Community-led approach reducing rheumatic fever

A community-based research project in the Northern Territory is providing hope to remote communities in reducing rheumatic fever cases and the bacterial infections that trigger the condition.

Rheumatic fever, caused by household crowding and high rates of untreated streptococcal infections in children, can have devastating consequences, such as causing heart disease at a young age.

Community-driven activities key to success

The study – part of a 4-year collaboration with Menzies School of Health Research, Telethon Kids Institute, Sunrise Health Service and NT Health – focused on reducing household health risks through community-based activities led by Aboriginal Community Workers, in a bid to curb infection rates.

Housing and environmental health support – such as fixing showerheads, broken pipes and other health hardware – as well as information-sharing about rheumatic fever and assisting families to navigate healthcare, made up the focus of the activities.

This helped people gain the knowledge needed to seek medical treatment, which initially increased the number of reported infections. Because those infections were then able to be properly treated, rates of infection decreased to below baseline levels, especially in children.

Study co-author and Chairperson of the Board for Sunrise Health Service, Anne-Marie Lee, said the findings suggested the community-led activities translated into a reduction of the types of infection that drive rheumatic fever. The number of new cases of rheumatic fever also decreased during the study.

“Indigenous people working on the ground from that community, it works well. It doesn’t work if an outsider thinks that they can come in. You have to get local people on the ground to do the job,” Ms Lee said.

Director of RHDAustralia and Aboriginal advisor for the study, Ms Vicki Wade, agreed.

“It is so important for rheumatic fever control to be community-led. Rheumatic fever is fuelled by the socio-economic determinants of health, so that’s what we need to tackle, using scientifically based approaches that are co-designed in partnership with communities,” Ms Wade said.

Members of the research team together in Northern Territory, Australia
Members of the research team together in Northern Territory, Australia (L-R): Dr Vicki Kerrigan, Angela Kelly, Anne-Marie Lee, Segora Babui, Professor Anna Ralph, Valerina Mungatopi, Catherine Halkon

First of its kind study in Australia

Study lead and Senior Clinical Research Fellow at Menzies School of Health Research, Professor Anna Ralph, said rheumatic fever had declined in southern parts of Australia and globally in high income countries in the mid-1900s as standards of living improved – otherwise known as primordial prevention.

“Translating the key components of primordial prevention into tropical and central Australia requires innovation and strong partnerships,” Professor Ralph said.

“This is the first time Australian data has been published on the health impacts of community-led rheumatic fever primordial prevention. These findings are promising but need to be scaled up to whole communities.”

The research has been published in the International Journal of Environmental Research and Public Health and funded by the National Health and Medical Research Council, the National Heart Foundation and Bupa Foundation.

Access to testing and treatment in prisons is crucial to hep C elimination

Hepatitis C testing and treatment in prisons is key to reducing infections, according to a Kirby Institute-led study involving over 3,600 incarcerated people.

Hepatitis C is a virus that affects the liver, and if left untreated, can lead to cirrhosis, cancer, liver failure and death. It is transmitted through blood-to-blood contact, and predominantly affects people who inject drugs in Australia and globally.

Curing hepatitis C

The World Health Organization has set the ambitious target of eliminating hepatitis C as a public health threat by 2030. Hepatitis C is curable with direct-acting antiviral (DAA) therapy, which has been available in Australia through the Pharmaceutical Benefits Scheme since 2016. Uptake has been very good in Australia, but there still remain some groups who could benefit from greater access.

A world-first Australian study has shown that broad access to hepatitis C testing and treatment in prisons halves the number of new infections in that setting.

The study, led by the Kirby Institute at UNSW Sydney, took place over five years, and was published in The Lancet Gastroenterology and Hepatology in May 2021. It involved testing over 3600 incarcerated people for hepatitis C, and offering treatment in the case of a positive result.

Increasing testing and access to treatment

“Australia is a world-leader in hepatitis C elimination, and we are on track to meet the World Health Organization’s elimination goal by 2030, thanks to accessible and affordable, curative DAA treatment, and well-targeted access to testing and clinical care,” says Professor Gregory Dore from the Kirby Institute, who is co-Chief Investigator on the study.

“We know there are high rates of hepatitis C transmission in prisons, so it is vital that strategies are in place to test and treat incarcerated people.”

“Our study has shown that by improving access to testing and treatment, hepatitis C transmissions are significantly reduced. This ultimately means lower rates of hepatitis C in our prisons, and by extension in the wider community. As encouraging as the findings are, we believe expansion of harm reduction in the prison setting would provide even greater prevention impact.”

Professor Gregor Dore, co-Chief Investigator, Kirby Institute, UNSW Sydney
Professor Gregor Dore

“Treatment-as-prevention”

The study tested the efficacy of a strategy known as ‘treatment-as-prevention’, which is the principle that by implementing broad testing and treatment of an infection, transmission pathways are interrupted, resulting in fewer infections. While there is already a body of evidence showing that treatment-as-prevention works for HIV, as well as people with both HIV and hepatitis C, this study is the first to test treatment-as-prevention for those living with or at risk of hepatitis C infection in prisons, and the largest to take place in any setting.

“The model we deployed in this study was shown to be highly successful in reducing hepatitis C transmission in prisons, and it’s a model that can be replicated in prisons across Australia and the world.”

Professor Andrew Lloyd also from the Kirby Institute, and co-Chief Investigator on the study.
Professor Andrew Lloyd

Creating a toolkit

“Using this evidence base, we have developed a toolkit for how to implement hepatitis C testing and treatment at scale in prisons with the aim of dramatically reducing or eliminating hepatitis C transmission using this treatment-as-prevention strategy.”

The Implementation Toolkit is designed for health service and corrections administrators, ensuring the swift implementation of the research findings into practical strategies to optimise health and eliminate disease.

The researchers say that, through a comprehensive public health approach across all sectors of the community, elimination of hepatitis C by 2030 is achievable. “Expanding access to hepatitis C testing and treatment within prison settings is key to achieving elimination both within the prison and the wider community. The evidence gained from this study makes the strong case, and provides a blueprint, for delivering these important health services in prisons across the world,” says Professor Lloyd. “From both a public health and human rights perspective, it is vitally important that incarcerated people have access to curative hepatitis C treatment and care.”

The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study was funded by the National Health and Medical Research Council and Gilead Sciences. The SToP-C Implementation Toolkit is accessible at https://stopc.org/. The toolkit is for health and corrections administrators and sets out a best-practice model to implement hepatitis C testing and treatment in prisons.