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Acute Rheumatic Fever and Rheumatic Heart Disease
Hi, Im Michael.
I live with my family in a remote community in
North Queensland.
I like playing footy, and havent missed a match
this year.
Last year I missed a lot of footy cos I got sick.
It took me ages to understand what it is, and
what me and my family have to do so I can
keep playing footy till I am older.
The people at the clinic and my family want
everybody to know about this Rheumatic Heart
Disease, so kids in my community stop getting
sick hearts.
I missed the first match of the season, cos I got
a sore leg, and couldnt run properly.
Aunty took me to the clinic to get a check up.
They then sent me and Aunty to the hospital in
town.
At the hospital, they told us I have a sick heart
from Rheumatic Heart Disease.
Id never heard of this Rheumatic Heart
Disease?!
MODULE 01
Acute Rheumatic Fever and Rheumatic Heart Disease
Hi, Im Cameron and Im a district medical
officer. Ive been working in rural and remote
regions of Australia for many years.
This e-learning package has been designed
for the health workforce to provide a basic
understanding of best practice approaches to
the prevention, diagnosis and management of
Acute Rheumatic Fever and Rheumatic Heart
Disease.
The information presented in this e-learning
package is based on The Australian Guideline
for prevention, Diagnosis and management of
Acute Rheumatic Fever and Rheumatic heart
disease, 2nd edition.
Over the course of this e learning package you
will meet a number of health workforce that
will work with Michael and his family towards
effective management of his rheumatic heart
disease.
MODULE 01
Acute Rheumatic Fever and Rheumatic Heart Disease
Lets get started!
Module 01 provides an overview of Acute
Rheumatic Fever and Rheumatic Heart
Disease in the Australian context.
MODULE 01
Acute Rheumatic Fever and Rheumatic Heart Disease
The following clip- Rheumatic Heart Disease,
Forgotten but not gone, provides an
introduction to some of the themes that we will
be discussing in this module.
It is presented by Professor Jonathan
Carapetis, a world expert on Rheumatic Heart
Disease.
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Acute Rheumatic Fever and Rheumatic Heart Disease
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Acute Rheumatic Fever and Rheumatic Heart Disease
Acute Rheumatic Fever, or ARF, is an illness
caused by a reaction to a bacterial infection
with Group A Streptococcus, also known as a
GAS infection.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Acute Rheumatic Fever causes an acute,
generalised inflammatory response.
Its an illness that affects only certain parts of
the body; mainly the heart, the joints, the brain
and the skin.
People with acute rheumatic fever can become
very unwell. They may have significant joint
pain, and require hospitalisation.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Despite the dramatic nature of an acute
episode, ARF leaves no lasting damage to the
brain, joints or skin.
But the damage to the heart, specifically the
mitral and aortic valves, may remain once the
episode of ARF has resolved.
This is known as Rheumatic Heart Disease.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Rheumatic Heart Disease, or RHD, is damage
to the heart that remains after an acute episode
of Acute Rheumatic Fever, has resolved.
People who have had ARF before are much
more likely to have subsequent episodes,
compared to the wider community
These recurrences of ARF may cause further
damage to the mitral and aortic valves of the
heart.
Rheumatic Heart Disease gets steadily worse
in people who have multiple episodes of Acute
Rheumatic Fever.
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Acute Rheumatic Fever and Rheumatic Heart Disease
This chart shows disease progression from an
acute episode of rheumatic fever to the chronic
condition of Rheumatic Heart Disease.
Stage One: Group A Streptococcal Infection
The progression to Rheumatic Heart Disease
may occur as the diagram presents.
An individual has a Group A Streptococcal
infection in the throat.
The throat is a common site for Group A
Streptococcal infection, known as pharyngitis.
An upper respiratory tract infection with Group
A Streptococcus has the potential to cause
Acute Rheumatic Fever.
Up to 3% of people with Group A Streptococcal
pharyngitis are susceptible to developing ARF.
Group A Streptococcal pharyngitis is a
common infection in children aged 5-14 years,
so ARF is predominantly seen in this age
group.
This slide also identifies the skin as another
potential site of infection.
There is circumstantial evidence that in
certain populations, (such as some Aboriginal
populations), Groups A Streptococcal skin
infections such as impetigo and/or infected
scabies may have the potential to cause ARF.
ARF generally occurs 1-3 weeks after an initial
infection of GAS in the throat
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Acute Rheumatic Fever and Rheumatic Heart Disease
Stage Two: Acute Rheumatic Fever
Untreated Group A Streptococcal infections can
lead to Acute Rheumatic Fever in some people.
Not everyone is susceptible to ARF, and not all
Group A streptococcal strains are capable of
causing Acute Rheumatic Fever.
Acute Rheumatic Fever affects only certain
parts of the body- mainly the heart, joints, brain
and skin. ARF leaves no lasting damage to the
brain, joints or skin, but can cause persistent
damage to the heart.
Stage Three: Recurrent Acute Rheumatic
Fever
If a person has recurrent and multiple episodes
of Acute Rheumatic Fever, each of these
recurrences may cause further cardiac valve
damage. This means that Rheumatic Heart
Disease steadily worsens in people that have
multiple episodes of ARF.
Stage Four: Rheumatic Heart Disease
The chronic condition of Rheumatic Heart
Disease can lead to reduced quality of life, and
premature death
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Acute Rheumatic Fever and Rheumatic Heart Disease
Globally, Rheumatic Heart Disease continues to
be the most common childhood and adolescent
cardiac disease.
It is the most common cause of cardiac
mortality in children and adults aged under
40 years.
But, almost all cases of RHD and associated
deaths are preventable.
The strategies for preventing Rheumatic Heart
Disease are proven, simple, and cost effective.
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Acute Rheumatic Fever and Rheumatic Heart Disease
There are at least 15.6 million people with
Rheumatic Heart Disease worldwide.
There are another 1.9 million with a history of
Acute Rheumatic Fever.
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Acute Rheumatic Fever and Rheumatic Heart Disease
There are 470,000 new cases of ARF
diagnosed every year.
And there are over 230,000 deaths due to RHD
annually.
However, these figures are in fact likely to be
an underestimate of the true burden of the
disease.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Almost all cases of death from RHD occur in
developing countries.
Some of the highest documented rates of ARF
and RHD in the world are found in Indigenous
Australians, Maoris and Pacific Island
populations.
The prevalence of RHD is also high in
sub-Saharan Africa, Latin America, the Indian
subcontinent, the Middle East and Northern
Africa.
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Acute Rheumatic Fever and Rheumatic Heart Disease
The burden of Acute Rheumatic Fever in
industrialised countries like Australia declined
dramatically during the 20th century. This was
mainly due to the reduced transmission of
Group A Streptococcus.
Reduced transmission was related to
improved living conditions and increased
hygiene standards, along with better access
to appropriate health services and increased
access to penicillin based medications.
Despite a dramatic reduction of rheumatic
heart disease in Australia overall, it is still a
major contributor to childhood and adult cardiac
disease in Indigenous communities throughout
northern and central Australia.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Currently, Australia has among the highest
recorded rates of ARF and RHD in the world,
and its a significant cause of disease among
Aboriginal and Torres Strait Islander children.
Aboriginal and Torres Strait Islander people
living in rural or remote settings, particularly
across central and northern Australia, are
known to be at high risk. Other Aboriginal and
Torres Strait Islander people living in urban
settings, as well as some immigrants from
developing countries may also be at high risk.
Aboriginal and Torres Strait islander people are
up to eight times more likely than other groups
to be hospitalised for Acute Rheumatic Fever
and Rheumatic Heart Disease, and nearly 20
times as likely to die.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Rheumatic Heart Disease is a disease
of poverty, poor hygiene and poor living
standards.
Living in remote communities is a contributing
factor to Acute Rheumatic Fever and
Rheumatic Heart Disease, and its also a
barrier for adequate follow-up and care.
The alleviation of poverty, social and
environmental disadvantage, along with
improved housing, education and healthcare
access are crucial in addressing ARF and RHD.
So are appropriate standards and quality of
care, which is why weve created this learning
package for health workforce.
There is consistent research that shows
an association between overcrowding and
Acute Rheumatic Fever risk across multiple
countries. This is mainly because of the
increased potential for Group A Streptococcal
transmission in overcrowded housing
conditions.
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Acute Rheumatic Fever and Rheumatic Heart Disease
To understand the prevention and control
strategies Acute Rheumatic Fever and
Rheumatic Heart Disease, we need to
understand the public health principles
behind them.
These prevention strategies are known as
primordial, primary, secondary and tertiary
prevention.
Primordial and primary prevention can be
defined as strategies, actions or measures
that aim to stop the disease occurring in the
first place.
Secondary and tertiary prevention strategies,
aim to limit the progression and reduce the
effect of established disease.
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Acute Rheumatic Fever and Rheumatic Heart Disease
This diagram represents the prevention and
control strategies in the context of Acute
Rheumatic Fever and Rheumatic Heart
Disease.
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Acute Rheumatic Fever and Rheumatic Heart Disease
In the case of ARF and RHD, primordial
prevention means preventing Group A
Streptococcal infections through measures that
target environmental, economic, social and
behavioral conditions.
Examples of this might be actions that
address socioeconomic and environmental
disadvantage to do with household
overcrowding and limited access to the
infrastructure needed to maintain hygiene.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Primary prevention in the context of Acute
Rheumatic Fever involves effectively treating
Group A Streptococcal infections in the throat
with penicillin to prevent the development of
ARF in individuals.
It also involves the treatment of Group A
Streptococcal associated skin infections like
impetigo.
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Acute Rheumatic Fever and Rheumatic Heart Disease
Secondary prevention refers to the early
detection of a disease and implementation
of measures to prevent it from recurring or
getting worse.
After the first episode of Acute Rheumatic
Fever, the priority is to prevent further episodes
which can lead to the development
of Rheumatic Heart Disease.
After the first episode of ARF, a patient should
be commenced on long term Benzathine
Penicillin G or BPG injections to prevent ARF
recurrence. This is referred to as secondary
prophylaxis
Long term administration of Benzathine
Penicillin G injections is the only rheumatic
heart disease strategy shown to be clinically
effective and cost-effective at both community
and population levels.
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Acute Rheumatic Fever and Rheumatic Heart Disease
The final prevention strategy is tertiary
prevention.
This involves medical and surgical interventions
in people with established Rheumatic Heart
Disease, to reduce symptoms and disability,
and to prevent premature death.
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