Jafesi Pulle

Background: Rheumatic heart disease (RHD) is estimated to result in nearly 400,000 deaths annually. In sub-Saharan Africa, estimates of RHD death rates are low relative to its high prevalence, especially in younger populations. The assumption that persons living with RHD die of other conditions has been contested by clinicians in endemic settings. This study aimed to describe the causes of death among Ugandans with RHD. Methods: We conducted a cross sectional study and performed verbal autopsies among family members of all persons enrolled in Uganda’s national RHD registry who had died between 15-06-2019 and 31-12-2024. We used Population Health Metrics verbal autopsy instrument previously developed and validated in low-and middle-income countries. Interviews were done between July and September 2025. The causes of death were determined from autopsy data using a computer certified verbal autopsy software, SmartVA Analyze 3.0, which uses an algorithm based on survey responses. A sensitivity analysis was done to assess for differences in death causes due to recall period.Findings: During the study period, 444 deaths were recorded among registrants. We successfully interviewed family members of 322 decedents (median age at death 26 [IQR 16-42] years). Of 316 deaths with assigned causes, 210 (66.5%, [95% CI 61.1, 71.4]) across all ages and both sexes were assigned to cardiovascular causes of death. Smaller percentages were due to tropical diseases/malaria (7.3%, [95% CI 4.9, 10.7]) and respiratory infections (5.1%, [95% CI 3.1, 8.1]). Only 172(53.4%, [95% CI 47.8, 59.0]) of deaths occurred in health settings. There were no differences in the distribution of causes of death in 2022-2024 compared to 2019-2021, arguing against recall bias. Interpretation: RHD was the probable cause of death among two-thirds of Ugandans with RHD in the national registry. Studies of RHD mortality can combine verbal autopsy and echocardiographic data to produce more accurate estimates.

Rheumatic heart disease (RHD) requires long-term secondary antibiotic prophylaxis to prevent disease progression, yet sustained patient engagement remains challenging in many low- and middle-income countries. Within Uganda’s first integrated decentralized RHD control program, Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Uganda (ADUNU), we applied a human-centered design (HCD) approach to co-develop strategies for improving engagement in care. Using two Group Level Assessment sessions (with n = 43 stakeholders) and three design focus group discussions (n = 23 stakeholders), participants identified and prioritized feasible implementation strategies. Strategies were synthesized into four domains: community integrated follow-up, structured patient health education and counselling, provider capacity and service delivery improvement, and strengthening stock planning for medicine availability. These co-developed strategies directly address barriers related to missed appointments, limited understanding of RHD, provider-patient interactions, and medicine stockouts within decentralized primary care settings. This participatory approach generated contextually grounded strategies, ready for prospective testing within decentralized RHD programs.

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 (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.

Introduction: Detection and treatment of streptococcal pharyngitis in children reduces acute rheumatic fever by 70–80%. However, investment in primary prevention is limited in rheumatic heart disease (RHD) endemic countries due to lack of diagnostic capacity. We conducted a pragmatic public health trial ( R heumatic Heart Diseas e Community Str e ptococcal T reatment Program (RESET)) to determine the effect of an integrated group A streptococcal (GAS) education and treatment programme on the echocardiographic burden of RHD among children aged 5–15 years in Uganda. Methods: We implemented our interventions within the primary healthcare system of Tororo district, Eastern Uganda, over 2 years. The primary outcome was a reduction in RHD prevalence. Secondary outcomes included improved provider and community knowledge and increased health-seeking behaviour for sore throat. Interventions targeted three key barriers to primary prevention: limited provider expertise in diagnosing and treating GAS pharyngitis, poor uptake of guideline-based treatment and low public awareness of the link between sore throat and RHD. Results: There was no significant change in RHD prevalence from baseline (0.66%, 95% CI 0.58% to 0.73%) to 2 years post-implementation (0.61%, 95% CI 0.51% to 0.71%). Primary training was completed by 101 healthcare workers with knowledge scores improving from 55% pre-training to 75% post-training. Secondary training reached 470 providers across 81 facilities. Facility assessments found only one-third met nearly all readiness metrics. Over 2000 community education events reached an estimated 380 000 people. Recognition of sore throat as a serious issue improved with 89% post-campaign identifying its link to heart disease. Health centre logs showed no increase in sore throat presentations over 22 months. Conclusion: As the first large-scale integrated primary prevention programme for RHD in sub-Saharan Africa, RESET demonstrated both feasibility of scaling up patient and provider education and implementation challenges in translating education into action. Ongoing research aims to identify care-seeking barriers and co-design a sore throat treatment model tailored to the community’s cultural and contextual needs. Trial registration number: NCT05276999 .

Introduction: Echocardiography screening for rheumatic heart disease (RHD) has gained support as a public health approach, but scale up of RHD screening services is complex. We sought to evaluate the effectiveness of a novel training program to build non-expert competency for RHD echocardiography screening within the Uganda public health system and to describe the human and material resources required to support it. Methods: Guided by a logic model, we evaluated the Accelerating Delivery of Rheumatic Heart Disease Prevention in Northern Uganda (ADUNU) Program, a novel RHD control program, 15 months after its implementation within the Ugandan public health care system. Results: Sixty-one healthcare workers (HCW) across 10 public health facilities started in training under the program, of which 58 (95%) advanced past the initial stage of training and earned conditional certification to screen for RHD with ongoing remote and in-person feedback and oversight. Of these, 17 (29%) completed all stages of training and earned full certification to independently screen for RHD with no ongoing oversight. A total of 17,927 community members were screened through ADUNU during the program’s first 15 months. After receiving final certification, 14 HCWs (93%) continued to perform screening echocardiograms (≥20/month) at median follow-up of 8 months [IQR 8–10]. HCW sensitivity and specificity were 61% and 96%, respectively. Conclusion: Development and deployment of a large scale RHD screening echocardiography training program within an existing public health system is feasible. Future program iterations are needed to improve HCW screening sensitivity and decrease the reliance on human resources.

Background: Early echocardiographic detection improves rheumatic heart disease (RHD) outcomes, but screening in endemic, resource‐limited settings remains a challenge. The Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Northern Uganda program was developed to integrate task‐shifted RHD screening into the existing health system in Kitgum, Uganda. We evaluated the program’s impact on RHD case detection and assessed screening performance during its first year. Methods: We conducted a programmatic evaluation of all individuals screened via the program from May 2023 to April 2024, describing demographic and echocardiographic findings. We assessed sensitivity, specificity, predictive values, and accuracy of screenings performed by health care workers who had completed the full training, using expert‐confirmed diagnoses as the gold standard. Results: Of 11 793 individuals screened, 806 (6.8%) screened positive, with 544 receiving confirmatory testing. A total of 126 new RHD cases were diagnosed (74 mild, 52 moderate/severe). Among 3243 screenings by fully trained health care workers, sensitivity was 55% (95% CI, 47%–63%), specificity 97% (95% CI, 97%–98%), positive predictive value 52% (95% CI, 45%–60%), negative predictive value 98% (95% CI, 97%–98%), and accuracy 95% (95% CI, 95%–96%). Accuracy varied with age, sex, and health care worker screening volume: older age (odds ratio [OR], 0.96 [95% CI, 0.93–0.98]) and female sex (OR, 0.46 [95% CI, 0.22–0.91]) were associated with decreased accuracy, whereas higher screening volume improved accuracy (OR, 5.24 [95% CI, 2.52–10.65]). Conclusions: Task‐shifted echocardiographic screening can be effectively integrated into low‐resource health systems. Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Northern Uganda trained a local screening workforce and identified 126 new RHD cases in its first year. Moderate sensitivity and subgroup variability indicate opportunities for improvement through targeted training and supportive technologies.

Acute rheumatic fever (ARF), the acute autoimmune sequela of group A Streptococcus infection, and its chronic life-threatening manifestation, rheumatic heart disease (RHD), which causes permanent heart valve damage, remain major drivers of preventable cardiovascular mortality and disability in low-income and middle-income countries. Since the mid-1990s, multidisciplinary and international collaborative research has yielded new insights into the role of superficial skin infections such as impetigo in ARF pathogenesis and the disease mechanisms that underlie the progression from ARF to RHD, and has explored novel treatments and delivery mechanisms in clinical trials and progressed the development of Strep A vaccines. Early detection and patient care have advanced, with revised echocardiographic screening criteria and the 2024 WHO guidelines, which provide a framework for evidence-based management and therapeutic strategies. Notwithstanding these advancements, considerable disparity persists in the care, control and treatment of advanced disease, necessitating coordinated programmes, prioritization by global agencies and local governments, and substantial involvement of those with RHD. Of note, few to no cardiac surgery programmes exist in some countries most burdened by RHD. Future research must encompass implementation studies for validated evidence-based therapies, translational technologies and applications, together with a definitive pathway to direct patient effect, to achieve the WHO target of eliminating RHD as a public health problem.

Introduction: Primary prevention of rheumatic heart disease (RHD) is aimed at timely diagnosis and treatment of superficial Group A Streptococcal infections, most commonly Strep sore throat. However, uptake and delivery of primary prevention for RHD-endemic regions has room for improvement. Community co-design is an important aspect of intervention development to increase sustainability and reach. Methods: Group-level assessment (GLA) sessions were used to understand the community’s priorities and insights around sore throat. Personas, or user archetypes, were then developed to capture the behaviours and characteristics of diverse future users of primary prevention in the district. Finally, these personas were used in community design workshops to identify barriers and facilitators to potential interventions, generate creative solutions to overcome identified barriers and prioritise implementation models based on impact and feasibility. The final list of implementation strategies was presented by workshop participants to the broader community for additional validation and feedback. Results: The GLA sessions identified five priority areas: (1) need for improved access to care, closer to home; (2) importance of mothers as caregivers; (3) strong influence of community leaders; (4) importance of community health workers and (5) role of traditional providers and practices. Five personas were created, including: hands-on caregiver, restricted caregiver, removed family decision-maker, helpful neighbour and influential leader. Design workshops identified the highest-rated interventions as: decentralisation of care delivery into the community (strategy 1), use of community health workers as key implementing partners (strategy 2) and streamlining sore throat services at public healthcare facilities (strategy 3). Participants proposed potential practical applications of these interventions. Conclusions: Community-based participatory research identified novel implementation strategies for an RHD primary prevention programme in Uganda. The value set and strategies developed in this study can now be used as guideposts to develop and test a package of implementation strategies for improving RHD primary prevention in Uganda.