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.

Efeito da penicilina G a cada três semanas sobre o surgimento de Streptococcus viridans resistentes à penicilina na microflora oral / Effect of penicillin G every three weeks on oral microflora by penicillin resistant Viridans Streptococci

FUNDAMENTO: Penicilina G benzatina a cada 3 semanas é o protocolo padrão para a profilaxia secundária para febre reumática recorrente. OBJETIVO: Avaliar o efeito da penicilina G benzatina em Streptococcus sanguinis e Streptococcus oralis em pacientes com doença valvular cardíaca, devido à febre reumática com recebimento de profilaxia secundária. MÉTODOS: Estreptococos orais foram avaliados antes (momento basal) e após 7 dias (7º dia) iniciando-se com penicilina G benzatina em 100 pacientes que receberam profilaxia secundária da febre reumática. Amostras de saliva foram avaliadas para verificar a contagem de colônias e presença de S. sanguinis e S. oralis. Amostras de saliva estimulada pela mastigação foram serialmente diluídas e semeadas em placas sobre agar-sangue de ovelhas seletivo e não seletivo a 5% contendo penicilina G. A identificação da espécie foi realizada com testes bioquímicos convencionais. Concentrações inibitórias mínimas foram determinadas com o Etest. RESULTADOS: Não foram encontradas diferenças estatísticas da presença de S. sanguinis comparando-se o momento basal e o 7º dia (p = 0,62). No entanto, o número existente de culturas positivas de S. oralis no 7º dia após a Penicilina G benzatina apresentou um aumento significativo em relação ao valor basal (p = 0,04). Não houve diferença estatística existente entre o momento basal e o 7º dia sobre o número de S. sanguinis ou S. oralis UFC/mL e concentrações inibitórias medianas. CONCLUSÃO: O presente estudo mostrou que a Penicilina G benzatina a cada 3 semanas não alterou a colonização por S. sanguinis, mas aumentou a colonização de S. oralis no 7º dia de administração. Portanto, a susceptibilidade do Streptococcus sanguinis e Streptococcus oralis à penicilina G não foi modificada durante a rotina de profilaxia secundária da febre reumática utilizando a penicilina G. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Benzathine penicillin G every 3 weeks is the standard protocol for secondary prophylaxis for recurrent rheumatic fever. OBJECTIVE: Assess the effect of Benzathine penicillin G on Streptococcus sanguinis and Streptococcus oralis in patients with cardiac valvular disease due to rheumatic fever receiving secondary prophylaxis. METHODS: Oral streptococci were evaluated before (baseline) and after 7 days (day 7) with Benzathine penicillin G in 100 patients receiving routine secondary rheumatic fever prophylaxis. Saliva samples were evaluated for colony count and presence of S. sanguinis and S. oralis. Chewing-stimulated saliva samples were serially diluted and plated onto both nonselective and selective 5% sheep blood agar containing penicillin G. The species were identified using conventional biochemical tests. Minimal inhibitory concentrations were determined with the Etest. RESULTS: No statistical differences were found in the presence of S. sanguinis comparing baseline and day 7 (p = 0.62). However, the existing number of positive cultures of S. oralis on day 7 after Benzathine penicillin G presented a significant increase compared to baseline (p = 0.04). No statistical difference was found between baseline and day 7 concerning the number of S. sanguinis or S. oralis CFU/mL and median minimal inhibitory concentrations. CONCLUSION: This study showed that Benzathine penicillin G every 3 weeks did not change the colonization by S. sanguinis, but increased colonization of S. oralis on day 7 of administration. Therefore, susceptibility of Streptococcus sanguinis and Streptococcus oralis to penicillin G was not modified during the penicillin G routine secondary rheumatic fever prophylaxis. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

Rheumatic Fever: New Ideas in Diagnosis and Management

Rheumatic heart disease remains a major cause of disability and death in developing countries. careful re-analysis of mid- 20th century data as well as the juxtaposition of well-funded research units and populations at risk have generated information that resulted in radical departures from standard approaches to the prevention; clinical recognition and treatment of acute rheumatic fever. As a result; rheumatic heart disease may be eliminated in the future

Epidemiology of Valvular Heart Diseases in Africa

Rheumatic heart disease (RHD) resulting from rheumatic fever (RF) is the main form of valve disease in Africa. Other forms of valve diseases such as myxomatous mitral valve disease; age-related valve disease; -valvular aneurysms or valve disease related to endomyocardial fi brosis are less common than RHD. In developed countries; RF and RHD are rare and no longer pose a public health problem; but the combination of poverty; lack of awareness; lack of infrastructure and resources; and social instability contribute to the persistence of RF and RHD in Africa. The presence of other major infectious diseases also shifts attention away om RF and RHD. Contemporary population-based epidemiologic data utilising echocardiography to detect valve disease suggests the prevalence of valve diseases in Africa is likely much higher than previously thought; meaning the estimated mortality; morbidity and socio-economic burden they cause could also be much higher than currently appreciated. Increased efforts are needed to defi ne the scope of the problem of valve diseases in Africa to draw attention to these illnesses and step up public health efforts to control and eradicate them as has already been achieved in other parts of the world. This article highlights the public health problem of valve diseases in Africa; the efforts underway to combat them and the attendant challenges

Rheumatic Fever and Rheumatic Heart Disease: Where are we now in South Africa?

South Africa continues to face unacceptably high rates of rheumatic fever (RF) and rheumatic heart disease (RHD); despite readily available and inexpensive preventive measures. However; in the past several years; key players in South Africa's healthcare and political realms in addition to key players from many African nations have come together to acknowledge the persistent health burden attributable to RF/RHD and have agreed to a pledge of action to reduce it.The plan of action is a comprehensive RF/RHD prevention and treatment programme known as ASAP. The ASAP programme targets efforts to raise Awareness; establish surveillance systems; Advocate for increased resources for treatment; and to promote Prevention strategies. South Africa currently has a demonstration site where activities in all of these key areas are currently underway. Efforts in the area of surveillance include a RHD prevalence study that aims to screen 4 000 school-aged children through the use of a mobile echo-surveillance unit. In addition to local efforts; South Africa will join an international initiative to create a global RHD registry that will aid in all aspects of prevention and treatment to further reduce the burden of disease attributable to RF/RHD

Curso de atualização em emergências médicas. Aula 10: faringoamigdalite e sinusites / Updating in medical emergencies course. Class 10: pharyngoamigdalitis and sinusites

As infecções das vias aéreas superiores constituem problema comum de Saúde Pública Mundial. Sua identificação adequada e o uso criterioso de antimicrobianos nestas situações evitam co-morbidades, como febre reumática e glomerunefrite, e diminuem consideravelmente o absenteísmo ao trabalho. Atualizamos "Faringoamigdalite e sinusite" na visão do clínico prático.

The infections of the upper airways constitute a common problem of the World's Public Health. Their adequate identification and the criterial usage of antimicrobial drugs in these situations avoid comorbities, such as rheumatic fever and glomerulonefritis and considerably diminishes absenteeism in the workplace. We update here "Pharyngoamigdalitis and sinusitis in the view of the general practitioner.

Penicillin clinic; a model program for prevention of rheumatic fever and rheumatic heart disease in Pakistan

Rheumatic Fever/Rheumatic Heart Disease [RF/RHD] is the most common cardiovascular disease in children and young adults and remains a major health problem in developing countries. Currently, it affects an estimated 15.6 million people world-wide. Recent data from Pakistan has shown a very high prevalence of RHD in both urban and rural population. In a large cross-sectional survey conducted on more than 25,000 urban school children from inner Lahore, has estimated prevalence of 22/1000

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.

Educação em saúde para a prevenção de Febre Reumática

Introdução: A Febre Reumática, doença resultante de uma faringoamigdalite estreptocócica não tratada adequadamente, pode cursar com seqüelas cardíacas graves e incapacitantes. Apesar de sua fácil prevenção, sua prevalência ainda é alta nos países subdesenvolvidos e em desenvolvimentos, em especial no Brasil, segundo dados do Data SUS. A falta de informação da população e dos próprios profissionais de saúde, é uma das causas que contribui para tais índices. No Rio de Janeiro, o Hospital Geral de Bonsucesso é um centro de referência para o acompanhamento de crianças e adolescentes portadores de febre reumática, sendo este, portanto cenário de atuação do presente trabalho. Materiais e métodos: Análise de 480 questionários elaborados e aplicados por estudantes de medicina do nono período e residentes; supervisionados por médicos do setor de cardiologia pediátrica e professores da UNESA. Objetivo: O objetivo geral do estudo é avaliar o grau de conhecimento de usuários, funcionários, estudantes e profissionais de saúde do HGB, a respeito da enfermidade - febre reumática. Com base nos dados obtidos são delineadas estratégias de atuação educacional visando à conscientização da prevenção da doença. Conclusão: Após análise dos dados colhidos de 480 questionários respondidos, constata-se a necessidade de uma maior divulgação interna do centro de referência de febre reumática do HGB e de seu campo de atuação, alem de se criar para a população leiga uma dinâmica de informação do diagnóstico precoce e tratamento correto das faringoamigdalites bacterianas, e reciclagem periódica para profissionais da área de saúde.

Beta-haemolytic streptococci in school children 5-15 years of age with an emphasis on rheumatic fever, in the tri-island state of Grenada / Estreptococos Beta-hemolíticos en Escolares de 5 a 15 años de edad con Énfasis en la Fiebre Reumática en el Estado Triinsular de Granada

The objective of this study is to determine the prevalence of beta-haemolytic streptococci in the pharynx and antibodies to beta-haemolytic streptococci in school children 5-15 years of age in the tri-island state of Grenada Blood samples and throat swabs were obtained from 1388 school children, aged 5-15 years old attending randomly selected schools in each parish of the tri-island state of Grenada. Serum samples were subjected to antistreptolysin o testing (ASOT) while throat swabs were cultured on sheep blood agar plates. The prevalence of positive throat swab was 15.4 (95 CI = 13.4, 17.2). The rate was highest in St Patrick (21.8) and lowest in Carriacou (5.7). The prevalence of antibodies was 38.6 (95 CI = 37.6, 42.8). It was highest in St Patrick (54.4) and lowest in Petit Martinique (26.8). In St Patrick, males were significantly more likely than females to have a positive ASOT (p = 0.0084). In St George's, males were significantly more likely than females to have a positive throat culture (p = 0.0172). Thirty-four per cent of the positive cultures were type A, 10 were type C and 56 type G. The data illustrate that there is a high prevalence of beta-haemolytic streptococci in school children in certain parishes in Grenada. Public health measures should address prevention and control of beta3-haemolytic streptococcal infection in order to prevent the possible sequelae of this disease

El objetivo de este estudio es determinar el predominio de estreptococos ß-haemolíticos en la región faríngea y los anticuerpos de los estreptococos ß-hemolíticos en escolares de 5 a 15 años de edad en el Estado tri-insular de Granada. Se obtuvieron muestras de sangres e hisopos de garganta de 1,388 escolares comprendidos en las edades de 5 a 15 años, que asistían a escuelas seleccionadas de manera aleatoria, en cada parroquia del Estado tri-insular de Granada. Muestras de suero fueron sometidas a la prueba de antistreptolisina O (ASTO), mientras que las muestras tomadas de los hisopos de garganta fueron cultivadas en placas de agar de sangre bovina. La prevalencia de muestras de garganta positivas fue 15.4% (95% CI = 13.4%, 17.2%). Los por cientos más elevados correspondieron a Saint Patrick (21.8%) y los más bajos a Carriacou (5.7%). El predominio de anticuerpos fue de 38.6% (95% CI = 37.6%, 42.8%). El más alto correspondió a Saint Patrick (54.4%) y el más bajo a Petit Martinique (26.8%). En Saint Patrick, la probabilidad de tener un ASTO positivo (p=0.0084) fue significativamente más alta en los hombres que en las mujeres. En Saint George's, la probabilidad de tener un cultivo de garganta positivo, fue significativamente más alta en los hombres (p = 0.0172) que en las mujeres. El treinta y cuatro por ciento de los cultivos positivos fueron del tipo A, el 10% fue del tipo C y el 56% del tipo G. Los datos indican que hay un alto predominio de estreptococos ß-hemolíticos en los niños escolares en ciertas parroquias de Granada. Las medidas de salud públicas deben dirigirse a la prevención y control de la infección estreptocócica ß-hemolítica, a fin de prevenir las posibles secuelas de esta enfermedad

A prevenção da febre reumática / The prevention of rheumatic fever

No início de um novo século, questões importantes sobre a pato- gênese e abordagem terapêutica da febre reumática (FR) permanecem sem respostas. Nas últimas décadas, ocorreu uma redução acentuada da freqüência da doença nos países desenvolvidos, concomitante à implementação do padrão social, econômico e cultural da população. O reaparecimento da doença em algumas áreas dos países industrializados deve ser considerado como um alerta de sua presença potencial, apesar do aparente controle. Nos países em desenvolvimento, a FR e sua seqüela, a cardiopatia reumática crônica, estão intimamente relacionadas à pobreza e continuam como desafio para todos os profissionais de saúde. Nessas áreas, a FR é a causa mais importante de doença cardíaca adquiri- da, representando um relevante problema de saúde publica, com significativos índices de morbimortalidade. Devido à impossibilidade de modificações dos fatores socioeconômicos em curto prazo, o controle da FR somente poderá ser alcançado através da implantação de programas educacionais e de assistência à saúde, envolvendo decisões políticas e planos de ação para implementar a adesão dos pacientes às profilaxias primária e secundária.

In the beginning of a new century, major questions about the pathogenesis and treatrnent of the rheumatic fever remain unanswered. The frequency of the disease has sharply declined in the developed countries and this fact was concomitant with the improvement in living stan- dardo Its recent resurgence in some areas of the industrialized countries must be considered as a warning for its potential presence, in spire of an apparent control. The rheumatic fever and its sequel, the rheumatic heart disease, are closely related with poverty and are still a challenge to rhose involved in providing health care in developing countries. In those areas, the rheumatic fever is the most importam cause of acquired heart disease and is still a relevant problem of public health with significant rates of morbidity and mortaliry. Owing to the impossibility to change the structural socioeconomic factors in a short time, the control of rheumatic fever can only be achieved by the setting up of healrh and educational programmes, involving political decisions and plans of action to provide better adherence from patients to primary and secondary prophylaxis.