Early Implementation and Clinical Outcomes of an Integrated Rheumatic Heart Disease Screening and Treatment Program in Northern Uganda

Abstract

BACKGROUND: The World Health Organization recommends echocardiographic screening and secondary prophylaxis for rheumatic heart disease (RHD), but evidence on how to implement these interventions within healthcare systems is limited. We report early implementation and clinical outcomes of an RHD program in northern Uganda. METHODS: From May 2023, the District Health Office in Kitgum trained primary healthcare workers in RHD screening and implemented registry-based secondary antibiotic prophylaxis in public facilities. We analyzed program and registry data through December 31, 2024. Data were obtained from aggregated program reports and individual-level records from the national RHD registry. We developed an RHD care cascade to examine screening uptake and outcomes, including adherence to secondary antibiotic prophylaxis. Adherence was categorized as perfect (100%), near perfect (90%–99%), acceptable (80%–89%), suboptimal (60% to 79%), or poor (<60%). Differences in mean adherence across subgroups were evaluated using 1-way ANOVA and χ 2 tests. Time-to-event analysis was conducted to assess the probability of receiving an injection over time since enrollment. RESULTS: Health workers screened about 1% of the district’s target population each month. Over 18 months, 25 358 people were screened, including 1213 (4.8%) positive screens and 333 (1.3%) confirmed RHD cases. Among those screened, 16 406 (64%) were female, and 10 746 (42%) and 7333 (28%) were children (aged 5 years–14 years) and adolescents (aged 15 years–24 years), respectively. Of those with positive screens, 972 (80%) received confirmatory echocardiograms. Confirmed cases were relatively young (mean age 28 years), and 224 (67%) were female. Overall, 220 (75%) individuals achieved at least acceptable adherence. Among those who defaulted, 79% did so within 6 months of enrollment. CONCLUSIONS: An integrated RHD program in Uganda achieved successful delivery of echocardiographic screening within primary healthcare and acceptable early outcomes. The care cascade framework can be used to monitor similar RHD programs and identify opportunities for improvement.