Rheumatic Heart Disease and fever .pptx

Rheumatic fever (RF) and rheumatic heart disease (RHD)
cannot be separated from an epidemiological point of
view . Rheumatic fever is a febrile disease affecting
connective tissues particularly in the heart and joints
initiated by infection of the throat by group A beta
haemolytic streptococci. Although RF is not a communicable
disease,
it
results
from
a
communicable disease
(streptococcal pharyngitis). Rheumatic fever often leads to
RHD which is a crippling disease. The consequences of RHD
include : continuing damage to the heart; increasing
disabilities; repeated hospitalization, and premature death
usually by the age of 35 years or even earlier. RHD is one of
the most readily preventable chronic disease. The incidence of rheumatic fever and rheumatic heart
disease has not decreased in developing countries.
Retrospective studies reveal developing countries to have
the highest figures for cardiac involvement and recurrence
rates of rheumatic fever. Worldwide, there are over
15 million cases of RHO with 282,000 new cases. During
2008, 220,000 deaths from this disease occurred which is
about 0.4 per cent of total deaths. RHO is a major cause of morbidity and a major cause of
mitral insufficiency and stenosis in the world. Variables that
correlate with the severity of valve disease include the
number of previous attacks of RF, the length of time between
the onset of disease and start of therapy, and sex (the disease
HEART DISEASE
is more severe in females than in males). Insufficiency from
acute rheumatic valve disease resolves in 60-80 per cent of
patients who adhere to antibiotic prophylaxis. AGENT : The onset of RF is usually preceded by a
streptococcal sore throat. Of the streptococci, it is the group
A streptococcus that has been incriminated as the causative
agent. It has been suggested that not all strains of group A
streptococci lead to RF; it is believed that there might be
some. strains with "rheumatogenic potential". The serotype
the high incidence of "juvenile mitral stenosis" in India (9,
10). The initial attack of RF occurs at a young age,
progresses to valvular lesions faster and is associated with
pulmonary arterial hypertension. The cause of the
"juvenile" disease in India is not known. (b) SEX : The
disease affects both sexes equally but prognosis is worse for
females than for males. (c) IMMUNITY : An immunological
basis for RF and RHD has been proposed. The most
prevalent concept is the toxic-immunological hypothesis.
According to this theory, group A streptococcal products
have certain toxic products, and components of the
streptococcus and of host tissues have an antigenic cross
relationship, leading to immunological processes that result
in an attack of RF (11). (d) SOCIO-ECONOMIC STATUS :
RF is a social disease linked to poverty, overcrowding, poor
housing conditions, inadequate health services.

1. Rheumatic Heart Disease Dr Hala Bashir Hashmi Community medicine

2. introduction Rheumatic fever (RF) and rheumatic heart disease (RHD) cannot be separated from an epidemiological point of view. Rheumatic fever is a febrile disease affecting connective tissues particularly in the heart and joints initiated by infection of the throat by group A beta hemolytic streptococci. Although RF is not a communicable disease, it results from a communicable disease (streptococcal pharyngitis).

3. Rheumatic fever often leads to RHD which is a crippling disease. The consequences of RHD include : continuing damage to the heart; increasing disabilities; repeated hospitalization, and premature death usually by the age of 35 years or even earlier. RHD is one of the most readily preventable chronic disease.

4. Problem

5. The incidence of rheumatic fever and rheumatic heart disease has not decreased in developing countries. Retrospective studies reveal developing countries to have the highest figures for cardiac involvement and recurrence rates of rheumatic fever. Worldwide, there are over 15 million cases of RHO with 282,000 new cases. During 2008, 220,000 deaths from this disease occurred which is about 0.4 per cent of total deaths

6. Determinants of RHD Determinants Group A Group B Socio-economic and . environmental factors : (poverty, undernutrition, overcrowding, poor housing). Rapid spread of group A streptococcal strains. Difficulties in accessing health care. Higher incidence of acute streptococcal-pharyngitis suppurative complications. Higher incidence of acute RE Higher rates of recurrent attacks. Health system related factors : shortage of resources for health care inadequate expertise of health care providers; Inadequate diagnosis and treatment of streptococcal pharyngitis. Misdiagnosis or late diagnosis of acute RE Low-level awareness of the disease in the community. Inadequate secondary prophylaxis and/or non-compliance with secondary prophylaxis.

7. Epidemiological factors

8. Agent Factors Agent The onset of RF is usually preceded by a streptococcal sore throat. Of the streptococci, it is the group A streptococcus that has been incriminated as the causative agent. Carriers Carriers of group A streptococcus are frequent, e.g., convalescent, transient and chronic carriers. In view of the high carrier rate, their eradication is not even theoretically possible

9. HOST & ENVIRONMENTAL FACTORS AGE : RF is typically a disease of childhood and adolescence (5-15 years) although it also occured in adults (20 per cent cases). IMMUNITY: group A streptococcal products have certain toxic products, and components of the streptococcus and of host tissues have an antigenic cross relationship, leading to immunological processes that result in an attack of RF SOCIO-ECONOMIC STATUS : RF is a social disease linked to poverty, overcrowding, poor housing conditions, inadequate health services, inadequate expertise of health-care providers and a low level of awareness of the disease in the community.

10. Clinical Features FEVER : Fever is present at the onset of acute illness and may be accompanied by profuse sweating. It may last for about 12 weeks or longer and has a tendency to recur.

11. b) POLYARTHRITIS: This occurs in 90 per cent of cases. Large joints like ankles, knees, elbows and wrists are involved; uncommonly smaller joints of hands and feet may be involved. The pain and swelling come on quickly and also subside spontaneously within 5-7 days. There is no residual damage to the joint.

12. {c) CARDITIS : Occurs in 60-70 per cent of cases. It starts early in the course of RE Moreover RHD may not be preceded by a clinically apparent attack of RE All layers of the heart- pericardium, myocardium and the heart valves - are involved. The involvement of heart is manifested by tachycardia, cardiac murmurs, cardiac enlargement, pericarditis and heart failure. The most common ECG finding is the first degree AV block.

13. (d) NODULES : Nodules below the skin tend to appear 4 weeks after the onset of RE They are small, painless and non-tender. They last for a variable period of time and then disappear leaving no residual damage. (e) It BRAIN INVOLVEMENT: This manifests as abnormal jerky purposeless movements of the arms, legs and the body. gradually disappears leaving no residual damage. {f) SKIN : Various types of skin rash are known to occur. It is thus obvious that except carditis all other manifestations of RF do not cause permanent damage.

14. Diagnosis a primary episode of RF recurrent attacks of RF in patients without RHD recurrent attacks of RF in patients with RHD rheumatic chorea insidious onset rheumatic carditis chronic RHD.

15. prevention The aim of primary prevention is to prevent the first attack of RF, by identifying all patients with streptococcal throat infection and treating them with penicillin. While this approach is theoretically simple, in practice, it is difficult to achieve and may not be feasible in many developing countries. In order to prevent a single case of RHD, several thousand cases of streptococcal throat infection must be identified and treated. Many infections are inapparent or if apparent are not brought to the attention of the health

16. Primary prevention: • Proper treatment of streptococcal pharyngitis • Drug of choice :Penicillin V orally for 10 days - Patients weighing >27 kg 500 mg bd or tds - Children weighing ≤27 kg 250 mg bd or tds • Benzylpenicillin, IM single dose - Adults and children with a body weight > 40 kg – 1.2 MIU - Children with a body weight < 40 kg – 600,000 IU • Amoxicillin - 50 mg per kg with a maximum dose of 1 g every 8 hours

17. Secondary Prevention (Preventing relapsing episodes of GAS pharyngitis) • Low risk patients: Benzathine penicillin G IM every 28 days • High risk patients: Benzathine penicillin G IM every 21 days • Dose: - Children weighing >27 kg 1.2 million U - Children weighing ≤27 kg 600,000 U - Penicillin V potassium 250 mg orally every 12 hours can be given as an alternative

18. Secondary Prevention Secondary prevention (i.e., the prevention of recurrences of RF) is a more practicable approach, especially in developing countries. It consists in identifying those who have had RF and giving them one intramuscular injection of benzathine benzyl penicillin (1.2 million units in adults and 600,000 units in children) at intervals of 3 weeks. This must be continued for at least 5 years or until the child reaches 18 years whichever is later. For patients with carditis (mild mitral regurgitation or healed carditis) the treatment should continue for 10 years after the last attack, or at least until 25 years of age, which ever is longer. More severe valvular disease or post-valve surgery cases need life-long treatment

19. Non medical treatment Non-medical measures for the prevention/control of RF are related to improving living conditions, and breaking the poverty-disease-poverty cycle. Evaluation In the evaluation of the programme , the prevalence of RHD in school children from periodic surveys of random samples is probably the best indicator.

20. Thank you