RHEUMATIC HEART DISEASE PROGRAMME IN TONGA RECEIVES HEART HERO AWARDDr Toakase Fakakovikaetau is the 2008 recipient of ProCor’s Louise Lown Heart Hero Award on behalf of the Rheumatic Heart Disease Prevention Programme activities developed by the Ministry of Health in Tonga. The award recognises innovative, preventive approaches to cardiovascular health in developing countries. Rheumatic heart disease neglectedGlobally, rheumatic heart disease kills more than 330,000 people a year. The disease has been all but eliminated in wealthy countries, so almost all of these deaths occur in developing countries. It is currently estimated that between 15 and 20 million people around the world are affected by the disease, but this is likely an underestimate because it is based on screening methods (listening for murmurs) that have been shown to miss a large proportion of those who are in early stages of the disease. Echocardiogram, while more accurate, requires both expensive equipment and specialised skills, so that it is rarely available for large-scale use in the countries where RHD is prevalent. Recognising the problemPrevalence of RHD is extremely high in many areas of the Pacific Islands, where patients with the severe heart damage that it causes must be sent abroad for surgery. When she began to practice paediatrics in Tonga, Dr Fakakovikaetau was concerned with how many patients she saw with the condition. “We saw a lot of RHD in clinic and almost always had a child suffering from it in the paediatric ward. That many cases mean a lot in a country with such a small population. There had been a World Health Organization RHD programme earlier, but the funding stopped and no one could find the register," she says, recounting a story heard in other Pacific Island States." A few studies had shown moderate prevalence among schoolchildren, but it seemed higher than that to me and to my colleagues. " Needless deathsDr Fakakovikaetau was discouraged by the heavy toll that RHD was taking among the children she treated. "There was one case that really touched me: a boy who had family problems. His parents did not bring him in regularly for the penicillin prophylaxis he needed to prevent progression of his heart damage. He would get a bit better when he came into the hospital and was treated with antibiotics, but then would go home and just come back later, even sicker. We found funds to send him for heart surgery, but his parents refused. I watched him get worse and worse until he died. It was such a needless death." Critical shortage of trained medical staffTonga has many islands, but 70% of its population of 120,000 lives on the main island of Tongatapu. The country has three hospitals. Like most Pacific Island States, it has no cardiologists. In fact, Dr Fakakovikaetau is Tonga's only paediatrician. Known as Toa to the many people who cannot manage her last name, she covers the country's only paediatric ward, the main hospital paediatric outpatient clinic and emergencies, and organizes paediatric references abroad; and is herself a mother of four. Screening in Tonga: highest prevalence confirmed to dateIn 2003–2004, Dr Fakakovikaetau worked with Dr Jonathan Carapetis, Chairman of the World Heart Federation RHD Council, to screen over 5,000 children in 27 schools in Tonga – over 30% of the total number of schoolchildren in government schools. What they found was the highest prevalence ever confirmed by echocardiography: 33.2 per 1,000 schoolchildren. Over half of the children they found with definite RHD had no heart murmur identified by auscultation. Developing a comprehensive control programmeSince the screening in 2004 Dr Fakakovikaetau has developed a register adapted from the model developed in the World Heart Federation RHD Programme in the Pacific. The register enables the Tongan Ministry of Health to follow and better coordinate secondary prevention and other medical care for over 400 people with RHD. Over 30 new cases were identified in 2007. Among the 139 people, mostly young people, who are now getting secondary prophylaxis, compliance is quite high (the median rate is 82%). "We don't have any special materials like pamphlets or posters, but we do a lot of education of patients and their parents and impress on them how important it is to come in for their penicillin injections" says Dr Fakakovikaetau. "It is a small place and people know each other: if a child's parents don't bring him to get his injections, another family from the neighbourhood that also has a child with RHD will realise it and go to ask why….that social pressure is very effective." Cost-effective prevention saves meagre health resourcesRHD cases use up the vast majority of the funds available to send Tongans abroad for surgery. "When Jonathan approached us about the possibility of screening, I was afraid" Toa recounts. "I didn't want to find more children who needed surgery: the waiting lists are already so long. But when I thought about how so many could be spared all of that by getting penicillin injections, I knew we had to do it. Sometimes it is hard to convince the system to invest in RHD because there are higher priority conditions, like diabetes. But preventing RHD actually liberates funds that are already being spent. Now we are sending up to twenty cases abroad a year. For the cost of sending one child to New Zealand for surgery we could screen all of the children in the country, and for the cost of sending a second one we could upgrade preventive services provided in our own primary care facilities so that they systematically provide the secondary prevention that keeps children with rheumatic fever from getting heart damage." ProCor award recognises innovation in cardiovascular preventionProCor’s Louise Lown Heart Hero award recognises preventive approaches to cardiovascular health in developing countries and other low-resource settings, identifying community innovators who mobilise people to live healthier lives. “We are hopeful that many other communities facing the challenge of RHD will learn from this inspiring programme,” said Dr Brian Bilchik, ProCor’s Director. The award was established in 2007 by Dr Bernard Lown, founder of ProCor, and the 2007 recipient was The Heart and Stroke Foundation South Africa Children's Programme. Useful Links:Results of Tonga screening > | |||||||
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