Category	No. cases	Crude rate of ARF at initial hospitalization/100,000 population	aRR (95% CI)	RR in 2010–2018 vs. 2000–2009 (95% CI)
Age†
<5	35	0.62	0.18 (0.13–0.25)	0.42 (0.20–0.88)
5–9	768	13.45	4.10 (3.57–4.70)	1.01 (0.88–1.17)
10–14	1,184	20.55	6.58 (5.77–7.51)	1.08 (0.96–1.21)
15–19	308	5.27	1.81 (1.54–2.13)	1.29 (1.03–1.62)
20–29	276	2.27	Referent	1.86 (1.45–2.38)
Sex‡
M	1,493	8.60	1.34 (1.24–1.45)	1.09 (0.99–1.21)
F	1,078	6.42	Referent	1.18 (1.05–1.33)
Ethnicity (prioritized)§
Māori	1257	16.77	11.84 (10.02–13.98)	1.09 (0.98–1.22)
Pacific Islander	1124	38.12	23.57 (19.88–27.94)	1.30 (1.16–1.47)
Asian	23	0.55	0.64 (0.41–0.99)	0.41 (0.18–0.98)
European and other	167	0.86	Referent	0.61 (0.44–0.84)
Socioeconomic deprivation level¶
1–2	61	1.06	Referent	0.63 (0.38–1.05)
3–4	128	2.16	1.65 (1.21–2.23)	0.85 (0.60–1.20)
5–6	160	2.51	1.60 (1.19–2.25)	0.91 (0.67–1.24)
7–8	405	5.57	2.58 (1.96–3.38)	1.31 (1.08–1.59)
9–10	1,817	20.58	5.21 (4.01–6.75)	1.16 (1.06–1.27)
District health board#
Northland	206	17.36	7.56 (4.39–13.02)	1.10 (0.84–1.45)
Counties Manukau, South Auckland	909	21.67	7.37 (4.32–12.53)	1.23 (1.08–1.41)
Tairawhiti, Gisborne	63	16.01	5.47(3.06–9.80)	1.45 (0.88–2.39)
South Island, 5 DHBs	67	0.91	Referent	1.21 (0.71–1.88)
Total	2,571	7.53		1.13 (1.04–1.22)

Table 1. Acute rheumatic fever initial hospitalizations and adjusted rate ratios for patients <30 years of age, according to key sociodemographic characteristics, New Zealand, 2000–2018*

*An additional 181 (6.6% of total) cases occurred among persons ≥30 years of age during 2000–2018. aRR, adjusted rate ratio; DHB, district health board; RR, rate ratio.
†RR adjusted for sex, ethnicity, and socioeconomic deprivation.
‡RR adjusted for age, ethnicity, and socioeconomic deprivation.
§RR adjusted for age, sex, and socioeconomic deprivation.
¶RR adjusted for age, sex, and ethnicity.
#RR adjusted for age, sex, ethnicity, and socioeconomic deprivation; 3 DHBs highest incidence and 1 DHB with lowest incidence shown. A full list of DHBs is provided in Appendix Table 1).

Characteristics	No. cases	Crude rate of RHD at initial hospitalization/100,000 population	aRR (95% CI)	RR in 2010–2018 vs. 2000–2009 (95% CI)
Age, y†
0–9	154	1.35	Referent	1.53 (1.11–2.11)
10–19	322	2.77	2.21 (1.82–2.68)	1.51 (1.21–1.88)
20–29	164	1.47	1.30 (1.04–1.62)	0.95 (0.69–1.29)
30–39	208	1.87	1.83 (1.49–2.26)	0.81 (0.62–1.07)
40–49	420	3.60	3.84 (3.19–4.62)	1.07 (0.88–1.30)
50–59	678	6.69	7.66 (6.43–9.14)	0.93 (0.80–1.08)
60–69	957	12.87	15.66 (13.18–18.61)	1.13 (1.00–1.29)
Sex‡
M	1,405	3.74	1.12 (1.04–1.21)	1.14 (1.03–1.26)
F	1,498	4.06	Referent	1.04 (0.93–1.15)
Ethnicity§
Māori	892	7.30	3.21 (2.93–3.52)	1.24 (1.09–1.42)
Pacific Islander	574	11.60	4.62 (4.16–5.15)	1.28 (1.08–1.51)
Asian	123	1.47	0.71 (0.59–0.86)	0.80 (0.56–1.14)
European and other	1,314	2.68	Referent	0.95 (0.86–1.10)
Socioeconomic deprivation level¶
1–2	222	1.60	Referent	0.79 (0.60–1.02)
3–4	324	2.34	1.42 (1.20–1.68)	0.85 (0.68–1.05)
5–6	441	3.05	1.76 (1.49–2.06)	1.07 (0.89–1.29)
7–8	642	4.15	2.19 (1.88–2.55)	1.12 (0.56–1.31)
9–10	1,274	7.58	3.10 (2.67–3.60)	1.21 (1.09–1.36)
District health board#
Northland	150	5.57	1.32 (1.03–1.69)	0.94 (0.68–1.29)
Counties Manukau, South Auckland	478	5.70	1.44 (1.16–1.78)	1.05 (0.88–1.26)
Tairawhiti, Gisborne	90	11.13	2.38 (1.79–3.16)	1.73 (1.12–2.66)
Hutt Valley, Wellington	107	4.33	1.51 (1.15–1.97)	1.38 (0.94–2.03)
Southern, South Island	110	2.14	Referent	1.11 (0.76–1.61)
Total	2,903	3.90		1.09 (1.01–1.17)

Table 2. Rheumatic heart disease initial hospitalization rates and adjusted rate ratios for patients <70 years of age according to key sociodemographic characteristics, New Zealand, 2000–2018*

*An additional 2,212 (43.2% of total) cases occurred among persons ≥70 years of age during 2000–2018. aRR, adjusted rate ratio; DHB, district health board; RHD, rheumatic heart disease; RR, rate ratio.
†RR adjusted for sex, ethnicity, and socioeconomic deprivation.
‡RR adjusted for age, ethnicity, and socioeconomic deprivation.
§RR adjusted for age, sex, and socioeconomic deprivation.
¶RR adjusted for age, sex, and ethnicity.
#RR adjusted for age, sex, ethnicity, and socioeconomic deprivation; 4 highest incidence DHBs, and the 1 lowest DHB shown. A full list of DHBs is provided in Appendix Table 1).

Category	No. deaths	Crude rate of RHD deaths/100,000 population	aRR (95% CI)	RR during 2010–2016 vs. 2000–2009 (95% CI)
Age, y†
<40	126	0.31	Referent	0.66 (0.45–0.96)
40–49	163	1.56	7.27 (5.76–9.18)	0.68 (0.49–0.94)
50–59	249	2.80	15.09 (12.17–18.72)	0.53 (0.41–0.70)
60–69	352	5.48	34.15 (27.80–41.95)	0.56 (0.45–0.69)
Sex‡
M	394	1.21	0.88 (0.75–0.98)	0.56 (0.45–0.69)
F	496	1.49	Referent	0.61 (0.51–0.73)
Ethnicity§
Māori	467	4.34	12.27 (10.32–14.58)	0.53 (0.44–0.65)
Pacific Islander	190	4.37	11.16 (9.05–13.76)	0.77 (0.57–1.02)
Asian	20	0.29	0.8 7(0.55–1.38)	0.09 (0.02–0.40)
European and other	213	0.49	Referent	0.63 (0.47–0.84)
Socioeconomic deprivation level¶
1–2	48	0.39	Referent	0.23 (0.11–0.46)
3–4	67	0.55	1.23 (0.85–1.78)	0.51 (0.30–0.84)
5–6	113	0.88	1.72 (1.23–2.42)	1.01 (0.70–1.46)
7–8	188	1.37	2.17 (1.57–2.99)	0.54 (0.40–0.73)
9–10	474	3.18	3.18 (2.34–4.33)	0.58 (0.48–0.71)
District health board#
Northland	52	2.18	1.13 (0.76–1.69)	0.48 (0.24–0.94)
Counties Manukau, South Auckland	168	2.28	1.65 (1.21–2.24)	0.75 (0.53–1.05)
Tairawhiti, Gisborne	33	4.56	2.22 (1.42–3.48)	0.35 (0.15–0.83)
South Island, 5 DHBs	81	0.53	Referent	0.50 (0.31–0.82)
Total	890	1.35		0.58 (0.51–0.67)

Table 3. Mortality rates of rheumatic heart disease and adjusted rate ratios for people <70 years of age, according to key sociodemographic characteristics, New Zealand, 2000–2016*

*An additional 1,545 (63.4% of total) deaths occurred among persons ≥70 years of age during 2000–2016. aRR, adjusted rate ratio; DHB, district health board; RHD, rheumatic heart disease; RR, rate ratio.
†RR adjusted for sex, ethnicity, and socioeconomic deprivation.
‡RR adjusted for age, ethnicity, and socioeconomic deprivation.
§RR adjusted for age, sex, and socioeconomic deprivation.
¶RR adjusted for age, sex, and ethnicity.
#RR adjusted for age, sex, ethnicity, and socioeconomic deprivation; 3 highest incidence DHBs and the DHB with lowest incidence shown. A full list of DHBs is provided in Appendix Table 1.

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Carapetis JR. Rheumatic heart disease in developing countries. N Engl J Med. 2007;357:439–41.
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CME / ABIM MOC

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018

Authors: Julie Bennett, PhD; Jane Zhang, MSc; William Leung, MSc; Susan Jack, PhD; Jane Oliver, PhD; Rachel Webb, MBChB, FRACP; Nigel Wilson, MBChB; Dianne Sika-Paotonu, PhD; Matire Harwood, PhD; Michael G. Baker, MBChB
CME / ABIM MOC Released: 12/22/2020
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 12/22/2021

Start Activity

Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, cardiologists, and other physicians who care for patients at risk for acute rheumatic fever (ARF).

The goal of this activity is to assess trends in the epidemiology of ARF and rheumatic heart disease (RHD) in a developed country.

Upon completion of this activity, participants will:

Analyze the global epidemiology of ARF and RHD
Distinguish risk factors for ARF in the current study
Evaluate trends in the epidemiology of ARF in the current study
Evaluate trends in the epidemiology of RHD in the current study

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Authors

Julie Bennett, PhD

Department of Public Health
University of Otago
Wellington, New Zealand

Disclosures

Disclosure: Julie Bennett, PhD, has disclosed no relevant financial relationships.

Jane Zhang, MSc

Department of Public Health
University of Otago
Wellington, New Zealand

Disclosures

Disclosure: Jane Zhang, MSc, has disclosed no relevant financial relationships.

William Leung, MSc

Department of Public Health
University of Otago
Wellington, New Zealand

Disclosures

Disclosure: William Leung, MSc, has disclosed no relevant financial relationships.

Susan Jack, PhD

Public Health South
Southern District Health Board
Dunedin, New Zealand

Disclosures

Disclosure: Susan Jack, PhD, has disclosed no relevant financial relationships.

Jane Oliver, PhD

Peter Doherty Institute for Infection and Immunity
University of Melbourne
Murdoch Children's Research Institute
Melbourne, Victoria, Australia

Disclosures

Disclosure: Jane Oliver, PhD, has disclosed no relevant financial relationships.

Rachel Webb, MBChB, FRACP

Faculty of Medical and Health Sciences
University of Auckland
Auckland, New Zealand

Disclosures

Disclosure: Rachel Webb, MBChB, FRACP, has disclosed no relevant financial relationships.

Nigel Wilson, MBChB

Faculty of Medical and Health Sciences
University of Auckland
Auckland, New Zealand

Disclosures

Disclosure: Nigel Wilson, MBChB, has disclosed no relevant financial relationships.

Dianne Sika-Paotonu, PhD

Deans Department of Pathology and Molecular Medicine
University of Otago
Wellington, New Zealand
Wesfarmers Centre for Vaccines and Infectious Diseases
Telethon Kids Institute
Perth, Australia
Faculty of Health
Victoria University of Wellington
Wellington, New Zealand
Maurice Wilkins Centre for Molecular Biodiscovery
University of Auckland
Auckland, New Zealand

Disclosures

Disclosure: Dianne Sika-Paotonu, PhD, has disclosed no relevant financial relationships.

Matire Harwood, PhD

General Practice and Primary Healthcare
University of Auckland
Auckland, New Zealand

Disclosures

Disclosure: Matire Harwood, PhD, has disclosed the following relevant financial relationships:
Received grants for clinical research from: Health Research Council NZ, Heart Foundation NZ

Michael G. Baker, MBChB

Department of Public Health
University of Otago
Wellington, New Zealand

Disclosures

Disclosure: Michael G. Baker, MBChB, has disclosed no relevant financial relationships.

Editor

Amy J. Guinn, MA

Copyeditor
Emerging Infectious Diseases

Disclosures

Disclosure: Amy J. Guinn, MA, has disclosed no relevant financial relationships.

CME Author

Charles P. Vega, MD

Health Sciences Clinical Professor of Family Medicine
University of California, Irvine School of Medicine

Disclosures

Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: GlaxoSmithKline

CME Reviewer

Stephanie Corder, ND, RN, CHCP

Associate Director Accreditation and Compliance Medscape, LLC

Disclosures

Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

CE Reviewer

Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

Associate Director Accreditation and Compliance Medscape, LLC

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Disclosure: Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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From Emerging Infectious Diseases

CME / ABIM MOC

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018

Authors: Julie Bennett, PhD; Jane Zhang, MSc; William Leung, MSc; Susan Jack, PhD; Jane Oliver, PhD; Rachel Webb, MBChB, FRACP; Nigel Wilson, MBChB; Dianne Sika-Paotonu, PhD; Matire Harwood, PhD; Michael G. Baker, MBChBFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC Released: 12/22/2020

Valid for credit through: 12/22/2021

processing....

Abstract and Introduction

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000–2018 and RHD mortality rates during 2000–2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0–14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9–27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9–3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2–5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3–14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1–13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.

Introduction

Acute rheumatic fever (ARF) is a preventable multisystem inflammatory disease that develops in <3% of persons with untreated group A Streptococcus (GAS) pharyngitis^[1,2]. Recently, GAS skin infections have been proposed to cause ARF, either directly or in combination with GAS pharyngitis^[3]. The severe sequela of ARF is rheumatic heart disease (RHD) with regurgitation from the mitral valve, aortic valve, or both. RHD is a serious condition that can lead to cardiac failure, stroke, and early death^[4].

ARF and RHD remain major causes of illness and death^[5]. In 2015, global prevalence of RHD was ≈34 million cases and ≈320,000 RHD-associated deaths occurred^[6]. During the 20th century, improved living conditions resulted in dramatic declines in ARF^[7]. The introduction of antimicrobial drugs in the 1950s and 1960s further reduced the burden of disease and ushered in an effective treatment for GAS pharyngitis^[8,9]. Although now rare in high-income countries, ARF and RHD continue to affect populations in economically disadvantaged areas^[10] and epidemic outbreaks occur in populations that are separated geographically^[11,12].

The incidence of RHD is highest in Oceania, South Asia, and central sub-Saharan Africa^[6]. However, some of the highest reported ARF rates are among indigenous and Pacific Islander populations in Australia and New Zealand^[13]. The incidence rate among indigenous children in Australia in the peak age group, 5–14 years, is 245–351 cases/100,000 population^[14], but in New Zealand, ARF almost exclusively affects indigenous Māori and Pacific Islander children living in socioeconomically deprived areas of the North Island^[15,16]. During 2017–2018, the rate of initial ARF hospitalizations among Māori children 5–14 years of age was 25 cases/100,000 population; among Pacific Islander children, the rate was 81 cases/100,000 population^[17].

Population-level burden estimates rarely are reported in international literature, partially because of challenges with diagnosing both ARF and RHD and a lack of high-quality surveillance systems for monitoring these conditions. ARF is notifiable to public health authorities in New Zealand, but RHD is not. In addition, historically there has been national undernotification of ARF cases^[18]. Consequently, coded hospitalization data, which is based on the coding system of the International Classification of Diseases (ICD), 9th Revision (ICD-9) and 10th Revision (ICD-10), provides the most comprehensive base for describing ARF and RHD incidence and distribution.

We assessed trends in the incidence of ARF, the frequency of initial hospitalizations for RHD, and RHD mortality rates in New Zealand during 2000–2018. In addition, we assessed the extent to which these conditions are concentrated in specific population groups, based on age, ethnicity, sex, socioeconomic deprivation, and geographic location.

Page 1 of 4

Methods

CME / ABIM MOC Information

Abstract and Introduction
Materials and Methods
Results
Discussion

References

References

Disclaimer

The educational activity presented above may involve simulated, case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient, whether living or deceased, is intended or should be inferred. The material presented here does not necessarily reflect the views of Medscape, LLC, or any individuals or commercial entities that support companies that support educational programming on medscape.org. These materials may include discussion of therapeutic products that have not been approved by the US Food and Drug Administration, off-label uses of approved products, or data that were presented in abstract form. These data should be considered preliminary until published in a peer-reviewed journal. Readers should verify all information and data before treating patients or employing any therapies described in this or any educational activity. A qualified healthcare professional should be consulted before using any therapeutic product discussed herein.

References

Faculty and Disclosures

Authors

Julie Bennett, PhD

Jane Zhang, MSc

William Leung, MSc

Susan Jack, PhD

Jane Oliver, PhD

Rachel Webb, MBChB, FRACP

Nigel Wilson, MBChB

Dianne Sika-Paotonu, PhD

Matire Harwood, PhD

Michael G. Baker, MBChB

Editor

Amy J. Guinn, MA

CME Author

Charles P. Vega, MD

CME Reviewer

Stephanie Corder, ND, RN, CHCP

CE Reviewer

Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

CME / ABIM MOC

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018

Target Audience and Goal Statement

Disclosures

Authors

Julie Bennett, PhD

Jane Zhang, MSc

William Leung, MSc

Susan Jack, PhD

Jane Oliver, PhD

Rachel Webb, MBChB, FRACP

Nigel Wilson, MBChB

Dianne Sika-Paotonu, PhD

Matire Harwood, PhD

Michael G. Baker, MBChB

Editor

Amy J. Guinn, MA

CME Author

Charles P. Vega, MD

CME Reviewer

Stephanie Corder, ND, RN, CHCP

CE Reviewer

Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018

Abstract and Introduction

Introduction

Table of Contents