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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
242
AFRICA
A programme to increase appropriate usage of
benzathine penicillin for management of streptococcal
pharyngitis and rheumatic heart disease in Zambia
Aidan Long, Joyce Chipili Lungu, Elizabeth Machila, Sherri Schwaninger, Jonathan Spector, Brigitta
Tadmor, Mark Fishman, Bongani M Mayosi, John Musuku
Abstract
Rheumatic heart disease is highly prevalent and associated
with substantial morbidity and mortality in many resource-
poor areas of the world, including sub-Saharan Africa.
Primary and secondary prophylaxis with penicillin has been
shown to significantly improve outcomes and is recognised
to be the standard of care, with intra-muscular benzathine
penicillin G recommended as the preferred agent by many
technical experts. However, ensuring compliance with therapy
has proven to be challenging. As part of a public–private
partnership initiative in Zambia, we conducted an educa-
tional and access-to-medicine programme aimed at increasing
appropriate use of benzathine penicillin for the prevention
and management of rheumatic heart disease, according to
national guidelines. The programme was informed early on
by identification of potential barriers to the administration of
injectable penicillin, which included concern by health work-
ers about allergic events. We describe this programme and
report initial signs of success, as indicated by increased use
of benzathine penicillin. We propose that a similar approach
may have benefits in rheumatic heart disease programmes in
other endemic regions.
Keywords:
rheumatic fever, rheumatic heart disease, benzathine
penicillin, pencillin allergy
Submitted 27/9/16, accepted 2/1/17
Cardiovasc J Afr
2017;
28
: 242–247
www.cvja.co.zaDOI: 10.5830/CVJA-2017-002
Rheumatic heart disease (RHD) is a major cause of morbidity
and mortality in sub-Saharan Africa (SSA).
1,2
Up to 3% of
school-aged children have definite or borderline RHD,
3-5
and
congestive heart failure stemming from valve damage in RHD
patients is a leading non-infectious cause of death in young
adults.
6,7
Acute heart failure from RHD in SSA has been
associated with a 35% one-year mortality rate
.
8
Yet RHD is preventable and, to some degree, treatable. Evidence
generated more than 60 years ago demonstrated that antibiotic
treatment of group A
Streptococcus
(GAS) pharyngitis, a practice
known as ‘primary prevention’, significantly reduced the risk of
rheumatic fever (RF).
9-11
Shortly thereafter, it was shown that
‘secondary prevention’, in which antibiotics are administered
continuously for a period of many years to patients with RHD,
was effective at suppressing new streptococcal infections and
decreased the incidence of recurrent RF.
10,12-14
The initial RF and
RHD studies used penicillin as the antibiotic of choice and, to this
day, GAS remains exquisitely sensitive to penicillin treatment.
15-17
Penicillin continues to be the standard of care for primary and
secondary prevention of RHD globally in non-allergic individuals.
2
In resource-constrained parts of the world where RHD is still
endemic, including SSA, the use of penicillin for RHDprevention
and treatment is widely recognised to be suboptimal.
18-20
The
reasons for this are complex and related to a multitude of
interacting factors, including drug supply, pharmaco-economics,
health service infrastructure and possibly socio-cultural drivers.
21
Indeed, a recent high-level report outlining the key actions
required to eradicate RHD in Africa identified variable supply
and suboptimal quality and use of penicillin as some of the
major barriers to achievement of this goal,
22
a position endorsed
by the World Heart Federation.
23
Penicillin comes in various formulations. Benzathine penicillin
G (BPG), a World Health Organisation essential medicine, is an
intramuscular injectable form with a long half-life, such that
only a single dose is required for primary prevention (in contrast
to a 10-day course of oral pills taken twice daily), and a single
monthly dose is needed for secondary prevention (compared
with a regimen of oral pills taken twice daily).
10
In SSA, leading technical authorities, including the
Pan-African Society of Cardiology (PASCAR), have advocated
the use of BPG for the treatment of streptococcal
pharyngitis
and the management of RHD to maximise the likelihood of
patient compliance with recommended regimens, an approach
that has met with success in other low-resource settings.
22,24,25
There is also evidence that BPG may be more effective than oral
penicillin for secondary prophylaxis of RHD and, consequently,
it is a commonly recommended therapy.
14,26,27
In 2012, a public–private partnership was launched in Zambia
with the goal of reducing and ultimately eliminating RHD.
28
This
Massachusetts General Hospital, Boston, USA
Aidan Long, MD,
aalong@mgh.harvard.eduUniversity Teaching Hospital, Lusaka, Zambia
Joyce Chipili Lungu, RN
Elizabeth Machila, RN
John Musuku, MD
Novartis Institutes for BioMedical Research, Cambridge,
USA
Sherri Schwaninger, MBA
Jonathan Spector, MD
Brigitta Tadmor, PhD
Harvard Stem Cell and Regenerative Biology Department,
Harvard University, Cambridge, USA
Mark Fishman, MD
Department of Medicine, Groote Schuur Hospital and
University of Cape Town, Cape Town, South Africa
Bongani M Mayosi, MD