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Ochora M, Kyasimire L, Lutasingwa D, Namata T, Ahmed M, Favina A, Kumbakumba E, Nampijja D. Primary Healthcare Workers' Awareness of Acute Rheumatic Fever & Rheumatic Heart Disease: A Study in Public Health Facilities in South Western Uganda. Pediatric Health Med Ther 2024; 15:223-229. [PMID: 38860188 PMCID: PMC11162961 DOI: 10.2147/phmt.s461168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/31/2024] [Indexed: 06/12/2024] Open
Abstract
Introduction Timely identification and treatment of a streptococcal throat infection prevents acute rheumatic fever (ARF) and its progression to Rheumatic Heart Disease (RHD). However, children in developing countries still present with established RHD, due to either missed, untreated or sub-optimally treated sore throats and ARF. We aimed to determine the level of knowledge, skills, and practices of primary health workers in South Western Uganda in providing care such children. Methods We conducted a comparative quantitative cross-sectional study to assess knowledge, practices, and skills regarding the care of a child with a sore throat, ARF, and RHD. The responses were scored against a structured guide. The Fisher's exact test and the chi-squared test with level of significance set at 0.05 were utilized to compare differences in knowledge, skills, and practices among health workers in private and public health facilities about ARF and RHD. Results Eighty health workers from health facilities were interviewed in Mbarara district with a median age of 29.5 years (IQR 27.34) and median duration in practice of 5 years (IQR: 2, 10). On average, there were at least 3 children with sore throats weekly. At least 95% (CI: 87.25%-98.80%) of the health worker had awareness about ARF and RHD. Only 43.75% (95% CI: 33.18%-54.91%) had good knowledge about ARF and RHD. Majority, 61.25% (95% CI: 50.03%-71.39%) did not know the proper prophylaxis and investigations for a child with ARF. There were no statistically significant differences but a clinically meaningful differentials in the level of knowledge among health workers in public and private facilities. Conclusion The knowledge and skill level of health workers in primary healthcare facilities about ARF and RHD in South Western Uganda remains low, with no difference between practitioners in public and private facilities.
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Affiliation(s)
- Moses Ochora
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Lydia Kyasimire
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Dan Lutasingwa
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Tamara Namata
- Department of Community Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Muna Ahmed
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Alain Favina
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Dorah Nampijja
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
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Rwebembera J, Ndagire E, Carvalho N, Webel AR, Sable C, Okello E, Sarnacki R, Spaziani AM, Mucunguzi A, Engelman D, Grobler A, Steer A, Beaton A. Intramuscular versus enteral penicillin prophylaxis to prevent progression of rheumatic heart disease: Study protocol for a noninferiority randomized trial (the GOALIE trial). Am Heart J 2024; 275:74-85. [PMID: 38797460 DOI: 10.1016/j.ahj.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/21/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) persists as a major cardiovascular driver of mortality and morbidity among young people in low-and middle-income countries. Secondary antibiotic prophylaxis (SAP) with penicillin remains the cornerstone of RHD control, however, suboptimal treatment adherence undermines most secondary prevention programs. Many of the barriers to optimal SAP adherence are specific to the intramuscular form of penicillin and may potentially be overcome by use of oral penicillin. This noninferiority trial is comparing the efficacy of intramuscular to oral penicillin SAP to prevent progression of mild RHD at 2 years. METHODS/DESIGN The Intramuscular vs Enteral Penicillin Prophylaxis to Prevent Progression of Rheumatic Heart Disease (GOALIE) trial is randomizing Ugandan children aged 5 to 17 years identified by echocardiographic screening with mild RHD (Stage A or B as defined by 2023 World Heart Federation criteria) to Benzathine Benzyl Penicillin G (BPG arm, every-28-day intramuscular penicillin) or Phenoxymethyl Penicillin (Pen V arm, twice daily oral penicillin) for a period of 2 years. A blinded echocardiography adjudication panel of 3 RHD experts and 2 cardiologists is determining the echocardiographic stage of RHD at enrollment and will do the same at study completion by consensus review. Treatment adherence and study retention are supported through peer support groups and case management strategies. The primary outcome is the proportion of children in the Pen V arm who progress to more advanced RHD compared to those in the BPG arm. Secondary outcomes are patient-reported outcomes (treatment acceptance, satisfaction, and health related quality of life), costs, and cost-effectiveness of oral compared to intramuscular penicillin prophylaxis for RHD. A total sample size of 1,004 participants will provide 90% power to demonstrate noninferiority using a margin of 4% with allowance for 7% loss to follow-up. Participant enrollment commenced in October 2023 and final participant follow-up is expected in December 2026. The graphical abstract (Fig. 1) summarizes the flow of echocardiographic screening, participant enrollment and follow-up. DISCUSSION The GOALIE trial is critical in global efforts to refine a pragmatic approach to secondary prevention for RHD control. GOALIE insists that the inferiority of oral penicillin be proven contemporarily and against the most important near-term clinical outcome of progression of RHD severity. This work also considers other factors that could influence the adoption of oral prophylaxis and change the calculus for acceptable efficacy including patient-reported outcomes and costs. TRIAL REGISTRATION ClinicalTrials.gov: NCT05693545.
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Affiliation(s)
- Joselyn Rwebembera
- Division of Adult Cardiology, Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda.
| | - Emma Ndagire
- Division of Paediatric Cardiology, Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Natalie Carvalho
- Economics of Global Health and Infectious Diseases Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Allison R Webel
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, Washington
| | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Emmy Okello
- Division of Adult Cardiology, Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Rachel Sarnacki
- Global Cardiology Research Initiative, Children's National Hospital, Washington, DC
| | - Alison M Spaziani
- Global Cardiology Research Initiative, Children's National Hospital, Washington, DC
| | - Atukunda Mucunguzi
- Department of Finance and Administration, Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala, Uganda
| | - Daniel Engelman
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Global Health Initiative, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anneke Grobler
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Andrew Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Global Health Initiative, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Andrea Beaton
- Department of Paediatrics, School of Medicine, University of Cincinnati, Cincinnati, OH; Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH
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3
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Aber-Odonga H, Nuwaha F, Kisaakye E, Engebretsen IMS, Babirye JN. Health facility readiness to screen, diagnose and manage substance use disorders in Mbale district, Uganda. Subst Abuse Treat Prev Policy 2023; 18:63. [PMID: 37925411 PMCID: PMC10625191 DOI: 10.1186/s13011-023-00570-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Substance use disorders (SUD) pose a significant public health problem in Uganda. Studies indicate that integrating mental health services into Primary Health Care can play a crucial role in alleviating the impact of SUD. However, despite ongoing efforts to integrate these services in Uganda, there is a lack of evidence regarding the preparedness of health facilities to effectively screen and manage SUD. Therefore, this study aimed to assess the readiness of health facilities at all levels of the health system in Mbale, Uganda, to carry out screening, diagnosis, and management of SUD. METHODS A health facility-based cross-sectional study was carried out among all the 54 facilities in Mbale district. A composite variable adapted from the WHO Service Availability and Readiness Assessment manual (2015) with 14 tracer indicators were used to measure readiness. A cut-off threshold of having at least half the criteria fulfilled (higher than the cutoff of 7) was classified as having met the readiness criteria. Descriptive analyses were performed to describe readiness scores across various facility characteristics and a linear regression model was used to identify the predictors of readiness. RESULTS Among all health facilities assessed, only 35% met the readiness criteria for managing Substance Use Disorders (SUD). Out of the 54 facilities, 42 (77.8%) had guidelines in place for managing SUD, but less than half, 26 (48%), reported following these guidelines. Only 8 out of 54 (14.5%) facilities had staff who had received training in the diagnosis and management of SUD within the past two years. Diagnostic tests for SUD, specifically the Uri stick, were available in the majority of facilities, (46/54, 83.6%). A higher number of clinical officers working at the health centres was associated with higher readiness scores (score coefficient 4.0,95% CI 1.5-6.5). CONCLUSIONS In this setting, a low level of health facility readiness to provide screening, diagnosis, and management for substance use disorders was found. To improve health facility readiness for delivery of care for substance use disorders, a frequent inventory of human resources in terms of numbers, skills, and other resources are required in this resource-limited setting.
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Affiliation(s)
- Harriet Aber-Odonga
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
| | - Fred Nuwaha
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda
| | - Esther Kisaakye
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda
| | - Ingunn Marie S Engebretsen
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, 7804, Norway
| | - Juliet Ndimwibo Babirye
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda
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Minja NW, Pulle J, Rwebembera J, de Loizaga SR, Fall N, Ollberding N, Abrams J, Atala J, Kamarembo J, Oyella L, Odong F, Nalubwama H, Nakagaayi D, Sarnacki R, Su Y, Dexheimer JW, Sable C, Longenecker CT, Danforth K, Okello E, Beaton AZ, Watkins DA. 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. BMJ Open 2023; 13:e071540. [PMID: 37898491 PMCID: PMC10619093 DOI: 10.1136/bmjopen-2022-071540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 09/19/2023] [Indexed: 10/30/2023] Open
Abstract
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.
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Affiliation(s)
- Neema W Minja
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania, United Republic of
| | - Jafesi Pulle
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Joselyn Rwebembera
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Sarah R de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ndate Fall
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica Abrams
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Reach, Cape Town, South Africa
| | - Jenifer Atala
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Jenipher Kamarembo
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Linda Oyella
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Francis Odong
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Haddy Nalubwama
- Department is Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rachel Sarnacki
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Judith W Dexheimer
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Craig Sable
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Kristen Danforth
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea Zawacki Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David A Watkins
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of General Medicine, University of Washington, Seattle, Washington, USA
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Karthikeyan G, Watkins D, Bukhman G, Cunningham MW, Haller J, Masterson M, Mensah GA, Mocumbi A, Muhamed B, Okello E, Sotoodehnia N, Machipisa T, Ralph A, Wyber R, Beaton A. 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. BMJ Glob Health 2023; 8:e012468. [PMID: 37914183 PMCID: PMC10618973 DOI: 10.1136/bmjgh-2023-012468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
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.
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Affiliation(s)
| | - David Watkins
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John Haller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - George A Mensah
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non-Communicable Diseases Division, Instituto Nacional de Saúde, Marracuene, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Babu Muhamed
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington, USA
| | - Tafadzwa Machipisa
- Cape Heart Institute (CHI), Department of Medicine, University of Cape Town, Rondebosch, South Africa
- Clinical Research Laboratory & Biobank-Genetic & Molecular Epidemiology Laboratory (CRLB-GMEL), Population Health Research Institute, Hamilton, Ontario, Canada
| | - Anna Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Rosemary Wyber
- END RHD Program, Telethon Kids Institute, Perth, Western Australia, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Canberra, Australian Capital Territory, Australia
| | - Andrea Beaton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Sable C, Li JS, Tristani‐Firouzi M, Fagerlin A, Silver RM, Yandel M, Yost HJ, Beaton A, Dale J, Engel ME, Watkins D, Spurney C, Skinner AC, Armstrong SC, Shah SH, Allen N, Davis M, Hou L, Van Horn L, Labarthe D, Lloyd‐Jones D, Marino B. American Heart Association's Children's Strategically Focused Research Network Experience. J Am Heart Assoc 2023; 12:e028356. [PMID: 36974754 PMCID: PMC10122897 DOI: 10.1161/jaha.122.028356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
The American Heart Association's Strategically Focused Children's Research Network started in July 2017 with 4 unique programs at Children's National Hospital in Washington, DC; Duke University in Durham, North Carolina; University of Utah in Salt Lake City, Utah; and Lurie Children's Hospital/Northwestern University in Chicago, Illinois. The overarching goal of the Children's National center was to develop evidence-based strategies to strengthen the health system response to rheumatic heart disease through synergistic basic, clinical, and population science research. The overall goals of the Duke center were to determine risk factors for obesity and response to treatment including those that might work on a larger scale in communities across the country. The integrating theme of the Utah center focused on leveraging big data-science approaches to improve the quality of care and outcomes for children with congenital heart defects, within the context of the patient and their family. The overarching hypothesis of the Northwestern center is that the early course of change in cardiovascular health, from birth onward, reflects factors that result in either subsequent development of cardiovascular risk or preservation of lifetime favorable cardiovascular health. All 4 centers exceeded the original goals of research productivity, fellow training, and collaboration. This article describes details of these accomplishments and highlights challenges, especially around the COVID-19 pandemic.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Norrina Allen
- Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Matthew Davis
- Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Lifang Hou
- Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Linda Van Horn
- Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Darwin Labarthe
- Northwestern University Feinberg School of MedicineChicagoILUSA
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Scheel A, Beaton AZ, Katzenellenbogen J, Parks T, Miller KM, Cherian T, Van Beneden CA, Cannon JW, Moore HC, Bowen AC, Carapetis JR. Standardization of Epidemiological Surveillance of Acute Rheumatic Fever. Open Forum Infect Dis 2022; 9:S41-S49. [PMID: 36128408 PMCID: PMC9474936 DOI: 10.1093/ofid/ofac252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Acute rheumatic fever (ARF) is a multiorgan inflammatory disorder that results from the body’s autoimmune response to pharyngitis or a skin infection caused by Streptococcus pyogenes (Strep A). Acute rheumatic fever mainly affects those in low- and middle-income nations, as well as in indigenous populations in wealthy nations, where initial Strep A infections may go undetected. A single episode of ARF puts a person at increased risk of developing long-term cardiac damage known as rheumatic heart disease. We present case definitions for both definite and possible ARF, including initial and recurrent episodes, according to the 2015 Jones Criteria, and we discuss current tests available to aid in the diagnosis. We outline the considerations specific to ARF surveillance methodology, including discussion on where and how to conduct active or passive surveillance (eg, early childhood centers/schools, households, primary healthcare, administrative database review), participant eligibility, and the surveillance population. Additional considerations for ARF surveillance, including implications for secondary prophylaxis and follow-up, ARF registers, community engagement, and the impact of surveillance, are addressed. Finally, the core elements of case report forms for ARF, monitoring and audit requirements, quality control and assurance, and the ethics of conducting surveillance are discussed.
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Affiliation(s)
- Amy Scheel
- Emory University School of Medicine , Atlanta, Georgia , USA
| | - Andrea Z Beaton
- Cincinnati Children’s Hospital Medical Center, The Heart Institute , Cincinnati, Ohio , USA
| | | | - Tom Parks
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital
| | - Kate M Miller
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, The University of Western Australia , Nedlands , Western Australia
| | | | | | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, The University of Western Australia , Nedlands , Western Australia
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health , Boston, Massachusetts , USA
| | - Hannah C Moore
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, The University of Western Australia , Nedlands , Western Australia
| | - Asha C Bowen
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, The University of Western Australia , Nedlands , Western Australia
- Perth Children’s Hospital , Nedlands , Western Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, The University of Western Australia , Nedlands , Western Australia
- Perth Children’s Hospital , Nedlands , Western Australia
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Ndagire E, Ollberding N, Sarnacki R, Meghna M, Pulle J, Atala J, Agaba C, Kansiime R, Bowen A, Longenecker CT, Oyella L, Rwebembera J, Okello E, Parks T, Zang H, Carapetis J, Sable C, Beaton AZ. Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system. BMJ Open 2022; 12:e050478. [PMID: 35318227 PMCID: PMC8943770 DOI: 10.1136/bmjopen-2021-050478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 01/28/2022] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Emma Ndagire
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rachel Sarnacki
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Murali Meghna
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Jafesi Pulle
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | - Jenifer Atala
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | - Collins Agaba
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | | | - Asha Bowen
- Telethon Kids Institute, Perth, Western Australia, Australia
| | | | - Linda Oyella
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | | | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Tom Parks
- London School of Hygiene & Tropical Medicine, London, UK
| | - Huaiyu Zang
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | | | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Andrea Z Beaton
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
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Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:pathogens11020179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade’s achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
- Correspondence: or ; Tel.: +256-779010527
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
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