Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000-2018 - CDC
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RESEARCH
Rising Ethnic Inequalities
in Acute Rheumatic Fever
and Rheumatic Heart Disease,
New Zealand, 2000–2018
Julie Bennett, Jane Zhang, William Leung, Susan Jack, Jane Oliver,
Rachel Webb, Nigel Wilson, Dianne Sika-Paotonu, Matire Harwood, Michael G. Baker
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Release date: December 22, 2020; Expiration date: December 22, 2021
Learning Objectives
Upon completion of this activity, participants will be able to:
• 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.
CME Editor
Amy J. Guinn, BA, MA, Copyeditor, Emerging Infectious Diseases. Disclosure: Amy J. Guinn, BA, 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, Irvine,
California. Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships: served as an advisor or consultant
for GlaxoSmithKline.
Authors
Disclosures: Julie Bennett, PhD; Jane Zhang, MSc; William Leung, MSc; Susan Jack, PhD; Jane Oliver, PhD; Rachel Webb,
MBChB, FRACP; Nigel Wilson, MBChB; Michael G. Baker, MBChB; and Dianne Sika-Paotonu, PhD have disclosed no relevant
financial relationships. Matire Harwood, PhD, has disclosed the following relevant financial relationships: received grants for clinical
research from Health Research Council NZ, Heart Foundation NZ.
Author affiliations: University of Otago, Wellington (J. Bennett, District Health Board, Auckland, New Zealand (R. Webb,
J. Zhang, W. Leung, D. Sika-Paotonu, M.G. Baker); Southern N. Wilson); University of Auckland, Auckland (D. Sika-Paotonu,
District Health Board, Dunedin, New Zealand (S. Jack); University M. Harwood)
of Melbourne, Melbourne, Victoria, Australia (J. Oliver); Murdoch
Children’s Research Institute, Melbourne (J. Oliver); Auckland DOI: https://doi.org/10.3201/eid2701.191791
36 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 27, No. 1, January 2021
Rheumatic Disease among Ethnic Groups, New Zealand
among Pacific Island children, the rate was 81 cas-
We describe trends in acute rheumatic fever (ARF), rheu-
es/100,000 population (17).
matic heart disease (RHD), and RHD deaths among popu-
lation groups in New Zealand. We analyzed initial primary Population-level burden estimates rarely are re-
ARF and RHD hospitalizations during 2000–2018 and RHD ported in international literature, partially because of
mortality rates during 2000–2016. We found elevated rates challenges with diagnosing both ARF and RHD and a
of initial ARF hospitalizations for persons of Māori (adjusted lack of high-quality surveillance systems for monitor-
rate ratio [aRR] 11.8, 95% CI 10.0–14.0) and Pacific Island ing these conditions. ARF is notifiable to public health
(aRR 23.6, 95% CI 19.9–27.9) ethnicity compared with authorities in New Zealand, but RHD is not. In addi-
persons of European/other ethnicity. We also noted higher tion, historically there has been national undernotifi-
rates of initial RHD hospitalization for Māori (aRR 3.2, 95% cation of ARF cases (18). Consequently, coded hospi-
CI 2.9–3.5) and Pacific Island (aRR 4.6, 95% CI 4.2–5.1) talization data, which are based on the coding system
groups and RHD deaths among these groups (Māori aRR
of the International Classification of Diseases (ICD),
12.3, 95% CI 10.3–14.6, and Pacific Island aRR 11.2, 95%
9th Revision (ICD-9) and 10th Revision (ICD-10),
CI 9.1–13.8). Rates also were higher in socioeconomically
disadvantaged neighborhoods. To curb high rates of ARF provide the most comprehensive base for describing
and RHD, New Zealand must address increasing social ARF and RHD incidence and distribution.
and ethnic inequalities. We assessed trends in the incidence of ARF, the
frequency of initial hospitalizations for RHD, and
A cute rheumatic fever (ARF) is a preventable mul- RHD mortality rates in New Zealand during 2000–
tisystem inflammatory disease that develops in 2018. In addition, we assessed the extent to which
180 days after a previous
peak age group, 5–14 years, is 245–351 cases/100,000 ARF discharge.
population (14), but in New Zealand, ARF almost ex- We defined initial RHD cases as a patient’s first
clusively affects indigenous Māori and Pacific Island hospitalization with a principal diagnosis of RHD
children living in socioeconomically deprived areas (ICD-10 codes I05, I06, I07, I09, or I09) and no pre-
of the North Island (15,16). During 2017–2018, the rate vious admission for RHD as principal or additional
of initial ARF hospitalizations among Māori children diagnoses since 1988. We defined RHD death as the
5–14 years of age was 25 cases/100,000 population; underlying cause of death (ICD-10 codes I05, I06,
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 27, No. 1, January 2021 37
RESEARCH
I07, I08, or I09) as recorded in the National Mortality increased to 4.9 million in 2018. The analysis used the
Collection (21). prioritized ethnicity categorizations, which is consis-
We excluded all non–New Zealand residents tent with national Ministry of Health ethnicity data
from these analyses because they are not part of the protocols (24). Ethnic groups included in the analysis
usual New Zealand population. We used the New were Māori, who make up 16.5% of New Zealand’s to-
Zealand Deprivation Index (NZDep13) to assess so- tal population; Pacific Islander (8.1%); Asian (15.1%);
cioeconomic deprivation (22). NZDep13 is an area- and European/other (70.2%). The major Pacific
based measure of socioeconomic deprivation based groups in New Zealand are Samoan, Tongan, Cook
on 9 variables from the 2013 census. Decile 10 rep- Island Māori, and Niuean. The major Asian groups
resents areas considered the most socioeconomically are Chinese, Indian, Filipino, and Korean.
deprived, and decile 1 represents areas with the least
deprivation scores. In this article, when we describe Ethics
the epidemiology of ARF and RHD, we generally are The University of Otago Human Research Ethics
referring to initial ARF or RHD hospitalizations. Committee granted ethical approval for this study
(approval no. HD19/033). The Ngāi Tahu Research
Statistical Analysis Consultation Committee also consulted on the study.
ARF and RHD data were used to calculate the fre-
quencies, rates, rate ratios (RRs), adjusted rate ra- Results
tios (aRRs), and 95% CIs across selected population
groups. To look for time trends, we split the obser- ARF Incidence Trends and Distribution
vation into 2 periods: 2000–2009 and 2010–2018 or During 2000–2018, we noted 2,752 initial hospital-
2010–2016 for RHD deaths, the timeframe for which izations with ARF as the principal diagnosis, an av-
mortality data are available. We examined rates of erage of 145 initial ARF hospitalizations per year.
ARF and RHD in relation to characteristics includ- Over the same period, 288 persons were rehospital-
ing age, sex, ethnicity, and the district health board ized with ARF as their principal diagnosis, an aver-
(DHB) in which cases occurred. We used DHBs for age of 15 recurrent cases per year and 9.5% of the
geographic analysis because they represent the pa- total ARF hospitalizations. Most (47.8%) recurrent
tient’s place of residence. We calculated rates and cases were among children 10–14 years of age. Dur-
RRs for ARF for persons
Rheumatic Disease among Ethnic Groups, New Zealand
Figure 1. Annual rates of initial
and recurrent acute rheumatic
fever hospitalizations, New
Zealand, 2000–2018. ARF,
acute rheumatic fever.
among Māori were 16.8 cases/100,000 population RHD Incidence Trends and Distribution
(Figure 3). During 2000–2018, a total of 12,094 hospitalizations
Initial ARF hospitalization rates peaked at 35.9 with a principal diagnosis of RHD were reported, an
cases/100,000 population among Māori children 5–14 average of 636 admissions per year. Of these, 5,109
years of age and at 79.6 cases/100,000 population persons were hospitalized with an initial RHD diag-
for Pacific Island children. By comparison, rates for nosis, an annual average of 269 persons. During the
European/other ethnicities were 1.6 cases/100,000 study period, national initial RHD hospitalization
population. The net effect of the elevated rates among rates ranged from 4.1 to 10.0 cases/100,000 popula-
Māori and Pacific Island children means that by age tion, an average incidence rate of 6.2 cases/100,000
20, the cumulative risk for hospitalized ARF is 1.2% population (Figure 4). Total rates of RHD hospital-
for Pacific Islanders, 0.5% of Māori, and 0.01% for izations as principal diagnosis, including initial and
other ethnicities. repeat admissions, ranged 11.5 to 17.9 cases/100,000
Patients with initial ARF hospitalizations were population, an annual rate of 14.3 cases/100,000
more likely (aRR 5.2, 95% CI 4.0–6.8) to come from population. The mean age of initial RHD hospital-
the most socioeconomically deprived areas of the ization was 60 years, with a median age of 67 years.
country (NZDep 9–10). The most socioeconomically We analyzed RHD cases according to sociode-
disadvantaged neighborhoods had greater increases mographic characteristics for patients aged
RESEARCH significant levels among persons
Rheumatic Disease among Ethnic Groups, New Zealand
Figure 3. Incidence of
initial acute rheumatic fever
hospitalizations by major
ethnic group and time
period among personsRESEARCH
Figure 4. New Zealand
annual incidence
rates of initial RHD
hospitalizations, all
ages, 2000–2018. RHD,
rheumatic heart disease.
(93.4%) initial ARF cases are among personsRheumatic Disease among Ethnic Groups, New Zealand Table 3. Mortality rates of rheumatic heart disease and adjusted rate ratios for people aged 70 years of age. Cur- gregating these characteristics shows independent rent trends reflect patterns of ARF that have oc- contributions from ethnicity, socioeconomic depri- curred over the past few decades (cohort effects) vation, and geographic location (Appendix Table and changes in clinical awareness and diagnostic 2). Among persons
RESEARCH
associated with deprivation and region in addi- hospitalizations might be overestimated due to
tion to an independent association with ethnicity. ICD-10 directives for RHD. Further clinical valida-
We noted steep declines in RHD mortality rates tion of ICD codes is needed to improve identifica-
during 2000–2016. Nonetheless, Māori and Pacific tion of RHD in administrative data in New Zealand
Islanders once more bear the greatest burden of dis- and globally. One approach that would greatly help
ease, accounting for 73.8% of deaths among persons validation would be implementation of a nationalRheumatic Disease among Ethnic Groups, New Zealand
children, and RHD, and RHD deaths dispropor- Med Scand. 1949;135(S234):109–17. https://doi.org/
tionately affecting Māori and Pacific Islander 10.1111/j.0954-6820.1949.tb05601.x
9. Quinn RW. Comprehensive review of morbidity and mortality
adults, particularly those living in high socioeco- trends for rheumatic fever, streptococcal disease, and scarlet
nomic deprivation. We saw evidence of a cohort fever: the decline of rheumatic fever. Rev Infect Dis.
effect; new cases of ARF were becoming rare in Eu- 1989;11:928–53. https://doi.org/10.1093/clinids/11.6.928
ropean/other children, RHD was declining among 10. Jaine R, Baker M, Venugopal K. Acute rheumatic fever
associated with household crowding in a developed country.
European/other adults, and RHD deaths were be- Pediatr Infect Dis J. 2011;30:315–9. https://doi.org/10.1097/
coming uncommon in European/other personsRESEARCH
25. Jaine R, Baker M, Venugopal K. Epidemiology of acute rheu- Public Health. 2019;16:E4515. https://doi.org/10.3390/
matic fever in New Zealand 1996–2005. J Paediatr ijerph16224515
Child Health. 2008;44:564–71. https://doi.org/10.1111/ 29. Seckeler MD, Hoke TR. The worldwide epidemiology of acute
j.1440-1754.2008.01384.x rheumatic fever and rheumatic heart disease. Clin Epidemiol.
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Scuffham PA. Mortality and hospitalisation costs of 30. Jaine R. Acute rheumatic fever in New Zealand:
rheumatic fever and rheumatic heart disease in New epidemiology and the role of household crowding.
Zealand. J Paediatr Child Health. 2012;48:692–7. Dissertation. University of Otago; 2007.
https://doi.org/10.1111/j.1440-1754.2012.02446.x 31. Wilson N, Mitchelson B, Peat B, Webb R, Anderson A,
27. Gurney JK, Stanley J, Baker MG, Wilson NJ, Sarfati D. Jack S, et al. The New Zealand rheumatic heart disease
Estimating the risk of acute rheumatic fever in New Zea- registry. Heart Lung Circ. 2018;27:S19. https://doi.org/
land by age, ethnicity and deprivation. Epidemiology & 10.1016/j.hlc.2018.05.141
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28. Baker MG, Gurney J, Oliver J, Moreland NJ, Address for correspondence: Julie Bennett, Department of Public
Williamson DA, Pierse N, et al. Risk factors for acute
Health, University of Otago, Wellington, 23A Mein St, Newtown,
rheumatic fever: literature review and protocol for a
case-control study in New Zealand. Int J Environ Res Wellington 6021, New Zealand; email: julie.bennett@otago.ac.nz
April 2020
Vectorborne Infections
• Stemming the Rising Tide of Human- •P
erson-to-Person Transmission of
Biting Ticks and Tickborne Diseases, Andes Virus in Hantavirus Pulmonary
United States Syndrome, Argentina, 2014
• Ecology and Epidemiology of Tickborne •O
utbreak of Dirkmeia churashimaensis
Pathogens, Washington, USA, Fungemia in a Neonatal Intensive Care
2011–2016 Unit, India
• Imported Arbovirus Infections in •R
ift Valley Fever Outbreak, Mayotte,
Spain, 2009–2018 France, 2018–2019
• Decreased Susceptibility to •C
rimean-Congo Hemorrhagic Fever
Azithromycin in Clinical Shigella Virus in Humans and Livestock,
Isolates Associated with HIV and Pakistan, 2015–2017
Sexually Transmitted Bacterial
•D
etection of Zoonotic Bartonella
Diseases, Minnesota, USA, 2012–2015
Pathogens in Rabbit Fleas,
• High Incidence of Active Tuberculosis Colorado, USA
in Asylum Seekers from Eritrea and •H
uman-to-Human Transmission of
Somalia in the First 5 Years after Monkeypox Virus, United Kingdom,
Arrival in the Netherlands October 2018
• Severe Dengue Epidemic, Sri Lanka, •W
hole-Genome Analysis of Salmonella
2017 enterica Serovar Enteritidis Isolates
• I ntensified Short Symptom Screening in Outbreak Linked to Online Food
• Severe Fever with Thrombocytopenia
Program for Dengue Infection during Delivery, Shenzhen, China, 2018
Syndrome, Japan, 2013–2017
Pregnancy, India
•P
ruritic Cutaneous Nematodiasis
• Comprehensive Profiling of Zika
•P
revalence of Antibodies to Crimean- Caused by Avian Eyeworm Oxyspirura
Virus Risk with Natural and Artificial
Congo Hemorrhagic Fever Virus in Larvae, Vietnam
Mitigating Strategies, United States
Ruminants, Nigeria, 2015
•N
ovel Rapid Test for Detecting
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•R
ecurrent Herpes Simplex Virus 2 Carbapenemase
Meropenem-Resistant Streptococcus
pneumoniae Spain-ST81, Taiwan Lymphocytic Meningitis in Patient with •A
rthritis Caused by MRSA CC398 in a
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etection of Rocio Virus SPH 34675
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Belgium 2016–2017 2011–2013
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Co-Infections, Peruvian Amazon Dogs from Sierra Leone, 2017 Mauritania
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46 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 27, No. 1, January 2021You can also read
