Lessons to be learned: Using National Immunisation strategies to improve adherence to acute rheumatic fever secondary prophylaxis

Abstract

Rheumatic heart disease, as a result of a single or recurrent episode of acute rheumatic fever (ARF), remains a significant cause of morbidity and mortality in northern and remote Australia; ARF has a peak incidence among 5-14-year-old Aboriginal and Torres Strait Islander children. Long-term regular benzathine penicillin G injections are the only currently successful secondary prevention strategy; however, rates of adherence remain critically low. In contrast, rates of adherence to immunisations on the National Immunisation Program (NIP) Schedule are high, even among this target population. This article compares strategies used to implement and improve ARF secondary prophylaxis with those used in the NIP. Some successful NIP strategies, such as Service Incentive Payment for health providers, home-visiting delivery models and integration into the National Immunisation Register, if applied to ARF secondary prophylaxis have the potential to improve benzathine penicillin G adherence.

Adherence to secondary prevention of rheumatic fever and rheumatic heart disease in young people: an 11‐year retrospective study

“…Some patients had unknown cessation of active care after 15 years. It is unknown what proportion were: a) transfers out of Townsville that were not notified to the register; b) never recommenced BPG after transfer; or c) lost to‐follow‐up during step‐down from paediatric outreach/school programs to community services in Townsville 6,19 . Deterioration of health outcomes during the transition period from paediatric to adult services is seen in many chronic diseases 20 .…”

“…The Queensland RHD register relies on the completeness of the database and may have recall bias by clinicians and underreporting 6 . The inability to detect or track patients that are not receiving care is a long‐standing issue of many state registers in Australia 19 . TUH medical records were used to supplement register data, however, cross‐validation of all providers was beyond the resources available for this study.…”

“…It is unknown what proportion were: a) transfers out of Townsville that were not notified to the register; b) never recommenced BPG after transfer; or c) lost tofollow-up during step-down from paediatric outreach/school programs to community services in Townsville. 6,19 Deterioration of health outcomes during the transition period from paediatric to adult services is seen in many chronic diseases. 20 Continuity of care in adolescents and young adults (15-24 years) is essential in RHD, as most morbidity and mortality from RHD occurs in adult life.…”

“…6 The inability to detect or track patients that are not receiving care is a long-standing issue of many state registers in Australia. 19 TUH medical records were used to supplement register data, however, cross-validation of all providers was beyond the resources available for this study. Internal processes are routinely used by the register to detect unregistered individuals with RHD.…”

Paths to improved rheumatic heart disease: screening and prophylaxis

“…Moreover, they recommended an increased focus on home visits as a method of service delivery, particularly in areas of poor health literacy. 2 In the coming years, the efficacy of secondary prophylaxis using benzathine penicillin G will be evaluated by Beaton et al in the GOAL trial; a randomised controlled trial currently being undertaken in Northern Uganda on a sample of 916 children between 5 and 7 years old confirmed to have borderline rheumatic heart disease or mild definite rheumatic heart disease. The trial takes place between 2018 and 2021 with the objective of determining if secondary prophylaxis with every-4-week injectable benzathine penicillin G improves outcomes for children diagnosed with latent rheumatic heart disease.…”