The most common heart disease in infants and children is congenital heart disease,represented over 90 percents  and over 95 percents are unpreventable.Congenital heart disease is the most common congenital anomalies causing death in infant. (2)

                        The incidence of congenital heart disease is approximately 0.8 to 1 percent of all live born infants world wide.  It is the most common serious birth defect.With the advance in recent technologies both in the diagnosis and treatment,almost all of the defects are correctable.In developing countries twentifive percents of these infant with congenital heart diseases may not survive the first year of life(3) and sixty percent of serious congenital heart disease died in the new born period (4).  Even in developed countries,twentyfive percents of neonate with congenital heart disease who died in the first week of life before the diagnosis was made and ten percents who died in the first year of life did not have the diagnosis made before death.(5)

                       The means and ways to reduce the mortality of infants and children with congenital heart disease is an early detection and early treatment.

                      This report will describe our experience in Thailand in the past 6 years how to achieve greater efficiency from our existing resourses. Training program for community nurses and health officers. The first training program was started in the year 2002 at Sukhothai province in the north of Thailand.(6)The training included a lecture and cases demonstration.The OSCE evaluation were done after the training.There were 70 people  trained.The passing score was 70 percents of fifteen stations.Ninty percents of the class passed the examination.After the training,these nurses and public health officers screened 51,201 primary school children.There were 461 suspected cases of heart diseases.They were further screened by local medical doctors.The number of suspected heart diseases after medical doctors examination was 188.A team of pediatric cardiologists did a final examination and further confirmed by echocardiogram.Sixtysix students were found to have heart diseases,prevalence 1.19 per 1000.There were 1.1:1000 congenital and 0.09 per 1000 were rheumatic heart disease.Of sixtyone congenital heart disease,39 cases(64%) were known cases and 22(36%) were new cases.Sixtyfive percents of all congenital heart disease were sent for surgery.Fiftynine percents of new cases needed surgery .Similar programs has been done in several regions of Thailand.We plan to do further screening in all parts of Thailand in the near future.

                       Mobile and extended pediatric cardiac clinic.This program was started in1993.A team of pediatric cadiologists   went to see infants and children suspected heart disease in the rural and capital of Thailand.These infants and children were originally seen by local physicians and suspected heart diseases. They were were further confirmed by echocardiogram.Up to date over 84 trips were done all over Thailand.Over 5000 infants and children were seen.Seventy percents were confirmed heart disease.Over 90 percents were congenital heart disease,and sixty percent needed surgery or intervention.This progam were done by volunteer pediatric cardiologists from The Cardiac Children Foundation of Thailand Under the Royal Patronage of Her Royal Highness Princess Kalayanivadhana Krom Luang Naradhivas Rachnakrinda.The benefits of this program included,reducing cost of traveling,lodging,improved local doctor skill,early referral for surgery and intervention and created networking and partnership among many agents involved.  

               A program of weekend and evening congenital heart  surgery.This program was started in 2002 after the government of Thailand started  implementig a universal health care coverage.In Thailand there are 800,000 infants born each year.The numer of infant born with congenital heart disease is approximately 8000.The number of congenital heart disease needed surgery and intervention is about 50 percent or 4000 cases.At present both public and private hospitals  can perform only 2500 cases a year.(7)There are 17 public and 4 private hospitals join the program.Up to date over 6000 patients were done with the mortality of less than 2 percents.Only simple cases were done.The benefit of this program is reducing surgical waiting lists.The Cardiac Children Foundation of Thailand supported the surgical teams,the National Security Office supported the cost of surgery ,the private hospitals absorb the extra cost of the procedures.  

                Discussion.From our previous studies(4) indicated that 46 percent of serious congenital heart disease died and 60 percent within the first month of life.Types of CHD in the new born infants are similar to Western reports,(8)and almost all of the defect are correctable.Early diagnosis and early referral is very important.   

               In Thailand,most of infants who are born in community hospitals usually visit community health center for immunization.There are no medical doctor at these clinics especially in the rural area. Even health centers in Bangkok metropolitan there is only one doctor.Immunization usually done by nurse practioner.All school health programs are the responsible for nurses and health officers.It is very useful to train these people how to detect heart diseases.Suspected cases of heart disease can be refer for early evauatio treatment. 

                 In remote area in Thailand,patients has to travel a long distance to cardiac centers.Although at present there are more new cardiac centers in the rural area,the surgery of CHD in infants and children need skill surgical teams.Moblie and extended pediatric cardiac clinic are very helpful.These infants and children who need surgery and intervention can be distributed to appropriate centers for further treatment early. 

                Although there are many cardiac centers in Thailand.Most of these centers operate on adult patients in over 60 percent of the cases causing a long surgical waiting lists.Evening and weekend cardiac surgery is very helpful especially in public hospitals.The problems of inadequate operating room and cardiac care unit postoperatively can also be solved by the cooperation of few private hospitals.Over 40 percent of all congenital heart surgery were operated during evening and weekend surgery with a very low mortality rate of less than 2 percent.(9) 

                 The most important risk factors for infants and children under the age of five years who were admitted and died with pneumonia is the underlying congenital heart(10).If these children were detected early ,early intervention can reduce the expense. 

                  Because many new born infants with critical CHD were not detected before being discharge from the hospital such as co_arctation of aorta,transposition of the great arteries and total anomalous pulmonary venous connection,pulse oxymetry both fingers ant toes is very helpful for  early detection and early surgery. (11)  

  Refences:

1.      Siripoonya P.and Tejavej A.Congenital anomalies in early neonatal period.J Med Ass Thailand.1976;59:444-447.

2.      Pongpanich B,Chesdavanijkul W,Chiemchanya S,Na Ayuthya PS and Tejavej A.Congenital heart disease in children born at Ramathibodi Hospital.J Med Ass Thailand.1978;261-66.

3.      Aroonsodsai W,Pongpanich B.The incidence of congenital heart disease born at Ramathibodi Hospital during one year period.Mahidol University Annual Research Abstract.1993

4.      Pongpanich B.Congenital heart disease in New born:Ten year experience with 100 cases of confirmed cardiac catheterization and postmortem examination.J Med Ass Thailand.1980;63:369-73.      

5.  Kuehl KS,Loffredo CA,Ferencz C.Failure to diagnose congenital heart disease in  infancy.Ped  1999;103:743-47  

6.  Mongkolsiri D.,Tetiwat P.and Panket P.Prevalence of congenital heart disease in elementary school children at Sukhothai province.Thai Med Coun Bull 2005;34:91-104

7.     Report from The Royal College of Cardiothorasic Surgeon of Thailand,2008

8.      Pongpanich B,Khowsathit P,Jamjureerak V,et al.Pattern of congenital heart disease born in 1994.A multicenters co-operative study in Thailand.Asean Heart J1996;4:62-65

9.      Pongpanich B.Report from the Cardiac Children Foundation of Thailand,2006

10.  Suwanjutha S,et al.Risk factors associated with morbility and mortality of pneumonia in children under 5.Southeast Asian J Trop Med Pub Health 1994;25(1):60-66

11.  Ruangritnamchai C,Bunjapami A and Pongpanich B.Pulse oxymetry screening for clinically unrecognized critical congenital heart disease in the new born.Pediatric Cardiology 2008. 507;30:1015

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Abstract

           The development of recent medical and surgical technology has led to early diagnosis and treatment of infants and children with congenital heart disease.In countries with limited resources,large number of infants and children with  correctable lesions do not survive and many who survive have severe limitations.

           Health care reform in Thailand in 2002,led to the adoption of universal health care coverage has resulted in development of ways and means to increase equity in health care delivery.

             In regards to congenital heart disease,training programs for primary health care personels were instituted for early recognition of heart diease in infants and children during school health examinations and routine immunization visits.This program was started in 2005 and are planning to do for the whole country . 

            Mobile and extended pediatric cardiac clinic were started in 1993 with the cooperation of public and private hospitals all over the country.To date over 5000 infants and children suspected heart disease were seen.

              A programme of weekend and evening cardiac surgery was started in 2002 to reduce the surgical waiting lists,over 6000 patients were operated.

               These works are supported by The Cardiac Children Foundation of Thailand,National Security Office,Ministry of Health and private hospitals.