~ q '-E <.? t.f

ie a ~

es PT~~WHO programme for the prevention of

rheumatic~ fever/rheumatic heart disease in

16 developing countries: report from Phase

(1986-90)WHO Cardiovascular Diseases Unit and principal investigators1

The programme was initiated in 1984 by WHO in close collaboration with the International Society andFederation of Cardiology (ISFC). Sixteen countries in five WHO Regions participated: Mali, Zambia andZimbabwe (in Africa); Bolivia, El Salvador and Jamaica (in the Americas); Egypt, Iraq, Pakistan andSildan (in the Eastern Mediterranean); India, Sri Lanka and Thailand (in South-East Asia); and China,Ihe Philippines and Tonga (in the Western Pacific). The programme was planned for implementation in!IIree phases: pilot study and control programme in a selected area, control programmes in all the$9Iec[ed communities, and their extension to the whole country.

In Phase I, a total of 1433710 schoolchildren were screened and 3135 cases of rheumatictgverlrheumatic heart disease (RF/RHD) were found, giving a prevalence of 2.2 per 1000 (higher in theA.fttcan and Eastern Mediterranean regions); 33 651 recently identified or already known cases were!egistered; completion of secondary prophylaxis was irregular but averaged 63.2% coverage; percen-z.ges of adverse reactions (0.3%) and recurrence of acute RF (0.4%) were very small; 24 398 healthP/ltsonnel and teachers were trained. Health education activities were organized for patients, theirr~tives. and the general public in hundreds of health education sessions. Thousands of pamphlets,brochures and posters were distributed, and health education programmes were broadcast on radioand television. The quality of care for RF/RHD patients improved under the programme, which hasbeen expanded to other areas.

tnlroduction

~matic fever / rheumatic hean disease (RF/RHD)"'I}r; most common cardiovascular disease in chil-~ and young adults and remains a major public

~ problem in developing countries (1). The costn~ high because of repeated hospitalizations,~ltn resulting in premature death), the enormous~s needed for medical and surgical treatmentI;llarge numbers of patients, and the suffering

caused to patients and relatives (2).8 The resurgenceof acute RF in the USA in the mid-1980s, with itsspecific epidemiological characteristics, plus otherisolated epidemics of RF (I, 2),8 and the absence ofan effective antirheumatic streptococcal vaccineor genetic marker to identify people at high risk ofdeveloping RF, point to the fact that intensifiedresearch is needed in these areas. Meanwhile, theavailable and feasible preventive methods must be

applied (I, 2).8WHO has been concerned with RF/RHD pre-

vention and control since 1954, when the WHOExpert Committee on Rheumatic Diseases suggested

-'"::---,.~ paper was prepared by Dr P. Nordet, WHO

~ascutar Diseases Unit, for the principal investigators~I' RnanleS and Institutes are given in the Annex (see page~ ~~ts for reprints should be sent to Cardiovascular

~~nil. World Health Organization, 1211 Geneva 27,

~ ~. 5268

~--

.Nordet, P. Rheumatic fever. Clinical and epidemiologicalaspects, Havana, Cuba, 1972-1987. Thesis. Havana, CubanMinistry of Health, 1988.

.",~ ...'d... WOrld Heallh ~ '0".

Jrganization, 70(2): 213-218 (1992) 2131:1 World Health Organization 1992

WHO and principal investigators

Each collaborating country hasnational plan of operation followingvided bymitrnent to extend programmesteps towards nationwide coverageplan of operation was signed by theHealth -indicate their endorsement of thecollaboration with WHO.

The programme's implementation

phases:.short-term (Phase I): planning and

pre-programme pilot study, andcontrol in the selected area;

.medium-term (Phase II):(consolidation and extension to the

community);.long-term (Phase III): nationwide

(consolidation and extension to the

the possibility of using antibiotics and sulfonamidesto prevent RF/RHD on a worldwide scale (3).Subsequently, other WHO Expert Committees havedirected their efforts towards public health practiceswith regard to the study, prevention and control ofgroup A streptococcal infections and RF/RHD (1,3-8).b, c

In the 1970s, WHO initiated an internationalcooperative study on RF/RHD prevention in sevendeveloping countries in: Africa, the Americas andAsia, and the Pan American Health Organization(PAHO) developed another study in seven LatinAmerican countries. Both of these demonstrated thatcommunity programmes for the secondary preven-tion of RF/RHD were not only feasible but also cost-effective in developing countries (9), and this hasbeen stressed in several WHO reports on RF/RHD

(1,6-10).b,c,dIn 1984, in response to a World Health

Assembly resolution (WHA36.32), WHO, in closecollaboration with the International Society andFederation of Cardiology (ISFC), initiated the globalprogramme for the prevention of RF/RHD in 16developing countries.d This programme, which wasdesigned to encourage the application of provencontrol measures to decrease morbidity and mortalitydue to RF/RHD and to support national strategies forHealth for All by the Year 2000, is partly funded bythe Arab Gulf Programme for United Nations

Development Organizations (AGFUND).

bothCollaborating countries. SixteenWHO Regions were identified in 1984been participating in the-Africa (population, 193615): Mali,

Zimbabwe-The Americas (140700): Bolivia8, El

Jamaica-Eastern Mediterranean (874813): ~

Pakistan, Sudan-South-East Asia (1 950000): India,

Thailand-Western Pacific (632000): China

Province)', Philippines, Tonga.

Methods

Based on the experiences from the earlier WHOcooperative research study (9), the present program-me was conceived and planned as a service-orientedactivity to be implemented through primary healthcare (PHC) and the national health care delivery sys-tem.d The Ministry of Health therefore has executiveresponsibility for the national programme, appoint-ing the national programme manager and a multi-disciplinary advisory committee, and .providing localinputs to maintain the programme at a viable level.

theProgramme approaches. These coverregistration, and secondary prophylaxis.

Three approaches are used forscreening surveys of schoolchildren;

retrospectivetion and referral ofpected case from hospital discharge, ,outpatient services or any other sources.

A central register was created tonames and main data of all confiflTledpatients. In some areas, there is -registration centre. There is a -confirm the diagnosis of the suspected

patients.Follow-up consultation and

laxis are conducted in the local -

--

b Report of an Advisory Committee Meeting on Streptococcal

Diseases Complex, Geneva, 15-18 November 1983. Unpub-lished WHO document BVI/STREP/85.1 , 1985.c Meeting on the assessment and further developmefii of the

WHO programmes on streptococcal diseases and meningococ-cal infection (Geneva, 10-13 October 1988). Unpublished WHOdocument WHO/MIM/STREP/CSM/89.2, 1989.d WHO Global Programme for the Prevention of Rheumatic

Fever/Rheumatic Heart Disease in sixteen developing countries(AGFUND supported). Meeting of national programme man-agers, Geneva, 4-6 November 1986. Unpublished WHO docu-ment WHO/CVD/87.1, 1987.

.Pre-programme pilot study only.f Target population. 5-15 years old.

214

Global programme for preventing rheumatic fever/rheumatic heart disease

Resume

Programme OMS de prevention du

rhumatisme articulaire aigu et des

cardiopathies rhumatismales dans 16

pays en developpement: rapport de la

Phase I {1986-1990)

Le programme a ete lance en 1984 par I'OMS encollaboration etroite avec la societe et Federationinternationale de Cardiologie (SFIC). Seize paysappartenant a cinq Regions OMS y participent:Mali, Zambie et Zimbabwe (Afrique); Bolivie, El

Salvador et Jamaique (Ameriques); Egypte, Iraq,Pakistan et Soudan (Mediterranee orientale);Inde, Sri Lanka et Thailande (Asie du Sud-Est);Chine, Philippines et Tonga (Pacifique occiden-tal). Le programme devait etre mis en reuvre entrois phases: etude pilote et programme de luttedans une region choisie, programmes de luttedans toutes les communautes choisies, extensiona I'ensemble du pays.

Au cours de la Phase I, un total de 1 411 910ecoliers ont ete depistes et 3135 cas de rhuma-tisme articulaire aigu ou de cardiopathie rhuma-tismale ont ete trouves, ce qui correspond a uneprevalence de 2,2 cas pour 1000 (avec deschiffres plus eleves dans la Region africaine et laRegion de la Mediterranee orientale); 33 651 casrecemment diagnostiques ou deja connus ont eteenregistres; la prophylaxie secondaire a ete irre-gulierement suivie, mais a atteint une couverturede 63,2%; les pourcentages de reactions indesi-rabies (0,3%) et de rechutes de rhumatisme arti-culaire aigu (0,4%) ont ete tres faibles; 24 398membres des personnels de sante et enseignantsont ete formes. Des activites d'education pour lasante ont ete organisees a I'intention desmalades, des families et du grand public, aucours de centaines de seances educatives. Desmilliers de brochures et d'affiches ont ete distri-bues, et des programmes d'education pour lasante ont ete diffuses a la radio et a la television.La qualite des soins aux malades atteints de rhu-matisme articulaire aigu et de cardiopathies rhu-matismales s'est amelioree au cours du program-me, qui a ete etendu a d'autres regions.

Region ';The level of secondary pro~hylaxis coverage is

--,,~ult to assess over Ion¥ penods, because of theuence of many c~n~u:aIn~s such as shortage of

Total ~thine benzylpenIcIllIn, Inadequate staff, weak

;" rt ; n O on activities, and low patient compliance

---"~ ~ "698 ~g some phases of the programme; hence, great

208: \:anations were observed between countries and in

jb!:six-monthly repo:ts fro.m the.same country. The

6104 '~ults in nine countrIes, WIth a hlgher-than-expected8800 ::j)moaverage of prophylaxis coverage and with low

~~ of RF recurren~e, resemble those from other

~~es on commu~lty control of ~/RHD (9,11;.;13). The proportIon of adverse. reactIons to the~icillin (mainly s~vere anaphylaxIs and .death) was~i and agrees WIth other reports (rangIng from 1

conduc1tt~c4per 10 000 courses of penicillin treatment) (1,"

:veloped iIi 14:.16).and heallh jPersonm~1 training and health education activi-

tivities fw~also varied between countries and during pro-

'7he generif!~SSof the programme, mainly because of a lack of

educatioo~urces. However, any improvement in these acti-hlets, bl\;~ili~sincreased the number of cases identified and::hools and ~~tered, as well as secondary prophylaxis cover-

"'7 c

r televi.\i(!l .

mducted i; ;f;7Phase I of the programme, which was completedted to tb: :~factorily in almost all the participating countriesI lillguistir;,}l~integration into the PHC system, led to greater

;~~1Jess of RF/RHD among patients, and increased~toverage for secondary prophylaxis and medical

~The recurrence rate d~creased and the govem-~rand health authorities also showed more inter-7:. , ..~~nthls disease.

was lo\\t! c,f;,~e experience gained from Phase I, or the pro-owed onlj;~~ shoul~ encourage the participating countries, of re~tnl: ~~ntlnue wIth Phase II. In addition, the. program--ascs m~,~\shoul~ be extended to other countrIes whereroblem jj ;B~D IS a problem, as recommended recently.'almost 3Jj \;~~'b~'the c~, ,~i!;j!,,",'c

nme welt;i~~I~,~

!1~Joint WHO/ISFC Global Strategy to prevent Rheumatic

~heumatic Heart Disease. Report of a Consultation,~ 26-27 February 1990. Unpublished WHO document

Cc cVD190e3. 1990.

,gion

G~

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93

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240---032

~-

~~knowledgementsc

~a:e grateful to Dr S.R.A. Dodu and Dr I. Gyarfas for

~l1g. implementing and developing the programme in{~,and for continuing to provide technical assistance

~evaltJate progress.The programme was supported financially by the

~~ of Health of the participating countries and by the

~GtJIl Programme for the United Nations Development-~IZa!iol1 (AGFUND).

References

1. WHO Technical Report Series, No.764, 1988

(Rheumatic fever and rheumatic heart disease:

report of a WHO Study Group).

c~~1inOMS Vol70 1992 217

~

WHO and principal investigators

Zimbabwe: Department of Medicine,Zimbabwe, Harare (J.A. Matenga).

American Region

Bolivia: Instituto Nacional del Torax,1auregui-Tapia assisted by E. Imana, V.M. Herrera).

El Salvador: Department of Meaicine,Hospital, San Salvador (1.1.Rivera de Cepeda, L. Urrutia & E. Maza).

Jamaica: Child Health Department,West Indies, Kingston (D. Millard).

for

bet\ I

Eastern Mediterranean Region

Egypt: Department of School Health,Health, Cairo (A.M.A. Hafez).

Iraq: Medical City Children's Hospital,AI Awqati & A.H. AI-Khazraji).Pakistan: Department of Medicirle, -L'

of Medical Sciences, c,

ted by S. Aziz, G. Alam, A. Khan, M.I;\

A.Q. Khan).Sudan: Department of Cardiology, Shaab",Hospital, Khartoum (S.I. Khalil). ,

South-East Asian Region

India: Ministry of Health & FamilyPostgraduate Institute of MedicalResearch, Chandigarh (P.L. WahiGrover, S. Iyengar, K.N. Ganguly, R.Kumar).Sri Lanka~ Department of CardiacGeneral Hospital, Colombo (N .

Thailand: Department of Medicalof Public Health, Bangkok (S.ted by P. Pinkulbut).

the

2. Markowitz, M. & Kaplan, E. Reappearance of rheu-matic fever. Adv. pediatrics, 36: 39-66 {1989).

3. WHO Technical Report Series, No.78, 1954.{Rheumatic diseases: first report of the ExpertCommittee).

4. WHO Technical Report Series, No.126, 1957.{Prevention of rheumatic fever: second report of theExpert Committee on Rheumatic Diseases).

5. WHO Technical Report Series, No.342, 1966.{Prevention of rheuflJatic fever: report of a WHOExpert Committee).

6. WHO Technical Report Series, No.732, 1986{ Community prevention and control of cardiovascu-lar diseases: report of a WHO Expert Committee).

7. Prevention and control of rheumatic fever in thecommunity. Washington, DC, Pan American HealthOrganization, 1985 {Scientific Publication No.399).

8. Community control of rheumatic heart disease indeveloping countries: 1. A major public health pro-blem. WHO Chronicle, 34: 336-345 {1980).

9. Strasser, T. et al. The community control of rheu-matic fever and rheumatic heart disease: report of aWHO international cooperative project. Bulletin ofthe World Health Organization, 59: 285-294 {1981 ).

10. WHO Technical Report Series, No.792, 1990{Prevention in childhood and youth of adult cardio-vascular diseases: time for action).

11. Nordet, P. [Rheumatic fever and rheumatic heartdisease: incidence and evolution after comprehen-sive medical care.] Revista Cubana de pediatria,60{2): 32-51 {1988) {in Spanish).

12. Gordis, L. Effectiveness of comprehensive careprogrammes in preventing rheumatic fever. NewEngland journal of medicine, 289: 331-335 {1973).

13. Majeed, H.A. et al. The natural history of acuterheumatic fever in Kuwait: a prospective six-yearsfollow-up report. Journal of chronic diseases, 39:361-369 {1986).

14. Idsoe, 0. et al. Nature and extent of penicillin side-reactions, with particular reference to fatalities fromanaphylactic shock. Bulletin of the World HealthOrganization, 38: 159-188 {1968).

15. Graff-Lonnevig, V. et al. Penicillin allergy~a rarepaediatric condition? Archives of disease in child-hood, 63: 1342-1346 {1988).

16. International Rheumatic Fever Study Group. Allergicreactions to long-term benzathine penicillin prophy-laxis for rheumatic fever. Lancet, 337: 1308-1310{1991).

Annex

Programme sites and principal investigators

African RegionMali: Hopital du point "0", Ecole Nationale deMedecine et de Pharmacie, Bamako (M.K. Toure).

Zambia: University Teaching Hospital, MedicalSchool, Lusaka (K. Mukelabai).

Western Pacific Region

China: Guangdong Cardiovascularzhou (Lo ZhengxiangXu-Xu Rao, Hui-Min He, Run-Chao CenNi).

Philippines: Preventive l:ardiologyPhilippine Heart Centre,ted by M.C.O. Claridad, P.U. Ortega,E. Manrique).

Tonga: Health Division, MinistryNuku'alofa (S. Foliaki).

218WHO Bulletin OMS;