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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
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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 • Rheumatic heart disease • Prevention and control ARF/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 ARF/RHD
Group A β-Hemolytic Streptococci: Clinical presentations • 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) ARF/RHD
Public Health Importance: • Group A β-Hemolytic Streptococci could be a precursor of two serious non-suppurativesequlae, namely: • Post streptococcal glomerulonephritis • Acute rheumatic fever and rheumatic heart disease ARF/RHD
Hallmarks of STREP sore throat • 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 ARF/RHD
Hallmarks of VIRAL sore throat • 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 ARF/RHD
What are the treatment regimens of streptococcal sore throat?
Primary Prevention of Rheumatic Fever by treating sore throat Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual ARF/RHD
Is it cost-effective to administer penicillin for all cases of 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 ARF/RHD
Is it cost-effective to administer penicillin for all cases of 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 ARF/RHD
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 ARF/RHD
General 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. ARF/RHD
Carapetis. Lancet 2005;366:155 ARF/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) ARF/RHD
Overview - 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. ARF/RHD
Overview - 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. ARF/RHD
Overview - 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. ARF/RHD
What is the incidence of acute rheumatic fever and rheumatic heart disease? • 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. ARF/RHD
Incidence of newly diagnosed 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. ARF/RHD
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 ARF/RHD
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. ARF/RHD
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. ARF/RHD
RHEUMATIC FEVER IS PREVENTABLE Costa Rica ARF/RHD Cuba
Primary Prevention of Rheumatic Fever by treating sore throat Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual ARF/RHD
Rheumatic Heart Disease:SECONDARY PREVENTION PICTURE TAKEN OUT FOR SPACE ISSUES
THIS IS TOO LATE ARF/RHD
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 ARF/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. ARF/RHD
Secondary prevention: Duration ARF/RHD • Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention
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. ARF/RHD
Secondary prevention: Adherence How can we reduce the pain associated with IM Penicillin? • 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 • . ARF/RHD
Secondary prevention: Adherence • 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. ARF/RHD