1. Mana Kidz Rheumatic Fever Prevention:
Tracy McKee

7. 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

8. 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 % will develop a first attack of ARF.
However the risk of a recurrence of ARF with subsequent GAS reinfection is 25-75%,

9. 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”

10. …… 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.

11. …From sore throat to damaged heart

13. 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

14. 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)

15. 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

16. 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

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

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

20. 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

21. 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

22. 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.

23. 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.

24. 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

25. 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
Differential Diagnosis?
Tonsillitis (Bacterial Pharangitis)
Viral Pharangitis
Infectious mononucleosis
Quinsy
Epiglottitis

27. 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

28. All children have the best start in life