1. Secondary prevention of acute rheumatic fever and
rheumatic heart disease
Christine Barclay
Public Health Nurse
SA RHD Control Program

2. Learning objectives What is secondary prevention of ARF/RHD?
Understand the tools of secondary prevention: their use and limitations
Recognise the role of a register-based program in secondary prevention
Understand the role of primary care facilities
Understand the practical challenges of secondary prevention
Know where to find relevant information

3. RHD prevention strategies
ARF
GAS infection
RHD
Stroke, endocarditis
Cardiac surgery
Death
Primordial prevention
Primary prevention
sore throat Rx
skin sore Rx
vaccine
Secondary prevention (prophylaxis)
3 - 4 weekly penicillin
Tertiary prevention
heart failure meds
surgery
anticoagulation
Often prolonged asymptomatic period of RHD
(screening)
So looking at this slide you can see that the prevention of RHD can be implemented at a number of different stages.
Primordial prevention looks at preventing risk factors for GAS and will be discussed later today.
Primary prevention which Claire has just talked about focuses on addressing behaviours that expose people to GAS and seeking prompt treatment.
Secondary prevention aims to detect and treat ARF early on to limit its progression to RHD or worsening RHD and its complications.
The main strategy for this is secondary prophylaxis.

4. What is secondary prophylaxis?
So what is secondary prophylaxis?
It’s the administration of antibiotic to prevent further GAS infection and, it’s given over an extended period of time for a minimum ten years.
SP clinically effective and cost-effective, which is why it forms the basis of RHD control programmes around the world, including those in Australia.

5. Antibiotic regimes Australian Guideline 2012
The gold standard regimen is: IM Benzathine Penicillin G injection. It’s given every days continuously for a minimum 10 years. Can I just say that this is Not Cilicaine or Benzyl penicillin.
If you find yourself drawing up Penicillin then you are giving the wrong type of Penicillin.
Oral penicillan can be given but is much less effective in preventing GAS infections and subsequent recurrence of RF and tight adherence to the medication is crucial.
For patients who are allergic to pencillin, Erythromicin (a non-beta-lactam antimicrobial) should be used instead of BPG.
In Pregnant patients BPG should continue to prevent RF recurrence and there is no evidence of birth defects as a result of BPG. Erythromicin is also considered safe.
Australian Guideline 2012

6. How does secondary prophylaxis with penicillin work?
Reduces the risk of infection with Group A Strep
Reduces the chance of an RF recurrence
Reduces chance of progression to RHD, or worsening of existing RHD
Helps prevent hospitalisation and death from RHD

7. BPG / Bicillin Benefits Challenges Short term: Long term:
Reduces risk of GAS infection and therefore ARF
Long term:
Reduces the risk of progression to serious cardiac disease, potential need for valve surgery and warfarin, high risk pregnancy and further risks (stroke, endocarditis, premature death)
Challenges
Long term commitment
Complications from IMI especially if needle administered poorly
e.g. haematoma, abscess, myositis
Potential for adverse penicillin reaction
Potential for other organisms to become penicillin resistant
Absolutely no doubt that pros outweigh cons, but need to acknowledge the cons, and make sure that patients know you appreciate how challenging it is for them to adhere long term treatment.

8. Concentration of penicillin in bloodstream over time, after a single injection
days
penicillin concentration in blood
Potential risk of acquiring
new strep infection when
penicillin levels are low
Definite risk of acquiring
new strep infection if
next dose not given on
time
This slide shows the penicillin concentration in the bloodstream after a single injection and how it slowly wanes over time.

9. Breakthrough ARF
Uncommon, but rare breakthroughs do occur despite regular injections
May be because needle was several days late
May be because their penicillin levels were not high enough and they had heavy exposure to group A Strep
These individuals are usually then prescribed 3-weekly injections, and need extra emphasis/education on primary measures.

10. Who needs it and for how long?

11. Duration of secondary prophylaxis
ARF or mild RHD only
For 10 years after last RF or until age 21 years (whichever is longer)
Moderate RHD
For 10 years after last RF or until age 35 years (whichever is longer)
Severe RHD
Until age 40 or longer
After heart valve surgery

12. Secondary prophylaxis
Must be continuous to protect the heart.
After day 28 the patient is “at risk” of ARF
It’s always better to give it early than late, can give from 21 days
Give Bicillin opportunistically, in hospital and at the clinic.

13. Dosing schedule Start recalling patient for next dose to be given
on or before day 28
Next dose can be given
on any of these days

14. Strategies to improve secondary prophylaxis
Later this afternoon there is a session on secondary prophylaxis and the patients experience.

15. Factors affecting adherence with secondary prophylaxis
Relationship with health service
Feeling valued
Family support
Pain of injection and long wait times
Access to culturally competent health services and educated staff members
Belief that the disease is chronic and serious and that treatment works

16. Strategies to reduce pain
Build respectful relationships with your patients – ask what helps?
Warm syringe to body temperature immediately before using
Allow alcohol from swab to dry before inserting needle
Apply firm pressure with thumb for 10 seconds before inserting needle
Deliver injection very slowly deep IM (preferably over minutes)
Utilise the knowledge and experience of dedicated local staff members and Aboriginal health workers to deliver the injections.
Focus on improving relationships

18. Model SDO for benzathine benzylpenicillin

19. Using the RHD Register to assist with
secondary prophylaxis

20. Using the RHD Register to support PHC

21. Using the RHD Register to support PHC
Three monthy prophylaxis reports are sent out to the various PHC.

22. Take Key messages After 28 days your patient is “at risk”!!!!
Every needle is an important opportunity to prevent ARF recurrence and progression of RHD.
Health staff are our greatest resource to improve secondary prophylaxis adherence.

23. For more information
About ARF/RHD (for health professionals and patients/families)
RHD Australia Training modules
SA RHD Program
Phone:
SA Health