RHD_7th Octo

The Prevention of Rheumatic Fever and Rheumatic Heart Disease : 

The Prevention of Rheumatic Fever and Rheumatic Heart Disease

Learning Objectives : 

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 08/10/2010 2

What is the pathogenesis of acute rheumatic fever? : 

What is the pathogenesis of acute rheumatic fever?

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. 08/10/2010 4

ACUTE RHEUMATIC FEVER : 

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. 08/10/2010 5

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Carapetis. Lancet 2005;366:155 08/10/2010 6

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RHEUMATIC HEART DISEASE : 

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. 08/10/2010 8

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RHEUMATIC HEART DISEASE : 

RHEUMATIC HEART DISEASE The commonest valves affecting are the mitral and aortic, in that order. However all four valves can be affected. 08/10/2010 10

RHEUMATIC HEART DISEASE : 

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. 08/10/2010 11

RHEUMATIC HEART DISEASE : 

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. 08/10/2010 12

What is the incidence of acute rheumatic fever and rheumatic heart disease? : 

What is the incidence of acute rheumatic fever and rheumatic heart disease?

Incidence of ARF: Population-based Studies : 

Incidence of ARF: Population-based Studies 08/10/2010 14

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What is the prevalence of rheumatic heart disease? : 

What is the prevalence of rheumatic heart disease? 08/10/2010 16

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RHEUMATIC FEVER IS PREVENTABLE Costa Rica Cuba 08/10/2010 20

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What are the clinical features of strep sore throat? : 

What are the clinical features of strep sore throat?

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Hallmarks 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 08/10/2010 25

Hallmarks of VIRAL sore throat : 

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 08/10/2010 26

What are the treatment regimens of streptococcal sore throat? : 

What are the treatment regimens of streptococcal sore throat?

Primary Prevention of Rheumatic Fever by treating sore throat : 

Primary Prevention of Rheumatic Fever by treating sore throat Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual 08/10/2010 28

Is it cost-effective to administer penicillin for all cases of suspected strep sore throat? : 

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 08/10/2010 29

Is it cost-effective to administer penicillin for all cases of suspected strep sore throat? : 

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 08/10/2010 30

Rheumatic Heart Disease:SECONDARY PREVENTION : 

Rheumatic Heart Disease:SECONDARY PREVENTION PICTURE TAKEN OUT FOR SPACE ISSUES

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THIS IS TOO LATE 08/10/2010 32

Secondary Prevention Stops sore throat, prevents recurrences of ARF and aids in regression of RHD : 

Secondary Prevention Stops sore throat, prevents recurrences of ARF and aids in regression of RHD Oral penicillin has been shown to be less effective than Penicillin IMI Anaphylaxis is extremely unusual 08/10/2010 33

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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. 08/10/2010 34

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Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention Secondary prevention: Duration 08/10/2010 35

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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. 08/10/2010 36

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Secondary prevention: Adherence 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 . How can we reduce the pain associated with IM Penicillin? 08/10/2010 37

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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. 08/10/2010 38

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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. 08/10/2010 39

What is the role of a register-based programme? : 

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. : 

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 patientsMost 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. : 

The purpose of a register: Collect data on demographic profiles Highlight deficiencies in service delivery Priority-based guidelines to evaluate and manage patientsMost 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 : 

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 08/10/2010 43

Summary : 

Summary Rheumatic heart disease is the only truly preventable chronic heart condition Primary prevention: Penicillin for suspected strep sore throat Secondary prevention Penicillin prophylaxis 08/10/2010 44

Learning Objectives : 

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 08/10/2010 45

Thank you ! : 

Thank you ! Dr. Naresh T Chauhan Asst Professor, Govt Med College, Bhavnagar. E-Mail-drnareshchauhan@rediffmail.com 08/10/2010 46