1. Diagnosis and Management of Rheumatic Heart Disease
Acute Rheumatic Fever
and
Rheumatic Heart Disease

2. This presentation is intended to support the Curriculum for training health workers and others involved in the diagnosis and management of acute rheumatic fever and rheumatic heart disease.
It has been made possible thanks to the support of the Vodafone Group Foundation and the International Solidarity, State of Geneva, and the ongoing support of Menzies School of Health Research, Caritas Australia, Fiji Water Foundation, Cure Kids and Accor Hospitality.

3. Introduction Acute Rheumatic Fever and Rheumatic Heart Disease

4. Introduction
Rheumatic Heart Disease is the most common cause of heart disease in children and young adults
Approximately 15.6 million people affected worldwide
Almost 500,000 new cases each year
Approx 350,000 deaths each year
Most disease occurs in developing countries.
Rheumatic Heart Disease is a disease of poverty
Rheumatic Heart Disease can be prevented.

5. Definitions Group A beta-haemolytic streptococci (GAS)
Humans are exposed to GAS in the environment
Throat and skin are common sites of GAS infection
GAS infections usually resolve without treatment
Untreated GAS infections can lead to acute rheumatic fever in some people.

6. Definitions Acute Rheumatic Fever (ARF) Rheumatic Heart Disease (RHD)
A delayed auto-immune response following untreated GAS infection
Develops after the GAS infection has resolved
Commonly affects the joints, heart, central nervous system and skin
Most common between the ages of 5 and 15 years
Can recur following further untreated GAS infections
Rheumatic Heart Disease (RHD)
Residual damage to heart valves following recurrent ARF
Valves become scarred, stiff, thickened
Blood leaks (blood flows backwards through valves which do not close properly)
Blood is blocked (blood can not flow through valves which do not open properly)

7. Risk Factors Risk factors ARF include Risk factor for RHD Prevention
Poverty
Poor housing, overcrowded housing
Lack of adequate health care
Untreated GAS infections
Risk factor for RHD
Recurrent ARF
Prevention
The first episode of ARF can be prevented by treating GAS infections with penicillin (primary prophylaxis)
If the first ARF episode is not prevented, recurrent ARF can be prevented with long-term penicillin (secondary prophylaxis)

8. Disease Progression

9. Control of Disease
ARF and RHD can be prevented by sustainable control strategies including
Trained health staff who diagnose and management disease effectively
Secondary prophylaxis to prevent further ARF and the development or worsening of RHD.
Community education and awareness
Screening for unknown RHD in the community.
Control strategies should focus on
Prompt identification and treatment of GAS infections
Identifying people who have had ARF once and preventing further ARF and the development of RHD.

10. Acute Rheumatic Fever Diagnosis and Management

11. Revised Jones Criteria
ARF can be confirmed if certain signs and symptoms are present.
The Revised Jones Criteria (below) can help guide the diagnosis.
MAJOR Manifestations
MINOR Manifestations
GAS Infection
Carditis
Fever
GAS on Throat swab (Culture)
Arthritis
Arthralgia
Anti-streptolysin O titre (ASOT)
Sydenham’s Chorea
↑ PR interval on ECG
Anti-deoxyribonuclease B (Anti-DNase B)
Erythema marginatum
ESR ≥30mm/hr or CRP ≥30mg/L
Subcutaneous nodules
MAJOR Criteria - signs and symptoms more often associated with ARF
MINOR Criteria - signs and symptoms that help support the diagnosis
Evidence of recent GAS Infection is required

12. Revised Jones Criteria
The World Health Organisation set the international standard for diagnosis of ARF.
First episode or recurrent episode of ARF (no RHD):
2 MAJOR manifestations or 1 MAJOR and 2 MINOR manifestations and
Evidence of preceding Group A streptococcal infection … (within 3 weeks before ARF symptoms)
ARF (with existing RHD):
2 MINOR manifestations and
** Individual country guidelines also exist **

13. Signs and Symptoms MAJOR Manifestations Arthritis Carditis
Painful, swollen joints (usually knees, ankles, wrists, elbows)
Very common with ARF, often the first symptom
Usually ‘migratory’- disappears from one joint as it starts in another (poly-arthritis), however may just be present in one joint (mono-arthritis).
Carditis
May present as a heart ‘murmur’
Chest pain and/or difficulty breathing may be present in more severe cases

14. Signs and Symptoms Sydenham’s chorea
Twitchy, jerking movements and muscle weakness (most obvious in the face, hands and feet)
May occur on both sides or only one side of body
More common in teenagers and females (rare after age 20)
May be associated with irritability and or depression
May begin up to 3-4 months after the streptococcal throat infection, and often occurs without other symptoms
Usually resolves within 6 weeks (may last 6 months or more)
May recur in females during pregnancy

15. Signs and Symptoms Subcutaneous nodules Erythema marginatum
Painless lumps on the outside surfaces of elbows, wrists, knees, ankles in groups of 3-4 (up to 12)
The skin is not red or inflamed
Last 1-2 weeks (rarely more than 1 month)
Nodules are more common when Carditis is also present.
Erythema marginatum
Painless, flat pink patches on the skin that spread outward in a circular pattern
Usually occurs early, may last months, rarely lasts years
Usually on the back or front of body, almost never on the face
Hard to see in dark-skinned people.

16. Signs and Symptoms MINOR Manifestations Fever Arthralgia
Occurs in the majority of cases, usually with the onset of symptoms
Usually ranging from 38.4 – 40.0º C ( º F)
Arthralgia
Usually involves large joints
May be mild or severe
Group A streptococcal infection
Group A beta-haemolytic streptococci may not be seen on a throat swab since the infection may be resolved at the time of onset of ARF symptoms.
ASOT – serum reaches a peak level around 3-6 weeks after infection and starts to fall at 6-8 weeks
Anti DNase B – reaches a peak level up to 6-8 weeks after infection and starts to fall at around 3 months after the infection.
** Normal antibody titre ranges vary with age and geography **

17. Difficulties with ARF Diagnosis
A combination of signs and symptoms is required to confirm ARF
People with ARF do not always present to the health system with symptoms because
Symptoms may not be considered serious
Transport to the health facility may be difficult
Health staff may not recognise the signs and symptoms of ARF
ARF may be confused with other illnesses, for example
Sore joints may be confused with a sports injury or ‘growing pains’

18. Treatment for ARF Treat the acute illness Relieve symptoms
Benzathine penicillin G injection or
Oral Penicillin for 10 days
Relieve symptoms
Bed rest
Relief of arthritis, pain and fever (Paracetamol or Aspirin)
Treat chorea (use Carbamazepine or Valproic acid if severe)
Anti-heart failure medication (e.g. Diuretics, ACEi, Digoxin if required)

19. ARF Management Plan
First dose of Benzathine penicillin G (start secondary prophylaxis)
Baseline echocardiogram (if available)
ARF alert on medical notes & computer systems (if applicable)
Education for person and family
Refer to local doctor / health facility
Dental examination
Long-term secondary prophylaxis plan

20. Management of Probable ARF
Treat the symptoms }
Dose of Benzathine penicillin G } as for ARF
Echocardiogram (if available) }
Medical officer review after one month, and
Repeat echocardiogram (if available)
If NOT ARF…cease Benzathine but monitor for ARF symptoms
If ARF… continue Benzathine and manage as for ARF

21. Summary
The Jones Criteria is used to guide the diagnosis of ARF with a combination of MAJOR Manifestations, MINOR Manifestations and evidence of recent GAS Infection
A long-term Management Plan should be established to prevent recurrence of ARF and development or worsening of RHD
Probable ARF cases should also be monitored

22. Secondary Prophylaxis to prevent recurrent ARF

23. Secondary Prophylaxis
Secondary prophylaxis is the terms used to describe regular delivery of antibiotics to prevent recurrence of GAS infection and subsequent development of ARF.
Secondary prophylaxis is recommended for people who have had ARF, or who have RHD to
Prevent further Group A Streptococcal infections
Prevent recurrence ARF
Prevent the development or worsening of RHD
Reduce the severity of RHD
Help reduce the risk of death from severe RHD.

24. Standard Treatment Benzathine penicillin G Penicillin V Erythromycin
1,200,000 units for ALL people ≥30kg
600,000 units for children <30kg
Every 3 or 4 weeks (by intramuscular injection)
Penicillin V
Given if needles cannot be given due to excessive bleeding
250mg twice daily (by mouth)
Erythromycin
Given if Penicillin allergy has been confirmed by a Medical Officer

25. Continue secondary prophylaxis during pregnancy
Considerations
When should secondary prophylaxis be considered?
ARF confirmed by the Revised Jones Criteria
RHD confirmed on echocardiogram
ARF or RHD not confirmed by the Revised Jones Criteria, but considered highly ‘probable’
Precautions
Do not give Benzathine Penicillin G or Penicillin V if there is a documented Penicillin allergy
Drug reactions are rare
Continue secondary prophylaxis during pregnancy
Continue secondary prophylaxis during anticoagulation (e.g. with Warfarin)

26. Guidelines for Secondary Prophylaxis
Length of time for secondary prophylaxis depends on a number of factors including
Age at first diagnosis of ARF (or RHD)
Severity of disease
If carditis was present with first ARF
Time (years) since last ARF illness
Ongoing risk factors (e.g. level of poverty)
If medication is received regularly
World Health Organisation guidelines for secondary prophylaxis duration:
Disease Classification
Duration of secondary prophylaxis
ARF
(no carditis)
Minimum of 5 years after last ARF, or
Until age 18 years (whichever is longer)
Mild-moderate RHD
(or healed carditis)
Minimum of 10 years after last ARF, or
Until age 25 years (whichever is longer)
Severe RHD
and after Surgery
Continue for life
** Secondary prophylaxis guidelines may vary **

27. Ceasing Secondary Prophylaxis
Secondary Prophylaxis should only be ceased following:
No ARF signs/symptoms for at least 5 years,
and
Medical Specialist review (Paediatrician / Physician / Cardiologist)
Echocardiogram to establish presence & severity of RHD (if available)

28. Benzathine Penicillin injection delivery
Assessment and Preparation
Confirm person’s identity
Review known drug allergies
Discuss and record any recent ARF or RHD symptoms (refer to medical officer if required)
Obtain consent for injection

29. Benzathine Penicillin injection delivery
Check medication name, dose and expiry date
Prepare medication according to the product information
Administer 1,200,000 units for all persons ≥ 30kg
Administer 600,000 units for small children <30kg
Administer with a size 23-gauge needle
Dispose of used needles and syringes in a puncture-proof container.
Use a new needle and syringe for each injection
Administer medication immediately after preparation

30. Documentation
Record in the Benzathine penicillin injection book and/or medical notes
Dose and batch number
Date given and date next due
Signature (of person giving injection)
Record next date due on a reminder card (if applicable)

31. Calculating Injection Delivery
Record the number of injections PRESCRIBED for the full year
13 injections should be given each year if prescribed every 4 weeks
17 injections should be given each year if prescribed every 3 weeks
Count the number of injections GIVEN in the full year
3. Calculate the number of injections GIVEN (10) divided by the number PRESCRIBED (13) and multiply by 100.
EXAMPLE: If 13 injections are PRESCRIBED, and 10 were GIVEN:
(10 ÷ 13) x 100 = 77% RECEIVED
In this example, 77% of injections were RECEIVED for the individual for the year.

32. Notes on Injection Delivery
Receiving less than 80% of injections places an individual at higher risk of recurrent ARF
Follow-up may be required
If injections were PRESCRIBED for the full year but none were GIVEN, record 0%.
Receiving less than 50% of injections places an individual at extreme risk of recurrent ARF and progression of RHD
Immediate intervention is required for this individual.

33. Factors affecting Injection Delivery
Relationship between the person with ARF/RHD & the health system
Education of the person, family & health workers
Person / family refusing treatment
Person forgetting treatment
Difficulty traveling to health facility
Pain and fear of injections
Health staff workloads and priorities
Alternative therapy use / distrust of health service

34. Strategies to improve Injection Delivery
Appoint a dedicated staff member at each clinic to oversee secondary prophylaxis coordination
Identify people who need secondary prophylaxis
Identify local health facility for each person
Develop systems for follow-up
Provide ongoing education for people who require injections and their families
Communicate with local RHD programme and other health service providers
Reduce injection pain
Discuss alternative therapy issues

35. Penicillin Allergy Symptoms Treatment
Skin rash
Itchy eyes
Treatment
Antihistamine (oral or injection)

36. Anaphylaxis Symptoms Treatment Adrenaline (subcutaneous injection)
Wheezing
Hives
Itching
Swelling of the face and lips
Difficulty breathing
Vomiting
Falling Blood pressure
Loss of consciousness
Cardiac arrest
Treatment
Adrenaline (subcutaneous injection)

37. Summary
Antibiotics need to be present in the body at all times to help prevent GAS infections and prevent recurrent ARF
Benzathine penicillin injections should be given unless there are contraindications to injections or documented penicillin allergy
Medical Specialist review is required before ceasing secondary prophylaxis
Strategies to improve secondary prophylaxis delivery:
Good relationships between community and health staff
Education for the community and health staff
Systems for follow-up
Communication between health services
Reduce injection pain
Document Benzathine Penicillin injections and monitor injection delivery

38. Rheumatic Heart Disease Diagnosis and Management

39. 50% of people with RHD do not remember having ARF
Introduction
Rheumatic heart disease is the result of damage to the heart valves which occur after repeated episodes of ARF
Early diagnosis and treatment of RHD are important to prevent progression of disease
Signs and symptoms may not develop for many years
The aim of RHD management is to prevent or delay heart valve surgery
RHD can be prevented if ARF is diagnosed and managed early.
50% of people with RHD do not remember having ARF

40. Definitions Valve Regurgitation suggests that heart valves
Are thickened and sticky against the walls of the heart
Do not meet in the middle
Leak (the blood flows backwards over the valve)
Valve Stenosis suggests that heart valves
Become stuck to each other
Do not allow blood to flow through easily (restricted forward flow)

41. Signs and Symptoms of RHD
Symptoms of RHD may not develop for many years
A murmur but no symptoms usually suggests mild-moderate disease
Symptoms usually suggest moderate-severe disease
Symptoms depend upon the type and severity of disease, and may include
Breathlessness with exertion or when lying down flat
Waking at night feeling breathless
Feeling tired
General weakness
Peripheral oedema

42. Heart valve involvement
Mitral valve is affected in over 90% of cases of RHD
Mitral regurgitation most commonly found in children & adolescents
Mitral stenosis represents longer term chronic disease, commonly in adults
Most common complication of mitral stenosis is atrial fibrillation
Aortic valve next most commonly affected
Generally associated with disease of the mitral valve.
Tends to develop as a long term complication of aortic regurgitation
Tricuspid and pulmonary valves are much less commonly affected
Usually affected in very severe RHD when all valves are affected

43. Clinical Examination Mitral regurgitation Mitral stenosis
A pansystolic murmur heard loudest at the apex and radiating laterally to the axilla
Mitral stenosis
A low-pitched, diastolic rumble heard best at the apex with the bell of the stethoscope and with the person lying in the left lateral position.
Aortic regurgitation
A diastolic blowing decrescendo murmur best heard at the left sternal border with the person sitting up and leaning forward in full expiration.
Aortic stenosis
A loud, low pitched mid-systolic ejection murmur best heard in the aortic area, radiating to the neck.

44. Investigations Electrocardiogram (ECG) Chest X-ray (CXR)
To determine sinus rhythm
Chest X-ray (CXR)
To determine size and placement of heart
To identify cardiac failure (pulmonary congestion)
Echocardiography
To identify heart valve damage
To estimate severity of disease
Useful to compare results with future echocardiogram results

45. Key element in RHD Management
Secondary prophylaxis
Functions of secondary prophylaxis with established RHD
Prevent Group A Streptococcal infections
Prevent the repeated development of ARF
Prevent the development of RHD
Reduce the severity of RHD
Help reduce the risk of death from severe RHD.

46. Elements in RHD Management
Effective baseline assessment, education and referral
Initial management
heart failure (treatment with diuretics and ACEi)
atrial fibrillation (Digoxin and anti-coagulation)
Routine review and structured care planning
Regular secondary prophylaxis
Regular clinical assessment and follow-up echocardiography (if available)
Dental care and Infective endocarditis prophylaxis plan
Family planning referral (for women)
Vaccination (if available)
Appropriate surgical intervention
Special consideration in particular circumstances (e.g. pregnancy)

47. RHD and Pregnancy
The cardiovascular changes which occur during pregnancy may threaten the health of the woman and the foetus. Changes include
increased heart rate and blood volume
reduction in systemic and pulmonary resistance
increased cardiac output.
RHD may be identified for the first time during pregnancy.
Highest risk of complications immediately after delivery

48. Management of RHD in Pregnancy
Management generally includes
restricting physical activity and salt intake
administering secondary prophylaxis (Benzathine penicillin can be continued during pregnancy)
avoiding community-acquired infectious diseases
education about monitoring own signs and symptoms and seeking care if shortness of breath
close monitoring of heart function (specifically in woman who have symptoms of RHD).
Special attention should be given to women with high risk RHD including women with
mitral and/or aortic stenosis
atrial fibrillation
prosthetic heart valves
those receiving anticoagulant therapy with warfarin.

49. Infective Endocarditis
Infective Endocarditis is a serious complication of RHD
Endocarditis is caused by bacteria in the bloodstream.
In RHD, endocarditis most commonly occurs in the mitral or aortic valves
Uncommonly occurs during dental or surgical procedures but often the source of the infection is not clear
May occur after heart valve surgery
Antibiotics prior to dental and surgical procedures are given to help prevent endocarditis.
All people with ARF and RHD should have regular dental care to prevent
dental decay and the potential risk of endocarditis.

50. Procedures that increase risk of Endocarditis
DENTAL PROCEDURES
OTHER PROCEDURES
Dental extractions
Tonsillectomy/adenoidectomy
Periodontal procedures
Bronchoscopy with a rigid bronchoscope
Dental implant placement
Surgery involving the bronchial mucosa
Gingival surgery
Sclerotherapy of oesophageal varices
Initial placement of orthodontic appliances
Dilatation of oesophageal stricture
Surgical drainage of dental abscess
Surgery of the intestinal mucosa or biliary tract
Maxillary or mandibular osteotomies
Endoscopic retrograde cholangiography
Surgical repair or fixation of a fractured jaw
Prostate surgery
Endodontic surgery and instrumentation
Cystoscopy and urethral dilatation
Intra-ligamentary local anaesthetic injections
Vaginal delivery in the presence of infection, prolonged labour or prolonged rupture of membranes
Dental cleaning where bleeding is expected
Surgical procedures of the genitourinary tract in the presence of infection
Placement of orthodontic bands

51. Surgery for RHD The need for surgery depends on
Severity of symptoms
Evidence that the heart valves are severely damaged
Left ventricular chamber size and function
Availability of long-term management after surgery (i.e. anticoagulation)
Heart valves can be repaired or replaced
Assessment before surgery includes
Echocardiogram to assess severity of heart valve damage
Complete dental assessment and treatment (if required)
Review and management of other health problems (e.g. kidney, vascular and chronic respiratory disease, cancers and obesity)

52. RHD Surgery Outcomes Heart valve REPLACEMENT Heart valve REPAIR
Anticoagulation required
Longer time before re-operation
No Anticoagulation
Shorter time before re-operation
RHD

53. Guidelines for managing Mild RHD
Definition - RHD with any trivial to mild valve lesion.
Secondary Prophylaxis
Long-term prevention of recurrent ARF
Primary care management
By local Medical Officer
Specialist medical review for children aged to 18 years
Every 12 months
Earlier if clinical deterioration
Echocardiogram (if available)
Every 2 years for children
Every 5 years for adults
Specialist medical review
Before ceasing secondary prophylaxis
Dental review following diagnosis
With appropriate endocarditis prevention

54. Guidelines for managing Moderate RHD
Definition - Any moderate valve lesion, no symptoms, and normal LV function with stable metallic prosthetic valves, or children (to 18 years old) with a history of chorea including those with no valve damage
Secondary Prophylaxis
Long-term prevention of recurrent ARF
Primary care management
By local Medical Officer
Specialist medical review
Every 12 months
Earlier if clinical deterioration
Echocardiogram (if available)
Every 1 years for children
Every 2 years for adults
Before ceasing secondary prophylaxis
Dental review following diagnosis
With appropriate endocarditis prevention

55. Guidelines for managing Severe RHD
Definition - Any moderate-severe valve lesion with shortness of breath, tiredness, oedema, angina or syncope and impaired or increased left ventricular function or a history of valve surgery including mitral valvotomy, any valve repair and bio-prosthetic valves (porcine and homograph)
Secondary Prophylaxis
Long-term prevention of recurrent ARF
Primary care management
By local Medical Officer
Specialist medical review
Every 6 months
Refer to Heart Specialist
Management Plan

56. Summary RHD presents as damage to the heart valves
The mitral valve is most commonly affected, followed by Aortic, Pulmonary and Tricuspid
RHD can be mild, moderate or severe
RHD may be asymptomatic
Management of RHD includes
Treatment of cardiac and other symptoms
Long-term secondary prophylaxis (to prevent recurrent ARF)
Regular medical and cardiology review
Management of existing pregnancy
Dental assessment, family planning referral

57. Notification of ARF & RHD
and Data Management

58. Elements of a Disease Register
A disease register is a list of people who have a common illness or disease.
For example:
Tuberculosis register
HIV/AIDS register
Vaccine-preventable diseases register (measles, rubella)
Acute Rheumatic Fever & Rheumatic Heart Disease
A disease register should be secure so that the information is not lost or damaged
A disease register can be a computer database or a paper list

59. Paper Register – Book or List
Paper registers may contain information for a local health facility, or may provide information to a larger, central computer register.
Possible Problems
Books may get lost or damaged (not safe)
The same people may be included more than once (duplicates)
Long lists be difficult to read and analyse
Important information may be missing
Benefits
No specialised training required
Books and lists can be transported easily
External support is not required (e.g. electricity as for computers)

60. Computer Register – Database
A computer registers is called a database. A database is able to record specific information for many people.
Possible Problems
Computers and connections usually cost money
Specialised training and support are usually required
Electricity and other interruptions cause barriers to use
The information may not be easily transportable
Benefits
The information can be secured (safe)
Duplicate entries can be avoided
Information can be searched, sorted and updated quickly
Reports can be produced automatically

61. Information on the Register
Information to identify each person (clinic or hospital number)
Personal information (name, date of birth, gender, contact details)
Current disease status (ARF only, or mild, moderate, severe RHD)
Diagnoses, date of diagnoses
How the diagnosis was made (hospital admission, screening programme)
Secondary prophylaxis details (medication, amount received each year)
Surgery details
Dates for next medical review (or for heart valve surgery)
Date and cause of death.

62. Notification of ARF and RHD
All people who have confirmed and suspected ARF and RHD should be notified to the RHD register so that health authorities can undertake the following:
Identify high risk individuals who require priority care
Coordinate secondary prophylaxis and follow-up programmes
Help identify others who may be at risk
Provide information on the local rates of disease

63. Sources of Information
The following sources may contain information on individuals for the RHD Register
Benzathine Penicillin injection books
Echocardiogram reports
Heart valve surgery lists
Notes from Medical Specialists, Heart Specialists, dentists and researchers
Hospital admission and discharge records (e.g. ICD-9 or ICD-10 coding)
School and community screening referrals

64. Reports from the Register
Lists of individuals needing urgent care
Lists of people receiving inadequate levels of secondary prophylaxis
Delivery of Benzathine penicillin injections (for each full year on treatment)
Specialist clinic lists
Echocardiogram and Surgery waiting lists
People who are deceased and cause of death
Rates of disease for the region or country

65. Summary A Disease Register can be on paper or computer
The information should be confidential and secure
The information on the register should
Help coordinate health care for individuals
Help describe the level of disease in the community
All confirmed and suspected cases of ARF and RHD should be notified to the register
Sources of information for the register may include
Benzathine penicillin injection books
Echocardiogram reports and surgery lists
Hospital admission books and computer systems
School screening referrals

66. RHD Control Programmes

67. WHO recommendations for RHD Control
A strong commitment from local Government
A committed and skilled RHD Advisory Group
An RHD Register of all people with confirmed and suspected ARF and RHD
A well-trained programme coordinator
Notification of ARF and RHD to the relevant health authority
Well-coordinated secondary prevention activities
A priority system to help deliver care to individuals at highest risk
Reliable resources including medications and laboratory support
Programmes established centrally and expanded regionally

68. Core Programme Objectives
Identify and register individuals with ARF and RHD
Standardise and improve delivery of secondary prophylaxis
Standardise diagnosis and management of ARF and RHD
Provide training and support for health workers
Provide support to the community
Report on the programme and rates of disease

69. Objective 1 - Identify & Register cases
Collect information on known cases of ARF & RHD
Benzathine Penicillin injection books and clinic records
Echocardiogram reports and cardiac surgery lists
Hospital admission & death reports
Identify new cases
Health centres or hospital when individuals present with ARF or RHD
School health (screening) programmes
Antenatal Clinics
Maintain a paper or computer register of all people with confirmed or suspected ARF & RHD

70. Objective 2 - Optimise Secondary Prophylaxis
Establish secondary prophylaxis delivery
Identify people who need secondary prophylaxis
Identify health facilities where individuals receive secondary prophylaxis
Improve secondary prophylaxis – identify specific barriers to treatment
Identify people who do not receive adequate Benzathine penicillin injections (>80% injections)
Establish recall and reminder systems
Support communication between health facilities
Refer new cases to peripheral health facilities for ongoing management
Identify people who move between health centres for treatment

71. Objective 3 – Training and Support for Health Workers
Standardise guidelines for diagnosis and management of ARF and RHD
Revised Jones Criteria for diagnosis of ARF
Standardise dosing and delivery of secondary prophylaxis
Train health workers
Curriculum development
Training programmes for students and trained staff
Updates for staff in rural and remote areas
Communicate
Referral of new cases to local community health facilities
Update staff about on local ARF/ RHD issues
Report on RHD in the community

72. Objective 4 – Community Support
Educate and Inform
Targeted education for people with ARF and RHD
Community education materials (posters & brochures)
Manage individuals with ARF & RHD
Promote ongoing medical care / echocardiogram / pregnancy counseling / dental care
Prioritise treatment for severe cases
Cardiac assessment
Surgery and support

73. Objective 5 – Screening for RHD
Screening may be undertaken when acute cases are identified and managed, and when time and resources become available.
Considerations for screening
Who to screened (e.g. school children are easier / RHD may be more common in adults)
Methods of diagnosis available (e.g. auscultation & clinical assessment, echocardiogram)
Availability of trained staff
Processes for reporting RHD cases to the RHD programme
Health resources available for long-term management of more RHD cases.

74. RHD Programme Difficulties
Lack of local resources (including dedicated staff)
Limited funds and other resources
Heavy workloads for primary care health staff
Priority of other health issues (e.g. TB, Malaria, HIV/AIDS, respiratory disease)
The RHD programme is complex
Difficulties around communication with remote health facilities
Limited travel to provide training & education
Demanding data management
Programme expanded too quickly

75. Summary An RHD Programme should have Local (Government) commitment
A manageable RHD Register
Well-trained, dedicated staff at all levels
Systems to identify known cases and refer of new cases
A priority system for severe cases
Secondary Prophylaxis monitoring and improvement
Ongoing support for health staff and the community.