Active surveillance for rheumatic heart disease in endemic regions: a systematic review and meta-analysis of prevalence among children and adolescents

Prevalence of rheumatic heart disease diagnosed according to the echocardiographic criteria of the World Heart Federation in Africa: A systematic review and meta-analysis

Rheumatic heart disease (RHD) is a chronic complication arising from acute rheumatic fever (ARF), an autoimmune response triggered by group A streptococcal infection. It primarily affects children and young adults in developing countries. RHD continues to show substantial global heterogeneity. Socioeconomic factors lead the virtual disappearance of RHD in industrialized countries with the introduction of penicillin. By contrast, RHD is still endemic in Africa, Asia, South America, and developing communities of Australasia. We provide an estimate of the current prevalence of latent RHD in Africa using the echocardiographic diagnostic criteria of the World Heart Federation (WHF). Systematic review and meta-analysis of 21 studies reporting the prevalence of RHD, encompassing 40.639 patients. Estimated prevalence of RHD was 25.5 cases per 1000 population (P ≤0.02; 95 % CI, 18.1-32.9 per 1000): definite RHD 13.1 cases per 1000 population (95 % CI, 7.7-18.5 per 1000): and borderline 12,4 cases per 1000 population (95 % CI, 7.7-17.0 per 1000). The prevalence of definite RHD was a significantly higher in adults (M = 28.2, SD = 6.1) compared to children (M = 10.3, SD = 9.2), t(17) = 2.6, p = .0179. Prevalence of definite RHD in schools was 7,92 cases per 1000 population (95 % CI, 4,49-11,35 per 1000) and in community was 26,17 cases per 1000 population (95 % CI, 12,27-40,06 per 1000). This meta-analysis may have produced a better estimate of the prevalence of RHD in Africa using only studies performed according to the 2012 WHF, and clearly showed the high prevalence of RHD in the community and in adults.

Burden of heart failure in Asia, 1990-2019: findings from the Global Burden of Disease Study 2019

OBJECTIVES

Heart failure (HF) is on the rise as a global health problem, but information on its burden in Asia is limited. This study aimed to assess the burden, trends, and underlying causes of HF in the Asian region.

STUDY DESIGN AND METHODS

Data on HF in Asia from 1990 to 2019, including prevalence, years lived with disability (YLD), and underlying causes, were extracted from the Global Burden of Diseases 2019. The cases, the age-standardized prevalence, and the YLD were compared between the age groups, the sexes, the sociodemographic index, and the locations. The proportion of age-standardized prevalence rates of HF attributable to 16 underlying causes was also analyzed.

RESULTS

In 2019, the age-standardized prevalence rate of HF per 100,000 persons in Asia was 722.45 (95% uncertainty interval [UI]: 591.97-891.64), with an estimated 31.89 million cases (95% UI: 25.94-39.25). From 1990 to 2019, the prevalence of age-standardized HF in Asia decreased by 4.51%, reflecting the global trend (-7.06%). Age-standardized YLD rates of HF exhibited patterns similar to prevalence rates. Among Asian countries, China had the highest age-standardized prevalence rate, followed by Kuwait and Jordan. Hypertensive heart disease was the leading cause of HF, followed by ischemic heart disease and rheumatic heart disease.

CONCLUSIONS

Although the burden of HF in Asia showed a gradual decline between 1990 and 2019, it remains a significant health challenge that requires increased attention. Regional disparities in HF burden are evident, emphasizing the need for urgent prevention and control measures at the regional and national levels.

Epidemiological study of pediatric rheumatic heart disease: An analysis from the Global Burden of Disease Study 2019

BACKGROUND

Rheumatic heart disease (RHD) is the most common acquired heart disease among children in developing countries. However, there is a lack of systematic studies on the epidemiology of pediatric RHD. This study aimed to report the burden of pediatric RHD at global, regional, and national levels between 1990 and 2019, which may provide some reference for policymakers.

METHODS

The numbers and age-standardized rates (ASRs) of incidence, prevalence, mortality, and disability-adjusted life years (DALYs) for childhood RHD from 1990 to 2019 were analyzed based on data obtained from the Global Burden of Disease Study 2019 (GBD 2019). In addition, Joinpoint regression analysis was used to assess temporal trends in the burden of childhood RHD.

RESULTS

Globally, the number of incidence and prevalence cases of RHD in children increased by 41.89% and 40.88%, respectively, from 1990 to 2019. Age-standardized incidence rate (ASIR) and age-standardized prevalence rate (ASPR) increased with an average annual percentage change (AAPC) of 0.75% and 0.66%, respectively. In contrast, the age-standardized DALY rate and age-standardized mortality rate (ASMR) decreased significantly since 1990 by an AAPC of -3.47% and - 2.65%, respectively. Girls had a significantly higher burden of RHD than boys during the study period. At the age level, the RHD burden was significantly highest in the age group of 10-14 years. Moreover, the ASRs of incidence, prevalence, mortality, and DALYs were negatively associated with sociodemographic index (SDI). Nationally, Fiji had the most significant increase in incidence and prevalence, and Philippines had the most remarkable rise in DALYs and mortality rates.

CONCLUSION

From 1990 to 2019, although the incidence and prevalence of childhood RHD increased globally, DALYs and mortality rates markedly reduced. Countries with lower levels of sociodemographic development shoulder a higher burden of childhood RHD. Children aged 10-14 years are critical populations for whom targeted measures are needed to reduce the RHD burden, while attention to girls cannot be neglected.

Outcomes of latent rheumatic heart disease: External validation of a simplified score in patients with and without secondary prophylaxis

BACKGROUND

Secondary antibiotic prophylaxis reduces progression of latent rheumatic heart disease (RHD) but not all children benefit. Improved risk stratification could refine recommendations following positive screening. We aimed to evaluate the performance of a previously developed echocardiographic risk score to predict mid-term outcomes among children with latent RHD.

METHODS

We included children who completed the GOAL, a randomized trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. Outcomes were determined by a 4-member adjudication panel. We applied the point-based score, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3 points), MV regurgitation jet length ≥ 2 cm (6 points), aortic valve focal thickening (4 points) and any aortic regurgitation (5 points)), to panel results. Unfavorable outcome was defined as progression of diagnostic category (borderline to definite, mild definite to moderate/severe definite), worsening valve involvement or remaining with mild definite RHD.

RESULTS

799 patients (625 borderline and 174 definite RHD) were included, with median follow-up of 24 months. At total 116 patients (14.5%) had unfavorable outcome per study criteria, 57.8% not under prophylaxis. The score was strongly associated with unfavorable outcome (HR = 1.26, 95% CI 1.16-1.37, p < 0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7-9 points) and high-risk (≥10 points) children at follow-up were 11.8%, 30.4%, and 42.2%, (p < 0.001) respectively (C-statistic = 0.64 (95% CI 0.59-0.69)).

CONCLUSIONS

The simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes.

Comparison of Cardiovascular Health Profiles Across Population Surveys From 5 High- to Low-Income Countries

Background

To facilitate the shift from risk-factor management to primordial prevention of cardiovascular disease, the American Heart Association developed guidelines to score and track cardiovascular health (CVH). How the prevalence and trajectories of a high level of CVH across the life course compare among high- and lower-income countries is unknown.

Methods

Nationally representative survey data with CVH variables (physical activity, cigarette smoking, body mass index, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the US for adults (aged 18-69 years and not pregnant). Data were harmonized, and CVH metrics were scored using the American Heart Association guidelines, as high (2), moderate (1), or low (0), with the prevalence of high scores (better CVH) across the life course compared across countries.

Results

Among 28,092 adults (Ethiopia n = 7686, 55.2% male; Bangladesh n = 6731, 48.4% male; Brazil n = 7241, 47.9% male; England n = 2691, 49.5% male, and the US n = 3743, 50.3% male), the prevalence of high CVH scores decreased as country income level increased. Declining CVH with age was universal across countries, but differences were already observable in those aged 18 years. Excess body weight appeared to be the main driver of poor CVH in higher-income countries, and the prevalence of current smoking was highest in Bangladesh.

Conclusions

Our findings suggest that CVH decline with age may be universal. Interventions to promote and preserve CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where the level of CVH remains relatively high, protection of whole societies from risk-factor epidemics may still be feasible.

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BACKGROUND

This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2).

METHODS

From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention.

RESULTS

Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012).

CONCLUSIONS

PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

The burden of rheumatic heart disease in the Middle East and North Africa region, 1990-2019

BACKGROUND

Rheumatic heart disease (RHD) is a treatable and preventable condition resulting from acute rheumatic fever.

AIM

To report the prevalence, mortality and disability-adjusted life-years (DALY) due to RHD in the Middle East and North Africa (MENA) region from 1990 to 2019, by sex, age group, country and sociodemographic index (SDI).

METHODS

Information on the prevalence, mortality and DALY associated with RHD were obtained from the Global Burden of Disease Study 2019. Data were gathered for all countries in the MENA region over the period 1990-2019. These data included counts and age-standardized rates per 100,000, accompanied by 95% uncertainty intervals (UIs).

RESULTS

The MENA region had an age-standardized point prevalence of 388.9 per 100,000 in 2019, which was 5.4% higher than in 1990. The annual incidence rate was 1.6, which was 63.4% lower than in 1990. There were 379.4 thousand DALY attributable to RHD in 2019, with an age-standardized rate of 67.1, which was 61.3% lower than in 1990. In 2019, an estimated 7.4 thousand deaths were due to RHD, and the age-standardized death rate was 63.4% lower in 2019 than in 1990. DALY rates rose steadily with increasing age in both males and females. The SDI correlated negatively with the rate of DALY for RHD throughout the study period.

CONCLUSION

The burden of RHD in MENA declined from 1990 to 2019, demonstrating the importance of regularly updating health data and identifying risk factors, and developing effective guidelines on prevention.

Global Access to Comprehensive Care for Paediatric and Congenital Heart Disease

Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide.

Detection and management of latent rheumatic heart disease: a narrative review

Rheumatic heart disease (RHD) is a public health concern in many developing nations around the world. Early detection of latent or subclinical RHD can help in reversing mild lesions, retarding disease progression, reducing morbidity and mortality, and improving the quality of life of patients. Echocardiography is the gold-standard method for screening and confirming latent RHD cases. The rates and determinants of progression of latent RHD cases as assessed by echocardiography have been found to be variable through studies. Even though latent RHD has a slow rate of progression, the rate of progression of its subtype, 'definite' RHD, is substantial. A brief training of nonexpert operators on the use of handheld echocardiography with a simplified protocol is an important strategy to scale up the screening program to detect latent cases. Newer advancements in screening, such as deep-learning digital stethoscopes and telehealth services, have provided an opportunity to expand screening programs even in resource-constrained settings. Newer studies have established the efficacy and safety profile of secondary antibiotic prophylaxis in latent RHD. The concerned authorities in endemic regions of the world should work on improving the availability and accessibility of antibiotic prophylaxis.

Rheumatic Heart Disease in the Developing World

Despite recent public policy initiatives, rheumatic heart disease (RHD) remains a major source of morbidity worldwide. Rheumatic heart disease occurs as a sequela of Streptococcus pyogenes (group A streptococcal [GAS]) infection in patients with genetic susceptibility. Strategies for prevention of RHD or progression of RHD include prevention of GAS infection with community initiatives, effective treatment of GAS infection, and secondary prophylaxis with intramuscular penicillin. The cardiac surgical community has attempted to improve the availability of surgery in RHD-endemic areas with some success, and operative techniques and outcomes of valve repair continue to improve, potentially offering patients a safer, more durable operation. Innovation offers hope for a more scalable solution with improved biomaterials and transcatheter delivery technology; however, cost remains a barrier.

Evaluating the implementation of a dynamic digital application to enable community-based decentralisation of rheumatic heart disease case management in Uganda: protocol for a hybrid type III effectiveness-implementation study

INTRODUCTION

Rheumatic heart disease (RHD) affects over 39 million people worldwide, the majority in low-income and middle-income countries. Secondary antibiotic prophylaxis (SAP), given every 3-4 weeks can improve outcomes, provided more than 80% of doses are received. Poor adherence is strongly correlated with the distance travelled to receive prophylaxis. Decentralising RHD care has the potential to bridge these gaps and at least maintain or potentially increase RHD prophylaxis uptake. A package of implementation strategies was developed with the aim of reducing barriers to optimum SAP uptake.

METHODS AND ANALYSIS

A hybrid implementation-effectiveness study type III was designed to evaluate the effectiveness of a package of implementation strategies including a digital, cloud-based application to support decentralised RHD care, integrated into the public healthcare system in Uganda. Our overarching hypothesis is that secondary prophylaxis adherence can be maintained or improved via a decentralisation strategy, compared with the centralised delivery strategy, by increasing retention in care. To evaluate this, eligible patients with RHD irrespective of their age enrolled at Lira and Gulu hospital registry sites will be consented for decentralised care at their nearest participating health centre. We estimated a sample size of 150-200 registrants. The primary outcome will be adherence to secondary prophylaxis while detailed implementation measures will be collected to understand barriers and facilitators to decentralisation, digital application tool adoption and ultimately its use and scale-up in the public healthcare system.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board (IRB) at Cincinnati Children's Hospital Medical Center (IRB 2021-0160) and Makerere University School of Medicine Research Ethics Committee (Mak-SOMREC-2021-61). Participation will be voluntary and informed consent or assent (>8 but <18) will be obtained prior to participation. At completion, study findings will be communicated to the public, key stakeholders and submitted for publication.

Analysis and comparison of the trends in burden of rheumatic heart disease in China and worldwide from 1990 to 2019

OBJECTIVES

This study aimed to describe the temporal trends in age and gender burdens of rheumatic heart disease (RHD) in China from 1990 to 2019, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), and to compare them with the global burden of the disease.

METHODS

Using open data from the Global Burden of Disease (GBD) database from 1990 to 2019, this study analyzed the characteristics of RHD burden in China and worldwide, including changes in incidence, prevalence, mortality, and DALYs. Joinpoint was used to calculate the average annual percentage change (AAPC) and the corresponding 95% confidence interval (95% CI) to reflect the trends in the burden of RHD. A comprehensive comparative analysis of the differences in RHD burden between China and the rest of the world was conducted from multiple dimensions, including age, gender, and time periods.

RESULTS

From 1990 to 2019, the age-standardized incidence rate (ASIR) of RHD in China decreased from 29.62/100,000 to 23.95/100,000, while the global ASIR increased from 32.69/100,000 to 37.40/100,000. The age-standardized prevalence rate (ASPR) in China decreased from 446.15/100,000 to 390.24/100,000, while the global ASPR increased from 451.56/100,000 to 513.68/100,000. The age-standardized rates of mortality (ASMR) in China decreased from 18.11/100,000 to 4.04/100,000, while the global ASMR decreased from 8.94/100,000 to 3.85/100,000. The age-standardized DALY rate (ASDR) in China decreased from 431.45/100,000 to 93.73/100,000, while the global ASDR decreased from 283.30/100,000 to 132.88/100,000. The AAPC of ASIR, ASPR, ASMR, and ASDR in China was - 0.73%, -0.47%, -5.10%, and - 5.21%, respectively, while the AAPC of the global burden of RHD was 0.48%, 0.45%, -2.87%, and - 2.58%, respectively. The effects of age and gender on the burden of RHD were different. ASIR generally decreased with increasing age, while ASPR increased first and then decreased. ASMR and ASDR increased with increasing age. Women had higher incidence and mortality rates of RHD than men.

CONCLUSION

From 1990 to 2019, the incidence, prevalence, mortality, and DALYs of RHD in China decreased, indicating a relative reduction in the burden of RHD in China. The burden of RHD is age-related, with a higher prevalence observed in the younger population, a peak incidence among young adults, and a higher mortality rate among the elderly population. Women are more susceptible to RHD and have a higher risk of mortality than men. Given China's large population and aging population, RHD remains a significant public health challenge in China.

The prevalence of rheumatic heart disease in Ethiopia: a systematic review and meta-analysis

Globally, more than 33 million people are living with rheumatic heart disease (RHD). A high prevalence of the disease is observed in people with poor socio-economic status, overcrowding, and low access to medical facilities. Even though different studies have been conducted in different settings, there is no reliable data regarding RHD prevalence. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence of RHD in Ethiopia. PubMed/Medline, SCOPUS, HINARI, and Google Scholar databases were used to search for peer-reviewed articles. Articles published in English between the years 1992 and 2022 September were considered. The pooled prevalence of RHD was calculated using a random-effect model at a 95% confidence interval, including the weight of each study. Finally, statistical meta-analysis STATA version 16.0 software was used to calculate the pooled prevalence of RHD.A total of twelve cross-sectional studies were included in the meta-analysis. Individual study prevalence ranges from 0.32 to 32.78%. The pooled prevalence of RHD was 3.19% (95% CI: 1.46-5.56%). The prevalence was higher among the population who visited hospitals at 5.42% (95% CI: 1.09-12.7%) compared to schoolchildren at 0.73% (95% CI: 0.30-1.34%) and community-based studies at 3.83% (95% CI: 3.16-4.55%). Addis Ababa had the lowest prevalence of RHD (0.75% (95% CI: 0.38-1.25%), whereas the highest prevalence was observed in the Amhara region (8.95% (95% CI: 7.21-11.06%). A significant variation in the overall estimated prevalence of RHD was not observed between males and females.Trial registration Protocol registration (PROSPERO): CRD42021251553, Date of registration May 28 2021.

Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report

Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. However, several important scientific issues around the secondary prevention paradigm remain unresolved. This report details research priorities for secondary prevention that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. These span basic, translational, clinical and population science research disciplines and are built on four pillars. First, we need a better understanding of RHD epidemiology to guide programmes, policies, and clinical and public health practice. Second, we need better strategies to find and diagnose people affected by ARF and RHD. Third, we urgently need better tools to manage acute RF and slow the progression of RHD. Fourth, new and existing technologies for these conditions need to be better integrated into healthcare systems. We intend for this document to be a reference point for research organisations and research sponsors interested in contributing to the growing scientific community focused on RHD prevention and control.

Rheumatic Heart Disease in East Africa: A Systematic Review and Meta-Analysis

Background

Despite being a grave problem, there is little information on rheumatic heart disease's prevalence in East Africa. Therefore, the purpose of this systematic review and meta-analysis was to estimate the pooled prevalence of rheumatic heart disease in East Africa.

Materials and Methods

A computerized systematic search of using multiple database searching engines was performed in search of relevant English articles from the inception of the databases to December 2019. It was done in accordance with the preferred reporting items for systematic review and meta-analysis (PRISMA) standard. The funnel plot was used to assess publication bias. R and RStudio for Windows were used for all statistical analysis. The random-effect model was used for calculating the pooled estimate of the prevalence of rheumatic heart disease.

Results

The database search retrieved 1073 papers, and 80 articles (78 cross-sectional and two cohort study designs) with a total of 184575 individuals were found to be appropriate for the review. In East Africa, the overall prevalence of rheumatic heart disease was 14.67% (95% CI: 13.99% to 15.35%). In Ethiopia, Uganda, Tanzania, and Sudan, respectively, the subgroup analysis of rheumatic heart disease pooled prevalence was 22% (95% CI: 13% to 36%), 11% (95%t CI: 5% to 20%), 9% (95%t CI: 5% to 16%), and 3% (95%t CI: 1% to 10%), while the pooled prevalence of rheumatic heart disease in adults was 20% (95% CI: 12% to 30%), and in children, it was 4% (95% CI: 2% to 8%).

Conclusions

From this report, the prevalence of rheumatic heart disease in East Africa is very high, affecting about one in seven people. Therefore, future strategies should emphasize preventive measures at appropriate times to minimize the burden of this type of preventable heart disease.

Comparison of cardiovascular health profiles across population surveys from five high- to low-income countries

Aims

With the greatest burden of cardiovascular disease morbidity and mortality increasingly observed in lower-income countries least prepared for this epidemic, focus is widening from risk factor management alone to primordial prevention to maintain high levels of cardiovascular health (CVH) across the life course. To facilitate this, the American Heart Association (AHA) developed CVH scoring guidelines to evaluate and track CVH. We aimed to compare the prevalence and trajectories of high CVH across the life course using nationally representative adult CVH data from five diverse high- to low-income countries.

Methods

Surveys with CVH variables (physical activity, cigarette smoking, body mass, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the United States (US). Participants were included if they were 18-69y, not pregnant, and had data for these CVH metrics. Comparable data were harmonized and each of the CVH metrics was scored using AHA guidelines as high (2), moderate (1), or low (0) to create total CVH scores with higher scores representing better CVH. High CVH prevalence by age was compared creating country CVH trajectories.

Results

The analysis included 28,092 adults (Ethiopia n=7686, 55.2% male; Bangladesh n=6731, 48.4% male; Brazil n=7241, 47.9 % male; England n=2691, 49.5% male, and the US n=3743, 50.3% male). As country income level increased, prevalence of high CVH decreased (>90% in Ethiopia, >68% in Bangladesh and under 65% in the remaining countries). This pattern remained using either five or all six CVH metrics and following exclusion of underweight participants. While a decline in CVH with age was observed for all countries, higher income countries showed lower prevalence of high CVH already by age 18y. Excess body weight appeared the main driver of poor CVH in higher income countries, while current smoking was highest in Bangladesh.

Conclusion

Harmonization of nationally representative survey data on CVH trajectories with age in 5 highly diverse countries supports our hypothesis that CVH decline with age may be universal. Interventions to promote and preserve high CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where CVH remains relatively high, protection of whole societies from risk factor epidemics may still be feasible.

Global, Regional, and National Advances Toward the Management of Rheumatic Heart Disease Based on the Global Burden of Disease Study 2019

Background Population growth, aging, and major alterations in epidemiologic trends inadvertently modulate the status of rheumatic heart disease (RHD) epidemiology. This investigation predicted RHD burden pattern and temporal trends to provide epidemiologic evidence. Methods and Results Prevalence, mortality, and disability-adjusted life-years data for RHD were obtained from the GBD (Global Burden of Disease) study. We performed decomposition analysis and frontier analysis to assess variations and burden in RHD from 1990 to 2019. In 2019, there were >40.50 million RHD cases worldwide, along with nearly 0.31 million RHD-related deaths and 10.67 million years of healthy life lost to RHD. The RHD burden was commonly concentrated within lower sociodemographic index regions and countries. RHD primarily affects women (22.52 million cases in 2019), and the largest age-specific prevalence rate was at 25 to 29 years in women and 20 to 24 years in men. Multiple reports demonstrated prominent downregulation of RHD-related mortality and disability-adjusted life-years at the global, regional, and national levels. Decomposition analysis revealed that the observed improvements in RHD burden were primarily due to epidemiological alteration; however, it was negatively affected by population growth and aging. Frontier analysis revealed that the age-standardized prevalence rates were negatively linked to sociodemographic index, whereas Somalia and Burkina Faso, with lower sociodemographic index, showed the lowest overall difference from the frontier boundaries of mortality and disability-adjusted life-years. Conclusions RHD remains a major global public health issue. Countries such as Somalia and Burkina Faso are particularly successful in managing adverse outcomes from RHD and may serve as a template for other countries.

High burden of rheumatic heart disease confirmed by echocardiography among Pacific adults living in New Zealand

BACKGROUND

Despite numerous echocardiographic screening studies of children in high incidence acute rheumatic fever (ARF)/rheumatic heart disease (RHD) communities, little is known about the prevalence of RHD in adults in these populations.We sought to determine the prevalence of RHD in an urban area of South Auckland, New Zealand, where previous studies had shown the prevalence of RHD in children to be around 2%.

METHODS

A cross-sectional screening study was conducted between 2014 and 2016. Echocardiography clinics were conducted at an urban Pacific-led primary healthcare clinic in New Zealand. Eligible persons aged 16-40 years were recruited according to a stratified randomised approach. Echocardiograms were performed with a standardised image acquisition protocol and reported by cardiologists.

RESULTS

There were 465 individuals who underwent echocardiograms. The overall prevalence of RHD (define and borderline) was 56 per 1000 (95% CI 36 to 78 per 1000). Definite RHD was found in 10 individuals (4 of whom were already under cardiology review at a hospital clinic) with a prevalence of 22 per 1000 (95% CI 9 to 36 per 1000). Non-rheumatic cardiac abnormalities were found in 29 individuals.

CONCLUSIONS

There is a high burden of both rheumatic and non-rheumatic cardiac abnormalities in this population. Rates described in New Zealand are as high as lower-middle-income countries in Africa. Addressing knowledge gaps regarding the natural history of RHD detected by echocardiography in adults is a priority issue for the international RHD community.

Descriptive Analysis of Rheumatic Heart Disease Related Complications in Pediatric Patients at Tertiary Hospital, Addis Ababa, Ethiopia

Introduction

Rheumatic heart disease continues to be a public health problem worldwide. In developing countries such as Ethiopia where rheumatic heart disease is endemic, most of the patients present with complaints related to complications including heart failure, arrhythmias, pulmonary hypertension, stroke, systemic embolic events and infective endocarditis.

Objective

To identify the types and magnitude of complications in pediatric patients with rheumatic heart disease.

Methodology

Hospital-based cross-sectional study was conducted at Saint Paul Hospital Millennium Medical College, pediatric and child health department. All pediatric cardiac patients with rheumatic heart disease seen from January 1, 2018 to December 30, 2021 were included in the study.

Conclusion

The majority of patients presented to our health facility with complications which implies the need for action at the community level to detect the disease at early stage.

Recommendations

We recommend a similar large-scale study to be conducted at the national level and introduce a national RHD registry to better understand the magnitude of the problem, based on which necessary action will be undertaken. There is also a need to assess the proper implementation of screening and preventive RHD programmes.

Global burden of heart failure: a comprehensive and updated review of epidemiology

Heart Failure (HF) is a multi-faceted and life-threatening syndrome characterized by significant morbidity and mortality, poor functional capacity and quality of life, and high costs. HF affects more than 64 million people worldwide. Therefore, attempts to decrease its social and economic burden have become a major global public health priority. While the incidence of HF has stabilized and seems to be declining in industrialized countries, the prevalence is increasing due to the ageing of the population, improved treatment of and survival with ischaemic heart disease, and the availability of effective evidence-based therapies prolonging life in patients with HF. There are geographical variations in HF epidemiology. There is substantial lack of data from developing countries, where HF exhibits different features compared with that observed in the Western world. In this review, we provide a contemporary overview on the global burden of HF, providing updated estimates on prevalence, incidence, outcomes, and costs worldwide.

Rheumatic heart disease in the heart of Himalayas

Rheumatic heart disease results from the damage to heart valves caused by one or more episodes of rheumatic fever leading to a variety of cardiac complications. Although less common in developed parts of the world, it is one of the most common acquired heart diseases in low- and middle-income countries including Nepal, affecting children and young people. Primary prevention with prompt treatment of streptococcal throat infections and long-term secondary antibiotic prophylaxis with benzathine penicillin G are the key intervention strategies. Echocardiography based screening in schoolchildren has become an effective measure for early identification of the cases. More coordinated policies and effective interventions are needed to successfully decrease the burden of the rheumatic heart disease in resource limited settings like Nepal.

Analysis of Rheumatic Heart Disease Mortality in the Chinese Population: A JoinPoint and Age-Period-Cohort Study

(1) Background: We aimed to analyze rheumatic heart disease (RHD) mortality trends in China's urban and rural areas and to determine the roles of age, period, and cohort effects. (2) Methods: Based on mortality data extracted from the China Health Statistics Yearbook, we calculated the crude mortality rate of RHD. Age-adjusted rates were computed by the direct method using the 2020 census as the standard population. The annual percentage change (APC) and average annual percentage change (AAPC) were determined by the JoinPoint regression model. The age-period-cohort model was used to estimate the effects of age, period, and cohort. (3) Results: From 2006 to 2020, the general trend in RHD standardized mortality declined. The RHD mortality rate was higher in rural than in urban areas and among females than males. The elderly (over 60 years old) were at high risk for RHD deaths in China. The age effect increased with age, and the cohort effect showed a declining trend as chronology grew, but the period effect was not significant. (4) Conclusions: China has achieved great success in RHD, but RHD mortality may increase with age. Compared with the period effect, age and cohort effects dominated the risk of RHD deaths.

Prevalence of latent structural heart disease in Nepali schoolchildren

BACKGROUND

The present study aimed to quantify the burden of structural heart disease in Nepali children.

METHODS

We performed a school-based cross-sectional echocardiographic screening study with cluster random sampling among children 5-16 years of age.

RESULTS

Between December 2012 and January 2019, 6573 children (mean age 10.6 ± 2.9 years) from 41 randomly selected schools underwent echocardiographic screening. Structural heart disease was detected in 14.0 per 1000 children (95% CI 11.3-17.1) and was congenital in 3.3 per 1000 (95% CI 2.1-5.1) and rheumatic in 10.6 per 1000 (95% CI 8.3-13.4). Rates of rheumatic heart disease were higher among children attending public as compared to private schools (OR 2.8, 95% CI 1.6-5.2, p = 0.0001).

CONCLUSION

Rheumatic heart disease accounted for three out of four cases of structural heart disease and was more common among children attending public as compared to private schools.

Invasive group A streptococcal disease in pregnant women and young children: a systematic review and meta-analysis

BACKGROUND

The incidence of invasive disease caused by group A streptococcus (GAS) has increased in multiple countries in the past 15 years. However, despite these reports, to the best of our knowledge, no systematic reviews and combined estimates of the incidence of invasive GAS have been done in key high-risk groups. To address this, we estimated the incidence of invasive GAS disease, including death and disability outcomes, among two high-risk groups-namely, pregnant women and children younger than 5 years.

METHODS

We did a systematic review and meta-analyses on invasive GAS outcomes, including incidence, case fatality risks, and neurodevelopmental impairment risk, among pregnant women, neonates (younger than 28 days), infants (younger than 1 year), and children (younger than 5 years) worldwide and by income region. We searched several databases for articles published from Jan 1, 2000, to June 3, 2020, for publications that reported invasive GAS outcomes, and we sought unpublished data from an investigator group of collaborators. We included studies with data on invasive GAS cases, defined as laboratory isolation of Streptococcus pyogenes from any normally sterile site, or isolation of S pyogenes from a non-sterile site in a patient with necrotising fasciitis or streptococcal toxic shock syndrome. For inclusion in pooled incidence estimates, studies had to report a population denominator, and for inclusion in pooled estimates of case fatality risk, studies had to report aggregate data on the outcome of interest and the total number of cases included as a denominator. We excluded studies focusing on groups at very high risk (eg, only preterm infants). We assessed heterogeneity with I2.

FINDINGS

Of the 950 published articles and 29 unpublished datasets identified, 20 studies (seven unpublished; 3829 cases of invasive GAS) from 12 countries provided sufficient data to be included in pooled estimates of outcomes. We did not identify studies reporting invasive GAS incidence among pregnant women in low-income and middle-income countries (LMICs) nor any reporting neurodevelopmental impairment after invasive GAS in LMICs. In nine studies from high-income countries (HICs) that reported invasive GAS in pregnancy and the post-partum period, invasive GAS incidence was 0·12 per 1000 livebirths (95% CI 0·11 to 0·14; I2=100%). Invasive GAS incidence was 0·04 per 1000 livebirths (0·03 to 0·05; I2=100%; 11 studies) for neonates, 0·13 per 1000 livebirths (0·10 to 0·16; I2=100%; ten studies) for infants, and 0·09 per 1000 person-years (95% CI 0·07 to 0·10; I2=100%; nine studies) for children worldwide; 0·12 per 1000 livebirths (95% CI 0·00 to 0·24; I2=100%; three studies) in neonates, 0·33 per 1000 livebirths (-0·22 to 0·88; I2=100%; two studies) in infants, and 0·22 per 1000 person-years (0·13 to 0·31; I2=100%; two studies) in children in LMICs; and 0·02 per 1000 livebirths (0·00 to 0·03; I2=100%; eight studies) in neonates, 0·08 per 1000 livebirths (0·05 to 0·11; I2=100%; eight studies) in infants, and 0·05 per 1000 person-years (0·03 to 0·06; I2=100%; seven studies) in children for HICs. Case fatality risks were high, particularly among neonates in LMICs (61% [95% CI 33 to 89]; I2=54%; two studies).

INTERPRETATION

We found a substantial burden of invasive GAS among young children. In LMICs, little data were available for neonates and children and no data were available for pregnant women. Incidences of invasive GAS are likely to be underestimates, particularly in LMICs, due to low GAS surveillance. It is essential to improve available data to inform development of prevention and management strategies for invasive GAS.

FUNDING

Wellcome Trust.

Breastfeeding does not protect against the development of carditis in children with acute rheumatic fever

INTRODUCTION

Acute rheumatic fever is an autoimmune disease that develops due to streptococcal infection. The positive effect of breastfeeding on the development of the child's immune system is well documented. In this study, we aimed to investigate the effect of breast milk intake period on the development of carditis.

MATERIALS AND METHODS

Patients (n: 182) who were diagnosed with acute rheumatic fever between 2010 and 2019 were enrolled in the study. The patients were divided into groups according to carditis development. The demographic, socio-economic, and breastfeeding data were compared between groups.

RESULTS

The mean age of the patients was 10.5 ± 3.4, and 43.4 % (n: 79) of them were female. Independent predictors of the development of carditis in the first acute rheumatic fever episode were the number of children at home (OR: 1.773, CI 95%: 1.105, 2.845; p: 0.018) and breast milk intake less than 6 months (OR: 0.404, CI 95%: 0.174, 0.934; p: 0.034). Independent predictors of the development of carditis in any of the acute rheumatic fever episodes were the number of children at home (OR: 1.858, CI 95%: 1.100, 3.137; p: 0.021) and female gender (OR: 3.504, CI 95%: 1.227, 10.008; p: 0.019). The only independently predictor of the development of chorea during acute rheumatic fever was female gender (OR: 3.801, CI 95%: 1.463, 9.874; p: 0.006).

CONCLUSION

Although the occurrence of carditis is less common during the first acute rheumatic fever attack in patients with breast milk intake less than six months, this advantage is lost in recurrent attacks. This study showed that breast milk does not have a negative effect on acute rheumatic fever carditis.

Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers

Background

Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understanding of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess the RHD-related health care systems in Namibia.

Methods

Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement in the systems.

Results

The outpatient register covered 0.032% of the adult Namibian population and combined with the cumulative incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05% and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-eastern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.

Conclusion

The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investigate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the “Awareness Surveillance Advocacy Prevention” framework supported by relevant resolutions by the WHO.

Global burden of rheumatic heart disease: trends from 1990 to 2019

Background

Rheumatic heart disease (RHD) is a critical public health issue worldwide, and its epidemiological patterns have changed over the decades. This article aimed to estimate the global trends of RHD, and attributable risks from 1990 to 2019.

Methods

Data on RHD burden were explored from the Global Burden of Disease Study 2019. Trends of the RHD burden were estimated using the estimated annual percentage change (EAPC) and age-standardized rate (ASR).

Results

During 1990–2019, increasing trends in the ASR of incidence and prevalence of RHD were observed worldwide, with the respective EAPCs of 0.58 (95% confidence interval [CI] 0.52 to 0.63) and 0.57 (95%CI 0.50 to 0.63). Meanwhile, increasing trends commonly occurred in low and middle Socio-Demographic Index (SDI) regions and countries. The largest increasing trends in the ASR of incidence and prevalence were seen in Fiji, with the respective EAPCs being 2.17 (95%CI 1.48 to 2.86) and 2.22 (95%CI 1.53 to 2.91). However, death and disability-adjusted life years (DALYs) due to RHD showed pronounced decreasing trends of ASR globally, in which the EAPCs were − 2.98 (95%CI − 3.03 to − 2.94) and − 2.70 (95%CI − 2.75 to − 2.65), respectively. Meanwhile, decreasing trends were also observed in all SDI areas and geographic regions. The largest decreasing trends of death were observed in Thailand (EAPC = − 9.55, 95%CI − 10.48 to − 8.61). Among the attributable risks, behavioral risk-related death and DALYs caused by RHD had pronounced decreasing trends worldwide and in SDI areas.

Conclusions

Pronounced decreasing trends of death and DALYs caused by RHD were observed in regions and countries from 1990 to 2019, but the RHD burden remains a substantial challenge globally. The results would inform the strategies for more effective prevention and control of RHD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02829-3.

Sense of coherence and quality of life in adolescents with heart disease

OBJECTIVE

The aim of this study was to assess the association between the Sense of Coherence (SoC) and Quality of Life (QoL) in adolescents with heart disease.

METHODS

A cross-sectional study was carried out with 164 adolescents with congenital or valvular heart disease, aged between 10 and 18 years, treated in a referral center in the city of Recife - Brazil. The information collected contains census data, type of heart disease, economic status identified according to the Brazilian Criteria for Economic Classification (ABEP), as well as an evaluation of the SoC and the QoL.

RESULTS

The SoC (50.09) and QoL (72.23) exhibited high average scores. The SoC was positively correlated with all dimensions of the QoL scale (p<0.001). The social and school dimensions, respectively, presented the highest and lowest scores. The linear regression analysis revealed that the SoC influenced the school and emotional dimensions.

CONCLUSIONS

This study demonstrates that the SoC is a protective factor in the life of adolescents. This factor helps on the improvement of perception of QoL and on successfully dealing with daily adversities and chronic stress.

Effectiveness of an educational intervention in improving healthcare workers' knowledge of early recognition, diagnosis and management of rheumatic fever and rheumatic heart disease in rural far-western Nepal: a pre/post-intervention study

OBJECTIVES

Rheumatic fever (RF) and rheumatic heart disease (RHD) remain among the major heart problems among children in Nepal. Although these conditions are preventable and treatable, the lack of proper knowledge and resources to diagnose and manage these conditions in rural health centres is a key concern. This study assessed the impact of educational sessions to improve the knowledge of healthcare workers in the early recognition, diagnosis, and management of RF and RHD in rural far-western Nepal.

DESIGN, SETTING AND PARTICIPANTS

This study used a pretest and post-test interventional design and was conducted among 64 healthcare workers in two primary healthcare centres and a peripheral district-level hospital in Achham district in the far-western region of Nepal. A self-administered questionnaire was used before and after the educational sessions. Data were analysed using SPSS V.21.

RESULTS

The overall test scores increased from 10 (SD=2.4) pre-intervention to 13.8 (SD=1.9) post-intervention (p<0.001). Similarly, participant confidence (graded 1-5) in differentiating bacterial from viral sore throat rose from 3.6 (SD=1.08) pre-intervention to 3.98 (SD=1.09) post-intervention (p<0.05). Confidence in managing RF increased from 3.9 (SD=0.88) pre-intervention to 4.30 (SD=0.8) post-intervention (p<0.001).

CONCLUSION

The findings suggest that the investigated educational sessions are promising with respect to improving the knowledge and confidence of healthcare workers in the early recognition, diagnosis, and management of RF and RHD at the primary healthcare level. Further studies with a larger sample size and conducted in different parts of the country are warranted to assess the effectiveness and impact of scaling up such educational interventions in Nepal.

Understanding the local and international stakeholders in rheumatic heart disease field in Tanzania and Uganda: A systematic stakeholder mapping

BACKGROUND

Our study aimed to systematically identify RHD stakeholders and categories of stakeholders to consider when developing a scorecard that reflects a broad stakeholder input.

METHOD

We used the Schiller et al.(2013) framework to identify RHD stakeholders and stakeholder categories in Tanzania and Uganda. The process involved identifying stakeholders by searching literature related to incidence, prevalence, morbidity, mortality, health services, or health outcomes of Group A streptococcus, acute rheumatic fever, or rheumatic heart disease in these countries. The strategy was completed for two electronic databases in 2016 and in 2020 to update the results. We also engaged known stakeholders to obtain practice-based insight. We then categorised and visually represented the identified stakeholders.

RESULTS

We identified 139 stakeholders in Uganda, with 68% being from 15 different countries across 31 locations. In comparison, local Ugandan stakeholders were dispersed in six locations across the country. In Tanzania, we identified 128 stakeholders, with 66% being locally based and dispersed in seven locations across the country and stakeholders from different countries were situated in 18 countries across 28 locations. We categorised all identified stakeholders into one or more of five categories 1) Civil Society and General Public, 2) Education Sector, 3) Research, Training and Capacity Building, 4) Healthcare service delivery, and 5) Health Policy and Administration.

CONCLUSION

The stakeholder categories identified include multiple sectors and stakeholders from multiple countries, this reflects the complexities of RHD. This also highlights the need for collaboration and partnership as a critical action for preventing and controlling RHD.

Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system

OBJECTIVE

To determine the ability to accurately diagnose acute rheumatic fever (ARF) given the resources available at three levels of the Ugandan healthcare system.

METHODS

Using data obtained from a large epidemiological database on ARF conducted in three districts of Uganda, we selected variables that might positively or negatively predict rheumatic fever based on diagnostic capacity at three levels/tiers of the Ugandan healthcare system. Variables were put into three statistical models that were built sequentially. Multiple logistic regression was used to estimate ORs and 95% CI of predictors of ARF. Performance of the models was determined using Akaike information criterion, adjusted R2, concordance C statistic, Brier score and adequacy index.

RESULTS

A model with clinical predictor variables available at a lower-level health centre (tier 1) predicted ARF with an optimism corrected area under the curve (AUC) (c-statistic) of 0.69. Adding tests available at the district level (tier 2, ECG, complete blood count and malaria testing) increased the AUC to 0.76. A model that additionally included diagnostic tests available at the national referral hospital (tier 3, echocardiography, anti-streptolysin O titres, erythrocyte sedimentation rate/C-reactive protein) had the best performance with an AUC of 0.91.

CONCLUSIONS

Reducing the burden of rheumatic heart disease in low and middle-income countries requires overcoming challenges of ARF diagnosis. Ensuring that possible cases can be evaluated using electrocardiography and relatively simple blood tests will improve diagnostic accuracy somewhat, but access to echocardiography and tests to confirm recent streptococcal infection will have the greatest impact.

Global Burden of Rheumatic Heart Disease and its Association with Socioeconomic Development Status, 1990-2019

AIMS

Rheumatic heart disease (RHD) remains an important health issue, yet global attention to RHD is diminishing. The aim of this study was to investigate the global burden of RHD and its relationship with socioeconomic development status.

METHODS AND RESULTS

Data were obtained from Global Burden of Disease (GBD) 2019 database. Incidence, prevalence, disability-adjusted life years (DALYs), and deaths numbers and rates for RHD were extracted and stratified by sex, level of socio-demographic index (SDI), country, and territory. In addition, the burden of RHD was compared across age groups. From 1990-2019, the age-standardized incidence and prevalence rates of RHD increased by 14.4% (11.2%-17.0%) and 13.8% (11.0%-16.0%), respectively. Incidence and prevalence rates showed an increasing trend in low SDI and low-middle SDI locations, while high-middle SDI and high SDI locations showed a decreasing trend. The age-standardized DALYs and deaths rates of RHD decreased by 53.1% (46.4-60.0) and 56.9% (49.8%-64.7%), and this downward trend more prominent in high-middle SDI and middle SDI locations. In addition, the age of incidence and prevalence rate were concentrated between 5-24 years and 15-49 years, predominantly in poor regions, and RHD appeared to be more common in women than in men.

CONCLUSION

The burden of RHD is negatively correlated with socioeconomic development status. In particular, the burden of RHD among children, adolescents, and women of childbearing age in poorer regions requires more attention. Policymakers should use the 2019 GBD data to guide cost-effective interventions and resource allocation for RHD.

Secondary Antibiotic Prophylaxis for Latent Rheumatic Heart Disease

BACKGROUND

Rheumatic heart disease affects more than 40.5 million people worldwide and results in 306,000 deaths annually. Echocardiographic screening detects rheumatic heart disease at an early, latent stage. Whether secondary antibiotic prophylaxis is effective in preventing progression of latent rheumatic heart disease is unknown.

METHODS

We conducted a randomized, controlled trial of secondary antibiotic prophylaxis in Ugandan children and adolescents 5 to 17 years of age with latent rheumatic heart disease. Participants were randomly assigned to receive either injections of penicillin G benzathine (also known as benzathine benzylpenicillin) every 4 weeks for 2 years or no prophylaxis. All the participants underwent echocardiography at baseline and at 2 years after randomization. Changes from baseline were adjudicated by a panel whose members were unaware of the trial-group assignments. The primary outcome was echocardiographic progression of latent rheumatic heart disease at 2 years.

RESULTS

Among 102,200 children and adolescents who had screening echocardiograms, 3327 were initially assessed as having latent rheumatic heart disease, and 926 of the 3327 subsequently received a definitive diagnosis on the basis of confirmatory echocardiography and were determined to be eligible for the trial. Consent or assent for participation was provided for 916 persons, and all underwent randomization; 818 participants were included in the modified intention-to-treat analysis, and 799 (97.7%) completed the trial. A total of 3 participants (0.8%) in the prophylaxis group had echocardiographic progression at 2 years, as compared with 33 (8.2%) in the control group (risk difference, -7.5 percentage points; 95% confidence interval, -10.2 to -4.7; P<0.001). Two participants in the prophylaxis group had serious adverse events that were attributable to receipt of prophylaxis, including one episode of a mild anaphylactic reaction (representing <0.1% of all administered doses of prophylaxis).

CONCLUSIONS

Among children and adolescents 5 to 17 years of age with latent rheumatic heart disease, secondary antibiotic prophylaxis reduced the risk of disease progression at 2 years. Further research is needed before the implementation of population-level screening can be recommended. (Funded by the Thrasher Research Fund and others; GOAL ClinicalTrials.gov number, NCT03346525.).

Prevalence of soil-transmitted helminth infections, schistosomiasis, and lymphatic filariasis before and after preventive chemotherapy initiation in the Philippines: A systematic review and meta-analysis

Objective

To estimate the impact of preventive chemotherapy on the prevalence and intensity of soil-transmitted helminth (STH) infections, schistosomiasis, and lymphatic filariasis in the Philippines, using systematic review and meta-analysis.

Methods

We included reports reporting prevalence of STH infections, schistosomiasis, or lymphatic filariasis in the Philippines published until 31 March 2021. Peer-reviewed studies were identified in electronic databases. Grey literature reports by the University of the Philippines and the Department of Health were also included. Pooled infection prevalence, before and after the initiation of preventive chemotherapy, stratified by age group, was calculated using the inverse variance heterogeneity model.

Findings

A total of 109 reports were included in the review and meta-analysis. Overall prevalence of moderate-heavy intensity Ascaris lumbricoides (6.6%) and Trichuris trichiura (2.7%) infection after initiation of preventive chemotherapy were significantly lower than the prevalence prior to initiation (23.6% for A. lumbricoides and 12.2% for T. trichiura). Prevalence reductions were also found in school and preschool-age children for A. lumbricoides and T. trichiura. Studies conducted after preventive chemotherapy initiation had significantly lower overall prevalence of moderate-heavy intensity schistosomiasis (3.1% vs 0.2%) and of schistosomiasis in school-age children (30.5% vs 1%). Pooled prevalence of lymphatic filariasis prior to preventive chemotherapy initiation was 3.2% across 12 provinces, while currently only two provinces still have prevalence of more than 1%. There were no published studies reporting prevalence of lymphatic filariasis after initiation of preventive chemotherapy. Heterogeneity was high with I² mostly above 90%.

Conclusion

The burden of STH infections and schistosomiasis in children were significantly lower in studies conducted following the initiation of preventive chemotherapy. Eliminating morbidity and interrupting transmission, however, may require expanded control initiatives including community-wide treatment, and improved water, sanitation, and hygiene. Lymphatic filariasis burden has decreased since the implementation of preventive chemotherapy, with all but two provinces having reached the elimination of lymphatic filariasis as a public health problem.

Mass treatment with anti-parasitic medications is a key control and elimination strategy for several helminth infections, namely intestinal worm infections, schistosomiasis, and lymphatic filariasis, which are common in the Philippines and other endemic countries. To gain insight into the impact of such a strategy that has been in place for more than 14 years, we used systematic review and meta-analysis to compare the prevalence of each of these helminth infections in the Philippines before and after the initiation of mass treatment. The review included 109 reports, composed of peer-reviewed studies and grey literature. The pooled overall prevalence of heavy intensity and the prevalence in children of intestinal worm infection and schistosomiasis were significantly lower in studies conducted after initiation of mass treatment. The studies included are highly heterogenous reflecting variability in sampling procedures, diagnostic tests, study sites, and years of data collection. Eliminating morbidity and interrupting transmission may require expanded control initiatives including community-wide treatment, and improved water, sanitation, and hygiene. The same significantly lower prevalence after initiation of mass treatment was observed for lymphatic filariasis where only two out of the initial 12 endemic provinces still require mass treatment due to prevalence above 1%.

Period Prevalence of Rheumatic Heart Disease and the Need for a Centralized Patient Registry in American Samoa, 2016 to 2018

Background

Rheumatic heart disease (RHD) is a severe, chronic complication of acute rheumatic fever, triggered by group A streptococcal pharyngitis. Centralized patient registries are recommended for RHD prevention and control, but none exists in American Samoa. Using existing RHD tracking systems, we estimated RHD period prevalence and the proportion of people with RHD documented in the electronic health record.

Methods and Results

RHD cases were identified from a centralized electronic health record system, which retrieved clinical encounters with RHD International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes, clinical problem lists referencing RHD, and antibiotic prophylaxis administration records; 3 RHD patient tracking spreadsheets; and an all‐cause mortality database. RHD cases had ≥1 clinical encounter with RHD ICD‐10‐CM codes, a diagnostic echocardiogram, or RHD as a cause of death, or were included in RHD patient tracking spreadsheets. Period prevalence per 1000 population among children aged <18 years and adults aged ≥18 years from 2016 to 2018 and the proportion of people with RHD with ≥1 clinical encounter with an RHD ICD‐10‐CM code were estimated. From 2016 to 2018, RHD was documented in 327 people (57.2%: children aged <18 years). Overall RHD period prevalence was 6.3 cases per 1000 and varied by age (10.0 pediatric cases and 4.3 adult cases per 1000). Only 67% of people with RHD had ≥1 clinical encounter with an RHD ICD‐10‐CM code.

Conclusions

RHD remains a serious public health problem in American Samoa, and the existing electronic health record does not include all cases. A centralized patient registry could improve tracking people with RHD to ensure they receive necessary care.

Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis

BACKGROUND

Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time.

METHODS

All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records.

RESULTS

Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery.

CONCLUSION

This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease.

Rheumatic Heart Disease Screening Based on Phonocardiogram

Rheumatic heart disease (RHD) is one of the most common causes of cardiovascular complications in developing countries. It is a heart valve disease that typically affects children. Impaired heart valves stop functioning properly, resulting in a turbulent blood flow within the heart known as a murmur. This murmur can be detected by cardiac auscultation. However, the specificity and sensitivity of manual auscultation were reported to be low. The other alternative is echocardiography, which is costly and requires a highly qualified physician. Given the disease's current high prevalence rate (the latest reported rate in the study area (Ethiopia) was 5.65%), there is a pressing need for early detection of the disease through mass screening programs. This paper proposes an automated RHD screening approach using machine learning that can be used by non-medically trained persons outside of a clinical setting. Heart sound data was collected from 124 persons with RHD (PwRHD) and 46 healthy controls (HC) in Ethiopia with an additional 81 HC records from an open-access dataset. Thirty-one distinct features were extracted to correctly represent RHD. A support vector machine (SVM) classifier was evaluated using two nested cross-validation approaches to quantitatively assess the generalization of the system to previously unseen subjects. For regular nested 10-fold cross-validation, an f1-score of 96.0 ± 0.9%, recall 95.8 ± 1.5%, precision 96.2 ± 0.6% and a specificity of 96.0 ± 0.6% were achieved. In the imbalanced nested cross-validation at a prevalence rate of 5%, it achieved an f1-score of 72.2 ± 0.8%, recall 92.3 ± 0.4%, precision 59.2 ± 3.6%, and a specificity of 94.8 ± 0.6%. In screening tasks where the prevalence of the disease is small, recall is more important than precision. The findings are encouraging, and the proposed screening tool can be inexpensive, easy to deploy, and has an excellent detection rate. As a result, it has the potential for mass screening and early detection of RHD in developing countries.

Outcomes of Echocardiography-Detected Rheumatic Heart Disease: Validating a Simplified Score in Cohorts From Different Countries

Background The natural history of latent rheumatic heart disease (RHD) detected by echocardiography remains unclear. We aimed to assess the accuracy of a simplified score based on the 2012 World Heart Federation criteria in predicting mid-term RHD echocardiography outcomes in children from 4 different countries. Methods and Results Patient-level baseline and follow-up data of children with latent RHD from 4 countries (Australia, n=62; Brazil, n=197; Malawi, n=40; New Zealand, n=94) were combined. A simplified echocardiographic scoring system previously developed from Brazilian and Ugandan cohorts, consisting of 5 point-based variables with respective weights, was applied: mitral valveanterior leaflet thickening (weight=3), excessive leaflet
tip motion (3), regurgitation jet length ≥2 cm (6), aortic valve
focal thickening (4), and any regurgitation (5). Unfavorable outcome was defined as worsening diagnostic category, persistent definite RHD or development/worsening of valve regurgitation/stenosis. The score model was updated using methods for recalibration. 393 patients (314 borderline, 79 definite RHD) with median follow-up of 36 (interquartile range, 25-48) months were included. Median age was 14 (interquartile range, 11-16) years and secondary prophylaxis was prescribed to 16%. The echocardiographic score model applied to this external population showed significant association with unfavorable outcome (hazard ratio, 1.10; 95% CI, 1.04-1.16; P=0.001). Unfavorable outcome rates in low (≤5 points), intermediate (6-9), and high-risk (≥10) children at 3-year follow-up were 14.3%, 20.8%, and 38.5% respectively (P<0.001). The updated score model showed good performance in predicting unfavorable outcome. Conclusions The echocardiographic score model for predicting RHD outcome was updated and validated for different latent RHD populations. It has potential utility in the clinical and screening setting for risk stratification of latent RHD.

Single-View Echocardiography by Nonexpert Practitioners to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy

Supplemental Digital Content is available in the text.

Background:

Echocardiographic screening can detect asymptomatic cases of rheumatic heart disease (RHD), facilitating access to treatment. Barriers to implementation of echocardiographic screening include the requirement for expensive equipment and expert practitioners. We aimed to evaluate the diagnostic accuracy of an abbreviated echocardiographic screening protocol (single parasternal-long-axis view with a sweep of the heart) performed by briefly trained, nonexpert practitioners using handheld ultrasound devices.

Methods:

Participants aged 5 to 20 years in Timor-Leste and the Northern Territory of Australia had 2 echocardiograms: one performed by an expert echocardiographer using a GE Vivid I or Vivid Q portable ultrasound device (reference test), and one performed by a nonexpert practitioner using a GE Vscan handheld ultrasound device (index test). The accuracy of the index test, compared with the reference test, for identifying cases with definite or borderline RHD was determined.

Results:

There were 3111 enrolled participants; 2573 had both an index test and reference test. Median age was 12 years (interquartile range, 10–15); 58.2% were female. Proportion with definite or borderline RHD was 5.52% (95% CI, 4.70–6.47); proportion with definite RHD was 3.23% (95% CI, 2.61–3.98).

Compared with the reference test, sensitivity of the index test for definite or borderline RHD was 70.4% (95% CI, 62.2–77.8), specificity was 78.1% (95% CI, 76.4–79.8).

Conclusions:

Nonexpert practitioners can be trained to perform single parasternal-long-axis view with a sweep of the heart echocardiography. However, the specificity and sensitivity are inadequate for echocardiographic screening. Improved training for nonexpert practitioners should be investigated.

Detection of subclinical rheumatic heart disease in children using a deep learning algorithm on digital stethoscope: a study protocol

INTRODUCTION

Rheumatic heart diseases (RHDs) contribute significant morbidity and mortality globally. To reduce the burden of RHD, timely initiation of secondary prophylaxis is important. The objectives of this study are to determine the frequency of subclinical RHD and to train a deep learning (DL) algorithm using waveform data from the digital auscultatory stethoscope (DAS) in predicting subclinical RHD.

METHODS AND ANALYSIS

We aim to recruit 1700 children from a group of schools serving the underprivileged over a 12-month period in Karachi (Pakistan). All consenting students within the age of 5-15 years with no underlying congenital heart disease will be eligible for the study. We will gather information regarding sociodemographics, anthropometric data, history of symptoms or diagnosis of rheumatic fever, phonocardiogram (PCG) and electrocardiography (ECG) data obtained from DAS. Handheld echocardiogram will be performed on each study participant to assess the presence of a mitral regurgitation (MR) jet (>1.5 cm), or the presence of aortic regurgitation (AR) in any view. If any of these findings are present, a confirmatory standard echocardiogram using the World Heart Federation (WHF) will be performed to confirm the diagnosis of subclinical RHD. The auscultatory data from digital stethoscope will be used to train the deep neural network for the automatic identification of patients with subclinical RHD. The proposed neural network will be trained in a supervised manner using labels from standard echocardiogram of the participants. Once trained, the neural network will be able to automatically classify the DAS data in one of the three major categories-patient with definite RHD, patient with borderline RHD and normal subject. The significance of the results will be confirmed by standard statistical methods for hypothesis testing.

ETHICS AND DISSEMINATION

Ethics approval has been taken from the Aga Khan University, Pakistan. Findings will be disseminated through scientific publications and to collaborators.

ARTICLE FOCUS

This study focuses on determining the frequency of subclinical RHD in school-going children in Karachi, Pakistan and developing a DL algorithm to screen for this condition using a digital stethoscope.

Persisting burden and challenges of rheumatic heart disease

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

Echocardiography for latent rheumatic heart disease in first degree relatives of children with acute rheumatic fever: Implications for active case finding in family members

BACKGROUND

Individuals with Acute Rheumatic Fever (ARF) often report a family history of ARF or Rheumatic Heart Disease (RHD) however the degree of familial susceptibility to RHD is poorly defined. This study aimed to determine RHD prevalence among first degree relatives of ARF patients using echocardiography.

METHODS

Children with ARF were recruited from Auckland, New Zealand. Parents and siblings ≥ 4years were offered echocardiography. Echocardiograms were reported according to World Heart Federation 2012 criteria. RHD prevalence in first degree relatives was compared to previously established population rates in the region.

FINDINGS

In total, 70 index cases with ARF were recruited. Echocardiography was performed in 94 parents and 132 siblings. There were 3 siblings with definite RHD and 9 with borderline RHD. There were 4 parents with definite RHD. Overall prevalence of RHD (definite and borderline) in siblings was 90/1,000 (95% CI 45-143/1,000) compared to 36/1,000 (95% CI 30-42/1,000) in New Zealand children from high ARF incidence populations (p 0.001). Prevalence of definite RHD in parents was 42/1,000 (95% CI 7-87/1,000) compared to 22/1,000 (95% CI 9-36/1,000) in adults from a high ARF incidence New Zealand population (p 0.249).

INTERPRETATION

RHD prevalence in siblings and parents of ARF cases is significantly greater than in comparable background populations. The contribution of hereditary versus environmental risk factors remains uncertain. We recommend targeted echocardiographic case-finding among siblings and parents of ARF/RHD cases in order to detect previously unrecognized latent RHD.

Prevalence and follow-up of subclinical rheumatic heart disease among asymptomatic school children in a north-western district of India based on the World Heart Federation echocardiographic criteria

BACKGROUND

The present study is based on the World Heart Federation (WHF) echocardiographic criteria to assess the prevalence of subclinical rheumatic heart disease (RHD) and elucidate evolution of the disease when the cases were placed on appropriate antibiotic prophylaxis and regular follow-up. The prevalence of subclinical RHD reported by previous active surveillance studies among asymptomatic school children is not comparable to our study because of major differences in screening methods.

METHODS

A random inclusion strategy was adopted to recruit urban and rural school children of Bikaner district in the state of Rajasthan, India. The diagnosis of RHD was based on the echocardiographic criteria proposed by the WHF. All studies were reported on-site by a single experienced cardiologist and the digitally preserved studies were reported by a second cardiologist off-site. The final diagnosis was made by consensus. The second echocardiogram was performed for cases diagnosed with RHD after two years from start of study to document early evolution of the disease with ongoing antibiotic prophylaxis.

RESULTS

A high prevalence of subclinical RHD was observed in the study population. Pathological mitral and/or aortic valve regurgitation was the commonest lesion, and a significant proportion of cases improved while on regular antibiotic prophylaxis. No case showed fixity of leaflets/ stenosis.

CONCLUSION

The prevalence of subclinical RHD is high in the study population, and the disease seems to regress over time in the presence of appropriate antibiotic prophylaxis.