Global Burden of Pediatric Rheumatic Heart Disease, 1990-2021: Analysis of the GBD 2021 Study

Background: Rheumatic heart disease (RHD) remains a major contributor to childhood cardiovascular morbidity and mortality globally, particularly in low-resource settings. This study offers a thorough evaluation of the global, regional, and national burden of RHD among children aged 0-14 years, from 1990 to 2021, utilizing data from the 2021 Global Burden of Disease (GBD) study. Methods: We analyzed age-standardized incidence, prevalence, mortality, and disability-adjusted life years (DALYs) for RHD in 204 countries and territories. Novel methodological approaches included APC analysis to decompose temporal trends into age, period, and cohort effects, and inequality analysis to assess socioeconomic disparities. We calculated age-standardized rates and average annual percentage changes (AAPC) by sex, region, and socio-demographic index (SDI) level. Results: From 1990 to 2021, the global age-standardized death rate due to RHD in children declined by approximately 74%, from 1.24 to 0.32 per 100,000 (AAPC: -4.27%). Similarly, DALY rates dropped from 117.22 to 41.56 per 100,000 (AAPC: -3.30%). Despite this progress, the global age-standardized incidence rate increased modestly from 55.84 to 66.76 per 100,000 (AAPC: 0.58%), and prevalence rates also rose (AAPC: 0.53%). Females consistently experienced higher burden across all metrics. Inequality analysis demonstrated a concerning divergence: while mortality and DALY inequalities narrowed substantially (mortality slope index of inequality (SII) improved from -1.35 to -0.31), incidence and prevalence inequalities widened (incidence SII worsened from -112.60 to -131.90), indicating growing disparities in disease occurrence despite improved survival. Conclusions: While global mortality and DALYs from childhood rheumatic heart disease have declined substantially over the past three decades, a troubling paradox has emerged: rising incidence rates alongside widening socioeconomic inequalities in disease occurrence. This represents a critical public health challenge demanding targeted intervention strategies. The divergent trends in health outcomes, namely, improved survival rates but increased disease burden, reveal that while access to treatment has advanced, upstream prevention efforts remain critically inadequate among socioeconomically disadvantaged populations.