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

Objectives

Provide a national framework for preventing, diagnosing, treating, reporting and monitoring rheumatic fever and rheumatic heart disease in Jamaica, promoting consistent management across health facilities and reducing recurrence, morbidity and mortality.[1]The framework prioritises primary prevention through prompt recognition and antibiotic treatment of group A streptococcal sore throats, alongside continuous secondary prophylaxis and follow-up for people with rheumatic fever or rheumatic heart disease.[2][3]

• Prevent initial rheumatic fever by diagnosing and adequately treating suspected group A streptococcal upper respiratory infection, using throat-swab culture where available and clinical management where testing cannot be undertaken.[4]
• Eradicate streptococcal infection with penicillin as the preferred treatment, while providing suitable alternatives for people with penicillin allergy.[5]
• Diagnose acute rheumatic fever, recurrent attacks, rheumatic chorea, insidious carditis and chronic rheumatic heart disease using the revised Jones criteria, evidence of preceding streptococcal infection where applicable, and exclusion of alternative diagnoses.[6][7]
• Manage acute manifestations including arthritis, carditis, chorea and cardiac failure, while referring suspected rheumatic fever cases to hospital for diagnosis and management.[7][8]
• Prevent recurrent disease through regular secondary antibiotic prophylaxis, tailored to clinical risk, age, cardiac involvement and susceptibility to recurrence.[3][9]
• Continue prophylaxis for life for patients with chronic rheumatic heart disease or artificial valves, and maintain prophylaxis during pregnancy with appropriate substitutions where required.[9]
• Prevent complications from treatment by maintaining preparedness for anaphylaxis and ensuring trained personnel, emergency equipment and observation after parenteral medication.[9][10]
• Prevent infective endocarditis in patients with rheumatic valvular heart disease through education and antibiotic prophylaxis before specified invasive or bleeding-producing procedures.[11][12]
• Increase public and patient awareness of sore-throat treatment, primary prevention and adherence to secondary prophylaxis through health-promotion activities targeted particularly at schoolchildren, teachers, parents and guardians.[13][14]

Implementation

Deliver the programme through medical officers, nurses, nurse practitioners, hospitals, health centres, parish health departments, parish coordinators and the national Surveillance Unit, combining clinical care, patient registration, defaulter tracing, standardised reporting and health education.[1][8][13]Secondary prophylaxis is intended to be accessible through the health centre nearest to a patient’s home, school or workplace, or the nearest hospital where this is more practical.[9]

• Administer intramuscular benzathine benzylpenicillin as the principal secondary-prophylaxis regimen, generally every 28 days after discharge, using safe injection preparation and technique and observing patients for at least 30 minutes.[8][3]
• Schedule appointments to support timely prophylaxis, provide oral medicines one month at a time where used, assess adherence through tablet counts, and record prophylaxis monthly on patient cards.[9]
• Conduct at least annual medical reviews and regular heart examinations, with referral to a regional internist or cardiologist when findings are uncertain.[9]
• Train health workers to recognise and manage anaphylaxis, rehearse management at least twice yearly, and maintain emergency trays, medicines and equipment at injection sites.[9][10]
• Register confirmed rheumatic fever and rheumatic heart disease cases at parish level and at selected prophylaxis sites, maintaining clinic registers, parish registers and a national electronic database.[11][12][15]
• Trace patients who miss prophylaxis through community health aides, beginning within two weeks and making at least three documented attempts, with cross-parish communication and home visits where necessary.[11]
• Notify suspected rheumatic fever within 24 hours to the parish health department or Surveillance Unit, investigate suspected or confirmed cases within two weeks, and use standardised notification and investigation forms.[8][3]
• Maintain active surveillance through weekly hospital reports, classify cases where possible, seek paediatric consultant advice for unresolved classifications, and update registers for new cases, migration, deaths, defaults and removals.[3][15]
• Submit consolidated parish programme reports monthly to the Surveillance Unit by the 15th of the following month, and submit parish-register copies quarterly to update the national register.[13][14]
• Monitor programme performance through incidence, prevalence, prophylaxis coverage, compliance, recurrences, carditis, hospital admissions, adverse events, health-education reach and numbers of health workers trained.[15][16][17]
• Define compliance as receipt of at least 90% of annual benzathine benzylpenicillin injections, specified as 12 of 13 doses, or 90% of prescribed oral prophylaxis; calculate centre compliance and injection coverage from registered patients and doses due.[14]
• Assign medical officers responsibility for prevention oversight, referrals, registers, coverage, compliance, annual review and emergency preparedness, while requiring nurses and nurse practitioners to investigate cases, administer prophylaxis, maintain records, educate patients and contact defaulters.[13]
• Maintain adequate supplies of penicillin, adrenaline, fluids, needles and syringes for prophylaxis and anaphylaxis management.[13]

Monitoring & Evaluation

The monitoring framework combines case notification and investigation, patient registers, secondary-prophylaxis follow-up, facility readiness, and parish and national reporting. Suspected rheumatic fever is a class 1 notifiable disease and must be reported to the parish health department or Surveillance Unit within 24 hours.[8]Programme records support identification of cases, documentation of clinical and cardiac involvement, prophylaxis management, primary-prevention activity, and review by responsible health personnel.[18][16]

• Notify suspected cases within 24 hours using the required notification and investigation forms, then complete investigations within two weeks. Hospital Medical Officers submit forms to the parish Medical Officer of Health, while assigned Public Health Nurses are responsible for ensuring timely completion.[8][3]
• Review investigation forms for completeness, assign classifications where possible, forward copies to the Surveillance Unit for verification, and seek Paediatric Consultant advice for cases that remain unclassified.[3]
• Maintain clinic or health-centre registers, parish registers, and an electronic national database, entering confirmed cases from investigation forms.[12][15]
• Update clinic prophylaxis registers monthly for new cases, migration and deaths; check them weekly or fortnightly for defaulters; and report removals to the coordinator.[12][15]
• Trace patients who miss secondary prophylaxis through community health aides, beginning within two weeks and making at least three documented attempts, including home visits and cross-parish communication where required.[11]
• Record prophylaxis monthly on patient cards, monitor oral-prophylaxis adherence through prescription control and tablet counts, and conduct at least one medical review annually, with specialist referral when findings are uncertain.[9]
• Use secondary-prophylaxis register data to calculate incidence, prevalence and compliance, enabling parishes to monitor and improve programme management.[15]
• Define compliance as receipt of at least 90% of annual benzathine benzylpenicillin injections, specified as 12 of 13 doses, or 90% of prescribed oral prophylaxis.[14]
• Calculate centre compliance as compliant patients divided by registered patients, and calculate prophylaxis coverage as injections administered divided by injections due.[14]
• Submit consolidated parish programme reports to the Surveillance Unit by the 15th of the following month, covering all prophylaxis sites and reasons for register removals; submit parish-register copies quarterly to update the national register.[13][14]
• Compile national data through the Surveillance Unit, using investigation forms, monthly reports, secondary-prophylaxis records, and weekly hospital active-surveillance reports; prepare annual programme reports.[15]
• Monitor monthly reports for registered and removed cases, deaths, admissions, suspected and confirmed cases, initial and recurrent attacks, carditis, injections due and administered, fully compliant clients, and anaphylaxis.[16]
• Track health-promotion delivery through measures covering education reach by setting, materials distributed or displayed, and health workers trained by professional category.[16][17]
• Review and sign parish reports through the parish Medical Officer (Health), and conduct monthly programme reviews by the medical officer and nurse-in-charge.[13][14]
• Maintain accountability through documented coordinator, investigator and notifier details, signatures, dates, comments, and Medical Officer of Health review.[18][16][17]
• Assess patients with carditis daily, provide close follow-up and regular heart examinations for probable rheumatic fever, and maintain regular secondary prophylaxis.[7]
• Observe patients receiving parenteral medication for at least 30 minutes and maintain emergency preparedness for anaphylaxis, including twice-yearly rehearsals and emergency trays at injection sites.[3][9][10]
• Monitor vital signs every 10 minutes during anaphylaxis treatment, observe patients medically for at least four hours, and provide hospital observation for 48 hours or longer after severe anaphylaxis has stabilised.[19]

Quality-of-care assessments and audits are to use the guidelines as their basis under Ministry of Health responsibility, and the guidelines may be modified periodically.[1]The source provides substantial operational indicators and reporting mechanisms, but does not specify programme-wide performance targets beyond prophylaxis compliance and coverage measures.[1][14]

Costing & Financing

Cost information is limited. Rheumatic fever and rheumatic heart disease are characterised as requiring substantial medical and surgical resources, including repeated hospitalisation and surgery.[2]A 1995 Jamaican hospital survey estimated both per-admission expenditure and annual expenditure across three hospitals, but the material provides no current programme budget or financing plan.[2]

• Estimate a cost of Jamaican dollars 105,000 for a 21-day admission per rheumatic fever or rheumatic heart disease case in the 1995 survey.[2]
• Estimate annual expenditure of Jamaican dollars 17 million in 1995 across Kingston Public Hospital, University Hospital and Bustamante Hospital.[2]
• Identify resource needs for prophylaxis and anaphylaxis management, including penicillin, adrenaline, intravenous fluids, needles, syringes, emergency trays, observation capacity, hospital referral, patient tracing and home visits.[10][19][11][13]
• Note that cefalosporins and newer macrolides are more expensive alternatives to penicillin.[5]

No budgets, allocations, funding sources, financing arrangements, resource-mobilisation measures, funding-gap estimates, or economic assumptions are specified for the control programme.[1][12][18]