The RHD Endgame Strategy; the blueprint to eliminate rheumatic heart disease in Australia by 2031

Abstract

Background Rheumatic heart disease (RHD) is a preventable yet deadly condition resulting from untreated Group A Streptococcus infection. Despite being eliminated from most high-income countries, RHD and its precursor acute rheumatic fever (ARF) persist in developing countries and settings of disadvantage. In Australia, Aboriginal and Torres Strait Islander people experience among the world's highest rates. Following five years of research, investigation and advocacy, the Endgame Strategy provides a technical foundation to eliminate RHD in Australia by 2031. Methods A range of potential strategies to reduce ARF and RHD were identified. Approaches at the social and environmental, primary, secondary and tertiary prevention levels were evaluated using the GRADE Evidence to Decision framework, together with structural review of the health system. Recommendations were made according to level of prevention opportunity and responsibility. Modelling was undertaken to estimate the health and economic impact of an indicative bundle of the most promising strategies. Results Reducing household crowding, improving health infrastructure, strengthening primary healthcare and enhancing delivery of secondary prophylaxis were identified as having the greatest potential impact on RHD. They are also largely acceptable, practical and readily implementable with investment. Modelling indicates that this approach would reduce ARF and RHD by 69% and 71% respectively, preventing 471 deaths and saving $188 million on healthcare expenditure to 2031. Conclusions Eliminating RHD is only possible with a holistic approach led by Aboriginal and Torres Strait Islander people with communities at the core. This will entail funding communities to develop programs, resourcing a national RHD unit to coordinate efforts across Australia, guaranteeing access to healthy housing and built environments, establishing comprehensive skin and throat programs and improving the health of those living with ARF and RHD. Key messages RHD demands responses from the health sector strengthened by political advocacy and engagement to drive evidence-based decision making. The evidence and collective experience now exist to eliminate RHD, an exemplar of the gap in health outcomes between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population.

Ending rheumatic heart disease in Australia: the evidence for a new approach

“…The burden of comorbid disease for Aboriginal and Torres Strait Islander people with RHD is high 10. Of the 3379 Aboriginal and Torres Strait Islander people aged < 55 years with RHD, 20% had previously been admitted to hospital for diabetes or chronic kidney disease.…”

“…In adulthood, the burden of comorbid ischaemic heart disease increases with at least 449 people (13%) having both RHD and ischaemic heart disease. A history of alcohol‐related admissions (including for conditions caused by alcohol) was also common (959 people, 28%), and was highest in the 40–54 years age‐group 10. More than a quarter (25.8%) of Aboriginal and Torres Strait Islander people aged 15–24 years with RHD had a history of smoking, with markedly higher smoking rates in those aged 25–54 years (65.8%) 10.…”

“…A history of alcohol‐related admissions (including for conditions caused by alcohol) was also common (959 people, 28%), and was highest in the 40–54 years age‐group 10. More than a quarter (25.8%) of Aboriginal and Torres Strait Islander people aged 15–24 years with RHD had a history of smoking, with markedly higher smoking rates in those aged 25–54 years (65.8%) 10. Preventing complications and supporting people living with RHD and other diseases requires a robust, responsive health system.…”

“…The End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE) received funding from the National Health and Medical Research Council in 2014 to develop an “endgame” for RHD in Australia. In the resulting publication — The RHD Endgame Strategy: the blueprint to eliminate rheumatic heart disease in Australia by 2031 (the Endgame Strategy) — we outlined a comprehensive list of potential strategies for reducing the incidence of RHD, evaluated them according to an evidence framework, and synthesised considerations for communities and decision makers 10. The focus is on preventing new cases of ARF and RHD, so the Endgame Strategy is weighted towards approaches which act early in the causal pathway from Strep A exposure to ARF.…”

“…Priority has also been given to implementable actions, focusing on what can be done now, with existing knowledge, to end RHD. This supplement is based on the Endgame Strategy, which included references identified in literature reviews conducted until November 2019 10. A small number of additional references, published up until 1 July 2020, are included in this supplement.…”