Mana Kidz
Rheumatic Fever Prevention:
Tracy McKee
http://opendoor.net.nz/watch/series-12
• http://www.youtube.com/watch?v=rqCOH
GAR0q8
Group A Streptococcus
• Causes broad
spectrum of
disease
• ARF, Glomerulonephritis and RHD post-strep complications
Disease Progression
Incubation period – 3 – 7 days
Infectious period – 24 hrs post
a/b’s or 2/52
GAS
ARF – 0.3 – 3%
GAS
Recurrence of ARF 25 – 75%
Further recurrent attacks =
higher risk of cardiac
damage
From sore throat to damaged heart…
• Environment (overcrowding, poor nutrition,
poor hygiene, young children lots of Strep A).
• Some specific genes (“HLA
haplotypes”) make some people
more susceptible to autoimmune disease.
• Some Strep A more “rheumatogenic”
……
• Some people react to some
Strep A abnormally.
• Antibodies react against heart tissue
‘molecular mimicry’.
• So rheumatic fever results from the body’s
immune system reacting against it’s own
tissue - rather than just against Strep.
…From sore throat to damaged heart
Affects
• Tissues in the:
–
–
–
–
Brain : chorea
Joints : arthritis
Heart : inflamed/damaged valves
Skin : erythema marginatum (rash) and
subcutaneous nodules (lumps under the skin)
– Fever
Diagnosis of Acute Rheumatic Fever
2 major or 1 major + 2 minor “Jones criteria”, plus evidence of a preceding
Strep A infection.
Major Criteria
Arthritis (most common symptom) –
inflamed joints
Carditis (heart inflammation) >>valves
Chorea (jerky movements)
Subcutaneous nodules (rare)
Erythema marginatum (skin rash)
Minor
Criteria
Arthralgia (joint aches), fever,
elevated acute phase reactants,
prolonged PR interval (change on
ECG)
Better Public Services Target
• Reduce the incidence of first episodes of
acute rheumatic fever by two thirds
• From 4.2 per 100,000 (2010/11) to 1.4 per
100,000 by June 2017
• Reduction in the total population hospital
admission rate
http://www.health.govt.nz/about-ministry/our-priorities/better-public-services
Prevention
Primordial Prevention
GAS
Primary Prevention
ARF
Secondary Prevention
RHD
Tertiary Prevention
Cardiac
Surgery
Stroke
Death
Access to Primary Healthcare
Baltimore Study 1960s
Improving access to healthcare
reduced ARF
Gordis L NEJM 1973;289(7):331-335
ANY Maori or Pacific child/young person
in South Auckland is at high risk and needs
a throat swab, with antibiotics asap.
Free comprehensive health service
Dedicated health team
RN
WSW
5-14 year olds
Five days per week
Free assessment and treatment of GAS+ sore
throats, skin infections and school health referrals
19
15
19
8
Union Health
Otara
Sore throat clinics
MOH ‘rapid response’ initiative
High risk children and young people (4-19 yo: M, P,
Q5)
Sore throat clinics offering free assessment and
treatment
Primary care: 30 clinics (600+ ‘high risk’)
Secondary schools: 19 clinics (decile 1)
 Free to ALL 4-19 year olds (incl. casual
patients)
 Nurse-led utilising standing orders
 Free treatment via PSO
 Follows the evidence based clinical protocol
 Fit-for-purpose electronic forms
Total ‘high risk’
65,424
Mana Kidz
23,424
STC Secondary schools
18,578
STC Primary care
32,820
1000
885 852
800
538
600
400
311
625
411
200
0
April
Primary care
May
June
Secondary school
Standing Order for Sore Throat Clinics for the treatment of Group A
Streptococcal throat infection in Primary Care Programme
Increased access to certain antibiotics for the Rheumatic Fever
Prevention Programme approved
http://www.goodfellowclub.org/case/primary‐
prevention‐rheumatic‐feverchildren‐ within‐pri
mary‐health‐care‐setting
Differential Diagnosis?
• Tonsillitis (Bacterial
Pharangitis)
• Viral Pharangitis
• Infectious mononucleosis
• Quinsy
• Epiglottitis
Rheumatic Heart Disease casts a long
shadow…
• Maori & Pacific child rates: 23 & 45 times > European
• Maori & Pacific communities carry the burden
• 60% of ARF cases develop RHD - lifelong management
• 145 deaths/yr (twice as many as cervical cancer) in NZ
• Causes death amongst younger adults
• Mortality rate 7.5x higher for Maori