33a-General NCD and Rheumatic Fever-21-6-2022.pdf

NON-COMMUNICABLE
CHRONIC DISEASES
(NCD)
Dr. Mohammad Mazharul Islam
MBBS
MPH (Community Medicine)
M Phil (Preventive & Social Medicine)
Dr. M. Mazharul Islam, mazhar2020@gmail.com

General considerations of NCDs

Definition of Chronic diseases & conditions
An EURO symposium in 1957 gave the
following definition:
An impairment of bodily structure
and or function that necessitates
a modification of the patient’s
normal life, and has persisted over
an extended period of time.

Chronic NCDs have the
following characteristics:
1. Permanent
2. Leave residual disability
3. Caused by non-reversible pathological
alteration
4. Require special training of the patient for
rehabilitation
5. May be expected to require a long period
of supervision, observation or care

Gaps in natural history:
1. No known agent
2. Multi-factorial
3. Long latent period
4. Indefinite onset

Risk factors of NCDs
 Modifiable
 Physical activity
 Food habit etc.
 Non-modifiable
 Age
 Genetic
 Sex etc.

Prevention and control
 Primordial / population approach
 Primary / high risk approach
 Secondary
 Tertiary

Specific diseases

Rheumatic
Fever
Dr. Mohammad Mazharul Islam
MBBS
MPH (Community Medicine)
M Phil (Preventive & Social Medicine)

Rheumatic fever is a systemic disease
affecting the peri-arteriolar connective
tissue and can occur after an untreated
Group A Beta hemolytic streptococcal
pharyngeal infection.

 an inflammatory disease that occurs
following a Group A streptococcal
infection,
 caused by antibody cross-reactivity
 can involve the heart, joints, skin, and
brain,
 typically develops two to three weeks after
a streptococcal infection

Acute rheumatic fever commonly
appears in children between the
ages of 5 and 15,
with only 20% of first-time
attacks occurring in adults.

 Rheumatic heart disease (RHD)
is squeal of rheumatic fever
(RF)
 Rheumatic heart disease is still
a major health problem in most
of the developing countries
 Prevalence of RHD has declined
considerably in the developed
countries

Epidemiology
o common worldwide
o responsible for many cases
of damaged heart valves
o in western countries, it
became fairly rare since the
1960s
o far less common in the
United States since the
beginning of the 20th
century
o has a mortality of 2–5%.

Epidemiology
o According to the annual report by the World Heart
Federation, an estimated 12 million people are
currently affected by rheumatic fever and
rheumatic heart disease worldwide responsible for
many cases of damaged heart valves
o Several studies were conducted on the prevalence
of rheumatic heart disease, reporting 0.14/1000 in
Japan, 1.86/1000 in China, 0.5/1000 in Korea,
4.54/1000 in India, and 1.3/1000 in Bangladesh.

Epidemiology
o Recent reports from the developing world have
documented rheumatic fever (RE) incidence
rates as high as 206/100,000 and RHD
prevalence rates as high as 18.6/1000.
o The decrease of the incidence of rheumatic
heart disease in developed countries had already
begun in 1910, and it is now below 1.0 per
100,000

Problem Definition in Bangladesh
• RHD is the commonest heart ailment in child
and young adults in Bangladesh.
• Prevalence of RHD was found to be 7.5 per
thousand population in 1976.
• In a multicentre study conducted in 1984-85
the prevalence of RF and RHD had been found
to be 15 per thousand population (Malik A, et
al., unpublished data).

• In a school survey in 1984 frequency of
RHD was found to be 6.3 per thousand
children (Awal et al., unpublished data).
• In a recent study among urban school
children a lower prevalence (2.8/1000
children) was observed.

• Rheumatic heart disease ranks second
amongst cardiovascular diseases in the
country, hypertension being the most
frequently occurring cardiovascular disease.
• Rheumatic heart disease constitutes 34%of
cardiac admission in the country.

A community-based study was done on 5923
rural Bangladeshi children aged 5-15 years to
determine the prevalence of rheumatic fever
(RF) and rheumatic heart disease (RHD). The
prevalence was found to be 1.2 (95%
confidence interval 0.3-2.1) per 1000 for RF
defined by revised Jones criteria and 1.3 (0.4-
2.2) per 1000 for Doppler echocardiography-
confirmed RHD.

RHEUMATIC FEVER AND
RHEUMATIC HEART DISEASE
 Rheumatic fever is not a communicable
disease
 It results from a communicable disease
 RF often leads to RHD

The consequences of RHD
1. Continuing damage to the heart
2. Increasing disabilities
3. Repeated hospitalization
4. Premature death (within 35 or less)
5. RHD is most readily preventable chronic disease

EPIDEMIOLOGICAL FACTORS
AGENT FACTORS:
a) Agent: group A beta hemolytic streptococci.
The strains with “rheamatogenic potential”.
b) Carriers:
Convalescent
Transient
Chronic

HOST FACTORS:
 Reservoir: human (Usually)
 Age: All ages are 5us acceptable 5-15 years are
common
 Sex: Both
 Immunity: Passive immunity occurs in newborns
with transplacental maternal antibodies
 The agent contain certain toxic substances that
acts antigenically with the host tissues causing
disease.

ENVIRONMENTAL FACTORS
a. Slum dwellers, living in barracks
b. Poverty overcrowding
c. Poor housing condition
d. Inadequate health services
e. Inadequate health care providers
f. Lack of awareness

MODE OF TRANSMISSION:
Respiratory transmission by-
a. Direct contact with patient or carrier
b. Indirect: rare by fomites or droplet nuclei
c. Nasal carriers are liable to transmit disease
Explosive outbreaks of streptococcal sore throat
may follow ingestion of contaminated milk or
other food.

INCUBATION PERIOD:
 Short
 1-3 days
 Symptoms appear after 2-3 weeks after
group A streptococcal infection.

DIAGNOSIS
Modified Jones criteria were first published in 1944 by T. Duckett
Jones, MD. They have been periodically revised by the American
Heart Association in collaboration with other groups.
According to revised Jones criteria, the
diagnosis of rheumatic fever can be made
when two of the major criteria, or one
major criterion plus two minor criteria are
present along with supportive evidence of
streptococcal infection.

Major criteria
1. Migratory polyarthritis
2. Carditis
3. Subcutaneous nodules
4. Erythema marginatum
5. Sydenham's chorea

Minor criteria
Clinical:
1. Fever
2. Polyarthralgia
Lab:
1. Raised ESR or C-reactive protein
2. Leukocytosis

Supportive evidences:
1. ECG showing features of heart block,
such as a prolonged PR interval.
2. Elevated or rising anti-streptolysin-O
(ASO) titer or other antistreptococcal
antibody.
3. Positive throat culture.
4. Rapid antigen test for group A
streptococci.
5. Recent scarlet fever.

Treatment
reduction of inflammation with anti-
inflammatory medications such as aspirin or
corticosteroids.
Individuals with positive cultures for strep
throat should also be treated with antibiotics.
 Aspirin is the drug of choice and should be
given at high doses of 100 mg/kg/day.
 The use of steroids may prevent
development of sequelae

Treatment
 Monthly injections of Longacting Penicillin
must be given for a period of 5 years in
patients having one attack of Rheumatic
fever.
 If there is evidence of carditis, the length of
Penidure therapy may be up to 40 years.
 Another important cornerstone in treating
rheumatic fever includes the continual use
of low dose antibiotics

Prevention
 Eradicating the acute infection and
prophylaxis with antibiotics.
 Screening school-aged children for sore
throats also aid in prevention.
There are two ways of prevention of RHD:
1. General measures
2. Drug-prophylaxis

1. General measures:
• Improvement of
socioeconomic condition.
• Avoidance of overcrowding
• Health Education

2. Drug prophylaxis:
a) Primary prophylaxis: It consists
of early treatment of upper
respiratory tract infection due to
group A beta hemolytic
streptococci to prevent an initial
attack of RF.
• Benzathine penicillin
• Phenoxymethyl penicillin
• Erythromycin

A. Drug prophylaxis:
b) Secondary prophylaxis: It involves
regular administration of an
antimicrobial agent to patients who
have had RF or is already suffering
from RHD in order to prevent
colonization and/or infection of upper
respiratory tract with group A beta
hemolytic streptococci and the
subsequent attack of RF.

• It has also been observed that 70% of
patients who suffered an attack of rheumatic
carditis, heart murmurs disappeared with
regular secondary prophylaxis.
• Secondary prophylaxis has also been found to
be cost-effective in reducing morbidity and
mortality.

33a-General NCD and Rheumatic Fever-21-6-2022.pdf

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