Rheumatic Heart Disease in Asia
2008; Lippincott Williams & Wilkins; Volume: 118; Issue: 25 Linguagem: Inglês
10.1161/circulationaha.108.774307
ISSN1524-4539
Autores Tópico(s)Antimicrobial Resistance in Staphylococcus
ResumoHomeCirculationVol. 118, No. 25Rheumatic Heart Disease in Asia Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBRheumatic Heart Disease in Asia Jonathan R. Carapetis, MBBS, PhD, FRACP, FAFPHM Jonathan R. CarapetisJonathan R. Carapetis From the Menzies School of Health Research, Charles Darwin University, Darwin, Australia. Originally published16 Dec 2008https://doi.org/10.1161/CIRCULATIONAHA.108.774307Circulation. 2008;118:2748–2753A few years ago, my colleagues and I conducted a systematic review of data relating to the global burden of group A streptococcal diseases.1,2 Population-based data on rheumatic heart disease prevalence from 1985 through 2002 were included. We estimated that there were a minimum of 15.6 million people in the world with rheumatic heart disease, with 282 000 new cases each year and 233 000 resultant deaths each year; however, we also noted that the estimates of the number of cases in school-aged children in China (176 500) and Asia Other (102 000; Asia excluding South-Central Asia and China) were based on very few studies, none of which used echocardiography to confirm the presence of rheumatic heart disease lesions. Moreover, 5 of the 6 studies included in the Asia Other estimate came from 1 country, the Philippines. We therefore urged caution in interpreting these data from Asia, other than South-Central Asia, and concluded that there was an urgent need for more population-based data from this part of the world. In the 5 years since that review was compiled, more data have emerged to clarify the burden of rheumatic heart disease in Asia, which will be summarized here.Clinical Perspective p 2753MethodsThe previous report included Medline searches and other searches to retrieve articles from 1980 to 2002 with population-based studies of rheumatic heart disease prevalence. To update these data for the present study, a Medline search was conducted with the terms rheumatic fever or rheumatic heart disease and Asia. The abstracts of all articles retrieved from 2003 through November 2007 were reviewed, and the manuscripts of relevant articles were reviewed in full. Population-based studies of the prevalence of rheumatic heart disease in school-aged children were used to update the regional prevalence estimates from the previous review. Additional studies in other age groups and non–population-based studies were also reviewed if they were thought to possibly offer insights into the burden of rheumatic heart disease in Asia.Updated denominator data were obtained from the United Nations Population Division (available at http://esa.un.org/unpp/, accessed on February 15, 2008). Regions of Asia were divided in the same way as the previous review: South-Central Asia (Afghanistan, Bangladesh, Bhutan, India, Iran, Kazakhstan, Kyrgyzstan, Maldives, Nepal, Pakistan, Sri Lanka, Tajikistan, Turkmenistan, and Uzbekistan), China, and "Asia Other" (all other Asian countries).The author takes full responsibility for the integrity of the data and agrees to the manuscript as written.ResultsFive population-based prevalence studies of rheumatic heart disease in school-aged children were found from South-Central Asia since 2003,3–7 along with 1 from China8 and 1 from Asia Other.9 Interestingly, 4 of 5 recent studies from South-Central Asia produced prevalence estimates substantially lower (range 0.68 to 1.3 per 1000) than the pooled estimate from this region in the previous review (2.2 per 1000), although 1 study from Pakistan gave a much higher estimate (between 7 and 12 per 1000).4 By contrast, the newer studies from China and Asia Other found prevalence rates higher than the previous estimate from those regions. The Chinese study reported a prevalence of 11 per 1000, which is dramatically higher than other estimates from Asia, but it is not clear whether echocardiographic confirmation was used in the study (Table 1).8Table 1. Studies Since 1985 of Rheumatic Heart Disease Prevalence in School-Aged Children in AsiaReferenceYear of StudyPlaceAge, yRHD Prevalence (per 1000)No. ScreenedNo. of CasesEchoType of StudyRHD indicates rheumatic heart disease; WHO, World Health Organization; ?, not clear from publication if echocardiography was used (response likely inferred from manuscript); and NK, not known.*Household survey of all ages. Data not presented separately for school-aged children, except for graphical depiction of rheumatic heart disease prevalence, by gender.†Article in Chinese; only the English abstract was reviewed.‡Prevalence estimate for those diagnosed clinically with echocardiographic confirmation. Separate estimate presented for screening of all children with echocardiography: 79 cases, prevalence 21.5 per 1000 (ie, 90% of rheumatic heart disease cases were subclinical).South-Central Asia Grover et al101988–1991India: north5–152.131 20066YesCommunity project Kumar et al111988–1990India: Rajasthan3.5–183.310 16834YesSchool survey Vashistha et al121989–1990India: Agra5–151.4844912YesSchool survey Patel et al131986India: Anand5–151.811 06920? YesSchool survey WHO141986Pakistan: Islamabad5–150.2611 7003? NoSchool survey Avasthi et al151987India: Ludhiana6–161.360058? YesSchool survey Agarwal et al161991–1992India: Uttar Pradesh0–156.4376024YesVillage screening Thakur et al17,181990sIndia: north5–162.915 08044YesSchool survey Gupta et al191991India: Jammu City6–161.410 26314YesSchool survey Shrestha et al201991Nepal (rural)5–161.444526YesSchool survey Ahmed et al31991Bangladesh (rural)5–151.359238YesCommunity survey Haque et al211992Bangladesh: Dhaka and Dhamrai5–152.215 79836YesSchool survey Joardar et al221992Bangladesh: Rajbari5–201.456861NoCommunity survey Begum et al231993Bangladesh: Dhaka5–152.410 53825YesSchool survey Rizvi et al41993–1994Pakistan: Rahim Yaar Khan5–147 to 12*NK*NK*YesHousehold survey Regmi and Pandey241997Nepal: Kathmandu5–161.247366YesSchool survey Bahadur et al52002Nepal: Kathmandu Valley5–181.2942011YesSchool survey Jose and Gomathi62001–2002India: Vellore6–180.68229 829157YesSchool survey Periwal et al72005India: Bikaner5–140.6730022YesSchool surveyChina WHO141986Guangdong Province5–150.831 18025? NoSchool screening Chen et al81993–1994Sichuan Province5–181146 595512Unknown†Community surveyAsia Other WHO141986Thailand: Bangkok and Nakornrajasima5–150.255 4659NoSchool survey Guzman251987–1990Philippines: Laguna5–150.891 69472? NoSchool survey Guzman251995–1997Philippines: La Union5–151.028 55429? NoSchool survey Guzman251996–1997Philippines: Mindanao5–151.310 63514? NoSchool survey Guzman251996–1997Philippines: Albay5–151.240 00048? NoSchool survey WHO141986Philippines: Laguna5–151.617 32027? NoSchool survey Marijon et al92001–2002Cambodia: Phnom-Penh6–172.2‡36778YesSchool surveyThe additional study from Asia Other is noteworthy. A school-based survey conducted in Phnom-Penh found a prevalence rate of echocardiographically confirmed clinical rheumatic heart disease (ie, in children with significant cardiac murmurs) of 2.2 per 1000.9 However, an additional feature of that study was that all children had echocardiography performed, with the result that many children without clinically significant heart murmurs were also diagnosed with rheumatic heart disease (the prevalence estimate increased almost 10-fold, to 21.5 per 1000, with the inclusion of these subclinical cases).A household survey in rural Pakistan used rigorous methodology and found an all-age prevalence of echocardiographically confirmed rheumatic heart disease of 5.7 per 1000.4 Unfortunately, detailed data on age subgroups were not presented, but a graph of rheumatic heart disease prevalence indicated a prevalence of ≈7 per 1000 in boys aged 5 to 14 years and 12 per 1000 in girls of the same age. The study also found that the highest prevalence of rheumatic heart disease in females occurred in those 45 to 54 years of age and in males in those 55 to 64 years of age.The data from these population-based prevalence studies in school-aged children were used to estimate the total number of rheumatic heart disease cases in Asia (Table 2). The estimate from South-Central Asia (≈450 000 cases) should be considered the most reliable, because it relied on 16 studies that used echocardiography. The estimate from China is based on 2 studies, neither of which could be confirmed as having used echocardiography. The estimate from Asia highlights the variability of the overall estimate depending on whether all studies are included (≈150 000 cases) or the 1 echocardiography-based study is used (≈390 000 cases). The overall estimate is between 1.96 and 2.21 million cases of rheumatic heart disease in Asian children 5 to 14 years of age. Table 2. Estimated Number of Rheumatic Heart Disease Cases in Children 5 to 14 Years of Age in AsiaRegionNo. of Studies (No. Using Echo)Median RHD PrevalenceNo. Screened (All Studies)RHD Prevalence (All Studies)No. Screened (Echo Studies)RHD Prevalence (Echo Studies)Population Aged 5–14 yEstimated RHD Cases (Using All Studies)Estimated RHD Cases (Using Echo Studies)Echo indicates echocardiography; RHD, rheumatic heart disease; and NA, not applicable because there were no echocardiographic studies.Prevalences are per 1000.*Includes all-studies estimate for China, because no echocardiographic studies were available.South-Central Asia18 (16)1.4392 0781.2379 6921.2365 731 000444 946455 608China2 (0)5.977 7756.9NANA198 485 0001 370 446NAAsia Other7 (1)1.2247 3450.836772.2178 694 000149 547388 782Total742 910 0001 964 9392 214 836*In the previous review, we detailed 4 studies that allowed an estimate of the proportion of rheumatic heart disease cases in the total population that could be expected to be found in the 5- to 14-year-old age group.16,26–28 We concluded that number of cases in school-aged children should be multiplied by 5.5 to 7.2 to estimate the total cases in all ages. The recent study from Pakistan supports this: Although sufficient data were not presented to make the same calculation, the graphical illustration of rheumatic heart disease prevalence by age group confirms that there was no decrease in prevalence (in fact, rates peaked in older age groups) between the 5- to 14-year-olds and the 55- to 64-year-olds.4 Applying these multiplication factors to the estimates in Table 2, one can estimate that the total number of rheumatic heart disease cases is between 10.8 million (lower estimate based on 5.5 multiplication factor and all studies) and 15.9 million (upper estimate based on 7.2 multiplication factor and echocardiographic studies only).In the previous review, we pointed out that accurate estimates of mortality due to rheumatic heart disease are not possible because of the lack of data from developing countries. Our best estimates were based on an expected mortality of 1.5% per year in rheumatic heart disease patients, which was based on prospective studies from North America and the United Kingdom during the 1960s.29–32 However, a 12-year cohort study from India published in 2002 found a mortality rate among rheumatic heart disease patients of 3.3% per year.33 Applying this to the estimates in Table 2, we estimate that rheumatic heart disease is directly responsible for 356 000 to 524 000 deaths each year in Asia.Other DataA number of recent publications added information regarding rheumatic heart disease in Asia. A cross-sectional study of 8080 middle-aged to elderly people in China during 2001 to 2002 found a prevalence of 2 cases of echocardiographically proven rheumatic heart disease per 1000 people.34 A 50-year retrospective study from 2 hospitals in Shanghai, China, found that cardiovascular admissions increased 3-fold over this period but that the proportion due to rheumatic heart disease declined 5-fold (from 50% to 10% of cardiac admissions).35 A prospective study conducted in Lebanon from 1999 to 2005 found that rheumatic heart disease was the most common acquired heart disease in children (36% of cases).36EndocarditisIn the last review, all of the data published globally since 1980 documenting the association of infective endocarditis and rheumatic heart disease had come from Asia. This interest in endocarditis persisted: An additional 8 studies37–48 from Asia were found during the preparation of the present report (Table 3). The recent studies from India, Turkey, and Lebanon all found that rheumatic heart disease was the most common underlying factor in endocarditis (range 33% to 66%),41,44,45,47 whereas studies from Hong Kong and Thailand found rheumatic heart disease in 18% and 12% of cases, respectively,42,46 and a study from Singapore found rheumatic heart disease in only 4% of endocarditis cases.48Table 3. Studies Since 1980 Documenting the Association of Rheumatic Heart Disease and Infective Endocarditis in AsiaReferenceYear of StudyCountryProportion of IE With RHD as Predisposing FactorRank of RHD as Predisposing FactorNotes/MortalityIE indicates infective endocarditis.Cetinkaya et al371974–1999Turkey65%Most commonBorer et al381980–1994Israel37%Most commonIncidence IE 1.2 per 100 000 in 1990s; deduced incidence of RHD-related IE=0.44 per 100 000Choudhury et al391981–1991India42%Most commonMortality 25%Dhawan et al401984–1990India49%Most commonKanafani et al411986–2001Lebanon33%Most commonLertsapcharoen et al421987–2004Thailand12%2nd most commonCongenital heart disease in 74%Agarwal et al431987–1988India68%Most commonMortality 21%Garg et al441992–2001India47%Most commonHeper and Yorukoglu451995–2000Turkey66%Most commonYiu et al461995–2005Hong Kong18%2nd most commonIncidence IE 2.8 per 100 000Khanal et al471995–1997India56%Most commonMortality 30%Liew et al481997–2004Singapore4%RareCongenital heart disease in 89%StrokeA population-based stroke registry in Iran found an incidence of ischemic stroke of 43 per 100 000 population, with 11.8% due to cardioembolism, in 45% of whom rheumatic heart disease was detected.49 The authors concluded that rheumatic heart disease caused 4.3 preventable strokes per 100 000 people per year in Iran.Pregnancy and Rheumatic Heart DiseaseAn 18-year study in Taiwan found that stroke occurred in 46.2 of 100 000 pregnancies, and 44% of cases had underlying rheumatic heart disease.50 Rheumatic heart disease was the most common underlying condition (27% of cases) found in pregnant patients admitted to the intensive care unit in a Saudi Arabian hospital between 1997 and 2002.51 In an Indian hospital between 1994 and 2000, rheumatic heart disease accounted for 88% of cardiac diseases in pregnant women.52DiscussionIt is often claimed that the burden of some infectious diseases in Asia may be different from that in other parts of the world. For example, there has been considerable discussion as to whether there is evidence that Haemophilus influenzae type b infections are less common in Asian children than in children in other less-developed regions.53,54Similarly, with the exception of a few countries in South-Central Asia (India, Bangladesh, and Pakistan most prominently), there has been little concern about rheumatic heart disease in most Asian countries.The data presented here suggest that rheumatic heart disease is indeed an ongoing problem in Asia. Although the regional estimates for prevalence in school-aged children may not be as high as, for example, in sub-Saharan Africa, the total burden of cases (between 10.8 and 15.9 million cases in all ages) and deaths (356 000 to 524 000 each year) warrants attention. Moreover, the 2 most rigorously performed studies, from Pakistan and Cambodia, confirm that careful research methodology will uncover many more cases than would otherwise have been detected, which suggests that the true number of rheumatic heart disease cases may be even greater than presented here.4,9The estimates presented here are only for clinically significant rheumatic heart disease, ie, for cases that as a minimum have a murmur of rheumatic valvular disease. The Cambodian study suggested that universal echocardiographic screening will uncover 10 subclinical rheumatic heart disease cases for every clinical case.9 If this can be confirmed in other studies, and if the significance of these subclinical cases is found to be similar to clinical cases, then there is an immense unrecognized burden of rheumatic heart disease in Asia that requires urgent attention.The Pakistan and Cambodia studies also highlight the importance of high-quality epidemiological studies in developing countries. Such studies, using echocardiography to confirm the diagnosis of rheumatic heart disease, are possible. Moreover, they are invaluable for providing the robust estimates of disease burden on which public health strategies must be based. It is clear from the studies outlined in Table 1 that there is a need for more and better studies from China and the Asia Other countries, and accordingly, the summary estimates from these places should be interpreted with caution.The studies on infective endocarditis confirm that in most Asian countries, at least half of all cases of this severe and often fatal disease are due to underlying rheumatic heart disease, although in some countries with emerging middle classes, this proportion is probably lower. Similarly, the prospective stroke registry data from Iran support those in the previous report that indicate that a substantial proportion of strokes in developing countries are due to rheumatic heart disease.49 If the incidence of strokes due to rheumatic heart disease in Iran (4.3 per 100 000 people per year) were to be applied to the population of Asia (3.9 billion), it could be estimated that rheumatic heart disease causes 167 000 preventable strokes each year in Asia.The compelling point about the data presented here is that almost all of these cases, severe complications and deaths, are preventable. Rheumatic heart disease can be prevented and controlled with the establishment of register-based coordinated control programs, the major focus of which is delivery of secondary prophylaxis to prevent recurrences of rheumatic fever.55 There is ample evidence that this strategy is cheap, cost-effective, and practical in developing countries.56 With the exception of some parts of a few countries in South-Central Asia, I am not aware of coordinated control programs in any Asian countries. Surely, it is time for health authorities in Asian countries and international organizations such as the World Health Organization to act on rheumatic heart disease in this region.The author thanks Andrew Steer, Kim Mulholland, and Martin Weber, who contributed to the original review article. The original review article was supported by a consultancy funded by the World Health Organization. No other funding sources were used in compilation of this article.DisclosuresThe author has received research support from various competitive funding bodies, including the Australian National Health and Medical Research Council and the US National Institutes of Health, along with consultancy funding from the World Health Organization. There are no other conflicts of interest to report.FootnotesCorrespondence to Jonathan Carapetis, Director, Menzies School of Health Research, PO Box 41096, Casuarina, Northern Territory 0811, Australia. E-mail [email protected] References 1 Carapetis JR. The Current Evidence for the Burden of Group A Streptococcal Diseases. Geneva, Switzerland: World Health Organization; March 2, 2004. WHO/FCH/CAH/05.07.Google Scholar2 Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005; 5: 685–694.CrossrefMedlineGoogle Scholar3 Ahmed J, Mostafa Zaman M, Monzur Hassan MM. 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