Abstract
BackgroundAlthough low socioeconomic status, and environmental factors are known risk factors for rheumatic heart disease in other societies, risk factors for rheumatic heart disease remain less well described in Uganda.Aims and ObjectiveThe objective of this study was to investigate the role of socio-economic and environmental factors in the pathogenesis of rheumatic heart disease in Ugandan patients.MethodsThis was a case control study in which rheumatic heart disease cases and normal controls aged 5–60 years were recruited and investigated for socioeconomic and environmental risk factors such as income status, employment status, distance from the nearest health centre, number of people per house and space area per person.Results486 participants (243 cases and 243 controls) took part in the study. Average age was 32.37+/−14.6 years for cases and 35.75+/−12.6 years for controls. At univariate level, Cases tended to be more overcrowded than controls; 8.0+/−3.0 versus 6.0+/−3.0 persons per house. Controls were better spaced at 25.2 square feet versus 16.9 for cases. More controls than cases were employed; 45.3% versus 21.1%. Controls lived closer to health centers than the cases; 4.8+/−3.8 versus 3.3+/−12.9 kilometers. At multivariate level, the odds of rheumatic heart disease was 1.7 times higher for unemployment status (OR = 1.7, 95% CI = 1.05–8.19) and 1.3 times higher for overcrowding (OR = 1.35, 95% CI = 1.1–1.56). There was interaction between overcrowding and longer distance from the nearest health centre (OR = 1.20, 95% CI = 1.05–1.42).ConclusionThe major findings of this study were that there was a trend towards increased risk of rheumatic heart disease in association with overcrowding and unemployment. There was interaction between overcrowding and distance from the nearest health center, suggesting that the effect of overcrowding on the risk of acquiring rheumatic heart disease increases with every kilometer increase from the nearest health center.
Highlights
[1] Rheumatic heart disease (RHD) and Acute Rheumatic Fever (ARF) affect about 16 million people worldwide, with over 70% in Sub-Saharan Africa where the prevalence has been found to be between 6.5 to 30 per1000 people. [2,3,4] no national prevalence data exists on RHD in Uganda, we have recently found a prevalence of per 1000 cases among randomly selected primary school children in Kampala district, the country’s capital. [5,6] Anecdotal data from a hospital based study done at Mulago National Referral Hospital ranked RHD as the commonest cause of heart disease in the to 49 age group, and second commonest cause of heart disease overall, after hypertension. [7]
Acute rheumatic fever prevalence has been seen to go down as living conditions improve. [8,9] A low socioeconomic status mainly characterized by poverty, illiteracy and unemployment has been associated with RHD, a direct link between these factors and the disease has not been confirmed. [10,11] While ARF/RHD has been described as a disease of poverty, its persistence in most developing countries, and reemergence in developed countries where it had nearly disappeared raises concern on the role of environmental and other factors, other than poverty, [12,13] and the consequential increase in group A Streptococci transmission
Overcrowding A previous study in Soweto, South Africa found a higher prevalence of RHD among suburban dwellers, usually the lower socioeconomic class, who tended to live in overcrowded residences, while a survey in Congo Kinshasa, found that children from overcrowded suburban families had a higher prevalence of RHD irrespective of income and social classes of their parents [4,24] More recently, Jaine et al, in an ecological study in New Zealand assessed 1249 cases of ARF diagnosed between 1996 and 2005 found a positive and significant association between ARF and overcrowding, this study was limited by its design [25]
Summary
Rheumatic heart disease (RHD) remains a forgotten yet preventable disease in developing countries, with devastating consequences for young adults. [1] RHD and Acute Rheumatic Fever (ARF) affect about 16 million people worldwide, with over 70% in Sub-Saharan Africa where the prevalence has been found to be between 6.5 to 30 per1000 people. [2,3,4] no national prevalence data exists on RHD in Uganda, we have recently found a prevalence of per 1000 cases among randomly selected primary school children in Kampala district, the country’s capital. [5,6] Anecdotal data from a hospital based study done at Mulago National Referral Hospital ranked RHD as the commonest cause of heart disease in the to 49 age group, and second commonest cause of heart disease overall, after hypertension. [7]The pathophysiology of RHD is thought to involve the triad of host genetic makeup, Group A streptococcal virulence and environmental factors. [10,11] While ARF/RHD has been described as a disease of poverty, its persistence in most developing countries, and reemergence in developed countries where it had nearly disappeared raises concern on the role of environmental and other factors, other than poverty, [12,13] and the consequential increase in group A Streptococci transmission. Some environmental factors such as overcrowding and poor ventilation have been directly related to susceptibility to ARF and RHD. Environmental factors are known risk factors for rheumatic heart disease in other societies, risk factors for rheumatic heart disease remain less well described in Uganda
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