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 economic development and precarious primary prevention - especially in low- and middle-income countries - perpetuate an environment in which RHD remains endemic and with increasing trends. Moreover, the increased mortality rate is largely due to the stage at which the disease is diagnosed, a classic example being the young woman who discovers severe mitral stenosis only when an acute pulmonary edema is identified during pregnancy. 28 This progressive increase was also confirmed by another national study, 27 which justifies the greater availability of echocardiography, with more sensitive criteria, especially for subclinical RHD. In these subclinical cases, echocardiography plays a crucial role because it can establish the diagnosis or even raise suspicion of a possible case in those patients who are going through the last phase of the disease, from the acute manifestations of RFA to the last complications of RHD. 29 When analyzing our data on mortality from RHD, we see, to a certain extent, the results of non-diagnosed ARF and the cases that were adequately treated in the past. This gap can last 10 to 20 years. 28 Similarly, by implementing population screening measures to identify the individuals that occupy this gray area, the results will also come after at least a decade. 29 As in Brazil, the proportion of reports of ARF and RHD in the Pacific islands has increased in recent years, where GAS disease rates seem to be unstoppable. 30 In the same study, where the annual incidence of ARF was 155 per 100,000, a 41% increase was reported between 2004 and 2009, attributed to improved case detection and reporting of a record and a health program coordinator. However, raising awareness and case reporting is unlikely to account for the high rates of ongoing ARF in this population, as the disease became notifiable in Australia in 1996, an example that should be followed in Brazil, not only notifying hospitalized cases, but compulsorily notifying all cases, allowing greater prophylaxis use. Rates are likely to remain high because of the failure to adequately address socioeconomic determinants of health, increasing the already high rates of infection. Consequently, this remains a significant concern for public health that deserves more attention. RHD presentation (considering a 10-20 year latency), in the absence of a history of ARF, actually suggests that detection, accurate diagnosis and reporting of ARF remain below ideal. Contributing factors may include lack of training or awareness among health staff, transient health professional staff in remote areas, poor access to medical services, and lack of use of health services due to many factors. 20 Differences between echocardiographic criteria considerably affect the apparent prevalence of rheumatic heart disease in screening surveys, and emphasize the difficulties in the diagnosis of subclinical disease. Some might argue that there is a wide range of definitions of normality and that echocardiography screening might lead to over- diagnosis. Although controversial, evidence supports a link between mild valvular lesions, detected by echocardiography, and rheumatic heart disease, particularly the substantially higher case detection rates of such lesions in populations at risk for acute rheumatic fever. 31 Sustained control of rheumatic heart disease at a population level requires a high-functioning health system that meets the needs of vulnerable people. In high-income settings, rheumatic heart disease demonstrates persistent inequality. 32 For instance, indigenous Australians in the Northern Territory under 35 are 122 times more likely to have rheumatic heart disease than their non-indigenous peers in the same region, reinforcing that a greater focus on RHD prevention and control by strengthening the existing record-based programs (or the development of such programs where they are absent) in countries with high disease burden, improving primary care and raising awareness about ARF and RHD, is critical. Governments, as well as clinicians, should prioritize RHD control to ensure continued funding and recognition of large regional organizations. 30 In a challenging clinical setting characterized by high ARF/RHD rates, as in Brazil, an Australian study showed a significant improvement in care for people with ARF/RHD in association with the implementation of a continuous improvement quality (CQI) based on participatory research principles. Key findings include improvement in key clinical care indicators, including the administration of scheduled injections of BPG, scheduling injections at the recommended 4-week interval, and periodic review of documentation by a medical specialist, whereas significant improvements in record keeping were also related to ARF/RHD. 33 Another study carried out in Bangladesh showed that rheumatic fever and rheumatic heart disease are the most common cardiovascular diseases in young people < 25 years of age and are important contributors to cardiovascular morbidity and mortality. It also shows that chronic RHD continues to prevail, and the real burden of disease may be much higher, indicating that large-scale epidemiological and clinical research is needed to formulate evidence-based national policies to address this important public health problem in the future. 34 As in Brazil, RHD continues to demand a high health and economic rate in African countries, but evidence-based prevention and treatment measures are currently underutilized. 35 An initial step for Brazil could be based on the report of the African Union Commission (AUC) Social Committee, which described actions that governments must take to eliminate ARF and eradicate RHD: (a) create prospective disease records in sentinel sites (b) decentralization of technical knowledge and technology for the diagnosis and management of ARF and RHD (including echocardiography), (c) establishment of national and regional centers of excellence for cardiac surgery, and (d) promoting international partnerships to mobilize resources and expertise. 36 Preventive task forces already well established, with the impact of worldwide campaigns, including Brazil, are Pink October and Blue November. We highlight that these two programs are related to prevention of breast cancer (BC) and prostate cancer (PC) mortality, of which magnitude is similar to that of ARF and RHD mortality. The Blue November began with a movement called Movember in Australia in 2003, taking advantage of the celebrations of the World Day to Fight Prostate Cancer, held 351