1. Secondary prevention of acute rheumatic fever and
rheumatic heart disease
Dr Anna Ralph
Clinical Researcher, Menzies School of Health Research
Infectious Diseases Specialist, Royal Darwin Hospital

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. What is secondary prophylaxis?

4. Tertiary Secondary Primary Primordial
Prevention of further ARF episodes
in people who have already had ARF &/or have already developed RHD
using an antibiotic to prevent streptococcal infection
for minimum of 10 years
Tertiary
Management of existing RHD
Secondary
Prevent ARF recurrences after 1st episode
Primary
Treat GAS infection
Primordial
Target the socio-ecomonic determinants

5. What is secondary prophylaxis?
Standard regimen: benzathine penicillin G (BPG; Bicillin) injections every 28 days, for a minimum of 10 years
For people with penicillin allergy
Clarify whether allergy truly present: only 10%-20% of patients reporting a history of penicillin allergy are truly allergic when assessed by skin testing
For true allergy, use oral erythromycin 250mg bd
Successful secondary prevention requires the support of a register-based program working within a well-functioning primary health system

6. Antibiotic regimens Agent Dose Route Frequency First line
Benzathine penicillin G (BPG / LAB / ‘Bicillin’)
900 mg (>20kgs)
=1,200,000 units
450 mg (<20kgs)
= 600,000 units
Deep IM injection
4 weekly
(or 3 weekly for selected individuals)
Second line – only in exceptional circumstances; much less effective than 1st line
Phenoxymethylpenicillin (Penicillin V)
250 mg
oral
Twice daily
Following documented penicillin allergy
Erythromycin
Oral
Australian Guideline 2012

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

8. Benefits Challenges Short term: Long term: Very onerous
Reduces risk of getting ARF, which can cause very painful, temporarily disabling arthritis, or chorea, which can be awkward and embarrassing
Long term:
Reduces the risk of progression to serious cardiac disease, potential need for valve surgery and warfarin, and further risks (stroke, endocarditis, premature death)
Challenges
Very onerous
monthly clinic contact for a painful needle- hard to commit to being in the right place, or having access to health care, every 28 days (what about school excursions, family holidays, going out bush, unexpected funerals to attend?)
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 patients know you appreciate how challenging it is for them to adhere long term

9. Breakthrough ARF cases can occur despite regular bicillin
Uncommon, but rare breakthroughs do occur despite regular injections, with examples seen in NT children in 2014.
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 then prescribed 3-weekly injections, and need extra emphasis on primordial / primary measures
Currently in NT, 19 of 1371 people (1.4%) are prescribed 3-weekly injections

10. penicillin concentration in blood Potential risk of acquiring
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

11. 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

12. Who needs it and for how long?

13. Secondary prophylaxis is usually required for many years to protect against streptococcal infections.
ARF only
For 10 years after last ARF or until age 21 years (whichever is longer)
Moderate RHD
For 10 years after last ARF or until age 35 years (whichever is longer)
Severe RHD
Until age 40 or longer
After heart valve surgery

14. How is adherence measured?

15. Master chart 1. Proportion of scheduled needles received 1 2 3 4 5 6 78 9 10 11 12 13
Samuel
Tracey
Susan
Brooklyn
Daniel
Martha P

16. 2. Days at risk days Peak in ASOT Peak in antiDNAseB GAS exposure GAS
Joint/
carditis ARF
Chorea ARF
2-3 weeks
6-9 weeks
penicillin concentration
in blood
days at risk
days

17. How successful is secondary prophylaxis delivery?
Every needle given is an important opportunity to prevent ARF
Most patients struggle to achieve full adherence
On average, people get about 60% of the required injections yearly
Only 20% of people receive over 80% of their injections
Each year 30% of ARF episodes are recurrences
ANY late or missed injection leaves the window open for a recurrence
Health staff, people on the program, their families and the community need to understand the message:
“Don’t be late. Never miss a jab! ”
NT RHD Prevention Program 2011

18. Barriers to adherence: clinic factors
Lack of streamlined triaging i.e. long waiting time
Failure to provide opportunistic bicillin
Right nurse not present
Poor relationship with clinic; a need to feel nurtured by the clinic (shared responsibility)
Clinic staff may not have explained to patient that when travelling to different communities, needle can be administered by any clinic
Mixed messages from different health staff, especially new staff not familiar with ARF

19. Barriers to adherence: patient factors
Chronic diseases in childhood through adolescence to adulthood often pose major adherence challenges.
Specific to ARF in Australia:
Patient expectations of health care may differ from what is offered by traditional western medical model
The treatment is a painful needle
Patient populations may be mobile
Health literacy in affected groups may be low
Healthcare staff turnover rates are exceptionally high in remote settings, and their knowledge of ARF is often poor
Parents may be unwilling to subject their child to the treatment, especially if benefits not made clear
Patients may not wish to acknowledge the presence of a chronic disease, especially in adolescence (stigma, shame)

20. Reducing the pain of IM BPG
Use a 21 gauge needle
Warm the syringe – at least to room temperature
Use the upper outer quadrant of the buttock
Prior to inserting the needle, apply firm pressure with thumb at the injection site for 10 seconds
If using an alcohol swab, ensure the skin has dried
Give the injection slowly (over 2-3 minutes)
Provide distraction

21. What are some creative solutions primary health care staff can use to help adherence?
Your needle
is due this week 

22. Helpful strategies Health systems improvements
in high burden areas, make sure the clinic has someone who takes responsibility for RHD coordination, and that turnover at least in that position is minimised
Identify and fix the barriers
Reduce problems related to getting needles – pain, waiting time, communicating with clinics at communities where the patient travels to
Educate and support staff
Communicate with the control program and RHD Australia
Use the educational / training resources which are available
Support patients
Self-management support
Improve health knowledge in a culturally competent way

23. What is the role of the register?

24. Objectives of register-based prevention program
1. Ensure success of 2ry prophylaxis by
Providing lists of people for secondary prophylaxis
Identifying when secondary prophylaxis is not being delivered and feeding information back to clinic
2. Facilitate coordination of ongoing care by
Generating regular reports to enable recall and review
Ensuring that patients are not lost to follow-up
Facilitating health education
3. Provide epidemiological data:
To monitor ARF/RHD incidence / prevalence
For program evaluation

25. Where can you seek information?

26. Resources
RHD Australia Training modules
National Guideline and RHD Australia patient and staff educational materials

27. Take home message
Secondary prevention of ARF/RHD is complicated and expensive, but it is the most cost-effective approach until successes in primordial prevention are achieved.
Secondary prevention comprises regular painful injections over many years, mostly to asymptomatic adolescents and young adults. Many challenges.
Ongoing education of health staff and people (children, adolescents and adults) in prevention programs, their families and the wider community is critical to the success of secondary prevention.
Prevent AT RISK days. “Don’t be late. Never miss a jab!”

28. Learning objectives What is secondary prevention of ARF/RHD?
Define and understand the principles
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