tag:theconversation.com,2011:/us/topics/rheumatic-fever-10867/articlesRheumatic fever – The Conversation2017-12-11T01:49:16Ztag: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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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>
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<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>
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<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>
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<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>
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<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>
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<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/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>
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<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>
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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>
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<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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<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>
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<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/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.