1982-83, 40 and 71% had carditis, respectively (severe in. 10 and 32%). Rheumatic fever was preceded by symptomatic sore throat in 52 and 41% of cases,.
10-year educational programme aimed
at rheumatic fever in two
French Caribbean islands
J F Bach, S Chalons, E Forier, G Elana, J Jouanelle, S
Kayemba,
Background In less developed countries, rheumatic fever a occurs. We started still long-term educational programme in two French Caribbean islands that directed at the public and at health-care workers to we
was see
could reduce the incidence of rheumatic fever.
Methods Our
10-year programme started in 1981 in Martinique and Guadeloupe, and was based in the community and in clinics and hospitals. The programme established a registry of all cases of primary and secondary rheumatic fever (diagnosed by Jones’ modified criteria), with systematic hospital admission of children. We graded carditis as severe, mild, or subclinical, and acute glomerulonephritis was defined by oedema, proteinuria, and haematuria for less than 3 months. The educational part of the programme targeted the public and health-care workers, including doctors, with written information distributed in schools or via radio and television broadcasts or videotapes. For the public, the benign clinical presentation of the initial streptococcal infection was contrasted with the severity of later heart disease. The first months of the programme led to a 10-20% increase in the number of rheumatic fever cases admitted to hospital, because of the renewed attention paid to the disease. Therefore we took 1982 as the baseline year. In 1982-83 the incidence of rheumatic fever was 19·6 per 100 000 inhabitants aged under 20 in Martinique, and 17·4 per 100 000 in Guadeloupe. In 100 Martinique children and 97 Guadeloupe children in 1982-83, 40 and 71% had carditis, respectively (severe in 10 and 32%). Rheumatic fever was preceded by symptomatic sore throat in 52 and 41% of cases, respectively. The disease was not seen in children with active streptococcal cutaneous infections. Disease frequency was highest in the poorest areas and families, a finding that persisted over time. The programme was associated with a progressive decline in the frequency of rheumatic fever: final reduction of 78% in Martinique and 74% in Guadeloupe. The frequency of carditis also fell. Apart from two outbreaks in one hospital, the frequency of
Findings
INSERM U 25, Hôpital Necker, Paris (Prof J F Bach MD); DDASS, Fort de France, Martinique (S Chalons MD, A Mosser MD); PMI, DASD, Jarrybaie-Mahault, Guadeloupe (E Forier MD); Service de Pediatrie Générale et Néonatale, Centre Hospitalier du Lamanetin, Martinique (G Elana MD); Laboratoire de Microbiologie, Hôpital Pierre Zobda Quitman, Fort de France, Martinique (J Jouanelle MD); Hôpital Louis Dommergue, La Trinite, Martinique (S Kayemba MD); Hôpital de Redoute, Fort de France, Martinique (D Delbois MD, C Sainte-Aimé MD); and Service de Pédiatre, CHU de Pointe à Pitre, Guadeloupe (ProfC Berchel MD) Correspondence to: Prof Jean-François Bach, INSERM U 25, Hôpital Necker, 75743 Paris Cedex 15, France
644
Saint-Aimé, C Berchel
glomerulonephritis also declined; 31% of cases had had sore throat, while 56% had skin infections. The cost of the programme during the 4 most intensive years was FFr 250000 (US$ 44 500) in each island. The cost of childhood rheumatic fever, excluding late sequelae, was initially (in 1982) about FFr 7·8 million (US$ 1 426 000). The cost fell to an average of FFr 550 000 (US$ 100 000) per year in 1991-92. acute
Summary
whether
D Delbois, A Mosser, C
A rapid decline in rheumatic fever incidence achieved at modest cost. Such a programme needs to be continued because of the risk of disease resurgence.
Interpretation was
Lancet 1996; 347: 644-48
Introduction Until the early 1950s, rheumatic fever was one of the main causes of childhood morbidity in developed countries. Systematic treatment of streptococcal pharyngitis with penicillin and improved economic standards led to decline and near disappearance of the disease in these countries. An outbreak was reported in Utah in 1987as were smaller outbreaks in other US states.3 Current cases of rheumatic fever in France involve immigrants from countries where rheumatic fever remains endemic. In less developed countries, rheumatic fever is still common.4-7 The economic level of the two French Caribbean islands of Martinique and Guadeloupe lies between that of developing countries and France. Medical assistance is well-structured, including a large number of physicians (>2 per 1000 inhabitants) and free access to drugs and medical care. But rheumatic fever persisted in the early 1980s at a high level in both islands, and the decision was taken to set up an eradication programme. In 1980, the incidence was approximately 50 per 100 000 in the age group 0-20, which was less than in some developing countries4-9 but higher than that in developed countries (
