Prevalence of latent structural heart disease in Nepali schoolchildren.

BACKGROUND: The present study aimed to quantify the burden of structural heart disease in Nepali children. METHODS: We performed a school-based cross-sectional echocardiographic screening study with cluster random sampling among children 5-16 years of age. RESULTS: Between December 2012 and January 2019, 6573 children (mean age 10.6 ± 2.9 years) from 41 randomly selected schools underwent echocardiographic screening. Structural heart disease was detected in 14.0 per 1000 children (95% CI 11.3-17.1) and was congenital in 3.3 per 1000 (95% CI 2.1-5.1) and rheumatic in 10.6 per 1000 (95% CI 8.3-13.4). Rates of rheumatic heart disease were higher among children attending public as compared to private schools (OR 2.8, 95% CI 1.6-5.2, p = 0.0001). CONCLUSION: Rheumatic heart disease accounted for three out of four cases of structural heart disease and was more common among children attending public as compared to private schools.

Effectiveness of Systematic Echocardiographic Screening for Rheumatic Heart Disease in Nepalese Schoolchildren: A Cluster Randomized Clinical Trial.

Importance: Echocardiographic screening allows for early detection of subclinical stages of rheumatic heart disease among children in endemic regions. Objective: To investigate the effectiveness of systematic echocardiographic screening in combination with secondary antibiotic prophylaxis on the prevalence of rheumatic heart disease. Design, Setting, and Participants: This cluster randomized clinical trial included students 9 to 16 years of age attending public and private schools in urban and rural areas of the Sunsari district in Nepal that had been randomly selected on November 17, 2012. Echocardiographic follow-up was performed between January 7, 2016, and January 3, 2019. Interventions: In the experimental group, children underwent systematic echocardiographic screening followed by secondary antibiotic prophylaxis in case they had echocardiographic evidence of latent rheumatic heart disease. In the control group, children underwent no echocardiographic screening. Main Outcomes and Measures: Prevalence of the composite of definite or borderline rheumatic heart disease according to the World Heart Federation criteria in experimental and control schools as assessed 4 years after intervention. Results: A total of 35 schools were randomized to the experimental group (n = 19) or the control group (n = 16). After a median of 4.3 years (interquartile range [IQR], 4.0-4.5 years), 17 of 19 schools in the experimental group (2648 children; median age at follow-up, 12.1 years; IQR, 10.3-12.5 years; 1308 [49.4%] male) and 15 of 16 schools in the control group (1325 children; median age at follow-up, 10.6 years; IQR, 10.0-12.5 years; 682 [51.5%] male) underwent echocardiographic follow-up. The prevalence of definite or borderline rheumatic heart disease was 10.8 per 1000 children (95% CI, 4.7-24.7) in the control group and 3.8 per 1000 children (95% CI, 1.5-9.8) in the experimental group (odds ratio, 0.34; 95% CI, 0.11-1.07; P = .06). The prevalence in the experimental group at baseline had been 12.9 per 1000 children (95% CI, 9.2-18.1). In the experimental group, the odds ratio of definite or borderline rheumatic heart disease at follow-up vs baseline was 0.29 (95% CI, 0.13-0.65; P = .008). Conclusions and Relevance: School-based echocardiographic screening in combination with secondary antibiotic prophylaxis in children with evidence of latent rheumatic heart disease may be an effective strategy to reduce the prevalence of definite or borderline rheumatic heart disease in endemic regions. Trial Registration: ClinicalTrials.gov Identifier: NCT01550068.

Surgical need in an ageing population: a cluster-based household survey in Nepal.

BACKGROUND: With an ageing global population comes major non-communicable disease burden, especially in low-income and middle-income countries. An unknown proportion of this burden is treatable or palliated with surgery. This study aimed to estimate the surgical needs of individuals aged 50 years or older in Nepal. METHODS: A two-stage, 30 randomised cluster by 30 households, community-based survey was performed in Nepal with the validated Surgeons OverSeas Assessment of Surgical Need (SOSAS). Respondents aged older than 50 years were included. After verbal informed consent was obtained, SOSAS collected household demographics, completed a verbal autopsy, and randomly selected household members for verbal head-to-toe examinations for surgical conditions. The Nepal Health Research Council in Kathmandu and the Nationwide Children's Hospital in Columbus, OH, USA, granted ethical approval. FINDINGS: The survey sampled 1350 households, totalling 2695 individuals (97% response rate); 49% were aged 50-59 years, 33% were 60-69 years, and 17% were 70 years and older. Of these, 273 surgical conditions were reported by 507 individuals. A growth or mass (including hernias and goiters) was the most commonly reported potentially surgical condition (25%), injuries and fractures were also common and had the greatest disability. Acquired deformities (13%), incontinence (11%), non-injury wounds (9%), and pelvic organ prolapse were also prevalent. Together, head and neck (24%) and back and extremity conditions (32%) were responsible for more than half of the conditions potentially treatable with surgery. These were followed by genitourinary (28%), abdominal (14%) and chest and breast conditions (2%). Extrapolated nationwide, roughly 1·25 million elderly individuals have a surgically treatable condition (32 150 per 100 000 people). There were 108 deaths in the year before to the survey. 20 (19%) were potentially preventable with surgery. Half of the deaths were due to a growth or mass, 20% to injury, 20% to abdominal pain or distension, and 10% to a non-injury wound. The age-standardised death rate of those with a potentially surgical condition was 24 per 1000 persons for individuals in their 6th decadte, 60 per 1000 for those in their 7th, and 44 per 1000 for those in their 8th. One in five deaths were potentially treatable or palliated by surgery. Literacy and distance to secondary and tertiary health facilities were associated with not receiving care for surgical conditions (p<0·05). INTERPRETATION: Surgical need is largely unmet among elderly individuals in Nepal. Literacy and distance from a capable health facility are the greatest barriers to care. Although verbal examination findings were used as proxies for surgical conditions, the survey tool has been previously validated. Also, there is potential for recall bias with overestimation of tragic deaths and underestimation of unknown or forgotten surgical causes of death and disease. However, this is the most comprehensive evaluation of surgical need in a developing country among the elderly. As the global population ages, there is an increasing need to improve access to surgical services and strengthen health systems to care for this group. FUNDING: The Association for Academic Surgery, Surgeons OverSeas, and the Fogarty International Center.

Surgical need in an aging population: A cluster-based household survey in Nepal.

BACKGROUND: With an aging global population comes an obligate and substantial burden of noncommunicable disease, especially in low- and middle-income countries. An unknown proportion of this burden is treatable with surgical expertise. For health system planning, this study aimed to estimate the operative needs of individuals older than 50 of age years in Nepal. METHODS: A 2-stage, cluster randomized, community-based survey was performed in Nepal using the validated Surgeons OverSeas Surgical Assessment Survey (SOSAS). SOSAS collects household demographics and selects household members randomly for verbal, head-to-toe examinations for surgical conditions; moreover, SOSAS also completes a verbal autopsy for deaths in the preceding year. Only respondents older than 50 years were included in the analysis. RESULTS: The survey sampled 1,350 households, totaling 2,695 individuals (97% response rate). Of these, 273 surgical conditions were reported by 507 persons ages ≥ 50 years. Extrapolating, there are potentially 2.1 million people older than 50 years of age with surgically treatable conditions who need care in Nepal (95% confidence interval 1.8-2.4 million; 46,000-62,600 per 100,000 persons). One in 5 deaths was potentially treatable or palliated by surgical care. Although growths or masses (including hernias and goiters) were the surgical condition reported most commonly (25%), injuries and fractures also were common and associated with the greatest disability. Literacy and distance to secondary and tertiary health facilities were associated with lack of care for operative conditions (P < .05). CONCLUSION: There is a large, unmet surgical need among the elderly in Nepal. Low literacy and distance from a capable health facility are the greatest barriers to care. As the global population ages, there is an increasing need to improve surgical services and strengthen health systems to care for this group.