THE PREVENTION OF RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE

LEARNING OBJECTIVES

To understand the pathogenesis of acute rheumatic fever and rheumatic heart disease To appreciate the burden of disease To recognize the features of a streptococcal sore throat To know the treatment regimens of a streptococcal sore throat To be aware of prevention measures To understand the role of a register-based programme
2

WHAT IS THE PATHOGENESIS OF ACUTE RHEUMATIC FEVER?

ACUTE RHEUMATIC FEVER

Autoimmune

consequence of infection with Group A streptococcal infection Results in a generalised inflammatory response affecting brains, joints, skin, subcutaneous tissues and the heart.
4

ACUTE RHEUMATIC FEVER

The

clinical presentation can be vague and difficult to diagnose. the modified DuckettJones criteria form the basis of the diagnosis of the condition.
5

Currently

Carapetis. Lancet 2005;366:155

6

RHEUMATIC HEART DISEASE

Rheumatic

Heart Disease is the permanent heart valve damage resulting from one or more attacks of ARF. It is thought that 40-60% of patients with ARF will go on to developing RHD.
8

RHEUMATIC HEART DISEASE

The

commonest valves affecting are the mitral and aortic, in that order. However all four valves can be affected.
10

RHEUMATIC HEART DISEASE

Sadly, RHD can go undetected with the result that patients present with debilitating heart failure. At this stage surgery is the only possible treatment option.

11

RHEUMATIC HEART DISEASE

Patients

living in poor countries have limited or no access to expensive heart surgery. Prosthetic valves themselves are costly and associated with a significant morbidity and mortality.
12

WHAT IS THE INCIDENCE OF ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE?

INCIDENCE OF ARF: POPULATION-BASED STUDIES

Figure 5: Trend in Incidence of First Attack of Acute Rheumatic Fever Over Time
USA (all ages) Martinique (<20yrs) New Zealand (<30yrs) Kuwait (5-14yrs) Iran (all ages

40
Incidence/100,000 population

35 30 25 20 15 10 5

1 2 3 4 5 6 7 Time (years)

0
8
9

10 11
14

15

WHAT IS THE PREVALENCE OF RHEUMATIC HEART DISEASE?

16

18

19

20

RHEUMATIC FEVER IS PREVENTABLE

Costa Rica Cuba

21

22

WHAT ARE THE CLINICAL FEATURES OF STREP SORE THROAT?

24

25

Cervical Lymphadenitis

26

HALLMARKS OF STREP SORE THROAT

Tender lymph nodes (cervical) Close contact with infected person Scarlet fever rash Excoriated nares( crusted lesions) in infants Tonsillar exudates in older children Abdominal pain

GOLD STANDARD: POSITIVE THROAT CULTURE

27

HALLMARKS OF VIRAL SORE THROAT Coryza: runny nose or mouth ulcers Other family with COLD symptoms Evidence of another viral infection Itchy watery eyes Hoarseness and cough: non-specific Fever: not specific Red Throat: not specific

28

WHAT ARE THE TREATMENT REGIMENS OF STREPTOCOCCAL SORE THROAT?

PRIMARY PREVENTION OF RHEUMATIC FEVER BY TREATING SORE THROAT

Antibiotic Benzathine benzyl penicillin Phenoxymethyl penicillin (Pen VK) Erythromycin ethylsuccinate Administration Single IM injection PO for 10 days Dose 1.2 MU > 30kg 600 000 U < 30 kg 250-500mg qds for 10 days 125mg qds X 10 if <30 kg Use same dose as above.

PO for 10 days

Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual
30

IS IT COST-EFFECTIVE TO ADMINISTER PENICILLIN FOR ALL CASES OF SUSPECTED STREP SORE THROAT?

An overall protective effect for the use of penicillin against acute rheumatic fever of 80% with an NNT of 60 children per year to prevent 1 episode of rheumatic fever. Mild hypertension: have to treat 800 people per year to prevent 1 episode of stroke
31

IS IT COST-EFFECTIVE TO ADMINISTER PENICILLIN FOR ALL CASES OF SUSPECTED STREP SORE THROAT? The estimated cost of preventing one case of rheumatic fever by a single intramuscular injection of penicillin is US$46 Valve replacement surgery for 1 case of RHD is at least US$15, 000 Cardiac surgery only available at limited places

32

RHEUMATIC HEART DISEASE: SECONDARY PREVENTION

PICTURE TAKEN OUT FOR SPACE ISSUES

THIS IS TOO LATE

34

SECONDARY PREVENTION
STOPS SORE THROAT, PREVENTS RECURRENCES OF ARF AND HELPS IN REGRESSION OF RHD
Antibiotic Benzathine benzyl penicillin Phenoxymethyl penicillin (Pen VK) Erythromycin ethylsuccinate Administration Single IM injection monthly BD PO daily Dose 1.2 MU > 30kg 600 000 U < 30 kg 250-500mg bd

BD po daily

Use same dose as above.

Oral penicillin has been shown to be less effective than Penicillin IMI Anaphylaxis is extremely unusual

35

During an episode of ARF, valve changes can be minor and are still able to regress.

After recurrent episodes of ARF, thickening of subvalvar apparatus, chordal thickening and shortening and progression to permanent valve damage is evident.
36

Secondary prevention: Duration

CATEGORY
All persons with ARF with no or mild carditis All persons with ARF and moderate carditis

DURATION OF PROPHYLAXIS MINIMUM 10 years after most recent episode or age 21 MINIMUM 10 years after most recent episode or age 35

All persons with ARF and severe carditis

MINIMUM 10 years after most recent episode or age 35 and then specialist review for need to continue. Post surgical cases definitely lifelong.
Awareness Surveillance Advocacy Prevention

37

Secondary prevention: specifics

PENCILLIN Secondary prophylaxis also reduces the severity of RHD. It is associated with regression of heart disease in approximately 50-70% of those with good adherence over a decade and reduces mortality. Route: BPG is most effective when given as a deep intramuscular injection.
38

Secondary prevention: Adherence

How can we reduce the pain associated with IM Penicillin? .
39

Use a 23-gauge needle- deeper is better Local pressure to area for 10 secs Warm syringe to room temperature First allow alcohol to dry or use ethylchloride spray

Secondary prevention: Adherence

Deliver injection very slowly(over 2-3mins) Distraction techniques Good rapport with the case, is a significant aid to injection comfort, compliance and understanding. Use 0.5-1ml of 1% lignocaine. Reduces pain significantly and excellent for younger patients.

40

Ensuring that patients understand their disease, are informed regarding their future and receive secondary prophylaxis

EDUCATION
Health education is critical at all levels

Lack of parental awareness of the causes and consequences of ARF/RHD is a key contributor to poor adherence amongst children on long-term prophylaxis.
41

WHAT IS THE ROLE OF A REGISTERBASED PROGRAMME?

IN 1972, THE WHO LAUNCHED A REGISTER-BASED PROGRAMME TO COMBAT RF.RHD. BY 1990, REGISTERS HAD BEEN ESTABLISHED IN 16 COUNTRIES WITH OVER A MILLION SCHOOLGOING CHILDREN INVOLVED. HOWEVER IN 2001, THE WHO CEASED ITS FUNDING TO THIS GLOBAL PROGRAMME. EXPERIENCE ELSEWHERE HOWEVER PROVIDES CONCLUSIVE EVIDENCE OF REGISTERS REALISING NOTABLE SUCCESSES IN REDUCING RF RECURRENCE.

THE PURPOSE OF A REGISTER: COLLECT DATA ON DEMOGRAPHIC PROFILES HIGHLIGHT DEFICIENCIES IN SERVICE DELIVERY PRIORITY-BASED GUIDELINES TO EVALUATE AND MANAGE PATIENTS MOST IMPORTANTLY: A REGISTER OF CASES OF RF AND RHD CAN BE USED TO IMPROVE TREATMENT ADHERENCE IN ORDER TO PREVENT RECURRENT RF AND THE DEVELOPMENT OF RHD, NECESSITATING SURGERY.

FOCUS AREAS FOR ACTION

Awareness raising: public, healthcare workers Surveillance: incidence, prevalence, temporal trends Advocacy: appropriate funding of the treatment and prevention programmes Prevention: application of existing knowledge in primary & secondary prevention

45

SUMMARY Rheumatic heart disease is the only truly preventable chronic heart condition Primary prevention: Penicillin for suspected strep sore throat Secondary prevention Penicillin prophylaxis

46

THANK YOU !
Dr. Naresh T Chauhan Asst Professor, Govt Med College, Bhavnagar. E-Mail-drnareshchauhan@rediffmail.com
47