Marc Remond

Variability in disease burden and management of rheumatic fever and rheumatic heart disease in two regions of tropical Australia.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) contribute to Aboriginal Australian and Torres Strait Islander health disadvantage. At the time of this study, specialist ARF/RHD care in the Kimberley region of Western Australia was delivered by a broad range of providers. In contrast, in Far North Queensland (FNQ), a single‐provider model was used as part of a coordinated RHD control programme.

Infective Endocarditis and Rheumatic Heart Disease in the North of Australia

BACKGROUND To prevent infective endocarditis (IE), Australian guidelines recommend providing prophylactic antibiotics to Indigenous patients with rheumatic heart disease (RHD) prior to procedures which may cause bacteremia. In northern Australia RHD remains prevalent. We aimed to determine whether RHD is associated with an increased risk of IE, which risk factors are associated with IE, and the incidence and aetiology of IE. METHODS A retrospective review of IE patients who fulfilled modified Duke criteria at two tertiary centres in northern Australia. RESULTS 89 patients were reviewed. The rate of IE was 6.5/100,000 person-years. IE was more common in people with RHD (relative risk (RR) 58), Indigenous Australians (RR 2.0) and men (RR 1.7). RHD-associated IE was not confined to Indigenous Australians with 42% being non-Indigenous. The commonest risk factors for IE were intracardiac prosthetic material, injecting drug use and previous IE. One in five patients died. CONCLUSIONS In northern Australia the principle risk factor for IE is not RHD. Whilst RHD increased the risk of IE it was not restricted to Indigenous Australians. Current Australian recommendations of providing prophylactic antibiotics to Indigenous patients with RHD prior to procedures which may cause bacteremia may need to be broadened to include non-Indigenous patients.

Acute rheumatic fever and rheumatic heart disease--priorities in prevention, diagnosis and management. A report of the CSANZ Indigenous Cardiovascular Health Conference, Alice Springs 2011.

Three priority areas in the prevention, diagnosis and management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) were identified and discussed in detail: 1. Echocardiography and screening/diagnosis of RHD – Given the existing uncertainty it remains premature to advocate for or to incorporate echocardiographic screening for RHD into Australian clinical practice. Further research is currently being undertaken to evaluate the potential for echocardiography screening. 2. Secondary prophylaxis – Secondary prophylaxis (long acting benzathine penicillin injections) must be seen as a priority. Systems-based approaches are necessary with a focus on the development and evaluation of primary health care-based or led strategies incorporating effective health information management systems. Better/novel systems of delivery of prophylactic medications should be investigated. 3. Management of advanced RHD – National centres of excellence for the diagnosis, assessment and surgical management of RHD are required. Early referral for surgical input is necessary with multidisciplinary care and team-based decision making that includes patient, family, and local health providers. There is a need for a national RHD surgical register and research strategy for the assessment, intervention and long-term outcome of surgery and other interventions for RHD.

Rheumatic Fever Follow-Up Study (RhFFUS) protocol: a cohort study investigating the significance of minor echocardiographic abnormalities in Aboriginal Australian and Torres Strait Islander children

BackgroundIn Australia, rheumatic heart disease (RHD) is almost exclusively restricted to Aboriginal Australian and Torres Strait Islander people with children being at highest risk. International criteria for echocardiographic diagnosis of RHD have been developed but the significance of minor heart valve abnormalities which do not reach these criteria remains unclear. The Rheumatic Fever Follow-Up Study (RhFFUS) aims to clarify this question in children and adolescents at high risk of RHD.Methods/designRhFFUS is a cohort study of Aboriginal and/or Torres Strait Islander children and adolescents aged 8–17 years residing in 32 remote Australian communities. Cases are people with non-specific heart valve abnormalities detected on prior screening echocardiography. Controls (two per case) are age, gender, community and ethnicity-matched to cases and had a prior normal screening echocardiogram. Participants will have echocardiography about 3 years after initial screening echocardiogram and enhanced surveillance for any history suggestive of acute rheumatic fever (ARF). It will then be determined if cases are at higher risk of (1) ARF or (2) developing progressive echocardiography-detected valve changes consistent with RHD.The occurrence and timing of episodes of ARF will be assessed retrospectively for 5 years from the time of the RhFFUS echocardiogram. Episodes of ARF will be identified through regional surveillance and notification databases, carer/subject interviews, primary healthcare history reviews, and hospital separation diagnoses.Progression of valvular abnormalities will be assessed prospectively using transthoracic echocardiography and standardized operating and reporting procedures. Progression of valve lesions will be determined by specialist cardiologist readers who will assess the initial screening and subsequent RhFFUS screening echocardiogram for each participant. The readers will be blinded to the initial assessment and temporal order of the two echocardiograms.DiscussionRhFFUS will determine if subtle changes on echocardiography represent the earliest changes of RHD or mere variations of normal heart anatomy. In turn it will inform criteria to be used in determining whether secondary antibiotic prophylaxis should be utilized in individuals with no clear history of ARF and minor abnormalities on echocardiography. RhFFUS will also inform the ongoing debate regarding the potential role of screening echocardiography for the detection of RHD in this setting.

Approaches to Improving Adherence to Secondary Prophylaxis for Rheumatic Fever and Rheumatic Heart Disease: A Literature Review with a Global Perspective.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are autoimmune conditions resulting from infection with group A streptococcus. Current management of these conditions includes secondary antibiotic prevention. This comprises regular 3 to 4 weekly long-acting intramuscular benzathine penicillin injections. Secondary antibiotic prevention aims to protect individuals against reinfection with group A streptococcus, thereby preventing recurrent ARF and the risk of further damage to the heart valves. However, utilization of benzathine penicillin can be poor leaving patients at risk of avoidable and progressive heart damage. This review utilizes the Chronic Care Model as a framework to discuss initiatives to enhance the delivery of secondary antibiotic prophylaxis for ARF and RHD. Results from the search strategy utilized revealed that there is limited pertinent published evidence. The evidence that is available suggests that register/recall systems, dedicated health teams for delivery of secondary antibiotic prophylaxis, education about ARF and RHD, linkages with the community (particularly between health services and schools), and strong staff–patient relationships may be important. However, it is difficult to generalize findings from individual studies to other settings and high quality studies are lacking. Although secondary antibiotic prophylaxis is an effective treatment for those with ARF or RHD, the difficulties in implementing effective programs that reduce the burden of ARF and RHD demonstrates the importance of ongoing work in developing and evaluating research translation initiatives.

Sharing success – understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease

BackgroundRheumatic fever (RF) and rheumatic heart disease (RHD) cause considerable morbidity and mortality amongst Australian Aboriginal and Torres Strait Islander populations. Secondary antibiotic prophylaxis in the form of 4-weekly benzathine penicillin injections is the mainstay of control programs. Evidence suggests, however, that delivery rates of such prophylaxis are poor.MethodsThis qualitative study used semi-structured interviews with patients, parents/care givers and health professionals, to explore the enablers of and barriers to the uptake of secondary prophylaxis. Data from participant interviews (with 11 patients/carers and 11 health practitioners) conducted in four far north Queensland sites were analyzed using the method of constant comparative analysis.ResultsDeficits in registration and recall systems and pain attributed to injections were identified as barriers to secondary prophylaxis uptake. There were also varying perceptions regarding responsibility for ensuring injection delivery. Enablers of secondary prophylaxis uptake included positive patient-healthcare provider relationships, supporting patient autonomy, education of patients, care givers and healthcare providers, and community-based service delivery.ConclusionThe study findings provide insights that may facilitate enhancement of secondary prophylaxis delivery systems and thereby improve uptake of secondary prophylaxis for RF/RHD.

Community‐acquired pneumonia in the central desert and north‐western tropics of Australia

Background: Community‐acquired pneumonia (CAP) results in significant morbidity in central and north‐western Australia. However, the nature, management and outcome of CAP are poorly documented. The aim of the study was to describe CAP in the Kimberley and Central Desert regions of Australia.

Screening for rheumatic heart disease in Aboriginal and Torres Strait Islander children.

Rheumatic heart disease is preventable but causes significant morbidity and mortality in Aboriginal Australian and Torres Strait Islander populations. Screening echocardiography has the potential to detect early rheumatic heart disease thereby enabling timely commencement of treatment (secondary prophylaxis) to halt disease progression. However, a number of issues prevent echocardiographic screening for rheumatic heart disease satisfying the Australian criteria for acceptable screening programs. Primarily, it is unclear what criteria should be used to define a positive screening result as questions remain regarding the significance, natural history and potential treatment of early and subclinical rheumatic heart disease. Furthermore, at present the delivery of secondary prophylaxis in Australia remains suboptimal such that the potential benefits of screening would be limited. Finally, the impact of echocardiographic screening for rheumatic heart disease on local health services and the psychosocial health of patients and families are yet to be ascertained.

Bronchiectasis in indigenous and non‐indigenous residents of Australia and New Zealand

Bronchiectasis not associated with cystic fibrosis is an increasingly recognized chronic lung disease. In Oceania, indigenous populations experience a disproportionately high burden of disease. We aimed to describe the natural history of bronchiectasis and identify risk factors associated with premature mortality within a cohort of Aboriginal Australians, New Zealand Māori and Pacific Islanders, and non‐indigenous Australians and New Zealanders.

Impact of an integrated diabetes service involving specialist outreach and primary health care on risk factors for micro- and macrovascular diabetes complications in remote Indigenous communities in Australia

OBJECTIVE To determine the impact of an integrated diabetes service involving specialist outreach and primary health care teams on risk factors for micro- and macrovascular diabetes complications in three remote Indigenous Australian communities over a 12-month period. DESIGN Quantitative, retrospective evaluation. SETTING Primary health care clinics in remote Indigenous communities in Australia. PARTICIPANTS One-hundred-and-twenty-four adults (including 123 Indigenous Australians; 76.6% female) with diabetes living in remote communities. MAIN OUTCOME MEASURES Glycosylated haemoglobin, lipid profile, estimated glomerular filtration rate, urinary albumin : creatinine ratio and blood pressure. RESULTS Diabetes prevalence in the three communities was high, at 32.8%. A total of 124 patients reviewed by the outreach service had a median consultation rate of 1.0 by an endocrinologist and 0.9 by a diabetes nurse educator over the 12-month period. Diabetes care plans were made in collaboration with local primary health care services, which also provided patients with diabetes care between outreach team visits. A significant reduction was seen in median (interquartile range) glycosylated haemoglobin from baseline to 12 months. Median (interquartile range) total cholesterol was also reduced. The number of patients prescribed glucagon-like peptide-1 analogues and dipeptidyl peptidase-4 inhibitors increased over the 12 months and an increase in the number of patients prescribed insulin trended towards statistical significance. CONCLUSION A collaborative health care approach to deliver diabetes care to remote Indigenous Australian communities was associated with an improvement in glycosylated haemoglobin and total cholesterol, both important risk factors, respectively, for micro- and macrovascular diabetes complications.