WHO programme for the prevention of rheumatic fever/rheumatic heart disease in 16 developing countries: report from Phase I (1986-90). WHO Cardiovascular Diseases Unit and principal investigators.

Research I Recherche WHO programme for the prevention of rheumatic fever/rheumatic heart disease in 16 developing countries: report from Phase I (1986-90) WHO Cardiovascular Diseases Unit and principal investigators1 The programme was initiated in 1984 by WHO in close collaboration with the International Society and Federation of Cardiology (ISFC). Sixteen countries in five WHO Regions participated: Mali, Zambia and Zimbabwe (in Africa); Bolivia, El Salvador and Jamaica (in the Americas); Egypt, Iraq, Pakistan and Sudan (in the Eastern Mediterranean); India, Sri Lanka and Thailand (in South-East Asia); and China, the Philippines and Tonga (in the Western Pacific). The programme was planned for implementation in three phases: pilot study and control programme in a selected area, control programmes in all the selected communities, and their extension to the whole country. In Phase I, a total of 1 433 710 schoolchildren were screened and 3135 cases of rheumatic fever/rheumatic heart disease (RF/RHD) were found, giving a prevalence of 2.2 per 1000 (higher in the African and Eastern Mediterranean regions); 33 651 recently identified or already known cases were registered; completion of secondary prophylaxis was irregular but averaged 63.2% coverage; percen- tages of adverse reactions (0.3°%) and recurrence of acute RF (0.4%) were very small; 24 398 health personnel and teachers were trained. Health education activities were organized for patients, their relatives, 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 radio and television. The quality of care for RF/RHD patients improved under the programme, which has been expanded to other areas. Introduction Rheumatic fever / rheumatic heart disease (RF/RHD) is the most common cardiovascular disease in chil- dren and young adults and remains a major public health problem in developing countries (1). The cost is very high because of repeated hospitalizations (often resulting in premature death), the enormous resources needed for medical and surgical treatment of large numbers of patients, and the suffering I This paper was prepared by Dr P. Nordet, WHO Cardiovascular Diseases Unit, for the principal investigators whose names and institutes are given in the Annex (see page 218). Requests for reprints should be sent to Cardiovascular Diseases Unit, World Health Organization, 1211 Geneva 27, Switzerland. Reprint No. 5268 caused to patients and relatives (2).a The resurgence of acute RF in the USA in the mid-1980s, with its specific epidemiological characteristics, plus other isolated epidemics of RF (1, 2),a and the absence of an effective antirheumatic streptococcal vaccine or genetic marker to identify people at high risk of developing RF, point to the fact that intensified research is needed in these areas. Meanwhile, the available and feasible preventive methods must be applied (1, 2).a WHO has been concemed with RF/RHD pre- vention and control since 1954, when the WHO Expert Committee on Rheumatic Diseases suggested a Nordet, P. Rheumatic fever. Clinical and epidemiological aspects, Havana, Cuba, 1972-1987. Thesis. Havana, Cuban Ministry of Health, 1988. Bulletin of the World Health Organization, 70(2): 213-218 (1992) © World Health Organization 1992 213 WHO and principal investigators the possibility of using antibiotics and sulfonamides to prevent RF/RHD on a worldwide scale (3). Subsequently, other WHO Expert Committees have directed their efforts towards public health practices with regard to the study, prevention and control of group A streptococcal infections and RF/RHD (1, 3-8).b, c In the 1970s, WHO initiated an intemational cooperative study on RF/RHD prevention in seven developing countries in Africa, the Americas and Asia, and the Pan American Health Organization (PAHO) developed another study in seven Latin American countries. Both of these demonstrated that community programmes for the secondary preven- tion of RF/RHD were not only feasible but also cost- effective in developing countries (9), and this has been stressed in several WHO reports on RF/RHD (1, 6-10). b, c, d In 1984, in response to a World Health Assembly resolution (WHA36.32), WHO, in close collaboration with the Intemational Society and Federation of Cardiology (ISFC), initiated the global programme for the prevention of RF/RHD in 16 developing countries.d This programme, which was designed to encourage the application of proven control measures to decrease morbidity and mortality due to RF/RHD and to support national strategies for Health for All by the Year 2000, is partly funded by the Arab Gulf Programme for United Nations Development Organizations (AGFUND). Methods Based on the experiences from the earlier WHO cooperative research study (9), the present program- me was conceived and planned as a service-oriented activity to be implemented through primary health care (PHC) and the national health care delivery sys- tem.d The Ministry of Health therefore has executive responsibility for the national programme, appoint- ing the national programme manager and a multi- disciplinary advisory committee, and providing local inputs to maintain the programme at a viable level. 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 development of the WHO programmes on streptococcal diseases and meningococ- cal infection (Geneva, 10-13 October 1988). Unpublished WHO document 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. Each collaborating country has prepared a national plan of operation following guidelines pro- vided by WHO, with objectives and targets and a com- mitment to extend programme activities in realistic steps towards nationwide coverage. Each approved plan of operation was signed by the Minister of Health and the respective WHO Regional Director to indicate their endorsement of the plan as a basis for collaboration with WHO. The programme's implementation was in three phases: * short-term (Phase I): planning and development, pre-programme pilot study, and programme of control in the selected area; * medium-term (Phase II): community control (consolidation and extension to the whole selected community); * long-term (Phase III): nationwide extension (consolidation and extension to the whole country. Collaborating countries. Sixteen countries from five WHO Regions were identified in 1984 and have been participating in the global programme. - Africa (population, 193 615): Mali, Zambia, Zimbabwe - The Americas (140 700): Boliviae, El Salvador, Jamaica - Eastern Mediterranean (874 813): Egypt, Iraq, Pakistan, Sudan - South-East Asia (1 950 000): India, Sri Lankae, Thailand - Western Pacific (632 000): China (Guangdong Province)", Philippines, Tonga. Programme approaches. These cover case-finding, registration, and secondary prophylaxis. Three approaches are used for case-finding: (1) screening surveys of schoolchildren; (2) hospital retrospective case surveys; and (3) continuing detec- tion and referral of any RF/RHD confirmed or sus- pected case from hospital discharge, private clinic, outpatient services or any other sources. A central register was created to record the names and main data of all confirmed RF/RHD patients. In some areas, there is more than one local registration centre. There is a referral centre to confirm the diagnosis of the suspected RF/RHD patients. Follow-up consultation and secondary prophy- laxis are conducted in the local registration centres * Pre-programme pilot study only. f Target population, 5-15 years old. 214 WHO Bulletin OMS. Vol 70 1992 Global programme for preventing rheumatic fever/rheumatic heart disease Table 1: Prevalence of RF/RHD, by Region No. of RF/RHD Prevalence WHO No. of No. of schoolchildren cases per 1000 Region surveys screened detected (range) Africa 11 173 408 818 4.7 (3.4-12.6) Americas 5 23 328 35 1.5 (0.1-7.9) Eastern Mediterranean 19 409 933 1807 4.4 (0.9-10.2) South-East Asia 6 195 142 26 0.12 (0.1-1.3) Western Pacific 17 631 899 449 0.7 (0.6-1.4) All Regions 58 1 433 710 3135 2.2 (0.7-4.7) or in the polyclinics, depending on the characteristics of the PHC available in the selected community. The criteria recommended by WHO (1) were used. Personnel training and health education. Health education was carried out by all collaborating coun- tries as an integral part of the programme. This meant training both school teachers and health per- sonnel (including doctors) to carry out education of healthy children, patients and their families, and the general public. The health education message was disseminated by the use of pamphlets, brochures and posters and regular television/radio sessions or news- paper articles. These activities were conducted by doctors, nurses and other trained personnel, under the responsibility of the programme manager and the programme advisory committee. Evaluation procedure. Continuous evaluation was maintained throughout the programme, and a six- monthly progress report was submitted by each centre to WHO on a standard form.9 This evaluation was based on the numbers of children screened, newly identified cases of RF/RHD, new cases regis- tered from any others sources, patients registered for secondary prophylaxis, patients who completed the prophylaxis course, patients with recurrence of acute RF, adverse reactions to benzathine benzylpenicillin, and any other concems. All the collaborating countries observed similar general principles and methods of operation, with some adaptations to local conditions. Results The results are based on the pre-programme pilot study report from the sixteen collaborating countries 9 See footnote d on page 214. and the six-monthly progress reports submitted to WHO from 14 centres between May 1986 and March 1990. Occasionally reports were not received from some centres or were delayed. Case-finding, registration and secondary pro- phylaxis A total of 1 433 710 schoolchildren were screened through 58 surveys carried out in the selected area of the collaborating countries, 3135 cases of RF/RHD were found, giving an average prevalence rate of 2.2 per 1000 (range, between 0.1 and 12.6), which was higher in the African and Eastern Mediterranean regions (4.7 and 4.4/1000) (Table 1). The countries with the highest prevalence rates were Zambia (12.6), Sudan (10.2), Bolivia (7.9) and Egypt (5.1). During the study period, 33 651 recently identi- fied patients or already known cases were registered: 8889 from hospital retrospective surveys and other sources (including 3135 through screening), and 24 762 known cases (Table 2). The percentage of recently identified cases was higher in the Eastern Mediterranean (81.0%). Secondary prophylaxis was administered to more than 30 000 registered patients, at first to 4394 in the pre-programme pilot study and then, depen- ding on the survey reports, to newly registered cases; patients who had completed their course of prophy- laxis or had died or moved elsewhere were excluded. An average of 12 000 patient-years was registered for prophylaxis.h The rate of coverage per 100 patients registered for secondary prophylaxis per month, although irregular, averaged 63.2% (range, 23.8-96.9%); coverage was higher in the Western Pacific and lower in the Americas and Eastern Mediterranean (Table 3). The countries with the lowest rates were El Salvador (23.8%), Mali (31.8%) and Egypt (39.4%). The expected coverage rate of h Patient-years: number of patients registered for secondary pro- phylaxis during a period of 12 months. WHO Bulletin OMS. Vol 70 1992 215 WHO and principal investigators Table 2: Case detection and registration, by Region Cases discovered WHO Other Known Total on Region Screening sources cases register Africa 818 91 6390 7299 Americas 35 881 8729 9645 Eastern Mediter- ranean 1807 3790 1323 6920 South-East Asia 26 685 6167 6878 Western Pacific 449 307 2153 2909 All Regions 3135 5754 24 762 33 651 .70% was reached by 9 of the 14 countries. Benzathine benzylpenicillin by injection was admi- nistered to 95.7% of the patients; adverse reactions were reported by 36 patients (0.3 per 100 patient- years, or 8 per 10 000 injections administered during the programme), including 11 cases of severe ana- phylaxis (0.09% patient-years, or 2 per 10 000 injec- tions), of whom 4 died (0.03% patient-years, or 0.8 per 10 000 injections). Pain was often reported in the area of injection. Recurrence of RF occurred in 53 patients (0.4 per 100 patient-years), of whom only two were receiving regular penicillin prophylaxis (3.8% of the recurrence and 0.02 per 100 patient- years). Those not included in the coverage data had dropped out or were irregular in completing the year's course of prophylaxis, which occurred more frequently with oral prophylaxis (Table 3). Personnel training and health education Training of doctors, nurses, other health personnel, and teachers to carry out health education or other Table 3: Coverage of Regiona secondary prophylaxis, by Table 4: Training of personnel, by type and Region Personnel WHO Other health School Total Region Doctors workers teachers Africa 91 169 438 698 Americas 123 1147 810 2080 Eastern Mediter- ranean 934 1672 3498 6104 South-East Asia 227 934 7648 8809 Western Pacific 763 1858 4086 6707 Total 2138 5780 16 480 24 398 technical aspects of the programme was conducted for a total of 24 398 persons. This was developed in several workshops, seminars, symposia and health education courses. Health education activities for patients, relatives, healthy children and the general public were supported by 1032 health education group sessions; and thousands of pamphlets, bro- chures and posters were distributed in schools and health centres. Also, a total of 124 radio or television programmes were broadcast. They were conducted in the 14 participating countries, and adapted to the local conditions and specific cultural and linguistic characteristics (Tables 4 and 5). Discussion The observed prevalence rate of RF/RHD was lower than expected, which may be because it showed only in some selected schools. The high number of recent- ly identified patients and already known cases indi- cates that RF/RHD remains an important problem for children, adolescents and young adults in almost all the participating countries, and that all the case- finding approaches used in the programme were useful. Average WHO coverage Range Regionb rate (%) (%) Africa 74.1 31.8 - 88.1 Americas 47.2 23.8 - 75.6 Eastern Mediterranean 51.5 39.4 - 83.9 South-East Asia 58.8 56.6 - 82.9 Western Pacific 90.2 80.2 - 96.9 All Regions 63.2 23.8 - 96.9 a 95.7% used benzathine benzylpenicillin, 2.1% oral penicillin, 0.1% sulfadiazine, and 2.1% erythromycin; 0.3% patient-years had adverse reactions to penicillin and 0.4% patient-years had a recurrence. b Three six-monthly country progress reports of inadequate qua- lity were excluded. Table 5: Activities for health education, by Region Radio or WHO Pamphlets and television Group Region brochures Posters programmes sessions Africa 1 600 - 17 13 Americas 24 304 28 22 93 Eastern Mediter- ranean 58 500 9 790 39 486 South-East Asia 45 284 24 581 36 200 Western Pacific 111 580 1 003 12 240 Total 767 768 35 402 126 1032 216 Global programme for preventing rheumatic fever/rheumatic heart disease The level of secondary prophylaxis coverage is difficult to assess over long periods, because of the influence of many constraints such as shortage of benzathine benzylpenicillin, inadequate staff, weak reporting on activities, and low patient compliance during some phases of the programme; hence, great variations were observed between countries and in the six-monthly reports from the same country. The results in nine countries, with a higher-than-expected 70.0% average of prophylaxis coverage and with low rates of RF recurrence, resemble those from other studies on community control of RF/RHD (9, 11-13). The proportion of adverse reactions to the penicillin (mainly severe anaphylaxis and death) was small and agrees with other reports (ranging from 1 to 4 per 10 000 courses of penicillin treatment) (1, 14-16). Personnel training and health education activi- ties also varied between countries and during pro- gress of the programme, mainly because of a lack of resources. However, any improvement in these acti- vities increased the number of cases identified and registered, as well as secondary prophylaxis cover- age. Phase I of the programme, which was completed satisfactorily in almost all the participating countries with integration into the PHC system, led to greater awareness of RF/RHD among patients, and increased the coverage for secondary prophylaxis and medical care. The recurrence rate decreased and the govern- ment and health authorities also showed more inter- est in this disease. The experience gained from Phase I of the pro- gramme should encourage the participating countries to continue with Phase II. In addition, the program- me should be extended to other countries where RF/RHD is a problem, as recommended recently.i i A Joint WHO/ISFC Global Strategy to prevent Rheumatic Fever/Rheumatic Heart Disease. Report of a Consultation, Geneva, 26-27 February 1990. Unpublished WHO document WHO/CVD/90.3, 1990. Acknowledgements We are grateful to Dr S.R.A. Dodu and Dr I. Gyarfas for planning, implementing and developing the programme in 1986, and for continuing to provide technical assistance and evaluate progress. The programme was supported financially by the Ministry of Health of the participating countries and by the Arab Gulf Programme for the United Nations Development Organization (AGFUND). Resume Programme OMS de pr6vention 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 l'OMS en collaboration etroite avec la Societe et F6deration internationale de Cardiologie (SFIC). Seize pays appartenant a cinq Regions OMS y participent: Mali, Zambie et Zimbabwe (Afrique); Bolivie, El Salvador et Jamaique (Am6riques); Egypte, Iraq, Pakistan et Soudan (Mediterranee orientale); Inde, Sri Lanka et Tha7lande (Asie du Sud-Est); Chine, Philippines et Tonga (Pacifique occiden- tal). Le programme devait etre mis en oeuvre en trois phases: 6tude pilote et programme de lutte dans une region choisie, programmes de lutte dans toutes les communaut6s choisies, extension a 1'ensemble du pays. Au cours de la Phase I, un total de 1 411 910 ecoliers ont 6t6 depistes et 3135 cas de rhuma- tisme articulaire aigu ou de cardiopathie rhuma- tismale ont ete trouves, ce qui correspond a une pr6valence de 2,2 cas pour 1000 (avec des chiffres plus 6lev6s dans la Region africaine et la R6gion de la Mediterran6e orientale); 33 651 cas recemment diagnostiqu6s ou deja connus ont ete enregistres; la prophylaxie secondaire a ete irre- gulierement suivie, mais a atteint une couverture de 63,2%; les pourcentages de reactions indesi- rables (0,3%) et de rechutes de rhumatisme arti- culaire aigu (0,4%) ont ete tres faibles; 24 398 membres des personnels de sant6 et enseignants ont ete formes. Des activites d'education pour la sante ont e organisees a l'intention des malades, des familles et du grand public, au cours de centaines de s6ances 6ducatives. Des milliers de brochures et d'affiches ont ete distri- buds, et des programmes d'6ducation pour la sant6 ont ete diffuses a la radio et a la tel6vision. La qualite des soins aux malades atteints de rhu- matisme articulaire aigu et de cardiopathies rhu- matismales s'est amelior6e au cours du program- me, qui a ete etendu a d'autres regions. References 1. WHO Technical Report Series, No. 764, 1988 (Rheumatic fever and rheumatic heart disease: report of a WHO Study Group). WHO Bulletin OMS. Vol 70 1992 217 WHO and principal investigators 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 Expert Committee). 4. WHO Technical Report Series, No. 126, 1957. (Prevention of rheumatic fever second report of the Expert Committee on Rheumatic Diseases). 5. WHO Technical Report Series, No. 342, 1966. (Prevention of rheumatic fever report of a WHO Expert 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 the community. Washington, DC, Pan American Health Organization, 1985 (Scientific Publication No. 399). 8. Community control of rheumatic heart disease in developing 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 a WHO international cooperative project. Bulletin of the 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 heart disease: 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 care programmes in preventing rheumatic fever. New England journal of medicine, 289: 331-335 (1973). 13. Majeed, H.A. et al. The natural history of acute rheumatic fever in Kuwait: a prospective six-years follow-up report. Journal of chronic diseases, 39: 361-369 (1986). 14. ldsoe, 0. et al. Nature and extent of penicillin side- reactions, with particular reference to fatalities from anaphylactic shock. Bulletin of the World Health Organization, 38: 159-188 (1968). 15. Graff-Lonnevig, V. et al. Penicillin allergy-a rare paediatric condition? Archives of disease in child- hood, 63: 1342-1346 (1988). 16. International Rheumatic Fever Study Group. Allergic reactions to long-term benzathine penicillin prophy- laxis for rheumatic fever. Lancet, 337: 1308-1310 (1991). Annex Programme sites and principal investigators African Region Mali: Hopital du point "G", Ecole Nationale de Medecine et de Pharmacie, Bamako (M.K. Toure). Zambia: University Teaching Hospital, Medical School, Lusaka (K. Mukelabai). Zimbabwe: Department of Medicine, University of Zimbabwe, Harare (J.A. Matenga). American Region Bolivia: Instituto Nacional del Torax, La Paz, (P. Jauregui-Tapia assisted by E. Imana, V.H. Zuazo & M. Herrera). El Salvador: Department of Medicine, Rosales Hospital, San Salvador (J.J. Femandez assisted by A. Rivera de Cepeda, L. Urrutia & E. Maza). Jamaica: Child Health Department, University of the West Indies, Kingston (D. Millard). Eastern Mediterranean Region Egypt: Department of School Health, Ministry of Health, Cairo (A.M.A. Hafez). Iraq: Medical City Children's Hospital, Baghdad (N. Al Awqati & A.H. Al-Khazraji). Pakistan: Department of Medicine, Pakistan Institute of Medical Sciences, Islamabad (A.H. Akhtar assis- ted by S. Aziz, G. Alam, A. Khan, M.I. Khan & A.Q. Khan). Sudan: Department of Cardiology, Shaab Teaching Hospital, Khartoum (S.I. Khalil). South-East Asian Region India: Ministry of Health & Family Welfare, Postgraduate Institute of Medical Education and Research, Chandigarh (P.L. Wahi assisted by A. Grover, S. Iyengar, K.N. Ganguly, R. Kumar & V. Kumar). Sri Lanka: Department of Cardiac Investigations, General Hospital, Colombo (N. Thenabadu). Thailand: Department of Medical Services, Ministry of Public Health, Bangkok (S. Phalakomkule assis- ted by P. Pinkulbut). Western Pacific Region China: Guangdong Cardiovascular Institute, Guang- zhou (Lo Zhengxiang assisted by Zhen-Dong Huang, Xu-Xu Rao, Hui-Min He, Run-Chao Cen & Ge-Min Ni). Philippines: Preventive Cardiology Department, Philippine Heart Centre, Manila (S.V. Guzman assis- ted by M.C.O. Claridad, P.U. Ortega, M.A. Parazo & E. Manrique). Tonga: Health Division, Ministry of Health, Nuku'alofa (S. Foliaki). 218 WHO Bulletin OMS. Vol 70 1992