Islands Business - Health: RHEUMATIC HEART DISEASE ON THE RISE

Pacific has highest incidence rate in the world

Ana Laqeretabua
Developing effective control programmes that could prevent children and adults from developing severe Rheumatic Heart Disease is a challenge that most Pacific Islands countries have yet to realise.

With statistics revealing the Pacific islands states as having the highest incidence rates of Rheumatic Fever in the world (six times the average of the next highest region) and the highest Rheumatic Heart Disease (RHD) prevalence, the figures are alarming.

In Tonga and Samoa, approximately 3% of all children, between the ages of 5-14 years, and 5-10% of young adults are estimated to be suffering from RHD due to the fact that they were not screened or treated in time.

A report from the World Heart Federation determines that these figures are almost certainly replicated throughout the Pacific Islands nations.

Large proportions of health budgets are spent on important, but essentially palliative heart surgery in the region.
Samoa currently spends 12% of the total health budget on open heart surgeries for children and young people who need to have heart valve repair or replacement. The knowledge that RHD is almost entirely preventable through simple, proven cost-effective measures makes the disease more of a concern.

The World Heart Federation estimates that it affects some 3% of all children; kills over 100,000 people a year; and causes the loss of nearly 1.8 million disability-adjusted life years in the South Pacific region.

It is with this backdrop that the World Heart Federation has introduced the Pacific Rheumatic Heart Programme in collaboration with the Ministries of Health of Fiji and Samoa and the Menzies School of Public Health in Darwin, Australia.

How’s the heart working? A Samoan doctor checks a child’s heart beat.

The programme has four components: two demonstration projects; a training initiative; and a web-based RHD resource centre.

The programme’s regional training component covers 20 Pacific Islands states, and is run in collaboration with the World Health Organisation. A grant from the Vodafone Group Foundation of the United Kingdom has enabled the federation to make a three-year commitment to the demonstration projects in Samoa and Fiji.

Though only anecdotal, the evidence of the impact of health worker training under the programme is strong.

Last year, a young girl was admitted to a district hospital in Fiji for pneumonia. For several years and over many visits to a local clinic, her Acute Rheumatic Fever (ARF) and RHD had not been identified and her joint pain and shortness of breath were treated with medication for pain and asthma.

A hospital nurse who had just attended the World Heart Federation RHD workshop identified her symptoms and she was immediately transferred to the main hospital in Suva, where the diagnosis was confirmed. Tragically, it was too late and the child died the day of her arrival.

RHD is a disease of poverty. Practically eliminated in developed countries, it remains the most common heart disease of children and young people in developing countries. It is caused by an autoimmune reaction to an untreated infection caused by Streptococcus A bacteria.

This reaction, acute rheumatic fever (ARF), develops days or weeks after this initial infection. It disappears in a few weeks, but the heart damage left behind will worsen progressively with each recurrence of ARF.

The diagnosis of ARF/RHD is often missed until the heart damage has progressed so far that only expensive and complicated surgery can save the patient’s life. This heart surgery is often completely out of reach of most people living in the Pacific islands countries and as few of the islands have the capacity to perform heart surgeries domestically, huge amounts—up to 10-15% of their total health budgets—are spent on sending RHD patients abroad for heart surgery.

Chairman of the Fiji RHD technical advisory group, Dr Joseph Kado explains the significance of early treatment at the rheumatic fever stage.

“Once a child has rheumatic fever, which is caused by bacteria, the treatment is to prevent them from getting another attack of the germ so the treatment is three weekly or four weekly injections. This amounts to about 13 or 14 injections a year.

“The cost of that would be ten cents per injection. But if we don’t pick up the signs and treat them and the child gets to a stage where they need surgery, they will either have to wait for the visiting cardiac team or need to fundraise or use their life savings to arrange to go overseas for surgery.

“Instead of maybe $2.50 for the preventative treatment, it runs into $25,000—$30,000 for an operation in Australia or New Zealand,” Dr Kado said.

The point is further emphasised by the revelation that out of the 32 heart surgeries performed by visiting cardiac teams to Fiji last year, 28 were related to RHD.

“Then your medication gets worse after surgery—you not only go for injections every three or four weeks, you take blood thinning medicine and often get tested to make sure that your blood is not too thin or too thick.

“If you don’t take your medicine, you have a blood clot, you get a stroke, if you take too much, you have a bleed in your head and you get a stroke, so it really gets complicated and you will have to balance yourself well. For us, the workload is really much heavier after the surgery compared to before where we can still cure and treat it.”

The Way Forward

The World Heart Federation (WHF) is promoting a coordinated register-based programme in the region which is recognised by WHO and others as the best approach to secondary prevention of RHD.

Through the programme, accurate, up-to-date registers of people with known or suspected past ARF and RHD are developed, with systems in place to ensure they receive prophylaxis (secondary prevention) and good clinical care.

According to the WHF, the programme is cheap, practical, proven with the ability to implement a national register-based programme in a Pacific Islands country for the cost of two to four valve operations each year.

In Fiji, a central register has been developed through the programme to enable the health system to follow up on all cases of RHD, coordinate their care as well as track compliance. The register database captures demographic, current disease information and ARF/RHD history on individuals.

It includes mechanisms to create unique lists of local treatment centers, ethnicities and places where cardiac surgery is done and contains a series of automated reports. Two project nurses have been employed to enter information on known cases from existing records, and to maintain communication links to ensure that new cases identified are notified for entry into the register.

Last month, more than 30 RHD patients in Fiji received free text messages through Vodafone Fiji Limited reminding them they were due for their next round of treatment.

Health systems

Whilst implementers of the programme are pleased with the progress made, the challenges of implementation remain.

As commonly known in the region, the lack of human and financial resources is compounded by isolation, and often also serious logistic problems serving populations dispersed over many small islands. Moves are being made to strengthen and expand RHD epidemiology, prevention and control in the Pacific Islands.

Last October, the first World Heart Federation and World Health Organisation workshop on Rheumatic Heart Disease was held at Nadi and attended by clinicians and public health officials from 11 Pacific islands nations, and representatives from several international organisations.

The workshop offered clinicians and health officials in isolated areas a much needed chance to share information and update knowledge and skills.

It included training on the use of the register database. Programme staff also gave technical assistance to clinicians from Vanuatu and Tonga to help them adapt the World Heart Federation database to their own programs.

At the end of the workshop, the group issued a Call to Action highlighting the magnitude of the burden of RHD in the Pacific and calling on governments and international organisations to establish and maintain RHD control programmes.

A committee was formed (with representatives from Tonga, Fiji, Palau, Vanuatu and Samoa) to guide strategies for developing a long-term regional RHD prevention programme.

A similar meeting is scheduled for October, this time including representatives from 20 Pacific islands countries.