Health systems strengthening for prevention of rheumatic heart disease in Zambia: a novel clinic-based curriculum to help advance knowledge and skills of health workers

ObjectiveTo determine the ability to accurately diagnose acute rheumatic fever (ARF) given the resources available at three levels of the Ugandan healthcare system.MethodsUsing 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.ResultsA 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.ConclusionsReducing 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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Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system

Ndagire

Ollberding

Sarnacki

et al. 2022

BMJ Open

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Effectiveness of an educational intervention in improving healthcare workers’ knowledge of early recognition, diagnosis and management of rheumatic fever and rheumatic heart disease in rural far-western Nepal: a pre/post-intervention study

Bhatt

Karki

Shrestha³

et al. 2022

BMJ Open

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ObjectivesRheumatic fever (RF) and rheumatic heart disease (RHD) remain among the major heart problems among children in Nepal. Although these conditions are preventable and treatable, the lack of proper knowledge and resources to diagnose and manage these conditions in rural health centres is a key concern. This study assessed the impact of educational sessions to improve the knowledge of healthcare workers in the early recognition, diagnosis, and management of RF and RHD in rural far-western Nepal.Design, setting and participantsThis study used a pretest and post-test interventional design and was conducted among 64 healthcare workers in two primary healthcare centres and a peripheral district-level hospital in Achham district in the far-western region of Nepal. A self-administered questionnaire was used before and after the educational sessions. Data were analysed using SPSS V.21.ResultsThe overall test scores increased from 10 (SD=2.4) pre-intervention to 13.8 (SD=1.9) post-intervention (p<0.001). Similarly, participant confidence (graded 1–5) in differentiating bacterial from viral sore throat rose from 3.6 (SD=1.08) pre-intervention to 3.98 (SD=1.09) post-intervention (p<0.05). Confidence in managing RF increased from 3.9 (SD=0.88) pre-intervention to 4.30 (SD=0.8) post-intervention (p<0.001).ConclusionThe findings suggest that the investigated educational sessions are promising with respect to improving the knowledge and confidence of healthcare workers in the early recognition, diagnosis, and management of RF and RHD at the primary healthcare level. Further studies with a larger sample size and conducted in different parts of the country are warranted to assess the effectiveness and impact of scaling up such educational interventions in Nepal.

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Active Case Finding for Rheumatic Fever in an Endemic Country

Okello

Ndagire

Atala

et al. 2020

JAHA

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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.

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Health systems strengthening for prevention of rheumatic heart disease in Zambia: a novel clinic-based curriculum to help advance knowledge and skills of health workers

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Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system

Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system

Effectiveness of an educational intervention in improving healthcare workers’ knowledge of early recognition, diagnosis and management of rheumatic fever and rheumatic heart disease in rural far-western Nepal: a pre/post-intervention study

Active Case Finding for Rheumatic Fever in an Endemic Country

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