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Streptococcal Infections: The Case of Acute Rheumatic Fever / Rheumatic Heart Disease

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

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  1. Streptococcal Infections: The Case of Acute Rheumatic Fever / Rheumatic Heart Disease Ahmed Mandil Prof of Epidemiology Family & Community Medicine Dept King Saud University

  2. Headlines • Streptococcal Infections • Sore throat (streptococcal versus viral) • Acute rheumatic fever • Rheumatic heart disease • Prevention and control ARF/RHD

  3. 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

  4. 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

  5. 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

  6. What are the clinical features of strep sore throat?

  7. ARF/RHD

  8. ARF/RHD

  9. 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

  10. 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

  11. What are the treatment regimens of streptococcal sore throat?

  12. Primary Prevention of Rheumatic Fever by treating sore throat Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual ARF/RHD

  13. ARF/RHD

  14. 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

  15. 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

  16. Acute Rheumatic Fever

  17. 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

  18. Incidence of ARF: Population-based Studies ARF/RHD

  19. 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

  20. Carapetis. Lancet 2005;366:155 ARF/RHD

  21. 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

  22. ARF/RHD

  23. Rheumatic Heart Disease

  24. 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

  25. 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

  26. 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

  27. 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

  28. ARF/RHD

  29. 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

  30. ARF/RHD

  31. What is the prevalence of rheumatic heart disease? ARF/RHD

  32. ARF/RHD

  33. ARF/RHD

  34. Prevention & Control

  35. 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

  36. 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

  37. 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

  38. RHEUMATIC FEVER IS PREVENTABLE Costa Rica ARF/RHD Cuba

  39. Primary Prevention of Rheumatic Fever by treating sore throat Oral penicillin is less efficacious than Penicillin IMI Anaphylaxis is extremely unusual ARF/RHD

  40. Rheumatic Heart Disease:SECONDARY PREVENTION PICTURE TAKEN OUT FOR SPACE ISSUES

  41. THIS IS TOO LATE ARF/RHD

  42. 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

  43. ARF/RHD

  44. 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

  45. Secondary prevention: Duration ARF/RHD • Awareness ♦ Surveillance ♦ Advocacy ♦ Prevention

  46. 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

  47. 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

  48. 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

  49. ARF/RHD

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