Project Details

Reducing New Cases of Rheumatic Heart Disease through a Community Streptococcal Treatment Program

Andrea Beaton, MD

Summary

Background Detection and treatment of streptococcal pharyngitis in children, reduces acute rheumatic fever by 70-80%. However, due to challenges in detecting group A streptococcal (GAS) infection, investment in primary prevention is limited in rheumatic heart disease (RHD) endemic countries. We conducted a pragmatic public health trial (RESET) to determine the effect of an integrated GAS education and treatment program on the echocardiographic burden of RHD among 5 to15 year-old children in Uganda. Methods We implemented our interventions within the primary health care system of Tororo district, Eastern Uganda, over a 2-year period. The primary outcome was a reduction in RHD prevalence. Secondary outcomes included improved provider and community knowledge and increased health-seeking behavior for sore throat. Interventions targeted three key barriers to primary prevention: limited provider expertise in diagnosing and treating GAS pharyngitis, poor uptake of guideline-based treatment, and low public awareness of the link between sore throat and RHD. Results There was no significant change in RHD prevalence from baseline (0.66%, 95% CI 0.58–0.73%) to two years post-implementation (0.61%, 95% CI 0.51–0.71%). Primary training was completed by 101 healthcare workers with knowledge scores improving from 55% pre-training to 75% post-training; comfort diagnosing and treating GAS pharyngitis rose from 6/10 to 9/10. Secondary trainings reached 470 providers across 81 facilities (100% facility coverage). Facility assessments found only one-third met nearly all readiness metrics. Over 2,000 community education events reached an estimated 380,000 people. Passive education exposure rose from 40% to 99%, and active education from 25% to 99%. Recognition of sore throat as a serious issue improved (mean score 3.11 to 3.90/4), with 89% post-campaign identifying its link to heart disease. Yet, health center logs showed no significant increase in sore throat presentations over 22 months (2% of 72,351 pediatric cases). Conclusion As the first large-scale integrated primary prevention program for rheumatic heart disease in sub-Saharan Africa, RESET demonstrated both feasibility of scaling up patient and provider education and implementation challenges in translating education into action. Ongoing research is identifying barriers to care-seeking and co-designing a culturally appropriate sore throat treatment model that may better align with community needs.