Rheumatic Fever: A Disease without Color / Febre Reumática: Uma Doença sem Cor

Abstract Background: Brazil has approximately 30.000 cases of Acute Rheumatic Fever (ARF) annually. A third of cardiovascular surgeries performed in the country are due to the sequelae of rheumatic heart disease (RHD), which is an important public health problem. Objectives: to analyze the historical series of mortality rates and disease costs, projecting future trends to offer new data that may justify the need to implement a public health program for RF. Methods: we performed a cross-sectional study with a time series analysis based on data from the Hospital Information System of Brazil from 1998 to 2016. Simple linear regression models and Holt's Exponential Smoothing Method were used to model the behavior of the series and to do forecasts. The results of the tests with a value of p < 0.05 were considered statistically significant. Results: each year, the number of deaths due to RHD increased by an average of 16.94 units and the mortality rate from ARF increased by 215%. There was a 264% increase in hospitalization expenses for RHD and RHD mortality rates increased 42.5% (p-value < 0.05). The estimated mortality rates for ARF and RHD were, respectively, 2.68 and 8.53 for 2019. The estimated cost for RHD in 2019 was US$ 26.715.897,70. Conclusions: according to the Brazilian reality, the 1-year RHD expenses would be sufficient for secondary prophylaxis (considering a Benzatin Penicillin G dose every 3 weeks) in 22.574 people for 10 years. This study corroborates the need for public health policies aimed at RHD.

Resumo Fundamento: O Brasil tem aproximadamente 30.000 casos de febre reumática aguda (FRA) por ano. Um terço das cirurgias cardiovasculares realizadas no país se deve às sequelas da doença reumática cardíaca (DRC), a qual é um importante problema de saúde pública. Objetivos: Analisar as séries históricas de taxas de mortalidade e custos das doenças, projetando tendências futuras para oferecer novos dados que possam justificar a necessidade de implementação de um programa de saúde pública para FR. Métodos: Foi realizado um estudo transversal com análise de séries temporais a partir de dados do Sistema de Informações Hospitalares do Brasil, de 1998 a 2016. Modelos de regressão linear simples e o método de suavização exponencial de Holt foram utilizados para modelar o comportamento das séries e fazer previsões. Os resultados dos testes com um valor de p <0,05 foram considerados estatisticamente significantes. Resultados: A cada ano, o número de mortes por DRC aumentou em média 16,94 unidades, e a taxa de mortalidade por FRA aumentou em 215%. Houve um aumento de 264% nas despesas de hospitalização por DRC, e as taxas de mortalidade por DRC aumentaram 42,5% (p-valor < 0,05). As taxas de mortalidade estimadas para FRA e DRC foram, respectivamente, 2,68 e 8,53 para 2019. O custo estimado para a DRC em 2019 foi de US$ 26.715.897,70. Conclusões: De acordo com a realidade brasileira, o gasto relativo a 1 ano de DRC seria suficiente para a profilaxia secundária (considerando uma dose de penicilina G benzatina a cada 3 semanas) em 22.574 pessoas por 10 anos. Este estudo corrobora a necessidade de políticas públicas de saúde direcionadas à DRC.

Rheumatic heart disease in the modern era: recent developments and current challenges

Abstract Rheumatic heart disease (RHD) remains a major cause of preventable death and disability in children and young adults. Despite significant advances in medical technology and increased understanding of disease mechanisms, RHD continues to be a serious public health problem throughout the world, especially in low- and middle-income countries. Echocardiographic screening has played a key role in improving the accuracy of diagnosing RHD and has highlighted the disease burden. Most affected patients present with severe valve disease and limited access to life-saving cardiac surgery or percutaneous valve intervention, contributing to increased mortality and other complications. Although understanding of disease pathogenesis has advanced in recent years, key questions remain to be addressed. Preventing or providing early treatment for streptococcal infections is the most important step in reducing the burden of this disease.

Sudan Rheumatic Heart Disease Control Initiative: achievements and challenges: 2012-2017. Sudan RHD Control Committee

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The rheumatic fever and rheumatic heart disease control programme: Jamaica / Programa de control de la fiebre reumática y la enfermedad reumática del corazón: Jamaica

BACKGROUND: Rheumatic fever (RF) and rheumatic heart disease (RHD) are significant causes of cardiovascular disease in young adults and children especially in developing countries. In 1984, the World Health Organization (WHO) and International Society and Federation of Cardiology (ISFC) initiated an International Programme for Prevention of RF/RHD in 16 developing countries, including Jamaica. The Jamaican RF/RHD National Control Programme began in July 1985. SUBJECTS AND METHOD: The Control Programme promotes the primary prevention of RF/RHD through the appropriate treatment of streptococcal throat infections. Secondary prevention has been the main focus of the Control Programme by administration of benzathine penicillin injections every four weeks to RF/RHD patients. Case finding activities have included two retrospective surveys of case records of RF/RHD patients admitted to the major hospitals in Kingston and St Andrew in the period 1975 - 1985 (Survey A) and 1989 - 1995 (Survey B). These surveys provided clinical and laboratory data on RF/RHD in Jamaican patients which were documented and analysed. RESULTS: Records of 1079 patients were reviewed in Survey A and records of 512 patients were reviewed in Survey B. Seventy-seven per cent of 524 patients were aged 5−15 years in initial attacks of RF in Survey A and in Survey B, 82% of 119 patients were between 5 and 15 years in initial attacks. There was no significant sex difference in RF in Survey A and Survey B. A diagnosis of RF had been made in 54% of records in Survey A and 55% of records in Survey B. Diagnosis conformed to the Modified Jones criteria. Carditis occurred in 41% and 70% of RF patients, respectively in survey A and B. Polyarthritis occurred in 73% in Survey A and 74% in Survey B. Chorea occurred in 3% of RF patients in both surveys. Erythema marginatum and subcutaneous nodules occurred rarely in both surveys. Evidence of recent streptococcal infections in RF was found in 74% and 64% in Survey A and B, respectively. Severe carditis occurred in 7% of initial attacks of RF in A and 26% in B. In RHD, mitral incompetence was the commonest valvular lesion, occurring in 82% and 68% in A and B, respectively. Rheumatic fever and rheumatic heart disease have relatively long and expensive hospital stays which are preventable by careful adherence to prevention programmes. CONCLUSION: The National Control Programme for RF/RHD in Jamaica began in 1985 and deserves careful monitoring and support to reduce the burden of RF/RHD. Analysis of clinical and laboratory data obtained in the retrospective surveys conducted for case finding provides important data on RF/RHD in Jamaica.

ANTECEDENTES: La fiebre reumática (FR) y la enfermedad reumática del corazón (ERC) constituyen causas significativas de la enfermedad cardiovascular en adultos jóvenes y niños en los países en vías de desarrollo. En 1984 la Organización Mundial de la (OMS) y la Sociedad y Federación Internacional de Cardiología (ISFC) iniciaron un Programa Internacional para la Prevención de FR/ERC en 16 países en vías de desarrollo, incluyendo Jamaica. El Programa Nacional de Jamaica para el control de FR/ERC, comenzó en julio de 1985. SUJETOS Y MÉTODO: El Programa de Control promueve la prevención primaria de FR/ERC a través del tratamiento apropiado de infecciones estreptocócicas de la garganta la prevención secundaria ha sido el foco principal del Programa de Control mediante la administración de inyecciones de penicilina benzatinica cada cuatro semanas a los pacientes de FR/ERC. Las actividades de detección de casos han incluido dos estudios retrospectivos de historias clínicas de casos de pacientes de FR/ERC ingresados en los hospitales principales de Kingston y Saint Andrew en el periodo 1975 - 1985 (Estudio A) y 1989 - 1995 (Estudio B). Estos estudios proporcionaron datos clínicos y de laboratorio de FR/ERC en pacientes jamaicanos. Dichos datos fueron documentados y analizados. RESULTADOS: Se examinaron las historias clínicas de 1079 pacientes en el Estudio A y se revisaron las historias clínicas de 512 pacientes en el Estudio B. El 77% de 524 pacientes tenían entre 5 - 15 años de edad al inicio de lo ataques de FR en el Estudio A, en tanto que en el Estudio B el 82% de 119 pacientes tenían entre 5 y 15 años de edad al inicio de los ataques. No hubo ninguna diferencia significativa en cuanto a sexo en FR en el Estudio A y el Estudio B. Se había realizado un diagnóstico de FR en el 54% de las historias clínicas del Estudio A y el 55% de las historias clínicas del Estudio B. El diagnóstico se ajustaba a los criterios de Jones modificados. Se presentó carditis en 41% y 70% de los pacientes de FR respectivamente en el estudio A y B. La poliartritis ocurrió en 73% en el Estudio A y 74% en el Estudio B. La corea ocurrió en 3% de pacientes de FR en ambos estudios. Ls manifestaciones de eritema marginatum y los nódulos subcutáneos raramente ocurrieron en ambos estudios. En el 74% y 64% de los Estudios A y B, respectivamente, se halló evidencia de recientes infecciones estreptocócicas de FR. La carditis severa ocurrió en el 7% de los ataques iniciales de FR en A y 26% en B. En la ERC, la incompetencia mitral fue la lesión valvular más común, presentándose en el 82% y 68% de A y B, respectivamente. La fiebre reumática y la enfermedad reumática del corazón tienen estadías de hospitalización relativamente largas y costosas, las cuales pueden prevenirse mediante la adhesión cuidadosa a los programas de la prevención. CONCLUSIÓN: El Programa Nacional de Jamaica para el control de FR/ERC, empezó en 1985 y requiere un monitoreo cuidadoso y apoyo constante a fin de reducir la carga de FR/ERC. El análisis de los datos clínicos y los datos de laboratorio obtenidos en los estudios retrospectivos conducidos para la detección de casos proporcionan datos importantes sobre la FR/ERC en Jamaica.

Microbiological diagnosis of streptococcal pharyngitis: lacunae and their implications.

Post-streptococcal sequelae, especially acute rheumatic fever/rheumatic heart disease continue to occur in significant proportions in many parts of the world. Despite several attempts with various intervention strategies, little success has been achieved in the control of acute rheumatic fever/rheumatic heart disease in India. The success of the control programmes depends upon timely primary prophylaxis with benzathine penicillin for which a microbiological confirmation of group A streptococcal pharyngitis is essential. Isolation of beta hemolytic streptococci from throat cultures and their identification as GAS in the laboratory, clinches the microbiological diagnosis while demonstration of a 'significant rise' in antibody titers such as Anti-streptolysin O and Anti-deoxyribonuclease B differentiates it from a group A streptococcal carrier state or pharyngitis of a viral etiology. Despite the easiness with which these can be achieved, many laboratories in India are not equipped to do so. Enhancing bacteriological and serological facilities in laboratories across the country will drastically improve the clinician's ability to diagnose bona fide GAS pharyngitis and help to institute penicillin prophylaxis at the appropriate time. This will go a long way in enhancing the compliance to penicillin prophylaxis which is the cornerstone of any RF/RHD control program.

Demanda hospitalaria, manifestaciones clínicas y prevención de fiebre reumática y cardiopatía en el Instituto de Salud del Niño 1989-1993 / Hospital demand, clinical sign and prevention of rheumatic fever and rheumatic cardiopathy in the Instituto de Salud del Niño 1989-1993

Se estudiaron retrospectivamente 66 pacientes hospitalizados en el Servicio de Cardiología del Instituto de Salud del Niño-entre 1989 y 1993- con el diagnóstico de fiebre reumática y cardiopatía reumática. Se encontró un aumento significativo en los 3 últimos años. El promedio en días de hospitalización se duplicó en 1993 respecto a 1989. El grupo etáreo más afectado fue entre los 11-15 años, con 39 pacientes (59 por ciento). El 74.5 por ciento tuvieron clase funcional III o IV, el 98 por ciento compromiso cardíaco; la lesión valvular más encontrada fue de insuficiencia aórtica (41 por ciento); la complicación más frecuente fue endocarditis infecciosa en 15 pacientes (23 por ciento). Fueron operados 8 pacientes sin mortalidad quirúrgica, 4 pacientes (6 por ciento) fallecieron de complicaciones clínicas. El severo compromiso cardiovascular mostrado en nuestra casuística se debe a una recurrencia elevada de carditis reumática por una ineficaz prevención. Ello hace imprescindible la implementación de un programa ampliado de prevención que considere la administración de fármacos y las condiciones sociales del enfermo para mejorar sus condiciones de vida.

Preventive and clinical aspects of cardiac problems among school children in Alexandria

A retrospective study of cardiac problems among school children in Alexandria has been done to determine some aspects of the pattern of the problem and to assess the secondary prophylaxis and follow-up measures. Of the 398 cases [mean age of 12.1 +/- 2.2 years] registered in the cardiac clinic of the student hospital in the city, 258 children [64.8%] were rheumatic heart disease [RHD] cases, while 51 children [12.8%] were congenital heart disease [CHD]. Other cases were rheumatic arthritis [13.8%], rheumatic chorea [5.0%], rheumatic fever [1./5%], and functional murmur [2.1%]. Mitral insufficiency was the major functional defect in RHD children [48%], while the ventricular septal defect [VSD] was the main lesion among CHD children [48%]. Within the last year of follow up, the RHD children experienced drop-out rate of secondary penicillin prophylaxis of 28.6% mainly due to parental ignorance [14.6%] and fear of penicillin injection [10.9%], while the recurrence rate of rheumatic fever among them was 29.4%, which increased significantly [P <0.01] to 48.6% among the dropout cases. Non-participation in school physical education was evident among 72.2% and 80% of RHD and CHD children, mainly due to the doctor's certificate and parental over-protection. It was concluded that rheumatic heart disease is the most common cause of heart diseases among school children in the city, and the drop-out of penicillin prophylaxis relatively high. A plan was recommended to improve secondary penicillin prophylaxis and participation in physical education by such group

Cardites rhumatismales de l'enfant: etude clinique et evolutive a propos de 45 cas

les auteurs etudient 45 cas de cardites rhumatismales colliges entre janvier 1989 et decembre 1992 dans le service de pediatrie du CHU de Brazzaville et repondant aux criteres de Jones revises. La frequence etait de 0;78 pour cent; l'age moyen de 10 ans et 4 mois. Il y avait 26 filles et 19 garcons. L'insuffisance cardiaque presente dans 32 cas; l'index cardiothoracique superieur a 0;60 dans 33 cas temoignent de la gravite de cette affection

Participation of health workers, school teachers and pupils in the control of rheumatic fever: evaluation of a training programme.

In a rural community block of north India we initiated a programme for control of rheumatic fever and rheumatic heart disease (RF/RHD). This included a training campaign for all 74 health workers, 773 school teachers and 12,500 older pupils (class V to X) to enable them to suspect and refer cases of RF/RHD and counsel them about secondary prophylaxis. Training material was used by project staff, medical officers and teachers to convey that this serious disease with onset between 5 and 15 years can be recognized by four simple criteria: fever with joint pain or swelling; breathlessness and fatigue; involuntary face and limb movements. One year later we evaluated awareness generated by training by administering a questionnaire to random samples in the intervention area and in a noncontiguous control area. Health workers, teachers and pupils of the intervention block were significantly better aware of the nature, severity and presentation of the disease and reported having recognized cases whom they had referred for diagnosis, prophylaxis and counselled for follow up. We conclude that a training protocol incorporating simple messages can effectively create practical awareness for RF/RHD control among teachers, health workers and pupils in a rural community.

Serum penicillin concentration in rheumatic patients on benzathine penicillin prophylaxis

The study included 40 selected patients with a documented history of rheumatic fever or clinical rheumatic heart disease [RHD]. They were 24 males and 16 females; aged 6-14 yrs. Group 1 included 20 patients on regular tri-weekly prophylaxis with benzathine penicillin [BPG] 1.2 mega units I.M., group 2 included 20 patients on irregular prophylaxis. Serum penicillin concentration was estimated at the end of the first, second and third weeks after administration, by the agar-diffusion microbiological assay. All cases in both groups had adequate serum panicillin levels at the end of the second week. However, at the end of the third week, 45% of patients in group 1, and 75% in group 2 had serum penicillin levels < 0.03 micro g/ml; [minimal therapeutic level = 0.03 micro g/ml]. None of patients in group I showed any rheumatic activity, while 5/9 from group 2 [55.5%] showed laboratory evidence of activity. Cardiac affection detected in 8/20 patients in group I remained stationary during a 5 years follow up, while 19/20 of group 2 patients had established valvular disease by the end of this period. This indicates the greater impact of rheumatic recurrences, clinical or subclinical, on progress of cardiac affection due to non compliance. We concluded that triweekly regimen of BPG is adequate provided that patient's compliance is assured

Clinical aspect of rheumatic valvular disease in children

This is a cross sectional study including 45 proved rheumatic valvular diseased children [21 males and 24 females], they were matched with 19 able bodied colleagues, their age ranged from 5-15 years and they were attendants of Bab El Sharyia University Hospital during 1989. All of the children were clinically examined besides roentgenographic study of 20 rheumatic valvular diseased children and 10 of the control group aiming at assessing their physical growth [weight and height] and bone age. Data obtained revealed that: Double mitral lesion constitutes 57.78% of the rheumatic valvular lesion, mitral stenosis constitute 20% while concurrent mitral and aortic lesions constitute 20% of the cases. The mean age of the rheumatic valvular diseased children at the study was 11.26 +/- 2.2 years, the mean age of the onset of the disease was 8.3 +/- 1.7 years. Their mean percentiles of weight and height were [32.3 +/- 14.6 and 30.0 +/- 15.7 respectively], they were [47.8 +/- 14 and 41.6 +/- 15.1] among the control group, the difference was statistically significant. Thirty percent of the roentgenographically studied rheumatic valvular diseased children showed retarded bone age, 83.33% of them were suffering from double mitral lesion, 10% only of the control group children showed retarded bone age. Children who had double mitral lesion as compared with the control group revealed significant lower mean weight and height and a higher incidence of retarded bone age