Rheumatic Fever Control Project

                                        Shared By:

Dr. Maher Abdel-Latife Rashed, Ph.D.

By:

Ibraheem Al-Kabbash, MD, prof. of epidemiology**.

Maher Abdel-Latife Rashed, Ph.D., cardiologist*.

Alaa Al-Ghamrawy, cardiologist*.

**College of medicine, Tanta university.

*Mahalla cardiac Centre, Ministry of health and population, Egypt.

Background

Rheumatic fever is generally classified as a diffuse inflammatory connective tissue or collagen vascular disease (Adnan, 1997); affecting the joints as well as the viscera, and the heart mainly. This disease usually includes the general aspects occurring after pharyngitis, due to group A-b hemolytic streptococcus (Congeni et al., 1987).

The importance of rheumatic fever centers in that it produces chronic heart lesions responsible for very significant morbidity and mortality over the years (Kaplan, 1978), as rheumatic heart disease was reported to be the most common cause of cardiovascular death in the first five decades of life in many countries (WHO, 1986). Adnan, (1997) has further reported that rheumatic fever is the most common cause of acquired heart disease in children and young adults worldwide.

Abdin et al., (1972) reported that fatalities due to rheumatic fever and rheumatic heart diseases in children over four years to be two or three times as fatalities due to all other chronic diseases of children of the same age group.

Unfortunately, Egypt is located in the geographical belt of rheumatic fever and rheumatic heart disease with other Asian and African countries (WHO, 1980). Also, Mahfouz et al., (1989) have reported that rheumatic fever and rheumatic heart disease still form a major health problem in developing countries including Egypt, where many socioeconomic factors predispose to its occurrence.

Recently, monitoring cardiovascular diseases network in Egypt was sponsored by WHO and Ain Shams university (MCDN) (Salah Mostafa and Khairy Abdel Dayem and others, 2000). The study reported patients attending outpatient clinic in the participating centers with medical history of rheumatic heart disease 10.4% of all cardiovascular diseases. While the inpatients' rheumatic heart disease was 15.0% of all cardiovascular diseases. At Mahalla cardiac Centre, 66% of all heart operations till may 2001 were secondary cases to rheumatic heart disease (Personal comment).

It is specially important for pediatricians and other primary care physicians to be aware that increased numbers of cases of acute rheumatic fever have been recognized in several geographic areas. Recent studies emphasizes that thirty percent of the rheumatic heart disease patients apparently received inadequate treatment. Thus evaluation of the office routines for the careful diagnosis and appropriate management of streptococcal pharyngitis must be undertaken by every practitioner (Kaplan and Hill, 1987).

Objectives

Specific Objective

1) Establishment a management information system (MIS) for rheumatic fever control that will enable families, schools and communities to:

a) Identify affected cases.

b) Identify and undertake effective interventions to manage affected cases, eliminate the causes and improve sanitary care status, and

c) Monitor and evaluate the impact of rheumatic fever control system on health status.

2) Management information system "MIS"

# Using appropriate information technologies, assist rheumatic fever control centers providing appropriate control services.

# Assess the impact of environmental changes in individual and collective child health.

# Provide information to support decision-making on interventions to improve health status.

Activities

1. Project staff has to build a rapport with first line health providers and general practioners, then conduct orientation sessions on the concept of rheumatic fever control system for local human resource development and population health nourishment.

2. After training, project staff has to create a simple computer spreadsheet.

(NOTE: a non-computer model has to be available for centers and/or districts without computers).

4. Project staff has to evaluate children's health status by individualized and/or global rheumatic fever status.

5. Project staff have to undertake individual, community, family and/or school-based interventions to correct the possible causes of rheumatic fever, and report causes to health care agencies to address those that cross-cut several communities.

Outputs:

# Improved rheumatic fever control performance.

# Parent/family-physician conferences to discuss rheumatic fever control's progress and supportive actions.

# Supportive health education programs to enhance life style modification and encourage follow-up.

# Physician training in action research for rheumatic fever control.

# Improvement of general practioners, scholastic health team providers for rheumatic fever control.

Community Objectives

1. Assist governorates to increase awareness about the rheumatic fever risks and their potential impact on health.

2. Promote activities that will assist selected governorates to recognize, assess and mitigate the effects of health e.g. setting up surveillance mechanisms, transferring and adapting successful interventions from experienced governorates.

3. Develop preventive health strategies adapted to the needs of the community addressing in particular the underprivileged sectors of the population.

4. Support the development of methodologies for information gathering and interpretation (i.e. a sound basis of evidence), for the assessment of risks and for dissemination of information to the relevant sectors.

Activities

These objectives will be implemented through specific activities in governorates and regions, planned according to: main problems identified, type of concern expressed by health authorities and professional bodies, and resources available.

# Improving water supply and sanitation facilities.

# Guide activity planning and increase primary as well as secondary preventive medical care systems.

# Upgrading physicians’ abilities to conduct action research within primary child health care centers.

Project Coverage

The Rheumatic Fever Control Project is a challenging first step approach in the primary as well as secondary prevention of rheumatic fever in Egypt. It has to promote positive improvements in health care system at all levels including the infra-structural level.

The Rheumatic Fever Control Project may start in a town (like Al-Mahalla Al-Kobra), as an initiative strategy i.e rheumatic fever project centre. This center will act as a service providing center in addition to its supervision and cooperation with other providing health district centers; i.e. primary care centers and scholastic health units..ect.

A standardized model of rheumatic fever control guidelines will be hold. Each rheumatic fever project centre will communicate all the network of health district centers with management information system, collecting and analyzing data, reporting statistical results and regular reevaluation and self-assessment.

Practical approach in rheumatic fever project

* Medical caravans

Children with age ranging from 3 to 15 years old will be included. Our study will involve urban and rural areas in the form of four villages in addition to a major geographical are in Al-Mahalla Al-Kobra Town.

For all cases the following will be done:

1) Complete medical history: age, sex, address, socioeconomic state including family size and family income.

2) Complete medical examination: weight, height, head circumference, neck, head, abdomen, chest, peripheries, with special focusing on heart examination for any detectable murmurs.

3) Diagnosis of Rheumatic fever will depend on Jones’s Criteria.

4) Suspected cases will be transferred to Mahalla Cardiac Center for extensive examination as electrocardiogram “ECG” and chest X-ray and Echocardiogram. Also, laboratory investigations will be considered with special stress on: (a) Erythrocyte Sedimentation Rate (E.S.R.) by Westergren method. (b) Antistreptolysin O Titer (A.S.O.T.). (c) C-reactive protein.

5) Cases suffering from rheumatic disease will be examined through public announcement by community leaders and at mosque before caravan activities.

5) High risk groups and cases of rheumatic fever will be registered and followed up to be given appropriate propgylactic measures.

* Training programs of health care providers

The activity will cover health care providers in rural and urban areas. The program will cover the following topics:

-         Epidemiological aspects of the problem.

-         Clinical aspects of streptococcal infection, rheumatic fever and rheumatic heart disease.

* Establishment of an information system for rheumatic fever

Requirments

# Project staff:

-         Peroject manager (1)

Responsible for administration and financial aspects of the project. Share in planing imp

Cardiologist, epidemiologist, social care specialist, nurses, lab technicians.

# Equipments: Echocardiogram, electrocardiogram and essentials for cardiology outpatient clinic.

# Laboratory: essential kits and requirments of simple tests of rheumatic fever activity.

# Transport

Objectives

General objective

Control of rheumatic fever affection.

Activity "1":

# Registration of cases, survielance and follow up.

# Prevention and early intervention of rheumatic fever and rheumatic heart disease.

# Health education: parents education, school programs, media health education.

# Rehabilitation of heart affected cases.

Output

# Increasing awareness of general practitioners and primary health care issues.

# Increasing awareness of general populations concerning the problematic affected rheumatic heart disease cases.

# Establishing a warning information system for widespread and/or epidemic episodes of rheumatic fever in according to demographic pattern and/or seasonal pattern so that assistance can help control efficiently and effectively.

# Identifying and assisting affected children and their families who are already suffering the disease.

Activity "2":

Building effective rheumatic fever control system country-wide.

Output:

# Helping communities to plan their rheumatic fever control activities with interests of the primary prevention.

# Establishing rheumatic fever control centers to assist affected cases in multilevel approach considering families, schools and communities.

# Counseling and referral services in order to prevent rheumatic fever complication.

# Providing assistance in the rescue, recover of rheumatic fever affected child, as well as providing rehabilitation for disadvantaged youth and adults.

# Transport: Mobile clinic.

Duartion of the project:

Two years to be extended according to consulting committee evaluation results

BUDGET

To be negotiated with the sponsoring agency.

References :

Salah Mostafa and Khairy Abdel Dayem and others (2000):

Monitoring cardiovascular diseases network in Egypt (MCDN), sponsored by WHO and Ain Shams university.

Adnan S D (1997):

Rheumatic fever.

Braunwalld Heart Diseases, Texetbook of Cardiovascular Medicine III (55):1769.

Congeni G., Rizzo C., Congeni J., and Steevansan V,. (1987):

Outbreak of acute Rheumatic fever in northeast Ohio.

J. Pediatrics, 111, 176.

Mahfouz M.H., Abu-El-Naga A.M., Zidan H.A., Abdel-Khalek E.R., Ibrahim M.H.M. and Khidr H.E. (1989):

The prevalence of rheumatic heart disease in school children in Shrkia.

The Egyptian Heart Journal, 31:37.

Park K. Myung (1996):

Acute rheumatic fever.

Pediadric Cardiology, Mosby-Year Book, inc, third ed., Ch. 20: 302.

Kaplan E.L., (1978):

Acute rheumatic fever.

Ped. Clin. of North Am., 25(4): 817.

WHO (1986):

Community prevention and control of cardiovascular disease.

Report of the WHO Tech. Rep. Ser., 732.

Abdin Z.H., Abul Fadl M.A.M., and Miniawi L.K.  (1972):

Rheumatic fever and rheumatic heart disease in Egyptian children.

Ain Shams Mdeical Journal., 33 (1).

WHO (1980):

Community control of rheumatic heart disease in developing countries: A major health problem.

WHO chronicle 34 (9):336.

Kaplan E.L., and Hill H., (1987):

Return of Rheumatic fever.

J. Pediatrics, 111, 244.