1. Rheumatic Fever & Rheumatic Heart Disease in New Zealand
Joel Burnett

2. New Zealand Island nation of ~ 4.5 million people
First settled by Polynesians, from which Maori culture emerged
Later a British colony
Known for spectacular landscapes
Map credit:

3. Auckland & The City Hospital
New Zealand’s largest city, with a population of ~ 1.5 million
Cultural hub of the country
Auckland City Hospital (ACH) is New Zealand’s largest public hospital and clinical research facility
Major referral center and teaching hospital
Photo credit: TermConditionsDirectorate/tabid/133/Default.aspx

4. http://www. nzherald. co. nz/nz/news/article. cfm

5. Topic of Interest: Rheumatic Fever & Heart Disease
Newspaper headlines addressing Rheumatic Fever in New Zealand caught my attention in the months prior to departure
Rates of Rheumatic Fever in New Zealand are among the highest in the developed world
Having undertaken an elective in Cardiology at Auckland City Hospital, I was interested in Rheumatic Fever and its most deadly sequela, Rheumatic Heart Disease

6. Rheumatic Fever
Acute Rheumatic Fever is caused by an autoimmune response to Group A Strep pharyngitis
Manifestations of disease include arthralgia, fever and other markers of acute inflammation, rash, subcutaneous nodules, chorea and, when involving the heart, new murmurs and heart failure
Diagnosis is made of clinical grounds with reference to the Jones criteria; treatment includes symptom management, antibiotics for GAS eradication and, if necessary, heart failure management

7. Rheumatic Heart Disease
Acute Rheumatic Fever can cause pancarditis; recurrent cases may lead to progressive chronic heart disease
Valvulitis is common and most frequently involves the mitral valve, though other valves may be involved
Treatment for mild cases is limited to secondary prophylaxis of Rheumatic Fever while severe cases may require valve surgery in addition to secondary prophylaxis

8. Rheumatic Fever in New Zealand
Despite near-eradication of Rheumatic Fever in developed countries, rates in New Zealand have remained stable at about 200 cases per year since 1980 (15 per 100,000)
Incidence corresponds with ethnicity and SES
Between , rates of Rheumatic Fever increased by 79% and 73% for Maori and Pacific children, whereas rates for non-Maori and non-Pacific children fell by 71%
70% of school-aged cases of Rheumatic Fever occurred in the most deprived quintile

9. Rheumatic Heart Disease in New Zealand
A recent study 74% of the 225 women undergoing valve replacement surgery in an Auckland registry were Maori or Pacific Island women with Rheumatic Heart Disease
Between there were 127 deaths per year as a result of Rheumatic Heart Disease in New Zealand
In 2005 and 2006 there were 175 and 186 deaths, respectively, as a result of Rheumatic Heart Disease

10. Prevention Efforts Primary prevention strategies include efforts to
improve access to timely sore throat treatment
reduce household overcrowding
raise public awareness
Secondary prevention includes
Community registries
Monthly IM penicillin
Photo credit: communicable-disease/acute-rheumatic-fever-and-sore-throats

11. Photo credit: http://www. hpa. org

12. Summary
Rheumatic Fever is a rare complication of Group A Strep pharyngitis and can be prevented with prompt and appropriate treatment with antibiotics
Rheumatic heart disease, a deadly sequela of Rheumatic Fever, most frequently manifests as disease of the mitral valve
Unlike most industrial nations, rates of Rheumatic Fever in New Zealand have remained stable at about 200 cases per year since (15 per 100,000)
Prevention strategies include efforts to reduce overcrowding, increase access to sore throat treatment, and raise awareness

13. Clinical Experience
Murmur auscultation on the cardiology wards was exciting and memorable
Many patients, including some with Rheumatic Heart Disease, awaited valve surgery on the wards and had interesting murmurs
Learning from master clinicians to distinguish murmurs from one another was a profound experience

14. Cultural Experience
New Zealand is known as a playground for outdoor sports and adventure
Completing the Tongariro Alpine Crossing, a 12 mile trek, was a cultural highlight
Tongariro National park is a World Heritage site

15. References
Marijon, Eloi et al. “Rheumatic Heart Disease.” The Lancet 379 (2012)
Milne, Richard et al. “Incidence of acute rheumatic fever in New Zealand children and youth.” Journal of Paediatrics and Child Health 48 (2012)
Wilson, Nigel. “Rheumatic Heart Disease in Indigenous Populations – New Zealand Experience.” Heart, Lung, and Circulation 19 (2010)