● Epidemiology
Epi-among
Demi-people
Logy-study
Epidemiology is the study or analysis of the occurrence, distribution, pattern, determinants
influencing in health and diseases in a defined population and this application of knowledge
helps in preventing and control the relevant health problems.
Study- surveillance, observation, screening, testing, research , disease frequency
Disease frequency - measurement of frequency of disease, disability or death in the form of
ratio or rates
Distribution - analysis bt time ,place, population,sex and age
In state/community -no. of patients affected I e bp , overweight
Determinat-geophysical biological, behaviour, environment, socioeconomic that influence
health.
● Rheumatic heart disease
It's a permanent damage to the heart valves caused by rheumatic fever, an autoimmune
inflammatory illness that follows an untreated infections of the throat by group A beta
haemolytic streptococcus
The consequences of RHD include continuing damage to the heart, increasing disabilities,
repeated hospitalization and premature death usually bt 35years or earlier
In India, RHD is prevalent in the range of 5-7 per thousand in 5-15 years age group and
there are about 1 million RHD cases in India. RHD constitutes 20-30% of hospital
admissions due to CVD in India (6). Streptococcal infections are very common especially in
children living in under-privileged conditions, and RF is reported to occur in 1-3 per cent of
those infections
Jai Vigyan Mission Mode project on Community Control of RF/RHD in India is being carried
out with four main components, viz. to study the epidemiology of streptococcalsore throats,
establish registries for RF and RHD, vaccine development for streptococcal infection and
conducting advanced studies on pathological aspects of RF and RHD
Epidemiological factors
1. AGENT FACTORS
(a) AGENT: The onset of RF is usually preceded by a streptococcal sore throat. Of the
streptococci, it is the group A streptococcus that has been incriminated as the causative
agent. It has been suggested that not all strains of group A streptococci lead to RF; it is
believed that there might be some strains with "rheumatogenic potential". The serotype that
has attracted special emphasis is M type 5 which is frequently associated with RF (8). All
group A streptococci are sensitive to penicillin. Unfortunately, the group consists of a great
number of immunologically different types with little cross immunity, defying all attempts to
produce an effective vaccine. Recently the virus (coxsackie B-4) has been suggested as a
causative factor and streptococcus acting as a conditioning agent. There are many gaps in
our knowledge about the causative agent and underlying pathogenic mechanisms. (b)
CARRIERS: Carriers of group A streptococcus are frequent, e.g., convalescent, transcient
and chronic carriers. In view of the high carrier rate, their eradication is not even theoretically
possible (9).
2. HOST AND ENVIRONMENTAL FACTORS
(a) AGE: RF is typically a disease of childhood and adolescence (5-15 years) although it
also occured in adults (20 per cent cases). Mention has already been made about the high
incidence of "juvenile mitral stenosis" in India (9, 10). The initial attack of RF occurs at a
young age, progresses to valvular lesions faster and is associated with pulmonary arterial
hypertension. The cause of the "juvenile" disease in India is not known. (b) SEX: The
disease affects both sexes equally but prognosis is worse for females than for males. (c)
IMMUNITY: An immunological basis for RF and RHD has been proposed. The most
prevalent concept is the toxic-immunological hypothesis. According to this theory, group A
streptococcal products have certain toxic products, and components of the streptococcus
and of host tissues have an antigenic cross-relationship, leading to immunological processes
that result in an attack of RF (11). (d) SOCIO-ECONOMIC STATUS: RF is a social disease
linked to poverty, overcrowding, poor housing conditions, inadequate health services,
inadequate expertise of health-care providers and a low level of awareness of the disease in
the community. It declines sharply when the standard of living is improved, but even in the
most affluent countries, there are areas where the disease still exists. (e) HIGH-RISK
GROUPS: The school-age children between 5 and 15 years; slum dwellers; and those living
in a closed community
Clinical features
(a) FEVER: Fever is present at the onset of acute illness and may be accompanied by
profuse sweating. It may last for about 12 weeks or longer and has a tendency to recur. (b)
POLYARTHRITIS: This occurs in 90 per cent of cases. Large joints like ankles, knees,
elbows and wrists are involved; uncommonly smaller joints of hands and feet may be
involved. The pain and swelling come on quickly and also subside spontaneously within 5-7
days. There is no residual damage to the joint. (c) CARDITIS: Occurs in 60-70 per cent of
cases. It starts early in the course of RF. Moreover RHD may not be preceded by a clinically
apparent attack of RF. All layers of the heart- pericardium, are involved. The myocardium
and the heart valves involvement of heart is manifested by tachycardia, cardiac murmurs,
cardiac enlargement, pericarditis and heart failure. The most common ECG finding is the first
degree AV block. (d) NODULES: Nodules below the skin tend to appear 4 weeks after the
onset of RF. They are small, painless and non-tender. They last for a variable period of time
and then disappear leaving no residual damage. (e) BRAIN INVOLVEMENT: This manifests
as abnormal jerky purposeless movements of the arms, legs and the body. It gradually
disappears leaving no residual damage. (f) SKIN: Various types of skin rash are known to
occur. It is thus obvious that except carditis all other manifestations of RF do not cause
permanent damage.
Determinant/effects/impact on rf and rhd
D-Socio-economic and
environmental factors: (poverty, undernutrition, overcrowding, poor housing).
E-Rapid spread of group A streptococcal strains.
Difficulties in accessing health care.
I-Higher incidence of acute streptococcal-pharyngitis and suppurative complications.
Higher incidence of acute RF. Higher rates of recurrent attacks.
D-Health-system related factors: - shortage of resources for health care;
E-Inadequate diagnosis and treatment of streptococcal pharyngitis.
I-Higher incidence ofacute RF and its recurrence.
-D-inadequate expertise of health-care providers;
E- Misdiagnosis or late diagnosis of acute RF.
I- Patients unaware of the first RF episode.
More severe evolution of disease.
D- Low-level awareness of the disease in the community.
EInadequate secondary prophylaxis and/or non-compliance with secondary prophylaxis.
I-Untimely initiation or lack of secondary prophylaxis.
Higher rates of recurrent attacks with more frequent and severe heart valve involvement,
and higher rates of repeated hospital admissions and expensive surgical interventions.
Diagnosis
The 2002-2003 WHO criteria for the diagnosis of RF and RHD are based on revised Jones
criteria (Table 2) and facilitate the diagnosis of :
a. a primary episode of RF
b. recurrent attacks of RF in patients without RHD
c. recurrent attacks of RF in patients with RHD
d. rheumatic chorea
e. insidious onset rheumatic carditis
f. chronic RHD.
For the diagnosis of a primary episode of RF, it is recommended that the major and minor
clinical manifestations of RF, the laboratory manifestations, and evidence of a preceding
streptococcal infection should all continue according to the 1988 WHO recommendations. In
the context of a preceding streptococcal infection, two major manifestations, or a
combination of one major and two minor manifestations, provide reasonable evidence for a
diagnosis of RF. WHO has continued to maintain that a diagnosis of a recurrence of RF in a
patient with established RHD should be permitted on the basis of minor manifestation plus
evidence of a recent streptococcal infection
Diagnostic categories
Primary episode of RF
Criteria
Two major or one major and two minor** manifestations plus evidence of a preceding group
A streptococcal infection***.
D-
Recurrent attack of RF in a patient without established rheumatic heart disease
C-Two major or one major and two minor manifestations plus evidence of a preceding group
A streptococcal infection.
D-Recurrent attack of RF in a patient with established theumatic heart disease.
C-Two minor manifestations plus evidence of a preceding group A streptococcal infection.
D-Rheumatic chorea. Insidious onset rheumatic carditis.b
C-
Other major manifestations or evidence of group A streptococcal infection not required
DChronic valve lesions of RHD (patients presenting for the first time with pure mitral stenosis
or mixed mitral valve disease and/or aortic valve disease)
C-Do not require any other criteria to be diagnosed as having rheumatic heart disease.
-*Major manifestations
carditis
polyarthritis
chorea
erythema marginatum
subcutaneous nodules
-**Minor manifestations
clinical; fever, polyarthralgia laboratory; elevated acute phase reactants (erythrocyte
sedimentation rate or leukocyte count)
-*** Supporting evidence of a preceding streptococcal infection within the last 45 days
electrocardiogram; prolonged P-R interval elevated or rising antistreptolysin-O or other
streptococcal antibody, or
a positive throat culture, or
rapid antigen test for group A streptococci, orrecent scarlet fever.
a Patients may present present with polyarthritis (or with only polyarthralgia or monoarthritis)
and with several (3 or more) other minor manifestations, together with evidence of recent
group A streptococcal infection. Some of these cases may later turnout to be rheumatic
fever. It is prudent to consider them as cases of "probable rheumatic fever" (once other
diagnoses are excluded) and advise regular secondary prophylaxis. Such patients require
close follow-up and regular examination of the heart. This cautious approach is particularly
suitable for patients
in vulnerable age groups in high incidence settings.
b Infective endocarditis should be excluded.
c Some patients with recurrent attacks may not fulfil these criteria. d Congenital heart
disease should be excluded.
Prevention
Two preventive approaches are possible:
a. PRIMARY PREVENTION
The aim of primary prevention is to prevent the first attack of RF, by identifying all patients
with streptococcal approach is theoretically simple, in practice, it is difficult to throat infection
and treating them with penicillin. While this achieve and may not be feasible in many
developing countries (4). In order to prevent a single case of RHD. several thousand cases
of streptococcal throat infection must be identified and treated. Many infections are
inapparent or if apparent are not brought to the attention of the health services; even if they
are reported, quick and reliable laboratory services are needed to confirm the diagnosis.
A viable approach is to concentrate on "high-risk groups such as school-age children. They
should be kept under surveillance for streptococcal pharyngitis. Ideally a sore throat should
be swabbed and cultured. If streptococci are present, the child should be put on penicillin.
Since facilities for throat swab culture are not easily available, it is justified to treat a sore
throat with penicillin even without having the culture. For this purpose, a single intramuscular
injection of 1.2 million units of benzathine benzyl penicillin for adults and 600,000 units for
children is adequate, or oral penicillin (Penicillin V or Penicillin G) should be given for 10
days. This is the least expensive method of giving penicillin for eradication of streptococci
from the throat. For patients with allergy to penicillin, erythromycin is the drug of choice. The
MCH and school health services should be utilized for this purpose.
In short, the impossible logistics of primary prevention coupled with enormous financial
constraints force us to concentrate on secondary prevention
b. SECONDARY PREVENTION
Secondary prevention (i.e., the prevention of recurrences of RF) is a more practicable
approach, especially indeveloping countries. It consists in identifying those who have had RF
and giving them one intramuscular injection of benzathine benzyl penicillin (1.2 million units
in adults and 600,000 units in children) at intervals of 3 weeks This must be continued for at
least 5 years or until the child
reaches 18 years whichever is later. For patients with carditis (mild mitral regurgitation or
healed carditis) the treatment should continue for 10 years after the last attack, or at least
until 25 years of age, which ever is longer. More severe valvular disease or post-valve
surgery cases need life-long treatment (12). This prevents streptococcal sore throat and
therefore recurrence of RF and RHD.
However, the crucial problem is one of patient compliance as penicillin prophylaxis is a
long-term affair. Studies have shown that secondary prevention is feasible. inexpensive and
cost-effective, when implemented through primary health care systems
c. NON-MEDICAL MEASURES
Non-medical measures for the prevention/control of RF are related to improving living
conditions, and breaking the poverty-disease-poverty cycle. Improvements in socioeconomic
condition will be long term reduce the incidence of RF.
Objective evaluation of available data indicates that penicillin alone will not lead to effective
control. Predictions suggest that many of the countries which suffer severe economic
constraints will not be likely to be able to raise their standards of living in the foreseeable
future to significantly alter the incidence of this disease
d. EVALUATION
In the evaluation of the programme, the prevalence of RHD in school children from periodic
surveys of random samples is probably the best indicator. It is suggested that surveys
should be carried out on samples of schools (not individuals) in the 6-14 years age group at
5-year intervals. The recommended sample size is 20,000 to 30,000 children depending
upon the expected prevalence