A preventable disease that persists in specific communities, revealing stark health disparities in modern Australia
Imagine a health condition so rare in most of Australia that many doctors have never seen a case, yet so severe that it can cause lifelong heart damage in children. This is the paradox of rheumatic infections in modern Victoria—a supposed "disease of the past" that continues to affect specific communities with devastating consequences 5 .
While most Victorians remain unaware of these conditions, for some families, particularly those from Aboriginal, Torres Strait Islander, and Pacific Islander backgrounds, acute rheumatic fever (ARF) and rheumatic heart disease (RHD) represent a persistent health crisis hiding in plain sight 1 7 .
What makes this situation particularly alarming is that these diseases are almost entirely preventable. The fact that they persist in 21st-century Victoria represents what researchers have called "a source of continuing national shame" 2 .
The journey from a common infection to lifelong heart damage begins with a bacterium called Group A Streptococcus (GAS) 1 . Most commonly, this bacterium causes strep throat or skin infections like impetigo—common childhood ailments easily treated with antibiotics.
But in a small percentage of cases, particularly when these infections are untreated or recurrent, something goes terribly wrong with the body's immune response 8 .
The immune system, confused by similarities between the bacteria and the body's own tissues, launches a misguided attack on healthy organs—a phenomenon known as molecular mimicry 3 . This "friendly fire" primarily targets the heart, joints, brain, and skin, resulting in the condition we know as acute rheumatic fever (ARF) 1 3 .
Group A Streptococcus causes strep throat or skin infections
Untreated infection triggers abnormal immune response
Immune system attacks body's own tissues
Inflammation of heart, joints, brain, and skin
Permanent heart valve damage requiring lifelong care
ARF manifests through a constellation of symptoms that vary from patient to patient:
When the heart valves are damaged during ARF, the resulting scar tissue can lead to rheumatic heart disease (RHD)—a permanent, progressive condition that may require open-heart surgery and can lead to heart failure, stroke, or premature death 1 5 . The damage is particularly devastating because it often affects children and young adults, burdening them with a lifelong chronic condition.
| Organ System | Manifestation | Frequency in First Episodes | Key Characteristics |
|---|---|---|---|
| Cardiovascular | Carditis | 50-70% | Valvulitis of mitral or aortic valves |
| Musculoskeletal | Arthritis | Up to 75% | Migratory polyarthritis of large joints |
| Central Nervous | Sydenham Chorea | Variable | Involuntary movements, emotional lability |
| Skin | Erythema Marginatum | <10% | Non-itchy, serpiginous rash |
| Skin | Subcutaneous Nodules | <10% | Firm, painless nodules over joints |
While ARF and RHD have been virtually eliminated from Victoria's general population, they persist at alarming rates in specific communities. The social determinants of health—housing, poverty, and access to care—rather than biology, drive these dramatic disparities 2 .
Recent research has uncovered that from 2010–2019, 108 Victorian children and adolescents were admitted to the state's two tertiary paediatric hospitals with ARF/RHD 7 . Of these, 45% were of Pacific Islander background (with Samoan children being the largest group) and 10% were Aboriginal and Torres Strait Islander 7 .
Annual incidence of ARF/RHD in Victoria by ethnicity (children aged 5-14 years) 7
The persistence of these diseases in specific communities has everything to do with social determinants and nothing to do with genetic susceptibility. Key risk factors include:
As one report starkly noted, rheumatic fever has become recognized as a "disease of social injustice" 7 —a marker of inequality that reveals gaps in our public health system.
| Population Group | Annual Incidence per 100,000 | Relative Risk Compared to General Population |
|---|---|---|
| General Victorian Population | 0.8 | 1x |
| Aboriginal and Torres Strait Islander | 4.0 | 5x |
| Pacific Islander | 32.0 | 40x |
While Victorian-specific experimental studies are limited, groundbreaking research from nearby regions provides crucial insights. A retrospective study conducted in Far North Queensland (FNQ) between 1997 and 2017 used state RHD register data to examine the relationship between socioeconomic disadvantage and RHD prevalence, severity, and treatment 2 .
This study was particularly significant because it linked registry data with long-term outcomes—something rarely possible for diseases that predominantly affect disadvantaged populations in resource-poor settings 2 .
Researchers identified 686 individuals with RHD confirmed by echocardiogram and reported by a specialist physician between January 1, 1997, and December 31, 2017 2 .
Demographic and clinical data were collected from the Queensland RHD register and medical records, with Indigenous status determined by self-identification 2 .
Each patient's socioeconomic status was quantified using the Socio-Economic Indexes for Areas (SEIFA) Score, a standardized measure developed by the Australian Bureau of Statistics 2 .
Adherence to secondary prophylaxis was measured by dividing the number of penicillin doses received by the number prescribed, with ≥10 doses per year defined as "good adherence" 2 .
The findings revealed several disturbing trends:
Perhaps most tellingly, the research found that patients living in socioeconomically disadvantaged areas were not only more likely to have RHD but were also less likely to receive valve surgery—revealing a double burden of disease and healthcare access issues 2 .
| Study Metric | Finding | Statistical Significance |
|---|---|---|
| RHD Incidence Increase | 4.7 to 49.4/100,000/year | p < 0.001 |
| Indigenous Representation | 90.7% of cohort | N/A |
| SEIFA Correlation | Inverse correlation (rho = -0.77) | p = 0.005 |
| Prophylaxis Adherence | 24.9% with good adherence | N/A |
| Valve Surgery | 17.3% required surgery | N/A |
| Mortality | 5.7% died during study | N/A |
Understanding and addressing ARF and RHD requires a diverse array of research and clinical tools. From diagnostic techniques to preventive strategies, here are the key components in the fight against these diseases:
Heart ultrasound imaging - Gold standard for RHD diagnosis, detects valve damage 1
Socioeconomic mapping - Links community disadvantage to disease prevalence 2
Research tool - Study molecular mimicry mechanisms between GAS and human tissues 3
Addressing rheumatic infections in Victoria requires intervention at multiple levels:
Improving social determinants like housing, sanitation, and reducing overcrowding 1
Several promising initiatives are underway to address the burden of rheumatic infections:
Aims to end RHD in Australia by 2031, emphasizing the critical role of housing and environmental health policies
Continues to offer hope for primordial prevention of streptococcal infections 5
In July 2023, ARF and RHD became notifiable conditions in Victoria, enabling better tracking and response 7
Qualitative research is highlighting the importance of community-based models and cultural safety 7
The story of rheumatic infections in Victoria is ultimately one of health inequity—a preventable disease that persists not for lack of medical knowledge, but for lack of social solutions. As one study concluded, the current medical model "appears to be having a limited impact on morbidity" and strategies must evolve to address "the personal, community and environmental factors that increase the risk of the disease" 2 .
The path forward requires more than just better drugs or diagnostic tools—it demands that we address the overcrowded housing, healthcare access barriers, and socioeconomic disadvantage that allow these diseases to persist. As Victorian researchers work to understand and combat these conditions, their efforts represent not just a medical mission, but a moral one—ensuring that all children in Victoria, regardless of their background, have the opportunity to grow up with healthy hearts.
Acute Rheumatic Fever (ARF): An autoimmune response following group A streptococcal infection that can cause inflammation of the heart, joints, brain, and skin.
Rheumatic Heart Disease (RHD): Permanent damage to the heart valves caused by one or more episodes of ARF.
Group A Streptococcus (GAS): Bacteria that cause strep throat and skin infections, which can trigger ARF in some individuals.
Molecular Mimicry: A process where the immune system confuses similarities between bacterial and human proteins, leading to autoimmune attacks.
Secondary Prophylaxis: Regular antibiotics (usually every 21-28 days) to prevent recurrent ARF episodes in people with prior ARF or RHD.
Socio-Economic Indexes for Areas (SEIFA): A standardized measure of socioeconomic disadvantage developed by the Australian Bureau of Statistics.