Acute Rheumatic Fever (ARF)
Notification form for clinicians
ARF is a notifiable condition. Report all confirmed and suspected cases by faxing this form to
your nearest Public Health Unit (PHU). PHU contact details on www.health.qld.gov.au
The PHU will inform the QLD RHD Register & Control Program.
Copies of notifications can be sent to [email protected]
Indigenous Status:
Patient details
Hospital/Clinic UR no: __________________________________
Surname: ____________________________________________
Given names: ________________________________________
Also known as: _______________________________________
Female
Date this form was completed
Aboriginal but not Torres Strait Islander origin
Notifying clinician
Torres Strait Islander but not Aboriginal origin
Clinician’s name:
Both Aboriginal and Torres Strait Islander origin
Neither Aboriginal nor Torres 6trait Islander origin
_________________________________
1RW6WDWHG8QNQRZQ
Date of birth: _____/_____/_____
Gender:
Notification Date: _____/_____/____
Male
Intersex or indeterminate
Address permanent: ___________________________________
Suburb/Town: ________________________ Postcode _______
Phone number(s): _____________________________________
Address temporary: ____________________________________
Suburb/Town: _______________________ Postcode ________
Clinician’s signature:
Other Ethnicity:
Pacific Islander – MaorL
_________________________________
Pacific Islander – Other
Hospital/Clinic name:
Other: ___________ please state ________________
Not stated/inadequately described
_________________________________
Contact email and phone:
Country of birth: ___ please state ________________
__________________________________
Healthcare service patient usually attends: _ i.e. GP practice_____________________________________________________
Current ARF episode This episode is:
RHD status
Select 1:
Initial ARF
Recurrent ARF
Select 2:
Confirmed
Probable
Unknown
RHD absent
RHD present
Date RHD identified: _____/_____/_____
2
Severity if known :
Earliest date patient exhibited symptoms of ARF (onset date): ____/_____/____
Priority 1 (severe)
Priority 2 (moderate)
1
Applying the Australian Modified Jones Criteria
MAJOR manifestations (tick all that apply)
Risk Groups
MINOR manifestations (tick all that apply)
High risk populations for ARF
include:
• Aboriginal and Torres Strait
Islander Australians
• Maori and Pacific Islander
people, and
• Migrant groups from high risk
areas.
Poly-arthralgia (high risk groups)
Poly-arthralgia (low risk groups)
Aseptic mono-arthritis (high risk groups)
Aseptic mono-arthritis (low risk groups)
Poly-arthritis
Mono-arthralgia (high risk groups)
Carditis
Fever (≥38 oC)
Sub-clinical carditis (high risk groups)
Prolonged P-R interval on ECG
Erythema marginatum
Elevated ESR (≥30 mm/hr): ______ mm/hr ____/____/____
CRP (≥30 mg/L):
Sydenham’s chorea
______ mg/L ____/____/____
Subcutaneous nodules
Evidence of preceding Group A Strep (GAS) infections
Date 1st specimen taken
Result
Date subsequent specimen
Result
Elevated ASOT
___/___/___
IU/mL ________
___/___/___
IU/mL ________
Elevated Anti-DNaseB
___/___/___
IU/mL ________
___/___/___
IU/mL _______
Submitting PHU: ________________
Priority 3 (mild)
Hospitalisation from: ____/____/____ Hospital name: ________________________
Date Bicillin given: _____/_____/______
Positive throat swab culture
Echo not performed
Positive skin swab culture
History of URTI / Strep throat
Date Submitted to NoCS: ____/____/____
NoCS Notification ID#: ________________
All other individuals are
low risk.
Age
3 - 12
12 - 16
≥ 17
PR Interval
in seconds
0.16
0.18
0.20
Age
1- 4
5 - 14
15 - 24
25 - 34
≥ 35
ASO
titre
170
276
238
177
127
AntiDNaseB
titre
366
499
473
390
265
For 1 and 2 see back page
NOTES ______________________________________________________________
____________________________________________________________________
____________________________________________________________________
For RHD Program admin
 Clinical presentation  Screening
 Pt not diagnosed at time of presentation
Retrospective notification  Pt not notified at time of presentation
Case found through
V8 – 21/06/16
If an Aboriginal, Torres Strait or Pacific Islander child presents with joint pain, redness or swelling,
ARF should be the first consideration.
ARF does not necessarily include arthritis or carditis.
1
Applying the modified JONES CRITERIA for the diagnosis of Acute Rheumatic Fever
U
U
Initial episode of ARF
2 Major manifestations
OR
1 Major and 2 Minor manifestations
Recurrent episode of ARF
2 Major manifestations
OR
1 Major and 1 Minor manifestations
OR
3 Minor Manifestations
PLUS
evidence of a preceding GAS infection
PLUS
evidence of a preceding GAS infection
Sydenham’s chorea alone is enough to confirm ARF
PROBABLE ARF definition: A clinical presentation that falls short by either one major or one minor manifestation, or the
absence of streptococcal serology results, but one in which ARF is considered the most likely diagnosis.
2
Priority/severity of disease
Priority 1 (severe)
Severe valvular disease
or
moderate/severe valvular lesion with symptoms
or
mechanical and/or tissue prosthetic valves and valve repairs, including balloon valvuloplasty
Priority 2 (moderate)
Any moderate valve lesion in the absence of symptoms, and with normal left ventricular
function
Priority 3 (mild)
ARF with no evidence of RHD
or
trivial to mild valvular disease
Reference: The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic
nd
heart disease (2 edition, 2012)
For more information on ARF & RHD visit www.RHDaustralia.org.au
V8 – 21/06/16