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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 .