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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.105 n.8 Pretoria Aug. 2015


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Rheumatic fever and rheumatic heart disease in Africa






Acute rheumatic fever (ARF), with its varied and potentially devastating cardiac complication of rheumatic heart disease (RHD), has largely been eradicated from developing countries, but continues to be a scourge mainly in poorly resourced areas of the world and also among the indigenous populations of some wealthy countries such as New Zealand and Australia.[1] The disease is particularly prevalent in populations where there is overcrowding and high levels of poverty. Efforts have been made to commit to the elimination of ARF/RHD in South Africa (SA) and the rest of Africa. The Drakensberg Declaration, which initiated and promoted the Awareness, Surveillance, Advocacy and Prevention (ASAP) programme to raise public awareness, establish surveillance programmes, advocate for support and promote prevention, was adopted at the 1st All Africa Workshop on Rheumatic Fever and Rheumatic Heart Disease held in the Drakensberg, SA, in 2005.[2] The ASAP programme has unfortunately not been expanded on a national scale so far. Subsequent attempts at solutions to controlling ARF and RHD globally have included the establishment of registers to track disease outcomes and outline strategies related to the ASAP proposal to improve disease control in low-income countries.[3]

Information about levels of ARF/RHD is scarce and poorly documented in less-developed areas of the world such as Africa.[4] The prevalence of RHD in SA has been reported occasionally since the landmark study by McClaren et al.[5] in 1975, which showed an overall prevalence rate of RHD (using clinical examination to establish the diagnosis) of 6 - 9/1 000 among schoolchildren in Soweto, Johannesburg. A prospective clinical registry of valvular heart disease using echocardiography to make the diagnosis during 2006/2007 among individuals older than 14 years at Chris Hani Baragwanath Academic Hospital in Soweto revealed an incidence of 23.5/100 000 patients with RHD presenting for the first time.[6] Recent information from the past decade concerning the prevalence of RHD in sub-Saharan Africa has emanated from echocardiography screening studies in asymptomatic schoolchildren. Marijon et al.[7] showed a very high prevalence rate of 30.4/1 000 in Mozambique in 2007. A similarly high prevalence rate of 15/1 000 in a much larger cohort of Ugandan schoolchildren was reported in 2012.[8] Two very recent cardiac clinic hospital-based study cohorts from Africa, using echocardiography to confirm diagnoses, showed RHD to be the most important heart condition in patients aged 10 - 19 years (affecting 62.1%) in Cameroon,[9] while RHD was present in 22.4% of children undergoing echocardiography at a centre in Malawi.[10]

In contrast, a recent publication from SA[11] has shown a dramatic decline in the number of children younger than 14 years with ARF and RHD presenting to the paediatric cardiology department at Chris Hani Baragwanath Academic Hospital over the 17-year period 1993 -2010. The referral population has not changed despite an increase in the number of patients referred to the unit during this period. The population served by this large tertiary care hospital is largely poor and includes the massive periurban population of Soweto, patients referred by secondary hospitals in southern and eastern Gauteng Province, and patients from North West Province. The majority of patients with ARF/RHD were found to have originated from outside Soweto, but the addresses provided could not be validated. Many patients who present with severe disease requiring surgery to repair or replace damaged heart valves are suspected to originate from rural areas, and they include people from beyond SA's borders who have made the informal settlements in and around Gauteng their home.[11]

A similar downward trend has been observed at a central hospital complex in Limpopo Province, where a decline in the prevalence of RHD among children up to 13 years old has also been documented. A record review of paediatric echocardiography reports for the period 2001 - 2012 showed that the number of cases decreased from 36 per year for the first 4 years of the study to an average of 14 and six per year in the middle and final 4 years of the study, respectively. During the same time period the number of cases of congenital heart disease diagnosed each year remained relatively constant. This information suggests a decreasing prevalence of childhood RHD in Limpopo Province.[12]

Anecdotally, numbers of children presenting to large tertiary hospitals with ARF/RHD have declined in Free State Province, but not in KwaZulu-Natal and rural parts of the Eastern Cape (personal communications, Prof. Stephen Brown, Dr Ebrahim Hoosen and Dr Lungile Pepeta, respectively).

Several sociopolitical changes in SA could have contributed to the documented decline in the numbers of children with ARF/RHD in Gauteng and Limpopo provinces. These include an improvement in the socioeconomic status of the broader population since the new political dispensation in 1994, less overcrowding in dwellings, free healthcare for children under the age of 6 years, more widespread availability of primary healthcare facilities, and easy access to penicillin for the treatment of all sore throats.[12] The latter resulted in a dramatic decline in the incidence of ARF in Costa Rica and Cuba, as has been well documented.[13,14]

Information on the incidence and prevalence rates of ARF and RHD in SA and the rest of Africa is needed to ensure targeting of susceptible populations with prevention and treatment programmes. Research opportunities should therefore continue to be created to allow for a pan-African survey of the frequency and origins of patients with ARF/RHD presenting to the larger central and secondary hospitals in SA and other parts of Africa, to assess the need for control strategies in vulnerable areas.

Other methods of detection, such as screening for RHD with echocardiography in schoolchildren, are excellent ways to seek out affected individuals so that secondary prophylaxis can be instituted. Echocardiographic screening is, however, a very costly undertaking requiring expensive equipment, specialised expertise, reliable and relevant diagnostic echocardiographic criteria that can easily be replicated, and time spent by physicians and technical echocardiographic personnel away from their hospital commitments.

The eradication of ARF/RHD is a complex process that needs to be addressed at various levels. These include education of vulnerable communities about the disease, provision of easy access to medical care, and increasing the availability of free penicillin to treat group A streptococcal pharyngitis and for secondary prophylaxis against further attacks of ARF in patients with established RHD. Just as important is to address poverty and overcrowding, which are associated with high levels of ARF and RHD, as improvement in socioeconomic conditions has also been shown to promote the control of ARF.[15] Improvement of economic circumstances in disadvantaged communities is therefore also an important component of the management of ARF/RHD. Until such communities are economically empowered, ARF/RHD will continue to be a problem despite interventions to control the disease. All these interventions may prove to be a challenge in some parts of SA and in countries in the rest of Africa.

A M Cilliers
Paediatric Cardiology Unit, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg



1. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis 2005;5(ll):685-694. []        [ Links ]

2. Mayosi B, Robertson K, Volmink J, et al. The Drakensberg declaration on the control of rheumatic fever and rheumatic heart disease in Africa. S Afr Med J 2006;96(3):246.         [ Links ]

3. Carapetis JR, Zuhlke LJ. Global research priorities in rheumatic fever and rheumatic heart disease. Ann Pediatr Cardiol 2011;4(1):4-12. [http://dx.doi:10.4103/0974-2069.79616]        [ Links ]

4. Tibazarwa KB, Volmink JA, Mayosi BM. Incidence of acute rheumatic fever in the world: A systematic review of population-based studies. Heart 2008;94(12):1534-1540. [http://dx.doi:10.1136/hrt.2007.141309]        [ Links ]

5. McLaren MJ, Hawkins DM, Koornof HJ, et al. Epidemiology of rheumatic heart disease in black school children of Soweto, Johannesburg. BMJ 1975;3(5981):474-478.         [ Links ]

6. Sliwa K, Carrington M, Mayosi BM, et al. Incidence and characteristics of newly diagnosed rheumatic heart disease in urban African adults: Insights from the Heart of Soweto study. Eur Heart J 2010;31(6):719-727. [http://dx.doi:10.1093/eurheart/eurheart/ehp530]        [ Links ]

7. Marijon E, Ou P, Celermajer DS, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med 2007;357(5):470-476. []        [ Links ]

8. Beaton A, Okello E, Lwabi P, et al. Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren. Circulation 2012;125(25):3127-3132. []        [ Links ]

9. Jingi AM, Noubiap JJ, Kamden P, et al. The spectrum of cardiac disease in the West Region of Cameroon: A hospital-based cross-sectional study. Int Arch Med 2013;6(1):44. []        [ Links ]

10. Kennedy N, Miller P. The spectrum of paediatric cardiac disease presenting to an outpatient clinic in Malawi. BMC Res Notes 2013;6:53 []        [ Links ]

11. Cilliers AM. Rheumatic fever and rheumatic heart disease in Gauteng on the decline: Experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. S Afr Med J 2014;104(9):632-634. [http://dx.doi:10.7196/SAMJ.8318]        [ Links ]

12. Sutton C. Ascertainment of rheumatic heart disease in children in the Limpopo Province of South Africa. Abstracts of Proceedings of the 15th Annual SA Heart Congress, Durban 2014. SA Heart, Journal of the South African Heart Association 2014;11(4):204.         [ Links ]

13. Arguiedas A, Mohs E. Prevention of rheumatic fever in Costa Rica. J Pediatr 1992;121(4):569-572. []        [ Links ]

14. Nordet P, Lopez R, Duenas A, Sarmiento L. Prevention and control of rheumatic fever and rheumatic heart disease: The Cuban experience (1986-1996-2002). Cardiovasc J Afr 2008;19(3):135-140.         [ Links ]

15. DiSciascio G, Taranta A. Rheumatic fever in children. Am Heart J 1980;99(5);635-658. []        [ Links ]



A M Cilliers

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Community- versus healthcare-acquired bloodstream infections at Groote Schuur Hospital, Cape Town, South Africa



R McKayI; C BamfordII, III

IMSc; School of Population and Public Health, University of British Columbia, Vancouver, Canada
IIMB ChB, FCPath, MMed; Division of Medical Microbiology, University of Cape Town, South Africa
IIIMB ChB, FCPath, MMed; National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa





BACKGROUND: Bloodstream infections (BSIs) cause considerable morbidity and mortality. The epidemiology of bacterial infections differs in community and hospital settings. Regular surveillance and reporting of pathogens and antimicrobial susceptibility can assist in appropriate management of BSIs
OBJECTIVES: To describe the distribution of organisms and of antibiotic susceptibility among isolates from blood cultures at a tertiary academic hospital during a 1-year period, stratifying by place of infection acquisition
METHODS: This was a retrospective descriptive study of bloodstream isolates from cultures from adults (>13 years of age) routinely submitted between 1 October 2011 and 30 September 2012 to the clinical laboratory at Groote Schuur Hospital, Cape Town, South Africa. Community-acquired infections were compared with healthcare-acquired infections, defined as infections developing at least 48 hours after admission or within 3 months of admission to a healthcare facility. Frequencies and proportions of infecting organisms are presented, along with susceptibility results for selected pathogens. The hospital-acquired isolates were stratified by ward (emergency, general medical or general surgical ward or intensive care unit (ICU)) to determine organism frequency and susceptibility patterns by hospital ward
RESULTS: Among adults, 740 non-duplicate pathogens were isolated from BSIs. Nearly three-quarters of infections were healthcare acquired. Enterobacteriaceae and non-fermentative Gram-negative bacilli were predominant among healthcare-acquired pathogens (39.2% and 28.5%, respectively), while Enterobacteriaceae and Gram-positive organisms were the most common among community-acquired pathogens (39.2% and 54.3%, respectively). The majority of community-acquired Enterobacteriaceae were highly susceptible to antibiotics (gentamicin 95.6%, ceftriaxone 96.1% and ciprofloxacin 92.2%), whereas 64.6% of healthcare-associated isolates were susceptible to gentamicin, 58.5% to ceftriaxone and 70% to ciprofloxacin. All community-acquired Staphylococcus aureus isolates v. 52.4% of healthcare-acquired isolates were susceptible to cloxacillin. The susceptibility of healthcare-acquired Pseudomonas aeruginosa and Acinetobacter baumanii complex isolates was <80% to all antibiotics with the exception of colistin. Klebsiella spp., S. aureus and Escherichia coli were the commonest causes of healthcare-acquired infections in all areas outside of the ICUs, whereas Acinetobacter was common in the ICUs and rare in all other areas
CONCLUSION: The distinction between community- and healthcare-acquired infections is critical in antibiotic selection because narrow-spectrum agents can be utilised for community-acquired infections. The considerable antibiotic resistance of healthcare-acquired pathogens highlights the importance of infection prevention and control. This type of surveillance could be incorporated into routine laboratory practice



Bloodstream infections (BSIs) cause considerable morbidity and mortality.[1,2] Estimates suggest that 10 - 13% of community-onset BSIs are fatal,[3,4] while 23% of nosocomial BSIs resulted in death in one study in the USA.[4] A paediatric cohort study in Kenya reported a case fatality rate of 24% for community-acquired and 53% for hospital-acquired bacteraemia.[5] A systematic review of admissions to hospital in various regions of Africa estimated that 13.5% of adults and 8.2% of children had community-acquired BSIs,[6] indicating these are a common cause of illness and account for a substantial proportion of all healthcare admissions. Rapid diagnosis, identification of the causative bacteria and appropriate treatment are essential in mitigating the morbidity and mortality associated with BSIs.

The epidemiology of bacterial infections differs in community and hospital settings. The predominant bacteria causing community-acquired infections are Gram-positive organisms, while hospital-acquired infections are more frequently caused by Gram-negative bacteria.[4] This distinction has relevance to empirical treatment of suspected bacterial infection.

In the past decade, an additional category of healthcare-associated infection has been recognised, to cover infections in patients who have had recent contact with the healthcare system.[7] Healthcare-associated infections are typically similar to hospital-acquired infections in terms of pathogens and susceptibility patterns. We have therefore chosen to combine hospital-acquired and healthcare-associated infections as healthcare-acquired infections.

Increasing antibiotic resistance complicates treatment of infections, in some cases seriously diminishing the options for effective therapy,[8] and is often associated with worse outcomes.[9] Laboratory-based surveillance data for BSIs in South Africa (SA) are available; however, these data do not distinguish between community- and hospital-acquired infection.[10] Regular surveillance and reporting of BSIs and antibiotic susceptibility, including differentiation of community- and healthcare-acquired infections, can assist in managing infections appropriately and in adapting local antibiotic stewardship policies.[11,12]

Groote Schuur Hospital (GSH) is a large tertiary academic and teaching hospital in Cape Town, SA. In this hospital, blood cultures are generally collected when a patient has clinical features of sepsis, typically before commencing or changing antibiotic therapy. However, there are no explicit guidelines or policies around indications for taking of blood cultures, and practices may vary from clinician to clinician.

This report describes the distribution of organisms isolated in blood cultures at GSH during a 1-year period. Additionally, we describe the distribution of antibiotic resistance among some groups of pathogens. We adapted routine laboratory practices to allow for classification of infections as healthcare or community acquired and applied this stratification to analysis of pathogens and antibiotic susceptibility results.

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