Can Acute Rheumatic Fever and Rheumatic Heart Disease be prevented?
Yes. There are several opportunities to prevent acute rheumatic fever (ARF) and rheumatic heart disease (RHD) along the disease pathway. Primordial and primary prevention focus on preventing ARF from occurring in the first instance, secondary prevention aims to prevent development of RHD after ARF has occurred, and tertiary prevention limits the progression of RHD and its complications.1
1. Primordial Prevention
Primordial prevention means reducing risk factors for disease by addressing the social determinants of health which cause or increase the risk of the disease in a population. For example: reducing the opportunity for streptococcal (Strep A) infections in people who are at risk of ARF.2,3
Social determinants are the circumstances in which people live, and they are influenced by environmental, cultural, social and political systems.4 If the systems that influence the way people live are strong and well-supported, the risk of disease is reduced. Examples include healthy housing and sanitation, reduced household crowding, cultural safety, access to quality education and employment, and access to health services.2 These measures are known to reduce the rates of ARF and RHD in the population.5,6
2. Primary Prevention
Primary prevention of ARF interrupts the link between a Strep A infection and the body’s response to the infection, the autoimmune response.7
This requires identifying and treating Strep A infections of the throat and skin in people at high risk of ARF. If given early in the infection, antibiotics, commonly penicillin, stop the body developing an autoimmune response, and ARF does not occur.8,9
3. Secondary Prevention
Secondary prevention broadly describes activities that help prevent a known disease from recurring. This includes medical treatment, support for patients and their families, coordination between health, education and other services, and dedicated disease control programs to help coordinate care.
Secondary prophylaxis is one element of secondary prevention, which in the case of ARF, involves regular, long-term antibiotics to prevent future Strep A infections and development of recurrent ARF.8
Antibiotics, usually penicillin, are given by intramuscular injection every 21 to 28 days to protect the person from future Strep A infections during the period at which they are at highest risk. For most people, secondary prophylaxis continues into early adulthood. 1,10
4. Tertiary Prevention
Tertiary prevention aims to slow disease progression and prevent complications once a disease is established.
For RHD, this means reducing symptoms to prevent or delay disability, and prevent premature death. People with RHD may require heart medications, monitoring and extra support during pregnancy, surgery to repair or replace damaged heart valves, and prevention of complications such as endocarditis, heart failure and stroke.1,11 People with RHD usually need life-long tertiary care.1
Primordial prevention includes a range of improvements to living conditions that reduce poverty and over-crowding in populations at risk of ARF and RHD. There have been dramatic reductions in the rates of ARF and RHD in populations that have experienced improvements in socioeconomic and environmental conditions.
- RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition), 2020.
- Coffey PM, Ralph AP, Krause VL. The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: A systematic review. PLOS Neglected Tropical Diseases 2018;12(6): e0006577
- Gillman MW. Primordial prevention of cardiovascular disease. Circulation. 2015;131(7):599-601.
- Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008.
- Watkins DA, Johnson CO, Colquhoun SM, et al. Global, Regional, and National Burden of Rheumatic Heart Disease, 1990–2015. The New England Journal of Medicine. 2017;377:713-722.
- Brown A, McDonald MI, Calma T. Rheumatic fever and social justice. The Medical Journal of Australia. 2007;186(11):557-558.
- Hurst JR, Kasper KJ, Sule AN, McCormick JK. Streptococcal pharyngitis and rheumatic heart disease: the superantigen hypothesis revisited. Infection, Genetics and Evolution. 2018;61:160-175.
- Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2009;119:1541-1551.
- Zühlke LJ, Karthikeyan G. Primary Prevention for Rheumatic Fever: Progress, Obstacles, and Opportunities. Global Heart. 2013;8(3)221-226.
- Antibiotic Expert Group, Therapeutic guidelines: antibiotic. Vol. 15. 2014, Melbourne: Therapeutic Guidelines Limited.
- Russell EA, Walsh WF, Costello B, et al. Medical Management of Rheumatic Heart Disease: A Systematic Review of the Evidence. Cardiology in Review. 2018;26(4):187-195.
LAST UPDATED 6 JUNE 2020