High prevalence of rheumatic heart disease in schoolchildren detected by echocardiography screening in New Caledonia

Influence of an oral health promotion program on the evolution of dental status in New Caledonia: A focus on health inequities

New Caledonia is a sui generis collectivity of overseas France situated in the south Pacific Ocean. Geographical and social inequalities are superimposed on ethnic disparities with high prevalence of chronic diseases such as oral diseases. In 2012, the health agency has evaluated the children's health status. Then, an oral health promotion program was developed in 2014. Another study was conducted in 2019 in New Caledonia to appreciate the evolution of children's oral health. A sample of 488 9-years-old children was randomly selected. Dental status was clinically recorded, families and children answered questionnaires about oral health determinants. The methodology (sampling, study variables…) was similar to the one used in the 2012 study. Multivariate mixed-models were conducted to compare 2012 and 2019 dental status and to explore the determinants of caries experience in 2019. Results indicated that caries prevalence and experience decreased between 2012 and 2019, with nonetheless various trends depending on the province or type of indexes. The number of carious lesions (d3t + D3T) in 2019 was used as an outcome variable in four models. Model 1 integrated social variables; ethnicity was found to be the only significant determinant. Model 2 was related to oral health care; participation in the program & and access to oral health care was found to be significant. For oral health behaviours (model 3), tooth brushing frequency and consumption of sugary snacks were significant risk factors. In a final model with significant variables from the previous models, ethnicity, accessibility of oral health care, number of sealed molars, consumption of sugary snacks remained explanatory factors. Five years after the implementation of the oral health promotion program, positive changes in oral health have been observed. However, health equity is still an issue with varying health status depending on ethnicity, behavioural factors and accessibility to oral health care.

Persisting burden and challenges of rheumatic heart disease

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

Prevalence of rheumatic heart disease among school children in East Africa: a systematic review and meta-analysis

Introduction

conducting researches and estimating the prevalence of rheumatic heart disease in school children is crucial to develop school-based strategies targeted to decrease the prevalence of this disease. Therefore, this systematic review and meta-analysis were aimed to estimate the overall prevalence of rheumatic heart disease (RHD) among school children in East Africa.

Methods

PubMed/MEDLINE, Google Scholar, Cochrane review, African Journals Online and African Index Medicus databases were searched to identify relevant research articles. The overall prevalence of rheumatic heart disease was pooled based on the weighted inverse variance random-effects model at a 95% confidence interval. The presence of heterogeneity, sensitivity analysis and presence of publication bias was tested. Results were presented with narrative synthesis, tables and forest plots.

Results

a total of thirteen research articles were included in the final analysis. The pooled prevalence of rheumatic heart disease in East African school children was 1.79% (17.9 cases per 1000 children (95% CI=11.6, 24.2; I²=95.1%; p<0.001)). From the subgroup analysis conducted by publication year, a lower prevalence of RHD in school children was reported among studies published after 2015 (six studies; overall prevalence=1.17% (11.7 cases per 1000 school children); with 95% CI=0.60, 1.73%; I²=88.8%; p<0.001). Additionally, the horn of Africa was found to have the lowest prevalence of RHD in school children among East African countries (six studies; overall prevalence=1.59% (15.9 cases per 1000 school children); with 95% CI=0.68, 2.51%; I²=94.2%; p<0.001).

Conclusion

the prevalence of rheumatic heart disease (RHD) among school children in East Africa was considerably higher than the results from high-income countries. Therefore, community education on strep throat and its complications should be implemented through mass media. Rheumatic heart disease preventive strategies should be integrated with schools to reduce the prevalence of RHD among school children.

Screening Rheumatic Heart Disease in 1530 New Caledonian Adolescents

BACKGROUND

In New Caledonia, a South Pacific archipelago whose inhabitants comprise Melanesians, Europeans/whites, Wallisians, Futunans, Polynesians, and Asians, the prevalence of rheumatic heart disease (RHD) is 0.9% to 1% at ages 9 and 10. It could be higher at the age of 16, but this remains to be verified.

METHODS AND RESULTS

A total of 1530 Melanesian, Métis, white, Wallisian, Futunan, Polynesian, and Asian adolescents benefited from a transthoracic echocardiogram. Definite or borderline RHD, nonrheumatic valve lesions, congenital heart defects, family and personal history of acute rheumatic fever, and socioeconomic factors were collected. The prevalence of cardiac abnormalities was 8.1%, made up of 4.1% RHD including 2.4% definite and 1.7% borderline RHD, 1.7% nonrheumatic valve lesions, and 2.3% congenital anomalies. In whites and Asians, there were no cases of RHD. RHD was higher in the Wallisian, Futunan, and Polynesian group (7.6%) when compared with Melanesians (5.3%) and Métis (2.9%). The number of nonrheumatic valve lesions was not statistically different in the different ethnicities. The prevalence of RHD was higher in adolescents with a personal history of acute rheumatic fever, in those living in overcrowded conditions, and in those whose parents were unemployed or had low‐income occupations, such as the farmers or manual workers.

CONCLUSIONS

RHD was 4 times higher in adolescents at age 16 than at ages 9 and 10 (4.1% versus 0.9%–1%). No cases of RHD were observed in whites and Asians. The determining factors were history of acute rheumatic fever and socioeconomic factors.

Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies

This systematic review and meta-analysis aimed to provide a contemporaneous estimate of the global burden of rheumatic heart disease (RHD) from echocardiographic population-based studies. We searched multiple databases between January 01, 1996 and October 17, 2017. Random-effect meta-analysis was used to pool data. We included 82 studies (1,090,792 participant) reporting data on the prevalence of RHD and 9 studies on the evolution of RHD lesions. The pooled prevalence of RHD was 26.1‰ (95%CI 19.2-33.1) and 11.3‰ (95%CI 7.2-16.2) for studies which used the World Heart Federation (WHF) and World Health Organization (WHO) criteria, respectively. The prevalence of RHD varied inversely with the level of a country's income, was lower with the WHO criteria compared to the WHF criteria, and was lowest in South East Asia. Definite RHD progressed in 7.5% (95% CI 1.5-17.6) of the cases, while 60.7% (95% CI 42.4-77.5) of cases remained stable over the course of follow-up. The proportion of cases borderline RHD who progressed to definite RHD was 11.3% (95% CI 6.9-16.5). The prevalence of RHD across WHO regions remains high. The highest prevalence of RHD was noted among studies which used the WHF diagnostic criteria. Definite RHD tends to progress or remain stable over time.

Health Challenges of the Pacific Region: Insights From History, Geography, Social Determinants, Genetics, and the Microbiome

The Pacific region, also referred to as Oceania, is a geographically widespread region populated by people of diverse cultures and ethnicities. Indigenous people in the region (Melanesians, Polynesians, Micronesians, Papuans, and Indigenous Australians) are over-represented on national, regional, and global scales for the burden of infectious and non-communicable diseases. Although social and environmental factors such as poverty, education, and access to health-care are assumed to be major drivers of this disease burden, there is also developing evidence that genetic and microbiotic factors should also be considered. To date, studies investigating genetic and/or microbiotic links with vulnerabilities to infectious and non-communicable diseases have mostly focused on populations in Europe, Asia, and USA, with uncertain associations for other populations such as indigenous communities in Oceania. Recent developments in personalized medicine have shown that identifying ethnicity-linked genetic vulnerabilities can be important for medical management. Although our understanding of the impacts of the gut microbiome on health is still in the early stages, it is likely that equivalent vulnerabilities will also be identified through the interaction between gut microbiome composition and function with pathogens and the host immune system. As rapid economic, dietary, and cultural changes occur throughout Oceania it becomes increasingly important that further research is conducted within indigenous populations to address the double burden of high rates of infectious diseases and rapidly rising non-communicable diseases so that comprehensive development goals can be planned. In this article, we review the current knowledge on the impact of nutrition, genetics, and the gut microbiome on infectious diseases in indigenous people of the Pacific region.

Echocardiographic prevalence of rheumatic heart disease in Indian school children using World Heart Federation criteria - A multi site extension of RHEUMATIC study (the e-RHEUMATIC study)

OBJECTIVES

Rheumatic heart disease (RHD) continues to be major public health burden in developing world. Echocardiographic screening in school children has shown that subclinical RHD cases are several times more than clinical cases. Recent reports have used World Heart Federation (WHF) criteria. Objective of present study was to determine RHD prevalence using WHF criteria in Indian children.

METHODS

Children (5-15years) from randomly selected schools across four sites were included. After focused clinical evaluation, echocardiography was performed using WHF criteria in all children. Images/loops of abnormal cases were analyzed independently by an additional experienced cardiologist. Children with murmur and confirmatory echocardiography were categorized 'clinical RHD'; those with abnormal echocardiography alone were labeled 'subclinical RHD'.

RESULTS

Among 16,294 children included, mean age was 10.8 ± 2.9years; 55.1% were males; 11,405 (70%) were from rural areas and 3978 (24.4%) were from government schools. We detected RHD by echocardiography in 125 children [prevalence: 7.7/1000 (95% CI 6.3, 9.0)]. Borderline RHD was present in 93 children (5.7/1000, 95% CI 4.6, 6.9), definite RHD in 32 (2/1000, 95% CI 1.2, 2.6), and clinical RHD in six [0.36/1000, 95% CI: 0.1-0.7]. On univariate analysis, older age, female gender, and higher waist circumference were associated while on multivariate analysis, older age (OR 1.18, 95% CI: 1.09, 1.26) and female gender (OR 1.61, 95% CI: 1.13, 2.3) were associated with RHD.

CONCLUSION

RHD prevalence varies in different parts of India. Echocardiographic prevalence is several times higher than clinical and underscores importance of echocardiographic screening in community.

Rheumatic heart disease in a developing country: Incidence and trend (Monastir; Tunisia: 2000-2013)

BACKGROUND

The penicillin therapy of β hemolytic streptococcal pharyngitis has aided in the decrease of rheumatic heart disease (RHD) in developing countries. Tunisia is an endemic area, however, and incidence of RHD is weakly documented. We aimed at establishing the standardized incidence rate (SIR) of RHD in Monastir governorate and at determining RHD prevalence among hospitalized patients in two cardiology departments.

METHODS

From the regional register of Monastir Hospital morbidity, we have selected newly diagnosed patients with RHD, residents of Monastir, and hospitalized to the 2 cardiology departments between 2000 and 2013 (2001 not included).

FINDINGS

We studied 676 newly admitted patients. We estimate 1060 to be the number of new annual RHD cases in Tunisia. The SIR per 10⁵ person-years was 10.97, being 9.3 in men and 19.1 in women, respectively. We have notified a negative trend of crude incidence rate/10⁵ Inhabitants (Inh) (CIR) (r=-0.23, p<10^-3), and a strong positive correlation between age and CIR/10⁵ Inh (r=0.989, p<10^-4). RHD lethality was 1%. We have registered 728 hospitalizations for RHD, representing 2.5% of all cardiology hospitalizations [95% CI: 2.3-2.7%], with a prevalence for 13.3% for women aged 15-29years. The median hospital stay was 9days (IQR: 5-15).

CONCLUSION

Our results confirm the RHD incidence decrease, consistent with epidemiological transition in Tunisia. We have also emphasized on the close trend of RHD with age and the predominance of RHD among women especially at the procreation age.

An epidemiological study to assess the true incidence and prevalence of rheumatic heart disease and acute rheumatic fever in New Caledonian school children

AIM

To provide in New Caledonian school children (i) the prevalence of rheumatic heart disease (RHD) detected by annual screening program using new World Heart Federation diagnostic criteria; (ii) the point prevalence of acute rheumatic fever (ARF); and (iii) to investigate socio-demographic risk factors associated with RHD.

METHODS

This study linked data from national ARF/RHD programs by combining ARF incidence data from the register with RHD prevalence data from echocardiographic screening data for a single age year of the population for overall point prevalence ARF/RHD rates. For the analysis, cases of echocardiographic detection of RHD are presumed to be synonymous with undiagnosed ARF. All results were weighted to minimise the bias introduced from absent pupils of each annual screening program. Incidence and prevalence were age-standardised to the WHO World Standard Population. Each 2013 cumulative prevalence of definite and borderline RHD was studied using a multivariate logistic regression adjusted for socio-demographic factors.

RESULTS

The overall age-standardised incidence of clinical and undiagnosed ARF (i.e. echocardiographic-detected RHD) was combined as point prevalence and estimated to be 99/10 000 cases in 2012 and 114/10 000 cases in 2013. This included 40/10 000 prevalent cases of asymptomatic RHD detected by screening each year. Being Melanesian, OR 23.2 (95% CI: 3.4-157.3), or Polynesian, OR 21.5 (95% CI: 2.9-157.7), was associated with a higher prevalence of having definite RHD compared with being Caucasian. Being a girl was associated with a higher risk of having borderline RHD, OR 1.9 (95% CI: 1.03-3.3).

CONCLUSION

Without echocardiographic screening, ARF/RHD burden is substantially underestimated.

Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening

OBJECTIVES

To compare regional differences in the prevalence of rheumatic heart disease (RHD) detected by echocardiographic screening in high-risk Indigenous Australian children, and to describe the logistical and other practical challenges of RHD screening.

DESIGN

Cross-sectional screening survey performed between September 2008 and November 2010.

SETTING

Thirty-two remote communities in four regions of northern and central Australia.

PARTICIPANTS

3946 Aboriginal or Torres Strait Islander children aged 5-15 years.

INTERVENTION

Portable echocardiography was performed by cardiac sonographers. Echocardiograms were recorded and reported offsite by a pool of cardiologists.

MAIN OUTCOME MEASURES

RHD was diagnosed according to 2012 World Heart Federation criteria.

RESULTS

The prevalence of definite RHD differed between regions, from 4.7/1000 in Far North Queensland to 15.0/1000 in the Top End of the Northern Territory. The prevalence of definite RHD was greater in the Top End than in other regions (odds ratio, 2.3; 95% CI, 1.2-4.6, P = 0.01). Fifty-three per cent of detected cases of definite RHD were new cases; the prevalence of new cases of definite RHD was 4.6/1000 for the entire sample and 7.0/1000 in the Top End. Evaluation of socioeconomic data suggests that the Top End group was the most disadvantaged in our study population.

CONCLUSIONS

The prevalence of definite RHD in remote Indigenous Australian children is significant, with a substantial level of undetected disease. Important differences were noted between regions, with the Top End having the highest prevalence of definite RHD, perhaps explained by socioeconomic factors. Regional differences must be considered when evaluating the potential benefit of widespread echocardiographic screening in Australia.

Echocardiographic screening for rheumatic heart disease-some answers, but questions remain

Despite being preventable, rheumatic heart disease (RHD) remains a significant global cause of cardiovascular disease. Echocardiographic screening for early detection of RHD has the potential to enable timely commencement of treatment (secondary prophylaxis) to halt progression to severe valvular disease. However, a number of issues remain to be addressed regarding its feasibility. The natural history of Definite RHD without a prior history of acute rheumatic fever (ARF) and Borderline RHD are both unclear. Even if they are variants of RHD it is not known whether secondary antibiotic prophylaxis will prevent disease progression as it does in "traditionally" diagnosed RHD. False positives can also have a detrimental impact on individuals and their families as well as place substantial burdens on health care systems. Recent research suggests that handheld echocardiography (HAND) may offer a cheaper and more convenient alternative to standard portable echocardiography (STAND) in RHD screening. However, while HAND is sensitive for the detection of Definite RHD, it is less sensitive for Borderline RHD and is relatively poor at detecting mitral stenosis (MS). Given its attendant limited specificity, potential cases detected with HAND would require re-examination by standard echocardiography. For now, echocardiographic screening for RHD should remain a subject of research rather than routine health care.

Screening for rheumatic heart disease: evaluation of a focused cardiac ultrasound approach

BACKGROUND

Rheumatic heart disease (RHD) remains a major public health problem worldwide. Although early diagnosis by echocardiography may potentially play a key role in developing active surveillance, systematic evaluation of simple approaches in resource poor settings are needed.

METHODS AND RESULTS

We prospectively compared focused cardiac ultrasound (FCU) to a reference approach for RHD screening in a school children population. FCU included (1) the use of a pocket-sized echocardiography machine, (2) nonexpert staff (2 nurses with specific training), and (3) a simplified set of echocardiographic criteria. The reference approach used standardized echocardiographic examination, reviewed by an expert cardiologist, according to 2012 World Heart Federation criteria. Among the 6 different echocardiographic criteria, first tested in a preliminary phase, mitral regurgitation jet length≥2 cm or any aortic regurgitation was considered best suited to be FCU criteria. Of the 1217 subjects enrolled (mean, 9.6±1 years; 49.6% male), 49 (4%) were diagnosed with RHD by the reference approach. The sensitivity of FCU for the detection of RHD was 83.7% (95% confidence interval, 73.3-94.0) for nurse A and 77.6% (95% confidence interval, 65.9-89.2) for nurse B. FCU yielded a specificity of 90.9% (95% confidence interval, 89.3-92.6) and 92.0% (95% confidence interval, 90.4-93.5) according to users. Percentage of agreement among nurses was 91.4%.

CONCLUSIONS

FCU by nonexperts using pocket devices seems feasible and yields acceptable sensitivity and specificity for RHD detection when compared with the state-of-the-art approach, thereby opening new perspectives for mass screening for RHD in low-resource settings.

Controlling acute rheumatic fever and rheumatic heart disease in developing countries: are we getting closer?

PURPOSE OF REVIEW

To describe new developments (2013-2014) in acute rheumatic fever (ARF) and rheumatic heart disease (RHD) relevant to developing countries.

RECENT FINDINGS

Improved opportunities for the primary prevention of ARF now exist, because of point-of-care antigen tests for Streptococcus pyogenes, and clinical decision rules which inform management of pharyngitis without requiring culture results. There is optimism that a vaccine, providing protection against many ARF-causing S. pyogenes strains, may be available in coming years. Collaborative approaches to RHD control, including World Heart Federation initiatives and the development of registers, offer promise for better control of this disease. New data on RHD-associated costs provide persuasive arguments for better government-level investment in primary and secondary prevention. There is expanding knowledge of potential biomarkers and immunological profiles which characterize ARF/RHD, and genetic mutations conferring ARF/RHD risk, but as yet no new diagnostic testing strategy is ready for clinical application.

SUMMARY

Reduction in the disease burden and national costs of ARF and RHD are major priorities. New initiatives in the primary and secondary prevention of ARF/RHD, novel developments in pathogenesis and biomarker research and steady progress in vaccine development, are all causes for optimism for improving control of ARF/RHD, which affect the poorest of the poor.

The emm-cluster typing system for Group A Streptococcus identifies epidemiologic similarities across the Pacific region

BACKGROUND

Group A Streptococcus (GAS)-related disease is responsible for high mortality and morbidity in the Pacific region. The high diversity of circulating strains in this region has hindered vaccine development due to apparently low vaccine coverage of type-specific vaccines.

METHOD

Prospective passive surveillance of all GAS isolates in New Caledonia was undertaken in 2012 using emm typing and emm-cluster typing. Molecular data were compared with the results from a prior study undertaken in the same country and with data from 2 other Pacific countries, Fiji and Australia.

RESULTS

A high incidence of invasive infection was demonstrated at 43 cases per 100 000 inhabitants (95% confidence interval, 35-52 cases per 100 000 inhabitants). Three hundred eighteen GAS isolates belonging to 47 different emm types were collected. In Noumea, only 30% of the isolates recovered in 2012 belonged to an emm type that was present in the same city in 2006, whereas 69% of the isolates collected in 2012 belonged to an emm cluster present in 2006. When comparing New Caledonian, Australian, and Fijian data, very few common emm types were found, but 79%-86% of the isolates from each country belonged to an emm cluster present in all 3 countries. A vaccine that could protect against the 10 most frequent emm clusters in the Pacific region would potentially provide coverage ranging from 83% to 92%.

CONCLUSIONS

This study confirms the high disease burden of GAS infection in New Caledonia and supports the added value of the emm-cluster typing system to analyze GAS epidemiology and to help inform global GAS vaccine formulation.

Increasing detection of rheumatic heart disease with echocardiography

Rheumatic heart disease (RHD) is estimated to affect over 20 million people worldwide, the vast majority being in developing countries. Screening for RHD has been recommended by the WHO since 2004. Conventionally, auscultation has been used for diagnosing RHD. Auscultation has its limitation and may not detect mild cases. A large number of studies have reported echocardiographic screening for RHD over the last several years. Most of these studies report an almost 10-fold higher prevalence of RHD by echocardiography as compared to conventional method of auscultation. Early diagnosis of such mild cases may be important as instituting secondary prophylaxis in such cases may reduce the burden of the disease. However, several concerns remain about the significance and natural history of these minor valvular changes detected by echocardiography. Whether secondary prophylaxis will reverse these abnormalities is also unclear. Long term follow up studies are required to answer some of these concerns.

Determinants of poor adherence to secondary antibiotic prophylaxis for rheumatic fever recurrence on Lifou, New Caledonia: a retrospective cohort study

Background

Incidence of acute rheumatic fever (ARF) and prevalence of rheumatic heart disease (RHD) in the Pacific region, including New Caledonia, are amongst the highest in the world. The main priority of long-term management of ARF or RHD is to ensure secondary prophylaxis is adhered to. The objectives of this study were to evaluate rates of adherence in people receiving antibiotic prophylaxis by intramuscular injections of penicillin in Lifou and to determine the factors associated with a poor adherence in this population.

Methods

We conducted a retrospective cohort study and we included 70 patients receiving injections of antibiotic prophylaxis to prevent ARF recurrence on the island of Lifou. Patients were classified as “good-adherent” when the rate of adherence was ≥80% of the expected injections and as “poor-adherent” when it was <80%. Statistical analysis to identify factors associated with adherence was performed using a multivariate logistic regression model.

Results

Our study showed that 46% of patients from Lifou receiving antibiotic prophylaxis for ARF or RHD had a rate of adherence <80% and were therefore at high risk of recurrence of ARF. Three independent factors were protective against poor adherence: a household with more than five people (odds ratio, 0.25; 95% confidence interval [CI], 0.08 to 0.75), a previous medical history of symptomatic ARF (odds ratio, 0.20; 95% CI, 0.04 to 0.98) and an adequate healthcare coverage (odds ratio, 0.21; 95% CI 0.06 to 0.72).

Conclusions

To improve adherence to secondary prophylaxis in Lifou, we therefore propose the following recommendations arising from the results of this study: i) identifying patients receiving antibiotic prophylaxis without medical history of ARF to strengthen their therapeutic education and ii) improving the medical coverage in patients with ARF or RHD. We also recommend that the nurse designated for the ARF prevention program in Lifou coordinate an active recall system based on an updated local register. But the key point to improve adherence among Melanesian patients is probably to give appropriate information regarding the disease and the treatment, taking into account the Melanesian perceptions of the disease.