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Background Rheumatic heart disease (RHD) is a preventable yet deadly condition resulting from untreated Group A Streptococcus infection. Despite being eliminated from most high-income countries, RHD and its precursor acute rheumatic fever (ARF) persist in developing countries and settings of disadvantage. In Australia, Aboriginal and Torres Strait Islander people experience among the world's highest rates. Following five years of research, investigation and advocacy, the Endgame Strategy provides a technical foundation to eliminate RHD in Australia by 2031. Methods A range of potential strategies to reduce ARF and RHD were identified. Approaches at the social and environmental, primary, secondary and tertiary prevention levels were evaluated using the GRADE Evidence to Decision framework, together with structural review of the health system. Recommendations were made according to level of prevention opportunity and responsibility. Modelling was undertaken to estimate the health and economic impact of an indicative bundle of the most promising strategies. Results Reducing household crowding, improving health infrastructure, strengthening primary healthcare and enhancing delivery of secondary prophylaxis were identified as having the greatest potential impact on RHD. They are also largely acceptable, practical and readily implementable with investment. Modelling indicates that this approach would reduce ARF and RHD by 69% and 71% respectively, preventing 471 deaths and saving $188 million on healthcare expenditure to 2031. Conclusions Eliminating RHD is only possible with a holistic approach led by Aboriginal and Torres Strait Islander people with communities at the core. This will entail funding communities to develop programs, resourcing a national RHD unit to coordinate efforts across Australia, guaranteeing access to healthy housing and built environments, establishing comprehensive skin and throat programs and improving the health of those living with ARF and RHD. Key messages RHD demands responses from the health sector strengthened by political advocacy and engagement to drive evidence-based decision making. The evidence and collective experience now exist to eliminate RHD, an exemplar of the gap in health outcomes between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population.

The RHD Endgame Strategy; the blueprint to eliminate rheumatic heart disease in Australia by 2031