الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Acute rheumatic fever and RHD remain the most common cause of acquired heart disease worldwide. They are the major cause of cardiovascular deaths in pediatric age group, so an accurate diagnosis of ARF and RHD is very important.
The present study was done to detect the incidence of ARF, the prevalence of RHD and to describe the clinical profile of RHD cases among primary and preparatory school children 6-15 years old in Alexandria governorate, Egypt.
A screening survey was done among 5700 children (2696 males and 3004 females) in 24 schools from four educational districts in Alexandria.
Careful cardiovascular examination was done for all students and any child with audible murmur was subjected to a thorough history taking, complete clinical examination and echocardiography study. Laboratory investigations (CBC, ESR, CRP and ASOT), chest x-ray and ECG were done to students diagnosed as ARF/RHD by echocardiography.
The study revealed the following main findings:
In the current study, 316 students (5.5%) had abnormal history and/or clinical examination indicating the need for performing echocardiography, 156 of them (49.4%) were receiving LAP, 137 cases (43.4%) had family history of ARF/RHD, and 144 cases (45.6%) had discovered murmur on auscultation.
The echocardiographic findings of 311 students examined by echocardiography were 7.7% definite RHD, with a prevalence rate of rheumatic valvular heart disease in primary and preparatory schools children in Alexandria of 4.23/1000.
Cases of RHD were seven males (29.2%) and 17 females (70.8%), 62.5% were from urban areas and 37.5% from rural areas. 70.8% were in primary schools and 29.2% in preparatory schools. according to socioeconomic level, 45.9% were of very low socioeconomic level, 20.8% were of low socioeconomic level while 12.5% and 20.8% were from middle and high socioeconomic level respectively.
All students with RHD had MR with different degrees of severity. Nearly two thirds of cases (66.7%) had moderate degree of MR while 20.8% had mild MR and 12.5% of cases had severe MR.
Aortic regurgitation was present in 12.5% of cases; one third of them were mild AR, another third had moderate AR and another third had severe AR. TR was present in 33.3% of cases, half of them were mild TR, 37.5 % had moderate TR and 12.5 % of cases had severe TR. The type of cardiac lesion and valve affected as diagnosed by echocardiography was MR (alone or with other valve lesions). AR and TR were present in 12.5% and 33.3% respectively but in combination with MR. More than half of cases (54.2%) had MR alone without other valve affection.
The current study also studied the determinants of RHD among students with RHD. The results revealed a significant statistical relationship between the type of school and having RHD where public school students were more prone to have RHD than students of private schools. There was also a significant statistical relationship between RHD and maternal employment. Regarding family income, students who belonged to families that have no enough income and borrow were more likely to have RHD. The results of the current study also revealed a significant relation between increased crowding index and RHD. Concerning socioeconomic level, students who belonged to very low socioeconomic level families were more likely to have RHD and the difference was statistically significant. Students with positive family history of ARF/RHD were more likely to have RHD and the difference was statistically significant.
The present study also studied the effect of RHD on affected students’ scholastic achievement and physical activity. The study revealed that students with RHD were more likely to have poor scholastic achievement and were physically inactive but the difference was not statistically significant.
The present study also estimated the incidence of ARF to be 40/100000 among school students in Alexandria governorate during the year 2018-2019.
6.2. Conclusion
Rheumatic heart disease is still a significant health problem among school children in Alexandria. The prevalence rate of RHD in primary and preparatory school children in Alexandria was estimated to be 4.23/1000 and the incidence rate of ARF was 40/100000 school children. RHD prevalence and ARF incidence are decreasing in school children in Alexandria.
RHD and ARF remain predominantly diseases of low socioeconomic groups in public schools. RHD was observed to be more common among students in governmental schools, students from crowded, low socioeconomic families and families with positive family history of ARF/RHD.
The combined use of echocardiography with clinical screening can prevent both overdiagnosis and underdiagnosis of RHD. Mitral valve was the most commonly affected valve among students with RHD.
6.3. Recommendations
Acute rheumatic fever and RHD remain a major cause of morbidity and mortality in Egypt and other developing countries. Factors such as a shortage of resources for providing quality health-care, inadequate expertise of health-care providers, and a low level of awareness of the disease in the community can all impact the expression of the disease in populations. Thus the following is recommended:
6.3.1. Recommendations at school level
6.3.1.1. Health education of students and teachers about the role of GABHS pharyngitis as a cause of ARF/RHD, mode of its transmission and risk factors that increases its transmission. Also, about the nature of the disease, its manifestations, its impact on health and the value of early diagnosis and treatment.
6.3.1.2. Improving school environment through good ventilation of classes, optimum number of students per classroom and using sanitary drinking fountain taps and feeding rooms.
6.3.1.3. Pre-service and in-service training of teachers on detecting and reporting suspected students with GABHS pharyngitis or ARF through good observation of children and immediate notification of any cases with fever, fatigue or any other abnormal signs of illness.
6.3.1.4. Enforcing the role of school doctors and school health visitors and working on supporting their existence in schools and improving their skills in case finding.
6.3.1.5. Supporting the health insurance system to all school children and applying proper school health programs through:
• Routine medical examination for students on school admission and periodically for early detection and prompt management of cases.
• Providing easily accessible medical services for suspected cases. Thus, most cases of fever or sore throat are examined and treated promptly, which greatly help in minimizing the occurrence of ARF and RHD.
• Early detection and proper management of any cases with ARF/RHD.
• Arranging regular follow up and providing required prophylaxis for cases diagnosed with ARF/RHD.
• Providing access to tertiary level of care for students who may need surgical treatment.
6.3.2. Recommendations at community level
6.3.2.1. Raising community awareness about the disease and its impact on children, young adults and community, and about the importance of early disease diagnosis and management in the prevention and control of ARF/RHD.
6.3.2.2. Governmental and nongovernmental organizations have to focus on primordial prevention of RHD through improving socio-demographic characteristics of population and improving housing conditions and overall socioeconomic status of population.
6.3.3. Recommendations to health authorities and health professionals
6.3.3.1. Conducting epidemiological surveys about ARF and RHD in both rural and urban areas in all parts of Egypt, and collecting and reporting data to higher health authorities in order to allocate resources and put strategies for disease control. Echocardiographic screening might be more accurate in detecting cases screened in school-age children.
6.3.3.2. Performing more research to compare between different valvular lesions of RHD as regards type and severity for better understanding of disease progression.
6.3.3.3. Increasing the number of health centres and public health units and training of general practionners and medical personnel through workshops about difficulties in ARF diagnosis, notification and registration of new cases and follow up of diagnosed cases for regular administration of penicillin.
6.3.3.4. Giving attention to the over-diagnosis of ARF/RHD and subsequent overuse of LAP with no echocardiography confirmation.
6.3.3.5. Increasing the number of RHD clinics in different localities in Alexandria.