World Antibiotic Awareness Week 2017 (November 13 to 19) is a World Health Organization global event around one of the most pressing challenges to health care – including the risk of relatively common infections developing resistance to the antibiotics usually used to treat them.

Late last year New Zealand’s Council of Medical Colleges facilitated the local launch of the global Choosing Wisely initiative in partnership with the Health Quality and Safety Commission and Consumer. The initiative – targeted at both health professionals and consumers – aims to avoid unnecessary clinical interventions including inappropriate prescribing of antibiotics.

Dr John Bonning, from the Council’s executive, said a growing number of infections, such as pneumonia, tuberculosis, and gonorrhoea, are becoming harder to treat as the antibiotics used to treat them become less effective. He said as part of the Choosing Wisely campaign the Council worked with Australasian and New Zealand Colleges and specialist societies to develop specific recommendations about antibiotic use.

“These recommendations include situations when antibiotics should not routinely be used – such as for upper respiratory tract infections, the use of topical antibiotics on surgical wounds, and for the treatment of fever in children without a bacterial infection.” (See list of recommendations and links below.)

The  Ministry of Health’s Director of Public Health, Dr Caroline McElnay, says New Zealand this year presented its Antimicrobial Resistance Action Plan as part of the commitment to tackling the global challenge.

Michael Baker, spokesperson for the College of Public Health Medicine said it was essential that New Zealand implemented the plan and echoed that antibiotic resistance was a global issue in which New Zealand “absolutely has to play its part”. “We need widespread commitment and leadership from medical, veterinary and agricultural sectors in New Zealand, working together.”

Hilary Graham-Smith of the New Zealand Nurses Organisation said nurses are in the frontline of helping patients around proper use of antibiotics. “Nurses have an integral part to play. Some nurses are prescribers now and more will come. Education about the importance of taking antibiotics as recommended by a health professional, not sharing them, and reporting adverse effects, is key to managing the use of antibiotics well.”

Wellington GP Dr Cathy Stephenson said it’s crucial to work out whether or not a person really needs an antibiotic.

“It’s partly about explaining to patients why antibiotics won’t help. But it’s also about giving them some practical advice that will help them, or their child, feel better – getting good rest, ensuring adequate fluid intake, and advising on proper pain relief. Often when you explain all this, people are actually very happy to avoid antibiotic use.”

Dr John Wyeth from Pharmac says they are charged with getting the best possible health outcomes for New Zealanders from the public medicines budget – and antimicrobial resistance could undermine that.

“We often forget that things we take for granted, like chemotherapy and surgery, would not be possible without antibiotics.”

Choosing Wisely antibiotic use recommendations

• Do not use antibiotics in asymptomatic bacteriuria.http://choosingwisely.org.nz/professional-resource/asid/#1
• Do not take a swab or use antibiotics for the management of a leg ulcer without clinical infection.http://choosingwisely.org.nz/professional-resource/asid/#2
• Avoid prescribing antibiotics for upper respiratory tract infection.http://choosingwisely.org.nz/professional-resource/asid/#3
• Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.http://choosingwisely.org.nz/professional-resource/anzsgm/#3
• Don’t use oral antibiotics for the treatment of atopic dermatitis unless there is clinical evidence of infection.http://choosingwisely.org.nz/professional-resource/nzds/#4
• Don’t routinely use topical antibiotics on a surgical wound.http://choosingwisely.org.nz/professional-resource/nzds/#5
• Do not routinely prescribe oral antibiotics to children with fever without an identified bacterial infection.http://choosingwisely.org.nz/professional-resource/pchd/#1
• Consider antibiotic de-escalation daily for intensive care patientshttp://choosingwisely.org.nz/professional-resource/anzics/#5

Choosing Wisely also encourages health professionals to share the campaign’s resources for consumers including:

• Antibiotics for sinusitis
• Antibiotics for your skin
• Coughs, colds & sore throats – manage symptoms without antibiotics
• Ear infection – treatments

‘WISE’ questions to help avoid unnecessary prescribing/interventions

• Why? What will this test, treatment or procedure change?
• Is there an alternative? Less invasive, less resource intensive?
• Seek clarification. Clarify why the doctor ordered this test
• Explore/explain. Be the patient’s advocate. Explore concerns, take time to explain why a test, treatment or procedure is/isn’t necessary

Source: From resources developed by the New Zealand Medical Students Association to support the Choosing Wisely campaign: choosingwisely.org.nz/professional-resource/nzmsa/

Yet few of us appreciate how it could hurt us individually.

An expert report released today by New Zealand’s leading body for science, Royal Society Te Aparangi, warns of a warmer world bringing heat waves, diseases, water contamination and air pollution.

Several degrees of warming this century could also have alarming implications for our mental health and social inequality – hitting Maori particularly hard.

It followed a global report in 2015 that bleakly warned how the past 50 years of health gains could be undone by the “medical emergency” that was the threat of climate change.

“If we think of the basic building blocks of health, such as our shelter, the air we breathe, water we drink and the food we eat, all will be affected by climate change,” said the society’s president, Professor Richard Bedford.

But if we knew what the risks were, he added, we could prepare for them and lower their impact.

Here are five big factors in the report.

Turning up the heat

If greenhouse gas emissions continue to climb close to current levels, many parts of our country will see more than 80 days a year above 25C by 2100.

By contrast, most places today typically see only between 20 and 40 days above that.

Cities, with their large, impermeable surfaces, would act as heat islands, pushing up the temperature of hot days and retaining the heat at night.

Already in Auckland and Christchurch temperatures above 20C each year resulted in around 14 heat-related deaths among those over 65.

Yet if global temperatures rise just one, two or three degrees above current levels, that death rate could rise to 28, 51 and 88 respectively.

Elderly populations are especially vulnerable to heatwaves.

With about one in four Kiwis projected to be 65 and over by 2043 – that’s including many people in their 40s today – the problem would be amplified.

Heat poses big risks to occupational health and labour productivity in areas where people work outdoors for many hours in susceptible regions.

Otago University public health expert Professor Michael Baker said that, in his own area of infectious diseases research, rises in temperature had been shown to contribute directly to an increased risk of foodborne diseases such as salmonellosis.

Hotter days could also lead to higher rates of aggression – and potentially heart attacks and strokes.

Data showed that when temperatures climbed above 18-20C, hospital and emergency room admissions increased for those with mental health or psychiatric conditions.

The problem could be eased or worsened by the magnitude and duration of the high temperatures – and the speed of temperature rise.

The report didn’t ignore the danger of one-off extreme events.

“Extreme events, such as the June 2015 flooding in South Dunedin and the 2017 Edgecumbe floods and Christchurch fires, pose immediate risks associated with being burned by fire, or being swept away when driving or walking through floodwaters or landslides.

“These extreme events may also have negative effects on wellbeing through disease outbreaks, toxic chemical contamination, effects of damp buildings, mental health issues, disruption to healthcare access and damage to homes, which can last from weeks to months after the initial event.”

Fouling the water

Implications for our marine and freshwater environments were as concerning as they were broad.

Climate change would increase our exposure to waterborne diseases caused by bacteria, viruses and micro-organisms such as giardia and cryptosporidium.

Changing weather patterns, bringing extreme rainfall and flooding, would combine with agricultural run-off to heighten the risk of contamination to the water we drink or swim in.

“Many of the short- to medium-term health effects will come via climate change’s impacts on freshwater,” said Otago University environmental health senior lecturer Dr Alex Macmillan, who served on the advisory group for the report.

“We already have declining freshwater quality in New Zealand as a result of increasing agricultural and urban pressures on rivers, lakes and drinking water sources.

“When these existing pressures are put together with warmer waters and heavier but more infrequent rainfall, then we are setting ourselves up for more outbreaks of waterborne illness like the one experienced by Havelock North in 2016.

“Protecting health from climate change will therefore require greater action on freshwater quality.”

With between 18,000 and 34,000 cases of gastroenteritis per year, New Zealand already had relatively high rates of waterborne illness compared with other high income countries.

By 2050, the World Health Organisation had suggested New Zealand could see around one to three more deaths of children due to all causes of diarrhoeal disease as a result of climate change.

Today’s report further highlighted a “significant impact” of higher temperatures on increasing diarrhoeal disease transmission, and increasing risk of illness which could range from days off work to hospitalisation.

Here and overseas, extreme rainfall events had been linked to increased levels of harmful micro-organisms like norovirus, and those causing cryptosporidiosis and giardiasis diarrhoea in treated drinking water supplies.

In our streams, concentrations of salmonella and E. coli could rise significantly over summer months, and following heavy rain.

The bacteria Leptospira, introduced into water from the urine of infected animals, could further bring illness, ranging from nausea to renal failure.

Small community or private groundwater wells, and other drinking water supplies where water was untreated or minimally treated, were especially susceptible to contamination after heavy deluges.

In ocean waters, the marine bacteria vibrio – whose growth rates were highly responsive to rising sea surface temperatures, particularly in coastal waters – could cause infected wounds, or diarrhoea or septicaemia if it contaminated sea food.

Algae, also fuelled by a warming climate, could cause problems in our waterways and shores.

In rivers and lakes, blue-algae produced toxins could cause liver damage, skin disorders, and gastrointestinal, respiratory and neurological symptoms.

In our marine environment, climate change could mean toxic algae spreading and becoming more abundant and toxic.

Polluting the air

Rising air pollution is a well-known risk of climate change – but in New Zealand, it isn’t just smog we would have to worry about.

Higher concentrations of CO2, together with higher temperatures and changes in precipitation, might extend the start or duration of the growing season – increasing the quantity and allergic potential of pollen.

Historical trends had shown climate change has forced shifts in the length of the growing season for certain plant species that were sources of allergenic pollens.

Studies had also found that increases in CO2 levels resulted in greater pollen production, and increased allergic potential of grass and pine trees.

While grasses formed the main source of atmospheric pollen in spring and summer here, annual birch pollen production in 2020 and 2100 was projected to be 1.3 and eight times higher respectively – with pollen season also arriving several weeks earlier.

Meanwhile, exposure to PM2.5 and PM10, two major man-made air pollutants, could rise with heightened seasonal fire severity.

Patients with underlying diseases, the elderly, and children were particularly sensitive.

Even in 2012, exposure to PM10 was estimated to have caused 1000 premature deaths and more than 500 hospital admissions in New Zealand.

PM2.5 was linked with serious chronic and acute health effects, among them lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, and asthma.

The amount of soil-derived PM10 dust in the air could also increase in areas more frequently affected by drought.

In Masterton, for example, soil had been found to contribute up to 14 per cent of the PM10 particulate matter in the air.

A new tide of pests and disease

We know there are many organisms – notably mosquitoes, ticks, and fleas – capable of spreading infectious diseases between us, or from animals.

The seasonality, range, and occurrence of diseases spread by these carriers are largely influenced by climatic factors – especially high and low temperature extremes, and precipitation patterns.

These factors can affect disease outbreaks by changing the population size, population density, and survival rates of the disease carriers.

Further, climate change could affect the relative abundance of other animals that are part of the disease cycle – and higher temperatures can increase the infectious agent’s own reproduction rates.

Collectively, these changes could contribute to an increase in the risk of the infectious diseases being spread to humans in some areas.

We would face an assortment of nasty bug-borne diseases we don’t have here already.

Worst among them are West Nile virus, dengue fever, Murray Valley encephalitis, Ross River virus and Barmah Forest virus.

Similarly, there were emerging pathogens that had recently spread across the globe – such as mosquito-borne Zika – which were present in the Pacific Islands today.

These could become more of a risk in New Zealand if climate change allowed important disease-spreading mosquitos to become established here.

Added to that were a host of parasitic diseases, also characteristic of warmer climates, that might arrive here, via flies whose larvae infested skin, or lung fluke-carrying snails.

Harmful species such as sea snakes or toxic jellyfish might similarly extend their range, while the invasive Australian redback spider, presently found only in Central Otago and Taranaki, could cross into other regions as they warmed.

The mental and social toll

Higher temperatures, extreme weather events and displacement of people from homes and communities would all have a major toll on our mental health and well-being.

Effects could range from minimal stress and distress symptoms to clinical disorders such as anxiety, depression, post-traumatic stress and suicidal thoughts, the report authors said.

Research in Australia during the decade-long drought which officially ended in 2012 revealed an increase in anxiety, depression, and possibly suicide in rural populations.

In these communities, concerns about financial and work-related issues were compounded by loss of hope for the future and by a sense of powerlessness or lack of control.

For Kiwis, our natural environment is at the heart of our nation’s identity – profoundly so for Maori – and shapes our economy, lifestyles and culture.

“There’s going to be a reduction in rain, particularly on the eastern side of the country – and more rain on the west – but the increase in drought frequency is going to put a lot of pressure on our rural economy,” University of Auckland epidemiologist and biostatistician Professor Alistair Woodward said.

“We know that there is a relationship between the rural economy, the welfare of the people working in the rural economy, and the frequency of mental health problems.”

Disruption of cherished bonds between individuals and their environment, such as during the managed retreat of threatened coastal communities, could cause grief, loss, and anxiety.

Even routine exposure to news articles like this one can add stress to an individual’s everyday environment.

Between 2005 and 2016 an average of 422 articles were published each month mentioning climate change or global warming in print and online media in the New Zealand region, according to the global media database.

In the United States, psychological responses to such stress have been shown to include heightened risk perceptions, general anxiety, pessimism, helplessness, eroded sense of self and collective control, stress, distress, sadness, loss, and guilt.

For Maori, climate change threatened to further entrench patterns of social disadvantage and unacceptable health inequities, said Dr Rhys Jones, an Auckland University senior lecturer and co-convenor of OraTaiao: NZ Climate and Health Council.

“On the flip side, the report highlights the significant health benefits that could be realised through well-planned climate action.”

A wake-up call

Mitigation measures could actually lower air pollution and its associated health problems – and dozens of lives could saved each year if we moved from driving cars to cycling.

One assessment of the effect of retrofitting houses in New Zealand with insulation suggested there could be savings of 217kg of CO2 per household per year through improved energy efficiency.

At the same time there would be fewer inpatient hospital respiratory admissions for the elderly, days off school for school-age children, and days off work for adults.

“A clear implication is that New Zealand must act urgently as part of global efforts to address climate change, and must do so in ways that centralise and prioritise the most vulnerable groups in society,” Jones said.

“A business-as-usual approach would predictably see the opportunities and benefits accrue disproportionately to those who are already privileged, leading to widening social and health disparities.

“This makes it critical that health and equity are at the core of decision making as we transition to a zero-carbon society.”

Macmillan echoed Jones’ call for urgent action.

“By bringing together such a comprehensive body of evidence, the report should be a wake-up call for us to shift from thinking about climate change as an environmental problem which will be expensive to address, to it being fundamentally an issue of health and quality of life for all New Zealanders,” she said.

Indeed, many of the health effects described in the report were already beginning to occur.

“The report adds further weight to arguments that New Zealand can no longer afford to delay urgent action as part of the global effort under the Paris Agreement.

“The overwhelmingly negative impacts of climate change on health require a co-ordinated health sector response – to adapt health services to expected changes, to reduce the health sector’s own climate pollution, and to ensure health is at the heart of climate decision-making.”

New Zealand and climate change

• Under present projections, the sea level around New Zealand is expected to rise between 30cm and 100cm this century. Temperatures could also increase by several degrees by 2100.
• Climate change would bring more floods; worsen freshwater problems and put more pressure on rivers and lakes; acidify our oceans; put even more species at risk and bring problems from the rest of the world.
• Climate change is also expected to result in more large storms compounding the effects of sea-level rise.
• New Zealand, which reported a 23 per cent increase in greenhouse gas emissions between 1990 and 2014, has pledged to slash its greenhouse gas emissions by 30 per cent from 2005 levels and 11 per cent from 1990 levels by 2030.
• The new coalition Government has promised greater action, with a proposed new Climate Coalition and Zero Carbon Act and goals for a carbon-neutral economy by 2050 and 100 per cent renewable energy by 2035.

The latest outbreak follows outbreaks that caused ward closures in September at Whangarei and Whakatane Hospitals.

Strict infection control have been put in place  in place in some Hawke’s Bay Hospital wards to prevent the spread of norovirus, the highly contagious vomiting and diarrhoea bug.

Chief Medical and Dental Officer John Gommans said norovirus was circulating in the community and infected patients had been admitted to hospital, affecting some hospital staff.

Dr Gommans said hospital visitors were reminded that they should stay away from visiting family or friends in hospital if they are sick.

“If you are unwell with vomiting and diarrhoea or have been around people who have been unwell, please do not visit the hospital for at least 48 hours.”

Visitors would also find that some wards were closed to new admissions, and visiting would be restricted and only allowed in exceptional circumstances to some areas of the hospital.

“The infection control measure we have put in place should contain any spread through the hospital, but as it is highly contagious we are being very vigilant, and will isolate other areas of the hospital to visitors if we have to,” Dr Gommans said.

Medical Officer of Health Nick Jones said it was likely the bug was circulating in the community.

“To help prevent the spread of the virus, it is very important for anyone with nausea, vomiting, diarrhoea and stomach cramps to stay away from work for 48 hours after symptoms disappear.”

He said sick children should also be kept away from school for the same period of time, he said.

It was advised if symptoms didn’t get better, or if people were becoming dehydrated, that they seek medical attention and phone ahead to your general practice clinic for advice if you become concerned.

Dr Jones said anyone attending the Hawke’s Bay show this week, should also be mindful that norovirus was circulating and wash their hands thoroughly before eating food and after using public toilets.

Good hand cleaning involves washing hands often with soap and warm water for at least 20 seconds before drying thoroughly.

The World Health Organization (WHO) has just verified that New Zealand has successfully eliminated endemic measles and rubella for the first time.

This means no measles or rubella cases have originated here for the past three years, the Ministry of Health’s director of public health Dr Caroline McElnay said.

The MMR vaccine protects against measles, mumps and rubella, all which can be serious in young adults. Measles is extremely contagious and more than 95 per cent of people need to be fully vaccinated to prevent sustained outbreaks, McElnay said.

“About 90 percent of young children have received both doses of MMR by age five in New Zealand, but only about 80 percent of teenagers and young adults have had both doses, which leaves them at risk.

“In New Zealand, people aged 12 to 32 years have lower vaccination rates than young children so are less likely to be protected against these diseases. That’s why teens and young adults have been most affected in the recent mumps outbreaks.”

Professor of public health at the University of Otago Michael Baker said it was the culmination of decades of work to achieve high coverage of vaccinations.

“It’s just a great success story for New Zealand… In the end it means a high level of safety and protection for our children.”

Baker explained that the term “elimination” did not mean that no one would ever get a case of the measles, but that there had been no occurrences of a transmission of measles lasting more than 12 months in the last three years and no case of congenital rubella in 20 years.

“It essentially fizzles out. That means you don’t get a sustained epidemic.”

The Bay of Plenty District Health Board says infection control measures are in place, including the restriction of access to the unit by both visitors and staff.

Chief operating officer Peter Chandler says everyone infected has been isolated.

He says visitors are being urged to stay away from the unit unless their visit is absolutely essential.

The DHB says the public shouldn’t visit the hospital’s emergency department unless their case is an emergency.

A likely norovirus outbreak has also affected 11 people at Whangarei Hospital and  strict infection control measures have been put in place on a ward.

The viral gastroenteritis outbreak was identified within Whangarei Hospital’s Ward One on around September 14. The outbreak, likely norovirus, has affected 11 patients who were isolated to prevent other patients being infected. As a further precaution, the ward was closed to new admissions and visiting restricted.

Strict infection control measures were put in place to reduce the risk for other patients within the hospital, said Clinical Microbiologist David Hammer.

Dr Hammer said that norovirus is currently widespread in the community and urged members of the public with any gastroenteritis-like symptoms not to visit patients in hospital. “We are asking members of the public – if you are unwell or have been around people who have been unwell – please do not visit the hospital for at least 48 hours,” he said.

The Auckland Regional Public Health Service had been notified of 300 cases of mumps from January 1 to September 4 this year.

“Mumps is now at large in the community and the only way we can stop this spreading further is to achieve high levels of MMR vaccination in the population,” Medical Officer of Health Dr Josephine Herman said.

She said the large number of mumps cases meant a large number of people were also at risk of contracting measles and rubella.

“The implications for young adults are deeply concerning, given the risk of non-immune pregnant women catching rubella. This can result in miscarriage or still birth and babies developing severe birth defects,” Herman said.

Mumps also posed a risk of miscarriage for women who were in their first three months of pregnancy, and in rare cases could cause male sterility.

She said there was a “lost generation” where many young people between 10 and 29 had not been vaccinated.

That was partly due to the now discredited MMR controversy from 1998 onwards and a pool of adults who may have missed out on receiving the second dose of the MMR vaccine when they were children when the timing of this dose was moved from 11 years to 4 years in 2001.

Herman said measles was an additional threat to communities with low vaccination coverage.

“It is likely we’ll see further measles outbreaks in schools similar to those in 2011, 2014 and 2016. The measles virus is highly contagious and can lead to serious medical complications as well,” Herman said.

Parents who were unsure about their family’s MMR vaccinations were being urged to check with their practice nurse or look up their children’s blue Well Child book.

According to national immunisation data, the coverage rates in young children up to the age of 12 years were about 80 per cent.

Today’s mid 20-year-olds had even lower rates, with a national coverage survey reporting that only 60 per cent of Pakeha children were fully immunised in 1991, with lower rates for Maori (42 per cent) and Pacific children (45 per cent).

These new research findings from the University of Auckland Centre for Longitudinal Research – He Ara ki Mua were published on 18 August in the journal Pediatrics. This publication reports the findings from a project that analysed the data from the longitudinal child study Growing Up in New Zealand.

Study senior author Professor Cameron Grant says that children need to receive scheduled vaccinations on time for national immunisation programmes to have their maximal health benefits. The series of immunisations for babies in the first months of life is particularly important as delays increase the risk of hospital admissions attributable to vaccine-preventable diseases.

As part of the study, more than 6,000 pregnant women were asked what information they had received about infant immunisation during a face-to-face interview in the final weeks of their pregnancies. With parental consent, the study then used the National Immunisation Register to check the timeliness of the women’s babies’ immunisations.

Fewer than half (44 per cent) of the 6,182 mothers interviewed recalled having received any information about the immunisations of their future children. Thirty per cent said they had received only encouraging information, while nine per cent received both encouraging and discouraging advice and five percent received only discouraging information.

Of those women who did not recall receiving any information during pregnancy, 70 per cent of their babies were immunised within a month of the vaccine due date. This compares with 57 per cent of babies of women who received discouraging information and 61 per cent of the babies of women who received both encouraging and discouraging information.

The babies of women who received only encouraging information about immunisation during their pregnancies were no more likely to be immunised on time than the babies of women who received no information.

The main sources of immunisation information identified by the women were healthcare providers (identified by 35 per cent), family and friends (14 per cent), and media (14 per cent).

Most said they received only encouraging information from healthcare providers, while the main sources of discouraging information were family and friends and media.

Professor Grant says he was concerned to see that one in six women who recalled receiving discouraging information identified healthcare providers as a source of that information.

“It is clear that pregnant women receiving information which discourages infant immunisation has a negative effect on subsequent healthcare delivery to that infant, even when they have also received information which encourages immunisation,” says Grant.

But receiving encouraging information about infant immunisation during the pregnancy was no more effective in ensuring timely immunisation than receiving no information.

“The ambiguity created by pregnant women receiving conflicting advice about infant immunisation is an area which requires some focused attention,” says Grant.

“We cannot prevent pregnant women from being exposed to information discouraging immunisation, but we can improve the ways in which we deliver encouraging information and ensure that they meet the information needs of everyone.”

Study details: Veerasingam P, Grant CC, Chelimo C, Philipson K, Gilchrist CA, Berry S, Atatoa Carr P, Camargo Jr CA, Morton S (2017). Vaccine education during pregnancy and timeliness of infant immunization. Pediatrics

Environmental Science and Research (ESR) figures show 188 people a week have been admitted to hospital and diagnosed with the flu since mid June, roughly double what it was at the same time last year.

The highest flu rates this season have been recorded in Auckland, Waikato and Wellington.

Auckland DHB’s chief nursing officer Margaret Dotchin said flu admissions for Auckland City Hospital were vastly up from 2016.

The action plan, published online at the weekend, is New Zealand’s contribution to fighting the global risk that increased antimicrobial resistance will see people needlessly die from infections and diseases that are currently treatable.

Better monitoring and reporting on antibiotic and other antimicrobials being used in hospitals and the community will be part of a national surveillance programme of antimicrobial resistance and antimicrobial use in humans, animals and agriculture to be established.

This will include analysing the dispensing of antibiotics to identify “prescriber types” with the data used to “develop and target interventions” to promote “appropriate” prescribing.  It will also examine the differences between the prescribing of antimicrobials in the community and hospitals.

Educating consumers about appropriate antibiotic use and developing resources to support better prescribing, including the possibility of prescriber targets, are priority actions.  Along with improving infection prevention and control in health facilities, schools and community-based services including promoting a “one-team” approach to infection prevention and control in health facilities.

Health Minister Dr Jonathan Coleman and Food Safety Minister David Bennett launched the finalised plan that was first aired at the 70th World Health Assembly in Geneva earlier this year.

Bennett said as a major food producer, New Zealand must manage antimicrobial resistance in animals and plants effectively.

You can view and download the plan here

The 18 action areas are built around the plan’s five objectives:

1. Awareness and understanding: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training.

2. Surveillance and research: Strengthen the knowledge and evidence base about antimicrobial resistance through surveillance and research.

3. Infection prevention and control: Improve infection prevention and control measures across human health and animal care settings to prevent infection and the transmission of micro-organisms.

4. Antimicrobial stewardship: Optimise the use of antimicrobial medicines in human health, animal health and agriculture, including by maintaining and enhancing the regulation of animal and agriculture antimicrobials.

5. Governance, collaboration and investment: Establish and support clear governance, collaboration and investment arrangements for a sustainable approach to countering antimicrobial resistance.

The hospital has swapped using an antibiotic cream applied in the nose before and after cardiac surgery – to prevent staphylococcus aureus (staph) surgical site infections – and replaced it with an antiseptic iodine nasal swab instead.

The change to the ‘anti-staph’ infection prevention bundle was initiated by infection prevention and control (IPC) clinical nurse specialist Karen Corban with the support of her mentors cardiothoracic surgeon Sean Galvin and microbiologist Professor Tim Blackmore.

Corban said the project arose when she chose to audit the hospital’s cardiac surgery anti-staph bundle as part of an IPC quality improvement course being offered through the Health Quality and Safety Commission (HQSC) and linked to its national surgical site infection (SSI) improvement project.

Wellington Hospital had introduced an anti-staph bundle two years ago, targeted at reducing cardiac SSIs, that included an antiseptic body wipe (chlorhexidine) and also applying mupirocin (also known as Bactroban) antibiotic cream in the nose before and after surgery.

Corban said the audit showed up low compliance with the mupirocin ointment component of the bundle, which involved applying the antibiotic cream the night before surgery and then twice a day for five days. A brain storming session with ward staff found non-compliance was due to a number of reasons including the cream going missing and not all staff being aware of the need for the twice-daily regime. Staff questioned why there wasn’t something that only needed to be done once to reduce the risk of nasal bacteria causing SSIs.

Looking for an answer she turned to her mentors Galvin, who was part of the HQSC’s group looking at preventing cardiac SSI, and Blackmore, who was leading the DHB’s antimicrobial stewardship project. At the same time late last year HQSC put out an anti-staph bundle discussion paper that examined the latest literature and suggested that an antiseptic nasal swab containing an iodine product could be just as effective as mupirocin. (See related research articles below).

Corban said using an antiseptic rather than an antibiotic was also seen to reduce the risk of patients becoming resistant to mupirocin and meant the antibiotic cream could be saved for when it was needed to fight an infection. Using povidone-iodine swabs to decolonise the nose was also much cheaper with iodine swabs costing around 80c each compared to $50 per tube of antibiotic ointment. Corban said the swabs also reduced the need for some laboratory tests and in total the swabs could save around $100 per patient so the project had already saved about $25,000 since it got underway in January.

Another advantage was that the swabs only needed to be done once – about one to two hours before the patient went to theatre – and provided cover for 12 hours.

So the decision to swap from the antibiotic cream to swabbing from the start of this year was backed by nurses who felt they were being listened to and saw the swabbing as a more practical alternative. She said the move had also been supported by HQSC which was exploring different options for introducing anti-staph bundles to DHBs across the country.

Corban said part of the project was developing a process for carrying out the antiseptic swabbing that including testing it out by inserting swabs up her own nose and the nose of a fellow IPC nurse specialist. “When we taught the process we gave everyone a swab that they could do themselves, or utilise on each other, so they knew what it felt like to be a patient and have that up their nose.”

The swabbing process involves one swab in the first nostril for 30 seconds, followed by another swab for 30 seconds in the second nostril and then repeated with a further 30 second swab to each nostril.

An important part of the antiseptic swabbing was amount of contact time with the mucosa so Corban developed a swabbing technique and pattern that takes 30 seconds to complete so nurses don’t have to keep an eye on a fob watch.

Corban, an ex-cardiothoracic charge nurse, followed up the swabbing training by coming in to the ward 6.30am every morning for five days a week for 20 weeks to observe pre-surgery swabs being given. She then followed it up with two months of observing five swabs a week and now is down to three-monthly checking of swabbing technique.

A staph aureus information sheet was developed for registered nurses plus an information sheet for patients about the process. She also surveyed a 100 patients with more than 90 per cent of them reporting the swab process was neither pleasant or unpleasant and it was found to be well-tolerated.

The DHB does about 550 cardiac surgeries a year but is now looking to roll out the anti-staph bundle to orthopaedic surgery.

Corban, who has a masters in public health, said the success of anti-staph bundle project has also seen her invited by HQSC to join its anti-staph bundle working group.

Further reading:

Discussion paper: Anti-staphylococcal bundle to reduce surgical site infections in orthopaedic and cardiac surgery (November 2016), HQSC

Anti-staphylococcal bundle to reduce surgical site infections in orthopaedic and cardiac surgery (March 2017) HQSC

Beboko S, Green D & Awad S (2015) Effect of a Preoperative Decontamination Protocol on Surgical Site Infections in Patients Undergoing Elective Orthopedic Surgery With Hardware Implantation. JAMA Surg. 2015;150(5):390-395. doi:10.1001/jamasurg.2014.3480

Anderson MJ, David M, Scholz M et al (2015) Efficacy of Skin and Nasal Povidone-Iodine Preparation against Mupirocin-Resistant Methicillin-Resistant Staphylococcus aureus and S. aureus within the Anterior Nares. Antimicrobial Agents and Chemotherapy 59(5)