How is it prevented?
The prevention of RHD can be implemented at a number of different stages. Primordial and primary prevention aim to stop development of ARF, while secondary and tertiary prevention aim to limit the development or progression of RHD and its complications.
Primordial prevention aims to minimise risk factors for a disease in a population. This means preventing group A streptococcus infections (which can lead to ARF) through improvement to environment, economic, social and behavioural conditions that are known to increase the risk of infections. Examples include improved housing and reduced overcrowding.
Primary prevention aims to prevent complications from a known problem. In Australia, primary prevention includes early diagnosis of group A streptococcus throat infections in people most at risk of ARF (typically children aged 5–14 years), and treatment with antibiotics, commonly penicillin. This helps prevent spread of the streptococcal infection to others and helps prevent the infected person’s body having an auto-immune reaction to the infection resulting in ARF.
Secondary Prevention refers to the early detection of disease and measures to prevent recurrent disease and worsening of the condition. This means preventing recurrent ARF which in turn prevents RHD or stops existing RHD worsening. Secondary prophylaxis with regular benzathine penicillin G (BPG) is the only RHD control strategy shown to be effective and cost-effective at both community and population levels. Secondary prevention should also include strategies aimed at improving the delivery of secondary prophylaxis and patient care, the provision of education, coordination of available health services and advocacy for necessary and appropriate resources.
Tertiary prevention aims to prevent complications once a disease is established. In the case of RHD, this means reducing symptoms to minimise disability and prevent premature death. Examples include heart valve surgery, medication to manage heart failure, and preventing stroke.
Primordial prevention includes a range of improvements to living conditions that reduce poverty and over-crowding in populations at risk of ARF and RHD. There have been dramatic reductions in the rates of ARF and RHD in populations that have experienced improvements in socioeconomic and environmental conditions.
Regular secondary prophylaxis is recommended for people with a history of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Secondary prophylaxis protects against future group A streptococcus bacterial infections during the period of highest risk. Benzathine penicillin G injections given at least every 28 days, is currently the treatment method of choice in Australia. It is vital people get injections within the 28 days and get 100% of their prescribed injections (this means at least 13 injections per year). Without the protection of timely, regular BPG injections, the person is at risk of a recurrence of ARF.
Alternatives to the injections are available, although they are less effective in preventing ARF and require careful monitoring.
- Penicillin tablets can be taken – two tablets every day – for the duration of treatment. Penicillin tablets are usually reserved for people who experience significant bleeding problems associated with injections.
- Erythromycin tablets can be taken – two tablets every day - for the duration of treatment. Erythromycin tablets are reserved for people who have a serious allergy to penicillin. True penicillin allergy is rare, so suspected allergy needs to be carefully investigated.
Length of treatment depends on a number of factors including age at most recent diagnosis of ARF, severity of RHD (if it exists), and potential harm to the heart from recurrent ARF. The minimum length of treatment is 10 years or until the age of 21 years (whichever is longer).
Challenges of secondary prophylaxis
A variety of factors combine to limit the uptake of long-term secondary prophylaxis. Primary care facilities should be aware of any local barriers to receiving secondary prophylaxis and work within the system and with patients and families to reduce these barriers. For example, adherence has been seen to improve when patients feel a sense of personalised care and “belonging” to the clinic, and when recall systems extend beyond the boundaries of the community.
Persistent high rates of recurrent acute rheumatic fever in Australia highlight the continued failure of secondary prevention. Patients from the Northern Territory with recurrent ARF receive on average less than 50% of their scheduled injections, and few patients receive the recommended benchmark of 80% of their scheduled injections.
Hospitalisation at diagnosis provides an ideal opportunity to begin or re-establish secondary prophylaxis, and to educate patients and families on how important it is to prevent future episodes of acute rheumatic fever. Appropriate continuing education and support by primary care staff should continue once the patient has returned home.
Strategies to promote continuing adherence include:
- identify local, dedicated staff members to deliver secondary prophylaxis and coordinate routine care
- focus on improving relationships between health staff and patients/families
- support and utilise the expertise, experience, community knowledge and language skills of Aboriginal health workers
- develop and implement recall and reminder systems (based on a local acute rheumatic fever/rheumatic heart disease register where established) to accommodate the high mobility of individuals and groups
- ensure that recall systems extend beyond community boundaries
- establish networks for timely communication between health clinics
- use a centralised coordinator and register to assist in monitoring movement
- minimise staff turnover in remote and rural primary health care centres and regional hospitals, or minimise the impact of staff turnover where possible
- promote the importance of secondary prophylaxis in preventing recurrent acute rheumatic fever and the development or worsening of rheumatic heart disease
- improve quality and delivery of ongoing health education and support for staff, patients and families
- implement measures to reduce pain of injections where indicated
- base routine care on standardised evidence-based guidelines.