Mana Kidz Rheumatic Fever Prevention: Tracy McKee

http://opendoor.net.nz/watch/series-12 http://www.youtube.com/watch?v=rqCOHGAR0q8

Group A Streptococcus Causes broad spectrum of disease ARF, Glomerulonephritis and RHD - post-strep complications MoH funding $1.377mil for 17 months to 30 June 2013 Throat swabbing & household contacts only 18 schools in Otara Funding for out-years & other localities in discussion CMDHB contribution $750k to 30 June 2013 Additional RF Prevention activity Provider contributions, philanthropy, or other financial support is being sought

Disease Progression Incubation period – 3 – 7 days Infectious period – 24 hrs post a/b’s or 2/52 GAS ARF – 0.3 – 3% GAS Recurrence of ARF - 25 – 75% Further recurrent attacks = higher risk of cardiac damage The incubation period for streptococcal pharyngitis is 3-7 days. Pharyngeal GAS is infectious until 24 hours after start of effective antibiotics. ARF and RHD are not infectious. GAS is particularly infectious during the acute illness and for the 2 weeks after it has been acquired, whereas the carrier state is less infectious. Of those with untreated pharyngeal GAS colonisation or exudative GAS pharyngitis 0.3 -3% will develop a first attack of ARF. However the risk of a recurrence of ARF with subsequent GAS reinfection is 25-75%,

From sore throat to damaged heart… Environment (overcrowding, poor nutrition, poor hygiene, young children lots of Strep A). Some specific genes (“HLA haplotypes”) make some people more susceptible to autoimmune disease. Some Strep A more “rheumatogenic”

…… Some people react to some Strep A abnormally. Antibodies react against heart tissue ‘molecular mimicry’. So rheumatic fever results from the body’s immune system reacting against it’s own tissue - rather than just against Strep.

…From sore throat to damaged heart

Affects Tissues in the: Brain : chorea Joints : arthritis Heart : inflamed/damaged valves Skin : erythema marginatum (rash) and subcutaneous nodules (lumps under the skin) Fever MoH funding $1.377mil for 17 months to 30 June 2013 Throat swabbing & household contacts only 18 schools in Otara Funding for out-years & other localities in discussion CMDHB contribution $750k to 30 June 2013 Additional RF Prevention activity Provider contributions, philanthropy, or other financial support is being sought

Diagnosis of Acute Rheumatic Fever 2 major or 1 major + 2 minor “Jones criteria”, plus evidence of a preceding Strep A infection. Major Criteria Arthritis (most common symptom) –inflamed joints Carditis (heart inflammation) >>valves Chorea (jerky movements) Subcutaneous nodules (rare) Erythema marginatum (skin rash) Minor Criteria Arthralgia (joint aches), fever, elevated acute phase reactants, prolonged PR interval (change on ECG)

Better Public Services Target Reduce the incidence of first episodes of acute rheumatic fever by two thirds From 4.2 per 100,000 (2010/11) to 1.4 per 100,000 by June 2017 Reduction in the total population hospital admission rate http://www.health.govt.nz/about-ministry/our-priorities/better-public-services

Prevention Primordial Prevention GAS Tertiary Prevention Primary Prevention Secondary Prevention Tertiary Prevention GAS ARF RHD It’s a grim picture but working in community/GP at the coal face, we have the best opportunity to make an impact on rates in all areas of prevention. Primordial Prevention: e.g. overcrowding, higher standards of living, better access to health care etc Primary Prevention: most importantly sore throat management and treatment for our at risk populations, vaccine. Education Secondary Prevention: Bicillin, oral hygiene – Echocardiography screening Tertiary Prevention: Warfarin, surgery, long term heart medications Where do you work? What can you do? Cardiac Surgery Stroke Death

Access to Primary Healthcare Baltimore Study 1960s Improving access to healthcare reduced ARF Gordis L NEJM 1973;289(7):331-335

ANY Maori or Pacific child/young person in South Auckland is at high risk and needs a throat swab, with antibiotics asap.

Free comprehensive school based nurse led health service for 5-14 year olds in identified schools – 1 team per school – avoid multiple health providers five days a week in schools with rheumatic fever prevention, skin assessments as well as school health referrals A dedicated school based nurse and whānau support worker allocated to each school Highly skilled and competent school based workforce with nurses working under standing orders Addressing wider determinants of health related to reduction of the incidence of rheumatic fever e.g. housing

RN WSW Free comprehensive health service Dedicated health team 5-14 year olds Five days per week Free assessment and treatment of GAS+ sore throats, skin infections and school health referrals Free comprehensive school based nurse led health service for 5-14 year olds in identified schools – 1 team per school – avoid multiple health providers five days a week in schools with rheumatic fever prevention, skin assessments as well as school health referrals A dedicated school based nurse and whānau support worker allocated to each school Highly skilled and competent school based workforce with nurses working under standing orders Addressing wider determinants of health related to reduction of the incidence of rheumatic fever e.g. housing

15 19 8 Identified schools - criteria 3 localities Currently agreed funding for 53 schools. More than 23k children of the districts high risk children covered in these low-decile schools. CMDHB is currently exploring options for providing RFP to the 8 schools in papakura.

Union Health Otara Mana Kidz involves a number of providers. NHC contracts with primary care providers, community health providers or Kidz First PHN to provide the service within the school. We currently have eight providers working across the 53 schools. Utilising multiple providers with different organisational knowledge has proved difficult. Time-consuming liaising with multiple providers through contracting, recruitment, training and implementation phases. Each provider brings its own strengths and knowledge to the programme. Differing experience working in school environments. Managing indepedent teams. The project was originally scheduled to have the first 18 clinics underway by June 2013 which would have allowed a slow and steady rollout. However, Ministry requirements changed which meant that this schedule was condensed dramatically. Fast-tracking the project meant condensing planning, training, contracting and school engagement and allowed less focus on communications activity, health promotion and primary care engagement. For example, One of the key challenges is the pressure on the teams in the schools. The workload is immense and exceeds the allocated FTE in many schools. The pressure on teams has been significant. Increased support in schools with the secondment of two nurse educators. We’ve also looked at ways of improving efficiencies e.g. reducing admin tasks. Currently each of the providers used their preferred IT system which has resulted in a number of different systems. This means that teams are treating in isolation with little ability to share information (discharge summaries current communication with primary care). Lack of a fit-for-purpose system, means that that processes and systems need to be adapted within each clinic (not always efficient), Workforce development – differing needs All providers are making contributions to the programme – all see value in the approach and are committed to making it work.

Sore throat clinics MOH ‘rapid response’ initiative High risk children and young people (4-19 yo: M, P, Q5) Sore throat clinics offering free assessment and treatment Primary care: 30 clinics (600+ ‘high risk’) Secondary schools: 19 clinics (decile 1) Free to ALL 4-19 year olds (incl. casual patients) Nurse-led utilising standing orders Free treatment via PSO Follows the evidence based clinical protocol Fit-for-purpose electronic forms Total ‘high risk’ 65,424 Mana Kidz 23,424 STC Secondary schools 18,578 STC Primary care 32,820

Standing Order for Sore Throat Clinics for the treatment of Group A  Streptococcal throat infection in Primary Care Programme  Increased access to certain antibiotics for the Rheumatic Fever Prevention Programme approved http://www.goodfellowclub.org/case/primary‐prevention‐rheumatic‐feverchildren‐ within‐primary‐health‐care‐setting  Differential Diagnosis? Tonsillitis (Bacterial Pharangitis) Viral Pharangitis Infectious mononucleosis Quinsy Epiglottitis

Rheumatic Heart Disease casts a long shadow… Maori & Pacific child rates: 23 & 45 times > European Maori & Pacific communities carry the burden 60% of ARF cases develop RHD - lifelong management 145 deaths/yr (twice as many as cervical cancer) in NZ Causes death amongst younger adults Mortality rate 7.5x higher for Maori

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