Download Diagnosis and Management of Acute Rheumatic Fever and

Diagnosis and Management of
Acute Rheumatic Fever
and
Rheumatic Heart Disease
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
Introduction
Acute Rheumatic Fever
and Rheumatic Heart Disease
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
Definitions
Acute Rheumatic Fever (ARF)
– 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)
©2007 World Heart Federation … Updated October 2008
Risk Factors
Risk factors ARF include
– 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)
©2007 World Heart Federation … Updated October 2008
Disease Progression
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
Acute Rheumatic Fever
Diagnosis and Management
©2007 World Heart Federation … Updated October 2008
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
MINOR
GAS
Manifestations
Manifestations
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
©2007 World Heart Federation … Updated October 2008
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
– Evidence of preceding Group A streptococcal infection … (within 3 weeks before ARF symptoms)
** Individual country guidelines also exist **
©2007 World Heart Federation … Updated October 2008
Signs and Symptoms
MAJOR Manifestations
Arthritis
– 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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
Signs and Symptoms
Subcutaneous nodules
– 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.
©2007 World Heart Federation … Updated October 2008
Signs and Symptoms
MINOR Manifestations
Fever
– Occurs in the majority of cases, usually with the onset of symptoms
– Usually ranging from 38.4 – 40.0º C (101-104º 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 **
©2007 World Heart Federation … Updated October 2008
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’
©2007 World Heart Federation … Updated October 2008
Treatment for ARF
Treat the acute illness
– 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)
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
Management of Probable ARF
1.
Treat the symptoms
2.
Dose of Benzathine penicillin G
3.
Echocardiogram (if available)
}
}
as for ARF
}
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
Secondary Prophylaxis
to prevent recurrent ARF
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
Standard Treatment
Benzathine penicillin G
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
250mg twice daily (by mouth)
©2007 World Heart Federation … Updated October 2008
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)
©2007 World Heart Federation … Updated October 2008
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)
– Time (years) since last ARF illness
– Severity of disease
– Ongoing risk factors (e.g. level of poverty)
– If carditis was present with first ARF
– If medication is received regularly
World Health Organisation guidelines for secondary prophylaxis duration:
Disease Classification
ARF
Duration of secondary prophylaxis
Minimum of 5 years after last ARF, or
Until age 18 years (whichever is longer)
(no carditis)
Mild-moderate RHD
(or healed carditis)
Severe RHD
and after Surgery
Minimum of 10 years after last ARF, or
Until age 25 years (whichever is longer)
Continue for life
** Secondary prophylaxis guidelines may vary **
©2007 World Heart Federation … Updated October 2008
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)
and
Echocardiogram to establish presence & severity of RHD (if available)
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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)
©2007 World Heart Federation … Updated October 2008
Calculating Injection Delivery
1.
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
2.
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.
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
Penicillin Allergy
Symptoms
Treatment
– Skin rash
– Itchy eyes
©2007 World Heart Federation … Updated October 2008
Antihistamine (oral or injection)
Anaphylaxis
Symptoms
Treatment
– Wheezing
– Hives
– Itching
– Swelling of the face and lips
– Difficulty breathing
– Vomiting
– Falling Blood pressure
– Loss of consciousness
– Cardiac arrest
©2007 World Heart Federation … Updated October 2008
Adrenaline (subcutaneous injection)
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
©2007 World Heart Federation … Updated October 2008
Rheumatic Heart Disease
Diagnosis and Management
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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)
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
Clinical Examination
Mitral regurgitation
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.
©2007 World Heart Federation … Updated October 2008
Investigations
Electrocardiogram (ECG)
– 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
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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)
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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)
©2007 World Heart Federation … Updated October 2008
Surgery Outcomes
Heart valve
REPLACEMENT
Heart valve
REPAIR
Anticoagulation required
No Anticoagulation
Longer time before re-operation
Shorter time before re-operation
RHD
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
Specialist medical review
Before ceasing secondary prophylaxis
Dental review following diagnosis
With appropriate endocarditis prevention
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
Notification of ARF & RHD
and Data Management
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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)
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
RHD Control Programmes
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008
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
©2007 World Heart Federation … Updated October 2008
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.
©2007 World Heart Federation … Updated October 2008