Prevention of rheumatic fever

Prevention of rheumatic fever

Prevention of rheumatic fever can be approached at three levels:

1. Primordial prevention
2. Primary prevention
3. Secondary prevention

Primordial prevention is preventing the development of ‘risk factors’ in the community to prevent the disease in the population and thus protect individuals.

Measures for primordial prevention of rheumatic fever

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 specially below the age of 15 years are the measures for primordial prevention.

Primary prevention of rheumatic fever

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 group-A beta hemolytic streptococcal sore throat and use of penicillin 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 injectable penicillin 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. Primary prevention is quite difficult to achieve. Oral penicillin may not be effective in preventing rheumatic fever. Rheumatic fever occurred in 15% to 48% children given oral penicillin for 10 days in a US epidemic. 400,000 units of procaine penicillin twice daily for 10 days may be needed.

Eagle Effect

Group A beta hemolytic streptococci (GABHS) are uniformly sensitive to penicillin. But penicillin is effective only on rapidly multiplying bacteria. After rapid division, GABHS may reach a stationary phase due to limited nutrients in the local milieu. This can lead to a relative resistance to penicillin.

Secondary prevention of rheumatic fever

Secondary prevention of rheumatic fever is the only viable preventive strategy. Options are:

Benzathine penicillin G 1 200 000 U every 4 weeks, administered intramuscularly (In high-risk situations, administration every 3 weeks is justified and recommended)
or
Penicillin V 250 mg twice daily, orally
or
Sulfadiazine 0.5 g once daily for patients 27 kg orally
(1.0 g once daily for patients >27 kg)

For individuals allergic to penicillin and sulfadiazine:
Erythromycin 250 mg twice daily, orally.

Duration of secondary rheumatic fever prophylaxis (Recommendations of American Heart Association [1])

Rheumatic fever with carditis and residual heart disease : At least 10 years since last episode and at least until  age 40 years, sometimes lifelong prophylaxis.

Rheumatic fever with carditis, but no residual heart disease (no valvar disease – clinical or echocardiographic evidence): 10 years or 21 years,  whichever is longer.

Rheumatic fever without carditis: 5 years or until age 21 years, whichever is longer.

Before stopping prophylaxis, an individual’s risk of exposure to streptococcal infection should be considered. Teachers, parents of young children and health care providers are at higher risk. Poor housing condition and overcrowding increase the risk of transmission of streptococcal infections. Hence there is variation in the duration of prophylaxis recommended by different countries. Benzathine penicillin injection is the cornerstone of secondary prevention of rheumatic fever. But adverse reactions in patients with advanced disease and difficulties in procurement are important challenges [2].

Reference

1. Michael A Gerber, Robert S Baltimore, Charles B Eaton, Michael Gewitz, Anne H Rowley, Stanford T Shulman, Kathryn A Taubert. 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. Circulation. 2009 Mar 24;119(11):1541-51.
2. Kumar RK , Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Reményi B, Sliwa-Hähnle K, Zühlke LJ, Sable C; American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association. Circulation. 2020 Nov 17;142(20):e337-e357.