Health in Scotland 2009 Time for Change

Annual Report of the Chief MediCal OffiCer

health in SCOtland 2009 time foR []ChanGe

Annual Report of the Chief Medical Officer

health in land Sco t

ISBN: 978-0-7559-9789-3 (web only)

This document is also available on the Scottish Government website: www.scotland.gov.uk

The Scottish Government St Andrew’s House Edinburgh EH1 3DG

APS Group Scotland DPPAS10144 (11/10) v contents 01 17 32 INTroDuCTIoN CHAPTEr 2 CHAPTEr 5 Scotland’s health – time for a change Work and health An outbreak of anthrax infection in drug users in Scotland Role for employers 18

02 the scottish Public sector 19 36 CHAPTEr 1 Impact of the recession 20 Trends in life expectancy Implications for healthcare services 20 CHAPTEr 6 and the continuing widening Welfare benefits 21 Significant trends in the incidence of the of health inequalities communicable diseases of public health An ageing workforce 22 importance in 2009 step changes in health status 05 the next generation 22 Achieving a step change 06 Gastro-intestinal and foodborne infections 36

What is salutogenesis? 06 23 Bloodborne virus and sexually transmitted infections 37 What would a “salutogenic” approach CHAPTEr 3 Healthcare associated infections 37 to health look like? 07 Scotland and problem drug use Vaccine preventable diseases 38 Asset based health improvement in action 09 A person’s journey 24 tuberculosis 39 Healthy Living centres 11 shared care 25 conclusion 40 Achieving a step change in health 15 An evolving healthcare problem 26 41 27 rEfErENCES CHAPTEr 4 Influenza A (H1N1) The Pandemic 2009

health in scotland 2009 contents 01

In last year’s Annual Report, I indicated that, men and 1.1 years for women while men and IntRoDUctIon although life expectancy (Le) has continued to women in the rest of scotland have seen improve in scotland, other western european increases in HLe of 2.9 and 2.3 years Scotland’s health – countries have experienced faster increases in respectively. the pattern of slow improvements the health of their populations. Most of our in health status in poor areas of scotland with time for a change closest european neighbours are reporting the wealthier improving faster, mirrors longer life expectancy at birth for both men and scotland’s international position. countries in women than in scotland. However, wealthier Western europe with higher life expectancies scots continue to experience a faster growth in than ours are often improving at a faster rate. life expectancy than their neighbours in poorer Unless scotland accelerates gains in life areas and in the past year, these trends have expectancy, particularly amongst the poorest continued. since 1999, life expectancy in males communities, it will continue to fall behind living in the poorest 15% of areas in scotland other countries. Many of the policies and has increased by 1.4 years while life projects currently underway have been expectancy for males living in the rest of designed to produce a change in approach and scotland has increased by 2.1 years. the to accelerate improvements. However, we need corresponding figures for females are 1.2 years to do more. At a time of economic uncertainty, for those living in the poorest areas and threats to the health of disadvantaged 1.6 years for the rest of scotland. individuals increase and, if scotland is to continue to progress and to do so at accelerated the widening gap is even more apparent when pace, new approaches to health creation need considering healthy life expectancy - the length to be considered. of time an individual might expect to live in good health. since 1999, residents of the DR Harry Burns poorest 15% of areas have seen a gain in The Chief Medical Officer for Scotland healthy life expectancy (HLe) of 2.1 years for

health in scotland 2009 Scotland’s Health – time for change 02

Figure 1 updates the trends identified in last wellbeing with residents of the more affluent cHAPteR 1 year’s report. there is a continued slight areas pulling away inexorably from their narrowing in the gap between men and women poorer neighbours. At present, scotland has the Trends in life in terms of life expectancy but, overall the lowest life expectancy of all Western european trend is disappointingly stable. countries. We sit between the countries of West and east europe (Figure 3). there is, however, expectancy and the Figure 2 is a statistical projection of the rate of evidence that some areas of eastern europe growth in Le in scotland for the next 2 decades. are achieving the kind of step change in health continuing widening It is likely that this average rate of growth will that seems likely to allow them to overtake continue to mask a widening difference in of health inequalities scotland in the coming years.

Figure 2: expectation of life at birth, Scotland, 1981-2033 Figure1: life expectancy and healthy life expectancy at birth, 1980 to 2008 85 90 Projected1 85

80 80

75 75

70 Age

70 65 LE/HLE in Years

60 65

60 50 1983 1988 1993 1998 2003 2008 2013 2018 2023 2028 2033 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Year 12008-based projections Males Females Men LE Men HLE Women LE Women HLE

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 03

there have been numerous initiatives over highest in Western europe, the male rate women) and breast cancer mortality, the past decades which have had positive has reduced considerably since the mid although still relatively high, have been effects on health in scotland and there have 1970s and is gradually moving closer to the falling and appear to be converging towards been significant reductions in mortality average for Western europe. this the Western european mean. Rates of from many of the most significant causes of encouraging trend is, in large part, a stomach cancer and pancreatic cancer death. the scottish Public Health reflection of the success of scotland’s mortality are close to Western european observatory monitors these trends. In a efforts to reduce smoking rates. Rates of average. report comparing scotland with other colorectal cancer mortality (for men and countries in europe, the scottish Public Health observatory concluded that, over Figure 3: life expectancy at birth, 2007, selected countries, males 90 the last 50 years, mortality from all causes has fallen in scotland in line with trends 80 across the rest of Western europe (scotPHo 70 2009). However, while mortality rates for scottish children are close to the Western 60 european average, mortality among 50 working age scots, both men and women, is the highest in Western europe and has been 40 since the late 1970s (Leon et al 2003). 30 scotland’s poor health is at its most obvious amongst working age men and women. 20 Life expectancy (years) trends in mortality amongst working age 10 adults (15-74 years) varied considerably when different causes of death were 0 Italy

considered. For example, scotland now has Spain Malta Latvia France Greece Poland Cyprus Ireland Austria Estonia Finland EU - 27 Sweden Belgium Bulgaria Portugal Slovakia Slovenia Hungary Romania Germany Denmark the highest rates of oesophageal cancer in Lithuania SCOTLAND Netherlands Western europe for both men and women. Luxembourg Czech Republic United Kingdom However, while, lung cancer mortality rates Country for men and women remain among the Source Eurostat and the Office for National Statistics (ONS)

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 04

there have been significant reductions in mortality rate for suicide is now twice the mortality from ischemic heart disease and level it was in 1955. one encouraging cerebrovascular disease for both men and observation is the fact that, mortality from women over the last half-century. Despite road accidents in scotland has declined this, mortality rates in scotland from both since the mid-1970s and scottish death causes remain among the highest in rates are now lower than in the majority of Western europe. However, there are signs Western european countries. (scottish that the gap between scottish mortality mortality in a european context 1950–2000 rates and the Western european average is An analysis of comparative mortality narrowing. Again, these encouraging trends trends. http://www.scotpho.org.uk) reflect, in part, the success of smoking there are, therefore, encouraging trends in cessation programmes as well as significant the reducing incidence of premature deaths improvements in treatment offered by the from a number of causes. Many of the nHs. Mortality rates from chronic conditions that are falling in incidence have obstructive pulmonary diseases such as been the subject of considerable effort on chronic bronchitis are among the highest in behalf of successive governments and the Western europe, although mortality for public health community within the nHs males has fallen considerably since the and local government over many years. 1960s. this observation suggests that organised Most worryingly, scottish mortality rates efforts to improve health in scotland have from chronic liver diseases such as those had a significant impact. However, there is caused by excess alcohol consumption have evidence that other regions of europe have risen steeply since the early 1990s among made a more rapid change – a step change – in men and women. Rates of mortality from health status. the rate of improvement in liver disease for scottish men and women these regions, which seem to be similar in are now the highest (or close to the highest) their socio-economic conditions to deprived in Western europe. the need for action to areas of scotland, has increased reduce alcohol consumption is pressing. dramatically. Unless scotland learns from these regions, it seems likely that we will suicide mortality among adult men in miss an opportunity to make our own step scotland has risen since 1975 and the male change in health. health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 05

Step changes in health status expectancy has been improving much faster expectancy among female residents of in the Polish region of Katowice than in Katowice is now greater than those living in Figure 4 is a comparison of trends in life scotland. the 4 year gap between the West of scotland, whereas in the 1980s expectancy in 20 regions in the UK and Katowice’s and the West of scotland’s male it was two years lower. similar mainland europe which have suffered life expectancy that was seen in the mid- accelerations in health status have been similar levels of deindustrialisation in the 1980s had been halved by 2003/05. If observed in other eastern european regions latter half of the 20th century. Walsh and current trends continue, male life following the emergence of democracy in his colleagues from the Glasgow centre for expectancy in Katowice will overtake that these countries. there appears to be a Population Health have shown that in some of the West of scotland in the near future. resilience in these populations which has regions of europe life expectancy is Indeed, among females this has already allowed them to benefit in health terms improving rapidly in some regions (Walsh happened: Figure 5 shows that life from changed socio-political circumstances. et al 2008). As Figure 4 shows, life

Figure 4: estimates of male life expectancy at birth: Katowice compared to Scotland, West of Scotland and GGC, Figure 5: estimates of female life expectancy at birth: Katowice compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages) 1982-2005 (3-year averages) 80 80 79 78 79 77 76 78 75 74 77 73 72 76 71 70 75 69 68 74 67 66 Life expectency at birth expectency Life Life expectency at birth expectency Life 73 65 64 72 63 62 71 61 60 70

1975-19771976-19781977-19791978-19801979-19811980-19821981-19831982-19841983-19851984-19861985-19871986-19881987-19891988-19901989-19911990-19921991-19931992-19941993-19951994-19961995-19971996-19981997-19991998-20001999-20012000-20022001-20032002-20042003-2005

Katowice GGC WoS Scotland Katowice GGC WoS Scotland

Source: Calculated from data from GRO(S) (Scotland) and Cancer Center & Institute of Oncology, Warsaw Source: Calculated from data from GRO(S) (Scotland) and Cancer Center & Institute of Oncology, Warsaw

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 06

Achieving a step change approach is robust and scotland may well In essence, a person with a well developed benefit from a closer look at the concept. soc when confronted by everyday stresses Albert einstein is said to have defined will: insanity as “Doing the same thing over and What is salutogenesis? over again and expecting different results”. • be motivated to cope (find life Herculean efforts to improve health and Basically, salutogenesis is a term first used meaningful); expenditure of significant resources has, by the American sociologist Aaron • believe that he has the capacity to over the past decades produced steady Antonovsky (1979). After a lifetime of understand the challenges of everyday improvements in health which has been study in many different cultures, he undermined by our failure to accelerate the suggested that individuals, throughout life, life (find life comprehensible); health status of those at the lower end of develop a set of resources which allow • believe that resources to cope are the socio-economic spectrum. If we are to them to make sense of the stresses they available (find life manageable). produce such an acceleration, perhaps we encounter in daily life so that, as he put it Failure to manage a difficult environment need to consider the methods we have himself, “the stimuli bombarding one from effectively, Antonovsky argues, will cause been using to improve health. Perhaps it is the inner and outer environments were the individual to be chronically stressed time for a change. perceived as information rather than as and, over a long period, impair his or her noise”. He termed the ability to make sense In last year’s report, I discussed the concept physical and mental health. of and understand the external world as a of salutogenesis, the art and science of “sense of coherence”. He defined it as the scientific evidence for chronically raised creating health. I argued that, by quality which: stress associated with deprived socio- concentrating too strongly on the treatment economic circumstances is now robust. of disease, we might be missing an “... expresses the extent to which one has a Antonovsky’s concept of creating health opportunity to build health more feeling of confidence that the stimuli through supporting individuals to effectively. there has been a growing deriving from one’s internal and external understand their social environment and to international interest in the past year in environments in the course of living are take control of it seems an important salutogenesis and its potential implications structured, predictable and explicable, that mechanism for reducing stress. It may be for health improvement. A number of one has the internal resources to meet the that an important element of attempts to regions in europe are now exploring the demands posed by these stimuli and, finally, improve scotland’s health should involve possible policies which might support that these demands are seen as challenges, developing methods to increase resilience effective creation of health and reorientate worthy of investment and engagement.” in our young people and supporting adults thinking away from a focus on disease who lack the incentives to engage with prevention. the scientific basis for this health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 07

their social environment to do so. Perhaps What would a salutogenic In contrast, asset models tend to accentuate the time has come to debate whether our approach to health look like? positive capability within individuals and approach to health improvement might support them to identify problems and Morgan and Ziglio (2007) have pointed out produce the necessary step change in activate their own solutions to problems that approaches to the promotion of health creation which scotland needs to which they themselves identify. they focus population health have been based on a accelerate gains in healthy life expectancy. on promoting health generating resources deficit model. that is, they tend to focus on that promote the self esteem and coping identifying the problems and needs of abilities of individuals and communities, populations. the organisational response to eventually leading to less dependency on these problems is to provide professional professional services. In effect, by resources and interventions which produce concentrating on the strengths of high levels of dependence on hospital and individuals and communities, their sense of welfare services. We do things to people control over their lives is enhanced and rather than doing things with them. We they experience less of the chronic stress reinforce their dependency and encourage which leads to a range of health passivity in the face of problems. consequences. these deficit models are important and Much of the evidence available to policy necessary to identify levels of needs and makers to inform decisions about the most priorities. But they need to be effective approaches to promoting health complemented by some other approaches and to tackling health inequities is based on as they have many adverse consequences. a deficit model and this has, inevitably, Deficit models tend to define communities produced policies and practices which and individuals in negative terms, disempower the populations and disregarding what is positive. Deficit communities which are supposed to benefit approaches miss opportunities to allow from them. An assets approach to health individuals and communities to react and development embraces a positive positively to the problems they encounter. notion of health creation and in doing so Instead of taking control, they are encourages the full participation of local encouraged to remain passive as others try communities in the health development to do things for them. process.

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 08

Morgan, Davies and Ziglio (2010) have alienated by society. In some intellectual say it was the sole reason for these things. developed this argument into one which circles it is treated almost as a new But it is a much greater factor in all of may offer a more resourceful approach to phenomenon. It has, however, been with us them than is generally recognised.” tackling health inequities. they suggest that for years. What I believe is true is that Inadvertently, in seeking to improve the lot by developing the stock of key assets today it is more widespread, more pervasive of the most disadvantaged members of our necessary for promoting health within than ever before. Let me right at the outset society, we may have made them more, individuals it should be possible to restore define what I mean by alienation. It is the rather than less alienated by doing things the balance between the assets and deficit cry of men who feel themselves the victims to them rather than with them. models for improving health of individuals of blind economic forces beyond their and communities. By developing assets control. It’s the frustration of ordinary which support health in individuals rather people excluded from the processes of than by doing things to them, thereby decision making; the feeling of despair and undermining a sense of control and self hopelessness that pervades people who feel esteem, it becomes more likely that a with justification that they have no real say positive attitude to health and wellbeing in shaping or determining their own would be created. Failing to develop the destinies. assets which allow individuals to be Many may not have rationalised it, may not resilient in the face of the various even understand, may not be able to circumstances which damage their health articulate it. But they feel it. It therefore may well be the factor which has limited conditions and colours their social attitudes. the effectiveness of many well intentioned Alienation expresses itself in different ways health improvement programmes in by different people. It is to be found in what scotland during the past decades. our courts often describe as the criminal the late Jimmy Reid described the problem anti-social behaviour of a section of the with great perception and eloquence in the community. It is expressed by those young speech he gave when installed as Rector of people who want to opt out of society, by Glasgow University in 1971: drop outs, the so-called maladjusted, those who seek to escape permanently from the “Alienation is the precise and correctly reality of society through intoxicants and applied word for describing the major social narcotics. Of course it would be wrong to problem in Britain today. People feel health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 09

Asset based health improvement in drug dealing and intimidation were action commonplace. there are many examples of interventions By 1985, quality of life in the area was which have been successful in improving plummeting. “It had the reputation of being wellbeing but which have, usually a ‘no go area’ for the police, crime and inadvertently, done so through developing vandalism were spiralling out of control, assets rather that filling perceived deficits. and the community had become more or one well known example comes from south less completely dissociated from the West england. statutory agencies.” (Durie et al) two local health visitors, Hazel stuteley Beacon and old Hill and Philip trenoweth are credited with When one thinks of cornwall, one usually beginning the regeneration of the area after has a mental image of beautiful countryside, a particularly disturbing series of events. In thatched cottages and afternoon teas. Yet, in the Health Visitors’ own words: the mid 1990s, cornwall housed one of the “The flashpoint came simultaneously for us most deprived council estates in Britain. both, literally in Rebecca’s case, when she Penwerris, the electoral ward comprising the witnessed the family car ignite following the Beacon and old Hill estates which had a planting of an incendiary device. She was population of 6000, had, according to a 11 years old then and although physically University of Bristol report, the largest unhurt, she was deeply traumatised by this. percentage in cornwall of children in Already in mourning for her friends’ pet households with no wage earners, the rabbit and tortoise, which had recently been second highest number of children living butchered by thugs from the estate, this was with lone parents. Unemployment rates on the final straw. the estates were 30% above the national As family Health Visitor for the past 5 years, average, child protection registrations were I was a regular visitor to her home. Her high, postnatal depression afflicted a Mum was a frequent victim of domestic significant number of mothers, domestic violence and severely post-natally depressed. violence was common and violent crime, My caseload had many similar families with

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 10

multiple health and social problems. Seeing that they mattered to others. social the story of Beacon and old Hill is one of a Rebecca and her family’s deep distress, I networks developed and problems became few individuals being motivated by the vowed then and there that change must shared. Importantly, solutions emerged failure of conventional approaches to a happen if this community was to survive. I from these interactions between people problem to try something different. In had been watching it spiral out of control for who had previously been alienated from listening rather than lecturing, they heard long enough.” each other. the members of the community outline solutions to their difficulties. Finally, they thereafter, the two health visitors “The most significant aspect of the were confident enough to allow solutions to embarked on a series of meetings in which regeneration process on the Beacon and Old emerge organically rather than through a they tried to engage statutory agencies Hill estate was that, from the outset, there conventional project planning approach with members of the community. of note was no initial funding, no hierarchy, no which relies on the outcome being was the fact that many individuals they targets, no business plan, only a shared predetermined. In effect, leadership in this thought would want to be involved in vision of what the community wanted to be, case did not involve taking a community in turning the area around refused to become rather than an obsession with what it had a predetermined direction, but rather involved and many of the public meetings to do. Thus, the regeneration process was held to encourage dialogue were described not a result of a predetermined plan. as ‘stormy’. What is apparent from the Rather, the process emerged as a descriptions of the process is that the consequence of the interactions between the people were listened to. the residents members of the community, and between identified the problems they were most the community and its environment, namely concerned about and statutory agencies the statutory agencies, the police, the engaged with the community in designing a council, and so forth. As the community response. Residents became co producers of evolved, so also the agencies and solutions rather that passive recipients of professional bodies co-evolved with the actions others had determined would be community.” (Durie et al) good for them. this was, in my view, a critical part of the process. People learned that expressing their concerns was not a waste of time. they learned their opinions had value and

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involved helping individuals discover their promotion activities, women and men should own direction by awakening within become equal partners. themselves the capacity to take control of the founding principles of health promotion their lives. they had used an asset model have included the ideas of enhancing rather than focussing on the deficiencies in control over life circumstances and the lives of the community. ensuring that citizens are equal partners in the asset model is not new. In 1986, the creating better lives from themselves. World Health organization held the First these principles are in use in many International conference on Health programmes across scotland. But, often, Promotion in ottawa. the conference they are most evident in small projects and culminated in the presentation of a charter it is not explicitly recognised that the which identified action necessary to project is developing assets in the achieve health for all by the year 2000. community rather than trying to fill deficits. Among the elements of the charter, it Among the many programmes and activities includes the following statements: which seem to focus on developing assets “Health promotion is the process of enabling is the work carried out in scotland’s people to increase control over, and to Health is created and lived by people within Healthy Living centres. improve their health. To reach a state of the settings of their everyday life; where complete physical, mental and social well- they learn, work, play and love. Health is Healthy Living Centres created by caring for oneself and others, by being, an individual or group must be able to Healthy Living centres (HLcs) aim to be at being able to take decisions and have control identify and to realize aspirations, to satisfy the heart of their communities. Around 200 over one’s life circumstances, and by needs, and to change or cope with the development staff and over 1200 ensuring that the society one lives in creates environment. Health is, therefore, seen as a volunteers in 26 HLcs engage with over conditions that allow the attainment of resource for everyday life, not the objective 130,000 local people every year. Around health by all its members. Caring, holism and of living. Health is a positive concept 250 local people are actively engaged in ecology are essential issues in developing emphasizing social and personal resources, the management and operation of HLcs strategies for health promotion. Therefore, as well as physical capacities. Therefore, through their voluntary participation as those involved should take as a guiding health promotion is not just the Board members. For every £1 of principle that, in each phase of planning, responsibility of the health sector, but goes Government and local authority support, beyond healthy life-styles to well-being. implementation and evaluation of health health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 12

HLcs have estimated that they bring a and enthusiasm of very young children to further £3 into their communities. HLcs try learn skills which are normally associated to make a difference because they take with adults is obvious. Moreover, it is local time, build trust and network, inspire adult volunteers who are involved in ambition, give hope and help individuals to camglen Radio who pass on and teach feel good about themselves, their families, those skills. Also demonstrated in this neighbours and communities and do well as example are the benefits of having the a result. Being positive and optimistic, appropriate and community-managed sometimes in the face of major difficulties resource of a well-equipped radio studio, and challenges is how HLcs work with their which encourages so many sections of the communities. Being responsive, flexible, community to engage with the project. this innovative and on occasion radical is how activity is in its third year. HLcs support individuals and communities A One-Stop Shop for Parents is organised to build resilience and confidence in weekly in community venues. It builds on themselves and in the future. this is the connections between various local particularly evident in the ways in which agencies who ‘set out their stall’ in an communities use their resources to invest informal setting which encourages parents in the health and wellbeing of their to generate their own ideas and sparks youngest members and their families. interest in other aspects of healthier living. these examples from HLcs reflect the The Chill Out Zone and Young People’s variety of ways in which they work: Forum is organised and managed in ways Camglen Community Radio Nursery Shows that redress the feeling that many young involve 3 and 4 year olds in producing people have that choices are made for radio shows which are broadcast live on them. some young people feel they have local radio organised by the HLc. this little control over their situation. the Forum activity demonstrates the willingness of puts young people in the driving seat. the local organisations and families to be discussions they have and the decisions involved in community activity. the ability they make shape and influence the services

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 13

they are actually using. no difficult subjects about mental health. over 3 months, more range of skills-based courses including are swept under the carpet. It makes sense than 400 people were engaged in creating Baby Massage and Baby Yoga, and a that they take it seriously. canvas art that expressed their thoughts relevant knowledge-base around stress and feelings about mental health. the HLc management, healthy eating, coping on a The Grassroots Programme engages and worked with existing groups in nurseries as budget and so on. this programme is a empowers local people to lead and develop well as other age groups and sections of the success largely due to the local volunteer- an infant and maternal health programme. community, and set up stalls in public areas run Fruit Barra which has been established Forty-six local volunteers deliver and to engage with families and general by the HLc in the community at various develop the programme. the volunteers’ population. the resulting art work is venues over nearly 16 years. the training gives both the local people on the exhibited as part of scotland’s Mental volunteers are all members of the local programme and the volunteers the Health Arts and Film Festival. Many community and have local knowledge and confidence and skills to take control over participants enjoyed the opportunity to personal experience which is shared with the decisions they make. the improved express their thoughts and feelings, and for the pregnant women in an informal manner social networks mean that both volunteers others it took courage to do so. Families while they are collecting their fruit and and young mums are much more involved with young children were able to explore a vegetables. this complements and in their own communities. sometimes difficult issue in a safe supplements the clinical service provided Parent Councils in nurseries are an environment using a fun medium. canvases by the nHs, and helps mums who may feel important community asset which has been by young children were exhibited and isolated to recognise and access the range engaged by an HLc through identifying valued alongside those painted by others, of networks and support available around parents on each Parent council who have including adult artists. It demonstrates the them. volunteered to be a ‘health link’ to the HLc. ability of the youngest members of our these projects build community networks the two way flow of information and community to participate, share and shape and enhance trust within communities. they mutual support in this new network and the the knowledge and attitudes of the try to help people enhance their skills for confidence it has given the parents to community as a whole. managing their lives and their work is suggest new health improvement activities Healthy Mums Programme works with shaped by dialogue with those involved in and seek support for them is making a women from 12 weeks of pregnancy their activities. significant contribution to the wellbeing of through 2 years post-birth. the core the children and their families. Another project which seeks to develop activity is the provision of free fruit and assets in those involved in it is a small, Mind Yer Heid is an anti-stigma activity vegetables. Additionally, mums can access a independent theatre company based in which engages the community in dialogue

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Glasgow. theatre neMo works to promote which will improve motivation to take up other We were surprised when they invited us to good mental health and wellbeing through social or education opportunities. They lead on consultation for the East End Local the creative arts by engaging and encourage interaction within the community Development Strategy (EELDS). They asked us supporting vulnerable individuals within and support recovery. Being involved and to assist in designing the process of the community, psychiatric hospitals and taking part in our performances and talks community engagement and associated events. prison. clients in the main are those from which we take out to the community and to We became facilitators in the process, active areas of high deprivation, where instances policy makers has helped give people a better members, making decisions. For us this was of mental ill health are more prevalent, and understanding of social and mental health utterly empowering. Throughout the experience who have difficulty accessing mainline issues. We break down some of the taboos, we were introduced to new ideas about health services. the founder of theatre neMo barriers and fears which surround people in and planning. Not only did this experience describes the work of the group in these difficult situations.” encourage us to explore the effects of the terms: living environment on our own individual lives, one of the most economically deprived but we began to consider the wider effects on “Our aim is to break down stigma and isolation communities in the UK also has one of the the community as a whole. With growing and to provide opportunities to explore lowest life expectancies. Yet, through knowledge and understanding we began to individuals’ potential to achieve a better life: effective community engagement, people in ask questions, challenge opinions and Bridgeton have developed great insight into We believe that Theatre Nemo is unique in prejudices and we considered how we could the processes likely to enhance their health Scotland in the inclusive nature of its work with influence regeneration in ways that would lead and wellbeing. they provided the following vulnerable people. Other groups work in the to positive change for our communities. mental health field but rarely offer the diverse thoughts on health improvement for this If we had been asked, just a year before, what activities that really engage hard to reach report: the social determinants of health were, we people. One of our strengths is that we really “Typically, consultation with our community would have assumed the questioner was from motivate people and have great attendance has always been carried out by men wearing another planet! However, during 2008, after records. Very seldom does anyone drop out of a suits and carrying clipboards. Our negative the EELDS was published we were invited by project. perceptions of the process were severely the National Social Marketing Centre in challenged when we met the North East These projects help people who have lost skills London to make a film of our involvement in Neighbourhoods Planning Team from Glasgow through life events to re-connect with their planning for health as an example of best City Council. They came to us with innovative community, increase confidence. They encourage practice for the rest of the UK! ideas about meaningful consultation instead of people to believe in themselves, develop new the tokenistic process we had come to expect. skills, developing a ‘want to learn’ attitude

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 15

At the conclusion of the EELDS, we became turn improves our wellbeing. We believe in Achieving a step change in health more involved in regeneration through that. Now we need to help others believe it I have argued that we need to develop an volunteering, study and even employment. too. We are not apathetic people, to blame for approach to health improvement which Several of us gained degrees in Community our environment. We are community assets, does more to unlock the assets within Development. This was a journey some of us able to contribute to the improvement of individuals which create a sense of control were making anyway. However, our ourselves and our areas. If we are to be and wellbeing. experience shows that involvement in EELDS gave us a new labelled, lets label ourselves with positive creating momentum behind such a perspective, better vision and growing words such as contributors, assets, useful movement takes time. to achieve a real knowledge which held us on this pathway and worthwhile, giving, involved, able and, of change in health status, it will probably be opened it up to others. course, HEALTHY!!! necessary to combine a salutogenic We are now actively involved with the Clyde We are no different from those in more approach with a targeted programme of Gateway Urban Regeneration Company and affluent areas, we just swim in a rougher part interventions provided by statutory have had the opportunity to see our work of the river.” agencies. these interventions would be influence new projects and ideas. As aimed at ensuring that people who our confidence and abilities have Figure 6: infant mortality in Scotland compared to want to improve their health have the grown, so, too, have our relationships Scandinavian countries 4.5 necessary opportunity to do so. with the very professionals we Figure 6 compares infant mortality in previously eyed with suspicion. We are 4.0 scotland with infant mortality in now involved in the Equally Well 3.5 scandinavian countries. Although project to help develop a community 3.0 scotland has, by a narrow margin, the version of Healthy Sustainable 2.5 lowest infant mortality amongst the Neighbourhoods Model and we are UK countries, it still has a higher developing new ideas for involving 2.0 mortality than any of its scandinavian people in other projects. 1.5 neighbours. Our communities are our homes, lives 1.0 and everything we are. If we 0.5 concentrate on the problems, we’ll per 1000 births infant rate, mortality 0.0 create them. If we visualise and focus on how our environment can be, then Iceland Sweden Finland Norway we create a healthier mindset which in Denmark Scotland health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 16

the significantly lower mortality in some of the nordic countries has been achieved by a series of actions which have caused a rapid decline in the rate of deaths in the first year of life. A rapid reduction in infant mortality might be achieved by a number of interventions. early access to antenatal care, stopping smoking or consuming alcohol during pregnancy, breastfeeding after birth and support for mothers who struggle to look Figure 7: smoking rates – a step change in NE England after their children will all contribute to 30% lower infant mortality. consistent 29% 29% application of evidence-based interventions for every child in every family would have 28% a significant impact on infant mortality. 27% Another example of a step change is the 26% decline in smoking in the north east region 25% of england. Between 2004 and 2008, 25% smoking rates in scotland fell by 1% and in 24% 24% england by 4%. In ne england, it fell by 8%, 24% 24% overtaking the scottish incidence. (Figure 7) this fall in smoking rate has been achieved 22% 22% by a consistent and comprehensive 22% application of appropriate interventions. 21% Basically, north east Regions has achieved 21% 20% these results because it has tried harder to 2004 2005 2006 2007 2008 do the right thing.

North East England Scotland

health in scotland 2009 chapter 1 – trends in life expectancy and the continuing widening of health inequalities 17

Most people in scotland who wish to work, However, we recognise that it is important cHAPteR 2 whether in a paid or unpaid capacity, are to ensure that those in work are protected able to do so. this contributes significantly from harm in the workplace and are Work and health to maintaining and improving health in all encouraged and supported to improve their our communities. Good employment is health and wellbeing. It has been estimated protective of health, whereas that ill health in the working age population unemployment contributes to poorer of Great Britain costs the economy around long-term health outcomes. £100 billion every year (Black 2007). this means that there are important roles for Good work, and indeed any meaningful employers, employees, health and safety activity (this could be, for example, enforcement agencies, trades unions, and volunteering or unpaid caring healthcare and employment service responsibilities), engenders a sense of providers. coherence in life, meeting important psycho social needs in a society where employment is the norm, helping to define an individual’s identity, social role and social status. However, jobs that are insecure, low-paid and that fail to protect employers from stress and danger make people ill (Marmot 2010). Fortunately, even in the current economic climate, the majority of people of working age in scotland are in paid employment and are able to undertake their work in a safe and healthy environment. consequently, most of these people will gain a benefit to their long term health outcomes from this work.

health in scotland 2009 chapter 2 – work and health 18

Role for employers encouraging healthier lifestyles. Many larger organisations offer on-site gyms or As noted above, by providing work, subsidised gym membership, healthy employers across all sectors make a choices in canteens, health checks or valuable contribution to improving and smoking cessation advice, for example. promoting health and wellbeing. employers other measures can include safe cycle have statutory duties in respect of storage, showers and lockers to encourage workplace health and safety, and, overall, running or cycling. we have a good record in scotland in minimising work-related fatalities and employers who create a positive work serious injuries. It is important that we environment and culture, and undertake continue to maintain systems in scotland activities that promote employee health do that support employers to keep their so, not for altruistic reasons, but because workforces safe and healthy, and that can they recognise the benefits that it brings identify and work with those industries for the organisation. Workers who have where there is highest risk to workers’ better health and wellbeing are more safety. motivated and productive, they take fewer days off sick and are more likely to remain Flexible working that allows employees to with the organisation (PWc 2007). All of fit their work around family care this adds to the bottom line for the requirements is highly valued by workers. employers and employees in scotland from employer. the employee’s health benefits Job design and control over how a job is the scottish centre for Healthy Working as well, contributing to longer term done, and fair and transparent appraisal Lives (www.healthyworkinglives.co.uk). employment prospects. In effect a win-win and reward structures are also important. outcome. effective and well managed organisations It is widely acknowledged that employers recognise the importance of good can be proactive in promoting the health However, it is important to recognise that management and leadership practices that and wellbeing of their workforce. In many smaller organisations do not have the encourage and promote good health and scotland we have many examples of good resources to offer the type of support wellbeing amongst the workforce (Vaughan practice where employers recognise the described above and that there are other –Jones and Barham 2010). A wealth of benefit that they can get from supporting less direct workplace practices that can advice and information is available to good workplace health and wellbeing and in equally contribute to wellbeing.

health in scotland 2009 chapter 2 – work and health 19

The Scottish Public Sector the Boorman review of the health and the sharing and adoption of good practice wellbeing of the nHs workforce in england across the public sector is more critical now Around a quarter of the working population (Boorman 2009) identified the close links than ever to ensure that the benefits of of scotland work in the public sector. As between good staff health and wellbeing improved motivation and productivity, and well as the importance this has for the and improved clinical outcomes. the review reducing sickness absence can contribute to economy, it presents an enormous concluded that nHs sickness absence in maintaining public services. opportunity for the public sector to take the england could be reduced by a third from lead in promoting health and wellbeing to its current rate with an estimated direct its workforce and beyond to their families cost saving of approximately £555 million. and communities. the recommendations of the Boorman Many public sector organisations have review are well worth considering both for already demonstrated a commitment to the nHs in scotland and for the wider workplace wellbeing through the public sector. attainment of a Healthy Working Lives Dame carol Black’s review of working age Award, including the scottish Government. health in Great Britain recognised the need there is, however, always room for for the inclusion of occupational Health improvement. the scottish Government is within mainstream healthcare. there is a working with nHsscotland and with cosLA challenge for the occupational health and to develop a public sector mandate on vocational rehabilitation communities to health and work. the intention is to establish clear professional leadership for empower the public sector to take a supporting the health of all working age coherent approach to workplace health, people. safety and wellbeing, attendance management, occupational health and work It is equally important that other parts of rehabilitation and return. It is important the scottish Public sector adopt these that these are approached as a whole principles, particularly local government system and not separate, siloed areas of which employs a significant proportion of activity. those working in the public sector.

health in scotland 2009 chapter 2 – work and health 20

Impact of the recession control for how individuals and teams do the patient’s work status is recognised and their work. that the patient’s health care plan supports the impact of the economic recession is them either to return to work or to access being felt across the whole of the scottish Implications for healthcare services employability services that will move them economy. this can have serious towards work. If the patient is in work, they repercussions for health amongst the For those people with a health barrier to will need to be given sufficient information working age population, both for those in remaining in or returning to work, the and support to discuss returning to work work and those seeking employment. We attitude of healthcare professionals towards with their employer. If they are out of know that unemployment has a negative the relationship between health and work is work, then the discussion should be started impact on health, but also that returning to critical. early enough for other services such as work very quickly starts to improve health As well as providing health benefits, work Jobcentre Plus or other employability and wellbeing (Waddell and Burton 2006). can be a part of the recovery and advice and support to be accessed in a For the newly unemployed it is important rehabilitation process. It is important that timely manner. that they receive advice on maintaining their wellbeing while looking for work and that the contribution of unemployment is recognised by healthcare professionals when supporting these people. employers too, should consider the impacts of restructuring their organisation. As well as the negative impact of health on those losing their jobs, the workers that remain can also experience poorer health, including worry that they might be next, the impact of work intensification or stresses from working in new and unfamiliar structures (Kieselbach et al 2007). employers can mitigate some of the effects of restructuring by ensuring that they involve the workforce in job design and delegate reasonable

health in scotland 2009 chapter 2 – work and health 21

the introduction of the ‘fit note’ to replace It is important, however, that the benefits the sicknote has moved us a significant way system itself does not create barriers to to encouraging health professionals to entering into work. Prolonged time spent on consider the importance of work. However, benefits erodes health and wellbeing, and we wish to do more. the scottish makes re-entering work increasingly Government is working with a wide range difficult. I would hope that the reforms of of healthcare professionals to develop a the welfare system proposed by the new ‘scottish Health offer’ which will set out government in Westminster will ensure that principles and standards for provision of any existing welfare barriers to work are health services to those with a health removed and that no new ones are erected, barrier to work. this will improve the whilst ensuring that sufficient support recognition by health professionals of the remains for those that need it. It is important contribution to health that work particularly important that people who are can make and the confidence and skills of moved from health-related to job-seekers staff to incorporate work issues in their benefits are not then abandoned to find interaction with patients. work themselves. otherwise we will surely see them again shortly, likely in a more Welfare benefits incapacitated state than before. As I have pointed out above, it is as At the time of writing, DWP have indicated important to address the health barriers of the ending of their condition Management those out of work as it is for those in work Programme in March 2011. those with to enable as many people as possible to get health conditions who would return to work the benefits of participating in some form of will continue to need access to support for meaningful activity. Most people will, with their condition and the scottish and UK the right support, be able to manage their Governments will need to work together to condition sufficiently for them to do so. ensure this need is met.

health in scotland 2009 chapter 2 – work and health 22

An ageing workforce The next generation We are entering a period when the first of Given the demographic make-up of the the baby boom generation are starting current workforce and the changes over the retirement and the last are moving into late next 10-20 years it is more important than middle age. this means a significant ever that the next generation of workers proportion of the working age population are ready and able to fully participate in are in their 50s and early 60s, with an the jobs market. these workers will need to increasing prospect of having to work better appreciate the important links longer before retirement. We can expect between work and health, to accept that this cohort to develop the common, long- they have responsibility for maintaining term conditions of late middle age – for their own health, but also to have an example arthritis, diabetes, osteoporosis – expectation of employers responsibility to as well as conditions such as cancer, where look after and promote the health and people can often continue to work. this will wellbeing of their staff. there needs to be present challenges for both healthcare room in the curriculum to prepare young services and employers. the nHs will need people for the world of work and to let to recognise the need to help keep this them know what can be expected of them population as healthy and active as possible and of their employers to ensure that they and to include work in care pathways. can all benefit from employment. employers, too, will need to recognise that they can contribute to keeping their workforce as healthy as possible, while also understanding the need to make adjustments in workplace practices to allow workers to receive healthcare or to manage their conditions.

health in scotland 2009 chapter 2 – work and health 23

scotland has a mature drug treatment recognising the need to act effectively to cHAPteR 3 capability – based on ‘shared care’. the prevent the development of drug problems. process of enhancing control within Whilst it is important that all individuals Scotland and problem individuals as outlined in previous chapters should be supported in their aspirations for is central to promotion of recovery. recovery it must be recognised that within drug use expectations contained in the promotion of a spectrum of people with substance use recovery and delivery of personalised care problems there is a huge gap in the distance must be balanced with the existing public some must travel to be re-integrated into health benefits of well evidenced mainstream society. approaches to reduce drug-related harm. treatment of substance misuse always More effective methods of primary care stimulates controversy and strong views engagement are required to increase the among politicians, the media and the caring likelihood of consistently delivering professions. Despite this, or perhaps evidence-based interventions in the users’ because of the resulting intense interest, own environments through effective scotland has concentrated considerable systems of shared care. this will also effort and expense in assembling a increase recovery capital and re-engage treatment service with many qualities. Born substance misusers with important care out of the disaster of HIV infection in systems which will be needed to address injecting drug users, the medical problems their emerging health needs. evident among young drug users, the strain substance misuse can be seen as a multi- on the criminal justice system as users fall factorial problem with biological, physical, into its orbit and the emotional and tragic mental and social components. clearly no child care implications associated with single discipline acting alone has the ability parental drug use, drug services have to effect a successful outcome. the scottish developed a range of approaches, designed Government has a widely supported to minimise these problems, to reduce drug strategy which recognises the need for deaths and improve prospects for drug harm reduction but also promotes recovery users and their families. support for these and prioritises the needs of children and controversial policies has come from all substance misusing parents as well as political parties. the conservative

health in scotland 2009 chapter 3 – Scotland and problem drug use 24

Government of the 1980s supported the physical or sexual abuse. the person can With this scenario in mind it is obvious that provision of needles and syringes (scotland afford the drugs and their lifestyle is not a range of interventions is necessary to had the first national policy endorsing this greatly affected. As their use continues more impact on an individual’s situation. this in the world), and successive governments of the drug needs to be taken for less effect. involves cooperation between housing, of all parties have supported opiate occasionally becomes frequently then daily. education, employment, criminal justice, substitute treatment as part of the overall Problems emerge physically and mentally, social services, specialist drug treatment care provided. Recently attention has with relationships, family and employer but services, and community based services focussed on child care and child protection their drug use is still functional and which must include the General Practitioner as well as driving forward a new agenda of continues. the second section: the person is and broader primary care team. the GP is holistic personal care designed to meet the now dependent and subject to cravings, loss well placed to assess and treat individuals aspirations of each individual in their of control, increased tolerance - so more with problem use, engaging them with local progress to their own personal drugs are needed or ingestion changes to specialist and generic services. this role manifestation of recovery. intra-venous use - withdrawal symptoms, should be a core primary care service, and physical and mental harm and the loss of not an ‘enhanced service’ that can be opted A person’s journey salient alternatives to drug taking to avoid out of. there is a maxim ‘If you are not part pain or induce pleasure. this person is of the solution you are part of the problem’. In a very simplistic sense, a person’s frequently unemployed and outwith family this is especially so in drug treatment journey through a dependency could be support, possibly homeless by this time and services. Government has the responsibility split into three sections. the treatment or well acquainted with the criminal justice to require services to provide a full range action which would be appropriate for each system. the drugs are still functional and the of effectively governed evidence based of these sections would necessarily be misuse goes on. the third section sees the treatments in each area without a “post different. Assessment and development of complete breakdown of the addicted code lottery”. When being in treatment at an individual care plan for each person is individual, physically, mentally and socially. the very least reduces the likelihood of vital to providing effective interventions. they are thoroughly exhausted by the premature death, exclusion from a cheap, consider the first section: initially the interventions of the criminal justice system cost effective, evidence based treatment quantity of drugs taken is small and use - usually imprisonment - and are often must be unacceptable. infrequent. the drugs are enjoyed homeless. the drugs are no longer functional (something not to be forgotten) and may and are only taken to keep withdrawal at provide relief from anxiety, give bay and to numb the mind to loss and excitement, or blot out emotions linked to misery.

health in scotland 2009 chapter 3 – Scotland and problem drug use 25

Shared care this approach to delivering a complex spectrum of services has become a model In the nHs opportunities arise to deliver for other parts of the nHs. Arising out of services to individuals with problem use in the HIV/AIDs and rapidly emerging drug specialist or general settings. Participants problems of the 1980s, shared care include specialist clinics led by a consultant approaches have been used in the team and General Practitioners/primary management of many chronic conditions care services. Recently community such as diabetes or chronic pharmacists have taken on an increased cardiopulmonary disease. establishing a role. Also involved are voluntary agencies functioning link among agencies, a flow of and private providers. Problem users information and an agreement of tasks to interact with social care and criminal justice be shared or assumed by different parts of agencies but increased medical provision effective. In areas where all agencies are the organisation represents a cost effective has been required to cater for an increasing functional this system works well, providing and person centred approach to delivering number of their needs. shared care has a robust and accountable infrastructure. In heath care. become the paradigm within which a range areas where any component is functioning Primary care may be a fundamental of service elements deliver interventions to in a less satisfactory way, however, strength or a fatal weakness in the shared individuals. these services deliver problems arise. When partial failure leads care model. Dissention or negative views programmes which aim to prevent harm to stress in the system this is most manifest from one practice/group can disable the and support recovery. they include primary in specialist clinics which carry the ultimate system whereas a vibrant primary care and secondary prevention, basic harm responsibility for local care and cannot opt sector can carry a large share of the burden minimisation to disorganised and chaotic out. Rising waiting lists, absence of primary providing an invaluable, local, integrated, individuals as well as family support, access care involvement or a malfunctioning family approach. If recovery has, at its to rehabilitation processes and, support services are warnings of failure of centre, normalisation, for many service increasingly, services aimed at encouraging the shared care model. other indicators are users an important step is the ability to be employability or housing support. this over reliance on one practitioner or practice cared for in their own community by their model therefore involves primary care in or fatigue in an overburdened part of the local doctor. At the present time there are close collaboration with many services. service. Leadership and peer support are examples of both effective and this path-finding model is envied by other critical and this requires skilled and realistic dysfunctional GP services. In some areas countries but depends fundamentally on support from local managers and shared care effectively doesn’t exist and the participation of each component to be commissioners. health in scotland 2009 chapter 3 – Scotland and problem drug use 26

HIV/AIDs, now have a rising caseload of in the 1980s to curb the epidemic of blood patients with liver disease due to hepatitis c borne viruses are now responsible for and are required to engage with new personal and individualised care for each manifestations of drug use such as the patient. In many ways the new demands recent anthrax outbreak. Anthrax and are simply an extension of existing tuberculosis in drug users has required provision. Health care workers involved shared care between public health, with people who use drugs would say that respiratory physicians, surgical teams and their interests are in total care including a the clinical microbiological services. A range recovery agenda for each individual. It is the responsibility defaults to secondary of medical conditions are presenting as important that the system focuses on care. the optional nature of enhanced early degenerative disorders in patients recovery as the overarching outcome it services allows the emergence of gaps in with opiate dependency. cardiologists and delivers. respiratory physicians are finding the system. Persuasion can come in the the challenges for the next few years are themselves responsible for drug related form of health board inducements or many. Improving services, refocusing the diseases. Premature cardiomyopathy from personal chemistry between individuals. aims and objectives of services and alcohol problems, early lung cancer in on a national basis adjusting the General restructuring the overall package to deliver heroin and cigarette smokers, chronic Medical services contract seems low on the recovery are recurring themes. How to pulmonary obstruction, and pneumonia are agenda of BMA negotiators but should achieve this without damaging the valuable presenting in extravagant form in nevertheless be encouraged. and effective elements of the existing chronically under nourished individuals. In system is work in progress. An evolving healthcare problem addition to this, specialists unfamiliar with opiate dependence treatment find specialist services have historically been themselves managing difficult patients the responsibility of Psychiatry. clinics tolerant to large doses of opiates. have, however, had to change to manage the complex problems becoming common in the capacity of treatment services has drug users better. As the drug using never been more tested. not only is population expands and ages, more areas of demand greater and the requirement for medicine need to join the collaboration. high quality scrutinised but newer more Infectious diseases, for many years testing responsibilities are being expected. critically important in managing cases of services which arose as a matter of urgency

health in scotland 2009 chapter 3 – Scotland and problem drug use 27

In April 2009 the first cases of a new strain infections, tonsillitis, septic shock, cHAPteR 4 of influenza were identified in Mexico and meningitis and encephalitis. the groups of then new cases in the UsA were classified people most likely to be admitted to Influenza A (H1N1) as a new type of influenza virus. Within hospital were those with underlying days, 2 scottish people who had recently medical conditions and pregnant women. The Pandemic 2009 returned from holiday in Mexico were complications in pregnant women included identified as the first UK cases. this new pneumonia and cardio-respiratory influenza strain was identified as Influenza complications. A (H1n1)v. In response to initial reports of Ministers took the key decisions within the significant illness and death in Mexico, the UK civil contingencies arrangements UK and scottish Governments and Public designed to respond to major threats to the Health organisations prepared to respond UK population. these UK-wide to a potential pandemic. the existing arrangements ensured that decisions were contingency and pandemic influenza plans taken as soon as evidence was gathered were enacted and UK-wide political, civil and reviewed and consensus was sought service and scientific advisory structures across the UK countries. once taken, were urgently established to manage the decisions were rapidly implemented and UK’s response to the potential pandemic. shared openly and quickly with the public the (H1n1)v virus spread very rapidly via the media. the relative novelty of this across the world and the World Health new strain of influenza meant however that organization (WHo) officially declared a time was necessary to collect enough pandemic on 11 June 2009. information to estimate the potential Like seasonal flu, infection with influenza A impact of (H1n1)v on the UK population. (H1n1)v could cause little or no symptoms, the scottish Government responded to the or cause an unpleasant but self-limiting pandemic using previously determined and disease. However, this virus did cause practised resilience and health protection severe illness in a minority of people who structures. the overall response was experienced bronchitis, viral pneumonia or effectively composed of two phases: the secondary bacterial pneumonia. other containment phase which aimed to limit the complications of (H1n1)v included ear spread of influenza infection and health in scotland 2009 chapter 4 – Influenza A (H1N1) The Pandemic 2009 28

the treatment phase which aimed to this information would increase the significant numbers were admitted to mitigate the impact of influenza on health effectiveness of any future pandemic- hospital in scotland and sadly a proportion, and ensure the continued routine specific vaccination programme. some of whom had been previously healthy, functioning of society. the UK operated a died. In light of this evidence the UK Health As the pandemic progressed affecting many containment policy for some two months Departments, with expert scientific advice, communities, scotland moved into the from the emergence of the (H1n1)v virus. offered immunisation to defined groups in treatment phase. surveillance, investigation the containment phase included: the population with the aim of lowering and risk assessment processes were their risk of significant disease and death. In • testing patients suspected of having adjusted and continued. emphasis was addition frontline nHs and social care staff (H1n1)v switched to limiting impact by treatment were offered the vaccine to reduce their risk and care, infection control and • offering antivirals to all suspected or when caring for those ill with (H1n1)v and immunisation. Health Protection scotland confirmed cases to limit the possible effect on health and (HPs) worked closely with other UK health social care provision. • taking throat swabs from suspected protection agencies to ensure a consistent cases UK response. the (H1n1)v immunisation programme formed an important part of the overall UK • treating cases without waiting for As the pandemic evolved, it became clear pandemic response aiming to mitigate the diagnostic confirmation that the original information coming out of impact of (H1n1)v rather than further Mexico on the severity of the illness was limiting spread. Health Protection scotland • contact tracing and prophylaxis of close not being replicated in europe and that the co-ordinated the influenza A (H1n1)v contacts with antivirals impact of the (H1n1)v pandemic would not vaccination programme working with the closure of schools based on health risk be as severe as first feared. (H1n1)v mainly • scottish Government, 20 nHs Boards, 1,024 affected younger people who on the whole, assessments General Practices, the scottish Prison had better health. However certain groups service, and 32 local authorities. the • self-isolation of cases in the community of people were particularly affected by this scottish Government established a steering Investigation of cases and contacts. influenza strain: • Group to oversee the programme. • those with ongoing illnesses such as the purpose of containment was to slow Surveillance: this was a key part of the heart disease, respiratory disease and the spread of the virus in the population response to (H1n1)v; monitoring the spread diabetes and gather more information about the and impact of the infection in scotland. the virus, including its severity, the groups at • Pregnant women scottish Influenza surveillance Reporting most risk and transmissibility of the virus. scheme collected information on the • children under 5 years of age. health in scotland 2009 chapter 4 – Influenza A (H1N1) The Pandemic 2009 29

number of consultations for influenza like Although experts eventually considered presentations of influenza like illness to illness or acute respiratory illness from that (H1n1)v was a virus causing illness of GPs in scotland and of the proportion of scottish General Practices. there was an relatively mild severity, influenza (H1n1)v throat swabs submitted and found to be increasing trend in consultations until mid still caused considerable illness in scotland. positive for (H1n1)v. the circulation of the to late november followed by a sharp From May 2010 nearly 100,000 people in (H1n1)v Influenza virus reached its height decline in December and a rise to a further, scotland were prescribed courses of in the final weeks of 2009 and effectively smaller peak in late December, followed a antiviral treatment. Figure 9 shows the ceased circulating after the first 3 months decreasing trend (see Figure 8). similarity in the time trends of of 2010.

Figure 8: consultation rates PIPeR practices FIGURE 9: ILIARI and swab positivity for (H1N1)v among GPs in Scotland 2009/2010 60 100

90 50 80

70 40 60

30 50

20 Rate per 100,000 30

Percentage H1N1v positive 20 10 10

0 0 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 Week number

H1N1v % +ve ILIARI rate per 100,000

health in scotland 2009 chapter 4 – Influenza A (H1N1) The Pandemic 2009 30

Immunisation: on 13 August 2009, the • those aged 5-64 years 52% who died about 70% had underlying scottish Government announced details of medical conditions including diabetes, • those aged 65 years 56%. the clinical priority groups for Phase 1 of respiratory conditions, obesity, renal/liver the immunisation programme: Ministers Apart from the thousands of people treated conditions, congenital abnormalities, agreed that frontline health and social care with (H1n1)v influenza at home or by immuno-suppression, pregnancy and staff workers would also be offered primary care services, a large number of cancer. In some cases, the patient had more vaccination alongside the first priority people experienced more severe illness. As than one of these conditions. Figure 10 groups as these staff were at increased risk at 1 March 2010, a total of 1540 people below shows how numbers admitted to of infection and of transmitting that with confirmed (H1n1)v infection had been hospital increased sharply during the last infection to susceptible patients. In admitted to hospital. sixty-nine people died 3 months of 2009, dropping equally sharply september 2009 the scottish Government of confirmed (H1n1)v infection. of those in the first few weeks of 2010 as the levels issued further guidance on the priority staff and occupational groups including Figure 10: cumulitive number of hospitalised cases of inﬂuenza (H1N1)v including new cases each week and death 09/10 definitions for staff providing healthcare in non nHs settings that would also be 200 1800 included in the vaccination programme. 180 1600 In november, 2009, Phase 2 of the 160 1400 140 immunisation programme offered 1200 120 vaccination to all young children aged over 1000 six months and up to five years of age. the 100 800 reason was that children under the age of 80 600 five years had consistently the highest 60 levels of hospital admissions with the 40 400 20 200 (H1n1)v infection. New cases and deaths each 0 0 Uptake figures for the (H1n1)v vaccine 5 campaign in scotland, estimated in April 27 32 37 42 47 52 10 2010 were: week

• those in clinical ‘at risk’ groups 54% new cases hospitalised each Cumulitive Deaths Cumulitive Hosptilisations week • those aged under 5 years 66%

health in scotland 2009 chapter 4 – Influenza A (H1N1) The Pandemic 2009 31

of circulating virus fell away and as scotland. But it is certain it will cause flu increasing numbers were protected by like illness in scotland this winter and those vaccination. in the groups offered influenza vaccination should have it. on 10 August 2010, WHo Director-General Dr Margaret chan announced that the I would like to take this opportunity to pay (H1n1)v influenza pandemic was over. tribute to the unceasing efforts of all However, localised outbreaks of various involved in responding to the 2009 magnitudes are likely to continue. the pandemic. A great many people in many world is now in the post-pandemic period. different services worked extremely hard to provide a coordinated and successful It is however, expected to re-appear as the response to what could have potentially dominant strain during the next flu season been a very severe threat to the health and in 2010-2011. Based on knowledge about wellbeing of the people of scotland. those past pandemics, the (H1n1)v (2009) virus is services responding did so with a degree of expected to continue to circulate as a professionalism that allowed normal seasonal virus for some years to come. services to continue to be provided. While the level of concern is now greatly diminished, vigilance on the part of national Finally, we must not drop our guard. this health authorities remains important. such was the first pandemic for nearly 50 years vigilance is especially critical in the and its virulence was not as severe as first immediate post-pandemic period, when the feared. However there are still many other behaviour of the (H1n1)v (2009) virus as a influenza viruses out there including the seasonal virus cannot be reliably predicted. avian strain - H5n1. these viruses constantly change and the probability of a In scotland, the seasonal trivalent vaccines new pandemic with a different virus is that are available do cover the (H1n1)v much the same as it was prior to May 2009. (2009) virus. the (H1n1)v virus is not currently known to be circulating in

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In December 2009 and the first part of injection of heroin. the affected individual cHAPteR 5 2010, scotland experienced a large was usually admitted to hospital some outbreak of Anthrax infection. Anthrax is a 4 days later. the range of symptoms was An outbreak of very rare but serious bacterial infection wide with no consistent type of caused by the organism ‘bacillus anthracis’. presentation to clinicians. the disease occurs most often in wild and anthrax infection the first cases presented to hospital in domestic animals in Asia, Africa and parts Glasgow. nHs Greater Glasgow initially of europe. the organism can exist as spores in drug users in established an outbreak control team (oct) that survive in soil and the environment for to determine the size and source of this many years. Humans are rarely infected Scotland outbreak. this oct investigated this usually by direct contact with skin or outbreak with the intention of establishing tissues of infected animals. People can also the numbers affected, to establish the cause be infected by inhaling or swallowing and then act to control the outbreak. those anthrax spores. involved in the oct included It was apparent early in the outbreak that microbiologists, strathclyde Police, Health those affected were drug users. these Protection scotland, and the Health individuals presented to GPs and hospitals Protection Agency (HPA) special Pathogens with inflammation or abscesses at the sites Reference Unit (sPRU) at Porton Down and in their body where they had injected others. the oct considered that heroin. Heroin users may sometimes smoke contaminated heroin or a contaminated or ‘snort’ heroin but many will inject it into ‘cutting agent’ was the most likely vehicle their body with needle and syringe. the of the anthrax infection. It regarded the risk regular injection of heroin and other to the general public as very low. substances into veins eventually leads to over the following weeks more individuals their damage and disappearance. When this across scotland were diagnosed with happens users may inject heroin directly Anthrax and Health Protection scotland into muscle or into the skin (skin or muscle established a national outbreak control ‘popping’). team. Representatives of the scottish Drugs In this outbreak anthrax symptoms usually Forum and national Forum on Drug Related began between one and two days after Deaths were important additions to the oct health in scotland 2009 chapter 5 – An outbreak of anthrax infection in drug users in Scotland 33

at this stage as it was vital to communicate the key messages to reduce harm included: potential for anthrax in those presenting the risk effectively to the many people who with symptoms consistent with this disease. • Avoid the use of any form of heroin if use heroin in scotland. possible the outbreak control team identified three the oct released information though a possible reasons for this anthrax outbreak. seeking alternatives via drug treatment number of routes advising the drug using • First, Anthrax may have entered the heroin community of this additional serious risk of services at any point in the supply chain from its taking heroin and that they should seek • Highlighting the symptoms and signs of original source to the point when it was urgent medical advice if they developed an infection. bought by the drug user. Heroin is often infection. the scottish Drugs Forum worked transported in skin carrier bags in with the oct to develop special information It was considered that smoking (or snorting) Afghanistan and other heroin producing leaflets and posters. heroin could lead to breathing in anthrax spores and the risk of inhalational anthrax. areas. the animal skins may be the source this combined with the risk of injecting of the anthrax spores. ANTHRAX anthrax spores into veins, muscles and skin secondly, the dissolving agent or cutting IS KILLING HEROIN USERS meant that the oct advised addiction agent was contaminated with anthrax. services and pharmacies that it was not ACROSS SCOTLAND thirdly, there was a undiscovered link possible to advocate any ‘safe route’ of between the cases. administration of heroin. this approach was in contrast to the outbreak of clostridium Although the majority of cases were novyi infection affecting Intravenous drug identified in scotland, a drug user in users in scotland in 2000 (McGuigan et al Germany died from anthrax in December 2002, taylor et al 2005). this organism did 2009 and, since then a further 4 anthrax not have the same potential for infection cases have been diagnosed in england. the

EARLY TREATMENT CAN SAVE YOUR LIFE. by inhalation. oct has not been able to identify any direct links between these cases to any scottish If you suspect you may have anthrax go to your nearest A&E the chief Medical officer alerted all general case so far. Despite intensive investigations, If you want advice on local drug treatment services contact: practitioners, hospital accident and Know The Score working with other agencies and countries, emergency departments, intensive care and 0800 587 587 9 the oct has not been able to identify a www.scottishdrugservices.com high dependency units, microbiologists, the specific cause for the outbreak or any ambulance service, nHs 24, services for source of contamination of heroin. those drug users and others, to be aware of the

health in scotland 2009 chapter 5 – An outbreak of anthrax infection in drug users in Scotland 34

infected with anthrax apparently took control and Prevention (Us cDc). cDc geographical pattern of the clostridium heroin by intramuscular, intravenous or experts have actively assisted the novyi outbreak in 2000. subcutaneous injection and/or by smoking investigation and continue to provide Although rare, there have been outbreaks or snorting. advice based on recent Us experience with or cases of illness among intravenous drug human anthrax infection. the national outbreak control team has users in recent years. In 2000 scotland worked closely with the Health Protection At the time of writing 47 people in scotland experienced such an outbreak with 60 Agency, colleagues in other parts of the UK have been confirmed as having contracted cases and 20 deaths. the organism, and the european centre for Disease anthrax. 35 men and 12 women. the clostridium novyi, was considered to have control. the oct has also worked closely average age was 35 years for both men and been the cause probably transmitted in a with anthrax experts from the centre for women. the first patient was admitted to contaminated batch of heroin (taylor et al Disease control (cDc) in Atlanta UsA. hospital in Glasgow on 7 December. the 2005, Ringerz et al 2000). In 2000 a majority (39) lived in the west of scotland heroin-injecting drug user in norway was Diagnosis has been confirmed by a with only 11 cases in the east (table 1). identified as suffering from ‘injectional’ combination of isolation of Bacillus Interestingly this distribution mirrors the anthrax and contaminated heroin was anthracis in blood cultures in some patients, supported by PcR (Polymerase chain Table 1: Cumulative Total of Anthrax cases in Scotland by NHS Board, 6 August 2010 Reaction) testing of blood or tissues at the Health Protection Agency (HPA) special NHS Board Confirmed Cases Deaths Pathogens Reference Unit (sPRU) at Porton Ayrshire and Arran 1 0 Down, england. Dumfries and Galloway 6 0 those infected with anthrax have been given intensive medical treatment with Fife 3 1 intravenous antibiotics, guided by expert Forth Valley 1 1 microbiologist advice. A significant number Greater Glasgow and clyde 20 7 of patients have required surgical treatment due to the loss, because of infection, of Lanarkshire 9 2 skin, muscle and other tissues. some Lothian 2 0 patients were treated with specialist anthrax immunoglobulin (AIG) supplied by tayside 5 2 the United states centres for Disease total 47 13

health in scotland 2009 chapter 5 – An outbreak of anthrax infection in drug users in Scotland 35

considered the source of infection (Brazier et al 2004). this tragic loss of life and disabling illness in young men and women again highlights the enormous risks faced by the large number of people in scotland who take drugs and, in particular, those who inject drugs. I would like to thank all those involved in the response to this complex and long lasting outbreak. I would highlight the continuing work of HPs. We are also particularly grateful to cDc in providing experts who travelled over to scotland in the new year period and for their supply of the specialist anthrax immunoglobulin (AIG) for treatment of scottish patients. the investigation is ongoing. the outbreak has not been declared over. the outbreak control team will publish a final report on this outbreak in due course.

health in scotland 2009 chapter 5 – An outbreak of anthrax infection in drug users in Scotland 36

Infections continue to be a major public norovirus (nV) infection is the most cHAPteR 6 health problem in scotland. Although common of the less severe GI infections in significant progress has been made in scotland. During 2009, 231 general Significant trends reducing their impact, much remains to be outbreaks of nV were reported to HPs, a done to further reduce disease and decrease of 28.7% compared to 2008. suffering. this chapter summarises in the incidence of A total of 237 confirmed cases of E. coli significant trends in the incidence of the o157 were reported to Health Protection communicable diseases of public health the communicable scotland during 2009. the rate of reports importance in 2009. per 100,000 population for the whole of diseases of public scotland was 4.6 in 2009, compared to 4.7 Gastro-intestinal and foodborne in 2008. the continued importance of both health importance infections foodborne and farm-related sources of Campylobacter infection remains the most infection (as highlighted by the E. coli o157 in 2009 common of the more severe GI infections task Force) was reinforced in 2009 by with 6,378 cases of Campylobacter infection inquiries on foodborne outbreaks in both being reported to HPs in 2009, an increase scotland and Wales, and by outbreaks in of 30.7% compared to the 4878 reports in england involving visitors to open farms. 2008 (a rate of 123.4 per 100,000 In addition to recently updated national compared to 96 per 100,000). the guidance on the public health management incidence of Campylobacter in scotland of Vtec, advice was published on reducing peaked in 2000 and then declined every risk amongst rural communities and year until 2004. the increase in 2009 visitors. brings the level of reported cases to slightly the rate of Salmonella infection below the peak of 2000. the rise was not substantially declined in 2009: 16.4 per the result of any identified outbreaks but 100,000 population (847 reports) compared rather a growth in the number of cases to 20.2 per 100,000 population 2008. throughout the year, across scotland. no there was an increase in reports of obvious reason for this increase has been Salmonella monophasic Group B (94 reports identified. in 2009 compared to 37 in 2008). Much of this increase was due to a strain with an health in scotland 2009 chapter 6 – Significant trends in the incidence of the communicable diseases of public health importance in 2009 37

indistinguishable molecular pattern and was In 2009, nHsscotland laboratories reported Healthcare associated infections associated with contact with reptiles. positive HIV-antibody test results for 417 numbers of cases of Staphylococcus aureus Investigations traced the source of the individuals not previously recorded as bacteraemia (blood poisoning) have been infection to imported feeder mice. HIV-positive. of the 417 recently reported monitored in scotland since 2001. In the HIV-positive individuals, 291 (70%) are last year there were 2046 cases of Bloodborne virus and sexually male, and 286 (69%) are aged between 25 Staphylococcus aureus bacteraemia in nHs and 44 years. the probable route of transmitted infections facilities in scotland. A quarter of these transmission was men who have sex with During 2009, 2,013 new cases of hepatitis were MRsA (n=533) and the majority MssA men (MsM) in 137 cases (including a small c antibody-positivity were diagnosed. this (n=1513). A significant year on year number who were also injecting drug users), figure compares with 1553 and 1725 for reduction of 6.1% has been observed since heterosexual intercourse in 196 cases, and 2007 and 2008, respectively. of the 2009 2005. MRsA bacteraemia has reduced year injecting drug use in 15 cases. of the cases, 47% (939) are known to have on year by 14.5% and MssA by 1.7%. the heterosexual cases, 109 probably acquired injected drugs, representing 90% of those majority of MRsA isolates (81%) typed by their infection abroad. For 60 cases, the with a known risk factor. At the time of the scottish MRsA reference laboratory, as transmission category is, as yet, diagnosis, 25% (510) were aged 20-29 part of the snapshot programme in the last undetermined. the cumulative total of years, 37% (749) were aged 30-39 years, year, were attributable to the epidemic known HIV-positive individuals in scotland 25% (498) were aged 40-49 years, 8% (163) strain eMRsA-15 and there have been is now 6247, of whom 4521 (72%) are male were aged 50-59 years and 3% (60) were substantial reductions in these infections and 1726 (28%) are female; 2445 (39%) of aged over 60 years. this brings the total to since this time. the 6247 total reports are presumed to 27,355 cases of hepatitis c antibody- have acquired their infection outwith Multiple infection prevention and control positivity ever diagnosed as at 31 December scotland. At least 26% are known to have interventions have been implemented since 2009, of whom 14% are known to have died. 2001. some of these, such as the hand died. Approximately one in 220 of hygiene campaign, will have made a scotland’s population had been diagnosed In 2009, 64 cases of AIDs were reported by contribution to reducing HAI overall. the hepatitis c antibody-positive. It is estimated clinicians, 30 of which were diagnosed in reduction in S. aureus bacteraemias may that the number of undiagnosed hepatitis c 2009 with 34 diagnosed in previous years. also result from nHs boards implementing antibody-positive cases in scotland still the cumulative number of AIDs cases is special measures to reduce infections exceeds the number of diagnosed cases. now 1552, of whom 1227 (79%) are male, associated with peripheral vascular while 999 (65%) are known to have died.

health in scotland 2009 chapter 6 – Significant trends in the incidence of the communicable diseases of public health importance in 2009 38

catheters (PVc). Whilst inroads in reducing service. this also includes implementation Vaccine preventable diseases these infections have been made, of over-arching strategic plans in nHs As measles has become rare in scotland, it nevertheless there continue to be boards to reduce the burden of cDI. this list is difficult to diagnose clinically without significant numbers of cases. It is is not exhaustive. laboratory tests. there were 172 anticipated that wider implementation of the relative impact of each action is notifications for measles in scotland in these measures will lead to further difficult to quantify because of concurrent 2009 and 17 were laboratory confirmed. reductions in S. aureus bacteraemias. implementation of a number of different this compares with 219 notifications and Clostridium difficile infection (cDI) strategies. 54 laboratory confirmed cases in 2008. In surveillance in nHsscotland identified 3625 Rates for surgical site infection (ssI) under every year, the majority of measles cases cases in the last year in those over 65 mandatory national surveillance are low by occur in unimmunised individuals. years. the annual overall rate for scotland comparison to cDI. Rates of infection in the the total number of mumps notifications in 2009 was 0.71 per 1000 total occupied hip arthroplasty and caesarean section and laboratory confirmed cases in 2009 was bed days), which is a decrease of 42% surgery categories have significantly 1105 and 583 respectively compared with compared to 2008. the significant reduced since surveillance became 720 mumps notifications and 172 laboratory decreases seen in scotland have been mandatory in 2001. In total, the confirmed cases in 2008. cases continue to mirrored in other parts of the UK. surveillance system detected 150 cases of be mainly among the young adult age group C. difficile infection rates in this country are ssI following hip arthroplasty surgery and (aged 15-24 years), who are often under undoubtedly high, but it is difficult to get a 595 cases following caesarean section immunised against mumps, not having been clear picture of how this compares to other surgery in 2009. Half of all ssI following routinely offered two doses of MMR vaccine countries; even within the UK, there are hip arthroplasty surgery were detected when they were children. there were 93 substantial differences in surveillance case after discharge and on readmission to notifications of rubella in 2009, and no definitions. hospital. continued implementation of the laboratory confirmed cases. this compares the reduction of cDI rates is likely to be a scottish Patient safety Programme controls with 106 notifications and four laboratory result of a combination of improved for ssI over the next year should continue confirmed cases in 2008. In 2009, uptake of infection control procedures (including to contribute to reducing these clinically one dose of MMR by 24 months was 93.6% improved hand-hygiene, environmental significant infections. and for those reaching 5 years of age, 96.1%, cleaning and adequate use of isolation thus remaining above the target of 95% of rooms), implementation of antimicrobial children receiving at least one dose by the stewardship, and improved education and age of 5. communication at all levels within the health in scotland 2009 chapter 6 – Significant trends in the incidence of the communicable diseases of public health importance in 2009 39

the total numbers of notifications and same seven serotypes of Streptococcus Tuberculosis laboratory confirmed cases of pertussis in pneumoniae as PcV-7 and 6 additional there were 503 notifications of 2009 were 83 and 99 respectively, serotypes. thirty nine cases of Invasive tuberculosis during 2009. this was similar compared with 134 notifications and 88 Pneumococcal Disease reported in 2009 to 2008 when there were 502 notifications, laboratory confirmed cases of pertussis in were in children aged under 5 years. this but this figure represents a continued 2008. Whooping cough is known to be compares with 34 cases in the same time increasing trend since 2005 when there under-notified in scotland. period of 2008. twenty-three cases were were 389 notifications. the last year in aged under 2 years and eligible for there have been no reported cases of which a comparable notification figure was vaccination. the majority of these cases meningococcal serogroup c infection since recorded was in 1996 when it was 509. (16; 69.6%) were caused by serotypes not four cases were reported in 2007, protected by PcV-7 but by PcV-13. there this increase in notifications of tuberculosis indicating the effectiveness of the were 3 cases aged 5 years or under who is mirrored by an increase in reports to the meningitis c vaccine campaign. A total of were infected with a serotype of enhanced surveillance of Mycobacterial 139 cases of other types of meningococcal Streptococcus pneumoniae covered by Infections (esMI) system. During 2009, the infection were reported to HPs in 2009 PcV-7. one case was aged less than 2 months esMI scheme provisionally reported 468 representing an annual incidence of 2.69 and not yet eligible for vaccination. the cases of tuberculosis (compared with 455 cases per 100,000 population. this remaining two cases (aged 3-11 months cases reported in 2008) which is the compares with 125 cases reported in the and 2 years) had not received the full highest ever number reported to the esMI same period of 2008 and 157 cases in course of PcV-7 vaccine. scheme since it began in 2000. 2007. Meningococcal disease occurred more frequently in younger age groups: 46.0% Vaccine uptake remains high in scotland. Analysis of the 2008 esMI data reveals that (64 cases) were aged less than 5 years. As of December 2009, uptake rates by the incidence in scotland of 8.8 cases per 24 months of age for completing primary 100,000 population remains within the Pneumococcal conjugate vaccine (PcV-7) courses of diphtheria, tetanus, pertussis, WHo target of less than 10 cases per has been part of the routine childhood polio, Hib, Menc and PcV were between 100,000 and is less than the rest of the UK immunisation schedule since september 96% and 98%. Uptake rates for the two (15.5 cases per 100,000 reported in 2006. the PcV-7 has now been replaced booster vaccines Hib/Menc and PcV, given england and 14.1 cases per 100,000 for the with a PcV-13 vaccine since late spring at 12 and 13 months, were at 93.9% and whole of the UK in 2008). (HPA 2009) 2010. the new vaccine will follow the same 94.1% respectively in children reaching three dose immunisation schedule at 2 and there has been a steady increase in the 24 months of age. (IsD 2009) 4 months of age followed by a booster at proportion of non-UK born cases since 13 months. PcV-13 will protect against the enhanced surveillance began in 2000. In health in scotland 2009 chapter 6 – Significant trends in the incidence of the communicable diseases of public health importance in 2009 40

total, 49.0% of cases reported to esMI in 2008 were born outwith the UK. the most common age group in the UK born cases was 55-64 years (35; 17.9%) compared to 25-34 years (90; 42.5%) in the non-UK born. In 2008 risk factors for the disease were identified for 96 (24.5%) cases. the most common was alcohol misuse (52 cases), being a refugee (34 cases), immunosuppression (32 cases), working in healthcare (15 cases), homelessness (12 cases), residency in a residential or corrective institution (six cases) and drug misuse (five cases).

Conclusion Infectious diseases still pose a considerable threat with significant numbers of people having to attend their GP or being admitted to hospital as an emergency. 2009 has seen welcome reductions in levels of infection especially healthcare associated infections and vaccine preventable diseases. the number of new cases of tuberculosis, HIV, hepatitis c and campylobacter infection demonstrates the continuing need for action on the underlying reasons as to why people are falling ill with these conditions and on the prevention of onward transmission of infection from them.

health in scotland 2009 chapter 6 – Significant trends in the incidence of the communicable diseases of public health importance in 2009 41

scotPHo (2009) scotland and the european Health for All (HfA) database 2009 ReFeRences http://www.scotpho.org.uk/home/Comparativehealth/InternationalComparisons Leon D, Morton M, cannegieter s, McKee M. (2003) Understanding the Health of scotland’s Populationin an International context. Report for the Public Health Institute of scotland Walsh D, taulbut M, Hanlon P. (2008) the Aftershock of Deindustrialisation. trends in mortality in scotland and other parts of post-industrial europe. A joint report by the Glasgow centre for Population Health and nHs Health scotland Antonovsky A (1979) Health, stress and coping. Josey-Bass san Francisco Morgan A, Ziglio e. (2007) Revitalising the evidence base for public health: an assets model Global Health Promotion 14:2, suppl 17-22 Morgan A, Davies M, Ziglio e. (2010) Health assets in a global context: theory, Methods, Action: Investing in assets of individuals, communities and organizations. springer. London Durie R, Wyatt K, stuteley H. community Regeneration and complexity http://www.healthcomplexity.net/files/Community_regeneration_and_complexity.doc. Marmot M. (2010), Fair society, Healthy Lives. the Marmot Review Black c (2008), Working for a Healthier tomorrow. Dame carol Black’s Review of the health of Britain’s working age population Vaughan-Jones H. and Barham L. (2010), Healthy Work. evidence into Action. Pricewaterhousecoopers LLP (2008), Building the case for wellness. Waddell G. and Burton K. (2006), Is Work Good for Your Health and Wellbeing? Kieselbach t. et al (2007), Health in Restructuring. Innovative Approaches and Policy Recommendations.

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McGuigan cc, Penrice GM, Gruer L, Ahmed s, Goldberg D, Black M, et al. Lethal outbreak of infection with clostridium novyi type A and other spore-forming organisms in scottish injecting drug users. J Med Micro. 2002; 51(11):971-7. taylor A, Hutchinson s, Lingappa J, Wadd s, Ahmed s, Gruer L, et al. severe illness and death among injecting drug users in scotland: a case control study. epidemiol Infect. 2005;133(2):193-204. Ringertz sH Hoiby eA, Jensenius M, Maehlen J, caugant D, Myklebust A, et al. Injectional anthrax in a heroin skin-popper. Lancet. 2000;356(9241):1574-5. Brazier Js, Gal M, Hall V, Morris te. outbreak of clostridium histolyticum infections in injecting drug users in england and scotland. euro surveill. 2004;9(9):pii=475. Available from: http://www.eurosurveillance.org/viewArticle.aspx?ArticleId=475

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