Rheumatic Fever & Rheumatic Heart Disease in New Zealand Joel Burnett

New Zealand Island nation of ~ 4.5 million people First settled by Polynesians, from which Maori culture emerged Later a British colony Known for spectacular landscapes Map credit: http://www.worldatlas.com/webimage/countrys/oceania/lgcolor/nzcolor.htm

Auckland & The City Hospital New Zealand’s largest city, with a population of ~ 1.5 million Cultural hub of the country Auckland City Hospital (ACH) is New Zealand’s largest public hospital and clinical research facility Major referral center and teaching hospital Photo credit: http://careers.adhb.govt.nz/JobSearch/CommunityLong TermConditionsDirectorate/tabid/133/Default.aspx

http://www. nzherald. co. nz/nz/news/article. cfm http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11743776

Topic of Interest: Rheumatic Fever & Heart Disease Newspaper headlines addressing Rheumatic Fever in New Zealand caught my attention in the months prior to departure Rates of Rheumatic Fever in New Zealand are among the highest in the developed world Having undertaken an elective in Cardiology at Auckland City Hospital, I was interested in Rheumatic Fever and its most deadly sequela, Rheumatic Heart Disease

Rheumatic Fever Acute Rheumatic Fever is caused by an autoimmune response to Group A Strep pharyngitis Manifestations of disease include arthralgia, fever and other markers of acute inflammation, rash, subcutaneous nodules, chorea and, when involving the heart, new murmurs and heart failure Diagnosis is made of clinical grounds with reference to the Jones criteria; treatment includes symptom management, antibiotics for GAS eradication and, if necessary, heart failure management

Rheumatic Heart Disease Acute Rheumatic Fever can cause pancarditis; recurrent cases may lead to progressive chronic heart disease Valvulitis is common and most frequently involves the mitral valve, though other valves may be involved Treatment for mild cases is limited to secondary prophylaxis of Rheumatic Fever while severe cases may require valve surgery in addition to secondary prophylaxis

Rheumatic Fever in New Zealand Despite near-eradication of Rheumatic Fever in developed countries, rates in New Zealand have remained stable at about 200 cases per year since 1980 (15 per 100,000) Incidence corresponds with ethnicity and SES Between 1993-2009, rates of Rheumatic Fever increased by 79% and 73% for Maori and Pacific children, whereas rates for non-Maori and non-Pacific children fell by 71% 70% of school-aged cases of Rheumatic Fever occurred in the most deprived quintile

Rheumatic Heart Disease in New Zealand A recent study 74% of the 225 women undergoing valve replacement surgery in an Auckland registry were Maori or Pacific Island women with Rheumatic Heart Disease Between 1992-1996 there were 127 deaths per year as a result of Rheumatic Heart Disease in New Zealand In 2005 and 2006 there were 175 and 186 deaths, respectively, as a result of Rheumatic Heart Disease

Prevention Efforts Primary prevention strategies include efforts to improve access to timely sore throat treatment reduce household overcrowding raise public awareness Secondary prevention includes Community registries Monthly IM penicillin Photo credit: http://www.arphs.govt.nz/healthinformation/ communicable-disease/acute-rheumatic-fever-and-sore-throats

Photo credit: http://www. hpa. org

Summary Rheumatic Fever is a rare complication of Group A Strep pharyngitis and can be prevented with prompt and appropriate treatment with antibiotics Rheumatic heart disease, a deadly sequela of Rheumatic Fever, most frequently manifests as disease of the mitral valve Unlike most industrial nations, rates of Rheumatic Fever in New Zealand have remained stable at about 200 cases per year since 1980 (15 per 100,000) Prevention strategies include efforts to reduce overcrowding, increase access to sore throat treatment, and raise awareness

Clinical Experience Murmur auscultation on the cardiology wards was exciting and memorable Many patients, including some with Rheumatic Heart Disease, awaited valve surgery on the wards and had interesting murmurs Learning from master clinicians to distinguish murmurs from one another was a profound experience

Cultural Experience New Zealand is known as a playground for outdoor sports and adventure Completing the Tongariro Alpine Crossing, a 12 mile trek, was a cultural highlight Tongariro National park is a World Heritage site

References Marijon, Eloi et al. “Rheumatic Heart Disease.” The Lancet 379 (2012) 953-64. Milne, Richard et al. “Incidence of acute rheumatic fever in New Zealand children and youth.” Journal of Paediatrics and Child Health 48 (2012) 685-691. Wilson, Nigel. “Rheumatic Heart Disease in Indigenous Populations – New Zealand Experience.” Heart, Lung, and Circulation 19 (2010) 282- 288.