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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
AFRICA
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medicines in the allergy kit are clearly displayed and labelled to
facilitate quick and proper use.
Ongoing supportive supervision in clinics
Nurses from UTH provide on-site supportive supervision once
or twice monthly to each clinic enrolled in the RHD control
programme. These visits have been determined to be necessary
in order to provide regular refresher education and training
relating to drug allergy and other aspects of the RHD control
programme (for example, primary and secondary prevention);
to answer questions and help solve problems that invariably
arise at the point of care; to check and re-stock the allergy kit as
necessary; and to confirm that each health centre’s pharmacy has
an adequate stock of penicillin, including BPG.
Assessment of BPG availability
Through the RHD control programme, free penicillin treatment
is offered to patients for primary and secondary prevention
of RHD. To help ensure availability of high-quality medicine,
in-country stocks of penicillin were augmented by a product
grant of 25 000 doses from Sandoz, in accordance with World
Health Organisation guidelines for medicine donations.
31
The
product grant was a supplement; we found that BPG procured
through normal government processes was virtually always also
available in enrolled clinics.
Training followed by supportive and mentorship visits have
also been commenced in provinces outside Lusaka, with the
first one being in Choma (Southern Province), where ongoing
supportive supervision in clinics and assessment of BPG
availability will be replicated.
Initial outcomes
Baseline information obtained from the initial workshop
indicated an extremely low (and perhaps even zero) rate of usage
of BPG for primary and secondary prevention of RHD among
health workers at UTH and Lusaka area government health
facilities. Now, two years later, we have observed substantial
changes in the pattern of BPG usage as a result of the
programme’s interventions.
We conducted structured interviews with 18 nurses, clinical
officers and pharmacists in seven clinics that had been enrolled
in the RHD control programme for four to six months. Ninety
per cent of respondents had administered injectable penicillin
since the training, and most of them reported that they had
administered the medicine on many occasions. Six of the 18
participants reported that using injectable penicillin to treat
pharyngitis was a new practice for them, which they had
learned as a result of the programme. None of the health
workers thought it was too much work to administer injectable
penicillin compared with pills. Only one nurse had apprehension
about giving injectable penicillin, and she requested from the
programme nurses more training on allergy recognition and
management; all other health workers reported that they felt
comfortable recognising and managing penicillin allergy as a
result of the knowledge and skills gained in the training.
All heath workers interviewed believed that patients actually
preferred injections to pills due to the perception that it was a
more effective treatment. Many of the respondents also reported
that they preferred the 1.2 million IU formulation to the 2.4
million IU formulation, since it was easier to dose in children.
While the number of participants in this pilot evaluation was
small, we believe that it provides an early signal on the impact
of the programme.
To date, 21 government health facilities in Lusaka have been
enrolled in the RHD control programme and records indicate
that more than 9 000 doses of BPG have been administered
since the programme started, the majority of which was used
for primary prevention of RHD (the incidence of pharyngitis
was much higher than the number of patients with RHD who
required secondary prophylaxis). Penicillin-allergy skin testing
prior to BPG administration was not routinely undertaken. No
case of anaphylaxis has been recorded. Further scale-up of the
RHD control programme in Lusaka Province is underway, as
is expansion to the Southern Province. Extension to additional
provinces is anticipated during 2017.
Discussion
Rheumatic fever and RHD are preventable and potentially
eradicable conditions that still account for significant morbidity
and mortality rates in Zambia, other countries in SSA and other
underdeveloped areas of the world. Low rates of penicillin use,
including BPG, in appropriate clinical circumstances are likely
to be a factor accounting for the continuing high prevalence of
these diseases.
18
From our experience, included among the important
underlying drivers that contribute to low rates of BPG usage
are a lack of appropriate knowledge regarding the confirmed
benefits to be derived from its use and the fear of potential
adverse events, including allergic reactions. Similar observations
have also been made in other regions of the world where RHD is
endemic.
32
That fear of penicillin allergy emerged as a significant
barrier to BPG use, which came as somewhat of a surprise, since
apprehension towards drug allergy has not been commonly
described among health workers in SSA, and scant literature
exists on adverse penicillin reactions in population-based studies
of RF and RHD.
A multinational study in 1991 that included 32 430 BPG
injections in 1 790 patients estimated the risk of anaphylaxis to
be exceedingly low, at approximately one in 10 000 injections,
33
and a 2014 retrospective study of BPG treatment in RF in
Turkey found confirmed allergy in one of 535 patients (0.18% of
17 641 injections) but documented no anaphylactic reactions.
34
Three fatalities that were temporally related to BPG injection
were reported from Zimbabwe more than 15 years ago, although
clinical details were not well described and so it is not clear that
drug allergy played a role.
35
We document here that relatively simple interventions,
including appropriate education of healthcare personnel,
together with confidence building around the recognition and
management of allergic drug reactions, followed by a number
of low-cost ongoing supportive measures have the potential to
significantly improve rates of BPG usage in the primary and
secondary prevention of RHD in a low-resource setting.
Our early data also suggest that there is no need to perform
routine penicillin-allergy testing prior to BPG administration in
patients without a prior history of adverse reactions to penicillin.