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Rheumatic fever in Aboriginal children

In this issue, Steer et al . review the role of environmental factors in rheumatic heart disease. 1 While low socio-economic status is a marker of regions where rheumatic fever and rheumatic heart disease remain common, the specific contributions of overcrowding, urbanization, nutrition and access to medical services have been difficult to assess. It is notable that rheumatic fever and rheumatic heart disease continue to be important causes of morbidity and mortality in the Indigenous population of central and northern Australia, as well as in Maori and Pacific Islanders in New Zealand, despite access to high-quality health services. In contrast, rheumatic fever is now extremely rare in non-Indigenous children throughout Australia. The rates of acute rheumatic fever (ARF) in Aboriginal children in the Top End of the Northern Territory are among the highest ever recorded, and current enhanced surveillance in central Australia is showing similar rates. In remote Aboriginal communities in the Northern Territory, 1–3% of the population has established rheumatic heart disease, usually as a result of cumulative valve damage from episodes of recurrent rheumatic fever. While rheumatic fever is thought to occur only in a subset of the population, this apparent immunological predisposition, which may be genetically based, is not restricted to any specific ethnic group. Rheumatic fever was commonly seen in the non-Aboriginal paediatric population in all Australian urban centres in the first half of last century. The current continuing high rates of rheumatic fever in Aboriginal children parallel overcrowding and poor living conditions, with very high levels of exposure to group A streptococci. The World Health Organization has recommended the use of rheumatic fever registers, primarily to co-ordinate individual patient management and improve availability of and adherence to secondary prophylaxis for the prevention of recurrent rheumatic fever. 2 In a retrospective review from the Top End of the Northern Territory, there were 555 episodes of ARF in 367 people, of which 543 were episodes in 355 Aboriginal patients, nearly all from remote communities. 3 None of the 12 nonAboriginal patients had a relapse, whereas 39.2% of the episodes in Aboriginal patients were recurrent ARF among 107 individuals with previously diagnosed rheumatic fever or rheumatic heart disease. All of these recurrences are a failure of availability of, or compliance with, secondary prophylaxis with penicillin. These data resulted in the establishment of a Rheumatic Fever Register and Programme for the Top End in November 1997. The proportion of ARF notifications that were recurrent ARF decreased to 28% in 1998 and 16% in 1999, suggesting benefits from the emphasis on secondary prophylaxis protocols. 4