The Prevention of Rheumatic Fever and Rheumatic Heart Disease

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  • Http://www.Who.Int/cardiovascular_diseases/resources/trs923/en
  • Http://www.Who.Int/cardiovascular_diseases/resources/trs923/en http://www.pascar.co.za/C_ASAP.asp
  • RF is a delayed autoimmune response to Group A streptococcal pharyngitis. The clinical manifestation of the response and its severity in an individual is determined by host genetic susceptibility, the virulence of the infecting pathogen and a conducive environment. RF is thought to occur only after GAS infection of the upper respiratory tract although this thinking has been challenged by those working in tropical areas where skin infections are rife. ( Low rates of streptococcal pharyngitis and high rates of pyoderma in Australian aboriginal communities where acute rheumatic fever is hyperendemic. McDonald MI, Towers RJ, Andrews RM, Benger N, Currie BJ, Carapetis JR.Clin Infect Dis. 2006 Sep 15;43(6):683-9. Epub 2006 Aug 9. ( The challenge of acute rheumatic fever diagnosis in a high-incidence population: a prospective study and proposed guidelines for diagnosis in Australia's Northern Territory. Ralph A, Jacups S, McGough K, McDonald M, Currie BJ. Heart Lung Circ. 2006 Apr;15(2):113-8. Epub 2005 Oct 27. )
  • Acute rheumatic fever is a systemic inflammatory disease occurring as a sequel to beta haemolytic streptococcal infection. The clinical presentation can be vague, complex and difficult to diagnose. The modified Duckett-Jones criteria to establish the diagnosis arose from research in North America and Europe during the first part of the 20 th century and may not apply in other parts of the world. It is thought that 0.3-30% of untreated group A beta haemolytic streptococcal infection progress to develop acute rheumatic fever. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, Taubert KA. Circulation. 2009 Mar 24;119(11):1541-51. Epub 2009 Feb 26
  • The pathogenic pathway for rheumatic heart disease starts with the susceptible individual. Twin studies have demonstrated that a genetic component may exist . ( add link) (Repeated streptococcal infections are thought to prime a susceptible individual resulting in a heightened response to an infection with rheumatogenic streptococcus. This results in acute rheumatic fever usually 3 weeks after the initial tonsilllopharyngeal infection. The precise pathogenetic mechanism has not yet been defined, yet strong evidence exists that an autoimmune response mediates the development of RF/RHD in a susceptible host. Genetically determined host factors interacting with the molecular similarity of the streptococcal antigens and host tissues results in the involvement of brain, joints, tissues and heart. The pathogenesis of RF/RHD is a complex maze of events involving major histocompatibility antigens, potential tissue-specific antigens, antibodies and superantigenic activation . However it remains clear that environmental factors such as overcrowding, poor living conditions and poor access to health care is the most significant determinant of disease distribution. Lancet. 2005 Jul 9-15;366(9480):155-68. Acute rheumatic fever. Carapetis JR , McDonald M , Wilson NJ .
  • The Jones criteria were introduced in 1944 as a set of clinical guidelines for the diagnosis of RHF. They have subsequently undergone significant modifications ,the final ones published in 2002. These revised WHO criteria speak to the diagnosis of : a primary episode of RF recurrent attacks of RF in patients without RHD recurrent attacks of RF with RHD rheumatic chorea insidious onset rheumatic carditis chronic RHD It is important to note that in the context of a preceding streptococcal infection , 2 major criteria, or a combination of one major and 2 minor, provide reasonable evidence for a diagnosis of RF. Major criteria: carditis, arthritis, chorea, subcutaneous nodules, erythema marginatum. Minor criteria: Clinical: fever, polyarthralgia Lab: elevated acute phase reactants ESR/CRP This little cartoon character demonstrates the features of acute rheumatic fever. Chorea (St Vitus dance) Flitting polyarthritis- it is important to be aware that monoarthritis is an important presenting complaint in patients from developing countries WEBLINK Erythema marginatum and subcutaneous nodules are the dermatological manifestations of ARF. The only manifestation of ARF with potentially life-threatening and permanent sequelae is the carditis- as evident either as valvulitis( the precursor to rheumatic heart disease) pericarditis and myocarditis.ie a pancarditis. Histologically Aschoff nodules is the hallmark pathognomonic feature and on special investigations the minor criteria such as high ESR or CRP is noted. Evidence of previous infection with GAS either via ASOT/anti-DNAse B titres or with precious evidence of streptococcus being cultured from the throat is an important adjunct to this diagnosis. Currently carditis as diagnosed by echo alone is not included in the major criteria despite repeated calls for its inclusion. It is currently recommended that all patients with the clinical diagnosis of ARF even those without clinical evidence of carditis be referred for an echocardiogram( if available)
  • Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9;116(15):1736-54. Epub 2007 Apr 19. Erratum in: Circulation. 2007 Oct 9;116(15):e376-7.
  • This graph depicts the relationship between incidence of acute rheumatic fever and the detection of rheumatic heart disease. Carapetis. Lancet 2005;366:155
  • It is important to note that the natural history of valve disease can differ in the developed and developing world with the progression to mitral valve stenosis(for example) having a latency period of several decades as opposed to the early and aggressive presentation of the same lesion in developing countries.
  • It has been suggested that the medical management of RHD must defer to operative intervention according to echocardiographic and clinical guidelines. The absence of access to cardiac surgery, a reality for many parts of Africa, India and Pacific Islands, implies that patients present in advanced stages of the disease, with cardiac failure and with significant complications. Cardiovasc J Afr. 2007 Sep-Oct;18(5):295-9. Epub 2007 Oct 22. Prevalence and pattern of rheumatic heart disease in the Nigerian savannah: an echocardiographic study.
  • In 2000, the average cost of surgery for RHD in Africa was around US$5000;in low income countries of sub-Saharan Africa with a GDP per capita of less than US$500, such as Ghana, the cost of surgery is therefore prohibitive and would also adversely affect any poverty reduction strategies. Rheumatic and nonrheumatic valvular heart disease: epidemiology, management, and prevention in Africa. Essop MR, Nkomo VT. Circulation. 2005 Dec 6;112(23):3584-91. Review
  • Carapetis JR. The current evidence for the burden of streptococcal diseases. WHO/FCH/CAH/05-07. Geneva: World Health Organization,2004:1-57. http://www.who.int/immunization/documents/WHO_IVB_05.12/en/ http://whqlibdoc.who.int/hq/2005/WHO_FCH_CAH_05.07.pdf Pediatr Clin North Am. 2009 Dec;56(6):1401-19. Acute rheumatic fever and rheumatic heart disease in indigenous populations. Steer AC , Carapetis JR .
  • Incidence of acute rheumatic fever in the world: a systematic review of population-based studies. Tibazarwa KB, Volmink JA, Mayosi BM. Heart. 2008 Dec;94(12):1534-40. Epub 2008 Jul 31. Review.
  • Incidence and characteristics of newly diagnosed rheumatic heart disease in Urban African adults: insights from the Heart of Soweto Study. Sliwa K, Carrington M, Mayosi BM, Zigiriadis E, Mvungi R, Stewart S.Eur Heart J. 2009 Dec 7.
  • Incidence and characteristics of newly diagnosed rheumatic heart disease in Urban African adults: insights from the Heart of Soweto Study. Sliwa K, Carrington M, Mayosi BM, Zigiriadis E, Mvungi R, Stewart S. Eur Heart J. 2009 Dec 7. [Epub ahead of print]
  • According to the WHO, 15.6 million people worldwide are living with RHD. Of the 500 000 who develop ARF each year, 300 000 go on to develop RHD and 233 000 deaths are attributable each year to ARF/RHD. The are conservative estimates and the true burden of disease is thought to be even greater. This mortality rates are higher than those of rotaviruses, meningitis and hepatitis B and half of those with malaria. Rheumatic fever: neglected again. Watkins DA, Zuhlke LJ, Engel ME, Mayosi BM. Science. 2009 Apr 3;324(5923):37. No abstract available.
  • Nordet P, Lopez R, Duenas A, Sarmiento L CVJSA 2008:19:135-140
  • Read more about the healthcare system in Cuba and the achievements in Cuba in the past decades. http://www.pitt.edu/~super1/lecture/lec9881/001.htm
  • Nordet P, Lopez R, Duenas A, Sarmiento L CVJSA 2008:19:135-140
  • Nordet P, Lopez R, Duenas A, Sarmiento L CVJSA 2008:19:135-140
  • An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline. Carapetis JR, Brown A, Wilson NJ, Edwards KN; Rheumatic Fever Guidelines Writing Group. Med J Aust. 2007 Jun 4;186(11):581-6.
  • Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children. Brook I, Dohar JE. J Fam Pract. 2006 Dec;55(12):S1-11; quiz S12. Review.
  • Robertson, Volmink and Mayosi BMC cardiovascular disorders 2005;5;11
  • Robertson, Volmink and Mayosi BMC cardiovascular disorders 2005;5;11
  • Prosthetic valve replacements are at a premium in developing countries despite the need for these. In addition prosthetic valves require anti-coagulation and close monitoring by echocardiography , both of which is difficult to administer in developing countries. The need for new surgical options is not supported by current funding as the largest target population lies within poverty-stricken communities. Biomaterials. 2008 Feb;29(4):385-406. Epub 2007 Oct 24. Prosthetic heart valves: catering for the few. Zilla P , Brink J , Human P , Bezuidenhout D .
  • There is evidence to suggest that oral penicillin results in poorer rates of adherence and serum penicillin concentration may also be less predictable compared to intramuscular penicillin. The rate of anaphylactic reactions is about 0.2% with fatalities being extremely rare.
  • Cochrane Database Syst Rev. 2002;(3):CD002227. Penicillin for secondary prevention of rheumatic fever. Manyemba J , Mayosi BM .
  • This long axis parasternal images demonstrates the progression of valvular disease in the period between ARF and RHD. It is important to remember that timeous diagnosis, treatment and secondary prevention may in cases prevent this progression. The efficacy of echocardiographic criterions for the diagnosis of carditis in acute rheumatic fever. Vijayalakshmi IB, Vishnuprabhu RO, Chitra N, Rajasri R, Anuradha TV. Cardiol Young. 2008 Dec;18(6):586-92. Epub 2008 Oct 10
  • Rheumatic fever diagnosis, management, and secondary prevention: a New Zealand guideline. Atatoa-Carr P, Lennon D, Wilson N; New Zealand Rheumatic Fever Guidelines Writing Group. N Z Med J. 2008 Apr 4;121(1271):59-69. Review.
  • KENYAN PROJECT PREVENTS RHEUMATIC HEART DISEASE The Kenyan-Heart National Foundation, with the help of the Danish Heart Foundation and the governments of Denmark and Kenya, is working to reduce the scourge of rheumatic heart disease in Kenya. Each year, it is estimated that Kenya has approximately 200,000 new cases of rheumatic heart disease, making it among the world’s hardest-hit countries. http://www.worldheart.org/publications/heart-beat-e-newsletter/heart-beat-augustseptember-2007/in-this-issue/rheumatic-heart-disease-in-kenya/
  • http://www.procor.org/news/news_show.htm?doc_id=984447 http://www.facebook.com/note.php?note_id=116183553359 http://www.worldheart.org/what-we-do/demonstration-projects/rheumatic-heart-disease-demonstration-projects/
  • Heart. 2005 Sep;91(9):1131-3. Preventing recurrent rheumatic fever: the role of register based programmes. McDonald M , Brown A , Noonan S , Carapetis JR .
  • Heart. 2005 Sep;91(9):1131-3. Preventing recurrent rheumatic fever: the role of register based programmes. McDonald M , Brown A , Noonan S , Carapetis JR .
  • Robertson KA et al SAMJ 2006:96:241-5 The PASCAR-driven( Pan-African Society of Cardiology) ASAP programme was launched in 2005 at a meeting in the Drakensberg and the Drakensberg declaration was published in 2006. This meeting brought together interested cardiologists and physicians from all over Africa dealing with rheumatic heart disease on a daily basis in an attempt to develop a method to eradicate rheumatic fever and rheumatic heart disease using a multi-pronged approach.
  • The Prevention of Rheumatic Fever and Rheumatic Heart Disease

    1. 1. The Prevention of Rheumatic Fever and Rheumatic Heart Disease Dr Liesl Zühlke Paediatric Cardiologist: Red Cross War Memorial Childrens Hospital Cape Town South Africa [email_address]
    2. 2. <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
    3. 3. <ul><li>Learning Objectives: </li></ul><ul><li>To understand the pathogenesis of acute rheumatic fever and rheumatic heart disease </li></ul><ul><li>To appreciate the burden of disease </li></ul><ul><li>To recognize the features of a streptococcal sore throat </li></ul><ul><li>To know the treatment regimens of a streptococcal sore throat </li></ul><ul><li>To be aware of secondary prevention measures </li></ul><ul><li>To understand the role of a register-based programme </li></ul>
    4. 4. <ul><li>Performance Objectives: </li></ul><ul><li>Examine the burden of disease within own communities </li></ul><ul><li>Timely recognition of a streptococcal sore throat with correct treatment </li></ul><ul><li>Institute secondary prevention programme </li></ul><ul><li>Institute the above measure within a register-based programme </li></ul><ul><li>Join the global community fighting Rheumatic fever and rheumatic heart disease </li></ul>
    5. 5. What is the pathogenesis of acute rheumatic fever?
    6. 6. ACUTE RHEUMATIC FEVER <ul><li>Autoimmune consequence of infection with Group A streptococcal infection </li></ul><ul><li>Results in a generalised inflammatory response affecting brains, joints, skin, subcutaneous tissues and the heart . </li></ul>
    7. 7. ACUTE RHEUMATIC FEVER <ul><li>The clinical presentation can be vague and difficult to diagnose. </li></ul><ul><li>Currently the modified Duckett-Jones criteria form the basis of the diagnosis of the condition. </li></ul>
    8. 8. Carapetis. Lancet 2005;366:155
    9. 10. RHEUMATIC HEART DISEASE <ul><li>Rheumatic Heart Disease is the permanent heart valve damage resulting from one or more attacks of ARF. </li></ul><ul><li>It is thought that 40-60% of patients with ARF will go on to developing RHD. </li></ul>
    10. 12. RHEUMATIC HEART DISEASE <ul><li>The commonest valves affecting are the mitral and aortic, in that order. However all four valves can be affected. </li></ul>
    11. 13. RHEUMATIC HEART DISEASE <ul><li>Sadly, RHD can go undetected with the result that patients present with debilitating heart failure. </li></ul><ul><li>At this stage surgery is the only possible treatment option. </li></ul>
    12. 14. RHEUMATIC HEART DISEASE <ul><li>Patients living in poor countries have limited or no access to expensive heart surgery. </li></ul><ul><li>Prosthetic valves themselves are costly and associated with a not insignificant morbidity and mortality. </li></ul>
    13. 15. What is the incidence of acute rheumatic fever and rheumatic heart disease?
    14. 16. <ul><li>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. </li></ul><ul><li>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. </li></ul>
    15. 17. Incidence of ARF: Population-based Studies
    16. 18. Incidence of newly diagnosed RHD <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li> </li></ul>
    17. 20. What is the prevalence of rheumatic heart disease?
    18. 24. 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.
    19. 25. RHEUMATIC FEVER IS PREVENTABLE Costa Rica Cuba
    20. 26. 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.
    21. 27. 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.
    22. 29. What are the clinical features of strep sore throat?
    23. 32. Hallmarks of STREP sore throat <ul><li>Tender lymph nodes </li></ul><ul><li>Close contact with infected person </li></ul><ul><li>Scarlet fever rash </li></ul><ul><li>Excoriated nares( crusted lesions) in infants </li></ul><ul><li>Tonsillar exudates in older children </li></ul><ul><li>Abdominal pain </li></ul><ul><li>GOLD STANDARD: POSITIVE THROAT CULTURE </li></ul>
    24. 33. Hallmarks of VIRAL sore throat <ul><li>Coryza: runny nose or mouth ulcers </li></ul><ul><li>Other family with COLD symptoms </li></ul><ul><li>Evidence of another viral infection </li></ul><ul><li>Itchy watery eyes </li></ul><ul><li>Hoarseness and cough: non-specific </li></ul><ul><li>Fever: not specific </li></ul><ul><li>Red Throat: not specific </li></ul>
    25. 34. What are the treatment regimens of streptococcal sore throat?
    26. 35. Primary Prevention of Rheumatic Fever by treating sore throat Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual
    27. 37. Is it cost-effective to administer penicillin for all cases of suspected strep sore throat? <ul><li>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. </li></ul><ul><li>Mild hypertension: have to treat 800 people per year to prevent 1 episode of stroke </li></ul>
    28. 38. Is it cost-effective to administer penicillin for all cases of suspected strep sore throat? <ul><li>The estimated cost of preventing one case of rheumatic fever by a single intramuscular injection of penicillin is US$46 </li></ul><ul><li>Valve replacement surgery for 1 case of RHD is at least US$15, 000 </li></ul><ul><li>Cardiac surgery only available in S Africa, Ghana and Egypt </li></ul>
    29. 39. Rheumatic Heart Disease: SECONDARY PREVENTION PICTURE TAKEN OUT FOR SPACE ISSUES
    30. 40. THIS IS TOO LATE
    31. 41. 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
    32. 43. 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.
    33. 44. <ul><ul><li>Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention </li></ul></ul>Secondary prevention: Duration CATEGORY DURATION OF PROPHYLAXIS All 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.
    34. 45. 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.
    35. 46. Secondary prevention: Adherence <ul><ul><li>Use a 23-gauge needle- deeper is better </li></ul></ul><ul><ul><li>Local pressure to area for 10 secs </li></ul></ul><ul><ul><li>Warm syringe to room temperature </li></ul></ul><ul><ul><li>First allow alcohol to dry or use ethylchloride spray </li></ul></ul><ul><ul><li>. </li></ul></ul>How can we reduce the pain associated with IM Penicillin ?
    36. 47. Secondary prevention: Adherence <ul><ul><li>Deliver injection very slowly(over 2-3mins) </li></ul></ul><ul><ul><li>Distraction techniques </li></ul></ul><ul><ul><li>Good rapport with the case, is a significant aid to injection comfort, compliance and understanding. </li></ul></ul><ul><ul><li>Use 0.5-1ml of 1% lignocaine. Reduces pain significantly and excellent for younger patients. </li></ul></ul>
    37. 48. <ul><ul><li>Ensuring that patients understand their disease, are informed regarding their future and receive secondary prophylaxis </li></ul></ul><ul><ul><li>EDUCATION </li></ul></ul><ul><ul><li>Health education is critical at all levels </li></ul></ul><ul><ul><li>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. </li></ul></ul>
    38. 49. “ Kenyan-Heart Talking Walls”: Dr. Aggrey Primary School Elizabeth Gatumia, Kenyan Heart Foundation/ Danish Heart Foundation
    39. 50. Rheumatic Fever Week South Africa, 7-13 August 2006
    40. 51. What is the role of a register-based programme?
    41. 52. 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.
    42. 53. 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.
    43. 54. A.S.A.P. Programme for the Control of RHD in Africa: Focus areas for action <ul><li>Awareness raising : public, healthcare workers </li></ul><ul><li>Surveillance : incidence, prevalence, temporal trends </li></ul><ul><li>Advocacy : appropriate funding of the treatment and prevention programmes </li></ul><ul><li>Prevention : application of existing knowledge in primary & secondary prevention </li></ul>
    44. 55. Summary <ul><li>Rheumatic heart disease is the only truly preventable chronic heart condition </li></ul><ul><li>Primary prevention: </li></ul><ul><ul><li>Penicillin for suspected strep sore throat </li></ul></ul><ul><li>Secondary prevention </li></ul><ul><ul><li>Penicillin prophylaxis </li></ul></ul><ul><li>It is a legal requirement to notify cases of acute rheumatic fever to the local authority in South Africa </li></ul>
    45. 56. Summary <ul><li>The A.S.A.P. Programme for the Eradication of Rheumatic Fever </li></ul><ul><li>in Africa: </li></ul><ul><li>An achievable goal </li></ul>

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