Health Equity and Rheumatic Heart Disease

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1 Health Equity and Rheumatic Heart Disease Reducing Rheumatic Fever in New Zealand Dr Mark Jacobs Director of Public Health New Zealand Ministry of Health

2 Rheumatic fever in New Zealand New Zealand has a history of high and increasing rates of rheumatic fever Around 180 new cases of acute rheumatic fever a year in NZ (4.2 cases per 100,000 population per year) Around 550 hospitalisations and 140 deaths for rheumatic heart disease a year Around 1,500 children and young people on regular antibiotic prophylaxis Burden is not evenly distributed- over 90% of rheumatic fever cases occur in Māori and Pacific children (approx 36% of 0-14 population)

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4 In New Zealand most rheumatic fever occurs in the North Island

5 Mostly a disease of relative deprivation 12 Annual Rheumatic fever admission rates by household crowding, NZDep2001, and income quintiles, 1996 to Rate per 100, Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile Household crowding NZDep2001 Household income Explanatory variable quintiles Data Source: Jaine R. Pediatr Infect Dis J 2011; 30(4):

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7 Reducing rheumatic fever now a major national priority in NZ The NZ Government has established a series of Better Public Services targets. Target areas chosen because they are important issues, which require action across government to address BPS gives focus and mandate for government agencies to work more closely together to get better value for money and results - cross sector and cross agency BPS goal to reduce the incidence of rheumatic fever by two thirds to 1.4 cases per 100,000 people per year by June 2017 Government has also added $45 million of central funding through the Ministry of Health over the last 3 years for addressing rheumatic fever, to add to other actions through District Health Boards, primary care, community organisations.

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9 Reducing rheumatic fever is complex Action is needed across all levels of the rheumatic fever pathway: Primordial (prevention of GAS throat infections) Primary prevention (treatment of GAS throat infections) Secondary prevention (antibiotic prophylaxis) Requires concerted effort involving the Ministry of Health, other government agencies, District Health Boards, primary health care services, public health services, professional bodies and the community. Key elements include: Improving early diagnosis and treatment of GAS throat infections Addressing some underlying determinants of close contact infectious diseases, especially housing conditions Raising awareness, including targeted home visiting and information campaigns Clinical tools for health practitioners Research (eg echocardiography, vaccine)

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11 Diagnosis and treatment of GAS throat infections Around $30 million of the total $45 million programme (though not all implemented yet) School-based clinics set up in areas with the highest incidence of rheumatic fever, and in particular schools located in areas of high deprivation with large enrolment of Māori and/or Pacific children By June 2013 approx 50,000 children covered by throat swabbing services Also now planned to create sore throat drop-in clinics outside schools. This nurse-led service will reach high-risk families whose children don t attend schools with throat swabbing services or when it s out of school term. Free clinics will be based in general practices and other community settings All in addition to mainstream primary care services

12 Improving housing quality Good evidence that household crowding increases the risk of close contact infectious diseases, including streptococcal infections However, less evidence on what works to improve crowding and that it will actually reduce rates of rheumatic fever Part of the problem is functional crowding where members of the household crowd into one or two areas of that house that can be more easily heated during cold seasons Part of solution is to continue to improve insulation of older NZ houses New funding of $3.75 million over four years towards healthy homes referral and advice service in Auckland (NZ s largest city). Requires collaborative effort of central and local health, housing and welfare agencies.

13 Programme challenges Sustainability of services and programme once central funding runs out (time limited extra funding) Getting community messages right (not same message for all) Reaching all at risk children and young people. Have prioritised those at most risk. Tackling the root causes crowding, poor housing, fuel poverty 45,000 children under 15yrs live in severely crowded houses in NZ Improving private housing stock Housing interventions that will be effective and not cause more harm

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