Rheumatic Heart Disease
The Western Cape Government Health believes that primary prevention is key to maintaining good health. In creating awareness about specific health conditions and how to prevent them, the WCGH will contribute significantly to the wellbeing and health of the citizens of the Western Cape.
The focus this month is on Rheumatic Heart Disease (RHD), which is a preventable disease using simple, proven and inexpensive antibiotics. The primary prevention consists of treating sore throat in a timely and effective manner. Early diagnosis and appropriate treatment with antibiotics provide an opportunity for prevention, yet RHD (and this is where the Department’s concern stems from) continues to affect and kill millions of children, adolescents and young adults in the developing world.
RHD accounts for the greatest cardiovascular related loss of disability-adjusted life years among 10-14-year-olds and continues to represent a major public health challenge in sub-Saharan Africa.
Acute rheumatic fever (ARF) is a serious illness which occurs mainly in children between the ages of 5 and 15 and results in Rheumatic Heart Disease (RHD) in up to 3% of untreated cases. Rheumatic fever is an inflammatory disease that follows a strep infection. It can affect many tissues, especially the heart, joints, skin, or brain. The infection may cause heart damage, particularly scarring of the heart valves. This forces the heart to work harder than usual to pump blood. The damage may resolve itself, or it may be permanent, eventually causing heart failure. Heart-related complications of rheumatic fever may develop months or even years after the initial strep infection.
In SA and many developing countries, RHD is the leading cause of acquired heart disease in children and young adults. Together, ARF & RHD affect about 33 million people worldwide, 2.4 million of whom are children between five and fourteen years old. ARF is an illness which thrives in poverty-stricken and developing countries especially in overcrowded, low-income areas, where housing conditions, nutrition, sanitation and health services are inadequate. After attacks of untreated ARF, chronic heart valve damage (RHD) may develop. This results in heart failure, atrial fibrillation and stroke and often, open-heart surgery is necessary to repair or replace heart valves.
The Department wishes to reiterate that prevention is always better than cure. Thus all citizens need to take responsibility for their health and the health of their children and assist to create awareness about diseases like RHD and others. Treatment is available and effective when it can be administered timeously, so if enough parents know about this disease, more children can be brought to the clinics and treated.
What are the causes?
Rheumatic fever is the consequence of an earlier infection of the throat by a specific organism, streptococcus which has been left untreated. ARF generally manifests around 3-6 weeks following the strep infection, which occurs mostly in children ages 3-15 years. Current estimates show that approximately 18% of all throat infections are caused by strep. This infection is infectious, and is especially prevalent in areas of poverty given overcrowding, etc. Given the lack of access to care, many patients are thus not given penicillin and it is in a percentage of these persons that RF occurs.
What are the symptoms of rheumatic fever?
The symptoms of rheumatic fever usually start about 1 to 5 weeks after your child has been infected with the Streptococcus bacteria. The following are the most common symptoms of rheumatic fever. However, each child may experience symptoms differently. Symptoms may include:
- Joint inflammation. This includes swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.
- Small nodules or hard, round bumps under the skin
- A change in your child's muscle control and movements. This is usually noted by a change in your child's handwriting and may also include unusual, jerky movements. May also have inappropriate behaviour associated with this.
- A pink rash with large, round, circular edges may be seen on the trunk of the body or arms and legs. The rash may come and go. It is often described as "snake-like" in appearance.
- Weight loss
- Chest pain or heart palpitations
- Shortness of breath
- Stomach pains
The symptoms of rheumatic fever may look like other conditions or medical problems. Always consult your child's health care provider for a diagnosis.
How can it be prevented?
Antibiotics can prevent streptococcal infection from developing into Rheumatic fever. Any child with a persistent sore throat should have a throat culture to check for strep infection. Penicillin or another antibiotic will usually prevent strep throat from developing into rheumatic fever.
Primary prevention is treating the first episode of strep throat with penicillin. This can be done if there is awareness of the connection between sore throat and heart disease. The Western Cape Department of Health believes that there isn’t enough awareness amongst parents, caregivers and families and by creating that awareness (connecting the dots) about the disease will contribute to more people taking their children to the clinic for the appropriate treatment.
Secondary prevention is ongoing treatment with monthly penicillin injections in those already diagnosed with ARF and RHD. In a recent study conducted in South Africa and 13 other developing countries, it was clear that the levels of secondary prevention were also sub-optimal.
Treatment is symptomatic in both ARF and RHD and there is no cure for the disease once it is established. Penicillin is the only ameliorating factor. These include heart failure medicines for those in heart failure, anti-coagulants for those in an abnormal rhythm or having had a stroke and surgery in those needing intervention.
If heart damage from rheumatic fever is identified in childhood or young adulthood, daily antibiotics may be required until the age of 25 or 30, to help prevent recurrence of rheumatic fever and avoid the development of infective bacterial endocartisis, an infection of the heart valves or lining of the heart. Additional treatment will depend on the type of heart damage.
Prevalence in the Western Cape
Prevalence in the Western Cape in school children is between 12-20 per thousand i.e. as much as 2 %.
There are specialist services available in the Western Cape at all three of the tertiary hospitals: Red Cross, Tygerberg and Groote Schuur dealing with RHD. All three hospitals are also involved in research programmes around the prevention, management and control of RHD.