Asian Cardiovasc Thorac Ann 2001;9:41-44
© 2001 Asia Publishing EXchange Pte Ltd
Prevalence of Rheumatic Fever and Rheumatic Heart Disease in Yemen
Abdul Nasser Al-Munibari, MD,
Thabet Mohsen Nasher, FRCP,1,
Siddig Ahmed Ismail, FRCP,
El-daw Ahmed Mukhtar, MD,1
Department of Cardiology
1 Department of Internal Medicine Faculty of Medicine and Health Sciences Sana'a University Sana'a, Yemen
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For reprint information contact: Abdul Nasser Al-Munibari, MD Tel: 967 1 67 2395 Fax: 967 1 24 1101 email: munibari{at}hotmail.com Department of Cardiology, Faculty of Medicine and Health Sciences, Sana'a University, P.O. Box 8831, Sana'a, Yemen.
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Abstract
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The major aim of this study was to determine the prevalence of rheumatic heart disease in Yemen. Between October 1997 and March 1998, a prospective cluster-sampling screening study was carried out on 5000 schoolchildren (2504 female and 2496 male), aged 5 to 18 years. Suspected cases were subjected to electrocardiography, chest radiography, and Doppler echocardiography. Although no case of active rheumatic fever was found, 12 girls and 6 boys were affected by the disease, giving a prevalence of 3.6 per 1000, which is higher than that reported from neighboring countries. All confirmed and suspected cases were given penicillin G benzathine every 3 weeks, according to body weight, after a test dose. Prevention programs for rheumatic fever, together with prevention of streptococcal throat infections, are goals for the near future.
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Introduction
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Rheumatic fever (RF) and rheumatic heart disease (RHD) cannot be separated from an epidemiological point of view. RF is a febrile disease affecting connective tissue, particularly in the heart and joints, initiated by infection of the throat by group A beta-hemolytic streptococci. Although RF is not a communicable disease, it results from streptococcal pharyngitis which is communicable. It often leads to RHD which is a crippling illness. The consequences of RHD include: continuing damage to the heart; increasing disability; repeated hospitalization; and premature death, usually by the age of 35 years or even earlier in the tropics and Third World.1 However, RHD can be readily prevented by prompt and effective treatment of rheumatogenic group A beta-hemolytic streptococcal infections.
Yemen, an underdeveloped country, still suffers from many diseases that have become history in developed countries. This study on the prevalence of RHD reflects its continuing impact in developing countries at the beginning of this millennium. The main aim of this study was to obtain baseline data on the extent and distribution of RF and RHD in Yemen, with a view to establishing a national register of patients. To this end, an epidemi-ological study of the prevalence of RF and RHD among schoolchildren in Sana'a city was undertaken.
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Patients and Methods
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With the help of an epidemiologist, a screening program for RF and RHD among schoolchildren was planned using random sampling with a stratified cluster method.2 A sample of 5000 schoolchildren was chosen from 50 of the 223 government schools in Sana'a city, which have a total enrolment of 248,335 students. A team consisting of a cardiologist, 5 general practitioners, 2 nurses, and a school health organizer, participated in this work between October 1997 and March 1998. Screening was carried out by cardiac examination of every child, using a specially devised clinical protocol. All cases of suspected RHD, on the basis of a murmur on auscultation, underwent electro-cardiography, chest radiography, and Doppler echocardio-graphic examination. Confirmation of RHD was based on the modified Jones Criteria and evidence of valvular or subvalvular deformity by echocardiography.3 All con-firmed and suspected cases were prescribed penicillin G benzathine every 3 weeks, according to body weight, after a test dose.
Data collected from all 5000 subjects were analyzed using Epi Info 6 software (Centers for Disease Control, Atlanta, GA, USA); all fields were designated and the different parameters and correlations were determined. Data of suspected and confirmed cases were put into a database program (Excel, version 5; Microsoft Corp., Redmond, WA, USA) for further analysis and production of figures and tables.
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Results
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Of the 248,335 students in government schools, there were 139,436 males (56.1%) and 108,899 females (43.9%). Among the 5000 screened for evidence of RF and RHD, 49.9% were male and 50.1% were female. The highest numbers of students were found at ages 7, 10, 12, 13, 14, and 15 years, as shown in Figure 1
. Place of residence was included in the data; most of the students were from the urban area (91.6%), while a minority come from a rural area (8.4%). There were 259 cases (5.18%) of suspected RHD; the sex and age distribution of the suspected cases of RHD are shown in Table 1. Among the suspected cases, 18 cases of definite RHD were documented; 6 had been previously diagnosed with RF without valvular lesions, but no case of active RF was seen. Confirmed RHD was more prevalent among girls (12/18) than boys (6/18). The age of the students with RHD varied from 8 to 18 years, the mean age was 13.28 years, and the disease was significantly more prevalent in girls aged 12 to 18 years (p < 0.001).
The socioeconomic class of each of the screened children was estimated and the majority were classified as middle class. Most confirmed cases of RHD were among the middle and lower class students (Table 2); only 1 case was found in the higher socioeconomic group (p < 0.04). All 18 confirmed cases of RHD were in children living in the urban area, but those from rural areas represented only 8.4% of the sample. Among these 18 children, a history suggestive of RF was given by 12, another 5 had suffered recurrent sore throat in association with arthralgia, and 1 had recurrent throat infection without any joint complaints. Four of these cases had been diagnosed with RHD before screening. Of the 14 patients diagnosed to have rheumatic valvular lesions on screening, 2 had been diagnosed previously to have RF; one was noncompliant with penicillin treatment, and no antibiotic prophylaxis had been given to the other patient. The 4 patients already diagnosed with RHD had been prescribed penicillin G benzathine (every 3 weeks in 3 patients, and monthly in the 4th); 1 was noncompliant with the treatment, another was taking oral anticoagulation after aortic valve replacement 3 years previously. Most of the patients were symptomatic; shortness of breath was detected in 8 patients who were in New York Heart Association functional class I to II. One student complained of irregular palpitations; after clinical evaluation and electrocardiography, she was found to have a ventricular bigeminy extrasystole.
Valvular lesions were mainly pure mitral regurgitation (8/18; 44%), combined aortic and mitral valve disease (5/18; 27%), and mitral stenosis with regurgitation (3/18; 17%), as shown in Figure 2. The patient who had undergone aortic valve replacement had a well-functioning mechanical prosthesis in association with mitral regurgita-tion. The remaining case had rheumatic mitral regurgitation (based on a history of RF, clinical examination, and echo-cardiographic criteria) in conjunction with congenital bicuspid aortic valve of no hemodynamic significance.
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Figure 2. The pattern of valvular diseases among cases of rheumatic heart disease. AVD = aortic valve disease, AVR = aortic valve replacement, CHD = congenital heart disease, MR = mitral regurgitation, MS = mitral stenosis, MVD = mitral valve disease.
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Discussion
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As in most developing countries, RF and RHD have their place among the cardiovascular problems in everyday practice in Yemen. RF and RHD are chronic illnesses in all age groups beyond infancy. The prevalence of RF and RHD in schoolchildren of Sana'a city was 3.6 per 1000. In industrialized countries, the incidence of RF has declined to 0.05 per 1000 per year.4,5 Rheumatic heart disease had declined in the United States (0.6 per 1000) and Japan (0.7 per 1000).6,7 It appears that schoolchildren in Yemen have a higher rate of RHD than many other developing countries, especially neighboring countries. Reports from Oman indicate a rate of 0.8 per 1000, and the prevalence of RHD in Saudi Arabia is 2.8 per 1000.8,9 The prevalence in our study is consistent with a 1994 study from Egypt giving a rate of 3.4 per 1000 among schoolchildren in the El-Menoufia area.10 Earlier reports from Egypt in the 1960s gave different figures: 1.3 per 1000 in the western desert coast; and 0.7 per 1000 in Alexandria.11,12 High rates of RF and RHD have been recorded in Zambia (12.6 per 1000), Sudan (10.2 per 1000), Bolivia (7.9 per 1000), Egypt (5.1 per 1000), and Kathmandu city, Nepal (1.2 per 1000) in the period 1986 to 1990.12,13 Although RF and RHD rates have shown remarkable declines in developed countries over the last 40 years, they still present a considerable burden to the healthcare systems of many developing nations where more than a third of all cardiac admissions are due to RHD.
There was a significant correlation between socioeconomic level and the prevalence of RF and RHD in Yemen. The high prevalence of RHD could be attributed largely to a low standard of living. The decline in the prevalence of RHD in industrialized countries has been attributed mainly to improvement in living standards, and where it persists, it is associated with low social circumstances and poverty.14–16 Low levels of education, income, and social status have previously been noted as factors related to the incidence of RHD.17,18 Poverty and illiteracy breed over-crowding that promotes the spread of many infections, and due to ignorance and scarcity of healthcare facilities, these are often neglected until complications set in, as in the case of RF.16,18,19
It is recommended that collection of further epidemio-logical data on RF and RHD in Yemen be carried out. As the main factor in the development of rheumatic fever is streptococcal throat infection, further study of this condition should be undertaken. A national register should be set up to record and document newly discovered cases. RF and RHD clinics are also needed. A Yemeni board should be established to coordinate these activities.
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References
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Abstract
Introduction
