Tairawhiti Rheumatic Fever Prevention Plan - Gisborne...

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Tairawhiti Rheumatic Fever

Prevention Plan

Rheumatic Fever is preventable and it is everyone’s problem

The answer lies within our community.

Ehara taku toa I te toa takitahi Engari taku toa he toa takitini

Success is not the work of one but the work of many

Tairawhiti District Health, Ngati Porou Hauora and

Te Hauora o Turanganui a Kiwa

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Table of Contents

List of Abbreviations ................................................................................................. 3

Introduction .............................................................................................................. 4

Summary of activities achieved to support development of Rheumatic Fever plan . 5

Section 1: Overview of Rheumatic Fever in Tairawhiti .............................................. 6

1.0 Background/Demographics .................................................................................. 6

1.1 Throat swabbing program background ................................................................. 8

1.2 Local implementation........................................................................................... 8

1.3 Throat swab analysis Tairawhiti.......................................................................... 10

Section 2: Commitment to reducing Rheumatic Fever in Tairawhiti ....................... 12

2.0 Stakeholders input and engagement ................................................................. 13

2.1 Local community consultation ........................................................................... 13

2.2 Rheumatic Fever champion ............................................................................... 15

2.3 Overarching actions to reduce the incidence of Rheumatic Fever ...................... 16

Section 3: Investment in reducing Rheumatic Fever Tairawhiti .............................. 18

3.0 Tairawhiti resources committed to reducing Rheumatic Fever 2013/14 ............ 19

3.1 Current investment ........................................................................................... 21

Section 4 : Tairawhiti Actions to prevent the transmission of Group A streptococcal

throat infections ...................................................................................................... 23

4.0 Housing .............................................................................................................. 23

4.1 Tairawhiti actions to prevent the transmission of Group A streptococcal

throat infections ...................................................................................................... 25

4.2 Improving general hygiene in education setting ................................................. 28

4.3 Reducing skin infections in schools, community and home settings ................... 29

Section 5: Actions to treat Group A streptococcal throat infections quickly

and effectively. ....................................................................................................... 31

Section 6: Actions facilitating the effective follow-up of identified Rheumatic

Fever cases ............................................................................................................. 33

6.0 Notifying the Medical Officer of Health .............................................................. 33

6.1 Action plan ......................................................................................................... 34

Section 7: Review of cases to identify known risk factors and system failure

points ...................................................................................................................... 39

7.0 Audit results ....................................................................................................... 39

7.1 Identify and follow up known risk factors and system failure points in cases of

Rheumatic Fever ...................................................................................................... 41

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Section 8: Actions to facilitate the effective follow-up of patients with Rheumatic

Heart Disease ......................................................................................................... 47

8.0 Interventions for patients who do not have established RHD ......................... .48

8.1 Interventions for patients who have established RHD ..................................... .48

Section 9: Summary of the Rheumatic Fever prevention plan ……………………………. 50

Appendix 1: Health promoting school focus at Gisborne Boys High School…………………….....53

Appendix 2: Stakeholders survey and feedback ………………………………………………………………….54

Appendix 3: Proposed activities………………………………………………………………….……………………….57

Appendix 4: ‘Sore throats matter’ poster…………………………………………………………………………...58

List of Abbreviations

ARF Acute Rheumatic Fever

ASH Ambulatory Sensitive Hospitalisation

CEO Chief Executive Officer

EECA Energy Efficiency and Conservation Authority

GAS Group A streptococcus

GP General Practice / Practitioner

HNZC Housing New Zealand Corporation

HSL HealthShare Limited

NPH Ngati Porou Hauora

MoH Ministry of Health

MOH Medical Officer of Health

PHN Public Health Nurse

PHO Primary Health Organisation

RHD Rheumatic Heart Disease

SES Smart Energy Solutions

TDH Tairawhiti District Health

TH Turanga Health

WINZ Work and Income New Zealand

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Introduction from Board Chair (Tairawhiti District Health Board)

Tairawhiti District Health Board’s campaign against Rheumatic Fever means much more than a campaign against ‘strep throat’ – a throat infection caused by a Group A Streptococcus (GAS) bacteria – that can, if left untreated, lead to the far more serious condition of rheumatic heart disease.

In our work in Tairawhiti, we have found that throat infections can sometimes be an indicator of unhealthy home environments. Cold damp houses and overcrowded living conditions provide the perfect place for Rheumatic Fever to strike.

Tairawhiti District Health’s contracted health providers offer an approach that attacks all these problems. Our children are being treated with antibiotics for throat infections for sore throats, while their homes are improved as part of a local home insulation subsidy scheme.

This approach is a very innovative and effective use of our health dollar. The Tairawhiti District Health Board believes that this plan – with its new goals and strategies – will not only expand the previous twelve months’ work, but will ultimately see our region removed from high on the list of worst symptomatic areas in the country.

David S Scott JP TDH Board Chair

From CEO (Tairawhiti District Health Board)

This Rheumatic Fever prevention plan details a range of activities to be undertaken across the health sector, and in the wider community, that I believe will prove effective in lowering and then eliminating the incidence of Rheumatic Fever in our community.

We must to do this because Rheumatic Fever is an insidious disease affecting our young people, and then displaying its most dramatic effects later in their lives in the form of damage to the heart. Rheumatic Fever’s impact is severe for the individuals who contract it, and for their families. The impact is more distressing because of its preventable nature, and our historical inability to provide an environment that completely protects our young people from the disease.

As Chief Executive of Tairawhiti District Health I know there are no “quick-fix” options for eradicating Rheumatic Fever. I totally support this plan to work towards eliminating both Rheumatic Fever and the actual cause of the disease itself. With the determination of our DHB, other health and social sector providers and the wider community of Tairawhiti, I believe we will be successful. Our young people are 30% of our population but 100% of our future. I want that to be a future without Rheumatic Fever.

Jim Green CEO TDH

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Summary of activities achieved to support development of Rheumatic Fever plan in Tairawhiti

Appointment of Tairawhiti District Health (TDH) Paediatrician and Clinical Director of

Woman, Child and Youth as Rheumatic Fever clinical champion.

Completion of Rheumatic Fever Prevention Plan as required by the Ministry: this has had

cross-sector involvement, stakeholder feedback on models of care utilised to date, and

agreement at a conceptual level as to the allocation and utilisation of the funding from July

2014 to December 2015 (noting that the three partnering organisations have agreed this

conceptual model requires further fleshing out of the operation detail before it can be

signed off).

Currently the model is considering a three- pronged approach:

Enhancement of primary care engagement

Supported community development so to facilitate community awareness,

ownership and management of Rheumatic Fever prevention at a community level.

Enhancement of the community based Kaiawhina role to further support health

messaging, referral pathway utilisation to housing insulation.

Audit of Rheumatic Fever admission cases

Preliminary discussions in regard to future management of secondary prophylaxis.

The first of what has been are on-going regional teleconferences facilitated by HealthShare.

Attendees at this were Ministry, DHB (Clinical and Management) and community NGO

representatives. The focus of this first teleconference was to:

Update on DHB Rheumatic Fever Prevention Plan

Identification by DHB of current issues, approaches and challenges in addressing

Rheumatic Fever

Similarity coming through from 4 of the 5 DHBs, Taranaki being the exception given

its low RF incidence rate).

Primary care involvement has been achieved through GP liaison, emails and GPs attending

Steering Group from Ngati Porou Hauora (NPH). Sore Throat guidelines have been

distributed to GPs. Positive swab and treatment details are communicated back to the

practices. We acknowledge the under-involvement of practice nurses a source of expertise

to be utilised in the future.

This is a dynamic plan that will develop and evolve over time with further community

consultation and engagement to ensure full integration.

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Section 1: Overview of Rheumatic Fever in Tairawhiti

1.0 Background

Tairawhiti has at times had the highest incidence rates of Rheumatic Fever in the country at 15.1 new cases annually per 100,000 population around 4 times the national average of 3.8 new cases per 100,000 (MoH 2011). This could be due to factors such as the socio economic status of the region. Table 1: District Health Boards with a high incidence of Rheumatic Fever

District Health Board Number per year

(based on 3-year average,

2009/10 to 2011/12)

Rate per year

(based on 3-year average,

2009/10 to 2011/12)

Tairawhiti 4 9.3

Note – the numbers and rates have been calculated using the criteria for acute Rheumatic Fever initial hospitalisation outlined in Appendix 3.

In 2010 a steering group was established to address the high Rheumatic Fever rate in Tairawhiti. The Ministry specified the following activities should to be undertaken by NPH, TDH and Turanga Health (TH). Throat swabbing and referral services, raising community awareness of Rheumatic Fever, reporting and monitoring.

Demographics

Tairawhiti has a high Maori population which makes up 48% of our total population (TDH Annual Plan 2013-2014). In our rural and coastal communities this can increase upwards of 80%. Of the 0-14 year old population, 66% identify as Maori or Pacific (PHO register, Oct 2013) Due to our low Pacific population numbers, Pacific and Maori are grouped together.

Age Range Maori/Pacific Non Maori Total

0-4 2,484 1,239 3,723

5-14 4,982 2,575 7,557

Total 7,466 3,814 11,280 Source: PHO Registers for Quarter starting 1 October 2013

The Tairawhiti district has an average deprivation score of 7 with a large proportion of our population living in the most deprived areas – 67% of Maori and 30% of Non-Maori living in deprivation deciles 9 and 10. Half (52%) of our children aged 0-14years14 years also live in these most deprived areas (TDH Annual Plan 2013-2014). Figure 1 below illustrates the levels of deprivation across the region. The link between deprivation levels and Rheumatic Fever is evident in Table 2, which shows that ARF cases are higher in areas with deprivation levels of 9 and 10.

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Figure 1: Deprivation levels in Tairawhiti (2006)

Table 2: The number of cases of Acute Rheumatic Fever by NZ dep score from 1997 to 2009 in Tairawhiti.

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1.1 Throat swabbing program background The Ministry of Health approved the joint proposal between Turanga Health, Ngati Porou Hauora and Tairawhiti District Health to deliver a Throat swabbing program across Tairawhiti from late 2010, as per the Ministry of Health service specifications which outline:

Provision of throat swabbing and referral services, raising community awareness of Rheumatic Fever and reporting and monitoring

Goals

Equity of incidence between Maori and Pacific and general population of NZ

Decrease incidence rate to 0.4 per 100,000 by 2020

Contribute to reduction of Rheumatic Fever hospitalisation rate (5 or less per year)

Objectives

To provide Throat swabbing in schools, homes, or other settings for children aged 5 – 14 years that present with sore throats in high risk areas and to other eligible whanau/families living with children

To develop relationships with other providers

Raise awareness of Rheumatic Fever – geography

Develop systems for lab testing/antibiotics/referrals and follow up for positive GAS sore throats

1.2 Local implementation The Throat swabbing program covers all children between 5 and 14 years attending decile 1,and 2 schools, including alternative education schools/centres. A rural decile 3 school was also included as these students were also considered to be at high risk of Group A Strep.(GAS). Other schools are serviced on referral in order to cover children who are part of the high risk population that attend higher decile schools. This service is provided through the existing Public Health Nurse referral system in place for each school. The service is also offered to whanau of the children (after three positive swabs) for Group A Streptococcal (GAS) pharyngitis in a three month period. Given our high rural and coastal populations, geographical spread and diverse challenges many of our communities face in accessing health services, each provider developed their own unique approach to implementing the program with their respective communities and populations. program. Ngati Porou Haurora (servicing Gisborne/East Coast) have undertaken intense promotion within schools and the school community to encourage families to take children with sore throats to the free clinics on the Coast for throat swabbing and treatment by either the Practice Nurse or GP. This

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model enhances sustainability and empowerment by supporting parents and whanau to identify and understand their children’s health concerns and seek assessment and treatment when needed. This is working well with significant numbers now attending these clinics. Turanga Health (servicing Gisborne/Western Rural) utilise both their clinical and non-clinical staff to raise community awareness of Rheumatic Fever in the Western Rural area. This has involved a number of health promotion activities in a range of settings such as schools, hui, marae and community events. Turanga Health also offered throat swabbing to all tamariki/rangatahi at the following schools: Te Karaka Area School, Matawai, Motu, Whatatutu, Patutahi, Manutuke and Muriwai. . This approach provided baseline level data comparing the percentage of symptomatic children who were positive in comparison to asymptomatic children that also returned positive GAS results. In follow up, tamariki/rangatahi and their whanau with sore throats were encouraged to visit their General Practice and or contact Turanga Health. All those with a positive GAS result were followed up for treatment and along with those newly diagnosed with Rheumatic Fever were referred to the Turanga Health Insulation project for follow up. Tairawhiti DHB (servicing Gisborne City) The Well Child Service provide the throat swabbing program through the Public Health Nurses already in place in twelve urban schools, alternative education centres and Stand Childrens Services Children’s Health Camp. This is practical for an urban area considering the volumes of children involved. Schools already have a good working relationship with the Public Health Nurses and no school has declined the programme. Public Health Nurses visit the schools three times a week and also take referrals in between visits. Like their colleagues at Ngati Porou Hauora and Turanga Health, the Public Health Nurses began the programme by providing education sessions to school staff, students, whanau and the wider school community. Consent for swabbing is sought from parents/caregivers either at the beginning of the year or when the child enrols at school. Parents are informed when a swab has been taken then notified of the result. Antibiotics can be given to children who return a positive throat swab under the established standing order. Kaiawhina and Public Health Nurses follow up medication compliance once the children have started on antibiotics. Following a particularly successful awareness raising program in Gisborne Boys High School ( see appendix 1), the DHB Population Health Team are now in collaboration with the school and the Public Health Nurses to develop a program template that can be transferred to other schools wanting to raise awareness on Rheumatic Fever amongst their students and school community. The team are also working on developing a template for all schools around sore throat management. It is envisaged this will be a laminated flow chart which will outline the options for schools when a child presents to staff with a sore throat. This will be accompanied by a presentation to school staff explaining the options.

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1.3 Throat swab analysis Tairawhiti

All throat swabs in Tairawhiti are analysed by TLab (sole provider of hospital and community laboratory services in Tairawhiti). Through their system it is possible to highlight the pattern of results from throat swabs Results are posted on isoft which is accessible by clinicians.

The graph below shows the results of all throat swabs performed in Tairawhiti. over a three year

period. Normal flora accounts for 60% of all results; with. GAS is the major pathogen and accounts

for 20% of swabs tested.

Interestingly some studies have reported carriage rates as high as 20%. (Tanz RR, Shulman ST.

Chronic Pharyngeal Carriage of Group A Streptococci. Pediatr Infect Dis J. 2007; 26(2): 175-176)

There were a total of 12.558 throat swab tests ordered by doctors in the Tairawhiti DHB region

during the period of 2010-mid-2013. These 12,558 tests were requested by 193 doctors signatories

that will include doctors and nurses.

Encouragingly the number of throat swabs performed in Tairawhiti is increasing annually.

The vast majority of swabs are performed within primary care in our region and this is shown in

Table 3 below. The school based program performs a quarter of all throat swabs.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Normalthroatflora

STREPTPYOGENES

STAPHAUREUS

CANDIDAALBICANS

GROUP CSTREPT

GROUP GSTREPT

GROUP BSTREPT

MRSA YEAST notCandidaalbicans

No growth

Graph showing results of all Throat swabs in Tairawhiti from 2010- mid 2013

2010 2011 2012 2013

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Table 3: Percentage of Throat swab requestors Tairawhiti during the period of 2010-mid-2013

25%

1%

74%

Throat swab requestors Tairawhiti

School based swabs Medical Officer of Health GPs

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Section 2: Commitment to reducing Rheumatic Fever in Tairawhiti

Tairawhiti District Health is committed to reducing the incidence of Rheumatic Fever to levels set by the Better Pubic Services targets. The specific targets for Tairawhiti are summarised in Table 4 and 5 along with the Midland and National targets.

Table 4: Acute Rheumatic Fever initial hospitalisation target rates per year by District Health Board (per 100,000 total population), 2012/13 to 2016/17

District Health Board 2009/10–2011/12

Baseline rate

(3-year average rate)

2012/13

Target:

Remain at baseline level

2013/14

Target:

10% reduction from baseline level

2014/15

Target:


2015 /16

Target:


2016/17 Target:

2/3 reduction from baseline level

Tairawhiti 9.3 9.3 8.4 5.6 4.2 3.1

Midland region 4.1 4.1 3.7 2.5 1.8 1.4

New Zealand 4.0 4.0 3.6 2.4 1.8 1.3


Table 5: Acute Rheumatic Fever initial hospitalisation target numbers per year by District Health Board (total population), 2012/13 to 2016/17

District Health Board 2009/10–2011/12

Baseline numbers

(3-year average rate)

2012/13

Target:

Remain at baseline level

2013/14

Target:


2014/15

Target:


2015 /16

Target:


2016/17 Target:

2/3 reduction from baseline level

Tairawhiti 4 4 4 3 2 1

Midland region 34 34 31 21 16 12

New Zealand 177 177 162 109 83 62


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2.0 Stakeholders input and engagement

Below is the list of organisations and communities involved in ongoing consultation, development

and delivery of the plan;

Stakeholders (Current) Stakeholders (To be approached from 2014)

Consumers/Whanau

Turanga Health(TH)

Ngati Porou Hauora (NPH)

Teachers,principals/school

receptionists

Primary Care/GPs/Receptionists

Practice nurses

Pharmacies

Well Child Tamariki Ora

Eastland Community Trust (ECT)

EECA

Housing NZ

Property Management Agencies

TDH Well Child Service

TDHPublic Health Nurses/Social

Workers

TDH Paediatric Outreach Nurses

TDH Maori Health Service

TDH Paediatric Inpatient Service TDH

Planning, Funding and Population

Health

Te Runanganui o Ngati Porou

(TRONPnui)

Te Runanga o Turanganui a Kiwa

(TROTAK)

Gisborne District Council (GDC)

Te Puni Kokiri (TPK)

Whanau Ora Regional Leadership

Group (RLG)

Te Aitanga a Hauiti Hauora (TAAHH)

Maori Women’s Welfare League

(MWWL)

Pacific Island Community Trust (PICT)

Tairawhiti Multicultural Council

(TMC)

WINZ

2.1 Local community consultation

Tairawhiti District Health is committed to “Working to Elevate the Wellbeing of Tairawhiti” by

supporting vulnerable children and their whanau to reduce disparities and improve health

outcomes especially for Maori. We work in partnership with key stakeholders and other sectorial

organisations to make progress in reducing the incidence of Rheumatic Fever.

The development of this plan provided the steering group with the opportunity time to evaluate

the Throat swabbing program to date and this process will be on-going throughout future program

implementation. To assist with identifying the strengths and weaknesses of the existing program as

well as opportunities for improvement and enhancement. Questions were developed (see appendix

2) and distributed to key stakeholders. This feedback has then been used to inform the

development of appropriate activities to include in the plan.

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Commitment to the plan from stakeholders has been gained through membership on the steering group as well as through existing MOUs already in place. Continued relationship management and communication on a regular basis will help ensure commitment remains at the level needed to bring about positive change.

Community consultation activities were conducted with two local communities (one town, one

coast). Surveys were distributed at a community event and a community meeting.

A discussion was also held at a monthly whanau hui at a local Te Kura Kaupapa Maori to gain a

sense of whanau understanding and awareness of sore throats and Rheumatic Fever. This is a

newly established Kura that is due to have the throat swabbing program in place for Term 1, 2014.

so it was useful to gain a sense of awareness and understanding prior to program implementation

with a follow up planned six months post implementation. Turanga Health discussed the program

with their staff and identified areas that were working well and opportunities for improvement.

Time constraints meant that a more thorough and comprehensive evaluation was unable to take

place. However the feedback provided is still important and useful in the development of this plan.

Consultation and evaluation will be ongoing with further activities planned for 2014-2015.

Outcomes from consultative process:

Increased focus on community awareness-raising activities.

A number of whanau and communities are still unaware of the importance of getting sore throats checked and the linkages with Rheumatic Fever.

A number of whanau are unaware of the school throat swabbing service delivered in their local schools

Improved consistency of input into schools

Consultation showed that some eligible schools are either not receiving the throat swabbing service or the service is not provided on a regular basis.

Ongoing engagement of community

All three providers will work with the local Maori health providers in the district to inform them of the Standing Order project. There will be specific actions to meet the needs of Maori.

A priority focus for the steering group is to work with Kura Kaupapa and Alternative Education Centres in Tairawhiti Kanohi ki te kanohi (face to face ) is always the preferred method of engagement for the steering group as this approach strengthens relationships, enhances interaction and produces meaningful dialogue and communication. Tairawhiti has a number of forums and networks and every opportunity to use the organisation’s own channels will be taken to disseminate project information and updates to as wide a network as possible, we are taking advantage of existing meetings where our team will present updates.

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The Tairawhiti District Health district does not have a large Pacific Island Community and will engage with the Pacific Island Community Trust to reach this target group. Meeting with the organisations detailed below to discuss Rheumatic Fever and to identify opportunities for future involvement and support is seen as a key activity for the Tairawhiti RF Steering Group for early 2014.

Te Runanganui o Ngati Porou (TRONPnui)

Te Runanga o Turanganui a Kiwa (TROTAK)

Gisborne District Council (GDC)

Te Puni Kokiri (TPK)

Whanau Ora Regional Leadership Group (RLG)

Te Aitanga a Hauiti Hauora (TAAHH)

Maori Women’s Welfare League (MWWL)

Pacific Island Community Trust (PICT)

Tairawhiti Multicultural Council (TMC)

On-going engagement will be supported through regular communications and meetings with key

stakeholders. Survey feedback from stakeholders identified a need for greater collaboration so the

possibility of setting up a community action group will also be explored as an opportunity to

identify possible shared projects, key messages and community events with Rheumatic Fever as a

focus. This will be integrated with other key Child Health projects.

2.2 Rheumatic Fever champion

Dr Hein Stander, Clinical Director of Women Child and Youth, has been identified as the Rheumatic Fever champion at senior executive level. This role will include:

Chair/Member of Rheumatic Fever steering group for Tairawhiti

Working with other services in the region to reduce ASH rates for children

Attending regional meetings at least annually to discuss implementation of the plan

Other tasks identified by DHB

The steering group would also like to explore the opportunity to appoint community champions to

help raise awareness and support the various local activities happening at a community level. This

may be in the form of a community group/school/individual or whanau.

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2.3 Overarching actions to reduce the incidence of Rheumatic Fever

Prevention Model

‘Human health cannot be fully understood without taking into account the wider environment’ (Mason Drurie)

Improve standards of living (social determinants of health)

Especially reducing overcrowding

Treat household of ARF cases

Improve access to healthcare

Primordial

Prevention

Promote sore throat / antibiotic guidelines

‘Sore throats matter’ message

School based Throat swabbing

Treat household contacts

Primary

Prevention

Rheumatic Fever register

Improved secondary prophylaxis

Promote Heart Foundation guidelines

Secondary

Prevention

Supported by improved ARF notification and monitoring

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Prevention (population based perspective)

As we assess cases of Rheumatic Fever, we identify that they have features in common, most of

which are actually social. The implication is that the social environment is related to the disease. It

is either related as an association (but not causation) ie, people getting Rheumatic Fever are found

in certain communities, but that being in those communities is a marker for something else.

Genetics might be included in this: Maori are more likely to live in less well-off areas, but the risk of

Rheumatic Fever relates to their genetic make-up, not poverty. While there is always some

variation in disease risk from one’s genetic make-up, the real evidence for this is limited or lacking:

people migrating from the UK should also be genetically at risk, as RF was common in the UK until

50 years ago.

A stronger local association is the overlap between RF cases and social environments. Local work

10 years ago showed that RF was even within NZ Dep areas 9 and 10, RF was unevenly distributed.

In NZ Dep 10 cases, there is a social gradient, with cases more likely in the ‘poor of the poor’.

Valve replacement

Ultrasound screening

Sore throats

Housing , Access to health care

Poverty , Unemployment

Structural marginalisation, racism colonisation/ToW

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Highlighting the links means that employing a ‘navigator’ so that this person explores the

immediate social environment for the family of a case, and also the whanau and social group of

that case.

If the infectious hypothesis is true, then the RF causing Strep should exist in greater prevalence in

that social milieu. Transmission and prevalence are tied to the social group, therefore addressing

the one household is not likely to break a chain or reduce the risk for that whole group.

Poverty remains an underlying commonality: whether that is marked as lack of disposable income,

it is a marker of lack of opportunity, often poverty of opportunity, poverty of access to service,

poverty of future gaze.

Section 3: Investment in reducing Rheumatic Fever Tairawhiti

A review of stakeholder/Community feedback plus a DHB audit on recent diagnosed cases of RF led to a review of what we have learned and development of actions for the future.

Figure 2: Plan- Do – Check – Act (PDCA) Cycle

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What we know/what we have learned from evidence, consultation and feedback.

Tairawhiti as a whole is high risk

MoH state the key focus needs to be on Rapid identification and treatment

Importance of community ownership and development if RF reduction activities going to be

sustainable

Emphasis on the value added role of Kaiawhina

Parents/caregivers need to be informed on when to act and to be empowered to access services

Need to focus program on GAS prevention alongside Throat swabbing.

Community programs are not just about swabbing children’s throats.

We need to consider and address social determinants as underlying factors (housing , overcrowding)

Engagement with primary and community care is critical

A key component of success needs to be that the community understand the link between GAS and

sore throats and Rheumatic Fever

All health workers need to be giving consistent messages

Multi media campaigns are needed with locally affected children fronting local campaigns

Messages must be simple and well understood,

We need collaboration and integration across the sector

Communications need to be engaging, culturally appropriate and supplemented by face to face

opportunities particularly for Maori and Pacific island parents/caregivers. For many

parents/caregivers communications alone will not support behavioral change due to health literacy

and a range of other barriers.

Health workers need to reduce the barrier of health literacy by providing appropriate

communication (eg: written and visual)

Housing referral pathways need to be clear and understood by people in the community

3.0 Tairawhiti resources committed to reducing Rheumatic Fever 2013/14

A Community Rapid Response Model has been developed by the key providers to ensure a population based and clinical model are integrated.

(see over page)

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Building a Community Rapid Response Model due to Tairawhiti having a ‘high risk’ population

Whole of community response

Empower families and schools Principles

Community ownership

Build on foundations

Consistent messages

Sustainability

Lower admissions to hospital

Changing behaviour and

education

Increasing involvement of Health protection team (use existing resource)

Actions

$15 Throat swab (pay lab costs)

Kaiti mall WINZ – Joint provider approach to WINZ clinics with one

year rapid response

Normalise people using primary care

Health messages - Up skill workers to do more of housing/home insulation

course

Swab - Action - Referral

Lifestyle and holiday programs

Community Champions leading the way

Rapid response programs in summer holidays – all 3 providers - other health

messages as well

Health promotion card

Spread MoH message

Whanau Ora develop capacity

Networks Housing New Zealand

Outcomes

Build community ownership and capacity

Long term investment compared to later cost of valve replacement

Utilise Kaiawhina to assist with medication compliance and swabbing

Pay GP nurses to train to reduce rate

Not only Nurse led clinics Practice nurses/Public health nurses/Outreach

nurses involved

Educate social services

Housing coordinator

Link to Oral health

Build on what we have

Parents to access Primary Care long term if accessible and

affordable

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3.1 Current investment

Early in 2012 the TDH Well Child Service within Tairawhiti DHB recruited a senior Public Health Nurse to lead the Rheumatic Fever in childhood program. This lead role has been pivotal particularly in providing a coordinated approach to education projects throat swabbing, laboratory processes and the standing order. Eighteen months into the program these processes are becoming embedded and becoming business as usual.

There is 0.3 FTE Kaiawhina hours dedicated to the Throat Swabbing program. Kaiawhina works alongside the lead RN and the Public Health Nurses. Collaboration with Health Promotion/ Health Protection team at Tairawhiti DHB is essential to the success of the program moving forward and will be business as usual.

Turanga Health initially took a population health approach by offering throat swabbing to all Tamariki attending the identified kura in the early phase of the Rheumatic Fever program. This resulted in a high number of throat swabs, approximately 16% of those were +ve GAS, for this period.

In addition Turanga Health also engaged communities with further information regarding Rheumatic Fever and sore throats with a focus on signs and symptoms, early treatment and intervention. At this time Turanga Health also had engaged the Tairawhiti Retrofit initiative and looked to connect with the Rheumatic Fever. Retrofitting is also a key component of their program and whanau returning positive GAS results are referred into the insulation program.

Turanga Health also undertakes workforce development activities to increase the capability and capacity of clinical and non-clinical staff.

Ngati Porou Hauora delivers the program through their rural health clinics and GP practice in Gisborne – a service which is free for their enrolled clients. The Rural Health Nurses provided schools and the wider community with information and education about the throat swabbing program and Rheumatic Fever prevention and encouraged families to take their children to the clinics if they had a sore throat.

Projected funding until 2016

Tairawhiti District Health has made a clear and genuine commitment to investment in Rheumatic Fever prevention activities as stated in the action plan out to 2017 and beyond. This will involve current and future resource (assuming ongoing MoH funding) and support as TDH needs to live ‘within it’s means’.

TDH will review the investment plan to 2017 in more depth and will report progress and details to MoH in the second quarter 2014.

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Initiative Volume 2014/15 2015/16 sustainable

Gisborne City Kaiawhina 1 FTE $60,000 $60,000 $60,000

Primary care for swabbing 5,500 Swabs

in 14/15 $82,500 $41,250

Laboratory Test for School Swabs 1,833 Tests per year in

14/15 $27,500 $13,750

Community development worker 0.5 FTE @

$100,000 pa $50,000 $25,000

Specialist School swabbing Public Health Nurse. This funding enables the Gisborne Based School Health Nurses to continue to swab.

1 FTE $100,000 $100,000 $100,000

Communication and Community Development discretionary funding

$20,000 $10,000

Medical Practitioner Supply Orders - Drug Orders

$25,000 $25,000 $25,000

Total $365,000 $275,000 $185,000

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Section 4: Tairawhiti actions to prevent the transmission of Group A streptococcal throat infections

Introduction

Overcrowding, low quality housing conditions and poor hygiene practices have been identified as a high risk for the transmission of group A strep throat infections. A goal of Tairawhiti DHB is to reduce this risk by addressing the standards of housing conditions and implementing initiatives with the aid of various community agencies.

4.0 Housing

Initial discussions have been held with various people and organisations involved in local housing and insulation projects in Tairawhiti to gain an understanding of what’s happening at a local level. These include:

Leighton Evans (CEO, Eastland Community Trust)

Dr. Bruce Duncan (TDH Medical Officer of Health)

Turanga Health

Carol Martin (Bronwyn Kay Property Management Agency)

Vicky Ngata (Area Manager, Housing NZ)

A group was set up in 2004/5 (discussions had been going from around 2003), including the Council, EECA and EnergyOptions (retrofitting company). The initial fit out of homes targeted people with higher levels of self-reported health needs. The program had a 100% funding component and a subsidised component. The initial program targeted about 200 houses. To reach a larger number of people in the community ECT provided funding to the scheme and combined with EECA funding we were able to massively expand the retrofit program. Data collected so far suggests a Tairawhiti-wide reduction in housing related preventable avoidable hospitalisations. Currently we are working on compiling a list of houses that have been retrofitted and to compared hospitalisations by address only for retrofitted vs non-retrofitted; but it has proved difficult to get the list of homes. A different trajectory of hospitalisation for the two groups would support retrofitting being the cause. However no funding was allocated for a formal evaluation of the local program as all funding was put into fitting out homes. One area of concern was that, by insulating houses (and draught excluding) we were perversely increasing health risks. Many houses are heated by un-flued gas heaters which are cheap to buy and run. However they have been banned in some countries due to the carbon monoxide they emit which can cause heart problems through the subtle blocking of haemoglobin’s ability to carry oxygen and cause deaths. These heaters also produce vast amounts of water vapour, producing damp homes which are harder to heat. In 2008 discussions were held about adding heating to the retrofit process. Heat pumps were suggested as an option but the local reality for the most vulnerable is that a heat pump would

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potentially cause more debt problems, as many of the most at risk are unable (through poverty) to pay a fuel bill. A local solution would be efficient wood burners, with development work to be done around firewood schemes for vulnerable families. The new providers for insulation locally are Smart Energy and Climatize: Community service card holders who are home owners are entitled to 100% insulation subsidy as per the ECCA website. It is positive to now note that Gisborne is now the leading district in New Zealand for home insulation (see website www.ect.org.nz/recent-projects/eastland-community-trust-healthy-homes/).

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4.1 Tairawhiti actions to prevent the transmission of Group A streptococcal throat infections

Key objective Intervention

Actions to deliver improved performance

Year 1-2013-14

Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17

Rationale Measured by

Collaboration with cross sector partners to achieve the Better Public Health Service targets with Health leading the Rheumatic Fever target.

Cross agency governance and monitoring

Promote the Better Public Health Service targets for RF.

Ongoing commitment to the BPS targets through the collaborative governance, including promoting improved housing

Ongoing

Ongoing

All are collaborative partnerships connected by the common vision and work to improve outcomes for children. These groups include iwi, education, housing, Te Puni kokiri, health MSD and Justice.

Stocktake results

Develop systems to ensure that families at high risk of RF living in crowded housing are identified and appropriately referred to local housing and/or social services for follow up & intervention.

Stocktake of Housing and Healthy Homes Initiative

Stocktake of current healthy homes initiatives –to identify agencies providing retrofitting, dry wood supply, curtain bank, adequate heating, adequate housing, clothing, affordable electricity.

Please refer appendix 3 for further proposed activities.

Maintain an up to date database of housing initiatives

Ongoing Ongoing There is evidence for a link between poor quality housing and Rheumatic Fever as well as comparative studies of a link between crowding in the home and Rheumatic Fever

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Work in partnership with Iwi to improve access insulated housing for Maori

Link up with the “Warm up New Zealand “ project with local Iwi.

Establish support worker position to work alongside Whanau Ora navigators and system innovators.

Approach to other agencies to become involved in programmes to improve housing. EECA, Housing NZ, Iwi services, Gisborne council.

Yearly stocktake and advocacy

re ongoing community agencies engagement

Develop referral pathways and systems.

Develop a systems approach to identifying children and families at high risk of RF when the children and families are seen by health services. System to enable agencies to flag children and families living in overcrowded and poor housing, including poor heating and clothing combined with presentations for respiratory illness, repeat GAS infections, ASH, vulnerable pregnant women, vulnerable children 0-5 years. Includes children referred to Childrens Team (in future).

Establish and implement the referral criteria, access and pathways to the appropriate social and health services for follow up and intervention.

Monitor and review the referral pathways.

Addressing crowding, damp and cold housing conditions has the potential to have a positive impact on reducing the rate of GAS and RF.

There are current audits of homes participating in the Warm up New Zealand project. This will be ongoing.

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Audit to determine status of existing home conditions and living arrangements including smoking of RF patients (temperature heating, occupancy)

Project involving home visitors (midwives, public health nurses, Paediatric outreach nurses) to audit winter temperatures in at risk homes.

Audit in particular improvements to housing conditions that have occurred through the healthy homes initiative by accessing community agencies

Ongoing Monitor and review the referral pathways

To have actual physical data on the housing conditions and possible improvements made for RF patients with in Tairawhiti.

Audits

To raise awareness of RF and RF prevention

RF communication plan

Partnering key iwi organisations to engage and partner with and support awareness around Rheumatic Fever and improving housing

Ongoing Ongoing Ongoing This is critical to the working partnership with Tairawhiti DHB and local Iwi in working towards the joint goal of awareness and improving housing conditions

Regular Meetings

Whanau Ora provider collective engagement to develop access to community services set up to improve housing referral pathways

Ongoing Ongoing Ongoing

Pacific Island – utilise Pacific Island workforce

Ongoing Ongoing Ongoing Key in working alongside the pacific island community for raising awareness and improving housing condition

Meetings

Feedback to child health forum cross sector governance body


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4.2 Improving general hygiene in education settings

The spread of Group A streptococcal throat infections can be reduced by promoting good hygiene practices in education settings. This combined with the early identification and treatment of Group A streptococcal throat infections is key to reducing the spread.

Key objective Intervention Actions Year 1 - 2013/14 Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


To reduce the spread of Group A streptococcal throat infections by promoting good hygiene practices

Targeted communications on general and hand hygiene, cough/sneeze etiquette

Key hand hygiene messages will be promoted to schools and ECE settings.

Hand hygiene resources will be available to reinforce key messages

Delivered in partnership.

Ongoing Ongoing Ongoing To promote better education on how to prevent transmission of GAS and other illnesses

By encouraging better general hygiene practice rates of GAS transmission can be reduced

Improving general hygiene report on a quarterly basis

Identify primary schools with substandard hand washing facilities and develop a joint plan to improve hygiene in these schools.

Relationship with Ministry of Education (MoE) developed at DHB regional level and Toi te Ora and Public health

Joint plan completed with MoE to identify schools.

Schools assessed and identified with substandard hand washing facilities

Improvements are made in schools with substandard hand washing facilities

Ongoing Number of schools assessed and referred to MoE

Number of schools where improve-ments made

Work with Ministry of Education at regional and DHB level to progressively improve hygiene conditions in

Include the use of the Ministry of Health hand washing guideline/protocols in higher priority schools, i.e. all schools with school based health services, throat swabbing and community awareness

Ongoing Ongoing Ongoing Public health Number of schools using hand washing guideline/ protocols

Reduction in number of GAS

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Year 4 – 2016/17


schools.

programmes positive siblings of positive cases

Promote the co-benefits of hand hygiene in reducing other infectious illness e.g. gastro, colds and influenza and skin infections

Promote healthy communal living habits in homes and schools

Ongoing Ongoing Ongoing Well Child/Tamariki Ora providers, PHNs, Hauora providers, Pacific Islands Community Trust, GPs, A&E departments in hospitals, community

Reduction in relevant ASH conditions

4.3 Reducing skin infections in schools, community and home settings

Serious skin infections are a major cause of avoidable hospitalisations in New Zealand. Whilst ARF is most frequently associated with Group A

streptococcal throat infections, there is some evidence that children with streptococcus pyogenes skin infections e.g. impetigo, may also be at risk

of Rheumatic Fever. Consequently, it may be beneficial to reduce the burden of bacterial skin infections in Tairawhiti.


Year 4 – 2016/17


To Increase awareness of the early detection, intervention and treatment of skin infections in Tairawhiti DHB

Undertake community awareness raising campaigns to increase understanding of skin infection prevention and management.

Develop skin infection communications plan Undertake awareness campaign

Ongoing Ongoing Ongoing Public Health Nurses, B4 School Nurses, whānau ora collectives ECEs,

Campaign evaluation

Skin infection admissions

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Year 4 – 2016/17


Improve responsiveness and effectiveness of primary and community health services in preventing and managing skin infections in the community

Promote the Map of Medicine skin infection pathway to health professionals. Support innovative projets.

Ongoing Ongoing Ongoing TDHB, GP Liaison, paediatricians / secondary care services .

Audit of admission rates by MoM.

To increase the early detection and treatment of skin infections in the Tairawhiti DHB population

Public Health Nursing, Outreach Paediatric Nurses, rural health nurses, practice focus on prevention and early treatment of skin infections

Implement skin infection clinical pathways and standing orders across school health services, child and youth community services and community care clinic.

To be initiated by the Paediatricians.

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Section 5: Actions to treat Group A streptococcal throat infections quickly and effectively

Ensure that primary care health professionals likely to see high risk children follow the most up-to-date sore throat management guidelines.

A Standing Order has been developed thereby enabling nurses to administer antibiotics appropriately, safely and in a timely way to children in the program with a sore throat. The Standing Order also details the Throat swabbing process. The document is being utilised by all three providers. The standing order is based on national best practice guidelines. The Standing Order also summarises an evidence based best practice for the guidance encompassing the population risk (ie that in in Tairawhiti everyone aged 3-45 years falls into a risk category who has a sore throat) and clinical assessment of sore throat based on the national guidelines.

A simple to follow algorithm guide then allows the user to determine if an antibiotic should be immediately commenced if there is clinical certainty without waiting for a result from the throat swab. Antibiotic options are clearly outlined in the standing order. Antibiotics are chosen according to this. A simple dosing regime is used with alternatives if there is an allergy.

This is summarised in the algorithm (Figure 2) which has been widely distributed to health care professionals in the region. The Standing Order includes documentation to support the Public Health Nurses using it, and the process for sign off by the appropriate medical practitioner and also for the antibiotic to be signed off by a Medical Officer of Health or Community Paediatrician community paediatrician.

TDH’s The GP Liaison representative at TDH regularly updates the local GPs when new standards or information is available, and is also kept informed by the Steering Group.

Continued training of TDH’s Public Health Nurses, Kaimahi, Kaiawhina and Child Development staff is delivered by Well Child Services at the Public Health unit.

Turanga Health has undertaken a deliberate strategy to increase the capacity and capability of non-clinical staff to complement the Rheumatic Fever strategy. This has been done to engage whanau with appropriate information delivered in an appropriate manner, and enlightenment and to assist whanau with wrap around services and also to assist and support clinical team.

Monitoring

The Tairawhiti Rheumatic Fever Steering Group provides advice and support for the providers and a forum for any relevant discussions re issues and challenges and potential solutions to these.

Treatment compliance

Whanau treated for +ve GAS are followed up midway through treatment for support and advice to ensure adherence from non clinical and clinical kaimahi

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Figure 2: Algorithm for sore throat management

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Section 6: Actions to facilitate the effective follow-up of identified

Rheumatic Fever cases

Introduction

This section outlines Tairawhiti DHB plan for implementing initiatives to provide excellent secondary care and prophylaxis care for identified Rheumatic Fever patients. All ARF patients in Tairawhiti are followed up, monitored and have their care audited annually. It is recognised that the provision of providing thorough care pathways for health professionals and encouraging the use of best practice guidelines is important in the work to ensure effective follow-up.

All patients identified with Rheumatic Fever have a designated Public Health Nurses/rural health

nurse who facilitates their care. Public Health Nurse/rural health nurses will provide the patients

with a comprehensive and appropriate education around self-care and importance of timely

antibiotic cover.

Patients are seen be the PHN before they leave hospital. Plans for home or school visits are made at

that time, this is also when the next dose of prophylactic antibiotic is given.

Turanga Health provides wrap around services to whanau with Rheumatic Fever receiving Bicillin

treatment particularly in the Western Rural areas this is lead by the clinical team.

6.0 Notifying the Medical Officer of Health

In Tairawhiti DHB an established protocol for the notification of patients with acute Rheumatic

Fever has been developed.

On suspicion of Rheumatic Fever the house officer responsible for the care of the patient will

contact the Medical Officer of Health (MOH). On confirmation of diagnosis the house officer will

start a Case Report Form and forward on to the Health Protection Officer responsible for Episurv.

MOH will again be contacted.

Public Health Nursing staff will also be made aware of the confirmation and the appropriate

communicable disease processes will commence.

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6.1 Action plan

Key objective Intervention Actions to deliver improved performance

Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Ensure patients with a history of Rheumatic Fever receive monthly antibiotics not more than 5 days after their due date

Up to date Rheumatic Fever database and register

Immediate notification of all ARF diagnosis to the RF nurse immediately.

Implemented referral system on all diagnosis to RH Fever nurse

Documentation to the register and Medical Officer of Health within 5 days of discharge

Ongoing maintenance of the register

Ongoing Ongoing See below Regular audits of prophylaxis data.

Ensure that all cases of acute RF are notified to the Medical Officer of Health within seven days of hospital admission

House officer to contact MOH if patient suffering from RF admitted to hospital.

System in place for Rheumatic Fever documentation on discharge to include notification to the register and notification to the Medical Officer of

Communication through the GP liason group to primary care to notify the Rh fever nurse of all patients with a history of ARF shifting into the DHB and to be entered on the register.

Rheumatic Fever register of all Rheumatic Fever patients with in Tairawhiti.

Monthly audit of bicillin delivery of all patients receiving bicillin.

Address all cases which have not received bicillin within the 5 day

Audit the register with the notifications to the Medical officer of Health and the discharge data of patients with ARF clinical coding

Review the current service delivery of bicillin.

Ongoing

Ongoing

The register has been implemented with the aim of having a main data centre for all RF patients with in Tairawhiti. With up to date information provided on patients prophylaxis treatment, care pathways, multidisciplinary teams involved. It gives the ability to audit in particular the bicilin prophylaxis care pathway with maintaining high percentage compliance with in five days of being due.

Regular audits of prophylaxis data.

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Health

timeframe

Monitor length of time between hospital admission and notification to MOH of all ARF patients.

Any exceptions are followed up with notifying doctor.

Ongoing

review

Ongoing

review

Regular review of monitoring systems in place for secondary care. Identifying risk factors for non compliance

Review process of the deliverance of secondary prophylaxis bicillin. Auditing practice, school, district and community outreach nurses and how successfully they administer bicillin in a timely manner, their rates of compliance. Identifying and addressing possible issues cause non compliance.

Ongoing Ongoing Ongoing The issue of compliance with the IM bicillin injection has been identified by Tairawhiti. Resources need to be assessed and refined integrated for improvement in compliance rates. To make the bicillin treatment easier for patients.

Quarterly Review

New Bicillin Protocol

A new bicillin protocol has been written and established with in Tairawhiti. It involves a less painful way of deliverance with the adding of lignocaine and the use of the buzzy bee device.

Recognised as first line administration method of the Bicillin injection

Ongoing Ongoing The deep IM injection has been known to be a painful experience. The aim with the new protocol is to decrease the pain level of the injection hence encouraging better compliance.

Yearly review

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Dental Care Pathway

Medical alert for dental services of patients with RF who have had carditis. Providing a guideline of oral hygiene, dental follow up required and antibiotic prophylaxis required before dental procedures

Notification to the Community Oral Health service of all enrolled children with ARF diagnosis

Increasing regular oral health check ups for children in the community Oral Health service to 6 monthly

Up and Running Ongoing Ongoing It is important to address high risk of recurrence of cardiac valve infection (endocarditis) for RF patients when having dental procedures if prophylactic antibiotics are not used.

Also the importance of maintaining good oral hygiene to prevent infection that has risk of leading to endocarditis.

Rheumatic Fever Care Pathway

Rheumatic fever care pathway has been written for implementation of a patient newly diagnosed. This commences during the patients hospital admission. It involves the multidisciplinary team with check list and resources provided for the patient’s current / future care . Involves notification of the medical officer with in seven days of hospital admission. Once diagnosis confirmed this includes:

Completion of the Rheumatic Fever register documentation

Notification to Public

Ongoing

Ongoing Ongoing There needed to be an all in one resource for the multidisciplinary team to be able to use for planning patients care. It involves current best practice guidelines and contact list of services that will need to be accessed. It also involves education guidelines for the patient and their whanau. The goal is for the patient to have all community services accessed before discharge in order to provide excellent ongoing

Yearly audit of care pathway used.

Review with input from health professionals involved.

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Map of Medicine

Health

Initiating Rheumatic Fever into Map of Medicine to have a national, regional approach to diagnosis and treatment and follow up for patients who have had a ARF diagnosis.

Prioritised for implementation of RF clinical guidelines

care.

Referral Pathway of child transition to adult care

A referral process to help co-ordinate the transition to adult based care once the patient turns 15 years of age.

This can also apply for patients transferring in and out of the district

Up and running Ongoing Ongoing Due to slightly different community services required for adults a thorough referral process will help provide ongoing care and support with a clear pathway of care provided for the patient and the community services required.

Audit of use of the referral pathway

Raising Awareness

Clinicians: Health Professionals Training Module consisting of New Zealand’s history and current statistics of Rheumatic Fever. National Heart Foundation Guidelines for diagnosing RF. Associated links with poverty, overcrowding, housing conditions. Illnesses such as skin infections, bronchiolitis, URTI , recurrent strep throat infections.

Ongoing

Ongoing

Ongoing

Due to the multi cultural group of doctors that come and go it is important to educate new doctors about New Zealand and its incidence with RFas they may not have had to address this health issue previously in the country they had come from i.e Britain, Scandinavia. Therefore need to bring GAS and RF to the forefront for their clinical assessment

Education attendances during orientation for new doctors.

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Further talk to Grand Round about Rheumatic Fever.

Ongoing

Ongoing

Ongoing

of our “at risk” groups.

Provides an early introduction for senior and junior doctors about diagnosis and treatment of RF.

Resources A quick doctor checklist for guidelines and resources – refer Algorithm in standing order.

Up and running Ongoing Ongoing An easy resource and checklist for doctors to follow to make sure all aspects of the care pathway have been addressed for the patient in order to implement excellence of care

Linkages with Midland Regional Services Plan

RAPHS clinical governance and Midland Locality Advisory Committee (by champions)

Ongoing collaboration of the Rheumatic Fever Steering Group consisting of the regions PHOs and DHBs with identified champions. To ensure progress on achieving the regional target for reducing incidence of Rheumatic Fever.

Ongoing Ongoing Ongoing The Rheumatic Fever Steering Group was set up with purpose of a joint collaboration process between NPH, TH and TDH to have unity in resources and initiatives with the joint goal of reducing rates of RF as per Ministry of Health prevention plan

Quarterly meetings

Appointed Clinical Director of WCY as champion

Dr Hein Stander – Clinical Director of Women Child and Youth and Paediatrician. Promoting clinical integration between public, primary, secondary and tertiary health services; and between

Review Review Review Those with established RF and RHD warrant ongoing follow up and supervision of their cardiac valve status. The required level of care will be determined and provided by paediatricians,

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


paediatric and adult cardiology services for ongoing management. Providing excellence of care for acute RF patients and those with rheumatic heart disease.

physicians, cardiologists and general practitioners delivering their care.

Section : 7 Review of cases to identify known risk factors and system failure points 7.0 Audit results As part of the strategic approach to the management of RF in Tairawhiti it has been agreed to undertake an audit of cases over the last year to ascertain factors that may contribute to the development of cases. The idea is that in future the RF management team will review all cases of ARF that are notified as part of an on-going audit of cases under the Medical Officer of Health. The aim of the audit is to identify factors contributing to the development of RF such as provision of antibiotics for sore throats in the school based program. The audit tool is shown at the end of this document.

The time has been taken as a year to October 2013 looking at new cases of Rheumatic Fever in children.

There were six new cases over the 1 year period. This compares to 14 new cases over a similar period one year earlier.

All the new cases were Maori children, ranging in age from 9 to 15 years.

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All the children had a history of sore throats. Five children had had throat swabs taken prior to admission. The majority were taken by the

cases GP and one child had their swab taken through the school based program. One child had two positive throat swabs however no

antibiotics were given. Two children were given antibiotics and did not complete the full course prior to admission.

The provisional findings indicate that there is more work to be done on the management of sore throats in our region. This audit has not been completed yet and further analysis by the management team needs to be done to reach further conclusions.(see action plans related to Community promotion including education and compliance).


Year 4 – 2016/17


Identify activities that will ensure known risk factors and system failure points in cases where Rheumatic Fever are identified

Notifications are reviewed by the MOH and the notifying clinician. All ARF cases are audited by the Rh Fever Champion and clinician Processes implemented that will ensure action is taken if system failures are identified. Risk plan developed (mitigation of risk if outcomes not met).

Develop a clear review process Medical Officer of Health and Rheumatic Fever champions to address all system failures. Results of findings and actions to be presented at Steering group/Governance group.

Feedback of information on a case by case basis and/ or when patterns emerge Where any cases were potentially preventable, recommendations are made for system improvements.

Ongoing Ongoing All cases are auditable for best practice. Systems in place for back up and system failure to prevent

Annual reporting

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7.1 Identify and follow-up known risk factors and system failure points in cases of Rheumatic Fever


Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Ensure primary care health professionals likely to see high risk children follow the most up-to-date sore throat management guidelines

Implement the RF and Sore throat clinical pathway as a priority in the roll out of the Map of Medicine clinical pathways process.

Provide input into localising the pathway and ensuring it aligns with the Heart Foundation guidelines

Review and monitor

Make any changes if necessary

Review and monitor


Review and monitor


Evidence based

Updated as necessary

Education and clinical updates for health professionals. Frontline clinicians, locums in primary health care and secondary care

Rheumatic Fever champions to lead updates

Timetabled and systematic approach

Written orientation package about Rheumatic Fever and the Tairawhiti population for all new doctors including locums in primary care and secondary care. Include rural PHN and practice nurses.

Include in primary care annual CME timetable

Implement across the sector the MOH Rheumatic Fever online training package currently under development

Annual updates

Included in orientation for clinicians

Annual updates

Included in orientation for clinicians

Distribution of National Heart Foundation Guidelines and resources for GP, public health, school nurses, Paediatric Outreach Nurses, rural health nurses.

Evidence based

Provision of Investigate the options around Work with primary

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


treatment immediately

dispensing Amoxycillin from the MPSO to high risk children and families who otherwise will not fill a prescription.

care on dispensing options

“Sore Throats Matter”

Community Campaign

Communications: Community - Wide distribution of resources “Sore throats Matter” message.

Identify all ‘key audiences’ in community, including Whanau Ora.

Enhance Health promotion in schools.

Enhance training for nurses and kaiawhina

Utilise social media.

Review of the campaign and its effectiveness

Align with consistent key messages. Identify options for integrating throat swabbing with other child health services.

Utilise MoH recommended resources (see appendix 3)

Build on success of Gisborne Bays High promotion/program (see appendix 1).

Yearly review and re-release

Ongoing The “sore Throats Matter” campaign has had a positive impact on the community and promotes the early recognition of GAS. It will be beneficial to continue this campaign with regular review of resources and education techniques.

Community and school auditing of resources and education used

Throat swabbing

TH, NPH and Well child have establishes a Throat swabbing program across the region.

Recognition that Tairawhiti is high risk – may include other decile schools.

Transition throat swabbing programme into business as usual pre-school and school based nursing.

Ensure ongoing access to sore throat assessment and treatment

Ongoing Ongoing This has promoted early identification and treatment of GAS amongst children of some low decile primary schools

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Throat Swabbing and Standing orders of amoxicillin in all secondary school clinics.

Ongoing education for all secondary school nurses about GAS and Rheumatic Fever. Standing orders have been written and given to the school nurses to commence early treatment of GAS.

Overseen by the Youth health doctors and primary care RF champion.

Review of this programme. Set a more structured criteria for commencing antibiotics

Ongoing Ongoing This provides early, easy and quick access to primary care. Catching an at risk group in one area.

Audit of occurrences of GAS and treatment administered and full course of antibiotics taken

Public Health Nursing/rural health nurses in primary schools to implement pathway into primary care for treatment of sore throats.

Public Health Nurses to develop a clinical pathway into primary care

Public Health Nurses to appoint a dedicated resource to champion RF prevention and skin treatment.

Raising Awareness

Teaching sessions at community churches, meetings particularly with Pacific Island and Maori communities. What is GAS, RF and where to go to get treatment

Ongoing Ongoing Ongoing It is important to educate our “at risk” community to promote early detection and treatment

Community involvement in planning of initiatives

Identify a community spokes person for Maori and Pacific Island to liaise with and co-ordinate initiatives.

Utilise Health promotion in schools.

Ongoing Ongoing Ongoing This forms a key partnership with TDH and the community. This encourages community guidance and involvement implementing the work

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


plan initiatives

Identify and address barriers to primary care access

Education of Health Professionals on importance of improving access to assessment and treatment

Implementing the clear message of the importance of urgent treatment of Strep throat amongst our “at risk” groups

Investigate options for providing free and easy access to primary care for children and young adults with sore throats

Work with primary care on implementing free and easy access to sore throat management for school aged children and family contacts of Strep A. Implement funding package across primary care for free access, nurse clinics. Short term investment enables free access to Primary Care.

Ongoing

Ongoing

Ongoing

Ongoing

To keep reiterating the messages of early diagnosis and treatment of GAS amongst our health professionals

To make sure health professionals are following current best practice

Review of public, primary and community health professionals and the implementa-tion of the best practice guidelines

Increase capacity of the community youth health services to provide free and easy access to young people with sore throats for assessment and treatment

Promote and advertise ‘Sore throats matter’ and use the Heart Foundation guidelines and work under standing orders for the diagnosis and treatment of sore throats.

Utilise Social Sector Trials to promote key messages.

Annual updates Policies, guidelines and standing orders reviewed. DHB-service agreements includes free access to sore throat management in youth health community clinics

Ongoing and review

Ongoing and review

Increase -School Attendance -NCEA Level 2 Achievement -Civic Participation, Entry into Services & -Trades Apprenticeships - Tertiary Education -Employment

Reduce, -Police Apprehensions -Teen Pregnancy -Sexually transmitted infections -Alcohol & Drug

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Early at risk detection

Referral pathway from child health services to GP regarding at risk children

Free sore throat care for school aged children following self referral pathway from the community to general practice nursing

Up and running Ongoing Ongoing To have an early detection process of at risk children that have presented to primary care services with sore throats

Mobile Clinic (partnership with TDH, TH and NPH)

“At Risk” community providing easy, early access to primary care-based in WINZ building, Kaiti Mall.

Provide free clinic in a mobile service eg: park in school grounds in holidays outside WINZ.

Ensure mobile service provides free, quick access to priority children and families Ongoing review of standing orders that they are current and are based on the Heart foundation guidelines and include treatment of skin infections.

Review

annually

Review annually

Current access to primary care can be a cost to the user hence preventing early and easy access. GP practices have an individualised fee system so differs from practice to practice.

Free mobile clinic will have a clientele that is disengaged with primary care.

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Ensure that children and family contacts being treated for Group A streptococcal throat infections under standing orders will complete a full course of antibiotics

Standing orders prescriber to be responsible for follow up , evaluation of treatment and compliance. Access increase support should it be needed through the Public health Nurses, child health nurses, family start.

Include the need to complete full course of antibiotics as a key message in awareness raising campaigns and health promotion initiatives. Include in standing orders and clinical pathways the follow up and evaluation of treatment and compliance On-going education of children, parents and whanau re the importance of completing antibiotics utilising appropriate health literacy approaches. Ensure pharmacists are aware of pathways.

Work with Pharmacy on whether bigger, highlighted messages can be given re compliance with courses of amoxicillin are dispensed.

Link with community support workers, whanau ora workers primary health care where high prevalence of high deprivation communities require support to access medicines and complete the course.

Ongoing review Ongoing review

Pharmacists reinforcing messages about throat swabbing and compliance.

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Section 8: Actions to facilitate the effective follow-up of patients with rheumatic heart disease Introduction Whilst this plan is aimed at preventing new cases of ARF, section 7 acknowledges the need to ensure appropriate clinical follow up of patients with an existing diagnosis of RF and RHD. This is a local priority and will not be reported on to the Ministry. This section will consider interventions for two patient categories:

i. those who do not have established (or documented) RHD ii. those who do have established RHD

8.0 Interventions for patients who do not have established RHD


Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


Effective treatment of patients who do not have established (or documented) RHD

Develop and implement a considered programme of recall, for clinical assessment echocardiography and clinical planning to occur. Those that have had comprehensive assessment, and do not have rheumatic valve

Develop plan and project approach. GP consideration of known patients beyond prophylaxis age groups (as per Heart Foundation Guidelines)

Implementation and review

Ongoing Ongoing With regard to historically diagnosed patients (when there was no easy availability of echocardiogram) many are likely to have had undiagnosed valvular disease.

Percentage of patients with written care plan / follow up

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Year 2 – 2014/15 Year 3 – 2015/16

Year 4 – 2016/17


disease, can then just receive the relevant care and follow up as per Heart Foundation Guidelines.

8.1 Interventions for patients who have established RHD


Year 4 – 2016/17


Effective treatment of patients with established RHD

These patients need at least initial re review so that health professionals can be confident that the patients understand what has occurred to them and is likely to occur.

Develop plan and project approach.


Audits of patient reviews completed and outcomes

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Year 4 – 2016/17


Provide information and education to empower the patients to care for themselves. This includes understanding the need for prophylaxis re subacute bacterial endocarditis.

Tairawhiti patients have a full yearly review. GP consideration of known patients beyond prophylaxis age groups (as per Heart Foundation Guidelines)

Ongoing

Ongoing

Ongoing

Those with established rheumatic valve disease warrant ongoing follow up and supervision of their valve status to be confident that all are receiving the health care they need. The required level of care needs are determined and then provided by the pediatricians and cardiologists and GPs delivering their care,(this already happens to a variable degree of adherence except for those who have been for a number of reasons “lost to the system”)

Yearly review of education techniques and material used . Yearly review

Hand outs on future clinical issues. Discussed pre discharge or by outreach nurse, cardiology and paediatric review. Interval follow up as per Heart Foundation Guidelines

Established Ongoing Ongoing Ongoing

Audit of follow up clinics and attendence

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Section 9 - Summary of the Rheumatic Fever Prevention plan Table 6: Summary of Rheumatic Fever Prevention plan for Tairawhiti

2013/14 2014/15 2015/16 2016/17

DHB target

(provided by the Ministry of Health)

8.4

5.6 4.2 3.1

Rheumatic Fever champion Hein Stander, Clinical director Women Child and Youth (WCY) WCY

RF Steering group

Ongoing review of the champions and RF steering group for targets being achieved



Key stakeholders and providers involved in implementation of the plan

Consumers/Whanau,Turanga Health(TH), Ngati Porou Hauora (NHP), Teachers,principals/school receptionists , Tairawhiti District Health , Primary Care/GPs/Receptionists, Practice nurses, Pharmacies, Well Child Tamariki Ora, Eastland Community Trust (ECT), EECA,Housing NZ, Property Management Agencies,Public Health Nurses/Social Workers,Paediatric Outreach Nurses,Te Runanganui o Ngati Porou (TRONPnui), Te Runanga o Turanganui a Kiwa (TROTAK),

Ongoing review of our partnership with current and future stakeholders

Ongoing review of our partnership with current and future stakeholders

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Gisborne District Council (GDC), Te Puni Kokiri (TPK), Whanau Ora Regional Leadership Group (RLG), Te Aitanga a Hauiti Hauora (TAAHH), Maori Women’s Welfare League (MWWL), Pacific Island Community Trust (PICT), Tairawhiti Multicultural Council (TMC), Te Puna Waiora, WINZ, Maori Health Service, Pediatric Inpatient Service

DHB financial investment See document

Ministry of Health financial investment See document

Total financial investment (DHB and Ministry of Health)

See document

Actions to prevent the transmission of Group A streptococcal throat infections

Healthy Homes initiatives

Referral pathways for children at risk

Raising Awareness

Ongoing stocktake of Healthy homes initiatives and current , future agencies involved

Auditing of number of homes enrolled in the programme

Ongoing review of community wide education initiatives







Actions to treat Group A streptococcal throat infections quickly and effectively

Raising Awareness

Throat swabbing

Ongoing review of the “sore throats matter “campaign.

Ongoing review of the “sore throats matter “campaign.

Ongoing review of the “sore throats matter “campaign

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Standing orders of amoxicillin amongst high schools

Education of

Health Professionals

Early at risk detection

Supply up to date best practice guidelines for quick diagnosis and treatment of GAS

Review of referral systems in place for recognition of “at risk”children, young person





Actions to facilitate the effective follow-up of identified Rheumatic Fever cases

Rheumatic Fever Register

Regular review of monitoring systems in place for secondary care.

Fully running register and regular auditing capabilities






Identifying risk factors for non compliance

Address and implement practices to improve non compliance rates



New Bicillin Protocol

Dental Care Pathway

Ongoing review Ongoing review Ongoing review

Rheumatic Fever Care Pathway Ongoing review Ongoing review Ongoing review

Referral Pathway of child transition to adult care

Ongoing review Ongoing review Ongoing review

Raising Awareness Ongoing review Ongoing review Ongoing review

Resources Ongoing education of current best practice guidelines for health professionals

Ongoing education of current best practice guidelines for health professionals

Ongoing education of current best practice guidelines for health professionals

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Appendix 1: Health promoting school focus at Gisborne Boys High School.

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Appendix 2: Stakeholders survey and feedback

Stakeholder Questions posed Primary Care 1. Are you aware of the sore throat swabbing programme running in local

schools 2. Do you feel the information provided to you practice about it has been

adequate or would you like more? 3. What interaction has the programme had with your practice 4. Have you noticed any differences in patterns of people coming into your

practice with sore throats? Has general community awareness of sore throats increased?

5. Do you feel you and your staff have adequate knowledge about treating sore throats for Rheumatic Fever prevention?

6. What information do you have available for family and whanau about sore throats and prevention Rheumatic Fever? Would you like access to more information resources?

7. How do you see the programme improving? Does your practice have any suggestions?

Schools 1. Please describe the general make up of your school 2. How supportive are your BOT members of the Throat Swabbing

Programme 3. Can you please describe how the programme works in your school? What

is the role of the school? What is the role of the staff? 4. From your perspective have you noticed any change in awareness of sore

throats or Rheumatic Fever in parents and whanau? 5. Have you noticed any change in awareness of sore throats or Rheumatic

Fever in staff members of the students? 6. What do you see as the main benefits of having the swabbing programme

in your school? 7. Are there any negative aspects associated with having the programme in

your school? 8. How could the process be improved to make it easier for schools? For

students? For staff? For whanau? 9. What information do you have available for parents/whanau, staff and

students about sore throats and preventing Rheumatic Fever? 10. Are these resources widely available? 11. Are there any gaps in the programme from your perspective? 12. What enhancements could be made to the programme?

Public Health How does the Rheumatic Fever Prevention Programme fit within your role? Do you see an opportunity to include this within your role? How?

1. What are you or your team doing to raise the community’s awareness of preventing Rheumatic Fever (e.g. treating sore throats, school programmes, housing and insulation)

2. What resources are you using? Are they widely available? Are they appropriate?

3. As far as you’re aware, what are other organisations in your area doing to raise community awareness?

4. What training do you receive on Rheumatic Fever prevention? Is this

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sufficient? Could it be improved? 5. What role do you see your team/service having in the programme in the

medium to long term? 6. From your experience of living and working in the community, have you

noticed any change in awareness of Rheumatic Fever prevention? In your view, why may that have happened?

7. What is your view on the best way to deliver the programme to the communities you work with? Schools, primary care, another approach?

8. What enhancements could be made to the programme? How could the programme be improved going forward?

Survey Feedback Primary care (6 responses) All practices that responded were aware of the programme although some were not sure how it exactly worked. In saying that, most stated they had received adequate information but some would like more and would like more. Most respondents stated they had been notified when a child was throat swabbed and treated in the programme. General practice does not routinely provide information to parents of children turning up with sore throats –they don’t have anything readily available.

Schools (5 responses; all low decile schools) All respondents were supportive of the programme Two rural schools stated they had no programme in their schools although one school confirmed apart from some earlier screening, they started receiving a service about a month ago. The other school responses were variable about the school activity. One stated the extra work was required by the schools with consent forms. Another stated the school nurses visited once a week while another school sent a notebook around the classrooms then made a referral to the nurse in schools. The schools with the programme believed parents/caregivers had an increased awareness with one school suggesting this does take time. Main benefits of the programme ranged from very little in the schools that did not get visited as part of the programme and increased awareness that sore throats matter in the others. When asked what could be improved one sated the consent for process conversely another stated this was easy. One school asked for a service while another rural school stated it was useless in its current form. Information to parents had been provided in the way of pamphlets and via the school newsletter. Gaps identified included no services to the schools through to no gaps. Other comments included the schools nurses coped very well given their limited resources and their input was appreciated. Another school hoped the service continued while another stated the current process did not have the desired effect. The latter comment was from a school that had only just started receiving the school based programme.

Stakeholder - Health Promotion, School Nurses, Clinical Nurse Manager, Medical Officer of Health

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(9 responses) Most were involved in awareness raising using MoH and National Heart Foundation resources. Not surprisingly all had an awareness of the organisations involved in the school based programme. All stakeholders had some training in Rheumatic Fever prevention from the one day initial training through to the Te Hotu Manawa Maori training provided by the National Heart Foundation. Overall there has been an increased awareness in schools and by GPs re the importance of sore throats. To improve the service there needs to be multiple ways to deliver the programme, increased collaboration across providers and be proactive in delivery the service including looking at social determinants. The biggest concern was providing the service once the MoH funding runs out, but does need to be de-medicalised and inertia decreased.

Elgin community (12 participants) and Ruatoria community (4 participants) Rheumatic Fever or sore throats was not mentioned in the top three priority concerns for children. There was variable awareness of what to do with a child who had a sore throat from home remedies through to taking the child to the doctor at the same time most demonstrated an awareness of the consequences of not getting sore throats treated. Some of the respondents had children who had been throat swabbed and treated at school and those that were treated their children took the full course of antibiotics.

Kura Kaupapa Maori Whanau (15 participants) Monthly whanau hui. Talked about sore throats and Rheumatic Fever of which no one knew the link between the two. Only one had heard of Rheumatic Fever – a father who had it as a child and his 13 year old daughter also has it. Whanau spoke about the steps they take when their children have sore throats – pamol, lemon drinks, stay home and go to doctor when no improvement. We spoke about Rheumatic Fever and the process when children are diagnosed (i.e. lengthy hospital stay, bed rest, possible surgery) and also the secondary prevention steps taken to prevent a further attack. Talked about the throat swabbing programme which will be implemented Term 1 2014 as this is a newly established Kura. Insulation and housing were also discussed. Overall, low level of awareness of importance of getting sore throats checked and link with Rheumatic Fever.

Turanga Health Identified components of programme that are working well: Non clinicians, easy access to schools. Good communication with the schools; good rapport with the students, regular visits to the schools. Good planning, education in the schools, TH created resources i.e. crosswords, glitter, integrated approach – clinical/non clinical, schools letting TH use their communication pathways (panui), using administrators as champions for their schools, open door policy with all rural schools. Identified possible areas for improvements: Better quality control between the Lab – Provider, empowering whanau of right to a throat swab, whanau need to know their rights on getting a throat swab, Inform whanau about other symptoms other than a sore throat, education on sore throat -need more whanau education, education at events/settings; short, sharp and consistent messages in simple terms, using local champions on posters/flyers/panui.

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Appendix 3: Proposed activities relating to Healthy Homes Gather all information on available schemes and initiatives and eligibility criteria for retrofitting

Develop a flow chart that maps out the schemes available in different communities and the pathway for accessing Include pathways for the following:

Children returning +GAS result

Children/families with Community Services Card

Children with respiratory problems or repeated chest/throat infections

Families in private rental accommodation

Families living in crowded/cold/damp housing

Low income families them.

Conduct audit with local workforce (Well Child, Public Health Nurses, Social Workers, Whanau Ora, Kaiawhina, Social Services etc) to find out what information they give to families about housing and insulation, referral pathways and who they refer to.

Use findings to inform development of a system that is consistent across the district and across providers to ensure families at risk are referred to appropriate housing and social services for follow up and intervention.

Ensure workforce have the most up to date information about the different schemes available and services they can refer onto for when they visit families.

Conduct research projects to identify impact insulation and retrofitting has had on health outcomes for families.

Use findings to inform development of appropriate health promotion key messages for housing, insulation and heating.

Develop two-way communication pathways between insulation providers/funders and the steering group for sharing of regular updates, data and information.

Identify opportunities for sharing the workload – those visiting or working with families often have limited time to discuss a range of issues with whanau. Either not enough time to discuss housing and insulation needs or whanau not willing to discuss. Consider kaiawhina approach (similar to Turanga Health) with a focus on housing and insulation. Also workforce have highlighted difficulties in not knowing which are the current schemes they are able to refer to and follow up with.

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Appendix 4: ‘Sore throats matter’ pamphlet

HPA w ebsit e (h t t p ://w w w .hpa.o rg.nz/w hat -w e-do /rheum at ic-f ever /resources)

http://www.hpa.org.nz/what-we-do/rheumatic-fever/resources

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