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Streptococcal Infections: The Case of Acute Rheumatic Fever / Rheumatic Heart Disease. Ahmed Mandil Prof of Epidemiology Family & Community Medicine Dept King Saud University. Headlines. Streptococcal Infections Sore throat (streptococcal versus viral) Acute rheumatic fever - PowerPoint PPT Presentation
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Streptococcal Infections: The Case of Acute Rheumatic Fever / Rheumatic Heart Disease
Ahmed MandilProf of Epidemiology
Family & Community Medicine DeptKing Saud University
Headlines
Streptococcal Infections Sore throat (streptococcal
versus viral) Acute rheumatic fever Rheumatic heart disease Prevention and control
April 20, 2023 2ARF/RHD
Types of Streptococcal Infections
According to reaction on blood-agar plates: Αlpha-hemolytic group (Streptococcus
viridans): produces hemolysis circled by a greenish ring surrounding the central colony
Βeta-hemolytic group (Streptococcus pyogenes): produces a completely clear zone around the central colony
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Upper respiratory infections (sore throat): acute pharyngitis or acute tonsillitis Skin infections: impetigo, pyoderma Other acute infections: scarlet fever, puerperal sepsis, septicemia, erysipelas,
cellulitis, mastoiditis, otitis media, pneumonia, rarely: toxic shock syndrome Non-suppurative complications: acute rheumatic fever (within 19 days on the
average), acute glomerulo-nephritis (within 1-5 weeks on the average), rheumatic heart disease (days-weeks)
Group A β-Hemolytic Streptococci: Clinical presentations
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Group A β-Hemolytic Streptococci could be a precursor of two serious non-suppurative sequlae, namely:
• Post streptococcal glomerulonephritis• Acute rheumatic fever and rheumatic
heart disease
Public Health Importance:
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What are the clinical What are the clinical features of strep sore features of strep sore throat?throat?
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Hallmarks of STREP sore Hallmarks of STREP sore throatthroat
Close contact with infected person Tender lymph nodes Excoriated nares (crusted lesions) in infants Tonsillar exudates in older children Scarlet fever rash Abdominal pain GOLD STANDARD: POSITIVE THROAT
CULTURE
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Hallmarks of VIRAL sore Hallmarks of VIRAL sore throatthroat
Other family member with COLD symptoms; evidence of other viral infection
Coryza: runny nose or mouth ulcers Itchy watery eyes Hoarseness and cough: non-specific Fever: not specific Red Throat: not specific
April 20, 2023 10ARF/RHD
What are the treatment What are the treatment regimens of streptococcal regimens of streptococcal sore throat?sore throat?
Primary Prevention of Primary Prevention of Rheumatic Fever by treating Rheumatic Fever by treating sore throatsore throat
Oral penicillin is less efficacious than Penicillin IMIAnaphylaxis is extremely unusual
April 20, 2023 12ARF/RHD
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Is it cost-effective to administer Is it cost-effective to administer penicillin for all cases of penicillin for all cases of suspected strep sore throat?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
April 20, 2023 14ARF/RHD
Is it cost-effective to administer Is it cost-effective to administer penicillin for all cases of penicillin for all cases of suspected strep sore throat?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 in African nations: available in Egypt, South Africa, and Ghana
April 20, 2023 15ARF/RHD
Acute Rheumatic Fever
Occurrence
Children: 3-18 years, more in developing nations compared to developed
Equal gender distribution Risk factors include: poor socio-economic
conditions and access to healthcare Peak in colder months 2-6 weeks
following GA-β hemolytic strep infection Sudden onset of fever, pallor, malaise
April 20, 2023 ARF/RHD 17
Incidence of ARF: Incidence of ARF: Population-based StudiesPopulation-based Studies
40
35
30
25
20
15
10
5
0
In
cid
en
ce
/1
00
,00
0 p
op
ula
tio
n
1 2 3 4
USA (all ages)Martinique (<20yrs)New Zealand (<30yrs)Kuwait (5-14yrs)Iran (all ages
11
5 6 7 8 9 10Time (years)
Figure 5: Trend in I ncidence of First Attack of Acute Rheumatic Fever Over Time
April 20, 2023 18ARF/RHD
General FeaturesGeneral Features
Autoimmune consequence of infection with Group A streptococcal infection
Results in a generalised inflammatory response affecting brains, joints, skin, subcutaneous tissues and the heart.
Currently the modified Duckett-Jones criteria form the basis of the diagnosis of the condition.
April 20, 2023 19ARF/RHD
Carapetis. Lancet 2005;366:155
April 20, 2023 20ARF/RHD
Jones’ Criteria
Major criteria: arthritis; carditis; Sydenham’s chorea; erythema marginatum; subcutaneous nodules
Minor criteria: fever; arthralgia; elevated C-reactive protein; Rising Erythrocyte Sedimentation Rate; prolonged PR-interval (on ECG examination)
April 20, 2023 ARF/RHD 21
April 20, 2023 22ARF/RHD
Rheumatic Heart Disease
Overview - 1Overview - 1
Rheumatic Heart Disease is the permanent heart valve damage resulting from one or more attacks of ARF.
It is estimated that 40-60% of patients with ARF will go on to developing RHD
The commonest affected valves are the mitral and aortic, in that order. However all four valves could be affected.
April 20, 2023 24ARF/RHD
Overview - 2Overview - 2
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.
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Overview - 3Overview - 3
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.
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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.
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What is the incidence of acute What is the incidence of acute rheumatic fever and rheumatic rheumatic fever and rheumatic heart disease?heart disease?
April 20, 2023 28ARF/RHD
Incidence of newly Incidence of newly diagnosed RHDdiagnosed 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.
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What is the prevalence of What is the prevalence of rheumatic heart disease?rheumatic heart disease?
April 20, 2023 31ARF/RHD
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Prevention & Control
Basic principles 1 In some developing countries, 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
April 20, 2023 ARF/RHD 36
Basic principles 2 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.
April 20, 2023 ARF/RHD 37
Basic principles 3 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.
April 20, 2023 ARF/RHD 38
RHEUMATIC FEVER IS RHEUMATIC FEVER IS PREVENTABLEPREVENTABLE
Costa Rica
CubaApril 20, 2023 39ARF/RHD
Primary Prevention of Primary Prevention of Rheumatic Fever by treating Rheumatic Fever by treating sore throatsore throat
Oral penicillin is less efficacious than Penicillin IMIAnaphylaxis is extremely unusual
April 20, 2023 40ARF/RHD
Rheumatic Heart Disease:Rheumatic Heart Disease:SECONDARY PREVENTIONSECONDARY PREVENTION
PICTURE TAKEN OUT FOR SPACE ISSUES
THIS IS TOO THIS IS TOO LATELATE
April 20, 2023 42ARF/RHD
Secondary Prevention Secondary Prevention Stops sore throat, prevents Stops sore throat, prevents recurrences of ARF and aids in recurrences of ARF and aids in regression of RHD regression of RHD
Oral penicillin has been shown to be less effective than Penicillin IMIAnaphylaxis is extremely unusual
April 20, 2023 43ARF/RHD
Review: Penicillin for secondary prevention of rheumatic feverComparison: 02 Two-weekly versus 4-weekly penicillin injectionsOutcome: 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 feverComparison: 03 Three-weekly versus 4-weekly intramuscular penicillinOutcome: 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
April 20, 2023 44ARF/RHD
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.
April 20, 2023 45ARF/RHD
Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention
Secondary Secondary prevention: prevention:
DurationDurationCATEGORY DURATION OF PROPHYLAXISAll persons with ARF with no or mild carditis
MINIMUM 10 years after most recent episode or age 21
All persons with ARF and moderate carditis
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.
April 20, 2023 46ARF/RHD
Secondary prevention: specificsSecondary prevention: specifics
PENCILLINSecondary 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.
April 20, 2023 47ARF/RHD
Secondary prevention: Secondary prevention: AdherenceAdherence
• 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?
April 20, 2023 48ARF/RHD
Secondary prevention: Secondary prevention: AdherenceAdherence
• 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.
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Ensuring that patients understand their disease, are informed regarding their future and receive secondary prophylaxis
EDUCATIONEDUCATIONHealth 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.
April 20, 2023 51ARF/RHD
What is the role of a What is the role of a register-based programme?register-based programme?
Background In 1972, the WHO launched a register-based
programme to combat ARF/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.
April 20, 2023 ARF/RHD 53
Purposes Collect data on demographic profiles; Highlight
deficiencies in service deliveryPriority-based guidelines to evaluate and manage patients
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.
April 20, 2023 ARF/RHD 54
A.S.A.P. Programme for the A.S.A.P. Programme for the Control of RHD in Africa: Focus Control of RHD in Africa: Focus areas for action 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
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ConclusionConclusion
Rheumatic heart disease is the only truly preventable chronic heart condition
Primary prevention: Penicillin for suspected strep sore
throat Secondary prevention
Penicillin prophylaxis
April 20, 2023 56ARF/RHD
References Heymann DL. Control of communicable
diseases manual. Washington DC: American Public Health Association, 2008
Zühlke L. The prevention of rheumatic fever and rheumatic heart disease. Cape-Town: Red Cross War Memorial Childrens Hospital.
http://www.who.int/cardiovascular_diseases/resources/trs923/en http://www.pascar.co.za/C_ASAP.asp
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Thank you for your kind attention
April 20, 2023 58ARF/RHD