Date of Award

January 2024

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Bernardo Lombo

Abstract

A SCHOOL-BASED STUDY OF THE PREVALENCE OF RHEUMATIC HEART DISEASE IN BALI, INDONESIAAlysha Rose, Douglas Barber, Luh Oliva Saraswati Suastika, Ida Bagus Rangga Wibhuti, Jorge Otero, Michael Mankbadi, Taylor Libera, Andrea Baldick, Robert McNamara, Lissa Sugeng, Bernardo Lombo. Section of Cardiology, Department of Internal Medicine, Yale University, School of Medicine, New Haven, CT. Rheumatic heart disease is a form of acquired heart disease that results from untreated or undertreated beta-hemolytic streptococcal pharyngitis. Its manifestations include valvular rigidity and deformity, commissural fusion, shortening and fusion of the chordae tendinae, and, over the course of decades, valvular dysfunction including stenosis and/or regurgitation. Rheumatic heart disease is a significant cause of morbidity and premature mortality across the developing world, causing over 300,000 preventable deaths annually, and causing approximately 15 to 20 percent of all heart failure in endemic countries. More than 80 percent of children worldwide live in countries where rheumatic heart disease is endemic. Estimates of rheumatic heart disease prevalence in low-income and middle-income countries range from 10 to 50 per 1,000, with an estimated prevalence of 18.28 per 1,000 in South Asia. Because early rheumatic heart disease can manifest sub-clinically, leading to delayed diagnosis and worsened long-term health outcomes, echocardiographic rheumatic heart disease screening programs in endemic regions are recommended by the World Heart Federation (WHF). The use of efficient, portable screening technologies is essential to the feasible implementation of this recommendation in rural and under-resourced settings. While recent studies have measured local prevalence of rheumatic heart disease in some regions of Indonesia, no study has yet investigated pediatric rheumatic heart disease prevalence in Bali province nor nationwide in Indonesia. This study aims to determine the prevalence of pediatric rheumatic heart disease in Bali, Indonesia using portable screening technology. This was a cross-sectional study of the prevalence of rheumatic heart disease among children aged 12 to 18 years in both rural and urban schools in Bali, Indonesia. Screening sites and subjects were selected randomly using a random number generator application. Six schools in Denpasar city, Bali, and three schools from each of two other urban Bali districts (six total district schools), were randomly selected, for a total of 12 schools screened. Randomly selected children received focused physical exams and echocardiographic screening for rheumatic heart disease. Clinician teams from Udayana University and Yale University used portable ultrasound machines (Terason T3200 and Terason 3300 [Massachusetts, USA], GE Vivid iQ [USA]) to acquire and interpret grayscale images and color and spectral Doppler interrogation in parasternal and apical views to assess each patient for definite or borderline rheumatic heart disease according to the 2012 WHF guidelines. We screened 701 children (mean age 14.9±1.8, 57 percent female) in 12 schools in Bali. Three subjects met WHF criteria for definite rheumatic heart disease, and seven for borderline rheumatic heart disease. Prevalence for definite rheumatic heart disease was 4.3 per 1,000 (95 percent confidence interval 0.9 to 12.5 per 1,000) among screened subjects in Bali, Indonesia. This pilot epidemiological study estimated the prevalence of rheumatic heart disease among schoolchildren aged 12 to 18 in Bali, Indonesia, with the use of portable tablet echocardiography screening. We conclude that portable tablet ultrasound devices are both feasible and appropriate tools for rheumatic heart disease screening and may support the achievement of the WHF recommendation for rheumatic heart disease screening in rural and under-resourced areas. This pilot study will support the development of a nationwide rheumatic heart disease screening program in Indonesia, which will enhance global understanding of rheumatic heart disease in Indonesia and inform the development of public health interventions to provide screening and treatment for affected individuals.

Comments

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