#JournalWatch: From sore throat to heart disease…it’s time to act

Melissa Sweet
Melissa Stoneham
Tuesday, February 26, 2019

Social determinants of health, Indigenous health, Cardiovascular disease, Public health and population health, Prevention

Action to implement environmental health strategies can save lives by preventing rheumatic heart disease, says Dr Melissa Stoneham in her latest #JournalWatch column.

Melissa Stoneham writes:

This month I am going to start the JournalWatch column at the end, with the recommendation at the end of the article being reviewed.

Published in Global Public Health, the article discusses the urgent need to develop global policy on rheumatic heart disease (RHD). Authored by Dr Marian Abouzeid from Deakin University (formerly of the Telethon Kids Institute in Perth), it recommends that, after numerous calls for action on both regional and global scales, a move from rhetoric to metric is needed.

Abouzeid states that data are needed to inform decisions about the need for and types of policy and programmatic responses required to make sure no one is left behind.

So let’s look at the metric. Globally, it is estimated that 32 million people are currently living with RHD across the world. Over 230,000 people die from the disease every year. There are another 1.9 million people with a history of acute rheumatic fever (ARF) and 470,000 new cases are diagnosed annually.

Most of these cases are in developing countries as this disease is associated with poverty. RHD is entirely preventable and treatable, but as Abouzeid states, has been a terribly neglected global issue.

It is no better when looking at the Australian scene. In fact, our statistics are disgraceful. We have one of the highest rates of ARF and RHD in the world. In 2018, Menzies researchers identified that the NT community of Maningrida had the highest known rates of RHD in the world.

More generally, Aboriginal Australians are up to eight times more likely than other groups to be hospitalised and nearly 20 times as likely to die from this disease. Up to 100 Indigenous children and young people die each year from RHD.

The disease is responsible for the highest gap in life expectancy between Indigenous and non-Indigenous Australians – higher than diabetes or kidney failure.

Longstanding concerns

RHD is not a new disease. The WHO first began to tackle it in 1954 through technical meetings and convening activities about rheumatic fever and RHD.

But it was not until 1984 that a concerted program of work was launched. This program focused on improving living standards, improving access to care and medications and planning, and implementing registry-based control programs – but was disbanded in 2002.

More recently, the World Heart Foundation launched a 25 × 25 < 25 campaign, calling for action towards a 25 percent reduction in RF/RHD mortality amongst individuals aged less than 25 years by 2025. In Australia, the ENDRHD program is beginning to have traction.

RHD is caused by infection by the Group A Streptococcus bacterium which can manifest as either a strep throat or impetigo (skin sores). If left untreated, and when combined with poor environmental conditions, it can lead to heart failure and premature death.

It seems almost unreal to think that a sore throat or skin sore can lead to heart diseases.

To explain, I will use Professor Jonathan Carapetis’ words. He states that when fighting a strep infection, a small percentage of people develop an abnormal response which leads to the body’s immune system attacking its own tissues. This happens due to a combination of bacterial, genetic and environmental factors, and results in acute rheumatic fever.

Symptoms include sore joints, fevers and inflammation of heart valves. When acute rheumatic fever occurs repeatedly, valve damage worsens and becomes permanent, resulting in rheumatic heart disease.

Prevention first

Yet RHD is preventable. Known risk factors include poverty, overcrowding and limited access to medical care for diagnosis and treatment.

So what can be done?

Abouzeid writes that the fundamental first step in developing a regional or national roadmap to end RHD is conducting a situational analysis to profile the local epidemiology and health system and policy environment – development of disease control programs and tailoring preventive initiatives requires an understanding of who and how many people live with and die from RHD, why and where. She states that data is needed at a granular level.

She goes on to suggest that universal health coverage, where everyone has the ability to access affordable and quality health care is another policy goal particularly given that the populations at greatest risk of RHD are also those who typically have least access to health services.

Knowledge gaps that exist in some critical clinical domains are discussed in the article, and a sector-supported set of RHD indicators that could monitor activity, identify gaps and needs and ensure that policy efforts to tackle RHD do not stagnate, is suggested.

And whilst I agree with all of these recommendations, I cannot help but wonder why the obvious solution was not discussed in any detail.

As a prevention specialist, it seems one of the most useful and sustainable solutions would be to address the environmental conditions in which people live. This is easier said than done as it would focus on functional bathrooms where children could wash their hands and face, regular access to working washing machines and basic hygiene within homes.

That might all sound like a lot of hard work. Yet in Western Australia, a small and dedicated group of practitioners is doing just this.

Partnership in action

A partnership between the WA Country Health Service, the Aboriginal Environmental Health Directorate (WA Health) and the Public Health Advocacy Institute of WA (Curtin University), has developed a safe bathroom audit as part of a broader trachoma prevention program.

Working with 41 ‘trachoma at risk’ remote communities, this program works with the Aboriginal Environmental Health Practitioners, most of whom live remotely, to enter people’s homes to audit bathrooms and also undertake minor maintenance. Free soap and soap socks are made available to community members.

These strategies are holistically embedded in community-led environmental health action plans that are progressively being developed across the 41 communities.

So, yes, data is needed; policy is needed – but action is possible. For these diseases linked to the environment in which people live, there are solutions.

They are not easy wins. They require considerable thought, buy-in by communities, active and genuine engagement and the ability to keep your eye on the prize.

Yet they are incredibly worthwhile and more importantly, they are making a difference.

The article: Time to tackle rheumatic heart disease: Data needed to drive global policy dialogues by Marian Abouzeid; Global Public Health; Vol 14, Issue 3; pages 456-468.

About JournalWatch

The Public Health Advocacy Institute WA (PHAIWA) JournalWatch service reviews 10 key public health journals on a monthly basis, providing a précis of articles that highlight key public health and advocacy related findings, with an emphasis on findings that can be readily translated into policy or practice. Read the previous columns.

The Journals reviewed include: