A vaccine to protect kids hearts

The international effort against Group A Strep

The Telethon Kids Institute is spearheading a trans-Tasman effort to develop a vaccine for rheumatic fever.

Institute director Professor Jonathan Carapetis said a vaccine would be a game-changer for this illness, which is caused by a group A streptococcus infection. What starts out as a sore throat can lead to permanent heart damage, known as rheumatic heart disease.

Continuing the work he did at the Menzies School of Health Research in Darwin, Professor Carapetis’ focus is on finding ways to prevent and better treat rheumatic heart disease in Australia.

Aboriginal, Torres Strait Islander, Maori and Pacific Islander populations have some of the highest rates of rheumatic heart disease in the world.

In remote communities, about 3-5 per cent of Aboriginal people will have the condition and the average age of death from it is in the 30s.

“In these areas, everyone knows someone who has got it or died of it,” Professor Carapetis said.

While treatments for patients are improving, it is far better to stop the disease from occurring in the first place.

Finding an effective and economically viable vaccine is the primary aim of the government-funded partnership between Australia and New Zealand, called the Coalition to Advance New Vaccines for Group A Streptococcus (CANVAS).

Professor Carapetis said the main obstacles standing in the way of a vaccine before now revolved around market and safety doubts.

“Our main goal is getting a vaccine through the early stages to make it much easier for pharmaceutical companies to get involved,” he said.

“By the end of this year, we will have evaluated three potential vaccines for their likelihood of being effective. We will also have compiled a definitive collection of the types of bacteria that we want a vaccine to prevent against and we will also have made an analysis of the economic case for investing in the vaccine.”

This will enable them to go back to the two governments to ask for a bigger financial commitment for the next stage.

“We want to be able to take at least one vaccine through to demonstrating that it can prevent strep infection in the throat and try to get the pharmaceutical industry engaged into taking it right through to be a rheumatic fever vaccine,” he said.

“This is absolutely a game-changer if we can make it happen.

“It is the first time for me in more than 20 years that I’ve been able to say that I think we will have a rheumatic fever vaccine in my lifetime.”

A vaccine will make the world of difference to Aboriginal kids living in rural and remote parts of the State.

Janice Forrester, clinical nurse manager at the WA Rheumatic Heart Disease Control Program in Broome, sees first hand the difficulties faced by families in the wake of a child having acute rheumatic fever.

Those needing immediate cardiac care have to be airlifted to Perth to be admitted to Princess Margaret Hospital. A caregiver who goes with them might find themselves living away from their community - and other children - for months.

Ms Forrester said it could also be onerous on the patient to keep coming back into a clinic for long-term treatment and it was often difficult to convey the importance of having penicillin injections every 28 days.

“A vaccine that would protect someone against group A strep would cut out the necessity of having to have these regular injections. It would provide cover for kids who would be vulnerable to getting acute rheumatic fever should they be exposed, so essentially it would help cut out the necessity for young people to have these interactions with clinics and have to deal with chronic disease.”

The Australian experience of acute rheumatic fever has also played a pivotal role in the recent revision of the American Heart Association’s (AHA) internationally accepted criteria for its diagnosis.

Professor Carapetis, who participated on the panel that wrote the new “Jones Criteria”, said because the disease had become rarer in the United States, the AHA had repeatedly changed the criteria over several decades, each time becoming stricter. This meant that many patients in places such as Australia were simply not meeting the criteria, even though they were likely to have rheumatic fever. As a result, Australia developed its own criteria in 2006, which made it easier to diagnose in indigenous people.

“For the first time the AHA recognised that our Australian approach has merit, that you need to have different criteria for people who come from populations with a lot of the disease,” he said.

The Telethon Kids Institute also contributed to a Menzies project that looked into the issue of group A strep and skin sores.
“If you go to a remote community, from 30 to 70 per cent of Aboriginal kids might have skin sores at any one time, which can lead to serious complications such as kidney disease, blood infections and rheumatic heart disease,” Professor Carapetis said.
The trial in the Northern Territory found that instead of relying on painful penicillin injections to treat skin sores, offering tablets or medicine of another widely available antibiotic could treat strep as effectively and was much better tolerated. This is now being incorporated into guidelines around Australia and, hopefully, around the world.

What is rheumatic fever?

• Rheumatic fever is caused by an immune reaction to infection with the group A streptococcus bacterium and targets several parts of the body, including the heart, joints, brain and skin. An acute episode or recurring rheumatic fever can cause irreparable damage to the major cardiac valves.
• Children aged between 5 and 14 are most likely to get rheumatic fever.
• The only effective way to stop rheumatic fever recurring is to have monthly penicillin injections, for 10 years or until the patient has turned 21.

What’s next
A national collaboration to strategically target research to define how we can eliminate rheumatic heart disease as a significant health problem in Australia. The new END RHD CRE program will aim to have a report ready within five years to provide a roadmap of how to get rid of this disease.
More focus on talking to affected people to understand the lived experience of rheumatic heart disease and how they can take better control of their own health.