Acute rheumatic fever and rheumatic heart disease in Fiji: prospective surveillance, 2005-2007

Current Clinical Profile of Acute Rheumatic Fever and Recurrent Acute Rheumatic Fever in Pakistan

Inclusion of echocardiography as diagnostic tool and polyarthralgia and monoarthritis as major criteria for high-risk populations in the Revised Jones Criteria 2015 is likely to surface substantial variability in clinical manifestations among various populations. This study aimed to compare clinical profile of patients presenting with first and recurrent episodes of acute rheumatic fever (ARF) using most recent criteria. 130 consecutive patients with ARF were included in the study from August 2019 to March 2022. World Heart Federation standardized echocardiographic criteria were used for cardiac evaluation. The socio-demographic variables, clinical details and relevant investigations were recorded. Median age was 13(6-26) years. Male to female ratio was 1.6:1. Majority was of low socioeconomic status (90%) and with > 5 family members in a house (83.8%). 27 patients (20.8%) were with ARF while 103 (79.2%) with recurrent ARF. Carditis was the most common presenting feature (n = 122, 93.8%), followed by polyarthralgia (n = 46, 35.4%), polyarthritis (n = 32, 24.6%), subcutaneous nodules (n = 10, 7.7%), monoarthritis (n = 10, 7.7%), and chorea (n = 5, 3.8%). Monoarthralgia was more common in ARF than recurrence (29.4% vs. 3.2%, p = 0.004). Carditis (97.1% vs. 81.5%, p = 0.01) and congestive cardiac failure (18.5% vs. 5.9%, p = 0.001) were more common in recurrent ARF than ARF. Diagnostic categorization of Jones criteria for different populations has highlighted important variability in clinical presentation of ARF. Monoarthralgia is common in first episode of ARF. Carditis is the most common feature in recurrent ARF. Polyarthralgia is seen with higher frequency that polyarthritis. Subcutaneous nodules seem to be more common in our population.

Population-based assessment of cardiovascular complications of rheumatic heart disease in Fiji: a record-linkage analysis

OBJECTIVE

To determine population-based rates of non-fatal complications of rheumatic heart disease (RHD).

DESIGN

Retrospective cohort study based on multiple sources of routine clinical and administrative data amalgamated by probabilistic record-linkage.

SETTING

Fiji, an upper-middle-income country, where most of the population has access to government-funded healthcare services.

PARTICIPANTS

National cohort of 2116 patients with clinically apparent RHD aged 5-69 years during 2008 and 2012.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was hospitalisation for any of heart failure, atrial fibrillation, ischaemic stroke and infective endocarditis. Secondary outcomes were first hospitalisation for each of the complications individually in the national cohort as well as in hospital (n=1300) and maternity (n=210) subsets. Information on outcomes was obtained from discharge diagnoses coded in the hospital patient information system. Population-based rates were obtained using relative survival methods with census data as the denominator.

RESULTS

Among 2116 patients in the national cohort (median age, 23.3 years; 57.7% women), 546 (25.8%) were hospitalised for an RHD complication, a substantial proportion of all cardiovascular admissions in the country during this period in those aged 0-40 years (heart failure, 210/454, 46.3%; ischaemic stroke 31/134, 23.1%). Absolute numbers of RHD complications peaked during the third decade of life with higher population-based rates in women compared with men (incidence rate ratio 1.4, 95% CI 1.3 to 1.6, p<0.001). Hospitalisation for any RHD complication was associated with substantially increased risk of death (HR 5.4, 95% CI 3.4 to 8.8, p<0.001), especially after the onset of heart failure (HR 6.6, 95% CI 4.8 to 9.1, p<0.001).

CONCLUSIONS

Our study defines the burden of RHD-attributable morbidity in the general population of Fiji, potentially reflecting the situation in low-income and middle-income countries worldwide. Hospitalisation for an RHD complication is associated with markedly increased risk of death, re-emphasising the importance of effective early prevention.

Global burden of rheumatic heart disease: trends from 1990 to 2019

Background

Rheumatic heart disease (RHD) is a critical public health issue worldwide, and its epidemiological patterns have changed over the decades. This article aimed to estimate the global trends of RHD, and attributable risks from 1990 to 2019.

Methods

Data on RHD burden were explored from the Global Burden of Disease Study 2019. Trends of the RHD burden were estimated using the estimated annual percentage change (EAPC) and age-standardized rate (ASR).

Results

During 1990–2019, increasing trends in the ASR of incidence and prevalence of RHD were observed worldwide, with the respective EAPCs of 0.58 (95% confidence interval [CI] 0.52 to 0.63) and 0.57 (95%CI 0.50 to 0.63). Meanwhile, increasing trends commonly occurred in low and middle Socio-Demographic Index (SDI) regions and countries. The largest increasing trends in the ASR of incidence and prevalence were seen in Fiji, with the respective EAPCs being 2.17 (95%CI 1.48 to 2.86) and 2.22 (95%CI 1.53 to 2.91). However, death and disability-adjusted life years (DALYs) due to RHD showed pronounced decreasing trends of ASR globally, in which the EAPCs were − 2.98 (95%CI − 3.03 to − 2.94) and − 2.70 (95%CI − 2.75 to − 2.65), respectively. Meanwhile, decreasing trends were also observed in all SDI areas and geographic regions. The largest decreasing trends of death were observed in Thailand (EAPC = − 9.55, 95%CI − 10.48 to − 8.61). Among the attributable risks, behavioral risk-related death and DALYs caused by RHD had pronounced decreasing trends worldwide and in SDI areas.

Conclusions

Pronounced decreasing trends of death and DALYs caused by RHD were observed in regions and countries from 1990 to 2019, but the RHD burden remains a substantial challenge globally. The results would inform the strategies for more effective prevention and control of RHD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02829-3.

Prevention of bacterial complications of scabies using mass drug administration: A population-based, before-after trial in Fiji, 2018-2020

BACKGROUND

Scabies is an important predisposing factor of impetigo which can lead to serious bacterial complications. Ivermectin-based mass drug administration can substantially reduce scabies and impetigo prevalence in endemic settings, but the impact on serious bacterial complications is not known.

METHODS

We conducted a before-after trial in the Northern Division of Fiji (population: 131,914) of mass drug administration for scabies control. Prospective surveillance was conducted from 2018 to 2020. Mass drug administration took place in 2019, involving two doses of oral ivermectin or topical permethrin, delivered alongside diethylcarbamazine and albendazole for lymphatic filariasis. The primary outcomes were incidence of hospitalisations with skin and soft tissue infections, and childhood invasive infections and post-streptococcal sequelae. Secondary outcomes included presentations to primary healthcare with skin infections and community prevalence of scabies and impetigo.

FINDINGS

The incidence of hospitalisations with skin and soft tissue infections was 17% lower after the intervention compared to baseline (388 vs 467 per 100,000 person-years; incidence rate ratio 0.83, 95% CI, 0.74 to 0.94; P = 0.002). There was no difference in incidence of childhood invasive infections and post-streptococcal sequelae. Incidence of primary healthcare presentations with scabies and skin infections was 21% lower (89.2 vs 108 per 1000 person-years, incidence rate ratio, IRR 0.79, 95% CI, 0.78 to 0.82). Crude community prevalence of scabies declined from 14.2% to 7.7% (cluster-adjusted prevalence 12.5% to 8.9%; prevalence ratio 0.71, 95% CI, 0.28 to 1.17). Cluster-adjusted prevalence of impetigo declined from 15.3% to 6.1% (prevalence ratio 0.4, 95% CI, 0.18 to 0.86).

INTERPRETATION

Mass drug administration for scabies control was associated with a substantial reduction in hospitalisations for skin and soft tissue infections.

FUNDING

National Health and Medical Research Council of Australia and Scobie and Claire Mackinnon Trust.

Incidence of acute rheumatic fever in northern and western Uganda: a prospective, population-based study

BACKGROUND

Acute rheumatic fever is infrequently diagnosed in sub-Saharan African countries despite the high prevalence of rheumatic heart disease. We aimed to determine the incidence of acute rheumatic fever in northern and western Uganda.

METHODS

For our prospective epidemiological study, we established acute rheumatic fever clinics at two regional hospitals in the north (Lira district) and west (Mbarara district) of Uganda and instituted a comprehensive acute rheumatic fever health messaging campaign. Communities and health-care workers were encouraged to refer children aged 3-17 years, with suspected acute rheumatic fever, for a definitive diagnosis using the Jones Criteria. Children were referred if they presented with any of the following: (1) history of fever within the past 48 h in combination with any joint complaint, (2) suspicion of acute rheumatic carditis, or (3) suspicion of chorea. We excluded children with a confirmed alternative diagnosis. We estimated incidence rates among children aged 5-14 years and characterised clinical features of definite and possible acute rheumatic fever cases.

FINDINGS

Data were collected between Jan 17, 2018, and Dec 30, 2018, in Lira district and between June 5, 2019, and Feb 28, 2020, in Mbarara district. Of 1075 children referred for evaluation, 410 (38%) met the inclusion criteria; of these, 90 (22%) had definite acute rheumatic fever, 82 (20·0%) had possible acute rheumatic fever, and 24 (6%) had rheumatic heart disease without evidence of acute rheumatic fever. Additionally, 108 (26%) children had confirmed alternative diagnoses and 106 (26%) had an unknown alternative diagnosis. We estimated the incidence of definite acute rheumatic fever among children aged 5-14 years as 25 cases (95% CI 13·7-30·3) per 100 000 person-years in Lira district (north) and 13 cases (7·1-21·0) per 100 000 person-years in Mbarara district (west).

INTERPRETATION

To the best of our knowledge, this is the first population-based study to estimate the incidence of acute rheumatic fever in sub-Saharan Africa. Given the known rheumatic heart disease burden, it is likely that only a proportion of children with acute rheumatic fever were diagnosed. These data dispel the long-held hypothesis that the condition does not exist in sub-Saharan Africa and compel investment in improving prevention, recognition, and diagnosis of acute rheumatic fever.

FUNDING

American Heart Association Children's Strategically Focused Research Network Grant, THRiVE-2, General Electric, and Cincinnati Children's Heart Institute Research Core.

The cost-of-illness due to rheumatic heart disease: national estimates for Fiji

BACKGROUND

Rheumatic heart disease (RHD) is a chronic valvular heart disease that is responsible for a heavy burden of premature mortality in low- and middle-income countries. The total costs of RHD are important to health policy and research investment decisions. We estimate for the first time the total cost of RHD for Fiji (2008-2012) using a cost-of-illness approach and novel primary data on RHD disease burden and costs.

METHODS

RHD cases were identified using probabilistic record linkage across four routine data sources: (1) the Fiji RHD Control Program, (2) national hospital admissions records, (3) the Ministry of Health database of cause-specific deaths and (4) hospital ECG clinic registers. For each individual with RHD, we obtained information on RHD hospital admissions, treatment and death. We conducted a prevalence-based cost-of-illness analysis, including bottom-up assessment of indirect and direct (healthcare) costs.

RESULTS

The estimated cost of RHD in Fiji for 2008-2012 was year-2010 $FJ91.6 million (approximately US$47.7 million). Productivity losses from premature mortality constituted the majority of costs (71.4%). Indirect costs were 27-fold larger than the direct costs.

CONCLUSIONS

RHD leads to a heavy economic burden in Fiji. Improved prevention strategies for RHD will likely confer substantial economic benefits to the country.

Prospective Surveillance of Primary Healthcare Presentations for Scabies and Bacterial Skin Infections in Fiji, 2018-2019

Scabies, impetigo, and other skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low-middle income settings, but information regarding their burden of disease is scarce. We conducted a surveillance of presentations of scabies and SSTIs, including impetigo, abscesses, cellulitis, and severe SSTI, to primary health facilities in Fiji. We established a monthly reporting system over the course of 50 weeks (July 2018-June 2019) for scabies and SSTIs at all 42 public primary health facilities in the Northern Division of Fiji (population, ≈131,914). For each case, information was collected regarding demographics, diagnosis, and treatment. There were 13,736 individual primary healthcare presentations with scabies, SSTI, or both (108.3 presentations per 1000 person-years; 95% confidence interval [CI], 106.6-110 presentations). The incidence was higher for males than for females (incidence rate ratio [IRR], 1.15; 95% CI, 1.11-1.19). Children younger than 5 years had the highest incidence among all age groups (339.1 per 1000 person-years). The incidence was higher among the iTaukei (indigenous) population (159.9 per 1000 person-years) compared with Fijians of Indian descent (30.1 per 1000 person-years; IRR, 5.32; 95% CI, 5.03-5.61). Abscesses had the highest incidence (63.5 per 1,000 person-years), followed by scabies (28.7 per 1,000 person-years) and impetigo (21.6 per 1,000 person-years). Scabies and SSTIs impose a substantial burden in Fiji and represent a high incidence of primary health presentations in this population. The incidence in low-middle income settings is up to 10-times higher than that in high-income settings. New public health strategies and further research are needed to address these conditions.

Toward the Knowledge of the Epidemiological Impact of Acute Rheumatic Fever in Italy

Background: To estimate the incidence of Acute Rheumatic Fever (ARF) in Tuscany, a region of Central Italy, evaluating the epidemiological impact of the new diagnostic guidelines, and to analyse our outcomes in the context of the Italian overview. Methods: A multicenter and retrospective study was conducted involving children <18 years old living in Tuscany and diagnosed in the period between 2010 and 2019. Two groups were established based on the new diagnostic criteria: High-Risk (HR) group patients, n = 29 and Low-Risk group patients, n = 96. Results: ARF annual incidence ranged from 0.91 to 7.33 out of 100,000 children in the analyzed period, with peak of incidence registered in 2019. The application of HR criteria led to an increase of ARF diagnosis of 30%. Among the overall cohort joint involvement was the most represented criteria (68%), followed by carditis (58%). High prevalence of subclinical carditis was observed (59%). Conclusions: Tuscany should be considered an HR geographic area and HR criteria should be used for ARF diagnosis in this region.

Echo workforce development in the Fiji Islands

Echocardiography has a wide scope of practice and requires many years of training and experience for one to be proficient; however, contextualised echo may be taught for the purpose of screening for rheumatic heart disease (RHD). In recent experience in the Fiji Islands, an echo workforce training programme was implemented with the intention of teaching general sonographers and physicians echo for the purpose of screening RHD with very positive results. This course was completed over three separate one week courses in a clinical setting.

Profile of newly diagnosed adult patients with rheumatic heart disease in sub-Himalayan region - A 5-year analysis

Introduction:

Rheumatic heart disease (RHD) is one of the leading acquired causes of cardiac diseases affecting the young population, worldwide.

Aims and Objectives:

The primary objective was to study the prevalence, profile, and complications of patients with RHD in a tertiary care hospital of Uttarakhand. The secondary objective was to assess the demographic and clinical parameters of patients with RHDs.

Materials and Methods:

All adult patients above the age of 18 years, diagnosed with RHD, over a period of 5 years from July 2008 to June 2013 were enrolled in the study. Detailed clinical data of the patients were obtained retrospectively from the hospital record section. Information regarding prevalence of RHD, profile, and complications of patients with RHD was collected from patient's case sheet and tabulated.

Results:

In all, 1001 patients age more than 18 years with RHD presented to either medical or cardiology outpatient departments over a period of 5 years from July 11 to June 2018. Mitral regurgitation (n = 610, 61.9%) was the most common RHD. Females (n = 538, 53%) outnumbered males (n = 464, 46.2%). Heart failure (n = 353, 35.1%), severe pulmonary arterial hypertension (n = 118, 11.7%), and atrial fibrillation (n = 212, 21.1%) were common complications. A total of 75 (7.4%) patients presented with bacterial endocarditis, whereas 32 (3.2%) patients succumbed to death due to RHD.

Acute rheumatic fever diagnosis and management: Review of the global implications of the new revised diagnostic criteria with a focus on Saudi Arabia

Rheumatic fever (RF) is a common cause of acquired heart disease in children worldwide. It is a delayed, nonsuppurative, autoimmune phenomenon following pharyngitis, impetigo, or scarlet fever caused by group A β-hemolytic streptococcal (GAS) infection. RF diagnosis is clinical and based on revised Jones criteria. The first version of the criteria was developed by T. Duckett Jones in 1944, then subsequently revised by the American Heart Association (AHA) in 1992 and 2015. However, RF remains a diagnostic challenge for clinicians because of the lack of specific clinical or laboratory findings. As a result, it has been difficult for some time to maintain a balance between over- and underdiagnosis of RF cases. The Jones criteria were revised in 2015 by the AHA, and the main modifications were as follows: the population was subdivided into moderate- to high-risk and low risk; the concept of subclinical carditis was introduced; and monoarthritis was included as a feature of musculoskeletal inflammation in the moderate- to high-risk population. This review will highlight the major changes in the AHA 2015 revised Jones criteria for pediatricians and general practitioners.

Acute rheumatic fever

Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes. Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.

In silico characterisation of the two-component system regulators of Streptococcus pyogenes

Bacteria respond to environmental changes through the co-ordinated regulation of gene expression, often mediated by two-component regulatory systems (TCS). Group A Streptococcus (GAS), a bacterium which infects multiple human body sites and causes multiple diseases, possesses up to 14 TCS. In this study we examined genetic variation in the coding sequences and non-coding DNA upstream of these TCS as a method for evaluating relationships between different GAS emm-types, and potential associations with GAS disease. Twelve of the 14 TCS were present in 90% of the genomes examined. The length of the intergenic regions (IGRs) upstream of TCS coding regions varied from 39 to 345 nucleotides, with an average nucleotide diversity of 0.0064. Overall, IGR allelic variation was generally conserved with an emm-type. Subsequent phylogenetic analysis of concatenated sequences based on all TCS IGR sequences grouped genomes of the same emm-type together. However grouping with emm-pattern and emm-cluster-types was much weaker, suggesting epidemiological and functional properties associated with the latter are not due to evolutionary relatedness of emm-types. All emm5, emm6 and most of the emm18 genomes, all historically considered rheumatogenic emm-types clustered together, suggesting a shared evolutionary history. However emm1, emm3 and several emm18 genomes did not cluster within this group. These latter emm18 isolates were epidemiologically distinct from other emm18 genomes in study, providing evidence for local variation. emm-types associated with invasive disease or nephritogenicity also did not cluster together. Considering the TCS coding sequences (cds), correlation with emm-type was weaker than for the IGRs, and no strong correlation with disease was observed. Deletion of the malate transporter, maeP, was identified that serves as a putative marker for the emm89.0 subtype, which has been implicated in invasive outbreaks. A recombination-related, subclade-forming DNA motif was identified in the putative receiver domain of the Spy1556 response regulator that correlated with throat-associated emm-pattern-type A-C strains.

Acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF, which can result from a single severe episode or from multiple recurrent episodes of the illness, is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in resource-poor settings around the world. Although our understanding of disease pathogenesis has advanced in recent years, this has not led to dramatic improvements in diagnostic approaches, which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed, penicillin has been the mainstay of treatment for decades and there is no other treatment that has been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent advances - including the use of echocardiographic diagnosis in those with ARF and in screening for early detection of RHD, progress in developing group A streptococcal vaccines and an increased focus on the lived experience of those with RHD and the need to improve quality of life - give cause for optimism that progress will be made in coming years against this neglected disease that affects populations around the world, but is a particular issue for those living in poverty.

Newly diagnosed rheumatic heart disease among indigenous populations in the Pacific

OBJECTIVES

Rheumatic heart disease (RHD) remains the leading acquired heart disease in the young worldwide. We aimed at assessing outcomes and influencing factors in the contemporary era.

METHODS

Hospital-based cohort in a high-income island nation where RHD remains endemic and the population is captive. All patients admitted with newly diagnosed RHD according to World Heart Federation echocardiographic criteria were enrolled (2005-2013). The incidence of major cardiovascular events (MACEs) including heart failure, peripheral embolism, stroke, heart valve intervention and cardiovascular death was calculated, and their determinants identified.

RESULTS

Of the 396 patients, 43.9% were male with median age 18 years (IQR 10-40)). 127 (32.1%) patients presented with mild, 131 (33.1%) with moderate and 138 (34.8%) with severe heart valve disease. 205 (51.8%) had features of acute rheumatic fever. 106 (26.8%) presented with at least one MACE. Among the remaining 290 patients, after a median follow-up period of 4.08 (95% CI 1.84 to 6.84) years, 7 patients (2.4%) died and 62 (21.4%) had a first MACE. The annual incidence of first MACE and of heart failure were 59.05‰ (95% CI 44.35 to 73.75) and 29.06‰ (95% CI 19.29 to 38.82), respectively. The severity of RHD at diagnosis (moderate vs mild HR 3.39 (0.95 to 12.12); severe vs mild RHD HR 10.81 (3.11 to 37.62), p<0.001) and ongoing secondary prophylaxis at follow-up (HR 0.27 (0.12 to 0.63), p=0.01) were the two most influential factors associated with MACE.

CONCLUSIONS

Newly diagnosed RHD is associated with poor outcomes, mainly in patients with moderate or severe valve disease and no secondary prophylaxis.

Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented.

OBJECTIVES

To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care.

METHODS

A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled.

RESULTS

Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly.

CONCLUSION

ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery.

Post-infectious group A streptococcal autoimmune syndromes and the heart

There is a pressing need to reduce the high global disease burden of rheumatic heart disease (RHD) and its harbinger, acute rheumatic fever (ARF). ARF is a classical example of an autoimmune syndrome and is of particular immunological interest because it follows a known antecedent infection with group A streptococcus (GAS). However, the poorly understood immunopathology of these post-infectious diseases means that, compared to much progress in other immune-mediated diseases, we still lack useful biomarkers, new therapies or an effective vaccine in ARF and RHD. Here, we summarise recent literature on the complex interaction between GAS and the human host that culminates in ARF and the subsequent development of RHD. We contrast ARF with other post-infectious streptococcal immune syndromes - post-streptococcal glomerulonephritis (PSGN) and the still controversial paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), in order to highlight the potential significance of variations in the host immune response to GAS. We discuss a model for the pathogenesis of ARF and RHD in terms of current immunological concepts and the potential for application of in depth "omics" technologies to these ancient scourges.

Health-related quality of life of patients after mechanical valve replacement surgery for rheumatic heart disease in a developing country

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) of people in Fiji (n=128) undergoing heart valve replacement (VR) surgery for rheumatic heart disease (RHD), conducted by Open Heart International.

METHODS

Patients who had undergone surgery from 1991 to 2009 (n=72) and patients undergoing surgery for the years 2010-2012 (n=56) were surveyed prospectively, preoperatively and/or postoperatively (the mean follow-up time 5.9 years) using the standard recall Short-Form 36, V.2 (SF-36v2) HRQoL Survey.

RESULTS

The sample had a mean age of 26.7 years and 56% (n=72) were women. Preoperative HRQoL is impaired but by early postoperative (1 year) there is significant improvement across all domains (p<0.05) apart from mental health (p=0.081). At mid-term (2 years), HRQoL remained substantially improved from preoperative measurement with mental health now significantly better (p=0.028). However, compared with the early follow-up outcomes, at mid-term physical function (p=0.001), role-physical (p=0.002) and role-emotional (p=0.042) domains significantly declined. By late follow-up (>2 years), all HRQoL domains, except for mental health, were significantly better than preoperative (p=0.066 ). Predictors of less improved HRQoL included having an isolated mitral valve replacement (MVR) (for six of eight health domains, p<0.05), older age (three domains; role-physical, vitality and bodily pain, p<0.05) and male gender (in the role-emotional domain, p<0.05).

CONCLUSIONS

This first investigation of the HRQoL of people in a developing country after VR surgery for RHD found significant improvement from surgery with this improvement generally sustained. The lack of improvement in mental health requires further exploration as does the influence of an isolated MVR, age and gender.

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.

Short- and long-term outcomes after valve replacement surgery for rheumatic heart disease in the South Pacific, conducted by a fly-in/fly-out humanitarian surgical team: a 20-year retrospective study for the years 1991 to 2011

OBJECTIVES

Fiji has one of the highest rates of rheumatic heart disease in the world. Humanitarian fly-in/fly-out surgical teams, including Open Heart International, have been conducting valve replacement surgery in Fiji since 1991. We sought to determine the short- and long-term outcomes of valve replacement for rheumatic heart disease.

METHODS

The Open Heart International team performed surgery on 167 patients from 1991 to 2011. Complete follow-up data to death or last evaluation on 149 patients (89.2%) and morbidity data for 152 patients (91%) were extracted from medical records.

RESULTS

Patients' average age at the time of surgery was 26.1 years, with the majority being female (63.5%). Valves replaced were isolated mitral valves (52%), isolated aortic valves (19%), and multiple valves (29%). The cumulative mortality rate at 30, 60, and 90 days and at 1, 5, and 10 years was 2.4%, 6.0%, 8.4%, 12.0%, 19.8%, and 23.9%, respectively. Major adverse valve-related events-free survival was 10.1 years (95% confidence interval [CI], 8.32-11.94). After adjusting for confounders, female patients were 3.03 times more likely to die postoperatively than male patients (odds ratio [OR], 3.03; 95% CI, 1.23-7.69). Patients undergoing isolated valve replacement were less likely to have a morbidity event than those undergoing multiple valve replacement (isolated mitral 67% less likely [OR, 0.33; 95% CI, 0.12-0.93] and isolated aortic 76% less likely [OR, 0.34; 95% CI, 0.06-0.96]).

CONCLUSIONS

The majority of people undergoing valve replacement for rheumatic heart disease have good outcomes. Mortality and morbidity rates at 1 and 5 years, particularly for female patients, are cause for concern and indicate a need for evaluation of resources toward systematic long-term postoperative surveillance and medical management.

Rheumatic heart disease in Tennessee: An overlooked diagnosis

Rheumatic heart disease, already a major burden in low- and middle-income countries, is becoming an emerging problem in high-income countries. Although acute rheumatic fever and rheumatic heart disease have almost been eradicated in areas with established economies, the emergence of this problem may be attributable to the migration from low-income to high-income settings. Between 2010 and 2012, we diagnosed a cluster of rheumatic heart disease cases in children from the Middle Tennessee area. The goal of this report is to increase awareness among clinicians as the incidence and prevalence of acute rheumatic fever remain relatively significant in large US metropolitan areas. Although acute rheumatic fever is seasonal, a high suspicion index may lead to the early diagnosis and prevention of its cardiac complications. Furthermore, screening procedures may be recommended for populations at risk for rheumatic heart disease in endemic areas, and active surveillance with echocardiography-based screening might become very important.

The heart and pediatric rheumatology

Recent advances in Kawasaki disease have included attempts to define genes involved in its pathogenesis. There have been recent advances in the studies of rheumatic carditis, leading to a better understanding of the mechanism of the disease. Histologic evaluation of patients with neonatal lupus erythematosus has revealed fibrosis with collagen deposition and calcification of the atrioventricular node. Therapy for cardiac involvement in systemic juvenile idiopathic arthritis should involve treatment of the underlying disease and systemic inflammatory state, and typically includes nonsteroidal antiinflammatory drugs, corticosteroids, disease-modifying drugs, and biologic therapies targeting tumor necrosis factor-alpha, interleukin-1, and interleukin-6.

Presenting features of newly diagnosed rheumatic heart disease patients in Mulago Hospital: a pilot study

Introduction

Rheumatic heart disease (RHD) continues to cause gross distortions of the heart and the associated complications of heart failure and thromboembolic phenomena in this age of numerous high-efficacy drugs and therapeutic interventions. Due to the lack of contemporary local data, there is no national strategy for the control and eradication of the disease in Uganda. This study aimed to describe the presenting clinical features of newly diagnosed patients with RHD, with particular reference to the frequency of serious complications (atrial fibrillation, systemic embolism, heart failure and pulmonary hypertension) in the study group.

Methods

One hundred and thirty consecutive patients who satisfied the inclusion criteria were recruited over a period of eight months from June 2011 to January 2012 at the Mulago Hospital, Uganda. Data on demographic characteristics, disease severity and presence of complications were collected by means of a standardised questionnaire.

Results

Seventy-one per cent of the patients were female with a median age of 33 years. The peak age of the study group was 20 to 39 years, with the commonest presenting symptoms being palpitations, fatigue, chest pain and dyspnoea. The majority of the patients presented with moderate-to-severe valvular disease. Pure mitral regurgitation was the commonest valvular disease (40.2%), followed by mitral regurgitation plus aortic regurgitation (29%). Mitral regurgitation plus aortic regurgitation plus mitral stenosis was found in 11% of patients. There was only one case involving the tricuspid valve. The pulmonary valves were not affected in all patients; 45.9% of patients presented in severe heart failure in NYHA class III/IV, 53.3% had pulmonary hypertension, 13.9% had atrial fibrillation and 8.2% had infective endocarditis. All patients presented with dilated atria (> 49 mm).

Conclusion

A significant proportion of RHD patients present to hospital with severe disease associated with severe complications of advanced heart failure, pulmonary hypertension, infective endocarditis and atrial fibrillation. There is a need to improve awareness of the disease among the population, and clinical suspicion in primary health workers, so that early referral to specialist management can be done before severe damage to the heart ensues.

Pilot study of nurse-led rheumatic heart disease echocardiography screening in Fiji--a novel approach in a resource-poor setting

We designed a pilot study of a training module for nurses to perform rheumatic heart disease echocardiography screening in a resource-poor setting. The aim was to determine whether nurses given brief, focused, basic training in echocardiography could follow an algorithm to potentially identify cases of rheumatic heart disease requiring clinical referral, by undertaking basic two-dimensional and colour Doppler scans. Training consisted of a week-long workshop, followed by 2 weeks of supervised field experience. The nurses' skills were tested on a blinded cohort of 50 children, and the results were compared for sensitivity and specificity against echocardiography undertaken by an expert, using standardised echocardiography definitions for definite and probable rheumatic heart disease. Analysis of the two nurses' results revealed that when a mitral regurgitant jet length of 1.5 cm was used as the trigger for rheumatic heart disease identification, they had a sensitivity of 100% and 83%, respectively, and a specificity of 67.4% and 79%, respectively. This pilot supports the principle that nurses, given brief focused training and supervised field experience, can follow an algorithm to undertake rheumatic heart disease echocardiography in a developing country setting to facilitate clinical referral with reasonable accuracy. These results warrant further research, with a view to developing a module to guide rheumatic heart disease echocardiographic screening by nurses within the existing public health infrastructure in high-prevalence, resource-poor regions.

Acute rheumatic fever and rheumatic heart disease: incidence and progression in the Northern Territory of Australia, 1997 to 2010

BACKGROUND

Although acute rheumatic fever (ARF) and its sequel, rheumatic heart disease (RHD), continue to cause a large burden of morbidity and mortality in disadvantaged populations, most studies investigating the effectiveness of control programs date from the 1950s. A control program, including a disease register, in the Northern Territory of Australia where the Indigenous population has high rates of ARF and RHD allowed us to examine current disease incidence and progression.

METHODS AND RESULTS

ARF and RHD incidence rates, ARF recurrence rates, progression rates from ARF to RHD to heart failure, and RHD survival and mortality rates were calculated for Northern Territory residents from 1997 to 2010. For Indigenous people, ARF incidence was highest in the 5- to 14-year age group (males, 162 per 100,000; females, 228 per 100,000). There was little evidence that the incidence of ARF or RHD had declined. The ARF recurrence rate declined by 9% per year after diagnosis. After a first ARF diagnosis, 61% developed RHD within 10 years. After RHD diagnosis, 27% developed heart failure within 5 years. For Indigenous RHD patients, the relative survival rate was 88.4% at 10 years after diagnosis and the standardized mortality ratio was 1.56 (95% confidence interval, 1.23-1.96).

CONCLUSIONS

For Indigenous Australians in the Northern Territory, ARF and RHD incidence and associated mortality remain very high. The reduction in ARF recurrence indicates that the RHD control program has improved secondary prophylaxis; a decline in RHD incidence is expected to follow.

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

AIM

Despite the well-documented burden of rheumatic heart disease (RHD) in several Pacific countries, the disease is poorly understood in New Caledonia. The aim of this study was to assess the prevalence of RHD detected by echocardiographic screening in school children.

METHODS

An annual RHD screening programme is conducted by the Health and Social Agency of New Caledonia for school-aged children in their fourth year of primary school. For the purpose of this study, we used data collected during this echocardiographic screening between 2008 and 2010.

RESULTS

Of 12,728 children screened, 50.2% were male and the mean age was 9.6 ± 0.6 years. Between 2008 and 2010, 114 children had RHD, corresponding to a prevalence of 8.9 cases per 1000 (95% confidence interval (CI) (7.3-10.6)). Prevalence of RHD was higher on the main island outside Greater Noumea (13.7 per 1000; 95% CI (9.8-17.5)) and in the outlying island groups (14.6 per 1000; 95% CI (8.4-20.9)) than in Greater Noumea (5.8 per 1000; 95% CI (4.1-7.5)). RHD was more prevalent in Melanesian children (13.5 per 1000; 95% CI (10.9-16.1)) than in European (1.8 per 1000; 95% CI (0.4-3.1)).

CONCLUSION

This study documented a high prevalence of RHD in New Caledonia, particularly in districts located outside Noumea and in children of Melanesian heritage. These results uncover a hitherto unknown burden of disease in New Caledonia and underline the importance of delivering secondary prophylaxis to reduce the prevalence of RHD.

A national prospective surveillance study of acute rheumatic fever in Australian children

BACKGROUND

Acute rheumatic fever (ARF) is an important cause of heart disease in Indigenous people of northern and central Australia. However, little is known about ARF in children across all Australian population groups. This national prospective study was conducted to determine patterns of disease, and populations and regions at highest risk.

METHODS

The Australian Paediatric Surveillance Unit surveillance model was used to collect data on children with ARF across Australia. Children up to 15 years of age were included if they had an ARF episode diagnosed between October 1, 2007 and December 31, 2010 that met the case definition.

RESULTS

ARF was identified in 151 children: 131 Indigenous Australians, 10 non-Indigenous Australians, 8 Pacific Islanders and 1 African (1 unknown). Common presenting features were joint symptoms, fever and carditis. Sydenham chorea was reported in 19% of children. Aseptic monoarthritis was a major manifestation in 19% of high-risk children. Seven non-Indigenous Australian children presented with classic, highly specific features compared with 23% of high-risk children, suggesting that subtle presentations of ARF are being missed in non-Indigenous children. Recent sore throat was reported in 33% of cases, including 25% of remote Indigenous children. There were delays in presentation to care and referral to higher-level care across urban/rural and remote areas.

CONCLUSIONS

ARF may be more common than previously thought among low-risk children. These data should prompt an awareness of ARF diagnosis and management across all regions, including strategies for primary prevention. There should be renewed emphasis on treatment of sore throat in high-risk groups.

Cutting edge issues in rheumatic fever

Although the incidence of acute rheumatic fever and rheumatic heart disease has decreased significantly in regions of the world where antibiotics are easily accessible, there remains a high incidence in developing nations as well as in certain regions where there is a high incidence of genetic susceptibility. These diseases are a function of poverty, low socioeconomic status, and barriers to healthcare access, and it is in the developing world that a comprehensive prevention program is most critically needed. Development of group A streptococcal vaccines has been under investigation since the 1960s and 50 years later, we still have no vaccine. Factors that contribute to this lack of success include a potential risk for developing vaccine-induced rheumatic heart disease, as well as difficulties in covering the many serological subtypes of M protein, a virulence factor found on the surface of the bacterium. Yet, development of a successful vaccine program for prevention of group A streptococcal infection still offers the best chance for eradication of rheumatic fever in the twenty-first century. Other useful approaches include continuation of primary and secondary prevention with antibiotics and implementation of health care policies that provide patients with easy access to antibiotics. Improved living conditions and better hygiene are also critical to the prevention of the spread of group A streptococcus, especially in impoverished regions of the world. The purpose of this article is to discuss current and recent developments in the diagnosis, pathogenesis, and management of rheumatic fever and rheumatic heart disease.

Environmental factors and rheumatic heart disease in Fiji

Rheumatic heart disease (RHD) is an important cause of cardiac morbidity and mortality globally, particularly in the Pacific region. Susceptibility to RHD is thought to be due to genetic factors that are influenced by environmental factors, such as crowding and poverty. However, there are few data relating to these environmental factors in the Pacific region. We conducted a case-control study of 80 cases of RHD with age- and sex-matched controls in Fiji using a questionnaire to investigate associations of RHD with a number of environmental factors. There was a trend toward increased risk of RHD in association with poor-quality housing and lower socioeconomic status, but only one factor, maternal unemployment, reached statistical significance (OR 2.6, 95% confidence interval 1.2-5.8). Regarding crowding, little difference was observed between the two groups. Although our data do not allow firm conclusions, they do suggest that further studies of socioeconomic factors and RHD in the Pacific are warranted. They also suggest that genetic studies would provide an insight into susceptibility to RHD in this population.

Molecular markers for the study of streptococcal epidemiology

Diseases caused by Streptococcus pyogenes (Group A streptococcus, GAS) range from superficial infections such as pharyngitis and impetigo to potentially fatal rheumatic heart disease and invasive disease. Studies spanning emm-typing surveillance to population genomics are providing new insights into the epidemiology, pathogenesis, and biology of this organism. Such studies have demonstrated the differences that exist in the epidemiology of streptococcal disease between developing and developed nations. In developing nations, where streptococcal disease is endemic, the diversity of GAS emm-types circulating is much greater than that found in developed nations. An association between emm-type and disease, as observed in developed countries is also lacking. Intriguingly, comparative genetic studies suggest that emm-type is not always a good predictor of the evolutionary relatedness of geographically distant isolates. A view of GAS as a highly dynamic organism, in possession of a core set of virulence genes that contribute to host niche specialization and common pathogenic processes, augmented by accessory genes that change the relative virulence of specific lineages is emerging. Our inability to definitively identify genetic factors that contribute to specific disease outcome underscores the complex nature of streptococcal diseases.

The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant public health concerns around the world. Despite decreasing incidence, there is still a significant disease burden, especially in developing nations. This review provides background on the history of ARF, its pathology and treatment, and the current reported worldwide incidence of ARF and prevalence of RHD.

Rheumatic heart disease and its control in the Pacific

Rheumatic fever and rheumatic heart disease continue to be a huge public-health burden on many Pacific Island countries. Prevalence reported in some nations are some of the highest seen globally, yet many countries in the region do not have national disease registers. Despite the will of many Pacific Island countries, there are a number of barriers to the implementation and sustainability of effective coordinated prevention programs, including limited funding and competing health priorities. In promising recent developments, a number of countries in the region have been able to develop or strengthen national rheumatic heart disease registers. These registers allow for more effective delivery of secondary prophylaxis, the mainstay of disease control in the Pacific. Primary prevention of rheumatic fever and screening for rheumatic heart disease are important adjunctive strategies. Recent advances in screening methods, focusing on portable echocardiography, may allow for the early detection of rheumatic heart disease in the community.

Differences among group A streptococcus epidemiological landscapes: consequences for M protein-based vaccines?

Group A streptococcus (GAS) is a bacterial pathogen responsible for a wide array of disease pathologies in humans. GAS surface M protein plays multiple key roles in pathogenesis, and serves as a target for typing and vaccine development. In this review, we have compiled GAS epidemiological studies from several countries around the world to highlight the consequences on the theoretical efficacy of two different M protein-based vaccine strategies.

Acute rheumatic fever and rheumatic heart disease in indigenous populations

Acute rheumatic fever and rheumatic heart disease are diseases of socioeconomic disadvantage. These diseases are common in developing countries and in Indigenous populations in industrialized countries. Clinicians who work with Indigenous populations need to maintain a high index of suspicion for the potential diagnosis of acute rheumatic fever, particularly in patients presenting with joint pain. Inexpensive medicines, such as aspirin, are the mainstay of symptomatic treatment of rheumatic fever; however, antiinflammatory treatment has no effect on the long-term rate of progression or severity of chronic valvular disease. The current focus of global efforts at prevention of rheumatic heart disease is on secondary prevention (regular administration of penicillin to prevent recurrent rheumatic fever), although primary prevention (timely treatment of streptococcal pharyngitis to prevent rheumatic fever) is also important in populations in which it is feasible.

Underdiagnosis of acute rheumatic fever in primary care settings in a developing country

OBJECTIVES

To determine the incidence rate, characterize the clinical features and assess the diagnostic evaluation of children presenting with features of acute rheumatic fever (ARF) at two clinics in a region of Fiji where rheumatic heart disease is known to be endemic.

METHODS

We reviewed 5 years (2003-2008) of primary care records from 15 841 patients aged 4-20 years using a pre-determined case definition for ARF; and we reviewed detailed clinical data from 944 cases with features of possible ARF.

RESULTS

The crude incidence of first episodes of definite ARF in this setting among patients aged 4-20 years was 24.9 per 100 000 person-years. Joint involvement suggestive of a potential first presentation of ARF but not sufficient for a definite retrospective diagnosis was documented in a further 94 records. There were another 514 cases of joint involvement less suggestive of ARF and 316 cases of unexplained fever with no evidence of localized infection. Patients presenting with potential features of ARF seldom had a diagnostic evaluation sufficient to exclude its diagnosis.

CONCLUSIONS

The incidence of ARF at these clinics is nearly twice that reported in a local hospital-based study, but it is likely to under-represent the actual number of cases presenting to primary care. There is a need for better surveillance for ARF and to develop simple and practical approaches to diagnosing ARF in primary care in low-resource settings.