Comparison Between Different Strategies of Rheumatic Heart Disease Echocardiographic Screening in Brazil: Data From the PROVAR (Rheumatic Valve Disease Screening Program) Study

Abstract

BackgroundConsidering the limited accuracy of clinical examination for early diagnosis of rheumatic heart disease (RHD), echocardiography has emerged as an important epidemiological tool. The ideal setting for screening is yet to be defined. We aimed to evaluate the prevalence and pattern of latent RHD in schoolchildren (aged 5–18 years) and to compare effectiveness of screening between public schools, private schools, and primary care centers in Minas Gerais, Brazil.Methods and ResultsThe PROVAR (Rheumatic Valve Disease Screening Program) study uses nonexperts and portable and handheld devices for RHD echocardiographic screening, with remote interpretation by telemedicine, according to the 2012 World Heart Federation criteria. Compliance with study consent and prevalence were compared between different screening settings, and variables associated with RHD were analyzed. In 26 months, 12 048 students were screened in 52 public schools (n=10 901), 2 private schools (n=589), and 3 primary care centers (n=558). Median age was 12.9 years, and 55.4% were girls. Overall RHD prevalence was 4.0% borderline (n=486) and 0.5% definite (n=63), with statistically similar rates between public schools (4.6%), private schools (3.5%), and primary care centers (4.8%) (P=0.24). The percentage of informed consents signed was higher in primary care centers (84.4%) and private schools (66.9%) compared with public schools (38.7%) (P<0.001). Prevalence was higher in children ≥12 years (5.3% versus 3.1%; P<0.001) and girls (4.9% versus 4.0%; P=0.02). Only age (odds ratio, 1.12; 95% confidence interval, 1.09–1.17; P<0.001) was independently associated with RHD.Conclusions RHD screening in primary care centers seems to achieve higher coverage rates. Prevalence among schoolchildren is significantly high, with rates higher than expected in private schools of high‐income areas. These data are important for the formulation of public policies to confront RHD.

Echocardiography in Indigenous Populations and Resource Poor Settings

“…[ 48,49] with generally good results. In Brazil, the Programa de RastreamentO da VAlvopatia Reumática (PROVAR) program has successfully used hand-held echocardiography in primary care settings to decrease wait times for specialty consultation [50]. Limited functionality of these devices remains an important consideration (Table 2), in most cases requiring confirmatory follow-up assessment for comprehensive evaluation.…”

Fighting Rheumatic Heart Disease: What are the next moves?

“…programs have proven useful for advocacy and awareness about the epidemiological significance of the disease, thereby contributing to bring this topic to policymakers. More than screening itself, many of these programs have implemented educational curriculums to children, school and healthcare staff with novel strategies 6 . Additionally, screening has expanded to beyond active case searches in younger ages and now evaluates the impact of RHD on pregnancy 7 and investigates the susceptibility of siblings of positive cases 8 , thereby unveiling previously unexplored territories.…”

“…Cuba has observed a dramatic drop in premature morbidity and mortality in children and young adults with a cost-saving intervention, with synergism between primary and secondary care 9 . In Brazil, the integration of education and screening into primary care seems to achieve better coverage and engagement, with an important role played by community health agents 6 . Similarly, in Uganda, the regionalization and decentralization of RHD care to the community level is proposed as a tool for improving retention in care 7,8 .…”

“…Additionally, research also focused on strategies to decentralize diagnostic services through pointof-care technologies (e.g. portable/handheld echocardiography and rapid antigen detection test kits), task-shifting and telemedicine, which may optimize case detection in areas with limited technology and skilled personnel and favor further integration with healthcare systems 6 . These investigations are of fundamental importance for future planning of healthcare actions and for reassuring the need for developing diagonal approaches.…”

Integration of echocardiographic screening by non-physicians with remote reading in primary care

“…The burden of CVD is affected by the high prevalence of rheumatic heart disease (RHD), still responsible for a great proportion of heart surgeries in adults 4. The considerable prevalence of subclinical disease5 suggests that strategies to detect its late sequelae in adults from low-resourced areas should be prioritised.…”