Epidemiology of Cardiovascular Disease in India

Epidemiology of Cardiovascular Disease in IndiaI. Rheumatic Heart Disease

By S. PADMAVATI, M.R.C.P. (London), F.R.C.P. (Edin.)

RHEUMATIC FEVER and rheumaticheart disease are generally believed to

be diseases of temperate climates and raritiesin tropical countries. This paper surveys theprevalence in all parts of the subcontinent,which has great regional variations in climate,diurnal variation in temperature, and rain-fall.

It was reported 30 years ago that rheumaticfever was practically unknown in the tropics,including India.'-5 Rogers' found one caseof rheumatic carditis in 4,800 postmortemexaminations over a period of 37 years. Thefirst to express a different opinion wasStott,6 7 who thought that rheumatic heartdisease was as common in India as in Londonand that chronic rheumatic infection wasmore common than the acute form in a ratioof 14:1. Since then many observers8-19 havetestified to the high incidence of rheumaticfever in diverse regions of India. Accordingto statistics after World War II, rheumaticheart disease accounted for between 22 and50 per cent of all cardiac cases and was themain cause of heart disease in all Indianstates except Punjab.'7

Present Sources of DataAutopsy Data and Vital Statistics

These sources of information are completelyunreliable at the present time in India, be-cause of the small number of postmortem ex-aminations and the vague nomenclature ofdiseases.Hospital Statistics

At the present time data are available fromMedical Schools in 10 centers regardingthe incidence of heart disease (table 1). In-

From the Lady iardinge Medical College andHospital, New Delhi, India.Read at the Second Asian Pacific Congress of

Cardiology at Melbourne, Australia, .1960.

asmuch as each center draws patients fromthe entire state they may be considered rep-resentative. All figures are after World WarII. Some were published and others fromMangalore, Amritsar, Agra, and Madras wereobtained by a questionnaire sent out espe-cially for the purpose of this paper. Rheu-matic heart disease accounts for 22 to 50 percent of all cardiac cases.8-21 The highest fig-ures were from Himachal Pradesh18 and thelowest figures were from Bombay.14' 20 Ae-cording to Paul22 rheumatic fever accountsfor 3 to 7 per cent of total admissions to thegeneral hospitals in Europe and the U.S.A.Population Surveys

Studies now being carried out in India mayyield valuable information about the inci-dence of rheumatic heart disease in the gen-eral population. A survey in Delhi among648 rural workers yielded an incidence of1.1 per cent of rheumatic heart disease.23 Ina study of 1,317 school children in Delhi from5 to 14 years there were two cases of rheu-matic heart disease, an incidence of 0.15 percent. In a survey of 1,515 school childrenin Simla (Himachal Pradesh) Devichand'8found 60 cases of rheumatic heart disease, anincidence of 3.96 per cent. The maximum in-cidence in his series was in the age group 9to 12 years. According to Keith24 the inei-dence is from 0.1 to 2.08 per cent for British,0.36 to 3.92 for Canadian, and 0.09 to 1.36for American children. According to Hedley25and Weiss28 the incidence has been given asfrom 2 to 4/1,000 for American children.Life Insurance Data

Limited data are available from this source,chiefly from the Employees' State InsuranceScheme for factory workers, covering 1,610,-500 workers in 11 cities.27' 28 The figures givenin the Employees' State Insurance Scheme

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PADMAVATI

Table 1Incidence of Rheumatic Heart Disease in Indian States (Hospital Admissions)

City

MadrasMangaloreVellore (Madras)

(Pediatric)CalcuttaBombayLucknow (U. P.)Agra (U. P.)

Simla(HimachalPradesh)

Amritsar(Punjab)

Delhi

'Hospital patients.tPrivate patients.

No. of cay

No. of medical oYear cases No. med

1956-58 462431959 46741955-59 5943

1943195419531959

30104

27502

1956-57 4461

1953

170374681

717186010003272*2145f395

No. of casesof rheumatic

rdiac cases heart disease,o of all % oflical cases No. cardiac cases

9 1526 36.6

8 123 32.9

11.4 166 24.4

7.16.2

7.78.8

500

1951-55 132794 2360 1.71953-58 8262 935 11.3

(Women only)

320 44.6461 24.7475 47.5

31.3809 37.8197 50.6

% of allmedicalcases

3.32.62.8

1.5

2.94.4

184 36.8

922 39.1 4.65501 52.5 6.1

Table 2Prevalence Rate of Rheumatic Heart Disease inDifferent Indian States (1957-58 and 1958-59)

States

BombayDelhiKeralaMadrasPunjabU. P.West Bengal

Total

Rheumatic heart diseasePer 1,000 population

1957-58 1958-59

0.91 0.170.07 0.071.63 0.821.23 0.580.43 0.290.18 0.310.77 0.590.67 0.56

report for 1957-58 and 1958-59 of the inci-dence of chronic valvular rheumatic heartdisease per 1,000 population per annum are

shown in table 2. It must be remembered thatthe Employees' State Insurance Scheme cov-

ers a select group of industrial workers andmay not be representative of the country as

a whole.Regional Differences

The map of India (fig. 1) shows that, de-spite different climatic conditions, the inei-

dence is of the same high order in the variousstates.Rheumatic heart disease accounts for very

nearly the sanme large percentage of all car-diae cases in the various states (table 1).Rheumatic heart disease expressed as a per-centage of cardiac cases might be a morereliable index of the true incidence of thedisease than as a percentage of medical ad-missions, since the latter vary from state tostate because of infectious diseases and tuber-culosis.Although India lies entirely within the

tropics the climate is extremely variable inthe different regions. Thus Himachal Pradeshhas an average altitude of over 3,000 feet andenjoys a temperate climate, being cool andwet most of the year. Madras, Bombay, andBengal are very hot and humid in summnerwith very mild winters and heavy rainfall,whereas the Punjab, Uttar Pradesh, andDelhi have very hot and dry summers andvery cold winters. The highest incidence iscertainly obtained in the temperate regionof Himachal Pradesh but Calcutta, Madras,

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RHEUMATIC HEART DISEASE IN INDIA

rigure 1Incidence of rheumatic heart disease in India.. Figures represent percentage of rheu-matic heart disease out of all cardiac cases.

and the Punjab, with an entirely differentclimate, are not very far behind. This obser-vation suggests that the etiology of rheumaticfever should be sought in the internal envi-ronment rather than the external one, andthat factors sueh as overcrowding and poornutrition are probably the determining fac-tors in the high incidence.

It was formerly believed29 that rheumaticfever was more common in high dry areas


with marked diurnal variation of tempera-ture, but this does not appear to be so inIndia. A recent study in Mexico City sug-gested that rheumatic fever was more preva-lent in temperate than in tropical zones.30This was not due to rarity of upper respira-tory infections in tropical zones where therate of streptococcal carriers was as high andthe antistreptolysin titer was higher than inthe temperate zones.30 The authors concluded

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PADMAVATI

Table 3IncTidence of Major Rheumatic Manifestations

No. of Acute carditis Polyarthritis ArthralgiaCity cases % % %

Mangalore 99 3.3 (4) 16.3 (20)Vellore (Pediatric) 161 14.4 (24) 2.4 (4) 25.3Calcutta 170 2.2 (7) 25.9 (83)Bombay 461 22.4 10.6 (49)Agra (1946-57) 1027 3.7 (17) 7.7 (35)Amritsar 1382 4.8 52.1Delhi 501 4.2 (21) 9.4 (47)U.S.A.Boston

(Massel et al.'2) 59.0 .. 90.0Boston

(Bland and Jones31) 65.3 41.0 40.1Louisiana

(Lieber and Holoubek43) 56.2 63.6

*Figures in parentheses indicate the total number of cases.

Table 4Major Criteria in 68 Cases of Acute RheumaticFever

ErythemaCarditis Polyarthritis Chorea Nodules marginatum

21 47 6 1 Nil30.9% 69.1% 8.8% 1.5% Nil

that the tropical climate affected the responseof the host to rheumatogenic influences.3"

Incidence of Acute Rheumatic FeverAll physicians writing on this subject are

agreed that chronic valvular disease is verymuch more common than acute rheumaticfever6"11'14 (table 3).

In Delhi, for instance, in 6 years (1953-1958) of 8,262 patients admitted to the med-ical wards there were 501 cases of chronicrheumatic valvular disease or an incidence of6 per cent, whereas only 68 cases (0.8 percent) were admitted as acute rheumatic fever(table 4). In the pediatric department of theLady Hardinge Medical College in a 4-yearperiod (1956-1959) of 4,759 medical admis-sions there were 38 cases of acute rheumaticfever, an incidence of 0.8 per cent. The inci-dence of the major criteria of rheumatic feverin these cases is shown in table 3.Among outdoor patients in the Delhi elinic

rheumnatic fever has been studied intensivelyfrom 1952 to 1959. Of 2,000 cardiac cases

attending the Cardiac Clinic there were 788eases of rheumatic valvular disease, an inci-dence of 39.4 per cent. The figures include a

large number of patients referred to the clinicfor surgery. AMajor manifestations of rheu-matic fever by history or physical examina-tion in these 788 cases are shown in table 5.Two hundred and seventy-four patients (34.7per cent) gave a history of arthralgia, buttbis is too vague a symptom to be regardedas specifie.

Fiigures from other parts of India are notcomplete (table 3) but from Mangalore and

Calcnitta and elsewbere14, 32 there is the same

wide disproportion between acute rheumaticfever and chronic valvular disease. In answer

to our questionnaire, physicians from Agra,Amritsar, and Madras stated that chorea,subeutaneous nodules, and erythema margi-niatumi were very infrequent in this series.

Polyarthritis exhibits a much lower incidencethan in Western countries. The almost com-

plete absence of erythenma marginatum and

the very low incidence of rheumatic nodules

and chorea are noteworthy.The age incidence of rheumatic heart dis-

ease and of acute rheumatic fever is shownin tables 6 and 7.


Chorea

0.1 (1)5.4 (9)0.3 (1)3.0 (14)1.5 (7)0.81.2 (6)

Nodules

0.1 (1)1.2 (2)0.6 (2)

0.30.2 (1)

Erythemamarginatum

0.00.00.0

0.1

11.0

7.1

0.6

12.0

51.8 8.8

9.3 3.1

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Table 5Rheumatic Manifestations in 788 Outdoor Patients

HistoryCarditis Polyarthritis Arthralgia Chorea Nodules of rash

54 162 274 12 5 96.84% 20.55% 34.77% 1.52% 0.63% 1.14%

Table 6Age Incidence of Rheumatic Heart Disease Among Outdoor Patients

0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80yr. yr. yr. yr. yr. yr. yr. yr. Total

41 206 368 126 36 10 0 1 7885.2% 26.1% 46.7% 15.9% 4.8% 1.2% Nil 0.1%

Socioeconomic Status

The great majority, 444 patients or 77.1per cent, belonged to the low-income group,with a monthly income below Rs 200/-. Onehundred and eighteen (20.48 per cent) were

in the middle-income bracket (monthly in-come Rs 200-1,000/-). Only 14 (2.4 per cent)were of higher economic class, with a moiithlvincome over Rs 1,000/-.

Laboratory Data

Throat cultures were routinely done in allcases of rheumatic heart disease (no specialculture technic was used). In our series of580 throat cultures, 87 (15 per cent) were

positive for beta hemolytic streptococei.Erythrocyte sedimentation rate and esti-

mations of antistreptolysin-0 titer althoughdone routinely in all cases were of particularinterest in the acute cases. Of 60 cases ofacute rheumatic fever the erythrocyte sedi-mentation rate was considerably raised in 57.The antistreptolysin-0 titer was raised above400 units in one third of these cases. Studiesof other antistreptolysin antibodies, i.e., antiD-nase have only just begun. We have notbeen able to correlate the erythrocyte sedi-mentation rate with the other acute-phasecriteria such as antistreptolysin-0 titer ande-reactive proteins, partly because of inabilityto obtain satisfactory specimens. The unre-

liability of these nonspecific tests in the diag-nosis of rheumatic activity has been stressedby other workers.33


Age IncidenceFever

Table 7of 68 Cases of Acute Rheumatic

0-10 11-20 21-30 31-40 41-50 51-60yr. yr. yr. yr. yr. yr.

8 26 30 3 1 011.8%o 38.2% 44.1% 4.4% 1.5% 0

Prophylaxis

Because of the high incidence of rheumaticheart disease a program of prophylaxis hasbeen carried out over the past 6 years inDelhi. The drugs used have been sulfadiazinein the great majority, oral and injected peni-cillin in a small minority. The ages of thepatients ranged from 5 to 30 years. Normallythese drugs are not given to patients afterthe age of 30 years. The difficulty of con-ducting a prophylactic program is great. Thesmall number showing the clinical featuresof rheumatic fever requires dependenceeither on laboratory data (such as repeatedthroat cultures, erythrocyte sedimentationrate, and estimations of antistreptolysin-0titer, and e-reactive protein) done at inter-vals or an assessment of the cardiac status.Chief reliance must be placed on serial car-diae enlargement, changing murmurs, andappearance of congestive heart failure (whennot attributable to pregnancy).At present, 338 patients are believed to be

regularly taking prophylactic drugs (259sulfadiazine, 60 oral penicillin, and 19 benza-

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Table 8Results of Prophylaxis in 335 Cacses

ErythrecyteAntistrep- sedimen-

Throat tolysin-0 tationNo. of Reacivation culture above ratepatients A ges Carditis Arthritis Misc. positive 200 units raised

3 3 Nil 40 8 129

1 1 Nil 9 4 25

1 Nil Nil 2 4 5

Table 9Comparative Incidence of Rheiease in Various Countries

Delhi Mexico45 Philippines37 ](1951-55) (1942) (1953)

2360 2400 430439.1% 41.0% 47.1%

thine penicillin). Table 8 shlapse rate on prophylaxis is:reported by workers in thparently similar difficultieswith prophylaxis even in th(

DiscussionThe belief current in m

that rheumatic heart diseaselent in temperate climates t]ics is a myth.

It is obvious from therheumatic heart disease ishealth problem in India. Itfrom the same disease in tein that, while the incidencevular lesions is very high,aeute rheumatic fever is loxis the single largest major n

lowed by acute carditis. Choierythema marginatunm are:relation to streptococcal inmore difficult to assess becautories and the lack of suitab]teria. The absence of acute i

difficult to explain. Is it diimmunologic response to th(face of malnutrition? Or i,other factor such as the trc

has been suggested in Mexico ?30 More workimatic Heart Dis- is needed with laboratory tests specific for

the streptococcus.36

New New Prophylaxis in India poses a great problemEngland44 Engla51) in the absence of acute maanifestations and

the lack of an adequate laboratory test for39.5% 23.5% the diagnosis of rheumatic fever.

Rheumatic heart disease is common in allbackward countries where presumably the

Ows that the re- conditions obtain. Thus in Mexico45 and

higher than that in the Philippines37 a similar high incidenceLe U.S.A.34 Ap- has been reported (table 9). It to be

are experieaced extremely common, contrary to popular be-e U.S.A.35 lief, in all tropical countries in most of which

the standard of living is low and overcrowd-

Ledical textbooks ing and malnutrition are prevalent.

,"is more preva- In Singapore rheumatic heart disease ac-

han in the trop- counted for 8.3 per cent of routine autopsies.In discussing the clinical features of rheu-

above data that matic heart disease in Singapore, Monteiro38a major public found that his 208 cases constituted 1.5 perappears to differ cent of total medical admissions to the Gen-mperate climates eral Hospital, Singapore, and 14.1 per centof chronic val- of all cases of heart disease. The majority of

the incidence of those affected belonged to social class 5, the

v. Polyarthritis class exposed most to overcrowding. In

nanifestation fol- Djakarta,39 in the hospital class, rheumatic

rea, nodules, and heart disease was the commonest type of heartinfrequent. The ailment. Among private patients it occupiedfections is even third place, the first two causes being coro-

ise of vague his- nary artery disease and hypertension. In

le diagnostic cri- Ceylon, Fernando40 gave an incidence of 3.6

manifestations is per cent of rheumatic heart disease of 178

ue to a different cardiac deaths and 1,100 total autopsies.e antigen in the In Australia and New Zealand, which are

s it due to some semitropical climatically, during a recent)pical climate as visit leading physicians were of the opinion


Prophylacticdrug

Sulfadiazine

Penicillin(oral)

Penicillin(injections)

256 6-34yrs.

60 3-38yrs.

19 8-32yrs.

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that rheumatic heart disease was uncommonexcept among recent migrants who probablyacquired the disease in the United Kingdom.Rheumatic heart disease formerly was thecommonest form of cardiac ailment in Eng-land, North Western Europe, and the U.S.A.This, however, has changed in the past 25years, and now rheumatic heart disease occu-pies third place to coronary artery and hyper-tensive heart disease.17 The changing patternmay be due to improvement in the livingstatus in western countries. In the SouthernUnited States it is reported that acute mani-festations are uncommon.4' It would seemreasonable that rheumatic heart disease ex-isted (and continues to exist) wherever thereis undernutrition and overcrowding andwhere low standards of living prevail. A tem-perate or tropical climate per se does notseem to predispose to rheumatic fever. Thehigh incidence in India can be explained onthe basis of overcrowding and poor nutrition,the result of poverty, and a low standard ofliving. Overcrowding, which causes easytransmission of throat infections, would seemto be the most important factor.

Summary and ConclusionsChronic rheumatic valvular disease ac-

counted for the largest number of cardiaccases (22 to 50 per cent) in 10 of 16 IndianStates from which data were available.The incidence of acute rheumatic manifes-

tations was comparatively low. Only 30 percent of cases gave a history of acute rheu-matic fever in any form.

There was little regional variation in prev-alence in spite of great differences in climateand humidity.The lowest income groups were most af-

fected and overcrowding and undernutritionrather than climate seemed to be the mostimportant causative factors.

It was difficult to assess the effect of pro-phylaxis because of lack of acute symptomsand of adequate laboratory criteria for diag-nosis.The prevalence of rheumatic heart disease

in other tropical and nontropical countriesis reviewed.

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They that endeavour to abolish Vice, destroy also Virtue; for contraries, tllough theydestroy one another, are yet the life of one another. Thus Virtue (abolish vice) is anIdea.-SIR THOMAS BROWNE. Religio Medici. Edited by W. A. Greenhill, M.D. London,AMacMillan and Co., Ltd., 1950, p. 100.


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S. PADMAVATIEpidemiology of Cardiovascular Disease in India: I. Rheumatic Heart Disease

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1962 American Heart Association, Inc. All rights reserved.

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