Cardiovascular Journal of Africa: Vol 30 No 6 (November/December 2019)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 6, November/December 2019 AFRICA 369
Availability and administration of benzathine penicillin G
for the prevention of rheumatic fever in Africa: report of
the Working Group on Penicillin, Pan-African Society of
Cardiology Task Force on Rheumatic Heart Disease
Sulafa Ali, Aidan Long, Jean B Nikiema, Geoffrey Madeira, Rosemary Wyber
Abstract
Methods: Penicillin is the cornerstone of management for
rheumatic heart disease (RHD), an important public health
problem in Africa. An online survey was used to collect data
from African health workers about availability and adminis-
tration of penicillin.
Results: There were 30 respondents from 14 countries.
Unavailability of benzathine penicillin G (BPG) was reported
by 30% of respondents. Skin testing was practiced by 40%
of respondents, 30% did not have administration guides and
only 30% had emergency kits available. The interval of BPG
for secondary prophylaxis varied between two and four weeks.
Major adverse reactions were observed by 30% of respond-
ents, including anaphylactic shock/death in six cases. Forty-
three per cent of respondents reported that health workers
had concerns about BPG administration, including worry
about reactions, pain and the viscosity of the solution, and
50% were not confident to manage BPG allergy.
Conclusion: BPG availability should be addressed and African
health workers’ knowledge and practices need to be augmented.
Keywords: penicillin, Africa, availability, administration
Submitted 5/11/18, accepted 14/7/19
Cardiovasc J Afr 2019; 30: 369–372
DOI: 10.5830/CVJA-2019-042
Rheumatic heart disease (RHD) affects about 33 million people
worldwide and leads to 320 000 deaths annually; most of these
cases occur in sub-Saharan Africa and Asia.1 Penicillin is the
principal antibiotic for prevention of acute rheumatic fever
(ARF) and RHD. Benzathine penicillin G (BPG) is a long-
acting formulation of penicillin that can be administered as a
single-dose treatment for bacterial pharyngitis and as three- to
four-weekly secondary prophylaxis of ARF. The four-weekly
interval was found to be less effective in reducing rheumatic fever
relapses when compared with two-weekly intervals, therefore
some countries use a two-weekly regimen. 2 Other indications for
BPG include treatment of syphilis, particularly prevention of
mother-to-child transmission, and management of hyposplenism
in sickle cell disease.
BPG has been included in each iteration of the World Health
Organisation (WHO) Essential Medicines list since the list was
developed.3 Therefore BPG is expected to be available in most
low- and middle-income countries where RHD is prevalent.
However, reports of shortages are widespread and use of the
drug has been further complicated by concerns about quality,
adverse events and optimal administration techniques.4
In 2016 the Pan-African Society of Cardiology (PASCAR)
initiated a broad RHD control agenda with support from the
African Union, codified in the Addis Ababa Communiqué. The
PASCAR approach focused on seven key actions to eradicate
RHD from Africa.5 The second of these actions was to address
the issues surrounding BPG and the Penicillin Working Group
was formed. The objective of the Penicillin Working Group in the
long term is to help establish safe and efficacious BPG and oral
penicillin supply and use at primary-care level in African countries.
This survey represents the first output of the Working
Group to document penicillin availability and utility in African
countries. This pragmatic approach is intended to identify
priorities for improving the use of penicillin in Africa.
Methods
An online survey was designed by the Working Group and
formulated in Survey Monkey. The survey questions can be
viewed online at
The survey tool addressed five key domains: availability, brands
and prices, administration, adverse reactions and health workers
concerns and needs. The questionnaire was sent to the PASCAR
RHD community (160 people) through e-mails and re-circulated
three times. Participants were asked to invite their colleagues
who work with RHD to fill in the questionnaire. Ethics approval
was not considered necessary or feasible for this low-risk survey
across a number of jurisdictions.
Paediatric Cardiology, University of Khartoum and Sudan
Heart Centre, Sudan
Sulafa Ali, FRCPCH, FACC,
Allergy and Clinical Immunology, Harvard Medical School,
USA
Aidan Long, MB BCh
Essential Medicines, WHO Regional Office for Africa,
Brazzaville, Congo
Jean B Nikiema, PhD
Ministry of Health, National Institute of Health of Mozambique
Geoffrey Madeira, MD
George Institute for Global Health and Head of Strategy,
END RHD, Telethon Kids Institute, Australia
Rosemary Wyber, MB ChB, MPH, FRACGP