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A developing world disease in a developed country: Why does New Zealand have one of the highest rates of rheumatic fever?

Olivia Lewis

Introduction

Globally, Acute Rheumatic fever (ARF) is a disease of poverty in developing countries (Lennon, 2017). New Zealand is known as a developed country that ranks highly in international comparisons on human development, quality of life, life expectancy and prosperity (Whitireia, 2017). Healthcare in New Zealand is not only accessible to majority of the population, but it is also free for children under 13 years old (Ministry of Health, 2016). Despite rheumatic fever being a “developing world disease”, New Zealand has one of the highest rates of rheumatic fever in the developed world. The rate of rheumatic fever in New Zealand is increasing - between 2005 and 2010, reported cases of rheumatic fever had doubled (Ministry of Health, 2011). There is significant evidence that community driven detection and treatment strategies reduce incidence of rheumatic fever (Sharpe, Miller, & Lowe, 2011).

This literature review explores numerous studies and research that has been completed on this topic. The aim is to create more of an understanding as to why this disease is so prevalent in New Zealand, and why incidence rates are on the rise. Through comparing New Zealand statistics and studies with that of other countries (both developed and developing), it will emerge as to why New Zealand has such a high rate. Collating literature on the various factors that lead to rheumatic fever, will be able to begin to answer the research question.

Search Question Identified

Through researching the different studies conducted on this topic, the main risk factors for acquiring rheumatic fever in New Zealand are uncovered. These include low socio-economic status, Maori and Pacific island ethnicity, age, gender, and geographical area.

PECOT MODEL (Whitehead, 2013)

The Clinical Issue

Rheumatic fever is a serious but preventable illness, mainly affecting children of Maori and Pacific descent, living in low socio-economic conditions (Ministry of Health, 2016).

An untreated strep throat can lead to rheumatic fever (Health Navigator, 2015). Rheumatic fever can ultimately cause rheumatic heart disease, especially with reoccurrences of ARF, which is the scarring of heart valves (Health Navigator, 2015). Treatment for rheumatic heart disease include secondary prophylaxis, which is a monthly penicillin injection for 10+ years, regular specialist treatment and even heart valve replacement surgery (Health Navigator, 2015). Rheumatic fever can also cause premature death if developed into rheumatic heart disease (Health Navigator, 2015). This combination of monthly injections, regular doctor visits, and the potential for a shortened life expectancy means that this is a serious and costly disease for the person who acquires it.

Evidence and Findings

Children living in poverty with poor housing conditions are more at risk for rheumatic fever than those who are not (UNICEF, 2016). Overcrowded living areas, as well as damp and wet houses, can cause germs and disease to spread from one person to another (UNICEF, 2016). Having warm rooms and adequate sleeping spaces available helps prevent the spread of diseases like strep throat – which can lead to rheumatic fever (Ministry of Health, 2016). These statements are supported by New Zealand literature. A study conducted in Northland, New Zealand, explored the incidences of acute rheumatic fever in the area from 2002-2011 (Robin, Mills, Tuck, & Lennon, 2013). This study concluded that the rates of rheumatic fever cases in Northland during 2002-2011 were similar to those seen in developing countries (Robin et al., 2013). In 2008 there were 12 reported cases in the Northland areas, and by 2011 rheumatic fever incidence had risen to 19 cases (Robin et al., 2013). The study gathered cases from various healthcare databases, and compared them with socio-economic deprivation using the “deprivation scale” (Robin et al., 2013).  Areas that are high on the deprivation scale (decile 7-10) are associated with over-crowded housing, poor housing conditions (e.g. damp, mouldy, and lack insulation), lower accessibility to healthcare, and health illiteracy (Gurney et Al., 2016). The deprivation scale rates areas from 1-10, 1 being the least deprived areas and 10 being the most deprived areas. 114 cases of rheumatic fever were reviewed in the Northland study. The results showed that 102 cases out of 114 resided in the most deprived areas of decile 8-10 (Robin, et al., 2013). The limitations to the Northland rheumatic fever study is the small population sample – only 114 cases were reviewed, therefore it would be difficult to generalise these findings to all of New Zealand. Another study I reviewed complemented these findings. This study looked at a total of 711 ARF cases in NZ. 500 of these cases resided in decile 9-10 areas (most deprived). Another 109 people out of 711 were living in decile 7-8 areas. Only 13 people who acquired rheumatic fever resided in a decile 1-2 area (Gurney, Stanley, Baker, Wilson, & Sarfati, 2016). Both these studies support the statement that rheumatic fever and areas of socioeconomic deprivation are strongly correlated. The Gurney et al. study is more reliable than the Northland study as there were more participants in the sample taken. However, the end results of both these studies highlight the urgent need to address ARF in areas of deprivation. As a result of improvements in socioeconomic conditions and healthcare access, rheumatic fever and rheumatic heart disease has almost been eradicated over the world (Robin et al., 2013). Rheumatic fever is preventable. If living conditions improved in New Zealand, it is inevitable that the rates of rheumatic fever would decrease.

New Zealand have high rates of rheumatic fever amongst Maori and Pacific children, compared to European children (Health Navigator, 2015). This statement is supported by Gurney et al. (2016), who discovered a strong link between Maori/Pacific people and ARF. Out of the 711 rheumatic fever cases studied, 92% were identified as being either of Maori or Pacific ethnicity. In the Northland study by Robin et al. (2013), out of the 115 cases, 95% were people of Maori and/or Pacific ethnicity. Another study by the Waikato DHB from 1998-2004, found 80% of all the ARF cases in Waikato were people of Maori or Pacific ethnicity (Atatoa-Carr, Bell, & Lennon, 2008). Gurney et al. (2016) suggested that the high Maori and Pacific representation could suggest a link between genetics and rheumatic fever. This statement is supported by a study on the relationship between genetics and ARF, which looked at sets of twins who had both acquired ARF. This study concluded that ARF is a disease that has high heritability (Engel, Stander, Vogel, Adeyemo, & Mayosi, 2011). One study by Jaine, Baker and Venugopal (2008) argues that instead of genetics, high ARF rates for Maori/Pacific people are attributed to poor socio-economic conditions, overcrowding, and inadequate access to healthcare. These studies, despite outlining different causes of ARF, all show a strong correlation with the disease between Maori and Pacific people. It can be concluded that genetic factors may contribute to ARF in some way - this could be a potential area for further future research. However, it has been proven that socio-economic deprivation and poor living conditions are the main contributors to children acquiring ARF. Maori and Pacific people experience large disparities compared to other ethnicities in New Zealand when it comes to standard of living. Over half the children living below the poverty line in New Zealand are Maori. Maori and Pacific people are also more likely to live in over-crowded households, and admitted to hospital as a result of neglect and maltreatment (Salmond, 2012). It is shocking to comprehend that there is such an imbalance in society for Maori people. This is an area that New Zealand needs to urgently address.

As New Zealand has such a high incidence of ARF, it would be interesting to look at other developed and developing countries for comparison. Around the world it has been estimated that around 471,000 cases of ARF occur each year, with 95% of those cases in low-middle income countries (World Health Organization, 2005).

In the United Kingdom, a developed country, incidence of rheumatic fever is low (NHS, 2015). Approximately 1 in every 100,000 people in the UK contract rheumatic fever each year (NHS, 2015). New Zealand statistics for ARF are well over double the rate of that in the UK. In contrast to this, Fiji, a developing country, has high rates of rheumatic fever, with approximately 15.5 cases per 100,000 people (Steer, Kado, Jenney, Batzloff, Waqatakirewa, Mulholland, & Carapetis, 2009). In Australia from 2008-2009, around $74 million was spent on ARF and RHD (Australian Institute of Health and Welfare, 2013). In a study by the Australian Institute of Health and Welfare (2013), it was found there were major inequalities with indigenous Australians and ARF. In the Northern territory of Australia, indigenous Australian ARF cases were at 1,379 compared to a mere 100 cases of non-Indigenous Australians (Australian Institute of Health and Welfare, 2013). Of the 939 patients with ARF that had progressed to rheumatic heart disease, 90% were of Aboriginal or indigenous descent (Australian Institute of Health and Welfare, 2013). A study in Cuba showed there has been a steady decline of ARF incidences over the past 30 years (Nordet, Lopez, Duenas, Sarmiento, 2008). Over just a 10-year-period, the incidences of ARF went from 18.6 cases per 100,000, to 2.5 cases per 100,000 (Nordet et al., 2008). Along with this decline, there were less incidences of re-occurrence with rheumatic fever. This decline in rheumatic fever was found to be attributed to excellent adherence to a secondary prophylaxis program (Nordet et al., 2008). This Cuban program included high media saturation for education on rheumatic fever, which increased awareness for the disease. New Zealand are currently taking similar measures to lower the high ARF rates with the high amount of media coverage, and amount of money being put into programs to create awareness for rheumatic fever. After reviewing the literature in relation to my research question, I have discovered that New Zealand does indeed have extremely high rates of ARF in comparison to other “developed” countries. Developing countries around the world like Cuba, Fiji and Africa have similar (yet slightly higher) incidence rates per 100,000 people, compared to New Zealand.

Recommendations

Two recommendations have been developed as a result of this literature review. These are recommendations that aim to help prevent ARF in the future, spread awareness, and lower the current high incidence rates.

Recommendation 1: Provide accessible information on rheumatic fever in Maori and Pacific communities.

In New Zealand, rheumatic fever is a disease that almost exclusively targets Maori and Pacific people (Sharpe, Miller, & Lowe, 2011). This literature review has provided sound evidence that supports this statement. It is essential that healthcare professionals know the ARF incidence rates in their areas, and provide education to people at risk whenever possible.

In high-risk communities, all Maori and Pacific people should have a throat swab taken if they present with a sore throat, no matter their age group. If there is a patient with a positive throat swab for strep-throat, and they live in a crowded housing situation, other people living in the same household should also be checked. Raising awareness in high-risk communities is essential in prevention. Healthcare in New Zealand is free for children so there should be no excuse as to why a parent cannot take their child to seek healthcare when a sore throat presents.

Many at-risk people for rheumatic fever experience poor living conditions and poverty. This could mean that they do not have access to television, internet, or radio. Therefore, it is important that people are targeted within the community setting. For example, getting a nurse to speak about rheumatic fever at local maraes could be beneficial. Another option could be at events like Kapa Haka competitions, and Pacifica festivals, flyers could be handed out to spread awareness of rheumatic fever. School based programs could be developed in high risk communities. Not only to spread awareness, but also educate children on rheumatic fever so they know to seek healthcare or speak up when they have a sore throat. Ensuring flyers are simple, clear and easy to read is essential. This is because for people whose first language is not English, they often have low health literacy levels (Statistics New Zealand, 2010). Along with information about rheumatic fever, these flyers could include warnings about house over-crowding, and tips for keeping a warm, dry home. Also reminding parents that prescription for children under 6-years old are free of charge. There is a need for information to be accessible for Maori and Pacific families. Spreading awareness is crucial in rheumatic fever prevention.

Recommendation 2: Provide adequate training for nurses to ensure secondary prophylaxis is adhered to.

People who have had acute rheumatic fever require secondary prophylaxis for at least 10 years after the incidence, to reduce the risk of developing heart disease (Sharpe et al., 2011). Secondary prophylaxis has been documented to significantly reduce recurrent rheumatic fever attacks (World Health Organisation, 1999). For rheumatic fever a course of penicillin injections is the most effective treatment available. The intramuscular injection is given every four weeks, or for high-risk patients it is given every three weeks (World Health Organisation, 1999). Health workers giving these injections need to be trained, as several technical related to penicillin injection can affect the bioavailability (World Health Organisation, 1999). An alternative to injections are a daily dose of oral phenoxymethylpenicillin – oral prophylaxis is known to be difficult for patients to adhere to, as remembering to take this everyday can be difficult (World Health Organisation, 1999). Following up patients who are undergoing prophylaxis for rheumatic fever is essential in preventing reoccurrence and further damage (World Health Organisation, 1999). Training nurses in how to administer the monthly penicillin injections, and training them in being able to recognise recurrent rheumatic fever is important. Nurses in the community should be aware of rheumatic fever, and efficiently follow up patients who are receiving treatment. Following patients up can be done through sending reminders via text, email, or calling, and even going to their homes through district nursing if they have no way to access their local healthcare centre. When patients do return for prophylaxis treatment on time, training nurses to validate the patients’ attendance is important in reinforcing good behaviour patterns (Sharpe et al., 2011).

My recommendation of accessible education for Maori and Pacific people in the community will ensure that more people are informed of this preventable disease. Many people in low-socioeconomic areas do not have access to televisions or the internet, therefore current media advertisements on rheumatic fever may not reach them. New Zealand is known as a developed, functional, and equal society. Yet we still have one of the highest rates of rheumatic fever in the world. These high rates are due to a combination of the Maori/Pacific ethnicity, low socio-economic areas, poor living conditions, lack of education, and over-crowded housing.

Conclusion

Spreading awareness for rheumatic fever, and educating nurses will ensure that the rheumatic fever incidence declines in New Zealand. What may seem an impossible task is not – this has been proven in many other countries, whose once high rheumatic fever rates have fallen to nearly zero in small amounts of time. This is through education, awareness, training programs for health professionals, and improved living conditions.

References

Australian Institute of Health and Welfare. (2013). Rheumatic heart disease and acute rheumatic fever in Australia: 1995-2012. Retrieved from http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129542747

Atatoa-Carr P, Bell A, Lennon DR. (2008). Acute Rheumatic Fever in the Waikato District Health Board region of New Zealand: 1998-2004. New Zealand Medical Journal (121) pp96-105.

Engel, M., Stander, R., Vogel, J., Adeyemo, AA., & Mayosi, BM. (2011). Genetic susceptibility to acute rheumatic fever: a systematic review and meta-analysis of twin studies. Retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0025326

Gurney, J., Stanley, J., Baker, M., Wilson, N., & Sarfati, D. (2016). Estimating the risk of acute rheumatic fever in New Zealand by age, ethnicity and deprivation. Epidemiology & Infection, 144(13), pp3058-3067. Retrieved from https://www.cambridge.org/core/journals/epidemiology-and-infection/article/div-classtitleestimating-the-risk-of-acute-rheumatic-fever-in-new-zealand-by-age-ethnicity-and-deprivationdiv/A2B79839DD640F281D773DBA767409C0/core-reader

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