It can start with a small wound or infected insect bite, and if untreated can end up as acute rheumatic fever.
The transmission mechanisms by which a minor skin irritation can lead to rheumatic fever and, potentially, rheumatic heart disease include overcrowding, poverty and poor access to healthcare.
Hawkes Bay nurse practitioner Helen August and the team she works with don’t have the power to fix poverty and the region’s long-running housing crisis, but they are doing everything they can to bring healthcare to children whose family circumstances are such that a skin ailment can spiral into a life-threatening illness.
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August is the clinical lead in a team of community-based nurses and kaiawhina (care workers with strong local links) tasked with, among other things, intervening in skin conditions and infestations affecting children before they escalate.
Staphylococcus bacteria live on the skin and can infect scratches and lesions, causing boils, cellulitis and impetigo. Group A streptococci bacteria are also commonly present on the skin, as well as the throat, and if they infect a wound can trigger rheumatic fever, which can develop into rheumatic heart disease requiring heart valve replacement, and can be fatal.
Rheumatic fever and rheumatic heart disease are widespread in developing countries. Despite being a rich nation, New Zealand’s Māori and Pasifika children suffer some of the highest rates in the world.
The backbone of the community team’s service is a close relationship with schools and early childhood services. They show the teachers what to look out for and provide resources that help identify sores needing treatment, so that teachers can then notify and support parents.
Referrals come from teachers, whānau, and 24-hour clinics where families have shown up with children suffering recurrent skin infections.
August’s team make contact with families, cold calling if necessary and working with kaiāwhina [health assistants] to establish trust. “Sometimes, the first visit isn’t about giving treatment. It’s just listening, and the second or third visit might be about giving treatment,” she says. “That first conversation is about hearing the person or the parent’s story. If you don’t stop and listen, you will never be able to move to the next step and give support and help to treat.”
Nurses in the child health team have been trained to prescribe, which is a key to the success of the skin programme in an area where 15,000 people are not enrolled with a GP. And even if a family is enrolled, the hurdles can be immense.
“Some of these parents are working two or three jobs, and how do you get your kid to a doctor when your job doesn’t allow you to take time off or they dock your pay, or you don’t have transport or petrol? So [they are] having to choose between putting food on the table or taking the child to the doctor,” says August.
“We combine education and medication, and our team stays alongside them and the school or early childhood centre, until we have got them through that episode, or for as long as they need us. We help with their health literacy, and in turn, they help other family members.
“We don’t just stop at the child, we look at the whole whānau. We assess if they are living in a high-risk area, and how many people are in the house. We check how many places the child might stay during the week, because often these kids live between multiple residences. We check if anyone else in the house has sores so that we can treat them if needed.”
Household crowding is a vector for strep and staph infection, not just because people are at close quarters but because they might be sharing towels, sheets, clothes and even toothbrushes. August says a large proportion of the whānau her team works with are in emergency motel accommodation, where the risks are magnified.
One of the key measures to prevent conditions such as eczema from becoming infected is bleach baths – literally adding a measure of plain household bleach to the child’s bath. This reduces the population of bacteria on the skin, thus reducing infection risk.
But how do you bathe a child in a motel unit that doesn’t have a bath? August’s team have taken to buying plastic tubs at hardware stores that fit on the floor of a motel shower, and showing parents how to bleach bath their children in those.
With 30 years of nursing experience, August brings not only a deep passion to her work in the community, but a sense of outrage at the brutal inequities the team see every day.
“It is madness that we are down to bathing kids in this country in buckets in motel rooms. But we have to try and keep on top of their skin problems because if we don’t, they are going to end up in hospital, and that’s not fair for our children or their whānau.”
