RESUMO
BACKGROUND: In less developed countries, rheumatic fever still occurs. We started a long-term educational programme in two French Caribbean islands that was directed at the public and at health-care workers to see whether we could reduce the incidence of rheumatic fever. METHODS: Our 10-year programme started in 1981 in Martinique and Guadeloupe, and was based in the community and in clinics and hospitals. The programme established a registry of all cases of primary and secondary rheumatic fever (diagnosed by Jones' modified criteria), with systematic hospital admission of children. We graded carditis as severe, mild, or subclinical, and acute glomerulonephritis was defined by oedema, proteinuria, and haematuria for less than 3 months. The educational part of the programme targeted the public and health-care workers, including doctors, with written information distributed in schools or via radio and television broadcasts or videotapes. For the public, the benign clinical presentation of the initial streptococcal infection was contrasted with the severity of later heart disease. FINDINGS: The first months of the programme led to a 10-20% increase in the number of rheumatic fever cases admitted to hospital, because of the renewed attention paid to the disease. Therefore we took 1982 as the baseline year. In 1982-83 the incidence of rheumatic fever was 19.6 per 100 000 inhabitants aged under 20 in Martinique, and 17.4 per 100 000 in Guadeloupe. In 100 Martinique children and 97 Guadeloupe children in 1982-83, 40 and 71% had carditis, respectively (severe in 10 and 32%). Rheumatic fever was preceded by symptomatic sore throat in 52 and 41% of cases, respectively. The disease was not seen in children with active streptococcal cutaneous infections. Disease frequency was highest in the poorest areas and families, a finding that persisted over time. The programme was associated with a progressive decline in the frequency of rheumatic fever: final reduction of 78% in Martinique and 74% in Guadeloupe. The frequency of carditis also fell. Apart from two outbreaks in one hospital, the frequency of acute glomerulonephritis also declined; 31% of cases had had sore throat, while 56% had skin infections. The cost of the programme during the 4 most intensive years was FFr 250 000 (US$ 44 500) in each island. The cost of childhood rheumatic fever, excluding late sequelae, was initially (in 1982) about FFr 7.8 million (US$ 1426 000). The cost fell to an average of Ffr 550 000 (US$ 100 000) per year in 1991-92. INTERPRETATION: A rapid decline in rheumatic fever incidence was achieved at modest cost. Such a programme needs to be continued because of the risk of disease resurgence.
Assuntos
Educação em Saúde , Serviços Preventivos de Saúde , Febre Reumática/prevenção & controle , Adolescente , Adulto , Criança , Pré-Escolar , Custos e Análise de Custo , Feminino , Educação em Saúde/economia , Pessoal de Saúde/educação , Hospitalização , Humanos , Incidência , Masculino , Martinica/epidemiologia , Programas de Rastreamento , Faringe/microbiologia , Serviços Preventivos de Saúde/economia , Sistema de Registros , Febre Reumática/epidemiologia , Fatores Socioeconômicos , Streptococcus/isolamento & purificação , Índias Ocidentais/epidemiologiaRESUMO
In Martinique, intestinal schistosomiasis was discovered at the beginning of this century. The intermediate host snail, Biomphalaria glabrata, was considered in the past as a common species in the different habitats of the island, but during the last decade it has been found only in water-cress beds. Several of these water-cress cultures contained mixed populations of B. glabrata and B. straminea. Moreover, these habitats also constituted transmission sites for Schistosoma mansoni infection. In 1979 the thiarid snail Thiara ( = Melanoides) tuberculata was discovered in Madame river, Fort-de-France, and in the following years at other sites. In 1983 a programme of biological control using this snail was started in two groups of water-cress beds. In 1981-1982 the study site, Roxelane valley, sheltered important populations of B. glabrata (45-256 individuals/m2) and of B. straminea (2-30 ind./m2). In January 1983 the competitor T. tuberculata was introduced into the two groups of water-cress beds (1.3 and 1.7 ind./m2 respectively) and during subsequent years snail population sampling was carried out. The results showed rapid colonization by the competitor snail, whose densities reached 178 and 325 ind./m2 in November 1983 and a maximum of 9941 and 13,388 ind./m2 in October 1984. During that time, B. glabrata populations declined: 153 and 41 ind./m2 in November 1983, 4 and 0 ind./m2 in October 1984, and 0 ind./m2 in the two groups of water-cress beds in October 1985. A similar phenomenon was observed for B. straminea. Since October 1985 neither planorbid species has been found by exhaustive sampling of the habitats.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Biomphalaria/crescimento & desenvolvimento , Vetores de Doenças , Controle Biológico de Vetores , Esquistossomose mansoni/prevenção & controle , Caramujos/crescimento & desenvolvimento , Animais , Martinica , Esquistossomose mansoni/transmissãoRESUMO
An epidemiological and clinical survey of rheumatic fever was carried out in Martinique. The clinical manifestations, portal of entry and socio-economic facilitating factors appeared to be the same as those observed in metropolitan France when the disease occurred with a similar frequency. The prevalence and severity of rheumatic fever in Martinique are still high (in 1982, 49 new cases in a population of 300,000, including 12 with severe carditis), but they tend to diminish as the eradication campaign goes on. The reasons for the persistence of the disease and the problems encountered in the eradication campaign are discussed in the light of epidemiological data collected during the last 3 years.