Oldest antibiotic prevents rheumatic heart disease, but India’s burden is still high. Here’s why

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New Delhi: Much has been written about India’s burden of non-communicable diseases such as diabetes and hypertension, but there’s also an infectious disease component to some of them. One of them is rheumatic heart disease, which primarily affects the heart’s valves.

Rheumatic heart disease (RHD) can start with something as innocuous as a sore throat. Though it has come down due to improvements in living conditions, India’s burden of RHD is among the highest in the world. And yet, the disease can be prevented by the use of penicillin — the oldest antibiotic known to humankind.

According to an ongoing Global Burden of Disease (GBD) study — which is overseen by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in absolute numbers, India accounts for a third of the global RHD burden.

The disability adjusted life yearDALY) is an internationally recognized metric to measure the morbidity and mortality associated with a particular disease. One DALY represents the loss of the equivalent of one year of full health.

The GBD study estimated that RHD led to 395 DALYs per 1,00,000 population in India, and 9.2/1,00,000 deaths in 1990, wrote authors from the Rajasthan University of Health Sciences in a 2020 article in the Journal of the Association of Physicians of India (JAPI). This declined to 270/1,00,000 DALYs and 7.9/1,00,000 deaths in 2017

In absolute numbers, RHD in 1990 led to 3.44 million (34.4 lakh) DALYs and 80,470 deaths in India, which increased to 3.73 million DALYs and 1,08,460 deaths in 2017, they further wrote.

According to the World Health Organization (WHO), “Rheumatic heart disease starts as a sore throat from a bacterium called Streptococcus pyogenes (group A streptococcus) which can pass easily from person to person in the same way as other upper respiratory tract infections.”

“Strep infections are most common in childhood. In some people, repeated strep infections cause the immune system to react against the tissues of the body including inflaming and scarring the heart valves. This is what is referred to as rheumatic fever. Rheumatic heart disease results from the inflammation and scarring of heart valves caused by rheumatic fever.”

Administration of long-acting penicillin can prevent progression of the infection to a stage where it affects the functioning of the heart, but the drug — discovered by Alexander Fleming in 1928 — is prone to periodic shortages. It’s too cheap for drug companies to make a profit and therefore, globally, countries that use it struggle to devise subsidy plans to keep the penicillin flow steady.

travelling, a 2019 study in The Lancet Medical journal analysing antibiotics usage in India — the findings of which were published Wednesday — shows that antibiotics of the penicillin class remain among the highest consumed in India, second only to cephalosporins.


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Not all sore throats need antibiotics

Doctors, however, are speculative about placing too much emphasis on the sore throat link, for fear of antibiotic overuse. Dr Ganesan Karthikeyan, professor of cardiology at the All India Institute of Medical Sciences (AIIMS), Delhi, told ThePrint: “An average child will probably have five sore throats a year. About 10-15 per cent of all sore throats are caused by Streptococcus and 0.3 per cent of those may go on to become RHD.”

According to Dr Karthikeyan, India’s RHD burden is large because it has a very large population. He added, “It is basically a disease of poverty and overcrowding and happens mostly in children. That is why, as living standards go up, the disease prevalence is also coming down. The last survey by ICMR, for example, showed that RHD prevalence is very low in Kerala. But primary prevention is not practical because it is a very expensive proposition even when penicillin is available.”

“Even countries like New Zealand did not find merit in that plan. Randomised trials of sore throat screening and primary prevention were not successful there in reducing the prevalence of RHD,” he added.

According to a 2019 article in the Indian Journal of Public HealthRHD is an endemic disease in India, accounting for 1,19,100 deaths every year. In 2015, India had the highest RHD burden in the world.

Rheumatic fever, which can occur several weeks after the sore throat episode caused by Streptococcus, can have the patient suffering from joint pain, fatigue and skin rashes apart from fever. The symptoms of heart valve damage may include chest pain, breathlessness, and rapid or irregular heartbeat.

‘Primary & secondary prevention’

Dr KS Reddy, former professor of cardiology at AIIMS and president of the Public Health Foundation of India, told ThePrint, “There are two aspects to this (prevention of RHD) — primary prevention and secondary prevention. It is believed that if a patient of sore throat suspected to be caused by the Streptococcus Bacteria is given penicillin early, the autoimmune reaction that causes rheumatic heart disease can be stalled.”

“But to confirm whether it is indeed Streptococcus, one needs to do a throat swab culture, which is not always easy. The accuracy is lower for rapid diagnostic tests,” he added.”

He added that there are risks of using penicillin indiscriminately without, given that almost 90 per cent sore throats have a confirmation viral origin.

“Some countries have tried diagnosis using a clinical score and giving penicillin to those patients that pass the pre-designated score.”

“There is a secular (long-term) trend of RHD coming down in India, but there is no doubt that the disease is associated with socioeconomic underdevelopment, overcrowding. There is also a problem in availability of long-acting penicillin since Hindustan Antibiotics closed down,” he said, referring to the Pune-based company, India’s first government-owned-drug manufacturer under the ownership of the Ministry of Chemicals and Fertilisers.

(Edited by Gitanjali Das)


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