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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 5, September/October 2018
AFRICA
273
Echocardiographic screening for rheumatic heart
disease in 4 515 Sudanese school children: marked
disparity between two communities
Sulafa Ali, Sara Domi, Bahja Abbo, Rabab Abbas, Tajudeen Bushari, Khalid Al Awad,
Abdelrahman Elhassan, Manar E Abdel-Rahman
Abstract
Introduction:
Echocardiographic (echo) screening has
unmasked a high prevalence of subclinical rheumatic heart
disease (RHD) in many countries, and it can be used as a
surveillance tool to control the disease.
Methods:
School children of 10 to 15 years of age were
selected in two areas of Sudan, Khartoum, the capital, and
Niyala in western Sudan. Echo screening using a hand-held
echo (HHE) was conducted in Khartoum using a three-view
protocol, and in Niyala, a one-view protocol, both modified
from the World Heart Federation protocol. Suspected cases
were referred for standard echo study. Training of health
personnel was conducted and health education sessions were
delivered to the public.
Results:
In Khartoum, a total of 3 000 school children were
screened; seven cases were positive for RHD using HHE and
one case was confirmed by standard echocardiography. The
prevalence of RHD using echocardiography was 0.3 per 1 000
children. In Niyala, a total of 1 515 school children were
screened. Using HHE, 59 cases were positive for RHD; 44
had definite and 15 borderline disease. Out of 34 who under-
went standard echocardiography, 29 (85.2%) were found to
have RHD; 22 had definite and seven borderline disease. The
prevalence using echocardiography was 19 per 1 000 children.
A total of 779 health workers were trained in South Darfur
and 50 000 posters and pamphlets were distributed.
Conclusion:
Using echocardiography, there was a significant
disparity in RHD prevalence between the two communities
in Sudan. Efforts to control RHD should be directed to this
area, and other rural communities should be investigated.
Keywords:
rheumatic heart disease, echocardiography, Sudan
Submitted 24/3/17, accepted 15/3/18
Published online 16/4/18
Cardiovasc J Afr
2018;
29
: 273–277
www.cvja.co.zaDOI: 10.5830/CVJA-2018-022
Rheumatic heart disease (RHD) is an immune response to group
A beta-haemolytic streptococcal infection and is considered a
leading cause of acquired heart disease in young people globally.
1
Sudan is the third largest country in Africa with a population
of 34 million, poverty rate of 46.4%, per capita income of
US$1 270, and human development index of 0.414. Political
conflict has resulted in social divides that caused internal
displacement of thousands of families in the Darfur area.
2
In Sudan, the last epidemiological study on RHD was
conducted in 1992 and showed a clinical prevalence of 11
per 1 000 in Khartoum’s school children.
3
In recent years,
echocardiographic (echo) screening has documented a prevalence
of RHD that is several fold higher than clinical auscultation.
4,5
The availability from the World Heart Federation (WHF)
of defined echo criteria for diagnosing subclinical RHD has
enabled many investigators to objectively study subclinical
carditis in different settings.
6
Hand-held echo (HHE), a small
and less costly machine, was proven to have a sensitivity of up to
97% for definite RHD, therefore it can be used as a surveillance
tool in resource-limited settings.
7
In Sudan, a World Health Organisation-based RHD control
programme ended in 1998 and since then, there has been no
active programme until 2012, when a national programme was
established.
8,9
A hospital-based register has shown that most
RHD patients come from a belt localised to Kordofan, Darfur,
White Nile and Gezira states in western and central Sudan.
10
This
study aimed to measure the prevalence of RHD in Khartoum
using echo for diagnosis, compare it to that of South Darfur, and
initiate a sentinel site for RHD control in the latter area.
Methods
Phase 1 of the study was conducted in Khartoum inner city,
Mayo area, from September 2015 to February 2016, and phase 2
in Niyala city, South Darfur state from July to September 2016.
The gap of four months was due to the school holidays. Schools
Department of Paediatrics, Faculty of Medicine, University
of Khartoum; and Department of Paediatric Cardiology,
Sudan Heart Centre, Khartoum, Sudan
Sulafa Ali, MD, FRCPCH, FACC,
sulafaali2000@gmail.comDepartment of Paediatric Cardiology, Sudan Heart Centre,
Khartoum, Sudan
Sara Domi, MD
Rabab Abbas
Tajudeen Bushari, MD
Abdelrahman Elhassan, MD
Department of Paediatrics, Niyala Hospital, South Darfur,
Sudan
Bahja Abbo, MD
Khalid Al Awad
Department of Statistics, Faculty of Mathematical
Sciences, University of Khartoum, Sudan; and Department
of Public Health, College of Health Sciences, Qatar
University, Doha, Qatar
Manar E Abdel-Rahman, PhD