Rheumatic Fever/Rheumatic Heart Disease: Guidelines for Prevention, Diagnosis and Management

Objectives

Provide a national clinical and programme framework for preventing, diagnosing, managing and monitoring rheumatic fever and rheumatic heart disease, a major acquired cardiovascular condition affecting children and young adults, particularly those aged 5 to 15 years.[1][2]The framework spans primary prevention, acute care, secondary prevention, notification, investigation, record keeping, defaulter management, prevention of infective endocarditis, emergency anaphylaxis management, and health promotion.[3]

• Prevent initial rheumatic fever by improving recognition, diagnosis and adequate antibiotic treatment of group A beta-haemolytic streptococcal sore throats, because no vaccine is available.[2]
• Apply the revised Jones criteria and World Health Organization diagnostic categories to identify primary and recurrent rheumatic fever, chorea, chronic rheumatic heart disease and insidious rheumatic carditis.[4]
• Manage acute rheumatic fever by eliminating streptococcal infection, treating arthritis, carditis, chorea and cardiac failure where present, and providing suitable rest and clinical supervision.[5][6]
• Prevent recurrent attacks through continuous secondary prophylaxis, with duration tailored to cardiac involvement, recurrence risk, age and history of rheumatic heart disease.[7][8]
• Maintain lifelong prophylaxis for patients with chronic rheumatic heart disease or artificial valves, while providing defined minimum durations for those without carditis or with healed carditis.[8]
• Protect patients from avoidable treatment-related harm through allergy assessment, safe injection procedures, observation after parenteral medicines, and preparedness to manage anaphylaxis.[8][9]
• Promote timely treatment of sore throats and sustained adherence to secondary prophylaxis through education for schoolchildren, teachers, parents or guardians, patients and families.[10]

The guidance does not set out a separate time-bound strategic plan, quantified national goals, budgeted targets or a formal mission statement beyond its clinical and programme purpose.[1][11]

Implementation

Deliver the programme through health facilities, parish health departments, hospitals and prophylaxis sites, using coordinated clinical care, case notification, patient registers, active follow-up, routine reporting and health education.[1][12][13]The Ministry of Health Jamaica Rheumatic Fever/Rheumatic Heart Disease Control Programme, parish Medical Officers of Health, nurses, the Surveillance Unit, hospital teams and specialist clinicians have defined operational roles.[7][11]

• Use throat-swab culture to confirm group A streptococcal infection where feasible, and make a clinical diagnosis and treat suspected infection where swabbing or culture is unavailable.[14]
• Use penicillin as the preferred treatment for group A streptococcal upper respiratory infection; provide a single intramuscular benzathine benzylpenicillin dose where indicated, continue oral penicillin for at least 10 days when used, and use erythromycin for patients allergic to penicillin.[15]
• Refer every suspected acute rheumatic fever case to hospital, exclude important differential diagnoses, confirm accepted diagnostic criteria before anti-inflammatory treatment, and undertake close cardiac follow-up for probable cases.[5]
• Administer intramuscular benzathine benzylpenicillin secondary prophylaxis generally every 28 days, with three-weekly injections for patients at high risk; observe recipients for at least 30 minutes after injection.[6][7]
• Provide prophylaxis through the health centre nearest to the patient’s home, school or workplace where possible, or through the nearest hospital when more convenient.[8]
• Monitor oral prophylaxis monthly through one-month dispensing and tablet counts, record treatment on patient cards, manage sore throats promptly, and conduct at least annual examination for rheumatic heart disease.[8]
• Train health workers to recognise and manage anaphylaxis, rehearse emergency management at least twice yearly, and ensure injection sites have required emergency medicines and equipment.[8]
• Register confirmed cases at parish health departments and secondary-prophylaxis sites, retain contact and next-of-kin information, and document prophylaxis separately from broader clinic records.[16][12]
• Identify defaulters through weekly or fortnightly register review, contact patients within two weeks of missed appointments, use community health aides and home visits where needed, and document at least three tracing attempts.[16][12][13]
• Notify suspected rheumatic fever, a class 1 notifiable disease, to the parish health department or Surveillance Unit within 24 hours; complete investigations within two weeks and refer unclassified cases to the Paediatric Consultant.[6][7]
• Maintain facility and parish registers, submit investigation forms, monthly programme reports and prophylaxis records to the Surveillance Unit, and use hospital active-surveillance reports to identify possible cases.[12]
• Consolidate parish reports from all prophylaxis sites and participating hospitals, obtain review and sign-off from the parish Medical Officer of Health, submit monthly reports by the 15th of the following month, and submit parish registers quarterly for national updating.[10]
• Use programme data to calculate incidence, prevalence, secondary-prophylaxis compliance and coverage; define compliance as receipt of at least 90% of annual injections or prescribed oral prophylaxis.[12][10]
• Deliver education through clinics, schools, communities, workshops, training sessions, printed materials and appropriate electronic media, reinforcing adherence at every prophylaxis visit.[10][17]

Medical officers oversee prevention, referral, notification, register review, compliance, programme reporting, annual clinical review and emergency readiness, while nurses investigate cases, administer prophylaxis, maintain records and supplies, educate families, follow up defaulters and rehearse anaphylaxis response.[13]The guidance requires drugs and supplies including penicillin, adrenaline, fluids, needles and syringes, but does not specify a programme budget, financing mechanism or resource-allocation plan.[13]

Monitoring & Evaluation

The programme combines case-based surveillance, routine reporting, register management, clinical follow-up and defined managerial review to monitor rheumatic fever and rheumatic heart disease prevention and care.[1][3][12][13]Monthly parish reporting, quarterly register submission and national database maintenance by the Surveillance Unit provide the principal programme-level accountability mechanisms.[12][10]

• Notify suspected rheumatic fever, a class 1 notifiable disease, to the parish health department or Surveillance Unit within 24 hours using the notification and investigation forms.[6]Complete, review and forward investigation forms for suspected or confirmed cases within two weeks, classify cases where possible and refer unclassified cases to the Paediatric Consultant.[6][7]
• Maintain patient registers at health centres or prophylaxis sites, compile parish registers, keep separate prophylaxis records and enter confirmed cases in the national electronic database maintained by the Surveillance Unit.[12]Update clinic registers monthly and review them weekly or fortnightly to identify defaulters.[12]
• Follow up patients who miss prophylaxis appointments within two weeks, document tracing attempts, use community health aides and home visits where needed, and communicate transfers between parish Medical Officers of Health.[16][18][13]Move patients absent for a consecutive two-year period to an inactive list, while reinstating those found not to meet cessation criteria or diagnosed again with rheumatic fever.[16][12][13]
• Monitor oral prophylaxis monthly through tablet counts and patient-card records, and examine patients at least annually for rheumatic heart disease, referring uncertain findings to the regional internist or University Hospital cardiologist.[8]
• Define patient compliance as receipt of at least 90% of annual benzathine benzylpenicillin injections, equivalent to 12 of 13 doses, or 90% adherence to prescribed oral prophylaxis.[10]Calculate centre compliance from compliant and registered patients, and calculate prophylaxis coverage from injections given and due.[10]
• Use register and prophylaxis data to calculate incidence, prevalence and secondary-prophylaxis compliance, support parish performance monitoring and inform annual programme reports.[12]
• Consolidate reports from all parish prophylaxis sites, including participating hospitals, and submit the monthly programme report to the Surveillance Unit by the 15th of the following month.[10]Require the parish Medical Officer of Health to review, comment on and sign reports before submission, and submit parish registers quarterly to update the national register.[10]
• Monitor monthly case totals, new, transferred and removed cases, deaths, injections due and given, compliance, anaphylaxis, hospital admissions, initial and recurrent attacks, and carditis through the programme report.[11][17]Record disease classification, cardiac involvement, echocardiogram findings, hospitalisation and duration of stay through the case-investigation form.[11]
• Track primary-prevention activity through the number and audience of education sessions, materials distributed or displayed, and health workers trained by cadre.[17]
• Assess clinical safety by rehearsing anaphylaxis management at least twice yearly and verifying that injection sites have minimum emergency medicines and equipment.[8]Monitor vital signs every 10 minutes during supportive treatment and retain patients under medical observation for at least four hours.[16]
• Conduct quality-of-care assessments and audits using the guidelines as their basis.[1]

The guidance does not specify a consolidated evaluation timetable, numerical programme targets, routine surveillance analyses or a broader formal accountability framework beyond the notification, reporting, register, clinical-review and sign-off procedures described.[1][6][10]

Costing & Financing

Financial information is limited. Rheumatic fever and rheumatic heart disease are described as requiring substantial medical and surgical resources, including repeated hospitalisation and surgery, but the guidance provides no programme budget, financing mechanism, funding-gap assessment, resource-mobilisation strategy or economic assumptions.[2]

• Record that a 1995 Jamaican hospital survey estimated a cost of 105,000 Jamaican dollars for a 21-day admission per case.[2]
• Record that the same survey estimated annual expenditure of 17 million Jamaican dollars across Kingston Public Hospital, University Hospital and Bustamante Hospital.[2]
• Recognise that cefalosporins and newer macrolides cost more than penicillin, without a quantified price comparison.[15]
• Provide drugs and supplies needed for delivery, including penicillin, adrenaline, fluids, needles and syringes, although no monetary allocation is given.[13]
• Maintain service resources for prophylaxis delivery, patient follow-up, register administration, training and anaphylaxis preparedness, without specified costs or funding sources.[8][12][13]

No further explicit machine-readable costs, budgets, allocations or funding sources are specified in the supplied material.[11][17]