New Zealand’s rheumatic fever prevention programme (RFPP)

The initiative

The New Zealand government aims to reduce rheumatic fever by two-thirds by 2017, as one of its 10 Better Public Services targets. In order to secure this objective, the New Zealand Ministry of Health established the Rheumatic Fever Prevention Programme (RFPP) in 2011, which focused on preventing, diagnosing, and treating throat infections. In 2012, the programme was significantly expanded.

“The RFPP has three key strategies to reduce rheumatic fever:

• Improve access to timely treatment for strep throat infections.
• Reduce household crowding and therefore reduce the spread of strep throat bacteria in families that live in crowded homes.
• Increase awareness of rheumatic fever, what causes it and how to stop it.” [4]

The National Heart Foundation of New Zealand and the Cardiac Society of Australia and New Zealand developed guidelines for the RFPP, based on a systematic review of the literature and consideration of cultural factors specific to New Zealand.

They aimed to increase public awareness through actions such as TV and radio commercials, information films shown in health clinics and social welfare offices, posters in bus stops, letters to nearly 20,000 homes, and promotion of the RFPP's website.

They provided information to health professionals via e-learning tools about rheumatic fever. They also set up sore throat clinics “in areas with the highest incidence of rheumatic fever, and in particular schools located in areas of high deprivation with large enrolment of Māori and/or Pacific children”. [5]

A fast-track scheme gives families at risk of rheumatic fever priority for appropriately sized social housing, in a bid to reduce overcrowding.

Each action is closely monitored and its efficacy evaluated. The resulting reports guide policy decisions for future iterations of the RFPP.

The challenge

Although rheumatic fever – “a preventable disease that occurs in some people following an infection of the throat” [1] – has been eradicated in most developed countries, it is still prevalent in New Zealand. “New Zealand's rate of acute rheumatic fever is 14 times the OECD average and the rate is 25 to 44 times greater for Māori and Pacific children - among the highest in the world.” [2] This equates to “around 180 new cases of acute rheumatic fever a year in NZ (4.2 cases per 100,000 population per year) [and] around 550 hospitalisations and 140 deaths for rheumatic heart disease a year”. [3]

The public impact

In 2015, “the national incidence of rheumatic fever was 2.1 cases per 100,000 people - a total of 98 people were admitted to hospital for the first time with rheumatic fever. This represents a statistically significant 45 percent decrease in first episode rheumatic fever hospitalisations from baseline (2009/10-2011/12).” [6]

By February 2016, “more than 47,400 eligible people have been checked and/or treated by one of the RFPP-funded free sore throat clinic services”. [7]

Stakeholder engagement

The Ministry of Health is the key stakeholder in this initiative. It is strongly engaged, continuing to fund, manage, evaluate and grow the RFPP.  Another government body, the Health Promotion Agency, develops and delivering successful public awareness campaigns.

The District Health Boards (DHBs) are important stakeholders, being involved in the policy design and delivery phases. In Counties Manukau, for example: “the DHB has both a Māori and a Pacific team which have both been involved in the development of this plan ... In addition key Clinical Leaders and Operational Managers from CM Health have been engaged in the development of this plan”. [8]

Health practitioners, such as GPs, hospital doctors and nurses, have demonstrated their engagement by staffing sore throat clinics and other initiatives. Schools in the target areas host sore throat clinics (see The initiative above) and managing the parent consent process.

The Māori and Pacific young people, who are most at risk of developing rheumatic fever, are also actively engaged in the RFPP, not just as patients but also as health promoters. For example, students from schools and community youth groups produced short films that “deliver rheumatic fever prevention messages through youth-appropriate language and scenes”. [9] Kaumatua (Māori elders), iwi groups (Māori community groups) and Pacific community leaders are working with the DHBs to help them target their initiatives in a culturally appropriate manner and engage with Māori and Pacific families.

Political commitment

Both major political parties in New Zealand are concerned by the high incidence of rheumatic fever and want to take action. The governing National Party (who began the RFPP in 2011 and continued it after re-election in 2014) is strongly committed to this initiative and has invested more than NZD65 million has been invested in the RFPP.

Reducing rheumatic fever is a political priority, as evidenced by its inclusion in the government's list of ten key Better Public Service targets. The opposing Labour Party does not support the RFPP, seeing the priorities as “reducing overcrowding, income inequality, improving housing quality and equality of access to primary care”. [10]

Public confidence

The National Party has won three successive elections, receiving 47% of the vote in 2014. This indicates that public confidence in the government behind this initiative is high.

There is no evidence available regarding public confidence in the RFPP. However, uptake rates are high which suggests that confidence is good:

• The majority of parents have given their consent for their children to be enrolled in a school-based swabbing programme.
• Māori and Pacific people (the target audience) felt that the public awareness campaigns were right for their cultures, suggesting that they are confident in the initiative.
• There is qualitative evidence that the public awareness campaigns have led to behaviour changes. “‘You've heard the words “rheumatic fever” but didn't know what it actually does to your heart, till that commercial came out.  If they had a sore throat, they stay home for a few days and I would say “you'll be right”. Now I take them to the doctor as soon as they've got a sore throat.  Yeah, that was through the commercial.'  (Māori parent).” [11]

Clarity of objectives

The three key strategies of the RFPP clearly outline the objectives of the initiative. [12]These are stated above, but in short are to improve rapid access to treatment for strep throat infections, to reduce household crowding and hence spreading of infections, and to increase awareness of rheumatic fever.

Strength of evidence

The decision to focus on establishing sore throat clinics and encouraging less crowded and healthier homes was based on a large body of literature exploring the relationships between overcrowding, poor housing and strep throat and rheumatic fever.

The in-school throat-swabbing initiative was piloted in Porirua, then rolled out across the country once it was demonstrated to be successful. “A pre-emptive programme to catch children's illnesses early has headed off strep infections in more than 100 eastern Porirua children since April … A pilot scheme ran at two schools last year and was rolled out to 10 more in 2012.” [13]

The public awareness campaign was based on a similar, successful campaign in French Polynesia.

The efficacy of each annual public awareness campaign is assessed through cost analysis, surveys, and focus groups. Evidence from these assessments is used to shape the following year's campaign (see also Measurement).

Feasibility

The cost has been addressed by the New Zealand government, which has committed millions of dollars to this initiative, and funds were also secured from DHBs.

DHBs already have highly trained nurses and doctors who are able to administer rheumatic fever prevention measures as part of their usual practice, or to use their existing skills in new clinics such as school-based throat swabbing centres.

The Ministry of Health has run health awareness campaigns before (e.g., smoking cessation), which indicated that the public awareness aspect of the RFPP would be feasible.

Management

The Ministry of Health oversees the RFPP. The DHBs in the 11 regions with the highest incidence of rheumatic fever are responsible for clinical interventions such as sore throat clinics. Within each DHB, there is a clear management structure.

For example, in Counties Manukau, the Rheumatic Fever Champion is a senior executive who “acts as a single point of contact to ensure information about the programme is shared with all relevant organisations in the DHB area”. [14]

At the community level, interventions are carried out by nurses and doctors utilising their regular management structures (e.g. in GP clinics, pharmacies, and hospitals).

The Ministry of Social Development oversees the social housing fast-track scheme. The Ministries of Health, of Youth Development, and for Pacific Peoples work together to develop and deliver awareness campaigns to Māori and Pacific youth.

Alliance Health (a Pacific-focused primary health organisation) coordinates the RFPP Pacific Engagement Strategy in the Auckland region via eight Pacific health providers.

Measurement

Each annual public awareness campaign is evaluated through focus groups, interviews, and surveys, and the results are used to shape the following year's campaign.

The sore throat clinic initiative is also regularly evaluated, and the results used to drive policymaking. For example, one review showed that schools using an opt-out consent system had greater sore throat clinic participation rates than schools using opt-in systems. This led to schools being encouraged to utilise an opt-out model.

Overall statistics about the incidence of rheumatic fever are also collected by the DHBs and the Ministry of Health and are used to assess the success of the RFPP and are published on its ‘Progress on the Better Public Services rheumatic fever target' web page.

Alignment

There is a great deal of cooperation between the principal actors in the RFPP: the government ministries and agencies, the DHBs and health practitioners. Health practitioners are concerned by the high rates of rheumatic fever in New Zealand. They are therefore aligned with the overall goals of the RFPP, and continue to cooperate and deliver services such as throat swabbing in special clinics and in surgeries.

Bibliography

Rheumatic fever, Ministry of Health, New Zealand

Rheumatic Fever Prevention Programme, February 2016, Ministry of Health, New Zealand

Progress on the Better Public Services rheumatic fever target, Ministry of Health, New Zealand

About us, Rheumatic Fever

Health Equity and Rheumatic Heart Disease: Reducing Rheumatic Fever in New Zealand, Dr Mark Jacobs, Director of Public Health, Ministry of Health, New Zealand

State House priority for rheumatic fever-risk families, 19 February 2014, stuff.co.nz

Rheumatic Fever Prevention Plan, 2013- 2017, Counties Manukau Health

Rheumatic fever, The 2016 Rheumatic Fever Awareness Campaign, Health Promotion Agency

Better Public Services: Supporting vulnerable children, 25 September 2013, last updated March 2014, State Services Commission, New Zealand

Sore throat checks prevent nasty fever, JIM CHIPP, 28 August 2012, The Dominion Post

EVALUATION OF THE 2015 RHEUMATIC, FEVER AWARENESS CAMPAIGN, 3 December 2015, Allen + Clarke