1. Burden of disease & the Australian Rheumatic Fever Strategy RHDA SA workshop March 2017 Menzies School Health Research Claire Boardman Deputy Director, RHDAustralia BN, Cert IC, MPH, CICP, Senior Lecturer Griffith University Qld.
Streptococcus pyogenes bacteria, Pappenheim’s stain

2. QUICK QUIZ Who: Lives or works remotely? Has seen a case of ARF?
Has given a shot of BPG (LA Bicillin)?
Knows when to give BPG?
Knows how to prevent RHD?
Knows how/whom to refer to?
Is aware of and using the National guidelines?
Has downloaded the App?
Has completed any of the modules?

3. RHDAUST BACKGROUND
Based at Menzies in Darwin, NCU established in 2009 to support control of RHD in Australia under DoHA Rheumatic Fever Strategy and funded until June 2017

4. Strategic Goals 2015-2017 Our Vision Our Mission
Identify and recommend strategies to improve patient outcomes
Supporting current control strategies, working with our research partners to translate research into practice, working in partnership to advocate for an improved model of care to eliminate RHD in Australia
Our Vision
No child dies
in Australia from
acute rheumatic fever
or its complications
Develop and deliver evidence based education and training programs and resources
Supporting and educating health workers, midwifes, doctors, nurses and allied health professionals, communities, families and patients through face to face education and training, innovative use of technology and traditional print media
Raise awareness of rheumatic fever and rheumatic heart disease
Implementing a comprehensive communications strategy targeting clinicians, researchers, affected individuals and communities and the general community
Responsive, innovative, integrity, quality, evidence based, collaborative
Our Mission
To prevent and reduce acute rheumatic fever and rheumatic disease in Australia
Our Mission
To prevent and reduce acute rheumatic fever and rheumatic heart disease
in Australia
Implement a data surveillance and quality improvement framework
Creating a data collection system with valid, credible and accurate data, supporting jurisdictions to improve data quality, integrity and analysis, using data to recommend quality improvement measures
Work collaboratively and in partnership towards common goals
Identifying opportunities for collaborative projects with State and Territory RHD control programs and Health Departments, Aboriginal controlled health sector and communities, like-minded not-for-profit organisations, peak and industry bodies

5. Born in 1812 England 2nd of 8 children One of Victorian England’s most popular novelists What does Charles Dickens have in common with rheumatic heart disease?

6. Rheumatic Fever - A Dickensian disease
Unemployment
Poverty
Rioting
Slums in large cities
Working conditions appalling for women and children

7. WHAT HISTORY TELLS US
RF was leading cause of death in people aged 5-20 years in US 100 years ago – ‘the putrid throat’
Mortality rate was 8-30% from carditis and valvulitis this decreased to 4% by 1930s.
Following penicillin use mortality rate < 0% by 1960s but remains at 1-10% in developing countries.
Before penicillin, 60-70% of patients developed valve disease, compared to 9-39% since penicillin was developed.

8. RHEUMATIC HEART DISEASE (RHD) NEGLECTED NCD OF POVERTY

9. The burden of disease – worldwide
Estimated million people worldwide live with RHD, 90% of whom live in developing countries
Acquired in childhood and symptomatic from 1st decade of life.
Causes 233, ,000 deaths each year.
RHD is a disease of the vulnerable and impoverished worldwide.
RHDAlliance atlas –

13. The burden of disease – Australia
> 6000 on RHD Control program registers
Highest prevalence of all jurisdictions in NT
Average age of ARF onset is between 5 – 14
ECHO screening study of Indigenous children 5–14 years, prevalence of RHD of 8.6/1000 with none detected in non-Indigenous cohort (Roberts 2016)
Reduced life expectancy following valve surgery years with survival time poorest within 30 days of surgery and at 5 years.

15. WHAT ARE WE MISSING? Refugee population
Pacific Islander/Maori population
Not nationally notifiable/no National register
NSW recently established register for ARF/RHD
Rates of hospitalisation:
NT 86/100,000
WA 12/100,000
Qld 15/100,000
Other states?
Reliable death data?
Survival time post surgery?
Economic burden ($ and QALYs)
WHAT ARE WE MISSING?

16. This is what we know

17. 1. Burden of disease
2. Exposure to GAS
3. Response to GAS infection
4. Diagnosis and management of sore throat
5. Diagnosis of ARF
6. Prevention of ARF recurrence
7. Early diagnosis of RHD
8. RHD in Pregnancy
9. Medical management
10. Surgical care for RHD

18. PRIMARY HEALTHCARE MODEL – 1978 WHO ALMA ATA DECLARATION
Social approach to health founded on human rights framework
Based on economic and social justice
Affordable, accessible, appropriate
Considers culture, environment, ethnicity
SOCIAL DETERMINANTS OF HEALTH INCLUDE:
Stress
Social exclusion
Unemployment
Addiction
Availability of healthy food
Availability of healthy transportation
Social support networks
Early childhood development
Social gradients (shorter life expectancy,
the poorer you are > disease risk)

19. THE GLOBAL GOAL (25 x 25 < 25)
Development of World Heart Federation (WHF) Position Statement on the Prevention & Control of RHD in 2010
Broader goal of reducing premature mortality from non-communicable diseases by 25% by 2025, endorsed by all WHO member states as part of the Global Action Plan on non-communicable diseases.
25% reduction in RHD mortality in those >25 years of age by 2025

20. TOWARD CLOSING THE GAP

21. Better Cardiac Care

22. 100 years ago RF and RHD was the leading cause of death in 5-20 year olds
And then….. In Australia and other high income countries …………….it disappeared And now….. In Australia we have the highest recorded rates ….…………… in the world
It was the best of times, it was the worst of times.