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Cooper J, Enkel SL, Moodley D, Dobinson H, Andersen E, Kado JH, Barr RK, Salman S, Baker MG, Carapetis JR, Manning L, Anderson A, Bennett J. "Hurts less, lasts longer"; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand. PLoS One 2024; 19:e0302493. [PMID: 38743745 PMCID: PMC11093343 DOI: 10.1371/journal.pone.0302493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/05/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Four-weekly intramuscular (IM) benzathine penicillin G (BPG) injections to prevent acute rheumatic fever (ARF) progression have remained unchanged since 1955. A Phase-I trial in healthy volunteers demonstrated the safety and tolerability of high-dose subcutaneous infusions of BPG which resulted in a much longer effective penicillin exposure, and fewer injections. Here we describe the experiences of young people living with ARF participating in a Phase-II trial of SubCutaneous Injections of BPG (SCIP). METHODOLOGY Participants (n = 20) attended a clinic in Wellington, New Zealand (NZ). After a physical examination, participants received 2% lignocaine followed by 13.8mL to 20.7mL of BPG (Bicillin-LA®; determined by weight), into the abdominal subcutaneous tissue. A Kaupapa Māori consistent methodology was used to explore experiences of SCIP, through semi-structured interviews and observations taken during/after the injection, and on days 28 and 70. All interviews were recorded, transcribed verbatim, and thematically analysed. PRINCIPAL FINDINGS Low levels of pain were reported on needle insertion, during and following the injection. Some participants experienced discomfort and bruising on days one and two post dose; however, the pain was reported to be less severe than their usual IM BPG. Participants were 'relieved' to only need injections quarterly and the majority (95%) reported a preference for SCIP over IM BPG. CONCLUSIONS Participants preferred SCIP over their usual regimen, reporting less pain and a preference for the longer time gap between treatments. Recommending SCIP as standard of care for most patients needing long-term prophylaxis has the potential to transform secondary prophylaxis of ARF/RHD in NZ and globally.
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Affiliation(s)
- Julie Cooper
- Department of Public Health, University of Otago, Wellington, New Zealand
| | | | - Dhevindri Moodley
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Hazel Dobinson
- Te Whatu Ora, Capital, Coast and Hutt Valley, Newtown, Wellington, New Zealand
| | - Erik Andersen
- Te Whatu Ora, Capital, Coast and Hutt Valley, Newtown, Wellington, New Zealand
| | - Joseph H. Kado
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- Centre for Child Health Research, The University of Western Australia, Crawley, WA, Australia
| | - Renae K. Barr
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Sam Salman
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- Clinical Pharmacology and Toxicology Unit, PathWest, Perth, Western Australia, Australia
- Internal Medicine, The University of Western Australia, Crawley, WA, Australia
| | - Michael G. Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jonathan R. Carapetis
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- Perth Children’s Hospital, Nedlands, Western Australia, Australia
- Centre for Child Health Research, The University of Western Australia, Crawley, WA, Australia
| | - Laurens Manning
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- Internal Medicine, The University of Western Australia, Crawley, WA, Australia
- Centre for Child Health Research, The University of Western Australia, Crawley, WA, Australia
- Fiona Stanley Hospital, Nedlands, Western Australia, Australia
| | - Anneka Anderson
- Faculty of Medical and Health Sciences, Te Kupenga Hauora Māori, University of Auckland, Auckland, New Zealand
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
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Brookes VJ, Henning CE, Worthing KA, Degeling C. Eliminate all risks: A call to reexamine the link between canine scabies and rheumatic heart disease. PLoS Negl Trop Dis 2024; 18:e0012115. [PMID: 38696362 PMCID: PMC11065235 DOI: 10.1371/journal.pntd.0012115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Rheumatic heart disease (RHD) and acute rheumatic fever (ARF) disproportionately affect individuals in low-resource settings. ARF is attributed to an immune response to Group A Streptococcus (GAS) following GAS pharyngitis and potentially GAS impetigo in which infection can be initiated by scabies infestation. The burden of ARF and RHD in Aboriginal and Torres Strait Islander people in Australia is among the highest globally. Following recent calls to include dog management programs in ARF and RHD prevention programs, we believe it is timely to assess the evidence for this, particularly since previous recommendations excluded resources to prevent zoonotic canine scabies. While phylogenetic analyses have suggested that the Sarcoptes mite is host specific, they have differed in interpretation of the strength of their findings regarding species cross-over and the need for canine scabies control to prevent human itch. Given that there is also indication from case reports that canine scabies leads to human itch, we propose that further investigation of the potential burden of zoonotic canine scabies and intervention trials of canine scabies prevention on the incidence of impetigo are warranted. Considering the devastating impacts of ARF and RHD, evidence is required to support policy to eliminate all risk factors.
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Affiliation(s)
- Victoria J. Brookes
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown, New South Wales, Australia
- Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney, Westmead, New South Wales, Australia
| | - Caitlin E. Henning
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kate A. Worthing
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown, New South Wales, Australia
- Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney, Westmead, New South Wales, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, Faculty of the Arts, Social Sciences and the Humanities, University of Wollongong, Keiraville, New South Wales, Australia
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Shimanda PP, Shumba TW, Brunström M, Iipinge SN, Söderberg S, Lindholm L, Norström F. Preventive Interventions to Reduce the Burden of Rheumatic Heart Disease in Populations at Risk: A Systematic Review. J Am Heart Assoc 2024; 13:e032442. [PMID: 38390809 PMCID: PMC10944073 DOI: 10.1161/jaha.123.032442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/30/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a devastating yet preventable condition that disproportionately affects low-middle-income countries and indigenous populations in some high-income countries. Various preventive interventions have been implemented across the globe, but evidence for the effectiveness of these measures in reducing the incidence or prevalence of acute rheumatic fever and RHD is scattered. This systematic review aims to assess the effectiveness of preventive interventions and identify the strategies used to reduce the burden of RHD. METHODS AND RESULTS A comprehensive search was conducted to identify relevant studies on RHD prevention interventions including interventions for primordial, primary, and secondary prevention. Effectiveness measures for the interventions were gathered when available. The findings indicate that school-based primary prevention services targeting the early detection and treatment of Group A Streptococcus pharyngitis infection with penicillin have the potential to reduce the incidence of Group A Streptococcus pharyngitis and acute rheumatic fever. Community-based programs using various prevention strategies also reduced the burden of RHD. However, there is limited evidence from low-middle-income countries and a lack of rigorous evaluations reporting the true impact of the interventions. Narrative synthesis was performed, and the methodological quality appraisal was done using the Joanna Briggs Institute critical appraisal tools. CONCLUSIONS This systematic review underscores the importance of various preventive interventions in reducing the incidence and burden of Group A Streptococcus pharyngitis, acute rheumatic fever, and RHD. Rigorous evaluations and comprehensive analyses of interventions are necessary for guiding effective strategies and informing public health policies to prevent and reduce the burden of these diseases in diverse populations. REGISTRATION URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020170503.
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Affiliation(s)
| | - Tonderai W Shumba
- Department of Occupational Therapy and Physiotherapy University of Namibia Windhoek Namibia
| | - Mattias Brunström
- Department of Public Health and Clinical Medicine, Cardiology Umeå University Umeå Sweden
| | | | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Cardiology Umeå University Umeå Sweden
| | - Lars Lindholm
- Department of Epidemiology and Global Health Umeå University Umeå Sweden
| | - Fredrik Norström
- Department of Epidemiology and Global Health Umeå University Umeå Sweden
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Fall N, Odong F, Thembo J, Pulle J, Hoekzema J, Rwebembera J, de Loizaga S, Nakagaayi D, Minja N, Webel A, Watkins D, Beaton A. User-Centered Design to Develop Automated Short Message Service Messaging for Patient Support of Rheumatic Heart Disease Secondary Antibiotic Prophylaxis. J Am Heart Assoc 2024; 13:e031252. [PMID: 38226514 PMCID: PMC10926829 DOI: 10.1161/jaha.123.031252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/31/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The Active Community Case Management Platform is a cloud-based technology developed to facilitate rheumatic heart disease case management by health care providers. This study aimed to design and pilot an automated short message service (SMS) intervention to support secondary prophylaxis adherence. METHODS AND RESULTS We developed a concise library of messages to support secondary antibiotic prophylaxis. The SMS intervention used TextIT, an interface that enables users to send out interactive SMS messages at scale. The message bank was piloted in a cohort of 50 patients with rheumatic heart disease randomized into 2 groups. Group 1 received standard support (nurse-led/Active Community Case Management Platform). Group 2 received standard support plus SMS intervention for 2 months in the Lira and Gulu districts of Northern Uganda. We collected qualitative data on participants' experiences and assessed treatment adherence. Using a sequential user-centered process consisting of 4 phases (phases 1-4), we developed a message bank (n=43) deployed during our pilot study. There were no between-group differences in treatment adherence or acceptance. Interviews of participants indicated that the intervention was viewed positively. A total of 75% of SMS recipients responded to the messages, and 25% called the study staff to acknowledge receipt of text messages. CONCLUSIONS This study has successfully developed a bank of SMS messages to support secondary antibiotic prophylaxis adherence. We have demonstrated the feasibility and acceptability of SMS technology in rheumatic heart disease care management. Future work will include integrating automated SMS into the Active Community Case Management Platform and a larger study of integrated SMS to reduce health care worker burden for patient support and improve adherence to secondary antibiotic prophylaxis.
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Affiliation(s)
- Ndate Fall
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
| | | | | | | | - Jacob Hoekzema
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
| | | | | | | | | | | | | | - Andrea Beaton
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
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Nakagaayi D, Pulle J, Otim I, Akiya OC, Otto OH, Danforth K, Longenecker CT, Ollberding N, Sarnacki R, Nakitto M, Buonfiglio S, Rwebembera J, Sable C, Sherr K, Su Y, Webel A, Beaton A, Okello E, Watkins D. A decentralized delivery program for rheumatic heart disease treatment and prevention in Uganda. Nat Med 2024; 30:12-13. [PMID: 38167934 DOI: 10.1038/s41591-023-02646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda.
| | - Jafesi Pulle
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Isaac Otim
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | | | | | - Kristen Danforth
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Miriam Nakitto
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Samantha Buonfiglio
- Department of Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joselyn Rwebembera
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Craig Sable
- Children's National Hospital, Washington, DC, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Yanfang Su
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Allison Webel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Andrea Beaton
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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Kado J, Salman S, Hla TK, Enkel S, Henderson R, Hand RM, Hort A, Page-Sharp M, Batty K, Moore BR, Bennett J, Anderson A, Carapetis J, Manning L. Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study. Antimicrob Agents Chemother 2023; 67:e0096223. [PMID: 37971244 PMCID: PMC10720493 DOI: 10.1128/aac.00962-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023] Open
Abstract
Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.
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Affiliation(s)
- Joseph Kado
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Sam Salman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Clinical Pharmacology and Toxicology Unit, PathWest, Western Australia, Australia
| | - Thel K. Hla
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Stephanie Enkel
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Henderson
- Medical Imaging Department, Perth Children’s Hospital, Nedlands, Western Australia, Australia
| | - Robert M. Hand
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Adam Hort
- Western Australian Country Health Service, Perth, Western Australia, Australia
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Kevin Batty
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Brioni R. Moore
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Anneka Anderson
- Te Kupenga Hauora Maori, University of Auckland, Auckland, New Zealand
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Fulurija A, Cunningham MW, Korotkova N, Masterson MY, Bansal GP, Baker MG, Cannon JW, Carapetis JR, Steer AC. Research opportunities for the primordial prevention of rheumatic fever and rheumatic heart disease-streptococcal vaccine development: a national heart, lung and blood institute workshop report. BMJ Glob Health 2023; 8:e013534. [PMID: 38164699 PMCID: PMC10729269 DOI: 10.1136/bmjgh-2023-013534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024] Open
Abstract
Streptococcus pyogenes, also known as group A streptococcus (StrepA), is a bacterium that causes a range of human diseases, including pharyngitis, impetigo, invasive infections, and post-infection immune sequelae such as rheumatic fever and rheumatic heart disease. StrepA infections cause some of the highest burden of disease and death in mostly young populations in low-resource settings. Despite decades of effort, there is still no licensed StrepA vaccine, which if developed, could be a cost-effective way to reduce the incidence of disease. Several challenges, including technical and regulatory hurdles, safety concerns and a lack of investment have hindered StrepA vaccine development. Barriers to developing a StrepA vaccine must be overcome in the future by prioritising key areas of research including greater understanding of StrepA immunobiology and autoimmunity risk, better animal models that mimic human disease, expanding the StrepA vaccine pipeline and supporting vaccine clinical trials. The development of a StrepA vaccine is a complex and challenging process that requires significant resources and investment. Given the global burden of StrepA infections and the potential for a vaccine to save lives and livelihoods, StrepA vaccine development is an area of research that deserves considerable support. This report summarises the findings of the Primordial Prevention Working Group-VAX, which was convened in November 2021 by the National Heart, Lung, and Blood Institute. The focus of this report is to identify research gaps within the current StrepA vaccine landscape and find opportunities and develop priorities to promote the rapid and successful advancement of StrepA vaccines.
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Affiliation(s)
- Alma Fulurija
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
| | - Madeleine W Cunningham
- Department of Microbiology and Immunology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Natalia Korotkova
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, Kentucky, USA
| | - Mary Y Masterson
- Center for Translation Research and Implementation Science (CTRIS), National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Geetha P Bansal
- John E Fogarty International Center, Bethesda, Maryland, USA
| | - Michael G Baker
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Jeffrey W Cannon
- Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Andrew C Steer
- Infection, Immunity and Global Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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Govender K, Müller A. Secondary Prophylaxis Among First Nations People With Acute Rheumatic Fever in Australia: An Integrative Review. J Transcult Nurs 2023; 34:443-452. [PMID: 37572036 PMCID: PMC10637076 DOI: 10.1177/10436596231191248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023] Open
Abstract
INTRODUCTION The prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) among Australia's First Nations populations are some of the highest in the world, accounting for 95% of the 2,244 ARF notifications between 2015 and 2019 in Australia. A key issue in treating ARF is long-term secondary prophylaxis, yet only one in five patients received treatment in 2019. This review identifies barriers to secondary prophylaxis of ARF in Australia's First Nations people. METHODS An integrative review was undertaken utilizing PubMed, CINAHL, ProQuest, and Wiley Online. Joanna Briggs Institute critical appraisal tools were used, followed by thematic analysis. RESULTS The key themes uncovered included: issues with database and recall systems, patient/family characteristics, service delivery location and site, pain of injection, education (including language barriers), and patient-clinician relationship. CONCLUSIONS A national RHD register, change in operation model, improved pain management, improved education, and need for consistent personnel is suggested.
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Affiliation(s)
| | - Amanda Müller
- Flinders University, Adelaide, South Australia, Australia
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9
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Minja NW, Pulle J, Rwebembera J, de Loizaga SR, Fall N, Ollberding N, Abrams J, Atala J, Kamarembo J, Oyella L, Odong F, Nalubwama H, Nakagaayi D, Sarnacki R, Su Y, Dexheimer JW, Sable C, Longenecker CT, Danforth K, Okello E, Beaton AZ, Watkins DA. Evaluating the implementation of a dynamic digital application to enable community-based decentralisation of rheumatic heart disease case management in Uganda: protocol for a hybrid type III effectiveness-implementation study. BMJ Open 2023; 13:e071540. [PMID: 37898491 PMCID: PMC10619093 DOI: 10.1136/bmjopen-2022-071540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 09/19/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Rheumatic heart disease (RHD) affects over 39 million people worldwide, the majority in low-income and middle-income countries. Secondary antibiotic prophylaxis (SAP), given every 3-4 weeks can improve outcomes, provided more than 80% of doses are received. Poor adherence is strongly correlated with the distance travelled to receive prophylaxis. Decentralising RHD care has the potential to bridge these gaps and at least maintain or potentially increase RHD prophylaxis uptake. A package of implementation strategies was developed with the aim of reducing barriers to optimum SAP uptake. METHODS AND ANALYSIS A hybrid implementation-effectiveness study type III was designed to evaluate the effectiveness of a package of implementation strategies including a digital, cloud-based application to support decentralised RHD care, integrated into the public healthcare system in Uganda. Our overarching hypothesis is that secondary prophylaxis adherence can be maintained or improved via a decentralisation strategy, compared with the centralised delivery strategy, by increasing retention in care. To evaluate this, eligible patients with RHD irrespective of their age enrolled at Lira and Gulu hospital registry sites will be consented for decentralised care at their nearest participating health centre. We estimated a sample size of 150-200 registrants. The primary outcome will be adherence to secondary prophylaxis while detailed implementation measures will be collected to understand barriers and facilitators to decentralisation, digital application tool adoption and ultimately its use and scale-up in the public healthcare system. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board (IRB) at Cincinnati Children's Hospital Medical Center (IRB 2021-0160) and Makerere University School of Medicine Research Ethics Committee (Mak-SOMREC-2021-61). Participation will be voluntary and informed consent or assent (>8 but <18) will be obtained prior to participation. At completion, study findings will be communicated to the public, key stakeholders and submitted for publication.
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Affiliation(s)
- Neema W Minja
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania, United Republic of
| | - Jafesi Pulle
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Joselyn Rwebembera
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Sarah R de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ndate Fall
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica Abrams
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Reach, Cape Town, South Africa
| | - Jenifer Atala
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Jenipher Kamarembo
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Linda Oyella
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Francis Odong
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Haddy Nalubwama
- Department is Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rachel Sarnacki
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Judith W Dexheimer
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Craig Sable
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Kristen Danforth
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea Zawacki Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David A Watkins
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of General Medicine, University of Washington, Seattle, Washington, USA
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10
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Baker MG, Masterson MY, Shung-King M, Beaton A, Bowen AC, Bansal GP, Carapetis JR. Research priorities for the primordial prevention of acute rheumatic fever and rheumatic heart disease by modifying the social determinants of health. BMJ Glob Health 2023; 8:e012467. [PMID: 37914185 PMCID: PMC10619085 DOI: 10.1136/bmjgh-2023-012467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/09/2023] [Indexed: 11/03/2023] Open
Abstract
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.
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Affiliation(s)
- Michael G Baker
- Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Mary Y Masterson
- Center for Translation Research and Implementation Science (CTRIS), National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Maylene Shung-King
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Andrea Beaton
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Geetha P Bansal
- HIV Research and Training Program, John E Fogarty International Center, Bethesda, Maryland, USA
| | - Jonathan R Carapetis
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
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11
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Rwebembera J, Cannon JW, Sanyahumbi A, Sotoodehnia N, Taubert K, Yilgwan CS, Bukhman G, Masterson M, Bruno FP, Bowen A, Dale JB, Engel ME, Beaton A, Van Beneden C. Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report. BMJ Glob Health 2023; 8:e012356. [PMID: 37914184 PMCID: PMC10619102 DOI: 10.1136/bmjgh-2023-012356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/24/2023] [Indexed: 11/03/2023] Open
Abstract
Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) encompasses the timely diagnosis and adequate treatment of the superficial group A Streptococcus (GAS) infections pharyngitis and impetigo. GAS is the only known inciting agent in the pathophysiology of the disease. However, sufficient evidence indicates that the uptake and delivery of primary prevention approaches in RHD-endemic regions are significantly suboptimal. This report presents expert deliberations on priority research and implementation opportunities for primary prevention of ARF/RHD that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. The opportunities identified by the Primary Prevention Working Group encompass epidemiological, laboratory, clinical, implementation and dissemination research domains and are anchored on five pillars including: (A) to gain a better understanding of superficial GAS infection epidemiology to guide programmes and policies; (B) to improve diagnosis of superficial GAS infections in RHD endemic settings; (C) to develop scalable and sustainable models for delivery of primary prevention; (D) to understand potential downstream effects of the scale-up of primary prevention and (E) to develop and conduct economic evaluations of primary prevention strategies in RHD endemic settings. In view of the multisectoral stakeholders in primary prevention strategies, we emphasise the need for community co-design and government engagement, especially in the implementation and dissemination research arena. We present these opportunities as a reference point for research organisations and sponsors who aim to contribute to the increasing momentum towards the global control and prevention of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Division of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Jeffrey W Cannon
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Amy Sanyahumbi
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Nona Sotoodehnia
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathryn Taubert
- American Heart Association International, Basel, Switzerland
- Department of Physiology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher Sabo Yilgwan
- Departments of Paediatrics and West African Center for Emerging Infectious Diseases, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Gene Bukhman
- Center for Integration Science in Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Fernando P Bruno
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Asha Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - James B Dale
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mark E Engel
- AFROStrep Research Initiative, Cape Heart Institute, Department of Medicine, University of Cape Town, Rondebosch, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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12
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Karthikeyan G, Watkins D, Bukhman G, Cunningham MW, Haller J, Masterson M, Mensah GA, Mocumbi A, Muhamed B, Okello E, Sotoodehnia N, Machipisa T, Ralph A, Wyber R, Beaton A. Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report. BMJ Glob Health 2023; 8:e012468. [PMID: 37914183 PMCID: PMC10618973 DOI: 10.1136/bmjgh-2023-012468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. However, several important scientific issues around the secondary prevention paradigm remain unresolved. This report details research priorities for secondary prevention that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. These span basic, translational, clinical and population science research disciplines and are built on four pillars. First, we need a better understanding of RHD epidemiology to guide programmes, policies, and clinical and public health practice. Second, we need better strategies to find and diagnose people affected by ARF and RHD. Third, we urgently need better tools to manage acute RF and slow the progression of RHD. Fourth, new and existing technologies for these conditions need to be better integrated into healthcare systems. We intend for this document to be a reference point for research organisations and research sponsors interested in contributing to the growing scientific community focused on RHD prevention and control.
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Affiliation(s)
| | - David Watkins
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John Haller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - George A Mensah
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non-Communicable Diseases Division, Instituto Nacional de Saúde, Marracuene, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Babu Muhamed
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington, USA
| | - Tafadzwa Machipisa
- Cape Heart Institute (CHI), Department of Medicine, University of Cape Town, Rondebosch, South Africa
- Clinical Research Laboratory & Biobank-Genetic & Molecular Epidemiology Laboratory (CRLB-GMEL), Population Health Research Institute, Hamilton, Ontario, Canada
| | - Anna Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Rosemary Wyber
- END RHD Program, Telethon Kids Institute, Perth, Western Australia, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Canberra, Australian Capital Territory, Australia
| | - Andrea Beaton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Vervoort D, Yilgwan CS, Ansong A, Baumgartner JN, Bansal G, Bukhman G, Cannon JW, Cardarelli M, Cunningham MW, Fenton K, Green-Parker M, Karthikeyan G, Masterson M, Maswime S, Mensah GA, Mocumbi A, Kpodonu J, Okello E, Remenyi B, Williams M, Zühlke LJ, Sable C. Tertiary prevention and treatment of rheumatic heart disease: a National Heart, Lung, and Blood Institute working group summary. BMJ Glob Health 2023; 8:e012355. [PMID: 37914182 PMCID: PMC10619050 DOI: 10.1136/bmjgh-2023-012355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
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.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Annette Ansong
- Outpatient Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | | | - Geetha Bansal
- Division of International Training and Research, John E Fogarty International Center, Bethesda, Maryland, USA
| | - Gene Bukhman
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Disease and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey W Cannon
- Department of Global Health and Population, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Marcelo Cardarelli
- Pediatric Heart Surgery, Inova Children Hospital, Falls Church, Virginia, USA
| | | | - Kathleen Fenton
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Melissa Green-Parker
- National Institutes of Health Office of Disease Prevention, Bethesda, Maryland, USA
| | | | - Mary Masterson
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Salome Maswime
- Global Surgery, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - George A Mensah
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jacques Kpodonu
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - B Remenyi
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory of Australia, Australia
| | - Makeda Williams
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Liesl J Zühlke
- South African Medical Research Council, Tygerberg, South Africa
- Department of Medicine, Red Cross War Memorial Children's Hospital, Rondebosch, Western Cape, South Africa
| | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
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14
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Masterson MY, Beaton AZ, Williams MJ, Fenton KN, Bansal GP, Mocumbi AO, Carapetis JR, Goff DC, Mensah GA. Prospects for the future: supporting the elimination of rheumatic heart disease - a National Heart, Lung, and Blood Institute Workshop Proceedings. BMJ Glob Health 2023; 8:e014300. [PMID: 37914186 PMCID: PMC10619103 DOI: 10.1136/bmjgh-2023-014300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Mary Y Masterson
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Andrea Z Beaton
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | | | - Geetha P Bansal
- John E Fogarty International Center, Bethesda, Maryland, USA
| | - Ana O Mocumbi
- Non Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jonathan R Carapetis
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - David C Goff
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - George A Mensah
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
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15
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Stacey I, Ralph A, de Dassel J, Nedkoff L, Wade V, Francia C, Wyber R, Murray K, Hung J, Katzenellenbogen J. The evidence that rheumatic heart disease control programs in Australia are making an impact. Aust N Z J Public Health 2023; 47:100071. [PMID: 37364309 DOI: 10.1016/j.anzjph.2023.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/16/2022] [Accepted: 02/26/2023] [Indexed: 06/28/2023] Open
Abstract
OBJECTIVE Rheumatic heart disease (RHD) comprises heart-valve damage caused by acute rheumatic fever (ARF). The Australian Government Rheumatic Fever Strategy funds RHD Control Programs to support detection and management of ARF and RHD. We assessed epidemiological changes during the years of RHD Control Program operation. METHODS Linked RHD register, hospital and death data from four Australian jurisdictions were used to measure ARF/RHD outcomes between 2010 and 2017, including: 2-year progression to severe RHD/death; ARF recurrence; secondary prophylaxis delivery and earlier disease detection. RESULTS Delivery of secondary prophylaxis improved from 53% median proportion of days covered (95%CI: 46-61%, 2010) to 70% (95%CI: 71-68%, 2017). Secondary prophylaxis adherence protected against progression to severe RHD/death (hazard ratio 0.2, 95% CI 0.1-0.8). Other measures of program effectiveness (ARF recurrences, progression to severe RHD/death) remained stable. ARF case numbers and concurrent ARF/RHD diagnoses increased. CONCLUSIONS RHD Control Programs have contributed to major success in the management of ARF/RHD through increased delivery of secondary prevention yet ARF case numbers, not impacted by secondary prophylaxis and sensitive to increased awareness/surveillance, increased. IMPLICATIONS FOR PUBLIC HEALTH RHD Control Programs have a major role in delivering cost-effective RHD prevention. Sustained investment is needed but with greatly strengthened primordial and primary prevention.
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Affiliation(s)
- Ingrid Stacey
- School of Population and Global Health, The University of Western Australia, Australia.
| | - Anna Ralph
- Menzies School of Health Research, Charles Darwin University, Australia; Department of Medicine, Royal Darwin Hospital, Australia.
| | - Jessica de Dassel
- Rheumatic heart disease Control Program, Northern Territory Health, Australia.
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Australia; Cardiology Population Health Laboratory, Victor Chang Cardiac Research Institute, Australia.
| | - Vicki Wade
- Menzies School of Health Research, Charles Darwin University, Australia; National Heart Foundation of Australia, Australia.
| | - Carl Francia
- School of Health and Rehabilitation Sciences, The University of Queensland, Australia; Department of Physiotherapy, The Prince Charles Hospital, Australia.
| | - Rosemary Wyber
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Australian National University, Australia; Telethon Kids Institute, Australia.
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Australia.
| | - Joseph Hung
- School of Medicine, The University of Western Australia, Australia.
| | - Judith Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Australia; Telethon Kids Institute, Australia.
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Murugasen S, Abdullahi LH, Moloi H, Wyber R, Abrams J, Watkins DA, Engel ME, Zühlke LJ. Burden of disease and barriers to comprehensive care for rheumatic heart disease in South Africa: an updated systematic review protocol. BMJ Open 2023; 13:e073300. [PMID: 37263687 PMCID: PMC10254900 DOI: 10.1136/bmjopen-2023-073300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Rheumatic heart disease (RHD) is responsible for a significant burden of cardiovascular morbidity and mortality, and remains the most common cause of acquired heart disease among children and young adults in low-income and middle-income countries. Additionally, the global COVID-19 pandemic has forced the emergency restructuring of many health systems, which has had a broad impact on health in general, including cardiovascular disease. Despite significant cost to the health system and estimates from 2015 indicating both high incidence and prevalence of RHD in South Africa, no cohesive national strategy exists. An updated review of national burden of disease estimates, as well as literature on barriers to care for patients with RHD, will provide crucial information to assist in the development of a national RHD programme. METHODS AND ANALYSIS Using predefined search terms that capture relevant disease processes from Group A Streptococcal (GAS) infection through to the sequelae of RHD, a search of PubMed, Scopus, ISI Web of Science, Sabinet African Journals, SA Heart and Current and Completed Research databases will be performed. All eligible studies on RHD, acute rheumatic fever and GAS infection published from April 2014 to December 2022 will be included. Vital registration data for the same period from Statistics South Africa will also be collected. A standardised data extraction form will be used to capture results for both quantitative and qualitative analyses. All studies included in burden of disease estimates will undergo quality assessment using standardised tools. Updated estimates on mortality and morbidity as well as a synthesis of work on primary, secondary and tertiary prevention of RHD will be reported. ETHICS AND DISSEMINATION No ethics clearance is required for this study. Findings will be disseminated in a peer-reviewed journal and submitted to national stakeholders in RHD. PROSPERO REGISTRATION NUMBER CRD42023392782.
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Affiliation(s)
- Serini Murugasen
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Rondebosch, South Africa
| | | | - Hlengiwe Moloi
- South African Medical Research Council, Tygerberg, South Africa
| | - Rosemary Wyber
- The George Institute for Global Health, Newtown, New South Wales, Australia
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Jessica Abrams
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Rondebosch, South Africa
| | - David A Watkins
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mark E Engel
- Department of Medicine, Cape Heart Institute, University of Cape Town Faculty of Health Sciences, Observatory, South Africa
| | - Liesl Joanna Zühlke
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Rondebosch, South Africa
- South African Medical Research Council, Tygerberg, South Africa
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17
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Namuyonga J, Ndagire E, Okumu D, Olugubuyi O, Lubega S, Omagino J, Lwabi P, Okello E. Positive impact of training rural health workers in identification and prevention of acute rheumatic fever in eastern Uganda. Cardiovasc J Afr 2023; 34:89-92. [PMID: 36162808 PMCID: PMC10512037 DOI: 10.5830/cvja-2022-029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 07/02/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Diagnosis of acute rheumatic fever (ARF) is mainly clinical. Delayed or missed diagnosis and failure to administer appropriate and timely treatment of ARF leads to rheumatic heart disease (RHD), which could necessitate expensive treatments such as open-heart surgery. Implementation of preventative guidelines depends on availability of trained healthcare workers. As part of the routine support supervision, the Uganda Heart Institute sent out a team to rural eastern Uganda to evaluate health workers' knowledge level regarding management of ARF. METHODS Health workers from selected health facilities in Tororo district, eastern Uganda, were assessed for their knowledge on the clinical features and role of benzathine penicillin G (BPG) in the treatment and prevention of ARF recurrence. Using the RHD Action Needs assessment tool, we generated and administered a pre-test, then conducted training and re-administered a post-test. Eight months later, health workers were again assessed for knowledge retention and change in practices. Statistical analysis was done using Stata version 15. RESULTS During the initial phase, 34 of the 109 (31%) health workers passed the pre-test, indicating familiarity with clinical features of ARF. The level of knowledge of BPG use in ARF was very poor in all the health units [25/109 (22.6%)] but improved after training to 80%, as shown by the chi-squared test ( χ2 = 0.000). However, retention of this knowledge waned after eight months and was not significantly different compared to pre-training (χ2 ≥ 0.2). CONCLUSIONS A critical knowledge gap is evident among health workers, both in awareness and treatment of ARF, and calls for repetitive training as a priority strategy in prevention.
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Affiliation(s)
- Judith Namuyonga
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda.
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Emma Ndagire
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - David Okumu
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
- Tororo District Local Government, Tororo, Uganda
| | - Oluwayomi Olugubuyi
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
- Department of Child and Adolescent Health, University of West Indies, Mona Jamaica
| | - Sulaiman Lubega
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - John Omagino
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Peter Lwabi
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Emmy Okello
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
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18
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Nalubwama H, Pulle J, Atala J, Sarnacki R, Nakitto M, Namara R, Beaton A, Kansiime R, Mwima R, Ndagire E, Okello E, Watkins D. A Qualitative Study of Patients' Experiences, Enablers and Barriers of Rheumatic Heart Disease Care in Uganda. Glob Heart 2023; 18:6. [PMID: 36846723 PMCID: PMC9951636 DOI: 10.5334/gh.1181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/16/2022] [Indexed: 02/25/2023] Open
Abstract
Introduction Rheumatic heart disease (RHD) remains a significant public health problem in countries with limited health resources. People living with RHD face numerous social challenges and have difficulty navigating ill-equipped health systems. This study sought to understand the impact of RHD on PLWRHD and their households and families in Uganda. Methods In this qualitative study, we conducted in-depth interviews with 36 people living with RHD sampled purposively from Uganda's national RHD research registry, stratifying the sample by geography and severity of disease. Our interview guides and data analysis used a combination of inductive and deductive methods, with the latter informed by the socio-ecological model. We ran thematic content analysis to identify codes that were then collapsed into themes. Coding was done independently by three analysts, who compared their results and iteratively updated the codebook. Results The inductive portion of our analysis, which focused on the patient experience, revealed a significant impact of RHD on work and school. Participants often lived in fear of the future, faced limited childbirth choices, experienced domestic conflict, and suffered stigmatization and low self-esteem. The deductive portion of our analysis focused on barriers and enablers to care. Major barriers included the high out-of-pocket cost of medicines and travel to health facilities, as well as poor access to RHD diagnostics and medications. Major enablers included family and social support, financial support within the community, and good relationships with health workers, though this varied considerably by location. Conclusion Despite several personal and community factors that support resilience, PLWRHD in Uganda experience a range of negative physical, emotional, and social consequences from their condition. Greater investment is needed in primary healthcare systems to support decentralized, patient-centered care for RHD. Implementing evidence-based interventions that prevent RHD at district level could greatly reduce the scale of human suffering. There is need to increase investment in primary prevention and tackling social determinants, to reduce the incidence of RHD in communities where the condition remains endemic.
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Affiliation(s)
| | | | | | | | | | - Rebecca Namara
- Department of Global Health, University of Washington, Seattle WA, USA
| | - Andrea Beaton
- Cincinnati Children’s Hospital Medical Center, Cincinnati OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - David Watkins
- Department of Global Health, University of Washington, Seattle WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
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Ralph AP, Kelly A, Lee AM, Mungatopi VL, Babui SR, Budhathoki NK, Wade V, de Dassel JL, Wyber R. Evaluation of a Community-Led Program for Primordial and Primary Prevention of Rheumatic Fever in Remote Northern Australia. Int J Environ Res Public Health 2022; 19:ijerph191610215. [PMID: 36011846 PMCID: PMC9407981 DOI: 10.3390/ijerph191610215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/02/2022] [Accepted: 08/14/2022] [Indexed: 06/09/2023]
Abstract
Environmental factors including household crowding and inadequate washing facilities underpin recurrent streptococcal infections in childhood that cause acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD). No community-based 'primordial'-level interventions to reduce streptococcal infection and ARF rates have been reported from Australia previously. We conducted a study at three Australian Aboriginal communities aiming to reduce infections including skin sores and sore throats, usually caused by Group A Streptococci, and ARF. Data were collected for primary care diagnoses consistent with likely or potential streptococcal infection, relating to ARF or RHD or related to environmental living conditions. Rates of these diagnoses during a one-year Baseline Phase were compared with a three-year Activity Phase. Participants were children or adults receiving penicillin prophylaxis for ARF. Aboriginal community members were trained and employed to share knowledge about ARF prevention, support reporting and repairs of faulty health-hardware including showers and provide healthcare navigation for families focusing on skin sores, sore throat and ARF. We hypothesized that infection-related diagnoses would increase through greater recognition, then decrease. We enrolled 29 participants and their families. Overall infection-related diagnosis rates increased from Baseline (mean rate per-person-year 1.69 [95% CI 1.10-2.28]) to Year One (2.12 [95% CI 1.17-3.07]) then decreased (Year Three: 0.72 [95% CI 0.29-1.15]) but this was not statistically significant (p = 0.064). Annual numbers of first-known ARF decreased, but numbers were small: there were six cases of first-known ARF during Baseline, then five, 1, 0 over the next three years respectively. There was a relationship between household occupancy and numbers (p = 0.018), but not rates (p = 0.447) of infections. This first Australian ARF primordial prevention study provides a feasible model with encouraging findings.
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Affiliation(s)
- Anna P. Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin 0810, Australia
- Rheumatic Heart Disease Australia, Menzies School of Health Research, Darwin 0810, Australia
| | - Angela Kelly
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Anne-Marie Lee
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
- Sunrise Health Corporation, Katherine 0850, Australia
| | - Valerina L. Mungatopi
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Segora R. Babui
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Nanda Kaji Budhathoki
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Vicki Wade
- Rheumatic Heart Disease Australia, Menzies School of Health Research, Darwin 0810, Australia
| | | | - Rosemary Wyber
- Telethon Kids Institute, Perth 6000, Australia
- George Institute for Global Health, Sydney 2000, Australia
- Australian National University, Canberra 2610, Australia
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Okeniyi JA, Ijaduola MY, Elugbaju OT, Fakoyejo OS, Adeyefa B, Bamigboye-Taiwo OT, Afolabi O, Akinroye K, Osibogun A. Community Advocacy and Capacity Building of Community Health Workers on Rheumatic Heart Disease in Osun State, Nigeria. West Afr J Med 2022:756-760. [PMID: 35929491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Rheumatic heart disease (RHD) is one of the leading causes of cardiovascular diseases in the world. The study aimed to assess awareness and capacity building on the diagnosis and prevention of RHD among Community Health Workers (CHWs) Nigeria. It was an interventional study, where 300 CHWs from public Primary Health Care (PHC) facilities were selected pre-assessed on the diagnosis and prevention of RHD before their training on RHD. Also, a post-test evaluation was done to reassess the CHWs awareness on RHD. Data were analyzed and RHD knowledge was scored and graded. Results showed, at pre-test evaluation, that 49% of the CHWs had good knowledge, 49.7% had fair knowledge while 4.1% had poor knowledge on the diagnosis and prevention of RHD, while post-test evaluation revealed that 100% of the CHWs had good knowledge. Awareness of the CHWs about the diagnosis and prevention of RHD was fair in the pre-test and improved after the training with all the CHWs having good knowledge. This showed the training was impactful. Intermittent assessment of the awareness and simultaneous training of the CHWs on RHD may be scaled up into a significant and effective measure in the armamentarium of community prevention of the disease.
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Affiliation(s)
- J A Okeniyi
- Department of Paediatric and Child Health, Obafemi Awolowo University (OAU)- Obafemi Awolowo University Teaching Hospital Complex, (OAUTHC), Ile Ife, Nigeria
| | - M Y Ijaduola
- Department of Community Health, Obafemi Awolowo University (OAU)- Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile Ife, Nigeria
| | - O T Elugbaju
- Department of Community Health, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria
| | - O S Fakoyejo
- Department of Community Health, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria
| | - B Adeyefa
- Department of Paediatrics, Obafemi Awolowo University Teaching Hospital Complex,(OAUTHC) Ile Ife, Nigeria
| | - O T Bamigboye-Taiwo
- Department of Paediatric and Child Health, Obafemi Awolowo University (OAU)- Obafemi Awolowo University Teaching Hospital Complex, (OAUTHC), Ile Ife, Nigeria
| | - O Afolabi
- Department of Community Health, Obafemi Awolowo University (OAU)- Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile Ife, Nigeria
| | - K Akinroye
- Nigerian Heart Foundation, No. 4, Akanbi Danmola Street, Off Ribadu Road, S.W. Ikoyi, Lagos Nigeria
| | - A Osibogun
- Nigerian Heart Foundation, No. 4, Akanbi Danmola Street, Off Ribadu Road, S.W. Ikoyi, Lagos Nigeria
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21
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Schoenfuss ES. Diagnosis, management, and prevention of acute rheumatic fever in the United States. JAAPA 2022; 35:21-27. [PMID: 35421873 DOI: 10.1097/01.jaa.0000824960.82938.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Acute rheumatic fever is a multisystem autoimmune disease caused by infection with group A streptococcus. The condition most commonly affects children ages 5 to 14 years who are from low-income populations. The diagnosis is clinical; however, the 2015 Jones Criteria can help support it. Acute rheumatic fever poses a significant health risk secondary to rheumatic heart disease. Although acute rheumatic fever is rare in the United States, outbreaks still occur, and certain populations continue to be at increased risk. This article describes how to identify acute rheumatic fever and provides prompt management and prevention strategies to reduce patient risk for lifelong complications.
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Affiliation(s)
- Erin S Schoenfuss
- Erin S. Schoenfuss practices at Aspirus Medical Group in Weston, Wis., and is a doctor of medical science candidate at A.T. Still University's Arizona School of Health Sciences in Mesa, Ariz. The author has disclosed no potential conflicts of interest, financial or otherwise
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22
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Finley JC. Antibiotic Prophylaxis for Latent Rheumatic Heart Disease. N Engl J Med 2022; 386:1673. [PMID: 35476662 DOI: 10.1056/nejmc2202301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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23
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Wyber R, Lizama C, Wade V, Pearson G, Carapetis J, Ralph AP, Bowen AC, Peiris D. Improving primary prevention of acute rheumatic fever in Australia: consensus primary care priorities identified through an eDelphi process. BMJ Open 2022; 12:e056239. [PMID: 35273057 PMCID: PMC8915338 DOI: 10.1136/bmjopen-2021-056239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Rosemary Wyber
- Health Systems Science, The George Institute for Global Health, Newtown, New South Wales, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Catalina Lizama
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Vicki Wade
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Glenn Pearson
- Aboriginal Health Institute Leadership Team, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Anna P Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- General Medicine and Inectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - David Peiris
- Health Systems Science, The George Institute for Global Health, Newtown, New South Wales, Australia
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Sanyahumbi A, Ali S, Benjamin IJ, Karthikeyan G, Okello E, Sable CA, Taubert K, Wyber R, Zuhlke L, Carapetis JR, Beaton AZ. Penicillin Reactions in Patients With Severe Rheumatic Heart Disease: A Presidential Advisory From the American Heart Association. J Am Heart Assoc 2022; 11:e024517. [PMID: 35049336 PMCID: PMC9075066 DOI: 10.1161/jaha.121.024517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Secondary antibiotic prophylaxis with regular intramuscular benzathine penicillin G (BPG) is the cornerstone of rheumatic heart disease management. However, there is a growing body of evidence that patients with rheumatic heart disease who have severe valvular heart disease with or without reduced ventricular function may be dying from cardiovascular compromise following BPG injections. This advisory responds to these concerns and is intended to: (1) raise awareness, (2) provide risk stratification, and (3) provide strategies for risk reduction. Based on available evidence and expert opinion, we have divided patients into low- and elevated-risk groups, based on symptoms and the severity of underlying heart disease. Patients with elevated risk include those with severe mitral stenosis, aortic stenosis, and aortic insuffiency; those with decreased left ventricular systolic dysfunction; and those with no symptoms. For these patients, we believe the risk of adverse reaction to BPG, specifically cardiovascular compromise, may outweigh its theoretical benefit. For patients with elevated risk, we newly advise that oral prophylaxis should be strongly considered. In addition, we advocate for a multifaceted strategy for vasovagal risk reduction in all patients with rheumatic heart disease receiving BPG. As current guidelines recommend, all low-risk patients without a history of penicillin allergy or anaphylaxis should continue to be prescribed BPG for secondary antibiotic prophylaxis. We publish this advisory in the hopes of saving lives and avoiding events that can have devastating effects on patient and clinician confidence in BPG.
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Vaughan G, Dawson A, Peek M, Sliwa K, Carapetis J, Wade V, Sullivan E. Rheumatic Heart Disease in Pregnancy: New Strategies for an Old Disease? Glob Heart 2021; 16:84. [PMID: 35141125 PMCID: PMC8698226 DOI: 10.5334/gh.1079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
RHD in pregnancy (RHD-P) is associated with an increased burden of maternal and perinatal morbidity and mortality. A sequellae of rheumatic fever resulting in heart valve damage if untreated, RHD is twice as common in women. In providing an historical overview, this commentary provides context for prevention and treatment in the 21 st century. Four underlying themes inform much of the literature on RHD-P: its association with inequities; often-complex care requirements; demands for integrated care models, and a life-course approach. While there have been some gains particularly in awareness, strengthened policies and funding strategies are required to sustain improvements in the RHD landscape and consequently improve outcomes. As the principal heart disease seen in pregnant women in endemic regions, it is unlikely that the Sustainable Development Goal 3 target of reduced global maternal mortality ratio can be met by 2030 if RHD is not better addressed for women and girls.
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26
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Kerrigan V, Kelly A, Lee AM, Mungatopi V, Mitchell AG, Wyber R, Ralph AP. A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia. BMC Health Serv Res 2021; 21:1127. [PMID: 34670567 PMCID: PMC8527302 DOI: 10.1186/s12913-021-07159-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/12/2021] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Vicki Kerrigan
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811 Australia
| | - Angela Kelly
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811 Australia
| | - Anne Marie Lee
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811 Australia
| | - Valerina Mungatopi
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811 Australia
| | - Alice G. Mitchell
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811 Australia
| | - Rosemary Wyber
- George Institute for Global Health, Level 5, 1 King Street, Newtown, New South Wales 2042 Australia
- Telethon Kids Institute, 15 Hospital Avenue, Nedlands, Western Australia 6009 Australia
| | - Anna P. Ralph
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811 Australia
- Royal Darwin Hospital, Darwin, Northern Territory 0811 Australia
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Haynes E, Walker R, Mitchell AG, Katzenellenbogen J, D'Antoine H, Bessarab D. Decolonizing Indigenous health: Generating a productive dialogue to eliminate Rheumatic Heart Disease in Australia. Soc Sci Med 2021; 277:113829. [PMID: 33895707 DOI: 10.1016/j.socscimed.2021.113829] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
In common with colonized Indigenous people worldwide, many Australian Aboriginal people experience inequitable health outcomes. While the commitment and advocacy of researchers and health practitioners has resulted in many notable improvements in policy and practice, systemic and structural impediments continue to restrain widespread gains in addressing Indigenous health injustices. We take Rheumatic Heart Disease (RHD), a potent marker of extreme health inequity, as a case study, and critically examine RHD practitioners' perspectives regarding the factors that need to be addressed to improve RHD prevention and care. This study is an important explanatory component of a broader study to inform new clinical practices, and health system strategies and policies to reduce RHD. A decolonising, critical medical anthropology (CMA) analysis of findings from 22 RHD practitioner in-depth interviews conducted in May 2016 revealed both practitioners' perceptions of health system shortcomings and a sense of hopelessness and powerlessness to transform existing health system inequities, the negative impacts of which were subsequently confirmed in a separate study of RHD patients' lived realities. We reveal how biomedical dominance, normalized deficit discourses and systemic racism influence the current policy and practice landscape, narrowing the intercultural space for productive dialogue and reinforcing the conditions that cause disease. To counter biomedical approaches that contribute to existing health inequities in health care, we recommend localized, strength-based, community-led research projects focused on actions that use critical decolonizing social science approaches to achieve system change. We demonstrate the importance of integrating biological and social sciences approaches in research, education/training, and practice to: 1) be guided by Indigenous strengths, knowledges and worldview, and 2) adopt a critical reflexive stance to examine systems, structures and practices. Such an approach facilitates productive cross-cultural dialogue and social transformation; providing direction and hope to practitioners, enhancing their knowledge, skills and capacity and improving Aboriginal health outcomes.
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Affiliation(s)
- Emma Haynes
- School of Population and Global Health, The University of Western Australia, Clifton Street Building, Clifton St, Nedlands, Perth, Western Australia, 6009, Australia.
| | - Roz Walker
- School of Population and Global Health, The University of Western Australia, Clifton Street Building, Clifton St, Nedlands, Perth, Western Australia, 6009, Australia.
| | - Alice G Mitchell
- Menzies School of Health Research, Charles Darwin University, PO Box 41096 Casuarina, Northern Territory, 0811, Australia.
| | - Judy Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Clifton Street Building, Clifton St, Nedlands, Perth, Western Australia, 6009, Australia.
| | - Heather D'Antoine
- Menzies School of Health Research, Charles Darwin University, PO Box 41096 Casuarina, Northern Territory, 0811, Australia.
| | - Dawn Bessarab
- School of Population and Global Health, The University of Western Australia, Clifton Street Building, Clifton St, Nedlands, Perth, Western Australia, 6009, Australia.
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Ndagire E, Kawakatsu Y, Nalubwama H, Atala J, Sarnacki R, Pulle J, Kyarimpa R, Mwima R, Kansiime R, Okello E, Lwabi P, Beaton A, Sable C, Watkins D. Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services. PLoS Negl Trop Dis 2021; 15:e0009164. [PMID: 33591974 PMCID: PMC7909659 DOI: 10.1371/journal.pntd.0009164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/26/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda. METHODOLOGY/PRINCIPAL FINDINGS This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare. CONCLUSIONS/SIGNIFICANCE Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.
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Affiliation(s)
- Emma Ndagire
- Uganda Heart Institute, Kampala, Uganda
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
| | - Yoshito Kawakatsu
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | | | - Rachel Sarnacki
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
| | | | | | | | | | | | | | - Andrea Beaton
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Craig Sable
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
- George Washington University School of Medicine, Washington, District of Columbia, United States of America
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Division of General Internal Medicine, University of Washington, Seattle, Washington, United States of America
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Arvind B, Saxena A, Kazi DS, Bolger AF. Out-of-pocket expenditure for administration of benzathine penicillin G injections for secondary prophylaxis in patients with rheumatic heart disease: A registry-based data from a tertiary care center in Northern India. Indian Heart J 2020; 73:169-173. [PMID: 33865513 PMCID: PMC8065366 DOI: 10.1016/j.ihj.2020.11.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/17/2020] [Accepted: 11/29/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Costs can be a major barrier to medication adherence in low and middle-income countries and are an important target for policy-level interventions. The use of benzathine penicillin G (BPG) for secondary prevention of rheumatic heart disease (RHD) averts substantial morbidity and mortality, yet the total out-of-pocket costs for patients receiving this intervention are unknown. OBJECTIVE To estimate the total out-of-pocket costs for obtaining BPG prophylaxis among RHD patients in India. METHODS We prospectively collected self-reported drug-, transportation-, and provider-related costs for secondary prophylaxis among RHD patients presenting for follow-up to a tertiary care centre in New Delhi, India. Monthly costs were estimated by adjusting unit costs by frequency of drug administration. RESULTS The cost data provided by 420 patients [mean age (±SD) 11.6 (±2.9) years] was analysed. Majority of the patients were male (65.2%), hailed from rural areas (87.1%), and belonged to lower socioeconomic strata (73.3%). The median monthly total out-of-pocket costs (IQR) for obtaining BPG injections was Indian rupee (INR) 62.5 (42.5-117.0). The median costs for procuring the drug (IQR) was INR 34.0(30.0-39.0). Whereas median costs (IQR) for health care provider and transportation was INR 16.0 [0-32.0]) and INR 11 [0-31.0] respectively. When expressed as mean (SD), the costs for transportation constituted 50% of the total costs, whereas the mean cost for drug procurement and drug administration constituted 30% and 22% of the total costs respectively. CONCLUSION RHD patients receiving BPG prophylaxis incur substantial out-of-pocket costs, with transportation costs constituting nearly half of the total expenditures. National investments in RHD control must be strategically directed at improving health care access and drug supply in order to lower the total costs of secondary prophylaxis and improve adherence rates.
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Affiliation(s)
- Balaji Arvind
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, 375 Longwood Ave, 4th Floor, Boston, MA, USA.
| | - Ann F Bolger
- University of California San Francisco, San Francisco, CA, USA.
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Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Reményi B, Sliwa-Hähnle K, Zühlke LJ, Sable C. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e337-e357. [PMID: 33073615 DOI: 10.1161/cir.0000000000000921] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.
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Katzenellenbogen JM, Bond‐Smith D, Seth RJ, Dempsey K, Cannon J, Stacey I, Wade V, de Klerk N, Greenland M, Sanfilippo FM, Brown A, Carapetis JR, Wyber R, Nedkoff L, Hung J, Bessarab D, Ralph AP. Contemporary Incidence and Prevalence of Rheumatic Fever and Rheumatic Heart Disease in Australia Using Linked Data: The Case for Policy Change. J Am Heart Assoc 2020; 9:e016851. [PMID: 32924748 PMCID: PMC7792417 DOI: 10.1161/jaha.120.016851] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/10/2020] [Indexed: 12/30/2022]
Abstract
Background In 2018, the World Health Organization prioritized control of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), including disease surveillance. We developed strategies for estimating contemporary ARF/RHD incidence and prevalence in Australia (2015-2017) by age group, sex, and region for Indigenous and non-Indigenous Australians based on innovative, direct methods. Methods and Results This population-based study used linked administrative data from 5 Australian jurisdictions. A cohort of ARF (age <45 years) and RHD cases (<55 years) were sourced from jurisdictional ARF/RHD registers, surgical registries, and inpatient data. We developed robust methods for epidemiologic case ascertainment for ARF/RHD. We calculated age-specific and age-standardized incidence and prevalence. Age-standardized rate and prevalence ratios compared disease burden between demographic subgroups. Of 1425 ARF episodes, 72.1% were first-ever, 88.8% in Indigenous people and 78.6% were aged <25 years. The age-standardized ARF first-ever rates were 71.9 and 0.60/100 000 for Indigenous and non-Indigenous populations, respectively (age-standardized rate ratio=124.1; 95% CI, 105.2-146.3). The 2017 Global Burden of Disease RHD prevalent counts for Australia (<55 years) underestimate the burden (1518 versus 6156 Australia-wide extrapolated from our study). The Indigenous age-standardized RHD prevalence (666.3/100 000) was 61.4 times higher (95% CI, 59.3-63.5) than non-Indigenous (10.9/100 000). Female RHD prevalence was double that in males. Regions in northern Australia had the highest rates. Conclusions This study provides the most accurate estimates to date of Australian ARF and RHD rates. The high Indigenous burden necessitates urgent government action. Findings suggest RHD may be underestimated in many high-resource settings. The linked data methods outlined here have potential for global applicability.
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Affiliation(s)
| | | | | | - Karen Dempsey
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
| | | | | | - Vicki Wade
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
| | - Nicholas de Klerk
- The University of Western AustraliaPerthAustralia
- Telethon Kids InstitutePerthAustralia
| | | | | | - Alex Brown
- Telethon Kids InstitutePerthAustralia
- South Australian Medical Research InstituteAdelaideAustralia
- The University of AdelaideAustralia
| | | | - Rosemary Wyber
- Telethon Kids InstitutePerthAustralia
- The George Institute for Global HealthSydneyNew South WalesAustralia
| | - Lee Nedkoff
- The University of Western AustraliaPerthAustralia
| | - Joe Hung
- The University of Western AustraliaPerthAustralia
| | | | - Anna P. Ralph
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
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Beaton A, Kamalembo FB, Dale J, Kado JH, Karthikeyan G, Kazi DS, Longenecker CT, Mwangi J, Okello E, Ribeiro ALP, Taubert KA, Watkins DA, Wyber R, Zimmerman M, Carapetis J. The American Heart Association's Call to Action for Reducing the Global Burden of Rheumatic Heart Disease: A Policy Statement From the American Heart Association. Circulation 2020; 142:e358-e368. [PMID: 33070654 DOI: 10.1161/cir.0000000000000922] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rheumatic heart disease (RHD) affects ≈40 million people and claims nearly 300 000 lives each year. The historic passing of a World Health Assembly resolution on RHD in 2018 now mandates a coordinated global response. The American Heart Association is committed to serving as a global champion and leader in RHD care and prevention. Here, we pledge support in 5 key areas: (1) professional healthcare worker education and training, (2) technical support for the implementation of evidence-based strategies for rheumatic fever/RHD prevention, (3) access to essential medications and technologies, (4) research, and (5) advocacy to increase global awareness, resources, and capacity for RHD control. In bolstering the efforts of the American Heart Association to combat RHD, we hope to inspire others to collaborate, communicate, and contribute.
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Taddio A, Pillon R, Pastore S, Monasta L, Tommasini A, Di Battista C, Mascheroni E, Berton E, Maggio MC, Simonini G, Breda L, Cimaz R, Pires Marafon D, Meli L, Bracaglia C, De Benedetti F, Ventura A. Acute rheumatic fever prophylaxis in high-income countries: clinical observations from an Italian multicentre, retrospective study. Clin Exp Rheumatol 2020; 38:1016-1020. [PMID: 31969217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/18/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The aim of the study is to evaluate the compliance rate to secondary prophylaxis and the presence of rheumatic heart disease (RHD) in a cohort of Italian patients with acute rheumatic fever (ARF). METHODS This is a multicentre retrospective study. The patients were divided into two groups by the presence or absence at last follow-up of RHD. Clinical features, ARF recurrences and the rate of compliance to secondary prophylaxis were evaluated. RESULTS Two-hundred and ninety patients were enrolled (137 females; 153 males). Carditis at onset was present in 244 patients (84.7%). At the end of follow-up, 173 patients manifested RHD. Adherence to secondary prophylaxis was low in 26% of patients. The presence of RHD at follow-up was associated with the presence of carditis and its severity at onset (p=0.001), but it was not related to secondary prophylaxis adherence (p=NS). No association between prophylaxis adherence and ARF recurrence was found (p=NS) nor between ARF recurrence and RHD at the end of follow-up (p=NS). CONCLUSIONS Poor adherence to secondary prophylaxis does not seem to be associated with increased risk of RHD in developed countries. Further studies are needed to confirm our data in a larger population.
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Affiliation(s)
- Andrea Taddio
- University of Trieste and Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.
| | | | - Serena Pastore
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Lorenzo Monasta
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Alberto Tommasini
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | | | | | - Emanuela Berton
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | | | - Gabriele Simonini
- Paediatric Rheumatology, Anna Meyer Children University Hospital, Florence, Italy
| | - Luciana Breda
- Department of Paediatrics, University of Chieti, Italy
| | - Rolando Cimaz
- Paediatric Rheumatology, Anna Meyer Children University Hospital, Florence, Italy
| | | | - Lidia Meli
- Rheumatology Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | | | | | - Alessandro Ventura
- University of Trieste and Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
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Ghamrawy A, Ibrahim NN, Abd El-Wahab EW. How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018). PLoS Negl Trop Dis 2020; 14:e0008558. [PMID: 32804953 PMCID: PMC7451991 DOI: 10.1371/journal.pntd.0008558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/27/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Abstract
Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.
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Affiliation(s)
- Alaa Ghamrawy
- Department of Non-Communicable Diseases, Ministry of Health and Population, Cairo, Egypt
| | - Nermeen N. Ibrahim
- Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Ekram W. Abd El-Wahab
- Department of Tropical Health, High Institute of Public Health, Alexandria University, Alexandria, Egypt
- * E-mail:
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Mensah GA. Cardiovascular health research, training, and capacity building for the eradication of rheumatic fever and rheumatic heart disease in our lifetime: the inaugural Bongani Mayosi Memorial Lecture. Lancet Glob Health 2020; 8:e1098-e1100. [PMID: 32710866 DOI: 10.1016/s2214-109x(20)30297-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/27/2020] [Indexed: 11/19/2022]
Affiliation(s)
- George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Yakimenko E, Zakatova L, Tbilieli V, Antipova N, Kolomiets S, Tikhonchuk N, Bondar V, Klochko V. [CURRENT TRENDS IN THE PREVENTION, DIAGNOSIS AND TREATMENT OF RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE (REVIEW)]. Georgian Med News 2019:88-94. [PMID: 32011302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The purpose of the work is to analyze the evolution of the clinical course, diagnosis, treatment and prevention of acute rheumatic fever (ARF) and chronic rheumatic heart disease (RHD), antibiotic therapy of streptococcal infection, using modern analysis of modern literature and our own observations. Diagnostic criteria for the disease were revised. Improving the capabilities of echocardiography can improve the prognosis of the disease through the early use of treatment and prevention. The level of ORL / RHD correlates with the economic development of countries. Mutation of the etiological factor of rheumatism - ß-HSA, the formation of antibiotic resistance, increased migration, tourist activity in countries with high morbidity due to ß-HSA can lead to new outbreaks of this infection. Prevention ARF/RHD is multistage. Thus, using the experience of healthcare in different countries, new approaches to prevention can improve disease control.
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Affiliation(s)
| | - L Zakatova
- Odessa National Medical University, Ukraine
| | - V Tbilieli
- Odessa National Medical University, Ukraine
| | - N Antipova
- Odessa National Medical University, Ukraine
| | | | | | - V Bondar
- Odessa National Medical University, Ukraine
| | - V Klochko
- Odessa National Medical University, Ukraine
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Beaton A, Okello E, Engelman D, Grobler A, Scheel A, DeWyer A, Sarnacki R, Omara IO, Rwebembera J, Sable C, Steer A. Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial. Am Heart J 2019; 215:95-105. [PMID: 31301533 DOI: 10.1016/j.ahj.2019.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/01/2019] [Indexed: 11/15/2022]
Abstract
Rheumatic heart disease (RHD) remains a high prevalence condition in low- and middle-income countries. Most individuals with RHD present late, missing the opportunity to benefit from secondary antibiotic prophylaxis. Echocardiographic screening can detect latent RHD, but the impact of secondary prophylaxis in screen-detected individuals is not known. METHODS/DESIGN This trial aims to determine if secondary prophylaxis with every-4-week injectable Benzathine penicillin G (BPG) improves outcomes for children diagnosed with latent RHD. This is a randomized controlled trial in consenting children, aged 5 to 17 years in Northern Uganda, confirmed to have borderline RHD or mild definite RHD on echocardiography, according to the 2012 World Heart Federation criteria. Qualifying children will be randomized to every-4-week injectable intramuscular BPG or no medical intervention and followed for a period of 2 years. Ongoing intervention adherence and retention in the trial will be supported through the establishment of peer support groups for participants in the intervention and control arms. A blinded echocardiography adjudication panel consisting of four independent experts will determine the echocardiographic classification at enrollment and trajectory through consensus review. The primary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic progression of latent RHD compared to those in the control arm. The secondary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic regression of latent RHD compared to those in the control arm. A sample size of 916 participants will provide 90% power to detect a 50% relative risk reduction assuming a 15% progression in the control group. The planned study duration is from 2018-2021. DISCUSSION Policy decisions on the role of echocardiographic screening for RHD have stalled because of the lack of evidence of the benefit of secondary prophylaxis. The results of our study will immediately inform the standard of care for children diagnosed with latent RHD and will shape, over 2-3 years, practical and scalable programs that could substantially decrease the burden of RHD in our lifetime. TRIAL REGISTRATION ClinicalTrials.gov: NCT03346525. Date Registered: November 17, 2017.
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Affiliation(s)
- Andrea Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | | | - Daniel Engelman
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anneke Grobler
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amy Scheel
- Emory School of Medicine, Atlanta, GA, USA
| | - Alyssa DeWyer
- Children's National Medical Center, Washington, DC, USA
| | | | | | | | - Craig Sable
- Children's National Medical Center, Washington, DC, USA
| | - Andrew Steer
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
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Giffard PM, Tong SYC, Holt DC, Ralph AP, Currie BJ. Concerns for efficacy of a 30-valent M-protein-based Streptococcus pyogenes vaccine in regions with high rates of rheumatic heart disease. PLoS Negl Trop Dis 2019; 13:e0007511. [PMID: 31269021 PMCID: PMC6634427 DOI: 10.1371/journal.pntd.0007511] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/16/2019] [Accepted: 06/03/2019] [Indexed: 11/21/2022] Open
Abstract
The prevalence of rheumatic heart disease (RHD) in the Aboriginal population of the Australian Northern Territory is high, and Streptococcus pyogenes skin infections likely contribute to this. A promising candidate S. pyogenes “30mer” vaccine is composed of 30 pharyngitis associated type-specific antigens from the S. pyogenes M protein. Cross opsonisation experiments suggest that 30mer vaccine protection may extend to non-cognate emm types. A new “emm cluster” scheme for classifying M protein is based on the full-length coding sequence, and correlates with functional and immunological properties, and anatomical tropism. Twenty-seven years of research in the Northern Territory has yielded 1810 S. pyogenes isolates with clinical and emm type data. The primary aim was to analyse these data with reference to the emm cluster scheme and cross opsonisation information, to inform estimation of 30mer vaccine efficacy in the Northern Territory. The isolates encompass 101 emm types. Variants of cluster A-C were enriched in throat isolates, and variants of emm cluster D enriched in skin isolates. Throat isolates were enriched for 30mer vaccine cognate emm types in comparison with skin isolates of which only 25% were vaccine emm types. While cross opsonisation data indicates potential for enhancing 30mer vaccine coverage, more than one third of skin isolates were within 38 emm types untested for cross opsonisation. Emm cluster D variants, in particular emm cluster D4, were not only all non-cognate with the vaccine, but were abundant and diverse, and less likely to be cross-opsonisation positive than other emm clusters. Long term persistence of many emm types in the study area was revealed. It was concluded that the 30mer vaccine efficacy in the Northern Territory will likely require both cross protection, and additional measures to elicit immunity against variants of emm cluster D. The bacterium Streptococcus pyogenes causes throat and skin infections. A danger from such infections is an immune response that attacks human heart tissue, leading to rheumatic heart disease, which is difficult to treat and potentially deadly. Disadvantaged populations such as the Indigenous people in remote tropical northern Australia have high burdens of S. pyogenes skin infection, and rheumatic heart disease. An effective vaccine would be a benefit, but none is approved for clinical use. We analysed data from 1810 S. pyogenes isolates from north Australia obtained over 28 years, to determine the potential of a previously described S. pyogenes vaccine candidate to be effective in this region. Only one quarter of the isolates from skin infections had a surface antigen corresponding to any one of the 30 antigen variants in the candidate vaccine. Previous work in animals indicates potential cross-protection from the vaccine against strains with mismatched antigens. However, even if this occurs in humans, protection against skin infection strains would likely remain compromised, unless there were additional components in the vaccine. Further studies on cross-protection are critical to defining the potential of this type of vaccine in populations burdened with S. pyogenes skin infections and rheumatic heart disease.
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Affiliation(s)
- Philip M. Giffard
- Menzies School of Health Research, Division of Global and Tropical Health, Darwin, Australia
- College of Health and Human Sciences, Charles Darwin University, Darwin, Australia
- * E-mail:
| | - Steven Y. C. Tong
- Menzies School of Health Research, Division of Global and Tropical Health, Darwin, Australia
- Victorian Infectious Disease Service, The Royal Melbourne Hospital, and Doherty Department University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Deborah C. Holt
- Menzies School of Health Research, Division of Global and Tropical Health, Darwin, Australia
- College of Health and Human Sciences, Charles Darwin University, Darwin, Australia
| | - Anna P. Ralph
- Menzies School of Health Research, Division of Global and Tropical Health, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Bart J. Currie
- Menzies School of Health Research, Division of Global and Tropical Health, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia
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Hand RM, Salman S, Newall N, Vine J, Page-Sharp M, Bowen AC, Gray K, Baker A, Kado J, Joseph J, Marsh J, Ramsay J, Sika-Paotonu D, Batty KT, Manning L, Carapetis J. A population pharmacokinetic study of benzathine benzylpenicillin G administration in children and adolescents with rheumatic heart disease: new insights for improved secondary prophylaxis strategies. J Antimicrob Chemother 2019; 74:1984-1991. [PMID: 30989171 PMCID: PMC6587412 DOI: 10.1093/jac/dkz076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/27/2019] [Accepted: 01/29/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Benzathine benzylpenicillin G (BPG) is recommended as secondary prophylaxis to prevent recurrence of acute rheumatic fever and subsequent rheumatic heart disease (RHD). Following intramuscular injection, BPG is hydrolysed to benzylpenicillin. Little is known of the pharmacokinetics of benzylpenicillin following BPG in populations at risk of RHD. METHODS We conducted a longitudinal pharmacokinetic study of children and adolescents receiving secondary prophylaxis throughout six monthly cycles of BPG. Dried blood spot samples were assayed with LC-MS/MS. Benzylpenicillin concentrations were analysed using non-linear mixed-effects modelling with subsequent simulations based on published BMI-for-age and weight-for-age data. RESULTS Eighteen participants contributed 256 concentrations for analysis. None had benzylpenicillin concentrations >0.02 mg/L for the full time between doses. The median duration above this target was 9.8 days for those with a lower BMI (<25 kg/m2), who also had lower weights, and 0 days for those with a higher BMI (≥25 kg/m2). Although fat-free mass was a key determinant of benzylpenicillin exposure after a standard dose of BPG, having a higher BMI influenced absorption and almost doubled (increase of 86%) the observed t½. CONCLUSIONS Few children and adolescents receiving BPG as secondary prophylaxis will achieve concentrations >0.02 mg/L for the majority of the time between injections. The discordance of this observation with reported efficacy of BPG to prevent rheumatic fever implies a major knowledge gap relating to pharmacokinetic/pharmacodynamic relationships between benzylpenicillin exposure and clinical outcomes.
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Affiliation(s)
- Robert M Hand
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Sam Salman
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Nelly Newall
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Julie Vine
- Department of Ambulatory Care, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Madhu Page-Sharp
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Asha C Bowen
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Katherine Gray
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Amy Baker
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Joseph Kado
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - John Joseph
- PathWest Laboratories, Nedlands, Perth, Western Australia, Australia
| | - Julie Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - James Ramsay
- Department of Cardiology, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Dianne Sika-Paotonu
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Dean’s Department and Department of Pathology & Molecular Medicine, Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand
- Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
| | - Kevin T Batty
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Laurens Manning
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Jonathan Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
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Abstract
INTRODUCTION Rheumatic heart disease (RHD) is a preventable chronic condition affecting the valves of the heart. RHD prevention and care programmes have historically originated in more developed countries, implemented in a targeted (or vertical) manner and evaluated using non-controlled approaches. Taking a broad view of the integration of RHD activities within the whole system is critical for health planning in low-income regions with a high burden of RHD and less robust health systems. Therefore, we propose to conduct a systematic review to assess RHD programme models in order to gain a better understanding of the extent of integration within relevant health systems. METHODS AND ANALYSIS A predefined search strategy will be used to search for relevant articles published in English from January 1990 to December 2017. Electronic databases PubMed, Scopus, Web of Science, Africa Wide, CINAHL, Cochrane Central Register of Controlled Trials, Google Scholar and Global Index Medicus will be searched, as well as reference lists of relevant articles published. A standardised data extraction form will be used to obtain information for analysis from the included studies. The quality, reliability and risk of bias of included studies will be assessed using design-specific criteria. Programme integration will be analysed according to stewardship and governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. Programme inputs, outputs and impact will also be described. ETHICS AND DISSEMINATION No ethical approval is required. Findings will be disseminated in a peer-review journal in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. PROSPERO REGISTRATION NUMBER CRD42017076307.
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Affiliation(s)
- Jessica Abrams
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - David Watkins
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Cape Town, Western Cape, South Africa
| | - Leila H Abdullahi
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
- Research, Evaluation, Analysis, Learning and Monitoring (REALM), Save the Children International, Nairobi, Kenya
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Western Cape, South Africa
| | - Liesl J Zuhlke
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
- Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
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Haynes E, Marawili M, Marika BM, Mitchell AG, Phillips J, Bessarab D, Walker R, Cook J, Ralph AP. Community-based participatory action research on rheumatic heart disease in an Australian Aboriginal homeland: Evaluation of the 'On track watch' project. Eval Program Plann 2019; 74:38-53. [PMID: 30849711 DOI: 10.1016/j.evalprogplan.2019.02.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 06/09/2023]
Abstract
Strategies to date have been ineffective in reducing high rates of rheumatic heart disease (RHD) in Australian Aboriginal people; a disease caused by streptococcal infections. A remote Aboriginal community initiated a collaboration to work towards elimination of RHD. Based in 'both-way learning' (reciprocal knowledge co-creation), the aim of this study was to co-design, implement and evaluate community-based participatory action research (CBPAR) to achieve this vision. Activities related to understanding and addressing RHD social determinants were delivered through an accredited course adapted to meet learner and project needs. Theory-driven evaluation linking CBPAR to empowerment was applied. Data collection comprised focus groups, interviews, observation, and co-development and use of measurement tools such as surveys. Data analysis utilised process indicators from national guidelines for Aboriginal health research, and outcome indicators derived from the Wallerstein framework. Findings include the importance of valuing traditional knowledges and ways of learning such as locally-meaningful metaphors to explore unfamiliar concepts; empowerment through critical thinking and community ownership of knowledge about RHD and research; providing practical guidance in implementing empowering and decolonising principles / theories. Lessons learned are applicable to next stages of the RHD elimination strategy which must include scale-up of community leadership in research agenda-setting and implementation.
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Affiliation(s)
- Emma Haynes
- University of Western Australia, Perth, Western Australia, Australia; Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia; Menzies School of Health Research, Darwin, Northern Territory, Australia; Charles Darwin University (CDU), Darwin, Northern Territory, Australia.
| | - Minitja Marawili
- Menzies School of Health Research, Darwin, Northern Territory, Australia; Charles Darwin University (CDU), Darwin, Northern Territory, Australia
| | | | - Alice G Mitchell
- Menzies School of Health Research, Darwin, Northern Territory, Australia; Charles Darwin University (CDU), Darwin, Northern Territory, Australia
| | - Jodi Phillips
- Menzies School of Health Research, Darwin, Northern Territory, Australia; Charles Darwin University (CDU), Darwin, Northern Territory, Australia
| | - Dawn Bessarab
- University of Western Australia, Perth, Western Australia, Australia
| | - Roz Walker
- University of Western Australia, Perth, Western Australia, Australia; Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Jeff Cook
- Laynhapuy Homelands Health Service, Yirrkala, Northern Territory, Australia
| | - Anna P Ralph
- Menzies School of Health Research, Darwin, Northern Territory, Australia; Charles Darwin University (CDU), Darwin, Northern Territory, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Abdullahi LH, Smit I, Engel ME, Watkins DA, Zühlke LJ. Task Sharing in the Diagnosis, Prevention, and Management of Rheumatic Heart Disease: A Systematic Review. Glob Heart 2019; 14:259-264. [PMID: 31103400 DOI: 10.1016/j.gheart.2019.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/03/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Globally, rheumatic heart disease (RHD) is a major contributor to the burden of cardiovascular disease. Major gaps in RHD prevention and treatment have been documented at all levels of health systems in low- and middle-income countries. Task sharing is an approach that could prove effective in remediating bottlenecks in RHD-related care. OBJECTIVES This study conducted a systematic review to assess the state of the evidence for the use of task sharing in the diagnosis, prevention, and management of RHD. METHODS Guided by a previously published protocol, we searched various databases using a systematic search strategy including MeSH and free-text terms for (1) group A streptococcus, acute rheumatic fever, and RHD and (2) strategies of task sharing in limited-resource settings. Two investigators independently screened the search outputs, selected the studies, extracted the data, and assessed the risk of bias, resolving discrepancies by discussion and consensus. RESULTS The publications search yielded 212 records, of which 18 articles were deemed as potentially eligible for inclusion. None of the studies, however, met with the inclusion criteria. CONCLUSIONS There is a lack of evidence for the use of task-sharing approaches in scaling up RHD prevention and treatment services in limited-resource settings. Considering the persistent burden of group A streptococcus, acute rheumatic fever, and RHD in low- and middle-income countries, this work highlights the urgent need to develop and test models of RHD-related care utilizing an evidence-based approach to task sharing. [Task Sharing in the Diagnosis, Prevention, and Management of Rheumatic Heart Disease: A Systematic Review; CRD42017072989].
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Affiliation(s)
- Leila Hussein Abdullahi
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Save the Children International, Somalia/Somaliland Country Office, Nairobi, Kenya
| | - Inge Smit
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mark Emmanuel Engel
- Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - David Alan Watkins
- Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Liesl Joanna Zühlke
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Save the Children International, Somalia/Somaliland Country Office, Nairobi, Kenya.
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Barik R. Secondary prophylaxis to control rheumatic heart disease in developing countries: Put into a cage if can't be killed. Indian Heart J 2018; 70:907-910. [PMID: 30580864 PMCID: PMC6306397 DOI: 10.1016/j.ihj.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/25/2017] [Accepted: 01/08/2018] [Indexed: 01/17/2023] Open
Abstract
A significant socioeconomic inequality is the main barrier to achieve primordial prevention of rheumatic heart disease (RHD) in the developing countries. An effective vaccine with affordable cost against Streptococcus yet to be identified. The subclinical nature of rheumatic fever (RF) is the main hurdle for effective primary prevention of RHD. When RF and RHD are recognized at the earliest, treated adequately and SP with penicillin is strictly followed, then this disease can be kept under control though cannot be eradicated.
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Read C, Mitchell AG, de Dassel JL, Scrine C, Hendrickx D, Bailie RS, Johnston V, Maguire GP, Schultz R, Carapetis JR, Ralph AP. Qualitative Evaluation of a Complex Intervention to Improve Rheumatic Heart Disease Secondary Prophylaxis. J Am Heart Assoc 2018; 7:e009376. [PMID: 30018166 PMCID: PMC6064865 DOI: 10.1161/jaha.118.009376] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/14/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rheumatic heart disease is a high-burden condition in Australian Aboriginal communities. We evaluated a stepped-wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prophylaxis for rheumatic heart disease. The trial did not improve penicillin adherence. This mixed-methods evaluation, designed a priori, aimed to determine the association between methodological approaches and outcomes. METHODS AND RESULTS An evaluation framework was developed to measure the success of project implementation and of the underlying program theory. The program theory posited that penicillin delivery would be improved through activities implemented at clinics that addressed elements of the chronic care model. Qualitative data were derived from interviews with health-center staff, informants, and clients; participant observation; and project officer reports. Quantitative data comprised numbers and types of "action items," which were developed by participating clinic staff with project officers to improve delivery of penicillin injections. Interview data from 121 health-center staff, 22 informants, and 72 clients revealed barriers to achieving the trial's aims, including project-level factors (short trial duration), implementation factors (types of activities implemented), and contextual factors (high staff turnover and the complex sociocultural environment). Insufficient actions were implemented addressing "self-management support" and "community linkage" streams of the chronic care model. Increased momentum was evident in later stages of the study. CONCLUSIONS The program theory underpinning the study was sound. The limited impact made by the study on adherence was attributable to complex implementation challenges.
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Affiliation(s)
- Clancy Read
- Telethon Kids Institute, University of Western Australia, Western Australia, Australia
| | | | | | - Clair Scrine
- Telethon Kids Institute, University of Western Australia, Western Australia, Australia
| | - David Hendrickx
- Telethon Kids Institute, University of Western Australia, Western Australia, Australia
| | - Ross S Bailie
- University of Sydney University Centre for Rural Health, Lismore, New South Wales, Australia
| | - Vanessa Johnston
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Graeme P Maguire
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Rosalie Schultz
- Centre For Remote Health, Alice Springs, Northern Territory, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia, Western Australia, Australia
- Perth Children's Hospital, Perth, Western Australia, Australia
| | - Anna P Ralph
- Charles Darwin University, Darwin, Northern Territory, Australia
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Abstract
Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes. Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Luiza Guilherme
- Heart Institute (InCor), University of São Paulo, Institute for Investigation in Immunology, National Institute of Science and Technology, São Paulo, Brazil
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Coffey PM, Ralph AP, Krause VL. The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: A systematic review. PLoS Negl Trop Dis 2018; 12:e0006577. [PMID: 29897915 PMCID: PMC6016946 DOI: 10.1371/journal.pntd.0006577] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 06/25/2018] [Accepted: 06/03/2018] [Indexed: 02/08/2023] Open
Abstract
Background Rheumatic heart disease (RHD) poses a major disease burden among disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These conditions are acknowledged as diseases of poverty, however the role of specific social and environmental factors in GAS infection and progression to ARF/RHD is not well understood. The aim of this systematic review was to determine the association between social determinants of health and GAS infection, ARF and RHD, and the effect of interventions targeting these. Methodology We conducted a systematic literature review using PubMed, the Cochrane Library and Embase. Observational and experimental studies that measured: crowding, dwelling characteristics, education, employment, income, nutrition, or socioeconomic status and the relationship with GAS infection, ARF or RHD were included. Findings for each factor were assessed against the Bradford Hill criteria for evidence of causation. Study quality was assessed using a standardised tool. Principle findings 1,164 publications were identified. 90 met inclusion criteria, comprising 91 individual studies. 49 (50.5%) were poor quality in relation to the specific study question. The proportion of studies reporting significant associations between socioeconomic determinants and risk of GAS infection was 57.1%, and with ARF/RHD was 50%. Crowding was the most assessed factor (14 studies with GAS infection, 36 studies with ARF/RHD) followed by socioeconomic status (6 and 36 respectively). The majority of studies assessing crowding, dwelling characteristics, education and employment status of parents or cases, and nutrition, reported a positive association with risk of GAS infection, ARF or RHD. Crowding and socioeconomic status satisfactorily met the criteria of a causal association. There was substantial heterogeneity across all key study aspects. Conclusion The extensive literature examining the role of social determinants in GAS infection, ARF and RHD risk lacks quality. Most were observational, not interventional. Crowding as a cause of GAS infection and ARF/RHD presents a practical target for prevention actions. Rates of rheumatic heart disease (RHD) are high in disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These are described as diseases of poverty, but exactly what components of poverty promote them has been unclear. The aim of this review was to find what specific social and environmental factors are associated with GAS infection, ARF and RHD, and if actions targeting these can reduce disease rates. We did a search of published literature and found 90 relevant articles. Many supported an association between GAS infection, ARF or RHD and crowding, dwelling characteristics, low education level and employment status, poor nutrition and low social class. There was enough evidence to show that crowding and socioeconomic disadvantage increase the risk of GAS infection and ARF/RHD. However, most studies were of fair to poor quality in their ability to answer the research question, and there was little interventional research. This may relate to challenges inherent in intervening to change social determinants of health, but may also suggest lesser research attention to health issues affecting disadvantaged populations. The association between crowding and disease risk strongly supports initiatives to reduce crowding. This should become a key target for ARF and RHD prevention.
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Affiliation(s)
- Pasqualina M. Coffey
- Centre for Disease Control, Department of Health, Darwin, Northern Territory, Australia
- * E-mail:
| | - Anna P. Ralph
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Vicki L. Krause
- Centre for Disease Control, Department of Health, Darwin, Northern Territory, Australia
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Abstract
INTRODUCTION Rheumatic heart disease (RHD) remains an important cause of cardiovascular morbidity and mortality globally due to weak health systems in many countries. RHD can be effectively prevented and managed; however, RHD-related interventions have not been widely adopted in countries with severe human resource constraints. Task sharing is a recognised approach to personnel shortages that could prove effective for RHD and has, anecdotally, been attempted in a few settings. We propose a systematic review and meta-analysis protocol to assess models that use non-physician workers to expand access to, and quality of, RHD-related healthcare. METHODS We will include randomised controlled trials (RCT), cluster RCTs, quasi-experimental and controlled before and after studies providing information on the effectiveness of non-physician workers in providing care for streptoccocal pharyngitis, rheumatic fever and RHD. We will search relevant electronic databases and grey literature using medical subject headings. Standardised data extraction forms will be used to collect effect sizes that will be pooled in random-effects models. We will also conduct subgroup analyses and note other important quantitative findings, such as cost reduction, and qualitative findings, such as patient satisfaction. We will also assess study quality and risk of bias and metabias. ETHICS AND DISSEMINATION Ethics approval is not required for this systematic review of previously published literature. The results of the systematic review will be broadly disseminated via conference presentations, multidisciplinary workshops and peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42017072989.
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Affiliation(s)
- Leila Hussein Abdullahi
- Save the Children International (SCI), Somalia/Somaliland Country Office, Nairobi, Kenya
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Inge Smit
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - David A Watkins
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Liesl Joanna Zühlke
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Groote Schuur Hospital, Cape Town, South Africa
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Chebrolu P, Jain P. Letter from Ganiyari. Natl Med J India 2018; 31:51-52. [PMID: 30348929 DOI: 10.4103/0970-258x.243420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Puja Chebrolu
- Jan Swasthya Sahyog Ganiyari Chhattisgarh and Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Priyank Jain
- Jan Swasthya Sahyog Ganiyari Chhattisgarh and Internal Medicine Cambridge Health Alliance, Cambridge, MA, USA
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Katzenellenbogen JM, Ralph AP, Wyber R, Carapetis JR. Rheumatic heart disease: infectious disease origin, chronic care approach. BMC Health Serv Res 2017; 17:793. [PMID: 29187184 PMCID: PMC5708129 DOI: 10.1186/s12913-017-2747-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/20/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. METHODS AND RESULTS In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs. CONCLUSION Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.
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Affiliation(s)
- Judith M Katzenellenbogen
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia.
- School of Population and Global Health, The University of Western Australia, Perth, Western, Australia.
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Rosemary Wyber
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia
- Princess Margaret Hospital for Children, Perth, Western, Australia
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50
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Affiliation(s)
- Magdi Yacoub
- Aswan Heart Centre, Aswan, Egypt; Heart Science Centre, Harefield, London UB9 6JH, UK.
| | - Bongani Mayosi
- The Deanery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ahmed ElGuindy
- Aswan Heart Centre, Aswan, Egypt; Heart Science Centre, Harefield, London UB9 6JH, UK
| | - Alain Carpentier
- Département de Chirurgie Cardio-Vasculaire et de Transplantation d'Organes, Hôpital Européen Georges Pompidou, Paris, France
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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