Active Case Finding for Rheumatic Fever in an Endemic Country

Abstract

Background Despite the high burden of rheumatic heart disease in sub‐Saharan Africa, diagnosis with acute rheumatic fever (ARF) is exceedingly rare. Here, we report the results of the first prospective epidemiologic survey to diagnose and characterize ARF at the community level in Africa. Methods and Results A cross‐sectional study was conducted in Lira, Uganda, to inform the design of a broader epidemiologic survey. Key messages were distributed in the community, and children aged 3 to 17 years were included if they had either (1) fever and joint pain, (2) suspicion of carditis, or (3) suspicion of chorea, with ARF diagnoses made by the 2015 Jones Criteria. Over 6 months, 201 children met criteria for participation, with a median age of 11 years (interquartile range, 6.5) and 103 (51%) female. At final diagnosis, 51 children (25%) had definite ARF, 11 (6%) had possible ARF, 2 (1%) had rheumatic heart disease without evidence of ARF, 78 (39%) had a known alternative diagnosis (10 influenza, 62 malaria, 2 sickle cell crises, 2 typhoid fever, 2 congenital heart disease), and 59 (30%) had an unknown alternative diagnosis. Conclusions ARF persists within rheumatic heart disease–endemic communities in Africa, despite the low rates reported in the literature. Early data collection has enabled refinement of our study design to best capture the incidence of ARF and to answer important questions on community sensitization, healthcare worker and teacher education, and simplified diagnostics for low‐resource areas. This study also generated data to support further exploration of the relationship between malaria and ARF diagnosis in rheumatic heart disease/malaria‐endemic countries.

Community Perspectives on Primary Prevention of Rheumatic Heart Disease in Uganda

“…At the same time, information-education-communication interventions have been shown to be effective at mobilizing communities to increase the use of RHD preventive services [21,22], and in Uganda, such interventions increased referrals for rheumatic fever evaluation [10,23]. In the Ugandan context, a communication intervention could have three major components: (1) teach communities about the causes of pharyngitis and the effectiveness and safety of FPHS, (2) leverage pre-existing enabling beliefs (e.g., that pharyngitis is serious and potentially deadly) to spur patients and families to action in the face of potential mistrust in the healthcare system, and (3) train health workers on proper pharyngitis management, including proper use of antimicrobials, while encouraging respectful and compassionate care for vulnerable populations.…”

“…Recently, the Uganda Ministry of Health partnered with the Uganda Heart Institute, a publiclyfunded, semi-autonomous research and clinical center in the capital city of Kampala, to develop a national strategy on RHD that would guide the local implementation of the World Health Assembly Resolution. This partnership led to a research initiative by the Uganda Heart Institute to better understand local rheumatic fever, RHD epidemiology and health service utilization patterns [4,10], and establish a baseline for monitoring the implementation of a national RHD program. The present study, which was part of this broader research initiative, sought to elicit community perceptions of pharyngitis and pharyngitis-related healthcare to inform the design of interventions that could increase the uptake of formal public-sector healthcare services for this condition and reduce the incidence of rheumatic fever and RHD.…”

Examining the Ugandan health system’s readiness to deliver rheumatic heart disease-related services

“…Awareness may have been increased due to concurrent RHD research activities in those two districts. [17] However, because the research programs were being conducted as epidemiological investigations without an explicit partnership with the ministry of health to scale up access to RHD-related care, we are confident that any influence the research had would be limited to provider awareness and would not extend to other components of care, such as availability of medicines and diagnostics at health facilities. While it is clear that training is needed, it is not known whether pre-service education, in-service education, or a combination of the two would lead to the most durable improvements in health worker knowledge and practice.…”

American Heart Association's Children's Strategically Focused Research Network Experience

“…Nearly a century after AHA began and half a century after commissioning of Cardiovascular Disease in the Young, the Children's Strategically Focused Research Network (SFRN) was established to apply state‐of‐the‐art basic, clinical, and population science strategies and train the next generation of pediatric cardiology scientists while still embodying Cardiovascular Disease in the Young's original focus on RHD, CHD, and preventive cardiology. The Children's SFRN directly and proudly builds on work done by the early pioneers in of pediatric cardiovascular science within AHA in the 1940s and 1950s.This article highlights the hypotheses, goals, accomplishments, challenges, and future directions of each center; provides an overview of collaboration efforts (Table 1 ) 1 , 2 , 3 , 4 and trainee accomplishments (Table 2 ) 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ; and summarizes how we can leverage the output of this SFRN to advance pediatric cardiovascular science.…”