Prevention and Control of Rheumatic Heart Disease in Kenya: Issues and Barriers
Rheumatic heart disease (RHD) is the most common acquired heart disease in children (common age group is 5 to 15 year olds) in developing countries. Over 15 million people suffer from the condition, resulting in about 233 000 deaths annually. RHD is a chronic heart condition caused by rheumatic fever – whose main symptoms include fever, muscle aches, swollen and painful joints, and in some cases, a red rash. Rheumatic fever is as a result of an untreated strep throat that is caused by bacteria called group A streptococcal (strep) infection. Overcrowding, poor housing conditions, undernutrition and lack of access to healthcare play a role in the persistence of this disease in developing countries.
According to the World Heart Federation (WHF), the “primary prevention of acute rheumatic fever (the prevention of initial attack) is achieved by treatment of acute throat infections caused by group A streptococcus. This is achieved by up to 10 days of an oral antibiotic (usually penicillin) or a single intramuscular penicillin injection.” Moreover, regular antibiotics (usually monthly injections) can prevent patients with rheumatic fever from contracting further strep infections and causing progression of valve damage. The decline of rheumatic fever in developed countries is believed to be the result of improved living conditions and availability of antibiotics for treatment of group A streptococcal infection.
Although Rheumatic Heart Disease (RHD) has been eradicated in the developed world (Carapetis 2007), it still imparts significant health and economic burdens in developing countries worldwide (Ozer et al. 2005, Nitin et al. 2013). The irony is that the disease is completely preventable. A study performed in western Kenya showed that 9 out of the 526 enrolled patients exhibited echocardiographic evidence of RHD (Holland 2012). The transthoracic echocardiograms were performed on randomly selected hospitalized patients, aged 5-35, who were not previously diagnosed with RHD, on the surgical wards.
The Issues and Barriers to RHD Control
RHD is a neglected ‘preventable’ chronic disease that requires continuous and expensive medical follow-up if not prevented or treated effectively as early as possible. RHD is closely associated with poverty and poor quality medical services, so most RHD patients are not able to access medical services in a timely or effective manner (Okello et al. 2012). After initiating treatment, most patients are lost to follow up. As a result, the disease often progresses to advanced stages with complicating comorbid conditions, in which treatment is rarely successful. This contributes to the high morbidity and mortality rates observed in patients diagnosed with RHD in Kenya.
Kenya’s health system is inappropriately designed and inadequately financed to prevent and to manage RHD – with poorly equipped hospitals, a low doctor to patient ratio, and unaffordable drugs such as penicillin. The issue is exacerbated by a flawed national health insurance plan through which patients are still unable to afford medical services (Kimani et al. 2012, Stone et al. 2014).
RHD requires specialized care, only accessible in Nairobi and a few urban centers across Kenya (Jowi 2012). Even in such places, availability of services at public hospitals is limited due to inadequate numbers of cardiologists or lack of necessary diagnostic and treatment facilities. “We need to treat approximately 500 patients with RHD, but we can only handle about 50 open heart surgeries locally due to resource constraints.” stated Prof Gerald Yonga, Chair Department of Medicine at the Aga Khan University Hospital, Kenya.
Widespread lack of awareness and accurate information about RHD in part explain why prevention is rare and many RHD cases are diagnosed too late to treat effectively (Mondo et al. 2013). Furthermore, the presentation of RHD often mimics many other tropical fevers (malaria, typhoid), and thus also presents a challenge to early detection. At presentation, many healthcare workers misdiagnose, prescribe inappropriate treatment, and do not design adequate follow-up mechanisms for their patients, contributing to late presentation, complications, and meager patient follow-up.
Action required to reduce barriers to RHD Prevention and Care
RHD is preventable by detecting and treating streptococcal sore throats early, ensuring access to penicillin as well as by streamlining the healthcare infrastructure. There is thus a role for urgent multi-sectoral promotion of holistic healthcare in Kenya to ensure early diagnosis and affordable access to health services for those at risk, so as to alleviate this preventable burden.
Part 2 of this blog highlights some multisectoral actions in place in Kenya to combat RHD.
- Carapetis, Jonathan R. 2007. “Rheumatic Heart Disease in Developing Countries.” New England Journal of Medicine 357 (5): 439–41. doi:10.1056/NEJMp078039.
- Holland, Thomas. 2012. “The Prevalence of Rheumatic Heart Disease in Western Kenya: An Echocardiographic Study”. Duke University. http://dukespace.lib.duke.edu/dspace/handle/10161/6204.
- Joseph Nitin, Deepak Madi, Ganesh S Kumar, Maria Nelliyanil, Vittal Saralaya, and Sharada Rai. 2013. “Clinical Spectrum of Rheumatic Fever and Rheumatic Heart Disease: A 10 Year Experience in an Urban Area of South India.” North American Journal of Medical Sciences 5 (11): 647–52. doi:10.4103/1947-2714.122307.
- Kimani James, Remare Ettarh, Catherine Kyobutungi, Blessing Mberu, and Kanyiva Muindi. 2012. “Determinants for Participation in a Public Health Insurance Program among Residents of Urban Slums in Nairobi, Kenya: Results from a Cross-Sectional Survey.” BMC Health Services Research 12 (March): 66. doi:10.1186/1472-6963-12-66.
- Mondo Charles, Charles Musoke, James Kayima, Jurgen Freers, Wanzhu Zhang, Emmy Okello, Barbara Kakande, and Wilson Nyakoojo. 2013. “Presenting Features of Newly Diagnosed Rheumatic Heart Disease Patients in Mulago Hospital: A Pilot Study.” Cardiovascular Journal of Africa 24 (2): 28–33. doi:10.5830/CVJA-2012-076.
- Okello Emmy, Barbara Kakande, Elias Sebatta, James Kayima, Monica Kuteesa, Boniface Mutatina, Wilson Nyakoojo, et al. 2012. “Socioeconomic and Environmental Risk Factors among Rheumatic Heart Disease Patients in Uganda.” PLoS ONE 7 (8). doi:10.1371/journal.pone.0043917. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428272/.
- Ozer Sema, Olgu Hallioğlu, Süheyla Ozkutlu, Alpay Celiker, Dursun Alehan, and Tevfik Karagöz. 2005. “Childhood Acute Rheumatic Fever in Ankara, Turkey.” The Turkish Journal of Pediatrics 47 (2): 120–24.
- Stone GS, Titus Tarus, Mainard Shikanga, Benson Biwott, Thomas Ngetich, Thomas Andale, Betsy Cheriro, and Wilson Aruasa. 2014. “The Association between Insurance Status and in-Hospital Mortality on the Public Medical Wards of a Kenyan Referral Hospital.” Global Health Action 7 (February). doi:10.3402/gha.v7.23137. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925809/.
- Jowi Christine Awuor. 2012. “African Experiences of Humanitarian Cardiovascular Medicine: A Kenyan Perspective.” Cardiovascular Diagnosis and Therapy 2 (3): 231–39. doi:10.3978/j.issn.2223-3652.2012.07.04.
Dr. Duncan M. Matheka is a Kenyan Medical Doctor and Public Health Researcher. He is a member of Young Professionals Chronic Disease Network (YPCDN) and is the Nairobi RHD Patient Club Coordinator. Twitter @duncoh1
Dr. Laura Musambayi is a Kenyan Medical Doctor and the Nairobi RHD Club Assistant Coordinator.
Mohamed A. Omar is a fourth year medical student at the University of Nairobi, Kenya.
Dr Kate Armstrong is the Founder and President of CLAN (Caring & Living As Neighbours) and the Executive Secretary of NCD Child (a global coalition committed to integrating children and adolescents within the global NCD, health and development discourse). Twitter @ncdchild