Echocardiographic prevalence of rheumatic heart disease in Brazilian schoolchildren: Data from the PROVAR study

Nascimento, Bruno Ramos; Beaton, Andrea; Nunes, Maria Carmo P.; Diamantino, Adriana C; Carmo, Gabriel Assis Lopes do; Oliveira, Kaciane K.B.; Oliveira, Carolina Soares Viana de; Meira, Zilda Maria Alves; Castilho, Sandra Regina Tolentino; Lopes, Eduardo L; Castro, I; Rezende, Vitória M. L. R. de; Chequer, Graziela; Landay, Taylor; Tompsett, Allison; Ribeiro, Antônio Luiz Pinho; Sable, Craig

doi:10.1016/j.ijcard.2016.06.088

Cited by 67 publications

(78 citation statements)

References 36 publications

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“…The high overall prevalence of RHD reinforces the preliminary findings of the PROVAR study,15 and again helps explain the great burden of severe late valvular sequelae, leading to interventions and posing great costs to the Brazilian public health system (SUS) 24. Despite these observations, no integrating national programs or public policies for disease surveillance, as recommended by international documents,25, 26 have been implemented in the past decades.…”

Section: Discussionmentioning

confidence: 62%

“…The method and the implementation of the PROVAR study have been described elsewhere14, 15: the study uses nonexperts for image acquisition, on portable (Vivid Q; GE Healthcare, Milwaukee, WI) and/or handheld (Vscan; GE Healthcare) devices for RHD echocardiographic screening, and telemedicine interpretation by experts in Brazil and the United States, according to the 2012 World Heart Federation9 criteria. The screening team consisted of 2 nurse research coordinators (KO and CG), 1 biomedical technician, and 1 imaging technician (CO); during the preparatory phase, these individuals underwent a combination of completing online RHD educational modules and at least 6 weeks of hands‐on training 20…”

Section: Methodsmentioning

confidence: 99%

“…In Brazil, an upper‐middle income country still classified among the most socially unequal in the world,13 the PROVAR (Rheumatic Valve Disease Screening Program) study (the first large‐scale screening program of the country) was implemented in 201414 and revealed an echocardiographic prevalence of 42/1000 in preliminary analyses. However, public schools of underserved neighborhoods highlighted a marginal participation (<40%) 15. Similar to other publications,16, 17, 18 this was presumably related to the following: (1) lack of involvement by authorities and schools' representatives; (2) low parental engagement, with poorest participation in areas with lowest socioeconomic conditions; and (3) difficulties in monitoring whether the consents were actually being delivered, because parents are not present at the time of interaction 14, 15.…”

Section: Introductionmentioning

confidence: 99%

“…However, public schools of underserved neighborhoods highlighted a marginal participation (<40%) 15. Similar to other publications,16, 17, 18 this was presumably related to the following: (1) lack of involvement by authorities and schools' representatives; (2) low parental engagement, with poorest participation in areas with lowest socioeconomic conditions; and (3) difficulties in monitoring whether the consents were actually being delivered, because parents are not present at the time of interaction 14, 15. In addition, difficulties related to simple procedures that affect school routine signify that school screening may not be the ideal approach.…”

Section: Introductionmentioning

confidence: 99%

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

Nascimento

Sable

Nunes

et al. 2018

JAHA

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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.

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Section: Discussionmentioning

confidence: 62%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Nascimento

Sable

Nunes

et al. 2018

JAHA

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“…In screening over 15,000 school children in Uganda, our team has detected a 3% prevalence of latent RHD 10, 11 . These findings have been replicated in other parts of Africa 12, 13 , Asia 14, 15 , South and Central America 8, 16 and the Pacific 17–20 – uncovering a large population that may benefit from early detection.…”

Section: Introductionmentioning

confidence: 78%

Latent Rheumatic Heart Disease

et al. 2017

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Background Screening echocardiography (echo) has emerged as a potentially powerful tool for early diagnosis of rheumatic heart disease (RHD). The utility of screening echo hinges on the rate of RHD progression and the ability of penicillin prophylaxis to improve outcome. We report the longitudinal outcomes of a cohort of children with latent RHD and identify risk factors for unfavorable outcomes. Methods This was a prospective natural history study conducted under the Ugandan RHD registry. Children with latent RHD and ≥1 year of follow-up were included. All echos were re-reviewed by experts (2012 WHF criteria) for inclusion and evidence of change. Bi- and multi- variable logistic regression, Kaplan-Meier analysis, as well as Cox proportional hazard models were developed to search for risk factors for unfavorable outcome and compare progression-free survival between those treated and not treated with penicillin. Propensity and other matching methods with sensitivity analysis were implemented for the evaluation of the penicillin effect. Results Blinded review confirmed 227 cases of latent RHD: 164 borderline and 63 definite (42 mild, 21 moderate/severe). Median age at diagnosis was 12 years and median follow-up was 2.3 years (IQR 2.0–2.9). Penicillin prophylaxis was prescribed in 49.3% with overall adherence of 84.7%. Of children with moderate/severe definite RHD, 47.6% had echo progression (including 2 deaths), and 9.5% echo regression. Children with mild definite and borderline RHD showed 26% and 9.8% echo progression and 45.2% and 46.3% echo improvement respectively. Of those with mild definite RHD or borderline RHD, more advanced disease category, younger age, and morphological mitral valve features were risk factors for an unfavorable outcome. Conclusions Latent RHD is a heterogeneous diagnosis with variable disease outcomes. Children with moderate to severe latent RHD have poor outcomes. Children with both borderline and mild definite RHD are at substantial risk of progression. While long-term outcome remains unclear, the initial change in latent RHD may be evident during the first 1–2 years following diagnosis. Natural history data is inherently limited and a randomized clinical trial is needed to definitively determine the impact of penicillin prophylaxis on the trajectory of latent RHD.

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