THE PREVENTION OF RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE

LEARNING OBJECTIVES

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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
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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.
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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 .

366:155 6 .Carapetis. Lancet 2005.

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8 .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.

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RHEUMATIC HEART DISEASE The commonest valves affecting are the mitral and aortic. in that order. 10 . However all four valves can be affected.

RHD can go undetected with the result that patients present with debilitating heart failure.RHEUMATIC HEART DISEASE Sadly.  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 .

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WHAT IS THE PREVALENCE OF RHEUMATIC HEART DISEASE? 16 .

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RHEUMATIC FEVER IS PREVENTABLE Costa Rica Cuba 21 .

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WHAT ARE THE CLINICAL FEATURES OF STREP SORE THROAT? .

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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? .

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 .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.

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?  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.

000  Cardiac surgery only available at limited places  32 .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.

RHEUMATIC HEART DISEASE: SECONDARY PREVENTION PICTURE TAKEN OUT FOR SPACE ISSUES .

THIS IS TOO LATE 34 .

Oral penicillin has been shown to be less effective than Penicillin IMI Anaphylaxis is extremely unusual 35 .2 MU > 30kg 600 000 U < 30 kg 250-500mg bd BD po daily Use same dose as above. 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.SECONDARY PREVENTION STOPS SORE THROAT.

During an episode of ARF. thickening of subvalvar apparatus. After recurrent episodes of ARF. valve changes can be minor and are still able to regress. chordal thickening and shortening and progression to permanent valve damage is evident. 36 .

Post surgical cases definitely lifelong. Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention 37 .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.

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? • • • • .deeper is better Local pressure to area for 10 secs Warm syringe to room temperature First allow alcohol to dry or use ethylchloride spray . 39 Use a 23-gauge needle.

compliance and understanding. • Use 0. is a significant aid to injection comfort.5-1ml of 1% lignocaine. Reduces pain significantly and excellent for younger patients.Secondary prevention: Adherence • Deliver injection very slowly(over 2-3mins) • Distraction techniques • Good rapport with the case. 40 .

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.Ensuring that patients understand their disease. 41 .

WHAT IS THE ROLE OF A REGISTERBASED PROGRAMME? .

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

.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.

healthcare workers  Surveillance: incidence. temporal trends  Advocacy: appropriate funding of the treatment and prevention programmes  Prevention: application of existing knowledge in primary & secondary prevention  45 . prevalence.FOCUS AREAS FOR ACTION Awareness raising: public.

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 .

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