Why Is Secondary Prevention Not Sufficient for Preventing RHD?
Unlike in developed countries, where access to health care is good and the health-seeking behavior of people favors early presentation, in poor countries, the first inciting episode of streptococcal pharyngitis goes largely undiagnosed and untreated. As a result, susceptible patients have already suffered substantial valve damage from unrecognized episodes of RF by the time they come to clinical attention. Often patients present for the first time with symptoms due to the hemodynamic consequences of the resulting valve disease. The subsequent clinical course of these patients is largely determined by the natural history of the valve lesions. Although secondary prophylaxis reduces recurrent RF episodes,14 there is no evidence to suggest that such treatment alters natural history once significant valve damage has occurred.5 Moreover, the early episodes of acute RF in children in Africa often follow a fulminant course, which may require surgery in the acute phase of illness.19–21 Therefor
