Handheld echocardiography for screening and control of rheumatic heart disease study in Gezira state, Sudan: a double approach model

Abstract

Background: Rheumatic heart disease (RHD) is prevalent in Sudan's rural areas including Gezira state in central Sudan. We initiated a control program aiming at measurement of the echocardiographic (echo) prevalence of RHD, training of health workers and public awareness.

Methods: This is a cross-sectional and interventional study conducted in Gezira State, Al Managil Locality from Nov 2016 to February 2018. We used handheld echo (HHE) to detect the prevalence of RHD in school children and those tested positives were referred for standard echo. In addition, training on detection of RHD for health professionals was offered using training modules for physicians and nurses. Evaluation of health facilities was carried out using a questionaire. This was coupled with educational sessions to increase public awareness about RHD using posters and pamphlets.

Results: Two thousand and one hundred twenty-nine school children were screened, 36 cases were positive by HHE, out of these 31 underwent standard echo and 5 were confirmed to have RHD, giving an echo prevalence of 2.3/1,000. All cases had mild mitral regurgitation. Knowledge, attitudes and practices of 175 health workers were assessed then a tailored training program was implemented. Practices that are not compatible with Sudan's RHD Guidelines were detected including performing skin testing prior to administration of benzathine penicillin and under-utilization of local anesthetic to decrease the pain when giving the injection. Benzathine penicillin was available in only 32% of health facilities and only 25% of their personnel received training in RHD management.

Conclusions: RHD echo prevalence in Gezira is relatively high and the health system needs to be strengthened. A double approach, screen-to-control program that utilizes HHE screening, health workers' training, public awareness and providing medical supplies in primary health care centers is feasible.

Keywords: Rheumatic heart disease (RHD); Sudan; children; heart failure.

Figure 1

Sudan’s map (left), Al Managil area magnified with the 9 screening sites shown.

Figure 2

Schematic figure showing the outcomes of the echo study.

Figure 3

Handheld echo image showing mild MR.

Figure 4

Physicians’ response (%) to questionnaire before and after the training session.

Figure 5

Health workers’ (%) response to questionnaire before and after the training session.

Figure 6

School children, teachers and research team member (HAH) during an awareness session.