Rheumatology Advance Access published March 31, 2010

RHEUMATOLOGY

Letter to the Editor (Other)

doi:10.1093/rheumatology/keq085 In addition, however, by affecting people in the prime of

Need for determining the incidence and prevalence
of JIA in developing countries: the Indian
predicament
SIR, Director-General Halfdan Mahler in his address to the
1976 World Health Assembly stated that ‘Perhaps the fun-
damental difficulty in regard to rheumatic diseases is that
the problem is insufficiently appreciated and understood.
Critical to this lack of appreciation is an information deficit’
[1]. Among musculoskeletal diseases, the least informa-
tion available seems to be regarding those afflicting the
their lives JIA leads to substantially greater loss of pro-
ductive years due to disability compared with adult
rheumatological illnesses. To provide perspective, the in-
direct cost, due to loss of productivity, in RA patients is
3–10 times the direct costs. The all-inclusive cost of dis-
ease in RA is 14 906 euros per year [8]. The study by
Minden et al. [9] also demonstrated that, contrary to popu-
lar perception, JIA tends to persist well into adulthood
with 41% of patients in their study showing persistent
tender and swollen joints at a median 16.5 years after
diagnosis. This leads to cumulative damage with time

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paediatric population. causing geometric increment in costs due to loss of
Juvenile idiopathic arthritis (JIA) is the most common productivity. Thus, a patient with JIA would have a much
chronic musculoskeletal disease of childhood. However, higher economic burden on the community than an adult
there seems to be little consensus on its prevalence in patient with RA. Families who have children diagnosed
developed Western countries with studies predicting with JIA suffer from not only a loss of income but also a
prevalence ranging from 1/1000 to 4/1000 children significant impairment of quality of life, caregiver burden
[2, 3]. The outlook is bleaker in developing countries as well as higher rates of psycho-emotional disorders [10].
where there is nearly a total absence of community-based This is quite frightening given the epidemiological
data. Based on hospital-based incidence of diagnosis of changes that are expected in various developing coun-
JIA as well as RA at a tertiary centre and the community tries in the near future, particularly India. From 1995 to
prevalence of RA in India, the prevalence of JIA was 2020 (and subsequently), India will be the country which
assumed to be around 1.25 per 1000 children [4, 5]. will add the most to the world’s population. By 2050
Filling the deficit in knowledge by measuring the burden India’s population will exceed that of China’s [11].
of JIA would ensure that these disorders receive higher Between 1997 and 2001, India’s working age popula-
priority in health strategies by helping consolidate political tion has grown to become a larger proportion of the total
will as well as increase focus of medical research on treat- population and this trend will continue till 2020 [12].
ment of the problem. An excellent example is the 1994 However, in the later decades (i.e. subsequent to 2050),
WHO Study Group on Osteoporosis. Their findings this big chunk of the working population will age and will
regarding the frequency of osteoporotic fractures led to not be replaced by a similar size of population given the
the setting up of The International Osteoporosis Education successful efforts at family planning. At that point in time
Project, which aims to improve the diagnosis and care of (i.e. beyond 2050), the population that constituted the
osteoporotic patients throughout the world [1]. working population between 2020 and 2050 will be de-
It is imperative that we increase focus on the manage- pendent on the population who would have been born
ment and research of JIA. Dr G. Harlem Brundtland, between 2020 and 2050. Thus we need to make sure
Director-General of the World Health Organization, in her that the population born between 2020 and 2050 are not
opening address to the WHO Scientific Group on the impeded in their ability to contribute to the economy and
Burden of Musculoskeletal Conditions meeting in thus prevent India and China from collapsing under the
Geneva in 2000, mentioned that although the diseases economic burden of caring for their own aged population.
that kill attract much of the public’s attention, musculo- Prevention of malnutrition and infectious diseases is im-
skeletal or rheumatic diseases are the major cause of portant. However, lifestyle diseases and chronic diseases
morbidity throughout the world, having a substantial influ- are already becoming more prevalent among Indian and
ence on health and quality of life, as well as inflicting an Chinese youth in response to better health parameters, an
enormous burden of cost on health systems [1]. immunization programme and improving lifestyle. We can
L ET T E R

Costs involved in the care of a patient with JIA include expect this trend to continue and therefore assume that
the cost of treatment, out of pocket expenses and loss of chronic diseases specifically musculoskeletal diseases
income for parents in the short term. These costs were such as JIA would be an important cause of morbidity in
estimated in a recent article from Germany by Minden the future population of children in these countries.
et al. [6] to vary between 2904 euros (persistent oligoar- Hence, by not taking active measures to prevent mor-
thritis) to 7876 euros (polyarthritis and systemic arthritis) bidity due to JIA in children now and in the near future,
per annum. In comparison, the direct cost of patients with China and India in the coming decades will face an un-
RA is estimated to be around 5167 euros per year [7]. enviable task. There will not only be a disproportionately

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Letter to the Editor
higher percentage of aged population to be supported,
but also a working population burdened by musculoskel-
etal morbidity on which this task will depend. Given that
around half of the world’s population will reside in these
two countries, by corollary, the rest of the world will be
forced to share this burden as well.
Rheumatology key message
. The burden of paediatric musculoskeletal diseases
should be determined in developing countries for
proper resource utilization.
Disclosure statement: The author has declared no con-
flicts of interest.
Sharath Kumar1
1
Pediatric Rheumatology Clinic, Amrita Institute of Medical
Sciences, Cochin, Kerala, India.
Accepted 23 February 2010
Correspondence to: Sharath Kumar, Pediatric Rheumatology
Clinic, Amrita Institute of Medical Sciences, Ponekarra PO,
Cochin-682041, Kerala, India.
E-mail: drsharath_k@yahoo.co.in
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