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Epidemiology of Rheumatic Fever. Prof.Dr .Selma KARABEY. Rheumatic fever. Rheumatic fever is a common cause of acquired heart disease in children and adolescents living in poor socioeconomic conditions .

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Epidemiology of Rheumatic Fever

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    1. Epidemiology of Rheumatic Fever Prof.Dr.Selma KARABEY

    2. Rheumaticfever • Rheumaticfeveris a commoncause of acquiredheartdisease in childrenandadolescentsliving in poorsocioeconomicconditions. • Acuterheumaticfeverfollowsuntreatedorinadequatelytreatedgroup A streptococcalinfection of thetonsillopharynxandmanifestsafter a latentperiod of aboutthreeweeks. (WHO,2011).

    3. Rheumaticfever • Acuterheumaticfeverprimarilyaffectstheheart, jointsandcentralnervoussystem. • Themajorimportance of acuterheumaticfever is itsabilitytocausefibrosis of heartvalvesleadingtocripplinghaemodynamics of valvularheartdisease, heartfailureanddeath. • Surgery is oftenrequiredtorepairorreplaceheartvalves in patientswithseverelydamagedvalves, • thecost of which is veryhighand a drain on thelimitedhealthresources of poorcountries (WHO,2011).

    4. Rheumaticfeverandrheumaticheartdiseasecontinuetoexert a significantburden on thehealth of lowsocioeconomicpopulations in LMICs. • Thediseasealmostdisappeared in thedevelopedworldoverthepastcentury. • Thedecline of rheumaticfever in developedcountries is believedto be theresult of improvedlivingconditionsandavailability of antibioticsfortreatment of group A streptococcalinfection.

    5. Epidemiology of rheumaticfeverandrheumaticheartdisease • 60% of acuterheumatic fever (ARF)caseswould go on to develop rheumatic heart disease (RHD)each year. • The remaining 40% of new ARF cases each year) with a history of ARF but no carditis presently requiring secondary prophylaxis. • Finally, there were over 492,000 deaths per year due to RHD, with approximately 468,000 of these occurring in less developed countries.

    6. Epidemiology of rheumaticfeverandrheumaticheartdisease • ARF is themostprevalentcause of heartdiseasesin theyeargroup5-30 . • RHDis themostprevalentcause of cardiacdiseasesunder 45 yearsold. • Accordingtoestimates,10-20 millionsnewcasesoccureachyear. • Morbidityandsequelasaremoreimportantthanmortality in ARF. • At least 15.6 million people areestimated to be currently affected by RHD . • RHD impactschildrenand young adults living in low-incomecountries. (WHO,2011)

    7. Epidemiology of rheumaticfeverandrheumaticheartdisease • Rheumaticfeverandrheumaticheartdiseaseremainimportantpublichealthproblems in theworld. • Rheumatic fever mostly affects children in developing countrieswherepoverty, overcrowding, malnutrition, andinadequatemedicalcarearefound. • Globally, almost 2% of deaths from cardiovascular diseases is related to rheumatic heart disease, while 42% of deaths from cardiovascular diseases is related to ischaemic heart disease, and 34% to cerebrovascular disease.

    8. Global Atlas on CVD PreventionandControl “Rheumaticheartdisease: A neglectedheartdisease of thepoor”

    9. Epidemiology of rheumaticfeverandrheumaticheartdisease • In 2005, it was estimated that over 2.4 million children aged 5-14 years are affected with RHD and 79% of all RHD cases come from less developed countries. • Further, the annual number of new ARF cases in children aged 5-14 years was more than 336,000. • 95% of cases come from less developed countries.

    10. Epidemiology of rheumaticfeverandrheumaticheartdisease • Even in industrializedsocieties, a relativelyhighprevalence of rheumaticfeverpersists in pockets of poverty, andoutbreakshavebeenreported in affluentareas. • Despitethat ARF is demonstrablypreventableand RHD has declineddramatically in mostindustrializednations, thisconditionremains a majorpublichealth problem. • Theoverallratio of malestofemalesis approximately4:5, confirmingthat RHD is slightlymorecommon in women.

    11. Global Atlas on cardiovasculardiseasepreventionandcontrol, WHO 2013

    12. Global Atlas on cardiovasculardiseasepreventionandcontrol, WHO 2013

    13. Epidemiology of rheumaticfeverandrheumaticheartdisease Geneticpredisposition: • Althoughthemechanism is not clear, geneticpredisposition has beendetermined. • Iffamilyhistory is positive, thepatientshould be examinedcarefuly. • Ifthere is a upperrespiratorytractinfectionthenthroatculturemust be done. Ifpositive, anti-streptococcictherapyshould be given.

    14. First ARF attack • is seenbetween 5-15 yearsold. • is rareunder 5 yearsold. • While ASO titration (serologicfinding of streptoccoccalupperrespiratorytractinfection) is lowerunder 2 yearsold, is abovethe normal valuesbetweenthe 6-14 yearsold.

    15. Epidemiology of rheumaticfeverandrheumaticheartdisease • Duringthe1960s,theincidence of acuterheumaticfeverrangedfrom23 to 55 per 100.000 urban childrenaged 2-14 yearsin the United States. • Insomeareas of South America, theprevalence of theacuterheumaticfever is significantlyhigher, rangingfrom1 to 10 percent of scool-agedchildren(PAHO 1970) • Similarhighratesareseen in areas of AsiaandAfrica . Reportedprevalence in schoolchildrenrangesfrom1 to 78/1000(WHO 2004)

    16. Epidemiology of rheumaticfeverandrheumaticheartdisease • TurkishRheumaticFeverStudyGroupdeclaredthattheprevalence of ARF was10.8/10.000 in thepatients of pediatricoutpatientdepartments. • Prevalencewas1.9 % in thepatients of pediatriccardiologyoutpatientdepartments (14 centers, year of 2000) • Accordingto a studycarriedout in Ankara, it has beendeterminedthat ARF prevalence has decreased 9-10 timesduringlast 20 years(1995).

    17. Definition of acuterheumaticfever • Themechanismsbywhichthisinfectionproducestheclinicalsyndrome of acuterheumaticfeverandsubsequentrheumaticheartdisease is wellstudied.(WHO 2004) • A group A streptococcalinfection of throat ( tonsillopharyngitis) can be followed,in approximately3 weeks, by an episode of acuterheumaticfever. • Therheumaticfeverattackresults in an inflammatuaryreactionwhichinvolvestheheart, jointsand/orthecentralnervoussystem.

    18. Symptoms of rheumatic heart disease • Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heart beats, chest pain and fainting. • Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach cramps and vomiting.

    19. Revised Jones Criteria for Acute Rheumatic Fever (ARF) A firm diagnosis requires that • two major or • one major and two minor criteria are satisfied in addition to evidence of recent streptococcal infection.

    20. Major Criteria • Carditis • Polyarthritis(knees, ankles, elbows and wrists) • Chorea(Syndenham’s chorea/St. Vitus´ dance) • ErythemaMarginatum • Subcutaneousnodules

    21. Erythemamarginatum

    22. Subcutaneousnodules

    23. Minor Criteria • Fever • Arthralgia • Previousrheumaticfeverorrheumaticheartdisease • Acutephasereactants(Leukocytosis, elevated ESR and CRP) • Prolonged P-R interval on electrocardiogram

    24. Evidence of preceding streptococcal infection Any one of the following is considered adequate evidence of infection: • Increased antistreptolysin O or other streptococcal antibodies • Positive throat culture for Group A beta-hemolytic streptococci • Positive rapid direct Group A strep carbohydrate antigen test • Recent scarlet fever.

    25. Evidence of preceding streptococcal infection-2 • Rapidantigentestsforthediagnosis of group A streptococcalthroatinfectionsarehighlyspecific, but lesssensitive. • While a positive test suggeststheneedfortreatment, a negative test indicatestheneedforthroatculture.(Dajani et al. 1995) • Antibodytests can confirm a recentgroup A streptococcalinfection.

    26. Prevention of rheumaticfever “Poverty alleviation and better living conditions are key for prevention of rheumaticheartdisease” (WHO, 2011)

    27. Primary prevention is achieved by treatment of acute throatinfections caused by group A streptococcus. This effectmay be achieved at relatively low cost if a single intramuscular penicillin injection is administered . • Secondaryprevention is used following an attack of acute rheumaticfever to prevent the progression to cardiac disease and has to be continued for many years. • Secondary preventionprogrammes are currently thought to be more cost effective for prevention of rheumatic heart disease than primary prevention and may be the only feasible option for LMICs in addition to poverty alleviation efforts.

    28. Prevention of rheumaticfever • Primaryprevention of acuterheumaticfever is therecommendedaproach • Throatculturesshould be performed on allpatientswithtonsillopharangitisandthosewith a positivecultureforgroup A streptococcalinfectionstreated (Dajani et al. 1950) • Antibiotictreatmentcan effectivelypreventacuterheumaticfeverevenwhengivenupto 9 daysfromtheonset of theinfection(Denny et al. 1950) • Antibiotictreatment can be either oral orbyinjection

    29. Prevention of rheumaticfever-2 • Primary prophylaxis is a proven method of prevention, however has not to date been proven to be cost-effective, resulting in secondary prophylaxis remaining the mainstay of RF/RHD management, as do IM benzathinebenzylpenicillin, oral phenoxymethylpenicillinand oral erythromycin.

    30. Prevention of rheumaticfever-3 • Early treatment of streptococcal sore throat can stop the development of rheumatic fever. • Regular long-term penicillin treatment can prevent repeat attacks of rheumatic fever which give rise to rheumatic heart disease and can stop disease progression in people whose heart valves are already damaged by the disease.

    31. Prevention of rheumaticfever-4 • Firstly whether IM benzathinebenzylpenicillin(considered first line for secondary prophylaxis) should be administered every four weeks, versus every two or three weeks. • The internationally accepted dose for the secondary prevention of ARF in adults is 1.2 million IU. • Current pharmacokinetic evidence suggests 600,000 IU be given to patients weighing less than 20kg, and 1.2 million IU be given to all other patients.

    32. Prevention of rheumaticfever -5 • Theindividualswith a history of acuterheumaticfever, thelikelihood of secondaryattackswithadditionaldamage is common, estimatedto be approximately 50 percent of thosewith an antibiotic is recommended (Dajani et al. 1995) • Ifgroup A streptococcalinfectionsareappropriatelydetectedandtreated, rheumaticheartdisease can be effectivelyprevented. • Inthosewhere it is not prevented, lifelongvalvularheartdiseaseresults in diminishingfunctionandprematuremortality.

    33. TurkishRheumeticFeverStudyGroup Duration of prophylaxisfor: • ArthritisandChorea : until 20 yearsold, • Carditis: lifelong “benzathinebenzylpenicillin” Inorderto stop prophylaxis: • Recurrencyshould not havebeenseen in last 5 years.

    34. Referencesand Web Sources • Oxford Textbook of PublicHealth,CardiovasculerandCerebrovasculerDiseases,RogerDetels, Robert Beaglehole, MaryAnnLansang, Martin Gulliford, Oxford UnivercityPress, 2009 • Maxcy-Rosenau-LastPublicHealthandPreventiveMedicine, HeartDisease, Robert B.Wallace, NealKohatsu, 2007 • Global Atlas on Cardiovasculardiseasepreventionandcontrol,ShantiMentis, PekkaPuska, BoNorrving,WHO in CollaborationwiththeWorldHeartFederationandtheWorldStrokeOrganization, 2011 • Thecommunitycontrol of rheumaticfeverandrhuumaticheartdisease:report of a WHO internationalcooperativeproject, Bulletin of theWorldHealthOrganization, 59(2) 285-294, T.Strasser,N.Dondog, A.El Kholy, 1981 • Cardiovasculerdiseases(CVDs) WHO • http://www.who.int./cardiovasculer_diseases/en/ • JonesCriteria • http://www.medicalcriteria.com/criteria/car-jones.htm • Treatment of rheumaticfever • http://www.who.int/selection-medicines/committees/subcommittee/2/RheumaticFever-review.pdf • TTB, STED,’’On soru on yanıt’’, Volume 12, number 2,2003 • http://www.ttb.org.tr./STED/sted0203/on-soru.pdf