David Watkins

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.

Background: Orthopaedic injuries are a major contributor to morbidity and mortality in low-income settings, driven by rising urbanisation and inadequate road safety measures. This study evaluates the cost-effectiveness of treatment for four common orthopaedic injuries in Malawi: femoral shaft fractures, patellar fractures, humeral shaft fractures and paediatric supracondylar humeral fractures (PSCHF). Methods: We developed a dynamic state-transition model to simulate fatal and non-fatal outcomes from a healthcare perspective from 2021 to 2031, informed by cost, epidemiological and population estimates. We estimated incremental cost-effectiveness ratios (ICER) for conservative and surgical management versus no treatment and each other, conducting one-way and probabilistic sensitivity analyses. We then modelled the population impact of scaling up the most cost-effective intervention under two scenarios. Findings: For femoral shaft fractures, surgical, conservative and no treatment resulted in disability-adjusted life years (DALYs) of 0.10, 0.21 and 0.23, with ICERs of approximately US$3000 and US$60 000 for surgical and conservative treatment. For patellar fractures, DALYs were 0.20, 0.22 and 0.32, with similar cost-effectiveness (ICERs of US$1400). For humeral shaft fractures, DALYs were 0.041, 0.056 and 0.11, with ICERs of US$3000 and US$1400. For PSCHF, DALYs were 0.04, 0.086 and 0.14, with ICERs of US$1600 and US$2600. Comparison of surgical and conservative strategies shows surgery was cost-saving for femoral shaft fractures, similar for patellar fractures, less efficient for humeral shaft fractures and more cost-effective for PSCHF. At Malawi’s willingness-to-pay threshold of US$65 per DALY averted, the probability of cost-effectiveness was low. Under the ambitious scale-up scenario, approximately 1800 DALYs (a 10% reduction relative to the baseline) were averted at an incremental cost of US$5 million. Conclusion: In Malawi, surgery is more cost-effective for femoral shaft and PSCHF fractures, whereas conservative care is more cost-effective for humeral shaft fractures. For patella fractures with an intact extensor mechanism, both treatments are similarly cost-effective. Targeted scale-up could yield substantial health gains, underscoring the importance of context-specific data for prioritising orthopaedic services in low-resource settings.

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.

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.

Background: The answer to whether females or males have better health, and which sex is the more disadvantaged, has depended in part on the metric and how the inequality is measured. This study introduces a new method for analyzing and interpreting sex inequalities in health outcomes—defined as the avoidable sex differences in health outcomes—that is systematic and potentially more objective. For this paper, we focus on life expectancy at different ages. Methods and findings: We introduce the adjusted sex ratio as a measure of sex inequalities and determining sex disadvantage. First, we calculated the sex ratio of life expectancy at ages 0, 5, 15, 35, 50, and 70. To understand what is achievable under favorable conditions, we identified countries in the 5th percentile of the highest life expectancy for each sex and used these values as benchmarks, and calculated the sex ratio of these best-performing countries (“frontier”). We calculated the country- and age-specific adjusted sex ratio by dividing country sex ratios by frontier sex ratios. This assumes that theoretically, under the current risk and healthcare environments, females all over the world have the potential to live up to the life expectancy of the females in the frontier countries, and separately, all males to their male-specific frontier. An adjusted ratio of greater than one indicates male disadvantage, while below one indicates female disadvantage. To avoid overinterpreting small differences, we defined a narrow range around equality (ratio of 1) within which we do not label either sex as disadvantaged. Before adjustment, males in all countries (except two) and at all ages had lower life expectancy than females. After adjustment, between 13% (at age 0) and 33% (at age 70) of the 237 countries shift from male to female disadvantage in life expectancy. More than half of the countries remain male-disadvantaged, indicating that males are generally disadvantaged in terms of life expectancy in most countries, even after our adjustments. India and approximately half of the countries in the Middle East and North Africa, North Atlantic, sub-Saharan Africa, and Western Pacific and Southeast Asia show female disadvantage. The number of countries with female disadvantage rises with age, especially in sub-Saharan Africa and Western Pacific and Southeastern Asia. Central and Eastern Europe show substantial male disadvantage across nearly all ages, even with adjustment. Our frontier selection and buffer range are empirical choices, and other definitions could be equally valid. Although our sex-specific benchmarks use the best-performing countries for each sex, they are not meant to represent purely biological differences, as observed sex gaps in life expectancy may also reflect unmeasured genetic variation, environmental exposures, and their interactions with sex. Conclusion: This study provides a novel, potentially more objective method for assessing sex inequalities in health outcomes, and presents the trends across countries, age, and time.

Introduction: Over 46 million people are living with rheumatic heart disease (RHD) globally, resulting in 380 000 premature deaths each year. Effective RHD prevention strategies are known but their implementation in low-resource settings has lagged. This study evaluated the feasibility and effectiveness of integrating secondary antibiotic prophylaxis into primary health centres to improve access and adherence to RHD care. Methods: We conducted a hybrid type III study using a mixed-method, pre–post design to evaluate a package of implementation strategies centred on decentralised RHD care and use of an electronic medical record in Gulu and Lira, Uganda. We combined clinical and programmatic data with provider and patient interviews to assess effectiveness, adoption and acceptability. The mean difference in the annualised percentage of days adherent to benzathine penicillin G (BPG) monthly injections predecentralisation and postdecentralisation was calculated using linear mixed effect regression. Thematic analysis was used to analyse qualitative data. Results: We decentralised 151 patients (median age 17.9 years, 64% female) from district hospitals to eight primary health centres. The percentage of days adherent to BPG was 77.2% predecentralisation and 80.5% postdecentralisation (mean difference 3.25, (95% CI −0.72 to 6.86), p=0.081), which was statistically non-inferior at the −10% non-inferiority margin. Interview data identified knowledge, confidence and intrinsic motivation as major determinants of provider adoption. Patients expressed mixed feelings towards pain control and provider services, but convenience and financial savings resulted in a high level of acceptability. The electronic registry presented challenges in a naive environment but showed a strong potential as an oversight tool at the district level. Discussion: This study is the first to demonstrate that decentralised RHD care is effective in sub-Saharan Africa. Lessons learnt provide a platform for future integration of RHD services countrywide, with implications for increasing access to and scale-up of secondary prevention measures for RHD care in Uganda.