Letter Regarding Article, “Echocardiography Screening for Rheumatic Heart Disease in Ugandan Schoolchildren”
To the Editor:
I applaud Beaton et al1 for reporting the largest echocardiographic survey of rheumatic heart disease among school children in Africa. This work represents a suitable response to the call of the Pan African Society of Cardiology for the control of rheumatic fever and rheumatic heart disease on the African continent through the Awareness Surveillance Advocacy and Prevention Programme.2
In my opinion, however, several issues need to be addressed by the authors of this report. First, the concluding statement of the abstract implies that this is the first echocardiographic survey of the prevalence of rheumatic heart disease in sub-Saharan Africa. The first echocardiographic survey of the prevalence of rheumatic heart disease, which is not cited by the authors, was conducted by Anabwani and Bonheoffer in Kenya in 1996.3 In a survey of 1115 children in Kenya, 3.0 had clinical and echocardiographic evidence of rheumatic heart disease, giving a prevalence rate of 2.7 per 1000, whereas 6.2% had trivial mitral regurgitation, 0.3% trivial aortic regurgitation, and 0.4% isolated mild-to-moderate regurgitation of the pulmonary valve. Therefore, the statement by the authors in the introductory section of the article that “the search for subclinical disease in this region, has thus far, been limited to Mozambique” may not be accurate.1
Second, although the authors refer to sub-Saharan Africa as the region of the world with the greatest burden of rheumatic heart disease, recent evidence suggests that this dubious distinction may apply to the 51 million people who live in the Central Asian republics of Kyrgyzstan, Tajikistan, Turkmenistan, Kazakhstan, and Uzbekistan. Among developing countries, Kyrgyzstan probably has the highest incidence of rheumatic fever and rheumatic heart disease of ≈543 per 100 000 population per year.4
Finally, it is curious that the authors do not indicate whether there is a national program for the primary, secondary, and tertiary prevention of rheumatic heart disease in Uganda. The World Health Organization has identified the development of national programs for the prevention and control of rheumatic fever and rheumatic heart disease as a priority for affected member states.5 The establishment of echocardiographic screening programs may be regarded as unethical in the absence of established health programs for the appropriate medical and surgical management of symptomatic patients who are identified through screening.
Bongani M. Mayosi, MBChB, DPhil
Department of Medicine
Groote Schuur Hospital and University of Cape Town
Cape Town, South Africa
- © 2012 American Heart Association, Inc.