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

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

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.

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.

Antibiotic regimes Australian Guideline 2012 The gold standard regimen is: IM Benzathine Penicillin G injection. It’s given every 21-28 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

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

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.

Concentration of penicillin in bloodstream over time, after a single injection 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 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.

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.

Who needs it and for how long?

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

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.

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

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

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

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 2 - 3 minutes) Utilise the knowledge and experience of dedicated local staff members and Aboriginal health workers to deliver the injections. Focus on improving relationships

Model SDO for benzathine benzylpenicillin

Using the RHD Register to assist with secondary prophylaxis

Using the RHD Register to support PHC

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

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.

For more information About ARF/RHD (for health professionals and patients/families) www.rhdaustralia.org.au www.sahealth.sa.gov.au/rhd RHD Australia Training modules http://rhdatest.docebosaas.com SA RHD Program Phone: 08 7425 7146 Email: rhd@sa.gov.au SA Health