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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 27-February-2009, Vol 122 No 1290

Comparison of the content of the New Zealand influenza pandemic plan with European pandemic plans
Nick Wilson, Michael G Baker
Abstract
Aim To critically review version 16 of the New Zealand (NZ) influenza pandemic plan in relation to the content of European pandemic plans.
Methods We used a published framework that had been developed for describing 29 European pandemic plans (all of which were available in 2006). This framework was used to rate the content of the NZ plan compared with the combined results for European plans.
Results In terms of plan content on border control aspects, the NZ plan scored higher than the average European plan (8.0 vs 4.9 out of 10.0 respectively) and similarly for the antiviral aspects (13.5 vs 10.6 out of 17.0). However, it scored slightly lower for the vaccine aspects (4.5 vs 5.3 out of 11.0). An alternate (more stringent) scoring system suggested that the relative quality of the NZ plan was poorer for antiviral aspects and fairly similar for vaccine aspects (to the average European plan). Even so, this framework had various limitations and probably favoured European countries which often have their own vaccine/antiviral production capacity. The NZ plan may also have scored more highly if the framework used considered other control measures (e.g. social distancing interventions). This comparison also identified some gaps which could be worth addressing in the planned 2009 version of the NZ plan (e.g. improved detail around priority groups for antivirals and pandemic vaccine and consideration of pneumococcal vaccine).
Conclusions The NZ influenza pandemic plan compared favourably with the average European plan in many aspects but not all. There is scope for further improvements and additions to be made in the next (2009) version of the NZ plan.

The threat of pandemic influenza remains a substantial concern globally. Recently the head of the World Health Organization (WHO) has commented on this threat:
Turning to the threat of pandemic influenza, [Margaret] Chan cautioned that ‘it has by no means receded, and we would be very unwise to let our guard down or slacken our preparedness measures.’ Countries with solid health infrastructures and efficient mechanisms for reaching vulnerable populations will be in the best position to cope, she said. 1
As well as being a concern for governments, survey data from the United States indicates that “avian flu” is one of the three biggest perceived health threats by the public (along with cancer and HIV/AIDS).2
New Zealand (NZ) has responded to the pandemic influenza threat by funding research,3 developing and revising very detailed national level pandemic plans,4 and running simulation exercises to test and refine the planning tools.5 There has also been active planning at the district health board level.6 An earlier analysis of plans in the Asia/Pacific region found the NZ national-level plan (version 14 in 2005) “compared favourably with the best European plans”.7
The current (version 16) NZ plan,4 has been compared with other plans in terms of its border control aspects and found to be comparatively well developed.8 But there have been no other published studies on this plan, despite the public health importance of such work and the ongoing process of plan revision being undertaken in this country.

Methods

Framework—We used a published framework that had been developed for describing the content of pandemic plans.9 This work was also the data source for the content information on the 29 European plans considered. Items in the framework that were excluded are in Table 1. All these European plans were eligible for inclusion if they were published before 30 September 2006 (which was the same year that the current version 16 NZ plan was published).
Table 1. Items included in the published framework9 but which were excluded from this analysis for specific reasons
Item
Reason for exclusion from this analysis
Restrictions anticipated on importing goods from affected countries considered
Most European countries referred to restrictions on poultry imports with regard to this item. However this specific issue is not relevant to NZ as live poultry imports are already illegal.
Plans to secure pre-purchase agreement with vaccine companies for the supply of pandemic strain vaccine
This item was considered less definite than the subsequent framework item which was focused on instead (i.e. if a secured pre-purchase agreement had been made).
Provisions to package active pharmaceutical ingredient in capsule described
This item was not considered relevant for NZ since the antiviral stockpile is of fully made-up capsules.
Country planning to stockpile antivirals
This item was not considered relevant since NZ already has a stockpile (instead the issue of the presence of a stockpile and its documentation was focused on in the framework used).
Antivirals planned for pre-exposure prophylaxis
This item was considered too similar to the preceding framework item which was focused on instead (i.e. “Antivirals planned for pre-exposure prophylaxis during a pandemic”).
Data abstraction and scoring—The data extraction tool developed and used by the authors of the European plan analysis9 could not be obtained from them. Therefore for the 29 European countries the combined data were abstracted from the three bar graphs in the published article.9 When compared with the numbers quoted in the text of this article, this abstraction process appeared to be 100% accurate (i.e. the scale of the bar graph was easily and accurately interpretable). The totals for all the countries were averaged within each domain (see the bottom row of Tables 2 to 4).
Under each of the categories in the framework, the NZ plan (including its associated appendices) was checked. This process involved a full reading of the plan and then systematic word searches of all the files that covered the full electronic version. A “yes” for content inclusion was scored as a “1.0”. Where the NZ plan was not entirely explicit in its coverage of a content area, this item was graded as “partly” and was scored as “0.5”. In a more stringent alternative approach the “partly” assessments were given a zero score.

Results

The NZ plan followed the general pattern of such plans having elements of both a strategic plan and an operational plan (i.e. 25/29 of the European plans had this pattern). In terms of page length, the NZ plan at 198 pages (with appendices) was the fourth longest. Longer plans were those from Finland (202 pages), the Netherlands (59 pages plus 246 pages of appendices) and Switzerland (249 pages in three parts).
In terms of plan content on border control aspects, the NZ plan scored higher than the average European plan (8.0 vs 4.9 out of 10.0 respectively) (Table 2). Similarly, for the antiviral aspects (13.5 vs 10.6 out of 17.0) (Table 4). However, the NZ plan scored slightly lower for the vaccine aspects (4.5 vs 5.3 out of 11.0) (Table 3).
Table 2. Coverage of border control measures mentioned in the national pandemic preparedness plans (29 European nations and NZ)
Measures detailed in the plan
For 29 European countries (N)
For NZ*
Comment with regard to the NZ plan
1.1) Absolute ban on the entry of people arriving from affected areas.**
5
Yes (p139)
Border closure from affected areas is detailed in the NZ plan.
1.2) Selective restrictions on the entry of people arriving from affected areas.**
16
Yes (p139)
This option exists in the plan and may be combined with requiring time in quarantine for people from certain pandemic-affected areas.
1.3) Mentions following WHO recommendations on travel
16
No
The plan frequently refers to WHO but not specifically to following WHO travel recommendations. Nevertheless, the plan does detail the provision of advice to travellers (e.g. p26).
1.4) Information for travellers
22
Yes (p26)
The plan provides examples of travel advice health educational materials (p197).
1.5) Measures at borders for international travellers coming from or going to affected areas
21
Yes
See below on exit screening and entry screening.
1.6) Entry screening anticipated.**
17
Yes (p44)
The plan mentions “intense surveillance” at the border and “enhanced screening” by the Customs Service (p129). Nevertheless, there is no specific mention of “health declarations” (for entry screening).
1.7) Exit screening anticipated
10
Yes (p141)
The plan is quite detailed on exit screening (i.e. health declarations and temperature measurements).
1.8) Quarantine of passengers coming from suspected areas anticipated.**
11
Yes (p134)
This issue is detailed in the plan. (Furthermore, local level planning for quarantine around international airports has also been undertaken).
1.9) Measures for travellers on board international conveyances from affected areas
9
No
There is no mention in the plan of separation measures or provision of masks to passengers/crew. But the plan does have detailed information about mask use in other settings.
1.10) International cooperation with neighbouring countries explicit
14
Yes (p26)
The plan specifically states such cooperation (especially with Australia) in many places.
Total score (out of 10 categories)
4.9/10.0 (average)
8.0/ 10.0
* Example pages for the NZ plan (i.e. in many cases there is additional detail in other parts of the plan).
** This measure is not actually in WHO guidelines and may even be advised against by WHO. Nevertheless, it was retained in the framework as it might actually be appropriate in some circumstances and for island nations which are likely to have better scope for successful border control (see also the Discussion).
In a more stringent alternative approach (where the “partly” assessments were given a zero score), the scores for vaccine aspects dropped further behind the average for the European plans (i.e. to 3.0 out of 11.0) (Table 3). For antiviral aspects the NZ plan score dropped to only just above the average for the European plans (i.e. to 11.0 out of 17.0) (Table 4).
Table 3. Coverage of vaccine strategy measures mentioned in national preparedness plans (29 European nations and NZ)
Measures detailed in the plan
For 29 European countries (N)
For NZ
Comment with regard to the NZ plan
2.1) A strategic plan for pandemic vaccination
28
Yes (p99)
The plan refers to vaccination in many places and states the pandemic vaccine will be ordered at the appropriate time (from an Australian manufacturer).
2.2) A strategic plan for pneumococcal vaccination in pandemic phase
11
No
There is no mention of pneumococcal vaccination in the plan.
2.3) A strategic plan to vaccinate the whole population
18
Partly (p169)
This is not entirely clear in the plan but it is probably implied by the statement: “until the population at large is protected by vaccination”.
2.4) Defined priority groups for influenza vaccination
26
Partly
The plan cross-refers to an associated online document on ethical issues,10 which gives some statements that support prioritisation towards health professionals and towards patients who would meet clinical criteria for treatment (e.g. “influenza vaccination”) during normal times. Appendix D of the plan also discusses issues around “reciprocity” and “fairness” which may inform the prioritisation issue. See the additional text in the Discussion section of this article.
2.5) Sizes of priority groups given or referenced
16
No
This is not detailed, even though some data are fairly readily available (i.e. the size of the health care workforce, the essential services workforce and numbers of people with chronic conditions such as diabetes—as per the latest NZ Health Survey11).
2.6) Provision of storage for vaccines described
12
No
The plan was written before a supply of pre-pandemic vaccine was subsequently imported into NZ.
2.7) Operational plan for the distribution of vaccines
14
No
The plan says this is still being developed: “The Ministry of Health is working on the logistics of mounting a mass immunisation campaign. This will be published as guidance for DHBs who will be tasked with operationalising such a campaign, if required” (p99).
2.8) Specifies which healthcare workers will administer vaccine
11
No
The role of district health boards (DHBs) is specified (p33), but not to the type of health worker level of detail.
2.9) Provisions of medical equipment (needles, syringes) to support vaccine administration
9
Yes (p99)
The plan states: “NZ has in store sufficient needles/syringes, sharps containers and other vaccination equipment and supplies to mount a mass vaccination campaign.”
2.10) Tender for H5N1 vaccine procurement
5
Partly (p99)
The plan states: “The purchase of a small quantity of vaccine effective against a clade of the H5N1 influenza virus is being considered. Such vaccines are still in development” (p99). (Since this time a stockpile of such vaccine has been purchased12).
2.11) Secured pre-purchase agreement with vaccine companies for the supply of pandemic strain vaccine
4
Yes (p99)
The plan refers to a pre-existing arrangement with an Australian manufacturer.
Total (out of 11 categories)
5.3/11.0 (average)
4.5/ 11.0
(Or 3.0/11.0 for the NZ plan using the alternative more stringent scoring approach).
Table 4. Coverage of antiviral drug strategy measures mentioned in national preparedness plans (29 European nations and NZ)
Measures detailed in the plan
For 29 European countries (N)
For NZ
Comment with regard to the NZ plan
3.1) Strategic plan for the use of antivirals
28
Yes (p172)
The plan refers to the use of antivirals as part of border control, for cluster control and for reducing morbidity and mortality from pandemic influenza (see Appendix I in the plan).
3.2) Specifies which antivirals will be used
22
Yes (p99)
Oseltamivir (Tamiflu) is the antiviral referred to. However, there is no mention of amantadine or zanamivir (Relenza).
3.3) Doses and duration of treatment recommended in the plan
20
Yes (p173)
See Appendix I in the plan.
3.4) Strategy for antiviral use in early containment
18
Yes (p47)
As part of intensive cluster control operations antivirals will be offered to close contacts (unless surveillance indicates clusters are already too widespread to attempt control).
3.5) Plans to use antivirals in people working with animals/birds during animal outbreak
20
Partly (p28)
This is probably implicit in the statement: “Ensure appropriate protection and training for animal workers and exposed humans (poultry and pigs most likely) to reflect WHO guidelines and NZ guidelines and legislation.”
3.6) Antivirals planned for treatment
28
Yes (p94)
The plan states that: “If and when the pandemic becomes more widespread within NZ, it is anticipated that antivirals will be reserved for the treatment of cases.” Elsewhere an antiviral distribution role is suggested for community-based assessment centres (CBACs)—“to those meeting agreed clinical criteria” (p97).
3.7) Antivirals planned for pre-exposure prophylaxis during a pandemic
22
Yes
See item 3.1 above on use in cluster control. In such settings antivirals can be used for people defined as contacts and for those living in a defined area where cases have occurred (and hence the antivirals will function as pre-exposure prophylaxis).
3.8) Antiviral use for treatment explicitly prioritized over that for prophylaxis
15
Yes (p170)
The plan states that: “in general, it is anticipated that National Reserve medication will be used for the early treatment of people who become ill, rather than for prophylaxis.” Also: “The NZ Pandemic Influenza Technical Advisory Group concurs with the WHO opinion that pre-exposure prophylaxis for the population at large, or for the workforce in general, is neither practical nor possible because of the very large volume of medication required. The use of National Reserve stocks in this way would unreasonably deprive many people of any chance of treatment should they become ill.”
3.9) Priority groups for treatment defined
19
Partly (p172)
The plan argues that it is not justified to be too specific at this point in time concerning prioritisation policies and criteria (p172). But it also states that “Should prioritisation become necessary, medication will be prioritised towards population groups that are suffering poorer outcomes in terms of morbidity and/or mortality AND who appear to be able to benefit most from antiviral medication, and to people who provide certain identified services and functions essential for effective direct pandemic responses.” (See the Discussion below for further comment).
3.10) Priority groups for prophylaxis defined
22
Yes
See the response to item 3.1 above (regarding border control and cluster control). Furthermore, the plan states that those on home quarantine may be on antiviral prophylaxis (p41).
3.11) Sizes of priority groups given or referenced
16
No
See responses to item 2.5 above.
3.12) Provisions for storage described
15
Yes (p168)
The plan states that: “supplies are stored in several locations in NZ, with ready-use supplies available to support a rapid response anywhere in the country within a few hours.”
3.13) Operational distribution plan for antivirals described
18
Partly
It is implied that such details exist but they are not spelled out in great detail: “Prepare for the release of National Reserve volumes of antivirals, and consider pre-positioning bulk supplies” (p39). Also: “Release antivirals for use according to policy in border management operations” (p44).
3.14) Named centres for local distribution
13
Partly
See item 3.6 above regarding CBACs.
3.15) Requirement for prescription for antivirals
11
Yes (p173)
There is no mention of any plans to change this status in a pandemic setting.
3.16) Country documents existing stockpile of antivirals
14
Yes (p168)
The precise size of the national reserve is not stated in the plan but this has been made publicly available by the Ministry (i.e. 855,000 courses13).
3.17) There is antiviral stockpile reserved specifically for early containment
6
Partly
It is planned to use some of the stockpile for cluster control (see item 3.4 above). However a set proportion of the stockpile has not been designated for this specific use (which might be appropriate given the advantages of a flexible response).
Total (out of 17 categories)
10.6/17.0 (average)
13.5/17.0
(Or 11.0/17.0 for the NZ plan using the alternative more stringent scoring approach).
In addition to the scoring process, the plan comparison resulted in various gaps in the NZ plan being identified. These gaps are briefly outlined in the tables with the major ones being around priority groups (Tables 3 and 4) and a strategic plan for pneumococcal vaccination (Table 3).

Discussion

Main findings and interpretation—The use of this framework suggests that the version 16 (current) NZ pandemic plan is generally more detailed relative to the average European plan (for those that were also available in 2006). This finding is reassuring, especially considering that the framework used had somewhat of a European focus. That is it included countries that are generally both larger and wealthier per capita than NZ and which sometimes even had their own influenza vaccine production facilities (8/29) or actual plans to develop influenza vaccine production capacity (4/29).
Some also have their own capacity to produce antivirals and all at least have near neighbours with vaccine/pharmaceutical industrial capacity. Furthermore, the framework ignored various social distancing interventions that might have allowed the NZ plan to score relatively more highly (see the limitations subsection below). Another possible disadvantage for NZ was that some of its planning work was in supporting documents that were not considered in this analysis of plans (e.g. work on ethical issues10 and evaluations of the simulation exercises that have been conducted).
The relatively favourable scores for aspects of the NZ plan are perhaps not surprising given the number of revisions the plan has undergone (currently at version 16), and the fact that the plan has benefited from fairly rigorous testing over several years.5 New Zealand society may also be relatively good at such planning given its small size, the relatively simple system of government (no state/federal system), and the fact that it needs to plan for a relatively high occurrence of other natural disasters (particularly floods, earthquakes, and volcanic events).
Nevertheless, the NZ plan is not very explicit on the issues of priority groups for vaccination and antivirals (e.g. items 2.4 and 3.9). Even so, the work from the National Ethics Advisory Committee (NEAC)10 would appear to justify being more explicit around frontline health workers being a priority group for both vaccines and antivirals. The NEAC noted that: “Opinion polls in NZ have suggested strong public support for the idea that frontline health workers should receive priority access to antiviral medication. This suggests reciprocity is a shared public value...”. (The opinion poll was reported in 200613). Similarly, other NEAC statements around patients who meet clinical criteria for care in normal times can be interpreted as also favouring the use of vaccination and antivirals for those who have greatest need.
These population groups include those already eligible for fully-subsidised seasonal influenza vaccine on the grounds of increased risk of adverse health outcomes from influenza infection. Being more explicit at a planning stage on prioritisation issues may give additional reassurance to key workers and reduce absenteeism in times of crisis (e.g. as was seen among some healthcare workers during the SARS epidemic). While the flexibility to change approach in light of the particular characteristics of a new pandemic strain is desirable, the scientific community probably knows enough about pandemic and seasonal influenza to still make reasonably detailed plans in the pre-pandemic period.
Indeed, 21 out of 22 of the European plans that covered pre-exposure antiviral prophylaxis suggested that health care workers be recipients of these.9 Another study of 31 countries reported that 84% had identified at least one priority group (and that health care workers were identified in all of these).14 As well as most other countries with plans having identified priority groups for scarce resources such as vaccines and antivirals,15 a number of these groups are specifically listed in WHO guidelines (tabulated elsewhere15). The most sophisticated prioritisation work to date may also help guide prioritisation efforts around different age groups based on years of life lost16 (albeit with potential adjustment as information on the new pandemic strain emerges). A recent major US report also highlights the need for an ethical framework to allow for prioritisation of antivirals.17
In line with these arguments, the Ministry of Health appears to be considering some prioritisation for its use of pre-pandemic vaccine. As stated on its website: “key front-line health workers and other front-line pandemic response personnel” are prioritised for this vaccine in its draft considerations.12 Prioritisation of antivirals is however far more complex given the trade-offs between potential use for the treatment of sick individuals at high risk of death and pre-exposure prophylaxis of front-line healthcare workers. The WHO recommends saving antiviral supplies for the former while Norway has explicitly prioritised antiviral prophylaxis for continuously exposed health care workers over treatment of sick patients so as to maintain a functioning health service.9
A further possible weakness of the NZ plan is the lack of specific attention to pandemic planning around avoiding the further exacerbation of health inequalities for already disadvantaged populations (as raised in the international literature18). The 1918 influenza pandemic had a disproportionately severe impact on Māori mortality19,20 and recent NZ research also indicates higher seasonal influenza hospitalisation rates among those in crowded housing and with young children.21
Another area in the NZ plan that could be strengthened is including discussion of pneumococcal vaccination (item 2.2). There is some new evidence for the impact of pneumococcal vaccine on reducing invasive disease in those aged 65 years and over.22 An earlier Cochrane systematic review also identified a benefit for preventing invasive pneumococcal disease (but not the incidence of pneumonia or death in adults with or without chronic illness).23 Various authors have recently argued for considering this vaccine in pandemic planning.24
Although NZ has taken an alternative path of stockpiling antibiotics, it could be that use of pre-pandemic pneumococcal vaccination is also worth considering and might provide additional reassurance (since it is less dependent on continued health service functioning). At least there could be evidence in the NZ plan that these issues have been given appropriate consideration by relevant experts.
Limitations of this analysis—This brief analysis has a number of limitations. A major one is that the framework used only focused on the domains of border control, vaccines, and antivirals. In particular the importance of quarantine appears to be under-rated in this framework and plans for various other non-pharmaceutical interventions are not considered at all: education strategies to reduce incoming traveller numbers; community restrictions such as school and workplace closures; media campaigns to promote hand hygiene and cough etiquette; strengthening surveillance systems; improving access to rapid diagnostic tests; promoting systems that allow remote diagnosis (e.g. via video-links over the Internet); contract tracing systems; and the promotion of voluntary sheltering (i.e. voluntary sequestration of healthy people to avoid exposure).
Furthermore, plans can also potentially have country-specific research agendas for pandemic preparedness and can demonstrate a “whole-of-government” approach to planning and these items are not in the framework used. If these issues had been considered in the framework, then the NZ plan may well have scored even higher relative to the average European plan since it does give consideration to many of these issues.
Another limitation of the framework used was that it does not weight variables according the country-specific characteristics (e.g. available resources such as vaccine production capacity mentioned above, and geographical isolation). For example, item 1.3 (mentioning following WHO recommendations on travel) was an item where the NZ plan scored “zero”. Yet this criterion might not be that appropriate for an island nation such as NZ which may wish to take a particularly rigorous approach to border control. Furthermore, WHO guidelines are fairly general and there is relatively little consideration of the special issues facing remote island nations in any WHO documents on pandemic influenza published to date.
Possibly the ideal is for there to be WHO pandemic plan assessment frameworks and guidelines that are more tailored to different types of countries and especially for island nations (given that islands may have more scope for border control and within-country control). Such frameworks could come with detailed scoring systems to allow more sophisticated approaches to quantifiable plan comparisons. This refinement would prevent the fairly crude approach to scoring undertaken in this article (i.e. where we could no obtain the data extraction tool used in the European analysis).
Earlier work by Mounier-Jack and Coker25 has been somewhat criticised for not including any site visits.26 These critics state that “the experience of the national assessments during country visits has demonstrated that looking at plans alone often gives an incomplete and sometimes misleading picture of a country’s state of preparedness.” These critics also noted that the pandemic plans in many of these European countries were rapidly superseded as a result of ongoing planning developments. These issues may also apply to some extent to this 2007 publication of European plans by Mounier-Jack et al that was used in this analysis. Nevertheless, this problem is largely unavoidable without conducting very much more expensive studies (with site visits) that are published quickly outside of the journal literature (i.e. without lengthy peer review and publishing processes).
Finally, the data extraction from the NZ plan for comparison purposes was done by only one person (NW) with no assessment for inter-observer reliability. Nevertheless, both authors do have a high level of familiarity with the content of this NZ plan as a result of ongoing research work around influenza control in recent years for different agencies.
Possible implications for future NZ planning—Based on the results and discussion above, the following specific issues could be addressed in the next (probably to appear in 2009) version of New Zealand’s pandemic plan. Some of these points may also be relevant for DHB level plans:
  • Consider the addition of more explicit details on the priority groups for vaccination, antivirals (for both treatment and prophylaxis) and other potentially limited resources (e.g. personal protective equipment). These details could extend to the different types of health workers (e.g. hospital doctors and nurses, primary care health workers, ambulance staff) and the different types of essential workers (e.g. police, fire-fighters, border control workers, defence personnel). In addition it may be desirable to specifically mention those who are currently eligible for fully-subsidised influenza vaccine due to increased risk of adverse sequelae (e.g. those over 65 years, and those with chronic heart disease, chronic respiratory disease, asthma treated with inhaled steroids).
Additional pandemic control provisions for the most needy New Zealanders could also be considered (e.g. those living in deprived areas, in crowded houses, and with large numbers of children in the house).
  • Consider adding discussion of pneumococcal vaccination in the NZ plan (item 2.2 and discussed above).
  • Consider various additions that are covered in the framework for border control (item 1.9) and with regard to vaccines (items 2.3, 2.5–2.8).
Furthermore, the NZ health sector could consider further studies of the pandemic plans of other countries (to see if additional lessons can be learnt), and could further expand its own pandemic research agenda.27,28 Possible priority plans are those from countries which have recently tested their plans in simulation exercises (e.g. Singapore, UK,29 France,30 and Australia31,32).
Other reviews of pandemic plans from multiple countries7,15 and of sub-national plans (e.g. of US states33) may also be worthy of further examination.
Competing interests: Both authors have undertaken past contract work on pandemic influenza epidemiology for the Ministry of Health, but have not participated in the drafting of the pandemic plan examined in this article. They have no other competing interests.
Author information: Nick Wilson, Senior Lecturer, Department of Public Health, University of Otago, Wellington; Michael G Baker, Associate Professor, Department of Public Health, University of Otago, Wellington
Acknowledgements: We thank the Ministry of Health for providing funding support for earlier aspects of this work (prepared in a section of a literature review for the Ministry) and for providing comment on an earlier draft of the manuscript. We note, however, that the views expressed do not necessarily reflect current Ministry of Health policy. We also thank the anonymous reviewers for the Journal who provided helpful critical comment on the manuscript.
Correspondence: Dr Nick Wilson, Department of Public Health, University of Otago Wellington, PO Box 7343 Wellington South, New Zealand. Email nick.wilson@otago.ac.nz
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