Rheumatic fever recurrences – Expert reaction

Most New Zealanders who suffered a repeated bout of rheumatic fever between 2010-14 were young adults, or had stopped their medication, according to a new study.

The research also found recurrences were strongly associated with severe rheumatic heart disease. The authors say the cost of medical and dental care could be a significant barrier to young adults continuing their penicillin prophylaxis prescription, and there should be culturally-tailored systems to help people keep up the medication.

The SMC asked experts to comment on the research. 

Dr Teuila Percival, Consultant Paediatrician, Middlemore Hospital; Senior Lecturer, School of Population Health, University of Auckland, comments:

“What is important is that 83 per cent of the rheumatic fever recurrences occurred in adolescents and young adults 16 years or older.

“Health services and health promotion are poorly designed for the needs of young people, who are much more mobile than young children and adults. This is understandable as they transitioning to independence, moving house, leaving school, finding work. For rheumatic fever recurrence, we see Pacific and Māori young people ending up with potentially preventable serious heart disease.

“For me, it points to the urgent need to design services in partnership with Pacific and Māori young people. We keep trying the top down approach and young people fall through the gap. Can we instead start with Pacific and Māori young people helping us to find the solution here?”

No conflict of interest declared.

Dr Julie Bennett, Department of Public Health, University of Otago, Wellington, comments:

“It is encouraging to see that recurrence rates of rheumatic fever have remained low, this is a testament to the effectiveness of secondary prevention programmes running throughout the country. While it appears that children are very adherent to painful monthly penicillin injections to prevent heart damage, the situation looks different for teenagers and young adults. There seems to be a mismatch between the system set up to administer ongoing treatment and the living situations and barriers to getting a shot every month for years on end.

“As well as finding culturally and age appropriate ways to address these shortcomings, we need to develop a fully functional national register. This would help to track and treat people diagnosed with rheumatic fever and heart disease. We can’t continue to allow these people to slip through the cracks.

“New Zealand has unacceptably high rates of rheumatic fever with an inequitable disease burden imposed on Māori and Pacific children. Health inequities such as income and housing are largely to blame for the striking ethnic disparities in the rates of rheumatic fever in this country. New Zealand urgently needs to look at how we invest in our children and address social factors that influence health inequity. It is not okay for New Zealand children to suffer for potentially their entire lifetime from an illness that is preventable.”

No conflict of interest.

Dr Aliitasi Su’a-Tavila, Senior Lecturer Pacific Health, Victoria University of Wellington, comments:

“The research findings as stated are not new and the New Zealand public health sector is still battling to combat rheumatic fever within Pacific people up to 24 years old. There is still a lot more work to do in order to address this health issue.

“Within the context of acute rheumatic fever study, cultural appropriateness includes the process of administering penicillin prophylaxis. It should be thorough and understood by the whole family, not just the parent/s. Who informs the patients regarding the treatment? What is the process during and post treatment. Cultural appropriateness in critical aspects such as health is to understand Pacific peoples’ context and environment, their responsibilities and relationships. The world view of Pacific people values a communal approach, because they are communal people.

“From observation and experience of evaluating the national rheumatic fever campaign in 2015, Pacific parents still lack knowledge of rheumatic fever symptoms. Raising awareness among communities is less effective and consideration should be given to the aspect of engaging Pacific communities in a culturally appropriate manner to ensure high participation when health programmes are implemented if the government wishes to make an impact. Notwithstanding multiple barriers in the system, partnership between the health sector and Pacific communities should be strengthened.

“One element to remember is that the Pacific population is one of the fastest growing in New Zealand and unless strategies are put in place to address Pacific people’s health, it will be very costly to the health system.”

No conflict of interest declared.