Secondary Prophylaxis

Secondary prophylaxis with regular benzathine penicillin G (BPG) is the only rheumatic heart disease (RHD) control strategy shown to be both clinically and cost effective at community and individual levels (Webb 2015, Wyber & Carapetis 2015, RHD Australia 2020). According to the clinical guidelines in place when the data in this report were collected, the recommended regimen to prevent recurrences of acute rheumatic fever (ARF) and progression of RHD involves regular intramuscular injections of BPG every 21 to 28 days, for a minimum of 10 years (RHD Australia 2012). (The 2020 guidelines now state a minimum of 5 years since the most recent ARF episode.) This treatment aims to provide penicillin in the blood over a period of 3 to 4 weeks, providing protection against Strep A infections (Wyber 2013). As the penicillin concentration wanes, the individual’s susceptibility to subsequent Strep A infection and to recurrent ARF will increase. 

Delivery of BPG every 28 days is challenging for health services, affected individuals and their families. In remote Indigenous communities, a major factor contributing to low levels of prophylaxis delivery is the availability and acceptability of health services. Personal factors such as injection refusal, pain caused by injections or a lack of knowledge and understanding of ARF and RHD may negatively influence adherence to secondary prophylaxis but are often not the major contributing factors (Parnaby & Carapetis 2010).

References

RHD Australia, (ARF/RHD writing group), National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand, 2012. The Australian guideline for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edn). Northern Territory: RHD Australia, Menzies School of Health Research.

RHD Australia, (ARF/RHD writing group). The 2020 Australian guideline for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edn). Northern Territory: RHD Australia, Menzies School of Health Research.

Parnaby M & Carapetis J 2010. Rheumatic fever in Indigenous Australian children. Journal of Paediatrics and Child Health 46:527–33.

Webb RH, Grant C, Harnden A. 2015. Acute Rheumatic Fever. British Medical Journal 351(8017).

Wyber R & Carapetis J. 2015. Evolution, evidence and effect of secondary prophylaxis against rheumatic fever. Journal of Practice of Cardiovascular Sciences 1(1) 9–14.

Wyber R, Taubert K, Marko S and Kaplan EL. 2013. Benzathine penicillin G for the management of RHD, concerns about quality and access, and opportunities for intervention and improvement. Global Heart 8(3):227–234.