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Original Investigation
April 2016

Prevalence of Subclinical Rheumatic Heart Disease in Eastern Nepal: A School-Based Cross-sectional Study

Author Affiliations
  • 1Department of Cardiology, Neuro Cardio and Multispeciality Hospital, Biratnagar, Nepal
  • 2Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
  • 3Clinical Trials Unit, University of Bern, Bern, Switzerland
  • 4Department of Cardiology, Hôpital de la Tour, Geneva, Switzerland
  • 5Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 6Department of Cardiology, Bern University Hospital, Bern, Switzerland
JAMA Cardiol. 2016;1(1):89-96. doi:10.1001/jamacardio.2015.0292

Importance  Although rheumatic heart disease has been nearly eradicated in high-income countries, 3 in 4 children grow up in parts of the world where it is still endemic.

Objectives  To determine the prevalence of clinically silent and manifest rheumatic heart disease as a function of age, sex, and socioeconomic status and to estimate age-specific incidence.

Design, Setting, and Participants  In this school-based cross-sectional study with cluster sampling, 26 schools in the Sunsari district in Eastern Nepal with 5467 eligible children 5 to 15 years of age were randomly selected from 595 registered schools. After exclusion of 289 children, 5178 children were enrolled in the present study from December 12, 2012, through September 12, 2014. Data analysis was performed from October 1, 2014, to April 15, 2015.

Exposures  Demographic and socioeconomic characteristics were acquired in a standardized interview by means of a questionnaire customized to the age of the children. A focused medical history was followed by a brief physical examination. Cardiac auscultation and transthoracic echocardiography were performed by 2 independent physicians.

Main Outcomes and Measures  Rheumatic heart disease according to the World Heart Federation criteria.

Results  The median age of the 5178 children enrolled in the study was 10 years (interquartile range, 8-13 years), and 2503 (48.3%) were female. The prevalence of borderline or definite rheumatic heart disease was 10.2 (95% CI, 7.5-13.0) per 1000 children and increased with advancing age from 5.5 (95% CI, 3.5-7.5) per 1000 children 5 years of age to 16.0 (95% CI, 14.9-17.0) in children 15 years of age, whereas the mean incidence remained stable at 1.1 per 1000 children per year. Children with rheumatic heart disease were older than children without rheumatic heart disease (median age [interquartile range], 11 [9-14] years vs 10 [8-13] years; P = .03), more commonly female (34 [64.2%] vs 2469 [48.2%]; P = .02), and more frequently went to governmental schools (40 [75.5%] vs 2792 [54.5%]; P = .002). Silent disease (n = 44) was 5 times more common than manifest disease (n = 9).

Conclusions and Relevance  Rheumatic heart disease affects 1 in 100 schoolchildren in Eastern Nepal, is primarily clinically silent, and may be more common among girls. The overall prevalence and the ratio of manifest to subclinical disease increase with advancing age, whereas the incidence remains stable at 1.1 per 1000 children per year. Early detection of silent disease may help prevent progression to severe valvular damage.