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Incidence of Rheumatic Fever in San Francisco children
I N C I D E N C E OF R H E U M A T I C F E V E R I N S A N F R A N C I S C O C H I L D R E N A TEN-YEAR STUDY
SAUL J. ROBINSON, M.D. SAN
FRANCISCO,
Registry maintained T Hb yE theCardiac San Francisco D e p a r t m e n t
CALIF.
l a r l y in the age group f r o m 5 to 20 years. I n 1948 the C M l d r e n ' s Bur e a u 4 r e p o r t e d a change in the t w e n t y five-year period f r o m 1919 to 1944 with a m a r k e d decrease in the mort a l i t y r a t e f r o m r h e u m a t i c f e v e r and r h e u m a t i c h e a r t disease a m o n g white children. This decrease was as high as 70 p e r cent f o r the age group 5 t h r o u g h 9 years, 64 per cent for the g r o u p 10 t h r o u g h 14 years, and 57 p e r cent f o r the age group 15 t h r o u g h 19 years. I n 1951 Wolff 5 r e p o r t e d the c o m p a r a t i v e m o r t a l i t y due to rheum a t i c f e v e r and h e a r t disease in the United States between 1919 a n d 1921 as c o m p a r e d with 1944 a n d 1945. There was again a 70 p e r cent decrease in m o r t a l i t y f r o m this disease in age groups f r o m 5 to 9 y e a r s and 10 to 14 years, with a 60 per cent decrease in the 15- to 19-year age group. I n 1951 Quinn a n d Quinn ~ r e p o r t e d similar d a t a f r o m N e w H a v e n in the y e a r s 1920 to 1948. I n 1952 the 3~etropolitan Life I n s u r a n c e Comp a n y 7 r e p o r t e d a g a i n t h a t a m o n g its policyholders f r o m 5 to 24 y e a r s of age the m o r t a l i t y rate f r o m organic h e a r t disease of all t y p e s declined f r o m a b o u t t w e n t y - e i g h t to f o u r p e r h u n d r e d t h o u s a n d in the period f r o m 1911 to 1950, with the m o r t a l i t y r a t e due to r h e u m a t i c f e v e r declining f r o m a b o u t seven to about one p e r h u n d r e d t h o u s a n d during this period.
of Public H e a l t h with the cooperation and aid of the San Francisco H e a r t Association has made it possible to keep a r e c o r d of the incidence of r h e u m a t i c f e v e r ill children in the years f r o m 1946 t h r o u g h 1955.1 I n addition, this R e g i s t r y has r e c o r d e d the n u m b e r of recurrences of rheumatic fever, the n u m b e r of children hospitalized with this disease, the n u m b e r of children placed in convalescent homes, and the n u m b e r of children who are receiving a p r o p h y lactic d r u g f o r the p r e v e n t i o n of recurrences of r h e u m a t i c f e v e r in the years 1949 t h r o u g h 1955. There has been an a p p a r e n t decrease in the m o r t a l i t y rate f r o m r h e u m a t i c f e v e r t h r o u g h o u t the United States a n d C a n a d a in the p a s t few years. The M e t r o p o l i t a n Life Insurance C o m p a n y in 19432 r e p o r t e d a 70 p e r cent decrease in deaths due to r h e u m a t i c f e v e r in its policyholders between the ages of 5 and 24 y e a r s in the i n t e r v a l s between W o r l d W a r [ and W o r l d W a r II. I n 1947 X e i t h and Pequeguat s reported a marked decline in the m o r t a l i t y rate f r o m r h e u m a t i c f e v e r in Canada, p a r t i e u From the Department of Public Health, Rheumatic Fever and Congenital tteart Disease Program, and the Bureau of Maternal and Child Health. E l l i s D. Sox, M.D., D i r e c tor, Department of Public Health; Margaret & Miller, M.D., D i r e c t o r , : B u r e a u o f M a t e r n a l and Child Health.
272
ROBINSON:
RHEUMATIC
FEVER IN
SAN FRANCISCO
CHILDREN
273
absent f o r a n y period of three d a y s or more in a n y one semester m u s t have a public health nurse visit or telephone to the home to determine the reason f o r such absence. The public health nurse receives a diagnosis f r o m either the p a r e n t or the physician and r e f e r s it t h r o u g h channels to the C a r d i a c Registry. 4. A n y child requiring a home t e a c h e r in San F r a n c i s c o must have a request s u b m i t t e d b y a physician w i t h the medical diagnosis noted thereon. 5. The San F r a n c i s c o D e p a r t m e n t of Public H e a l t h u n d e r the Crippled Children Services P r o g r a m offers financial aid as needed to a n y child w i t h r h e u m a t i c f e v e r or r h e u m a t i c h e a r t disease f o r diagnosis, hospitalization, eo~valeseent care a n d treatment, including drug" t h e r a p y and d r u g s f o r the p r e v e n t i o n of recurrences. M a n y physicians a v a i l themselves of the facilities of this p r o g r a m a n d thus r e p o r t eases Of r h e u m a t i c f e v e r while r e n d e r i n g a medical rep o r t or requesting aid for his patient. 6. The San F r a n c i s c o H e a r t Association cooperates b y referring" to this R e g i s t r y a n y eases which m a y come to its a t t e n t i o n t h r o u g h its v a r i e d educational a n d public relation ehannels. 1. The San F r a n c i s c o D e p a r t m e n t As a result of these m a n y sources of Public H e a l t h has supervision of of i n f o r m a t i o n the R e g i s t r y has been school health in b o t h p r i v a t e a n d able to obtain a r e p o r t of the inciparochial schools, w i t h f r e q u e n t redence of r h e u m a t i c f e v e r in San F r a n ports to this a g e n c y b y public health cisco, p a r t i c u l a r l y in children of school age. All children who have nurses. been r e p o r t e d to the R e g i s t r y as hav2. R h e u m a t i c f e v e r is a r e p o r t a b l e ing h a d a h i s t o r y of r h e u m a t i c f e v e r disease in the State of California and or r h e u m a t i c h e a r t disease are on a in San Francisco, a l t h o u g h this is not time file. E v e r y t h i r t y days the a reliable index. 3. The San F r a n c i s c o B o a r d of p h y s i c i a n e a r i n g f o r a child with active r h e u m a t i c f e v e r receives a card E d u c a t i o n has a rule t h a t a n y child r e g u l a r l y a t t e n d i n g school who i s . which he m a y check off, noting the
I n 1955 Wallace and Rich s reported on the c h a n g i n g status of r h e u m a t i c f e v e r and r h e u m a t i c h e a r t disease in children a n d y o u t h in N e w Y o r k City, showing t h a t t h e r e h a d been a significant reduction in deaths due to r h e u m a t i c h e a r t disease and rheumatic f e v e r in children a n d y o u t h in the p a s t decade. While there h a v e been m a n y reports r e g a r d i n g the decreased mortality rate f r o m r h e u m a t i c f e v e r a n d r h e u m a t i c h e a r t disease, there have been few r e p o r t s r e g a r d i n g the decreased incidence of this disease in the p a s t decade. The causes for this decrease have been ascribed to (1) more a c c u r a t e differential diagnosis, (2) the liberal a n d e a r l y use o f p e n i cillin for t r e a t m e n t of b e t a hemolytic streptococcal infections, and (3) the p r e v e n t i o n of r e c u r r e n c e s b y the utilization of (a) a small daily dose of an antibiotic such as sulfadiazine or penicillin, or (b) the m o n t h l y injection of a l o n g - a c t i n g penicillin. There are some who believe t h a t the incidence of r h e u m a t i c f e v e r m a y have b e g u n its decline p r i o r to the establishment of a n y of the influencing f a c t o r s noted above. The San F r a n c i s c o Cardiac Regist r y obtains its i n f o r m a t i o n f r o m the following sources :
274
THE
JOURNAL
OF P E D I A T R I C S
19o
L81
18o
tTh
-...,
17o 16o
\
15o lbO
i
130 1 12o
ii0
100 ~o
\
i ~70
\
60
62
ko 3o
10 0 Chart I.--Total
number
of a c t i v e r h e u m a t i c
fever cases reported,
1946 t h r o u g h
1955.
130 121
120 116
_
ii0 I00 90 8O 70
61
60 ~0 ~0
30 ~0
lO o
19~
19~,?
19~
191o
19~
195:1
1952
1953
195h
1955
t"F,,AI~
Chart II.--lqumber
o f r e p o r t e d c a s e s of r h e u m a t i c
f e v e r w i t h i n i t i a l o n s e t s d u r i n g 1946 to 1955,
ROBINSON :
RHEUMATIC
FEVER
c u r r e n t status of the child. I f the child has a p p a r e n t l y r e c o v e r e d f r o m r h e u m a t i c f e v e r he is either listed as potential or h i s t o r y of r h e u m a t i c fever, or as inactive v a l v u l a r rheumatic h e a r t disease. The physician receives cards at s i x - m o n t h intervals, on which he notes the c u r r e n t status of such a child. I f the p h y s i c i a n reports t h a t the child has not a p p e a r e d for an e x a m i n a t i o n in a n y significant i n t e r v a l of time, the social w o r k e r s
IN
SAN
FRANCISCO
CHILDREN
275
s u p p l y i n g of p r o p h y l a c t i c drugs to those requiring them, was instituted because it w a s n o t e d t h a t the incidence of r h e u m a t i c f e v e r h a d shown a s t e a d y decrease, b u t the relative incidence of r e c u r r e n c e s of the disease h a d r e m a i n e d high. (See Charts I I I and IV.) C h a r t I indicates the total n u m b e r of active r h e u m a t i c f e v e r eases rep o r t e d each y e a r a n d includes those p a t i e n t s whose onset of the disease
--] P~CURRENTATTACKS
~
INITIAATTACKS L
8o ~o
f~ 60
5o
3o
20 i0 19h9
195o
1951
1952
1953
195k
1955
YK~y3
Ch~rt III.--Tot&l n u m b e r of reported ~tt&eks of rheumatic fever, 1949 through 1955.
in the Crippled Children Services P r o g r a m contact the p a r e n t s a n d att e m p t to stimulate a visit to the physician as necessary. In 1953 the Crippled Children Services P r o g r a m i n s t i t u t e d a p l a n f o r s u p p l y i n g p r o p h y l a c t i c d r u g s to those children u n d e r its p r o g r a m . A t t h a t time a c o p y of the 1953 bulletin on The Prevention of Rheumatic Fever and Its Recurrences as published by The A m e r i c a n H e a r t Association was mailed to e v e r y p h y s i c i a n in San ]~'rancisco. This p r o g r a m of education to physicians, as well as the
was d u r i n g the p r e c e d i n g y e a r but who still h a d active r h e u m a t i c fever on the first d a y of the sueeeeding year, a n d thus were included in the t o t a l for t h a t y e a r as well. C h a r t I I shows the n u m b e r of cases of r h e u m a t i c f e v e r with the initial onsets d u r i n g t h a t year, but does not include recurrences. C h a r t I I I shows the relationship of r e c u r r e n t to initial a t t a c k s of rheu= marie fever. C h a r t I V shows the n u m b e r of cases of r e c u r r e n t r h e u m a t i c f e v e r r e p o r t e d f r o m 1949 t h r o u g h 1955.
276
THE
JOURNAL
OF P E D I A T R I C S
C h a r t V shows the n u m b e r of children w i t h r h e u m a t i c f e v e r who were either hospitalized or placed in convalescent homes f r o m 1949 t h r o u g h 1955.
w i t h obvious v a l v u l a r disease or without a n y a p p a r e n t residual r h e u m a t i c v a l v u l a r h e a r t disease. This c h a r t is difficult to i n t e r p r e t because despite the a t t e m p t s to clarify the difference
ho -
31
s
22 2o
\0"----.a o
19h9
Chart
IV.--Number
i950
1951
of c a s e s of r e c u r r e n t
1952
rheumatic
D
?0
195h
z955
f e v e r r e p o r t e d , 1949 t h r o u g h
1955.
HOSPITALIZED
m
80
1953
IN CONVALESCENT HO~w~
18
60 50 ~o 58
3o
I0 o
19t:9
195o
1951
19~2
z953
z99,
z955
Y~ Chart
V.--Number
of c h i l d r e n r e p o r t e d a s h a v i n g b e e n h o s p i t a l i z e d or in a c o n v a l e s c e n t h o m e for rheumatic fever.
C h a r t V I shows the n u m b e r of children r e p o r t e d as h a v i n g recovered f r o m active r h e u m a t i c fever, either
b e t w e e n so-called p o t e n t i a l r h e u m a t i c h e a r t disease and r h e u m a t i c h e a r t disease w i t h obvious v a l v u l a r disease,
ROBINSON:
RHEUMATIC
277
FEVER I N S A N F R A N G I S C O C H I L D R E N
m a n y physicians still confuse the two terms and i n t e r c h a n g e them when rep o r t i n g the c u r r e n t status of the child.
1953, but in 1954 there was a drop f r o m t w e n t y r e c u r r e n t cases to six r e c u r r e n t cases, this decrease being maintained t h r o u g h 1955. I n 1949 there were eighteen children hospitalized with the diagnosis of rheumatic fever, and this n u m b e r declined to a low of five in 1954, although there was an increase to ten in 1955. I n 1949 there were fifty-eight children
Table I is a summation of the charts and includes as well a classification of those children who h a d rheumatic fever as to sex, age group, and mort a l i t y rate for those u n d e r 21 years of age. U
WITH RHEUMATIC HEART DISEASE (OBVIOUS VALVULAR DISEASE)
160
WITHOUT RESIDUAL RHEUMATIC HEART DISEASE
15o 14o 58
13o 12o s 11o s s 90
51
8o
~ 7o
5* 4o 3o 2o lO 0
19
Chart VI.--Number
1947
1948
of c h i l d r e n
1949
1950
1951
1952
1953
reported as h a v i n g recovered f r o m 2946 t h r o u g h 1955.
DISCUSSION
F r o m the foregoing charts and table it can be seen that there has been an appreciable reduction in the incidence of rheumatic fever in San Francisco children from 1946 t h r o u g h 1955. This m a r k e d decrease in the n u m b e r of cases of active rheumatic fever was not paralleled b y a similar decrease in the n u m b e r of cases of recurrent rheumatic fever from 1949 to
1954 active
1955 rheumatic
" fever,
in convalescent homes with the diagnosis of rheumatic fever, but in 1955 there were only seventeen such cases. The m o r t a l i t y rate from rheumatic fever in San Francisco has never been high. I n 1949 there were five children r e p o r t e d as dying f r o m rheumatic f e v e r or its complications. I n 1953 and 1954 this c o m m u n i t y had the enviable record of no deaths in children a t t r i b u t e d to rheumatic
N u m b e r of c h i l d r e n w h o died d u r i n g y e a r
N u m b e r of children still ill as of ] / 1 _ _
W i t h r h e u m a t i c h e a r t disease W i t h o u t r h e u m a t i c h e a r t disease
:Number of children w h o r e c o v e r e d f r o m rheumatic fever
1- 3 4- 6 7-12 13-16 17-21 75 21 54 80
157 58 99 17
47
3 39 82 27 5
80
91
2 48 102 20 2
76
83
29 105
134
13 46 105 15 2
79
Females:
N u m b e r of c h i l d r e n w h o h a d r h e u m a t i c f e v e r in the f o l l o w i n g age g r o u p s :
102
121
]15
116
l~iales :
N u m b e r of children w h o h a d r h e u m a t i c f e v e r as to sex:
N u m b e r of children who were h o s p i t a l i z e d f o r rheumatic fever during year N u m b e r of children w h o w e r e in a c o n v a l e s c e n t home f o r r h e u m a t i c f e v e r d u r i n g y e a r
156
I 194s
174
I 1947
181
t 1946
49 1
5
28 36
64
1 20 53 31 20
5]
74
50
21 72
93
2 36 84 32 5
74
85
45
58
41.3%
20.7% 15
31
16
18
44
50
82
1
36
28 37
65
2 19 58 21 8
42
66
53
22
2
33
23 41
64
21 52 29 4
0
59
47
49
13
33.8%
22
43
41
106
0
27
22 37
59
3 13 43 21 10
49
41
40
10
0
18
16 27
43
7 36 12 6
]
34
28
]9
5
1
12
19 23
42
0 11 31 9 5
32
24
12.1%
4
29
23
56
I ~955
15.5%
6
33
23
62
I 1954
35.0%
20
37
33
90
I 1952 } 1953
30.5%
22
50
36
108
} 1951
61
125
t 1950
159
I 1949
Y e a r l y Statistical R e p o r t f o r Ten Y e a r s (1946 T h r o u g h 1955)
SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTtt--]~HEUI~ATIC FEVER PROGRAM
'Total n u m b e r of active rheumatic fever cases during year N u m b e r of children ill with rheumatic fever at b e g i n n i n g of year (ill d u r i n g year and still ill at beginning of next y e a r ) / q u m b e r of rheumatic fever cases with onsets durh~g year N u m b e r of recurrent rheumatic fever cases during year P e r c e n t a g e of r e c u r r e n t r h e u m a t i c f e v e r cases out of t o t a l n u m b e r of r e p o r t e d cases d u r i n g year
TABLE I.
5'2
>
9
Z
r 9
--I Qo
ROBINSON:
RHEUMATIC FEVER IN SAN FRANCISCO CHILDREN
fever, but in 1955 one child with rheumatic carditis died. SUMMARY
T h r o u g h the utilization of an active R h e u m a t i c F e v e r R e g i s t r y which m a i n t a i n s a c u r r e n t r e p o r t of all cases of active r h e u m a t i c f e v e r rep o r t e d in the City a n d County of San Francisco in children up to the age of 21 years, it has been n o t e d t h a t there has been an appreciable decrease in the n u m b e r of active rheumatic f e v e r cases f r o m 1946 t h r o u g h 1955, an i n t e r v a l of ten years. This has been a c c o m p a n i e d b y a decrease in the n u m b e r of children who were hospitalized or were p l a c e d in convalescent homes w i t h this condition d u r i n g these years, and p a r t i c u l a r l y f r o m 1949 on. A t the same time it was n o t e d t h a t the n u m b e r of cases of r e c u r r e n t r h e u m a t i c f e v e r remained r e l a t i v e l y high until 1954 when, a f t e r an e d u c a t i o n a l c a m p a i g n for physicians a n d l a y persons and with the a v a i l a b i l i t y of p r o p h y l a c t i c drugs t h r o u g h the C r i p p l e d Children Services P r o g r a m , there was an appreciable drop which m a i n t a i n e d itself through 1955. C0/NCLUSION
An analysis of the statistics maintained b y a R h e u m a t i c F e v e r Regist r y i n s t i t u t e d b y the San Francisco H e a r t Association a n d m a i n t a i n e d b y the San F r a n c i s c o D e p a r t m e n t of Public H e a l t h indicates t h a t there has been a decrease in the incidence of r h e u m a t i c f e v e r in S a n F r a n c i s c o school children. T h e r e has been a m u c h slower decrease in the n u m b e r of cases of r e c u r r e n t r h e u m a t i c fever, but a p p a r e n t l y since the a d v e n t of a c a m p a i g n of education of physicians
279
and p a r e n t s r e g a r d i n g the use of penicillin or sulfa d r u g s for the prevention of these recurrences, as well as the increased a v a i l a b i l i t y of these drugs through a program originated b y the State of California Crippled Children Services, t h e r e has been an appreciable decrease in the n u m b e r of r e c u r r e n c e s as well. Thus there has been a decrease in the incidence of a disease which at one time was considered to be the most common cause of d e a t h in children between the ages of 5 a n d 15 years. ' R h e u m a t i c f e v e r is a p p a r e n t l y b e g i n n i n g to assume a m u c h less i m p o r t a n t role not only in m o r t a l i t y b u t in morbidity, as evidenced b y the above figures. However, the p r o b l e m s involved in the recognition of r h e u m a t i c f e v e r are still great, its m a n a g e m e n t has still not been stabilized, a n d there m u s t be no diminution in the measures necessary to suppress this disease. I wish to t h a n k XVilss Ruth Rieve for her help in the p r e p a r a t i o n of this paper. REFERENCES 1. Robinson, S. J., Aggeler, D. M., and Daniloff, G. T.: H e a r t Disease lu Sma Francisco School Children, J. PEDIA.T. 33: 49, 1948. 2. Metropolitan Life Insurance Co. Statist. Bull. 2 4 : 9 (Sept.), 1943. 3. Keith, J. D., and Pequeguat, L. A.: Some Observations of the Prevalence of Rheumatic H e a r t Disease. in Canada, Canad. J. Pub. Health 38: 111, 1947. 4, Childhood M o r t a l i t y From Rheumatic F e v e r and H e a r t Disease, Children's Bureau Publication 322, Government Printing Office, 1948. 5. Wolff, G.: D e a t h Toll From Rheumatic F e v e r in Childhood, J. A. M. A. 145: 719, 1951. 6. Qulnn, R. W., and Quinn, J. P.: Mort a l i t y Due to Rheumatic H e a r t Disease in the Socio-Economie Districts of New Haven, Connecticut, Yale J. Biol. & Med. 24: 15, t951. 7. Ds L i f e Insurance Co. Statist. Bull. 3 3 : 8 (Oct.), 1952. 8. Wallace, H. M., and Rich, H.: Changing Status of Rheumatic Fever and Rheumatic H e a r t Disease ia Children and Youth~ Am. J. Dis. Child. 89: 7, 1955.
SAUL J. ROBINSON, M.D. SAN
FRANCISCO,
Registry maintained T Hb yE theCardiac San Francisco D e p a r t m e n t
CALIF.
l a r l y in the age group f r o m 5 to 20 years. I n 1948 the C M l d r e n ' s Bur e a u 4 r e p o r t e d a change in the t w e n t y five-year period f r o m 1919 to 1944 with a m a r k e d decrease in the mort a l i t y r a t e f r o m r h e u m a t i c f e v e r and r h e u m a t i c h e a r t disease a m o n g white children. This decrease was as high as 70 p e r cent f o r the age group 5 t h r o u g h 9 years, 64 per cent for the g r o u p 10 t h r o u g h 14 years, and 57 p e r cent f o r the age group 15 t h r o u g h 19 years. I n 1951 Wolff 5 r e p o r t e d the c o m p a r a t i v e m o r t a l i t y due to rheum a t i c f e v e r and h e a r t disease in the United States between 1919 a n d 1921 as c o m p a r e d with 1944 a n d 1945. There was again a 70 p e r cent decrease in m o r t a l i t y f r o m this disease in age groups f r o m 5 to 9 y e a r s and 10 to 14 years, with a 60 per cent decrease in the 15- to 19-year age group. I n 1951 Quinn a n d Quinn ~ r e p o r t e d similar d a t a f r o m N e w H a v e n in the y e a r s 1920 to 1948. I n 1952 the 3~etropolitan Life I n s u r a n c e Comp a n y 7 r e p o r t e d a g a i n t h a t a m o n g its policyholders f r o m 5 to 24 y e a r s of age the m o r t a l i t y rate f r o m organic h e a r t disease of all t y p e s declined f r o m a b o u t t w e n t y - e i g h t to f o u r p e r h u n d r e d t h o u s a n d in the period f r o m 1911 to 1950, with the m o r t a l i t y r a t e due to r h e u m a t i c f e v e r declining f r o m a b o u t seven to about one p e r h u n d r e d t h o u s a n d during this period.
of Public H e a l t h with the cooperation and aid of the San Francisco H e a r t Association has made it possible to keep a r e c o r d of the incidence of r h e u m a t i c f e v e r ill children in the years f r o m 1946 t h r o u g h 1955.1 I n addition, this R e g i s t r y has r e c o r d e d the n u m b e r of recurrences of rheumatic fever, the n u m b e r of children hospitalized with this disease, the n u m b e r of children placed in convalescent homes, and the n u m b e r of children who are receiving a p r o p h y lactic d r u g f o r the p r e v e n t i o n of recurrences of r h e u m a t i c f e v e r in the years 1949 t h r o u g h 1955. There has been an a p p a r e n t decrease in the m o r t a l i t y rate f r o m r h e u m a t i c f e v e r t h r o u g h o u t the United States a n d C a n a d a in the p a s t few years. The M e t r o p o l i t a n Life Insurance C o m p a n y in 19432 r e p o r t e d a 70 p e r cent decrease in deaths due to r h e u m a t i c f e v e r in its policyholders between the ages of 5 and 24 y e a r s in the i n t e r v a l s between W o r l d W a r [ and W o r l d W a r II. I n 1947 X e i t h and Pequeguat s reported a marked decline in the m o r t a l i t y rate f r o m r h e u m a t i c f e v e r in Canada, p a r t i e u From the Department of Public Health, Rheumatic Fever and Congenital tteart Disease Program, and the Bureau of Maternal and Child Health. E l l i s D. Sox, M.D., D i r e c tor, Department of Public Health; Margaret & Miller, M.D., D i r e c t o r , : B u r e a u o f M a t e r n a l and Child Health.
272
ROBINSON:
RHEUMATIC
FEVER IN
SAN FRANCISCO
CHILDREN
273
absent f o r a n y period of three d a y s or more in a n y one semester m u s t have a public health nurse visit or telephone to the home to determine the reason f o r such absence. The public health nurse receives a diagnosis f r o m either the p a r e n t or the physician and r e f e r s it t h r o u g h channels to the C a r d i a c Registry. 4. A n y child requiring a home t e a c h e r in San F r a n c i s c o must have a request s u b m i t t e d b y a physician w i t h the medical diagnosis noted thereon. 5. The San F r a n c i s c o D e p a r t m e n t of Public H e a l t h u n d e r the Crippled Children Services P r o g r a m offers financial aid as needed to a n y child w i t h r h e u m a t i c f e v e r or r h e u m a t i c h e a r t disease f o r diagnosis, hospitalization, eo~valeseent care a n d treatment, including drug" t h e r a p y and d r u g s f o r the p r e v e n t i o n of recurrences. M a n y physicians a v a i l themselves of the facilities of this p r o g r a m a n d thus r e p o r t eases Of r h e u m a t i c f e v e r while r e n d e r i n g a medical rep o r t or requesting aid for his patient. 6. The San F r a n c i s c o H e a r t Association cooperates b y referring" to this R e g i s t r y a n y eases which m a y come to its a t t e n t i o n t h r o u g h its v a r i e d educational a n d public relation ehannels. 1. The San F r a n c i s c o D e p a r t m e n t As a result of these m a n y sources of Public H e a l t h has supervision of of i n f o r m a t i o n the R e g i s t r y has been school health in b o t h p r i v a t e a n d able to obtain a r e p o r t of the inciparochial schools, w i t h f r e q u e n t redence of r h e u m a t i c f e v e r in San F r a n ports to this a g e n c y b y public health cisco, p a r t i c u l a r l y in children of school age. All children who have nurses. been r e p o r t e d to the R e g i s t r y as hav2. R h e u m a t i c f e v e r is a r e p o r t a b l e ing h a d a h i s t o r y of r h e u m a t i c f e v e r disease in the State of California and or r h e u m a t i c h e a r t disease are on a in San Francisco, a l t h o u g h this is not time file. E v e r y t h i r t y days the a reliable index. 3. The San F r a n c i s c o B o a r d of p h y s i c i a n e a r i n g f o r a child with active r h e u m a t i c f e v e r receives a card E d u c a t i o n has a rule t h a t a n y child r e g u l a r l y a t t e n d i n g school who i s . which he m a y check off, noting the
I n 1955 Wallace and Rich s reported on the c h a n g i n g status of r h e u m a t i c f e v e r and r h e u m a t i c h e a r t disease in children a n d y o u t h in N e w Y o r k City, showing t h a t t h e r e h a d been a significant reduction in deaths due to r h e u m a t i c h e a r t disease and rheumatic f e v e r in children a n d y o u t h in the p a s t decade. While there h a v e been m a n y reports r e g a r d i n g the decreased mortality rate f r o m r h e u m a t i c f e v e r a n d r h e u m a t i c h e a r t disease, there have been few r e p o r t s r e g a r d i n g the decreased incidence of this disease in the p a s t decade. The causes for this decrease have been ascribed to (1) more a c c u r a t e differential diagnosis, (2) the liberal a n d e a r l y use o f p e n i cillin for t r e a t m e n t of b e t a hemolytic streptococcal infections, and (3) the p r e v e n t i o n of r e c u r r e n c e s b y the utilization of (a) a small daily dose of an antibiotic such as sulfadiazine or penicillin, or (b) the m o n t h l y injection of a l o n g - a c t i n g penicillin. There are some who believe t h a t the incidence of r h e u m a t i c f e v e r m a y have b e g u n its decline p r i o r to the establishment of a n y of the influencing f a c t o r s noted above. The San F r a n c i s c o Cardiac Regist r y obtains its i n f o r m a t i o n f r o m the following sources :
274
THE
JOURNAL
OF P E D I A T R I C S
19o
L81
18o
tTh
-...,
17o 16o
\
15o lbO
i
130 1 12o
ii0
100 ~o
\
i ~70
\
60
62
ko 3o
10 0 Chart I.--Total
number
of a c t i v e r h e u m a t i c
fever cases reported,
1946 t h r o u g h
1955.
130 121
120 116
_
ii0 I00 90 8O 70
61
60 ~0 ~0
30 ~0
lO o
19~
19~,?
19~
191o
19~
195:1
1952
1953
195h
1955
t"F,,AI~
Chart II.--lqumber
o f r e p o r t e d c a s e s of r h e u m a t i c
f e v e r w i t h i n i t i a l o n s e t s d u r i n g 1946 to 1955,
ROBINSON :
RHEUMATIC
FEVER
c u r r e n t status of the child. I f the child has a p p a r e n t l y r e c o v e r e d f r o m r h e u m a t i c f e v e r he is either listed as potential or h i s t o r y of r h e u m a t i c fever, or as inactive v a l v u l a r rheumatic h e a r t disease. The physician receives cards at s i x - m o n t h intervals, on which he notes the c u r r e n t status of such a child. I f the p h y s i c i a n reports t h a t the child has not a p p e a r e d for an e x a m i n a t i o n in a n y significant i n t e r v a l of time, the social w o r k e r s
IN
SAN
FRANCISCO
CHILDREN
275
s u p p l y i n g of p r o p h y l a c t i c drugs to those requiring them, was instituted because it w a s n o t e d t h a t the incidence of r h e u m a t i c f e v e r h a d shown a s t e a d y decrease, b u t the relative incidence of r e c u r r e n c e s of the disease h a d r e m a i n e d high. (See Charts I I I and IV.) C h a r t I indicates the total n u m b e r of active r h e u m a t i c f e v e r eases rep o r t e d each y e a r a n d includes those p a t i e n t s whose onset of the disease
--] P~CURRENTATTACKS
~
INITIAATTACKS L
8o ~o
f~ 60
5o
3o
20 i0 19h9
195o
1951
1952
1953
195k
1955
YK~y3
Ch~rt III.--Tot&l n u m b e r of reported ~tt&eks of rheumatic fever, 1949 through 1955.
in the Crippled Children Services P r o g r a m contact the p a r e n t s a n d att e m p t to stimulate a visit to the physician as necessary. In 1953 the Crippled Children Services P r o g r a m i n s t i t u t e d a p l a n f o r s u p p l y i n g p r o p h y l a c t i c d r u g s to those children u n d e r its p r o g r a m . A t t h a t time a c o p y of the 1953 bulletin on The Prevention of Rheumatic Fever and Its Recurrences as published by The A m e r i c a n H e a r t Association was mailed to e v e r y p h y s i c i a n in San ]~'rancisco. This p r o g r a m of education to physicians, as well as the
was d u r i n g the p r e c e d i n g y e a r but who still h a d active r h e u m a t i c fever on the first d a y of the sueeeeding year, a n d thus were included in the t o t a l for t h a t y e a r as well. C h a r t I I shows the n u m b e r of cases of r h e u m a t i c f e v e r with the initial onsets d u r i n g t h a t year, but does not include recurrences. C h a r t I I I shows the relationship of r e c u r r e n t to initial a t t a c k s of rheu= marie fever. C h a r t I V shows the n u m b e r of cases of r e c u r r e n t r h e u m a t i c f e v e r r e p o r t e d f r o m 1949 t h r o u g h 1955.
276
THE
JOURNAL
OF P E D I A T R I C S
C h a r t V shows the n u m b e r of children w i t h r h e u m a t i c f e v e r who were either hospitalized or placed in convalescent homes f r o m 1949 t h r o u g h 1955.
w i t h obvious v a l v u l a r disease or without a n y a p p a r e n t residual r h e u m a t i c v a l v u l a r h e a r t disease. This c h a r t is difficult to i n t e r p r e t because despite the a t t e m p t s to clarify the difference
ho -
31
s
22 2o
\0"----.a o
19h9
Chart
IV.--Number
i950
1951
of c a s e s of r e c u r r e n t
1952
rheumatic
D
?0
195h
z955
f e v e r r e p o r t e d , 1949 t h r o u g h
1955.
HOSPITALIZED
m
80
1953
IN CONVALESCENT HO~w~
18
60 50 ~o 58
3o
I0 o
19t:9
195o
1951
19~2
z953
z99,
z955
Y~ Chart
V.--Number
of c h i l d r e n r e p o r t e d a s h a v i n g b e e n h o s p i t a l i z e d or in a c o n v a l e s c e n t h o m e for rheumatic fever.
C h a r t V I shows the n u m b e r of children r e p o r t e d as h a v i n g recovered f r o m active r h e u m a t i c fever, either
b e t w e e n so-called p o t e n t i a l r h e u m a t i c h e a r t disease and r h e u m a t i c h e a r t disease w i t h obvious v a l v u l a r disease,
ROBINSON:
RHEUMATIC
277
FEVER I N S A N F R A N G I S C O C H I L D R E N
m a n y physicians still confuse the two terms and i n t e r c h a n g e them when rep o r t i n g the c u r r e n t status of the child.
1953, but in 1954 there was a drop f r o m t w e n t y r e c u r r e n t cases to six r e c u r r e n t cases, this decrease being maintained t h r o u g h 1955. I n 1949 there were eighteen children hospitalized with the diagnosis of rheumatic fever, and this n u m b e r declined to a low of five in 1954, although there was an increase to ten in 1955. I n 1949 there were fifty-eight children
Table I is a summation of the charts and includes as well a classification of those children who h a d rheumatic fever as to sex, age group, and mort a l i t y rate for those u n d e r 21 years of age. U
WITH RHEUMATIC HEART DISEASE (OBVIOUS VALVULAR DISEASE)
160
WITHOUT RESIDUAL RHEUMATIC HEART DISEASE
15o 14o 58
13o 12o s 11o s s 90
51
8o
~ 7o
5* 4o 3o 2o lO 0
19
Chart VI.--Number
1947
1948
of c h i l d r e n
1949
1950
1951
1952
1953
reported as h a v i n g recovered f r o m 2946 t h r o u g h 1955.
DISCUSSION
F r o m the foregoing charts and table it can be seen that there has been an appreciable reduction in the incidence of rheumatic fever in San Francisco children from 1946 t h r o u g h 1955. This m a r k e d decrease in the n u m b e r of cases of active rheumatic fever was not paralleled b y a similar decrease in the n u m b e r of cases of recurrent rheumatic fever from 1949 to
1954 active
1955 rheumatic
" fever,
in convalescent homes with the diagnosis of rheumatic fever, but in 1955 there were only seventeen such cases. The m o r t a l i t y rate from rheumatic fever in San Francisco has never been high. I n 1949 there were five children r e p o r t e d as dying f r o m rheumatic f e v e r or its complications. I n 1953 and 1954 this c o m m u n i t y had the enviable record of no deaths in children a t t r i b u t e d to rheumatic
N u m b e r of c h i l d r e n w h o died d u r i n g y e a r
N u m b e r of children still ill as of ] / 1 _ _
W i t h r h e u m a t i c h e a r t disease W i t h o u t r h e u m a t i c h e a r t disease
:Number of children w h o r e c o v e r e d f r o m rheumatic fever
1- 3 4- 6 7-12 13-16 17-21 75 21 54 80
157 58 99 17
47
3 39 82 27 5
80
91
2 48 102 20 2
76
83
29 105
134
13 46 105 15 2
79
Females:
N u m b e r of c h i l d r e n w h o h a d r h e u m a t i c f e v e r in the f o l l o w i n g age g r o u p s :
102
121
]15
116
l~iales :
N u m b e r of children w h o h a d r h e u m a t i c f e v e r as to sex:
N u m b e r of children who were h o s p i t a l i z e d f o r rheumatic fever during year N u m b e r of children w h o w e r e in a c o n v a l e s c e n t home f o r r h e u m a t i c f e v e r d u r i n g y e a r
156
I 194s
174
I 1947
181
t 1946
49 1
5
28 36
64
1 20 53 31 20
5]
74
50
21 72
93
2 36 84 32 5
74
85
45
58
41.3%
20.7% 15
31
16
18
44
50
82
1
36
28 37
65
2 19 58 21 8
42
66
53
22
2
33
23 41
64
21 52 29 4
0
59
47
49
13
33.8%
22
43
41
106
0
27
22 37
59
3 13 43 21 10
49
41
40
10
0
18
16 27
43
7 36 12 6
]
34
28
]9
5
1
12
19 23
42
0 11 31 9 5
32
24
12.1%
4
29
23
56
I ~955
15.5%
6
33
23
62
I 1954
35.0%
20
37
33
90
I 1952 } 1953
30.5%
22
50
36
108
} 1951
61
125
t 1950
159
I 1949
Y e a r l y Statistical R e p o r t f o r Ten Y e a r s (1946 T h r o u g h 1955)
SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTtt--]~HEUI~ATIC FEVER PROGRAM
'Total n u m b e r of active rheumatic fever cases during year N u m b e r of children ill with rheumatic fever at b e g i n n i n g of year (ill d u r i n g year and still ill at beginning of next y e a r ) / q u m b e r of rheumatic fever cases with onsets durh~g year N u m b e r of recurrent rheumatic fever cases during year P e r c e n t a g e of r e c u r r e n t r h e u m a t i c f e v e r cases out of t o t a l n u m b e r of r e p o r t e d cases d u r i n g year
TABLE I.
5'2
>
9
Z
r 9
--I Qo
ROBINSON:
RHEUMATIC FEVER IN SAN FRANCISCO CHILDREN
fever, but in 1955 one child with rheumatic carditis died. SUMMARY
T h r o u g h the utilization of an active R h e u m a t i c F e v e r R e g i s t r y which m a i n t a i n s a c u r r e n t r e p o r t of all cases of active r h e u m a t i c f e v e r rep o r t e d in the City a n d County of San Francisco in children up to the age of 21 years, it has been n o t e d t h a t there has been an appreciable decrease in the n u m b e r of active rheumatic f e v e r cases f r o m 1946 t h r o u g h 1955, an i n t e r v a l of ten years. This has been a c c o m p a n i e d b y a decrease in the n u m b e r of children who were hospitalized or were p l a c e d in convalescent homes w i t h this condition d u r i n g these years, and p a r t i c u l a r l y f r o m 1949 on. A t the same time it was n o t e d t h a t the n u m b e r of cases of r e c u r r e n t r h e u m a t i c f e v e r remained r e l a t i v e l y high until 1954 when, a f t e r an e d u c a t i o n a l c a m p a i g n for physicians a n d l a y persons and with the a v a i l a b i l i t y of p r o p h y l a c t i c drugs t h r o u g h the C r i p p l e d Children Services P r o g r a m , there was an appreciable drop which m a i n t a i n e d itself through 1955. C0/NCLUSION
An analysis of the statistics maintained b y a R h e u m a t i c F e v e r Regist r y i n s t i t u t e d b y the San Francisco H e a r t Association a n d m a i n t a i n e d b y the San F r a n c i s c o D e p a r t m e n t of Public H e a l t h indicates t h a t there has been a decrease in the incidence of r h e u m a t i c f e v e r in S a n F r a n c i s c o school children. T h e r e has been a m u c h slower decrease in the n u m b e r of cases of r e c u r r e n t r h e u m a t i c fever, but a p p a r e n t l y since the a d v e n t of a c a m p a i g n of education of physicians
279
and p a r e n t s r e g a r d i n g the use of penicillin or sulfa d r u g s for the prevention of these recurrences, as well as the increased a v a i l a b i l i t y of these drugs through a program originated b y the State of California Crippled Children Services, t h e r e has been an appreciable decrease in the n u m b e r of r e c u r r e n c e s as well. Thus there has been a decrease in the incidence of a disease which at one time was considered to be the most common cause of d e a t h in children between the ages of 5 a n d 15 years. ' R h e u m a t i c f e v e r is a p p a r e n t l y b e g i n n i n g to assume a m u c h less i m p o r t a n t role not only in m o r t a l i t y b u t in morbidity, as evidenced b y the above figures. However, the p r o b l e m s involved in the recognition of r h e u m a t i c f e v e r are still great, its m a n a g e m e n t has still not been stabilized, a n d there m u s t be no diminution in the measures necessary to suppress this disease. I wish to t h a n k XVilss Ruth Rieve for her help in the p r e p a r a t i o n of this paper. REFERENCES 1. Robinson, S. J., Aggeler, D. M., and Daniloff, G. T.: H e a r t Disease lu Sma Francisco School Children, J. PEDIA.T. 33: 49, 1948. 2. Metropolitan Life Insurance Co. Statist. Bull. 2 4 : 9 (Sept.), 1943. 3. Keith, J. D., and Pequeguat, L. A.: Some Observations of the Prevalence of Rheumatic H e a r t Disease. in Canada, Canad. J. Pub. Health 38: 111, 1947. 4, Childhood M o r t a l i t y From Rheumatic F e v e r and H e a r t Disease, Children's Bureau Publication 322, Government Printing Office, 1948. 5. Wolff, G.: D e a t h Toll From Rheumatic F e v e r in Childhood, J. A. M. A. 145: 719, 1951. 6. Qulnn, R. W., and Quinn, J. P.: Mort a l i t y Due to Rheumatic H e a r t Disease in the Socio-Economie Districts of New Haven, Connecticut, Yale J. Biol. & Med. 24: 15, t951. 7. Ds L i f e Insurance Co. Statist. Bull. 3 3 : 8 (Oct.), 1952. 8. Wallace, H. M., and Rich, H.: Changing Status of Rheumatic Fever and Rheumatic H e a r t Disease ia Children and Youth~ Am. J. Dis. Child. 89: 7, 1955.