South Africa - Rheumatic heart disease screening in South Africa: early diagnosis to prevent needless deaths

Citation

(2009), "South Africa - Rheumatic heart disease screening in South Africa: early diagnosis to prevent needless deaths", International Journal of Health Care Quality Assurance, Vol. 22 No. 6. https://doi.org/10.1108/ijhcqa.2009.06222fab.010

South Africa - Rheumatic heart disease screening in South Africa: early diagnosis to prevent needless deaths

Article Type: News and views From: International Journal of Health Care Quality Assurance, Volume 22, Issue 6

Keywords: Healthcare screening programmes, Ill health prevention, Healthcare education, Healthcare quality

In a study of some 3,000 children in Cape Town, over 900 school-aged children have been screened for RHD. The screening enables children and young people with the disease to get the simple and inexpensive antibiotic prophylaxis that halts the progression towards dangerous and debilitating heart damage.

The study is part of a demonstration project led by Prof. Bongani Mayosi at the Groote Schuur Hospital in Cape Town and represents the “S” in the ASAP approach: Advocacy, Surveillance, Awareness and Prevention. Developed by specialists from around Africa, the ASAP approach was articulated in the “Drakensberg Declaration” drafted at a 2005 meeting especially convened by the Pan African Society of Cardiology (PASCAR).

Screening in Cape Town, which began in May 2008, is being conducted by a mobile unit that visits schools in two low-income neighbourhoods of the Vanguard Township, located 10 km from central Cape Town. Only about 38 per cent of the population in these areas are employed and the majority live in conditions in which RHD thrives: overcrowding, informal housing and limited access to healthcare. “Rheumatic heart disease is preventable; it kills and disables our young people needlessly,” said Prof. Mayosi, who leads the project. “Mostly, it affects the poor, and because it has been nearly eliminated in wealthy countries, it has been neglected for decades by researchers, health educators, and the media. Very little is done to educate children, parents, teachers or primary health care providers about how to detect the disease early or what to do when they suspect it. Even less is done to detect it early, so it is seldom caught before it is dangerous and crippling, and survival depends on costly heart surgery.” Even the lucky few who can get surgery remain at high risk and are limited in their activities; afterwards they require life-long medical follow-up.

Screening by echocardiogram identifies children with heart valve damage, even when they still seem healthy. They are then sent to a clinic to get regular antibiotic prophylaxis that protects them from the streptococcal infections that set off recurrences of rheumatic fever, and are entered into a disease register that helps track their compliance and medical care. This information will enable healthcare services to provide better follow-up and monitor services. The register used in the project is about to be piloted in three centres in South Africa and one in Zambia.

“Ensuring the compliance needed to make the prophylaxis work takes more than just good medicine,” explained Dr John Lawrenson, Paediatric Cardiologist at the Red Cross Childrens’ Hospital. “If screening and prophylaxis are to really be effective, children and young people affected with the disease and their parents, teachers, healthcare workers and other community members need to understand why early detection and compliance with prophylaxis are so important. The South African Ministry of Health has established a national Rheumatic Fever awareness week and we work with partners like the Heart and Stroke Foundation to organize events, interactive radio shows, and TV and newspaper coverage to get the message across.”

“We know that sub-Saharan Africa is a hot-spot for rheumatic heart disease, and our paediatric cardiologists who see patients in late stages of the disease say that we are in the midst of an epidemic” said Mark Engel, Research Fellow at the University of Cape Town who coordinates the ASAP programme, “but we have little reliable data on disease prevalence”. There are national guidelines for education, diagnosis, treatment, referral, notification and follow-up of rheumatic fever and rheumatic heart disease, but a study of rheumatic heart disease cases shows that cases are seriously underreported by healthcare professionals and the system does not work as it should.” This study complements studies conducted from Groote Schuur such as a US National Institute of Health-funded study on the epidemiology of sore throat.

The study in Cape Town involves comprehensive assessment, auscultation by a paediatric cardiologist, followed by a full echocardiogram. It will help appraise echocardiography as a screening tool for RHD in developing countries. Two previous studies of RHD in South Africa estimated a prevalence of just under seven cases per 1,000 school children but like most RHD prevalence studies conducted around the world, screening was done by auscultation. “Screening by auscultation may seriously underestimate disease prevalence” said Dr Liesl Zühlke, the Paediatric Cardiologist who coordinates the clinic aspects of the study. “Recent studies in Mozambique, Cambodia and Tonga using portable echocardiography have shown that auscultation identifies 10 per cent of the children who have heart valve damage from rheumatic heart disease.”

Dr Zühlke added “echocardiography requires expensive machines so on the face of it seems less cost-effective than the stethoscope. But it takes training and experience to tell which heart murmurs might indicate heart disease; echocardiography catches damage even in cases when a highly-trained specialist cannot hear a murmur. If it misses more than half of the children with the disease, the stethoscope loses out on the “effectiveness” side of equation. Our study will help determine what is most practical for the low-resource settings where rheumatic heart disease occurs”.

The University of Cape Town Medical School provides human resources for the screening and the programme is supported by the local medical research council. Life Foundation, the funding arm of the Life Healthcare private hospitals group, donated the mobile unit and the World Heart Federation provided an echocardiography machine. Dr Mayosi commented that “Rheumatic heart disease is a condition that too often falls through the cracks of our specialties: cardiologists tend to focus on ischemic disease, and paediatricians and public health practitioners focus on more common problems like malaria, diarrhoea and HIV/AIDS. We have to step out of traditional ideas of ‘turf’ to deal with the problem effectively”.

The South African team is sharing the tools, experiences and findings generated by the demonstration project in Cape Town with RHD control programmes in Zambia, Rwanda, Ethiopia, Ghana, and Kenya, through workshops at PASCAR meetings and ongoing communications coordinated by Mark Engel. Developed in close cooperation with the World Heart Federation council on rheumatic fever and rheumatic heart disease, the project also benefits from extensive exchange with the World Heart Federation’s Rheumatic Heart Disease Control Programme in the Pacific. After returning recently to Cape Town, the programme coordinator in the Pacific, Samantha Colquhoun, compared the programmes: “They don’t face a lot of the logistical challenges in Cape Town that we do in the Pacific: roads are all paved, there is always electricity, and they have easy access to specialised staff: it is amazing to see what they can do.”

Dr John Lawrenson, who visited the programme’s demonstration site in Fiji and attended the 2008 Pacific regional workshop, commented: “It was really encouraging to see that it is possible to run an effective control programme over a vast area: our project is just beginning, but will face many of the same challenges if we try to apply it more broadly in Africa; seeing what is possible has been a tremendous motivation to expand our work”.

“Rheumatic heart disease kills some 300,000-500,000 people a year and is estimated to affect some 13.5 million people globally. There is more and more reason to believe this figure is seriously underestimated,” said Dr Jonathan Carapetis, Chairman of the World Heart Federation Council on Rheumatic Fever and Rheumatic Heart Disease. “It is a real tragedy, a classic disease of poverty and neglect. We can, hopefully, make important strides toward eliminating the disease, but need to work together to mobilise the resources and political will to do it”.

For more information: www.world-heart-federation.org