Prevention of rheumatic fever

Prevention of rheumatic fever

Rheumatic fever is a disease which affects mostly the joints and heart valves, though manifestations can be there in the brain and skin. Heart valve damage leading to severe narrowing of the valves or major leaks in the valves or a combination are the hallmark of rheumatic heart disease. Prevention of rheumatic fever has been divided into three levels called as primordial prevention, primary prevention and secondary prevention.

Rheumatic fever is an immune response to infection by bacteria known as streptococci, which causes sore throat in children. Antibodies produces against the bacteria cross react with the cells of the joints, heart, brain and skin producing the major manifestations of rheumatic fever. Initial manifestation is often pain and swelling of joints. Certain patches in the skin and small nodules under the skin may occur. Brain involvement manifests as involuntary movements. Involvement of heart valves produces leaks in the valves and heart failure initially. Narrowing of the heart valves occur much later, as a long term complication of rheumatic fever.

Primordial prevention is preventing the development of ‘risk factors’ in the community to prevent the disease in the population and thus protect individuals. Improvement in socio-economic status, prevention of overcrowding, prevention of undernutrition and malnutrition, availability of prompt medical care and public education regarding the risk of rheumatic fever from sore throat especially below the age of 15 years are the measures for primordial prevention.

Primary prevention of rheumatic fever is theoretically feasible but practically almost impossible to achieve at the community level. It can be practised on an individual basis by identification of the bacteria in case of sore throat and use of antibiotics to eradicate the streptococci from the throat. Improving public awareness regarding danger of rheumatic fever from sore throat, identification of sore throat as being streptococcal and use of appropriate antibiotics to cure the streptococcal infection are the measures which are likely to be useful.

Primary prevention is difficult to achieve because of the following factors. Only 3 – 20% of sore throats are streptococcal in origin. Of these only 0.3 – 3% result in rheumatic fever. If 10,000 sore throats are treated, of which 300 to 2000 will be streptococcal, it will prevent rheumatic fever in 1 to 6 children. Hence primary prevention is not a feasible option at the community level.

Secondary prevention of rheumatic fever is the only viable preventive strategy. Secondary prevention is prevention of recurrence after an episode of rheumatic fever has occurred. This is because recurrent episodes of rheumatic fever cause more damage to heart valves. Secondary prevention is achieved by regular use of appropriate antibiotics as periodic injections or daily oral medicines, for a very long period. Period is decided based on whether there was involvement of heart valves during the initial episode and whether residual damage of heart valves is persisting. Minimum period is usually 5 years after the last episode of rheumatic fever. In those with rheumatic heart disease, it may be required lifelong. Probability of getting infections by streptococci in the local community is also taken into account.