Comment: Sedation as part of secondary prophylaxis to prevent recurrent rheumatic fever in Aboriginal and Torres Strait Islander peoples: time for a reset?

Watson Watson,Ward Ward,Ricciardone Ricciardone,Pungana Pungana

doi:10.22605/rrh6866

Abstract

Australia's national clinical practice guidelines recommend intramuscular (IM) penicillin every 28 days for persons diagnosed with an initial episode of acute rheumatic fever (ARF). This antibiotic coverage is initiated to reduce recurrent ARF episodes by preventing repeat infections with the causative bacterium, group A Streptococcus. Because disease has already occurred, this regimen is known as secondary prophylaxis (SP), done in order to prevent more episodes of ARF (known as recurrences). In 2020, eight authors shared with readers of Rural and Remote Health their experience of introducing off-label an oral, centrally acting, alpha agonist sedative to the prescribed SP regimen of IM penicillin for each of three Aboriginal children previously diagnosed with ARF. The living environments of the three children increased their risk for repeat group A Streptococcus infections and subsequent recurrences of ARF. We find the clinical case report perpetuates a troubling academic tone about this singular priority for SP. Injecting a child with IM penicillin appears to supersede all other objectives. Off-label sedation in remote settings is legitimised in order to succeed in this imperative. Those articles that peer-reviewed medical journals choose to publish privilege directions for priorities, policy and practice. In this commentary, we present alternative perspectives and initiatives for consideration.

Highlights

Poor environmental infrastructure including sanitation, overcrowding due to inadequate housing and inadequate access to culturally safe primary health care contribute to high rates of acute rheumatic fever (ARF) in Australia’s Aboriginal and Torres Strait Islander peoples[1]
Since 2009, the Australian Government has spent $54 million on an unwritten rheumatic fever strategy including significant allocations to establish rheumatic heart disease (RHD) registers with mandatory centralised reporting and monitoring of secondary prophylaxis (SP) provision in four state and territory jurisdictions in which ARF is endemic among Aboriginal and Torres Strait Islander peoples
33% of those Aboriginal and Torres Strait Islander peoples with ARF or RHD receive less than half their prescribed annual SP regimen[9]

Summary

Introduction

Poor environmental infrastructure including sanitation, overcrowding due to inadequate housing and inadequate access to culturally safe primary health care contribute to high rates of ARF in Australia’s Aboriginal and Torres Strait Islander peoples[1]. 1. In view of the poor quality of the available evidence, well-designed randomised controlled trials comparing the effectiveness of penicillin injections with oral phenoxymethylpenicillin are required. Since 2009, the Australian Government has spent $54 million on an unwritten rheumatic fever strategy including significant allocations to establish RHD registers with mandatory centralised reporting and monitoring of SP provision in four state and territory jurisdictions in which ARF is endemic among Aboriginal and Torres Strait Islander peoples.

Results

Conclusion