Academic journal article Bulletin of the World Health Organization

Strategy for Controlling Rheumatic Fever/rheumatic Heart Disease, with Emphasis on Primary Prevention: Memorandum from a Joint WHO/ISFC Meeting

Academic journal article Bulletin of the World Health Organization

Strategy for Controlling Rheumatic Fever/rheumatic Heart Disease, with Emphasis on Primary Prevention: Memorandum from a Joint WHO/ISFC Meeting

Article excerpt


Rheumatic fever/rheumatic heart disease (RF/RHD) is the most common cardiovascular disease in children and young adults and remains a major public health problem, especially in developing countries. It results in suffering caused to patients and their relatives, high costs because of repeated hospitalizations (often leading to premature death or disability), and the necessity for increased resources to support the medical and surgical treatment of large numbers of patients (1-6).(a,b)

RF/RHD was a devastating childhood disease in economically developed countries in the 19th century. The decline in RF incidence in these areas was slow but steady after 1900, much more pronounced after the 1940s, and really dramatic in the late 1960s. At present its occurrence is nil or very low, with an incidence below 5.0 per 100 000 population per year, and a prevalence below 0.5 per 1000 schoolchildren (1-3).(b) However, the recent resurgence of rheumatic fever and other severe streptococcal infections in some industrialized countries has demonstrated that this is not just a problem in the developing countries, and emphasizes the need for a more intensive approach to public health prevention programmes (1-3).(b)

In contrast, RF/RHD was believed to be a rare disease in tropical and subtropical countries during the 19th century. However, since the 1940s it has become a significant health problem, often with very severe effects similar to those observed in Europe a century ago. To date, in developing countries with available data, the RHD mortality rate varies from 0.9 to 8.0 per 100 000 population. Children and young adults still die from acute rheumatic fever; the prevalence in schoolchildren ranges from 1.0 to 10 per 1000 and the incidence from 10 to 100 per 100 000, with a high rate of recurrence and severity. RHD occurs in from 12% to 65% of all cardiac patients and from 1.5% to 4% of all patients admitted to hospital (1-9). In most developing countries, more than 50% of RF/RHD patients are unaware of their disease, and more than 70% do not receive monthly doses of benzathine penicillin for secondary prophylaxis (1-5, 9-11).(c) From these figures, we may conservatively assume that an estimated 12 million people are affected by RF/RHD, with 400 000 deaths annually, and that hundreds of thousands of mainly children and young adults are disabled.

The pathogenetic mechanism of rheumatic fever is still unknown; however, there are two concurrent required factors necessary to initiate the process: a group A beta-haemolytic streptococcal infection of the upper respiratory tract and a specific susceptibility of the individual human host (1-3, 10, 11).(c,d) Hence, the preventive efforts must be directed towards both these factors.

Pharyngitis or sore throat is common in the community, and occurs throughout the world, especially during childhood. It has been estimated that every child has at least one episode per year and that during endemic conditions Group A beta-haemolytic streptococci (GABHS) can usually be isolated from 20-35% of clinically acute sore-throat cases, in both developed and developing countries. Relatively few individuals (0.3-3%) contract rheumatic fever after acute streptococcal pharyngitis (1-3, 10).(c,d)

Appropriate case management of symptomatic streptococcal sore throat is important in order to:

- reduce the incidence of suppurative and nonsuppurative complications;

- reduce the inappropriate use of antibiotics for upper respiratory infections (when medical information and health education on prevention of rheumatic fever are effective);

- reduce the incidence of symptomatic streptococcal sore throat and the average level of streptococcal antibody in the community;

- reduce the infection contagion rate;

- alter the chain of transmission of GABHS and thus diminish the chance of increasing its virulence.


WHO has been concerned with RF/RHD prevention and control since 1954. …

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