluated the sharing of ESBL- and ACBL-producing E. coli isolates between humans and companion animals. We found that in some households, dogs carried the same strain of ESBL-producing E. coli as the household member with a UTI. This suggests that transmission events between humans and animals (or vice versa) are likely occurring within the home environment and, therefore, the community as a whole. This is significant from a health perspective, when considering measures to minimize community transmission, and highlights that in order to manage community spread, we need to consider interventions at the household level.

Stringent nonpharmaceutical interventions (NPIs) such as lockdowns and border closures are not currently recommended for pandemic influenza control. New Zealand used these NPIs to eliminate coronavirus disease 2019 during its first wave. Using multiple surveillance systems, we observed a parallel and unprecedented reduction of influenza and other respiratory viral infections in 2020. This finding supports the use of these NPIs for controlling pandemic influenza and other severe respiratory viral threats., New Zealand has been relatively successful in controlling COVID-19 due to implementation of strict non-pharmaceutical interventions. Here, the authors demonstrate a striking decline in reports of influenza and other non-influenza respiratory pathogens over winter months in which the interventions have been in place.

We aimed to determine the effectiveness of surveillance using testing for SARS-CoV-2 to identify an outbreak arising from a single case of border control failure in a country that has eliminated community transmission of COVID-19: New Zealand.A stochastic version of the SEIR model CovidSIM v1.1 designed specifically for COVID-19 was utilised. It was seeded with New Zealand population data and relevant parameters sourced from the New Zealand and international literature.For what we regard as the most plausible scenario with an effective reproduction number of 2.0, the results suggest that 95% of outbreaks from a single imported case would be detected in the period up to day 36 after introduction. At the time point of detection, there would be a median number of five infected cases in the community (95% range: 1-29). To achieve this level of detection, an ongoing programme of 5,580 tests per day (1,120 tests per million people per day) for the New Zealand population would be required. The vast majority of this testing (96%) would be of symptomatic cases in primary care settings and the rest in hospitals.This model-based analysis suggests that a surveillance system with a very high level of routine testing is probably required to detect an emerging or re-emerging SARS-CoV-2 outbreak within five weeks of a border control failure in a nation that had previously eliminated COVID-19. Nevertheless, there are plausible strategies to enhance testing yield and cost-effectiveness and potential supplementary surveillance systems such as the testing of town/city sewerage systems for the pandemic virus.

Objectives: In preparation for the future arrival of a group A Streptococcus (GAS) vaccine, this study estimated the economic and health burdens of GAS diseases in New Zealand (NZ). Methods: The annual incidence of GAS diseases was based on extrapolation of the average number of primary healthcare episodes managed each year in general practices (2014–2016) and on the average number of hospitalizations occurring each year (2005–2014). Disease incidence was multiplied by the average cost of diagnosing and managing an episode of disease at each level of care to estimate the annual economic burden. Results: GAS affected 1.5% of the population each year, resulting in an economic burden of 29.2 million NZ dollars (2015 prices) and inflicting a health burden of 2373 disability-adjusted life years (DALYs). Children

Background Over one-third of the population of Havelock North, New Zealand, approximately 5500 people, were estimated to have been affected by campylobacteriosis in a large waterborne outbreak. Cases reported through the notifiable disease surveillance system (notified case reports) are inevitably delayed by several days, resulting in slowed outbreak recognition and delayed control measures. Early outbreak detection and magnitude prediction are critical to outbreak control. It is therefore important to consider alternative surveillance data sources and evaluate their potential for recognizing outbreaks at the earliest possible time. Objective The first objective of this study is to compare and validate the selection of alternative data sources (general practice consultations, consumer helpline, Google Trends, Twitter microblogs, and school absenteeism) for their temporal predictive strength for Campylobacter cases during the Havelock North outbreak. The second objective is to examine spatiotemporal clustering of data from alternative sources to assess the size and geographic extent of the outbreak and to support efforts to attribute its source. Methods We combined measures derived from alternative data sources during the 2016 Havelock North campylobacteriosis outbreak with notified case report counts to predict suspected daily Campylobacter case counts up to 5 days before cases reported in the disease surveillance system. Spatiotemporal clustering of the data was analyzed using Local Moran’s I statistics to investigate the extent of the outbreak in both space and time within the affected area. Results Models that combined consumer helpline data with autoregressive notified case counts had the best out-of-sample predictive accuracy for 1 and 2 days ahead of notified case reports. Models using Google Trends and Twitter typically performed the best 3 and 4 days before case notifications. Spatiotemporal clusters showed spikes in school absenteeism and consumer helpline inquiries that preceded the notified cases in the city primarily affected by the outbreak. Conclusions Alternative data sources can provide earlier indications of a large gastroenteritis outbreak compared with conventional case notifications. Spatiotemporal analysis can assist in refining the geographical focus of an outbreak and can potentially support public health source attribution efforts. Further work is required to assess the location of such surveillance data sources and methods in routine public health practice.

Background Following an initial reduction in human campylobacteriosis in New Zealand after the implementation of poultry food chain-focused interventions during 2006–2008, further decline has been relatively small. We report a year-long study of notified campylobacteriosis cases, incorporating a case control study combined with a source attribution study. The purpose was to generate up-to-date evidence on the relative contributions of different sources of campylobacteriosis in New Zealand. Methods The study approach included: • A case-control study of notified cases (aged six months or more) sampled in a major urban centre (Auckland, every second case) and a mixed urban/rural area (Manawatū/Whanganui, every case), between 12 March 2018 and 11 March 2019. • Source attribution of human campylobacteriosis cases sampled from these two regions over the study period by modelling of multilocus sequence typing data of Campylobacter jejuni and C. coli isolates from faecal samples of notified human cases and relevant sources (poultry, cattle, sheep). Results Most cases (84%) were infected with strains attributed to a poultry source, while 14% were attributed to a cattle source. Approximately 90% of urban campylobacteriosis cases were attributed to poultry sources, compared to almost 75% of rural cases. Poultry consumption per se was not identified as a significant risk factor. However specific risk factors related to poultry meat preparation and consumption did result in statistically significantly elevated odds ratios. Conclusions The overall findings combining source attribution and analysis of specific risk factors indicate that poultry meat remains a dominant pathway for exposure and infection.

It is important for all countries to secure themselves against infectious disease threats, including potential global catastrophic biological risks. The Global Health Security Index (GHSI), first published in 2019, is a comprehensive, objective assessment of health security capabilities across 195 States Parties to the International Health Regulations. The GHSI is a broader assessment than the World Health Organization Joint External Evaluation and emphasises public documentation of preparedness as well as sustainable capabilities. New Zealand scored 54/100 on the GHSI (35th in the world). But also worryingly, the range of scores for New Zealand's Pacific neighbours was 19.2-27.8, highlighting potential regional vulnerabilities. Clearly, the New Zealand Government needs to do more to ensure its own optimal preparedness for global biological threats, and document these preparations to assure the international community. But it should also provide additional overseas development assistance (bringing this assistance up to 0.7% of GNI as per UN recommendations) and work with Pacific Nations to enhance health security in the region.

To assess the burden of disease related to unsafe and substandard housing conditions in New Zealand from 2010 to 2017.We focused on substandard housing conditions most relevant for New Zealand homes: crowding, cold, damp or mould, and injury hazards linked to falls. We estimated the population attributable fraction using existing estimates of the population exposed and exposure-response relationships of health disorders associated with each housing condition. We used government hospitalization data, no-fault accident insurance claims and mortality data to estimate the annual disease burden from the most severe cases, as well as the resulting costs to the public sector in New Zealand dollars (NZ$). Using value of a statistical life measures, we estimated the indirect cost of deaths.We estimated that illnesses attributable to household crowding accounted for 806 nights in hospital annually; cold homes for 1834 hospital nights; and dampness and mould for 36 649 hospital nights. Home injury hazards resulted in 115 555 annual accident claims. We estimated that direct public sector costs attributable to these housing conditions were approximately NZ$ 141 million (100 million United States dollars, US$) annually. We also estimated a total of 229 deaths annually attributable to adverse housing and the costs to society from these deaths at around NZ$ 1 billion (US$ 715 million).Of the conditions assessed in this study, damp and mouldy housing accounted for a substantial proportion of the burden of disease in New Zealand. Improving people's living conditions could substantially reduce total hospitalization costs and potentially improve quality of life.Évaluer l'impact qu'exercent les maladies imputables aux conditions de logement dangereuses et précaires en Nouvelle-Zélande entre 2010 et 2017.Nous nous sommes concentrés sur les conditions de logement précaires les plus fréquentes dans le pays: surpeuplement, froid, humidité ou moisissure, et risques de traumatismes causés par des chutes. Nous avons calculé la fraction attribuable dans la population en usant d'estimations existantes relatives à la population exposée et aux relations exposition-réponse des problèmes de santé associés à chaque type de logement insalubre. Nous avons également employé les informations gouvernementales concernant les hospitalisations, les demandes d'indemnisation sans égard à la faute et les données de mortalité afin de déterminer l'impact annuel des maladies les plus graves ainsi que les coûts engendrés pour le secteur public en dollars néo-zélandais (NZD) Enfin, nous avons établi le coût indirect des décès en utilisant les mesures de valeur d'une vie statistique.Selon nos calculs, les maladies imputables aux logements surpeuplés ont entraîné 806 nuits d'hôpital par an; le froid régnant à l'intérieur des habitations a représenté l'équivalent de 1834 nuits d'hôpital; tandis que l'humidité et la moisissure ont débouché sur 36 649 nuits d'hôpital. Les risques de traumatismes survenant au domicile ont donné lieu à 115 555 demandes d'indemnisation chaque année. Nous estimons que les conditions de logement génèrent des coûts annuels directs d'environ 141 millions NZD (100 millions de dollars américains, USD) pour le secteur public. Nous pensons en outre qu'un total de 229 décès annuels sont liés à l'insalubrité des habitations, ce qui représente un coût de près de 1 milliard NZD (715 millions USD) pour la société.De toutes les situations examinées dans le cadre de cette étude, c'est la présence d'humidité et de moisissure qui a le plus d'impact sur la santé en Nouvelle-Zélande. Améliorer les conditions de logement de la population pourrait grandement contribuer à la diminution du coût total des hospitalisations et à une meilleure qualité de vie.Evaluar el impacto de la enfermedad relacionada con las condiciones de vivienda inseguras y precarias en Nueva Zelanda entre 2010 y2017.Nos hemos centrado en las condiciones de precariedad de la vivienda más relevantes para los hogares neozelandeses: el hacinamiento, el frío, la humedad o el moho, y los riesgos de traumatismos relacionados con las caídas. Calculamos la fracción atribuible a la población utilizando las estimaciones existentes de la población expuesta y las relaciones exposición-respuesta de los problemas de salud asociados a cada tipo de infravivienda. También utilizamos información gubernamental sobre ingresos hospitalarios, reclamaciones de seguros de accidentes sin culpa y datos de mortalidad para estimar el impacto anual de las enfermedades más graves, así como los costes resultantes para el sector público en dólares neozelandeses (NZD). Por último, determinamos el coste indirecto de las muertes utilizando medidas de valor de una vida estadística.Se calculó que las enfermedades causadas por el hacinamiento en el hogar suponían 806 noches de hospitalización al año; el frío en los hogares, 1.834 noches de hospitalización; y la humedad y el moho, 36.649 noches de hospitalización. Los riesgos por traumatismos en el hogar dieron lugar a 115.555 reclamaciones anuales por accidentes. Estimamos que las condiciones de la vivienda generan unos costes anuales directos para el sector público de aproximadamente 141 millones de NZD (100 millones de USD). Además, creemos que un total de 229 muertes al año están relacionadas con las malas condiciones de la vivienda, lo que cuesta a la sociedad casi 1.000 millones de dólares neozelandeses (715 millones de dólares estadounidenses).De todas las situaciones analizadas en este estudio, es la presencia de humedad y moho la que tiene mayor impacto en la salud en Nueva Zelanda. La mejora de las condiciones de la vivienda de la población podría contribuir en gran medida a reducir el coste total de la hospitalización y a mejorar la calidad de vida.الغرض تقييم العبء المرضي المتعلق بظروف السكن غير الآمن ودون المستوى، في نيوزيلندا، خلال الفترة من 2010 إلى 2017. الطريقة قمنا بالتركيز على ظروف السكن دون المستوى الأكثر شيوعاً في المنازل بنيوزيلندا: الازدحام، أو البرد، أو الرطوبة، أو العفن، ومخاطر الإصابة المرتبطة بالسقوط. قمنا بتقدير الشريحة السكانية المعنية باستخدام التقديرات الحالية للسكان المعرضين، والعلاقات المعتمدة على الاستجابة للتعرض، مع الاضطرابات الصحية المرتبطة بكل ظرف من الظروف السكانية. قمنا باستخدام البيانات الحكومية للعلاج بالمستشفيات، ومطالبات التأمين ضد الحوادث غير الخاطئة، وبيانات الوفيات، لتقدير عبء المرض السنوي من أشد الحالات سوءاً، بالإضافة إلى التكاليف الناتجة على القطاع العام بالدولار النيوزيلندي (NZ$). وباستخدام قيمة مقاييس الحياة الإحصائية، قمنا بتقدير التكلفة غير المباشرة للوفيات. النتائج لقد قدرنا أن الأمراض التي تُعزى إلى الازدحام في المسكن قد نتج عنها 806 ليلة في المستشفى سنويًا؛ أدت المنازل الباردة إلى قضاء 1834 ليلة في المستشفى؛ وأدت والرطوبة والعفن إلى قضاء 36649 ليلة بالمستشفى. أدت مخاطر الإصابات المنزلية إلى 115555 مطالبة حوادث سنوية. وقد قدرنا أن التكاليف المباشرة للقطاع العام المنسوبة إلى ظروف السكن هذه كانت 141 مليون دولار نيوزيلندي تقريبًا (100 مليون دولار أمريكي) سنويًا. كذلك قدرنا إجمالي 229 حالة وفاة سنويًا تُعزى إلى الظروف المعاكسة للسكن، وكانت خسائر المجتمع من هذه الوفيات حوالي مليار دولار نيوزيلندي (715 مليون دولار أمريكي). الاستنتاج من بين الظروف التي تم تقييمها في هذه الدراسة، شكلت المساكن الرطبة والمصابة بالعفن نسبة كبيرة من عبء المرض في نيوزيلندا. إن تحسين الظروف المعيشية للأشخاص يمكن أن يؤدي إلى تقليل التكاليف الإجمالية للعلاج بالمستشفى إلى حد كبير، ومن المحتمل أن يحسن جودة الحياة.旨在评估 2010 年至 2017 年期间与新西兰不安全及不合格住房条件有关的疾病负担。.我们侧重于讨论与新西兰房屋最相关的不合格住房条件：拥挤、寒冷、潮湿或发霉，以及因跌倒导致的受伤风险。我们使用现有的人群暴露估计值以及与各种住房条件相关的疾病的暴露-反应关系来估计人群归因分值。我们使用政府报告的住院患者数据、无过错事故保险索赔和死亡率数据来估计最严重病例导致的年度疾病负担，以及由此产生的公共部门成本（以新西兰元计）。我们使用统计生命价值指标估计了死亡的间接成本。.我们估计每年有人因住房拥挤而导致的疾病住院 806 天；住房寒冷导致住院 1834 天；以及潮湿和发霉导致住院 36,649 天。家庭伤害危险导致每年 115,555 起事故索赔。我们估计每年因这些住房条件而产生的直接公共部门成本约为 1.41 亿新西兰元（1 亿美元）。我们还估计每年总共有 229 人因不良住房而导致死亡，这些死亡对社会造成的损失约为 10 亿新西兰元（7.15 亿美元）。.在这项研究所评估的条件中，潮湿和发霉的住房是导致新西兰绝大部分疾病负担形成的主要原因。改善人们的生活条件可以大幅降低住院总成本并有可能改善生活质量。.Оценить бремя болезней, связанных с небезопасным и обветшалым жильем, в Новой Зеландии за период 2010–2017 гг.Авторы сосредоточились на условиях в обветшалых жилищах, которые наиболее актуальны для домов в Новой Зеландии: тесноте, холоде, сырости или плесени, а также опасности травм, связанных с падениями. Была рассчитана добавочная доля популяционного риска с использованием существующих оценок количества подверженного населения и взаимосвязей «подверженность-реагирование» для нарушений здоровья, связанных с каждым жилищным условием. Для этого использовались правительственные данные о госпитализации, страховые требования по случаям страхования без вины и данные о смертности, чтобы оценить годовое бремя болезней в наиболее тяжелых случаях, а также итоговые затраты для государственного сектора в новозеландских долларах. Используя статистические показатели продолжительности жизни, авторы оценили косвенные затраты в связи со смертью.Было определено, что на долю болезней, связанных с проживанием в условиях скученности, приходилось 806 больничных суток ежегодно, а на долю болезней, связанных с проживанием в холодных помещениях, — 1834 больничных суток, госпитализация в связи с сыростью и плесенью в домах составила 36 649 больничных суток. Из-за травмоопасности жилищ было зафиксировано 115 555 жалоб ежегодно. По нашим оценкам, прямые затраты государственного сектора, связанные с такими жилищными условиями, составили приблизительно 141 миллион новозеландских долларов (100 миллионов долларов США) в год. Было также определено, что с неблагоприятными жилищными условиями в общей сложности ежегодно связаны 229 смертей и ущерб для общества от этих смертей составляет примерно 1 миллиард новозеландских долларов (715 миллионов долларов США).Из условий, оцениваемых в рамках данного исследования, значительная часть бремени болезней в Новой Зеландии приходилась на сырость и плесень в жилищах. Улучшение условий жизни людей может существенно снизить общие расходы на госпитализацию и потенциально улучшить качество жизни.

The risk to human populations from new and pandemic infectious agents has probably never been higher.1,2 Synthetic bioweapons are an additional threat. Two recent publications have speculated on the possibility of island nation refuges closing their borders to protect a human population against a catastrophic pandemic that poses an existential risk to humanity.3,4 The most recent paper described an index based on characteristics of an island nation’s population, location, resources and society. The authors used this index to conclude that Australia and New Zealand are the island nations most likely to be able to be both isolated from the rest of humanity in a pandemic and to also have the resources to reboot a thriving technological society following a pandemic that devastated the rest of global society as we know it, thereby acting as ‘island refuges’.4 Previous analysis in this journal has argued the economic case for border closure by island nations in the face of extreme pandemics.5 This work reported that 100 per cent border closure for six months by New Zealand, that results in the country avoiding any pandemic cases, could have a net present value of NZ$7.86 (US$5.29) billion for its “Scenario A” (involving half the mortality rate of the 1918 influenza pandemic) and NZ$144 (US$96.9) billion for preventing a pandemic with 10 times this mortality. There is evidence for travel restrictions being successful in controlling the spread of influenza between countries, and small islands successfully used protective sequestration and maritime quarantine to avoid the 1918–1919 influenza pandemic ). However, the 1918- 19 pandemic still appeared to reach most of the world’s islands. Drastic measures such as border closure have potentially large benefits (if successful) but also potentially major harmful consequences including economic harm. Some of these potential trade-offs are illustrated by the 2014 Ebola outbreak where the GDP of countries affected fell by 12% during the emergency even without successful complete border closures. The question remains, which pandemics, if any, might ever plausibly justify partitioning a segment of the human population through border closure by island nations to reduce major burdens of morbidity and mortality? It is this question we address in the present commentary.