Decline of Rheumatic Fever

London physician G. B. Longstaff (1905) may have been the first to suggest that the prevalence of rheumatic fever was decreasing. He deduced this from death certificates in England and Wales during 1881-1900. During these 20 years, 51,666 deaths were attributed to "rheumatic fever" or "rheumatism of the heart," and 3.3 times as many (171,298) to "valvular disease of the heart." In comparing the 5-year periods 1881-5 and 1896-1900, death rates per million due to rheumatic fever declined 15.6 percent, from 97.6 to 82.4, and those for "residual rheumatism" declined 19.1 percent from 35.0 to 28.3. Data collected by J. A. Glover (1930) for the same region showed a lower incidence of deaths for 1901 than Longstaff had calculated (67 per million), but indicated continuity of the decline: to 46 per million in 1910 and 38 per million in 1928.

The two most common sources of epidemiological data other than death reports have been hospital admissions and recurrence rates among patients who were being followed in rheumatic fever clinics. In order for hospitalization data to be intrinsically comparable, one must assume a socioeconomically stable service area and consistent admissions policies, both of which assumptions are risky. Clinic data tend to yield the most detailed information, but if the clinic is effective, its prevalence information cannot be extrapolated to communities that lack similar services.

Annual admissions data for rheumatic fever were recorded between 1906 and 1925 for hospitals in Montreal, Boston, New York, New Orleans, and the Panama Canal Zone. A comparison of the proportion of total admissions for rheumatic fever between 1906-8 and 1923-5, as reflected in Table VIII.117.2, shows a decline from 59 percent (New York Belle-vue) to 79 percent (New Orleans Charity) (Seegal and Seegal 1927).

Table VIII.117.2. Cases of rheumatic fever per 1,000 admissions, various hospitals

Hospital/City 1906-10 1921-25 1906-25

Royal Victoria Hospital,

33.5

14.6

22.6

Montreal

Mass. General Hospital,

25.3

12.4

16.1

Boston

Charity Hospital, New

12.9

2.7

6.9

Orleans

Bellevue Hospital, New

16.8

7.5

8.6

York

General Hospital, Ancon,

7.00

2.00

3.35

Panama Canal Zone

Source: Data from Seegal and Seegal (1927).

Source: Data from Seegal and Seegal (1927).

A comparison of the prevalence of rheumatic fever among U.S. military personnel during the two world wars shows that, as serious as the problem was during World War II, this diagnosis was made in only 10 percent as many army and 38 percent as many navy personnel. The contribution of more precise diagnosis and prophylactic programs to this improvement is uncertain.

The lengthiest clinical evaluation of rheumatic fever patients was carried out by M. G. Wilson and collaborators (1958) in New York. Beginning in 1916 and continuing in the same area for 40 years, it reported a steady decline in recurrences of rheumatic fever, unrelated to treatment. During 1921— 43, 25 percent of children 6.to 13 years of age and 6.1 percent of those aged 14 to 20 suffered recurrences, whereas during 1944-56 only 15.1 percent of the younger and 2.8 percent of the older age group were so affected.

Antimicrobial prophylaxis began to be used in 1952. Yet the age-adjusted recurrence rate for the 5 years 1942-6 was 7.9 percent, and for 1952-6 it was 6.1 percent; this difference was not significant. The socioeconomic circumstances of the area served by the clinic had improved during these decades, but no improvement in the recurrence rate was observed in the poorest segment of the population (Wilson, Lim, and Birch 1958).

A study of the economic correlates of the occurrence of primary and recurrent rheumatic fever in Baltimore during 1960-4 also demonstrated a strong correlation between low economic status and the occurrence of the disease, but only among the white subjects. The annual incidence was consistently greater among blacks, with only slight improvement related to higher socioeconomic category, whereas the incidence among whites diminished markedly with higher socioeconomic category. Thus, the annual incidence of rheumatic fever among blacks in the lowest fifth on the socioeconomic scale was 56 percent greater than among comparable whites, whereas the difference reached 478 percent when the most affluent fifths were compared (Gordis, Lilien-feld, and Rodriguez 1969).

In weighing the relative importance of rheumatic fever and rheumatic heart disease against other potentially lethal problems of childhood, we find that in the United States during 1939-41, the pair still ranked second, behind accidents, as the leading causes of death in the 10- to 14-year age group. There was a significant sex- and race-related gradient, from 11.2 deaths per 100,000 white boys to 17.4 deaths per 100,000 nonwhite girls (Wolff 1951). This amounted to an average of 4,000 deaths per year for that period. But by 1972-4, an average of only 179 deaths were reported annually, and by 1982-4, deaths had declined to 78 cases per year. Similarly, as Table VIII.117.3 indicates, the reported national incidence of rheumatic fever declined from 10,470 cases in 1961 to 2,793 cases in 1971 and 264 cases in 1981.

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