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Objective: Influenza reemerged after a 2020-2021 hiatus in 2022, but understanding the resurgence needs pre-COVID era surveillance. We compared age- and ethnicity-specific incidence of severe acute respiratory infection (SARI) from a hospital network in Auckland, New Zealand, in 2022 against a baseline, 2012-2019., Methods: Annual and monthly influenza SARI incidence per 1000 persons by age and ethnic group between 2012 and 2022 was calculated using resident population as the denominator. The hospitals capture most severe illness of the resident population., Results: Influenza SARI incidence was highest among <1 year olds (2.62; 95% CI: 1.84-3.61) during 2012-2019, lowest at 6-14 years, and did not significantly increase until 50-64 years (0.35; 95% CI: 0.27-0.45), reaching 1.19 (95% CI: 0.57-1.55) in those ≥75 years. In all age groups, incidence was at least threefold higher in Māori and Pacific Peoples. No influenza SARI was identified in 2020-2021. In 2022, despite an early peak, annual incidence (<65 years) was lower than baseline in all ethnic groups, but incidence (≥65 years) in Māori (2.06; 95% CI: 1.22-3.26) and Pacific (3.94; 95% CI: 2.97-5.13) peoples was higher in 2022 than most baseline years, whereas incidence in NMNP (0.22; 95% CI: 0.14-0.32) was lower than any baseline year., Conclusion: After no influenza 2020-2021, Auckland had an early, high, narrow peak in 2022. Stratification by age and ethnicity revealed striking discrepancies in incidence among Māori and Pacific adults over 65 years compared with NMNP adults, with implications for targeted vaccination strategies., (© 2024 The Author(s). Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Forecasting models predicting trends in hospitalization rates have the potential to inform hospital management during seasonal epidemics of respiratory diseases and the associated surges caused by acute hospital admissions. Hospital bed requirements for elective surgery could be better planned if it were possible to foresee upcoming peaks in severe respiratory illness admissions. Forecasting models can also guide the use of intervention strategies to decrease the spread of respiratory pathogens and thus prevent local health system overload. In this study, we explore the capability of forecasting models to predict the number of hospital admissions in Auckland, New Zealand, within a three-week time horizon. Furthermore, we evaluate probabilistic forecasts and the impact on model performance when integrating laboratory data describing the circulation of respiratory viruses., Methods: The dataset used for this exploration results from active hospital surveillance, in which the World Health Organization Severe Acute Respiratory Infection (SARI) case definition was consistently used. This research nurse-led surveillance has been implemented in two public hospitals in Auckland and provides a systematic laboratory testing of SARI patients for nine respiratory viruses, including influenza, respiratory syncytial virus, and rhinovirus. The forecasting strategies used comprise automatic machine learning, one of the most recent generative pre-trained transformers, and established artificial neural network algorithms capable of univariate and multivariate forecasting., Results: We found that machine learning models compute more accurate forecasts in comparison to naïve seasonal models. Furthermore, we analyzed the impact of reducing the temporal resolution of forecasts, which decreased the model error of point forecasts and made probabilistic forecasting more reliable. An additional analysis that used the laboratory data revealed strong season-to-season variations in the incidence of respiratory viruses and how this correlates with total hospitalization cases. These variations could explain why it was not possible to improve forecasts by integrating this data., Conclusions: Active SARI surveillance and consistent data collection over time enable these data to be used to predict hospital bed utilization. These findings show the potential of machine learning as support for informing systems for proactive hospital management., (© 2024. The Author(s).)

Background: Changes in the epidemiology of illnesses caused by respiratory syncytial virus (RSV) infection following the COVID-19 pandemic are reported. The New Zealand (NZ) COVID-19 situation was unique; RSV community transmission was eliminated with the 2020 border closure, with a rapid and large increase in hospitalizations following the relaxation of social isolation measures and the opening of an exclusive border with Australia., Methods: This active population-based surveillance compared the age-specific incidence and seasonality of RSV-associated hospitalizations in Auckland, NZ, for 2 years before and after the 2020 border closures. Hospitalisation rates between years were compared by age, ethnicity (European/other, Māori, Pacific and Asian) and socioeconomic group (1 = least, 5 = most deprived)., Results: There was no RSV transmission in 2020. In all other years, hospitalisation rates were highest for people of Pacific versus other ethnic groups and for people living in the most deprived quintile of households. RSV hospitalisation rates were higher in 2021 and 2022 than in 2018-19. The epidemic peak was higher in 2021, but not 2022, and the duration was shorter than in 2018-19. In 2021, the increase in RSV hospitalisation rates was significant across all age, sex, ethnic and socioeconomic groups. In 2022, the increase in hospitalisation rates was only significant in one age (1- < 3 years), one ethnic (Asian) and one socioeconomic group (quintile 2)., Conclusions: COVID pandemic responses altered RSV-related hospitalisation seasonal patterns. Atypical features of RSV hospitalisation epidemiology were the increase in rates in older children and young adults, which lessened in 2022. Despite these variations, RSV hospitalisations in NZ continue to disproportionately affect individuals of Pacific ethnicity and those living in more socioeconomically deprived households. Whilst future public health strategies focused on RSV disease mitigation need to consider the potential shifts in epidemiological patterns when the transmission is disrupted, these variances must be considered in the context of longer-standing patterns of unequal disease distribution., (© 2024 The Author(s). Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: New Zealand's (NZ) complete absence of community transmission of influenza and respiratory syncytial virus (RSV) after May 2020, likely due to COVID-19 elimination measures, provided a rare opportunity to assess the impact of border restrictions on common respiratory viral infections over the ensuing 2 years., Methods: We collected the data from multiple surveillance systems, including hospital-based severe acute respiratory infection surveillance, SHIVERS-II, -III and -IV community cohorts for acute respiratory infection (ARI) surveillance, HealthStat sentinel general practice (GP) based influenza-like illness surveillance and SHIVERS-V sentinel GP-based ARI surveillance, SHIVERS-V traveller ARI surveillance and laboratory-based surveillance. We described the data on influenza, RSV and other respiratory viral infections in NZ before, during and after various stages of the COVID related border restrictions., Results: We observed that border closure to most people, and mandatory government-managed isolation and quarantine on arrival for those allowed to enter, appeared to be effective in keeping influenza and RSV infections out of the NZ community. Border restrictions did not affect community transmission of other respiratory viruses such as rhinovirus and parainfluenza virus type-1. Partial border relaxations through quarantine-free travel with Australia and other countries were quickly followed by importation of RSV in 2021 and influenza in 2022., Conclusion: Our findings inform future pandemic preparedness and strategies to model and manage the impact of influenza and other respiratory viral threats., (© 2024 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

In this article we review the COVID-19 pandemic experience in Aotearoa New Zealand and consider the optimal ongoing response strategy. We note that this pandemic virus looks likely to result in future waves of infection that diminish in size over time, depending on such factors as viral evolution and population immunity. However, the burden of disease remains high with thousands of infections, hundreds of hospitalisations and tens of deaths each week, and an unknown burden of long-term illness (long COVID). Alongside this there is a considerable burden from other important respiratory illnesses, including influenza and RSV, that needs more attention. Given this impact and the associated health inequities, particularly for Māori and Pacific Peoples, we consider that an ongoing respiratory disease mitigation strategy is appropriate for New Zealand. As such, the previously described "vaccines plus" approach (involving vaccination and public health and social measures), should now be integrated with the surveillance and control of other important respiratory infections. Now is also a time for New Zealand to build on the lessons from the COVID-19 pandemic to enhance preparedness nationally and internationally. New Zealand's experience suggests elimination (or ideally exclusion) should be the default first choice for future pandemics of sufficient severity., Competing Interests: Nil., (© PMA.)

Migrants and refugees generally experience immunization inequities compared to their host populations. Childhood vaccination coverage rates are influenced by a complex set of interrelated factors, including child and parental nativity. Coverage rates for MMR, pertussis, and HPV vaccines were compared among children born in Aotearoa New Zealand (NZ) of overseas-born parents or NZ-born parents. A nationwide retrospective cohort study was conducted using linked, de-identified data. Logistic regression models examined the most influential factors contributing to differences in timely vaccine uptake. Of the total study population who had received all scheduled vaccines ( N  = 760,269), 32.9% were children of migrant parents. Children of migrant parents had higher rates of complete and timely uptake for MMR, pertussis, and HPV vaccinations compared to non-migrant children. NZ-born children of migrant parents were significantly more likely to receive MMR and pertussis-containing vaccines on-time compared to those of non-migrants. All included factors, except for the child's gender and parents' English ability, significantly influenced vaccine uptake. Among NZ-born children of migrant parents, additional logistic modeling found significant differences based on parental duration of residence, visa group, and region of nationality. Findings point to the importance of differentiating between parent versus child nativity when examining immunization coverage. While vaccination rates were higher for NZ-born children of migrant parents, compared to non-migrant parents, timely coverage rates across both groups were below national targets. Continued efforts are needed to improve timely immunization service delivery to address suboptimal and inequitable coverage.

Aim: Maternal immunisation coverage is suboptimal in Aotearoa New Zealand. Our objective was to highlight discrepancies resulting from how maternal immunisation coverage for pertussis and influenza is measured in Aotearoa New Zealand., Method: A retrospective cohort study of pregnant people was undertaken using administrative datasets. Maternity and immunisation data from three sources (National Immunisation Register [NIR], general practice [GP], and pharmaceutical claims) were linked to determine the proportion of immunisation records not recorded in the NIR but captured in claims data, and to compare this with coverage data available from Te Whatu Ora - Health New Zealand., Results: We found that while increasing numbers of maternal immunisations are being captured in the NIR, around 10% remain unrecorded on the NIR, but within claims datasets., Conclusion: Accurate maternal immunisation coverage data is important for public health action. Implementation of the whole-of-life Aotearoa Immunisation Register (AIR) is an important opportunity to improve completeness and consistency of maternal immunisation coverage reporting., Competing Interests: Nil.HRC Activation Grant (21/999): generating evidence to improve uptake and equity in maternal immunisation., (© PMA.)

Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Amber Young reports financial support and travel were provided by Health Research Council of New Zealand. Natalie Gauld reports a relationship with Counties Manukau District Health Board that includes: employment.

Background: Maternal vaccinations for influenza and pertussis are recommended in New Zealand to protect mothers and their infant from infection. However, maternal immunisation coverage in New Zealand is suboptimal. Furthermore, there is unacceptable inequitable maternal immunisation rates across the country with Māori and Pacific women having significantly lower maternal immunisation rates than those of other New Zealanders., Methods: This research set out to explore what pregnant/recently pregnant Māori and Pacific women knew about immunisation during pregnancy and what factors influenced their decision to be vaccinated. A semi-structured interview guide was developed with questions focusing on knowledge of pertussis and influenza vaccination during pregnancy and decision-making. Māori and Pacific women aged over 16 years were purposively sampled and interviewed in Dunedin and Gisborne, New Zealand between May and August 2021. Interviews were analysed following a directed qualitative content approach. Data were arranged into coding nodes based on the study aims (deductive analysis) informed by previous literature and within these participant experiences were inductively coded into themes and subthemes., Results: Not all women were aware of maternal vaccine recommendations or they diseases they protected against. Many underestimated how dangerous influenza and pertussis could be and some were more concerned about potential harms of the vaccine. Furthermore, understanding potential harms of infection and protection provided by vaccination did not necessarily mean women would choose to be vaccinated. Those who decided to vaccinate felt well-informed, had vaccination recommended by their healthcare provider, and did so to protect their and their infant's health. Those who decided against vaccination were concerned about safety of the vaccines, lacked the information they needed, were not offered the vaccine, or did not consider vaccination a priority., Conclusions: There is a lack of understanding about vaccine benefits and risks of vaccine-preventable diseases which can result in the reinforcement of negative influences such as the fear of side effects. Furthermore, if vaccine benefits are not understood, inaccessibility of vaccines and the precedence of other life priorities may prevent uptake. Being well-informed and supported to make positive decisions to vaccinate in pregnancy is likely to improve vaccine coverage in Māori and Pacific Island New Zealanders., (© 2022. The Author(s).)

Background: Adequate maternal vaccination coverage is critical for the prevention and control of infectious disease outbreaks such as pertussis, influenza, and more recently COVID-19. To guide efforts to increase vaccination coverage this study examined the extent of vaccination coverage in pregnant New Zealand women over time by area-level deprivation and ethnicity., Methods: A retrospective cohort study was used consisting of all pregnant women who delivered between 01 January 2013 and 31 December 2018, using administrative health datasets. Outcomes were defined as receipt of influenza or pertussis vaccination in any one of the relevant data sources (National Immunisation Register, Proclaims, or Pharmaceutical collection) during their eligible pregnancy. Ethnicity was prioritised as Māori (NZ indigenous), Pacific, Asian, and Other or NZ European and deprivation was defined using New Zealand Index of Multiple Deprivation (IMD)., Results: Between 2013 and 2018, Asian women had the highest maternal vaccination coverage (36%) for pertussis, while Māori and Pacific women had the lowest, 13% and 15% respectively. Coverage of pertussis vaccination during pregnancy in low deprivation Māori women was 24% and 28% in Pacific women. This is in comparison to 30% and 25% in high deprivation Asian and European/Other women, respectively. Similar trends were seen for influenza., Conclusion: Between 2013 and 2018 maternal vaccination coverage increased for pertussis and influenza. Despite this coverage remains suboptimal, and existing ethnic and deprivation inequities increased. There is an urgent need to focus on equity, to engage and support ethic communities by creating genuinely accessible, culturally appropriate health services., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

The recent COVID-19 vaccine mandate among early childhood education (ECE) staff highlights the important role ECE staff have in the transmission of infectious diseases. However, there are no data on general vaccine uptake for this group in New Zealand. Additionally, the importance of ECE staff vaccination as a strategy to prevent illness has been rarely promoted in the past, and recommendations for other vaccinations in this group are lacking. Here we present a section of data accessed from an ECE-sector employment survey of more than 4,000 teaching staff, which inquired into the immunisation status of respondents. The data indicated that self-reported immunisation coverage for whooping cough, hepatitis A, and hepatitis B among ECE staff was approximately 50%. Self-reported immunisation status was higher for measles, mumps, rubella, and chickenpox in this group. The findings highlight the need for more comprehensive vaccination policy and research in ECE settings., Competing Interests: Nil.

Aim: The National Immunisation Register (NIR), which is derived from general practice management systems, is an important tool for the provision of clinical services, national immunisation programme evaluation and immunisation research in New Zealand. However, the accuracy of the NIR data has not yet been quantified. This study aimed to examine, describe and quantify the extent of discrepancy in the NIR compared to Well Child Tamariki Ora parent-held health record books (Health Books)., Method: Immunisation data for vaccinations given between birth and four years old for children born between 2006 and 2019 were compared between the Health Books and the NIR. Health Book records were used as the reference standard to calculate performance measures: sensitivity, specificity, positive and negative predictive values for the NIR., Results: Overall, NIR performance was high: sensitivity ranged from 90% to 93%, specificity from 78% to 85%, the positive predictive value from 91% to 94% and the negative predictive value from 77% to 84%. NIR performance was higher for National Immunisation Schedule (NIS) vaccines compared with non-NIS vaccines., Conclusion: This study indicates the NIR data accuracy generally performs well compared with international equivalents, especially for NIS vaccine records. Further work is required to ascertain why discrepancies between the Health Books and NIR continue to occur, with particular attention to important subgroups and translating records across from migrant populations. Also, future work is required to understand the accuracy of vaccination records for groups who experience lower-quality healthcare and a higher burden of infectious diseases., Competing Interests: All authors have been involved in research utilising NIR data for vaccine effectiveness, safety and coverage studies. Additionally, Nikki Turner is a GP.

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.

Background: Immunisation is an important public health policy and measuring coverage is imperative to identify gaps and monitor trends. New Zealand (NZ), like many countries, does not routinely publish coverage of immunisations given during pregnancy. Therefore, this study examined pregnancy immunisation coverage of all pregnant NZ women between 2013 and 2018, and what factors affected uptake., Methods: A retrospective cohort study of pregnant women who delivered between 2013 and 2018 was undertaken using administrative datasets. Maternity and immunisation data were linked to determine coverage of pertussis and influenza vaccinations in pregnancy. Generalised estimating equations were used to estimate the odds of receiving a vaccination during pregnancy., Results: From 2013 to 2018 data were available for 323,622 pregnant women, of whom 21.7% received maternal influenza immunisations and 25.7% maternal pertussis immunisations. Coverage for both vaccines increased over time, pertussis increased from 10.2% to 43.6% and influenza from 11.2% to 30.8%. The odds of being vaccinated, with either vaccine, during pregnancy increased with increasing age and decreasing deprivation. Compared to NZ European or Other women, Māori and Pacific women had lower odds of receiving a maternal pertussis (OR:0.55, 95% CI: 0.54, 0.57; OR:0.60, 95% CI: 0.58, 0.62, respectively) and influenza (OR: 0.69, 95% CI: 0.67, 0.71; OR:0.90, 95% CI: 0.87, 0.94, respectively) immunisations during pregnancy. Women were also more likely to be vaccinated against pertussis if they received antenatal care from a General Practitioner or Obstetrician compared to a Midwife. A similar pattern was seen for influenza vaccination., Conclusion: Gaps in maternal coverage for pertussis and influenza exist and work is needed to reduce immunisation inequities., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: NG is a member of the National Executive of the Pharmaceutical Society of New Zealand and has received funding from Green Cross Health (a provider of primary health care services including pharmacy and general practice), the Pharmacy Guild of New Zealand and the Pharmaceutical Society of New Zealand for reclassifying vaccinations to allow pharmacist administration. NG has led an investigator-led study funded by GSK. JP and ASH have been investigators on GSK funded studies., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The CREBRF missense variant (p.Arg457Gln) is paradoxically associated with lower risk of type 2 diabetes, yet higher body mass index (BMI). Here we sought to determine whether this CREBRF variant might be associated with adult height., Methods: Linear regression was used to analyse the association of the CREBRF minor (A) allele with height in 2286 Māori and Pacific adults living in Aotearoa/New Zealand. A potential type 2 diabetes index event was corrected to account for a bias that may be the cause of paradoxical association between the CREBRF diabetes-protective allele and higher BMI and height., Results: The CREBRF protective allele was associated with increased adult height (ß = 1.25 cm, P = 3.9 × 10 -6 ), with the effect being more pronounced in males. The lower odds of diabetes remained similar when analyses were adjusted for height (OR = 0.67-0.65). We found no evidence of a diabetes index event bias to explain the paradoxical effect of CREBRF with either BMI or height and diabetes. The orthologous CREBRF p.Arg457Gln variant was created in knock-in mice to independently assess the effect of the variant, and length was found to be greater in male mice at 8 weeks of age., Conclusion: These data taken together indicate that CREBRF p.Arg457Gln is associated with taller stature in Māori and Pacific adults.

Aim: We aimed to conduct a preliminary analysis of any association between the 1918 influenza pandemic and its impact on birth rates in New Zealand., Methods: Official data covering the period 1910 to 1930 were sourced from multiple New Zealand Yearbooks. Estimates were made of the size of the natality impacts and estimates made of the potential causes., Results: In 1919 there were 3,756 fewer non-Māori and 239 fewer Māori births than the pre-pandemic year of 1917, with these representing reductions in birth rates per 1,000 population of 16.6% and 19.8% respectively. The birth rate reductions in the pandemic year of 1918 (relative to 1917) were less at 8.8% and 6.7% reductions respectively. We estimated the likely major driver of the natality deficit in 1919 was embryonic and fetal loss due to influenza infection in pregnancy. Smaller roles were plausibly played by adult deaths during the pandemic and reduced sexual activity associated with the social turbulence of the peak pandemic months., Conclusions: The reduction in birth rates in New Zealand in 1918 and especially 1919 are consistent with international data associated with the 1918 influenza pandemic. The relatively higher natality loss for Māori for 1919 is also consistent with other epidemiological data on the unequal burden from this pandemic. Pandemic planning needs to consider ways to prevent such future burdens and associated inequalities. There is also a need to improve on the current low level of routine influenza vaccination in pregnancy so as to minimise fetal loss from seasonal influenza infection., Competing Interests: Dr Turner is the Director of the Immunisation Advisory Centre (IMAC). IMAC runs annual national influenza symposia. These symposia accept small amounts of funding through private industry sponsorship. This funding is provided in the form of educational grants that are not targeted for any specific topic within the symposia (www.immune.org.nz/funding).

Effective national immunisation programmes require a high proportion of the population to be immunised. Although New Zealand has made significant progress towards immunisation goals over the last two decades, immunisation coverage remains inadequate to prevent intermittent outbreaks of disease, and immunisation inequities persist between geographic, ethnic and socioeconomic groups. Here we summarise a recent literature review that was conducted to identify and examine key factors that influence immunisation coverage, timeliness of vaccinations and the core drivers that affect vaccine uptake. We conclude that well designed systems, taking a holistic approach with multiple components, gain broader community acceptance and trust; early and continual engagement with well-informed healthcare professionals builds trust and improves uptake; the family's experience during vaccination events is important; community-led vaccine advocacy is required to target specific populations to help to promote and improve access to immunisation. Coercive approaches can be marginally effective, but risk disproportionately penalising those already experiencing mistrust and hardship., Competing Interests: Nil.

Background: Hospitalization rates for infectious diseases in New Zealand (NZ) children have increased since 1989. The highest burden is among Māori and Pacific children, and the most socioeconomically deprived. New Zealand introduced pneumococcal conjugate vaccine (PCV)7 in June 2008, PCV10 in 2011, and PCV13 in 2014., Methods: A retrospective cohort study of NZ children aged <6 years between 2006 and 2015 was performed using administrative databases. Demographics and hospitalizations were linked to evaluate the impact of the PCV vaccination program on cases of invasive pneumococcal disease (IPD), all-cause pneumonia (ACP), and otitis media (OM), defined by ICD-10-AM codes, and to explore the effect by ethnicity and deprivation., Results: Between 2006 and 2015, there were 640 children hospitalized with IPD, 26589 for ACP, and 44545 for OM. IPD hospitalizations declined by 73% between 2005 and 2015 for children <6 years of age, whereas ACP and OM declined by 8% and 25%, respectively. The highest rates for all diseases were among Māori and Pacific children and those from high deprivation. However, the declines were highest among Māori and Pacific children and those from socioeconomically deprived areas. IPD hospitalizations declined by 79% and 67% for Māori and Pacific children, respectively, between 2006 and 2015. ACP declined by 12% in Māori and 21% in Pacific children. OM declined by 51% in Māori children., Conclusion: In contrast to the increasing trend of hospitalization rates for infectious disease in New Zealand, the use of PCV appears associated with reductions in ethnic and socioeconomic disparities in hospitalization for IPD, ACP, and OM., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Understanding the attack rate of influenza infection and the proportion who become ill by risk group is key to implementing prevention measures. While population-based studies of antihemagglutinin antibody responses have been described previously, studies examining both antihemagglutinin and antineuraminidase antibodies are lacking., Methods: In 2015, we conducted a seroepidemiologic cohort study of individuals randomly selected from a population in New Zealand. We tested paired sera for hemagglutination inhibition (HAI) or neuraminidase inhibition (NAI) titers for seroconversion. We followed participants weekly and performed influenza polymerase chain reaction (PCR) for those reporting influenza-like illness (ILI)., Results: Influenza infection (either HAI or NAI seroconversion) was found in 321 (35% [95% confidence interval, 32%-38%]) of 911 unvaccinated participants, of whom 100 (31%) seroconverted to NAI alone. Young children and Pacific peoples experienced the highest influenza infection attack rates, but overall only a quarter of all infected reported influenza PCR-confirmed ILI, and one-quarter of these sought medical attention. Seroconversion to NAI alone was higher among children aged <5 years vs those aged ≥5 years (14% vs 4%; P < .001) and among those with influenza B vs A(H3N2) virus infections (7% vs 0.3%; P < .001)., Conclusions: Measurement of antineuraminidase antibodies in addition to antihemagglutinin antibodies may be important in capturing the true influenza infection rates.

Background: Little is known about inactivated influenza vaccine effectiveness (IVE) in preventing very severe disease, including influenza-associated intensive care unit (ICU) admissions., Methods: The Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance (SHIVERS) project enrolled adults (aged ≥ 18 years) with acute respiratory illness (ARI) in general ward (GW) hospital settings (n = 3034) and ICUs (n = 101) during 2012-2015. IVE was assessed using a test-negative design comparing the odds of influenza vaccination among influenza positives vs. negatives (confirmed by real-time reverse transcription polymerase chain reaction). All models were adjusted for season, weeks from season peak, and a vaccination propensity score., Results: Influenza virus infection was confirmed in 28% of GW hospital and 41% of ICU patients; influenza vaccination was documented for 56% and 41%, respectively. Across seasons, IVE was 37% (95% confidence intervals [CI] = 23-48%) among GW patients and 82% (95% CI = 45-94%) among ICU patients. IVE point estimates were > 70% against ICU influenza and consistently higher than IVE against GW influenza when stratified by season, by virus (sub)types, and for adults with or without chronic medical conditions and for both adults aged <65 and ≥65 years old. Among hospitalized influenza positives, influenza vaccination was associated with a 59% reduction in the odds of ICU admission (aOR = 0.41, 95% CI = 0.18-0.96) and with shorter ICU lengths of stay (LOS), but not with radiograph-confirmed pneumonia or GW hospital LOS., Conclusion: Inactivated influenza vaccines prevented influenza-associated ICU admissions, may have higher effectiveness in ICU than GW hospital settings, and appeared to reduce the risk of severe disease among those who are infected despite vaccination., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: New Zealand has funded the administration of tetanus, diphtheria and acellular pertussis (Tdap) vaccine during pregnancy to prevent infant pertussis since 2013. The aim of this study was to assess the safety of Tdap vaccine administered to pregnant women as part of a national maternal immunisation programme., Methods: We conducted a national retrospective observational study using linked administrative New Zealand datasets. The study population consisted of pregnant women eligible to receive funded Tdap vaccination from 28 to 38 weeks gestation in 2013. Primary study outcomes were based on prioritised adverse events for the assessment of vaccine safety in pregnant women, as defined by WHO and Brighton Collaboration taskforces. We examined the effect of Tdap vaccination on prioritised maternal outcomes using Cox proportional hazard models. Adjusted hazard ratios controlled for key confounding variables., Results: In the cohort of 68,550 women eligible to receive funded antenatal Tdap vaccination during 2013, 8178 (11.9%) were vaccinated and 60,372 (88.1%) were unvaccinated. The use of Tdap in pregnancy was not associated with an increase in the rate of primary outcomes, including preterm labour; pre-eclampsia; pre-eclampsia with severe features; eclampsia; gestational hypertension; fetal growth restriction; or post-partum haemorrhage. Tdap also did not increase secondary outcomes, including gestational diabetes mellitus; antenatal bleeding; placental abruption; premature rupture of membranes; preterm delivery; fetal distress; chorioamnionitis; or, maternal fever during or after labour. Lactation disorders was the only secondary maternal outcome with a significantly increased hazard ratio. Tdap vaccine had a protective effect on pre-eclampsia with severe features, preterm labour, preterm delivery, and antenatal bleeding., Conclusion: We did not detect any biologically plausible adverse maternal outcomes following Tdap vaccination during pregnancy. This study provides further assurance that Tdap administration during pregnancy is not associated with unexpected safety risks., (Copyright © 2018. Published by Elsevier Ltd.)

INTRODUCTION Outreach Immunisation Services (OIS) enable children who have not been immunised on time at general practice to be immunised in the community, thereby improving immunisation coverage and reducing equity gaps. AIM To identify the most effective service delivery models and make recommendations for more effective and cost-efficient OIS delivery in New Zealand. METHODS Data collection and thematic analysis through a detailed review of OIS contracts and service specifications, an online survey and in-depth interviews with stakeholders and providers, and an analysis of cost data was conducted. RESULTS In total, 28 OIS providers completed survey questionnaires, 28 OIS staff were interviewed, and cost effectiveness data were obtained from 11 providers. The surveys and interviews identified key themes around identifying clients with the highest needs, effective engagement strategies, staffing requirements, and service challenges. On average, each OIS referral costs NZ$361 (median NZ$257), and each vaccination event costs NZ$636, ranging from NZ$145 to NZ$2403. Characteristics for two separate models of service delivery were identified based on provider size. CONCLUSION There is considerable range in costs and style of OIS delivery, and efficiencies can be gained. Models need to fit with locality needs and include adequate resourcing, staff with good local knowledge, close relationships with other key child health services and preferably co-location, sustainable funding, and regular service reviews. OIS are part of an effective integrated service that relies on accurate data, positive relationships and a rapid response when children fail to present for vaccination in a timely fashion.

INTRODUCTION The role of healthcare providers and their use of systems is one of the most important factors in vaccination uptake. AIM To identify reasons and find patterns behind why immunisation providers code the word 'decline' in their system for childhood immunisation events. METHODS A qualitative study involving face-to-face semi-structured interviews with staff members involved in immunisation delivery. General practices were purposively selected for having either high or low rates of registered children coded on the electronic practice management system as having declined immunisation events. Thematic analysis was undertaken using an inductive approach to link themes to the data. RESULTS A total of 35 interviews were conducted with practice nurses; 21 were from practices with high rates of registered children recorded as having declining immunisation events, and 14 practices with low rates of declining. Common themes were: effective use of systems, early and ongoing engagement, adequate health care practitioner time and practitioner experience. Practices with low rates of coded decliners had stronger approaches for early and ongoing engagement, and were less likely to use formalised decline forms. As practice immunisation coverage rates improved over time, there was perceived to be less expressed vaccine hesitancy from families. CONCLUSIONS The reasons for coding individuals as 'decliners' are a complex mixture of individual, community, practitioner and practice systems. Front-line providers need adequate tools, time and resourcing to support effective and ongoing engagement with families. Community factors have influence but can change over time.

Background: We aimed to estimate the protection afforded by inactivated influenza vaccine, in both community and hospital settings, in a well characterised urban population in Auckland during 2014., Methods: We used two different comparison groups, all patients who tested negative for influenza and only those patients who tested negative for influenza and had a non-influenza respiratory virus detected, to calculate the vaccine effectiveness in a test negative study design. Estimates were made separately for general practice outpatient consultations and hospitalised patients, stratified by age group and by influenza type and subtype. Vaccine status was confirmed by electronic record for general practice patients and all respiratory viruses were detected by real time polymerase chain reaction., Results: 1039 hospitalised and 1154 general practice outpatient consultations met all the study inclusion criteria and had a respiratory sample tested for influenza and other respiratory viruses. Compared to general practice patients, hospitalised patients were more likely to be very young or very old, to be Māori or Pacific Islander, to have a low income and to suffer from chronic disease. Vaccine effectiveness (VE) adjusted for age and other participant characteristics using all influenza negative controls was 42% (95% CI: 16 to 60%) for hospitalised and 56% (95% CI: 35 to 70%) for general practice patients. The vaccine appeared to be most effective against the influenza A(H1N1)pdm09 strain with an adjusted VE of 62% (95% CI:38 to 77%) for hospitalised and 59% (95% CI:36 to 74%) for general practice patients, using influenza virus negative controls. Similar results found when patients testing positive for a non-influenza respiratory virus were used as the control group., Conclusion: This study contributes to validation of the test negative design and confirms that inactivated influenza vaccines continue to provide modest but significant protection against laboratory-confirmed influenza., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Preliminary results for influenza vaccine effectiveness (VE) against acute respiratory illness with circulating laboratory-confirmed influenza viruses in New Zealand from 27 April to 26 September 2015, using a case test-negative design were 36% (95% confidence interval (CI): 11-54) for general practice encounters and 50% (95% CI: 20-68) for hospitalisations. VE against hospitalised influenza A(H3N2) illnesses was moderate at 53% (95% CI: 6-76) but improved compared with previous seasons.

Objective: To develop a natural language processing software inference algorithm to classify the content of primary care consultations using electronic health record Big Data and subsequently test the algorithm's ability to estimate the prevalence and burden of childhood respiratory illness in primary care., Design: Algorithm development and validation study. To classify consultations, the algorithm is designed to interrogate clinical narrative entered as free text, diagnostic (Read) codes created and medications prescribed on the day of the consultation., Setting: Thirty-six consenting primary care practices from a mixed urban and semirural region of New Zealand. Three independent sets of 1200 child consultation records were randomly extracted from a data set of all general practitioner consultations in participating practices between 1 January 2008-31 December 2013 for children under 18 years of age (n=754,242). Each consultation record within these sets was independently classified by two expert clinicians as respiratory or non-respiratory, and subclassified according to respiratory diagnostic categories to create three 'gold standard' sets of classified records. These three gold standard record sets were used to train, test and validate the algorithm., Outcome Measures: Sensitivity, specificity, positive predictive value and F-measure were calculated to illustrate the algorithm's ability to replicate judgements of expert clinicians within the 1200 record gold standard validation set., Results: The algorithm was able to identify respiratory consultations in the 1200 record validation set with a sensitivity of 0.72 (95% CI 0.67 to 0.78) and a specificity of 0.95 (95% CI 0.93 to 0.98). The positive predictive value of algorithm respiratory classification was 0.93 (95% CI 0.89 to 0.97). The positive predictive value of the algorithm classifying consultations as being related to specific respiratory diagnostic categories ranged from 0.68 (95% CI 0.40 to 1.00; other respiratory conditions) to 0.91 (95% CI 0.79 to 1.00; throat infections)., Conclusions: A software inference algorithm that uses primary care Big Data can accurately classify the content of clinical consultations. This algorithm will enable accurate estimation of the prevalence of childhood respiratory illness in primary care and resultant service utilisation. The methodology can also be applied to other areas of clinical care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We present preliminary results of influenza vaccine effectiveness (VE) in New Zealand using a case test-negative design for 28 April to 31 August 2014. VE adjusted for age and time of admission among all ages against severe acute respiratory illness hospital presentation due to laboratory-confirmed influenza was 54% (95% CI: 19 to 74) and specifically against A(H1N1)pdm09 was 65% (95% CI:33 to 81). For influenza-confirmed primary care visits, VE was 67% (95% CI: 48 to 79) overall and 73% (95% CI: 50 to 85) against A(H1N1)pdm09.

This study reports the first vaccine effectiveness (VE) estimates for the prevention of general practice visits and hospitalisations for laboratory-confirmed influenza from an urban population in Auckland, New Zealand, in the same influenza season (2013). A case test-negative design was used to estimate propensity-adjusted VE in both hospital and community settings. Patients with a severe acute respiratory infection (SARI) or influenza-like illness (ILI) were defined as requiring hospitalisation (SARI) or attending a general practice (ILI) with a history of fever or measured temperature ≥38 °C, cough and onset within the past 10 days. Those who tested positive for influenza virus were cases while those who tested negative were controls. Results were analysed to 7 days post symptom onset and adjusted for the propensity to be vaccinated and the timing during the influenza season. Influenza vaccination provided 52% (95% CI: 32 to 66) protection against laboratory-confirmed influenza hospitalisation and 56% (95% CI: 34 to 70) against presenting to general practice with influenza. VE estimates were similar for all types and subtypes. This study found moderate effectiveness of influenza vaccine against medically attended and hospitalised influenza in New Zealand, a temperate, southern hemisphere country during the 2013 winter season.

Background: Few studies report the effectiveness of trivalent inactivated influenza vaccine (TIV) in preventing hospitalisation for influenza-confirmed respiratory infections. Using a prospective surveillance platform, this study reports the first such estimate from a well-defined ethnically diverse population in New Zealand (NZ)., Methods: A case test-negative design was used to estimate propensity adjusted vaccine effectiveness. Patients with a severe acute respiratory infection (SARI), defined as a patient of any age requiring hospitalisation with a history of a fever or a measured temperature ≥38°C and cough and onset within the past 7 days, admitted to public hospitals in South and Central Auckland were eligible for inclusion in the study. Cases were SARI patients who tested positive for influenza, while non-cases (controls) were SARI patients who tested negative. Results were adjusted for the propensity to be vaccinated and the timing of the influenza season., Results: The propensity and season adjusted vaccine effectiveness (VE) was estimated as 39% (95% CI 16;56). The VE point estimate against influenza A (H1N1) was lower than for influenza B or influenza A (H3N2) but confidence intervals were wide and overlapping. Estimated VE was 59% (95% CI 26;77) in patients aged 45-64 years but only 8% (-78;53) in those aged 65 years and above., Conclusion: Prospective surveillance for SARI has been successfully established in NZ. This study for the first year, the 2012 influenza season, has shown low to moderate protection by TIV against influenza positive hospitalisation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Recent experience with pandemic influenza A(H1N1)pdm09 highlighted the importance of global surveillance for severe respiratory disease to support pandemic preparedness and seasonal influenza control. Improved surveillance in the southern hemisphere is needed to provide critical data on influenza epidemiology, disease burden, circulating strains and effectiveness of influenza prevention and control measures. Hospital-based surveillance for severe acute respiratory infection (SARI) cases was established in New Zealand on 30 April 2012. The aims were to measure incidence, prevalence, risk factors, clinical spectrum and outcomes for SARI and associated influenza and other respiratory pathogen cases as well as to understand influenza contribution to patients not meeting SARI case definition., Methods/design: All inpatients with suspected respiratory infections who were admitted overnight to the study hospitals were screened daily. If a patient met the World Health Organization's SARI case definition, a respiratory specimen was tested for influenza and other respiratory pathogens. A case report form captured demographics, history of presenting illness, co-morbidities, disease course and outcome and risk factors. These data were supplemented from electronic clinical records and other linked data sources., Discussion: Hospital-based SARI surveillance has been implemented and is fully functioning in New Zealand. Active, prospective, continuous, hospital-based SARI surveillance is useful in supporting pandemic preparedness for emerging influenza A(H7N9) virus infections and seasonal influenza prevention and control.

Introduction: General practice immunisation audits do not always match the national rates recorded on the New Zealand (NZ) National Immunisation Register (NIR)., Aim: To complete audits at one general practice for infants requiring the primary series of immunisations (6-week, 3-month and 5-month vaccines) over a 12-month period and compare findings with the NIR audit., Methods: A manual and electronic practice management system (PMS) audit were compared with identical NIR audit parameters for completion of the 5-month vaccination from 1 February 2011 to 1 February 2012. All three results were then combined with further sub-audits of the total practice newborn population to produce a multifaceted audit, identifying further eligible patients. The NIR database query tool was used to corroborate data on partially immunised and unimmunised patients identified., Results: All three initial audits produced different results for vaccinated and eligible patients: NIR 31/36; PMS audit 39/43; manual audit 41/48. The multifaceted audit identified 48 eligible infants. All 48 (100%) started their primary series-95.8% (46 of 48) fully immunised; 4.2% (2 of 48) partially immunised, missing only one injection. None were unimmunised, contrary to initial audits. Lower levels of timeliness of delivery were confirmed for this practice, with 52.1% (25 of 48) immunised on time., Discussion: Results show 9.7% higher levels of immunisation than reported by NIR statistics for this practice (95.8% vs 86.1%), above current NZ government and World Health Organization targets. The multifaceted audit produced the best estimate of eligible patients and identified deficiencies in vaccine delivery.

For the past 20 years, New Zealand has experienced low immunisation coverage levels. Following the introduction of the National Immunisation Register (NIR) in 2005 many practitioners envisaged improved overall immunisation uptake through enhanced surveillance and monitoring capacities. This study aimed to investigate the geographical distribution and variables associated with disparities in immunisation uptake in New Zealand using a large NIR data set of children aged 12 months old in 2007-2009. DHB immunisation uptake was adjusted for individual ethnicity and deprivation status, year of birth and geographic location. Substantial variations in uptake by ethnicity and District Health Board (DHB) level were evident. Māori (NZ indigenous) and 'Other' ethnicity remain a substantial risk factor for low immunisation uptake after controlling for socio-economic deprivation. In addition, a general north-south gradient was confirmed across New Zealand. Current immunisation programme strategies for planners and providers in New Zealand need to recognise varying DHB compositions in order to provide efficient service provision and to focus on those groups at higher risk of not being immunised., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Children who have missed or delayed immunisations are at greater risk of vaccine-preventable diseases and getting their first scheduled dose on time strongly predicts subsequent complete immunisation. Developing a relationship with an infant's parents and general practice staff soon after birth followed by a systematic approach can reduce the number of delayed first immunisations., Aim: To assess the effectiveness of a general practice-based pre-call intervention to improve immunisation timeliness., Methods: Clustered controlled trial of general practices in a large urban district randomised to either delivery of pre-call intervention to all babies at aged four weeks or usual care., Results: Immunisation timeliness for infants receiving the primary series of immunisations among their nominated Auckland general practices was higher than expected at 98% for the six week event. The intervention was statistically but not clinically significant. Coverage was significantly lower among infants with no nominated practice which reduced overall coverage rate for the district., Discussion: Pre-call letters with telephone follow-up are simple interventions to introduce into the practice management system and can be easily implemented as usual standard of care. Early identification of newborn infants, primary care engagement and effective systems including tracking of infants not enrolled in general practices has the greatest potential to improve immunisation coverage rates even further.

Objective: To evaluate and compare rates of febrile events, including febrile convulsion, following immunisation with four brands of inactivated 2010 and 2011 influenza vaccine in NZ infants and children., Design: Retrospective telephone surveys of parents of infants and children who received at least one dose of the vaccines of interest., Setting: 184 NZ General Practices who received the vaccines of interest., Participants: Recipients of 4088 doses of trivalent inactivated vaccines Fluvax(®), Vaxigrip(®), Influvac(®) and Fluarix(®) and/or monovalent Celvapan. Vaccinees were identified via the electronic Practice Management System and contacted consecutively., Main Outcome Measures: Primary outcome was febrile convulsive seizure. Secondary outcomes were presence of fever plus other organ system specific symptoms., Results: The parental response rate was 99%. Of 4088 doses given, 865 were Fluvax(®), 2571 Vaxigrip(®), 204 Influvac(®), 438 Fluarix(®) and 10 Celvapan. Three febrile convulsions followed Fluvax(®), a rate of 35 per 10,000 doses. No convulsions occurred following any dose of the other vaccines. There were nine febrile events that included rigors, all following Fluvax(®). Fever occurred significantly more frequently following administration of Fluvax(®) compared with the other brands of vaccines (p<0.0001) and Fluvax recipients were more likely to seek medical attention. Influvac(®) also had higher rates of febrile reactions (OR 0.54, 0.36-0.81) than the other two brands Vaxigrip(®) (OR 0.21, 0.16-0.27) and Fluarix(®) (OR 0.10, 0.05-0.20). After multivariable analysis vaccine, European ethnicity and second dose of vaccine were significantly associated with reporting of fever within 24h of vaccination., Conclusions: Influenza vaccines have different rates of reactogenicity in children which varies between ethnic groups. High rates of febrile convulsions and reactions in children receiving Fluvax(®) and to a lesser extent the higher fever rates in those receiving Influvac(®) compared with the other two brands of influenza vaccines in this study suggests that reactogenicity profiles need to be considered prior to national policy advice each season. The risk-benefit profile in children might not be equally favourable for all licensed paediatric influenza vaccines. More attention needs to be given to comparative research for all trivalent seasonal vaccines, and with all strain changes., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

New Zealand continues to grapple with poor and inequitable child health and wellbeing outcomes. The associated high economic costs, the long-term impact on adult health and New Zealand's international children's rights obligations provide further grounds for action. Although there have been many different reports offering solutions and some key areas of progress, gains have been limited and there has not been sufficient clarity and agreement on wider actions. The environment is complex and solutions cross agency and disciplinary boundaries. This paper reviews the current situation and proposes a set of actions to improve child health and equity. These include a group of recommendations on high-level leadership and coordination, actions to address social conditions, and a range of specific health and wellbeing actions. Progress will require the will, commitment and courage of many to acknowledge the issues and find a way forward. Preventing suffering and ensuring the wellbeing of our youngest citizens during their formative years is an ethical issue for our nation, an issue of what we value as a society, and the best investment for a highly productive, innovative and resilient nation for the future.

Introduction: Delay in receipt of the first vaccine dose in the primary series is one of the strongest and most consistent predictors of subsequent incomplete immunisation., Aim: To describe the on-time immunisation delivery of New Zealand infant scheduled vaccines by primary care practices and identify characteristics of practices, health professionals and patients associated with delays in receipt of infant immunisations., Methods: Timeliness of immunisation delivery and factors associated with timely immunisation were examined in 124 randomly selected primary care practices in two large regions of New Zealand., Results: A multiple regression model of demographic, practice, nurse, doctor and caregiver association explained 68% of the variance in immunisation timeliness between practices. Timeliness was higher in practices without staff shortages (ß-coefficient -0.0770, p= 0.01), where nurses believed parental apathy (ß-coefficient 0.0819, p=0.008) or physicians believed parental access (ß-coefficient 0.109, p=0.002) was a barrier, and lower in practices with Maori governance (ß-coefficient -0.0868, p=0.05), higher social deprivation (ß-coefficient -0.0643, <0.001) and where caregivers received immunisation-discouraging information (ß-coefficient -0.0643, p=0.04)., Discussion: Interventions supporting practice teams and providers in primary care settings could produce significant improvements in immunisation timeliness.

Introduction: Effective immunisation programmes require a stable cold chain to maintain potency of vaccines from national stores through to delivery sites., Aim: To assess the effectiveness of the New Zealand cold chain and examine the possible impacts of policy changes over the same time period on cold chain effectiveness., Methods: Heat- and freeze-sensitive monitors were attached to 5% of randomly selected childhood vaccines from 2002 to 2008. Six-monthly reports on data collected from monitor cards were collated and analysed to look for changes over time in freeze and heat exposure failures for vaccines., Results: From December 2002 to June 2008 a total of 21,431 monitor cards were included in vaccines distributed from the national store; 9474 (44.2%) of all cards were returned and 8249 (38.5% of total) were correctly completed. Over this period the percentage of valid returns recorded as heat exposed decreased from 38% to 7% (χ² 371, p<0.001); heat failures decreased from 3% to 0.3% (χ² 371, p<0.0001); freeze failures decreased from 16% to 2% (χ² 134.228, p<0.0001), and overall wastage from 17% to 2% (χ² 163.83, p<0.0001), giving estimated annual savings of nearly NZ$4 million., Discussion: Significant improvements can be made in cold chain management with resulting savings in vaccine wastage. This study demonstrates that such improvements have been made in New Zealand in recent years. This is likely to be due to a combination of improving equipment, systems, education and training, increased provider attention and quality standards.

Activity-based costing (ABC) and Data Envelopment Analysis (DEA) share similar views of resource consumption in the production of outputs. While DEA has a high level focus typically using aggregated data in the form of inputs and outputs, ABC is more detailed and oriented around very disaggregated data. We use a case study of immunisation activities in 24 New Zealand primary care practices to illustrate how DEA and ABC can be used in conjunction to improve performance analysis and benchmarking. Results show that practice size, socio-economic environment, parts of the service delivery process as well as regular administrative tasks are major cost and performance drivers for general practices in immunisation activities. It is worth noting that initial analyses of the ABC results, using contextual information and conventional methods of analysis such as regression and correlations, did not result in any patterns of significance. Reorganising this information using the DEA efficiency scores has revealed trends that make sense to practitioners and provide insights into where to place efforts for improvement.

Aim: To identify primary care factors associated with immunisation coverage., Methods: A survey during 2005-2006 of a random sample of New Zealand primary care practices, with over-sampling of practices serving indigenous children. An immunisation audit was conducted for children registered at each practice. Practice characteristics and the knowledge and attitudes of doctors, nurses and caregivers were measured. Practice immunisation coverage was defined as the percentage of registered children from 6 weeks to 23 months old at each practice who were fully immunised for age. Associations of practice, doctor, nurse and caregiver factors with practice immunisation coverage were determined using multiple regression analyses., Results: One hundred and twenty-four (61%) of 205 eligible practices were recruited. A median (25th-75th centile) of 71% (57-77%) of registered children at each practice was fully immunised. In multivariate analyses, immunisation coverage was higher at practices with no staff shortages (median practice coverage 76% vs 67%, P = 0.004) and where doctors were confident in their immunisation knowledge (72% vs 67%, P= 0.005). Coverage was lower if the children's parents had received information antenatally, which discouraged immunisation (67% vs 73%, P = 0.008). Coverage decreased as socio-economic deprivation of the registered population increased (P < 0.001) and as the children's age (P = 0.001) and registration age (P = 0.02) increased. CONCLUSIONS Higher immunisation coverage is achieved by practices that establish an early relationship with the family and that are adequately resourced with stable and confident staff. Immunisation promotion should begin antenatally., (© 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Unlabelled: Due to a dramatic increase in reported febrile convulsions in Western Australia following a routine pediatric influenza vaccination programme we evaluated parental recall of fever in their child following 2010 trivalent influenza vaccine manufactured by either Sanofi Pasteur (Vaxigrip(®)) or CSL Biotherapies (Fluvax(®)) to determine if the rates of febrile events in infants and children 5 years and under following administration of either Vaxigrip(®) or Fluvax(®) were significantly different., Method: A convenience sample of New Zealand General practices who had received stocks of the vaccines of interest consecutively contacted parents of infants and children under 5 years of age who received at least one dose of 2010 influenza vaccine. A brief questionnaire was administered with the main outcome parental recall of fever within 24 h of vaccination., Results: Response rate was 99%. There were 327 parents of children aged 6 months to 5 years attending one of 23 primary care practices who had received a dose of either the Vaxigrip(®) or Fluvax(®) vaccine between 4th March and 28th June 2010 surveyed. A total of 422 doses were given of which 267 were Vaxigrip(®), 133 were Fluvax(®) and 22 another vaccine. Fever occurred significantly more frequently within 24 h following administration of Fluvax(®) compared with Vaxigrip(®) RR 4.33 (2.44-7.70). When fevers were measured they were, on average, higher in the Fluvax(®) vaccines (38°C compared with 39°C). Additionally, recipients were more likely to seek medical advice for fever following Fluvax(®) RR 23.11 (2.96-180.12)., Conclusions: There is considerable variation in reactogenicity between two 2010 seasonal vaccines in infants and young children. Vaxigrip(®) is significantly less reactogenic when compared to Fluvax(®) in this population in which Fluvax(®) is associated with unacceptably high rates of febrile reactions. There has been insufficient safety evaluation of seasonal influenza vaccine safety in this population., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The intention of this viewpoint article is to prompt discussion and debate about primary health care funding for children under the age of six. While New Zealand offers a superb natural environment for childhood, our child health outcomes continue to be poor, ranking lowest amongst 29 countries in a recent report by the Organisation for Economic Co-operation and Development. Since 1996, various funding arrangements have been introduced with the goal of achieving free primary health care for children under six years of age and nearly 80% of practices now offer care to this group without charge. Universal no cost or very low cost access for young children, however, remains elusive, particularly for after-hours care, and this is important given that at least one in five children lives in poverty. We are under no illusions about the complexity of primary care funding mechanisms and the challenges of supporting financially-sustainable systems of after-hours care. Good health care early in life, however, is a significant factor in producing a healthier and more productive adult population and improving access to primary care lessens the impact of childhood illness. We suggest that reducing cost barriers to primary care access for young children should remain an important target, and recent examples show that further reductions in cost for primary care visits for young children, including after-hours, is possible. Further funding is needed to make this widespread, in conjunction with innovative arrangements between funding authorities, primary care providers, and emergency departments. We encourage further debate on this topic with a view to resolving the question of whether the goal of free child health care for young children in New Zealand can be realised.

Introduction: Childhood immunisation is one of the most cost-effective activities in health care. However, New Zealand (NZ) has failed to achieve national coverage targets. NZ general practice is the primary site of service delivery and is funded on a fee-for-service basis for delivery of immunisation events., Aim: To determine the average cost to a general practice of delivering childhood immunisation events and to develop a cost model for the typical practice., Methods: A purposeful selection of 24 diverse practices provided data via questionnaires and a daily log over a week. Costs were modelled using activity-based costing., Results: The mean time spent on an immunisation activity was 23.8 minutes, with 90.7% of all staff time provided by practice nurses. Only 2% of the total time recorded was spent on childhood immunisation opportunistic activities. Practice nurses spent 15% of their total work time on immunisation activity. The mean estimated cost per vaccination event was $25.90; however, there was considerable variability across practices. A 'typical practice' model was developed to better understand costs at different levels of activity., Conclusions: The current level of immunisation benefit subsidy is considerably lower than the cost of a standard vaccination event, although there is wide variability across practices. The costs of delivery exceeding the subsidy may be one reason why there is an apparently small amount of time spent on extra opportunistic activities and a barrier to increasing efforts to raise immunisation rates.

Background: Missed immunization opportunities (MOs) are a significant barrier to achieving high immunization coverage., Objective: To describe the nature of MOs to immunize within primary care in New Zealand and their effect on immunization completeness., Methods: Audit of medical records of approximately 10 randomly selected children <2 years old from each of 62 primary care practices in Auckland, New Zealand., Results: The 616 audited children made 10 094 visits to primary care practices. MOs occurred at 97% (60) of practices, in 556 (5.5%) of visits, and 31% of the children had one or more visits that were an MO. Overall, children who had any recorded MO visit were 3.1 times more likely to be incompletely immunized than children who had no recorded MO (95% CI 1.87-5.14). Children with the greater percentage of overall visits that were MOs had up to a 9 times increased likelihood of incomplete immunization compared to those who had no MO visits. Nurse visits have less MOs than doctor (1.5% versus 6%) but are more likely to occur within well-child visits., Conclusions: MOs are common in primary care practices, occurring in nearly one-third of visiting children. The risk of under-immunization increases with the increasing percentage of visits that are MOs. Overall strategies directed at reducing MOs need to focus on a range of aspects for the practitioner and the practice system.