The Health of the Grampian Population:
A Review of Current and Future Health
Challenges
Original report prepared by Dr Lesley Wilkie and
Dr Catriona Hughes October 2009
Updated by Dr Emmanuel Okpo 2010
Contents
Foreward ................................................................................................................... 8
Childhood ................................................................................................................ 9
Children in Grampian ................................................................................................ 9
Births ....................................................................................................................... 10
Health of newborns and young children................................................................... 11
Life expectancy at birth ........................................................................................... 15
Ill health in childhood ............................................................................................... 17
Preventing illness in childhood ................................................................................ 21
Immunisation ........................................................................................................... 21
Dental health ........................................................................................................... 23
Lifestyle issues in later childhood ............................................................................ 24
Mortality in infants and childhood ............................................................................ 29
Working age population........................................................................................ 31
Mortality .................................................................................................................. 31
Morbidity ................................................................................................................. 34
Behavioural risk factors ........................................................................................... 36
Screening in adults .................................................................................................. 39
Infectious diseases .................................................................................................. 41
Elderly population .................................................................................................... 43
Mortality .................................................................................................................. 45
Morbidity ................................................................................................................. 45
Preventing ill health ................................................................................................. 48
Diseases of significant concern ........................................................................... 51
Cancer .................................................................................................................... 51
Coronary Heart Disease (CHD) ............................................................................... 52
Stroke...................................................................................................................... 56
Chronic Obstructive Pulmonary Disease (COPD) .................................................... 59
Chronic Kidney Disease (CKD) ............................................................................... 60
Diabetes .................................................................................................................. 61
Mental health........................................................................................................... 61
Protecting the health of the population ............................................................... 63
Outbreaks of gastrointestinal infections ................................................................... 65
Immunisation and vaccine preventable diseases..................................................... 65
Description of the UK immunisation programme ...................................................... 66
Vaccine update results - overview of 2009/2010 ..................................................... 66
Primary immunisation uptake rate by deprivation .................................................... 67
Uptake of HPV vaccine ........................................................................................... 68
Tuberculosis (TB) .................................................................................................... 71
Pandemic influenza ................................................................................................. 71
References ............................................................................................................. 72
2
List of Figures and Tables
Figure 1: percentage of children aged between 0-14 years in Grampian by
local council area (based on mid 2008 population estimates) .......................... 9
Figure 2: Projected percentage change in population aged 0-15 (2006 based),
by Grampian Council Areas 2006-2031 ......................................................... 10
Figure 3: Number of live births per year by council area4 .............................. 11
Figure 4: Smoking at Booking Grampian 2000-2006 ..................................... 12
Figure 5: Trends in percentage of women smoking during pregnancy in
Grampian 1995-2008 ..................................................................................... 12
Figure 6: Percentage of mothers smoking during pregnancy by CHP 19952008 ............................................................................................................... 13
Table 1: Proportion of mothers in Grampian breastfeeding at 6 weeks
2006/2007. ..................................................................................................... 13
Table 2: Percentage low weight live births weight Babies in Grampian & CHPs
(Singleton Births) 3 year averages 2005/06–2007/08. ................................... 14
Figure 7: Average BMI by gender and year15................................................. 14
Figure 8: Life expectancy in Grampian compared to Scotland (1981-2007) .. 16
Figure 9: Life expectancy at birth for Aberdeen City, Aberdeenshire and Moray
(1981-2007) ................................................................................................... 16
Table 3: Life expectancy at birth (2005-2007)10 ............................................. 17
Figure 10: Causes of elective admissions in children in Grampian 2007/08 7. 18
Figure 11: Causes of emergency admission in children in Grampian 2007/08 7
....................................................................................................................... 19
Table 4: Rates of unintentional injuries in the home, 3 year average crude rate
2004-200617 ................................................................................................... 19
Table 5: Emergency hospital admissions as a result of an unintentional injury
in Children aged under 15 in Grampian NHS Community Health Partnership,
and Scotland year ending 31 March 2009 ..................................................... 20
Table 6: Unintentional injury in children, 2007/087 ......................................... 20
Table 7: Uptake rates-Percentage completing primary course by 24 months of
age (1 April 2009 to 31 Marcn 2010) in Grampian, Grampian CHP areas and
Scotland ......................................................................................................... 21
3
Table 8: Percentage completing primary course by 5 years of age (1 April
2009 to 31 March 2010) in Grampian, Grampian CHP areas and Scotland .. 22
Figure 12: Percentage of Primary 1 children with no decay. .......................... 23
Figure 13: Percentage of school-aged children who have ever had a proper
alcoholic drink in Grampian 2006 compared with 2002 .................................. 24
Figure 14: Percentage of school-aged children who are regular smokers in
Grampian 2006 compared with 2002 ............................................................. 25
Figure 15: Percentage of school-aged children who have used drugs in the
month prior to the survey ............................................................................... 26
Figure 16: Teenage Pregnancy rates per 1000 women in Grampian and
Scotland 1994-2007 ....................................................................................... 27
Figure 17: Teenage pregnancy in Grampian by age group and deprivation
quintile, 2007.................................................................................................. 27
Table 9: Stillbirth and infant mortality rates per 1000 live births 3 year
averages 2006-20085 ..................................................................................... 29
Figure 18: Deaths in children under 15 years of age by SIMD14 .................... 30
Table 10: Projected percentage changes in population (2006-based), by
council areas and Grampian selected years .................................................. 31
Figure 19: Main causes of death in all age groups in Grampian, 2008. ......... 32
Table 11: Most frequent causes of death in Scotland by age group .............. 33
Figure 20: Main causes of premature death in Grampian, 2008. ................... 33
Table 12: Percentage of population reporting limiting long-term illness, 2001
census17 ......................................................................................................... 34
Table 13: Incidence rates of long term condition discharges from hospital per
100,000 Population, Grampian and Scotland 2008/2009 ............................... 34
Table 14: Incidences rates of main diagnosis discharges from hospital per
100,000 population by Financial Year in Grampian (all ages) ........................ 35
Table 15: QOF prevalence data per 100 registered patients31....................... 36
Figure 21: Percentage of population smoking by SIMD quintile, Scotland
200734. ........................................................................................................... 37
Table 16: Estimated percentage of smokers in the adult population by age and
sex, 2003/0433................................................................................................ 37
4
Figure 22: Estimated levels of harmful drinking in the adult Scottish population
by type of harmful drinking36. ......................................................................... 38
Figure 23: Percentage of selected Grampian population groups taking the
recommended level of physical activity per week. ......................................... 39
Figure 24: Persons in Grampian reported to be hepatitis C antibody positive
1999 to 31 March 200943 ............................................................................... 41
Figure 25: HIV incidence rate by year, Grampian and Scotland44.................. 42
Figure 26: Elderly population of the North east hospital region (1959-2008) . 43
Table 17: Projected population aged 65 and over (persons) 2006-2031 in
thousands ...................................................................................................... 44
Figure 27: Population projections for the 75 and over age group in Grampian 2
....................................................................................................................... 44
Figure 28: Self-perception of health by age group46 ...................................... 45
Figure 29: Trend of Admission Rates per 100,000 Population of All
Emergency Admissions for Patients Aged 65+ by Financial Year, Scotland,
Grampian and CHP........................................................................................ 46
Figure 30: Admission Rates per 100,000 Population of All Emergency
Admissions for Patients Aged 65+ by 5 year age group Grampian 2008/2009
....................................................................................................................... 47
Table 18: NHS Grampian Staphylococcus aureus bacteraemia rates January
2006-June 2009 ............................................................................................. 48
Table 19: Numbers of cases and rates of CDAD in patients 65 years and older
51 .................................................................................................................... 49
Figure 31: Deaths associated with CDAD in Grampian by year52 .................. 49
Table 20: Projected number of cases of cancer in Grampian54...................... 51
Figure 32: Projected cases per 5 year period by ICD code for Grampian 54 ... 51
Figure 33: European age-standardised incidence (2001-2005) and mortality
(2003-2007) rates for cancer in Scotland, by SIMD 2006 deprivation quintile 57.
....................................................................................................................... 52
Figure 34: CHD mortality rates among under 75 year olds in the most
deprived 15% areas (SIMD 2006); rate per 100,000 European agestandardised (EASR) 3 year rolling averages 1998-2008 .............................. 53
Figure 35: Incidence of CHD (from first hospital admission) .......................... 54
5
Figure 36: Trend, Age-sex standardised incidence rate from CHD (Standard
European population) per 100, 000 population. CHP, Grampian and Scotland
2000-2009 (all age groups) ............................................................................ 54
Figure 37: Trend, Age-Sex standardised mortality rate from CHD (Standard
European Population) per 100, 000 population. CHP, Grampian and Scotland
1999-2008 (all age groups) ............................................................................ 55
Figure 38: Trend, Age-Sex Standardised Incidence rate of cerebrovascular
disease (by first hospital admission) Grampian, CHP area and Scotland 20002009 66............................................................................................................ 56
Figure 39: Trend, Age-sex standardised mortality rates from stroke per
100,000 population (Grampian, CHP, Scotland) 2000-2009. ......................... 57
Figure 40: Standardised rates (%) of patients surviving for 30 days after an
emergency admission for Stroke in NHS Grampian Hospitals 1998-200765 .. 58
Figure 41: Age-sex standardised mortality rates (under 75) from stroke per
100,000 population in Grampian 2000-2009: Progress against targets ......... 58
Table 21: QOF Prevalence Estimates of COPD in Grampian and CHP ........ 59
Table 22 : Episodes of Care as a Consequence of COPD & Bronchiectasis
Grampian Residents ...................................................................................... 60
Figure 42: Rates of neurotic disorder by subcategory71 ................................. 62
Table 23: Admissions to mental illness specialities in Grampian hospitals by
type of admission 2007/2008 ......................................................................... 62
Figure 43: E Coli o157 2005 to 2010 ............................................................ 63
Table 24: Number of cases of reported and notified communicable disease in
Grampian in 2005-2009 ................................................................................. 64
Table 25: Number of outbreaks of gastrointestinal infection by date reported to
Health Protection Scotland 2005-2009 .......................................................... 65
Table 26: Location of outbreaks of Norovirus infection reported by NHS
Grampian ....................................................................................................... 65
Table 27: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 12
months of age in Grampian 1 April 2009 to 31 March 2010 ........................... 66
Table 28: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 24
months of age in Grampian by CHP area, 1 April 2009 to 31 March 2010 .... 67
Table 29: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 5 years
of age in Grampian by CHP area, 1 April 2009 to 31 March 2010 ................. 67
6
Figure 44: Uptake of immunisation by deprivation ......................................... 68
Figure 45: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP
Year 1 (2008/2009) ........................................................................................ 69
Table 30: Uptake of HPV Immunisation in Girls eligible for catch-up
vaccination in Grampian (year 1) ................................................................... 69
Figure 46: Uptake of HPV Immunisation in Girls eligible for the catch-up
vaccination in year 1 (2008/09) in Grampian by CHP area ............................ 70
Figure 47: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP
Year 2 (2009/2010) ........................................................................................ 71
7
Foreword
The Health of the Grampian Population brings together a range of information
regarding the health status of the population and was produced to inform the NHS
Grampian Health Plan. A life course approach has been taken in order to highlight
the range of needs which require to be addressed across the population, an
approach which appears particularly appropriate given the changes in the population
structure which are predicted in the coming years. Whilst topics have been placed
within this structure it is acknowledged that many aspects of health and disease are
of importance throughout the life course, and that health and disease do not
necessarily follow the traditional boundaries of young, middle and “old" age.
The majority of information presented in this report is routinely available and has
largely been sourced from the websites of Information Services Division (ISD),
General Register Office for Scotland (GROS) and Scottish Public Health Observatory
(ScotPHO). Local data that is not available from these sources has been provided by
Fred Nimmo, Health Intelligence at NHS Grampian or from documents produced for
NHS Grampian.
8
Childhood
Children in Grampian
Improving the health outcome for children and young people is a key priority for NHS
Grampian and its partners. The Children’s Services (Scotland) Bill 2006; ‘Getting it
right for every child’, gives clear authority and responsibility to agencies,
professionals, children, families and local communities, to work together in a way that
brings practicality and reality to the vision for Scotland's children. Fundamental to the
transition from childhood to adulthood is good health, and NHS Grampian has made
it clear that raising the health status of children and young people in Grampian is one
of its main challenges.
The most recent data about the population of Grampian is the mid -2008 population
estimates. It is estimated that there are around 88,466 children aged between 0-14
years of age in Grampian. This accounts for around 18% of the Grampian
population1. Out of which 48.7% are in Aberdeenshire, 34.9% in Aberdeen city and
16.4% in Moray (figure 1).
Figure 1 below shows the percentage of children aged between 0-14 years in each of
the local council area in Grampian based on the 2008 population estimates.
Figure 1: percentage of children aged between 0-14 years in Grampian by local
council area (based on mid 2008 population estimates)
Moray, 16.4
Aberdeen city, 34.9
Aberdeenshire, 48.7
Source: GROS, 2008
It is predicted that this population would decrease from levels estimated in 2006 by
approximately 12% by the year 20312.
This predicted change in population would vary within Grampian. However,
Aberdeenshire would see a small increase in the number of children aged 15 years
and under by approximately 0.1%2. In contrast, it is projected that this population
9
would fall by about 20% and 25% respectively in Moray and Aberdeen City2 (figure
2).
Figure 2: Projected percentage change in population aged 0-15 (2006 based),
by Grampian Council Areas 2006-2031
Projected percentage change in population
5
0
% change
-5
-10
-15
-20
-25
% Change
Sco tland
Grampian
A berdeen City
A berdeenshire
M o ray
-6.9
-12
-24.6
0.1
-19.9
Source: GRO 2008
Births
In recent years the number of births registered in Scotland each year has been
steadily increasing since 2002, with 2008 seeing the highest number of births since
19953. The number of births in Grampian follows a similar trend as can be seen in
figure 3 below. In 2008, there were 6,060 live births in Grampian compared to 5,027
live births in 2002. This figure excludes deliveries at home and births at non-NHS
hospitals.
General fertility rates across each council area have risen in keeping with this. In
2008, Moray had a live birth rate of 63 per 1000 women aged 15-44 years compared
to Aberdeenshire (61.9 per 1000) and Aberdeen City (56 per 1000). These rates are
higher than the Scottish average of 57.2 per 1000 except for Aberdeen City where
the rate is lower than the Scottish average4.
10
Figure 3: Number of live births per year by council area4
Source: GRO 2008
The proportion of live births to mothers of UK origin has decreased in recent years in
Grampian. Births to mothers of UK origin accounted for 85% of all births in 20062008 compared with 92% of all births in 2001-2003. The proportion of births to
mothers of European origin, excluding the UK and Ireland, has increased from 2% to
6% during this period, with births to mothers from all other countries increasing by
about 2% to an average of 9%4.
This increase in the proportion of births to mothers of non UK origin has significant
implications for healthcare provision in Grampian especially in the way that a wide
range of services e.g. maternity and child health services are provided.
Health of newborns and young children
There are a number of specific factors including lifestyle and health behaviour during
pregnancy which can influence the health and wellbeing of newborns and children.
Smoking in pregnancy
Smoking in pregnancy is a serious health hazard for both the mother and the unborn
child. The effect of smoking in pregnancy continues to affect the infant even long
after birth. There is conclusive evidence that a pregnant women who smokes is more
likely to have a baby with a low or very low birth weight.
In Grampian the number of women who currently smoke at their first antenatal
booking visit is comparable with that of other mainland boards. In 2007, 20.3% of
women in Grampian were current smokers at their first antenatal booking visit
compared to 24.2% in 2003. Average figures for all of Scotland during the same
period were 20.8% and 25.3% respectively.
11
Figure 4: Smoking at Booking Grampian 2000-2006
Smoking at Booking
100%
Percentage
80%
Never %
60%
Former %
Not Known %
40%
Current %
20%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008
r
p
Year end March
Source: ISD 2009
In Scotland, rates of smoking in the most deprived groups are much higher despite
improvements in rates across all deprivation quintiles. Similar trends are seen in
Grampian and across the three local council areas. In 2007/08 only 10% of Grampian
mothers in the most affluent quintile smoked during pregnancy whilst 42% of mothers
in the most deprived quintile were recorded as smoking (figure 5)7
Figure 5: Trends in percentage of women
during pregnancy in
Figure smoking
7
Grampian
1995-2008
Trend in Percentage of Mothers Smoking During Pregnancy in Grampian (1995/2008)
60
50
% Smoking
40
30
20
10
0
1995/96
1996/97
1997/98
1998/99
1999/00
2000/01
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
Quintile 5
49.9
51.32
51.53
48.84
49.1
53.76
50.58
56.05
54.91
49.39
53.6
41.45
42.39
Quintile 4
39.12
42.84
46.35
40.86
39.3
43.86
39.89
44.85
46.46
35.31
39.68
35.58
34.82
Quintile 3
31.1
29.32
31.46
32.51
30.26
30.17
30.3
34.78
29.8
27.05
26.18
25.18
24.5
Quintile2
20.66
20.19
19.83
19.89
18.52
20.18
18.35
19.72
21.96
19.56
18.4
17.66
16.17
Quintile 1
12.7
12.74
13.22
10.63
12.18
10.95
10.28
13.93
13.2
11.54
11.43
11.21
10.1
Year
Quintile 5
Quintile 4
Quintile 3
Quintile2
Quintile 1
12
Similar trend are seen across the 3 CHPs in Grampian (figure 6).
Figure 8
Figure 6: Percentage
mothers
smoking
during by
pregnancy
by CHP 1995-2008
Percentage of
of Mothers
Smoking
During Pregnancy
CHP (1995/2008)
30
25
% Smoking
20
15
10
5
0
1995/96
1996/97
1997/98
1998/99
1999/00
2000/01
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
Year
Aberdeen
Aberdeenshire
Moray
Breastfeeding19
Breast feeding has important health benefits for both mother and baby and it plays a
major role in reducing health inequalities. Breastfeeding helps to protect babies
against gastroenteritis, childhood asthma diabetes, obesity and ear and skin
infections. In mothers breastfeeding helps to protect the mother against osteoporosis,
breast and ovarian cancers.
In Grampian, breast feeding rates vary widely across the 3 local authority areas.
Since the introduction of the UNICEF Baby Friendly Breastfeeding Initiative the rates
of breastfeeding (exclusive or combination) and exclusive breastfeeding in Grampian
has been increasing. In 2007, the rate of exclusive breastfeeding in Grampian was
above the HEAT target of 33.3%. However there are still some areas in Grampian
where breastfeeding rates are very low. In Aberdeen City 33.7% of new mums were
exclusively breastfeeding at 6 weeks; however rates were as low as 14.8% in some
practices. Similarly, whilst rates of 42.9% were seen in Aberdeenshire Central, in
Aberdeenshire North only 25.4% of new mums were exclusively breastfeeding.
Table 1: Proportion of mothers in Grampian breastfeeding at 6 weeks
2006/2007.
Exclusive breastfeeding
Breastfeeding (exclusive or
combination)
2007
34.6%
2006
33.6%
47.5%
47.0%
Source: Grampian Breast feeding Audit, June 2009
13
Low birth weight (LBW)
Low birth weight is a key child health indicator6. It is associated with infant morbidity
and mortality. Babies born weighing less than 2500 grams (LBW) are more likely to
die in the first year of life and have more health and educational problems at age of
seven years. LBW is linked with a variety of social and environmental factors such as
maternal smoking, maternal age, deprivation and drug and alcohol use. In Scotland,
mothers living in a highly deprived area are twice as likely to have a LBW baby (baby
weighing less than 2500 grams at birth) compared to mothers living in a less
deprived areaa. As can be seen in table 2, levels of low weight live births in
Grampian are comparable with Scottish figures7. In 2007, around 5.7% of singleton
births in Grampian were of low birth weight7. Across the CHPs, Aberdeen City had
the highest low birth weight rate.
Table 2: Percentage low weight live births weight Babies in Grampian & CHPs
(Singleton Births) 3 year averages 2005/06–2007/08.
2005/06
2006/07
2007/08
2008/09
Aberdeen City
7.0
6.1
6.3
6.5
Aberdeenshire
5.2
4.6
4.4
4.7
Moray
5.6
5.4
5.7
5.6
Grampian
6.2
5.4
5.5
5.7
Scotland
4.9
6.1
5.5
5.8
Source: ISD Scotland 2009
Obesity
A steady increase in the body weight of high school children, as measured by BMI,
has been seen over the last 12 years in Grampian in keeping with national trends.
Since 2001, although there has been little change in weight in boys there has been
some continued increase in weight of girls15.
Figure 7: Average BMI by gender and year15
Ave rage BM I by Ge nde r
1995, 1998, 2001 and 2007
21
20.5
20
BMI
19.5
19
Males
Females
18.5
18
17.5
17
16.5
1995
1998
2001
2007
Males
18.1
19.9
20.4
20.3
Females
18.2
19.9
19.9
20.6
Ye ar
Source: Grampian Youth Lifestyle Survey, 2007
a
ISD 2009, Births in Scottish hospitals, financial year 2007/2008
http://www.isdscotland.org/isd/6026.html
14
National data (data from 10 health boards not including Grampian) for 2007/08
demonstrate that around 20% of Primary 1 children are overweight, 7.9% obese and
3.9% severely obese20. The levels of high BMI are now similar to that of 2000/01
having decreased slightly in the last 2 years after the gradual increases seen
between 2000/01 and 2005/0620.
Exercise15
Exercise holds many health benefits as well as influencing levels of obesity. In the
Grampian Youth Lifestyle Survey only 57% of boys and 34% of girls aged 16 years or
less met the national recommendations on physical activity.
Alcohol
There is currently limited data available on the use of alcohol during pregnancy.
Drug use
Data on drug use in pregnancy is incomplete, however provisional results for 2006/07
show that of all maternities (pregnancies resulting in a live or still birth) in Grampian
3.3 per 1000 recorded drug misuse8. Rates vary significantly from year to year due
to the small numbers involved8.
Life expectancy at Birth
Life expectancy at birth is used as the measure of the progress being made in
tackling health inequalities. It is frequently misinterpreted as the number of years a
child born in a particular area can, on average, expect to live. Life expectancy in a
given time period is actually an estimate of the average number of years a person
would survive if he or she experienced a particular area’s age-specific mortality rates
for that time period throughout the rest of his or her life. The figure reflects mortality
among those living in the area in each time period, rather than mortality among those
born in each area. It is therefore not the number of years a person in the area could
actually expect to live, as both the death rates of the area and place of residence of
an individual are likely to change in the future.
Over the last 20 years life expectancy at birth has been increasing for both men and
women in the Scottish population generally9. Trends during the same period for
Grampian population is shown in figure 8 below9. Life expectancy at birth for both
male and females in Grampian has continued to increase and is significantly above
the Scottish figure.
15
Figure 8: Life expectancy in Grampian compared to Scotland (1981-2007)
83
81
79
Life Years at Birth
77
75
73
71
69
67
2005-07
2004-06
2003-05
2002-04
2001-03
2000-02
1999-01
1998-00
1997-99
1996-98
1995-97
1994-96
1993-95
1992-94
1991-93
1990-92
1989-91
1988-90
1987-89
1986-88
1985-87
1984-86
1983-85
1982-84
1981-83
65
Base Year
Grampian - Female
Grampian - Male
Scotland - Female
Scotland - Male
Over the same period, life expectancy across the 3 different local council areas in
Grampian has also been increasing (figure 9).
Figure 9: Life expectancy at birth for Aberdeen City, Aberdeenshire and Moray
(1981-2007)
84
82
80
76
74
72
70
68
66
Base Year
Aberdeen - Male
Aberdeen - Female
Shire - Male
Shire - Female
Moray - Male
Moray - Female
16
2005-07
2004-06
2003-05
2002-04
2001-03
2000-02
1999-01
1998-00
1997-99
1996-98
1995-97
1994-96
1993-95
1992-94
1991-93
1990-92
1989-91
1988-90
1987-89
1986-88
1985-87
1984-86
1983-85
1982-84
64
1981-83
Life Years at Birth
78
In 2005-2007, the life expectancy at birth for men born in Aberdeen city (75.2),
Aberdeenshire (77.5) and Moray (75.9) were significantly higher than that of the
Scottish population (74.8)9. Aberdeenshire men had a significantly higher life
expectancy at birth than men born in the other council areas10.
Table 3: Life expectancy at birth (2005-2007)10
Scotland
Aberdeen City
Aberdeenshire
Moray
Life expectancy at birth (years) 2005-2007
Males
Females
74.8
79.7
75.2
80.2
77.5
81.3
75.9
80.2
Source: GRO Scotland 2008
Life expectancy of Scottish population reaching the age of 65 has increased up
to16.2 years in men and 18.8 years in women (2006-2008)10. Similar to the trends
seen for life expectancy at birth, Grampian residents, and particularly Aberdeenshire
residents, have a higher life expectancy at age 65 than the Scottish population
generally10. Healthy life expectancy, which is an estimate of how many years a
person may expect to live in good health, has increased with increasing life
expectancy. However, whilst the proportion of life spent in good health does not
appear to have changed this does mean that the number of years spent in poor
health has increased with the populations increasing life expectancy11. In 2007 it
was estimated that at birth men may expect 67.9 years and women 70.2 years of
healthy life11.
Although life expectancy is improving there still remains a significant difference
according to level of deprivation at birth. Life expectancy at birth for those born in the
10% least deprived areas (2004-2006) in Scotland is around 13.1 years longer for
men and 8.6 years longer for women than those born in the most deprived areas at
this time9. Within Grampian the life expectancy at birth of those born in Aberdeen
City (2003-2007) was 75 years and 80 years respectively for men and women. For
the most deprived 15% of this population the life expectancy was significantly lower
at 69.6 years and 75.9 years respectively10.
Ill Health in Childhood
Whilst the majority of children have good health there are significant numbers who
have chronic health problems although of variable severity. 18% of respondents to
the Grampian Youth Lifestyle Survey (2007) of secondary school children reported
long term illness or disability with 10% reporting a diagnosis of asthma15.
Hospital admissions
Children under the age of 15 years are more likely to be admitted as an emergency
than an elective admission, with children under 5 years having the highest admission
rates at 128.9 per 1,000 population (Scotland)16.
17
The most common cause of elective admission in children in 2007/08 in Grampian
was disorders of the digestive tract7. In Scotland this primarily included disorders of
the teeth, tongue and mouth, accounting for 21.8% of elective admissions in 2007/08.
These admissions were largely attributable to dental caries16. Similarly, operations
on the tooth accounted for 23.4 % of all elective procedures in this age group in
2007/08 in Scotland16. This does not include tooth extraction under sedation by
general dental practitioner or within the community dental services16. Other common
causes of elective admission are congenital anomalies, disorders/diseases of the eye
and ear, and cancers16.
Figure 10: Causes of elective admissions in children in Grampian 2007/087.
Source: PH intelligence NHS Grampian, 2009
Of emergency admissions to hospital in children under 15 years in Grampian both
‘respiratory disorders’ and ‘symptoms and signs without definitive diagnosis’
accounted for 26% of admissions7. ‘Unintentional injury’ accounts for 17.7% of
emergency admissions7. These findings are similar to those found in the Scottish
population16.
18
Figure 11: Causes of emergency admission in children in Grampian 2007/087
Source: PH intelligence NHS Grampian, 2009
In children aged 15 years and below, unintentional injuries often are the result of road
traffic accidents (RTAs), poisoning, falls, burns & scalds, drowning, choking,
exposure to animate/inanimate mechanical forces, assault, non RTA transport
accidents, over exertion and accidental exposure to unspecified factors. The
importance of reducing injuries in children is highlighted by the prominence of
accidents and injuries as both a cause of death and of hospital admission in children.
Table 4 shows that the crude rate of unintentional injuries in the home in children
under 15 years between 2004 and 2006. The rate was significantly higher in
Aberdeen City and Aberdeenshire than in Scotland16.
Table 4: Rates of unintentional injuries in the home, 3 year average crude rate
2004-200617
Unintentional injuries in the home <15 years (crude rate per
100,000 population)
Scotland
Aberdeen City
Aberdeenshire
Moray
Source: NHS Grampian Health Intelligence, 2009
1,123.5
1,950.0
1,346.4
1,071.1
Similar findings come from looking at single year figures for the year ending 31
March 2008. Emergency admissions as a result of an unintentional injury in
Grampian accounted for 13% of such admissions in Scotland. The higher than
expected results for Grampian were most prominent within the younger age groups7
During the same period, the standardised discharge ratio also showed that Grampian
as a whole and Aberdeen City CHP had significantly more emergency admissions in
children under 15 years compared to Scotland17. The increased rates in Grampian
could be due to admission practices at local hospitals, small numbers as well as an
absolute level of injuries. Thus caution should be applied when interpreting the data.
19
Table 5: Emergency hospital admissions as a result of an unintentional injury
in Children aged under 15 in Grampian, Community Health Partnerships, and
Scotland year ending 31 March 2009
Standardised
Discharge Rate
SDR
Scotland
Grampian
Aberdeen City
Community Health Partnership
Aberdeenshire
Community Health Partnership
Moray Community Health &
Social Care Partnership
100.0
123.1
Confidence intervals
Lower
Upper
100.0
100.0
115.8
130.4
157.3
143.4
171.2
108.4
98.6
118.3
92.8
77.1
108.5
Trend data from the information service division ISD, Scotland shows that on the
overall the incidence of unintentional injury discharges from hospital per 100,000
population in Grampian is falling. In 2008/09 the rate per 100,000 population in
Grampian was 1,346 compared to 1709 per 100,000 population in 2004/05.
Table 6: Unintentional injury in children, 2007/087
Number of children (Grampian)
% of Scottish population in age group
Admissions for unintentional injury
(Grampian)
% of Scottish emergency admission for
unintentional injury
Age <1 year
6,269
10.5%
84
Age 1-4
23,143
10.4%
247
21%
14%
Source: NHS Grampian Health Intelligence, 2009
Death due to unintentional injury in children under 15 years is a very rare event. In
the 5 year period between 2004 and 2008, there were a total of 117 deaths in
children less than 15 years due to unintentional injury, 15 of these where in
Grampian. During this period the Standardised Mortality Ratio (SMR) showed that
death from unintentional injury in Grampian children was 24.3% (SMR 124.3 CI 61.4
-187.2) higher than the Scottish rate. This was however not statistically significant.
SMRs reported across the Scottish health boards ranged from 154.2 in Western Isles
to 62.9 in Orkney 192 in Fife to 71.9 in Ayrshire and Arran. It is important to point out
that these are based on very small numbers and the ratios will fluctuate markedly
from year to year
20
Preventing illness in childhood
Immunisation
Many infectious diseases which can cause morbidity in childhood are included within
the childhood vaccination schedule. This has resulted in continued low levels of
these infectious diseases.
The World Health Organisation (WHO) recommends that at least 95% of children
should receive three primary doses of diphtheria, tetanus, polio and pertussis in the
first year of life; and at least 95% should receive a first dose of a measles, mumps
and rubella (MMR) containing vaccine by 2 years of age. In addition, at least 90%
should receive a booster dose of tetanus, diphtheria and polio between 13 to 18
years of age.
Vaccination uptake rates in Grampian remain satisfactory and in line with rates seen
in Scotland. In Grampian, between 1st April and June 2009, 95.2% and 92.3% of
eligible 2 year olds and 5 year olds had received their MMR1 and MMR2 vaccines
respectively (table 7 & 8)21.
Table 7: Uptake rates-Percentage completing primary course by 24 months of
age (1 April to 30 June 2009) in Grampian, Grampian CHP areas and Scotland
Percentage completing primary course by 24 months of age
Diphtheria Tetanus Pertussis Polio Hib MenC PCV MMR1
Aberdeen City CHP
98.6
98.6
98.6 98.6 98.2
94.8 95.7
95.8
Aberdeenshire CHP
98.1
98.1
98.1 98.1 97.8
96.7 97.2
94.8
Moray CH&SCP
99.2
99.2
99.2 99.2 99.2
98.5 98.5
94.6
Grampian
98.4
98.4
98.4 98.4 98.1
96.1 96.7
95.2
Scotland
98.4
98.4
98.3 98.3 98.1
96.3 96.4
93.3
Source ISD 2009
Similar trend are seen across the CHPs (table 6 and 7). However, there is increasing
concerns across the UK and Scotland with increasing number of measles cases.
Since the start of 2009, there have been 96 notifications of measles in Scotland with
16 of these cases laboratory-confirmed21. These figures include two children under
13 months old and none of the children had received MMR vaccination. Children less
than 13 months of age are normally too young for MMR vaccination and generally
rely on high levels of vaccination in the community (Herd immunity) to prevent
circulation of the infection21. This highlights the need to maintain and improve current
levels of vaccination uptake.
21
Table 8: Percentage completing primary course by 5 years of age (1 April to 30
June 2009) in Grampian, Grampian CHP areas and Scotland
Percentage completed primary course by 5 years
D
T
P
Pol
Hib MenC MMR1
Percentage
completed booster course by 5 years
D
T
P
Pol MMR2
97.7
97.7
97.7
97.7
96.3
94.2
96.3
94.0
94.0
94.0
94.0
92.2
97.0
97.0
97.0
97.0
96.5
95.9
95.6
92.9
92.9
92.9
92.9
91.0
99.1
99.1
99.1
99.1
99.1
99.1
97.4
97.0
97.0
97.0
97.0
96.1
97.6
97.6
97.6
97.6
96.9
95.8
96.2
94.0
94.0
94.0
94.0
92.3
Scotland
98.3
Source: ISD 2009
98.3
98.3
98.2
97.3
97.6
96.2
89.6
89.6
89.5
89.5
87.5
Aberdeen City
CHP
Aberdeenshire
CHP
Moray
CH&SCP
Grampian
Screening
The aim of population screening programmes is to identify those who are at
increased risk of having or developing a particular disease so that early diagnosis,
prevention and treatment may be provided. This should then reduce the burden of
deaths and ill health as a result of the disease.
Screening in pregnancy
Women are screened during pregnancy for the following infectious diseases:
 hepatitis B;
 rubella;
 syphilis; and
 HIV;
All of these diseases can have significant implications for the child, for future
pregnancies, as well as for the mother. In Grampian, the number of women engaging
with these services is good with an uptake of over 95% in recent years22.
Screening for Down’s syndrome and Neural Tube Defects, as well as Sickle Cell
Disease and other foetal anomalies, is also offered during pregnancy. Work is
underway in Grampian to implement the changes to the national screening
programme for these conditions. Recent surveys indicate that more and more
Grampian women are accepting to be screened. This increase in screening request
and new developments in the screening programme means that more resources are
required to maintain the current service workload.
Screening in children
Screening in the first days of life involves a physical examination and bloodspot
testing. The bloodspot currently tests for three metabolic disorders including Cystic
Fibrosis, Congenital Hypothyroidism and Phenylketonuria. This is currently being
extended to detect Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD)
and Sickle Cell Disease, disorders in which an early diagnosis can offer considerable
health advantages. Laboratory testing of bloodspots is undertaken at the Scottish
Newborn Screening Laboratory in Glasgow, but investment is required within
Grampian in order to ensure that staff and pregnant women understand the
implications of changes to this screening test and can make informed choices. In
addition, the follow-up of any abnormalities detected will impact on local resources.
22
Children in NHS Grampian are also invited for screening through the Universal
Newborn Hearing Screening Programme and the Pre-school Orthoptic Vision
Screening Programme.
Dental health23
Dental health in Grampian has fluctuated over the years however the 2007/2008
survey of oral health in Primary 1 children showed the best results to date with 58.6%
of children showing no signs of dental decay. This was close to the target of 60% to
be achieved by 2010 and just above the Scottish level of 57.7%.
Despite the improvements over 500 children started school with dental abscesses
and/or gross disease in Grampian, many requiring urgent care. Significant
discrepancies are seen between the community health partnerships, with Aberdeen
City continuing to be well below the national target. 13.7% of children starting school
in Aberdeen City in 2007/08 had gross disease.
Figure 12: Percentage of Primary 1 children with no decay.
Source: NHSGrampian National Inspection Programme, 2007/2008
Results vary significantly even within council areas. The largest variations are seen
within Aberdeen City. In some schools over 90% of primary 1 children had no decay
whilst in others less than 20% had no decay. Nationally there is a clear correlation
between tooth decay and deprivation with the most deprived groups some way from
reaching the target of 60%.
23
Lifestyle Issues in later childhood
There are a number of behaviours influencing health that may be explored in later
childhood including alcohol, smoking, drug use and sexual behaviour.
Alcohol
There was a significant decrease in the proportion of 13 and 15 year olds in
Grampian who had ever had an alcoholic drink from 91% of 15 year olds and 71% of
13 year olds in 2002 to 87% and 60% in 2006 respectively. Similar declining trends in
drinking prevalence of 15 and 13 year old school children although to a lesser degree
were noticed across the three Grampian Local Authority Areas during the same
period (figure 13).24
15 year olds
Moray
Aberdeenshire
Aberdeen city
Grampian
Moray
Aberdeenshire
Aberdeen city
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Grampian
Percentage
Figure 13: Percentage of school-aged children who have ever had a proper
alcoholic drink in Grampian 2006 compared with 2002
13 year olds
2002
2006
Source: Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS), 2008
In 2006, boys in Aberdeen city were significantly more likely to have an alcohol drink
in the last week prior to the survey compared to girls. There was no significant
difference in the proportion of boys and girls in Aberdeenshire and Moray who had
had an alcoholic drink in the last week prior to the survey.
The Grampian Youth Lifestyle Survey 2007 of secondary school pupils found that
45% of pupils reported consuming alcohol in the seven days prior to the survey,
ranging from 28% of 1st year students to 94% of 6th year students15. Whilst there was
a decrease in the number of young people drinking alcohol in comparison with 200115
consistent with the SALSUS 2008 survey24, the average number of units consumed
by young people who did drink had increased15. Numbers of young people recorded
to be drinking on 3 or more days per week has remained static since 199515.
24
Smoking
The numbers of young school-aged children in Grampian reporting that they smoke
regularly is decreasing. The 2006 Scottish Schools Adolescent Lifestyle and
Substance Use Survey SALSUS showed similar decreasing trends across the 3 local
council areas (Figure 14). There is no significant difference in the proportion of boys
and girls who smoke regularly24. The same survey found that smoking in secondary
school pupils had decreased overall to 12%15.
Figure 14: Percentage of school-aged children who are regular smokers in
Grampian 2006 compared with 2002
30%
Percentage
25%
20%
15%
10%
5%
15 year olds
Moray
Aberdeenshire
Aberdeen city
Grampian
Moray
Aberdeenshire
Aberdeen city
Grampian
0%
13 year olds
2006
2002
Source: Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS), 2008
Drugs
Both the Grampian Youth Lifestyle Survey 2007 and the SALSUS surveys have
shown a decrease in the number of Grampian children (13 and 15 year olds) being
offered drugs15,24. There has also been a decrease in the number of Grampian
children reporting that they have ever used or taken drugs in 2006 compared with
2002. Similarly the was a decrease in the number of children in both age groups who
reported that that they had used drugs in the month prior to the 2006 survey.
However, across the three CHPS, there was a significant decrease in the proportion
of 15 year olds and 13 years olds in Aberdeenshire who had ever used drugs in 2006
compared to 2002, whereas in Aberdeen city, this decrease was only seen in 15 year
olds. In Moray there was no significant change in the proportion of children of both
age groups who had ever used a drug in 2006 compared to 2002. In the one month
prior to the 2006 survey compared to the 2002 survey, the was a significant decrease
in the proportion of 13 and 15 year olds who reported that they had used drugs in
Aberdeen City and Aberdeenshire. In Moray, the decrease was only seen in 15 year
olds. In those who reported that they had used drugs, the average age when a pupil
tried drugs was 12 years in Aberdeen City compared to 13 years in Aberdeenshire
and Moray24. The Grampian Youth Lifestyle survey has also shown a decreasing
trend in the use of drugs. The survey showed that 14% of pupils reporting trying
drugs in the 2007 survey compared with 21% in 2001 and 30% in 199815. Cannabis
25
remains the most widely used drug. Of concern 14% of children who had tried drugs
reported using cocaine and 19% had used gas/glue and other solvents15.
Figure 15: Percentage of school-aged children who have used drugs in the
month prior to the survey
45%
40%
Percentage
35%
30%
25%
20%
15%
10%
5%
15 year olds
Moray
Aberdeenshire
Aberdeen city
Grampian
Moray
Aberdeenshire
Aberdeen city
Grampian
0%
13 year olds
2006
2002
Source: Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS), 2008
Sexual health25
Reducing unintended teenage pregnancy is a national target for the Scottish
Government. Whilst for some young women this will be a positive life decision, in
many cases the pregnancy will be unplanned, unwanted and an indication of unsafe
sexual behaviours. Teenage pregnancy rates have been fairly steady across
Grampian over the last 14 years (figure 16). From 2001 onwards, Grampian rates (all
age groups) have been consistently lower than the Scottish average. Over the
period 2005-2007 just over half of teenage pregnancies in those less than 18 years in
Grampian resulted in abortions.
26
Figure 16: Teenage Pregnancy rates per 1000 women in Grampian and
Scotland 1994-2007
70.0
Rates per 1,000 women
60.0
50.0
Scotland > 20
Grampian >20
40.0
Scotland >18
Grampian >18
30.0
Scotland >16
Grampian >16
20.0
10.0
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
-
Year
Source: ISD 2009, Teenage pregnancy data
Teenage pregnancy is associated with deprivation and rates of teenage pregnancy in
deprived areas are more than three times those of the least deprived areas (Figure
17).
Figure 17: Teenage pregnancy in Grampian by age group and deprivation
quintile, 2007
Source: ISD 2009, teenage pregnancy data
However, within Grampian, Aberdeen City has rates above the national average
whilst rates in Aberdeenshire and Moray are significantly lower. Rates of teenage
pregnancy in the two most deprived quintiles were higher than equivalent
communities in Scotland each year between 2003-2006, in 2007 this was only seen
in SIMD 4.
27
Sexually transmitted infections (STIs) affect all age groups. Of concern are the
increasing levels of these infections particularly among young people. Almost a
quarter of all acute STI diagnoses, in GUM clinics in 2008, were in those aged less
than 20 years26.
The Grampian Youth Lifestyle Survey 2007 highlighted concern over knowledge of
sexually transmitted infection amongst secondary school pupils. Knowledge of HIV
amongst young people was found to have fallen since 200115. However, 74% of
pupils reported never to have had sexual intercourse and of those who were sexually
active an increased number reported using condoms (90%)15.
Chlamydia27
There has been a 26% increase in
Chlamydia between 2003 and 2007.
Over 70% of diagnoses are in those less
than 25 years, the majority aged 20-24.
Rates of diagnoses in Grampian in 2007
were just below those of Scotland.
Genital herpes27
Diagnoses have been increasing in
Scotland. More than half are in women
and most diagnoses were made in
women aged 20-24 and men aged 25-34.
Rates in women in Grampian are among
the lowest at around 30 per 100,000,
however rates in men are the second
highest in Scotland at around 45 per
100,000.
Syphilis27
Diagnoses have increased since the reemergence in 2000/2001. Between 2003
and 2007 there has been a three-fold
increase in diagnoses. Increases have
been primarily in men who have sex with
men (MSM), however, between 2006 and
2007 the number of cases of
heterosexually acquired syphilis
increased by 28%, with the largest
increases in those aged 20-24 and aged
35-44. Rates of diagnoses of syphilis in
men in Grampian are below those for
Scotland.
Genital warts27
The annual number of new diagnoses in
both men and women has increased by
35% over the past 10 years. In 2007
more than two thirds of new diagnoses in
men were aged 20-34, with two thirds of
female cases in those aged 15-24. The
greatest increases in 2007 were among
men aged 25-34 and in women aged 1519. Rates in Grampian are around the
lowest in Scotland in 2007.
28
Mortality in infants and childhood
Infant mortality (death rates in infants) is a useful indicator of the health of the
overall population and the quality of health services. It is strongly associated with
deprivation. Grampian stillbirth, perinatal, neonatal and infant death rates compare
favourably with the Scottish rate5.
Table 9: Stillbirth and infant mortality rates per 1000 live births 3 year averages
2006-20085
Scotland
Aberdeen City
Aberdeenshire
Moray
Stillbirths
Infant deaths
5.4
6.0
4.3
5.5
4.5
4.6
3.1
3.5
.
However, within the three local council areas in Grampian, variations in these rates
can be seen5. Infant mortality rate (2006-2008) in Aberdeen city was 4.6 per 1000
live births compared to 3.1 and 3.5 per 1000 live births in Aberdeenshire and Moray
respectively. The rate in Aberdeen City was higher than the corresponding figure for
Grampian and the Scottish. Caution must however be exercised when interpreting
these figures as death in infancy is a rare event and even one additional death, or life
saved can make a large difference to the rates calculated as they are based on small
numbers of deaths.
Childhood mortality: The number of deaths that occur in childhood in Scotland is
small in keeping with most developed countries. In Grampian there were only 26
deaths in children under the age of 15 years in 20087. Of those deaths that do occur,
many are related to genetic diseases which cause death in early childhood.
The small numbers of deaths involved make it appropriate to analyse trends at a
Scottish level rather than within Grampian. Preliminary 2008 figures show that more
than two thirds of the 356 deaths in childhood in Scotland occurred in children under
the age of one with almost 50% occurring before the age of 4 weeks12. The major
causes of death in children are perinatal conditions, such as disorders relating to
prematurity and respiratory and cardiovascular disorders. Congenital anomalies are
the second most common cause of death13.
The main causes of death in childhood in Scotland between the age one and
fourteen are external causes of death (29%) which include accidents, self harm or
assault, or cancer (18%)12.
29
Figure 18: Deaths in children under 15 years of age by SIMD14
There is a clear association between rates of death in children and the environment
into which they are born in terms of the levels of deprivation of their parents14.
30
Working age population
The working age population accounts for 68% of the male population and 59% of the
female population of Grampian1. Within Grampian, corresponding figures for working
age group are for Aberdeen City (71% of male population and 62% of female
population), Aberdeenshire (66% male and 58% female) and Moray (66% male and
55% female)
Based on the 2006 mid year population estimates, it is projected that the population
aged 15-64 years will decrease by 5 % in Grampian by 2031. Between 2011 and
2031, Aberdeen City and Moray will seen a year on year decrease in the population
of those aged 15- 64 years, whereas, Aberdeenshire will see a slight increase in the
working age during the same period (table 10).
Table 10: Projected percentage changes in population (2006-based), by council
areas and Grampian selected years
2011
Aberdeen City
Aberdeenshire
Moray
Grampian
2016
0
4
1
2
2021
-3
7
1
2
2026
-7
8
-2
1
2031
-10
10
-4
0
-16
8
-10
-5
Source GRO, 2009
Mortality
All ages
The main causes of death in the Scottish population are ischaemic heart disease and
malignancy and this is mirrored in the Grampian population. In 2008, there were
5322 deaths (all age groups) in Grampian compared to 5317 in 2007. Of the 5322
deaths in Grampian in 20087;
 1479 deaths (28%) were due to cancer with 6% of all deaths due to cancer of the
bronchus and lung and 2% due to cancer of the breast,
 824 deaths (16%) were due to coronary heart disease,
 675 deaths (13%) were due to diseases of the respiratory system,
 505 deaths (10%) were due to cerebrovascular disease,
 286 deaths (5%) were due to mental and behavioural disorders,
 253 deaths (5%) were due to diseases of the digestive system, with 1% of all
deaths due to chronic liver disease,
 217 deaths (4%) were due to external causes including accidents (2% of all
deaths), falls, poisoning, intentional self harm and assault.
31
Figure 19: Main causes of death in all age groups in Grampian, 2008.
Others
26%
Cancer
28%
Injury etc
4%
Digestive
5%
Respiratory
13%
CHD
15%
Stroke
9%
Source: NHS Grampian Public Health Intelligence 2009
Working age group
Mortality in the working age population under 65 years of age is described as
premature mortality. The main causes of death in all age groups in Scotland are
somewhat similar to the most frequent causes of death in those aged 65 years and
below except that in those aged 65 years and below, lifestyle risk factors such as
alcohol and drug misuse contribute significantly to the main causes of death in this
age group28. This difference can be seen in table 11 below.
32
Table 11: Most frequent causes of death in Scotland by age group
Most frequent causes of death in Scotland, 2005-2007
All ages
1. Acute myocardial infarction
2. Cancer of the bronchus and lung
3. Chronic ischaemic heart disease
4. COPD
5. Pneumonia
6. Stroke
7. Dementia
8. Sequelae of cerebrovascular
disease
9. Breast cancer
10. Alcoholic liver disease
Those aged 65 years and below
1. Cancer of the bronchus and lung
2. Acute myocardial infarction
3. Chronic ischaemic heart disease
4. Alcoholic liver disease
5. Breast cancer
6. COPD
7. Intentional self-harm
8. Mental and behavioural disorders
due to alcohol use
9. Mental and behavioural disorders
due to opioid use
10. Oesophageal cancer
Source Scottish Public Health Observatory, 2009
In Grampian in 2008 there were 1023 premature deaths7. Of these deaths (figure
20);






362 deaths (35%) were due to cancer,
140 deaths (14%) were due to external causes,
131 deaths (13%) were due to coronary heart disease,
79 deaths (8%) were due to diseases of the digestive system,
44 deaths (4%) were due to diseases of the respiratory system,
29 deaths (3%) were due to cerebrovascular disease.
Figure 20: Main causes of premature death in Grampian, 2008.
Others
23%
Cancer
35%
Injury
14%
Digestive
8%
Respiratory
4%
CHD
13%
Stroke
3%
Source: NHS Grampian Public Health Intelligence 2009
33
Morbidity
Long-term conditions contribute significantly to both mortality and morbidity within the
population. Although long-term conditions can affect any age group, they are more
common in the elderly population. The prevalence of long-term conditions is
increasing because of the increasingly elderly population and medical advances that
has allowed people to live longer with these conditions. These long-term conditions
have significant impact on the individual patient, and their family and place an
increasing strain on health services due to the need for ongoing medical care. In the
2001 census, around 20% of adults in Scotland reported having a limiting long-term
illness17. Rates in each council area in Grampian were significantly below the
Scottish rate17.
Table 12: Percentage of population reporting limiting long-term illness, 2001
census17
Adults reporting limiting long term illness
17.5%
15.3%
16.7%
20.3%
Aberdeen city
Aberdeenshire
Moray
Scotland
Source: Scottish Public Health Observatory, 2009
The prevalence of chronic, long-term conditions is associated with social deprivation.
Whilst just over 10% of the least deprived population reported limiting long term
illness over 20% of the most deprived population reported these problems17.
Neuropsychiatric conditions, disorders of vision, hearing loss and alcohol use
disorders are dominant as nonfatal but disabling conditions. It is estimated that
neuropsychiatric disorders, including depression, alcohol use disorders, dementia
and drug use disorders, cause around one third of the ‘years of life disabled’ in high
income countries such as the UK.
Other leading causes of disability are
osteoarthritis, chronic obstructive pulmonary disease, diabetes mellitus and
asthma29.
Table 13: Incidence rates of long term condition discharges from hospital per
100,000 Population, Grampian and Scotland 2008/2009
Scotland
Grampian
Aberdeen
City
Aberdeenshi
re
Moray
Diabete
s
Mellitus
42
33
Hypertensi
ve
Diseases
19
10
Angina
Pectori
s
109
62
Acute
Myocardi
al
Infarction
151
155
Other
Ischaemi
c Heart
Disease
137
167
Heart
Failur
e
92
79
COP
D
126
95
Asthm
a
71
55
33
8
64
168
160
63
104
67
28
51
14
6
49
96
140
172
160
213
86
104
78
127
47
51
Source ISD 2009
34
Hospital admissions30
The most common diagnoses resulting in hospital admission in the Grampian
population in 2007/08 were diseases of the digestive system, followed by diseases of
the circulatory system and neoplasm’s (table 14). Admissions due to ‘injury,
poisoning and certain other consequences of external causes’ and diseases of the
respiratory system also resulted in significant numbers of hospital admissions.
Table 14: Incidences rates of main diagnosis discharges from hospital per
100,000 population by Financial Year in Grampian (all ages)
Rates per 100,000 Population by Financial Year
Diagnosis
Description
2004/05 2005/06 2006/07 2007/08
2008/09
Certain infectious and
parasitic diseases
Neoplasms
Diseases of the nervous
system
Diseases of the eye and
adnexa
Diseases of the
circulatory system
Diseases of the
respiratory system
Diseases of the digestive
system
Diseases of the skin and
subcutaneous tissue
Diseases of the
musculoskeletal system
and connective tissue
Diseases of the
genitourinary system
Injury, poisoning and
certain other
consequences of external
causes
Source ISD 2009
235
793
228
786
225
768
239
772
249
844
261
264
250
233
244
169
189
222
223
300
1,277
1,242
1,293
1,250
1,267
913
950
1,012
1,032
1,029
1,909
1,955
1,960
2,115
2,341
277
275
282
275
285
846
997
1,013
999
1,084
903
910
918
905
1,017
1,508
1,502
1,453
1,494
1,477
GP consultations31
The table below demonstrates that for the selected clinical conditions which are part
of the Quality and Outcome Framework, prevalence in Grampian is comparable to
prevalence in the Scottish population. A number of these conditions will be
examined in more detail later in the report.
35
Table 15: QOF prevalence data per 100 registered patients31
QOF prevalence data for Scotland and Grampian for 2007/08
Grampian
Scotland
Hypertension
12.09
12.88
Obesity
8.63
7.34
Depression
5.27
6.95
Asthma
5.60
5.51
Coronary Heart Disease
4.04
4.48
Hypothyroidism
3.98
3.25
Diabetes
3.49
3.70
Chronic Kidney Disease
3.27
2.71
Stroke and TIA
1.75
2.00
COPD
1.36
1.87
QOF prevalence data for Scotland and Grampian for 2007/08 (cont.)
Grampian
Scotland
Cancer
0.92
1.09
Heart failure
0.81
0.86
Mental health
0.72
0.79
Epilepsy
0.66
0.70
Dementia
0.61
0.57
LVD
0.51
0.61
Learning disabilities
0.46
0.43
Behavioural risk factors
Many of the conditions resulting in significant mortality and morbidity in the
population are potentially preventable, particularly as a cause of premature mortality.
On a global scale it is estimated that at least 80% of premature deaths from
cardiovascular disease and strokes could be prevented through a healthy diet,
regular physical activity and avoiding the use of tobacco32.
Smoking
In 2004 an estimated 24% of all deaths in Scotland, or 13,473 deaths, were attributed
to smoking33. This figure does not include those who may have died due to passive
smoking. Findings are similar in both men and women although there are signs that
smoking attributable deaths in men are falling whilst little change has been seen in
women33. In Grampian 21% of all deaths, or 5,418 deaths, between 2000-2004 were
estimated to be attributable to smoking33.
The proportion of individuals smoking generally decreases with age34. Although
traditionally smoking rates were significantly higher amongst men there is now little
difference between the sexes in the levels of smoking34. Higher proportions of
individuals from the most deprived areas are smokers. The 2007 Scottish Household
Survey shows that 42% of individuals in the 15% most deprived communities smoke
in comparison to 23% in the rest of the population34.
36
Figure 21: Percentage of population smoking by SIMD quintile, Scotland
200734.
The estimated percentage of smokers in the adult population by age and sex in
2003/04 is shown in the table below. Rates of smoking at this time were highest in
Aberdeen City (26.5%) and lowest in Aberdeenshire (22.8%)30. Both the QOF
prevalence figures31 and new survey results from the Scottish Health Survey 200734
suggest around 21% of the population are smokers. This would represent an
improvement in levels of smoking in Grampian.
Table 16: Estimated percentage of smokers in the adult population by age and
sex, 2003/0433
Males
Females
All
16-24
28.2
29.6
28.9
25-34
31.6
27.6
29.6
35-44
26.9
25.1
26.0
45-54
26.1
25.5
25.8
55-64
22.8
22.7
22.8
65-74
16.5
17.3
16.9
75+
9.9
10.4
10.2
16+
25.2
23.5
24.4
Alcohol
Alcohol intake in excess of recommended limits and binge drinking which, is defined
as drinking over double the daily recommended limit both have health consequences.
These consequences may be long term health problems or acute illness; and very
often there are also associated significant social consequences. 1 in 20 deaths in
Scotland are estimated to be attributable to alcohol whilst 1 in 20 of all patient
discharges is related to alcohol35. In Grampian there were 97 deaths on average per
year between 2005 and 200735. Deaths attributable to alcohol are proportionately
higher in younger age groups and in men. One in four deaths in men aged 35-44
years old in Scotland in 2003 were attributable to alcohol consumption35. Whilst it is
well recognised that diseases such as alcoholic liver disease are wholly attributable
to alcohol therefore potentially avoidable, there are many illnesses not routinely
recognised by the public to be related to alcohol use. For example approximately
20% of breast cancer mortality and morbidity in Scotland is estimated to be due to
alcohol consumption35.
It is estimated that around 22% of the adult population drink alcohol at hazardous or
harmful levels with little variation in these figures seen across Scotland36. Around 5%
37
of the adult population is thought to have alcohol dependence36. Some estimates of
the levels of harmful alcohol use in the population are shown in figure 22 below36.
Figure 22: Estimated levels of harmful drinking in the adult Scottish population
by type of harmful drinking36.
There is little variation in the proportion drinking above recommended limits by age
until age 65-74 when consumption starts to reduce36. However, the proportion of
each age group consuming more than twice the recommended limits in the week
preceding the survey decreases with age36. There is a mixed picture in regard to
drinking patterns according to level of deprivation. Average consumption on the
heaviest drinking day increases with increasing deprivation in men however there is
little difference between women in the SIMD quintiles36. In contrast men and women
in the most affluent quintile are more likely to exceed weekly limits36.
Obesity
Overweight and obesity are most commonly assessed using the body mass index
(BMI) which is calculated according to weight and height. Obesity is defined as a
BMI greater than 30 kg/m2 which is a level at which the risk of developing many
diseases increases.
There is limited data available on the prevalence of obesity in the population. Quality
and Outcome Framework data estimates a prevalence of obesity in the Grampian
population of 8.63 per 100 population31 but is likely to significantly underestimate the
extent of the problem. Estimates from the 2003 Scottish Health Survey suggest that
around 24.2% of the Scottish population are obese37. By both these measures, levels
of overweight and obesity are similar in the Grampian population and in the Scottish
population31,37. The mean BMI in men in Scotland is estimated as 27.0 kg/m2 and in
women 27.2 kg/m2 37. The number of individuals who are overweight or obese tends
to increase with age until age 74 before declining37. There is an association between
obesity and increasing deprivation however the picture is mixed in regard to
overweight. Men in the highest income households are more likely to be overweight
whilst the women in these household are least likely to be overweight37.
Exercise
The recommended levels of physical activity for health are:
 Adults: 30 minutes of moderate intensity activity on 5 or more days per week
 Children: 60 minutes of moderate intensity activity on 5 or more days per week
National survey data indicates that 44% of adult men and 33% of adult women meet
the minimum recommended activity levels for health. Local data shows that only 57%
38
of boys and 34% of girls (aged 12-16 years) and 38% of male and 24% of females
(aged 18-25 years) achieve the physical activity recommendations38.
Figure 23: Percentage of selected Grampian population groups taking the
recommended level of physical activity per week.
Percentage (%)
Percentage of population taking
recommended levels of exercise per week
90
80
70
60
50
40
30
20
10
0
Target
Male
Female
All Adults
Young People
(aged 18-25)
Youths (aged 1216)
Screening in adults
A number of screening programmes are offered to the adult population with new
programmes recently offered or likely in coming years.
Screening for breast cancer is offered to all women aged 50 to 70 years of age. In
contrast to screening for cervical cancer the uptake of breast cancer screening has
remained consistently above the target of over 80% of eligible women attending for
screening34. In Grampian the uptake of breast screening has risen to 83.1% of
eligible women for the 3 year period 2005/06 – 2007/0839. This compares to a
Scottish average of 76.2% and is one of the highest rates amongst the Scottish
health boards39.
Screening for cervical cancer is the longest running population screening
programme. Through the detection of premalignant conditions, cervical screening
has the ability to prevent the occurrence of cancer as well as detecting malignancy at
an earlier stage. In recent years a consistent decline has been seen nationally in the
uptake of cervical screening, especially in younger age groups, with uptake falling to
69.7% in Scotland in 2007/0840. A rise in uptake of 4% was seen in 2008/09 thought
to be attributable to the publicity around the death of Jade Goody from cervical
cancer and the HPV vaccination campaign40. Whilst this is promising uptake remains
significantly below levels seen 1995 to 200540.
Bowel cancer is the third most common cancer in the UK and the second leading
cause of cancer death41. The screening programme aims to identify cancers at an
early stage but also prevent some cancers by removing polyps before they develop
any malignant changes. The programme is being rolled out across Scotland
between 2007 and 2009 and involves men and women aged 50-74 years being
screened every two years. Grampian was a pilot area for the programme and
therefore among the first of the health boards to provide this service. Uptake in
Grampian between June 2007 and May 2009 was 60.5%, above the target of 60%
and the national figure of 56.8%41. Uptake in Grampian, as in Scotland, is lower
amongst men (56.5%) than women (64.4%)41. More cancers were detected in men
than in women41. Uptake is lower in deprived areas with an uptake of 64.8% in the
39
most affluent areas in Grampian compared with an uptake of only 42.2% in the most
deprived areas41.
The Diabetic Retinopathy Screening Programme in Grampian (2000) for ages 12
and over continues to experience a high volume of referrals for screening. This
reflects the substantial and ongoing increase in the number of people in Grampian
being diagnosed with diabetes22. Over the 5 years since the establishment of the
service until 2006 the number of people diagnosed with diabetes in Grampian almost
doubled22. Information from the 2005 Scottish Diabetes Survey suggested that
77.9% of people registered as having diabetes mellitus in Grampian had a record of
having retinal screening within the previous 15 months. These rates were higher
than the Scottish average of 67.7%22.
Screening for Abdominal Aortic Aneurysm is also likely to be introduced in coming
years for men over 65 years. The prevalence of this condition is high (5% in men
aged 60-69) and increases with age22. It may remain asymptomatic for years
however aneurysms over a certain size carry a high risk of rupture22. Mortality after
rupture is high – approximately 80% in those who reach hospital and 50% in those
undergoing emergency surgery22. Introduction of this new screening programme
nationally will require investment in resources within Grampian and produce
significantly increased activity within radiology and vascular surgical departments
both during the screening process and in treating those identified.
40
Infectious diseases
In developed countries infectious diseases no longer account for the majority of
illness and death. However, there are a number of infectious diseases which are of
concern currently.
Hepatitis C42
Hepatitis C was first identified in 1989 and is a slowly progressive disease of the
liver. It can lead to liver failure and/or liver cancer, however it is potentially treatable.
In many cases it will cause no symptoms leaving infected individuals unaware that
they may have the disease whilst complications are developing. There are estimates
that around 1% of Scotland’s population has been infected with the great majority
aged less than 50 years. As at 31 March 2009, approximately one in 240 of
Scotland’s population had been diagnosed hepatitis C antibody-positive. Around
11% of those identified in Scotland are resident in Grampian. Since 1990, a total of
2928 cases of hepatitis C antibody positive cases have been diagnosed in Grampian.
Figure 24 gives a break down of the number of cases of hepatitis C antibody
positivity per year. It is estimated that the number of undiagnosed hepatitis C
antibody-positive cases in Scotland still exceeds the number of diagnosed cases.
Figure 24: Persons in Grampian reported to be hepatitis C antibody positive
1999 to 31 March 200943
350
300
Numbers
250
200
150
100
50
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
290
259
245
204
198
167
Year
177
187
148
184
58
Source: HPS weekly surveillance report, July 2009
HIV27
New diagnoses of HIV have increased in recent years in Scotland and in Grampian.
This may be in part attributable to the increasing trend to offer and recommend an
HIV test to all genitourinary medicine clinic attendees suspected of having a sexually
transmitted infection. Since 2000 more new HIV infections have been diagnosed in
heterosexual individuals than in men who have sex with men (MSM). Around 76% of
non-intravenous drug using heterosexual cases probably acquired their infection
abroad, predominantly in African countries.
41
Figure 25: HIV incidence rate by year, Grampian and Scotland44
Source: Health Protection Unit NHS Grampian
There has been a downward trend in AIDS diagnoses and AIDS related deaths since
the introduction of effective therapies in 1996 – around three-fold and twelve-fold
decreases respectively. In 2007, 2668 HIV-infected persons were receiving HIV
specialist care in Scotland, 203 in Grampian.
42
Elderly population
The population of people aged 65 years and over in Grampian has been increasing
steadily over the last 40 years. The greatest rise has been in the over 85 year age
group (figure 26). The 2008 mid-year population estimate shows that there are
currently about 86,398 individuals aged 65 years and over in Grampian. This
accounts for about 16% of the population of Grampian. Overall, this increase in the
elderly population is significantly more in female (24%) than in the male (14%)
population1.
Figure 26: Elderly population of the North east hospital region (1959-2008)
20000
18000
16000
14000
Population
12000
10000
8000
6000
4000
2000
Year
Males 75-84
Females 75-84
Males 85+
Females 85+
Source: GROS, 2009
Based on 2006 population estimate, it is projected that the population of those aged
65 years and over in Grampian will increase by 51% by 2031 making up 28% of the
total Grampian population2. Within Grampian, the projected population of those of
pensionable age by 2031 will be greatest in Aberdeenshire (75.9%) compared to
Aberdeen City (27.5 %) and Moray (38.8%)2.
43
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1973
1971
1969
1967
1965
1963
1961
1959
0
Table 17: Projected population aged 65 and over (persons) 2006-2031 in
thousands
Age
Group
Aberdeen city
Aberdeenshire
2006
2011
2016
2021
2026
2031
65-74
16.9
16.8
19.9
22.3
23.3
24.5
75+
15.3
16.5
17.6
18.9
22.6
25.5
65-74
20.0
23.7
30.0
33.8
35.2
37.9
75+
16.5
19.2
22.8
28.1
35.9
42.3
65-74
8.5
9.2
10.6
11.3
11.4
12.4
6.8
7.8
8.9
10.4
12.4
13.8
Moray
75+
Source: GROS, 2009
In those aged 75 year and over, the projected increase in the population in Grampian
is 27.6% (49,304) by 20162. By 2031 the estimated increase in this section of the
population Figure 27) is around 111% on 2006 values2. This projected increase is
above the national projections of an 81% increase2. The projected increase in the
Aberdeenshire population aged 75 and over is 156%, a change from around 16,500
to 42,3002. This is the greatest projected rise in Scotland2.
Figure 27: Population projections for the 75 and over age group in Grampian2
Number of people aged 75+
Population projections for the 75 and over
age group in Grampian
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
2006
2011
2016
2021
2026
2031
Source: GROS, 2009
This predicted rise in the population of older people has considerable implications for
the provision of health and social care within Grampian. This is because older people
have considerable needs for health services and are high users of health services.
Furthermore, once admitted, patients in this age group typically have a longer length
of stay in hospital compared to other age groups. In addition, the predicted decline in
birth rate will shift the balance of the population of working age compared to the
dependent population. Thus the proportion of people likely to be economically active
in relation to the proportion of people more likely to be supported by the state will
change. As with much of the UK, the dependency ratio (i.e. the number of people
aged 16-64 per person aged over 65) across Grampian is likely to drop. This will
44
result in less people of working age being available to care for and support older
people. It is estimated that almost 40% of health and social care spending across
Scotland is on caring for people aged over 65 years old45.
Mortality
The causes of mortality in this age group are reflected in the most frequent causes of
mortality figure (table 11). The majority of deaths occur in this age group12. Of the
5317 deaths in Grampian in 2008, 81% were in those aged 65 years and over with
62% of deaths in those 75 years and over7. As is reflected in these tables, deaths
due to pneumonia, cerebrovascular disease and dementia are increasingly common
in this age group7.
Morbidity
In Scotland, a significant proportion of individuals over the age of 65 have long term
health condition with many individuals having multiple medical conditions.
Individuals in this age group may increasingly have mobility problems or pain not
captured in routinely collected data. However, the 2007/08 Scottish Household
Survey data suggests that around 52% of women and 48% of men over 70 years in
Scotland have a long-standing illness, health problem or disability46. Despite this the
majority of this population report their health to be ‘fairly good’. This may reflect nonlimiting illness however it may also be a reflection of the expectation of poorer health
with increasing age46. The proportion of those reporting ‘good’ health contrasts with
the 16-44 year old population where between 65% and 68% report ‘good’ health46.
Figure 28: Self-perception of health by age group46
Source: Scottish Household Survey 2007/2008 report
The leading causes of disability in this age group include hearing loss, arthritis,
disorders of vision and dementia. Ischaemic heart disease, chronic obstructive
pulmonary disease and cerebrovascular disease are also significant causes of
disability29.
Hospital admissions
In 2007/2008 there were 45,004 discharges from hospitals in Grampian for patients
aged 65 and older47. This accounts for 40% of the 111,620 admissions within
45
Grampian47. The most common conditions resulting in admission were diseases of
the circulatory system (18%) followed by neoplastic disease (14%) 47 and a significant
number of these admissions were emergency admissions. In 2007/2008, there were
about 18,725 emergency admissions in those aged 65 years and over. These
admissions resulted in 301,660 emergency bed days, averaging 16 days per
admission47. The emergency admission rate per 100,000 population for patients
aged 65 years with 1 admission in a given year increased from 21,981 in 2007/08 to
22,187 in 2008/09. There has been a slight decrease in this rate to 4,091 in 2008/09.
Rates of emergency admissions per 100,000 population were lower in Grampian,
Aberdeenshire and Moray than Scotland47. The rate in Aberdeen City was higher
than the Scottish and Grampian figures (Figure 29).
Figure 29: Trend of Admission Rates per 100,000 Population of All Emergency
Admissions for Patients Aged 65+ by Financial Year, Scotland, Grampian and
CHP
30,000
Per 100,000 population
25,000
20,000
All Scottish Residents
Grampian
15,000
Aberdeen City
Aberdeenshire
10,000
Moray
5,000
19
99
/0
20 0
00
/0
20 1
01
/0
20 2
02
/0
20 3
03
/0
4
20
04
/0
20 5
05
/0
20 6
06
/0
20 7
07
/0
20 8
08
/0
9
0
Financial Year
Source ISD Scotland, 2009
Among those aged 65 years and over, emergency admission rate increases steadily
with increasing age. In 2008/09, the emergency admission rate per 100,000
population was 46,577 in those aged 85 years and over compared to 12, 332 in
those aged 65-69 years (figure 30).
46
Figure 30: Admission Rates per 100,000 Population of All Emergency
Admissions for Patients Aged 65+ by 5 year age group Grampian 2008/2009
50,000
45,000
per 100,000 population
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
65-69
70-74
75-79
80-84
85+
Age-Group
Source ISD, 2009
Whilst many of these admissions are necessary on medical grounds there is
recognition that increased support in the community and better management of
chronic disease may prevent some of these admissions. In preventing these
admissions pressure on hospital services may be reduced and there will also be
significant benefits to our older residents in terms of less discomfort, improved quality
of life and avoidance of hospital acquired infections.
47
Preventing ill health
Hospital acquired infections
Although hospital acquired infections can affect any age group, due to other health
problems and the increased use of hospital services this population can be most
vulnerable. The two hospital acquired infections which have become key problems
are MRSA and clostridium difficile.
Staphylococcus aureus is a bacteria that colonises about 30% of the healthy
population generally with no adverse effects48. It can however cause serious
infection. Both meticillin-sensitive (MSSA) and meticillin-resistant (MRSA) remain
endemic in many UK hospitals and new and more virulent clones are arising in the
community48.
The annual number of S. aureus bacteraemia reported in Scotland has fallen by
5.9% per year since 2005/200648. The most recent report for the period April - June
2009, shows that the annual number of S.aureus bacteraemia in NHS Grampian has
fallen by 5.7% per year since 2005/06. In the second quarter of 2009, the total
number of S. aureus bacteraemia cases identified in Grampian was 47; of which 13
were MRSA bacteraemias (28 %) and 34 were MSSA bacteraemias (72 %) a
decreased of about 4.1% compared with the same quarter in of 2008 where 49 S.
aureus bacteraemia cases were recorded (table 18).
Table 18: NHS Grampian Staphylococcus aureus bacteraemia rates January
2006-June 2009
Quarter
Jan 06-Mar
06
Apr 06-Jun
06
Jul 06-Sep
06
Oct 06-Dec
06
Jan 07-Mar
07
Apr 07-Jun
07
Jul 07-Sep
07
Oct 07-Dec
07
Jan 08-Mar
08
Apr 08-Jun
08
Jul 08-Sep
08
Oct 08-Dec
08
Jan 09-Mar
09
Apr 09-Jun
09
S aureus
bacteraemia
(SAB) No
Acute Bed
Days
Occupied
AOBDs
MRSA per
1000
AOBDs
MSSA per
1000
AOBDs
153787
0.182
0.280
0.462
59
150314
0.146
0.246
0.393
51
67
148326
0.108
0.344
0.452
15
39
54
146061
0.103
0.267
0.370
22
36
58
148575
0.148
0.242
0.390
17
40
57
144291
0.118
0.277
0.395
16
36
52
142931
0.112
0.252
0.364
18
35
53
145936
0.123
0.240
0.363
23
30
53
151200
0.152
0.198
0.351
16
33
49
144968
0.110
0.228
0.338
16
36
52
139623
0.115
0.258
0.372
20
31
51
145633
0.137
0.213
0.350
10
38
48
148522
0.067
0.256
0.323
13
34
47
141424
0.092
0.240
0.332
MRSA
No
MSSA
No
28
43
71
22
37
16
SAB per
1000
AOBDs
Source: Health Protection Scotland 2009
In 2008, MRSA was an underlying cause of death or contributory factor to death in
214 deaths in Scotland in 2008, the first decrease in these figures since 1996 when
48
only 34 deaths were recorded49. Twenty three (23) of these deaths occurred in
Grampian50.
Clostridium difficile
The main risk factors for clostridium difficile associated disease (CDAD) are prior
treatment with antibiotics and increasing age. Around 20% of cases occur in the
under 65 age group of which the majority occurred in those aged 50-64 years50. An
incidence rate of 1.87 per 1000 acute occupied bed days (AOBD) in those aged 65
and over is compared with 0.85 per 1000 AOBDs in those below this age50.
Recent reports have highlighted the need to do more to tackle CDAD in Grampian.
The HEAT target, as a minimum, is to reduce the rate of CDAD among patients aged
65 and over by at least 30% by March 2011 from 2007/2008 levels. In contrast to the
majority of boards NHS Grampian has not met its interim target51.
Table 19: Numbers of cases and rates of CDAD in patients 65 years and older 51
Total cases
Rates per 100 total OCBD (elderly)
Jan 2009-Mar
Jan 09-March
2008 (Oct 07-Sept
2009
09
08)
Grampian
203
1.67
1.66
Scotland
1152
0.88
1.29
Source: Health Protection Scotland.
CDAD can result in significant discomfort for patients and prolonged hospital stays
and these effects should not be underestimated. In a minority of cases it can also
cause death or contribute to the death of a frail individual. Clostridium difficile was
recorded as either the underlying cause of death or as a contributory factor in 765
deaths in Scotland in 200852. This has increased substantially since 116 deaths
were recorded in 200052. Eighty two (82) of these Scottish deaths occurred in
Grampian in 2008. Although the increasing number of deaths being seen may be
related to higher levels of infection there may also have been a change in the
reporting of deaths where patients have evidence of CDAD52.
Figure 31: Deaths associated with CDAD in Grampian by year52
Source: GROS, 2009
49
Seasonal influenza
Although influenza is generally a mild illness some patients develop serious
complication such as pneumonia. Whilst these complications can occur in any age
the elderly, very young and those with chronic health problems are most at risk.
76.3% of the 65 and over age group in Scotland in 2008/09 took up the offer of the
seasonal influenza vaccine, in excess of targets53. Uptake in Grampian is at a similar
level. The uptake in those at risk in the under 65 age group is estimated to be around
48.5%, below the target of 60%53.
50
Diseases of significant concern
The following section looks in more detail at some of the diseases which are of
significant concern. These diseases are highlighted due to their high contribution to
the burden of disease in our population. In some cases this relates to the increasing
prevalence of these diseases and the implications for future health care.
Cancer36
The number of patients diagnosed with cancer is anticipated to increase substantially
over the coming decade. It is projected that during the period 2016 – 2020, there will
be, on average, 3689 patients in Grampian diagnosed with cancer each year, an
increase of 1106 patients per annum relative to each of the years during the period
2001 – 200554. As seen in the QOF prevalence figures, prevalence in Grampian is
comparable to that of the Scottish population31 although there are some cancer
types, such as colorectal cancer, for which incidence in our population is above what
would be expected55.
Table 20: Projected number of cases of cancer in Grampian54
Actual cases
Projected number of cases
Grampian
2001-2005
2006201120162010
2015
2020
Cases per 5 year period
12917
14841
16517
18443
(Average per annum)
(2583)
(2968)
(3303)
(3689)
Source ISD 2009
The increase in the numbers of malignancies seen will vary significantly between
different groups of cancers. As can be seen in the figure below, large increases are
anticipated in some cancers whilst for other cancers the number of new
presentations will remain unchanged or fall slightly54.
Figure 32: Projected cases per 5 year period by ICD code for Grampian54
Projected cases per 5 year period by ICD code for Grampian
Colorectal
Breast
Lung
Prostate
Bladder
Non-Hodgkin lymphoma
Head and Neck
Oesophagus
Melanoma skin
Stomach
Renal
Ovary
Pancreas
Leukaemia
Corpus Uteri
Brain, meninges and CNS
Cervix
Testis
Hodgkin disease
Other and unspecified
Projected cas es for 2006-10
Projected cas es for 2011-15
Projected cas es for 2016-20
-
500
1,000
1,500
2,000
2,500
3,000
3,500
Projected number of cas es
Source ISD Scotland 2009
51
Many cancers are known to be potentially preventable. The World Cancer Research
Fund (WCRF) estimates that 26% of all cancers in the UK are attributable to factors
including diet, exercise, body fatness and alcohol consumption56. For some specific
cancers, the proportion of cases that are potentially preventable within the UK is
assessed as being much higher, for example breast cancer (42%), colorectal cancer
(43%), stomach cancer (45%), endometrial cancer (56%)56. Furthermore, these
estimates did not take smoking into account.
Both the risk of cancer and mortality from cancer increases with increasing
deprivation although this relationship is not seen for all individual cancer types.
Cancers which show this relationship often have modifiable lifestyle risk factors which
are more common in deprived communities.
Figure 33: European age-standardised incidence (2001-2005) and mortality
(2003-2007) rates for cancer in Scotland, by SIMD 2006 deprivation quintile57.
All malignant neoplasms excluding non-melanoma skin cancer
Age-standardised incidence and mortality rates by SIMD 2006
deprivation quintile, persons
Rate per 100,000
500
400
300
Incidence
200
Mortality
100
0
1 (Least
deprived)
2
3
4
5 (Most
deprived)
Deprivation quintile
Source ISD Scotland 2009
There is a wide spectrum of care needs amongst those with cancer from those
receiving their diagnosis and primary treatment, to those being treated for recurrent
disease or those in the terminal stages of the disease. The number of patients
surviving cancer in Scotland has improved significantly in recent years and services
will increasingly have to meet the needs, both physical and psychological, of this
group of patients. During the period 2000 – 2004, five-year relative survival among
men and women in Scotland diagnosed with malignant disease (excluding nonmelanoma skin cancer) was 42% and 51% respectively58. This represents a 17% and
13% increase compared to the period 1980 – 198458.
Coronary heart disease (CHD)
Coronary heart disease encompasses a spectrum of illness from patients with
occasional episodes of chest pain or shortness of breath, to those presenting with an
acute myocardial infarction. It also includes a group of patients with chronic
debilitating symptoms significantly affecting quality of life. Alongside aiming to
prevent coronary heart disease from developing, steps can be taken at each stage to
reduce symptoms, reduce the risk of progression and death, and improve the quality
of life of patients. In Scotland it remains one of the leading causes of death. About
16% of premature deaths in Scotland in 2007 were as a result of coronary heart
disease59.
52
Coronary heart disease is a preventable disease and the main risk factors are
behavioural. As with many of the diseases which are currently of concern in our
population, smoking, obesity, lack of physical activity and poor diet play a role in the
risk of coronary heart disease59. Other health conditions which can be treated or
prevented in many cases such as high blood cholesterol, high blood pressure and
type 2 diabetes mellitus are also strong risk factors59. The proportion of coronary
heart disease attributable to the five key modifiable risk factors is estimated to be59;
 High blood cholesterol (46%)
 Physical inactivity (37%)
 Smoking (19%)
 High blood pressure (13%)
 Obesity (6%)
These estimates from the National Heart Forum reflect that people can have more
than one risk factor and a combination of factors often act together to increase risk.
Socioeconomic deprivation is also a well recognised risk factor for CHD60. Mortality
rates from CHD in the most deprived areas in Scotland are almost double those of
the least deprived areas60. For premature deaths the inequality gap is even greater
with standardised mortality ratios for the most deprived groups around four times
those of the least deprived (SIMD deciles, 2003-2007)60. similar trends are seen in
Grampian (figure 34).
Figure 34: CHD mortality rates among under 75 year olds in the most deprived
15% areas (SIMD 2006); rate per 100,000 European age-standardised (EASR) 3
year rolling averages 1998-2008
250.0
EASR per 100,000
200.0
150.0
100.0
50.0
0.0
19982000
19992001
Males Scotland
20002002
20012003
Males Grampian
20022004
20032005
Female Scotland
20042006
20052007
20062008
Female Grampian
Source ISD Scotland 2009
53
The incidence of, and mortality from, coronary heart disease has been falling in
Scotland in recent years although rates remain amongst the highest in western
Europe60.
Figure 35: Incidence of CHD (from first hospital admission)
Source ISD Scotland 2009
Figure 35 and 36 show that the incidence of coronary heart disease has been falling
in Grampian and across the CHP areas as has been the trend in Scotland, although
this may not be occurring at the same rate60. This data includes only first incidences
of hospital admission therefore patient management practices or a population with
high turnover, as well as underlying disease incidence, may influence these findings.
Figure 36: Trend, Age-sex standardised incidence rate from CHD (Standard
European population) per 100, 000 population. CHP, Grampian and Scotland
2000-2009 (all age groups)
Rate per 100,000 Population
600.0
500.0
400.0
300.0
200.0
100.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year (ending 31st March)
Aberdeen City Male
Aberdeen City Female
Aberdeenshire Male
Aberdeenshire Female
Moray Male
Moray Female
Scotland Male
Scotland Female
Grampian Male
Grampian Female
Source: ISD Scotland
54
Although the incident rate of CHD is falling, the prevalence is much higher, being
influenced by both new cases and increasing number of people living with the
disease. The crude prevalence of CHD per 100 population is closely related to age
and it is highest in those aged 65 years and over. SMR1 data suggests that the crude
prevalence rate of CHD per 100 population in Grampian is about 3.15 per 100
compared with the Scottish rate of 3.51 per 100 population. Corresponding estimates
for Aberdeen City,, Aberdeenshire and Moray CHP areas are 3.14, 3.03 and 3.50 per
100 population respectively. QOF data suggest that around 4.04 per 100 registered
population in Grampian have coronary heart disease, below the Scottish figure of
4.48 per 100 registered31. This is still likely to be an underestimate of the true
prevalence of disease. It is estimated that around 8.2% of men and 6.5% of women
are living with coronary heart disease in Scotland60.
Recent trend show that the mortality rate of CHD is falling in all age groups across
Scotland. Similar trends are seen in Grampian and across the three local Authority
areas of Grampian. The fall in mortality from coronary heart disease can be attributed
in part to improvements in emergency treatment and treatment of risk factors in those
with the disease. It is suggested that improvements in these areas account for
around 1/3 of the decreased deaths from coronary heart disease61,62. However,
around 2/3 of the decreased deaths from coronary heart disease are likely to be due
to preventing the disease61,62. The reductions in smoking in particular but also
treatments for hypertension and cholesterol are felt to have had the biggest
impact63,64.
Rate per 1000,000 population
Figure 37: Trend, Age-Sex standardised mortality rate from CHD (Standard
European Population) per 100, 000 population. CHP, Grampian and Scotland
1999-2008 (all age groups)
350.0
300.0
250.0
200.0
150.0
100.0
50.0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year of death registration
Scotland Male
Scotland Female
Grampian Male
Grampian Female
Aberdeen City Male
Aberdeen City Female
Aberdeenshire Male
Aberdeenshire Female
Moray Male
Moray Female
Source ISD, Scotland 2009
The importance of preventing coronary heart disease is highlighted by the fact that
around 70% of all deaths from acute myocardial infarction occur out of hospital61.
Around 40% of those experiencing a first myocardial infarction will die before they
reach the hospital61 and for many this will be the first manifestation of coronary heart
disease62. Prognosis at 30 days following emergency admission is good with 86% of
patients surviving a myocardial infarction and 98% surviving an admission with
angina60. Age and sex standardised mortality rates show that rates outcomes in
55
Grampian remain comparable with those of Scotland65. However of those who are
admitted to hospital around 30% die within 1 year of their first myocardial infarction61.
The percentage of patients surviving for 30 days after an emergency admission for
Acute Myocardial Infarction in NHS Grampian hospitals (Aberdeen Royal Infirmary,
Dr Grays Hospital, Woodend general hospital) can be found at
http://www.indicators.scot.nhs.uk/Trends_Jan_2009/AMI.html 65
Stroke
Stroke is a major cause of death in Scotland with mortality rates amongst the highest
in Western Europe and more than 5,000 people killed every year66. Stroke is also
the largest single cause of severe disability in the Scottish population67. Stroke is
predominantly a disease of elderly people with around 75% of first strokes each year
being in those over 65 years old67.
The single largest risk factor for stroke is age66. Whilst sex (incidence rates are
higher for men), family history and race can contribute to the risk of stroke, there are
key lifestyle factors and modifiable medical conditions which are also implicated.
Smoking, alcohol consumption, poor diet and a lack of exercise all increase the risk
of stroke, and high blood pressure and cholesterol are important risk factors66. There
is also a clear association between premature mortality from stroke and higher levels
of deprivation66.
Both the incidence of and mortality from stroke has fallen over time in the Scottish
population but the rates remain high compared to most other western European
countries. Rates of premature mortality have also reduced by almost half between
1998 and 200766.
Figure 38: Trend, Age-Sex Standardised Incidence rate of cerebrovascular
disease (by first hospital admission) Grampian, CHP area and Scotland 20002009 66
Rate per 100,000 population
250.0
200.0
150.0
100.0
50.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year (ending March 31st)
Aberdeen City
Aberdeenshire
Moray
Grampian
Scotland
Source ISD Scotland, 2009
56
As seen in figure 38, the incidence rate of cerebrovascular disease in Grampian and
across the three CHP areas is lower than in the Scottish figure and has also fallen
over the last 10 years66. Figure 39 shows that mortality rate from stoke has been on
a downward trend in Grampian and across the CHP areas. This is in line with
national trends.
Figure 39: Trend, Age-sex standardised mortality rates from stroke per 100,000
population (Grampian, CHP, Scotland) 2000-2009.
Rate per 100,000 population
60.0
50.0
40.0
30.0
20.0
10.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year (ending March 31st)
Aberdeen City
Aberdeenshire
Moray
Grampian
Scotland
Source ISD, Scotland
For patients with stroke admitted to hospital as an emergency prognosis at 30 days is
improving with 81% of patients surviving66. As can be seen in the figure below 30 day
survival in Grampian is comparable to results for Scotland65. One of the most
important factors in improving the outcome after a stroke is admission to an
organised hospital stroke unit where an 18% reduction in death, 20% reduction in
death or insitutional care and 22% reduction in death or dependency can by seen in
comparison with a general medical ward67.
.
57
Figure 40: Standardised rates (%) of patients surviving for 30 days after an
emergency admission for Stroke in NHS Grampian Hospitals 1998-200765
Standardised Rate 30 Days (%)
100
95
90
85
80
75
70
65
60
55
50
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year (ending 31st Dec)
Standardised Rate 30 Days
Upper Control Limit
Upper Warning Limit
Scotland Crude Rate 30 Days
Lower Warning Limit
Lower Control Limit
The majority of patients will survive a stroke, however although around 30% of those
who survive a stroke will be independent within three weeks and 50% by six months
a significant proportion will be left with a severe limiting disability66.
In the 1999 White Paper ‘Towards a Healthier Scotland', and the Coronary Heart
Disease and Stroke Update of 2004, the Scottish government set a target for
reductions in deaths from cerebrovascular disease in those aged under 75 year by
50% in the 15 years between 1995 and 2010. Figure 41 below shows progress to
date against this target.
Figure 41: Age-sex standardised mortality rates (under 75) from stroke per
100,000 population in Grampian 2000-2009: Progress against targets
40.0
Rate per 100,000 Population
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
1995
1996
1997
1998
1999
2000
2001
2002
Male European Age Standardised Rate of Mortality
Female European Age Standardised Rate of Mortality
Both Sexes European Age Standardised Rate of Mortality
2003
2004
2005
2006
2007
2008
2009
2010
Male Trend to Target
Female Trend to Target
Both Sexes Trend to Target
Source ISD Scotland 2009
58
COPD68
Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease that affects
breathing but also causes weight loss, nutritional disturbances and muscle problems.
It produces chronic and limiting breathing problems but is also associated with acute
exacerbations often related to the increased rate of respiratory infection associated
with this disease. Some of these acute exacerbations will require hospitalisation.
COPD is also frequently associated with and can contribute to numerous co-existing
diseases such as heart disease.
COPD is an important cause of morbidity and mortality in Scotland. By far the most
significant risk factor for COPD is cigarette smoking. The population attributable risk
of COPD from smoking ranges between 50 and 70%. Despite lower rates of
smoking the prevalence of COPD and deaths from COPD are continuing to rise,
particularly in women, as the rate of COPD may only fall many years after declines in
smoking rates. Today’s young and middle age smokers are at high risk of
developing COPD in later life unless they can be helped to stop smoking. COPD is
primarily a chronic disease managed in primary care or by the patient themselves
and the prevalence data from the QOF which, is derived from practice-based disease
registers shows that in 2009 the prevalence of COPD in Grampian was estimated to
be 1.38 per 100 registered patients compared to 1.8 per 100 registered patients in
Scotland. Although this figure is less than the Scottish figure, it still equates to over
7000 patients and it is estimated that as many as two thirds of cases are
undiagnosed.
Table 21: QOF Prevalence Estimates of COPD in Grampian and CHP
QOF COPD prevalence for the
year 2007/2008 per 100
patients registered
QOF COPD prevalence
per 100 registered
patients applied to the
2007 General Register
Office for Scotland midyear population
estimates
Aberdeen City CHP
1.37
Individual practices within the
CHP: 0.27 – 2.51
2888
Aberdeenshire CHP
1.36
Individual practices within the
CHP: 0.70 – 3.29
3300
Moray CHP
1.48
Individual practices within the
CHP: 0.89 – 2.56
1199
Grampian
1.38
7387
Scotland
1.8
-
Source: ISD, Scotland 2009, NHS Grampian PH Intelligence Team 2009
Nevertheless, it produces a significant burden on secondary care. In 2008, there
were over 1800 episodes of acute hospital care due to COPD among Grampian
residents (table 22). Over the preceding 5 years from 2008, the number of episodes
59
of care due to COPD involving male patients has remained stable with a slight
decline in trend compared with female patients where the number of episodes has
remained relatively stable. The majority of these episodes of care due to COPD
involve patients aged 65 – 85 years of age. In 2006, the annual number of
emergency admissions in Scotland due to COPD was 14,653 and admissions with a
principal diagnosis of COPD have risen more than 2.5-fold in the last 25 years.
Estimates of bed occupancy levels for Aberdeenshire residents from March 2007 to
May 2008 suggested that COPD patients accounted for 22% of occupied beds.
Table 22 : Episodes of Care as a Consequence of COPD & Bronchiectasis
Grampian Residents
Recorded number of episodes of care
(2008)
Aberdeen City CHP
699
Aberdeenshire CHP
850
Moray CHP
263
Grampian
1812
Source: NHS Grampian PH intelligence Team, 2009
Comparison of UK COPD Audit Data with NHS Grampian data for 2003/04
suggested that readmission rates, 90 day mortality rates following admission and
mortality rates on admission were worse than for the UK. A 90 day mortality of 23%
was seen and a readmission rate of 47%. The early supported discharge service
commenced in 2002/03 and has seen the average length of stay for respiratory
wards fall by around 2 days (7 days to 5 days) from 2001./02 to 2005/06.
Chronic Kidney Disease (CKD) 69
It is estimated that 5-11% of the population may have evidence of kidney impairment.
In the past, very few of these people were identified as having CKD (<0.2% of the
population). In Scotland, there are estimated to be in excess of 200,000 people who
until recently were undiagnosed and unknown to services.
People with CKD are at an increased risk of kidney failure (end stage kidney disease)
requiring some sort of replacement therapy (dialysis) or transplant. As with
individuals who have diabetes they are also at increased risk of other diseases,
particularly cardiovascular disease and cardiovascular death. In population studies
in Norway, >20% of people with evidence of stage 3 disease died of a cardiovascular
event within 8 years. In England, screening for CKD is part of the vascular risk
screening programme currently being discussed.
In the last 5 years, a number of developments have led to greater awareness and
diagnosis of CDK. In Grampian, the introduction of new national lab reporting
methods coincided with a 50% increase in new referrals for CKD. Whilst these
patients are being identified there is still much that we do not know about their
management. A substantial, and as yet poorly defined, sub group of people labelled
with CKD will experience no health consequences of their impaired kidney function.
At what point the benefits of labelling and actively managing someone with CKD
60
outweigh the harms of investigations and treatments is a challenging clinical
decision.
Diabetes 70
The most recent Scottish Diabetes Survey (2008) estimated that around 4.3% of the
Scottish population had a diagnosis of diabetes at the end of 2008, with prevalence
ranging between 3.8% and 4.7% between NHS Boards. A prevalence of 4% of the
population was found in Grampian. These estimates are somewhat higher than the
QOF prevalence figures but both show prevalence in Grampian to be below that of
Scotland. A clear majority of disease, 87%, was attributable to type 2 diabetes.
Although the causes of both type 1 and type 2 diabetes are not fully understood it is
clear that much type 2 disease is potentially preventable. Prevalence in Scotland is
increasing rapidly as in many other countries. Although this is influenced by
increased awareness of the disease, more complete recording, and an increasingly
elderly population, poor diet and low physical activity are also contributing with
overweight and obesity key risk factors. The Scottish Diabetes Survey found that
33% of patients with a recorded BMI were overweight, with 50% of patients obese.
Prevalence of diabetes also rises with deprivation. The odds of having type 2
diabetes is 77% higher among the most deprived compared with the most affluent.
Diabetes mellitus is an important cause of disability and is associated with increased
risk of other key diseases, including coronary heart disease, cerebrovascular disease
and renal failure. For example, the Scottish Diabetes Survey found that 9.5% of
diabetes patients had had and survived a myocardial infarction. Whilst the disease
itself can be prevented, good diabetic control, management of risk factors for
associated disease, and early detection of complications such as diabetic eye
disease is important in reducing disability and mortality.
Mental Health
Mental health problems
Mental health problems occur at significant levels in our population often resulting in
disability for individuals affected and an increasingly recognised burden to society. It
is predicated that depression will be in second place as an international health
burden by 2030 behind only HIV and AIDS. Capturing the extent of these problems
with routinely collected data is difficult. Not only are the majority of mental health
problems managed in the community, a significant proportion of illness will not
present to the health service.
Community surveys estimate that neurotic disorders including depression, anxiety
disorders and obsessive compulsive disorder affect around 15% of the population,
with prevalence higher in the female population71. It is estimated that 5.8% of men
and 9.5% of women will experience a depressive episode in any given year 71.
Prevalence of probable psychotic disorders is estimated at around 5 per 1,000
population aged 16-74 years71.
61
Figure 42: Rates of neurotic disorder by subcategory71
In 2007/08, there were a total of 23,377 psychiatric admissions in Scotland. Of this
1733 were in Grampian. Table 23 below shows the corresponding figures for the
CHP areas during the same period.
Table 23: Admissions to mental illness specialities in Grampian hospitals by
type of admission 2007/2008
Total
819
Aberdeen City
638
Aberdeenshire
298
Moray
1 755
Grampian
23 377
Scotland
Source ISD, Scotland 2009
1st admission
226
244
91
561
6 930
Readmission
512
345
178
1 035
13 542
transfer
76
47
27
150
2 252
others/not known
5
2
2
9
653
Suicide itself is a leading cause of mortality among young people72. Scotland’s
suicide rate is higher than in other parts of the UK with 843 deaths from suicide in
200872. Suicide rates in men are around three times those seen in women72. Rates
in Grampian are below those for the Scottish population, with rates in the female
population significantly lower72. Suicide rates increase with increasing deprivation,
almost doubling between the least and most deprived areas in Scotland72.
Mental Wellbeing
There is increased interest in the full spectrum of mental health including mental
wellbeing, or positive mental health73.
This captures features such as life
satisfaction, purpose and positive relationships and is influenced by broader societal
attributes as well as individual factors73. Good mental wellbeing is recognised as
enabling people to realise their potential, fulfil social roles and in turn adds to societal
welfare73. The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) and the life
satisfaction score have been developed to assess this. In 2006 the mean WEMWBS
score for the adult Scottish population was 51 (scale 14 to 70) with 14% of those
surveyed having “good” mental health, 73% “average” mental health, and 14% “poor”
mental health74. The mean life satisfaction score amongst adults in 2006 was 7.4 on
a scale of 0 to 10, with 10 being extremely satisfied74. This has not changed
significantly since 200274. There is some evidence from this survey that mental
wellbeing is improved among those receiving a higher income, in those with good
health and in those who have had no experience of psychiatric disorder74.
62
Protecting the health of the population
Health Protection is now the accepted term to describe the work that encompasses
the surveillance, investigation, control and prevention of communicable disease and
environmental hazards to human health.
NHS Grampian works closely with the three Local Authorities and other partner
agencies to deliver services to protect the health of the Grampian population.
We see some infections regularly, although the numbers do vary from year to year
(see Table 24). Grampian continues to have one of the highest rates of gastrointestinal infections in Scotland i.e. infections caused by Campylobacter, Salmonella,
Cryptosporidium and E coli O157. Some of these infections are the result of our
lifestyles. For example, risky behaviours known to be associated with these and other
bacteria are contact with animals, the use of untreated or poorly maintained private
water supplies, poor hand washing after handling raw food and travel abroad.
The higher number of cases of some gastrointestinal infections e.g. E coli O157
infection may be attributed to the increased exposure to animal faeces that may
occur in a rural location with a large number of cattle and sheep combined with a
large number of households on poorly treated and maintained private water supplies,
especially in Aberdeenshire.
Many of these infections show a seasonal pattern. For example we see an increase
in reports of Salmonella and Campylobacter infections in the summer months
possibly associated with travel abroad and outdoor living. The numbers of E coli
O157 infections tend to increase in August and September, especially after heavy
rain
Figure 43 E Coli o157 2005 to 2010
Monthly EColi 0157 2005 to 2010
18
16
14
12
2005
2006
2007
2008
2009
2010
10
8
6
4
2
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
63
Table 24 Number of cases of reported and notified communicable
disease in Grampian in 2005 - 2009
Disease
Dysentery
Botulism
Campylobacter
Chickenpox
Diphtheria
Erysipelas
Food poisoning: Total
Aeromonas*
Cryptosporidium*
E coli O157*
Entamoeba histolytica *
Giardia*
Salmonella*
Yersinia*
Vibrio parahaemolyticus*
Legionellosis
Leptospirosis
Lyme Disease#
Malaria
Measles
Meningococcal infection
Mumps
Q Fever
Rubella
Scarlet fever
TB respiratory
TB non respiratory
Typhoid
Hepatitis A
Hepatitis B (acute)
Hepatitis B (chronic)
Hepatitis C
Whooping Cough
2005
2006
2007
2008
2009
23
0
668
1887
0
1
428
87
100
45
0
23
134
30
1
5
0
1
14
7
12
570
0
13
21
16
9
0
1
6
28
125
4
9
1
648
2016
0
0
397
73
83
54
4
17
138
20
0
1
2
12
7
14
13
271
1
14
23
25
13
1
1
4
29
130
9
13
0
664
2283
1
2
386
87
67
55
4
12
135
25
0
2
1
53
12
5
11
145
0
14
22
20
22
0
2
1
43
124
16
12
0
665
1464
0
0
398
91
79
56
6
17
127
21
0
1
0
65
12
4
12
37
0
5
19
17
22
0
2
1
63
136
20
6
0
801
1697
1
1
401
85
107
57
4
17
105
26
0
2
0
49
12
4
10
81
0
5
28
27
23
0
3
3
60
124
15
Notes
* These infection are included in Food Poisoning figures
# The apparent increase in Lyme disease reflects a change in reporting by the
laboratory.
Figures are based on clinical notifications and laboratory isolated organisms.
64
Outbreaks of gastrointestinal infections
These figures are derived from the Health Protection Scotland (HPS) ObSurv
surveillance system for general outbreaks of intestinal diseases in Scotland and are
by date of report to HPS.
Table 25 Number of outbreaks of gastrointestinal infection by date reported to
Health Protection Scotland 2005-2009
Pathogen
2005
Campylobacter
0
C. perfringens
0
E.coli
2
Norovirus
25
Rotavirus
0
Salmonella
0
Scombrotoxin
0
Shigella sonnei
0
Staph. aureus
0
Unknown
4
Viral
1
Total
32
* 2009 data is still provisional
2006
0
1
2
34
1
1
0
0
0
2
0
41
2007
1
1
2
38
0
0
0
1
0
2
0
45
2008
0
1
1
41
0
0
1
0
0
1
0
45
2009*
0
0
1
47
0
0
0
0
1
0
0
49
Norovirus is the commonest cause outbreaks of gastrointestinal infections in
Grampian - 85% (185/218) of all reported outbreaks. These outbreaks affected an
estimated 4502 individuals between 2005 -2009 and Table 26 shows location of the
outbreaks.
Table 26 Location of outbreaks of Norovirus infection reported by NHS
Grampian
Location
Hospital
Residential Institution
Hotel
Restaurant
School
Armed services camp
Other
2005
11
11
0
0
2
0
1
2006
7
18
2
1
1
0
5
2007
20
17
0
0
0
1
0
2008
20
11
3
1
4
0
2
2009
9
30
3
2
3
0
0
A total of 1780 (40%) cases were reported in residential institutions and 1874 (42%)
cases were reported in hospitals.
Immunisation and vaccine preventable diseases
Immunisations are the most effective and economical way of reducing the burden of
morbidity and mortality associated with serious infectious disease in children. Apart
from its protective effect in an individual child, immunisation produces an indirect
effect known as ‘herd immunity’. Herd immunity occurs when a high proportion of the
population have been vaccinated. This reduces the opportunity for specific infections
to circulate in the community, thereby protecting those children who remain
unvaccinated. To ensure herd immunity 95% of the eligible population usually need
to be immunised against each disease.
65
Description of the UK immunisation programme
The programme is extensive and complex and comprises:
 Vaccination against 10 diseases (Diphtheria, Tetanus, Polio, Whooping
Cough, Haemophilus influenzae type B (Hib), Meningococcal C (MenC)
infection, Pneumococcal infection (PCV), Measles, Mumps, Rubella) to
all children.
 Hepatitis B and BCG (TB) vaccination are offered to selected children
based on risk assessment
 Human Papilloma Virus vaccination is offered to all teenage girls up to 18
years of age
 Pneumococcal and seasonal flu vaccination is offered to individuals aged
less than 65 years who are at increased clinical risk and to all adults aged
65 years or more.
Protection against each disease requires one or more doses of vaccine (given at
specific intervals) to establish initial immunity, with some diseases requiring further
booster doses of vaccine to maintain immunity throughout life.
.
Vaccine uptake results- Overview of 2009/2010
The uptake of childhood immunisation is the proportion of children who have
received an appropriate vaccine for their age. Generally, uptake rates for all
immunisation remains high in Grampian compared with the Scottish average.
Summary uptake figures for children reaching ages 12 months, 24 months and five
years in financial year ending 31 March 2010 in Grampian are shown in the tables
and figures below.
Table 27: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 12
months of age in Grampian 1 April 2009 to 31 March 2010
Area
Aberdeen City
CHP
Aberdeenshire
CHP
Diphtheria
Tetanus Pertussis
Polio
Hib
MenC
PCV
97.1
97.1
97.1
97.0 96.9
95.4
95.9
98.6
98.6
98.6
98.6 98.5
97.9
98.1
Moray CHCP
97.6
97.6
97.6
97.5 97.6
97.1
96.9
Grampian
97.8
97.8
97.8
97.7 97.6
96.6
96.9
97.4
97.4
97.4
97.4 97.3
97
97.2
Scotland
Source: ISD
66
Table 28: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 24
months of age in Grampian by CHP area, 1 April 2009 to 31 March 2010
Primary course
Booster course
D
T
P
Pol
Hib
Men
C
Aberdeen City
CHP
98.
6
98.
6
98.
6
98.
6
98.
0
94.5
Aberdeenshire
CHP
99.
1
97.
9
98.
7
98.
4
99.
1
97.
9
98.
7
98.
4
99.
1
97.
9
98.
7
98.
4
99.
0
97.
9
98.
7
98.
4
98.
8
97.
9
98.
3
98.
2
Moray CH&SCP
Grampian
Scotland
Source: ISD, 2010
96.9
96.7
95.9
96.4
PC
V
95.
4
MMR Hib/Me
1 nC
97.
3
96.
7
96.
4
96.
5
PCV
B
95.5
93.9
94.3
95.0
95.5
95.1
95.4
95.3
95.7
95.2
94.8
94.8
93.7
94.0
94.2
Table 29: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 5 years of
age in Grampian by CHP area, 1 April 2009 to 31 March 2010
D
Aberdeen City
T
Primary course
P
Pol Hib
MenC
D
Booster course
T
P
Pol
97.6 97.6 97.6 97.6 95.8
94.4
93.5
93.5
93.5
93.5
Aberdeenshire 98.5 98.5 98.3 98.4 97.8
97.4
94.9
94.9
94.9
94.9
Moray
98.1 98.1
98 98.1 97.7
97.4
95.9
95.9
95.9
95.9
Grampian
98.0 98.0 97.9 97.9 96.9
96.1
94.4
94.4
94.4
94.4
Scotland
98.4 98.4 98.4 98.3 97.4
Source ISD 2010
97.4
91.9
91.9
91.9
91.9
Primary Immunisation Uptake rate by Deprivation
Across Scotland, there are noticeable differences in uptake as children age, and this
appears to be closely related to deprivation. Children in more deprived areas appear
to be vaccinated at a later age compared with children in the less deprived areas
(ISD, 2010)
However, whilst there remains significant variation between individual general
practices in Grampian, data on uptake of vaccination by deprivation (January to
December 2009) shows overall uptake of primary vaccinations by 12 months old to
be highest in the most deprived areas in Grampian (SIMD 1). This reflects the effort
67
being made by health visitors and local general practices to encourage high uptake
across all social groups.
Figure 44: Uptake of Immunisation by Deprivation
Diphtheria1,3 uptake by 12 m onths by SIMD category
Evaluation period: January to Decem ber 2009
Grampian
Scotland
% Uptake
98.1
96.8
97.3
96.9
97.7
97.5
97.6
97.9
97.4
90
98.0
100
80
70
60
50
5
4
Le a s t de priv e d
3
SIMD Category
2
1
M o s t de priv e d
Uptake of HPV vaccine
In November 2007 the Scottish Government confirmed a universal HPV
immunisation programme for girls aged 12-13 years would commence in September
2008. Alongside the school based programme, a 3 year phased catch-up programme
for older girls aged 17-18 years was also commenced. The HPV vaccine is
administered as a 3 dose schedule usually within 0-6months. To be fully immunised,
girls must receive all 3 doses.
HPV year 1
Available data show the uptake of HPV in Grampian schools has been generally
high. For year 1 of the programme, 91.7% of all girls in S2 received 3 doses of the
vaccine compared to 91.4% across Scotland. Similar high uptake rates were
observed within the 3 CHP areas in Grampian (figure 45). This is higher than the
80% uptake rate required to make the programme cost effective.
68
Figure 45: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP
Year 1 (2008/2009)
93.6
91.4
94.4
93.7
91.7
94.5
95.1
93.3
95.8
94.4
92.6
95.2
89.7
93.0
100
90
80
70
60
50
40
30
20
10
0
92.1
Percentage uptake
HPV Immunisation Uptake rates for girls in second year of
secondary school (S2)
Year 1 (2008/2009)
as at 15 February 2010
Aberdeen City
CHP
Aberdeenshire
CHP
Moray CH&SCP
Grampian
Scotland
1st dose
2nd dose
3rd dose
ISD 2010
However, uptake rate for girls in the catch-up category, especially those who are out
of school has been less successful. There are significant differences in uptake
between girls in secondary school and those who have left school. Table 30 shows
the uptake rate in all girls in the catch–up cohort, eligible for immunisation during
year 1 of the programme. These are girls in S5, S6 during the school year 2008/09
and girls aged 16 to less than 18years on 1 September 2008 who have left school.
Table 30: Uptake of HPV Immunisation in Girls eligible for catch-up vaccination
in Grampian (year 1)
Uptake of HPV Immunisation in Girls in the catch-up Cohort
September 2008 – August 2009 (Year 1 of the catch-up).
Completed
doses of HPV
vaccine
Percentage of all
girls eligible for
catch-up
vaccination in
2008/09 who
have been
vaccinated
Percentage of
girls in S5 who
have been
vaccinated
Percentage of
girls in S6 who
have been
vaccinated
Grampian
Grampian
Grampian
(Scotland)
(Scotland)
(Scotland)
68.1 (70.9)
94.4 (94.6)
92.6 (93.0)
First dose
65.2 (67.7)
93.2 (93.5)
92.0 (91.8)
Second dose
55 (59.7)
90.1 (89.9)
88.5 (86.6)
Third dose
ISD statistics for year 1 of the HPV programme (Sep 2008-Aug 2009)
Percentage of
girls out of
school who
have been
vaccinated
Grampian
(Scotland)
43.5 (48.5)
38.6 (43.4)
21.9 (31.8)
69
As of 15 February 2010, uptake rate for all three doses in the catch-up cohort was
generally low in Grampian (43.5%, 38.6% and 21.9% respectively) compared to
Scottish average (48.5%, 43.4% and 31.8% respectively). Uptake for girls in the
catch-up group in Grampian who had left school were significantly lower (21.9%)
compared to uptake rates in girls in the catch-up cohort in S5 (90.1%) and S6
(88.5%). Similar low uptakes were recorded within the 3 CHP areas (table 46 and
figure 47).
Figure 46: Uptake of HPV Immunisation in Girls eligible for the catch-up
vaccination in year 1 (2008/09) in Grampian by CHP area
HPV Vaccine uptake in school leavers catch-up cohort by CHP
Year 1 (2008/09)
as at 15 Feb 2010
80
31.8
43.4
48.5
21.9
38.6
43.5
22.2
45.8
25.2
42.0
47.4
18.1
36.3
40
20
50.8
60
32.0
Percentage uptake
100
0
Aberdeen City
CHP
Aberdeenshire
CHP
Moray CH&SCP
1st dose
2nd dose
Grampian
Scotland
3rd dose
ISD statistics for year 1 of the HPV programme (Sep 2008-Aug 2009)
HPV year 2
Based on data recorded on the CHI system as at 30th June 2009 and SIRS system
as at 15 February 2010, uptake of routine HPV immunisation in girls currently in S2
for the second year of the programme continues to remain exceptionally high in
Grampian; 92.1% for the first dose and 89.2% for the second dose. Similar high
uptake rates are observed within the 3 CHP areas in Grampian (figure 47). These
uptake rates are likely to increase especially for the second dose as some girls may
have started their course of the HPV vaccinations later in the school year. It is also
possible that some vaccinations may have been given but have not yet been
recorded on CHSP.
70
Figure 47: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP
Year 2 (2009/2010)
HPV Vaccine Uptake for Girls in S2 in Grampian by CHP
Year 2 (2009/10)
as at 15 Februrary 2010
85.8
91.9
89.2
92.1
88.1
90.7
89.6
93.0
89.4
90
80
70
60
50
40
30
20
91.7
Percentage uptake
100
10
0
Aberdeen City
CHP
Aberdeenshire
CHP
Moray CH&SCP
1st dose
Grampian
Scotland
2nd dose
A more detailed report of the performance of immunisation services within Grampian
will be available in November 2010.
Tuberculosis (TB)
Cases of Tuberculosis have continued their upward trend, rising from 24 in 2004 to
50 Grampian residents diagnosed with TB disease during 2009. Locally, over the last
3 years, 72% of cases occurring in Grampian have been in people with a non-UK
country of origin. The majority of these individuals have developed symptoms of
active TB disease some 2 -3 years (or more) following arrival in Grampian and it is
likely this represents reactivation of long-standing latent infection. In response to this
increase in TB incidence, a local initiative has been established to offer more
accessible TB screening to new entrants coming from selected high TB incidence
countries. During 2010, the Grampian Tuberculosis Policy has been revised to take
account of Scottish Guidance on prevention and management of TB published in
2009. A Scottish TB Action Plan is being developed nationally with anticipated
publication in 2011 and this will inform future local action.
A more detailed report about TB in Grampian will be available in December 2010.
Pandemic influenza
Influenza A H1N1 (v), a new strain of influenza virus was first seen in Mexico in
March 2009. Immunity to this new strain was limited and therefore it had the potential
to spread quickly. NHS Grampian participated in national surveillance, assessment
and treatment of symptomatic patients, mounted a vaccination programme and
provided infection control advice to a range of NHS, private and charitable
organisations
There is a separate report available describing the NHS Grampian response.
71
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