Rheumatic heart disease in Indigenous young peoples

Rheumatic heart valve disease: navigating the challenges of an overlooked autoimmune disorder

Despite being a leading cause of morbidity and mortality among young people, affecting predominantly women, rheumatic heart disease (RHD) remains neglected and understudied. This autoimmune condition arises from a complex continuum that begins with repeated Group A Streptococcal (GAS) pharyngitis, leading to acute rheumatic fever (ARF) that eventually results in damage to the heart, mainly affecting the mitral valve. While RHD has been nearly eradicated in high-income countries, it continues to be a significant and active health issue in low- and middle-income countries. The resolution of this disease faces several challenges, including the difficulty of diagnosis and the lack of access to preventive measures in resource-poor communities. Addressing these issues will require a global health collaboration involving healthcare professionals, policymakers, and advocacy groups. However, over the past two decades, there has been a revival of scientific interest, fostering optimism for the future. Recent research has significantly advanced our understanding of RHD, shedding light on the immune-to-autoimmune transition, neoangiogenesis, and lymphangiogenesis processes. Additionally, perspectives of discoveries in biomarkers and the development of genetic, transcriptomic, and provide a solid foundation for further advancements in the field.

Inequities in Indigenous Youth with Rheumatic Fever in the USA: A Single-Center Study

OBJECTIVE

Rheumatic heart disease (RHD) is the most common acquired heart disease in children in the USA and worldwide. This study compares the diagnosis and outcomes of Indigenous and non-Indigenous youth with acute rheumatic fever (ARF) and RHD at a US children's hospital serving a several state catchment area with a large Indigenous population (>270 tribes representing 9.2% of the total US Indigenous population).

METHODS

This study involved a retrospective analysis of patients presenting to a major children's hospital between 2008 and 2018. Individuals aged 4-17 with a diagnosis of ARF or RHD were identified using International Classification of Diseases, Ninth and Tenth Revision (ICD-9, 10) codes. Patients with congenital heart disease were excluded.

RESULTS

Chart review was performed on 132 individuals with ARF/RHD. 61% of individuals with non-missing race identified as Indigenous (defined as American Indian, Alaska Native, Native Hawaiian, or Pacific Islander). Average age at diagnosis was found to be 10.3 years for Indigenous youth, compared to 9.1 years for non-Indigenous youth. Indigenous youth were more likely to have cardiac involvement at the time of diagnosis. Indigenous youth had higher rates of aortic regurgitation on initial echocardiography, but no other significant differences were found in incidence of echocardiographic findings.

CONCLUSION

Indigenous youth were diagnosed with rheumatic fever at a later age than non-Indigenous youth, and more likely to have cardiac involvement at time of diagnosis, indicating disparities between the two populations. This suggests a need for further study and development of screening tools.

The responsiveness of surgical research to Māori in Aotearoa, New Zealand-a scoping review

Background

Māori, the Indigenous people of Aotearoa, New Zealand (NZ), experience significant inequities in access to surgery and postoperative outcomes. This scoping review aimed to present a synopsis of the extent and nature of research concerning Māori in surgery in NZ and evaluated the responsiveness of this evidence base to Māori using two Indigenous frameworks.

Methods

Utilising a Kaupapa Māori methodological stance, a scoping review of all studies related to Māori and surgical care in NZ (2000-2024) was performed. The studies underwent thorough evaluation using the CONSIDER and MĀORI frameworks to assess responsiveness to Indigenous Māori.

Findings

A total of 254 studies were included, most being quantitative (N = 230, 91%) and most categorised under General Surgery (N = 139, 55%). Māori responsiveness assessments of each study highlighted significant shortcomings, with 96% of studies (N = 243/254) rated as low quality as per the adapted CONSIDER framework and 68% (N = 172/254) rated as low quality in accordance with the MĀORI framework. More than half of all studies (55%) did not report Māori leadership, governance, and co-authorship. Studies that utilised Kaupapa Māori research were more likely to be considered high-quality.

Interpretation

This study shows that the current surgical evidence base is not responsive to Māori. It calls for a review of research practices and encourages monitoring of the surgical evidence base for all Indigenous peoples.

Funding

This study was supported by a Health Research Council of New Zealand Health Delivery Research Activation Grant (21/860) and Māori Health Knowledge Translation Grant (25/234). The funders had no role in the study design, conception, data collection, analysis, interpretation, or report writing. They also had no role in submitting our study for publication.

The intricate pathogenicity of Group A Streptococcus: A comprehensive update

Group A Streptococcus (GAS) is a versatile pathogen that targets human lymphoid, decidual, skin, and soft tissues. Recent advancements have shed light on its airborne transmission, lymphatic spread, and interactions with neuronal systems. GAS promotes severe inflammation through mechanisms involving inflammasomes, IL-1β, and T-cell hyperactivation. Additionally, it secretes factors that directly induce skin necrosis via Gasdermin activation and sustains survival and replication in human blood through sophisticated immune evasion strategies. These include lysis of erythrocytes, using red cell membranes for camouflage, resisting antimicrobial peptides, evading phagocytosis, escaping from neutrophil extracellular traps (NETs), inactivating chemokines, and cleaving targeted antibodies. GAS also employs molecular mimicry to traverse connective tissues undetected and exploits the host's fibrinolytic system, which contributes to its stealth and potential for causing autoimmune conditions after repeated infections. Secreted toxins disrupt host cell membranes, enhancing intracellular survival and directly activating nociceptor neurons to induce pain. Remarkably, GAS possesses mechanisms for precise genome editing to defend against phages, and its fibrinolytic capabilities have found applications in medicine. Immune responses to GAS are paradoxical: robust responses to its virulence factors correlate with more severe disease, whereas recurrent infections often show diminished immune reactions. This review focuses on the multifaceted virulence of GAS and introduces novel concepts in understanding its pathogenicity.

Global Disparities in Outcomes of Pregnant Individuals With Rheumatic Heart Disease: A Scoping Review

Background

Rheumatic heart disease (RHD) remains as 1 of the major contributors to indirect pregnancy-related mortality and morbidity worldwide and disproportionately affects marginalized populations.

Objectives

In this scoping review, the authors sought to explore the socioeconomic, cultural, and health care access-related causes of global disparities in outcomes of pregnancy among individuals with RHD.

Methods

We performed a literature search of all studies published between January 1, 1990, and January 1, 2022, that investigated causes for disparate outcomes in pregnant individuals with RHD.

Results

Of the 3,544 articles identified, 16 were included in the final analysis. The key reasons for disparate outcomes included lack of secondary antibiotic RHD prophylaxis; late and more severe RHD diagnosis, differences in management and antenatal care access; lack of expert and coordinated multidisciplinary care; suboptimal patient health education; inadequate access to RHD medication, intervention and surgery in pregnancy; and limited financial and economic resources.

Conclusions

These findings illustrated using a life-course approach demonstrate opportunities for clinical and public health interventions to improve outcomes in this population.

Burden and Temporal Trends of Valvular Heart Disease-Related Heart Failure From 1990 to 2019 and Projection Up to 2030 in Group of 20 Countries: An Analysis for the Global Burden of Disease Study 2019

BACKGROUND

The aim of this study was to characterize the burden of valvular heart disease (VHD)-related heart failure (HF) in Group of 20 (G20) countries.

METHODS AND RESULTS

Using data from the 2019 Global Burden of Disease Study, we estimated VHD-related HF burdens (cases, age-standardized prevalence rates, and years lived with disabilities rates) in G20 countries from 1990 to 2019 by age, sex, and sociodemographic index. The burden of VHD-related HF increased in G20 countries from 1990 to 2019, exhibiting heterogeneity across VHD subtypes. In 2019, Italy, the United States, and the Russian Federation had the highest age-standardized prevalence rates of nonrheumatic VHD-related HF, whereas India, Brazil, and Mexico had the lowest. Rheumatic VHD-related HF was most prevalent in China, India, and Italy, whereas the Republic of Korea, Brazil, and Turkey had the lowest. Nonrheumatic VHD-related HF prevalence peaked among G20 countries in individuals ≥85 years of age, whereas rheumatic VHD-related HF peaked in those 75 to 84 years of age in several countries, including China, India, the Russian Federation, Mexico, Argentina, and Turkey. Age-standardized prevalence rates of nonrheumatic VHD-related HF showed a decreasing trend, more pronounced in women, whereas rheumatic VHD-related HF increased in both sexes, with a lower increase in men. Nonrheumatic VHD-related HF burden correlated with age and sociodemographic index, whereas rheumatic VHD-related HF burden was highest in middle sociodemographic index countries for those <75 years of age. Years lived with disabilities rates for VHD-related HF represented about 9.0% of the overall burden across populations.

CONCLUSIONS

The increasing burden of VHD-related HF in G20 countries highlights the need for timely interventions to mitigate this growing public health challenge.

Health care delivery of kidney transplantation to indigenous Māori in Aotearoa New Zealand: A qualitative interview study with clinician stakeholders

OBJECTIVES

Indigenous people experience higher rates of kidney failure than do non-Indigenous Peoples. However, compared to Indigenous patients, health care systems deliver kidney transplantation to non-Indigenous patients at a substantially higher rate and more frequently as the first treatment of kidney failure. Indigenous Māori patients in Aotearoa New Zealand report numerous barriers to kidney transplantation. We explore the perspectives of clinicians as stakeholders in the delivery of kidney transplantation.

METHODS

In 2021/2022 we conducted in-depth qualitative interviews with key stakeholder clinicians within kidney transplantation services in Aotearoa New Zealand, asking them about the issues for Māori patients. We used thematic analysis informed by critical theory to identify key findings and used structural coding to categorize the themes at the level of society, health system, and health services.

RESULTS

We interviewed 18 clinicians (nine nephrologists, including two transplant nephrologists, and nine nurses, including six transplant coordinators). We identified nine themes from stakeholders related to delivery of kidney transplantation services to Māori patients and whānau (family), categorized according to three main levels: Firstly, at the level of society (the impact of colonization and distrust). Secondly, the health care system (failure to prevent and manage kidney disease, health care model delivers inequitable outcomes, and inadequate Māori health professional workforce). Thirdly, health care services (transplantation reliant on patient and family resources, complex assessment causes untimely delays, clinical criteria for transplantation, and lack of clinician ability to effect change).

CONCLUSIONS

Delivery of kidney transplantation to Indigenous Peoples is impacted at the level of society, health care system, and health care service. To address inequities, a broad approach that addresses each of these levels is required.

Housing Initiatives to Address Strep A Infections and Reduce RHD Risks in Remote Indigenous Communities in Australia

Group A Streptococcus (Strep A) skin infections (impetigo) can contribute to the development of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This is of particular concern for Indigenous residents of remote communities, where rates of ARF and RHD are much higher than their urban and non-Indigenous counterparts. There are three main potential Strep A transmission pathways: skin to skin, surface to skin, and transmission through the air (via droplets or aerosols). Despite a lack of scientific certainty, the physical environment may be modified to prevent Strep A transmission through environmental health initiatives in the home, identifying a strong role for housing. This research sought to provide an outline of identified household-level environmental health initiatives to reduce or interrupt Strep A transmission along each of these pathways. The identified initiatives addressed the ability to wash bodies and clothes, to increase social distancing through improving the livability of yard spaces, and to increase ventilation in the home. To assist with future pilots and evaluation, an interactive costing tool was developed against each of these initiatives. If introduced and evaluated to be effective, the environmental health initiatives are likely to also interrupt other hygiene-related infections.

Clinical profile of paediatric acute rheumatic fever and rheumatic heart disease in Western Australia: 1987 to 2020

AIM

To describe the clinical profile of acute rheumatic fever (ARF) presentations to paediatric cardiology tertiary services in Western Australia (WA).

METHODS

A retrospective clinical audit of individuals with confirmed ARF referred to the only paediatric tertiary cardiac service in WA (1 January 1987 to 31 December 2020). Comparisons between inpatient, outpatient, remote and non-remote groups were assessed.

RESULTS

Four hundred seventy-one episodes of ARF in 457 individuals (235 male; median age = 8 years) met clinical criteria. The majority were Aboriginal and Torres Strait Islander children (91.2%), with 62.1% living in remote areas. The number of ARF and rheumatic heart disease (RHD) diagnoses per year increased from 1987 to 2017 with notable peaks in 2013 and 2017. The average annual incidence of tertiary-referred ARF in WA of 4-15-year-olds from 1987 to 2020 was 4.96 per 100 000. ARF features included carditis (59.9%), chorea (31%), polyarthritis (30%) and polyarthralgia (24.2%). RHD was evident in 61.8% of cases and predominantly manifested as mitral regurgitation (55.7%). Thirty-four children (7.4%) with severe RHD underwent valvular surgery. 12% had at least one recurrent ARF episode. Remote individuals had more than double the rate of recurrence compared to non-remote individuals (P = 0.0058). Compared to non-remote episodes, remote presentations had less polyarthritis (P = 0.0022) but greater proportions of raised ESR (P = 0.01), ASOT titres (P = 0.0073), erythema marginatum (P = 0.0218) and severe RHD (P = 0.0133).

CONCLUSION

The high proportion of Aboriginal and Torres Strait Islander Australians affected by ARF/RHD in WA reflects the significant burden of disease within this population. Children from remote communities were more likely to present with concurrent severe RHD. Our study reinforces the persisting need to improve primary and secondary ARF initiatives in rural and remote communities.

The roles of immuno-modulator treatment and echocardiographic screening in rheumatic fever and rheumatic heart disease control: research from Aotearoa, New Zealand

This review summarises advances in research from Aotearoa, New Zealand (NZ) that have potential to reduce the inequitable distribution of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). ARF incidence and RHD prevalence are unacceptably inequitable for Māori and Pacifica. Recent qualitative research has demonstrated mismatches between the lived experience of those with ARF/RHD and health service experience they encounter. NZ-led research has contributed knowledge to all stages of disease prevention (primordial, primary and secondary) and for tertiary management. Modifiable risk factors for ARF are racism across health sectors, household crowding, barriers to accessing primary health care, a high intake of sugar-sweetened beverages and preceding sore throat and skin infections. NZ research has evaluated the impact of a large-scale sore throat management programme and Streptococcal A vaccine development. This review highlights two programme domains of research by the authors that have the potential to reduce the burden of chronic RHD: firstly, effective immunomodulation of ARF to reduce the severity of carditis, with current clinical trials of hydroxychloroquine in NZ; secondly, the development of echocardiographic screening of previously undetected RHD. This now meets criteria for an effective screening test and has potential translation for disease control of RHD.

Research priorities for the primordial prevention of acute rheumatic fever and rheumatic heart disease by modifying the social determinants of health

The social determinants of health (SDH), such as access to income, education, housing and healthcare, strongly shape the occurrence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) at the household, community and national levels. The SDH are systemic factors that privilege some more than others and result in poverty and inequitable access to resources to support health and well-being. Primordial prevention is the modification of SDH to improve health and reduce the risk of disease acquisition and the subsequent progression to RHD. Modifying these determinants using primordial prevention strategies can reduce the risk of exposure to Group A Streptococcus, a causative agent of throat and skin infections, thereby lowering the risk of initiating ARF and its subsequent progression to RHD.This report summarises the findings of the Primordial Prevention Working Group-SDH, which was convened in November 2021 by the National Heart, Lung, and Blood Institute to assess how SDH influence the risk of developing RHD. Working group members identified a series of knowledge gaps and proposed research priorities, while recognising that community engagement and partnerships with those with lived experience will be integral to the success of these activities. Specifically, members emphasised the need for: (1) global analysis of disease incidence, prevalence and SDH characteristics concurrently to inform policy and interventions, (2) global assessment of legacy primordial prevention programmes to help inform the co-design of interventions alongside affected communities, (3) research to develop, implement and evaluate scalable primordial prevention interventions in diverse settings and (4) research to improve access to and equity of services across the RHD continuum. Addressing SDH, through the implementation of primordial prevention strategies, could have broader implications, not only improving RHD-related health outcomes but also impacting other neglected diseases in low-resource settings.

An outbreak of acute rheumatic fever in a remote Aboriginal community

OBJECTIVES

We describe the public health response to an outbreak of acute rheumatic fever (ARF) in a remote Aboriginal community.

METHODS

In August 2021, the Northern Territory Rheumatic Heart Disease Control Program identified an outbreak of acute rheumatic fever in a remote Aboriginal community. A public health response was developed using a modified acute poststreptococcal glomerulonephritis protocol and the National Acute Rheumatic Fever Guideline for Public Health Units.

RESULTS

12 cases were diagnosed during the outbreak; six-times the average number of cases in the same period in the five years prior (n=1.8). Half (n=6) of the outbreak cases were classified as recurrent episodes with overdue secondary prophylaxis. Contact tracing and screening of 11 households identified 86 close contacts.

CONCLUSIONS

This outbreak represented an increase in both first episodes and recurrences of acute rheumatic fever and highlights the critical need for strengthened delivery of acute rheumatic fever secondary prophylaxis, and for improvements to the social determinants of health in the region.

IMPLICATIONS FOR PUBLIC HEALTH

Outbreaks of acute rheumatic fever are rare despite continuing high rates of acute rheumatic fever experienced by remote Aboriginal communities. Nevertheless, there can be improvements in the current national public health guidance relating to acute rheumatic fever cluster and outbreak management.

Tertiary prevention and treatment of rheumatic heart disease: a National Heart, Lung, and Blood Institute working group summary

Although entirely preventable, rheumatic heart disease (RHD), a disease of poverty and social disadvantage resulting in high morbidity and mortality, remains an ever-present burden in low-income and middle-income countries (LMICs) and rural, remote, marginalised and disenfranchised populations within high-income countries. In late 2021, the National Heart, Lung, and Blood Institute convened a workshop to explore the current state of science, to identify basic science and clinical research priorities to support RHD eradication efforts worldwide. This was done through the inclusion of multidisciplinary global experts, including cardiovascular and non-cardiovascular specialists as well as health policy and health economics experts, many of whom also represented or closely worked with patient-family organisations and local governments. This report summarises findings from one of the four working groups, the Tertiary Prevention Working Group, that was charged with assessing the management of late complications of RHD, including surgical interventions for patients with RHD. Due to the high prevalence of RHD in LMICs, particular emphasis was made on gaining a better understanding of needs in the field from the perspectives of the patient, community, provider, health system and policy-maker. We outline priorities to support the development, and implementation of accessible, affordable and sustainable interventions in low-resource settings to manage RHD and related complications. These priorities and other interventions need to be adapted to and driven by local contexts and integrated into health systems to best meet the needs of local communities.

Modalities of group A streptococcal prevention and treatment and their economic justification

Infection by group A Streptococcus (Strep A) results in a diverse range of clinical conditions, including pharyngitis, impetigo, cellulitis, necrotising fasciitis, and rheumatic heart disease. In this article, we outline the recommended strategies for Strep A treatment and prevention and review the literature for economic evaluations of competing treatment and prevention strategies. We find that most economic evaluations focus on reducing the duration of illness or risk of rheumatic fever among people presenting with sore throat through diagnostic and/or treatment strategies. Few studies have evaluated strategies to reduce the burden of Strep A infection among the general population, nor have they considered the local capacity to finance and implement strategies. Evaluation of validated costs and consequences for a more diverse range of Strep A interventions are needed to ensure policies maximise patient outcomes under budget constraints. This should include attention to basic public health strategies and emerging strategies such as vaccination.

Skin morbidity in Indigenous children in relation to housing conditions in remote communities in Northwestern Ontario, Canada

BACKGROUND

Elevated rates of eczema and skin infections in Canadian First Nation (FN) communities are of concern to families, community leaders and healthcare professionals.

AIM

To determine whether skin morbidity was associated with indoor environmental quality factors in Canadian FN children living in remote communities.

METHODS

We quantified indoor environmental quality (IEQ) in the homes of FN children aged < 4 years of age living in four remote communities in the Sioux Lookout region of Northwestern Ontario, Canada. We conducted a quantitative housing inspection, including measuring surface area of mould (SAM), and monitored air quality for 5 days in each home, including carbon dioxide and relative humidity and quantified endotoxin in settled floor dust. We reviewed the medical charts of participating children for skin conditions and administered a health questionnaire. Relationships between IEQ and skin infections or eczema were evaluated using multivariable regression.

RESULTS

In total, 98 children were included in the descriptive analyses, of whom 86 had complete data and were evaluated in multivariate analyses for dermatological outcomes (mean age 1.6 years). Of these 86 children, 55% had made ≥ 1 visits to the local health centre (HC) for skin and soft tissue infections and 25.5% for eczema. Unexpectedly, annualized eczema visits were inversely associated with SAM (RR = 0.14; 95% CI 0.01-0.93). There was a trend suggesting an inverse relationship between endotoxin and HC encounters for eczema and skin and soft tissue infections.

CONCLUSION

Skin infections were common in this population of FN children. IEQ did not appear to be associated with skin infections or eczema. Mould exposure appeared to be inversely associated with HC encounters for eczema, possibly related to complex microorganism-host interactions occurring early in life.

The projections of global and regional rheumatic heart disease burden from 2020 to 2030

BACKGROUND

Rheumatic heart disease (RHD) remains the leading cause of preventable death and disability in children and young adults, killing an estimated 320,000 individuals worldwide yearly.

MATERIALS AND METHODS

We utilized the Bayesian age-period cohort (BAPC) model to project the change in disease burden from 2020 to 2030 using the data from the Global Burden of Disease (GBD) Study 2019. Then we described the projected epidemiological characteristics of RHD by region, sex, and age.

RESULTS

The global age-standardized prevalence rate (ASPR) and age-standardized incidence rate (ASIR) of RHD increased from 1990 to 2019, and ASPR will increase to 559.88 per 100,000 population by 2030. The global age-standardized mortality rate (ASMR) of RHD will continue declining, while the projected death cases will increase. Furthermore, ASPR and cases of RHD-associated HF will continue rising, and there will be 2,922,840 heart failure (HF) cases in 2030 globally. Female subjects will still be the dominant population compared to male subjects, and the ASPR of RHD and the ASPR of RHD-associated HF in female subjects will continue to increase from 2020 to 2030. Young people will have the highest ASPR of RHD among all age groups globally, while the elderly will bear a greater death and HF burden.

CONCLUSION

In the following decade, the RHD burden will remain severe. There are large variations in the trend of RHD burden by region, sex, and age. Targeted and effective strategies are needed for the management of RHD, particularly in female subjects and young people in developing regions.

Standardization of Epidemiological Surveillance of Rheumatic Heart Disease

Rheumatic heart disease (RHD) is a long-term sequela of acute rheumatic fever (ARF), which classically begins after an untreated or undertreated infection caused by Streptococcus pyogenes (Strep A). RHD develops after the heart valves are permanently damaged due to ARF. RHD remains a leading cause of morbidity and mortality in young adults in resource-limited and low- and middle-income countries. This article presents case definitions for latent, suspected, and clinical RHD for persons with and without a history of ARF, and details case classifications, including differentiating between definite or borderline according to the 2012 World Heart Federation echocardiographic diagnostic criteria. This article also covers considerations specific to RHD surveillance methodology, including discussions on echocardiographic screening, where and how to conduct active or passive surveillance (eg, early childhood centers/schools, households, primary healthcare), participant eligibility, and the surveillance population. Additional considerations for RHD surveillance, including implications for secondary prophylaxis and follow-up, RHD registers, community engagement, and the negative impact of surveillance, are addressed. Finally, the core elements of case report forms for RHD, monitoring and audit requirements, quality control and assurance, and the ethics of conducting surveillance are discussed.

Access to Cardiovascular Care for Indigenous Peoples in Canada: A Rapid Review

Indigenous peoples in Canada are at an increased risk of cardiovascular disease compared to non-Indigenous people. Contributing factors include historical oppression, racism, healthcare biases, and disparities in terms of the social determinants of health. Access to and inequity in cardiovascular care for Indigenous peoples in Canada remain poorly studied and understood. A rapid review of the literature was performed using the PubMed/MEDLINE, Web of Science, and Indigenous Studies Portal (iPortal) databases to identify articles describing access to cardiovascular care for Indigenous peoples in Canada between 2002 and 2021. Included articles were presented narratively in the context of delays in seeking, reaching, or receiving care, or as disparities in cardiovascular outcomes, and were assessed for their successful engagement in indigenous health research using a preexisting framework. Current research suggests that gaps most prominently present as delays in receiving care and as poorer long-term outcomes. The literature is concentrated in Alberta, Manitoba, and Ontario, as well as among First Nations people, and is largely rooted in a biomedical worldview. Additional community-driven research is required to better elucidate the gaps in access to holistic cardiovascular care for Indigenous peoples in Canada. Healthcare professionals, researchers, and policymakers should reflect further upon their actions and privilege, educate themselves about historical facts and the Truth and Reconciliation Commission, tackle prevailing disparities and systemic barriers in the healthcare systems, and develop culturally safe and ethically appropriate healthcare interventions to improve the health of all Indigenous peoples in Canada.

Serologic testing for Bartonella in Manitoba, Canada, 2010-2020: a retrospective case series

BACKGROUND

Bartonella are gram-negative bacilli not identified by routine bacterial culture. The objectives of this study were to review the results of all serologic testing for Bartonella ordered in Manitoba, Canada, and to review cases with positive test results among adults to assess species identification, risk factors, clinical manifestations and outcomes.

METHODS

This retrospective study included all Bartonella serologic tests ordered in Manitoba and performed at the National Microbiology Laboratory, Winnipeg, from Jan. 1, 2010, until Dec. 31, 2020. We analyzed the aggregate data for all serologic tests for Bartonella for patients of all ages. We reviewed the charts of adult (age ≥ 18 yr) patients with serologic positivity for Bartonella who had a medical chart at 1 of Winnipeg's 2 largest hospitals (Health Sciences Centre and St. Boniface Hospital) to extract clinical and demographic data and create a case series. Descriptive statistics were performed.

RESULTS

During the study period, 1014 Bartonella serologic tests were ordered in adult and pediatric patients, of which 24 (2.4%) gave a positive result. Sixteen adults (12 men and 4 women; mean age 48 yr) seen at a participating hospital had a positive result. Molecular species-level identification occurred on explanted cardiac valves in 5 (31%) of the 16 cases; B. quintana was identified in all 5. Six patients (38%) were diagnosed with probable B. quintana infection, for a total of 11 B. quintana cases (69%); 8 (73%) of the 11 had endocarditis. Four cases of B. quintana infection (36%) were associated with rural residence. Four cases (25%) of probable B. henselae were identified; 2 patients had fever and lymphadenopathy, and 2 had endocarditis. The remaining patient was deemed to have a false-positive result as his B. henselae titre was at the threshold for positivity, his B. quintana serologic test gave a negative result, and his clinical syndrome was not suggestive of Bartonella infection. Two patients died; both had multivalvular B. quintana endocarditis with ruptured intracranial mycotic aneurysms.

INTERPRETATION

Bartonella quintana was a common cause of Bartonella serologic positivity among adults in Manitoba in 2010-2020 and was associated with endocarditis and systemic embolization. As B. quintana is transmitted by body lice, active case finding for people who lack suitable housing, both in urban and rural settings, should prioritize those with elevated Bartonella titres to receive echocardiography and detect endocarditis before systemic embolization occurs.

Improving primary prevention of acute rheumatic fever in Australia: consensus primary care priorities identified through an eDelphi process

OBJECTIVES

To establish the priorities of primary care providers to improve assessment and treatment of skin sores and sore throats among Aboriginal and Torres Strait Islander people at risk of acute rheumatic fever (ARF) and rheumatic heart disease (RHD).

DESIGN

Modified eDelphi survey, informed by an expert focus group and literature review.

SETTING

Primary care services in any one of the five Australian states or territories with a high burden of ARF.

PARTICIPANTS

People working in any primary care role within the last 5 years in jurisdiction with a high burden of ARF.

RESULTS

Nine people participated in the scoping expert focus group which informed identification of an access framework for subsequent literature review. Fifteen broad concepts, comprising 29 strategies and 63 different actions, were identified on this review. These concepts were presented to participants in a two-round eDelphi survey. Twenty-six participants from five jurisdictions participated, 16/26 (62%) completed both survey rounds. Seven strategies were endorsed as high priorities. Most were demand-side strategies with a focus on engaging communities and individuals in accessible, comprehensive, culturally appropriate primary healthcare. Eight strategies were not endorsed as high priority, all of which were supply-side approaches. Qualitative responses highlighted the importance of a comprehensive primary healthcare approach as standard of care rather than disease-specific strategies related to management of skin sores and sore throat.

CONCLUSION

Primary care staff priorities should inform Australia's commitments to reduce the burden of RHD. In particular, strategies to support comprehensive Aboriginal and Torres Strait Islander primary care services rather than an exclusive focus on discrete, disease-specific initiatives are needed.

Long-term outcomes following rheumatic heart disease diagnosis in Australia

Aims 

Rheumatic heart disease (RHD) is a major contributor to cardiac morbidity and mortality globally. This study aims to estimate the probability and predictors of progressing to non-fatal cardiovascular complications and death in young Australians after their first RHD diagnosis.

Methods and results 

This retrospective cohort study used linked RHD register, hospital, and death data from five Australian states and territories (covering 70% of the whole population and 86% of the Indigenous population). Progression from uncomplicated RHD to all-cause death and non-fatal cardiovascular complications (surgical intervention, heart failure, atrial fibrillation, infective endocarditis, and stroke) was estimated for people aged <35 years with first-ever RHD diagnosis between 2010 and 2018, identified from register and hospital data. The study cohort comprised 1718 initially uncomplicated RHD cases (84.6% Indigenous; 10.9% migrant; 63.2% women; 40.3% aged 5–14 years; 76.4% non-metropolitan). The composite outcome of death/cardiovascular complication was experienced by 23.3% (95% confidence interval: 19.5–26.9) within 8 years. Older age and metropolitan residence were independent positive predictors of the composite outcome; history of acute rheumatic fever was a negative predictor. Population group (Indigenous/migrant/other Australian) and sex were not predictive of outcome after multivariable adjustment.

Conclusion 

This study provides the most definitive and contemporary estimates of progression to major cardiovascular complication or death in young Australians with RHD. Despite access to the publically funded universal Australian healthcare system, one-fifth of initially uncomplicated RHD cases will experience one of the major complications of RHD within 8 years supporting the need for programmes to eradicate RHD.

A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia

BACKGROUND

In Australia's north, Aboriginal peoples live with world-high rates of rheumatic heart disease (RHD) and its precursor, acute rheumatic fever (ARF); driven by social and environmental determinants of health. We undertook a program of work to strengthen RHD primordial and primary prevention using a model addressing six domains: housing and environmental support, community awareness and empowerment, health literacy, health and education service integration, health navigation and health provider education. Our aim is to determine how the model was experienced by study participants.

METHODS

This is a two-year, outreach-to-household, pragmatic intervention implemented by Aboriginal Community Workers in three remote communities. The qualitative component was shaped by Participatory Action Research. Yarning sessions and semi-structured interviews were conducted with 14 individuals affected by, or working with, ARF/RHD. 31 project field reports were collated. We conducted a hybrid inductive-deductive thematic analysis guided by critical theory.

RESULTS

Aboriginal Community Workers were best placed to support two of the six domains: housing and environmental health support and health navigation. This was due to trusting relationships between ACWs and families and the authority attributed to ACWs through the project. ACWs improved health literacy and supported awareness and empowerment; but this was limited by disease complexities. Consequently, ACWs requested more training to address knowledge gaps and improve knowledge transfer to families. ACWs did not have skills to provide health professionals with education or ensure health and education services participated in ARF/RHD. Where knowledge gain among participant family members was apparent, motivation or structural capability to implement behaviour change was lacking in some domains, even though the model was intended to support structural changes through care navigation and housing fixes.

CONCLUSIONS

This is the first multi-site effort in northern Australia to strengthen primordial and primary prevention of RHD. Community-led programs are central to the overarching strategy to eliminate RHD. Future implementation should support culturally safe relationships which build the social capital required to address social determinants of health and enable holistic ways to support sustainable individual and community-level actions. Government and services must collaborate with communities to address systemic, structural issues limiting the capacity of Aboriginal peoples to eliminate RHD.

Sydenham's chorea: from pathophysiology to therapeutics

Sydenham's chorea is an autoimmune chorea emerging after a group A beta-hemolytic streptococcal (GABHS) infection, i.e. a rheumatic chorea with or without the presence of carditis or arthritis. The disorder, defined by the presence of chorea, is also associated with cognitive and behavioral symptoms, including emotional lability, anxiety, depressive and obsessive-compulsive symptoms. The authors review the pathophysiology, clinical characteristics, and available evidence on therapeutic strategies, the latter including the secondary prevention of GABHS infections, reduction of chorea, and immune modulation. Sydenham's chorea has been regarded as a model for pediatric autoimmune neuropsychiatric disorders, however, the field is marked by conflicting results and controversies. Regarding therapeutics, there are limited high-quality interventional studies and the selection of treatment strategy often relies on the clinician's experience. A serial treatment algorithm is presented based upon the severity of clinical presentation and response to symptomatic pharmacotherapy.