The Journal of the Arkansas Medical Society Issue 11 Vol 114 | Page 20

have suggested an association of RHD with specific HLA alleles , 15 although to our knowledge this has not yet been studied in the Pacific Island nations . Socioeconomic factors appear to play a role as well : household crowding , low maternal education , and maternal unemployment have all been associated with ARF and persistence of RHD . 8 , 16 In addition to limited health literacy and financial and language barriers to health care access , the Marshallese population in general has a cultural distrust of Western governments and health care systems stemming partly from the effects of the nuclear testing of the 1940s-50s .

Primary prevention of rheumatic fever by treating group A streptococcal pharyngitis is the ideal method of reducing RHD . Failing that , the recognition of children with ARF allows secondary prophylaxis to be initiated . But in low-resource settings the initial episode of ARF may often go undiagnosed as it did in two of our patients , making it reasonable to screen high-risk patients for RHD . Even children with “ borderline ” echocardiographic changes have an eight-fold increased risk of recurrent ARF and progression to definite RHD . 17 Secondary prophylaxis for patients with subclinical RHD reduces this risk and may even cause minor valve lesions to regress 8 , 17 , 18 Screening for asymptomatic RHD has traditionally relied on auscultation of pathologic murmurs , which fails to detect most RHD — in one high risk Australian group , the sensitivity ranged from 18-47 %. 19

Echocardiography is the gold standard in detecting RHD . Field studies in Uganda using handheld echo ( with modified diagnostic criteria ) show it to be a promising screening tool in low-resource settings . 20-23 In higher-income countries , standard portable echo-based screening is still likely costeffective . 24 , 25 An echo-based screening approach in our setting would need to incorporate culturally appropriate outreach efforts for the Marshallese population , possibly church-based community health screenings . In the meantime , we suggest health care providers working with these patients should maintain an increased index of suspicion for ARF and RHD . When applicable , efforts should be made to educate about the importance of diagnosing and treating strep throat .

Acknowledgments

The authors wish to thank Dr . Nia Aitaoto and the UAMS Center for Pacific Islander Health for their helpful insights regarding Marshallese culture .

References

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2 . See comment in PubMed Commons below Reményi B , Wilson N , Steer A , et al . World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease – an evidence-based guideline . Nat Rev Cardiol . 2012 ; 9 ( 5 ): 297-309 .

3 . Carapetis JR , Steer AC , Mulholland EK , Weber M . The global burden of group A streptococcal diseases . Lancet Infect Dis 2005 ; 5 ( 11 ): 685-694 .

4 . Jackson SJ , Steer AC , Campbell H . Systematic review : estimation of global burden of nonsuppurative sequelae of upper respiratory tract infection : rheumatic fever and post-streptococcal glomerulonephritis . Trop Med Int Health . 2011 ; 16 ( 1 ): 2-11 .

5 . US Department of State , Bureau of East Asian and Pacific Affairs . US Relations with the Marshall Islands Fact Sheet . 4 Feb 2015 . http :// www . state . gov / r / pa / ei / bgn / 26551 . htm

6 . US Census Bureau , 2010 census .

7 . EPIC ( Empowering Pacific Islander Communities ). A Community of Contrasts : Native Hawaiians and Pacific Islanders in the United States , 2014 .

8 . Mirabel M , Fauchier T , Bacquelin R , et al . Echocardiography screening to detect rheumatic heart disease : A cohort study of schoolchildren in French Pacific Islands . Int J Cardiol . 2015 ; 188:89-95 .

9 . Mirabel M , Tafflet M , Noël B , et al . Newly diagnosed rheumatic heart disease among indigenous populations in the Pacific . Heart . 2015 ; 101 ( 23 ): 1901-1906 .

10 . Steer AC , Kado J , Jenney AW , et al . Acute rheumatic fever and rheumatic heart disease in Fiji : prospective surveillance , 2005-2007 . Med J Aust . 2009 ; 190 ( 3 ): 133-135 .

11 . Seckeler MD , Barton LL , Brownstein R . The persistent challenge of rheumatic fever in the Northern Mariana Islands . Int J Infect Dis . 2010 ; 14 ( 3 ): e226-229 .

12 . Roberts K , Maguire G , Brown A , et al . Echocardiographic screening for rheumatic heart disease in high and low risk Australian children . Circulation . 2014 ; 129 ( 19 ): 1953-1961 .

13 . Webb R , Wilson N . Rheumatic fever in New Zealand . J Paediatr Child Health . 2013 ; 49 ( 3 ): 179- 184 .

14 . Kurahara DK , Grandinetti A , Galario J , et al . Ethnic differences for developing rheumatic fever in a low-income group living in Hawaii . Ethn Dis . 2006 ; 16 ( 2 ): 357-361 .

15 . Guilherme L , Ramasawmy R , Kalil J . Rheumatic fever and rheumatic heart disease : genetics and pathogenesis . Scand J Immunol . 2007 ; 66 ( 2-3 ): 199-207 .

Contact AMS for a complete list of references .

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