Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012

Tier 1—Health conditions—1.06 Acute rheumatic fever and rheumatic heart disease

The HPF was designed to measure the impact of the National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH) and will be an important tool for developing the new National Aboriginal and Torres Strait Islander Health Plan (NATSIHP).

Page last updated: 15 November 2012

Why is it important?:

Acute rheumatic fever (ARF) is a disease caused by an auto-immune reaction to an infection with the bacterium group A streptococcus (GAS). ARF is a short illness, but can result in permanent damage to the heart—rheumatic heart disease (RHD). A person who has had ARF once is susceptible to repeated episodes, which can increase the risk of RHD. Following an initial diagnosis of RHD, patients require long-term treatment, including long-term antibiotic treatment to avoid further infections that may damage the heart (Steer et al. 2009).

ARF and RHD are associated with environmental factors such as poverty and poor living conditions. The incidence of ARF and the prevalence of RHD among Aboriginal and Torres Strait Islander peoples living in some remote areas have been reported as being among the highest in the world (AIHW 2004a).

ARF and RHD are now rare diseases in populations with good living conditions and easy access to quality medical care (Parnaby et al. 2010). Yet Aboriginal and Torres Strait Islander peoples will remain at risk of ARF/RHD while socioeconomic disadvantage and barriers to accessing health care persist.

The Northern Territory Rheumatic Heart Disease Program currently provides the strongest source of data on ARF and RHD, although additional data are gradually emerging from Qld and WA with the development of register and control programs in those states. A number of smaller, geographically limited studies have also been conducted.Top of page

Findings:

Acute rheumatic fever

In the period 2007–10, there were 226 new or recurrent cases of ARF in the NT. The majority (approximately 98%) were for Aboriginal and Torres Strait Islander peoples. ARF is largely restricted to older children and young adults: among Aboriginal and Torres Strait Islander peoples, 61% of cases occurred in children aged 5–14 years, with a further 24% in the 15–24 years age group. Females comprised 63% of all cases of ARF in 2007–10 (139 females, 82 males).

Outside the NT, a study of ARF incidence in North Qld over the period 2004–09 showed an increase in notifications but fewer recurrences, suggesting enhanced awareness of the disease (Hanna et al. 2010).

A recent study identified twenty-six admissions for ARF to a paediatric hospital in Sydney between 2000–08. The majority of these cases were Pacific Islander and Aboriginal and Torres Strait Islander children from suburban Sydney. This suggests that ARF is not exclusively a disease associated with remote areas. The authors found that 69% of the children with this disease were from families in the two most disadvantaged quintiles of socioeconomic advantage/disadvantage. Additionally, barriers to timely diagnosis were identified in 81% of children, including delayed presentation and delayed referral (Smith et al. 2011).

Rheumatic heart disease

In December 2010, there were 1,379 Aboriginal and Torres Strait Islander people recorded as having RHD in the NT. The prevalence of RHD in Indigenous people was higher in the Top End of the NT compared with Central Australia (29 versus 18 per 1,000 persons). Females comprised 66% of Indigenous Australians in the NT with RHD. After adjusting for differing population age structures, the prevalence of RHD was 32 times as high among Aboriginal and Torres Strait Islander peoples as it was among non-Indigenous residents of the Top End of the NT, and 16 times as high in Central Australia.

Between 2006 and 2010 there was a 54% decline in new registrations of RHD among Indigenous Australians in the NT.Top of page

A recent study of patients with RHD living in five communities around Katherine in the NT found that around two-thirds of patients were receiving ongoing secondary preventive treatment in accordance with guidelines: 56% of patients received prophylactic penicillin injections; 63% received echocardiograms and 59% had a specialist review (Stewart et al. 2007).

Implications:

The NT is the only jurisdiction in which there is information about trends over time for ARF. The incidence of ARF among Indigenous Australians is apparently lower in North Qld than in the NT, but is still far higher than for other Australians.

Interventions that focus on improving housing, socioeconomic circumstances and health care will be important for preventing and managing these conditions.

Improved access to appropriate treatment for pharyngitis/tonsillitis is likely to reduce the rate of ARF. Although it has been suggested that GAS skin infections may be a risk factor for ARF, particularly in Australia, there is currently insufficient evidence to justify recommending skin health programs exclusively for the prevention of ARF. More research is needed on the association between GAS skin infections and ARF (RHDAustralia et al. 2012).

There is considerable scope for the secondary prevention of ARF/RHD through the implementation of disease registers and control programs, education of patients and their families, treatment with penicillin prophylaxis, and regular clinical review and access to specialists and hospital care. There is evidence that current practice could be improved (Stewart et al. 2007).

RHD registers are a central element of secondary disease prevention programs to prevent recurrence of ARF and reduce the occurrence or severity of RHD. The Australian Government provided $11.2 million over five years from 2007–08 for a Rheumatic Fever Strategy to help improve the detection and diagnosis of acute rheumatic fever and rheumatic heart disease, and improve access to the antibiotic injections that prevent repeated attacks of acute rheumatic fever. The strategy funds register and control programs in the NT, WA and Qld, and a national coordination unit, RHDAustralia. This unit supports the state-based programs to operate in accordance with best practice clinical guidelines, and is developing a performance monitoring system to improve the collection of data and reporting on incidence and prevalence. Control programs improve case-detection, and are the most effective way of improving compliance to treatment regimes and supporting clinical follow-up of people with RHD. The issues of improving care for those with advanced RHD, including surgical and other interventions also need to be considered (Maguire et al. 2012).Top of page
Figure 26—Rate of new rheumatic heart disease registrations for Aboriginal and Torres Strait Islander peoples, Top End of the NT and Central Australia, 2006–10
Figure 26—Rate of new rheumatic heart disease registrations for Aboriginal and Torres Strait Islander peoples, Top End of the NT and Central Australia, 2006–10
Source: AIHW analysis of Northern Territory Rheumatic Heart Disease Program
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Table 8—Age-specific rheumatic heart disease prevalence (as at 31 December 2010) by age groups for Aboriginal and Torres Strait Islander peoples in the NT
Age groupNumberPer centRate(a)Ratio(b)
0–14
121
8.8
5.4
15–24
305
22.1
24.1
120.1*
25–34
323
23.4
31.0
131.1*
35–44
290
21.0
34.6
80.6*
45–54
199
14.4
36.2
40*
55–64
93
6.7
33.7
21.8*
65+
48
3.5
25.8
6*
Total
1,379
100.0
25.7
27.3*
(a)Rate per 1,000 persons. Age-specific rates calculated using the 2006 estimated resident Indigenous population for the Northern Territory. Total is age standardised.
(b)Ratio is the Indigenous rate divided by non-Indigenous rate
*Represents results with statistically significant differences in the Indigenous/ Non-Indigenous comparisons at the p<.05 level.
Source: AIHW analysis of Northern Territory Rheumatic Heart Disease Program
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