By InfectedNZ 22/11/2016


jess-berenston-shaw-blog-headerIn another life I used to sit on teams that developed something called ‘clinical guidance’. We would draw together published evidence and make recommendations on what best practice should look like. I sat on one such group for rheumatic fever.

Rheumatic fever (RF) is a disease now seen mainly in developing countries (apart, of course, from the poor pockets of New Zealand where it runs at near epidemic rates). If rheumatic fever is not caught early, it leads to rheumatic heart disease (RHD) that in turn leads to serious heart damage – the sort of damage that can see people die in their late 30s.

On this rheumatic fever clinical guidance group that I sat on, I heard a story about the antibiotics that are used to treat the disease. I heard that many of the kids with rheumatic fever live rurally and getting treatment to them is a challenge. I heard that the antibiotics needed to be kept at temperatures lower than a few degrees. I heard that these antibiotics are often driven around the dusty roads of rural New Zealand in the height of a Kiwi summer, eventually getting to families warm and possibly no longer effective. What I heard was that kids who needed the antibiotics the most were being let down by basic logistical stuff-ups.

Is this story representative? Are vulnerable low-income children missing out on antibiotics? And if children are already missing out on antibiotics when they need them in New Zealand, how will population-wide antibiotic resistance affect these children? Children who, coming from low income families, are already at greater risk of infectious disease than other children in New Zealand?

The story for low-income kids and antibiotics is complex & resistance is not going to make things better

Children living on low incomes in New Zealand have more infections (requiring antibiotic treatment) than other children. Rheumatic fever is one disease they contract at higher rates, especially as overcrowding and poor quality housing continues unabated in Auckland. But we also know from the Child and Youth Epidemiology Service, who reports on child health in New Zealand each year, that skin infections plague children from poorer communities. We also know that respiratory infections put them in hospital at a much greater rate than others. And when diseases like measles break out, they tend to do so in low-income communities, with the bulk of the health effects being felt by the children of low -income families. These are the children who need antibiotics and need them to work. Even with antibiotics, children are still dying in New Zealand from diseases of the third world.

Poor children need antibiotics more than other children, but are they getting them?

The situation is complex. We have data showing us that antibiotic prescribing in Counties Manukau in Auckland (a large low-income community) is greatest for those living in overcrowded households [1]. Overcrowding is one of the indicators of poverty in New Zealand.

Below we can see the relationship between antibiotic prescribing and overcrowded households in Counties Manukau. We see as the ratio goes up (representing more people in a bedroom) antibiotic scripts rise too. This finding is understandable in the context of how infectious diseases spread – through close contact with other infected people.

Antimicrobial scripts per capita versus people-bedroom ratio
Reproduced with permission.

But does the higher prescribing rate of antibiotics for the vulnerable mean all the children who need them are also getting them? A prescription for antibiotics is not a measure of antibiotics used. We can look at the dispensing of antibiotic use for some clues.

Researchers examined the dispensing of antibiotics (pharmacies filling a prescription) in another part of New Zealand. The town was a rural town at least an hour from other towns with a pharmacy. Researchers found that individuals living in lower income areas of that community were much less likely to be dispensed antibiotics.[2]

So we see that infections are higher for low-income children in New Zealand, and prescriptions may also be higher, but that actual use may be lower for this group.

Low-income children do have the worst access to healthcare in New Zealand

The data present a complex picture, but not one those working in health are unfamiliar with. It highlights what we see across all societies – those that need healthcare the most may be accessing it the least. We call it the inverse care law.

We can speculate based on this evidence what is happening with low-income children in New Zealand. It may be that children of low-income families are getting to the GP but not getting the antibiotics on board. It may be that even getting to the GP is such a challenge that low-income children are not being seen till very late – we certainly know that low-income children see medical professionals a lot later down the path of an infectious disease making treatment more difficult and spread and recurrence more likely.

It may be that low-income families cannot easily access the antibiotics even once they are prescribed. We know that in New Zealand the children who don’t get to the GP because they have no transport (a measure of material deprivation & poverty) are the children of low-income parents, as the data below demonstrates.

New Zealand children who did not visit a GP due to lack of transport at any point in the past 12 months

New Zealand has a government funded primary healthcare system, with free GP visits for children under 13 and low cost prescriptions. But in reality, there is an imbalance in who accesses this funded healthcare. It not just healthcare itself that costs families – the opportunities to access the care also costs: time off work; access to transport; being free of other health debts and social stigma; having someone who can care for any other children. These are all resources a parent needs to be able to draw upon to access healthcare for their child. In many cases, low-income families have fewer of all of these resources. While the data has gaps, it certainly indicates that there is likely to be a problem in terms of low-income children’s access to and use of antibiotics when they need them.

What happens when we add antibiotic resistance into the mix?

Nothing good. For children who need antibiotics the most, resistance has the most serious impact. For a group of children who are already disadvantaged by being poor, we have at least always had the hope that, if they can equitably access timely treatment, we can overcome some of the disadvantage they suffer. With resistance looming this will not be the case, and the children who will die at the greatest rate from what are now just everyday infections will of course be those already getting the worst deal from the imbalance in New Zealand society. But we can do something about this.

What can be done?

As always the ambulance parked at the bottom of the cliff will not assist us here. Research into antibiotic alternatives needs funding, and a huge reduction in unnecessary antibiotic use is needed (including in animals and farming).

However, there is something we can do right now for children living on low-incomes – we can correct the imbalance in their health outcomes through strong policy. Research tells us there are many effective ways to address this imbalance, and most of them lie outside of the control of the health workforce.

Bringing families with children up over the various poverty lines using unconditional cash assistance is an area that has significant potential to improve children’s health. Housing affordability, quality and access is another area with serious potential to improve low-income children’s health. The best evidence shows that improvements to the physical aspects of the home (e.g., ensuring it is the appropriate size for a family, it can affordably be kept warm, it is insulated and not damp) improves health (especially in those with existing respiratory illness), may improve and promote relationships in the family, and may reduce absences from school or work. The findings are especially applicable in low-income households where the need is greatest.[3]

The end of antibiotics as we know is upon us. However, in the time between their discovery and their demise, let us finally deliver for low-income children a good society, one that ensures we are all already in the same boat as we work to find solutions together.

References

[1] Walls, G., Vandal, A. C., du Plessis, T., Playle, V., & Holland, D. J. (2015). Socioeconomic factors correlating with community antimicrobial prescribing. NZ Med J, 128(1417), 16-23.

[2] Norris, Pauline, Gordon Becket, and Denise Ecke. “Demographic variation in the use of antibiotics in a New Zealand town.” The New Zealand Medical Journal (Online) 118.1211 (2005).

[3] Thomson H, Thomas S, Sellstrom E, Petticrew M. Housing improvements for health and associated socio-economic outcomes. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD008657. DOI: 10.1002/14651858.CD008657.pub2.


About

Dr Jess Berentson-Shaw works at the Morgan Foundation Policy Think Tank and writes about science, children and families at The Spinoff Parents. You can follow her on Twitter @DrJessBerentson


This article was originally published on Te Punaha Matatini as part of InfectedNZ – an online campaign to raise awareness about infectious diseases and antimicrobial resistance. Read the original article.