Once vanquished by penicillin, a disease of poverty stages a quiet return in vulnerable communities.
A remarkable medical triumph seemed to unfold over the 20th century. Acute rheumatic fever (ARF), a devastating illness that was once the leading cause of death in American children by the 1920s, virtually disappeared from most developed nations 1 2 . This autoimmune condition, triggered by a common strep throat infection, can cause the immune system to attack the body's own tissues, particularly the heart valves, leading to lifelong rheumatic heart disease (RHD) 3 4 . For decades, Victoria shared in this success story, with hospital admissions plummeting by over 95% since the 1940s 5 .
Yet, beneath this veneer of victory, a persistent and inequitable health crisis was simmering. Recent research reveals that ARF and RHD never truly left Victoria; they merely retreated into the most marginalized corners of our society, quietly affecting the lives of children and adolescents while the broader population remained unaware 6 . This is the story of a preventable disease that continues to thrive on disadvantage, and the scientific detective work that uncovered its hidden presence.
Group A Streptococcus infection
Autoimmune reaction
Permanent heart damage
To understand the significance of ARF and RHD, it's essential to grasp their nature and relationship. ARF is an autoimmune reactive disease that can develop 2-3 weeks after an infection with Group A Streptococcus bacteria—the common cause of strep throat 2 . In susceptible individuals, the antibodies produced to fight the bacteria mistakenly attack the body's own tissues, particularly the heart, joints, brain, and skin 3 .
The condition progresses through three distinct stages: bacterial sore throat → acute rheumatic fever → rheumatic heart disease 2 . Approximately 60% of those who experience an ARF episode will develop RHD within a decade, with recurrent attacks dramatically worsening existing heart damage 2 .
Carditis is the most serious manifestation, occurring in 50-80% of first ARF episodes and potentially leading to permanent valve damage 3 . The disease primarily affects children between 5 and 15 years of age, with RHD remaining a leading cause of acquired heart disease in young people worldwide 2 3 .
For years, the epidemiology of ARF and RHD in Victoria remained poorly documented, with the assumption that these were historical diseases of little contemporary concern. This changed with a groundbreaking 2022 study that comprehensively described the clinical epidemiology of children and adolescents with ARF and RHD at two major tertiary paediatric hospitals in Victoria between 2010 and 2019 6 .
The research team employed a rigorous retrospective audit design, reviewing records from The Royal Children's Hospital and Monash Children's Hospital 6 . Their case-finding approach was exhaustive:
Potential cases were identified by searching Health Information Services records for relevant ICD-10-AM codes, electronic medical records for documented diagnoses, and echocardiogram reports.
Researchers manually reviewed electronic health records of all potential cases to determine eligibility, including only those aged 21 years and younger at initial diagnosis.
For confirmed cases, they collected comprehensive data on demographics, clinical features, comorbidities, and management strategies.
The study revealed several crucial aspects of ARF and RHD in contemporary Victoria:
| Population Group | Incidence per 100,000 | Incidence Ratio |
|---|---|---|
| Overall Victorian Population | 0.8 | 1x |
| Aboriginal and/or Torres Strait Islander | 3.8 | 4.75x higher |
| Pacific Islander | 32.1 | 40x higher |
Eligible patients identified with ARF/RHD
Recurrence rate of ARF episodes
Moderate to severe RHD cases
To appreciate the significance of these findings, we must examine the historical trajectory of rheumatic infections in Victoria. A separate study tracking ARF and RHD in Melbourne from 1937 to 2013 reveals a dramatic story of rise and fall—but not disappearance 5 .
During this period, the mean annual incidence rate of ARF/RHD hospitalisations at The Royal Children's Hospital reached a staggering 40.1 per 100,000 children aged 5-14 years 5 .
The decline that followed was sharp and sustained, largely attributed to improved living conditions, the introduction of penicillin, and improved access to healthcare 1 2 5 .
By this period, the mean annual incidence rate had fallen to just 1.6 per 100,000—a 96% reduction from the peak 5 .
The 2022 study confirms that this decline bottomed out, and the diseases persist at low but significant levels, disproportionately affecting specific ethnic groups 6 .
The persistence of ARF and RHD in specific communities is not random but follows well-established social and biological determinants. Recent research has identified key modifiable risk factors:
A New Zealand case-control study found a strong association between household crowding and ARF, with an odds ratio of 3.88—meaning nearly four times higher risk 7 . Overcrowding facilitates the spread of streptococcal infections.
Those with a family history of ARF had a five-fold higher risk (OR 4.97), highlighting the role of genetic susceptibility 7 .
Self-reported skin infections (OR 2.53) were significantly associated with developing ARF 7 .
Difficulties accessing primary health care more than doubled the risk of ARF (OR 2.07) 7 . This includes financial barriers, transportation issues, and cultural barriers.
The Victorian study found that 69.4% of cases came from the lower three socioeconomic quintiles, confirming the disease's strong association with poverty 6 .
Modern management of ARF and RHD involves a multifaceted approach with specific tools and strategies:
Now recommended for all confirmed or suspected ARF cases regardless of murmur presence, this technology enables early detection of subclinical carditis 8 .
The standardized diagnostic criteria for ARF, recently revised to include different thresholds for low-risk and moderate/high-risk populations 8 .
The cornerstone of secondary prevention, administered as intramuscular injections every 3-4 weeks to prevent recurrent ARF episodes 9 .
Aspirin and other anti-inflammatories are used to manage symptoms during acute ARF episodes 9 .
Rapid antigen tests and throat cultures enable diagnosis of streptococcal pharyngitis, with appropriate antibiotic treatment preventing initial ARF episodes 9 .
Specialized services and disease registers help coordinate care, improve adherence to prophylaxis, and prevent complications 6 .
The recent findings from Victoria underscore several critical points for policymakers and healthcare providers. First, ARF and RHD remain preventable diseases of poverty that reflect deep-seated health inequities. The dramatic disparities observed in Aboriginal, Torres Strait Islander, and Pacific Islander communities demand targeted interventions addressing housing, healthcare access, and socioeconomic disadvantage 6 .
Australia has established an ambitious goal: the elimination of RHD by 2031 6 .
Achieving this will require enhanced surveillance, register-based control programs, and most importantly, addressing the social determinants that allow these preventable diseases to persist in vulnerable communities.
The story of rheumatic infections in Victoria serves as both a warning and an opportunity—a warning about how health inequalities can perpetuate preventable diseases, and an opportunity to demonstrate how targeted, equitable health policies can finally consign these historical diseases to history.
This article synthesizes findings from recent scientific studies published in peer-reviewed journals and public health guidelines from authoritative sources. The data presented reflect the most current understanding of acute rheumatic fever and rheumatic heart disease epidemiology in Victoria as of the most recent available studies.