Critical issues in prevention and control of rheumatic fever and rheumatic heart disease

The evidence base for public health and therapeutic interventions to prevent and control acute rheumatic fever (ARF) and rheumatic heart disease (RHD) still has some big gaps. Resolving critical issues in the pathogenesis of ARF should accelerate vaccine development and provide reassurances about vaccine safety. The basis of the genetic restriction of ARF predisposition and of the “immunogenic” determinants within group A streptococci (GAS) are critical to define. Also important is whether other bacteria such as groups C and G streptococci can be rheumatogenic and whether skin streptococci can cause ARF, either directly or via secondary throat colonization. Benzathine penicillin remains the mainstay of secondary prevention by preventing recurrent ARF and progression of RHD. However, there remain major issues of quality, supply, dosing, optimal timing of dosing and how best to incorporate secondary prophylaxis into primary care with either vertical or horizontal programs. Alternative secondary prophylaxis regimens remain to be developed.