Karki P, Uranw S, Bastola S, Mahato R, Shrestha NR, Sherpa K, Dhungana S, Odutayo A, Gurung K, Pandey N, Agrawal K, Shah P, Rothenbühler M, Jüni P, Pilgrim T. Effectiveness of Systematic Echocardiographic Screening for Rheumatic Heart Disease in Nepalese Schoolchildren: A Cluster Randomized Clinical Trial.
JAMA Cardiol 2021;
6:420-426. [PMID:
33471029 PMCID:
PMC7818193 DOI:
10.1001/jamacardio.2020.7050]
[Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Question
Is echocardiographic screening of schoolchildren in regions with an endemic pattern of rheumatic heart disease followed by secondary antibiotic prophylaxis in children with evidence of subclinical rheumatic heart disease effective in reducing the prevalence of rheumatic heart disease?
Findings
This cluster randomized clinical trial found a nonstatistically significant lower prevalence of definite or borderline rheumatic heart disease in schools with echocardiographic screening 4 years after intervention compared with control schools with no previous screening. An auxiliary repeated cross-sectional analysis of experimental schools found a significant reduction in the odds of definite or borderline rheumatic heart disease.
Meaning
A lower prevalence of rheumatic heart disease in schools with prior echocardiographic screening warrants further study of the effectiveness of early detection and timely treatment of rheumatic heart disease in children and adolescents.
Importance
Echocardiographic screening allows for early detection of subclinical stages of rheumatic heart disease among children in endemic regions.
Objective
To investigate the effectiveness of systematic echocardiographic screening in combination with secondary antibiotic prophylaxis on the prevalence of rheumatic heart disease.
Design, Setting, and Participants
This cluster randomized clinical trial included students 9 to 16 years of age attending public and private schools in urban and rural areas of the Sunsari district in Nepal that had been randomly selected on November 17, 2012. Echocardiographic follow-up was performed between January 7, 2016, and January 3, 2019.
Interventions
In the experimental group, children underwent systematic echocardiographic screening followed by secondary antibiotic prophylaxis in case they had echocardiographic evidence of latent rheumatic heart disease. In the control group, children underwent no echocardiographic screening.
Main Outcomes and Measures
Prevalence of the composite of definite or borderline rheumatic heart disease according to the World Heart Federation criteria in experimental and control schools as assessed 4 years after intervention.
Results
A total of 35 schools were randomized to the experimental group (n = 19) or the control group (n = 16). After a median of 4.3 years (interquartile range [IQR], 4.0-4.5 years), 17 of 19 schools in the experimental group (2648 children; median age at follow-up, 12.1 years; IQR, 10.3-12.5 years; 1308 [49.4%] male) and 15 of 16 schools in the control group (1325 children; median age at follow-up, 10.6 years; IQR, 10.0-12.5 years; 682 [51.5%] male) underwent echocardiographic follow-up. The prevalence of definite or borderline rheumatic heart disease was 10.8 per 1000 children (95% CI, 4.7-24.7) in the control group and 3.8 per 1000 children (95% CI, 1.5-9.8) in the experimental group (odds ratio, 0.34; 95% CI, 0.11-1.07; P = .06). The prevalence in the experimental group at baseline had been 12.9 per 1000 children (95% CI, 9.2-18.1). In the experimental group, the odds ratio of definite or borderline rheumatic heart disease at follow-up vs baseline was 0.29 (95% CI, 0.13-0.65; P = .008).
Conclusions and Relevance
School-based echocardiographic screening in combination with secondary antibiotic prophylaxis in children with evidence of latent rheumatic heart disease may be an effective strategy to reduce the prevalence of definite or borderline rheumatic heart disease in endemic regions.
Trial Registration
ClinicalTrials.gov Identifier: NCT01550068
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