prevalence of rhd in shimla town

8/14/2019 Prevalence of RHD in Shimla Town

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PROJECT WORK INDEPARTMENT OFCOMMUNITYMEDICINE

PREVALENCE OF

Rheumatic Heart Disease

in School-Children ofShimla.

2007-2008.


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DEPARTMENT OF Community

Medicine

Indira Gandhi Medical College

Shimla, Himachal

CERTIFICATEDept. of Community Med. IGMC/Batch 2004/ Prevalence of RHD in SchoolChildren of Shimla


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This is to certify that the work contained in

the project entitled Prevalence of Rheumatic Heart

Disease in School-Children of Shimla has been carried

out by Mr. Vaibhav Sharma, Mr. Vikrant Sharma, Mr.

Vikrant Thakur, Mr. Vineet Bhardwaj, Mr. Virat Kuntalam

& Mr. Virender Chauhan of batch 2004 themselves under

one direct supervision and guidance of the undersigned.

The data incorporated in this project is

original and genuine.

Dr. A. K. Bhardwaj

MD, FIPSM, FIPHA

Professor & Head

Dept. of Community Medicine

Indira Gandhi Medical College, Shimla, 171001

Table of ContentsAcknowledgement

5

Dept. of Community Med. IGMC/Batch 2004/ Prevalence of RHD in SchoolChildren of Shimla


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Introduction

.6

Why our Study is

Relevant?..............................................................................................................

. 7

Aims and

Objectives

..9

Material and

Methods

..11

Sampling

Technique

12

Modified Jones

Criteria

.13

Tools Used in

Study

.14

Review of

Literature15

Epidemiology

17

Etiopathogenesis

17

Age

Pattern

18

Previous

Studies

.19

Observations

.21

Graphical Representations..

.23



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Summary

.25

Conclusion..

.26

Constrains.

..27

Recommendations.

.28

ANNEXURE

29

Performa

30

Bibliography

32

ACKNOWLEDGEMENT

We have the greatest privilege of expressing out

heartiest thanks to Dr. (Mrs.) Anupam Parashar, Assoc. Professor and

Dr. (Mrs.) Renu P.G. Student, Department of Community Medicine,

Indira Gandhi Medical College, Shimla for their constant

encouragement, invaluable guidance and constructive suggestions

without which this work would have not been successfully completed.

We are also highly obliged and extremely thankful to Dr.

Ashok Kr. Bhardwaj, Prof. & Head Dept. of Community Medicine,

Indira Gandhi Medical College, Shimla for providing us with the



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opportunity to conduct such a study and understand the basics of an

Epidemiological Study. We are also thankful for his expert guidance

and vast and immense practical experience to make our project a

success.

We also extend our thanks to Dr. Anmol Gupta, Assoc.

Professor Dept. of Community Med. IGMC for his invaluable

guidance on project presentation via electronic media.We alsoexpress our heartfelt gratitude to all the faculty members of the Dept.

of Community Medicine who helped us by all possible means.

We would be failing in our duty if we dont thank all thestudents who became our subject of study without whom none of this

would have been possible.

Vaibhav Sharma (0458)

Shimla Vikrant Sharma (0459)

May, 2008. Vikrant Thakur (0460)

Vineet Bhardwaj (0461)

Virat Kuntalam (0463)Virender Chauhan (0464)



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INTRODUCTION

INTRODUCTION

Rheumatic Heart Disease (RHD) is a noncommunicable but crippling disease, it is the cardiac

manifestation of Rheumatic Fever, which is a febrile disease

affecting connective tissue particularly in heart, joints,

subcutaneous tissue in the form of sub cutaneous nodules and

rarely does it affect the CNS. Initiated by infection of throat



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by a Group A beta haemolytic streptococcus (GABHS), the

heart lesions are the only one which can lead to chronic

illness, disability and early death. Prognosis depends on

seriousness of Carditis and frequency of recurrent attacks.

Most of the time, it is preceded by an episode of sore throat.

RHD is a world wide problem especially in

population living in over crowded and low socioeconomic

circumstances. It is especially prevalent in school children

which happen to be the most vulnerable group. It can be

called as profession hazard of school.

Why our study is relevant?

1. Crippling our Future generation

2. Catches them young

3. RHD Constitutes 20-25% of hospital admission due toCVD.

4. Prevalence low but Significant Morbidity & Mortality.

5. School going Children constitutes 20-25% of total

population of India.

6. Average age at the time of death due to RHD is 35 yrs.

An epidemiological study of RHD in school going

children in hilly area was done which gave the prevalence of

2.98 per thousand with no significant difference between the

age groups of 5-10 and 11-16 or in either sex.



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With the advent of Penicillin and newer drugs,

incidence and prevalence, mortality & morbidity associated

with RHD has considerably reduced.

Rheumatic Fever being an occupational disease of

school children, it can effectively be screened.



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AIMS

&

OBJECTIVES

Aims and Objectives



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1. To determine the prevalence of RHD among

school children of Shimla.

2. To study the relation of RHD with factors likeage and sex.

3. To learn the basics of conducting an

epidemiological study.



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Material

&

Methods

Materials and methods

Geographical Area-

Himachal Pradesh comprises of varied

geographical terrains like plains, hills, valleys and mountains.

The state has area of 55673 sq. km. and is divided into 12

districts.



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Shimla is capital of H.P. situated at an altitude

of 2130 mts. With an area of 18 sq. km. town has temperature

variation in winter (max. 18 degrees, min. -1 degrees) and

summer (33 degrees max. and min. of 1degree)

Sampling technique

In the cross sectional study, a stratified

random sample of 217 children was selected from one school

in the age group of 5 to 15 years of age.

Way of conducting survey

Survey was conducted by the way of

questionnaires. The questionnaire was structural already andthe questions in it were close ended questions which had their

answers in only YES or NO.

Criteria for study of RHD

According to modified Jones criteria, the

clinical features of rheumatic fever are divided into major and

minor manifestations which lead to diagnosis of rheumatic

fever.

Modified Jones CriteriaDept. of Community Med. IGMC/Batch 2004/ Prevalence of RHD in SchoolChildren of Shimla


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For Diagnosis of Rheumatic Heart Disease

Fig. Showing the Modified Jones Criteria for Diagnosis of RHD

Tools of methods used in the study

The school was visited with prior approval of

the principal and purpose and nature of study were already

discussed with her.



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Children were randomly selected from classes and

were examined after a detailed history was taken on the basis

of pre-formed questionnaire.

Then cardiovascular examination was done and

murmurs were auscultated which was done in erect, left lateral

and recumbent positions.

There was only one case of murmurs with

parasternal heave and was referred to Dept. of Cardiology

IGMC Shimla.



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REVIEW OF

LITERATURE

REVIEW OF LITERATURE

Historically the disease was recognised by Hippocrates who

categorically stated that:



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child who has pain in legs is going to become short of

breath.

The name rheumatic was given by

Haygarth in 1805 A.D. Its association to heart was established

in 1800A.D. by Pit Cairn and Jenner.

Before Second World War, relatively little

was understood about epidemiology and pathogenesis of these

infections and chains sequel. The lab studies of Rebecca

Lancefield and those by Dr. Rammal Kamp and his colleaguesmade significant contribution to the understanding and control

of RHD. Only studies on repository penicillin was another

major achievement causing a significant decrease in incidence

of RF/RHD. However, since mid 1980s with the resurgence of

severe GABHS infections and their suppurative and non-

suppurative sequel, the disease reoccupied its previous statusin epidemiologic and clinical studies.

Currently success has been achieved not only

in accurate diagnosis of GABHS in infection but also in

secondary & primary prevention of RHD.

EPIDEMIOLOGY

Rheumatic fever or RHD presents a problem

in all parts of world especially in developing countries. RF is



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the most common cause of heart disease in the 5-30 yrs age

group throughout the world. Rheumatic Heart Disease

constitutes 30-35% of hospital admission due to Cardio-

Vascular Diseases.

ETIOPATHOGENESIS

The disease is an example of molecular mimicry type ofautoimmunity. The complete pathogenesis of this disease is

unknown. There are three main factors.

1. Group A beta-haemolytic streptococcal infection of

upper respiratory tract.

2. Specific susceptibility of human host.

3. Environmental factors like altitude, crowding

&dampness.

This disease is triggered by infection with

group A beta haemolytic streptococci & the serotype that

has attracted special emphasis is M- type 5 which is

frequently associated with RF.

ETIOPATHOGENESIS



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Fig: Showing the Etiopathogenesis of RF

AGE PATTERN

RHD is common in children particularlyschool going children i.e. 5-15 yrs. With almost equal

incidence among age groups 5-10 years and 11-16 years.

PREVIOUS STUDIES IN INDIA



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There have been many studies on this issue in

India in past but few major ones are worth to mention here.

As per the study conducted by Indian Council of Medical

Research (ICMR), the prevalence of RHD was found to be

2.1/1000 to 11/1000 in different regions of the country.

Average prevalence was around 7/1000 with no male or

female predilections.

One of the largest studies conducted so far on

this subject is the study conducted by Dept. of Cardiology,

Christian Medical College (CMC), Vellore. The study

sample consisted of more than 2 Lakh (n = 229,829) and in

that study prevalence was found to be 0.68/1000. Thereason for such a low prevalence was that the final

evaluation was done by the experts after echocardiography

which omitted the possible false positive cases.

PREVIOUS STUDIES HIMACHAL

PRADESH

Few studies have been done in hilly areas of

North India and they have shown progressive decline in the

prevalence of RHD. A study conducted in and around

Shimla in 1994 showed the prevalence of 2.98/1000.



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Earliest study in this region of country dates

back to 1956 when prevalence was found to be 3.9/1000

which happen to be the highest reported prevalence rate

through out the country at that time.

Another study was conducted in 1998 by

Dept. of Community Medicine, IGMC, Shimla reported a

prevalence rate of 3.627/1000.

As per the ongoing study being conducted byDept. of Community Medicine, IGMC, Shimla so far only

one case of RHD is reported in approximately 5000 student

surveyed.



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OBSERVATIO

NS



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OBSERVATIONS

Out of 217 students studied there were 91 Girls and 126

Boys. All were in the age Group of 5-11 years.

Out of these, 23 (10.5%) reported to have cough at the

time of study. 16 (7.4%) of them complained of having sore

throat at that time or in the passed week.

Shortness of Breath was reported by 14 students i.e.5.1%. 8 students said that they have some degree of chest pain

off and on. This group comprised 3.7% of the total.

7 students complained of occasional episodes of syncope

i.e. approx 3% student have had syncope.

Joint Pains were reported by 5 students (2.3%).

Other complaints reported by students were Pain

abdomen (2), giddiness etc. which were largely irrelevant to

our study.



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Fig. Showing findings in the form of Bars

Most of the children reported with cough and

sore throat that can be explained if we keep in mind thetime of study. The study was conducted in the month of

Feb. when the weather here was freezing.

Findings of cyanosis on physical examination

can also be attributed to cold surroundings prevalent at the

time of study.



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Fig. Showing the observations in the form of Pie.

Fig. Showing the findings on GPE

In the above graph, the most frequent finding is shown by the complete

cone while rest of the cones show the frequency of events relative to the

most frequent finding.



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SUMMARY



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SUMMARY

A stratified sample of 217 school children in

the age group 5 years to 11 years was taken in a school in

Shimla town. Since the main motive was to learn the basics

involved in an epidemiological study and also there was a

lot of constrains in the form of money, material and time.

Therefore, such a small sample was chosen. Also it was the

month of Feb. when most of the schools were closed.

Percentages of absentees were 5 percent.

In our study, no case was found to be positive

for Rheumatic Heart Disease (RHD) on clinical grounds,

though lot of positive findings were found related to

cardiovascular system.

CONCLUSION

Clinical Examination as the method of

identifying a case of Rheumatic Heart Disease is neither

very specific nor it is sensitive. Parents were reluctant to

get their child evaluated by the expert. There was no case of

Rheumatic Heart Disease in our study. Pallor was positive

in significant proportion (17%) of the subjects.



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CONSTRAINTS

Like any other epidemiological study, our

study too was limited by constraints of money, material and

time. Other than these the major limitations in our studies

were:

1. Inadequate sample size combined with a very low

prevalence.

2. Selection bias i.e. may be some of the students who were

suffering from RHD might not have attended the school

owing to their illness and thus were left out.

3. Our limited knowledge in the concerned fields. We are

students only.

4. Compliance of children was also a limitation, but this

was limited only to the younger age groups.5. Reliability of the history given.

6. Clinical features of the disease are not very specific and

there is wide range of overlap.



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RECOMMMENDATIONS

Based on our findings we make following

recommendations in the benefit of health of school

children:

1. Teachers are recommended to remain ultra vigilant for

the warning symptoms of the disease.

2. Practical suggestions like opening certain windows for

effective cross ventilation are advocated. But that is bit

difficult to follow especially in the winters.

3. We also suggest that at least one parents-teacher meeting

should be held every quarterly to discuss the progress of

their wards in the fields of studies and health as well.



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ANNEXURE



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PERFORMA

Name: ____________________ Age: ____Sex: __

School: __________________________________

Address: ____________________

_____________________

HISTORY:

H/o Recurrent Sore Throat Yes/No

H/o Chest Pain Yes/No

H/o Palpitation Yes/No

If Yes, Is it aggravated by activities? Yes/No

Is it even present at rest? Yes/No

H/o Syncope (any postural association) Yes/No

H/o Fever/Body aches/Chills/Rigors/Sweats Yes/No

H/o fleeting joint pains Yes/No

H/o abnormal movements of limbs Yes/No



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H/o any penicillin prophylaxis for RHD Yes/No

(If Yes then when and how long?)

H/o Shortness of Breath Yes/No

H/o PND/ Orthopnoea Yes/No

H/o Cough Yes/No

H/o Haemoptysis Yes/No

H/o Discharge from Ear/Ear aches Yes/No

Any Significant past History Yes/No

GENERAL PHYSICAL EXAMINATION:

Pallor: Yes/No

Icterus: Yes/No

Cyanosis: Yes/No

Clubbing: Yes/No

Lymphadenopathy Yes/No

JVP: Raised/Not Raised



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Detailed CVS Examination:

Inspection:

Chest Symmetry:

Apex Beat:

Thrill:

Palpation:

Palpable Thrill/Murmur:

Parasternal Heave:

Percussion:

Cardiac Dullness:

Auscultation:

1st and 2nd heart sounds:

Murmur:

Any added Sounds:



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BIBLIOGRAPHY

1. Thakur JS, Negi PC, Ahluwalia SK, Vaidya NK. Epidemiological

survey of RHD among school children in Shimla hills of Northern

India: Prevalence and Risk Factors; Journal of Epidemiology &

Community Health 1996 Feb; 50(1); 62-67.

2. RF & RHD: Report of a WHO study Group. WHO Tech Rep Ser No.

764, 1988.

3. Jose VJ, Gomathi M. Declining Prevalence of Rheumatic Heart

Disease in Rural School Children in India: 20012002;Indian Heart J2003; 55: 158160.

4. Lalchandani A, Kumar HRP, Alam SM. Prevalence of rheumatic fever

and rheumatic heart disease in rural and urban school children of

district Kanpur [Abstract].Indian Heart J2000; 52: 672.

5. K Rajesh, Controlling RHD in Developing Countries; Public Health

Practice; 1995.

6. Mahajan BK, 5th edition Methods in Biostatistics 1991. New Delhi:

Jaypee Brothers, 87-101.

7. Park K, 19th edition Parks Textbook of Preventive and Social

Medicine 2007. Jabalpur: M/s Banarsidas Bhanot Publishers; 315-318,

696-706.

prevalence of rhd in shimla town

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