Incidences of Rheumatic Fever In Pediatric Age Group In The Southern Region, KSA
Background of the Study
Rheumatic fever (RF) is an autoimmune disease that develops when treatment for any streptococcal throat infection is delayed or incomplete. Despite the disease being associated with strep throat, it is not an infection; but rather an inflammatory response to the throat infection. According to Jones (1944), the five cardinal manifestations of the disease include carditis, subcutaneous nodules, arthritis, chorea, and erythema marginatum. These features have been used by health professionals over the years to clinically diagnosis RH, albeit with little adjustments. Accordingly, the American Heart Association (AHA) has revised Jones criteria twice; first in 1992 and most recently in 2015. In the latest revision, the major criteria for clinical diagnosis of RH are supplemented by echocardiographic examination; while there is also a new concept of subclinical carditis and the isolation of low, medium, and high-risk populations among patients (Gewitz et al., 2015).
Initially, RF was common across all populations, but at present, improved living conditions and treatment of superficial S. pyogenes has resulted in reduced incidences of the disease in the developed world (Carapetis, J. R. (2007). It follows that the most affected populations are the low and middle-income nations (Carapetis, J. R. (2007). Although the global burden of RF is significant and predominant in populations with low-resource settings, some wealthy nations still have to grapple with the disease (Sika-Paotonu, Beaton, Raghu, Steer, & Carapetis, 2017). This is attributed to cases of delayed or incomplete treatment of S. pyogenes in some of the developed countries; thus allowing for the development of rheumatic heart disease (RHD) – the harmful post-infection sequel of RF (Carapetis, J. R. (2007).
Carapetis, Mulholland, & Weber (2005) opine that upper respiratory tract infection by Group A streptococcal (GAS) infection is among the leading human pathogens responsible for mortality and morbidity; only exceeded by the Human Immunodeficiency Virus (HIV), Malaria, and TB. Therefore, the World Heart Federation (WHF) and the World Health Organization have recognized RF/RHD as the most neglected tropical disease (Remenyi, Carapetis, Wyber, Taubert, & Mayosi, 2013; Wyber, Zühlke, & Carapetis, 2014). Worldwide, half of the RF patients exhibit carditis; presented as pericarditis, myocarditis, and vulvitis (Marijon, Mirabel, Celermajer, & Jouven, 2012). All RF manifestations tend to resolve except valvular damage, a permanent condition that is responsible for most cases of mortality and morbidity of the disease (Reményi et al.; 2012).
Further, estimates indicate that approximately 60% of RF patients in endemic countries end up developing RHD (Undas, & Szczeklik, 2013). It has also been noted that female RF patients have a 1.6 – 2% higher risk of developing RHD than male patients. However, children are the most susceptible to RF and the subsequent development of RDH (Kamal et al., 2019). The situation in Saudi Arabia is such that cases of RF are still significant with incidences in the pediatric age range being higher than the global rates (Ferretti, Stevens, & Fischetti, 2016; Alqantish, JAlfadhel, Albaleli, & Alqahtani, 2019). Therefore, studies on the incidences of RF in vulnerable segments of the population, such as children are recommended in Saudi Arabia and other parts of the world with similar problems.
Problem Statement
During the last century, the WHO made great efforts to deal with RH and its sequel RHD; through collaborations with relevant organizations and various countries. As a consequence, there have been significant decreases in RH cases, mostly in developed countries. However, the disease still affects Arab Gulf countries, Africa, Asia the Pacific, as well as indigenous populations and New Zealand (Eltohami, Hajar, Folger, & Eltohami, 1997; Seckeler, & Hoke, 2011). There is limited recently published data about the prevalence of RF in Saudi Arabia, hindering efforts to understand the current impact of the disease on different segments of the population (Alqantish et al., 2019). Additionally, Saudi Arabia has not put in place any prevention and control program for dealing with the disease (Al-Harbi, 2019). Therefore, there are high incidences of RH and RHD in the country with children recoding the highest rates as reported in studies carried out between 1991 and 2003.
One of the studies, the last large RF research in the country which was conducted in 1991 established that the disease had a prevalence of 0.3 per 1000, 2.8 per 1000 for chronic RF and thus a total of 3.1 per 1000 for school-age children (Al Qurashi, 2009). Another study was hospital-based research from the capital Riyadh, among patients with RF between 1994 and 2003. Results in this study showed that within the ten years, a total of 96 children with a mean age of 9 years had been diagnosed with the disease (Al Qurashi, 2009). The Annual incidence of RH/RHD peaked in 1994 and 1995 with 17 diagnosed incidences in each of the years; while there a dramatic in 2003 when only two cases were reported (Al Qurashi, 2009).
Despite the progress made in the socio-economic development in Saudi Arabia, RF/RHD is still a serious complication especially in the rural area where medical attention and medical care is less (Al Qurashi, 2009). The Southern part of Saudi Arabia has a significant portion classified as rural; thus, there is a high likelihood of cases of RF being high. It follows that the research following this proposal aims to ascertain the incidences of RF among those in the pediatric age in the Southern region of the Kingdom of Saudi Arabia; with a focus on the reasons for the high rates of RF in the region, education of the population in the region about the disease, as well as how to minimize the occurrence of the disease.
Objectives of the Study
Broad objective. The broad objective of the research following this proposal is to ascertain the incidences of RF in the pediatric age group in the southern region of Saudi Arabia.
Specific objectives. Specific objectives are to:
- Identify the reasons for the high rate of RF in the pediatric age group in the southern region of Saudi Arabia.
- Educate the local population in the pediatric age group in the Southern region of Saudi Arabia about the diagnosis, treatment, and management of RF.
- Reduce the incidence of the occurrence of RF in the pediatric age group in the Southern region of Saudi Arabia.
Research questions and Hypotheses
Research questions with the corresponding null and alternative hypotheses for the proposed study are listed as follows:
RQ1: What is the correlation between the level of urbanization and incidence of RF in the pediatric age group in the southern region of Saudi Arabia?
HA1: There is a significant positive correlation between the level of urbanization and the incidence of RF in the pediatric age group in the southern region of Saudi Arabia.
Ho1: A significant positive correlation does not exist between the level of urbanization and the incidence of RF in the pediatric age group in the southern region of Saudi Arabia.
RQ2: What is the correlation between the education of the local population about RF and the reduction of its incidences in the pediatric age group in the Southern region of Saudi Arabia?
HA2: There is a significant positive correlation between the education of the local population about RF and the reduction of its incidences in the pediatric age group in the Southern region of Saudi Arabia.
Ho2: A significant positive correlation does not exist between the education of the local population about RF and the reduction of its incidences in the pediatric age group in the Southern region of Saudi Arabia.
Literature Review
Historical perspective. The major clinical manifestations of RF were not known until 1685 when an English physician by the name Thomas Sydenham managed to distinguish an acute, febrile polyarthritis as well as the recognizing that the disease attacked the “young and vigorous” (Hajar, 2016). More knowledge in the area then developed between the 17th and 20th century, courtesy of the studies and observations of several physicians including Mathew Baillie who in 1797 noted the thickening of heart valves in autopsies of patients who had died of acute rheumatism; Richard Bright who connected RF to febrile polyarthritis in 1839; and Jean-Baptiste Bouillaud who ascertained the correlation between rheumatism and the heart disease (Hajar, 2016).
In the early years of the 20th Century, RF was a major cause of morbidity and mortality even in the developed countries of that period (Bland, 1987). For instance, the situation in the United States at the time was such that RF was a leading cause of death among individuals aged between 5 and 20 years; and second only to tuberculosis for people in the age group of between 20 and 30 years (Hajar, 2016). Accordingly, RF used to be a fatal disease but in the last half-century, the prevalence of the disease has continued to decrease in the developed nations. However, RF still a major cause of morbidity and mortality among young people in developing countries (Carapetis et al., 2005).
Epidemiology. The occurrence of RF is common among children of the school-going age of 5 -14 years (Meira, Goulart, Colosimo, & Mota, 2005). The disease occurs throughout the world but its epidemiology is varied in different geographical areas. Today, the annual incidence rate of RF ranges from less than 0.5 per 100,000 in the developed countries to 100 per 100,000 in the developing nations (Gewitz et al., 2015). In the first attack, mean incidence rates for RF range from 5 to 51 per 100,000 (Tibazarwa, Volmink, & Mayosi, 2008). A comparison of different regions across the world reveals that America and Western European countries have the lowest RF annual incidence rate of less than 10 per 100,000; while Eastern Europe, Asia, Australia, the Middle East, and Africa have a relatively higher RF annual incidence rates of more than 10 per 100,000 (Tibazarwa, Volmink, & Mayosi, 2008). On a global scale, it is estimated that about 500,000 cases of RF are recorded each year which mortality rates being about 230,000 annually (Webb, Grant, & Harnden, 2015).
Sources of Burden of Disease Data. Multiple sources of information can be used to show the burden of RF and RHD. Such sources include hospital and health records, death records, extrapolations from similar countries, historical estimates, disease notification, echocardiography screening, and global burden disease data (Wyber et al., 2018). To begin with, hospital or health records contain patient information such as admission or discharge diagnosis for inpatients; thus valuable information about RF can be captured. However, some data is potentially missed because only those who present themselves to a hospital will have their details captured; leaving out people who can’t access hospitals or have symptoms that are too mild to warrant a visit to the hospital (Bryant, Robins-Browne, Carapetis, & Curtis, 2009). As for death records, it is possible to tell the burden of disease based on the numbers and causes of deaths. One major challenge that can be attributed to this method is significant underreporting (Binagwaho et al., 2013).
Concerning extrapolations from similar countries, it is possible to estimate the burden of disease from similar areas or countries. For instance, countries in the Middle East tend to have settings with similar economic development and ethnicity, thus providing credible guidance for estimating the RF/RHD burden (Wyber et al., 2018). Historic estimates as a source of information on the RF/RHD disease burden can be through data collected through cardiac auscultation of school-going children in the past (Singh, Carapetis, Buadromo, Samberkar, & Steer, 2008). Although auscultation has been associated with the true burden of the disease, it can still be used to estimate the current prevalence of RF. Disease notification is also useful in communicating the burden of disease at a place where RF/RHD is a notifiable condition. However, this method is susceptible to change due to education or outreach activities at a place.
Echocardiographic screening of school-going children is the current gold standard for estimating the rate of occurrence of RF/RHD. Accordingly, rigorous echocardiographic screening can be useful in providing the burden of disease baseline data. However, the role of this method of data collection in the clinical management of RF/RHD is still being studied (Marijon et al., 2007). Finally, the global burden of disease data can be used to do local estimates and thus providing a credible check for plausibility (Carapeti et al., 2005).
RF among individuals in the pediatric age group. Many studies have established that the incidence of RF/RHD is highest among individuals in the pediatric age group (Meira et al., 2005; Carapetis et al., 2005; Al Qurashi, 2009; Ferretti et al., 2016; Alqantish et al., 2019). The onset of the disease is usually sudden, and covers between 1 to 8 weeks after recovery from a sore throat or scarlet fever and may manifest through a combination of joint pain, chest pain or palpitations, fever, jerky uncontrollable movements, small bumps under the skin or a rash. Although acute episodes are typically self-limited, there is a high likelihood that they can lead to a chronic and progressive heart disease as well as cardiac compensation (Esmaiel, Fouda, & Elkazh, 2014). Some cases of RF/RHD in children and even older people have been associated with the genetic susceptibility of the patients (Bryant et al., 2014).
The extent of the effects of RF in children’s lifestyles may be influenced through medical or social factors. As pertains medical factors, a child’s lifestyle may be affected through difficulties in adhering to the rheumatic regimen, complications resulting from the disease or the duration between the onset of the disease and the start of medical intervention (Esmaiel et al., 2014). On the other hand, social factors may include the ae, gender and nursing intervention (Esmaiel et al., 2014). Nursing care for a child suffering from RF can be complex, rewarding, and also challenging. If there is careful nursing assessment, diagnosis, treatment and evaluation of a sick child then there is likely to be a success in the recovery and rehabilitation of the patient (Esmaiel et al., 2014).
Methodology
The research will use different methods to acquire information. The methods used will be questionnaires, interviews and observation. Questionnaires will be issued to victims and relatives of victims of the rheumatic disease who agree to take part in the research conducted. Observation will be done on children suffering from rheumatic fever to deduce the cause of the disease, the progress they have to while under the medication, and how they are responding to treatment.
Research Design
The research will use research designs such as field surveys, secondary data analysis and case research. The field surveys will be to ascertain the occurrences of the disease by finding out those suffering from the disease. The case research design will be used to follow up on the individual cases of those found with the disease and agreed to take part in the research. The secondary data analysis design will be used to get more information on the previous cases of the rheumatic fever diseases that have been dealt with by a selected number of medical facilities.
Sampling Technique
The sample size determination will be done in line with Fishers et al. (1998) formula of sample size determination given as n=z2pq/d2. Consequently, suitable sample size will be drawn from the population of patients and relatives of victims of the rheumatic disease who agree to take part in the research conducted.
Budget Plan
The research is going to incur expenses on labor on the personnel who will be involved, travelling costs when following up on different patients who will be participating in the research, and buying several things that will be required to carry out the research successfully and efficiently throughout the time of the project. It follows that the project will cost an estimated 100,000 Saudi Riyals for it to be complete and successful. Below is a table showing the different items and their estimated costs.
| ITEM | COST (SAR) |
| Labor | 30,000 |
| Travel | 20,000 |
| Research Equipment | 25,000 |
| Research Materials | 20,000 |
| Publication and Dissemination | 5,000 |
| TOTAL | 100,000 |
Project Time Plan
The proposed research will be conducted over 6 months on the cases of rheumatic fever that will have occurred in the course of that period. Below is a table showing the six-month project time plan; with activities and the scheduled time for each of them.
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References
Al-Harbi, K. (2019). Clinical Spectrum and Considerations of Rheumatic Fever and Rheumatic Heart Disease: Call for National Disease Prevention and Control Programme in Saudi Arabia.
Al Qurashi, M. (2009). The pattern of acute rheumatic fever in children: Experience at the children’s hospital, Riyadh, Saudi Arabia. Journal of the Saudi Heart Association, 21(4), 215-220.
Alqantish, J., Alfadhel, A., Albaleli, A. & Alqahtani, D. (2019). Acute rheumatic fever diagnosis and management: Review of the global implications of the new revised diagnostic criteria with a focus on Saudi Arabia. Journal of the Saudi Heart Association, 31(4): 273-281. DOI: 10. 1016/j.jsha.2019.07.002
Khalid Al-Harbi. (2019). Clinical Spectrum and Considerations of Rheumatic Fever and Rheumatic heart disease: Call for National Disease Prevention and Control Programme in Saudi Arabia. Journal of Dental and Medical Sciences (IOSR-JDMS), 18(3): 37-42.
Marijon, E., Mirabel, M., Celermajer, D. S., & Jouven, X. (2012). Rheumatic heart disease. The Lancet, 379(9819), 953-964.
Marijon, E., Ou, P., Celermajer, D. S., Ferreira, B., Mocumbi, A. O., Jani, D., … & Jouven, X. (2007). Prevalence of rheumatic heart disease detected by echocardiographic screening. New England Journal of Medicine, 357(5), 470-476.
Meira, Z. M. A., Goulart, E. M. A., Colosimo, E. A., & Mota, C. C. C. (2005). Long term follow up of rheumatic fever and predictors of severe rheumatic valvar disease in Brazilian children and adolescents. Heart, 91(8), 1019-1022.
Remenyi, B., Carapetis, J., Wyber, R., Taubert, K., & Mayosi, B. M. (2013). Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease. Nature Reviews Cardiology, 10(5), 284.
Reményi, B., Wilson, N., Steer, A., Ferreira, B., Kado, J., Kumar, K., … & Mocumbi, A. O. (2012). World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease—an evidence-based guideline. Nature Reviews Cardiology, 9(5), 297.
Seckeler, M. D., & Hoke, T. R. (2011). The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clinical epidemiology, 3, 67.
Sika-Paotonu, D., Beaton, A., Raghu, A., Steer, A., & Carapetis, J. (2017). Acute rheumatic fever and rheumatic heart disease. In Streptococcus pyogenes: Basic Biology to Clinical Manifestations [Internet]. University of Oklahoma Health Sciences Center.
Singh, P. I., Carapetis, J. R., Buadromo, E. M., Samberkar, P. N., & Steer, A. C. (2008). The high burden of rheumatic heart disease found on autopsy in Fiji. Cardiology in the Young, 18(1), 62-69.
Tibazarwa, K. B., Volmink, J. A., & Mayosi, B. M. (2008). Incidence of acute rheumatic fever in the world: a systematic review of population-based studies. Heart, 94(12), 1534-1540.
Undas, A., & Szczeklik, A. (2013). Interna Szczeklika. Podręcznik chorób wewnętrznych. Medycyna Praktyczna, 162.
Webb, R. H., Grant, C., & Harnden, A. (2015). Acute rheumatic fever. Bmj, 351, h3443.
Wyber, R., Johnson, T., Perkins, S., Watkins, D., Mwangi, J., & La Vincente, S. (2018). Tools for Implementing Rheumatic Heart Disease Control Progammes (TIPs) Handbook.
Wyber, R., Zühlke, L., & Carapetis, J. (2014). The case for global investment in rheumatic heart-disease control. Bulletin of the World Health Organization, 92, 768-770.
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