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Bring the fever down

By Alex Wilde

3 August 2006 - A health scourge among indigenous Australians demands a national response.
A painful and potentially fatal disease that is almost never seen elsewhere in Western society has reached world-record levels among indigenous Australians.

It can start with a simple sore throat. But without treatment, the Streptococcus A bacterial infection leads to a severe fever and attacks the joints, skin, heart and sometimes the brain; it often causes irreparable damage to the major cardiac valves, known as rheumatic heart disease, which can be fatal.

In the 1940s, acute rheumatic fever and rheumatic heart disease was as common in Melbourne as it is among indigenous Australians today, who are eight times more likely to be hospitalised for it than other ethnic groups, and 20 times more likely to die from it.

In a bid to improve diagnosis and management of both disorders, the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand have released Australia's first evidence-based guidelines, which aim to ensure that high-risk populations receive an equal standard of care.

The lead author, Professor Jonathan Carapetis, director of the Menzies School of Health Research in Darwin, says the guidelines provide the first national consensus on how acute rheumatic fever and rheumatic heart disease should be treated, and how health services should be organised to control and prevent it.

"The streptococcus bug sits just behind the big ones: HIV, malaria and TB. Having clear guidelines has already worked to control TB in the Aboriginal population," Carapetis says.

"An annual investment of $2-3 million is needed for a nationally co-ordinated strategy to ensure people get access to what is a very simple regimen of treatment and prevention for acute rheumatic fever and rheumatic heart disease, which would not only be cost-effective but represent a cost saving in the long term."

The latest figures from the Australian Institute of Health and Welfare's report, Australia's Health 2006, released in June, show cases of acute rheumatic fever in Aborigines and Torres Strait Islanders are still soaring.

The current rate among Aboriginal children aged 5 to 14 is 63 per cent, an increase of 13 per cent between 2002 and 2004.

In 2004, there were 1133 cases of chronic rheumatic heart disease among Aborigines and Torres Strait Islanders of all ages in the Top End and Central Australia - up from 979 cases two years earlier, the report found. Research suggests the true figure may be three times higher.

Standard treatment to prevent further attacks of acute rheumatic fever is a series of deep, intramuscular injections of benzathine penicillin G, which have to be given every three to four weeks for at least 10 years.
Without treatment, acute rheumatic fever can recur repeatedly into adulthood, causing cumulative harm to the mitral and aortic valves of the heart. Valve damage remains long after the acute fever has passed, requiring major life-saving surgery.

As a first step towards establishing co-ordinated prevention and control programs, the guidelines call for acute rheumatic fever to be made a nationally notifiable disease. Acute rheumatic fever meets World Health Organisation criteria for such diseases, but as yet it is only notifiable in the Northern Territory and Queensland. Carapetis says that acute rheumatic fever also meets international benchmarks for routine screening strategies but no co-ordinated detection programs are in place.

"The best way to treat this disease is to find it early by screening children. Screening programs have picked up children with heart murmurs due to rheumatic heart disease and the majority of those kids are essentially cured five or 10 years later," Carapetis says.

"We want to prevent people getting this and needing very expensive surgery or dying at a very early stage of their life. There are a lot of health interventions, but the best is, without a doubt, immunisation."
Since 2002, the National Heart Foundation, in collaboration with the Menzies School of Health Research, has funded world-class work at the Queensland Institute of Medical Research into developing a vaccine, but Carapetis predicts a successful vaccine is still a decade away.

"A vaccine could prevent 500,000 deaths from rheumatic heart disease per year worldwide. The upshot is that if we get a vaccine that works, there's also a whole list of other diseases caused by the same bug that we can treat, many of which are big health problems in Western communities; from strep throat to serious streptococcal infections like fleshing-eating bacteria."

The National Heart Foundation's chief medical officer, Professor Andrew Tonkin, says the guidelines will enable cost-effective measures such as the establishment of co-ordinated registers of people who have acute rheumatic fever and rheumatic heart disease.

"Registers would form a basis for the secondary prevention program, such as penicillin treatment. The final challenge is how you manage those people who have established chronic rheumatic heart disease," he says.

Source: The Sydney Morning Herald

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