{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T11:45:27Z","timestamp":1782819927092,"version":"3.54.5"},"reference-count":34,"publisher":"Ubiquity Press, Ltd.","issue":"1","license":[{"start":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T00:00:00Z","timestamp":1779062400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100000925","name":"National Health and Medical Research Council","doi-asserted-by":"crossref","award":["2025252"],"award-info":[{"award-number":["2025252"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100025520","name":"Medical Research Future Fund","doi-asserted-by":"crossref","award":["APP 1197177"],"award-info":[{"award-number":["APP 1197177"]}],"id":[{"id":"10.13039\/501100025520","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["gh"],"abstract":"<jats:p>Intramuscular (IM) injection of benzathine benzylpenicillin G (BPG) forms the cornerstone of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) secondary prophylaxis. BPG is available as either a low-cost powdered formulation or a costlier pre-filled suspension. Most of the global RHD burden lies in low- and middle-income countries, which rely on the powdered formulation. Prospects of achieving RHD control targets continue to be hindered by global BPG supply issues. Guided by a preliminary consultation of global stakeholders published in 2016 which outlined the desired characteristics and changes to the existing BPG product, much progress has been made in improving tolerability of BPG for ARF\/RHD secondary prophylaxis. A second stakeholder consultation of experts and consumer representatives was convened during the World Congress on Rheumatic Heart Disease in Abu Dhabi, UAE, in November 2023 with the objective of evaluating alternate delivery models and the need for new BPG formulations. Topics explored included current barriers and enablers to local secondary prophylaxis uptake, desired changes to the delivery model and ways to improve access to secondary prophylaxis in resource-limited settings. Our findings highlight inadequacies of the current one-size-fits-all approach and the need for education, access to health systems and personnel as well as flexibility and adaptability to meet individual and community needs for effective programme delivery while new and improved BPG formulations, which will overcome current barriers, are eagerly awaited.<\/jats:p>","DOI":"10.5334\/gh.1555","type":"journal-article","created":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T05:55:00Z","timestamp":1779083700000},"page":"39","source":"Crossref","is-referenced-by-count":0,"title":["Stakeholders Want a Menu of Choices: Findings from a Consultation Workshop on Improving Access to Secondary Prophylaxis of Rheumatic Fever and Rheumatic Heart Disease"],"prefix":"10.5334","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5233-4438","authenticated-orcid":false,"given":"Thel K.","family":"Hla","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4075-0781","authenticated-orcid":false,"given":"Stephanie L.","family":"Enkel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3121-4397","authenticated-orcid":false,"given":"Joseph","family":"Kado","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Eadie-Mirams","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3904-9269","authenticated-orcid":false,"given":"Rosemary","family":"Wyber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1182-9792","authenticated-orcid":false,"given":"Jonathan","family":"Carapetis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4334-5351","authenticated-orcid":false,"given":"Laurens","family":"Manning","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"3285","published-online":{"date-parts":[[2026,5,18]]},"reference":[{"key":"key20260518055456_B1","unstructured":"World Health Organization. WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease. Geneva; 2024. Available from: https:\/\/iris.who.int\/server\/api\/core\/bitstreams\/fbd835e1-b9b7-414a-b6aa-9c279472bbdf\/content [Accessed 23\/04\/2026]."},{"key":"key20260518055456_B2","unstructured":"RHD Action. Global status of BPG report. 2016. Available from: https:\/\/rhdaction.org\/resources\/global-status-bpg-report [Accessed 24\/05\/2024]."},{"key":"key20260518055456_B3","unstructured":"Ryan B. Antibiotic shortage could worsen syphilis epidemic. The New York Times. 2023 [Internet]. Available from: https:\/\/www.nytimes.com\/2023\/07\/07\/health\/syphilis-epidemic-antibiotic-shortage-pfizer.html [Accessed 14\/05\/2025]."},{"issue":"25","key":"key20260518055456_B4","doi-asserted-by":"crossref","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global burden of cardiovascular diseases and risk factors, 1990\u20132019: Update from the GBD 2019 study","volume":"76","year":"2020","journal-title":"Journal of the American College of Cardiology"},{"issue":"3","key":"key20260518055456_B5","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.gheart.2013.08.011","article-title":"Benzathine penicillin G for the management of RHD: Concerns about quality and access, and opportunities for intervention and improvement","volume":"8","year":"2013","journal-title":"Global Heart"},{"issue":"10495","key":"key20260518055456_B6","doi-asserted-by":"crossref","first-page":"2164","DOI":"10.1016\/S0140-6736(25)00185-0","article-title":"Acute rheumatic fever","volume":"405","year":"2025","journal-title":"The Lancet"},{"issue":"5","key":"key20260518055456_B7","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1038\/nrcardio.2013.34","article-title":"Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease","volume":"10","author":"World Heart F","year":"2013","journal-title":"Nature Reviews Cardiology"},{"key":"key20260518055456_B8","unstructured":"World Health Organization. Model list of essential medicines. Available from: https:\/\/www.list.essentialmeds.org\/ [Accessed 25\/03\/2026]."},{"issue":"5","key":"key20260518055456_B9","doi-asserted-by":"crossref","first-page":"223","DOI":"10.5694\/mja2.52590","article-title":"Shortages of benzathine benzylpenicillin G in Australia highlight the need for new sovereign manufacturing capability","volume":"222","year":"2025","journal-title":"The Medical Journal of Australia"},{"issue":"12","key":"key20260518055456_B10","article-title":"Shortages of benzathine penicillin for prevention of mother-to-child transmission of syphilis: An evaluation from multi-country surveys and stakeholder interviews","volume":"14","year":"2017","journal-title":"PLoS Medicine"},{"issue":"3","key":"key20260518055456_B11","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1093\/inthealth\/ihad087","article-title":"Securing the supply of benzathine benzylpenicillin: A global perspective on risks and mitigation strategies to prevent future shortages","volume":"16","year":"2024","journal-title":"International Health"},{"key":"key20260518055456_B12","unstructured":"World Health Organization. World Health Organization Model List of Essential Medicines. 23rd list. In The selection and use of essential medicines 2023: Executive summary of the report of the 24th WHO Expert Committee on the Selection and Use of Essential Medicines. Geneva; 2023. Available from: https:\/\/www.who.int\/publications\/i\/item\/WHO-MHP-HPS-EML-2023.02 [Accessed 21\/05\/2024]."},{"issue":"1","key":"key20260518055456_B13","doi-asserted-by":"crossref","first-page":"9","DOI":"10.5334\/gh.1527","article-title":"Implementing the World Health Organization guidelines for rheumatic heart disease in highly endemic settings: Balancing evidence with reality","volume":"21","year":"2026","journal-title":"Global Heart"},{"key":"key20260518055456_B14","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/j.idcr.2016.02.001","article-title":"Myositis complicating benzathine penicillin-G injection in a case of rheumatic heart disease","volume":"4","year":"2016","journal-title":"IDCases"},{"issue":"9960","key":"key20260518055456_B15","doi-asserted-by":"crossref","first-page":"2132","DOI":"10.1016\/S0140-6736(14)60841-2","article-title":"Short-course oral co-trimoxazole versus intramuscular benzathine benzylpenicillin for impetigo in a highly endemic region: An open-label, randomised, controlled, non-inferiority trial","volume":"384","year":"2014","journal-title":"The Lancet"},{"issue":"6","key":"key20260518055456_B16","article-title":"Quality of benzathine penicillin G: A multinational cross-sectional study","volume":"8","year":"2020","journal-title":"Pharmacology Research & Perspectives"},{"issue":"2","key":"key20260518055456_B17","article-title":"Severe adverse events following benzathine penicillin G injection for rheumatic heart disease prophylaxis: Cardiac compromise more likely than anaphylaxis","volume":"11","year":"2019","journal-title":"Heart Asia"},{"issue":"5","key":"key20260518055456_B18","article-title":"Severe adverse reactions to benzathine penicillin G in rheumatic heart disease: A systematic review and meta-analysis","volume":"20","year":"2025","journal-title":"PLoS One"},{"issue":"5","key":"key20260518055456_B19","article-title":"Penicillin reactions in patients with severe rheumatic heart disease: A Presidential Advisory from the American Heart Association","volume":"11","year":"2022","journal-title":"Journal of the American Heart Association"},{"issue":"1586","key":"key20260518055456_B20","doi-asserted-by":"crossref","first-page":"9","DOI":"10.26635\/6965.e1586","article-title":"Aotearoa New Zealand clinicians respond to the 2022 American Heart Association Presidential Advisory Statement regarding penicillin reactions in people with severe rheumatic heart disease","volume":"136","year":"2023","journal-title":"The New Zealand Medical Journal (Online)"},{"issue":"1","key":"key20260518055456_B21","doi-asserted-by":"crossref","first-page":"8","DOI":"10.5334\/gh.1393","article-title":"Acceptability and implementation challenges of benzathine penicillin G secondary prophylaxis for rheumatic heart disease in Ethiopia: A qualitative study","volume":"20","year":"2025","journal-title":"Global Heart"},{"key":"key20260518055456_B22","unstructured":"RHD Australia (ARF\/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3.2 Edition, March 2022); 2020. Available from: https:\/\/www.rhdaustralia.org.au\/system\/files\/fileuploads\/arf_rhd_guidelines_3.2_edition_march_2022.pdf [Accessed 14\/05\/2024]."},{"issue":"5","key":"key20260518055456_B23","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1007\/s13346-016-0313-z","article-title":"Preliminary consultation on preferred product characteristics of benzathine penicillin G for secondary prophylaxis of rheumatic fever","volume":"6","year":"2016","journal-title":"Drug Delivery and Translational Research"},{"issue":"12","key":"key20260518055456_B24","article-title":"Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: A phase 1 open-label population pharmacokinetic study","volume":"67","year":"2023","journal-title":"Antimicrobial Agents and Chemotherapy"},{"issue":"5","key":"key20260518055456_B25","article-title":"\u201cHurts less, lasts longer\u201d; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand","volume":"19","year":"2024","journal-title":"PLoS One"},{"issue":"4","key":"key20260518055456_B26","article-title":"Qualitative assessment of healthy volunteer experience receiving subcutaneous infusions of high-dose benzathine penicillin G (SCIP) provides insights into design of late phase clinical studies","volume":"18","year":"2023","journal-title":"PLoS One"},{"issue":"10","key":"key20260518055456_B27","doi-asserted-by":"crossref","first-page":"2951","DOI":"10.1093\/jac\/dkaa282","article-title":"Subcutaneous administration of benzathine benzylpenicillin G has favourable pharmacokinetic characteristics for the prevention of rheumatic heart disease compared with intramuscular injection: A randomized, crossover, population pharmacokinetic study in healthy adult volunteers","volume":"75","year":"2020","journal-title":"Journal of Antimicrobial Chemotherapy"},{"issue":"2","key":"key20260518055456_B28","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1111\/jpc.12400","article-title":"Reducing the pain of intramuscular benzathine penicillin injections in the rheumatic fever population of Counties Manukau District Health Board","volume":"50","year":"2014","journal-title":"Journal of Paediatrics and Child Health"},{"issue":"11","key":"key20260518055456_B29","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1016\/S1473-3099(05)70267-X","article-title":"The global burden of group A streptococcal diseases","volume":"5","year":"2005","journal-title":"The Lancet Infectious Diseases"},{"issue":"1","key":"key20260518055456_B30","article-title":"Patient preferences for prophylactic regimens requiring regular injections in children and adolescents: A systematic review and thematic analysis","volume":"8","year":"2024","journal-title":"BMJ Paediatrics Open"},{"key":"key20260518055456_B31","first-page":"240","article-title":"Development of a sustained release implant of benzathine penicillin G for secondary prophylaxis of rheumatic heart disease","year":"2023","journal-title":"European Journal of Pharmaceutics and Biopharmaceutics"},{"key":"key20260518055456_B32","unstructured":"Yadav P. Executive order to lower U.S. Drug prices could hurt the poorest countries. Think Global Health; 2025. Available from: https:\/\/www.thinkglobalhealth.org\/article\/executive-order-lower-us-drug-prices-could-hurt-poorest-countries [Accessed 25\/03\/2026]."},{"issue":"1","key":"key20260518055456_B33","article-title":"International reference pricing comes to America: The MFN policies explained","volume":"12","year":"2026","journal-title":"Value & Outcomes Spotlight"},{"key":"key20260518055456_B34","unstructured":"Danzon PM, Epstein AJ. Effects of regulation on drug launch and pricing in interdependent markets. National Bureau of Economic Research (NBER Working Paper 14041); 2011. 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