Response to Godown and Beaton—Handheld echocardiography: A new tool for rheumatic heart disease in the developing world?

Drs. Godown and Beaton’s correspondence (1) regarding the use of handheld echocardiography (HAND) for rheumatic heart disease (RHD) screening in developing countries highlights a number of issues that will be important in the development of future screening programs.

While we agree that HAND has the potential to lower some of the costs of RHD screening programs, we question whether its use is likely to be a decisive factor in determining their overall financial viability. Given that the specificity of HAND for definite and borderline RHD reported in Godown et al.’s recent study (2) was 87%, it is probable that any HAND screening program would require standard echocardiography (STAND) access to confirm positive screening results. Thus, any initial capital cost savings associated with the use of HAND over STAND equipment may potentially be negated by the extra workload associated with confirmation of diagnoses made on HAND. Such confirmation of positive screenings would be especially important given the long-term nature of follow-up and treatment/prophylaxis that is required for individuals with RHD.

A second consideration in the feasibility of screening is that the greatest costs in any RHD screening program are likely to be associated with human resources and subsequent management of individuals with positive screening results. Given this, if the costs associated with acquiring STAND equipment are prohibitive in a particular setting then it seems unlikely that sufficient resources would be available for implementing a screening program even if screening were moved into the hands of non-experts. Further, while it may be argued that the cost of benzathine penicillin for secondary prophylaxis is low, the costs to any health care system associated with its delivery can be high.

One of the requirements of a viable screening program is that there exists an effective, available, and easily accessible treatment that is acceptable to all patients with the recognised disease (3,4). Benzathine penicillin has been demonstrated to be effective in retarding progression of valvular damage associated with RHD (5). However, current evidence suggests that delivery of benzathine penicillin is less that optimal in many countries including Australia (6), Egypt (7), Taiwan (8), Brazil (9) and South Africa (10). While echocardiographic screening for RHD, including HAND screening, may be effective in uncovering undiagnosed RHD, it is vital that any screening program be complemented by initiatives to improve the delivery and uptake of benzathine penicillin in those individuals with a positive test (11).

A further point in relation secondary prophylaxis relates to its role in latent RHD. There is as yet no evidence to show that echocardiographically diagnosed definite RHD on WHF criteria in the absence of a previous documented episode of ARF will respond to benzathine penicillin in the same way as classically diagnosed RHD. While it seems logical to suggest that progression of valvular damage in such individuals can be prevented by secondary benzathine penicillin, this still remains to be demonstrated.

Finally, the issue of how to manage individuals whose screening echocardiograms reveal valvular changes that do not meet criteria for definite RHD still remains to be addressed. We recently found that 1 in 6 Indigenous Australian children diagnosed with borderline RHD on screening echocardiography progressed to definite RHD within 2.5-5 years (12). Perhaps of more concern was our finding that 1 in 10 children with non-specific valvular changes that do not meet WHF criteria for borderline RHD also progressed to definite RHD. These findings raise two important questions. First, what degree of valvular damage detected during echocardiographic screening should be considered as a “positive” test? In particular, what would be the implications to patients of drawing the cut-off at definite RHD or borderline RHD? Second, when such valvular damage is revealed by echocardiographic screening, what follow-up is appropriate for affected individuals? If the clinical decision is taken to implement enhanced surveillance, repeat echocardiography, or indeed benzathine penicillin treatment then such action may have an important impact on already scarce and often finite health care resources.

Godown and colleagues are to be congratulated for their continued work to make echocardiographic screening for RHD more affordable and accessible, particularly as the highest burden of disease is seen in low and middle income countries. Nevertheless, viable RHD screening programs will require further evidence regarding the management of non-specific valvular changes, improvements in delivery of secondary prophylaxis, major investments in human and health service resources, and detailed and realistic economic analysis to ensure they do not divert finite resources from possibly more pressing and effective health care interventions.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Godown J, Beaton A. Handheld echocardiography: A new tool for rheumatic heart disease screening in the developing world? Transl Pediatr 2015;4:252-3.
2. Godown J, Lu JC, Beaton A, et al. Handheld echocardiography versus auscultation for detection of rheumatic heart disease. Pediatrics 2015;135:e939-44. [PubMed]
3. Council of Europe Committee of Ministers. Recommendation No.R (94) 11 of the Committee of Ministers to member states on screening as a tool of preventive medicine. Available online: https://wcd.coe.int/com.instranet.InstraServlet?command=com.instranet.CmdBlobGet&InstranetImage=534532&SecMode=1&DocId=514336&Usage=2
4. Australian Health Ministers' Advisory Council. Population based screening framework. Commonwealth of Australia, 2008. Available online: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/16AE0B0524753EE9CA257CEE0000
5. WHO technical report series; 923. Rheumatic fever and rheumatic heart disease : report of a WHO Expert Consultation. Geneva: 2001.
6. Rémond MG, Severin KL, Hodder Y, et al. Variability in disease burden and management of rheumatic fever and rheumatic heart disease in two regions of tropical Australia. Intern Med J 2013;43:386-93. [PubMed]
7. Bassili A, Zaher SR, Zaki A, et al. Profile of secondary prophylaxis among children with rheumatic heart disease in Alexandria, Egypt. East Mediterr Health J 2000;6:437-46. [PubMed]
8. Lue HC, Chen CL, Wei H. Some problems in long-term prevention of streptococcal infection among children with rheumatic heart disease in Taiwan. Jpn Heart J 1976;17:550-9. [PubMed]
9. Pelajo CF, Lopez-Benitez JM, Torres JM, et al. Adherence to secondary prophylaxis and disease recurrence in 536 Brazilian children with rheumatic fever. Pediatr Rheumatol Online J 2010;8:22. [PubMed]
10. Walker KG, Human DG, De Moor MM, et al. The problem of compliance in rheumatic fever. S Afr Med J 1987;72:781-3. [PubMed]
11. Rémond MG, Coyle ME, Mills JE, et al. Approaches to improving adherence to secondary prophylaxis for rheumatic fever and rheumatic heart disease: a literature review with a global perspective. Cardiol Rev 2015. [Epub ahead of print]. [PubMed]
12. Rémond M, Atkinson D, White A, et al. Are minor echocardiographic changes associated with an increased risk of acute rheumatic fever or progression to rheumatic heart disease? Int J Cardiol 2015;198:117-22. [PubMed]