Relationship between Environmental Factors and Rheumatic Heart

Disease

Tina Christina Lumban Tobing

, Teddy Ontoseno

, Sri Endah Rahayuningsih

, Ratna Akbari Ganie

Yahwardiah Siregar

Department of Child Health, Medical School, Universitas Sumatera Utara

Department of Child Health, Medical School, Universitas Airlangga

Department of Child Health, Medical School, Universitas Padjajaran

Department of Clinical Pathology, Medical School, Universitas Sumatera Utara

Biochemistry Department, Medical Faculty, Universitas Sumatera Utara

Keywords: children, environmental, rheumatic heart disease

Abstract: Rheumatic fever and rheumatic heart disease are the most common acquired heart diseases in children and

the most common cause of death in the field of pediatric cardiology. Environmental factors play an

important role in RHD. The prevalence of RF and RHD tend to decrease as socioeconomic status improves.

To determine the relationship between environmental factors and RHD in children. A case-control study

was conducted in the Department of Child Health, Haji Adam Malik Hospital from April to June 2017. The

case group has consisted of children aged 5-18 years with RHD while the control group has consisted of

healthy children. Demographic, anthropometric, and laboratory data were collected along with

environmental factors. Statistical analysis was done using Statistical Product and Service Solution (SPSS).

A P value of <0,05 at 95% confidence interval was considered significant. A total of 39 children were

enrolled in each group. Subjects’ median age was 13.0 years. Males were dominant compared to females.

Fathers who went to elementary and junior high school had a higher risk of having children with RHD (OR

28; P value 0,032 and OR 15,75; P value 0,011, respectively). Mothers who went to junior high school had

7 times higher risk of having children with RHD (P-value 0,026). Low monthly income increased the risk of

RHD (OR 3,68; P value 0,009). Tap water usage, meat consumption more than once per week, and

feasibility to buy clothes more than 1 pair per year decreased the risk of RHD at 0,31 (P value 0,013), 0,3

(P-value 0,016), and 0,04 times (P-value <0,001), respectively. Parent’s education, monthly family income,

water source, consumption of meat, and feasibility to buy clothes are related to RHD in children.

1 INTRODUCTION

Rheumatic fever (RF) and rheumatic heart

disease (RHD) are the most common acquired heart

diseases in children and the most common cause of

death in the field of pediatric cardiology. Rheumatic

heart disease causes permanent damage to heart

valve tissue and in a chronic condition may lead to

congestive heart disease, stroke, endocarditis, and

death (Park, 2008; Seckeler, 2011). A study in India

reported an annual mortality rate in children from

RF and RHD as high as 3,3%. The estimation of

annual death from RF and RHD in Asia lied between

356.000 and 524.000 (Carapetis, 2008; Kumar,

2002).

Rheumatic fever and RHD are complex diseases

influenced by genetic, the virulence of bacteria, and

environmental factors (Guilherme, 2012).

Environmental factors such as overcrowding and

lack of ventilation play important role in RHD. The

prevalence of RF and RHD tend to decrease as

socioeconomic status improves (Ibrahim-Khalil,

1992; Grover, 1993, Cheng, 2009). Low

socioeconomic status is marked with a high poverty

level, low educational status, high illiteracy rate, and

high unemployment rate. Those are related to RF

and RHD even though direct relationships have not

been proven at present (Kerdemelidis, 2010; Steer,

2002; Vlajinac, 1989; Vlajinac, 1991).

Rheumatic fever and RHD can be prevented with

primary and secondary prophylaxis. Primary

180

Tobing, T., Ontoseno, T., Rahayuningsih, S., Ganie, R. and Siregar, Y.

Relationship between Environmental Factors and Rheumatic Heart Disease.

DOI: 10.5220/0009862901800184

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 180-184

ISBN: 978-989-758-469-5

prophylaxis for children with pharyngitis is carried

out with a well-planned program along with

sanitation, health infrastructure, and socioeconomic

status improvements. This is proven to reduce the

incidence of RF in Australia, Sweden, and the USA

(Carapetis, 2005; Seckeler, 2011).

Our objective is to determine the relationship

between environmental factors and RHD in children

in Medan, Indonesia.

2 METHOD

An observational case-control study was

conducted in the Department of Child Health, Haji

Adam Malik hospital Medan from April to June

2017. Subjects were obtained using consecutive

sampling method. Children aged 5-18 years and

diagnosed with RHD were enrolled in case of the

group while the control group has consisted of

healthy children. Demographic and anthropometric

data were collected along with laboratory results.

Environmental factors were obtained from each

patient and his/her parents including parents'

education, monthly family income, water source,

frequency of meal, consumption of meat, feasibility

to buy clothes, house's dweller, household's fuel, and

house's profiles. All subjects underwent

echocardiography evaluation. Children with

congenital heart disease were excluded from this

study. Informed consent was obtained before

conducting the procedure. This study was approved

by the Health Research Ethical Committee, Medical

School, Universitas Sumatera Utara.

Statistical analysis was done using computer

software. Chi-square and Fisher's exact tests were

used to analyze the relationship between categorical

variables. Mann-Whitney tests were used to

determine the relationship between categorical and

continuous variables. The analysis was conducted at

a 95% confidence interval and a P value of <0,05

was considered significant.

3 RESULTS AND DISCUSSION

Rheumatic heart disease is caused by an

immunologic response toward Streptococcus

pyogenes infection. The infection usually manifests

as tonsillopharyngitis. The M protein from bacteria's

cell wall has a similar structure (molecular mimicry)

with several proteins in heart valve tissue. The

molecular mimicry triggers an autoimmune reaction

and causes tissue damage (Guilherme, 2005).

A total of 78 subjects were enrolled in this

study. Male subjects were dominant with the median

age of 13,0 years (range 5,0-18,0 years). Most

subjects had normal antistreptolysin titer O (ASTO)

and C-reactive protein (CRP) levels. A study in 2012

showed a similar result to our study. The highest

prevalence of RHD was observed in children aged 5-

16 years, followed by children aged more than 16

years. They found no RHD case in children aged

under 5 years (Prajapati, 2013). Rheumatic fever and

RHD rarely occurred before 4 years old and even

rarer before 2 years of age. The underlying cause of

this condition is that the peak incidence of

tonsillopharyngitis occurs between 5-15 years of age

(Anderson, 2010). There was no gender predilection

in RHD (Anderson, 2010) as observed in this study.

Baseline characteristics of subjects were described

in Table 1.

Table 1: Baseline characteristics of subjects.

Characteristics n=78

Median age, year (range) 13,0 (5,0-18,0)

Gender, n (%)

Male

Female

43 (55,1)

35 (44,9)

Mean body weight, kg

(SD)

31,6 (10,61)

Median body height, cm

(range)

139,0 (60,0-173,0)

Mean hemoglobin level,

g/dL (SD)

11,5 (1,74)

Mean hematocrit, % (SD) 35,4 (5,30)

Median leukocyte level,

-1

(range)

9.905,0 (3.900,0-

23.690,0)

Mean thrombocyte level,

-1

(SD)

336.346,2 (125.053,2)

ASTO level, n (%)

≤200 IU

>200 IU

50 (64,1)

28 (35,9)

CRP level, n (%)

≤0.7 mg/L

>0.7 mg/L

52 (66,7)

26 (33,3)

Most subject’s parents went to senior high

school and had monthly income at or lower than

minimum regional standard. Median subject’s house

size was 60,0 m

with median house’s dwellers of

5,0 persons. Distribution of environmental factors as

described in Table 2.

Relationship between Environmental Factors and Rheumatic Heart Disease

181

Table 2: Distribution of subjects’ environmental factors.

Characteristics n=78

Father’s education, n (%)

University

Senior high school

Junior high school

Elementary school

8 (10,3)

39 (50,0)

26 (33,3)

5 (6,4)

Mother’s education, n (%)

University

Senior high school

Junior high school

Elementary school

No formal education

9 (11,5)

32 (41,0)

30 (38,5)

5 (6,4)

2 (2,6)

Monthly family income, n (%)

> minimum regional standard

≤ minimum regional standard

27 (34,6)

51 (65,4)

Median house size, m

(range) 60,0 (24,0-180,0)

Median house’s dwellers, person

(range)

5,0 (2,0-7,0)

House floor material, n (%)

Bamboo

Cement

Ceramic

2 (2,6)

57 (73,1)

19 (24,4)

House wall material, n (%)

Palm leaves

Wood

Brick

Wall

2 (2,6)

7 (9,0)

17 (21,8)

52 (66,7)

Latrine possession, n (%)

Yes

76 (97,4)

2 (2,6)

House’s electricity, n (%)

Available

Not available

78 (100,0)

0 (0,0)

Water source, n (%)

Well

Tap water

37 (47,4)

41 (52,6)

Household’s fuel, n (%)

Firewood

Charcoal

Kerosene

Gas

3 (3,8)

15 (19,2)

57 (73,1)

Consumption of meat, n (%)

Once/week

> once/week

52 (66,7)

26 (33,3)

Feasibility to buy clothes, n (%)

1 pair/year

> 1 pair/year

40 (51,3)

38 (48,7)

Frequency of meal, n (%)

< 3 times daily

≥ 3 times daily

7 (9,0)

71 (91,0)

Parent's education, monthly family income,

water source, consumption of meat, and feasibility to

buy clothes were related to RHD in this study.

Fathers who went to elementary and junior high

school had a higher risk of having children with

RHD at 28,0 times (P-value 0,032) and 15,75 times

(P-value 0,011), respectively compared to fathers

who went to university. Mothers who went to junior

high school also had 7,0 times higher risk of having

children with RHD (P-value 0,026). Lower monthly

family income would increase the risk of RHD.

Family with monthly income at or lower than

minimum regional standard had 3,68 times higher

risk of having children with RHD (P-value 0,009)

compared to a family with monthly income higher

than minimum regional standard. These findings are

confirmed by several studies. A study in 2005

showed that poverty, overcrowding, and lower

parent’s education were risk factors of RHD (Meira,

2005). Improvement in socioeconomic status was

related to decreasing RHD prevalence in North India

(Negi, 2013).

Consumption of meat and feasibility to buy

clothes also affected the incidence of RHD. Risk of

RHD was lower in a family which able to consume

meat more than once per week (OR 0,3; P value

0,016) and which able to buy clothes more than 1

pair per year (OR 0,04; P-value <0,001) compared to

their counterparts (Table 3). These variables

represent a family's socioeconomic status. The more

frequent consumption of meat in a family and the

more clothes a family can afford, the better it's

socioeconomic status. The better socioeconomic

status allows the family to fulfill adequate nutritional

support, complete access to healthcare facility

including immunization, and good housing. These

factors play an important role in preventing

streptococcal tonsillopharyngitis as the preceding

event of RHD (Feikin, 2009; Abdullah, 2010).

Worse housing quality and low socioeconomic

status would increase the susceptibility of RHD

according to a study by Dobson, et al (Dobson,

2011). In our study, a family which used tap water

as the water source was less likely to have children

with RHD (OR 0,31; P value 0,013). Families which

can afford tap water pipeline generally have better

housing quality and socioeconomic status. Better

housing quality ensures good hygiene and prevents

the incidence and transmission of

tonsillopharyngitis.

We found no relationship between overcrowding

and RHD in this study. This is in contrast with

several other studies. Okello stated that the risk of

RHD was increased in the overcrowded population

(Okello, 2012). A similar result was reported by

Jaine (Jaine, 2011). The different result may be

caused by the high population in Indonesia so that

the number of house's dwellers were similar between

case and control groups.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

182

Table 3: Relationship between demographic and

environmental factors and RHD.

Factors RHD No

RHD

OR 95% CI

Median age,

year (range)

13,0

(5,0-

18,0)

13,0

(5,0-

18,0)

N/A

Gender, n (%)

Male

Female

(53,8)

(46,2)

(56,4)

(43,6)

1,109

0,454-

2,708

Father’s

education, n

(%)

University

Senior high

school

Junior high

school

Elementary

school

1 (2,6)

(41,0)

(46,2)

4 (10,3)

7(17,9)

(59,0)

8 (20,5)

(2,6)

Ref

4,870

15,750

28,000

Ref

0,545-

43.523

1,652-

150.141

1,350-

580.591

Mother’s

education, n

(%)

University

Senior high

school

Junior high

school

Elementary

school

None

2 (5,1)

(30,8)

(51,3)

4 (10,3)

1 (2,6)

7(17,9)

(51,3)

(25,6)

1 (2,6)

Ref

2,100

7,000

14,000

3,500

Ref

0,374-

11.807

1,222-

40.089

0,944-

207.597

0,145-

84.694

Monthly

family

income, n (%)

> minimum

regional

standard

≤ minimum

regional

standard

(79,5)

8 (20,5)

(51,3)

(48,7)

3,681

1,355-

9,998

Median house

size, m

(range)

60,0

(24,0-

180,0)

48,0

(25,0-

144,0)

N/A

Median

house’s

dwellers,

person (range)

5,0

(2,0-

7,0)

5,0

(3,0-

7,0)

N/A

House floor

material, n

(%)

Bamboo

Cement

Ceramic

1 (3,1)

(96,3)

(87,5)

1 (3,7)

(96.3)

(92,3)

Ref

1,192

0,583

Ref

0,071-

20,011

0,031-

10,863

House wall

material, n

(%)

2(40,0)

0 (0,0)

Ref

Palm leaves

Wood

Brick

Wall

(60,0)

(83.3)

(92,3)

(100,0)

N/A

Latrine

possession, n

(%)

Yes

(100,0)

2 (5,1)

(94,9)

0 (0,0)

N/A

House’s

electricity, n

(%)

Available

Not

available

(100,0)

0 (0,0)

(100,0)

0 (0,0)

N/A

Water source,

n (%)

Well

Tap water

(61,5)

(33,3)

(66,7)

0,313

0,124-

0,790

Household’s

fuel, n (%)

Firewood

Charcoal

Kerosene

Gas

2 (5,1)

1 (2,6)

(30,8)

(61,5)

1 (2,6)

2 (5,1)

(7,7)

(84,6)

Ref

0,250

2,000

0,364

Ref

0,008-

7,542

0,133-

30,162

0,031-

4,245

Consumption

of meat, n (%)

Once/week

> once/week

8 (20,5)

(79,5)

(46,2)

(538)

0,301

0,111-

0,819

Feasibility to

buy clothes, n

(%)

1 pair/year

> 1 pair/year

6 (15,4)

(84,6)

(82,1)

7 (17,9)

0,040

0,012-

0,131

Frequency of

meal, n (%)

< 3 times

daily

≥ 3 times

daily

5 (12,8)

(87,2)

2 (5,1)

(94,9)

0,368

0,067-

2,021

Mann Whitney test

Chi square test Fischer's exact test *P<0,05

Our study had several limitations. There is no

strict classification of socioeconomic status in

Indonesia so we only gathered factors which

influence poverty based on Badan Pusat Statistik

criteria (Badan Pusat Statistik, 2017). We did not

Relationship between Environmental Factors and Rheumatic Heart Disease

183

match subjects in case and control groups and this

might cause selection bias. Our data was also not

normally distributed, preventing us to perform a

parametric study. Further study enrolling more

subjects from several centers is needed to confirm

the result of this study.

4 CONCLUSION

Parent’s education, monthly family income, water

source, consumption of meat, and feasibility to buy

clothes are related to RHD in children. Lower

parent’s education and monthly family income will

increase the susceptibility of having children with

RHD. Tap water usage, frequent consumption of

meat, and feasibility to buy more clothes are

protective factors of RHD.

ACKNOWLEDGMENTS

The researchers are grateful to all subjects and their

families and to all persons/institution who support

our study.

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