Leveraging School Health Programs in Africa: Integrated Screening for Rheumatic Heart Disease and Dental Caries.

Background: Rheumatic heart disease (RHD) and dental caries (DC) disproportionately affect children and young adults in sub-Saharan countries, with major impact on schoolchildren's health and education. DC in children with RHD constitutes an important risk for fatal complications. Our study aimed at assessing the feasibility of simultaneous RHD and DC screening in school environment. Methods: March 20-24, 2022, we performed an observational descriptive study of schoolchildren in a public school in Maputo City, Mozambique. RHD screening involved two stages: first, a physical examination (including cardiac auscultation and direct observation of the oral cavity), and second, an abbreviated echocardiography performed by a cardiologist. Rapid testing for group A Streptococcus (GAS) was done to every eighth child in the classroom and for those with signs suggesting recent infection, in accordance with the study protocol developed for screening. A multidisciplinary team collected the data. Data were analyzed using descriptive statistics. Findings: A total of 954 students (median age 9; range 6-15) were screened. One hundred and twenty-five participants were eligible for a rapid antigen test, of which 6 (4.8%) tested positive. On clinical evaluation 52 children (5.3%) presented a heart murmur. Echocardiography on 362 children showed borderline RHD in 35 children and definite RHD in 2 (0.6%); 1 child had a ventricular septal defect. Dental cavities were present in 444 (48.4%), despite 904 out of 917 students reporting brushing of their teeth once to three times daily (98.6%). Conclusion: School-based integrated oral and cardiovascular screenings and use of rapid tests for GAS carriage provide crucial information to create customized preventive strategies for rheumatic fever (RF) and RHD in low- and middle-income countries (LMICs), in addition to detecting children at very high risk of bacterial endocarditis. The sustainability of such interventions and acceptability by health providers needs to be assessed.

Empowering Frontline Primary Healthcare Workers in a Global Health Partnership Training of Trainers Intervention to Strengthen the Prevention and Control of Cardiovascular Disease in Mozambique.

Background: Unpreparedness of health professionals to address non-communicable diseases (NCD) at peripheral health facilities is a critical health system challenge in Mozambique. To address this weakness and decentralize NCD care, training of the primary care workforce is needed. We describe our experience in the design and implementation of a cascade training of trainers (ToT) intervention to strengthen the prevention and control of cardiovascular disease. Methods: Between October 2018 and March 2020 a multidisciplinary global technical partnership was used to train frontline primary care health professionals from a resource-poor suburban setting in Maputo, Mozambique. Following engagement with local policy makers, clinicians, and academics, core training materials were developed, and a ToT cascade was implemented, supported by an on-site pilot clinic. Knowledge and confidence acquisition by participants and new local trainers were assessed using pre- and post-training surveys, while trainees and trainers completed further evaluation surveys at the end of the program. Results: Three ToT workshops trained 60 mixed cadre healthcare workers in assessment, diagnosis and management of hypertension, diabetes, and cardiovascular risk; of these, 11 became new local trainers. Mean pre- and post-test scores improved in all three training workshops (53% to 90%, 59% to 78%, and 58% to 74% respectively). New local trainers were highly rated by their trainees and reported increased confidence as trainers (mean Likert scale 3.0/5 pre-training to 4.8/5 post-training). Conclusion: This global health partnership delivered interprofessional training with good knowledge acquisition and increased self-reported confidence. Intensive local supervision and hands-on training empowered a new cohort of trainers to strengthen the prevention and control of cardiovascular disease and is likely to improve coordination and integration at primary care level as well as support the national scale up of NCD care delivery.

Pulmonary vascular disease in Africa: Lessons from registries.

The epidemiology of pulmonary vascular disease (PVD) remains unclear in Africa, where health systems do not reach the majority of the population and heath information systems are poorly developed. In this context, registries are particularly important in gathering crucial information on PVD, aiming at improving knowledge of the epidemiology and/or quality of care. While population-based registries are the main tool to identify incident cases, and be a better indicator of pulmonary vascular disease burden, hospital-based registries can give an indication of the demand for specific care services, which is useful for health policy and planning. The only registry for pulmonary hypertension in Africa - the Pan African Pulmonary Hypertension Cohort (PAPUCO) - involved four countries, and was a pragmatic study that revealed a unique pattern of environmental risks, issues related to low access to health care, and ill-equipped health facilities for diagnosis and management of pulmonary hypertension. In addition, disease specific registries for conditions such as congenital heart disease and rheumatic heart disease uncovered high occurrence of PVD that can be managed and/or prevented with improvements in community awareness, surveillance, management and prevention. It is suggested that existing networks of experts and researchers develop regional registries to determine the epidemiology of PVD in Africa, assess geographic, environmental and seasonal differentials, as well as inform policy and care provision in the continent.