Echocardiographic screening in a resource poor setting: Borderline rheumatic heart disease could be a normal variant

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Abstract

Objective

To estimate the echocardiography confirmed prevalence of rheumatic heart disease (RHD) in school children in Fiji.

Design

Cross-sectional observational study.

Setting

Ten primary schools in Fiji.

Patients

School children aged 5–14 years.

Interventions

Each child had an echocardiogram performed by an echocardiographic technician subsequently read by a paediatric cardiologist not involved with field screening, and auscultation performed by a paediatrician.

Main outcome measures

Echocardiographic criteria for RHD diagnosis were based on those previously published by the National Institutes of Health (NIH) and World Health Organization (WHO), and data were also analyzed using the new World Heart Federation (WHF) criteria. Prevalence figures were calculated with binomial 95% confidence intervals.

Results

Using the modified NIH/WHO criteria the prevalence of definite RHD prevalence was 7.2 cases per 1000 (95% CI 3.7–12.5), and the prevalence of probable RHD 28.2 cases per 1000 (95% CI 20.8–37.3). By applying the WHF criteria the prevalence of definite and borderline RHD was 8.4 cases per 1000 (95% CI 4.6–14.1) and 10.8 cases per 1000 (95% CI 6.4–17.0) respectively. Definite RHD was more common in females (OR 5.1, 95% CI 1.1–48.3) and in children who attended school in a rural location (OR 2.3, 95% CI 0.6–13.50). Auscultation was poorly sensitive compared to echocardiography (30%).

Conclusion

There is a high burden of undiagnosed RHD in Fiji. Auscultation is poorly sensitive when compared to echocardiography in the detection of asymptomatic RHD. The results of this study highlight the importance of the use of highly sensitive and specific diagnostic criteria for echocardiography diagnosis of RHD.

Section snippets

Introduction and background

Pacific Island countries have among the highest prevalence of rheumatic heart disease (RHD) and incidences of acute rheumatic fever (ARF) documented in the world [1], [2], [3], [4]. The Global Burden of Disease study estimated that RHD caused 4126 deaths in 2010 in the Oceania and Australasia regions, with 37,789 disability-adjusted life years lost [5], [6]. The true figures are likely to be higher as death reporting in many Pacific countries is poor and autopsies to confirm the cause of death

Setting

Fiji is a nation of approximately 300 islands located in the Western Pacific. It has a population of 837,271 people comprised of 2 main racial groups: iTaukei (Melanesian) (56.8%) and Indo-Fijians (37.5%) with the remaining 5.7% of the population consisting of people of other racial backgrounds (other Pacific Islanders, Chinese, Europeans and mixed race ethnicities) [10]. This project was undertaken in the Central Medical Division of Fiji on the Island of Viti Levu. In Fiji, there is a very

Echocardiography

We screened 1666 children with echocardiography. The most common finding detected by echocardiography was mitral regurgitation with 616 (37%) of all participants having some degree of mitral regurgitation in at least one view. However, only 72 (4.3%) and 34 (2.0%) had a mitral regurgitant jet measurement  1.5 cm and ≥ 2 cm in one view respectively. There were 65 children (3.9%) in whom morphological changes of the mitral valve were seen, and of these, 25 children (0.3% of total cohort) had more

Discussion

This study found a characteristic distribution of definite RHD in iTaukei female children and in children attending school in a rural location when using both the modified NIH/WHO and WHF criteria, consistent with previous published data [13], [15]. In contrast these associations disappeared or reversed for the probable RHD cases, with more males, more children of Indo-Fijian ethnicity and a predominance of children attending school in an urban location. The lack of classical RHD risk factor

Funding

This project was funded by the National Institutes of Health, Department of Microbiology and Infectious Diseases (DMID funding mechanism: U01AI60579). The funding body assisted with the development of the study protocol only. All data collection, analysis and interpretation of the study data was undertaken by the study team.

Acknowledgements

The authors thank the children and families in Fiji who participated in this study as well as the teachers and nurses who assisted in coordinating the field work. We also wish to acknowledge the Fiji GrASP research team; Frances Matanatabu, Laisiana Matatolu, Kavita Prasad and Sera Rayasidamu for their dedicated work in the field that made the completion of this project possible. We thank the cardiologists/paediatricians at the Starship Children's Hospital, Auckland New Zealand, who assisted in

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