Screening for Rheumatic Heart Disease in Eastern Nepal

The burden of rheumatic heart disease in developing countries is persistently high. A systematic review¹ of active surveillance studies found that 28.0 per 1000 people are affected with the disease in Southeast Asia, 14.0 per 1000 people in Oceania, and 7.9 per 1000 people in Africa. A previous surveillance study² led to estimates that 50 million to 100 million people may be affected with rheumatic heart disease worldwide. Furthermore, a prospective study³ of symptomatic patients indicated that there are serious gaps in the translation of effective interventions into clinical practice, resulting in suboptimal use of proven interventions, such as antibiotic prophylaxis to prevent acute rheumatic fever and surgical treatment for patients with heart failure. It is therefore not surprising that rheumatic heart disease is a leading cause of premature death and an important economic burden in developing countries where age-standardized death rates may be more than twice those reported in current global estimates.⁴

The article by Shrestha et al⁵ in this issue of JAMA Cardiology reports the prevalence and incidence of latent rheumatic heart disease in schoolchildren in rural and urban areas of the Sunsari district of Eastern Nepal. The authors sought to determine the prevalence of clinically silent and manifest rheumatic heart disease as a function of age, sex, and socioeconomic status and to estimate age-specific incidence by means of a school-based cross-sectional design with cluster sampling. Twenty-six schools with 5467 eligible children 5 to 15 years of age were randomly selected from 595 registered schools. After exclusion of 289 children, 5178 children were enrolled in the study. Cardiac auscultation and transthoracic echocardiography were performed by 2 independent physicians, and the main outcome measure was rheumatic heart disease according to the World Heart Federation criteria. Rheumatic heart disease was found in1 in 100 schoolchildren in Eastern Nepal, was mostly clinically silent, and was more common among girls. The overall prevalence and the ratio of manifest to subclinical disease increased with advancing age, whereas the incidence remained stable at 1.1 per 1000 children per year. Although the estimate of the prevalence of rheumatic heart disease was lower than that reported in previous studies¹ in the region, the overall thrust of the results is consistent with the findings from other developing countries, such as Ethiopia.⁶

The key priority in the global agenda for rheumatic heart disease is to reduce mortality arising from this disease by 25% by the year 2025, especially in patients who are younger than 25 years. Do active surveillance studies of asymptomatic children, such as the one reported by Shrestha et al,⁵ help in achieving the global objective of control of rheumatic heart disease and elimination of acute rheumatic fever? The answer to this question is a disappointing no because of a lack of epidemiologic evidence to indicate that screening of asymptomatic individuals reduces mortality and morbidity in rheumatic heart disease.⁷ What is known, however, is that a comprehensive rheumatic heart disease control program is effective in reducing morbidity and mortality from the disease in a cost-effective manner.⁸ The elements of a successful control program include awareness raising (ie, training of health care professionals, health education and promotion, and community involvement), surveillance through disease registers, advocacy, and application of primary and secondary prevention strategies (the ASAP approach).⁶ The application of these principles of rheumatic heart disease control in the Pinar del Rio province of Cuba resulted in a progressive decrease in the incidence and severity of acute rheumatic fever, with a marked decrease in the prevalence of RHD in schoolchildren and in the number and severity of patients requiring hospitalization and surgical care.⁸

The report by Shrestha et al⁵ is a wake-up call to the government of Nepal and other governments in endemic countries to establish comprehensive national programs to end rheumatic heart disease using the ASAP approach. Although ultrasonographic screening can detect rheumatic heart disease in asymptomatic individuals, the effect of screening on the prognosis of rheumatic heart disease is unproved. Screening should not be introduced into clinical practice until further information is available from randomized clinical trials designed to assess rheumatic heart disease screening’s effect on mortality and morbidity, associated adverse effects, and cost-effectiveness.⁷

Corresponding Author: Bongani M. Mayosi, DPhil, FCP(SA), Department of Medicine, Groote Schuur Hospital and University of Cape Town, Groote Schuur Dr, J Floor, Old Main Bldg, Observatory 7925, Cape Town, South Africa (bongani.mayosi@uct.ac.za).

Published Online: March 2, 2016. doi:10.1001/jamacardio.2015.0303.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.