Resurgence of Rheumatic Fever Is Feared

Rheumatic fever, which had all but vanished in this country, could be making a comeback, doctors said Thursday.

Outbreaks among children and adults “suggest the potential for resurgence of this illness,” according to a report published by San Diego researchers in this week’s Journal of the American Medical Assn.

Rheumatic fever, still common in developing countries, is caused by strep throat, or Group A streptococcus. Thirty years ago, there were about 25 cases for every 100,000 individuals annually. When this rate plummeted to less than one case per 100,000 in 1980, many doctors stopped worrying about the disease, said Dr. Timothy Mastro, a medical epidemiologist with the Centers for Disease Control in Atlanta.

“Until these outbreaks, rheumatic fever hadn’t been seen for a couple of decades,” said Dr. Mark Wallace of the Navy Hospital and an author of the study.

And, because doctors stopped seeing the disease, they became complacent; some health officials argued that it was no longer necessary to take throat cultures on all children who suffered sore throats.

But some doctors are now concerned about recent rheumatic fever outbreaks among schoolchildren and an earlier one involving 10 recruits at San Diego’s Naval Training Center in 1986 and 1987.

“This doesn’t mean everybody needs to go out and be frightened by this,” said Dr. Edward Kaplan, professor of pediatrics at the University of Minnesota and head of the World Health Organization’s streptococcal reference laboratory.

In a separate telephone survey of 56 doctors in 50 cities throughout the nation, 47% said they were seeing a “definite” yearly increase in cases of rheumatic fever, said Kaplan, who conducted this study with Rae-Ellen Kavey, of the State University of New York’s Health Science Center. And 21% said they had seen five or more cases each year during the current decade. From 1985-88, these doctors reported 194 cases, or more than double the number they had seen in previous years, Kaplan said.

“We cannot be complacent about rheumatic fever because it is a potential problem,” said Mastro, who recommends that people with sore throats have their doctors take cultures.

Rheumatic fever, characterized by fever, pain and swelling of the joints, can cause permanent damage to heart valves and even death. Among children, whom the disease strikes with greater frequency, the symptoms can also include hard nodules under the skin and a snake-shaped rash on the upper-body and thighs.

The disease usually affects children 5 through 15 years old and may occur several weeks after the child has recovered from strep throat. Doctors say only a small number of strep throats evolve into rheumatic fever. But, among those children who do develop rheumatic fever, about one-third suffer damaged heart valves, which can cause them to suffer shortness of breath or fainting spells.

For the medical community, red flags have been going up since 1985 after outbreaks in Salt Lake City, Pittsburgh, Columbus, Akron, Dallas and San Diego. In Utah, where the biggest outbreak occurred so far, 138 cases of rheumatic fever were diagnosed among children. And about 65% of those children suffered heart damage.

But, because doctors are not required to report rheumatic fever, the figures on the number of cases across the nation are sketchy, experts say. And the problem is further complicated because there is no specific test for the disease.

Rheumatic fever has had a record of striking the military, and striking hard.

At the Naval Training Center, which has 25,000 to 30,000 recruits in boot camp a year, officials decided to move quickly before the disease escalated beyond their control. From October to April, every recruit now gets a shot of penicillin to prevent him from getting strep throat, which can lead to rheumatic fever. Those months are considered prime time for strep throat, a disease that strikes every adult about once in his life, Mastro said.

The expense of the Navy’s preventive measure--$2.25 per dose--has paid off. Today, doctors see about one case of strep throat for every 1,000 recruits each week.