DR.PRAKASH RAJ REGMI MD President Nepal Heart Foundation

1. PREVENTION AND CONTROL OF RHD IN NEPAL
DR.PRAKASH RAJ REGMI MD
President
Nepal Heart Foundation

2. Presentation Highlights
1. Brief introduction of NEPAL HEART FOUNDATION
2. RHD burden in Nepal
3. National RHD control program
4. Community based programs on RHD control in Nepal
5. Conclusions

3. Nepal Heart Foundation
1. NGO Established in 1985
2. 63 district branches throughout Nepal
3. Five National programs focusing on prevention
4. National RHD control Program in collaboration with
Government of Nepal since 2008
5. Preparing for the launching of a new National program
GO GREEN FOR CHILDREN

4. RHD IN NEPAL
PREVALENCE OF RHD IN SCHOOLCHILDREN
1990 1.35 / 1000 DR.UKS / DR.MRP
1994 1.0 / 1000 DR.TNB
1996 1.2 / 1000 DR.PRR / DR.MRP
2003 1.17 / 1000 DR.MBKC
2011 1.1 / 1000 DR.PRR

5. RHD IN NEPAL
MORBIDITY FROM RHD
DATA FROM NATIONAL HEART CENTRE
ADMITTED CASES
Year CAD % RHD %
2002 39.5 20.8
2003 39.3 27.7
2004 37.9 26.1
2005 39.1 20
2006 42.5 23.3
2011 40 24
SURGERY
2006 11% 29 %
2011 10% 30%

6. RHD IN NEPAL
MORTALITY FROM RHD
Estimated by NHF
2 per 1000 children( age 5-16 years) suffer
0.2 per 1000 die
20 per 100000 die
1000 child death ( age 5-16 yrs)
annually

7. END STAGE HEART DISEASE IN NEPAL
Main cause
SEV. RHD
Grossly dilated heart
Severe and multiple valve
damage
Very high PAP
CCF

8. TREND OF CVD PREVALENCE IN NEPAL
CAD
INCREASING RAPIDLY
RHD
STABLE ( Not declining)
Severe RHD in children
has declined
Awareness on RHD has increased

9. National RHD control program in Nepal
• 1ST heart disease prevention
program of Nepal at national
level
• Announced in 2007 June
• Allocated annual budget of
50000 USD
• MOH&P authorized Nepal
Heart Foundation for
implementation of the
program in 2008 March
• NHF launched the program
June 2008

10. MAIN OBJECTIVES
1. Provide Secondary
prevention through
hospitals
2. Plan for Primary
prevention
3. Reduce morbidity &
mortality from RHD

11. OTHER OBJECTIVES
• Supply inj. BPG to RF/RHD
patients free of cost
• Make inj. BPG available
• Make inj. BPG delivery easily
accessible and safe
• Maintain RF/RHD Registry
• Prepare guidelines for skin
testing
• Prepare Nepalese guideline
for RF/RHD control

12. WHAT WE DO
1. Keep records of RHD pts and Supply them inj. BPG ,
Erythromycin and Pen V FOC
2. Arrange health institutions to deliver inj. BPG FOC
3. Issue penicillin injection card to the pt
4. Maintain RF/RHD Registry
5. Prepare guidelines for skin testing
6. Provide training to doctors and paramedics involved in
secondary prophylaxis
7. Upgrade facilities in the penicillin inj. rooms
8. Evaluation and monitoring, Screening , case detection
and research
9. Public awareness activities and advocacy. Community
and School focused programs
10. Reporting to the ministry of Health

13. PARTICIPATING HOSPITAL 38
Central hospitals
Regional hospitals
Sub Regional hospitals
Zonal hospitals
District hospitals
Community hospitals
Heart Clinics run by NHF
Total patients till 2012 May 9762
ARF 652 RHD 9110

14. RF/RHD REGISTRY
PENICILLIN INJ. REGISTERS
1. Hospital Registers ( Paper Register )
2. Central Register ( Computer Data Register )

15. REGISTER
Components
1. Pts on inj. BPG
2. Pts on Erythromycin and Pen V
3. Age : < 18 yrs, > 18 yrs
4.Sex : males / females
5 Diagnosis : RF / RHD, Severity
6. Manifestations of ARF
7. Number of pts allergic to penicillin
8. Number of death due to allergy
9. Compliance to secondary prophylaxis

16. Inj.BPG delivery
SAFETY MEASURES
Upgrading facilities in Penicillin injection room
Rooms have
• Emergency medicines( Adrenaline, Atropine compulsory)
• Oxygen, IV stand, Pt trolley, suction
• Intubation set , Ambubag
• Emergency care kit box with all necessary drugs and instruments
• Inj. Adrenaline loaded before injecting BPG

17. PENICILLIN INJ. ROOM

18. Inj.BPG delivery
SAFETY MEASURES
NHF guidelines for SKIN TESTING
Even skin test may result in anaphylaxis
1. First penicillin injection
2. Change in Batch number
3. Change in Brand name

19. Inj.BPG delivery
SAFETY MEASURES
Guidelines to inject with less pain
1. Shake the dissolved medicine well
2. Separate 21G needle for IM inj.
3. N/S in the needle
4. Inj. site finger pressure for 10 sec
5. Distraction of attention
6. Inject slowly over 2-3 mins in outer
upper quadrant of buttock
7. ½ to 1 ml 1% Lignocaine if sev pain

20. Recognize and Treat
ANAPHYLACTIC SHOCK early
Not a dose dependent reaction
Reaction in seconds; IgE mediated
• Low BP
• Tachycardia
• Sweating
• Dizziness
• Dyspnoea
• Syncope
• Death if not treated

21. Recognize and Treat
VASO-VAGAL REACTION
Reaction to pain
• Low BP
• Bradycardia
• Dizziness
• Syncope

22. HURDLES TO PENICILLIN COMPLIANCE
1. Fear of anaphylaxis and death
2. Pain
3. Inj. BPG shortage time to time
4. Refusal by paramedics to inject BPG
5. Absence of paramedics in remote villages
6. Expensive overall treatment of RHD ( although inj. BPG
is cheep)
7. Paramedics are overloaded with other works
In Nepal
We follow 3 weekly regimen ( 17 injection per year )
Compliance to Penicillin is good in > 85% pts

23. Heart Screening of school children
1. Nepal heart foundation has screened > 100000 children
till date.
2. Prevalence of RHD is 1.2 / 1000 school children
3. In 2012 screening of 25000 school children done in
Lalitpur district with support from Rotary clubs.
Method used was auscultation followed by echo test of
suspected cases. 38 community schools were visited
by 5 doctors. 42 RHD cases detected . They were put
on secondary prophylaxis. 4 Sev RHD case operated in
National heart centre. Detail data analysis and final
report will be published soon.

24. Echocardiography Screening of school
children
1. Not yet started due to lack of portable echo machine
2. Planning to screen 10000 school children as soon as
portable echo machine is available

25. Pilot project on primary prevention of ARF
1. MOU signed between Nepal heart foundation and
public health department of lalitpur district with
population of 400000 people to start Primary
prevention program of ARF from Mid March 2013
2. 42 health centres will participate
3. Registers will be maintained
4. Amoxycillin for 7 days or Azithromycin for 5 day will be
given to treat streptococcal throat infection
5. Paramedics will be trained to diagnosed strep throat
and to give necessary treatment

26. Community based programs for
RHD control
1. Advocacy for RHD control
2. Training for RHD control
3. Awareness activities for RHD control

27. Advocacy for RHD control
Methods used
1. Preparation of fact sheets
2. Lobbying( Individual, organizational, social )
3. Dialoguing and debating with the politicians and
beurocrats
4. Networking with the stakeholders
5. Mass Media Mobilization
6. Sensitizing the RHD issue
7. Publications and distribution of public education
materials

28. Advocacy for RHD control
1. Fact sheets information
a. High prevalence in poor community
b. Lifelong treatment
c. Expensive Surgery
d. High morbidity & mortality
e. Cheep Preventive methods

29. Advocacy for RHD control
2. Lobbying at all levels
personal, organizational , social, political etc
a. Using personal influences to the minister , secretary
of health, chief of planning division ( Very Effective )
b. Repeated visits to the Health Minister and secretary
made by NHF team.
c. Repeatedly Inviting health minister and/or secretary
to public meetings related to RHD as chief guest
d. Lobbying the opposition party leaders

30. Advocacy for RHD control
3. Dialoguing and debating with the politicians and
beurocrats and also threatening them
a. People need social change
b. people are demanding for RHD control program
c. Many poor children are dyeing everyday
If you don’t do anything to address this issue
people will punish you !!!!

31. Advocacy for RHD control
4. Networking with the stakeholders
a. Nepal Heart Net was established in 2006 that includes
20 heart related organizations
b. Nepal RHD Forum- a group of medics and health
journalists
c. Nepal RHD net- network of 7 Cardiologists working in
different geographical regions of Nepal

32. Advocacy for RHD control
5. Mass Media mobilization
a. Press conference on RHD
b. Articles in leading newspapers
c. Television shows on RHD issues
d. RHD Forum includes health journalists

33. Advocacy for RHD control
6. Sensitizing the RHD issues
a. Wrong message in school text book on RHD
b . Press conference
c. During World Heart Day celebration
d. National Seminar on RHD Control

34. Advocacy for RHD control
7. Publication and distribution of public
education materials
a. Books on RHD in Nepal, Prevention & control of
heart diseases in Nepal made to be published by
Ministry of health
b . Injection Penicillin video shows at many places
c. Stickers and posters in the health ministry premises
and public places
d. Calendars, pamphlets

35. Training for RHD control
Methods
1. Orientation training(OT) to secondary prevention staffs
2. Heart Disease Prevention Volunteer Training ( HDPVT)
3. Community Cardiac Assistant Training ( CCAT)
4. Training of Youths ( TOY )
5. Training of Teachers ( TOT)
6. Training of mothers ( TOM )

36. Training for RHD control

37. Awareness activities for RHD control
Methods used
1. Hording boards through out the country
2. Mass Media Mobilization
3. RF / RHD materials in educational curricula
4. Production and distribution of public education
materials
5. Street drama
6. Mobilization of celebrities, champions
7. Special & sensitizing save heart campaign

38. Awareness for RHD control
1. Hoarding boards through out the country

39. Awareness for RHD control
2. Mass Media Mobilization
FM Radio
National TV
Newspapers
Production and telecast of documentary on
RHD
.

40. Awareness activities for RHD control
3. RF / RHD materials in school curricula

41. Awareness activities for RHD control
4. Production & distribution of public education
materials

42. Awareness activities for RHD control
5. Street drama on RHD

43. Awareness activities for RHD control
6. Mobilization of celebrities and champions

44. Awareness activities for RHD control
7. Special & sensitizing
save heart campaign
From sea level to top of
Everest.
Save heart expedition 2013

45. GO GREEN FOR CHILDREN
SCHOOL FOCUSED PROGRAM ANNOUNCED BY NHF ON
WHD 2012
Main Objectives
1. RF/RHD prevention
2. Prevention of CVD risk factors
Activities
Various activities to promotion healthy lifestyle in children

46. CONCLUSIONS
1. RHD control program are effective when run by the
government and supported by public and private
sector
2. Advocacy at all levels is necessary to initiate a RHD
control program
3. Secondary prevention program should be initiated
first then followed by primary prevention program
4. Public awareness activities and trainings are essential
components of RHD control program
5. Efforts should be made to increase compliance of
patients to Penicillin

47. THANK YOU