Disease Control

In addition to these aims, control programs quite importantly monitor health outcomes among communities and produce epidemiological reports that help improve activities for the delivery of long-term secondary prophylaxis.

RHD is currently regarded as a notifiable condition in WA, NT and QLD, which means that doctors are required by law to report cases of ARF to the Department of Health [3]. Maintaining such registers of people with RHD or with a history of ARF is a key element of RHD control at individual, community and national levels [6]. In tackling RHD, WHO recommends centralised, register-based control programs in which the priorities are improved patient care and the delivery of secondary prophylaxis in order to reduce hospitalisations [2]. Register-based programs also provide a mechanism for monitoring patient movements, orientating staff to a patient's care requirements (for example BPG injections, echocardiograms or appointments) and identifying individuals with poor adherence to therapy who can be targeted for educational interventions [6].

Despite the benefits of register-based control programs, Australia is unable to obtain consistent national data on disease incidence or prevalence and high rates of recurrent ARF episodes still persist in high-risk populations [6]. This demonstrates a need to refine the control methods that are being employed and alter how these are being implemented in different communities. Of the aims described above, future control programs should focus on improving the delivery of prophylaxis and patient care, the provision of education, coordination of health services and advocacy for the necessary resources [7]. A number of international examples provide an exemplary display of how register-based control programs can significantly reduce the incidence and prevalence of ARF and RHD, including the Caribbean nation of Cuba.

References

[1] Dowdle WR. The principles of disease elimination and eradication. Bull World Health Organ. 1998;76(Suppl 2):22-5.

[2] WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: Report of a WHO Expert Consultation, Geneva, 29 October-1 November 2001 [Internet]. Geneva: World Health Organisation; 2004 [cited 2017 Feb 23]. Available from: http://apps.who.int/iris/bitstream/10665/42898/1/WHO_TRS_923.pdf.

[3] McDonald M, Brown A, Noonan S, Carapetis JR. Preventing recurrent rheumatic fever: the role of register based programmes. Heart. 2005;91:1131-3.

[4] Parnaby MG, Carapetis, JR. Rheumatic fever in Indigenous Australian children. J Paediatr Child Health. 2010;46:527-33.

[5] Carapetis J, Brown A, Maguire G, Walsh W, Noonan S, Thompson D. The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition). Casuarina: Menzies School of Health Research; 2012.

[6] Carapetis JR, Brown A, Wilson NJ, Edwards KN. An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline. Med J Aust. 2007;186(11):581-6.

[7] Australian Institute of Health and Welfare. Rheumatic heart disease and acute rheumatic fever in Australia: 1996-2012 [Internet]. 2013 [cited 2017 Feb 23]; AIHW cat. no. CVD 60. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129542747.

[8] Nordet P, Lopez R, Dueñas A, Sarmiento L. Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002). Cardovasc J Afr. 2008;19(3):135-40.

Posted 23rd February, 2017

In contrast to disease prevention, disease control specifically focuses on “the reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction” - Dowdle, WHO [1].

A coordinated control program is regarded as one of the most effective approaches in improving adherence to secondary prophylaxis and ensuring the clinical follow-up of patients with RHD [2,3].

In 2009 the Australian Federal Government commenced the National Rheumatic Fever Strategy with recurrent funding for control programs in NT, QLD and WA [4]. The Australian Guideline for the Prevention, Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease has outlined the core aims of these control programs, which are summarised below [5]:

A Cuban Case Study: Pinar del Rio

Pinar del Rio is a western Cuban province that had one of the highest incident rates of ARF in the 1980's and a prevalence and severity of RHD that required large-scale hospitalisation and cardiac surgery [8]. Between 1986 and 1996 a comprehensive 10-year prevention control program was executed in Pinar del Rio and its efficacy evaluated five years later. What did this program do?

1. Establish a permanent provincial ARF/RHD register closely linked to primary health care centres and family physicians, which conducted registration, follow-up and secondary prophylaxis, providing extensive and permanent medical care for patients.

2. Train healthcare and education personnel for the early detection and treatment of streptococcal pharyngitis (primary prophylaxis), the importance of treatment and follow-up, how to monitor compliance with secondary prophylaxis and measures for dealing with non-compliance cases.

3. Disseminate healthcare educational activities among the general population and schools, covering all aspects of ARF and RHD including correct diagnosis, treating strep throats and adhering the secondary prophylaxis.

What did they find at the conclusion of the control program?

ARF and RHD prevalence among school children declined 4 and 10-fold respectively.
Compliance with secondary prophylaxis increased progressively from 50% of patients complying regularly to 94% in 1996.
A marked decline (of 86.1%) in the direct cost of managing disease, primarily as a result of fewer and less severe cases.
The implementation of the program as a part of the normal healthcare system ensured the continuation of activities even several years after the program ended [8].

Image: Pinar del Rio. Source: Nordet et al. [8].

Note: Images in the graphic above were sourced from Take Heart TV: http://www.takeheart.tv/