CHAPTER I INTRODUCTION

Rheumatic heart disease is cardiac inflammation and scarring triggered by an autoimmune reaction to infection with group A streptococci. In the acute stage, this condition consists of pancarditis, involving inflammation of the myocardium, endocardium, and epicardium. Chronic disease is manifested by valvular fibrosis, resulting in stenosis and/or insufficiency.1 A WHO Expert Consultation on Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD) met in WHO/HQ, Geneva from 29 October to 1 November 2001 to update the WHO Technical Report 764 on Rheumatic Fever and Rheumatic Heart Disease, first published in 1988. Dr. Rafael Bengoa, Director Division of Management Noncommunicable Diseases, opened the meeting on behalf of the Director-General.2 RF and RHD remain significant causes of cardiovascular diseases in the world today. Despite a documented decrease in the incidence of acute RF and a similar documented decrease in the prevalence of RHD in industrialized countries during the past five decades, these non-suppurative cardiovascular sequel of group A streptococcal pharyngitis remain medical and public health problems in both industrialized and industrializing countries even at the beginning of the 21 st century. The most devastating effects are on children and young adults in their most productive years. For at least five decades this unique non-suppurative sequel to group A streptococcal infections has been a concern of the World Health Organization and its member countries. Sentinel studies conducted under the auspices of the WHO during the last four decades clearly documented that the control of the preceding infections and their sequelae is both cost effective and inexpensive.

Without doubt, appropriate public health control programs and optimal medical care reduce the burden of disease.2 Although the responsible pathogenic mechanism(s) still remain incompletely defined, methods for optimal prevention and management have changed during the past fifteen years (58). To make this information available to physicians and public health authorities, WHO convened this expert consultation to both update and to expand the 1988 document. RF and RHD remain to be conquered, but until that can be accomplished, optimal methods of prevention and management are required. The recommendations in this document are based upon current medical literature. Every attempt has been made to make this a practically useful document and at the same time to furnish appropriate references with additional information for the practitioner.2 Rheumatic fever is rare before age 5 years and after age 25 years; it is most frequently observed in children and adolescents. The highest incidence is observed in children aged 5-15 years and in underdeveloped or developing countries where antibiotics are not routinely dispensed for pharyngitis and where compliance is low.2 The average annual incidence of acute rheumatic fever in children aged 5-15 years is 15.2 cases per 100,000 population in Fiji [2] compared with 3.4 cases per 100,000 population in New Zealand, [3] and it less then 1 case per 100,000 population in the United States. Although rheumatic fever was previously the most common cause of heart valve replacement or repair, this disease is currently relatively uncommon, trailing behind the incidence of aortic stenosis due to degenerative calcific disease, bicuspid aortic valve disease, and mitral valve prolapse.2