Preventing Rheumatic Heart Disease in Developing Countries

IN RESPONSE:

We thank Dr. Schwankhaus for his interesting and provocative correspondence. His description of the overcrowded conditions and disproportionately high relative prevalence of rheumatic heart disease in the cardiology ward of the Bach Mai Hospital in Hanoi, Vietnam, are unfortunately all too familiar and appear to parallel our experience among blacks in South Africa [1]. Indeed, the extremely high prevalence of rheumatic heart disease among the Vietnamese is similar to that reported 21 years ago among school children in Soweto near Johannesburg, South Africa [2]. One wonders what proportion of the patients observed by Dr. Schwankhaus was younger than 30 years of age. It would also be of interest to know the mortality rate among this particular subset of patients with extremely limited access to cardiac surgical procedures. We contend that these figures might be alarmingly similar to those reported in the early part of the century by Bland and Jones [3] before the dramatic decrease in prevalence of both acute rheumatic fever and rheumatic heart disease in the United States [1, 4]. We fully endorse the author's contention that prevention is better than cure for this condition, which continues to ravage socioeconomically deprived communities throughout the world. Unfortunately, as indicated by McLaren and colleagues [5] in the editorial that accompanied our article, substantial decreases in the incidence of rheumatic fever through improvements in socioeconomic status and living conditions or decreases in the frequency of streptococcal infections are unlikely to occur in the near future. The application of molecular biological techniques to the creation of a safe and effective streptococcal vaccine directed against the surface M protein of the organism may represent our best hope for the ultimate eradication of this disease.