Epidemiology of Rheumatic Heart Disease in India and

KeralaDr.Vinit Kumar

MCH.Trivandrum

Five Typical Stages of Epidemiologic Transition

STAGE TYPICAL PROPORTIONOF DEATHS CAUSEDBY CVD (%)

PREDOMINANT TYPESOF CVD

Pestilence andfamine

<10 RHD,cardiomyopathies caused byinfection and malnutrition

Receding pandemics 10-35 Rheumatic valvular disease,hypertension, CHD, stroke

Degenerative andmanmade diseases

35-65 CHD, stroke

Delayed degenerativediseases

40-50 CHD, stroke, congestive heartfailure

Inactivity and obesity 33

RF and RHD remain significant causes of CV morbidity and mortality

Incidence of acute RF and prevalence of RHD in developed countries have declined during the past five decades

However RHD remains a major public health problem in developing countries

Group A streptococci - most common bacterial cause of pharyngitis, with a peak incidence in children 5–15 years of age

Streptococcal pharyngitis is less frequent among children in the first three years of life and among adults.

Most children develop at least 1 episode of pharyngitis /year, 15–20% of which are caused by GAS and nearly 80% by viral pathogens

Asian developed countries Hong Kong, Singapore ,Israyel –similar rapid decline

Developed countries : RF incidence : < 1 /1,00,000 RHD prevalence : < 0.5 / 1000

Developing countries

World Health Statistics Annual ; WHO 1992

Prevalence of RHD in India

Earliest report of RHD : 1910

Most common HD in pre independent era – 40 % of all cardiac cases

Data : based on hospital admn records, autopsy series,population surveys and school surveys

Hospital Admission data

Inadequacy of hospital admn stats and individual hospital admn policies influence prevalence data.

Only severe casese represented

Trends of hospitalization from a single hospital more useful : AIIMS: Declining prevalence 39.1 % (1976-80) to 32.5 % (1981-85) Krishnaswamy et al (Vellore) Significant fall in no: of cases over 1960

- 89 RHD : 800 /yr – 500 / yr RF : 85/yr - 0/yr

SCB Medical College CuttackSN Routray IHJ 2003 152-157

RHD and RF 1981 to 85 vs 1996 – 2000 : 46.2 % vs 44.4

Sri Jaydeva ICSR: IB Vijayalakshmi

1998- 2010 10% of total admission

M.K.C.G. Medical College and Hospital, Berhampur:TK Mishra

Reported that there is no significant decline in prevalence of ARF/RHD in India 1981 – 1990 :9.2% of admitted cases 1991 – 2000 :8.9% of admitted cases

Table I. Percentage of RHD patients in hospital admission

Author Place Year (%)

Kutumbiah13Madras (Chennai) 1941 39.5 Sanjeevi15 Madras (Chennai) 1946 46.8 Vakil16 Bombay (Mumbai) 1954 24.7 Padmawati17 Delhi 1958 39.1 Devichand18 Shimla 1959 50.6 Mathur19 Agra 1960 35.1 Malhotra20 Punjab 1963 27.6 Bannerjea14 Calcutta (Kolkata) 1965 44.6

Autopsy Data

Earlier data : RHD underlying lesion in 30 – 40 % of deaths due to cardiac causes

More recent data : Jaya Deshpande et al –TN Medical

College and Seth GS Med College Mumbai IHJ- 2002;54

1993 – 97 434 cases of RHD ( 29% of cardiac

autopsies) Definite history of RF and RHD : 41 cases

(9.4%) 138 pts had undergone previous surgery /

BMV 1971 – 77 : Data from 298 autopsies (30%) No apparent decline in mortality due to RHD Pattern changed – More cases due to

restenosis and valve dysfunction

Life Insurance Data: ESI Scheme Prevalence Rate of Rheumatic Heart

Disease

States 1957-58 1958-59Bombay 0.91 0.17

Delhi 0.07 0.07Kerala 1.63 0.82Madras 1.23 0.58Punjab 0.43 0.29U. P. 0.18 0.31West

Bengal0.77 0.59

Population based surveysGrover A. et al .Bulletin of WHO 71(1):59-66,

1993

Ambala District ; Haryana Population : 114610 Folowed up : 1988 - 91 102 cases of RHD and RF - Prevalence 0.09 % 48 pts – first attack of RF - Incidence – 0.54 per 1000 per year

Verma K D et al : IHJ -2004 Vilage population - 4326 Incidence of RF : 0.4 / 1000 Prevalence : 4.58 /1000

Problems of population studies: Non representative sampling , Overdiagnosis (MVP BAV, innocent

murmurs) Variable examiner skill

Bhardwaj et al. : JAPI May 2012

Himachal Pradesh- Village population 1882 (909 were male and 973 were female)

Prevalence 5.8/1000. Prevalence in female was around ten

times higher than males.

Berry et al: Prevalence survey for RHD in northern India

Chandigarh 33,36I subjects Prevalance per 1000 male female 1.23 2.07

Table II. Prevalence of RHD in population surveys

Age group (yr) N Prevalence Roy23 5-30 4847 2.2 Mathur et al24 5-30 7953 1.8

School SurveysAcute RF

Mukul Mishra et al : IHJ 2007; 59 118,212 children – no single case of RF

( 61 pts with RHD – prevalence : 0.5/1000)

Lack of follow up data on absentees and school drop outs

Table III. Prevalence of rheumatic heart disease (RHD) in school surveys

Place Year Age (yr) Prevalence

Kerala(Alleppy) 1975 5-15 2.2 Punjab 1988-91 5-15 2.1 Gujarat 1986 8-18 2.03 Punjab 1987 6-16 1.3 Uttar Pradesh 2000 7-15 4.54 Tamil Nadu 2001-25-18 0.68 Rajasthan33 2006 5-14 0.67 Trivandrum 2013-14 5-15 5.83

Kumar et al11 1988–1990 India: Rajasthan 3.5–18 3.3 10168 34 Yes School survey

Vashistha et al12 1989–1990 India: Agra 5–15 1.4 8449 12 Yes School survey

Patel et al13 1986 India: Anand 5–15 1.8 11069 20 ? Yes School survey

Avasthi et al15 1987 India: Ludhiana 6–16 1.3 6005 8 ? Yes School survey

Agarwal et al16 1991–1992 India: Uttar Pradesh 0–15 6.4 3760 24 Yes Village screening

Thakur et al17,18 1990s India: north 5–16 2.9 15080 44 Yes School survey

Gupta et al19 1991 India: Jammu City 6–16 1.4 10 263 14 Yes School survey

Jose and Gomathi6 2001–2002 India: Vellore 6–18 0.68 229 829 157 Yes School survey

Periwal et al7 2005 India: Bikaner 5–14 0.67 3002 2 Yes School survey

Declining prevalence of RHD in rural school children in India: 2001-2002. Jose VJ, Gomathi M. ; IHJ 2003;55:158-60.

One of the largest school study of RHD prevalence

229,829 school children in Vellore aged 6-18 years.

Initial screening : 374 children with suspected RHD (1.63/1000).

RHD confirmed by ECHO in only 157 children (0.67/1000).

MVP : 57 pts (0.25/1000).

Prevalence of Rheumatic Heart Disease in SchoolChildren in Bikaner : An Echocardiographic Study

KL Periwal et al . JAPI 2006 ; 54: 279-282

3292 school children, age range 5-14 years

RHD prevalence based on clinical diagnosis : in 50 children (16.7/1000)

RHD was demonstrated on echo in 2 children (0.67/1000).

CHD in 5 (1.66/1000) and MVP in 37 (12.3/1000).

ICMR has conducted three school-based surveys in children 5 to 14 yr in age over a 40-year period between

1970 and 2010

The first survey from 1972 to 1975 was in schools at Agra, Alleppy, Bombay (Mumbai), Delhi and Hyderabad.

The second from 1984 to 1987 included schools at Delhi, Varanasi and Vellore

The third study included children from 10 centres in the country located at Shimla, Jammu, Chandigarh, Jodhpur, Indore, Kochi, Wayanad, Mumbai, Vellore and Dibrugarh

ICMR has conducted three school-based surveys in children 5 to 14 yr in age over a 40-year period between 1970 and 2010

Years No of Children

Prevalence

1 1972-1975

133000 0.8-11.0(5.3)

2 1984-1987

53786 1.0-5.6(2.9)

3 2007-2010

176904 0.13-1.5(0.9)

Studies by ICMR in school children in late 1980’s : Prevalance in per 1000.

All these studies were based on clinical criteria alone. Recent studies using echo validation : much lower prevalence

Place of Study Prevalence

Delhi 1.0Vellore 2.9Varanasi 5.4

RHD prevalence/ 1000 in school children (ICMR 3rd Study)

Centre No preva

Chandigarh 54390 0.9

Vellore 35137 1.2

Kochi 22734 0.1

Indore 25676 0.3

Wayanad 10371 0.2

Mumbai 12726 0.3

Dibrugarh 12164 0.1

Jodhpur 10011 0.9

Shimla 12596 1.0

Jammu 10000 0.6

The data suggest a progressive decline in RHD from 5.3 to 2.9 to below 1.0/1000 between 1970 to 2010

Soman et al

Place- Cochin Year- 2003-6 Age group- 5-16yrs Sample- 25033 Prevalance- 0.12 /1000

Bigesh Nair et al: Rheumatic Heart Disease in Kerala: A Vanishing Entity?

An Echo Doppler Study in 5–15-Years-Old School Children

2060 school children from five government and two private school

the largest school survey of south India prevalence of 5.83 cases per 1000

Problems of school surveys

Lack of standardized methodology Uncertain reproducibility Absentees School drop outs and non school going

children

Estimated RHD pts in India

RFKerala Recent Times

66

4942

15 14

4

5 6

16

148

2

24

14

13

30

10

2009 2010 2011

Trivandrum AlappuzhaKottayamTrichurKozhikode

( 5 Govt Medical Colleges )

SOUTH INDIA RHD

1972 - 75 D.V.Nair etal Alapuzha 2.2 / 1000

1981 Koshy, G. Cherian Vellore 4.9 /1000

1984 SATH Hospital RF /RHD 1.24 % of Admission

WHAT HAS BEEN HAPPENING TO RHEUMATIC FEVER

SATH, Medical College ,tvpm Total admissions for RF / RHD Total M F

1998 157 86 711999 161 86 752000 190 110 802001 173 103 702002 151 87 64

020406080

100120140160180200

1998 1999 2000 2001 20020

20406080

100120140160180200

1998 1999 2000 2001 2002

FFF F

F

M M M M M

157 161

190173

152

RF -SATHNew Cases

0

20

40

60

80

100

120

140

1998 1999 2000 2001 2002

87

116 123

10393

RF -SATH New Cases /Total

020406080

100120140160180200

1998 1999 2000 2001 20020

20406080

100120140160180200

1998 1999 2000 2001 2002

157 161

190173

151

7045

6770

58

11687

123103 93

RF /Total RF /RHDPercentages over years

0

10

20

30

40

50

60

70

80

1998 1999 2000 2001 2002

N-87 116 123 103 93

55.4

72.064.0 60.0 61.6

0

20

40

60

80

100

120

140

1985 1993 1998 1099 2000 2001 2002

1985 to 2002RF

100

113

87

116123 103

93 ??

N - 680

1985 2002RF /RHD

N - 785

76Non Rh

24.0RF /RHD

19.2RF/RHD

80.8NonRh

Admission 14600 15161

CVS

0

20

40

60

80

100

120

1985 8yr 1993 8yr 2001

RF over the years

100113

103

RF /RHD GENERAL HOSPITAL,

TVPM

Modified District hospital, Thiruvananthapuram Admission / year : 2500-3000 /yr (pediatric) Adm 2002: 2666

0

2

4

6

8

10

12

0

2

4

6

8

10

12

2000 2001 2002

INCIDENCE OF RF GENERAL HOSPITAL, TVPM

10 10 9

F FF

M M M

RF is declining in periphery ?

Is it true ??

Does not the Hospital data a reflection of

what is happening in the community ?

Over a span of nearly 2 decades ( 1985 - 2002 )

There is no discernible or significant fall in

hospital admissions for Rheumatic Fever

COMMENTARY

COMMENTARY

Hospital Data ( Tertiary, Teaching Hospital) show

that there is NO declining trend in Rheumatic Fever

in Kerala

Possible Explanation for ‘Aparent Lack of Decline’

• Less of ‘ Indulgence’ with Alternative Medicine

in suspected ‘ Rheumatism’ - over

the years seeking modern medicine hospitals

& subsequent referral• ‘ Health seeking Behavior’ of Keralites biased

towards major / teaching hospitals

Conclusion RHD prevalence may have declined in India but

is still is a major cause of debilitating VHD Preventable but yet not conquered- more and

more children and young adults affected Receives much less attention compared to CAD Improvement of living conditions, early detection

through school health surveys and PHCs and meticulous secondary prophylaxis through SHS,PHCs and GPs are required .