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1999 Health in Scotland

Meningococcal Infection

Following the annual increases in notified cases of meningococcal disease seen in Scotland since 1995 (Figure 2.12), the incidence rate in 1999 was virtually identical to that of 1998 for the first three quarters of the year, leading to hopes that incidence rates were levelling out. However, the major influenza outbreak in December 1999 was accompanied by a large and rapid increase in the number of cases of meningococcal infection, which resulted in 1999 having the highest annual total for 25 years.

Figure 2.12 Annual notifications of meningococcal infection, Scotland 1975-99

This late increase was also notable for the high proportion of infections due to Neisseria meningitidis Group B (Figure 2.13); Group C infections had been commoner in Scotland in 1998 and for most of 1999. One possible reason for this shift was the introduction in November 1999 of a phased programme of vaccination against Group C disease. The increase in cases overall was particularly marked in adults and contributed to the higher than expected mortality seen over the winter months. Influenza A outbreaks are known to be associated with increases in incidence of meningococcal infection, and the rise in meningococcal cases was subsequently confirmed to be transitory, as expected. The effect of the vaccination campaign on the overall epidemiology of meningococcal disease is still unclear, but the enhanced surveillance programme, Meningococcal Invasive Diseases Augmented Surveillance (MIDAS), implemented in November 1999 should help to provide early detailed information as the situation develops.

Figure 2.13 Percentage of typed meningococcal infection by Group, by quarter for 1999

The launch of the new conjugate vaccine against Group C meningococcal disease in November 1999 presented an opportunity to exploit and upgrade the existing enhanced surveillance system operated for many years jointly by the Scottish Meningococcal & Pneumococcal Reference Laboratory (SMPRL) and SCIEH. MIDAS collates information on vaccination status of cases and use of vaccine in contact management, in addition to details of disease presentation and outcome, laboratory tests, clustering of cases and demographic details.

Immunisation

Primary immunisation uptake rates in Scotland remain generally high, and continue to compare favourably with those for England, Wales, and Northern Ireland (Table 2.3). Rates vary between health boards, but in some areas, shortcomings in data collection may contribute to apparently low rates of vaccine uptake (Table 2.4).

Table 2.3 Primary immunisation uptake rates, United Kingdom, 1999*

Table 2.4 Primary immunisation uptake rates, by Health Board area, Scotland, 1999

Measles, mumps and rubella

The uptake of measles, mumps, and rubella (MMR) vaccine at 24 months remained the same for 1999 as for 1998. However, the higher rates of uptake in the latter half of 1999 may reflect increased public confidence (Figure 2.14). As MMR is offered at 12-15 months of age, children attaining their second birthday during the fourth quarter of 1999 would have been offered MMR during the period September 1998 to March 1999.

Figure 2.14 Vaccine uptake rates by age 24 months, Scotland by quarters, 1995-1999

Meningitis C immunisation programme

Approximately half of all cases of meningococcal infection in Scotland are caused by Group C organisms. Although a vaccine effective against Group C meningococci has been available for a number of years its value is limited, particularly because it does not produce an effective response in infants and very young children.

In October 1999 a new meningococcal C conjugate vaccine was licensed; clinical trials had shown this vaccine to be safe and effective in infants, children and young adults. Three doses of meningococcal C conjugate vaccine (MenC) at 2, 3 and 4 months of age were introduced into the UK immunisation schedule from the end of November 1999. At the same time a "catch up" programme was started with the aim of immunising all children and young adults under the age of 18 years (approximately one million individuals in Scotland) before the end of 2000.

As a high risk group, pupils in secondary school classes S4, S5 and S6 were the first to be targeted in November and December 1999. Pre-school children will be immunised by general practitioners in the first half of 2000 and children aged 5 to 14 years will be immunised in school from March 2000 onwards. Early indications are that uptake of vaccine has been high in all the groups targeted.

Scotland contributed to the introduction of MenC with field trials of the vaccine in toddlers in Fife, Tayside, Lanarkshire and Ayrshire, the study being co-ordinated by SCIEH. The effect of MenC introduction on meningococcal disease is now being closely monitored. The Chief Scientist Office is funding a consortium of SCIEH, Greater Glasgow Health Board and the Scottish Meningococcus and Pneumococcus Reference Laboratory to study the effects of MenC vaccine introduction upon the carriage of hypervirulent meningococci, as part of a larger UK study.

THE HEALTH OF CHILDREN AND YOUNG PEOPLE

As in 1998, a substantial part of this Annual Report is devoted to the health and welfare of children, reflecting the very high priority the Scottish Executive places on improved health for young people. A healthy, happy childhood is in itself an important goal. It is also increasingly recognised that our health as children has a profound effect on the frequency and severity of the diseases we experience in later life. Cardiovascular diseases, cancer, mental health, diabetes and obesity have all been related to the life circumstances and lifestyles we experience in childhood and in some cases to the circumstances pertaining before birth. Child health is not therefore simply important in its own right, it is also a substantial factor in the very poor health of Scotland's adults, particularly those from deprived backgrounds.

Recognising that the health of children is central to the future health and well-being, the White Paper Towards a Healthier Scotland identifies child health as a priority health topic. The extant Priorities and Planning Guidance for the NHS in Scotland requires Health Boards to include consideration of services for children in all aspects of health service planning. Children are not simply small adults but are constantly developing and reacting to the world around them. Child health and well-being is much more complex than simply physical health or experience of disease. Our whole life experiences are shaped by the circumstances in which we live as children.

The United Nations Convention on the Rights of the Child was ratified by the UK Government in 1991. It sets out the key principle that in all actions concerning children, the interests of the child shall be the paramount consideration. The Convention aims to;

• promote the health and well-being of children;
• provide services which meet their needs and take their views in consideration; and
• protect them from harm.

Health service activity to ensure child health consists principally of child health surveillance, health promotion, disease prevention and the diagnosis and management of illnesses. However, the greatest influence upon any child's well being is the circumstances in which they live and the relationships that they have with those around them. Particular attention needs to be given to families as the health and well-being of the family has a profound impact on the health and development of the child. The most effective mechanisms to promote and improve child health will often involve supporting parents, families and carers as well as paying attention to children themselves. The UK Government has recently announced its intention to eradicate child poverty within 20 years, an achievement that would have a huge impact on the health and well-being of Scotland's children and consequently on the future health and well-being of Scotland's adults.

Life circumstances

The most important objective in promoting health and well being of children and their families is to improve life circumstances. Towards a Healthier Scotland clearly sets out the Scottish Executive's commitment to address social deprivation and inequalities in health. The commitment to tackling social exclusion will particularly assist those families who are most in need.

Children are the first and most vulnerable victims of poverty, deprivation and social exclusion. There is growing recognition of the fact that the environment and experiences we encounter in childhood make the largest contributions and differences in our health as adults. As long ago as 1976 the Court Report stated that 'Children who grow up in poverty or in squalor, whose homes are grossly overcrowded, or who live in decaying inner city neighbourhoods, children who are neglected or handicapped, or who are discriminated against on grounds of race, language, colour or religion; children whose parents are sick or psychiatrically disordered, who quarrel incessantly or who are absent; such children are in different ways 'disadvantaged'. They face greater odds than other children, they are more likely to suffer from physical illness or psychiatric disorder, or to fail educationally or to drop out of school or be 'early leavers', more likely to truant or become delinquent, or to leave school for unemployment or poorly skilled jobs'.

Food and fuel poverty are real issues for many of Scotland's families. Housing issues relevant to health are also well known and include dampness, overcrowding, window and lift safety, asbestos, productive leisure and play facilities, and housing to meet special needs. Promoting the health and well-being of children and their families is therefore dependent upon a whole range of actions to tackle life circumstances and inequalities in health.

The importance of early childhood experiences

The early years of development from conception to age 6, and in particular the first 3 years, set the base for competence and coping skills that will affect learning, behaviour and health throughout life. We also know that the physical environment and nourishment of the fetus and of the young child profoundly affects the chances of developing particular diseases in adult life. It is important therefore that we consider child health interventions not just for young children but also for adults of reproductive age from preconception through pregnancy and throughout parenthood. It is of concern that children who do not receive the nutrition and stimulation necessary for good development in the earliest months and years of life will have great difficulty overcoming these deficits later.

Working together to improve child health

Promoting child health and well-being is about ensuring that every individual has the opportunity to reach his or her maximum potential. This requires a "joined up" multi-sectoral approach around the sort of framework promoted by the Ottawa charter for child health promotion. This sets out mechanisms to:

• develop personal skills;
• create supportive environments;
• strengthen community action;
• reorientate the health service;
• build healthy public policy;
• mobilise other sectors;
• address equity and health; and
• ensure that health services co-ordinate and guide multisectoral action.

The role of the health sector in improving child health

The NHS has an important opportunity to improve child health particularly in the early months and years, given that it is the main contact point for expectant parents, children under 18 months and their families. Other sectors, most notably education, play increasingly important roles as children move towards school age. Promoting multi-sector child and community health will be enhanced by the work of local healthcare co-operatives, by primary care and by health visitors. This is a significant focus in the ongoing review of the contribution of nurses to public health being conducted by the Chief Nursing Officer.

Child nutrition

Many Scottish children are still nutritionally disadvantaged from birth. Many are not breast fed, receive solid food in the appropriate form of cereal foods too early in life, are weaned on to an unhealthy diet, and establish a pattern of eating that is too high in fat, in refined extrinsic sugars and in sodium. The diet consumed by many Scottish children is also one that we would now expect to be conducive to the development of adult chronic disease and dental caries. Inappropriate eating habits are all too often established in early infancy and a dramatic change in population eating habits and public health strategy is needed.

There is enormous potential for health gain through improved nutrition, the promotion of breastfeeding and the introduction of an appropriate weaning diet. Nutrition is important because factors that reflect nutritional status in fetal life and infancy (eg. birth weight and infant growth rate) appear to be linked with adult health. Co-ordinated multi-level action as described in the 1996 Diet Action Plan for Scotland (Scotland's Health - A Challenge to Us All) is still required and the emphasis must be on access to affordable and nutritious food for all Scots, a particular issue for disadvantaged and rural communities. A number of innovative approaches to improving children's nutrition are currently being evaluated including breakfast bars in schools and food co-operatives.

Smoking in childhood and adolescence

No consideration of the promotion and protection of children's health is complete without discussion of the profound effects of maternal and paternal smoking habits. Maternal smoking during pregnancy is clearly related to the early delivery of infants of low birth weight. This increases the potential for adverse perinatal events and perinatal mortality. Smoking around infants is well known to significantly increase the chances of sudden infant death syndrome and passive smoking is an important contributor to childhood respiratory infections and the development of wheeze. In addition, the children of parents who smoke are more likely to go on to become smokers themselves in adulthood. Expectant parents are, however, often most receptive to the idea of stopping smoking for the benefit of their unborn child. It is important to harness this willingness by providing smoking cessation programmes for parents who wish to stop smoking.

The Health Education Board for Scotland and child health

Targeting the health of children and young people has always been a central activity of HEBS and this recognises that there can be both immediate and longer-term benefits. Much of the ongoing work of HEBS programmes is developed directly or indirectly to promote the health of children. Some of this work is described elsewhere in this report in the context of health promoting schools, new publications and initiatives. The section that follows provides information about HEBS activities that are specifically related to the health of children and young people.

The need to promote the mental well-being of children provided the impetus to develop Rosie's World, a video-based resource for teachers to use with primary school children. Confidence to Learn, produced in association with Lothian Health, was published as a training and development support for teachers. Promoting mental health has also been the focus for collaborative work (between HEBS, Community Learning Scotland's Health Issues Unit and Lanarkshire Health Board) in an initiative aimed at assessing the mental health information needs of young people. HEBS Cyberschool was launched in 1999 and gives secondary school pupils the opportunity to obtain health information in ways that are both accessible and fun. Other HEBS work included mounting a health-related screen saver competition for the HEBS Cyberschool and contributing to a UK-wide food hygiene pack for secondary school age children.

A major plank of HEBS work targeted at young people continues to be the innovative and highly visible Think About It television advertising campaign. The campaign involves showing a broad-based advertisement encouraging young people to consider the health implications of their actions, and is complemented by advertisements on specific topics. Existing materials on smoking and alcohol were shown during 1999 and new advertisements on drug misuse and sexual health were added to the portfolio.

For parents or carers of babies and children under 5, materials were developed on dental/oral health and breastfeeding, together with a revised edition of Ready, Steady Baby which provides information on development from pregnancy through to the toddler stage. A major new initiative was the production of educational materials to support the introduction of the new Meningococcal Group C vaccination programme. This included materials for both parents and health and education professionals. HEBS also held a seminar for health professionals on the findings and implications of research into the attitudes of parents to MMR immunisation.

The health behaviours of school-aged children

HEBS provides funding support for the Scottish component of the 'Health Behaviour in School-aged Children' survey (HBSC), which is supported by the World Health Organization and undertaken across Europe countries every four years. A comparative analysis of data from 1990 to 1998 was published during 1999, identifying trends in health-related behaviour as reported by the children themselves. The findings from the 1998 survey refer to 2091 Scottish pupils with a mean age of 11.6 years. They are compared with the results of the HBSC survey findings of 1990 or 1994 in 11 year olds, and can be used to identify areas for future health promotion action on smoking, alcohol, healthy eating and physical activity.

The following key findings relating to children in primary 7 (P7), point up areas in which there is scope for improvement, areas of little change and others in which progress is being made.

Scope for improvement - areas showing a significant increase in the proportion of:

• girls who report having ever smoked (12.4% to 18.6%);
• boys and girls who report ever having tasted an alcoholic drink (boys: 79.8% to 84.2%; girls: 69.6% to 80.4%);
• boys and girls who report drinking alcohol at least once a week (boys: 7.2% to 11.2%; girls: 3.0% to 5.7%);
• boys and girls who report daily consumption of chips (boys: 31.8% to 46.7%; girls: 27.8% to 38.8%) and sweets (boys: 67.2% to 74.8%; girls: 61.2% to 71.5%);
• boys who report daily consumption of hamburgers/meat pies/sausages (17.7% to 29.0%).

Little change - areas showing no significant change in the proportion of:

• boys and girls who report daily consumption of cooked vegetables (in 1998, boys: 41.6% and girls: 48.5%) and fish (in 1998, boys: 15.9% and girls: 9.8%);
• boys and girls who report daily consumption of crisps (in 1998, boys: 74.1% and girls: 74.2%) and sugary fizzy drinks (in 1998, boys: 65.1% and girls: 60.5%);

Progress - areas showing:

• a significant increase in the proportion of boys and girls who report daily consumption of fruit (boys: 55.0% to 69.2%; girls: 63.6% to 74.7%), vegetables and salads (boys: 16.5% to 29.5%; girls: 22.4% to 38.5%), low fat milk (boys: 41.7% to 54.7%; girls: 37.9% to 51.2%), and pasta or rice (boys: 15.9% to 22.3%; girls: 13.4% to 24.2%)
• a significant increase in the proportion of boys and girls who report that they exercise four or more hours a week in their free time (boys: 24.6% to 42.9%; girls: 17.6% to 26.5%)
• a significant decrease in the proportion of boys and girls who report that they exercise less than two hours a week in their free time (boys: 52.3% to 31.3%; girls: 60.9% to 46.7%)

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