Response to Letter Regarding Article, “Is Primary Prevention of Rheumatic Fever the Missing Link in the Control of Rheumatic Heart Disease in Africa?”
We thank Dr Carapetis for his comments on our article. Our statement relating to arguments against adopting primary antibiotic prophylaxis for the prevention of rheumatic fever and rheumatic heart disease as a public health intervention in the community has been misunderstood. Taken in context, our statement refers only to the relative importance given to a strategy of primary prevention vis-ă-vis secondary prevention in the literature. We apologize to Dr Carapetis and any others who feel that we have misrepresented their position. This was definitely not our intention, and we do hope that readers will view our statement within the context of our broader argument.
Throughout the article we have repeatedly emphasized the need for a strategy of primary prophylaxis only as part of a comprehensive rheumatic heart disease control program that includes secondary prevention, and we have diligently avoided “making specific claims about the likely effectiveness at the population level of primary prophylaxis alone.”1 We agree that a strategy of systematic bacteriologic screening for streptococcal sore throats, followed by treatment of patients with positive results, may not be cost effective in developing countries (although an analysis from India2 has suggested that it may be). We therefore advocate nonmicrobiological diagnosis of sore throats to offset the personnel and equipment costs of bacteriologic confirmation of streptococcal infection. This approach is based on the proven effectiveness of antibiotics in preventing acute rheumatic fever after an episode of suspected streptococcal pharyngitis that is diagnosed on clinical grounds.3
The positive experiences in Cuba and Costa Rica provide proof of the concept for such a strategy. Although these were ecological studies, reduction of rheumatic heart disease was not observed in adjacent provinces and in countries that did not implement primary prevention measures. The inclusion of the primary prevention component also did not add significantly to costs.4,5 Therefore, there is no reason why such a strategy should not be adopted in Africa and other developing regions. We wish to reemphasize the fact that most patients with rheumatic heart disease in the developing world present for the first time with established valve disease, and simply treating streptococcal sore throats in the community can reduce the burden of disease. This is the most compelling argument for incorporating a strategy of primary prevention into existing rheumatic heart disease prevention programs.