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Risk Factors 6262ournal of Epidemiology and Community Health 1996;50:62-67 Epidemiological survey of rheumatic heart J Epidemiol Community Health: first published as 10.1136/jech.50.1.62 on 1 February 1996. Downloaded from disease among school children in the Shimla Hills of northern India: prevalence and risk factors Jarnail S Thakur, Prakash C Negi, Surendra K Ahluwalia, Nand K Vaidya Abstract (RF)/RHD and this constitutes a major health Study objective - To determine the pre- problem.' The extent and nature ofthe problem valence ofrheumatic heart disease (RHD) has been well documented by both hospital and and study the relationship of this disease community based studies. This malady affects to factors such as age, sex, housing, and adversely a large proportion of the population. socioeconomic status in Shimla town and It has been estimated that about two million the adjoining rural area. children are affected by this disease in India. A Design - A cross sectional survey, carried multicentre study on the epidemiology ofRHD, out by a specially trained examiner in car- under the aegis of Indian Council of Medical diology. Research (ICMR) gave the national average of Setting - The study involved high risk RHD prevalence as 6 per thousand in the age school children (5-16 years of age) from group of 5-16 years.2 The only preliminary Shimla town and the adjoining rural area study undertaken in the hilly area of Himachal of Kasumpti-Suni Block in the period Pradesh was in 1956. This showed a prevalence 1992-93. of39 per thousand among the 1515 school chil- Subjects - A total of 15 080 children on the dren in Shimla, the highest prevalence ever re- school register (8120 boys and 6960 girls) ported in India.3 The obvious pitfall ofthis study were examined generally and specifically was that investigatingfacilities were meagre then for evidence of RHD. and there was considerable lack of awareness Main results - Of the 15 080 children amongthepublic about this illness. We therefore screened, the prevalence of rheumatic undertook a school based study to investigate fever (RF)/RHD was 2-98 per thousand the current extent of the problem. with no significant difference between the age groups of 5-10 and 11-16 years or in either sex (p>0'05). The prevalence was Methods significantly greater in rural schools (4-8/ GEOGRAPHIC AREA 1000) than in urban schools (1 98/1000) Himachal Pradesh is a picturesque hilly state in (p<0.05). There was overcrowding and northern India, with a population of 5 170 877 http://jech.bmj.com/ poor housing in most cases. There were and a population density of 93 km2. The study fewer cases of RHD with severe valvular was based on a survey carried out among school lesions in the younger age group than in children in Shimla town and the adjoining area the older children. The mitral valve was of Kasumpti-Suni Block, Shimla District, Hi- the valve most commonly affected by RFI machal Pradesh. RHD. Conclusions - RHD continues to be a ser- on September 29, 2021 by guest. Protected copyright. ious health problem. Regular surveys are METHOD OF SAMPLING Department of needed to identify cases early and to ensure All the schools in Shimla town and Kasumpti- Community Medicine secondary prophylaxis with penicillin is J S Thakur Suni Block were grouped into four categories - S K Ahluwalia given thereby preventing recurrence ofRF rural government, urban government, convents, N K Vaidya and progression ofthe severity ofthe valv- and private schools. There were 141 rural gov- ular lesion. Echocardiography is necessary Department of ernment, 99 urban government, 15 convent, Cardiology to identify cases ofRF/RHD. Strategies for and 9 private schools in the survey area, and of P C Negi preventing RHD should involve primary these 31, 18, 8, and 5 respectively were selected prevention to avert the first attack of car- Indira Gandhi randomly. A stratified random sample of 16 082 Medical College, ditis and strengthening of secondary pro- children out of40 950 children in the age group Shimla - 171001 phylaxis through improved education and of 5-16 years from these schools were selected Himachal Pradesh, motivation ofpatients, parents, and phys- India for the study. icians. All the children present in a class at the time Correspondence to: of the visit were examined in one sitting by a Dr J S Thakur, Health Department of Community (J7 Epidemiol Community 1996;50:62-67) doctor (JST) who had trained for six months in Medicine, Postgraduate Institute of cardiology especially for this purpose. History Medical Education and Rheumatic heart disease (RHD) is a problem ofpast and present jointpains, fever, sore throat, Research, Chandigarh - 160012. India. that affects each corner of the globe, especially palpitation, fatigue, shortness of breath, and on an ini- Accepted for publication the developing countries. In India, 32-50% of chest pain were elicited and recorded September 1995 all cardiac cases result from rheumatic fever tial screening proforma. Clinical examination Epidemiological survey of rheumatic heart disease among school children in the Shimla Hills of northern India: prevalence and risk factors 63 J Epidemiol Community Health: first published as 10.1136/jech.50.1.62 on 1 February 1996. Downloaded from Table 1 Age and sex distribution of children screened * Acute RF: those patients who fulfilled revised Age group Children screened Children recaled Suspected Definite Jones criteria at the time ofscreening, with no (y) RF/RHD RFIRHD M F M F M F M F history of RF in the past. * Probable RHD: thickening ofmitral and/or tri- 5-10 3567 2987 262 237 16 12 7 8 valve seen on 11-16 4553 3973 292 302 28 45 16 14 cuspid echocardiography, with previous history ofRF or thickening ofaortic M = male; F = female; RF = rheumatic fever; RHD = rheumatic heart disease valve and without Doppler evidence of valv- ular dysfunction. * Definite RHD: clinical and echocardiographic evidence of chronic RHD. was performed to look for objective evidence of RF and RHD. Particular care was taken in Results auscultating the child in erect, left lateral, and AGE AND SEX DISTRIBUTION OF THE CHILDREN recumbent positions. In doubtful cases, chil- The age and sex distribution of the children is dren were also auscultated after exercise. An at- shown in Table 1. A total of 15 080 (93 7%) tempt was made to include the absentees during school children were examined out of a sample subsequent visits or by home visits (maximum of 16 082 children selected for the study. Al- two visits). together 8120 (53-8%) of the total children Parents of the children aged below 10 years screened were boys whereas only 6960 (46 2%) and all the children aged above 10 years were were girls. 6554 (43 5%) children were in the asked about the family income. A modified Pra- age group of5-10 years and 8526 (56 6%) were sad's classification based on family income was in the age group of 11-16 years. There was al- used to determine the socioeconomic status of most equal distribution ofmale and female chil- the children.4 dren in both age groups (p>005). The following types of patients were then re- called to the Indira Gandhi Hospital to be ex- amined by a cardiologist to rule out observer's PREVALENCE OF RF AND RHD bias: Out of 15 080 children screened, 1116 (7A4%) with a history of RF and a heart murmur on * Suspected and definite cases of RHD; clinical examination, or both, were called for * History of RF with or without carditis; detailed examination by a cardiologist. Twenty * History suggestive of RF with or without car- three (2%) children were non-responders - nine ditis; were suspected RF/RHD and congenital heart o Past history of RF or previous history sug- gestive of disease (CHD), and five had a functional mur- RF; mur. * Suspected and definite cases of congenital heart diseases; * Patient with an ejection systolic murmur with Suspected and definite cases ofRHD grade I-II/VI functional murmur with or without history ofRF. After a second screening by a cardiologist, 101 cases were suspected ofhaving RF/RHD (table Thefollowing types ofpatients were subjected 1) and 49 were suspected ofhaving CHD. The http://jech.bmj.com/ to detailed echocardiographic examination after rest of the children were found to have a func- evaluation by the cardiologist: tional murmur or a history of non-rheumatic joint pains and hence did not undergo further * Suspected and definite cases of RHD and congenital heart disease; investigations. All the children suspected ofhav- ing RF/RHD and CHD had echocardiography * History of RF with or without carditis; and other investigations. A past history of RF * Past history of RF; with or without carditis was present in 38 * Previous history suggestive of RF with func- on September 29, 2021 by guest. Protected copyright. tional murmur. (37 6%). Fifty seven (56 4%) had a history sug- gestive ofRF, with or without carditis, and in six These cases were also subjected to following (5 9%) there was no past history of RF. investigations: chest x ray (PA view); 12 lead A clinically definite diagnosis of RHD was electrocardiogram, haemoglobin, total leu- made in 26 (25.7%) children, confirmed on cocyte count, differential leucocyte count, echocardiography, and a probable diagnosis in erythrocyte sedimentation rate, ASO titre, and 75 (74.25%) cases. Six (8%) of the clinically C reactive protein; and a throat swab for ,-hae- probable group were found to be suffering from molytic streptococci (BHS). An Advanced definite RHD and 12 (16%) had echo- Technology Laboratories (ATL) Ultramark 7 cardiographic evidence suggestive of RHD. Of echocardiograph with facilities for2D, M mode, the six with definite RHD, three (50%) had Gr and Doppler ultrasonography was used for the II/VI ejection systolic murmur at the mitral area study.
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