Background: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant global health challenges, leading to preventable morbidity and mortality. There is limited evidence on effective prevention strategies. This study aimed to identify environmental risk factors for ARF in children from Pakistan, Brazil, Malawi, and Timor-Leste to inform strategies for reducing its prevalence.
Methods: Children recruited through the ARC network completed questionnaires assessing environmental, socioeconomic, and healthcare access factors associated with ARF and RHD.
Results: The study included 256 children with ARF/RHD, 152 healthy controls, and 115 with overlapping diagnoses. The ARF/RHD group had a higher median age (11 years, IQR: 9–13) compared to healthy controls (10 years, IQR: 8–13.5) and those with overlapping diagnoses (8 years, IQR: 5–11; P < 0.0001). Household crowding was greater in the ARF/RHD group (median: 3, IQR: 1.73–4.58) compared to healthy controls (2, IQR: 1.33–3) and overlapping diagnoses (1.67, IQR: 1–2.67; P < 0.0001). Socioeconomic status was lowest in the ARF/RHD group (median WAMI: 0.5, IQR: 0.41–0.65) compared to healthy controls (0.77, IQR: 0.59–0.91; P < 0.0001). Secondhand smoke exposure was more frequent in ARF/RHD cases (41%) than in controls (30%) or overlapping diagnoses (17%; P < 0.0001). Recurrent throat infections (≥2 episodes) were also more common in ARF/RHD cases (22.7%) compared to controls (13.2%; P < 0.0001).
Conclusion: Household overcrowding, socioeconomic disparities, and environmental exposures are key risk factors for ARF/RHD. Addressing these social determinants is crucial to reducing the global burden of these diseases.