Andersons pediatric cardiology 1473

EarlyDetection:Echocardiographic
Screening
TheclinicaldiagnosisofARFremainschallenging.Asaconsequence,the
majorityofthepatientsevenwithadvancedRHDdonothaveapreviously
documentedhistoryofARFandhencemissoutonlifesavingsecondary
prophylaxis.15Theregionsoftheworldthatarecrippledbythehumanand
socioeconomiccostofsevereRHDarecurrentlycarefullyevaluatingtheroleof
earlydetectionofRHDviaechocardiographicscreening,whichwouldallowfor
detectionofdiseasebeforesymptomaticheartfailuredevelopsandexpensive
cardiacsurgeryorpercutaneousinterventionaretheonlylifesavingoptions.
TheoptimumapproachforearlydetectionofRHDisyettobedefinedbut
potentiallyinvolvespopulation-basedoralternativelyopportunistic
echocardiographicscreeningoftheyoung.In2012,theWorldHeartFederation
developedechocardiographicdiagnosticcriteriaforRHDtofacilitateearlycase
detection(seeBox55.1).22Ithasprovedtobebothsensitive21,84and
specific.85,86However,unansweredquestionsremain,includingthenatural
historyofsubclinical(definiteandborderline)RHD.Evenpatientswith
borderlineRHDareatsubstantialriskofARFanddiseaseprogression.87–89
Longitudinalevaluationofechocardiographicscreeningprogramsisneededto
definetheabsolutebenefit/costratiobecausetwofactorsrestrictitswidespread
useinresource-poorsettings:theexpenseofportableequipmentandthe
shortageofhighlyspecializedhealthcareworkforces.Initialstudiesshow
promisingfindingsforechocardiographicscreeningprogramsledby
nurses/nonexperts,althoughfurtherevaluationandrefinementsareneeded.90,91


EstablishingCentersforRheumatic
HeartDisease
OneoftheunmetneedsinthefightagainstARFandRHDisthegrossshortage
orvirtualnonexistenceofstrategicallylocatedspecializedcentersofexcellence
todeal,inacomprehensivemanner,withdifferentaspectsofthedisease.72,92–94

ThishasbeenclearlyemphasizedintheAddisAbabacommunique95andCairo
Accordrecommendations94(Box55.5)alongwithotherimportantstrategiesfor
theeradicationofRHD.Thescopeofthesecenterswouldideallyinclude
prevention,treatment,andresearchatpopulation,basicscience,translational,
andclinicallevels.Attemptsatenhancingthequalityoftheservicesofferedin
thesecentersarebeingmadebyestablishingdedicatedconsortiainthe
developingcountries.96


Box55.5

RecommendationstotheAfricanUnion
CommissionandMemberStatesFromthe
ThirdAll-AfricaWorkshoponARFandRHD:
“AddisAbabaCommuniqué”ProvidingSeven
KeyActionstoEradicateRheumaticHeart
DiseaseinAfrica 5
1.EstablishprospectiveRHDregistersatsentinelsitesinaffectedmember
statesinordertomonitorRHD-relatedhealthoutcomes,includingthe
achievementofa25%reductioninmortalityfromRHDbytheyear
2025.
2.Ensureadequatesuppliesofhigh-qualitybenzathinepenicillinthatcanbe
administeredinthemosteffectivemanner,inordertoachieveprimary
andsecondarypreventionofRHD.
3.Guaranteeuniversalaccesstoreproductivehealthservicesforwomen


withRHDandotherNCDs,inwhompregnancycarriesspecificand
oftenfatalrisks,andforwhomcontraceptioncanreducematernaland
fetalmortality.

4.Decentralizeappropriatetechnicalexpertisetotheprimaryanddistrict
levelsinordertoimprovethediagnosisofARF(whichis
underdiagnosedinAfrica)andearlydetection,diagnosis,secondary
preventionandtreatmentofRHDusingcross-cuttingpoint-of-care
technologiessuchascardiacultrasound,anticoagulationtestingandrapid
antigentestsforgroupAstreptococcalpharyngitis.
5.Establishcentersofexcellenceforcardiacsurgery,whichwillsustainably
deliverstate-of-the-artsurgicalcare,trainthenextgenerationofAfrican
cardiacpractitioners,andconductresearchonendemiccardiovascular
diseases,includingRHD.
6.FostermultisectoralandintegratednationalRHDcontrolprogramsledby
theMinistryofHealth,whichwilloverseetheimplementationof
nationalRHDactionplansinordertoachievethegoalofreducing
mortalityfromRHDandotherNCDsby25%bytheyear2025.
7.Cultivate,throughastrongcommunicationframework,partnerships
betweentheAUC,ministriesresponsibleforhealth,international
agencies,governments,industry,academia,civilsocietyandother
relevantstakeholders,inordertoensuretheimplementationoftheabove
actions,andtheconnectionofAfricanRHDcontrolmeasureswiththe
emergingglobalmovementtowardsRHDcontrol
ARF,Acuterheumaticfever;NCDs,noncommunicablediseases;RHD,
rheumaticheartdisease.
FromRobertsK,MaguireG,BrownA,etal.Rheumaticheartdiseasein
IndigenouschildreninnorthernAustralia:differencesinprevalenceandthe
challengesofscreening.MedJAust.2015;203(5):219;andWatkins,D,Zuhlke
L,EngelM,etal.Sevenkeyactionstoeradicaterheumaticheartdiseasein
Africa:theAddisAbabacommunique.CardiovascJAfr.2016;27(3):184–187.
Importantly,thesecentersshouldguaranteesustainabilityandaccessibilityto
thesurroundingaffectedcommunities.Fundingofthecentersofexcellencecan
beachievedbynongovernmentorganizations,harnessingtheeffortsofthelocal

andinternationalcommunities,tobefollowedgraduallybytheestablishmentof