ARF and RHD in Queensland Video
Video transcript
Speaker 1 Acute rheumatic fever and rheumatic heart disease are contemporary health issues in Queensland, which continue to cause significant health impacts and premature death amongst First Nations, Māori and Pasifika people. Both conditions are preventable and if not recognised and treated early, can result in lifelong heart disease, cardiac failure and death. Acute rheumatic fever or ARF, is an abnormal inflammatory immune complication that can occur after common group A streptococcal infections, such as streptococcal pharyngitis and impetigo.
Speaker 1 Rheumatic heart disease, or RHD, is a separate but subsequent condition where heart valves become damaged by one or more episodes of ARF. In Queensland, the highest rates of ARF and RHD are seen in Aboriginal and Torres Strait Islander peoples, predominantly across Northern Queensland, with high rates also seen in Māori and Pasifika people in Southeast Queensland.
Speaker 1 From strep A infection to ARF and then RHD, several opportunities exist to interrupt the disease pathway. Outside of the clinical setting, primordial prevention measures are aimed at improving living conditions, including functional health hardware in homes to reduce strep A infections.
Speaker 1 In a clinical setting, active interventions to prevent ARF and RHD involve recognising and treating strep A infections, diagnosing and notifying ARF episodes to prevent disease progression to RHD, providing regular long term antibiotic prophylaxis to prevent recurrent ARF episodes, monitoring for heart damage and severe complication with cardiac surveillance echocardiograms and diagnosing, managing and notifying RHD.
Speaker 1 While skin conditions like scabies and impetigo are common in some areas, these conditions all require prompt diagnosis and treatment to prevent significant downstream consequences. Patients presenting with a sore throat or skin sores who are at high risk for ARF should have a swab for microscopy culture and sensitivity, and be treated empirically with antibiotics. This reduces both the risk of immune priming and a systemic inflammatory reaction to group A strep infections.
Speaker 1 Clinicians working in Queensland should follow regional guidelines and treatment pathways to best inform antimicrobial use. Recommended resources include the Therapeutic Guidelines, Primary Clinical Care Manual, Australian ARF and RHD Guidelines, and for a pictorial resource, The National Healthy Skin Guidelines. Clinicians should consider ARF in patients presenting with fever and joint pain who identify as Aboriginal, Torres Strait Islander, Māori or Pasifika.
Speaker 1 There is no single diagnostic test for ARF. Therefore, all recommended investigations should be performed for every suspected episode. Investigation results are applied to the Jones Criteria to inform a clinical diagnosis. Tools such as the Queensland suspected ARF clinical pathway and the Think ARF video provide more detailed guidance around diagnostic workup. ARF should continue to be considered in high risk populations until a differential diagnosis is made.
Speaker 1 Where a diagnosis remains uncertain, seek clinical support from a senior medical officer or public health unit, and for patients presenting to primary care, consider referral to the local hospital for further assessment. In Queensland, every episode of suspected and confirmed ARF is required to be notified to public health under the Public Health Act. Notification forms are available online or on the Queensland Health RHD web page.
Speaker 1 Cases of ARF should be referred for an echocardiogram and, where necessary, specialist review for assessment of cardiac function. Hospital admission should also be considered, particularly for paediatric patients.
Speaker 2 Patients diagnosed with ARF require regular long term care, including specialist reviews, appropriately timed echocardiograms, and regular dental reviews. Patients also require intramuscular Benzathine benzylpenicillin G, also known as BPG or Bicillin, every 21 to 28 days. Termed secondary prophylaxis, consistent BPG administration is the most effective evidence based measure in preventing further ARF episodes. The aim is to protect the heart, and ideally the first dose should be given at the time of diagnosis.
Speaker 2 Given the painful nature and frequency of BPG injections, adequately managing pain, particularly with initial doses and in paediatric patients, is a significant consideration. Responsive and culturally safe models of care that recognise patient’s need to return frequently for painful injections over many years plays a critical role in long term engagement and can positively impact a patient's disease trajectory. Where possible, attend promptly to patients who present for BPG administration, listen to patients preferences regarding therapeutic injection, and provide opportunistic administration if overdue.
Speaker 2 Continuing to promptly and empirically treat any sore throats and skin infections remains important, even if a patient has regular secondary prophylaxis injections. Acute skin or throat infections require additional treatment, as serum levels of long acting penicillin wane after seven days to reach a prophylactic level, which is lower than treatment levels.
Speaker 2 Rheumatic heart disease is a condition where one or more heart valves have been damaged by acute rheumatic fever. RHD remains a major cause of premature morbidity and mortality in young people from high risk backgrounds in Queensland. In a normal and healthy heart, the four valves open and close to ensure blood flows in only one direction. With RHD, damage occurs from inflammation of the heart during an episode of ARF, causing stretching, thickening, or scarring of the valve leaflets.
Speaker 2 Over time, untreated repeated episodes of inflammation can leave valves permanently damaged, with the mitral and aortic valves most commonly affected. When valve leaflets are stretched and unable to close properly, backwards flow of blood results. This is known as regurgitation. When leaflets are scarred, thick, or stiff, it's difficult for blood to pass through and this is called stenosis. This damage impacts the heart's ability to pump blood effectively, and patients with severe disease are at risk of stroke, arrhythmia, pulmonary embolism, cardiac failure, and death.
Speaker 2 RHD is diagnosed on echocardiogram where changes to the structure and function of the valves can actually be seen. Many people with mild valve damage don't experience any symptoms. Patients with previously undiagnosed RHD may present to a health service for the first time, with significant cardiac symptoms or complications at an advanced stage of disease. It's particularly important to consider RHD in pregnant or postpartum women from high risk backgrounds who present with new shortness of breath, orthopnea, wheeze, or increased fatigue.
Speaker 2 RHD is notifiable in Queensland and requires a separate notification to ARF. Notification forms are available online or on the Queensland Health RHD web page. Management of patients with RHD is aimed at monitoring and preventing progression to severe disease. This may include regular secondary prophylaxis and specialist cardiac surveillance. Robust and proactive local recall processes are required to ensure patients receive secondary prophylaxis injections on time every 21 to 28 days, and are aware of cardiac monitoring appointments.
Speaker 2 For patients with severe disease, open heart surgery may be required to fix or replace affected valves and may include lifelong anticoagulation. For women of childbearing age with RHD, effective contraceptive methods and early preconception planning are important to prevent increased perinatal morbidity and negative foetal outcomes. When it comes to ARF and RHD, the key points to remember are; ARF and RHD are entirely preventable.
Speaker 2 Strep A infections need prompt treatment to prevent serious long term consequences of ARF and RHD. Think ARF in high risk groups presenting with fever and joint pain. Consider undiagnosed RHD in high risk symptomatic patients, including pregnant women. And remember patients with ARF and RHD require long term management. They need positive engagement with health care providers, and they need consideration around cultural supports.
Speaker 3 The Queensland RHD Register is a statewide disease register that supports healthcare providers with long term management of patients living with ARF and RHD. The Register relies on timely updates from healthcare providers regarding patient treatment, management and movements to maintain accurate and current patient information. The Register sends recall lists to health services for patients who are due or overdue treatment or review.
Speaker 3 It also sends information to The Viewer allowing healthcare providers timely access to patient information. Information on The Viewer for patients of The Register includes the patient's diagnosis details, care plans, disease severity and secondary prophylaxis, and echocardiogram details. All Queensland Health employees and eligible health practitioners external to Queensland Health can access The Viewer. Useful information and resources can be found on the Queensland Health ARF and RHD web page.