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[ Scientific Activities - Actividades Científicas ]

WHO Global Programme for the Prevention and Control of Rheumatic Fever / Rheumatic Heart Disease

Porfirio Nordet, MD Sc


Medical Officer Cardiovascular Disease Programme World Health Organization, Geneva

I. Introduction

III WHO activities
IV. The WHO Global Programme
V. Future initiatives

 

I. Introduction

Rheumatic fever/rheumatic heart disease (RF/RHD) is the most common cardiovascular disease in children and young adults. It is a major public health problem in developing countries.1-7

RF/RHD is both a biological and a social problem. Its public health importance is not only a direct result of its high occurrence rates (mortality, prevalence and incidence), but also the population affected (children and young adults). Its economic consequences, both in health care related costs and in indirect costs to society (often resulting in premature death or disability), are very significant.1-3

Prevention of the severe consequences of RF/RHD is achievable and cost-effective. Indeed, of all serious chronic conditions, rheumatic heart disease is one of the most readily preventable.1-11

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III WHO activities (Figure 1)

 

RHEUMATIC FEVER/RHEUMATIC HEART DISEASE (RF/RHD)
PREVENTION AND CONTROL WHO ACTIVITIES

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Fig. 1

WHO has been concerned with RF/RHD prevention and control since 1954 when the first WHO expert committee meeting on "Rheumatic disease" was held, (TRS No 78, 1954).12 Since then, several WHO expert committees have directed their efforts towards public health practice with regard to the study, prevention and control of group A streptococcal infections and RF/RHD.12-16, 17-23 Their recommendations have been followed, either as general or specific policy by the health services of most of WHO´s Member States, and as a strategy for large numbers of physicians. The result has been a marked decrease in the occurrence and severity of RF/RHD.

In the 1970s, WHO initiated "The community control of RF/RHD"20, an international cooperative study in seven developing countries from Africa, America and Asia, and the Pan American Health Organization (PAHO) developed another study in seven Latin American countries following the same protocol. This protocol was based on: i) establishment of a RF register; ii) surveillance; iii) secondary prophylaxis and iv) promotion of RF/RHD prevention for physicians, health workers and the general public.

The study confirmed not only the effectiveness and feasibility of secondary prevention, because the recurrence rate and the number of streptococcal infections decreased, but also emphasized its cost-effectiveness through a reduction in health care expenditure by limiting the number of days spent in hospital, worsening of the disease, incapacity, invalidity and early death. (Figure 2)

This pilot programme led to the WHO global programme based on secondary prevention, which was initiated in 1984 in response to WHA resolution 36.32, 1983.11,22 It is a service-oriented plan, integrated into the national public health structure and facilities.

In 1994 a WHO/ISFC meeting on strategy for controlling rheumatic fever/RHD, with emphasis on primary prevention 1,6 strongly endorsed the use of primary prevention 2  measures whenever feasible in addition to the secondary prevention programme as a most complete way for RF/RHD prevention and control.


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Fig. 2

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 IV. The WHO Global Programme

The main goal of the programme is: to assist countries in developing a practical strategy for implementing community-based prevention and control of rheumatic fever/rheumatic heart disease (RF/RHD) in developing countries, through improving expertise and training of health personnel as well as developing practical health information and health education strategies.

4.1 Objectives:  (Figure 3)

General:

To reduce morbidity, mortality and disability caused by RF/RHD and its complications.

To reduce the occurrence and severity of Group A streptococcal infection and its suppurative and non-suppurative complications.

 

WHO GLOBAL PROGRAMME FOR THE PREVENTION AND CONTROL OF RHEUMATIC FEVER/RHEUMATIC HEART DISEASE

OBJECTIVES

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Fig. 3

4.2 Programme approaches:  (Figure 4)

This is a service-oriented action plan, integrated into the national public health structure and facilities of the MOH which involves:

a) RF/RHD primary prevention activities (early detection, diagnosis and effective treatment for patients with Group A streptococcal pharyngitis);

b) RF/RHD secondary prevention activities (case detection, registration, surveillance, follow-up and secondary prophylaxis for RF/RHD patients) aiming to prevent recurrence of acute RF and more severe RHD;

c) Personnel training and medical information;

d) Health education, including school health education, development of health education material and mass media participation.

e) Programme-related activities. These activities will provide information on the magnitude and characteristics of the problem and evaluate the trends, progress of the programme and outcomes.

i) Epidemiological surveillance.

ii) Programme-related research.

WHO GLOBAL PROGRAMME FOR THE PREVENTION AND CONTROL OF RHEUMATIC FEVER/RHEUMATIC HEART DISEASE

RF/RHD
NATIONAL/LOCAL PROGRAMME

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Fig. 4

4.3. Programme implementation  (Figure 5)

The programme is planned in three phases:

- Phase I pilot study: 1-2 years (implementing a RF/RHD programme strategy in a selected area),

- Phase II community control: 2-5 years (extension of Phase I strategy to the whole of the selected community, or to other city/provinces or regions): and

- Phase III nation-wide control (progressive extension of the programme to all the country).

WHO GLOBAL PROGRAMME FOR THE PREVENTION AND CONTROL OF RHEUMATIC FEVER/RHEUMATIC HEART DISEASE

PROGRAMME IMPLEMENTATION

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Fig. 5

4.4. The global programme includes four subprogrammes  (Figure 6)

1. The WHO/AGFUND 3 supported programme.

2. WHO/ISFC supported programme.

3. WHO/ISFC/UNESCO joint task force on RF/RHD prevention and health promotion in schoolchildren

4. Assistance to WHO regional offices and Member States on implementing WHO strategy for RF/RHD prevention and control.

WHO GLOBAL PROGRAMME FOR THE PREVENTION AND CONTROL OF RHEUMATIC FEVER/RHEUMATIC HEART DISEASE

SUBPROGRAMMES

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Fig. 6

4.5. Outcomes and Results  (Figure 7)

- The WHO/AGFUND programme is ongoing in 16 developing countries. Despite financial difficulties in participating countries, Phase I was successfully implemented in all centres13, Phase II has been developed in most countries since 1991; a marked improvement in case finding and secondary prophylaxis compliance, as well as a decrease in the number of RF's recurrence attacks and severity of RHD, and an increase in the medical care of RHD patients in participating areas have been noted. A total of 114 000 cases have been registered. During 1996 the secondary prophylaxis coverage rate was between 62.0 and 100.0 percent. Currently, there are five countries which have started Phase III and primary prevention activities.

- The WHO/ISFC programme is ongoing in 6 countries. Phase I was successfully implemented in six countries1, which are currently implementing Phase II. A total of 5169 cases have been registered through all available sources. During 1995-96 the secondary prophylaxis coverage rate was between 70.8 and 100.0 percent. One country has started Phase III, and the primary prevention approach is being applied in 2 countries. These 6 countries have also reached successful results in participating areas.

- WHO/ISFC/UNESCO joint collaboration began with the development of a simple booklet on streptococcal pharyngitis and rheumatic fever/rheumatic heart disease prevention for schoolchildren, their families and teachers. It was strengthened by a concise reference booklet for physicians and paramedical personnel at the primary health care level. Both are available in English, French and Spanish, Portuguese and Arabic, and have been translated into Viet Namese, Urdu, Bengali and two African dialects (Yoruba and Fon) for free distribution. This joint collaboration has improved programme activities in the school setting4 in participating areas.

In general the programme has resulted in:

WHO GLOBAL PROGRAMME FOR THE PREVENTION AND CONTROL OF
RHEUMATIC FEVER/RHEUMATIC HEART DISEASE
AUTCOMES AND RESULTS

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Fig. 7

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V. Future initiatives:  (Figure 8)

The ISFC, WHO and UNESCO are endeavouring to establish a community-based project for RF/RHD prevention and health promotion in schoolchildren in as many countries as possible, wherever RF/RHD remains a major public health problem. We urge Ministries of Health in all of these countries, as well as nongovernmental organizations and donor agencies, to intensify their efforts to promote and support the establishment of at minimum a local prevention programme on RF/RHD as an national entry point for a feasible and cost-effective way to decrease RHD. We also urge the scientific community to promote efforts towards further research for developing an antistreptococcal vaccine.

WHO GLOBAL PROGRAMME FOR THE PREVENTION AND CONTROL OF
RHEUMATIC FEVER/ RHEUMATIC HEART DISEASE

  • To establish RF/RHD prevention and health promotion in schoolchildren in as many countries as possible, wherever RF/RHD remains a major public health problem
  • We urge Ministries of Health in all of these countries, as well as nongovernmental organizations and donor agencies, to intensify their efforts to promote and support the establishment of at least a local/provincial programme on RF/RHD prevention and control.

Fig.  8

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References

1. A Joint WHO/ISFC Meeting on rheumatic fever/rheumatic heart disease control with emphasis on primary prevention, Geneva, 7-9 September 1994. WHO document WHO/CVD 94.1., World Health Organization, Geneva (1994)
2. Rheumatic fever and rheumatic heart disease. Report of a WHO Study Group. Technical Report Series No. 764, World Health Organization, Geneva (1988).
3. Nordet P. Rheumatic Fever. Clinical and epidemiological aspects. Havana, Cuba. 1972-1987. Thesis for Scientific Degree. Cuban Ministry of Health, Havana, Cuba (1988).
4. Markowitz M. and Kaplan E. Reappearance of Rheumatic Fever. Adv. Pediatrics, 36: 39-66 (1989).
5. Kaplan E. Global assessment of Rheumatic Fever and Rheumatic Heart Disease at the Close of the Century. Influences and Dynamics of Population and Pathogens: A Failure to Realize Prevention. Circ. 88 (4) part 1: 1964-72, 1993.
6. Nordet P. WHO/ISFC global programme for the prevention and control of Rheumatic Fever/Rheumatic Heart Disease. Heartbeat, 3: 4-5 July, 1993.
7. Taranta and Markowitz. Rheumatic Fever, Second Edition. Boston/London, Kluwer Academic Publishers, 1988.
8. Majeed, H.A. et al. Office diagnosis and management of group A streptococcal pharyngitis employing the rapid antigen detecting test. A 1-year prospective study of reliability and cost in primary care centres, Ann Trop Paed, 13: 65-72, 1993.
9.     Brant L.J. et al. Evaluation of an Alaskan Streptococcal Control Program:Importance of the Program's Intensity and Duration. Prev Med, 15: 632-642, 1986.
10. Nordet P. et al. Fiebre reumatica in Ciudad de la Habana, 1972-82. Incidencia y caracteristicas. Rev. Cub. Pediatr., 60(2) 32-51, 1988.
11. Arguedas A and Mohs E. Prevention of Rheumatic Fever in Costa Rica. J Pediatr. 121 (4):569-72, 1992
12. Rheumatic diseases. First Report of the Expert Committee. Technical Report Series No. 78, World Health Organization, Geneva (1954).
13. WHO/CVD Unit and Principal Investigators. WHO programme for the prevention of rheumatic fever/rheumatic heart disease in Sixteen Developing Countries: report from Phase I (1986-90), Bulletin of WHO, 70(2): 213-218, 1992.
14. Prevention of rheumatic fever. Report of a WHO Expert Committee. Technical Report Series No. 342, World Health Organization, Geneva (1966).
15.  Recent advances in Rheumatic Fever control and future prospects. A WHO Memorandum. Bull WHO , 56 (6): 887-912,1978,and WHO unpublished documents CVD/RF/75.5 and CVD/76.1
16. Community prevention and control of cardiovascular diseases. Report of a WHO Expert Committee. Technical Report Series No. 732, World Health Organization, Geneva (1986).
17. Prevention and control of rheumatic fever in the community. Scientific Publication No. 399, PanAmerican Health Organization, Washington, D.C. (1985).
18. Report of an Advisory Committee Meeting on streptococcal diseases complex, Geneva, 15-18 November 1983. WHO document BVI/STREP/85.1, World Health Organization, Geneva (1985), and a Meeting on the assessment and further development of the WHO programmes on streptococcal diseases and meningococcal infection (Geneva, 10-13 October 1988). WHO document WHO/MIM/STREP/CSM/89.2, World Health Organization, Geneva (1989).
19. Community control of rheumatic heart disease in developing countries: 1. A major public health problem. WHO Chronicle, 34: 336-345, World Health Organization, Geneva (1980).
20. Strasser, T. et al. The community control of Rheumatic Fever and Rheumatic Heart Disease: report of a WHO international cooperative project. Bulletin of the World Health Organization, 59(2): 285-294, World Health Organization, Geneva (1981).
21. Progress and issues on prevention of Rheumatic Fever and Rheumatic Heart Disease,UNICEF-WHO unpublished document JC 24/UNICEF-WHO/83.4.
22. WHO Global Programme for the prevention of rheumatic fever/rheumatic heart disease in sixteen developing countries (AGFUND supported). Meeting of National Programme Managers. Geneva: 4-6 November 1986. WHO document WHO/CVD/87.1, World Health Organization, Geneva (1987).
23. A Joint WHO/ISFC Global Strategy to prevent rheumatic fever/rheumatic heart disease. Report of a Consultation, Geneva, 26-27 February 1990. WHO document WHO/CVD/90.3., World Health Organization, Geneva (1990).

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