The danger that rheumatic heart disease poses in Kenya

It is 8:00a.m. on a Thursday morning and patients begin to fill the cardiac unit reception area at Kenyatta National Hospital. Among them is 24-year-old Fraciah Njeri. Her small frame is covered by a black trench coat and a maroon shawl. Although the morning weather is chilly, she seems to feel a bit colder. Struggling to find a comfortable chair to sit on, she moves to a chair in the second row.

Njeri is here for a ballistocardiograph (BCG) and echocardiograph, which are tests carried out on patients to diagnose and monitor heart disease. She is here with her younger brother and mother, Elizabeth Njoki, who tries to coax her to eat something - she takes about three bites of the fruit then stops.

The young lady suffers from rheumatic heart disease, which according to the World Heart Federation, accounts for 200,000 heart disease cases reported in Kenya annually.

Data from the World Health Organisation (WHO) has placed cardiovascular disease as the number one global killer. There have been calls to mitigate the soaring numbers and one such initiative is World Heart Day, celebrated on September 29 every year, which seeks to have people across the globe “take part in the world’s biggest intervention against cardiovascular disease”.

According to the WHO, three quarters of cardiovascular deaths take place in low and middle-income countries such as Kenya. It further observes that out of 16 million deaths of people under the age of 70 caused by non-communicable diseases, 37 per cent are due to cardio vascular diseases and 82 per cent are in low and middle-income countries.

In Kenya, medics say the most common types of cardio vascular diseases are ischemic heart disease, which is caused by narrowing of the coronary arteries, decreasing blood supply to the heart and rheumatic heart disease, which is caused by damage to the heart valves.

According to Mzee Ngunga, a cardiologist at Aga Khan Hospital in Nairobi, ischemic heart disease is found mostly among the affluent, while the latter appears most prevalent in low-income populations.

“We attribute ischemic heart disease to consumption of a high cholesterol diet and majority of patients suffering from this condition are Asians and Somalis aged between 50 and 60 years,” he says.

Dr Ngunga said majority of the patients who visit the Heart and Cancer Centre at Aga Khan Hospital are found to be suffering from this kind of heart disease.

Things are however, very different at the Kenyatta National Hospital where Resident Cardiologist Bernard Gitura says rheumatic heart disease is the most common heart complication and cause of heart surgery at the hospital.

According to Dr Gitura, rheumatic heart disease begins with a sore throat caused by the streptococcus virus, which if not effectively treated using antibiotics, causes rheumatic fever that begins to affect heart valves.

The damaged heart valves narrow resulting in decreased blood flow or they may leak causing blood to flow in the wrong direction. Heart muscles could also be damaged, resulting in poor pumping function, or heart failure.

“Children between the ages five to 15 are most susceptible to it and every recurring sore throat further affects the heart valves such that by the time they are in their 20s and 30s, these valves have been seriously or permanently damaged.

The message that needs to go out there is that rheumatic disease is preventable,” Dr Gitura says.

Njoki tells us that her daughter’s condition was discovered in 2002, when she was 13-years-old following a misdiagnosis that she had a ‘cold’ that would simply not go away. It was not until they were referred to Nazareth Hospital where she was diagnosed with rheumatic heart disease.

“It was difficult for me to hear this from the doctors and I was also shocked when they told me I would needed to bring her for a penicillin jab every month,” she says.

Patients who have already contracted rheumatic fever and rheumatic heart disease are required to take this monthly injection of benzathin penicillin in order to prevent further infections.

Njeri has so far been sitting quietly listening to the conversation and she tells us in a barely audible voice how having the illnesses has hampered her life.

“I could not play or run like other children my age. I had to, on many occasions, stay home because I was too sick to attend school,” she says before laying her head on the table, too tired to speak anymore.

Soon her name is called out and she enters the exam room only to be told that the echo exam cannot be done since the machine is not working. They recommend she returns after a week. Her mum tells me that this was the same case last month.

Her family is getting concerned because Njeri has been very sick for the last three months. The combination of her illness and the strong medications she is taking has caused her to lose a lot of weight.

“She is now but a shell of her old self. Her lively and hardworking nature is no more. This is a beautician who went to her place of work every morning. She was very warm and jovial,” her brother tells us.

Njeri’s health is indeed deteriorating and doctors have told her that she needs urgent surgery because her valves are severely damaged. However, like many families, they cannot afford it.

The cost of replacing one heart valve is Sh175,000 and Sh275,000 for two. This is a subsidised cost for a patient covered by the National Hospital Security Fund (NHIF). Yet, even if she were to raise this amount, she would have to wait for another two years since all dates are fully booked.

Dr Gitura, who is part of the Rheumatic Heart Disease Global Registry (Remedy) offers to examine Njeri.

“He says I cannot go home, I have to be admitted,” a teary-eyed Njeri tells me after leaving the doctor’s office. She walks sluggishly as they leave, stopping after every five steps, to catch her breath and clings to her brother’s hand for support.

Her mother is relieved at the hope of her child receiving treatment.

“We have not been able to get the jab for the last three months and this is has adversely affected her condition. At least having her here means the doctors can monitor her and give her medication for the infection,” she says.

Gitura knows the challenges patients like Njeri face and he laments that this all-essential jab is not readily available at Government run health facilities

“The viscosity of this injectable drug is also very high, which makes it very painful yet patients sometimes have to be injected more than once just to get the medicine through the veins,” he says.

It is for reasons such as this that Remedy, which comprises heart doctors from 14 African countries carrying out research on the prevention, management and elimination of the illness, petitions governments for better eradication and management policies.

Specifically, Remedy want to see policies put in place that will lead to procurement of quality injectable drugs that are of lower viscosity to ease the pain for young patients. They are also carrying out studies to find out whether there are genetic aspects that would predispose some children to strep throat. They also aim at lobbying governments to subsidise the cost of surgery and replacing valves.

“The Government needs to devolve the skill of open-heart surgery to county hospitals. At the moment, Kenyatta National Hospital is the only public hospital that offers open-heart surgery apart from Coast General Hospital, which recently carried out three surgeries,” he says.