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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

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Headlines

• Streptococcal Infections
• Sore throat (streptococcal versus viral)
• Acute rheumatic fever
• Rheumatic heart disease
• Prevention and control

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Types of Streptococcal Infections

• According to reaction on blood-agar plates
• ?lpha-hemolytic group (Streptococcus viridans)
  produces hemolysis circled by a greenish ring
  surrounding the central colony
• ?eta-hemolytic group (Streptococcus pyogenes)
  produces a completely clear zone around the
  central colony

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Group A ß-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)

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Public Health Importance

• Group A ß-Hemolytic Streptococci could be a
  precursor of two serious non-suppurative
  sequlae, namely
• Post streptococcal glomerulonephritis
• Acute rheumatic fever and rheumatic heart
  disease

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What are the clinical features of strep sore
throat?
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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

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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

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What are the treatment regimens of streptococcal
sore throat?
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Primary Prevention of Rheumatic Fever by treating
sore throat
Antibiotic Administration Dose
Benzathine benzyl penicillin Single IM injection 1.2 MU gt 30kg 600 000 U lt 30 kg
Phenoxymethyl penicillin (Pen VK) PO for 10 days 250-500mg qds for 10 days 125mg qds X 10 if lt30 kg
Erythromycin ethylsuccinate PO for 10 days Use same dose as above.
Oral penicillin is less efficacious than
Penicillin IMI Anaphylaxis is extremely unusual
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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

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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 US46
• Valve replacement surgery for 1 case of RHD is at
  least US15, 000
• Cardiac surgery in African nations available in
  Egypt, South Africa, and Ghana

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Acute Rheumatic Fever
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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-ß
  hemolytic strep infection
• Sudden onset of fever, pallor, malaise

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Incidence of ARF Population-based Studies
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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.

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Carapetis. Lancet 2005366155
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Jones Criteria

• Major criteria arthritis carditis Sydenhams
  chorea erythema marginatum subcutaneous nodules
  
• Minor criteria fever arthralgia elevated
  C-reactive protein Rising Erythrocyte
  Sedimentation Rate prolonged PR-interval (on ECG
  examination)

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Rheumatic Heart Disease
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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.

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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.

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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.

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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 lt10 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 gt80/100,000 per year.

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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.

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What is the prevalence of rheumatic heart disease?
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Prevention Control
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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

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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.

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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.

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RHEUMATIC FEVER IS PREVENTABLE
Costa Rica
Cuba
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Primary Prevention of Rheumatic Fever by treating
sore throat
Antibiotic Administration Dose
Benzathine benzyl penicillin Single IM injection 1.2 MU gt 30kg 600 000 U lt 30 kg
Phenoxymethyl penicillin (Pen VK) PO for 10 days 250-500mg qds for 10 days 125mg qds X 10 if lt30 kg
Erythromycin ethylsuccinate PO for 10 days Use same dose as above.
Oral penicillin is less efficacious than
Penicillin IMI Anaphylaxis is extremely unusual
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Rheumatic Heart DiseaseSECONDARY PREVENTION
PICTURE TAKEN OUT FOR SPACE ISSUES
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THIS IS TOO LATE
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Secondary Prevention Stops sore throat, prevents
recurrences of ARF and aids in regression of RHD
Antibiotic Administration Dose
Benzathine benzyl penicillin Single IM injection monthly 1.2 MU gt 30kg 600 000 U lt 30 kg
Phenoxymethyl penicillin (Pen VK) BD PO daily 250-500mg bd
Erythromycin ethylsuccinate BD po daily Use same dose as above.
Oral penicillin has been shown to be less
effective than Penicillin IMI Anaphylaxis is
extremely unusual
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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.
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Secondary prevention Duration
CATEGORY DURATION OF PROPHYLAXIS
All persons with ARF with no or mild carditis MINIMUM 10 years after most recent episode or age 21
All persons with ARF and moderate carditis MINIMUM 10 years after most recent episode or age 35
All persons with ARF and severe carditis MINIMUM 10 years after most recent episode or age 35 and then specialist review for need to continue. Post surgical cases definitely lifelong.
Awareness ? Surveillance ? Advocacy ?
Prevention
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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.
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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
• .

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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.

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Ensuring that patients understand their disease,
are informed regarding their future and receive
secondary prophylaxis
EDUCATION Health education is critical at all
levels Lack of parental awareness of the causes
and consequences of ARF/RHD is a key contributor
to poor adherence amongst children on long-term
prophylaxis.
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What is the role of a register-based programme?
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Background

• In 1972, the WHO launched a register-based
  programme to combat ARF/RHD
• By 1990, registers had been established in 16
  countries with over a million school-going
  children involved. However in 2001, the WHO
  ceased its funding to this global programme.
• Experience elsewhere however provides conclusive
  evidence of registers realising notable successes
  in reducing RF recurrence.

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Purposes

• Collect data on demographic profiles Highlight
  deficiencies in service deliveryPriority-based
  guidelines to evaluate and manage patients
• A register of cases of RF and RHD can be used to
  improve treatment adherence in order to prevent
  recurrent RF and the development of RHD,
  necessitating surgery.

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A.S.A.P. Programme for the Control of RHD in
Africa Focus areas for action

• Awareness raising public, healthcare workers
• Surveillance incidence, prevalence, temporal
  trends
• Advocacy appropriate funding of the treatment
  and prevention programmes
• Prevention application of existing knowledge in
  primary secondary prevention

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Conclusion

• Rheumatic heart disease is the only truly
  preventable chronic heart condition
• Primary prevention
• Penicillin for suspected strep sore throat
• Secondary prevention
• Penicillin prophylaxis

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References

• Heymann DL. Control of communicable diseases
  manual. Washington DC American Public Health
  Association, 2008
• Zühlke L. The prevention of rheumatic fever and
  rheumatic heart disease. Cape-Town Red Cross War
  Memorial Childrens Hospital.
• http//www.who.int/cardiovascular_diseases/
• resources/trs923/en
• http//www.pascar.co.za/C_ASAP.asp

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• Thank you for your kind attention