Challenges and opportunities in paediatric cardiac services: Time for action

The 6th World Congress of Paediatric Cardiology and Cardiac Surgery recently held in Cape Town attracted over 3 000 registered delegates, the vast majority of which were scientific attendees. This congress, hosted by the South African Heart Association and organised by the Paediatric Cardiac Society of South Africa, highlighted the needs of children and adults with highly complex congenital cardiac lesions as well as those with acquired preventable disease such as rheumatic heart disease and noncommunicable cardiovascular diseases with their origins in childhood. The scientific programme addressedthe most recent advances in paediatric cardiac disease and reflected new developments in treatment, diagnosis and management while constantly reminding delegates of inadequacies, inequalities and health system concerns affecting patient care

Computer-assisted auscultation as a screening tool for cardiovascular disease : a cross-sectional study

Includes synopsis.Includes bibliographical references.Cardiac auscultation is inherently qualitative, highly subjective and requires considerable skill and experience. Computer- assisted auscultation (CAA) is an objective referral-decision support tool that aims to minimise inappropriate referrals. This study evaluated the sensitivity and specificity of 2 CAA systems, Cardioscan® and Sensi®, in detecting echo-confirmed cardiac abnormalities in 79 consecutive patients referred for assessment to a tertiary cardiac clinic. CAA demonstrated suboptimal sensitivity and specificity in detecting cardiac abnormalities in children and adults. As both systems demonstrate 100% sensitivity in detecting acyanotic heart disease, and theoretically carry significant potential in resource-limited settings, further development of current technologies to improve sensitivity and specificity for clinical applications is still warranted

Outcomes of asymptomatic and symptomatic rheumatic heart disease

Includes bibliographical referencesRheumatic Heart Disease (RHD) is a leading cause of heart disease in children and young adults in the developing world, with significant associated morbidity and mortality. Early secondary prophylaxis may retard the deleterious progression from its antecedent, acute rheumatic fever to permanent heart valve damage, and thus several echocardiographic screening programmes to detect asymptomatic RHD and institute early prophylaxis have been conducted. While effective interventions are available for ameliorating the effects of RHD, research on their use in different settings is scant. Key questions remain regarding the natural history of asymptomatic RHD and the optimal method for early detection. In addition, there is a lack of contemporary estimates of mortality and morbidity among the symptomatic population in the developing world. The primary purpose of the thesis was to determine the outcomes of asymptomatic and symptomatic RHD. More specifically, I sought to quantify the incidence, prevalence and outcomes of RHD in South Africa over the past two decades, determine the natural history of asymptomatic RHD and validate a focused protocol for screening in schoolchildren from Cape Town. In addition, I determined the baseline characteristics, prevalent sequelae and gaps in evidence-based implementation in children and adults from14 developing countries. Finally, I investigated the independent predictors for mortality and morbidity of RHD over a two-year period in patients from Cape Town, South Africa. My thesis has five key findings. Firstly, a systematic review of the literature showed that the incidence and prevalence of RHD over the past two decades in South Africa remains high, although there is evidence of falling cause-specific mortality at a population level. Secondly, asymptomatic RHD has a variable natural history that ranges from regression to a normal state, to persistence of disease, and progression to symptomatic RHD. Thirdly, a focused hand-held echocardiography protocol shows promising levels of sensitivity and specificity for detecting subclinical RHD. Fourthly, the baseline data from the global rheumatic heart disease registry demonstrates significant gaps in the implementation of medical and surgical interventions of proven effectiveness in low- and middle-income countries. Finally, the annual mortality rate for children and adults with RHD in Cape Town over a two-year period is 4.1%with cardiovascular events occurring at a rate of 0.18 events per patient per year. The findings encapsulated in this thesis have important implications for policy, practice and research related to the management of asymptomatic and symptomatic RHD in the world

Is it time for developing countries to adopt neonatal pulse oximetry screening for critical congenital heart disease?

Critical congenital heart disease is often missed with resultant death or severe circulatory collapse and morbidity. Pulse oximetry screening has now been recommended for use in the United States of America and adopted in other developed world settings as part of the compulsory newborn screening programme. In this review we detail the rationale behind neonatal pulse oximetry screening, summarise the recent evidence and present data on method, cost-effectiveness and acceptance. However, differences in health systems in the developed world and developing countries are clearly refl ected in the discrepancies in management and outcome of congenital heart disease. We discuss the importance of embedding a neonatal screening programme within local situations and suggest a method, using the infant mortality rate and other neonatal indicators, to position neonatal pulse oximetry screening into existing newborn screening programmes

The challenge of screening for asymptomatic rheumatic heart disease in South Africa

Acute rheumatic fever and rheumatic heart disease remain common in the population of South Africa. A recent screening study of asymptomatic schoolchildren in Mozambique and Cambodia makes a compelling case for a shift in the approach to screening for rheumatic heart disease from auscultation to portable echocardiography. Rheumatic heart disease meets all the epidemiological criteria for screening in the South African population. The incorporation of echocardiographic screening programmes into the school health system and in antenatal clinics for the pre-symptomatic diagnosis of rheumatic heart disease could result in the reduction of morbidity and mortality through the early and wide application of secondary antibiotic prophylaxis

The Importance of Awareness and Education in Prevention and Control of RHD

AbstractAcute rheumatic fever and rheumatic heart disease are diseases of poverty, low socioeconomic status, and inadequate access to health care. These preventable diseases remain largely ignored by the developed world while they continue to cause significant mortality and morbidity in the developing world. In the face of no existing cure, we need to focus on prevention and control methods. To this end, creating awareness of the disease and its effects on millions of people in the world is critically important. In this review, we will outline the importance of these efforts, discuss the barriers to awareness and education, and highlight some important models in this arena. We strongly support awareness-raising and health promotion strategies as an integral part of a rheumatic heart disease prevention and control program

Time to end Rheumatic Heart Disease: Lessons and opportunities from observational registries

The fight against Rheumatic Heart Disease (RHD) is at a critical juncture. Despite the adoption of a global resolution by the World Health Assembly against RHD in May 2018, practitioners working in countries where RHD is endemic continue to be faced with an overwhelming clinical burden, lack of surgical and interventional resources, and insufficient opportunities and funding for research. Recent years have seen the publication of several observational registries, most of which were investigator-initiated, not supported by larger research funders, and coordinated by small teams using paper-based infrastructure. This commentary reflects on the lessons and opportunities that these registries have afforded the field and suggests some areas for further investigation

Rheumatic fever and rheumatic heart disease: Where are we now in South Africa?

South Africa continues to face unacceptably high rates of rheumatic fever (RF) and rheumatic heart disease (RHD), despite readily available and inexpensive preventive measures. However, in the past several years, key players in South Africa’s healthcare and political realms in addition to key players from many African nations have come together to acknowledge the persistent health burden attributable to RF/RHD and have agreed to a pledge of action to reduce it. The plan of action is a comprehensive RF/RHD prevention and treatment programme known as ASAP. The ASAP programme targets efforts to raise Awareness, establish Surveillance systems, Advocate for increased resources for treatment, and to promote Prevention strategies. South Africa currently has a demonstration site where activities in all of these key areas are currently underway. Efforts in the area of surveillance include a RHD prevalence study that aims to screen 4 000 school-aged children through the use of a mobile echo-surveillance unit. In addition to local efforts, South Africa will join an international initiative to create a global RHD registry that will aid in all aspects of prevention and treatment to further reduce the burden of disease attributable to RF/RHD

Primary Prevention for Rheumatic Fever Progress, Obstacles, and Opportunities

ABSTRACT Acute rheumatic fever and rheumatic heart disease are noninfectious sequelae of group A streptococcal pharyngeal infection. These diseases represent a huge public health burden in developing countries with significant mortality and morbidity. Early diagnosis and appropriate antibiotic treatment with group A streptococcal pharyngitis provides an opportunity for prevention of acute rheumatic fever and rheumatic heart disease. The use of locally adapted clinical algorithms for diagnosing group A streptococcal pharyngitis has great potential in resource-poor settings for earlier diagnosis and early treatment. Intramuscular penicillin is the drug of choice in developing country settings. Recent work has demonstrated the cost-effectiveness of a treat-all strategy with intramuscular penicillin, whereas incorporating a clinical decision rule remains the preferred strategy. We strongly support the adoption of a comprehensive prevention and control program for acute rheumatic fever and rheumatic heart disease, incorporating primary prevention, as critical to underpinning the efforts in many parts of the world to stem the tide of this devastating disease. Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) continue to kill children, adolescents, and young adults living in poverty. Yet, a cheap and effective preventative agent to these sequelae of group A streptococcal (GAS) infection has existed for decades in the form of penicillin. Despite strong evidence of penicillin's efficacy in primary prevention of ARF, debate still rages on regarding the appropriate role for primary prevention within RHD prevention and control strategies. Some of the arguments against the incorporation of primary prevention into RF/RHD control strategies are based on the expense and logistics of delivery, but as has been discussed elsewhere [1], these need not be limiting factors. Conversely, a recent publication has demonstrated the cost-effectiveness of such a strateg

Refractory, missed and severe Kawasaski disease: Diagnostic and therapeutic challenges

Kawasaki disease (KD) is an acute generalised vasculitis of childhood with a predilection for the coronary arteries causing ectasia and aneurysms with subsequent potential ischaemic heart disease and even sudden death. This risk is signifi cantly reduced by early treatment with intravenous immunoglobulin together with a high dose of aspirin. However, the diagnosis is often diffi cult to make as many childhood illnesses may mimic KD. In addition, presentations may be atypical or incomplete. We discuss a series of 3 recent cases to focus on the management of 3 potentially troublesome aspects of the disease namely: severe coronary vascular involvement, failure to recognise the disease and disease which is refractory to standard therapy. We will also provide a suggested treatment algorithm for refractory KD with reference to current and future research strategies