Rheumatic Heart Disease in Developing Countries: The Consequence of Inadequate Prevention

In economically developed countries, rheumatic fever and rheumatic heart disease have become uncommon health problems. In contrast, in Third World areas such as India, the Middle East, sub-Saharan Africa, and Latin America, rheumatic fever remains the leading cause of heart disease in children and young adults [1-3]. The epidemiology of rheumatic fever and rheumatic heart disease in South Africa is particularly interesting because both of these disparate trends exist simultaneously in the same country. Among the white minority, who have experienced a more privileged socioeconomic and health care status under the apartheid system, rheumatic fever has decreased, as it has in economically developed countries [4]. Among the sociopolitically deprived black majority, the trends are comparable with those of Third World communities. Twenty-one years ago, a screening study [5] for rheumatic heart disease among 12 050 school children in Soweto (the large black ghetto area near Johannesburg) showed the highest reported prevalence of this disease at the time: 6.9 per 1000 children overall, with a maximum of 20 per 1000 among 7th and 8th grade children. The investigators [5] concluded that “a comprehensive prevention campaign is urgently needed, directed at both primary and secondary prevention of rheumatic heart disease”.

In this issue of Annals, Marcus and colleagues [6] report on the frequency of pure mitral regurgitation among patients with rheumatic mitral valve lesions (hemodynamically severe) in “a developing country”. That developing country is South Africa, and, coincidentally, two of the authors of the current study [6], as well as one of us (MJM), participated in the earlier Soweto study [5]. The investigation by Marcus and colleagues [6] involved an enormous study population: 748 consecutive black patients with rheumatic heart disease who had mitral valve surgery at a major tertiary care hospital during a 3-year period (1983 to …