Third world rheumatic fever stats shock nurse into action

1 September 2012

Wielding a big needle once a month doesn’t make Sandra Ball many friends with her young rheumatic fever patients.

The district nurse grits her teeth as she injects the painful but necessary thick antibiotic paste deep into the child’s thigh or buttock.

“It drives me nuts because it’s a really nasty procedure,” she says.

“Usually, the kids leave limping, and you know you’re not their best friend as it hurts, but it keeps them well.”

For most of her 20 years as a district nurse in Opotiki, she accepted as “pretty much normal” delivering monthly penicillin injections to stop these kids facing further bouts of rheumatic fever and risking major heart damage.

But then she got a bee in her bonnet about so many kids getting rheumatic fever in the first place. She became one of the driving forces behind Opotiki in 2009 becoming a pilot school in the throat swabbing programme for the Eastern Bay of Plenty Primary Health Alliance. Other programmes have followed in Kawerau, Murupara, and most recently, a Tuhoe project. Ball now splits her time between district nursing for the Bay of Plenty District Health Board and being clinical lead for the Eastern Bay of Plenty throat swabbing programmes.

Third world stats

Ball, a mother of five, says it was her postgraduate studies that opened her eyes to the scale of the rheumatic fever problem in her community. A diploma paper asked her to look in-depth at a prophylactic treatment she carried out in her practice and she chose to look at the much-hated bicillin treatment.

“It was then that I realised our (rheumatic fever) figures here were shocking, huge … third world stats!”

Around the same time, a 2008 research project by public health physician Dr Belinda Loring, for Bay of Plenty’s Toi Te Ora Public Health Service, revealed that the true number of cases of rheumatic fever was double the official numbers registered and 90 per cent of the cases were Māori. It was found that a child in Murupara had a one in 39 chance of developing rheumatic fever during their childhood and a child in Opotiki one in 70. These compared with a one in 10,000 chance for the average Pākehā kid around the country.

The statistics hit home hard and the district health board’s Toi Te Ora-Public Health Service started a series of major initiatives to increase community awareness that ‘sore throats matter’, including a web page, major newspaper and radio ad campaigns, resource material, and educating local GPs and practice nurses about the Heart Foundation rheumatic fever guidelines. Coordinating rheumatic fever initiatives alone is now half of Toi Te Ora communicable disease nurse Lindsay Lowe’s job.

Ball still had a bee in her bonnet, and with the motivation of ‘fabulous paediatrician’ John Malcolm and the word from Belinda Loring that funding could be available, she started lobbying her local primary health organisation (PHO) to back a school throat swabbing project modelled on Whangaroa’s intervention.

A cry for help

She made the very most of the Opotiki district nursing office being just down the corridor from the office of the PHO manager.

“So every time we did a bicillin and the child cried, you’d whip round the corner and say ‘Did you hear that child cry? That’s preventable. It shouldn’t be happening.’ and kind of planted the seed with them.”

Not surprisingly, the PHO came in behind her, and in mid-2009, successfully sought DHB funding for Opotiki to be a school throat swabbing pilot project for the Eastern Bay of Plenty area using a local iwi provider.

With “immense” support from the DHB’s public health service, including publicity advice and ensuring proper research evaluation was imbedded in the project, the Opotiki pilot programme got underway in term three of 2009, with Ball as part-time clinical lead.

There are now four programmes underway covering more than 4000 pupils in 26 low decile schools. In term two, nearly 3500 swabs were taken, with 12 per cent coming back positive, prompting antibiotic prescriptions to keep rheumatic fever at bay.

Ball says an important part of the programme was engaging the GP practices they rely on for prescribing, at a nominal fee, the essential antibiotics. And to prescribe the ‘best practice’ once a day amoxicillin for ten days rather than expecting stressed mums and kids to remember to take antibiotics three times a day.

As clinical lead, Ball trains and supports the nine community health workers – mostly local young mums but also one “amazing” 73-year-old Nan – who do the day-by-day school visits offering, twice-a-week, every kid in every class the chance to put their hand up and say they have a sore throat that needs swabbing.

The big picture

Awareness promotion by the community workers, including using popular resources like the Heart Foundation Bro’ Town comic series, have helped bring the sore throats matter message home. Another promotion was the use of localised pamphlets for Opotiki, Kawerau, and Murupara, produced by Lindsay Lowe and the Toi Te Ora Public Health Service team, each featuring a home town kid on the cover who’d had rheumatic fever – two of them resulting in heart valve surgery. Ball says it means a lot to local kids that the pamphlets feature someone they know.

“The kids are absolutely fantastic … they are really, really good, and they’ve got the message that sore throats matter.”

To date, rheumatic fever has not been entirely eliminated in the throat-swabbing communities, but research evaluator, Russell Ingram- Seal, assures Ball the numbers are trending downwards.

“I kind of get reminded not to get disheartened because of the big picture stuff – the fact that the kids do have the message really strongly now and the families too really have it on board. In the big picture, what we are doing is working.”