|LETTER TO EDITOR
|Year : 2018 | Volume
| Issue : 2 | Page : 114-117
Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||3-Jul-2019|
Dr. Ramachandra Barik
All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Barik R. Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated. Nig J Cardiol 2018;15:114-7
|How to cite this URL:|
Barik R. Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated. Nig J Cardiol [serial online] 2018 [cited 2020 Feb 19];15:114-7. Available from: http://www.nigjcardiol.org/text.asp?2018/15/2/114/262002
Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops 2–4 weeks after a streptococcal throat infection. Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic nonitchy rash known as erythema marginatum. The RF is diagnosed using well-known modified Jones criteria. Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur initial episode. The chronic RHD is characterized by both valvular regurgitation and valvular stenosis. Acute RF and RHD remain the major causes of heart failure, atrial fibrillation, stroke, infective endocarditis, and death among the young men, young women, and middle age people despite being entirely preventable and effectively treatable.,,, The prevalence of this scourge is directly related to socioeconomic status, level of education, and the quality of lifestyle as evidenced by almost zero prevalence of RHD and RF in the developed countries which dates back to 1980. RF and RHD have a decreasing trend globally. There lies a significant gradient in the prevalence and incidence of RHD between developed and developing nations. In the contemporary, the morbidity and mortality related to RHD are worst in developing countries., This is because of the poor infrastructure to support all the level of care which is required for the prevention and treatment. Far away from industrialized areas, the prevalence is worse. The true prevalence is underreported and is quite variable because of poor documentation, even though the initial desires to eradicate this disease dates to 1960., RHD causes significant additional financial burden by crippling and killing the most contributing age group. The affected country spends a lot on prevention, catheter-based intervention, and cardiac surgery for valvular damage. Every patient with significant valvular heart disease has no access to cardiac surgery and intervention in the local areas. Hence, also every patient cannot afford the cost of surgery which may be available traveling far off. As this disease has very long natural history and needs active follow-up for lifetime even after surgery, it is difficult for the financially challenged people to afford. In the most of the remote areas from the city, long-acting penicillin is not available round year. It is even more difficult to find a competent personnel who can give the injection with due safety. A well-organized strategy with vision is must at all the levels of care [Figure 1] for eradicating this disease in near future. In the context, some of the major barriers in preventing and treating RHD are addressed in [Table 1]. Primordial prevention seems to be not reachable soon in developing countries because of the wide variation in the available health infrastructure and socioeconomic status. There are no randomized control trial or large size observational studies regarding the role of secondary penicillin prophylaxis in the later stage of the disease. However, some of the long-term follow-up studies have proved that the early initiation of SP is very effective to stop or slow down the further progress of RHD., However, most of the patients in India with Group A streptococcal (GAS) sore throat present either with RF or rheumatic heart disease because of lack of awareness. There is also no sine-qua-non prototype in the clinical course from GAS pharyngitis to RF which is a significant barrier for primary prevention. The candidate vaccine for RF is still in the developing stage to meet the criteria of its effectiveness against the various strains. The affordability of all the patients to the vaccine in research pipeline irrespective of their financial status and geographical territory yet to be tested. Therefore, in the contemporary, the SP with long-acting penicillin is the only feasible strategy to keep the morbidity and mortality in check until there is a significant and uniform improvement in the socioeconomic status. As SP is most effective when started in the subclinical form, the 2012 World Heart Federation criteria have recommended the echocardiography to pick up this diseases at the earliest. A handheld echo Doppler probe would be quite helpful to pick up subclinical cases at the community level as an alternative epidemiological study tool.,,,, Adherence to SP using long-acting intramuscular injection regularly in every 3 weeks is associated with certain practical hurdles such as perennial availability of penicillin in the local area, fear of anaphylaxis, availability of trained person to give injection in regular interval with reasonable safety, painful intramuscular injection, lifelong prophylaxis even after surgery, lack of awareness, distance from hospitals, and financial constraint., Therefore, the frontline researches, such as developments in pathogenesis, identification of early biomarkers, and effective and affordable vaccine with parallel improvement in socioeconomic status, are the need as early as possible.
|Figure 1: Level of intervention to prevent and treat rheumatic fever and rheumatic heart disease. A: Primordial prevention; B: Primary prevention; C: Secondary prevention; D: Tertiary prevention (catheter-based intervention or surgery to repair the established structural damage)|
Click here to view
|Table 1: The major strategies to reduce morbidity and mortality associated with rheumatic heart disease in developing countries|
Click here to view
At present, the strategy which would be quite appropriate for developing countries is a national level initiative for prevention and treatment of rheumatic heart disease to assure SP with long-acting intramuscular penicillin to all the patients with RF or RHD in the earliest part of the clinical course. It would be like rheumatic heart disease can be put into a cage if cannot be eradicated so soon until there are significant progress in socioeconomic status, level of education, level of awareness, and an effective and affordable vaccine.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. Lancet 2012;379:953-64.
Remenyi B, Carapetis J, Wyber R, Taubert K, Mayosi BM, World Heart Federation. et al.
Position statement of the world heart federation on the prevention and control of rheumatic heart disease. Nat Rev Cardiol 2013;10:284-92.
Ralph AP, Carapetis JR. Group a streptococcal diseases and their global burden. Curr Top Microbiol Immunol 2013;368:1-27.
Zühlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Cupido-Katya Mauff B, et al.
Clinical outcomes in 3343 children and adults with rheumatic heart disease from 14 low – And middle-income countries: Two-year follow-up of the global rheumatic heart disease registry (the REMEDY study). Circulation 2016;134:1456-66.
Gordis L. The virtual disappearance of rheumatic fever in the United States: Lessons in the rise and fall of disease. T. Duckett Jones memorial lecture. Circulation 1985;72:1155-62.
Watkins D, Colquhoun S, Johnson C, Carapetis J, Karthikeyan G, Naghavi M, et al
. PM214 Trends in the global burden of rheumatic heart disease during 1990-2013: Findings from the global burden of disease 2013 study. Global Heart 2016;11:e106-7.
GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the global burden of disease study 2013. Lancet 2015;385:117-71.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al.
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the global burden of disease study 2010. Lancet 2012;380:2095-128.
Roberts K, Colquhoun S, Steer A, Reményi B, Carapetis J. Screening for rheumatic heart disease: Current approaches and controversies. Nat Rev Cardiol 2013;10:49-58.
Dougherty S, Khorsandi M, Herbst P. Rheumatic heart disease screening: Current concepts and challenges. Ann Pediatr Cardiol 2017;10:39-49.
Padmavati S. Rheumatic fever and rheumatic heart disease in developing countries. Bull World Health Organ 1978;56:543-50.
Arokiasamy P, Uttamacharya, Kowal P, Chatterji S. Age and socioeconomic gradients of health of Indian adults: An assessment of self-reported and biological measures of health. J Cross Cult Gerontol 2016;31:193-211.
ARF/RHD Writing Group. The Australian Guideline for Prevention, Diagnosis, and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 2nd
ed. Darwin: Menzies School of Health Research; 2012.
Congeni BL. The resurgence of acute rheumatic fever in the United States. Pediatr Ann 1992;21:816-20.
Robertson KA, Volmink JA, Mayosi BM. Antibiotics for the primary prevention of acute rheumatic fever: A meta-analysis. BMC Cardiovasc Disord 2005;5:11.
Lennon D, Anderson P, Kerdemilidis M, Farrell E, Crengle Mahi S, Percival T, et al.
First presentation acute rheumatic fever is preventable in a community setting: A School-based intervention. Pediatr Infect Dis J 2017;36:1113-8.
Carapetis JR. Letter by carapetis regarding article, “Is primary prevention of rheumatic fever the missing link in the control of rheumatic heart disease in Africa?” Circulation 2010;121:e384.
Steer AC, Carapetis JR, Dale JB, Fraser JD, Good MF, Guilherme L, et al.
Status of research and development of vaccines for Streptococcus pyogenes
. Vaccine 2016;34:2953-8.
Wyber R, Grainger Gasser A, Thompson D, Kennedy D, Johnson T, Taubert K, et al
. Tools for Implementing RHD Control Programmes, Quick TIPS Summary. World Heart Federation and RhEACH. Perth, Australia 2014.
Manyemba J, Mayosi BM. Penicillin for secondary prevention of rheumatic fever. Cochrane Database of Systematic Reviews 2002.
Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis 2005;5:685-94.
Australia RH. Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand; 2012.
Culliford-Semmens N, Tilton E, Webb R, Lennon D, Paku B, Malcolm J, et al.
Adequate adherence to benzathine penicillin secondary prophylaxis following the diagnosis of rheumatic heart disease by echocardiographic screening. N Z Med J 2017;130:50-7.
Musoke C, Mondo CK, Okello E, Zhang W, Kakande B, Nyakoojo W, et al.
Benzathine penicillin adherence for secondary prophylaxis among patients affected with rheumatic heart disease attending Mulago hospital. Cardiovasc J Afr 2013;24:124-9.
Manyemba J, Mayosi BM. Intramuscular penicillin is more effective than oral penicillin in secondary prevention of rheumatic fever – A systematic review. S Afr Med J 2003;93:212-8.
de Dassel JL, Fittock MT, Wilks SC, Poole JE, Carapetis JR, Ralph AP, et al.
Adherence to secondary prophylaxis for rheumatic heart disease is underestimated by register data. PLoS One 2017;12:e0178264.
Stewart T, McDonald R, Currie B. Acute rheumatic fever: Adherence to secondary prophylaxis and follow up of indigenous patients in the Katherine region of the Northern Territory. Aust J Rural Health 2007;15:234-40.
Gasse B, Baroux N, Rouchon B, Meunier JM, Frémicourt ID, D'Ortenzio E, et al.
Determinants of poor adherence to secondary antibiotic prophylaxis for rheumatic fever recurrence on Lifou, New Caledonia: A retrospective cohort study. BMC Public Health 2013;13:131.
Saxena A, Ramakrishnan S, Roy A, Seth S, Krishnan A, Misra P, et al.
Prevalence and outcome of subclinical rheumatic heart disease in India: The RHEUMATIC (Rheumatic heart echo utilisation and monitoring actuarial trends in Indian children) study. Heart 2011;97:2018-22.
Ralph AP, Read C, Johnston V, de Dassel JL, Bycroft K, Mitchell A, et al.
Improving delivery of secondary prophylaxis for rheumatic heart disease in remote indigenous communities: Study protocol for a stepped-wedge randomised trial. Trials 2016;17:51.
Mishra TK, Routray SN, Behera M, Pattniak UK, Satpathy C. Has the prevalence of rheumatic fever/rheumatic heart disease really changed? A hospital-based study. Indian Heart J 2003;55:152-7.
Courtney HS, Niedermeyer SE, Penfound TA, Hohn CM, Greeley A, Dale JB, et al.
Trivalent M-related protein as a component of next generation group A streptococcal vaccines. Clin Exp Vaccine Res 2017;6:45-9.
Tadele H, Mekonnen W, Tefera E. Rheumatic mitral stenosis in children: More accelerated course in Sub-Saharan patients. BMC Cardiovasc Disord 2013;13:95.
Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, et al.
World heart federation criteria for echocardiographic diagnosis of rheumatic heart disease – An evidence-based guideline. Nat Rev Cardiol 2012;9:297-309.
Zühlke LJ, Watkins DA, Perkins S, Wyber R, Mwangi J, Markbreiter J, et al.
A comprehensive needs assessment tool for planning RHD control programs in limited resource settings. Glob Heart 2017;12:25-31.
Beaton A, Okello E, Lwabi P, Mondo C, McCarter R, Sable C, et al.
Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren. Circulation 2012;125:3127-32.
Beaton A, Lu JC, Aliku T, Dean P, Gaur L, Weinberg J, et al.
The utility of handheld echocardiography for early rheumatic heart disease diagnosis: A field study. Eur Heart J Cardiovasc Imaging 2015;16:475-82.
Weinberg J, Beaton A, Aliku T, Lwabi P, Sable C. Prevalence of rheumatic heart disease in African school-aged population: Extrapolation from echocardiography screening using the 2012 world heart federation guidelines. Int J Cardiol 2016;202:238-9.
Watkins D, Zuhlke L, Engel M, Daniels R, Francis V, Shaboodien G, et al.
Seven key actions to eradicate rheumatic heart disease in Africa: The Addis Ababa communiqué. Cardiovasc J Afr 2016;27:184-7.
Rémond MG, Coyle ME, Mills JE, Maguire GP. Approaches to improving adherence to secondary prophylaxis for rheumatic fever and rheumatic heart disease: A Literature review with a global perspective. Cardiol Rev 2016;24:94-8.