Evidence-based policy to end rheumatic heart disease in Australia

Abstract

Rheumatic heart disease (RHD) stems from an abnormal immune response to Streptococcus pyogenes infection. The disease affects 40 million people globally, overwhelmingly in settings where resource constraints and equity gradients are large. In Australia, more than 5000 people live with RHD or its precursor acute rheumatic fever (ARF), the vast majority of whom are Aboriginal or Torres Strait Islander people.

In this thesis, I outline a framework for reducing the burden of RHD among Aboriginal and Torres Strait Islander people in Australia. I use this framework to outline the international evidence for disease control strategies, synthesise approaches to eliminate RHD in Australia, and present empiric findings for selected approaches in primary care prevention.

Section 1 introduces the issue of RHD and the scope of this thesis. Section 2 contextualises RHD control in Australia and internationally, beginning with Chapter 1 outlining RHD control programs and registers. Chapter 2 provides an overview of awareness of RHD and advocacy initiatives worldwide. Chapter 3 addresses the direct and indirect drivers of the disproportionate burden of RHD experienced by Indigenous people living in high-income countries. Section 3 addresses the opportunities for RHD control in Australia, first in Chapter 4 by synthesising evidence for strategies to achieve RHD elimination in Australia. Chapter 5 explores mathematical modelling of these strategies. Section 4 examines primary care interventions for prevention of ARF in more detail, beginning with review of current guidelines in Chapter 6. Chapter 7 outlines recommendations for Australian primary care providers for primary prevention of ARF and uses an eDelphi prioritisation method to understand primary care provider preferences for improving care delivery. Finally, Chapter 8 outlines the evaluation of a community-based intervention addressing environmental health and support for households affected by RHD.

In Section 5, I discuss how, collectively, these studies provide a consolidated approach to addressing RHD in Australia at community, provider, health system and policy levels. This thesis offers new evidence for effective environmental health and primary prevention strategies to reduce rheumatic fever incidence and provides a comprehensive foundation for action to eliminate RHD in the next decade in Australia.