ABC | Volume 113, Nº3, September 2019

Original Article Figueiredo et al. Rheumatic fever: a disease without color Arq Bras Cardiol. 2019; 113(3):345-354 As shown in Figure 3A, total expenditures with hospitalization in Brazil for RHD increased by 264% in the analyzed period, from R$ 23.077.356,65 (US$ 7.006.288,21) in 1998 to R$ 84.080.772,39 (US$ 25.526.924,01) in 2016. The costs in the analyzed period were recorded in 2013 (R$ 99.476.203,42 or US$ 30.200.975,35). Therefore, applying Holt’s Exponential Smoothing method, the predicted values for total costs related to RHD (Figure 3B) were R$ 86.691.610,00 (US$ 26.319.572,79) and R$ 87.997.028,00 (US$ 26.715.897,70) for 2018 and 2019, respectively. Considering this hypothetic scenario, where all the morbidities required at least one hospitalization and the regular values of cardiac surgeries, the expenses for the Brazilian public health system would have a minimum annual cost of R$ 56.726.131,10 (US$ 15.981.534,55), as shown in Figure 4. Taking as reference the mortality rates from two diseases with a high global prevalence, breast cancer and prostate cancer, of which magnitude generated the preventive task force established by worldwide campaigns (Pink October and Blue November), RHD mortality behaves in a similar manner (Figure 5). In this sense, we highlight that growth trends of RHD and BC are significant; however, there are no significant differences between them, which is demonstrated by the overlap of confidence intervals. Moreover, the PC trend was not statistically significant (p-value = 0.334) for the comparison of confidence intervals. Discussion Rheumatic heart disease (RHD) is one of the leading noncommunicable diseases in low- and middle-income countries and accounts for up to 1.4 million deaths annually. There are few contemporary data systematically collected on disease characteristics, treatments, complications, and long‑term outcomes in RHD patients. 16 Despite the magnitude of the problem, Brazil does not have a specific database for this pathology. Thus, because we did not have weekly or monthly data, it was not possible to statistically evaluate disease seasonality. Although these numbers may be underestimated by the lack of a health surveillance strategy during the entire studied period, it is observed that, each year, the number of deaths increases on average 16.94 units, as obtained from the model equation for the trend of the RHD mortality rate (Figure 1C and D). Indeed, ARF and RHD are included in the Brazilian list of preventable death causes for children under 5 years and for the age group of 5 to 75 years. The avoidable or reducible causes of death are defined as those totally or partially preventable by effective health care services, accessible at a certain place and time. Herein, this mortality rate refers to the overall Brazilian population, without distinction of age, with predictive values for 2019 at the magnitude of 8.53 for RHD and 2.68 for ARF, which are higher than the ones from 2017 11 (6.70 for RHD and 1.94 for ARF), representing an increase of 27.3% and 38.1% for the respective pathologies. Figure 2 – GAS: Group A β-hemolytic Streptococcus. Hypothetical scenario based on the current panorama of rheumatic fever in Brazil, after crossing data from the Brazilian Institute of Geography and Statistics with data from the REMEDY study, 16 showing the evolution of Acute Rheumatic Fever to Rheumatic Heart Disease, with their respective morbidities in numbers. GAS infection in Brazil Acute Rheumatic Fever Rheumatic Heart Disease Rheumatic Heart Disease Morbidity 10 million people annually 30.000 cases per year No 7.000 people Heart Failure 7.014 cases Atrial Fibrillation 4.578 cases Stroke 1.491 cases Surgery 8.904 cases Endocarditis 840 cases Yes 21.000 people 348