Sequelae of the initial attack of acute rheumatic fever in children from north India. A prospective 5-year follow-up study

We determined the outcome of acute rheumatic fever in 85 children from North India who had received regular antistreptococcal prophylaxis after their first attack. By the end of the 5-year follow-up, 33 patients had rheumatic heart disease. Mitral insufficiency, the most common valvular lesion, appeared in 91% of the patients, whereas mitral stenosis developed in only 18%. Initial carditis, congestive heart failure, cardiomegaly or moderate-to-severe mitral insufficiency significantly increased the risk of rheumatic heart disease (p less than 0.001). The recurrence rate of acute rheumatic fever in children who received continuous prophylaxis was 0.006 per patient-year. Most recurrence (92%) mimicked the first attack and produced further cardiac damage in five patients with carditis and in one patient with chorea. Cardiac status during the first attack of rheumatic fever and the continuity of prophylaxis were the major determinants of outcome. Statistical comparisons disclosed that with continuous prophylaxis, the prevalence rate, evolution and clinical spectrum of the sequelae of acute rheumatic fever in children from India do not differ significantly from those in the West.

Cost-benefit of a streptococcal surveillance program among Navajo Indians

A school-based streptococcal surveillance program has been in effect among Navajo Indians for more than 4 years. Throat cultures of symptomatic children are obtained when indicated, and routine throat cultures are performed monthly. Children whose cultures are positive for group A beta-hemolytic streptococci are treated. During 4 academic years, between 48 percent and 56 percent of elementary school children attended the schools that had 4 or more monthly surveys in each year, but only 24 percent (7 of 29) of the acute rheumatic fever (ARF) cases occurred in children at those schools. Six of seven children attending covered schools were not cultured before their ARF episodes. Five cases occurred in children attending previously covered schools, during years in which participation lapse. Three or four ARF cases per year appeared to have been prevented, but the program's costs were five times the estimated costs of the prevented cases, even excluding risks of allergic reactions to penicillin. There is little evidence that most asymptomatic carriers are at risk to develop ARF. The authors recommend that streptococcal surveillance efforts be confined largely to culturing throat swabs of children with pharyngitis.

Factors affecting streptococcal colonization among children in selected areas of Alaska

The epidemiology of streptococcal disease affecting 706 Alaskan Eskimo children was investigated by analysis of data on throat cultures obtained during a long-term surveillance program begun in 1971. A binary variable multiple-regression model was used to study the association between streptococcal colonization of these children and six potential risk factors: age, sex, number of children in household, region, health-aide rating, and colonization rate for each child the previous year. Factors found to be significantly associated with streptococcal colonization included age, past colonization, competence of local health-aide in providing care, and health-care region. Age varied most in the standardized colonization ratio (percentage of corresponding adjusted rate to overall crude colonization rate), ranging from 122 percent for children 3--6 years old to 67 percent for children 13--18 years old. The number of children in over-crowded homes and a child's sex were not apparently important. The method of analysis can be used to provide health-care planners with a simple means of identifying potentially important areas of concern for planning effective and economical health-care strategy.

The community control of rheumatic fever and rheumatic heart disease: report of a WHO international cooperative project

The feasibility and effectiveness of a programme for the community control of rheumatic fever and rheumatic heart disease were studied in a cooperative multicentre project initiated and coordinated by the World Health Organization. The programme was carried out in seven centres in various developing countries of Africa, America, and Asia according to a common protocol, and is under way in a further eight countries in Latin America. Pilot community programmes were shown to be practicable and effective in reducing the burden of rheumatic heart disease in developing countries and their extension to cover entire populations should be encouraged.

Rheumatic fever and rheumatic heart disease in rural South Indian children

A preliminary pilot study of streptococcal infection and sequelae was initiated in 23 villages in 1973 using trained field workers for case detection. Part of the pilot programme, in 1974-75, involved 374 rural and 664 urban schoolchildren, and revealed that 14.9% of them had streptococcal pyoderma while pharyngitis was seen in 4.2%. The pilot study also revealed a high prevalence of rheumatic fever (RF) and rheumatic heart disease (RHD) in both rural (5.4/1000) and urban (6.0/1000) pupils. A long-term surveillance study was then undertaken in 3890 pupils attending 15 rural schools, from July 1975 to December 1978, when the prevalence of RF was found to be 0.5/1000 and of RHD, 4.4/1000, giving an overall rate of 4.9/1000. The incidence rate was found to be 1.7/1000 per year in 1976, 1.6/1000 per year in 1977, and 0 in 1978. The rate of compliance with primary prophylaxis was 90-100%, and with secondary prophylaxis was 92-93% of the 27 cases.

Acute rheumatic fever and rheumatic heart disease on the Navajo reservation, 1962-77

The occurrence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) among Navajos was ascertained for the period from 1962 through 1977 by means of hospital discharge diagnoses and patients' charts. The annualized attack rate for ARF was 12.4 per 100,000 population, with no clear evidence of an overall secular trend. The proportion of recurrences (19.6 percent) and clinical features were similar to those reported elsewhere, but no seasonal variation in attack rates was noted. Between 1962-71 and 1972-77, the age of RHD patients increased, suggesting few newly diagnosed cases and the aging of known patients. A streptococcal disease control program was instituted in many Navajo elementary schools before 1975. In the program, throat cultures were performed routinely for some asymptomatic children and for all symptomatic children. During the subsequent 3 years, ARF rates declined from 13.5 to 8.2 per 100,000 in areas covered by the program, while in the noncovered areas the rates showed little change-9.5 to 10.1 per 100,000.