Download Helping to Prevent Rheumatic Fever

Table of Contents
Glossary and terms of abbreviations
3
Introduction
4
What is ‘strep throat’ and how can it cause rheumatic fever?
5
Objectives……………………………………………………………………………..
5
What is ‘strep throat’? ……………………………………………………………….
5
Why do sore throats matter? …….…………………………………………………
5
Do all sore throats lead to rheumatic fever? ………………………………………
6
How can the GAS bacteria be prevented from spreading? ...……………………
6
How can rheumatic fever be prevented? ......………………………………………
6
Signs and symptoms of rheumatic fever
8
Rheumatic heart disease – how does rheumatic fever affect the heart?
9
Objectives………………………………………………………………………………
9
Structure and function of the heart ….………………………………………………
10
Rheumatic heart disease ……….……………………………………………………
10
What happens if a child is diagnosed with ARF? …………………………………
11
What happens if a child is diagnosed with RHD? ...................……………………
11
Appendix 1 Teaching ideas
Appendix 2 Rheumatic fever resources
2
Glossary and Terms of Abbreviations
Term/Abbreviation or Acronym
Definition or Description
Autoimmune Reaction
An autoimmune reaction occurs when the body's
immune system mistakenly reacts against some of its
own tissue and produces antibodies to attack itself
Carditis
Inflammation of the heart
Infective Endocarditis
Inflammation of the inner surface of the heart (the
endocardium which includes the heart valves) caused
by infection from a micro-organism (e.g. bacteria)
‘Strep throat’
Throat infection caused by
bacteria
ARF
Acute rheumatic fever
DHB
District health board
GAS
Group A streptococcal bacteria
RF
Rheumatic fever
RHD
Rheumatic heart disease
CRHD
Chronic rheumatic heart disease
3
group A streptococcal
Introduction
Rheumatic fever is a serious preventable disease which may cause permanent heart damage.
Rheumatic fever is almost three times more common in the Bay of Plenty than in New Zealand
overall.1 Those most at risk of developing rheumatic fever are:

Maori and Pacific children between the ages of 5 -14 years (90% of cases in the Bay of
Plenty are Maori)

people with family/whanau who have had rheumatic fever

people who share a house with lots of others
Because rheumatic fever rates are highest amongst children aged 5-14 years, parents,
teachers, health professionals and others in daily contact with school children are well placed to
promote awareness about rheumatic fever.
This information book is designed to help increase awareness about group A streptococcal
bacteria, ‘strep throat’, rheumatic fever and rheumatic heart disease.
The key messages are summarised below:

Rheumatic fever is a serious disease that can cause permanent heart damage.

An untreated sore throat caused by group A streptococcus (‘strep throat’) can lead to
rheumatic fever.

Rheumatic fever is preventable, provided sore throats are diagnosed and treated correctly.

If a child complains of a sore throat make sure they are checked by a doctor.

If a ‘strep throat’ is diagnosed, the doctor will usually prescribe a 10 day course of
antibiotics.

It is important to complete the whole 10 day course to prevent rheumatic fever from
developing.

Sore throats matter – get them checked!
4
What is ‘strep throat’ and how can it cause rheumatic fever?
‘Strep throat’
Group A streptococcal bacteria
Objectives
 To understand what ‘strep throat’ is

To understand why sore throats matter
What is strep throat?
 Group A streptococcal bacteria (or strep bacteria) can infect the throat and make it sore this is called ‘strep throat’ or pharyngitis.

Typical symptoms of a ‘strep throat’ include:
- a sore red throat, sometimes there may be thick pus like fluid around the tonsils
- However the throat may also appear quite ‘normal’ with no obvious signs of
infection.
- fever and chills
- enlarged and tender lymph nodes in and around the neck
- vomiting and abdominal complaints – especially in children
Why do sore throats matter?

Sore throats matter because an untreated ‘strep throat’ can trigger an auto immune reaction
which leads to rheumatic fever.

An autoimmune reaction occurs when the body's immune system mistakenly reacts against
some of its own tissue and produces antibodies to attack itself.
5

In the case of rheumatic fever this reaction may cause inflammation (swelling) of other parts
of the body, particularly the joints, heart, skin and brain.

Inflammation of the heart may lead to long-term damage of the heart valves.
“Rheumatic fever licks the joints but bites the heart”
Do all sore throats lead to rheumatic fever?
 Most sore throats are caused by a virus and go away in a few days.

BUT… if a sore throat is caused by the group A streptococcus bacteria (‘strep throat’) it
could lead to rheumatic fever.

‘Strep throat’ is a common cause of sore throats in Maori and Pacific children.

Only a throat swab can tell if the group A streptococcus bacteria is present.

If a child or young person complains of a sore throat make sure they get checked by a
doctor or health professional.
How can the group A strep bacteria be prevented from spreading?
 Group A strep bacteria are highly contagious and easily spread through:
- coughing and sneezing around others
- unwashed hands
- sharing toothbrushes
- sharing drinks and kai.

Ensure children/tamariki wash and dry their hands, especially after coughing or sneezing.

Teach children/tamariki to cover their mouths when coughing or sneezing.
How can rheumatic fever be prevented?

If the throat swab shows that the group A strep bacteria is present, the doctor will usually
prescribe antibiotics which will need to be taken for 10 days.

It is really important that the whole 10 day course is completed to prevent rheumatic fever
from developing.

Alternatively, the doctor may give one IM Penicillin injection.

By taking sore throats seriously, we can help to prevent life long illness and suffering for our
tamariki.

The diagram below provides a good visual guide to the correct and incorrect treatment of a
sore throat.2
6
7
Signs and symptoms of rheumatic fever
Rheumatic fever often starts with an untreated ‘strep
throat’. A few weeks later the following symptoms may
develop:






sore or swollen joints
a skin rash
a fever
stomach pain
fatigue
jerky movements
Although these symptoms may disappear, the heart valves may be permanently damaged – this
is called rheumatic heart disease (RHD).
People who have had rheumatic fever can get it again if they are not treated, which may result
in further heart damage. This is why prevention and treatment of rheumatic fever is so
important.
Only a small percentage of people who have a strep throat will develop rheumatic fever.
Those most at risk are:

children between the ages of 5 -14 years

Maori and Pacific children (90% of cases in the Bay of Plenty are Maori)

people with family/whanau who have had rheumatic fever

people who share a house with lots of others

people with limited access to health care

people living in lower socio economic areas
8
Rheumatic Heart Disease
How does rheumatic fever affect the heart?
Objectives
 To understand the basic structure and function of the heart

To explain how rheumatic fever can damage heart valves and cause rheumatic heart
disease
9
The structure and function of the heart

The heart is a double pump.

The right side of the heart takes blood low in oxygen from the body and pumps it to the
lungs, where it becomes rich in oxygen.

The left side of the heart receives blood full of oxygen from the lungs and pumps it around
the body.

Each side of the heart has two chambers. Each chamber is sealed with a valve. The valves
are shown in white in the diagram of the heart.

The valves open and close in one direction only, so that the blood can not flow backwards.

Healthy valves are essential for the function of the heart as a pump.
Rheumatic heart disease

Rheumatic fever may damage the heart valves. This is called rheumatic heart disease.

Rheumatic heart disease can occur after one episode of acute rheumatic fever, or as a
result of several attacks.

The mitral valve (on the left side of the heart) is affected in over 90% of cases of rheumatic
heart disease.

The valves become scarred and thickened.

Often the heart valves can not open or shut properly. This means that:
- 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

When the heart valve is damaged it can cause breathlessness, tiredness and heart
palpitations.

Surgery may be required to repair or replace the damaged heart valve(s).
10
What happens if a child is diagnosed with acute rheumatic
fever (ARF)?

Children who are diagnosed with ARF will need to go to hospital for bed rest, antibiotics,
blood tests and heart checks.

Hospital admissions for ARF are generally prolonged – with an average stay of 22 days.

Once discharged from hospital they need to receive injections of penicillin every 21-28 days
for at least 10 years (or until they are 21 years, whichever is longer) to prevent a recurrence
of ARF and subsequent heart damage.

They will need regular doctor visits and dental checks.

They will need extra antibiotics before some types of dental treatment to prevent tiny
bacteria or bugs from entering into the blood stream and causing further damage to the
heart (this is called infective endocarditis).
What happens if a child is also diagnosed with rheumatic
heart disease (RHD)?

If a child has damage to their heart valve they may need to stay in hospital for longer.

They may have penicillin injections for longer (for at least 10 years or until they are 30 years
old). The duration of monthly injections depends on a number of factors including: age,
severity of carditis (inflammation of the heart), risk of ‘strep throat’, the length of time since
the last episode of ARF.

They will need special care when visiting the dentist and may eventually need surgery to
repair the damaged valve.

In New Zealand around 80% of ARF cases have some cardiac involvement and in 20% of
those the carditis is moderate-severe requiring cardiac surgery.3
11
Appendix 1
Teaching Ideas
Suggestions for teaching good hand and respiratory hygiene
to prevent the spread of ‘strep throat’
Objectives


To understand how group A strep bacteria is spread
To understand how good hand and respiratory hygiene can help prevent the spread of strep
bacteria

Demonstrate and practice correct hand washing and drying techniques.
How can the group A strep bacteria be prevented from spreading?
Group A strep bacteria are highly contagious and easily spread from person to person through:

coughing and sneezing around others

unwashed hands

sharing toothbrushes

sharing drinks and kai
Hand Hygiene
Ensure children/tamariki to wash and dry their hands, especially after coughing or sneezing.
Steps to remember when washing your hands
1. Wet your hands with warm water
2. Put soap in the palm of your hands, rub palm to palm then spread the soap
all over
3. Rub your hands together, back, front and in between your fingers and thumbs
and underneath your nails
4. Rinse ALL of the soap off
5. Dry your hands thoroughly for 20 seconds with a towel or 45 seconds using a
hand drier until hands are completely dry

Younger children can wash and dry their hands whilst singing “Happy birthday to you”
twice.

Times WHEN you wash your hands
As well as washing our hands when they look or feel dirty, there are other times
when you should wash your hands:
1. After using the toilet
2. Before touching/eating food and drink
3. After playing with/touching animals
4. After coughing, sneezing and nose blowing
5. After playing outside
Respiratory Hygiene
Teach children/tamariki to cover their mouths when coughing or sneezing.
Spray bottle experiment

Use a spray bottle filled with water. Spray water on the children's hands.

Explain that the water on their hands represents the strep germs that come out of their
mouths when they cough and sneeze.

Now have the children touch an object (e.g. a desk or chair).

Ask them what happened to the object they touched (it became damp).

Explain this is what happens when we sneeze into our hands and then touch an object (the
strep germs on our hands are transferred on to the object).

Discuss what might happen if one of their friends touches the object while it is moist (they
might pick up the strep germs and get strep throat).

Explain that if you wash (and dry) your hands after sneezing or coughing in them the strep
germs will be washed away and this will reduce the chance of other people becoming sick.
Appendix 2
Rheumatic fever resources
Free to print and use
Pamphlets and posters also available from Toi Te Ora - Public Health
www.toiteorapublichealth.govt.nz
Sample letter for parents/school newsletter
Sore Throats Matter!
Dear Parents/Whanau/Caregivers
Your child has been given a pamphlet on sore throats and rheumatic fever. Rheumatic fever is a
serious preventable disease which can result in permanent heart damage.
Please take time to read and talk about this pamphlet with your child.
Why do sore throats matter?

Sore throats matter because an untreated streptococcal bacterial throat infection (‘strep
throat’) can cause a reaction which leads to rheumatic fever.

Rheumatic fever is preventable, provided sore throats are treated correctly.

If a child complains of a sore throat make sure they get checked by a doctor.

If a ‘strep throat’ is diagnosed, the doctor will usually prescribe a 10 day course of
antibiotics.

It is important that the child takes all the antibiotics exactly as prescribed so all the strep
bacteria are killed and rheumatic fever is prevented.

By taking sore throats seriously, we can help prevent life long illness and suffering for our
tamariki.
For further information talk to your doctor or nurse or visit: www.toiteorapublichealth.govt.nz
A child at school has had rheumatic fever.
Rheumatic fever is a serious disease that can damage the
heart. It usually starts with a sore throat caused by the
streptococcal bacteria (a ‘strep throat’).
If anyone in your family has a sore throat for more than
48 hours, makes sure they get it swabbed by a doctor or
nurse.
Antibiotics for a sore throat can stop rheumatic fever.
For more information contact your doctor or visit:
www.toiteorapublichealth.govt.nz
* Design Acknowledgement: Hawkes Bay DHB
Useful Website Addresses
www.toiteorapublichealth.govt.nz
Toi Te Ora - Public Health Service
http://www.nhf.org.nz
National Heart Foundation of New Zealand
www.kidshealth.org.nz (search ‘sore throat’)
Paediatric Society of NZ and the Starship Foundation
http://www.heartchildren.org.nz/
Heart children New Zealand
References
1
Loring, B (2008). Rheumatic Fever in the Bay of Plenty and Lakes District Health Boards: A
review of the evidence and recommendations for action. Toi Te Ora – Public Health, Tauranga.
Available at
http://www.toiteorapublichealth.govt.nz/Rheumatic_Fever_GP
2
Acknowledgement: Lakes DHB Rheumatic Fever Project Steering Group – ‘Sore Throats
Matter’ pamphlet
3
Lennon, D (2007) in: Feigin RD, Cherry JD, Demmler, GJ, Kaplan SL, eds. Textbook of
pediatric infectious diseases. 6th ed Vol. 1. Philadelphia: Saunders, 413-26.