Secondary prevention broadly describes activities that help prevent a known disease from recurring. This includes public health initiatives, medical treatment, support for patients and their families, coordination between health, education and other services, and dedicated disease control programs to help coordinate care. For those with known RHD and/or past ARF, an enhanced emphasis on primordial and primary prevention of Strep A infections (see below) is of benefit in addition to secondary prophylaxis with antibiotics.

Secondary prophylaxis is one element of secondary prevention, which in the case of acute rheumatic fever (ARF) involves the administration of regular, long-term antibiotics to prevent future Strep A infections and recurrent ARF.1^,2

Antibiotics are most effectively delivered as deep intramuscular benzathine benzylpenicillin (BPG) injections at least every 28 days during the period of highest risk. For most people, this continues at least into early adulthood.3^,4 Each injection needs to be given no later than day 28 after the last injection to ensure the consistent protection of penicillin.5 Alternatives to the injections are available, particularly for people with a documented penicillin allergy, although they may be less effective in preventing ARF and require careful monitoring:6^,7

The length of time required for secondary prophylaxis treatment depends on several factors including age, diagnosis, severity of RHD if it is present, and the impact on the heart following recurrent ARF.8 BPG injections and tablet alternatives are safe during pregnancy and breastfeeding and should continue as prescribed.9 An echocardiogram and comprehensive review by a medical specialist are required before secondary prophylaxis can be ceased to ensure that there is no progressive heart valve damage and the individual’s future risk of recurrent ARF is low.10

Injections can be painful and inconvenient for some people and providing and receiving regular treatment over many years can be difficult.11 Oral prophylaxis, if prescribed, may not be taken as indicated which puts the person at increased risk of recurrent ARF and further heart damage.

Health services can support people who experience difficulties with secondary prophylaxis and their families by:

• prioritising secondary prophylaxis service delivery.
• providing skilled injection technique and culturally safe care.
• giving people the opportunity to receive injections in their preferred anatomical site and with their preferred method of pain management (if required).
• enhancing patient-provider shared decision making.
• employing recall and reminder systems for injections due.
• providing outreach injection services where possible.
• placing the expertise, experience, community knowledge and language skills of Aboriginal Health Workers and Aboriginal Health Practitioners at the centre of service.
• promoting the importance of secondary prophylaxis through culturally safe education.
• identifying barriers to treatment and working within the system and with patients and families to address and overcome those barriers.

For more information, see Chapter 10 of the RHDAustralia 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition).

• 1. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2009;119:1541-1551. View Source
• 2. World Health Organization. Rheumatic fever and rheumatic heart disease: report of a WHO expert consultation, Geneva, 29 October–1 November 2001. WHO Technical Report Series 923 2004. View Source
• 3. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition), 2020. View Source
• 4. Antibiotic Expert Group, Therapeutic guidelines: antibiotic. Vol. 15. 2014, Melbourne: Therapeutic Guidelines Limited.
• 5. de Dassel JL, Malik H, Ralph AP, Hardie K, Reményi B, Francis JR. Four-weekly benzathine penicillin G provides inadequate protection against acute rheumatic fever for some children (in Australia’s Northern Territory). American Journal of Tropical Medicine and Hygiene. 2019;100(5):1118-1120. View Source
• 6. Feinstein A, Wood HF, Epstein JA, et al. A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of the study, including methods for evaluating the maintenance of oral prophylaxis. New England Journal of Medicine. 1959;260(14):697-702. View Source
• 7. Wood H, Feinstein AR, Taranta A, et al. Rheumatic fever in children and adolescents. A long-term epidemiological study of subsequent prophylaxis, streptococcal infections and clinical sequelae. III. Comparative effectiveness of three prophylaxis regimes in preventing streptococcal infections and rheumatic recurrences. Annals of Internal Medicine. 1964;60(S5):31-46. View Source
• 8. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition), 2020. View Source
• 9. Department of Health Therapeutic Goods Administration. Medicines and TGA classifications. 2019.
• 10. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition), 2020. View Source
• 11. Mitchell AG, Belton S, Johnston V, et al. Aboriginal children and penicillin injections for rheumatic fever: how much of a problem is injection pain? Australian and New Zealand Journal of Public Health. 2018;42:46-51. View Source