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 Figure 5 – Comparison between the increase of mortality rates for Rheumatic Heart Disease (RHD), Prostate Cancer (PC) and Breast Cancer (BC). According to the adjustment of a simple linear regression for each of the series, the trends for RDH (0.15 [0.12, 0.17]) and BC (0.14 [0.07, 0.22]) were significant (p-value < 0.050) and did not show any significant difference, as the confidence intervals overlapped. The trend for PC (0.04 [-0.04; 0.12]) was not significant (p-value > 0.050). Mortality rate Mortality rate RHD BC PC 10 9 8 7 6 5 4 1998 2000 2002 2004 2006 Time 2008 2010 2012 2014 2016 (R$ 56,726,131.35 or U$ 15,981,534.55; Figure 4). Thus, we highlight that this amount would be enough to carry out secondary prophylaxis of RHD (considered a BPG dose every 3 weeks) in 22,574 people for 10 years. Unfortunately, the low BPG accessibility is not a Brazilian problem, only. Minimal access to BPG was reported in almost all 24 countries in Africa, the Asia-Pacific region, and Central and South America in 2011, 22 with some respondents indicating no access to BPG at all. Of 39 respondents, 35% indicated that their BPG supply is inadequate to treat all of their patients using the recommended prophylaxis schedules. 22 Although there are no national data on access to BPG in Brazil, the concern about its lack of availability has increased in recent years. 23 This lack of an acceptable domestic supply of BPG is a significant problem in several global sites where RF/RHD is prevalent. Without consistent access to an inexpensive and high quality supply of BPG, children in areas with a high prevalence of RF/RHD will remain at risk of developing this crippling and life-threatening condition. 22 The increasing trend in the RHD and ARF mortality rates, with increments of 27.3% and 38.1% respectively (2017‑2019), as well as the comparison between the total costs of the RHDmorbidities and the use of BPG, indicates the need for public policies and programs for ARF / RHD control, leading to the early diagnosis and the prevention of disease development and its morbidities. Despite the lack of ARF/RHD control programs in Brazil, this prevention strategy has been already applied in many countries with positive responses, as evidenced by the following data. The 10-year program in Pinar del Rio (Cuba) dramatically reduced morbidity and premature mortality in children and young adults and was cost-effective. 24 A study carried out in Zambia has shown that understanding public perceptions and behaviors related to neck pain is critical to informing health programs aimed at eliminating new cases of RHD in endemic regions. This cross-sectional study found that pharyngitis is common among school children and adolescents, with women reporting significantly more episodes of sore throats than males. Parents/guardians have varying knowledge of the frequency of sore throats in their offspring, and management of pharyngitis may be suboptimal for many children, with more than one quarter receiving treatment without a qualified evaluation, providing a view of the need for public awareness campaigns aimed at reducing RHD, 25 which further reinforces the need for greater visibility regarding RHD in Brazil, with program implementation, considering the alarming perspectives of mortality shown in this article. This increase in mortality may be a matter of discussion considering the possible development of factors, such as better diagnosis, mortality notifications and BPG accessibility. Merely approximately 5% of all carriers of rheumatic fever have a symptomatic acute phase, whereas the majority of patients with severe cardiac rheumatic sequelae are diagnosed only in the final phase of the disease. In fact, these figures may be underestimated, and of these 5% symptomatic individuals, only about 5% need hospitalization, 26 according to DATASUS data. In Brazil, the PROVAR study 27 (the country's first large-scale screening program) was implemented in 2014 and revealed an echocardiographic prevalence of 42/1.000 in the preliminary assessment, contrasting with the IBGE prevalence of 7/1.000 1 . This shows that populational screening policies are needed to identify these asymptomatic patients, and it partially explains the increase in prevalence due to better diagnostic methods, but more studies are required to understand the real causes of this increase. The same study shows that although the prevalence of RHD has declined in high-income countries, lack of social and 350