Community-based prevalence of rheumatic heart disease in rural Ethiopia: Five-year follow-up

Background As little is known about the prevalence and clinical progression of subclinical (latent) rheumatic heart disease (RHD) in sub-Saharan Africa, we report the results of a 5 year follow-up of a community based, echocardiographic study of the disease, originally carried out in a rural area around Jimma, Ethiopia. Methods Individuals with evidence of RHD detected during the baseline study as well as controls and their family members were screened with a short questionnaire together with transthoracic echocardiography. Results Of 56 individuals with RHD (37 definite and 19 borderline) in the original study, 36 (26 definite and 10 borderline) were successfully located 57.3 (range 44.9-70.7) months later. At follow-up two thirds of the definite cases still had definite disease; while a third had regressed. Approximately equal numbers of the borderline cases had progressed and regressed. Features of RHD had appeared in 5 of the 60 controls. There was an increased risk of RHD in the family relatives of borderline and definite cases (3.8 and 4.0 times respectively), notably among siblings. Compliance with penicillin prophylaxis was very poor. Conclusions We show the persistence of echocardiographically demonstrable RHD in a rural sub-Saharan population. Both progression and regression of the disease were found; however, the majority of the individuals who had definite features of RHD had evidence of continuing RHD lesions five years later. There was an increased risk of RHD in the family relatives of borderline and definite cases, notably among siblings. The findings highlight the problems faced in addressing the problem of RHD in the rural areas of sub-Saharan Africa. They add to the evidence that community-based interventions for RHD will be required, together with appropriate ways of identifying active disease, achieving adequate penicillin prophylaxis and developing vaccines for primary prevention. Author summary Although chronic rheumatic heart disease is one of the most important causes of heart disease in sub-Saharan Africa it is still poorly understood. In particular, little is known about the frequency, severity and progression of the disease in the rural areas where most of the population live. In 2017, we reported the results of a community-based study in a rural area of south-west Ethiopia using ultrasound imaging of the heart (echocardiography) which showed a high prevalence of the disease. In a follow-up of the cases originally identified in the study, we found that there was considerable variability of the disease with some individuals showing progression and others regression of the heart abnormalities. The majority of affected individuals, however, had evidence of continuing disease five years later. We also found an increased risk in the family relatives of cases, notably among siblings. Although affected individuals were instructed to take prophylactic penicillin to prevent the disease progressing, compliance with this was very poor. The findings highlight the problems faced in addressing rheumatic heart disease in rural Africa. They suggest that community-based interventions will be required together with innovative ways of identifying active cases, achieving adequate antibiotic prophylaxis and primary prevention.