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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 1  |  Page : 162-166

Prevalence of rheumatic heart disease in school children aged 6–15 years


1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatrics, Aga Central Hospital, Aga, Dakahlia, Egypt

Date of Submission30-Aug-2018
Date of Decision11-Oct-2018
Date of Acceptance14-Oct-2018
Date of Web Publication25-Mar-2020

Correspondence Address:
Ahmed M Badawy
Aga, Dakahlia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_264_18

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  Abstract 

Objective
The aim of the study was to detect the prevalence of rheumatic heart disease among school children aged 6–15 years old.
Background
Acute rheumatic fever is a disease that affects skin, subcutaneous tissue, joints, brain and heart. Before the availability of echocardiography, the diagnosis of rheumatic carditis depended upon clinical evidence of valvulitis. Nowadays, patients with definite rheumatic fever or suspected cases should undergo echocardiography to identify carditis.
Patients and methods
A permission was obtained from the ethical committee on the research. This study was done on 5000 student aged 6–15 years. The children had comprehensive history taking and clinical examination for signs of rheumatic heart disease. Those with any abnormality in history or clinical examination were investigated by echocardiography.
Results
A total of 5000 school children aged 6–15 years were included in this study. An abnormal cardiac examination and abnormal history were reported in 48 students. Overall, 13 students refused to undergo echocardiography. The result of echocardiography done was as follows: five cases had definite rheumatic heart disease, 10 cases had mitral regurge not meeting the criteria of rheumatic heart disease, one case had aortic regurge not meeting the criteria, one case had a ventricular septal defect, and the others were normal.
Conclusion
The use of echocardiography as diagnostic criteria of rheumatic heart disease can prevent both overdiagnosis and underdiagnosis of that disease. The prevalence rate of rheumatic heart disease in our study was found to be one per thousand (0.1%), which is less than other studies done in Egypt.

Keywords: carditis, echocardiography, rheumatic fever, rheumatic heart disease


How to cite this article:
Deraz SE, El-Zayat RS, Badawy AM. Prevalence of rheumatic heart disease in school children aged 6–15 years. Menoufia Med J 2020;33:162-6

How to cite this URL:
Deraz SE, El-Zayat RS, Badawy AM. Prevalence of rheumatic heart disease in school children aged 6–15 years. Menoufia Med J [serial online] 2020 [cited 2020 Jun 6];33:162-6. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/162/281287




  Introduction Top


Rheumatic heart disease is a chronic disease caused by damage to heart valves owing to single severe or multiple recurrent acute rheumatic fever attacks. This means that despite the occurrence of rheumatic heart disease in children, its prevalence peaks occur in adults, mostly between 25 and 45 years of age[1].

The incidence of acute rheumatic fever and rheumatic heart disease is high in children between 5 and 14 years of age. However, the first episode can occur in younger children aged 2–3 years of age[2].

In most studies, rheumatic heart disease prevalence is high in rural areas. For instance, indigenous Australians living in distant communities are 3.3 times more likely to develop acute rheumatic fever than indigenous people living in urban centers in the same region[3]. Similar findings have been recorded from other regions[4].

The mechanisms by which acute rheumatic fever occurs remain incompletely understood. Obviously, pharyngeal infection with Streptococci spp. must be present, and genetic susceptibility may be present. Moreover, the evidence is sparse that toxins produced by the Streptococci spp. are important. Within this framework, molecular mimicry is believed to play a leading role in the initiation of the tissue injury. However, the factors responsible for maintenance of the process remain unclear[5].

Guidelines for acute rheumatic fever diagnosis were first established in 1944 and are known as the Jones criteria[6]. These criteria, which have been modified several times (in 1956, 1965, 1984, and 1992) according to changes in characteristics of the disease, provide obvious definitions that help in the assessment of borderline cases. These guidelines after each modification have become more specific but less sensitive. These criteria have become less appropriate for usage in populations with a high incidence[7].

The 2002–2003 WHO criteria for the diagnosis of rheumatic fever and rheumatic heart disease (based on revised Jones criteria) are divided into major and minor criteria. The major criteria include carditis, arthritis (migratory), Sydenham's chorea, and subcutaneous nodule. The minor criteria include fever, arthralgia, elevated C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) and prolonged PR interval. Evidence of group A streptococcal infection or recent scarlet fever infection should be present[8].

There is strong evidence that silent rheumatic valve damage (subclinical carditis) which is detected by echocardiography is a part of the spectrum of rheumatic carditis and should not be missed. This was confirmed by examiners in many countries around the world with high rates of rheumatic fever. Subclinical carditis can be differentiated from physiological regurgitation using echocardiography[9].

Before the introduction of echocardiography, the diagnosis of rheumatic carditis depended upon clinical evidence of valvulitis or pericarditis, supported by radiological evidence of cardiomegaly. Nowadays, echocardiography should be done for all patients with suspected or definite rheumatic heart diseases[10].

The aim of this study was to detect the prevalence of rheumatic heart disease among school children aged 6–15 years old in Aga town, Mansoura district, Dakahlia Governorate, and the effect of misuse of long-acting penicillin and the use of echocardiography on the prevalence rate.


  Patients and Methods Top


An approval and permission were obtained from the ethical committee on the research.

This study was done on 5000 students aged 6–15 years (2485 male and 2485 females) from 16 primary and eight preparatory school children, randomly selected from among 69 024 school children.

They were screened for rheumatic heart disease according to standard clinical and echocardiographic criteria, which were selected by stratified random sample and further proportional allocation method[11] from the total number of children in the district in this age group.

The statistically approved sample in each school was invited to participate after an oral informed consent was obtained from their parents or legal guardians. For each child, a full questionnaire has been obtained including history and a detailed clinical examination. Those students who elicit any abnormality in either history taking or in the cardiac examination, such as murmur, were investigated by echocardiography.

The children had a comprehensive history taking and clinical examination for signs of rheumatic heart disease. Those with any abnormality in history or clinical examination were investigated by echocardiography, ESR, antistreptolysin O titer, and CRP.

Any student who had a past history of arthritis or a positive family history of rheumatic heart disease or taking long-acting penicillin represented as a suspected group.

The overall samples were distributed among nine class levels, with a representative sample in each class level, to ensure an even age distribution. For each class level, classrooms were selected by means of a systematic randomization procedure. The selected school children covered eastern and western Aga.

History taking includes detailed personal history; complaint; detailed history of the presenting complaints; past history of rheumatic fever, rheumatic heart disease, tonsillitis, or tonsillectomy; and family history of consanguinity, similar conditions in other siblings, and family history of rheumatic fever and rheumatic heart disease.

A full examination of the students including general examination of height; weight; BMI; vital data (pulse, temperature, blood pressure, and respiratory rate); head and neck for peripheral signs of aortic regurge (AR), pallor, jaundice, cyanosis, etc.; and local examination of the heart for heart sounds, murmurs, or any adventitious sounds.

Suspected students were investigated by CRP, ESR, antistreptolysin O titer, and echocardiography.

The echocardiogram system used in this study was VIVID 5S, model MDC 10, Alkan Company (El Gazaer Street, off<C; El-Nasr Rd, New Maadi<C; Cairo Governorate 11435), Norway (it is two-dimensional echo with Doppler study).

The modified WHO criteria define rheumatic heart disease using echocardiography and fulfilling Doppler criteria as a regurgitant jet of greater than 1 cm in length, regurgitant jet in at least two planes, a mosaic color jet with a peak velocity of greater than 2 m/s, and jet persisting throughout systole or diastole, associated with at least two morphologic signs including leaflet restriction, subvalvular thickening, and valve leaflet thickening. Other criteria for diagnosing 'definite' rheumatic heart disease (RHD) by echocardiography included mitral stenosis, mitral valve involvement with AR in the absence of other cause of AR, and isolated mitral regurge with a documented history of rheumatic fever[12].

The collected data were organized, tabulated, and statistically analyzed using statistical package for the social sciences (SPSS) version 19 (SPSS Inc., Chicago, Illinois, USA), running on IBM compatible computer. For qualitative data, frequency and percentage distributions were calculated.


  Results Top


The study was done on 5000 students, and the mean age was 10.4 ± 2.4 years. The distribution of studied students according to sex was 2485 (49.7%) males and 2515 (50.3%) females; according to residence was, in rural group 3975 (79.5%) students, and in urban group, 1025 (20.5%) students; according to the type of school was 99.62% of the studied students were from governmental schools in the district and 0.38% of the studied students were from private schools; according to level of education was in primary school 3145 (62.9%) children and preparatory school 1855 (37.1%) children; and according to socioeconomic level was 1775 (35.5%) student with low socioeconomic level, 2905 (58.1) student with middle, and others with high (6.4%) [Table 1].
Table 1: Sociodemographic characteristics of the studied students

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The study was done on 5000 students, where 48 (0.96%) cases had abnormal history and examination, 35 of them (0.7%) receive long-acting penicillin, two (0.04%) cases had a family history of rheumatic heart disease, and 11 (0.22%) cases had murmur on auscultation [Table 2].
Table 2: Past laboratory data of the studied students

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The echocardiographic findings of the 35 selected students were as follows: 14.28% had definite rheumatic heart disease, 0.0% borderline rheumatic heart disease, 34.3% had abnormal structural heart, and 51.42% were normal (13 cases refused to undergo echocardiography) [Table 3].
Table 3: Echocardiographic findings among selected students (n=35)

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The differential diagnosis of the positive studied cases (n = 17) was as follow: five (29.4%) definite rheumatic heart disease in the form of pathological mitral regurge (MR) and two morphological characteristics of rheumatic heart disease; 0.0% borderline rheumatic heart disease; 10 (58.8%) had mitral valve regurgitation not meeting criteria of rheumatic heart disease (physiological mitral regurge) in the form of variable degree of mitral valve prolapse in five (29.4%) cases and grade I mitral regurge of undetermined etiology in five (29.4%) cases; one (5.9%) case had AR not meeting criteria of rheumatic heart disease (physiological AR); and one (5.9%) case had congenital heart disease in the form of ventricular septal defect [Table 4].
Table 4: The differential diagnosis in positive studied cases (n=17)

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The prevalence rate of rheumatic heart disease in our study is one case for every 1000 cases, means 0.1% [Table 5].
Table 5: Prevalence of rheumatic heart disease among selected students by echocardiography

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  Discussion Top


This study was done on 5000 student aged 6–15 years (2485 male and 2515 females) from 16 primary and eight preparatory school children.

This study was done by taking a detailed history and clinical examination for signs of rheumatic heart disease. Those with any abnormality in history or clinical examination, echocardiography had been performed on them using 2012 WHF criteria for detecting rheumatic heart disease, and they were categorized as having definite rheumatic heart disease, borderline rheumatic heart disease, and no rheumatic heart disease.

Of the 5000 children examined, 48 children showed abnormality in history taking or abnormal examination, 22 had arthralgia with long-acting penicillin use, 13 of them had tonsillitis with long-acting penicillin use, two had a family history of rheumatic heart disease, and 11 of them had a murmur on auscultation. Overall, 13 students of the selected children refused to undergo echo. The result of the echo done was five cases had definite rheumatic heart disease (0.1%), no borderline cases, 10 cases had mitral regurge not meeting the criteria of rheumatic heart disease, one case had AR not meeting the criteria of rheumatic heart disease, one case had congenital heart disease in the form of ventricular septal defect, and the other 18 cases were normal.

The prevalence rate of rheumatic heart disease in primary and preparatory school children in Aga town, Mansoura District, Dakahlia Governorate, was found to be one per thousand according to the present study (0.1%). This ratio (0.1%) in our study is lower than the previous studies done in Egypt.

Regarding the previous data, we noticed that 35 cases of the 48 suspected cases were on long-acting penicillin. This demonstrates misuse of long-acting penicillin owing to arthralgia or growing pain, which is confused with arthralgia and also uses of long-acting penicillin with recurrent tonsillitis. This misuse of long-acting penicillin may be one of the important causes of the decreased incidence of rheumatic fever and rheumatic heart diseases. Moreover, from history, a large number of students received antibiotics repeatedly owing to tonsillitis; this use of antibiotics and seeking medical advice and fear of parents from rheumatic heart disease encourage them to seek medical consultation in cases of tonsillitis, and in cases of arthralgia, this also may be a cause of the decrease in the incidence of rheumatic heart diseases.

This prevalence rate (0.1%) in our study is lower than the previous studies done in Egypt. In El Menofia Governorate (2000), a study was done by Bassili et al.[13], which found the prevalence rate to be 5.1 per thousand of school children which is higher than our present study. On the contrary, there was a study done by Khaled and Saeid[14], in Cairo (1991), in which the prevalence rate was 0.99 per thousand of school children in a study done on 8901 children in primary schools in Cairo; this rate is slightly lower than our present study, which is one per thousand. This may be owing to that the present study was done on relatively lower social class children.

Rheumatic heart disease distribution varies between continents. Sub-Saharan Africans and Indigenous Australians have the highest prevalence[15]. In Pacific Islanders and Indigenous Australians, the prevalence is 5–10 per 1000 school children. In Asia rheumatic heart disease prevalence varies, for example, in rural Pakistan, it has a prevalence in the community as high as 12 per 1000 people (40). In South and Central America, rheumatic heart disease has a lower reported prevalence (1.3 per 1000 school children)[16].

Most of the studies in Africa reported a prevalence of 2.4–10.2/1000 based on clinical detection of murmur with confirmation by echocardiography[16] Echocardiographic surveys in Uganda and Mozambique reported a higher prevalence of rheumatic heart disease than previously thought (14 and 30 per 1000, respectively)[17]. 1990s reported a rural prevalence of 4.6/1000 and an urban prevalence Auscultation-based surveys in Ethiopia conducted in the late of 6.4/1000[18]. One recent collaborative echocardiographic screening project from Jimma, ET, and Cape Town, SA, using the World Heart Federation (WHF) criteria reported a definite rheumatic heart disease prevalence of 16 per 1000[19].


  Conclusion Top


Although rheumatic heart disease occurs in children, its prevalence peaks in adulthood, usually between 25 and 45 years old. The use of echocardiography as diagnostic criteria can prevent both overdiagnosis and underdiagnosis of rheumatic heart disease. Considering the several publications in the last few years on the subject, we started to consider subclinical carditis, diagnosed through echocardiographic alterations, as a major criterion for the diagnosis of rheumatic fever and not only clinical carditis. It is recommended that epidemiological data from both rural and urban areas in all parts of Egypt and incidence and prevalence data about rheumatic fever and rheumatic heart disease should be collected, which greatly help in controlling rheumatic fever and rheumatic heart disease. This is done by doing survey programs in all governorates under the supervision of the ministry of health and faculties of medicine to detect early cases and proper management of them. Screening survey was done on 5000 students in 16 primary and eight preparatory schools. The prevalence rate of rheumatic heart disease in primary and preparatory school children in our study was found to be one per thousand (0.1%). This ratio is less than other studies done in Egypt. There is a misuse of long-acting penicillin which may be one of the important causes of the decrease in the prevalence of rheumatic fever and rheumatic heart disease in Egypt.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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