tag:theconversation.com,2011:/fr/topics/rheumatic-heart-disease-10868/articlesRheumatic heart disease – The Conversation2023-01-16T23:36:08Ztag:theconversation.com,2011:article/1976172023-01-16T23:36:08Z2023-01-16T23:36:08ZStrep A cases are rising. We must remember our earliest hygiene lessons as vaccine trials continue<figure><img src="https://images.theconversation.com/files/504594/original/file-20230116-19027-w9fwaw.jpg?ixlib=rb-1.1.0&rect=38%2C66%2C6298%2C4151&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cute-likable-mixed-race-teen-600w-1974397403.jpg">Shutterstock</a></span></figcaption></figure><p>Group A streptococci, also known as “strep A”, were the first organisms ever identified to be the cause of a disease. </p>
<p>In the mid-1800s, Hungarian physician <a href="https://www.pbs.org/newshour/health/ignaz-semmelweis-doctor-prescribed-hand-washing">Ignaz Semmelweis</a> first noted the link between a lack of hygienic practices – such as handwashing – among medical staff and puerperal (or childbirth) fever. Louis Pasteur subsequently <a href="https://www.ncbi.nlm.nih.gov/books/NBK333430/">demonstrated</a> that it was caused by the microbe we now refer to as strep A. </p>
<p>Puerperal fever, a life-threatening condition, is much less common now, but strep A has not gone away. In fact, it is known to cause more types of disease than any other single micro-organism. </p>
<p>And infections appear to be <a href="https://www.abc.net.au/news/2023-01-17/group-a-streptococcal-explainer-cases-in-australia/101854070">on the rise</a>.</p>
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<h2>A common organism that can cause everyday and rare illnesses</h2>
<p>Strep A organisms commonly live on people and, while they don’t usually cause disease, they can become virulent. Their propensity to cause illness depends on the strain of the organism, the simultaneous presence of other microbes (often viruses), and the level of immunity the person may already have. </p>
<p>The most common diseases <a href="https://www.cdc.gov/groupastrep/diseases-public/index.html">caused by strep A</a> are tonsillitis (also called “strep throat”) and impetigo (also known as “school sores”). </p>
<p>These conditions are relatively benign, but if untreated can give rise in some individuals to deadly complications, including “invasive” strep A disease and <a href="https://www.who.int/news-room/fact-sheets/detail/rheumatic-heart-disease#:%7E:text=The%20disease%20results%20from%20damage,death%20or%20life%2Dlong%20disability.">rheumatic heart disease</a>, which is the most commonly acquired heart disease in people younger than 25. </p>
<p>Other conditions caused by strep A include erysipelas and cellulitis (infections of the skin), glomerulonephritis (inflammation of the kidneys), <a href="https://www.cdc.gov/groupastrep/diseases-public/scarlet-fever.html">scarlet fever</a> (named for the red rash it causes) and <a href="https://www.cdc.gov/groupastrep/diseases-public/streptococcal-toxic-shock-syndrome.html">toxic shock syndrome</a> (which can cause organ failure and death).</p>
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Read more:
<a href="https://theconversation.com/strep-a-three-doctors-explain-what-you-need-to-look-out-for-195972">Strep A: three doctors explain what you need to look out for</a>
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<h2>Rising cases in children</h2>
<p>Recently, there is concern because case numbers of invasive streptococcal disease (now a <a href="https://nindss.health.gov.au/pbi-dashboard/">notifiable disease</a> in Australia) are <a href="https://www.theage.com.au/national/victoria/two-children-die-amid-marked-increase-in-invasive-strep-a-infections-20230103-p5ca0e.html">rising</a>, particularly among children. </p>
<p>Invasive disease occurs when an otherwise simple infection of the tonsils or skin spreads beyond the local tissue and invades deep tissue. From there it can spread to distant sites in the body, leading to shock, potential loss of limbs, and death. </p>
<p>Although cases are <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON429">on the rise</a> in multiple countries, the chances of an individual case of strep throat progressing to invasive disease are low. Worldwide there is an <a href="https://pubmed.ncbi.nlm.nih.gov/16253886/">estimated incidence</a> of around 700 million cases of tonsillitis or school sores every year, of which about 1 in 1,000 lead to invasive disease.</p>
<p>The reason for the recent jump in case numbers of invasive disease is unclear. </p>
<p>A new strain may be responsible but this needs more investigation. We know there are <a href="https://pubmed.ncbi.nlm.nih.gov/23464795/">hundreds of strains</a> of strep A.</p>
<p>In the United Kingdom, which has also seen a <a href="https://www.gov.uk/government/publications/group-a-streptococcal-infections-activity-during-the-2022-to-2023-season/group-a-streptococcal-infections-first-update-on-seasonal-activity-in-england-2022-to-2023">significant rise</a> in cases, a few strains seem to dominate. But these same strains have been circulating in the community for several years. </p>
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<a href="https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="young baby with red cheeks on bed" src="https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504595/original/file-20230116-20-kxxo8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Young children and older people are the ones most at risk of Strep A complications.</span>
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Read more:
<a href="https://theconversation.com/what-are-school-sores-and-how-do-you-get-rid-of-them-86930">What are school sores and how do you get rid of them?</a>
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<h2>Is it because of lockdowns?</h2>
<p>It seems likely, both in the UK and here, that the main reason we are seeing more cases now is because we are experiencing more respiratory infections across the board as we come out of COVID-imposed isolation, especially from influenza. </p>
<p>Co-infection with influenza and strep A can render <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800185/">both infections</a> significantly more dangerous and difficult to control.</p>
<p>I am not aware of data showing invasive strep A cases are occurring more in people also infected with SARS-CoV-2 (the virus that causes COVID), but this requires investigation also.</p>
<p>Should we be alarmed? We are rightly nervous when we see a sudden jump in any serious infectious disease, but early indications are that the rates of invasive disease are similar to pre-pandemic rates.</p>
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<h2>Old lessons and future protections</h2>
<p>The population groups most at risk are those under ten years or over 65 years of age. People with chronic conditions such as diabetes, cancer or who are immunosuppressed are also less able to fight off infection. These groups and those who care for them need to be more vigilant. </p>
<p><a href="https://www.health.vic.gov.au/health-advisories/health-warning-on-invasive-group-a-streptococcal-disease">Warning signs</a> are a sore throat and high fever, especially if combined with a skin rash (scarlet fever), severe pain from an infected skin sore, and any difficulties with breathing. Prompt medical attention is required for any of these symptoms.</p>
<p>Hygiene practices are also important for prevention. Strep A is highly contagious and as such we should adhere to the habits we all learnt during the pandemic – washing hands frequently, coughing or sneezing into a tissue and staying home if symptomatic. These measures will limit spread and are no less important now than they were when Semmelweis first proposed them in 1847.</p>
<p>In the long term, a vaccine to prevent strep A infection would completely prevent invasive strep A disease and rheumatic heart disease. </p>
<p>A few groups worldwide are developing strep A vaccines. <a href="https://news.griffith.edu.au/2021/02/24/potential-vaccine-to-prevent-deadly-strep-a-infection/">Our group</a> has one that is undergoing a <a href="https://theconversation.com/vaccine-for-strep-throat-and-rheumatic-fever-to-be-trialled-in-humans-63390">clinical trial</a> in Alberta, Canada. The vaccine was developed at Griffith University and is aimed at preventing infection of the throat or skin from all strains of strep A. </p>
<p>If it does this, it will also prevent invasive strep A disease and rheumatic heart disease. Globally, that could save as many as 500,000 lives each year.</p>
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Read more:
<a href="https://theconversation.com/vaccine-for-strep-throat-and-rheumatic-fever-to-be-trialled-in-humans-63390">Vaccine for strep throat and rheumatic fever to be trialled in humans</a>
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<p class="fine-print"><em><span>Michael Good works for Griffith University He receives grant funding from NHMRC, the Snow Foundation, the Li Ka Shing Institute (University of Alberta), the Lowitja Institute and the Heart Foundation.</span></em></p>Strep A is a common infection that can give you a passing sore throat or something much more serious. Cases seems to be rising around the world.Michael Good, Professor and NHMRC Investigator Fellow, Institute for Glycomics, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1251852019-11-11T13:18:10Z2019-11-11T13:18:10ZHow a simple scan helped children suffering with hidden heart diseases in South Africa<figure><img src="https://images.theconversation.com/files/301089/original/file-20191111-194669-15zzh4m.jpg?ixlib=rb-1.1.0&rect=18%2C0%2C5988%2C3998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A simple heart scan can save the lives of children suffering with conditions such as rheumatic heart disease. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/stethoscope-heart-listening-ultrasound-sensor-lie-511682635?src=e168f308-7f88-4bff-8038-6ee2c1e0e5fa-1-84">Shidlovski/Shutterstock</a></span></figcaption></figure><p>The polite, well-behaved ten-year-old girl lying patiently in the makeshift clinic in her school in Cape Town, South Africa, is exactly like all her friends – active and smiley. Also, like her friends, she’s under strict instructions from her teachers to put “jokes in your pockets, smiles on your faces”. But the ultrasound waves bouncing back from her heart during an echocardiography scan show that she is different: she has <a href="https://www.nhs.uk/conditions/Congenital-heart-disease/">congenital heart disease</a>, which means her heart did not develop properly in the womb, and it makes each heartbeat less efficient.</p>
<p>This birth defect can lead to abnormal heart rhythms, shortness of breath, fatigue and an increased risk of cardiovascular disease in later life. A child with the same heart condition in the UK would have received treatment when they were a baby and would be closely monitored throughout their life. However, though the girl has had an operation to treat her heart abnormality, her parents have been too worried about medical costs to bring her in for further follow-up. Without this, the surgery she had hasn’t entirely fixed the problem with her heart. She desperately needs further care. </p>
<p>This is just one of the hidden heart conditions spotted by a team of ten echocardiographers from around the globe, during a five-day trip to Cape Town in September 2019. The group was a mix of cardiac physiologists, who use echocardiography to diagnose patients with heart conditions, consultant doctors, and university researchers. Our group came together as part of a humanitarian project that aimed to screen for hidden heart conditions in South Africa – especially rheumatic heart disease. </p>
<p>This condition might be uncommon in most parts of the developed world, such as the US and the UK. However, it’s the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26247792">single biggest cause of heart-related death</a> in children and young people in the developing world. An estimated 250,000 people, most of them under 35 years old <a href="https://www.sciencedirect.com/science/article/pii/S0140673611611719?via%3Dihub#bib2">die of rheumatic heart disease each year</a> across the world. In South Africa, two out of every 100 children are affected by the disease. But most have no idea that they’re affected, let alone receive treatment for the condition. </p>
<p>Rheumatic heart disease is an unfortunate side effect of rheumatic fever. <a href="https://www.nhs.uk/conditions/rheumatic-fever/">Rheumatic fever</a> is a rare complication that may develop after a bacterial throat infection, such as <a href="https://www.cdc.gov/groupastrep/diseases-public/rheumatic-fever.html">strep throat and scarlet fever</a>, and causes inflammation in the heart, joints, skin, and brain. </p>
<p>The inflammation characteristic of rheumatic fever sometimes infiltrates the heart, where it can <a href="https://www.rhdaustralia.org.au/what-rheumatic-heart-disease#:%7E:targetText=Rheumatic%20heart%20disease%20(RHD)%20is,the%20heart%20has%20become%20inflamed.">damage the heart valves</a> – meaning that some blood may flow in the wrong direction through the valves, rather than being pumped around the body properly. The disease can ultimately cause disability because of heart failure, and lead to patients dying young. </p>
<p>Luckily, this kind of heart damage can be visible to trained eyes. Our team of echocardiographers – which are in short supply in South Africa – use hand-held echocardiographic devices to spot the disease. Caught early enough, the disease is <a href="https://www.who.int/selection_medicines/committees/subcommittee/2/RheumaticFever_review.pdf">easily treated with antibiotics</a>. </p>
<p>We were trained by a cardiologist from Cape Town, before heading to three primary schools in the area where we provided free heart scans to over 1,000 children, aged eight to 15. </p>
<p>At the first primary school we visited, we found a boy with a serious heart condition. Two of the cusps – the flaps of tissue that form heart valves – had fused together, meaning his aortic valve consists of two cusps, rather than the normal three. He had no idea that he was living with this condition. While this disease is not rheumatic, this sort of bicuspid heart valve can mean that he could potentially develop trouble breathing, chest pain, and fatigue later in life – and these could be life threatening, especially as he gets older. This child will now be monitored closely and get the surgery he needs if required.</p>
<p>On the same day, we find the smiling girl who turns out to have a congenital heart defect that has been “lost to follow-up” after her surgery. We learn from Dr Luke Hunter, a cardiologist from Cape Town who trained our volunteer group, that this is a common problem because many families fear how medical costs may cripple their family. Finding out that this child needs further medical follow-up might mean that she lives a longer, healthier life with follow-up. </p>
<p>The next day, we travel to the less developed area of Grabouw and find the first confirmed case of rheumatic heart disease in another primary schoolgirl. The team finds a few more borderline cases of rheumatic heart disease too, finding a total of 16 cases that week alone – plus another case of congenital heart disease, taking the total to three. All of these findings are life-changing for the children and the families affected. </p>
<p>Our work found fewer cases of rheumatic heart disease in the area than <a href="https://esc365.escardio.org/Congress/ESC-Congress-2018/Poster-Session-6-Pathophysiology-and-mechanisms-in-valve-disease/177655-echocardiographic-screening-for-rheumatic-heart-disease-the-potential-for-misclassification-of-borderline-cases#abstract">the previous year</a>, which might mean that the disease is declining in the area. However, continued work in Cape Town will help continue to detect silent heart disease in the area, which is tragically shortening the lives of young people in Africa.</p><img src="https://counter.theconversation.com/content/125185/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cameron Dockerill does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hidden heart conditions, like rheumatic heart disease, can have deadly consequences if not treated properly – or not treated at all.Cameron Dockerill, Research Assistant, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1044632018-10-11T10:41:17Z2018-10-11T10:41:17ZWomen with heart disease in sub-Saharan Africa face challenges, but stigma may be worst of all<figure><img src="https://images.theconversation.com/files/240081/original/file-20181010-72117-yz379.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse in Uganda uses a stethoscope to listen for heart problems at a screening and educational event Oct. 31, 2017.</span> <span class="attribution"><span class="source">Tao Farren-Hefer</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Heart disease is the number one killer of women, <a href="https://www.goredforwomen.org/fight-heart-disease-women-go-red-women-official-site/about-heart-disease-in-women/facts-about-heart-disease/">claiming a female life every minute</a>. Yet it is often seen as a “man’s disease.” This disparity is magnified in sub-Saharan Africa, where we have recently <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194030">conducted an investigation</a> into the experiences of women living with rheumatic heart disease. </p>
<h2>Rethinking heart disease in the developing world</h2>
<p>Another prevailing myth that we often encounter is that cardiovascular disorders are not a major issue in the developing world. To the contrary, heart disease is already the <a href="http://www.who.int/mediacentre/factsheets/fs310/en/index1.html">number one cause of death</a> worldwide as well as in low- and middle-income countries. </p>
<p>This shift has, in part, been due to ongoing successes in fighting contagious epidemics, particularly HIV/AIDS and childhood infections. Industrialization and economic development of low-income nations has brought more food security and decreased reliance on manual labor. Yet, these changes have fueled an increase in noncommunicable disease such as diabetes, high blood pressure and high cholesterol, leading to a surge in cardiovascular disease.</p>
<p>In contrast to their high-income counterparts, patients in poor countries are struck by, and die from, <a href="https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.0708">cardiovascular conditions at younger ages</a>. Their health systems are often unprepared to combat the dual tides of infectious and noncommunicable illnesses. Furthermore, the <a href="http://circ.ahajournals.org/content/circulationaha/132/17/1667.full.pdf">causes of heart disease</a> are somewhat different in poor countries, where the proliferation of “Western” maladies like heart attacks and hypertension are accompanied by “endemic” cardiovascular diseases of poverty such as rheumatic heart disease.</p>
<h2>An old foe, revisited</h2>
<p>Rheumatic heart disease is a preventable disorder that is a late effect of rheumatic fever, which ravaged Western Europe and the United States only a generation ago, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1603693">but is rarely seen now in these settings</a>. It is triggered by Group A <em>streptococci</em>, which causes strep throat. Some individuals will develop a systemic reaction known as acute rheumatic fever, which can <a href="https://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/rheumatic_heart_disease_85,P00239">permanently damage the heart valves</a>.</p>
<p>In the developed world, acute rheumatic fever is rarely seen, because strep throat is regularly treated with antibiotics. In developing nations, however, appropriate medications are often missed or are financially unfeasible. Rheumatic heart disease afflicts up to 43 million people worldwide and <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1603693">leads to up to 1.4 million deaths each year</a>. It can have terrible consequences, including heart failure, irregular heart rhythms and debilitating <a href="http://rhdaction.org/what-rhd/complications-rhd">stroke</a>.</p>
<h2>Impact on women</h2>
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<span class="caption">Women at an educational health event in Kampala, Uganda on Oct. 31, 2017.</span>
<span class="attribution"><span class="source">Tao Farren-Hefer</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>Women of childbearing age with rheumatic heart diseases are especially vulnerable, as the disorder places them at increased risk of <a href="http://www.pascar.org/uploads/files/Materna_and_fetal_outcome_in_women_with_RHD-_A_3_years_observation_study.pdf">complications during pregnancy</a>. Furthermore, the blood-thinning medications used to treat RHD can also raise the risk of <a href="http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/10/10/22/03/anticoagulation-during-pregnancy-evolving-strategies">miscarriage and maternal hemorrhage</a>. Although pregnancy in this population is high-risk, only 3.6 percent of women with RHD of childbearing age <a href="https://academic.oup.com/eurheartj/article/36/18/1115/2293200">are on contraceptives</a>.</p>
<p>Our research group recently concluded a mixed methods study in Uganda of <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194030">women of reproductive age living with rheumatic heart disease</a> to better understand the lived experience of this population.</p>
<p>Several themes emerged: First, we discovered that female rheumatic heart disease patients understood that their disease increased their risk of complications and death during pregnancy. Nevertheless, they still felt pressure to take the risk, citing the societal pressures to have many children. In fact, 100 percent of our participants answered that society would look poorly upon a woman who cannot bear children.</p>
<p>Further, our findings suggest that it may not be women themselves who control reproductive decision-making: Male partners were usually drivers of reproductive intent, both directly (by petitioning their spouses for children) or indirectly (due to women’s fears of abandonment if unable to bear children). Tragically, 28 percent of participants reported that they had been left by their husbands or boyfriends due to perceived limitations in fertility, while 36 percent of participants confessed fear of abandonment by their male partners.</p>
<p>Compounding their challenges, participants suggested that contraception may be criticized, leading to poor adoption – a social norm <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0141998">previously reported</a> in Uganda and its <a href="https://www.ncbi.nlm.nih.gov/pubmed/26085021">neighbors</a>.</p>
<p>Perhaps the most striking finding, however, was that women living with heart disease experience considerable stigma. Because of its ubiquity, we do not consider cardiovascular conditions to be the source of much stigma in the developed world, yet it was spontaneously reported by our group. Several participants were suspected by friends and family of having HIV because they were observed taking medications for a prolonged period of time (as opposed to short durations for drugs such as antibiotics). </p>
<p>More surprisingly, our patients reported that they felt it may be preferable to have HIV than heart disease. They attributed this to the fact that having HIV may not limit their reproductive potential the way cardiac conditions do.</p>
<h2>Building systems, targeting future efforts</h2>
<p>In light of these sobering findings, our team also asked participants how they thought the current medical system could better serve their needs. First, patients suggested that health care providers discuss the reproductive consequences of the illness and its therapies. This concern has been echoed by women living with <a href="https://www.ncbi.nlm.nih.gov/pubmed/24238664">serious chronic disease</a> in Europe as well. In addition, women stated that doctors should involve male partners and family members in discussions about heart disease.</p>
<p>To that end, Uganda’s health system has commissioned an initiative to better care for women of reproductive age living with heart disease. Uganda’s first Women’s Heart Center is a collaboration between cardiology and obstetrics, a multidisciplinary effort to cross-refer patients who are pregnant or plan to become pregnant and have heart conditions. From the lessons we learned from our study, we hope to incorporate family counseling and public awareness campaigns to fight stigma against cardiovascular disease in women.</p>
<p>Our study suggests that there is still work to be done in identifying the comorbidities and downstream outcomes of this population. These are areas of ongoing investigation for our team. Nevertheless, we are optimistic that there are opportunities for improved family and societal education programs and community engagement, leading to better outcomes and patient empowerment.</p><img src="https://counter.theconversation.com/content/104463/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allison Webel has received funding from the National Institutes of Health, the American Heart Association, Gilead Sciences, and the Midwest Nursing Research Society. </span></em></p><p class="fine-print"><em><span>Andy Chang was supported by a National Institutes of Health, National Center for Advancing Translational Science, Clinical and Translational Science Award (TL1TR001084). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.</span></em></p>Noncommunicable diseases are a growing problem in Africa. Among women, heart disease is a particular concern. Medication to treat it can interfere with pregnancy, making women undesirable partners.Allison Webel, Assistant Professor of Nursing, Case Western Reserve UniversityAndrew Chang, Cardiology Fellow Physician, Stanford UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/914822018-02-11T19:11:25Z2018-02-11T19:11:25ZTo close the health gap, we need programs that work. Here are three of them<figure><img src="https://images.theconversation.com/files/205783/original/file-20180210-51697-1r3qj3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While death rates from heart and kidney disease have dropped among Indigenous people, death rates from cancer are on the rise.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The tenth Closing the Gap report to be tabled in Parliament today is expected to show progress in the two health targets – to close the gap in life expectancy by 2031 and halve the child mortality (death) gap by 2018. But only the latter is on track.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=751&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=751&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=751&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=944&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=944&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205784/original/file-20180210-51697-15c81tx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=944&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The gap in life expectancy between Indigenous and non-Indigenous Australians won’t be closed by 2031.</span>
<span class="attribution"><a class="source" href="https://www.aihw.gov.au/getmedia/5d39a104-a2d5-4ab5-900c-697ee0e5a1d8/ah16-5-8-main-contributors-indigenous-life-expectancy-gap.pdf.aspx">AIHW (screenshot)</a></span>
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<p>The Indigenous death rate has dropped by 15% (from 1998-2015), but <a href="https://closingthegap.pmc.gov.au/">we’re not on track</a> to meet the deadline. Chronic diseases such as diabetes, heart disease and cancer are <a href="https://www.aihw.gov.au/getmedia/5d39a104-a2d5-4ab5-900c-697ee0e5a1d8/ah16-5-8-main-contributors-indigenous-life-expectancy-gap.pdf.aspx">responsible for the majority of this gap</a>. </p>
<p>While <a href="https://closingthegap.pmc.gov.au/healthy-lives">death rates</a> from heart and kidney disease have dropped among Indigenous people, death rates from cancer are on the rise, and the gap here is widening.</p>
<p>The child death rate has dropped by 33% for the 1998-2015 period, and is reportedly on track to meet the target.</p>
<p>But overall, progress is slow. As governments talk about “refreshing” targets, three experts – in diabetes, maternal and infant health care, and rheumatic heart disease – provide evidence for how giving more support, funding and control to the Indigenous community leads to actual results.</p>
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Read more:
<a href="https://theconversation.com/closing-the-gap-is-failing-and-needs-a-radical-overhaul-72961">Closing the Gap is failing and needs a radical overhaul</a>
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<h2>Remote diabetes services</h2>
<p>Diabetes is <a href="https://www.pmc.gov.au/sites/default/files/publications/Aboriginal_and_Torres_Strait_Islander_HPF_2014%20-%20edited%2016%20June2015.pdf">three times more prevalent</a> in Aboriginal and Torres Strait islander people compared with non-Indigenous Australians. Rates in remote communities are even higher – up to 30% in some. The reasons are complex and include lifestyle factors such as poor diet and lack of exercise, poverty, and poor access to medical care and health literacy. Genetics and epigenetics also <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-4887.1999.tb01782.x/full">play a major role</a>, but aren’t yet well defined.</p>
<p>Over the past eight years, the Baker Heart and Diabetes Institute has been involved in remote diabetes services – as part of our <a href="https://www.baker.edu.au/impact/aboriginal-health">outreach health services</a>. </p>
<p>We’ve been shocked by the extreme levels of ill health associated with poorly controlled diabetes in these communities. The remote clinical services we visit are generally ill-equipped to manage complex chronic disease and the type of diabetes we see is aggressive and unusually resistant to treatment. </p>
<p>Diabetes contributes to illness and death through its complications, which include heart disease, kidney failure and limb amputations. Control of blood glucose (sugar) levels is central to managing complications.</p>
<p>Our service is made up of five doctors, and two diabetes educators. We visit eight communities in central Australia and intensively manage patients with poorly controlled diabetes. The doctors, based in Melbourne and Alice Springs, work closely with the nurse educators based in Alice Springs. The educators frequently visit the communities. Their follow-up and feedback are critical to overall management.</p>
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Read more:
<a href="https://theconversation.com/type-2-diabetes-increasingly-affects-the-young-and-slim-heres-what-we-should-do-about-it-61283">Type 2 diabetes increasingly affects the young and slim; here's what we should do about it</a>
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<p>The program’s evaluation (not yet published) has shown significant improvements in glucose levels and cholesterol in more than 100 patients. We’ve also had success in finding effective medications for these types of diabetes and initiated a <a href="http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=indigenous+exenatide&conditionCategory=&conditionCode=&interventionCodeOperator=&interventionCode=&ageGroup=&healthyVolunteers=&gender=&allocationToIntervention=&dateOfRegistrationFrom=&dateOfRegistrationTo=&trialStartDateFrom=&trialStartDateTo=&recruitmentCountryOperator=&countryOfRecruitment=&primarySponsorType=&fundingSource=&healthCondition=&interventionDescription=&phase=&recruitmentStatus=&registry=&ethicsReview=&studyType=&isBasic=True&postcode=&distance">clinical trial</a> of a once-weekly diabetes medication in these communities. This less frequent dosage helps with adherence rates and we have so far seen improvements in patients involved in the trial. </p>
<p>With more funding and resources for remote clinical services, and greater involvement and feedback from the communities and community leaders, the impact of diabetes and its complications can be greatly reduced. – <strong>Neale Cohen</strong></p>
<h2>Birthing on Country</h2>
<p>Birthing on Country – a movement that has been benefiting Indigenous women in <a href="https://www.saxinstitute.org.au/wp-content/uploads/Birthing-on-Country1.pdf">Canada</a> for decades – is about <a href="https://www.saxinstitute.org.au/wp-content/uploads/Birthing-on-Country1.pdf">bringing birth back to community</a> and back to country. It’s also about offering safe and culturally appropriate maternity services for Aboriginal and Torres Strait Islander mothers and babies. </p>
<p>In Australia, we’ve been running a Birthing On Country service in Brisbane since 2013, but tailoring it to an urban setting. We call it <a href="http://www.iuih.org.au/Services/Child_and_Maternal_Health">Birthing in Our Community</a>. </p>
<p>Key aspects of our program include an Indigenous governance framework and 24/7 midwifery care in pregnancy to six weeks postnatal care by a named midwife. This is supported by Indigenous health workers and an Indigenous team coordinator. Our program also offers support for Indigenous student midwives through cadetships and placement.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/kymu_pW_Z7Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Birthing on Country has been shown to be effective, and is strongly supported by Indigenous organisations.</span></figcaption>
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<p>Evaluation of <a href="https://espace.library.uq.edu.au/view/UQ:435004">Birthing in Our Community</a> has shown significant reductions in preterm birth, caesarean sections, and low birth weight infants and babies being admitted to the neonatal nursery. We’ve seen more women coming to us in early pregnancy, as they feel safe to do so. There has been an increase in antenatal care, normal birth and breastfeeding rates. </p>
<p>Currently, Birthing in Our Community is run and <a href="https://espace.library.uq.edu.au/view/UQ:435004">funded through a partnership</a> between the Institute for Urban Indigenous Health, the Aboriginal and Torres Strait Islander Community Health Service Brisbane and the Mater Mothers’ Hospital. Evaluation of the program is funded by the National Health and Medical Research Council.</p>
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Read more:
<a href="https://theconversation.com/birthing-on-country-could-deliver-healthier-babies-and-communities-31180">Birthing on Country could deliver healthier babies and communities</a>
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<p>We recommend scaling up the Birthing in Our Community program to address the preterm birth rate, which hasn’t changed since Closing the Gap targets were released in 2008. This would also impact positively on infant and child mortality in Australia. </p>
<p>We also recommend full implementation of Birthing On Country in urban, rural and remote areas, with dedicated funding for Indigenous organisations to establish their own Birth Centres and structural barriers to this (regarding insurance and regulation) removed by government. </p>
<p>Birthing On Country was recommended by the <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/8AF951CE492C799FCA257BF0001C1A4E/$File/maternityplan.pdf">national maternal services policy</a>, released in 2010. It is also supported by international evidence, the <a href="https://health.act.gov.au/sites/default/files/Birthing%20on%20Country%20Workshop%20Report,%204%20July%202012.pdf">Indigenous community</a> and <a href="http://catsinam.org.au/static/uploads/files/birthing-on-country-position-statement-endorsed-march-2016-wfaxpyhvmxrw.pdf">professional organisations</a>. – <strong>Sue Kildea and Ms Jody Currie (CEO of Aboriginal and Torres Strait Islander Community Health Service, Brisbane and a Yugambeh woman).</strong></p>
<h2>Rheumatic heart disease</h2>
<p>Rheumatic heart disease is a rarity in mainstream Australia. But in remote communities of northern and central Australia, it continues largely unabated. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/25169025">average age of death</a> from the disease in Aboriginal people is 40. Many children and adolescents are among those who die. Rheumatic heart disease is responsible for the <a href="http://www.aihw.gov.au/publication-detail/?id=6442467995">highest gap in life expectancy</a> between Indigenous and non-Indigenous Australians; higher than diabetes or kidney failure.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">Why are Aboriginal children still dying from rheumatic heart disease?</a>
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<p>Yet, it is preventable. It’s caused by an abnormal immune reaction to infections by the <em>group A Streptococcus</em> bacterium (that causes strep throat and <a href="https://theconversation.com/why-simple-school-sores-often-lead-to-heart-and-kidney-disease-in-indigenous-children-86066">skin sores</a>). The reaction causes inflammation in heart valves (part of the condition known as rheumatic fever). If left untreated, this can progress to rheumatic heart disease. </p>
<p>The disease can result in heart failure, and causes death and disability in children, adolescents and young adults.</p>
<p>Until now, rheumatic heart disease has been largely tackled entirely within the health system. That doesn’t work for a disease that is inherently complex and made up of many factors. And for one that starts as an infectious disease in childhood but ends up as a chronic disease of adolescents and young adults.</p>
<p>There are medical approaches to treatment and prevention, such as regular penicillin injections to prevent strep A infections. But housing, living conditions and education are core determinants for preventing infection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=493&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=493&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=493&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=619&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=619&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205787/original/file-20180210-51706-1bmc6t2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=619&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>The <a href="https://endrhd.telethonkids.org.au/">END RHD Centre for Research Excellence</a> – that began in 2014 (through funding by the National Health and Medical Research Council) – is developing a strategy to eliminate rheumatic heart disease in Australia. A critical aspect is <a href="https://endrhd.telethonkids.org.au/globalassets/subsite-media/subsite-documents/end-rhd/briefing-note-secondary-prophylaxis-delivery--lessons-learnt-to-date.pdf">to help communities take ownership</a> of ways to target rheumatic heart disease as a condition requiring attention, provide leadership and training within health services, connect the health service with clients, families and communities, and engage other services outside of the health system. </p>
<p>We recently <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1166-y">conducted research</a> in ten remote communities in the Northern Territory, trialling a number of ways to assist local clinics to improve care and prevention of rheumatic heart disease. We found the communities that did best were those that tackled multiple aspects of prevention and treatment of the disease. </p>
<p>This meant delivering preventive treatments through streamlining systems at the clinic, and embracing ways to connect community members to the health service in culturally sensitive and appropriate ways.</p>
<p>Rheumatic heart disease is almost uniquely a disease of Aboriginal people in Australia. It deserves particular attention as part of closing the gap. To eliminate it from Australia, we need to identify it as a priority, and equip communities with the information and tools they need to tackle it. – <strong>Jonathan Carapetis</strong></p><img src="https://counter.theconversation.com/content/91482/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neale Cohen receives funding from Astra Zeneca for a clinical trial in remote communities. The Baker Institute recieves Federal government funding for their outrech clinical diabetes service. </span></em></p><p class="fine-print"><em><span>Jonathan Carapetis receives funding from the National Health and Medical Rearch Council, the Telethon Perth Childrens Hospital Fund, AusTrade, Novartis Institute for Biomedical Research.</span></em></p><p class="fine-print"><em><span>Sue Kildea receives funding from the National Health and Medical Research Council, the Canadian Institutes of Health Research, the National Institute of Health, the Mater Foundation and the Queensland Government. She has undertaken funded consultancy work on 'Birthing On Country' for the Sax Institute, State and Commonwealth governments. She works in partnership with Indingeous and other Organisations to establish and evaluate Birthing on Country services and they have their own funding sources: the Institute for Urban Indigenous Health, the Aboriginal and Torres Strait Islander Community Health Service Brisbane the South Coast Women’s Health and Welfare Aboriginal Corporation (Waminda); the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, the Australian College of Midwives and Rhodanthe Lipsett Indigenous Midwifery Charitable Fund with colleagues from University Queensland and Sydney University.</span></em></p>Politicians make sweeping statements on how to close the gap. But here’s advice from people working directly with Indigenous communities who have evidence for what actually works.Neale Cohen, General Manager Diabetes Services, Baker Heart and Diabetes InstituteJonathan Carapetis, Professor, Paediatrics, Telethon Kids InstituteSue Kildea, Professor of Midwifery, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860662017-12-11T01:49:16Z2017-12-11T01:49:16ZWhy simple school sores often lead to heart and kidney disease in Indigenous children<figure><img src="https://images.theconversation.com/files/195398/original/file-20171120-18528-ltzud6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Impetigo happens when itching causes the skin to break and let in disease-causing bacteria.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Impetigo, also known as school sores, is a highly contagious bacterial skin infection that occurs in children far more frequently than adults. It is one of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">most common bacterial infections</a> in children aged two to five years. Impetigo happens when a break in the skin, from scratching an insect bite for instance, lets in disease-causing bacteria.</p>
<p>The bacteria responsible for impetigo are <em>Staphylococcus aureus</em> (<em>S. aureus</em> or staph) and <em>Streptococcus pyogenes</em> (<em>S. pyogenes</em> or group A strep). People with diabetes or other conditions that may affect the immune system, such as HIV infection, and those on medications that suppress immunity, are more susceptible.</p>
<p>While the infection itself is treatable, if left untreated it can lead to more serious conditions such as <a href="https://www.healthdirect.gov.au/cellulitis">cellulitis</a> (infection of the inner layers of skin) or <a href="https://www.healthdirect.gov.au/abscesses">abscess</a> (painful collections of pus that build up under the skin). It can also progress to kidney disease, or it could <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000467">cause acute rheumatic fever</a>, which can affect the heart, joints, brain or skin.</p>
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<p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-chronic-kidney-disease-and-why-are-one-in-three-at-risk-of-this-silent-killer-81942">Explainer: what is chronic kidney disease and why are one in three at risk of this silent killer?</a>
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<p>Around 162 million children worldwide <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">suffer from impetigo</a> at any one time. They mostly live in resource-poor tropical countries or underprivileged populations in developed countries. In Australia, about 15,000 Indigenous children are <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">estimated to suffer</a> from impetigo – representing 40% of children in Indigenous communities.</p>
<h2>Causes and symptoms</h2>
<p>Impetigo can occur on top of other skin conditions, particularly itchy ones like eczema, scabies, insect bites, and head lice. Scratching the skin can break it and let the disease-causing bacteria in. A sore can be infectious for as long as it is weeping fluid, as the fluid and crusts of the sore contain infectious bacteria. </p>
<p>The time between becoming infected and developing symptoms is around four to ten days. Contact with the sore, or with things that have been in contact with the sore, can spread the infection to other people. </p>
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Read more:
<a href="https://theconversation.com/health-check-how-do-you-catch-and-get-rid-of-head-lice-43699">Health Check: how do you catch – and get rid of – head lice?</a>
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<p>There are two forms of impetigo: non-bullous and bullous. Non-bullous, also known as the crusted form of impetigo, accounts for about 70% of all cases and can be <a href="http://www.aafp.org/afp/2014/0815/p229.html">caused by both</a> <em>S. aureus</em> and <em>S. pyogenes</em>. It has a thick, soft, yellow crust below which is often a wet, red area. </p>
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<a href="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Crusted forms of impetigo are the most common.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Impetigo_crouteux_jambes.jpg">Wikimedia Commons</a></span>
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<p>Non-bullous <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1470.1994.tb00092.x/abstract">impetigo spots grow slowly</a> and are smaller than the fully grown spots of bullous, or blistering, impetigo. They are not usually painful but can be itchy. The lesions generally appear on the face and extremities, often at the location of already broken skin, such as an insect bite or eczema.</p>
<p>The bullous (blistering) form of impetigo is <a href="http://www.mdedge.com/jfponline/dsm/1310/infectious-diseases/impetigo">characterised by the formation</a> of a large, fluid-filled irritating blister under the skin. It is caused exclusively by <em>S. aureus</em> and <a href="http://www.aafp.org/afp/2014/0815/p229.html">usually occurs</a> where two skin surfaces touch or rub together, such as the armpits. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=884&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=884&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=884&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1111&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1111&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1111&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Blistering impetigo infections usually occur where two skin surfaces touch, like the armpits.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Impetigo.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>The blisters grow rapidly in size and number. They burst quickly and leave slightly wet or shiny areas with a brown crust at the edge. Those spots continue to grow quickly even after they break open and can be many centimetres wide. They are not usually painful but can be itchy. </p>
<h2>What are the treatments?</h2>
<p>As impetigo is highly contagious, good <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">hygiene practices are essential</a> for stopping the spread of infection. These include washing hands with soap, washing of infected clothes and towels, and covering the sore with a sticking plaster. </p>
<p>It’s also recommended that the infected child be <a href="https://www.ncbi.nlm.nih.gov/pubmed/21976576">kept away from other children</a> and school for 24 hours after starting treatment. </p>
<p>Impetigo is generally considered a mild disease that can resolve without treatment after a few weeks. But because it can cause more serious conditions, the child should be examined by a doctor and treated with appropriate antibiotics. </p>
<p>Topical antibiotics (creams) like mupirocin are recommended for mild forms of the infection. Oral antibiotics are used in more <a href="https://www.mayoclinic.org/diseases-conditions/impetigo/symptoms-causes/syc-20352352">severe cases of impetigo</a>, such as when multiple sores are present, or when topical treatments have been ineffective. The treatment should continue until all sores are completely healed. With treatment, symptoms are likely to be improved or cleared up after seven days.</p>
<h2>What happens if it’s not treated?</h2>
<p>A possible consequence of untreated impetigo is an autoimmune kidney disease called acute post-streptococcal glomerulonephritis (APSGN). It’s not frequently seen in developed countries but one <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">estimate suggests</a> that more than 390,000 children in less developed countries are affected, compared with about 13,000 children in more developed countries.</p>
<p>In Australia, data collected from 1991-2008 in the Northern Territory revealed that 95% of cases occurred in <a href="https://www.ncbi.nlm.nih.gov/pubmed/21976576">Indigenous Australians</a>, with 98% of affected individuals living in remote locations. The average age was seven years old, with children younger than 15 accounting for 88% of all cases. </p>
<p>Given the association between APSGN and chronic kidney disease, it is important that predisposing skin infections are treated promptly and appropriately, and the risk of transmission or recurrences is minimised. Around 97% of deaths from APSGN occur in resource-poor countries or communities.</p>
<p>Acute rheumatic fever is another potential consequence of untreated impetigo. It is an autoimmune response to an untreated group A strep infection, and repeated episodes can <a href="https://www.ncbi.nlm.nih.gov/pubmed/19962028">damage the heart</a>, leading to rheumatic heart disease. </p>
<p>Both rheumatic fever and rheumatic heart disease are preventable and generally not seen in industrialised countries. But rates of <a href="https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/rheumatic-heart-disease-and-acute-rheumatic-fever/contents/table-of-contents">rheumatic fever and rheumatic heart diseases</a> in Indigenous communities are up to 26 times those in non-Indigenous populations.</p>
<hr>
<p><strong><em><a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">Why are Aboriginal children still dying from rheumatic heart disease?</a></em></strong></p>
<hr>
<p>Between 1997 and 2013, <a href="http://www.aafp.org/afp/2014/0815/p229.html">97% of patients</a> diagnosed with acute rheumatic fever in the NT were Indigenous, despite Indigenous Australians <a href="http://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/649/1/NT%20Demography%20Factsheet%202015.pdf">representing about 30%</a> of the NT population. Similarly, 94% of people diagnosed with rheumatic heart disease during this time were Indigenous, and Indigenous patients were younger than the non-Indigenous patients.</p>
<p>Poor hygiene, close living and lack of access to medical care are associated with impetigo and its related complications. Resources that help lessen these risk factors will also reduce the burden of impetigo and the diseases that can develop as a consequence.</p>
<hr>
<p><em>Dr Kavya E. Baby, a basic physician trainee with ACT health, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/86066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jackson Thomas received funding from government e.g. RIRDC, ACT Gov, NSW Pharmacy Council, Goodwin aged care facilities, and consultant fee and/or grants from biotech companies</span></em></p><p class="fine-print"><em><span>Asha Bowen receives research funding from the National Health and Medical Research Council of Australia for research to reduce the burden of skin sores in remote Indigenous Australians. </span></em></p><p class="fine-print"><em><span>Erin Walker, Gregory Peterson, Julia K. Christenson, and Nathan M D'Cunha do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While school sores – or impetigo – is a treatable condition, if left untreated it can lead to much more serious illness such as kidney and heart disease.Jackson Thomas, Assistant Professor/Senior Lecturer in Pharmacy, University of CanberraErin Walker, Medical Science Research Fellow, University of CanberraGregory Peterson, Deputy Dean (Research) Faculty of Health, University of TasmaniaNathan M D'Cunha, Sessional Academic, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/843772017-10-19T03:43:54Z2017-10-19T03:43:54ZChildhood heart disease has a profound impact and is under-recognised<figure><img src="https://images.theconversation.com/files/190065/original/file-20171012-31418-avdat7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people assume heart disease is a lifestyle illness that only affects adults. </span> <span class="attribution"><span class="source">Kylie Kennedy</span>, <span class="license">Author provided</span></span></figcaption></figure><p>We are all aware of heart disease in men and women. But childhood heart disease, and its often profound impact on the health and wellbeing of children and their families, is almost invisible.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/22078432">Every day</a> in Australia, eight babies are born with heart disease, worldwide there are about 1.35 million babies with heart disease each year. Childhood heart disease is fundamentally different from heart disease diagnosed in adult life, which typically occurs as arteries become blocked and heart valves deteriorate with age.</p>
<p>Lifestyle factors often contribute to poor heart health in adulthood, but most childhood heart disease is unrelated to lifestyle. There are many different heart conditions that can occur in childhood, with the main distinction being those present from birth and those that develop during childhood.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-a-simple-test-could-save-babies-from-dying-of-heart-disease-6945">How a simple test could save babies from dying of heart disease</a>
</strong>
</em>
</p>
<hr>
<h2>Congenital heart disease</h2>
<p>The most common type is congenital heart disease, in which structural abnormalities of the heart are present at birth. This affects <a href="https://www.ncbi.nlm.nih.gov/pubmed/22078432">one in every 110 newborns</a> and common examples include “holes” in the walls dividing the two sides of the heart, malformed heart valves or chambers, and distortion or obstruction of the main arteries leaving the heart.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190066/original/file-20171012-31381-swq09y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">For some children heart disease may be mild, while some require surgery.</span>
<span class="attribution"><span class="source">Kimberley Low</span>, <span class="license">Author provided</span></span>
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</figure>
<p>Some children with congenital heart disease have minor abnormalities that never affect their health or need intervention. Others have more complex heart abnormalities that critically impact wellbeing or survival. Many complex forms of congenital heart disease are now identified before birth, when a baby’s heart is just the size of a pea. </p>
<p>Babies and children with complex congenital heart disease require care by highly skilled heart health teams. Sometimes care involves a single but major procedure, usually an open heart operation, while others need a series of operations throughout infancy and childhood. There is a small but real risk of death (<a href="https://www.ncbi.nlm.nih.gov/pubmed/28385359">7%</a>) and other important complications. </p>
<p>Congenital heart disease is the <a href="http://www.anzics.com.au/Downloads/2014%20ANZPICR%20Annual%20Report.pdf">most common reason</a> babies are admitted to paediatric intensive care. It’s <a href="https://www.aihw.gov.au/reports/children-youth/a-picture-of-australia-s-children-2012/contents/table-of-contents">also a leading cause of infant death</a>, and one of the <a href="https://www.aihw.gov.au/reports/burden-of-disease/australian-burden-of-disease-study-impact-and-causes-of-illness-and-death-in-australia-2011/contents/highlights">leading causes of disease-related disability</a> in children under the age of five. </p>
<p>The cause of most congenital heart disease is still not known, but we’re <a href="https://www.ncbi.nlm.nih.gov/pubmed/28209227">increasingly finding genes</a> that play an important role. Medical advances have also resulted in marked improvements in survival, with many <a href="https://www.ncbi.nlm.nih.gov/pubmed/27210301">more adults now living</a> with complex congenital heart disease.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-we-dont-know-what-causes-most-birth-defects-78592">Why we don't know what causes most birth defects</a>
</strong>
</em>
</p>
<hr>
<h2>Arrhythmias</h2>
<p>Abnormalities of the heart beat (arrhythmias) can occur at any time in life. For some, these occur in childhood, resulting in abnormal and occasionally dangerous variations in heart rhythm. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190067/original/file-20171012-31381-1r9rhdb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Childhood heart disease has a profound impact on wellbeing.</span>
<span class="attribution"><span class="source">The Children’s Hospital at Westmead.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>For most children, medication and sometimes cardiac catheterisation (long “wires” inserted in an artery or vein and threaded through the blood vessels to the heart), can offer a “normal” quality of life. </p>
<p>There are rare types of arrhythmia conditions without simple cure and where, even in small babies, pacemakers may be needed to sustain normal heart rate or implantable cardiac defibrillators are used to deliver corrective shocks.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">How Australians Die: cause #1 – heart diseases and stroke</a>
</strong>
</em>
</p>
<hr>
<h2>Cardiomyopathies</h2>
<p>Cardiomyopathies are abnormalities of the heart muscle itself, often occurring in families, and can lead to abnormal heart muscle thickening or weakness. Although the majority of these conditions affect adults, changes in the heart can begin in childhood. </p>
<p>Some conditions can lead to sudden death, with medical and psychological interventions key to providing the best possible protection and preservation of quality of life. In rare cases, a heart transplant in childhood will be needed.</p>
<h2>Acquired heart disease</h2>
<p>Heart disease may also develop (or be acquired) in childhood. Rheumatic heart disease can occur after selected bacterial (Streptococcal Group A) infections, and Kawasaki disease (causing inflammation of the blood vessels throughout the body) may impact the circulation of blood in the heart. Muscle damage after certain viral illnesses can reduce the strength of the heart muscle or prevent the heart muscle from functioning properly (such as in myocarditis).</p>
<p>Despite a reducing disease burden worldwide, rheumatic heart disease <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1603693">remains a major challenge in developing countries</a>, and persists in disadvantaged populations in developed countries, where it could be prevented.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">Why are Aboriginal children still dying from rheumatic heart disease?</a>
</strong>
</em>
</p>
<hr>
<h2>Where to from here?</h2>
<p>As our understanding of the genetics of childhood heart disease advances, so too does our capacity for more accurate prediction of risk, more tailored and personalised treatments, and the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1616361">potential for prevention</a>, and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1510687#t=article">improved survival</a> and quality of life.</p>
<p>Research is also finding new strategies for best practice medical and psychological care, <a href="https://www.mja.com.au/journal/2016/205/3/congenital-heart-health-how-psychological-care-can-make-difference">including interventions to “buffer” young children</a> from the psychological consequences of serious medical illness early in life.</p>
<p>Heart disease is an important childhood illness and for those with more complex conditions, there are implications across all stages of life. Although much progress has been made, we need more research, better transition from paediatric to adult heart health care and greater emphasis on mental health care to minimise the lifelong impact of childhood heart disease.</p><img src="https://counter.theconversation.com/content/84377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nadine Kasparian receives funding from the National Heart Foundation of Australia, the National Health and Medical Research Council (NHMRC), and HeartKids Australia. </span></em></p><p class="fine-print"><em><span>David Winlaw receives funding from the National Health and Medical Research Council, HeartKids Australia and previously the National Heart Foundation.</span></em></p><p class="fine-print"><em><span>Gary Sholler receives funding from the National Health and Medical Research Council (NHMRC) and HeartKids Australia.</span></em></p>Children can have heart disease too, and many are born with it.Nadine Kasparian, Associate Professor of Medical Psychology, UNSW SydneyDavid Winlaw, Professor in Paediatric Cardiac Surgery, University of SydneyGary Sholler, Associate Professor in Paediatric Cardiology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/745682017-03-28T15:08:23Z2017-03-28T15:08:23ZWhy palpitations or an irregular heartbeat need urgent attention<figure><img src="https://images.theconversation.com/files/160917/original/image-20170315-5344-1h2l4eg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A normal heart rate is between 60 and 100 beats per minute.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>When your heart’s rhythm is faster than the recommended 60 to 100 <a href="http://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/heart-rate/faq-20057979">beats</a> per minute, it’s time to listen to it. The Conversation Africa’s Health and Medicine Editor Joy Wanja Muraya spoke to Dr Harun Argwings Otieno on why your heart is sending those chaotic electric signals and how this can be managed.</em></p>
<p><strong>What causes an irregular and often rapid heart rate? Why is it so dangerous?</strong></p>
<p>When your heart has an irregular or abnormally slow or fast rhythm, it fails to pump blood around your body as efficiently as it should. </p>
<p>This condition known as <a href="http://www.nhs.uk/conditions/atrial-fibrillation/Pages/Introduction.aspx">atrial fibrillation</a> is characterised by a rapid, irregular pulse and has a significant association with an underlying heart disease.</p>
<p>Though the exact cause isn’t clearly understood there’s evidence that the abnormal electrical signals arising from the left atrium lead to the chaotic, disorganised beats that are characteristic of<a href="https://www.bhf.org.uk/heart-health/conditions/atrial-fibrillation"> atrial fibrillation</a>. There’s a strong association with high blood pressure, ageing, diabetes mellitus, valvular heart disease and coronary artery disease. </p>
<p>In <a href="http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---Coronary-Heart-Disease_UCM_436416_Article.jsp#.WMjv_W-GPIU">coronary heart disease</a>, your arteries are narrowed or blocked by a build-up of cholesterol. Lack of treatment can lead to heart attacks.</p>
<p>In <a href="http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/valvular_heart_disease.html">valvular heart disease</a>, a defect or damage to one of the four heart valves allows blood to leak abnormally. </p>
<p>The valves may either be too narrow to open fully, or they are unable to close completely thus blood flow in and out of the heart is uncoordinated. Valvular heart disease may require surgical treatment to correct the defect. </p>
<p>Atrial fibrillation frequently develops in patients with severe rheumatic heart valve disease involving the mitral valve. </p>
<p><a href="http://www.world-heart-federation.org/press/fact-sheets/rheumatic-heart-disease/">Rheumatic heart disease</a> which is caused by an untreated streptococcal throat infection is another culprit that affects the heart this way.</p>
<p>Some lifestyle <a href="http://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/symptoms-causes/dxc-20164936">conditions</a> like excessive alcohol intake and abnormalities of the thyroid function can also lead to atrial fibrillation. </p>
<p><strong>How does the heart work and how does this disease affect its functionality?</strong></p>
<p>The <a href="http://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/heart-rate/faq-20057979">normal</a> heart rate lies between 60 and 100 beats per minute.</p>
<p>This function originates from the top side of the heart known as the atrial pacemaker that sends signals to the bottom of the heart, ventricles, in a coordinated fashion, known as <a href="https://www.uptodate.com/contents/normal-sinus-rhythm-and-sinus-arrhythmia">normal sinus rhythm</a>.</p>
<p>When the heart is affected, some of the <a href="https://www.heartfoundation.org.au/your-heart/heart-conditions/atrial-fibrillation-arrhythmia">prominent symptoms </a>of the disease includes an irregular heartbeat, easy fatigability, fainting or dizziness.</p>
<p>The real danger with atrial fibrillation is that it may lead to a stroke.</p>
<p><strong>What’s the situation of atrial fibrillation in Kenya?</strong></p>
<p>Kenyan data on this heart condition is scarce. But between 2008 and 2010, we conducted a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734872/">study</a> at the Aga Khan University Hospital Nairobi.</p>
<p>We recruited 162 patients with confirmed atrial fibrillation from 22,144 general hospital medical admissions over a three year period. The average age of patients was 67 years. We analysed them for risk factors and treatment. </p>
<p>Close to 70% of them had high blood pressure, 38% had heart failure, 33% had diabetes mellitus and 19% coronary artery disease. A third of the patients experienced palpitations, dizziness or fainting but 15% had a serious complication of a stroke or an abnormal blood clot.</p>
<p>About 6% died within six months and about 12% were readmitted to hospital.</p>
<p><strong>What needs to be done in the long term to prevent it?</strong></p>
<p>The best management measures are prevention and maintaining a <a href="http://www.mayoclinic.org/healthy-lifestyle">healthy lifestyle</a> which includes balanced meals, regular exercise, proper stress management and quitting smoking and alcohol. </p>
<p>Controlling blood pressure, cholesterol and preventing diabetes are other tips to keep fit.</p>
<p>When the heart condition occurs, seeking a medical consultation to establish the underlying cause is paramount. It’s important to get an ECG (electrocardiograph) to diagnose atrial fibrillation. When ever you experience palpitations, make sure you have your heart checked.</p>
<p>A medical consultation with a cardiologist will advise on how to control the heart rate to prevent worsening of symptoms.</p>
<p>Prescription of strong <a href="https://medlineplus.gov/bloodthinners.html">blood thinners</a> to prevent a stroke is another option to prevent this devastating complication. </p>
<p>In some cases, when detected early, cardiologists can use a <a href="http://www.webmd.com/heart-disease/electrical-cardioversion-defibrillation-for-a-fast-heart-rate">controlled electrical shock</a> to the heart to restore the normal heart rhythm. Medication is also used sometimes for this purpose. </p>
<p><strong>How does new research promise to solve atrial fibrillation?</strong></p>
<p>New medications called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4742513/">direct or novel oral anticoagulants</a> are used to prevent stroke. </p>
<p>They work better than the older medication because one doesn’t need to have regular blood tests to check for the effectiveness of the blood thinner. </p>
<p><a href="http://www.webmd.com/heart-disease/electrical-cardioversion-defibrillation-for-a-fast-heart-rate">Warfarin</a>, a prescription medication used to prevent harmful blood clots from forming or growing, is commonly used.</p>
<p>But its use must be monitored frequently as the medication warns to stay away from certain foods or medications which could interfere with the effectiveness of the blood thinners.</p>
<p>New approaches to treatment include <a href="http://www.webmd.com/heart-disease/atrial-fibrillation/radiofrequency-catheter-ablation-for-atrial-fibrillation">atrial fibrillation ablation</a>, where an electrical current or cold therapy is delivered directly to the heart through specialised plastic tubes or catheters and restores the normal heart rhythm. </p>
<p>This technology is only just maturing and is performed by highly trained heart specialist doctors called <a href="http://www.everydayhealth.com/heart-health/do-you-need-an-electrophysiologist.aspx">electrophysiologists</a>. These doctors manage the heart’s electrical system or heart rhythm disorders. </p>
<p><a href="http://circ.ahajournals.org/content/116/7/782">Genetic studies</a> may reveal underlying factors associated with this condition. </p>
<p>In all, the most important factor in atrial fibrillation is stroke prevention, through careful risk assessment, safe and effective use of blood thinners , controlling the heart rate and restoration of normal rhythm when possible.</p><img src="https://counter.theconversation.com/content/74568/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harun Argwings Otieno does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Atrial fibrillation is a condition that causes a
rapid and irregular heartbeat. The normal heart rate lies between 60 and 100 beats per minute.Harun Argwings Otieno, Senior Lecturer of cardiology, Interventional Cardiologist, Aga Khan University HospitalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/638142016-09-14T20:16:12Z2016-09-14T20:16:12ZWhy are Aboriginal children still dying from rheumatic heart disease?<figure><img src="https://images.theconversation.com/files/135908/original/image-20160830-28253-1dsvhza.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Indigenous Australians in the Northern Territory are more than 100 times as likely to have rheumatic heart disease than their non-Indigenous counterparts.</span> <span class="attribution"><a class="source" href="https://www.youtube.com/watch?v=Prl7t8e8tKM">Screenshot/Take Heart - Strep: Group A Streptococcal Infection</a></span></figcaption></figure><p><em>This article is one in our <a href="https://theconversation.com/au/topics/indigenous-health-package-31054">three-part series</a> on blinding, deafening and sometimes deadly conditions in Indigenous Australian children that have little to no impact on their non-Indigenous counterparts.</em></p>
<hr>
<p>It seems far-fetched to think a sore throat or skin sore could take a lasting toll on your health, leading to heart failure and premature death. But this is the reality for many Indigenous children and young people in Australia’s most vulnerable communities. </p>
<p>For these young people, what we might consider a relatively harmless infection with streptococcus bacteria, in the throat or on the skin, can be the start of a tragic pathway towards life-threatening rheumatic heart disease (RHD). </p>
<p>Yet this pathway is completely avoidable; indeed in mainstream Australia, it is usually avoided. Today, most doctors in major Australian cities will not see a case of acute rheumatic fever, the precursor to RHD. Only around 50 years ago, though, children’s hospital wards were full of children with the two conditions.</p>
<p>The reality is different for Indigenous people. Young Indigenous Australians in the Northern Territory are up to <a href="http://www.aihw.gov.au/publication-detail/?id=60129542750">122 times more likely</a> to have rheumatic heart disease than their non-Indigenous counterparts.</p>
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<p>Rheumatic heart disease is responsible for the <a href="http://www.aihw.gov.au/publication-detail/?id=6442467995">highest gap in life expectancy</a> between Indigenous and non-Indigenous Australians; higher than diabetes or kidney failure.</p>
<p>So why is the condition still prevalent among Indigenous Australians?</p>
<h2>From sore throat to heart disease</h2>
<p>Infection by the <em>Group A Streptococcus</em> bacterium can manifest as either a strep throat or impetigo, commonly known as skin sores.</p>
<p>When fighting a strep infection, around 3% to 6% of people develop an abnormal response which leads to the body’s immune system attacking its own tissues. This happens due to a combination of bacterial, genetic and environmental factors and results in acute rheumatic fever. Symptoms include sore joints, fevers and inflammation of heart valves – which is the most damaging.</p>
<p>When acute rheumatic fever occurs repeatedly, often over many years, valve damage worsens and becomes permanent, resulting in rheumatic heart disease. </p>
<p>Heart valves are like doors in the heart that allow blood to move in one direction only. When they are damaged, the valves allow blood to leak in the wrong direction. This reduces the heart’s ability to pump blood effectively and ultimately leads to heart failure, stroke and sometimes early death. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/136986/original/image-20160908-25272-xvx817.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Heart valves are like doors in the heart that allow blood to move in one direction only.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The pathway to rheumatic heart disease and its complications can be stopped at various points along the way. Acute rheumatic fever can be prevented if the original strep infection is accurately diagnosed and promptly treated with the antibiotic penicillin. But even if acute rheumatic fever occurs, it is not too late to intervene. </p>
<p>After even just a single episode of acute rheumatic fever, young people need <a href="https://www.rhdaustralia.org.au/arf-rhd-guideline">monthly injections of penicillin</a> for at least a decade, often longer. This protects them from further strep infections, subsequent episodes of rheumatic fever and further damage to the heart valves. Although this strategy works, it requires painful injections that need to be given on time, every month, for at least a decade.</p>
<p>In addition to these injections, people with rheumatic fever require long-term check-ups. If they have rheumatic heart disease, they require life-long clinical review, regular heart scans and long-term medication to treat heart failure or heart-rhythm abnormalities.</p>
<p>If the heart-valve damage is severe, surgery may be needed to repair or even replace the valve. This can only be done in major hospitals, often thousands of kilometres away from where the person lives. Surgery can be life-saving, although it doesn’t cure rheumatic heart disease.</p>
<h2>RHD in Australia and the world</h2>
<p>Rheumatic heart disease was common until the 1960s in wealthy populations, including major Australian cities.</p>
<p>Since then, improved living standards in high-income countries have reduced the transmission of the bacterial infection. A combination of less crowded housing, improved sanitation and better access to health services also resulted in a dramatic decrease in the incidence of acute rheumatic fever and resultant heart disease. </p>
<p>Penicillin has also had an added impact, both in preventing initial episodes of rheumatic fever by treating sore throat, and in preventing recurrences that enable slow disease progression. </p>
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<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=493&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=493&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=493&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=619&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=619&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137322/original/image-20160912-3766-hibjbz.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=619&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The above are critical elements of the Endgame Strategy, currently under development by the END RHD Centre of Research Excellence. See www.rhdaustralia.org.au.</span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>Over the last few decades, however, an uncontrolled epidemic of rheumatic heart disease has been uncovered in developing countries and our own Indigenous populations, especially those living in rural and remote areas of northern and central Australia.</p>
<p>Today, rheumatic heart disease affects more than 32 million people worldwide and claims more than 275,000 lives each year. Almost all cases <a href="http://rhdaction.org/atlas/">occur in low and middle-income countries</a>, with the greatest burden being among some of the most disadvantaged populations.</p>
<p>Particular hotspots include sub-Saharan Africa, parts of South Asia and the South Pacific. However, the highest rates of rheumatic heart disease are in Australia.</p>
<p>The social, economic and human consequences of the disease are profound. Indigenous Western Australians with rheumatic heart disease die, on average, <a href="http://www.ncbi.nlm.nih.gov/pubmed/25070793">at 40 years old</a>. Children must travel for heart surgery; young adults live with premature disability; and pregnant women face high-risk pregnancies.</p>
<p>Rheumatic heart disease remains an outstanding, preventable blight for a nation committed to closing the life-expectancy gap. Australia has a national approach to acute rheumatic fever and rheumatic heart disease control. We must not only ensure this approach continues, but that it expands, with properly funded, evidence-based interventions.</p><img src="https://counter.theconversation.com/content/63814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Carapetis receives funding from National Health and Medical Research Council, Austrade, Novartis Institutes for BioMedical Research & Medtronic Foundation.</span></em></p>Rheumatic heart disease is responsible for the highest gap in life expectancy between Indigenous and non-Indigenous Australians; higher than diabetes or kidney failure.Jonathan Carapetis, Professor, Paediatrics, Telethon Kids InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/633902016-08-03T20:10:59Z2016-08-03T20:10:59ZVaccine for strep throat and rheumatic fever to be trialled in humans<figure><img src="https://images.theconversation.com/files/132900/original/image-20160803-7769-12swq85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Not only will a nasal vaccine avoid the 'ouch' factor, it gets the vaccine straight to the most common site of infection.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Infection with group A streptococcus bacteria (strep A) leads to a wide array of diseases. These range from uncomplicated infections such as strep throat (tonsillitis) and skin sores (impetigo), through to severe invasive diseases such as deep soft tissue infection, sepsis and streptococcal toxic shock syndrome. </p>
<p>If strep infections are left untreated, they can lead to rheumatic fever and rheumatic heart disease. These are caused by the immune system’s response to the initial infection.</p>
<p>Globally, <a href="http://www.ncbi.nlm.nih.gov/pubmed/16253886">more than 616 million</a> new cases of strep throat are recorded each year. While this places a significant burden on health systems and causes substantial productivity losses, the invasive and post-infectious diseases are responsible for the most death and disease. </p>
<p>It is estimated at least <a href="http://www.ncbi.nlm.nih.gov/pubmed/16253886">18.1 million people</a> have rheumatic fever or rheumatic heart disease and there are more than 645,000 new cases each year. In urban China, rheumatic heart disease affects <a href="http://www.ncbi.nlm.nih.gov/pubmed/16503258">approximately 2 million</a> middle-aged to elderly people (186 people per 100,000). This is about ten times higher than the rate in countries such as Canada (22 people per 100,000) and Japan (14 people per 100,000).</p>
<p>Of particular significance to Australia is the rate of rheumatic heart disease in our Indigenous population, estimated to be a <a href="http://www.ncbi.nlm.nih.gov/pubmed/8628132">staggering 651 per 100,000 people</a>.</p>
<p>Overall, strep A is responsible for more than 500,000 deaths worldwide each year. This is <a href="http://www.who.int/malaria/publications/world-malaria-report-2015/report/en/">more deaths worldwide than malaria</a>. </p>
<h2>Strep A vaccine</h2>
<p>The development of a vaccine to combat strep A has been particularly challenging. Group A streptococcus is a gram-positive bacterial pathogen, meaning they have no outer membrane and are thus generally more susceptible to antibiotics. More than 200 known strains are circulating globally. </p>
<p>Not only do we need a vaccine able to address the diversity of various strains of strep A in the community, we also need to ensure the vaccine itself does not induce autoimmune complications.</p>
<p>Our team has invented a vaccine candidate comprising a small peptide (part of a protein) found on the surface of all strains of the bacteria. We found this peptide is effective at stimulating the body’s immune system to protect against infection by multiple strains of streptococcus A.</p>
<p>Our latest discovery is to embed this peptide into a liposome (a tiny, synthetic ball), which mimics the structure of microorganisms to better stimulate the correct immune response.</p>
<p>Our vaccine has the additional advantage of being delivered needle-free (via a spray into the nose) and directly to the lining of the upper respiratory tract. Not only is this method of delivery less invasive (and hence preferential to a jab in the arm), it elicits a better response from the immune cells in the respiratory tract lining, which is the most common site of strep A infections.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=357&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=357&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=357&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=449&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=449&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132901/original/image-20160803-7749-15antsh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=449&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mechanism of the streptococcus A vaccine.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>When will it be available?</h2>
<p>Griffith University has just entered into a major co-development and licence arrangement with Chinese vaccine company Olymvax Biopharmaceuticals Inc. We have demonstrated in the laboratory that our vaccine is effective, so now we will be able to manufacture vaccine material and complete phase one human clinical trials in healthy volunteers.</p>
<p>We plan to conduct parallel trials in China and Australia within the next two years. In Australia, we propose to conduct studies in an Indigenous population – where it is most urgently needed. </p>
<p>We plan to have the vaccine on the market within six to eight years. Olymvax has the rights to commercialise the vaccine in China, while Griffith retains the ability to commercialise the vaccine in Australia and other global markets.</p>
<p>Given its global significance, there is a very strong case for a strep A vaccine to be incorporated into universal immunisation programs, in particular the routine childhood vaccination schedule.</p>
<hr>
<p><em>Dr Phil Ellery, Business Manager, Institute for Glycomics, Griffith University, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/63390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Davis works for Griffith University. As General Manager, he does not receive funding for research from any organisation. </span></em></p><p class="fine-print"><em><span>This work was supported by the National Health and Medical Research Council (NHMRC) program grant (496600). M.Z. is funded by the NHMRC Peter Doherty - Australian Biomedical Fellowship (APP1069915).
M.F.G. and M.Z. are co-inventors on patents related to the liposome technology. These patents have been licensed to Olymvax Biopharmaceuticals.</span></em></p><p class="fine-print"><em><span>Michael Batzloff received funding from National Heart Foundation of Australia and the NHMRC. </span></em></p><p class="fine-print"><em><span>Michael Good and all of the authors above work for Griffith University who own the IP attached to this vaccine and will potentially benefit from future dividends. Michael Good also receives funding from the NHMRC, the National Heart Foundation, the CRC for Aboriginal Health, the CRC for vaccine Technology, the National Institutes of Health (USA) and The Prince Charles Hospital Foundation.</span></em></p>Infection with streptococcus bacteria leads to a wide array of diseases ranging from strep throat to rheumatic heart disease.Chris Davis, General Manager Executive, Institute for Glycomics, Griffith UniversityMehfuz Zaman, Research Fellow, Institute for Glycomics, Griffith UniversityMichael Batzloff, Research Leader, Institute for Glycomics, Griffith UniversityMichael Good, Professor of Glycomics, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/243462014-06-17T04:46:26Z2014-06-17T04:46:26ZIndigenous Australia left behind in rheumatic heart disease fight<figure><img src="https://images.theconversation.com/files/50466/original/vhm2t93w-1402033576.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rheumatic fever and rheumatic heart disease are endemic in Australia's Indigenous communities. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/publik16/2595564253/sizes/o/">Flickr: publik16</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Vintage medical textbooks are filled with diagnoses unfamiliar to contemporary doctors – wandering wombs, blackwater fever, biliousness and other historic curios. Acute rheumatic fever has become one of these anachronisms in developed countries but Australia has a shameful secret.</p>
<p>Improvements in living standards, reduction in overcrowding and access to health care have made the acute rheumatic fever rare in most of the country. Yet, in low-resource settings, including in Aboriginal and Torres Strait Island communities, the illness remains painfully real.</p>
<h2>How it works</h2>
<p><a href="http://www.rhdaustralia.org.au/sites/default/files/arf_rhd_qrg_01.pdf">Acute rheumatic fever</a> is an abnormal immune response to throat and skin infections from the bacteria group A streptococcus. Usually, the bacteria are harmless colonisers of the nose and mouth, but an active infection causes people develop a “<a href="http://newsroom.heart.org/news/diagnosing-treating-strep-throat-228156">strep throat</a>”. </p>
<p>This prompts the body’s immune system to respond. In most cases, the immune response is appropriately targeted to kill bacteria and the infection resolves. </p>
<p>In some cases, the body mistakenly targets normal tissues in the body, including the heart, skin and joints. This causes the joint pain and fevers characteristic of acute rheumatic fever. </p>
<p>Approximately 3% of children are susceptible to acute rheumatic fever after a strep throat infection. The determinants of this susceptibility are a combination of environmental factors (overcrowding, for instance, or inadequate housing), genetics, and bacterial characteristics (including the subtype of the bacteria). The way these factors interact to cause disease remains unclear.</p>
<p>Young people who develop the illness experience <a href="http://www.rhdaustralia.org.au/sites/default/files/arf_rhd_qrg_02.pdf">symptoms</a>, such as fevers, painful joints, skin and movement changes, two or three weeks after infection. Most will also experience inflammation of the heart membrane, muscle and valves, which is known as carditis. </p>
<p>The fever and joint pains that typify acute rheumatic fever tend to resolve over a period of weeks, but damage to the heart valves generally persists. </p>
<p>Those who’ve had one episode of the illness are much more likely to have recurrent episodes because of factors that made them susceptible in the first place. Each recurrence causes further heart damage. </p>
<p>Eventually, the valves of the heart become scarred. This chronic phase of the disease is called rheumatic heart disease. Over time, it increases the risk of heart rhythm disturbances, stroke and heart valve infections, and culminates in heart failure.</p>
<p>Once common worldwide, both illnesses have declined due to economic development and improved access to health care, antibiotics and treatment of the causal “strep throat”. </p>
<p>Today, more than 80% of people living with rheumatic heart disease worldwide are from low and middle-income countries, reflecting poverty, overcrowding, under-nutrition and limited access to health care. </p>
<h2>Australia’s shame</h2>
<p>Rheumatic fever and rheumatic heart disease are also endemic in Australia’s Indigenous communities. Indigenous Australians are <a href="http://www.aihw.gov.au/publication-detail/?id=60129542750">122 times</a> more likely to live with rheumatic heart disease than their non-Indigenous peers. </p>
<p>Statistics too readily sanitise the human reality of rheumatic heart disease, which contributes tremendous personal, social, economic and community harm to young people in the prime of life. In the Kimberly, the average age of death from the illness is <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12112/abstract">41 years</a>. </p>
<p>The greatest tragedy is that it’s possible to reduce the burden of rheumatic heart disease and control the development of new cases.</p>
<p>Preventing the first bout of the illness requires timely diagnosis of strep throat infections and prompt delivery of antibiotics. The goal is to prevent the abnormal immune response that causes acute rheumatic fever.</p>
<p>Antibiotics can prevent almost all cases but require medical evaluation of all sore throats. The problem is that in Indigenous Australian populations, sore throats are comparatively rarely seen to by doctors. The fact that sore throats may be mild makes it difficult to diagnose and treat infections. </p>
<p>People who have a demonstrated susceptibility to acute rheumatic fever require regular antibiotics, with the goal of preventing new strep throat infections. Young people who’ve had the disease, or who are known to have rheumatic heart disease, need penicillin for at least a decade – until the highest risk of recurrence has passed. </p>
<p>The most reliable form of penicillin for this purpose is a long-acting injection delivered into muscle every four weeks. But the health system struggles to contact people in remote settings who move frequently or don’t have reliable telecommunications to remind them about injections. </p>
<p>Sending a nurse to give the injection or arranging for people to come to the clinic can be complicated. And, the injections are painful, inconvenient and frequent for people living with rheumatic heart disease. </p>
<p>Although there are early signs of progress in disease control, both illnesses remain persistent and present an indefensible disparity between Indigenous and non-Indigenous Australians.</p>
<p>The functional disappearance of acute rheumatic fever is a triumph, but the continued burden of disease in Indigenous Australia precludes celebration. Greater and better targeted efforts are needed to make acute rheumatic fever and rheumatic heart disease anachronisms across all of Australia.</p><img src="https://counter.theconversation.com/content/24346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rosemary Wyber does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Vintage medical textbooks are filled with diagnoses unfamiliar to contemporary doctors – wandering wombs, blackwater fever, biliousness and other historic curios. Acute rheumatic fever has become one of…Rosemary Wyber, Global health and rheumatic heart disease researcher at Telethon Kids Institute, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.