Rheumatic heart disease and socioeconomic development
Authors: Bruno R Nascimento, Andrea Z Beaton
Journal: The Lancet Global Health (2019)

Despite near elimination of rheumatic heart disease in high-resource settings, 40 million people worldwide have rheumatic heart disease and 300 000 die from rheumatic heart disease each year.1Watkins DA Johnson CO Colquhoun SM et al.Global, regional, and national burden of rheumatic heart disease, 1990–2015.N Engl J Med. 2017; 377: 713-722Crossref PubMed Scopus (398) Google Scholar Most are socioeconomically disadvantaged, living in low-income and middle-income countries (LMICs) or in marginalised populations within high-income countries.1Watkins DA Johnson CO Colquhoun SM et al.Global, regional, and national burden of rheumatic heart disease, 1990–2015.N Engl J Med. 2017; 377: 713-722Crossref PubMed Scopus (398) Google Scholar Advocacy, action, and investment to reduce the burden of rheumatic heart disease has been largely neglected. However, the 2018 passage of WHO Global Rheumatic Heart Disease Resolution now mandates action. Prioritising investment depends on improved disease estimates that highlight areas of highest burden, such as the data provided by Ordunez and colleagues2Ordunez P Martinez R Soliz P Giraldo G Mujica OJ Nordet P Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990–2017: a population-based study.Lancet Glob Health. 2019; 7: e1388-e1397Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar in The Lancet Global Health. Several key messages emerge from this important study. Overall, children in the Americas have a smaller rheumatic heart disease burden than those in the rest of the world: prevalence is 30% lower, mortality 51% lower, and disability-adjusted life-year rates 50% lower than globally. Childhood rheumatic heart disease mortality has improved across this region, far surpassing improvements elsewhere. Decreasing years of life lost (YLL) accounts for the majority of these gains, as the prevalence of children (5–14 years) with rheumatic heart disease in the region has remained relatively stable. The most poignant story in these data is that of those left behind. Here, Ordunez and colleagues2Ordunez P Martinez R Soliz P Giraldo G Mujica OJ Nordet P Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990–2017: a population-based study.Lancet Glob Health. 2019; 7: e1388-e1397Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar quantify this association through the slope index of inequality and the health inequality concentration index (HCI). Despite the undoubtable reduction in inequalities in the Americas, depicted by the drop in excess premature mortality between the poorest and richest strata of income gradient from 191·7 YLL per 100 000 (95% UI 68·6 to 314·8) in 1990 to 66·8 per 100 000 (6·4 to 127·2) in 2017, a considerable concentration of burden among the poorer half of the population persists. The HCI also improved from −16·5 (95% CI −27·7 to −5·3) to −7·5 (–18·7 to 3·8) during this period, but this relative health inequality gradient remains remarkable, and 20% of the poorest countries still have 24% of the regional rheumatic heart disease burden. Other examples of the association between rheumatic heart disease and economic prosperity exist. In the USA, the incidence of acute rheumatic fever declined dramatically with socioeconomic development, even before the arrival of penicillin for primary rheumatic fever prevention.3Gordis L The virtual disappearance of rheumatic fever in the United States: lessons in the rise and fall of disease. T Duckett Jones memorial lecture.Circulation. 1985; 72: 1155-1162Crossref PubMed Scopus (184) Google Scholar In India, rheumatic heart disease has dramatically declined in areas that have seen the fastest economic development.4Nair B Viswanathan S Koshy AG Gupta PN Nair N Thakkar A Rheumatic heart disease in Kerala: a vanishing entity? An echo Doppler study in 5–15-years-old school children.Int J Rheumatol. 2015; 2015930790Crossref PubMed Scopus (10) Google Scholar Conversely, rheumatic heart disease burden increases in areas that experience economic and societal turmoil: acute rheumatic fever and rheumatic heart disease increased in Central Asia after the fall of the Soviet Union.5Omurzakova NA Yamano Y Saatova GM et al.High incidence of rheumatic fever and rheumatic heart disease in the republics of Central Asia.Int J Rheum Dis. 2009; 12: 79-83Crossref PubMed Scopus (27) Google Scholar The challenge, then, is how to uncouple rheumatic heart disease burden from socioeconomic disadvantage. In other words, how do we eliminate rheumatic heart disease before we achieve global prosperity? Examples of contemporary success stories also exist. In 1986, Cuba implemented a comprehensive rheumatic heart disease prevention programme that included primary and secondary prevention, training of health workers, public education, and a register-based programme for rheumatic heart disease care. In 10 years, the prevalence of rheumatic heart disease decreased from 2·27 per 1000 school children to 0·24 cases per 1000 school children.6Nordet P Lopez R Duenas A Sarmiento L Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986–1996–2002).Cardiovasc J Afr. 2008; 19: 135-140PubMed Google Scholar In 1981, a similar programme was implemented in the French Caribbean, with a 74–78% reduction in rheumatic fever cases in 10 years.7Bach JF Chalons S Forier E et al.10-year educational programme aimed at rheumatic fever in two French Caribbean islands.Lancet. 1996; 347: 644-648Crossref PubMed Scopus (99) Google Scholar Both programmes were integrated into the existing health-care infrastructure, addressed multiple health systems issues, and strengthened the primary and secondary health-care systems rather than creating vertical programmes. These examples highlight that global rheumatic heart disease control, even in lower resourced settings, might largely be a matter of will. This is encouraging, because we are currently in a period of global reinvigoration around rheumatic heart disease. The WHO Global Rheumatic Heart Disease Resolution has called on Member States, stakeholders, and the Director-General of WHO to act. The American Heart Association formally adopted rheumatic heart disease control into its global aspiration for 2020–30. The resource hub, RHDAction was formed to provide practical tools for countries, including the TIPS toolkit,8Wyber R Grainger Gasser A Thompson D et al.Tools for implementing RHD control programmes (TIPS) handbook. World Heart Federation and RhEACH, Perth, Australia2014Google Scholar for implementing rheumatic heart disease control programmes. Furthermore, the rheumatic heart disease-specific organisation RhEACH was formed to provide technical support to local, regional, and global rheumatic heart disease control efforts. With these resources available, countries implementing national rheumatic heart disease control programmes should focus on evidence-based interventions, such as improving diagnosis and treatment of streptococcal sore throat9Robertson KA Volmink JA Mayosi BM Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis.BMC Cardiovasc Disord. 2005; 5: 11Crossref PubMed Scopus (129) Google Scholar and improving adherence to secondary prophylaxis for patients with acute rheumatic fever and rheumatic heart disease. Creative strategies for burden assessment, education, and capacity building might be needed to overcome challenges (table). New advances are also on the horizon. Coordinated international efforts to develop and deploy a group A streptococcal vaccine are moving forward.10Vekemans J Gouvea-Reis F Kim JH et al.The path to group A Streptococcus vaccines: WHO research and development technology roadmap and preferred product characteristics.Clin Infect Dis. 2019; 69: 877-883Crossref PubMed Scopus (50) Google Scholar Continued research in reformulation of penicillin, novel diagnostics for group A Streptococcus and acute rheumatic fever, the efficacy of early rheumatic heart disease detection through echocardiographic screening, and the use of telemedicine to support control programmes, among other ongoing research, could inform future strategies.11Nascimento BR Sable C Nunes MCP et al.Comparison between different strategies of rheumatic heart disease echocardiographic screening in Brazil: data from the PROVAR (Rheumatic Valve Disease Screening Program) study.J Am Heart Assoc. 2018; 7e008039Crossref PubMed Scopus (28) Google ScholarTableChallenges for rheumatic heart disease control in the Americas and possible strategies to overcome themStrategies to considerIncomplete epidemiological data (prevalence, morbidity, mortality, outcomes, and need for procedures for advanced sequelae)Make ARF and RHD reportable or notifiable health conditionsImplement ARF and RHD registriesDevelop specific coding for RHD and related procedures where it's still unavailableUse active case finding as an early detection tool in high-prevalence areasLow public health literacy around ARF and RHDInclude RHD into public health education programmesIncentives for private funding of RHD-related educational actionsMandate ARF and RHD education for school students in endemic regionsShare educational materials with other programmes, nationally and internationallyInsufficient capacity for ARF and RHD prevention and care in the primary health-care systemImprove primary care coverage, including family health strategiesMandate ARF and RHD in the curriculum for all health workersEnsure ARF and RHD prevention and treatment are included in universal health coverageIntegrate metrics for primary prevention and treatment of pharyngitis in primary care systemsEnsure availability of penicillin in primary careConsider telemedicine to support decentralised diagnosis and careLack of infrastructure for advanced procedures (surgery, interventional procedures, and tertiary care)Develop international collaborations for ARF and RHD. Capacity building, including physician and nurse trainingDevelop regional centers of excellenceExplore financial (government and private sector) incentives for building or equipping facilities for RHD careInsufficient funding for ARF and RHDDevelop international north–south collaborationsLeverage research funding to improve health-care capacityExplore public incentives for donations or funding directed to RHD programmesAdvocate with ministries of health to act on the 2018 Global RHD ResolutionARF=acute rheumatic fever. RHD=rheumatic heart disease. Open table in a new tab ARF=acute rheumatic fever. RHD=rheumatic heart disease. The data from Ordunez and colleagues2Ordunez P Martinez R Soliz P Giraldo G Mujica OJ Nordet P Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990–2017: a population-based study.Lancet Glob Health. 2019; 7: e1388-e1397Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar highlight that rheumatic heart disease is a disease of social inequity, which still needs to be adequately addressed in the Americas. However, we must not be resigned to waiting for economic development in endemic countries, because socioeconomic factors are linked to rheumatic heart disease but not inseparable. Although further multisectoral investment is urgently needed, the current groundswell of activity is moving rheumatic heart disease prevention and treatment, research, and advocacy toward the eminently achievable goal of global rheumatic heart disease elimination. We declare no competing interests. Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990–2017: a population-based studyThe Americas have greatly reduced premature mortality due to rheumatic heart disease since 1990. These health gains were paired with a substantial reduction in the magnitude of income-related inequalities across countries, which is consistent with overall socioeconomic and health improvements observed in the Region. Countries with less favourable rheumatic heart disease situations should be targeted for strengthening of their national programmes. Full-Text PDF Open Access