Reducing New Cases of Rheumatic Heart Disease through a Community Streptococcal Treatment Program
BACKGROUND: There are two main strategies for rheumatic heart disease (RHD) prevention: (1) detection and treatment of symptomatic strep infections in children (primary prevention) and (2) regular administration of antibiotic prophylaxis to individuals with ARF/RHD to prevent recurrent ARF (secondary prevention). While secondary prevention has been favored in low-income settings, it has proven woefully inadequate to reduce the burden of RHD globally, with nearly 40 million people currently affected. GAP: Despite strong historic evidence that primary prevention reduces ARF prevalence by 70-80%, there is no contemporary data on the effect of a pragmatic primary prevention program to decrease the community burden of RHD in Africa (or other low-income settings). HYPOTHESIS: We hypothesize that a pragmatic RHD primary prevention program will reduce RHD prevalence among 5-to-15-year-old children by at least 25% in 2 years. A conservative impact of 25% reduction in RHD prevalence (baseline childhood RHD prevalence 1%) was chosen based on data from successful programs in Cuba and the Caribbean demonstrating 50-75% reduction in cases over 5-10 years. METHODS: We propose a pragmatic prospective cohort study integrated into the primary healthcare system that will increase awareness of sore throat and utilize guideline-based diagnosis and treatment of strep sore throat to reduce the burden of childhood RHD. The study will be conducted in Tororo, Uganda where our primary outcome measure will be the difference in echo prevalent RHD among 5-to- 15-year-old children measured prior to and 2 years after deployment of our interventional package. RESULTS: Our results will include our primary outcome: the change in RHD prevalence prior to and 2- years after intervention, and secondary outcomes including an assessment of healthcare worker knowledge and adherence to guideline-based care, changes in sore throat evaluations in the formal healthcare sector and an assessment of the impact on community knowledge of Strep, ARF and RHD. IMPACT: Global control of RHD is eminently achievable; no child born today should die from RHD. These data will provide the critical push needed to make the global investment case for primary prevention in order to end RHD for the next generation.