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Transcript
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