PREVENTION OFPREVENTION OF RHEUMATIC FEVERRHEUMATIC FEVER

Dr. Animesh Mishra, DM (Delhi University)Dr. Animesh Mishra, DM (Delhi University)Associate ProfessorAssociate Professor

Department of CardiologyDepartment of CardiologyNEIGRIHMSNEIGRIHMSShillong-12Shillong-12

What is Acute Rheumatic fever ?What is Acute Rheumatic fever ?

• Infectious

• Immunological

• Genetic

• Collagen Vascular Disease

• Or an unidentified factor.

Is It Possible to Prevent Rheumatic Is It Possible to Prevent Rheumatic Fever ?Fever ?

• Primordial Prevention

• Primary Prevention

• Secondary Prevention

Primordial preventionPrimordial prevention

Preventing the development of ‘risk factors’

Measures for Primordial Prevention

1- Improvement in Socio-Economic Status

2- Prevention of overcrowding

3- Availability of Prompt Medical care

4- Public Education

Primary PreventionPrimary Prevention

Measures for Primary Prevention Identification (GAS) Eradication (Penicillin) Susceptible individuals ? Anti Streptococcal Vaccine

Theoretical possibility at the community but Possible at individual level

Community level prevention Community level prevention ‘‘Sledge Hammer ApproachSledge Hammer Approach’ ’

3%-20% of sore throat are GAS

.3% of GAS sore throat result in RF

90% of Patients of RF develops RHD

10000 Sore throats

300 2000

.

.3% RF1 6

90%RHD1 5

10000

3%-20% GAS

Identification and Eradication of Identification and Eradication of GAS -Not Feasible at community GAS -Not Feasible at community

levellevel 1- Asymptomatic sore throat 2- Diagnosis at mass level 3- Identification Methods not 100%senstive and specific 4- Route of infection 5- Non compliance with the oral Treatment 6- Treatment failure (Penicillin failure)

Susceptible individualsSusceptible individuals

• HLA-D 1,2,3,4

• HLA –D 8/17 Indian population

• B cell alloantigen

Results can not be utilized at community level

Rheumatic VaccineRheumatic Vaccine

Strain specific M-Protein

Caveats 1-Hundreds of Strains 2- Fast mutation rate 3- Virulent GAS may not produce M-Protein

Polyvalent vaccines- Tried, but not successful

Conserved C-Terminus of M-protein

C-5a Peptidase

Fibro nectin surface binding Protein (sfb-1)

Chemaric peptide J8

Polysaccharide conjugated with protein

Health Education (5-16 years)

Education by Parents

Teachers

All India Radio

Doordarshan

NICs, CICs

Health Education (5-16 years)

Education by Parents

Teachers

All India Radio

Doordarshan

NICs, CICs

Secondary PreventionSecondary PreventionSecondary Attack Rate -50%Secondary Attack Rate -50%

• Penicillin Prophylaxis – Every 2-3 weeks (Depending upon the Age, Wt, Muscle mass ) Duration of prophylaxis – LIFE LONG 10Yrs/ Adulthood 5Yrs/ 18Yrs. 1YrsAnaphylactic Shock: 1: 1000000= 10

5

Secondary Prevention cannot reduce the burden of RHDSS