Al-Munibari
PREVALENCE OF RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE IN YEMEN
Table 2. Rheumatic Heart Disease in Relation to Socioeconomic Class
Social Class
No. of Students
No. of Cases
% of Sample
Incidence per 1000
Low
1160
2860
980
7
10
1
0.14
0.20
0.02
6.0
3.5
1.0
Middle
High
healthcare systems of many developing nations where
more than a third of all cardiac admissions are due to
RHD.
There was a significant correlation between socioeconomic
level and the prevalence of RF and RHD in Yemen. The
high prevalence of RHD could be attributed largely to a
low standard of living. The decline in the prevalence of
RHD in industrialized countries has been attributed mainly
to improvement in living standards, and where it persists,
it is associated with low social circumstances and
poverty.14–16 Low levels of education, income, and social
status have previously been noted as factors related to the
incidence of RHD.17,18 Poverty and illiteracy breed over-
crowding that promotes the spread of many infections,
and due to ignorance and scarcity of healthcare facilities,
these are often neglected until complications set in, as in
the case of RF.16,18,19
Figure 2. The pattern of valvular diseases among cases of rheumatic
heart disease. AVD = aortic valve disease, AVR = aortic valve
replacement, CHD = congenital heart disease, MR = mitral regurgitation,
MS = mitral stenosis, MVD = mitral valve disease.
(3/18; 17%), as shown in Figure 2. The patient who had
undergone aortic valve replacement had a well-functioning
mechanical prosthesis in association with mitral regurgita-
tion. The remaining case had rheumatic mitral regurgitation
(based on a history of RF, clinical examination, and echo-
cardiographic criteria) in conjunction with congenital
bicuspid aortic valve of no hemodynamic significance.
It is recommended that collection of further epidemio-
logical data on RF and RHD in Yemen be carried out. As
the main factor in the development of rheumatic fever is
streptococcal throat infection, further study of this
condition should be undertaken.Anational register should
be set up to record and document newly discovered cases.
RF and RHD clinics are also needed. A Yemeni board
should be established to coordinate these activities.
DISCUSSION
As in most developing countries, RF and RHD have their
place among the cardiovascular problems in everyday
practice in Yemen. RF and RHD are chronic illnesses in
all age groups beyond infancy. The prevalence of RF and
RHD in schoolchildren of Sana’a city was 3.6 per 1000.
In industrialized countries, the incidence of RF has
declined to 0.05 per 1000 per year.4,5 Rheumatic heart
disease had declined in the United States (0.6 per 1000)
and Japan (0.7 per 1000).6,7 It appears that schoolchildren
in Yemen have a higher rate of RHD than many other
developing countries, especially neighboring countries.
Reports from Oman indicate a rate of 0.8 per 1000, and
the prevalence of RHD in Saudi Arabia is 2.8 per 1000.8,9
The prevalence in our study is consistent with a 1994
study from Egypt giving a rate of 3.4 per 1000 among
schoolchildren in the El-Menoufia area.10 Earlier reports
from Egypt in the 1960s gave different figures: 1.3 per
1000 in the western desert coast; and 0.7 per 1000 in
Alexandria.11,12 High rates of RF and RHD have been
recorded in Zambia (12.6 per 1000), Sudan (10.2 per
1000), Bolivia (7.9 per 1000), Egypt (5.1 per 1000), and
Kathmandu city, Nepal (1.2 per 1000) in the period 1986
to 1990.12,13 Although RF and RHD rates have shown
remarkable declines in developed countries over the last
40 years, they still present a considerable burden to the
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ASIAN CARDIOVASCULAR & THORACIC ANNALS