Prevalence of rheumatic heart disease in Zambian school children

John Musuku, Mark E Engel, Patrick Musonda, Joyce Chipili Lungu, Elizabeth Machila, Sherri Schwaninger, Agnes Mtaja, Evans Mulendele, Dorothy Kavindele, Jonathan Spector, Brigitta Tadmor, Marcelo M Gutierrez, Joris Van Dam, Laurence Colin, Aidan Long, Mark C Fishman, Bongani M Mayosi, Liesl J Zühlke, John Musuku, Mark E Engel, Patrick Musonda, Joyce Chipili Lungu, Elizabeth Machila, Sherri Schwaninger, Agnes Mtaja, Evans Mulendele, Dorothy Kavindele, Jonathan Spector, Brigitta Tadmor, Marcelo M Gutierrez, Joris Van Dam, Laurence Colin, Aidan Long, Mark C Fishman, Bongani M Mayosi, Liesl J Zühlke

Abstract

Background: The large global burden of rheumatic heart disease (RHD) has come to light in recent years following robust epidemiologic studies. As an operational research component of a broad program aimed at primary and secondary prevention of RHD, we sought to determine the current prevalence of RHD in the country's capital, Lusaka, using a modern imaging-based screening methodology. In addition, we wished to evaluate the practicality of training local radiographers in echocardiography screening methods.

Methods: Echocardiography was conducted on a random sample of students in 15 schools utilizing a previously validated, abbreviated screening protocol. Through a task-shifting scheme, and in the spirit of capacity-building to enhance local diagnostic and research skills, general radiographers based at Lusaka University Teaching Hospital (UTH) were newly trained to use portable echocardiography devices. Students deemed as screen-positive were referred for comprehensive echocardiography and clinical examination at UTH. Cardiac abnormalities were classified according to standard World Heart Federation criteria.

Results: Of 1102 students that were consented and screened, 53 students were referred for confirmatory echocardiography. Three students had definite RHD, 10 had borderline RHD, 29 were normal, and 11 students were lost to follow-up. The rates of definite, borderline, and total RHD were 2.7 per 1000, 9.1 per 1000, and 11.8 per 1000, respectively. Anterior mitral valve leaflet thickening and chordal thickening were the most common morphological defects. The pairwise kappa test showed fair agreement between the local radiographers and an echocardiographer quality assurance specialist.

Conclusion: The prevalence of asymptomatic RHD in urban communities in Zambia is within the range of results reported in other sub-Saharan African countries using the WHF criteria. Task-shifting local radiographers to conduct echocardiography was feasible. The results of this study will be used to inform ongoing efforts in Zambia to control and eventually eliminate RHD.

Trial registration: The study was registered on clinicaltrials.gov ( #NCT02661763 ).

Keywords: Cardiovascular disease; Control strategies; Echocardiography; Epidemiology; Prevalence; Rheumatic fever; Rheumatic heart disease; Screening; Streptococcal pharyngitis; Zambia.

Conflict of interest statement

Ethics approval and consent to participate

The study was registered on clinicaltrials.gov (#NCT02661763) and approved by the Biomedical Research Ethics Committee at the University of Zambia (REF. No. 002–10-13 on 6th December 2013), the Ministry of Health, the Ministry of Education, and the Ministry of Community Development, Mother and Child Health. Written informed consent for participation in the study was required from parents or legal guardians. Children were verbally informed about the study at the time of screening and were required to provide written assent with their name or thumbprint in order to participate.

Consent for publication

The manuscript does not contain any individual person’s data. The student photographed in Fig. 1 provided written consent for use of the photo.

Competing interests

SS, JS, MG, JVD, and LC are employees of Novartis.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
A radiographer from Lusaka University Teaching Hospital uses ultraportable echocardiography to screen an adolescent for rheumatic heart disease as part of the study (photograph used with permission of participant)
Fig. 2
Fig. 2
Student disposition in study methodology
Fig. 3
Fig. 3
Flowchart of schools of students involved in the study

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