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Prevention of Rheumatic Fever and Rheumatic Heart Disease

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Prevention of Rheumatic Fever and Rheumatic Heart Disease Powered By Docstoc
					 The Prevention of
Rheumatic Fever and
  Rheumatic Heart
     Disease
                Dr Liesl Zühlke
    Paediatric Cardiologist: Red Cross War
         Memorial Childrens Hospital
           Cape Town South Africa
               Liesl.zuhlke@uct.ac.za
•   I graduated from University of Cape Town medical School in 1991 and
    qualified as a pediatrician in 1999 and as a paediatric cardiologist in 2007. I
    am currently a doctoral fellow involved in full-time research related to
    rheumatic fever and rheumatic heart disease working within the framework
    of the A.S.A.P programme.
•   Sub-Saharan Africa remains a hotspot for rheumatic fever and rheumatic
    heart disease. It is the only truly preventable chronic cardiac condition, yet
    still reigns rampant in poor countries years after virtual eradication in
    developed nations.
•   Rheumatic heart disease is a major killer of children, adolescents and
    young adults. Health practioners practising in resource-poor settings such
    as Africa, need to work together to raise awareness of this condition,
    survey incidence, prevalence and temporal trends , be advocates for
    patients whose lives are affected by rheumatic heart disease and institute
    prevention strategies.
•    Rheumatic heart disease is a neglected disease of poverty – we need to
    turn the tide and address the fundamental issues surrounding this condition
    that still remain.
•   As a paediatric cardiologist seeing patients with rheumatic heart disease on
    a regular basis, I feel passionate about being part of the solution and
    working towards the eradication of rheumatic heart disease in our lifetime-
    a very achievable goal.
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 secondary prevention measures
• To understand the role of a register-based programme
Performance Objectives:

•   Examine the burden of disease within own communities
•   Timely recognition of a streptococcal sore throat with
    correct treatment
•   Institute secondary prevention programme
•   Institute the above measure within a register-based
    programme
•   Join the global community fighting Rheumatic fever and
    rheumatic heart disease
  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.
 ACUTE RHEUMATIC FEVER


• The clinical presentation can be
  vague and difficult to diagnose.

• Currently the modified Duckett-
  Jones criteria form the basis of
  the diagnosis of the condition.
Carapetis. Lancet 2005;366:155
   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.
     RHEUMATIC HEART
         DISEASE

• The commonest valves affecting
  are the mitral and aortic, in that
  order. However all four valves
  can be affected.
     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.
   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
  not insignificant morbidity and
  mortality.
     What is the
 incidence of acute
rheumatic fever and
   rheumatic heart
      disease?
• In the Pacific Islander population of
  New Zealand the incidence rate of
  ARF is 80-100 per 100 000 compared
  to non-indigenous new Zealanders <10
  per 100 000.
• In a recent systematic review of the
  incidence of first attack of rheumatic
  fever, a Maori community in New
  Zealand has a disturbingly high
  incidence of >80/100,000 per year.
   Incidence of ARF:
Population-based Studies
  Figure 5: Trend in Incidence of First Attack of Acute
              Rheumatic Fever Over Time
                                                           40
                                    USA (all ages)
                                                           35




                                                                Incidence/100,000 population
                                    Martinique (<20yrs)
                                    New Zealand (<30yrs)
                                    Kuwait (5-14yrs)       30
                                    Iran (all ages
                                                           25

                                                           20

                                                           15

                                                           10

                                                           5
1 2                                                        0
     3 4
          5 6
                7   8
   Time (years)         9   10 11
      Incidence of newly
        diagnosed RHD
• A prospective , clinical registry captured data
  from new presentation of structural and
  functional valvular heart disease presenting to
  the department of cardiology in 2006/7.
• Of the 4005 de novo cases, 344 (8.6%) were
  diagnosed as having RHD. A significant
  proportion presented with complications and
  22% subsequently underwent surgery.
 What is the
prevalence of
  rheumatic
heart disease?
In some developing countries , however,
remarkable progress has been made in terms
of decreasing incidence of ARF.
In 1986 a comprehensive 10-year prevention
programme was conducted in a Cuban
province.

This programme relied on comprehensive
primary and secondary prevention of RF/RHD
as well as awareness and education
programmes.
    RHEUMATIC FEVER IS
      PREVENTABLE




Costa Rica

                   Cuba
The main content of the activities focused
around early detection and treatment of
sore throats and streptococcal pharyngitis.

The project also included primary and
secondary prevention of RF/RHD, training
of personnel, health education,
dissemination of information, community
involvement and epidemiological
surveillance.
There was a progressive decline in the
occurrence and severity of acute RF and RHD,
with a marked decrease in the prevalence of
RHD in school children.
 A marked and progressive decline was also seen
in the incidence and severity of ARF.

There was an even more marked reduction in
recurrent attacks of RF as well as in the number
and severity of patients requiring hospitalisation
and surgical care.
What are the
   clinical
features of
 strep sore
  throat?
       Hallmarks of STREP
           sore throat
•   Tender lymph nodes
•   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
    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
What are the
  treatment
 regimens of
streptococcal
 sore throat?
     Primary Prevention of
      Rheumatic Fever by
      treating sore throat
Antibiotic          Administration        Dose
Benzathine          Single IM injection   1.2 MU > 30kg
benzyl penicillin                         600 000 U < 30 kg
Phenoxymethyl       PO for 10 days        250-500mg qds for 10 days
penicillin                                125mg qds X 10 if <30 kg
(Pen VK)
Erythromycin        PO for 10 days        Use same dose as above.
ethylsuccinate

Oral penicillin is less efficacious than Penicillin IMI
Anaphylaxis is extremely unusual
   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
     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 in S Africa,
  Ghana and Egypt
 Rheumatic Heart Disease:
SECONDARY PREVENTION

        PICTURE TAKEN
        OUT FOR SPACE
        ISSUES
THIS IS TOO
   LATE
        Secondary Prevention
Stops sore throat, prevents recurrences of ARF and
             aids in regression of RHD

Antibiotic          Administration        Dose
Benzathine          Single IM injection   1.2 MU > 30kg
benzyl penicillin   monthly               600 000 U < 30 kg
Phenoxymethyl       BD PO daily           250-500mg bd
penicillin
(Pen VK)
Erythromycin        BD po daily           Use same dose as above.
ethylsuccinate

Oral penicillin has been shown to be less effective than
Penicillin IMI
Anaphylaxis is extremely unusual
Review:           Penicillin for secondary prevention of rheumatic fever
Comparison:       02 Two-weekly versus 4-weekly penicillin injections
Outcome:          02 Streptococcal throat infections

Study                                2-weekly injections             4-weekly injections                   RR (fixed)                       Weight          RR (fixed)
or sub-category                             n/N                             n/N                             95% CI                           %               95% CI

Kassem 1996                              38 / 190                     57 / 170                                                              100.00   0.60 [0.42, 0.85]

                                                                                           0.1   0.2    0.5     1       2      5       10
                                                                                           Favours treatment        Favours control




Review:           Penicillin for secondary prevention of rheumatic fever
Comparison:       03 Three-weekly versus 4-weekly intramuscular penicillin
Outcome:          02 Streptococcal throat infections

Study                                3-weekly injections             4-weekly injections                   RR (fixed)                       Weight          RR (fixed)
or sub-category                             n/N                             n/N                             95% CI                           %               95% CI

Lue 1996                                 39 / 124                     59 / 125                                                              100.00   0.67 [0.48, 0.92]

                                                                                           0.1   0.2    0.5     1       2      5       10
                                                                                            Favours 3-weekly        Favours 4-weekly
                              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.
             Secondary
         prevention: Duration
CATEGORY              DURATION OF PROPHYLAXIS
All persons with      MINIMUM 10 years after most recent
ARF with no or mild
carditis              episode or age 21
All persons with      MINIMUM 10 years after most recent
ARF and moderate
carditis              episode or age 35

All persons with      MINIMUM 10 years after most recent
ARF and severe
carditis              episode or age 35 and then specialist
                      review for need to continue. Post surgical
                      cases definitely lifelong.
                                              Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention
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.
      Secondary prevention:
           Adherence
    How can we reduce the pain associated with
    IM Penicillin?

•   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.
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.
  “Kenyan-Heart Talking Walls”: Dr. Aggrey Primary
  School




Elizabeth Gatumia, Kenyan Heart Foundation/ Danish Heart
Foundation
    Rheumatic Fever Week
South Africa, 7-13 August 2006
What is the role of
 a register-based
   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 school-going
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.
   A.S.A.P. Programme for the
    Control of RHD in Africa:
        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
        Summary
• Rheumatic heart disease is the only
  truly preventable chronic heart condition
• Primary prevention:
   – Penicillin for suspected strep sore
     throat
• Secondary prevention
   – Penicillin prophylaxis
• It is a legal requirement to notify
  cases of acute rheumatic fever to
  the local authority in South Africa
     Summary
The A.S.A.P. Programme for the
     Eradication of
    Rheumatic Fever
          in Africa:
   An achievable goal

				
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