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Rheumatic fever is a "Third World disease" related to poverty and overcrowding. It has been eradicated in practically all developed countries and in many developing countries, but has persisted in New Zealand over the past 30 years;1,2 it is also prevalent in our Pacific neighbour Samoa as outlined in an article by Viali and colleagues in this issue of the NZMJ.3 Rheumatic fever occurs alongside other childhood diseases including chest and skin infections which are also related to social deprivation.Rheumatic fever and resultant rheumatic heart disease reflect gross and intolerable health inequalities—being 23 and nearly 50 times more likely in Māori and Pacific people respectively than in European/other, and 29 times more likely in the most deprived socioeconomic groups (NZDep 9-10) compared with least deprived socioeconomic groups (NZDep 1-2).4 The local "hot spots" for occurrence, where recent clusters of cases have continued to occur—in the Northern, Midland and Central regions of New Zealand's North Island—are well identified.This is a shameful situation, embarrassing and intolerable in the sense of our designation as a developed country. Rheumatic fever deserves topmost priority for eradication and should be regarded as a key indicator of child health and how we as a community value our children. The disease which is eminently preventable "casts a long shadow" with a large consequent adult disease burden and a high cost to individuals, families, the community and the health system. More broadly, as a measure of relative inequalities, social and economic conditions, it is a clear indicator of the need for urgent leadership and coordination for improvement.The rationale for monitoring child health even more closely during an economic recession through the development of a Children's Social Health Monitor has been proposed recently.5This should include rheumatic fever as a specific indicator amongst a number of indicators monitoring prevailing economic conditions, health and wellbeing.Rheumatic fever can indeed be eradicated as has been shown even in poorer countries through a comprehensive public health approach with open access to primary care.6,7 In New Zealand, success has been achieved in Whangaroa county through a community-led, school-based clinic.8 A target for total eradication in New Zealand within 10 years is entirely realistic and achievable.The current work and dedication of many individuals and organisations in this area over a long period should be acknowledged. From this strong base, a more comprehensive and coordinated national approach across the continuum of prevention can now be established and coupled with higher levels of community empowerment to accelerate progress towards eradication.Indeed, 2010 has seen the establishment of a national steering group to work alongside the Ministry of Health and with providers to raise the profile of rheumatic fever in the sector and in the community, coordinate linkages, and work to promote effective evidence-based interventions for accelerated improvement.What then should we do better? As previously stated, rheumatic fever is derived from conditions of social deprivation and crowding. Solutions involve multiple agencies working together in partnership with vulnerable families and communities as articulated in the Government's Whanau Ora Approach. At the primordial level there is a need for ongoing support for housing improvement which has been shown to significantly reduce hospital admissions for infectious diseases.9Primary prevention through general child health clinics and more highly focused community and school-based sore throat clinics in areas of high prevalence could be very effective and rapidly reduce cases by more than half.10 Such clinics require high quality standards, ongoing monitoring and evaluation for success and need to be joined with heightened community awareness that "sore throats matter" and open access to primary care. An appropriate targeted approach for antibiotic treatment for Group A streptococcal pharyngitis in high-risk settings is outlined in existent Heart Foundation guidelines for rheumatic fever prevention.11Rigorous early identification, registration and follow-up of cases for secondary prophylaxis with appropriate household testing and treatment are complementary essentials for eradication. Preliminary echocardiographic screening studies in high risk communities in New Zealand indicate that for every known case there may be another unknown case of rheumatic heart disease with no known history of acute rheumatic fever that would benefit from penicillin prophylaxis.12At the moment there is optimism that rheumatic fever—an indicator of the most striking health inequalities in New Zealand children—can be eradicated in New Zealand. However, there are also other childhood diseases which show similar unnecessary and avoidable differences between population groups. For instance, in a 2009 report from the Organisation for Economic Co-operation and Development (OECD), New Zealand ranked 29th out of 30 countries for child health and safety.13Significant improvement is unlikely for rheumatic fever or our other "Third World diseases" unless child health is given higher priority and there is an increased proportion of health sector spending on services for children.If rheumatic fever is still existent in New Zealand in another decade the shame will certainly remain. Conversely, if we eradicate rheumatic fever, then we will have made New Zealand a better place for our children.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Norman Sharpe, Medical Director, Heart Foundation, Auckland, PO Box 17-160, Greenlane, Auckland, New Zealand. Fax: +64 (0)9 571919

Acknowledgements

Correspondence

Correspondence Email

NormanS@heartfoundation.org.nz

Competing Interests

'-  Jaine R, Baker M, Venugopal K. Epidemiology of acute rheumatic fever in New Zealand 1996-2005. J Paediatr Child Health. 2008 Oct;44(10):564-71.--  Thornley C, McNicholas A, Baker M, Lennon D. Rheumatic fever registers in New Zealand. NZ Public Health Rep. 2001;8:41-4.--  Viali S, Saena P, Futi V. Rheumatic fever programme in Samoa. N Z Med J. 2011;124(1329).--  Craig E, Jackson C, Han DY, NZCYES Steering Committee. Monitoring the Health of New Zealand Children and Young People: Indicator Handbook. Auckland: Paediatric Society of New Zealand, New Zealand Child and Youth Epidemiology Service; 2007.--  Introduction to the Childrens Social Health Monitor [webpage].The New Zealand Child and Youth Epidemiology Service; 2009. http://www.nzchildren.co.nz/introduction.php--  Nordet P, Lopez R, Duenas A, Sarmiento L. Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002). Cardiovasc J Afr. 2008 May-Jun;19(3):135-40.--  Arguedas A, Mohs E. Prevention of rheumatic fever in Costa Rica. J Pediatr. 1992 Oct;121(4):569-72.--  Wilson N. Rheumatic heart disease in indigenous populations - New Zealand experience. Heart Lung Circ. 2010 May-Jun;19(5-6):282-8. Epub 2010 Apr 14.--  Jackson G, Thornley S, Woolston J, et al. Reduced acute hospitalisation with the Healthy Housing programme. 2011 (In press).--  Lennon D, Kerdemelidis M, Arroll B. Meta-analysis of trials of streptococcal throat treatment programs to prevent rheumatic fever. Pediatr Infect Dis J. 2009 Jul;28(7):e259-64.--  New Zealand Guidelines for Rheumatic Fever. 2 - Group A Streptococcal Sore Throat Management. Auckland: Heart Foundation of New Zealand, Cardiac Society of Australia and New Zealand; 2008.http://www.heartfoundation.org.nz/files/Rheumatic%20Fever%20Guideline%202.pdf--  Webb R, Wilson N, Lennon D et al. Population-based echocardiographic screening for Rheumatic Heart Disease in high-risk New Zealand children. Cairns: 5th World Congress of Paediatric Cardiology and Cardiac Surgery; 2009.--  OECD. Comparative Child Well-being across the OECD. In: Doing Better for Children. Paris: Organisation for Economic Cooperation and Development; 2009. http://www.oecd.org/dataoecd/19/4/43570328.pdf-

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Rheumatic fever is a "Third World disease" related to poverty and overcrowding. It has been eradicated in practically all developed countries and in many developing countries, but has persisted in New Zealand over the past 30 years;1,2 it is also prevalent in our Pacific neighbour Samoa as outlined in an article by Viali and colleagues in this issue of the NZMJ.3 Rheumatic fever occurs alongside other childhood diseases including chest and skin infections which are also related to social deprivation.Rheumatic fever and resultant rheumatic heart disease reflect gross and intolerable health inequalities—being 23 and nearly 50 times more likely in Māori and Pacific people respectively than in European/other, and 29 times more likely in the most deprived socioeconomic groups (NZDep 9-10) compared with least deprived socioeconomic groups (NZDep 1-2).4 The local "hot spots" for occurrence, where recent clusters of cases have continued to occur—in the Northern, Midland and Central regions of New Zealand's North Island—are well identified.This is a shameful situation, embarrassing and intolerable in the sense of our designation as a developed country. Rheumatic fever deserves topmost priority for eradication and should be regarded as a key indicator of child health and how we as a community value our children. The disease which is eminently preventable "casts a long shadow" with a large consequent adult disease burden and a high cost to individuals, families, the community and the health system. More broadly, as a measure of relative inequalities, social and economic conditions, it is a clear indicator of the need for urgent leadership and coordination for improvement.The rationale for monitoring child health even more closely during an economic recession through the development of a Children's Social Health Monitor has been proposed recently.5This should include rheumatic fever as a specific indicator amongst a number of indicators monitoring prevailing economic conditions, health and wellbeing.Rheumatic fever can indeed be eradicated as has been shown even in poorer countries through a comprehensive public health approach with open access to primary care.6,7 In New Zealand, success has been achieved in Whangaroa county through a community-led, school-based clinic.8 A target for total eradication in New Zealand within 10 years is entirely realistic and achievable.The current work and dedication of many individuals and organisations in this area over a long period should be acknowledged. From this strong base, a more comprehensive and coordinated national approach across the continuum of prevention can now be established and coupled with higher levels of community empowerment to accelerate progress towards eradication.Indeed, 2010 has seen the establishment of a national steering group to work alongside the Ministry of Health and with providers to raise the profile of rheumatic fever in the sector and in the community, coordinate linkages, and work to promote effective evidence-based interventions for accelerated improvement.What then should we do better? As previously stated, rheumatic fever is derived from conditions of social deprivation and crowding. Solutions involve multiple agencies working together in partnership with vulnerable families and communities as articulated in the Government's Whanau Ora Approach. At the primordial level there is a need for ongoing support for housing improvement which has been shown to significantly reduce hospital admissions for infectious diseases.9Primary prevention through general child health clinics and more highly focused community and school-based sore throat clinics in areas of high prevalence could be very effective and rapidly reduce cases by more than half.10 Such clinics require high quality standards, ongoing monitoring and evaluation for success and need to be joined with heightened community awareness that "sore throats matter" and open access to primary care. An appropriate targeted approach for antibiotic treatment for Group A streptococcal pharyngitis in high-risk settings is outlined in existent Heart Foundation guidelines for rheumatic fever prevention.11Rigorous early identification, registration and follow-up of cases for secondary prophylaxis with appropriate household testing and treatment are complementary essentials for eradication. Preliminary echocardiographic screening studies in high risk communities in New Zealand indicate that for every known case there may be another unknown case of rheumatic heart disease with no known history of acute rheumatic fever that would benefit from penicillin prophylaxis.12At the moment there is optimism that rheumatic fever—an indicator of the most striking health inequalities in New Zealand children—can be eradicated in New Zealand. However, there are also other childhood diseases which show similar unnecessary and avoidable differences between population groups. For instance, in a 2009 report from the Organisation for Economic Co-operation and Development (OECD), New Zealand ranked 29th out of 30 countries for child health and safety.13Significant improvement is unlikely for rheumatic fever or our other "Third World diseases" unless child health is given higher priority and there is an increased proportion of health sector spending on services for children.If rheumatic fever is still existent in New Zealand in another decade the shame will certainly remain. Conversely, if we eradicate rheumatic fever, then we will have made New Zealand a better place for our children.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Norman Sharpe, Medical Director, Heart Foundation, Auckland, PO Box 17-160, Greenlane, Auckland, New Zealand. Fax: +64 (0)9 571919

Acknowledgements

Correspondence

Correspondence Email

NormanS@heartfoundation.org.nz

Competing Interests

'-  Jaine R, Baker M, Venugopal K. Epidemiology of acute rheumatic fever in New Zealand 1996-2005. J Paediatr Child Health. 2008 Oct;44(10):564-71.--  Thornley C, McNicholas A, Baker M, Lennon D. Rheumatic fever registers in New Zealand. NZ Public Health Rep. 2001;8:41-4.--  Viali S, Saena P, Futi V. Rheumatic fever programme in Samoa. N Z Med J. 2011;124(1329).--  Craig E, Jackson C, Han DY, NZCYES Steering Committee. Monitoring the Health of New Zealand Children and Young People: Indicator Handbook. Auckland: Paediatric Society of New Zealand, New Zealand Child and Youth Epidemiology Service; 2007.--  Introduction to the Childrens Social Health Monitor [webpage].The New Zealand Child and Youth Epidemiology Service; 2009. http://www.nzchildren.co.nz/introduction.php--  Nordet P, Lopez R, Duenas A, Sarmiento L. Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002). Cardiovasc J Afr. 2008 May-Jun;19(3):135-40.--  Arguedas A, Mohs E. Prevention of rheumatic fever in Costa Rica. J Pediatr. 1992 Oct;121(4):569-72.--  Wilson N. Rheumatic heart disease in indigenous populations - New Zealand experience. Heart Lung Circ. 2010 May-Jun;19(5-6):282-8. Epub 2010 Apr 14.--  Jackson G, Thornley S, Woolston J, et al. Reduced acute hospitalisation with the Healthy Housing programme. 2011 (In press).--  Lennon D, Kerdemelidis M, Arroll B. Meta-analysis of trials of streptococcal throat treatment programs to prevent rheumatic fever. Pediatr Infect Dis J. 2009 Jul;28(7):e259-64.--  New Zealand Guidelines for Rheumatic Fever. 2 - Group A Streptococcal Sore Throat Management. Auckland: Heart Foundation of New Zealand, Cardiac Society of Australia and New Zealand; 2008.http://www.heartfoundation.org.nz/files/Rheumatic%20Fever%20Guideline%202.pdf--  Webb R, Wilson N, Lennon D et al. Population-based echocardiographic screening for Rheumatic Heart Disease in high-risk New Zealand children. Cairns: 5th World Congress of Paediatric Cardiology and Cardiac Surgery; 2009.--  OECD. Comparative Child Well-being across the OECD. In: Doing Better for Children. Paris: Organisation for Economic Cooperation and Development; 2009. http://www.oecd.org/dataoecd/19/4/43570328.pdf-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Rheumatic fever is a "Third World disease" related to poverty and overcrowding. It has been eradicated in practically all developed countries and in many developing countries, but has persisted in New Zealand over the past 30 years;1,2 it is also prevalent in our Pacific neighbour Samoa as outlined in an article by Viali and colleagues in this issue of the NZMJ.3 Rheumatic fever occurs alongside other childhood diseases including chest and skin infections which are also related to social deprivation.Rheumatic fever and resultant rheumatic heart disease reflect gross and intolerable health inequalities—being 23 and nearly 50 times more likely in Māori and Pacific people respectively than in European/other, and 29 times more likely in the most deprived socioeconomic groups (NZDep 9-10) compared with least deprived socioeconomic groups (NZDep 1-2).4 The local "hot spots" for occurrence, where recent clusters of cases have continued to occur—in the Northern, Midland and Central regions of New Zealand's North Island—are well identified.This is a shameful situation, embarrassing and intolerable in the sense of our designation as a developed country. Rheumatic fever deserves topmost priority for eradication and should be regarded as a key indicator of child health and how we as a community value our children. The disease which is eminently preventable "casts a long shadow" with a large consequent adult disease burden and a high cost to individuals, families, the community and the health system. More broadly, as a measure of relative inequalities, social and economic conditions, it is a clear indicator of the need for urgent leadership and coordination for improvement.The rationale for monitoring child health even more closely during an economic recession through the development of a Children's Social Health Monitor has been proposed recently.5This should include rheumatic fever as a specific indicator amongst a number of indicators monitoring prevailing economic conditions, health and wellbeing.Rheumatic fever can indeed be eradicated as has been shown even in poorer countries through a comprehensive public health approach with open access to primary care.6,7 In New Zealand, success has been achieved in Whangaroa county through a community-led, school-based clinic.8 A target for total eradication in New Zealand within 10 years is entirely realistic and achievable.The current work and dedication of many individuals and organisations in this area over a long period should be acknowledged. From this strong base, a more comprehensive and coordinated national approach across the continuum of prevention can now be established and coupled with higher levels of community empowerment to accelerate progress towards eradication.Indeed, 2010 has seen the establishment of a national steering group to work alongside the Ministry of Health and with providers to raise the profile of rheumatic fever in the sector and in the community, coordinate linkages, and work to promote effective evidence-based interventions for accelerated improvement.What then should we do better? As previously stated, rheumatic fever is derived from conditions of social deprivation and crowding. Solutions involve multiple agencies working together in partnership with vulnerable families and communities as articulated in the Government's Whanau Ora Approach. At the primordial level there is a need for ongoing support for housing improvement which has been shown to significantly reduce hospital admissions for infectious diseases.9Primary prevention through general child health clinics and more highly focused community and school-based sore throat clinics in areas of high prevalence could be very effective and rapidly reduce cases by more than half.10 Such clinics require high quality standards, ongoing monitoring and evaluation for success and need to be joined with heightened community awareness that "sore throats matter" and open access to primary care. An appropriate targeted approach for antibiotic treatment for Group A streptococcal pharyngitis in high-risk settings is outlined in existent Heart Foundation guidelines for rheumatic fever prevention.11Rigorous early identification, registration and follow-up of cases for secondary prophylaxis with appropriate household testing and treatment are complementary essentials for eradication. Preliminary echocardiographic screening studies in high risk communities in New Zealand indicate that for every known case there may be another unknown case of rheumatic heart disease with no known history of acute rheumatic fever that would benefit from penicillin prophylaxis.12At the moment there is optimism that rheumatic fever—an indicator of the most striking health inequalities in New Zealand children—can be eradicated in New Zealand. However, there are also other childhood diseases which show similar unnecessary and avoidable differences between population groups. For instance, in a 2009 report from the Organisation for Economic Co-operation and Development (OECD), New Zealand ranked 29th out of 30 countries for child health and safety.13Significant improvement is unlikely for rheumatic fever or our other "Third World diseases" unless child health is given higher priority and there is an increased proportion of health sector spending on services for children.If rheumatic fever is still existent in New Zealand in another decade the shame will certainly remain. Conversely, if we eradicate rheumatic fever, then we will have made New Zealand a better place for our children.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Norman Sharpe, Medical Director, Heart Foundation, Auckland, PO Box 17-160, Greenlane, Auckland, New Zealand. Fax: +64 (0)9 571919

Acknowledgements

Correspondence

Correspondence Email

NormanS@heartfoundation.org.nz

Competing Interests

'-  Jaine R, Baker M, Venugopal K. Epidemiology of acute rheumatic fever in New Zealand 1996-2005. J Paediatr Child Health. 2008 Oct;44(10):564-71.--  Thornley C, McNicholas A, Baker M, Lennon D. Rheumatic fever registers in New Zealand. NZ Public Health Rep. 2001;8:41-4.--  Viali S, Saena P, Futi V. Rheumatic fever programme in Samoa. N Z Med J. 2011;124(1329).--  Craig E, Jackson C, Han DY, NZCYES Steering Committee. Monitoring the Health of New Zealand Children and Young People: Indicator Handbook. Auckland: Paediatric Society of New Zealand, New Zealand Child and Youth Epidemiology Service; 2007.--  Introduction to the Childrens Social Health Monitor [webpage].The New Zealand Child and Youth Epidemiology Service; 2009. http://www.nzchildren.co.nz/introduction.php--  Nordet P, Lopez R, Duenas A, Sarmiento L. Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002). Cardiovasc J Afr. 2008 May-Jun;19(3):135-40.--  Arguedas A, Mohs E. Prevention of rheumatic fever in Costa Rica. J Pediatr. 1992 Oct;121(4):569-72.--  Wilson N. Rheumatic heart disease in indigenous populations - New Zealand experience. Heart Lung Circ. 2010 May-Jun;19(5-6):282-8. Epub 2010 Apr 14.--  Jackson G, Thornley S, Woolston J, et al. Reduced acute hospitalisation with the Healthy Housing programme. 2011 (In press).--  Lennon D, Kerdemelidis M, Arroll B. Meta-analysis of trials of streptococcal throat treatment programs to prevent rheumatic fever. Pediatr Infect Dis J. 2009 Jul;28(7):e259-64.--  New Zealand Guidelines for Rheumatic Fever. 2 - Group A Streptococcal Sore Throat Management. Auckland: Heart Foundation of New Zealand, Cardiac Society of Australia and New Zealand; 2008.http://www.heartfoundation.org.nz/files/Rheumatic%20Fever%20Guideline%202.pdf--  Webb R, Wilson N, Lennon D et al. Population-based echocardiographic screening for Rheumatic Heart Disease in high-risk New Zealand children. Cairns: 5th World Congress of Paediatric Cardiology and Cardiac Surgery; 2009.--  OECD. Comparative Child Well-being across the OECD. In: Doing Better for Children. Paris: Organisation for Economic Cooperation and Development; 2009. http://www.oecd.org/dataoecd/19/4/43570328.pdf-

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