Rheumatic heart disease 2025 – current status and future challenges

Rheumatic heart disease (RHD) remains a blight on the Australian health system. It is deeply upsetting to see RHD’s persistence into 2025, distorting the reflection of a health system meant to be modern, equitable, and just. It serves as a sobering reminder to the healthcare community that many in our Aboriginal and Torres Strait Islander communities remain, in Noel Pearson’s words, ‘unloved’ by the very systems meant to care for them. Just last month, the Australian Institute of Health and Welfare published its updated statistics – there are still 7192 Australians living with this entirely preventable disease that most of our society would have you believe was (or should have been) eliminated in the 1980s.¹

There has, however, been a global re-emergence of RHD awareness and initiatives since the turn of the 21st century. Encouragingly, nine Cochrane reviews are currently underway in RHD management and prevention, demonstrating a growing evidence-base. The focus of these reviews are diverse, including adherence strategies, antibiotic prophylaxis, local anaesthesia for injections, handheld echocardiography, penicillin allergy testing, and supportive interventions.² Such efforts represent vital steps towards advancing evidence-based RHD care.

In Australia, the RHD Endgame Strategy outlines the blueprint to eliminating RHD in Australia by 2031.³ Building on this, the National Aboriginal Community Controlled Health Organisation (NACCHO) has developed the first Aboriginal and Torres Strait Islander sector-led initiative to combat RHD across the country. As part of this program of work, local community healthcare workers are now leading community-based handheld echocardiographic screening for RHD and environmental health initiatives aimed at reducing Group A Streptococcal (GAS) infections locally.⁴ Additionally, the Federal and Northern Territory Governments have announced a joint A$4 billion dollar investment for housing in remote communities across the Northern Territory.

Beyond this, there are a growing number of additional solutions in development. The advocacy efforts of the Australian Strep A Vaccine Initiative have contributed to a global effort to fast-track GAS vaccine development. There are now three GAS vaccine candidates being tested in clinical trials or scheduled for phase I clinical trials.⁵ Efforts are also underway to enhance the detection and monitoring of GAS through point-of-care testing and to improve acute rheumatic fever diagnosis using biomarkers.^6,7 A phase 1 pharmacokinetic study has shown promising results for the development of a subcutaneous alternative to the monthly intramuscular benzathine penicillin injections.⁸

Several more speculative ideas merit further exploration and hold potential for meaningful impact. For example, should the separate, jurisdictional RHD registers be unified as a single National Registry within the proposed inaugural Australian Centre for Disease Control? This may address current limitations in case ascertainment and would potentially enable more accurate epidemiological monitoring and consistent, real-time patient care, better aligning with the geographic movement patterns seen in some high-risk communities.⁹ Positioning RHD as a national issue, rather than a jurisdictional problem isolated to Northern Australia, would also underscore the need for coordinated, nationwide action. Additionally, we propose a new body of work to develop adult RHD care, modelled on the progress seen in the adult congenital heart disease (ACHD) space. This could include establishing centres of excellence to manage advanced rheumatic valvular disease in adulthood, leveraging existing expertise and infrastructure. A final speculative idea draws inspiration from the geographic information systems work conducted for ACHD in NSW.¹⁰ Could a similar approach be applied to RHD to address geospatial challenges and resource constraints, to place cost-efficient services in areas of maximal need where they can be optimally accessed?

Implementing all the solutions – current, potential, and speculative – will require integrated approaches. Key actions include fostering multidisciplinary teams, advocating for supportive policies, and establishing robust monitoring and evaluation frameworks. Sustained collaboration, led by NACCHO and supported by those with lived experience, frontline clinicians, and leading researchers, will be essential. Despite the potential impact of these solutions, RHD reduction efforts remain concerningly underfunded compared to other diseases of inequity.¹¹ Closing this funding gap is critical to ensuring that these RHD solutions receive the resources needed to be implemented sustainably, and ultimately eliminate the disease from Australia.