Adherence to secondary benzathine penicillin prophylaxis among children with acute rheumatic fever before and after COVID-19 in Samoa: a retrospective mixed-methods study
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Keywords
acute rheumatic fever, rheumatic heart disease, Benzathine penicillin, COVID-19, medication adherence
Abstract
Introduction: Acute rheumatic fever and its chronic complication, rheumatic heart disease, remain major public health concerns in low-resource settings, particularly in Pacific Island nations such as Samoa. Secondary prophylaxis with intramuscular benzathine penicillin G (BPG) is effective in preventing disease recurrence and progression, but its success depends on consistent long-term adherence.
Aim: To assess the impact of Samoa’s first COVID-19 outbreak on adherence to secondary BPG prophylaxis among children with acute rheumatic fever.
Methods: A retrospective mixed-methods study was conducted at Tupua Tamasese Meaole Hospital (TTMH), Samoa. Adherence to secondary penicillin prophylaxis among children aged 5–12 years was compared between a true pre-pandemic period (2020–2021) and the post-COVID-19 recovery period (2023–2024). Quantitative adherence was calculated as the proportion of scheduled doses received and analysed using descriptive statistics, Wilcoxon signed-rank testing, and categorical analysis. Semi-structured interviews with caregivers were thematically analysed to explore barriers and facilitators of adherence. Unlike many countries, Samoa did not experience community transmission of COVID-19 until 2022, allowing 2020–2021 to serve as a true pre-pandemic baseline.
Results: Thirty paediatric patients receiving secondary BPG prophylaxis were included. Mean adherence declined from 80.3% (SD 32.7) before-2022 to 61.5% (SD 45.6) after 2022, representing a clinically important reduction following Samoa’s first COVID-19 outbreak. Adherence became substantially more variable after2022, reflecting increased inconsistency across patients. A significant difference in adherence distributions was observed between periods (Wilcoxon p = 0.026). Using an adherence threshold of at least 80%, categorical analysis demonstrated a unidirectional deterioration, with no children demonstrating improvement from poor to adequate adherence after 2022 (Fisher’s Exact Test, p < 0.001). Qualitative findings identified clinic access disruption, transport limitations, and caregiver anxiety as key contributors to missed injections.
Discussion: COVID-19 was associated with reduced consistency and increased inequity in paediatric penicillin prophylaxis in Samoa, disproportionately affecting previously vulnerable children. These findings highlight the need for continuity-focused, equity-oriented strategies to sustain chronic disease management during public health emergencies.
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