ARF & RHD Primordial and Primary Prevention
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1 ARF & RHD Primordial and Primary Prevention Bart Currie Infectious Diseases Department, Royal Darwin Hospital Global and Tropical Health Division, Menzies Northern Territory Medical Program, Flinders & CDU
2 Quick Quiz
3 Group A Streptococcal Diseases Streptococcus pyogenes = Gp A streptococcus = GAS Pharyngitis Pyoderma Cellulitis Invasive Diseases Septicemia Pneumonia, osteomyelitis, septic arthritis, meningitis Puerperal sepsis # # Necrotising fasciitis Streptococcal toxic shock (like) syndrome - STSS Post-streptococcal sequelae Acute rheumatic fever (ARF) Glomerulonephritis (APSGN)
4 What determines GAS clinical disease?
5 What determines GAS clinical disease? Site of infection throat, skin Infecting organism load GAS strain factors >200 emm genotypes differential virulence genes; M protein & many more Host innate immunity & other genetic variabilities Host risk factors diabetes, renal disease, immunosuppression Host acquired immunity to GAS from prior infections cumulative strain-specific immunity with age some cross-protection amongst emm types; emm clusters Anti-toxin acquired immunity; eg anti-speb antibodies? can pan-immunity develop with age Access to hygiene & access to and timing of antibiotics
6 Pharyngitis Pyoderma Cellulitis Group A Streptococcal Diseases Invasive Diseases Septicemia Pneumonia, osteomyelitis, septic arthritis, meningitis Puerperal sepsis # # Necrotising fasciitis Streptococcal toxic shock (like) syndrome - TSS Post-streptococcal sequelae Acute rheumatic fever (ARF) Glomerulonephritis (APSGN)
7 Pharyngitis Pyoderma Cellulitis Group A Streptococcal Diseases Invasive Diseases Septicemia Pneumonia, osteomyelitis, septic arthritis, meningitis Puerperal sepsis # # Necrotising fasciitis Streptococcal toxic shock (like) syndrome - TSS Post-streptococcal sequelae Acute rheumatic fever (ARF) Glomerulonephritis (APSGN)
8 Acute Post-Streptococcal Glomerulonephritis
9 Acute Post-Streptococcal Glomerulonephritis
10 Acute Post-Streptococcal Glomerulonephritis
11 Acute Post-Streptococcal Glomerulonephritis
12 Acute Post-Streptococcal Glomerulonephritis
13 Pharyngitis Pyoderma Cellulitis Group A Streptococcal Diseases Invasive Diseases Septicemia Pneumonia, osteomyelitis, septic arthritis, meningitis Puerperal sepsis # # Necrotising fasciitis Streptococcal toxic shock (like) syndrome - TSS Post-streptococcal sequelae Acute rheumatic fever (ARF) Glomerulonephritis (APSGN)
14 Pathogenesis of Acute Rheumatic Fever Organism factor(s) ( Rheumatogenicity ) Host factor(s) (Genetic susceptibility) Abnormal immune response Acute rheumatic fever
15 Age and Gp A streptococcal sequelae John Mathews drew this many years back.
16 Throat and skin and ARF and APSGN? ARF Skin GAS?? priming Throat GAS APSGN
17 Strep infection of throat Acute rheumatic fever Recurrent ARF Rheumatic heart disease Heart Failure Stroke, endocarditis Cardiac surgery Death
18 Key Performance Indicators? No child in Australia dying from complications of ARF/RHD
19 Preventing ARF and RHD GAS infection ARF Primordial prevention Primary prevention -Sore throat Rx -? Vaccine -? Skin sore Rx Often prolonged asymptomatic period of RHD Secondary prevention -Regular penicillin RHD Tertiary prevention -Heart failure medication -Surgery -Anticoagulation Cardiac surgery Stroke, endocarditis Death
20 Preventing ARF and RHD GAS infection ARF Primordial prevention Primary prevention -Sore throat Rx -? Vaccine -? Skin sore Rx Often prolonged asymptomatic period of RHD Secondary prevention -Regular penicillin RHD Tertiary prevention -Heart failure medication -Surgery -Anticoagulation Cardiac surgery Stroke, endocarditis Death
21 Prof Graeme Maguire
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24 Primordial prevention of ARF/RHD Housing Education Employment Communications Transport & access to services McDonald E et al. BMC Public Health 2008; 8:153 McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
25 What we know we don t know Who are the 3-6% susceptible? what is the genetic basis of this? What is the immunopathogenetic process? we need a diagnostic blood test for ARF Which Gp A strep emm types how restricted? what about GCS and GGS (horiz gene transfer)? What have skin GAS got to do with it? How to make primordial prevention a reality? How to best choose when to Tx throats What is the PK/PD of benzathine penicillin? How do we optimise secondary prophylaxis? dosing, intervals, adherence, pain, site, i-fat?
26 GAS Transmission and Crowding Warren Air Force Base, Wyoming USA Bed distance from colonised barracks mate correlated with GAS acquisition 0-5 feet > 60 GAS acquisitions/100,000 man weeks > 30 feet < 20 GAS acquisitions/100,000 man weeks Wannamaker LW. 1954
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28 Preventing ARF and RHD GAS infection ARF Primordial prevention Primary prevention -Sore throat Rx -? Vaccine -? Skin sore Rx Often prolonged asymptomatic period of RHD Secondary prevention -Regular penicillin RHD Tertiary prevention -Heart failure medication -Surgery -Anticoagulation Cardiac surgery Stroke, endocarditis Death
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31 Primary Prevention of ARF/RHD Prophylactic antibiotics for GAS Treating GAS pharyngitis Treating GAS pyoderma? A GAS vaccine
32 Prof Graeme Maguire
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35 Primary Prevention of ARF/RHD Prophylactic antibiotics for GAS Treating GAS pharyngitis Treating GAS pyoderma? A GAS vaccine
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39 What we know we don t know Who are the 3-6% susceptible? what is the genetic basis of this? What is the immunopathogenetic process? we need a diagnostic blood test for ARF Which Gp A strep emm types how restricted? what about GCS and GGS (horiz gene transfer)? What have skin GAS got to do with it? How to make primordial prevention a reality? How to best choose when to Tx throats and skin? What is the PK/PD of benzathine penicillin? How do we optimise secondary prophylaxis? dosing, intervals, adherence, pain, site, i-fat?
40 Crowding Hot Weather Water Supply Humidity Hygiene Scabies Dermatophytes Skin Damage- GAS Pyoderma Insect Bites Trauma APSGN Invasive GAS ARF? direct
41 Crowding Hot Weather Water Supply Humidity Hygiene Scabies Dermatophytes Skin Damage- GAS Pyoderma Insect Bites Trauma APSGN Invasive GAS ARF? direct
42 Crowding Hot Weather Water Supply Humidity Hygiene Scabies Dermatophytes Skin Damage- GAS Pyoderma Insect Bites Trauma APSGN Invasive GAS ARF? direct
43 Extreme burden of scabies & skin sores in infants 2 remote Top End Communities; Scabies Skin sores Clucas D et al. Bull WHO 2008;86:275 81
44 Pyoderma = Skin sores = Impetigo
45 Streptococcal pyoderma from Gp A streptococcus
46 The Big Picture Now, I keep saying that I don t care what colour you are or where you come from, but if you re living in a small house with large numbers of people, then you re going to get sick. Puggy Hunter, NACCHO Chairman, 2001
47 Rate of pyoderma (per visit) Pyoderma and crowding No. of people per bedroom McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
48 Primordial prevention of pyoderma Housing Education Employment Communications Transport & access to services McDonald E et al. BMC Public Health 2008; 8:153 McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
49 What we know we don t know Who are the 3-6% susceptible? what is the genetic basis of this? What is the immunopathogenetic process? we need a diagnostic blood test for ARF Which Gp A strep emm types how restricted? what about GCS and GGS (horiz gene transfer)? What have skin GAS got to do with it? How to make primordial prevention a reality? How to best choose when to Tx throats What is the PK/PD of benzathine penicillin? How do we optimise secondary prophylaxis? dosing, intervals, adherence, pain, site, i-fat?
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51 Primary prevention of pyoderma Hand washing can it become routine and sustainable? Swimming pools positive reports but confounders Treatment of scabies directed and mass treatment Galiwin ku trial Community campaigns and healthy skin days Wadeye and East Arnhem data BPG in APSGN outbreaks stop GAS transmission? Vaccines for Gp A Strep and scabies; imminent?? Carapetis J et al. Pediatr Infect Dis J 1997 ;16:494-9 Johnston F et al. Pediatr Infect Dis J 1999;18: Wong LC et al. Med J Aust 2001;175: Lehmann D et al. BMJ 2003;327:415-9 Luby S et al. Lancet 2005;366: La Vincente S et al. PloS Neglected Trop Dis 2009;3:e444 Andrews R et al, PLoS Neglected Trop Dis 2009;3:e554
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53 Crowding Hot Weather Water Supply Humidity Hygiene Scabies Dermatophytes Skin Damage- GAS Pyoderma Insect Bites Trauma APSGN Invasive GAS ARF? direct
54 Crowding Hot Weather Water Supply Humidity Hygiene Scabies Dermatophytes Skin Damage- GAS Pyoderma Insect Bites Trauma APSGN Invasive GAS ARF? direct
55 Extreme burden of scabies & skin sores in infants 2 remote Top End Communities; Scabies Skin sores Clucas D et al. Bull WHO 2008;86:275 81
56 Primary prevention of pyoderma Hand washing can it become routine and sustainable? Swimming pools positive reports but confounders Treatment of scabies directed and mass treatment Galiwin ku trial Community campaigns and healthy skin days Wadeye and East Arnhem data BPG in APSGN outbreaks stop GAS transmission? Vaccines for Gp A Strep and scabies; imminent?? Carapetis J et al. Pediatr Infect Dis J 1997 ;16:494-9 Johnston F et al. Pediatr Infect Dis J 1999;18: Wong LC et al. Med J Aust 2001;175: Lehmann D et al. BMJ 2003;327:415-9 Luby S et al. Lancet 2005;366: La Vincente S et al. PloS Neglected Trop Dis 2009;3:e444 Andrews R et al, PLoS Neglected Trop Dis 2009;3:e554
57 Primary prevention of pyoderma Hand washing can it become routine and sustainable? Swimming pools positive reports but confounders Treatment of scabies directed and mass treatment Galiwin ku trial Community campaigns and healthy skin days Wadeye and East Arnhem data BPG in APSGN outbreaks stop GAS transmission? Vaccines for Gp A Strep and scabies; imminent?? Carapetis J et al. Pediatr Infect Dis J 1997 ;16:494-9 Johnston F et al. Pediatr Infect Dis J 1999;18: Wong LC et al. Med J Aust 2001;175: Lehmann D et al. BMJ 2003;327:415-9 Luby S et al. Lancet 2005;366: La Vincente S et al. PloS Neglected Trop Dis 2009;3:e444 Andrews R et al, PLoS Neglected Trop Dis 2009;3:e554
58 Scabies
59 Why is scabies so hard to eradicate? : population mobility
60 Primordial prevention of scabies Housing Education Employment Communications Transport & access to services McDonald E et al. BMC Public Health 2008; 8:153 McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
61 Primordial prevention of pyoderma Housing Education Employment Communications Transport & access to services McDonald E et al. BMC Public Health 2008; 8:153 McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
62 Primordial prevention of trachoma Housing Education Employment Communications Transport & access to services McDonald E et al. BMC Public Health 2008; 8:153 McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
63 Primordial prevention of ARF/RHD Housing Education Employment Communications Transport & access to services McDonald E et al. BMC Public Health 2008; 8:153 McDonald M et al. Clin Infect Dis 2006;43:683-9 Bailie R et al. BMC Public Health 2010; 10:147
64 What we know we don t know Who are the 3-6% susceptible? what is the genetic basis of this? What is the immunopathogenetic process? we need a diagnostic blood test for ARF Which Gp A strep emm types how restricted? what about GCS and GGS (horiz gene transfer)? What have skin GAS got to do with it? How to make primordial prevention a reality? How to best choose when to Tx throats What is the PK/PD of benzathine penicillin? How do we optimise secondary prophylaxis? dosing, intervals, adherence, pain, site, i-fat?
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66 Support for RHD control programs Develop high quality education and training resources Assist with data interpretation and surveillance reports Advice and support on resource allocation and program planning Technical advice relating to clinical aspects of service delivery Participate in governance committees (steering committees, advisory groups)
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68 Coordination of graceful delivery (of service)
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