Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated

Ramachandra Barik

doi:10.4103/njc.njc_29_17

LETTER TO EDITOR

Year : 2018 | Volume : 15 | Issue : 2 | Page : 114-117

Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated

Ramachandra Barik
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Web Publication

3-Jul-2019

Correspondence Address:
Dr. Ramachandra Barik
All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/njc.njc_29_17

How to cite this article:
Barik R. Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated. Nig J Cardiol 2018;15:114-7

How to cite this URL:
Barik R. Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated. Nig J Cardiol [serial online] 2018 [cited 2023 May 29];15:114-7. Available from: https://www.nigjcardiol.org/text.asp?2018/15/2/114/262002

Sir,

Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops 2–4 weeks after a streptococcal throat infection. Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic nonitchy rash known as erythema marginatum. The RF is diagnosed using well-known modified Jones criteria. Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur initial episode. The chronic RHD is characterized by both valvular regurgitation and valvular stenosis. Acute RF and RHD remain the major causes of heart failure, atrial fibrillation, stroke, infective endocarditis, and death among the young men, young women, and middle age people despite being entirely preventable and effectively treatable.^{[1],[2],[3],[4]} The prevalence of this scourge is directly related to socioeconomic status, level of education, and the quality of lifestyle as evidenced by almost zero prevalence of RHD and RF in the developed countries which dates back to 1980.^[5] RF and RHD have a decreasing trend globally.^[6] There lies a significant gradient in the prevalence and incidence of RHD between developed and developing nations.^[7] In the contemporary, the morbidity and mortality related to RHD are worst in developing countries.^[8],[9] This is because of the poor infrastructure to support all the level of care which is required for the prevention and treatment. Far away from industrialized areas, the prevalence is worse.^[1] The true prevalence is underreported and is quite variable because of poor documentation,^[10] even though the initial desires to eradicate this disease dates to 1960.^[11],[12] RHD causes significant additional financial burden by crippling and killing the most contributing age group. The affected country spends a lot on prevention, catheter-based intervention, and cardiac surgery for valvular damage. Every patient with significant valvular heart disease has no access to cardiac surgery and intervention in the local areas. Hence, also every patient cannot afford the cost of surgery which may be available traveling far off. As this disease has very long natural history and needs active follow-up for lifetime even after surgery, it is difficult for the financially challenged people to afford. In the most of the remote areas from the city, long-acting penicillin is not available round year. It is even more difficult to find a competent personnel who can give the injection with due safety. A well-organized strategy with vision is must at all the levels of care [Figure 1] for eradicating this disease in near future. In the context, some of the major barriers in preventing and treating RHD are addressed in [Table 1]. Primordial prevention seems to be not reachable soon in developing countries because of the wide variation in the available health infrastructure and socioeconomic status.^[29] There are no randomized control trial or large size observational studies regarding the role of secondary penicillin prophylaxis in the later stage of the disease.^[30] However, some of the long-term follow-up studies have proved that the early initiation of SP is very effective to stop or slow down the further progress of RHD.^[20],[21] However, most of the patients in India with Group A streptococcal (GAS) sore throat present either with RF or rheumatic heart disease because of lack of awareness.^[31] There is also no sine-qua-non prototype in the clinical course from GAS pharyngitis to RF which is a significant barrier for primary prevention. The candidate vaccine for RF is still in the developing stage to meet the criteria of its effectiveness against the various strains. The affordability of all the patients to the vaccine in research pipeline irrespective of their financial status and geographical territory yet to be tested.^[32] Therefore, in the contemporary, the SP with long-acting penicillin is the only feasible strategy to keep the morbidity and mortality in check until there is a significant and uniform improvement in the socioeconomic status.^[33] As SP is most effective when started in the subclinical form, the 2012 World Heart Federation criteria have recommended the echocardiography to pick up this diseases at the earliest.^[34] A handheld echo Doppler probe would be quite helpful to pick up subclinical cases at the community level as an alternative epidemiological study tool.^{[35],[36],[37],[38],[39]} Adherence to SP using long-acting intramuscular injection regularly in every 3 weeks is associated with certain practical hurdles such as perennial availability of penicillin in the local area, fear of anaphylaxis, availability of trained person to give injection in regular interval with reasonable safety, painful intramuscular injection, lifelong prophylaxis even after surgery, lack of awareness, distance from hospitals, and financial constraint.^[35],[40] Therefore, the frontline researches, such as developments in pathogenesis, identification of early biomarkers, and effective and affordable vaccine with parallel improvement in socioeconomic status, are the need as early as possible.

Figure 1: Level of intervention to prevent and treat rheumatic fever and rheumatic heart disease. A: Primordial prevention; B: Primary prevention; C: Secondary prevention; D: Tertiary prevention (catheter-based intervention or surgery to repair the established structural damage)

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Table 1: The major strategies to reduce morbidity and mortality associated with rheumatic heart disease in developing countries

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At present, the strategy which would be quite appropriate for developing countries is a national level initiative for prevention and treatment of rheumatic heart disease to assure SP with long-acting intramuscular penicillin to all the patients with RF or RHD in the earliest part of the clinical course. It would be like rheumatic heart disease can be put into a cage if cannot be eradicated so soon until there are significant progress in socioeconomic status, level of education, level of awareness, and an effective and affordable vaccine.

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