|Year : 2019 | Volume
| Issue : 1 | Page : 1-3
Rheumatic heart disease: A neglected public health priority
IJPH Advisory Board Member, Professor and Head, Department of Community Medicine, School of Public Health, Dean (Academic), Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||12-Mar-2019|
IJPH Advisory Board Member, Professor and Head, Department of Community Medicine, School of Public Health, Dean (Academic), Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar R. Rheumatic heart disease: A neglected public health priority. Indian J Public Health 2019;63:1-3
The epidemiological association of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) with Group A streptococcal (GAS) sore throat was established in the first half of the last century., In 1954, the World Health Organization (WHO) had formulated guidelines for the prevention and control of RHD., However, RHD still continues to be a significant cause of preventable Cardiovascular Disease morbidity and mortality among children (5–14 years) and young adults (15–24 years).
According to the Global Burden of Disease (GBD) estimates, worldwide RHD caused 33,194,900 cases and 319,400 deaths in 2015. About 25.5% of left heart failures and 5.3% of right heart failures are considered to be due to RHD. Globally, RHD accounts for the loss of 10,513,200 disability-adjusted life years every year. In addition, RHD is also a significant cause of maternal mortality. Primarily, RHD burden is located in low- and middle-income countries (LMICs) of Asia and Africa. These countries contribute about 80% of the RHD global burden. Besides, the premature loss of life, RHD also imposes huge economic burden.
Contrary to the popular belief that RHD is declining, GBD study revealed that in the last 25 years there is hardly any decline of RHD in the LMICs; whereas in high-income countries, it has been controlled to a large extent, but it is still a significant burden among their aboriginal populations. In India, RHD is an endemic disease; there were about 13.17 million cases of RHD in the year 2015, and about 1, 19, 100 RHD deaths occur every year.
Despite the high morbidity and mortality load, RHD has not attracted enough attention of policymakers and program planners in India, although evidence-based effective prevention and control strategies are available which can be implemented even in weak health systems at low cost. Ideally, improvement in living standards (primordial prevention) and better access to medical care for treatment of GAS sore throat (primary prevention) can prevent large number of ARF cases. The prompt diagnosis of ARF and RHD cases and administration of long-acting penicillin injections every month (secondary prevention) can prevent recurrence of ARF to avoid further damage to heart valves. However, currently, most of the RHD cases are recognized at late stage when expensive tertiary level care remains the only option for the prevention of premature mortality (tertiary prevention).
The treatment of RHD patients includes medical and surgical management of the heart failure. Repeated hospitalizations for balloon valvotomy and heart valve repair/replacement, pose huge burden on families as there are limited facilities for tertiary level care and for monitoring of anticoagulant therapy among those who undergo surgical interventions. It also imposes economic burden due to the high cost of mechanical and bioprosthetic valves. Adherence to long-term follow-up for antibiotic prophylaxis (Injection Benzathine Penicillin) after the heart valve surgery is often difficult.
There is a need to leverage the existing health system infrastructure to implement early diagnosis of ARF/RHD to provide secondary prophylaxis through a coordinated registry-based program. The duration of secondary prophylaxis depends on the patients' age, the date of their last attack, and most importantly the severity of RHD. Poor adherence to secondary prophylaxis is one of the major issues. The key factors for non-adherence include fear of anaphylaxis following penicillin injection and difficulties in accessing health care (traveling to the health facility is a costly proposition for people living in remote rural areas), low parental knowledge about the disease consequences and lack of training of community health workers about it.
Ideally, the primary prophylaxis should prevent the first attack of ARF, particularly if given shortly after a sore throat episode, thereby preventing the occurrence of RHD. Various studies in middle of the last century had established the effectiveness of primary prophylaxis for the prevention of ARF cases by treating sore throats. Successful campaigns of primary prophylaxis in Costa Rica, launched in 1970s, lead to a dramatic decline in ARF incidence over two decades.
The implementation of primary prophylaxis is a challenge in most of the developing nations due to inadequate laboratory resources to identify GAS infection, and higher cost as large number of sore throat cases need to be treated to prevent single case of RHD. Moreover, due to the fear of anaphylaxis, single long-acting penicillin injection is not used for primary prophylaxis, and the adherence to 10-day oral penicillin regimen is difficult. In addition to this, there are many RHD cases which are not preceded by sore throat. Therefore, the possibility for primary prevention by vaccine development needs to be explored. A recent 30-valent M-protein-based vaccine looks promising, however, ubiquitous vaccines using highly conserved antigens will be the ideal solution.
While efforts for vaccine development and trial need to be accelerated, emphasis should be on creating awareness in the community about the treatment of sore throat and its repercussions if left untreated, training of health providers for early diagnosis and treatment of streptococcal pharyngitis and improving access to primary care for primary prophylaxis. RHD prevention and control programs based on secondary prophylaxis can be successfully implemented within the existing health system. Ministry of Health and Family Welfare Government of India has included RHD in Rashtriya Bal Swasthya Yojna (RSBY) as one of the four diseases to be screened among school children, but RHD registries have not yet been established to organize follow-up on the national scale. Efforts for the elimination of risk factors of GAS infection should also be launched by reducing overcrowding. However, improvements in housing conditions, malnutrition, etc., require the implementation of long-term policies for improvements in socio-economic status.
Prevention strategies are the most appealing option for sustainable disease control in developing nations. Hence, concerted efforts by cardiologists, paediatricians, community physicians, microbiologists, bio-medical scientists, and public health advocates are required to attract the attention of policymakers towards RHD prevention and control. Recent developments in echocardiography, immune-pathology, vaccinology  and a call by the WHO recently has increased the focus on RHD. However, several complex issues need to be resolved to break through the barriers which impede RHD prevention and control efforts.
Despite the fact that epidemiological association of GAS throat infections was established in the last century, exact pathogenic mechanisms that link GAS exposure to RHD are not well understood, which has hampered GAS vaccine development efforts. Lack of a robust point-of-care diagnostic test and an effective non-invasive short-course treatment of GAS infection has held-back community health workers from the treatment of GAS sore throat, which is a common infection of childhood. On an average one GAS sore throat occurs per child per year in 5–15 years of age group. Health-care providers do not like to prescribe painful injections of penicillin due to the fear of anaphylactic reactions. Although developments in echocardiography have made RHD screening and diagnosis more accurate it is still not clear whether mild cases of RHD picked up in echocardiographic examination require long-term prophylaxis with injection benzathine penicillin.
In summary, the burden of RHD continues to be high in developing nations including India due low level of awareness in the community regarding the disease and limited access to health care system. Therefore, there is a need for the National RHD Control Programme with sufficient budget. Emphasis should be on registration and follow-up of RHD patients identified in RBSK. Surveillance studies are also needed to track time trends and emergence of new GAS types. Efforts are also required to put in place research programs for the development of vaccine using Indian GAS types. Cost-effectiveness studies of various RHD prevention and control strategies are also required to place RHD on national policy agenda.
I would like to thank Dr. Shankar Prinja, Additional Professor, Dr. Vivek Sagar, Assistant Professor, and Dr. Jyoti Dixit, Junior Research Fellow from the School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh for their assistance.
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