Lack of adherence to the national guidelines on the prevention of rheumatic fever

Objectives. To explore the extent to which current practices for the secondary prevention of rheumatic fever (RF) in Cape Town adhere to those outlined in the national guidelines on the primary prevention and prophylaxis of RF and rheumatic heart disease (RHD) for health professionals at primary level. Methods. A combination of qualitative tools was used to evaluate the four priority issues identified in the guidelines as fundamental elements of a comprehensive programme for the secondary prophylaxis of RF/RHD: (i) health education and promotion; (ii) case detection of RF and RHD; (iii) secondary prophylaxis every 3 - 4 weeks at primary level; and (iv) notification of acute rheumatic fever (ARF). The qualitative tools included parent/child interviews of cases diagnosed with ARF in the Cape metropole area during the period 1999 - 2003; a physician questionnaire focused on awareness and adherence to the national guidelines; and a review of the records on acute rheumatic fever notification in the Cape metropole area from 1999 to 2003. Results. The evaluation revealed four key findings. First, patient knowledge on the disease was almost non-existent. Despite this lack of knowledge, adherence to secondary prophylactic treatment was good. Second, the physicians most likely to encounter a case of rheumatic fever were least likely to be aware of and to comply with the national guideline. Third, the guidelines do not clearly state how increased detection of ARF will be achieved. Finally, the RF notification system is dysfunctional, with discrepancies in the reporting of cases at hospital, city and provincial levels. Conclusions. Since the publication of the national guidelines in 1997, little progress has been made towards achieving the implementation of a comprehensive programme for the secondary prevention of RF/RHD. S Afr Med J 2005; 95: 52-56

Towards a uniform plan for the control of rheumatic fever and rheumatic heart disease in Africa - the Awareness Surveillance Advocacy Prevention (ASAP) Programme

Over the last 150 years the developed world has experienced a dramatic decline in the incidence and prevalence of rheumatic fever and rheumatic heart disease (RF/RHD) through improved living conditions and the widespread use of penicillin for the treatment of streptococcal pharyngitis. Despite the proven effectiveness and availability of penicillin for both primary and secondary prevention of RF, developing countries continue to face unacceptably high rates of the disease.1 RF/RHD is the most common cardiovascular disease in children and young adults in the world, because 80% of the world’s population live in developing countries where the disease is still rampant. Recent research estimates that RF/RHD affects about 15.6 million people worldwide, with 282 000 new cases and 233 000 deaths each year. There are 2.4 million affected children between 5 and 14 years of age in developing countries, 1 million of whom live in sub-Saharan Africa, making the continent the major RF/RHD hotspot.

Notification of rheumatic fever in South Africa - evidence for underreporting by health care professionals and administrators

Objective To determine whether under-reporting of rheumatic fever occurs at hospital, municipal, provincial and national levels of the South African health system.Background: Information on the incidence of rheumatic fever (RF) and the prevalence of rheumatic heart disease (RHD) is required for the prevention of valvular heart disease in developing countries. In South Africa, RF was made a notifiable condition in 1989. It has recently been suggested that the reporting of RF cases may be incomplete, possibly because of underreporting by health care professionals and deficient administration of the disease notification system in South Africa. Method and results: We assessed whether underreporting of RF cases occurs by comparing the numbers of RF cases reported per year at hospital, municipal, provincial and national levels from 1990 to 2004. There was a fall in the number of RF cases reported per year at national and provincial level over the 15 years of observation. A detailed analysis of the number of RF cases reported at hospital, municipal and provincial level for a 5-year period showed that more cases were diagnosed in one hospital (serving a smaller population) than were captured at municipal and provincial level (serving a larger population), suggesting underreporting by health care professionals. There were discrepancies in the number of cases reported at municipal, provincial and national level, suggesting poor administration of the notification system.Conclusion: There appears to be underreporting of RF cases by health care professionals, and poor administration of the RF notification system. Health care professionals need to be educated about the statutory requirement to notify all RF cases in South Africa. An effective national disease notification system is required.South African Medical Journal Vol. 96 (3) 2006: 206-20

Notification of rheumatic fever in South Africa - evidence for underreporting by health care professionals and administrators

Objective. To determine whether under-reporting of rheumatic fever occurs at hospital, municipal, provincial and national levels of the South African health system. Background. Information on the incidence of rheumatic fever (RF) and the prevalence of rheumatic heart disease (RHD) is required for the prevention of valvular heart disease in developing countries. In South Africa, RF was made a notifiable condition in 1989. It has recently been suggested that the reporting of RF cases may be incomplete, possibly because of underreporting by health care professionals and deficient administration of the disease notification system in South Africa. Method and results. We assessed whether underreporting of RF cases occurs by comparing the numbers of RF cases reported per year at hospital, municipal, provincial and national levels from 1990 to 2004. There was a fall in the number of RF cases reported per year at national and provincial level over the 15 years of observation. A detailed analysis of the number of RF cases reported at hospital, municipal and provincial level for a 5-year period showed that more cases were diagnosed in one hospital (serving a smaller population) than were captured at municipal and provincial level (serving a larger population), suggesting underreporting by health care professionals. There were discrepancies in the number of cases reported at municipal, provincial and national level, suggesting poor administration of the notification system. Conclusion. There appears to be underreporting of RF cases by health care professionals, and poor administration of the RF notification system. Health care professionals need to be educated about the statutory requirement to notify all RF cases in South Africa. An effective national disease notification system is required

Lack of adherence to the national guidelines on the prevention of rheumatic fever

Objectives. To explore the extent to which current practices for the secondary prevention of rheumatic fever (RF) in Cape Town adhere to those outlined in the national guidelines on the primary prevention and prophylaxis of RF and rheumatic heart disease (RHD) for health professionals at primary level. Methods. A combination of qualitative tools was used to evaluate the four priority issues identified in the guidelines as fundamental elements of a comprehensive programme for the secondary prophylaxis of RF/RHD: (i) health education and promotion; (ii) case detection of RF and RHD; (iii) secondary prophylaxis every 3 - 4 weeks at primary level; and (iv) notification of acute rheumatic fever (ARF). The qualitative tools included parent/child interviews of cases diagnosed with ARF in the Cape metropole area during the period 1999 - 2003; a physician questionnaire focused on awareness and adherence to the national guidelines; and a review of the records on acute rheumatic fever notification in the Cape metropole area from 1999 to 2003. Results. The evaluation revealed four key findings. First, patient knowledge on the disease was almost non-existent. Despite this lack of knowledge, adherence to secondary prophylactic treatment was good. Second, the physicians most likely to encounter a case of rheumatic fever were least likely to be aware of and to comply with the national guideline. Third, the guidelines do not clearly state how increased detection of ARF will be achieved. Finally, the RF notification system is dysfunctional, with discrepancies in the reporting of cases at hospital, city and provincial levels. Conclusions. Since the publication of the national guidelines in 1997, little progress has been made towards achieving the implementation of a comprehensive programme for the secondary prevention of RF/RHD

Multiple risk factor interventions for primary prevention of cardiovascular disease in low- and middle-income countries.

BACKGROUND: In many low- and middle-income countries (LMICs) morbidity and mortality associated with cardiovascular diseases (CVDs) have grown exponentially over recent years. It is estimated that about 80% of CVD deaths occur in LMICs. People in LMICs are more exposed to cardiovascular risk factors such as tobacco, and often do not have access to effective and equitable healthcare services (including early detection services). Evidence from high-income countries indicates that multiple risk factor intervention programmes do not result in reductions in CVD events. Given the increasing incidence of CVDs and lower CVD health awareness in LMICs it is possible that such programmes may have beneficial effects. OBJECTIVES: To determine the effectiveness of multiple risk factor interventions (with or without pharmacological treatment) aimed at modifying major cardiovascular risk factors for the primary prevention of CVD in LMICs. SEARCH METHODS: We searched (from inception to 27 June 2014) the Cochrane Library (CENTRAL, HTA, DARE, EED), MEDLINE, EMBASE, Global Health and three other databases on 27 June 2014. We also searched two clinical trial registers and conducted reference checking to identify additional studies. We applied no language limits. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of health promotion interventions to achieve behaviour change (i.e. smoking cessation, dietary advice, increasing activity levels) with or without pharmacological treatments, which aim to alter more than one cardiovascular risk factor (i.e. diet, reduce blood pressure, smoking, total blood cholesterol or increase physical activity) of at least six months duration of follow-up conducted in LMICs. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility and risk of bias, and extracted data. We combined dichotomous data using risk ratios (RRs) and continuous data using mean differences (MDs), and presented all results with a 95% confidence interval (CI). The primary outcome was combined fatal and non-fatal cardiovascular disease events. MAIN RESULTS: Thirteen trials met the inclusion criteria and are included in the review. All studies had at least one domain with unclear risk of bias. Some studies were at high risk of bias for random sequence generation (two trials), allocation concealment (two trials), blinding of outcome assessors (one trial) and incomplete outcome data (one trial). Duration and content of multiple risk factor interventions varied across the trials. Two trials recruited healthy participants and the other 11 trials recruited people with varying risks of CVD, such as participants with known hypertension and type 2 diabetes. Only one study reported CVD outcomes and multiple risk factor interventions did not reduce the incidence of cardiovascular events (RR 0.57, 95% CI 0.11 to 3.07, 232 participants, low-quality evidence); the result is imprecise (a wide confidence interval and small sample size) and makes it difficult to draw a reliable conclusion. None of the included trials reported all-cause mortality. The pooled effect indicated a reduction in systolic blood pressure (MD -6.72 mmHg, 95% CI -9.82 to -3.61, I² = 91%, 4868 participants, low-quality evidence), diastolic blood pressure (MD -4.40 mmHg, 95% CI -6.47 to -2.34, I² = 92%, 4701 participants, low-quality evidence), body mass index (MD -0.76 kg/m², 95% CI -1.29 to -0.22, I² = 80%, 2984 participants, low-quality evidence) and waist circumference (MD -3.31, 95% CI -4.77 to -1.86, I² = 55%, 393 participants, moderate-quality evidence) in favour of multiple risk factor interventions, but there was substantial heterogeneity. There was insufficient evidence to determine the effect of these interventions on consumption of fruit or vegetables, smoking cessation, glycated haemoglobin, fasting blood sugar, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and total cholesterol. None of the included trials reported on adverse events. AUTHORS' CONCLUSIONS: Due to the limited evidence currently available, we can draw no conclusions as to the effectiveness of multiple risk factor interventions on combined CVD events and mortality. There is some evidence that multiple risk factor interventions may lower blood pressure levels, body mass index and waist circumference in populations in LMIC settings at high risk of hypertension and diabetes. There was considerable heterogeneity between the trials, the trials were small, and at some risk of bias. Larger studies with longer follow-up periods are required to confirm whether multiple risk factor interventions lead to reduced CVD events and mortality in LMIC settings

Cochrane corner: beta-blockers for hypertension

Beta-blockers refer to an assorted group of medications that block the action of endogenous catecholamines on beta-adrenergic receptors.1 The ß1 and ß2 receptorsare the primary beta-adrenergic receptors in the human cardiovascular system. Beta- blockers differ in their ß1/ ß2-receptor selectivity and vasodilatory properties. Based on this diversity, beta-blockers have been categorised into first, second and third generation. First-generation beta-blockers, also referred to as non-selective blockers, possess equal affinity for ß1 and ß2 receptors. Second-generation (or selective) beta-blockers exercise more affinity for ß1 than ß2 receptors. Neither of these traditional beta-blockers has vasodilatory properties, which is an intrinsic characteristic of third-generation beta-blockers.IS

Non-Communicable Diseases in Sub-Saharan Africa: The Case for Cohort Studies

Michelle Holmes and colleagues argue that there is an urgent need for longitudinal cohorts based in sub-Saharan Africa to address the growing burden of noncommunicable diseases in the region

Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime?

[No abstract available]Articl