What is the burden of rheumatic heart disease?


Dr Jones Nghaamwa

In Namibia, rheumatic heart disease is the commonest acquired heart condition and the reason for heart surgery 90 percent of the time. Between 1990 and 2013 there has been a less than 5% decrease in prevalence of rheumatic heart disease. This reality reflects on many aspects of Namibian society, social development, healthcare, education, economy and specifically the continuously widening gap of income disparity. Globally the disease affects more than 30 million people and accounts for 300,000 deaths per year. Developing countries have the highest prevalence with poor communities mostly affected. As a result over the decades, the developed world with all its resources paid little attention to rheumatic heart disease. Recent efforts by developing countries culminated in a new perspective, redirected priorities and ultimately the adoption of a new resolution by the 71st World Health Assembly in Geneva. Death and disability caused by rheumatic heart disease negatively affect communities and thwart national development. Such morbidity and mortality is preventable.

Just because the disease does not affect rich nations, doesn’t mean it should be neglected and it’s impact ignored. Prevention, treatment and control of rheumatic heart disease deserve top priority just like Alzeimer’s disease, HIV, coronary artery disease, etc. Locally, Namibia will gain plenty from eradicating rheumatic heart disease and such efforts will be in concert and congruent with the National Development Plan goals (NDP 5), Vision 2030 and the Harambee Prosperity Plan (HPP). We need to recognise the impact of concerted, small, goal directed interventions at multiple levels of our society.

Diagnosing and treating acute rheumatic fever and rheumatic heart disease
A change in attitude towards the way individuals, parents, families, society at large as well as healthcare professionals look at a simple SORE THROAT should be a starting point. We need to raise awareness regarding acute rheumatic fever and rheumatic heart disease. High vigilance and diligence must the sine qua non in our efforts towards eradication.
If your child, yourself or a person you know has a sore throat, they should seek medical attention even if they think the symptoms are not severe enough. Group A Streptococcus is easily treated with an antibiotic called Penicillin. Healthcare workers will examine your throat, confirm the diagnosis and prescribe appropriate treatment. There are many causes of a sore throat and medical professionals should be able to run a series of tests to confirm or refute infection with GAS. A penicillin injection is generally much more effective.
As previously mentioned, a high index of suspicion is required to make the diagnosis of acute rheumatic fever since the symptoms are non-specific. A set of criteria (revised Jones criteria) are used by clinicians to make the diagnosis. High awareness levels amongst healthcare professionals, especially in endemic areas including Namibia will ensure the possibility of acute rheumatic fever is always entertained when patients present with high fevers, joint pains, heart failure, abnormal movements or the rarer skin manifestations. Echocardiography (imaging of the heart) is very helpful in diagnosing valve lesions and disease that is not clinically evident (sub-clinical carditis). Likewise, clinical examination and echocardiography are the cornerstone of diagnosing and assessing rheumatic heart disease. It is thus imperative that access to quality primary health care of all citizens is ensured. Further, patients with rheumatic heart disease should have access to cardiovascular specialists and healthcare facilities where their disease can be assessed, treated and monitored.
Screening with echocardiography can significantly reduced disease morbidity and mortality, especially among populations where the disease is endemic. Namibia can benefit from such a mass screening program in schools. With the new adopted resolution it is hoped that all spheres of society contribute towards prevalence reduction and eventual eradication of rheumatic heart disease. This is an open call to the private sector in Namibia to assist with efforts to improve the health of Namibians.
There has been little change in the way that acute rheumatic fever is treated and most healthcare professionals are expected to have sufficient knowledge to treat the disease. Rheumatic heart disease is treated with medicine, cardiovascular interventions and surgery as a last resort. Because the article is aimed at non-medical people it is hoped that this brief explanation on treatment suffices. Certain aspects of treatment will be discussed in subsequent parts of the heart series articles.

Prevention of acute rheumatic fever and rheumatic heart disease

The old adage that prevention is better than cure applies strongly to acute rheumatic fever and rheumatic heart disease. Prevention in this case involves three areas:

A. Primordial prevention
This involves national strategies that must be aimed at:
• raising awareness about the disease;
• improving education;
• improving housing;
• ensuring good sanitation and hygiene levels amongst communities;
• improving nutrition, eradicating hunger and poverty;
• ensuring access to quality healthcare for all citizens.

B. Primary prevention
This mode of prevention aims at preventing infection with group A Streptococcus from causing acute rheumatic fever by treating bacterial sore throats with injectable Penicillin. This is difficult as symptoms of sore throat may be ignored or downplayed by the affected person. Medical attention may not be sought and “minor” bouts of acute rheumatic fever may occur ultimately leading to rheumatic heart disease in the future. Hence the earlier call for increased vigilance amongst the public and healthcare practitioners with the aim of creating a lower threshold for treating SORE THROATS with inexpensive Penicillin.

C. Secondary prevention or prophylaxis
A single patient may experience many bouts of sore throat. This may lead to acute rheumatic fever and consequently rheumatic heart disease. Recurrent bouts of rheumatic fever continue to damage the heart (specifically the heart valves) even if such bouts are not severe enough to prompt the person to seek a doctor’s help. The “small battles” continue silently like covert operations ultimately manifesting as rheumatic heart disease. All people diagnosed with acute rheumatic fever and rheumatic heart disease need thus to take Penicillin to prevent future infections with GAS and thus avoid developing acute rheumatic fever. The international standard is 3 weekly injections with BENZATHINE PENICILLIN and this has to carry on into adulthood (specific guidelines exist). Penicillin tablets are second best. There is a worldwide call to ensure that this inexpensive treatment is made securely available at all times to those that need it. The onus rest on the administrators to implement this call.

New resolution, what now?
The adoption of a resolution by the 71st World Health Assembly in Geneva is a welcome milestone. Rheumatic heart disease now has a spot in the limelight that it deserves. According to the World Health Organization, the resolution outlines priority activities for all stakeholders of member states. These include:

• Acceleration of multi-sectoral efforts to reduce poverty;
• Estimation of national burden of rheumatic heart disease, registry creation;
• Implementation and resourcing of rheumatic heart disease programmes in endemic countries;
• Improving access to primary healthcare;
• Ensure timely access to technologies and medicines for diagnosis and treatment of rheumatic heart disease.

Time is ripe for Namibia, for the love of her citizens, to heed the call of this resolution and lead in the race to reduce the prevalence of acute rheumatic fever and rheumatic heart disease. Continued commitment at all levels of government is required to achieve this goal. In so doing we will be contributing to the realization of all 5 pillars of the Harambee Prosperity Plan.
A diagnosis of rheumatic heart disease need not be a death sentence. The condition can be managed and morbidity as well as mortality avoided. People living with the disease should take ownership of their health, adhere to treatment plans, live positive lives and spread awareness amongst their communities. All citizens should be advocates for improved healthcare.

In a nutshell
• Acute rheumatic fever and rheumatic heart disease are common amongst the world’s poor;
• Rheumatic heart disease accounts for more than 300,000 deaths per year globally;
• Rheumatic heart disease is very common in Namibia;
• A sore throat infection caused by Group A Streptococcus leads to acute rheumatic fever via an autoimmune phenomenon;
• Acute rheumatic fever leads to rheumatic heart disease predominantly affecting the heart valves;
• A GAS sore throat is treated with Penicillin;
• Improvements in living standard of populations significantly reduce the diseases;
• Secondary prophylaxis with Penicillin is crucial;
• The World Health Assembly has adopted a resolution on rheumatic heart disease;
• Multi-sectoral implementation of comprehensive strategies is required;
• Live positively;
• Let’s reduce poverty.

(This was a continuation from last week’s article on rheumatic heart disease. The next article in the heart series will focus on de-mystifying heart surgery. NB: The illustrations are obtained from websites available on request and are not the author’s work.)

* Dr Jones Nghaamwa is a cardiothoracic, heart and lung surgeon at Windhoek Central Hospital and Lady Pohamba Hospital.


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