Cluster Randomized Clinical Trial Suggests Effectiveness of Systematic Echocardiographic Screening of Children for Latent Rheumatic Heart Disease

December 17, 2020

Results of the NEPAL II trial presented in the Late Breaking Clinical Science Session at the American Heart Association’s Scientific Sessions 2019 in Philadelphia.

Early detection of latent stages of rheumatic heart disease in children and timely initiation of secondary antibiotic prophylaxis may reverse subclinical valvular lesions, prevent disease progression and contain the reservoir for further spread. We performed a cluster randomized clinical trial to investigate the effectiveness of systematic echocardiographic screening for latent rheumatic heart disease in children in regions with an endemic pattern of rheumatic heart disease. A total of 35 public and private schools in rural and urban areas in Nepal were randomly assigned to systematic echocardiographic screening of all children 5 to 12 years of age, or control with no screening. Children found to have evidence of definite rheumatic heart disease were started on secondary antibiotic prophylaxis. After a median of 4.3 years, 17 out of 19 schools in the experimental arm and 15 out of 16 schools in the control arm underwent echocardiographic follow-up, including 2648 and 1325 children, respectively. The prevalence of definite or borderline rheumatic heart disease was 10.8 per 1000 children (95% CI 4.7 to 24.7) in the control arm and 3.8 per 1000 children (95% CI 1.5 to 9.8) in the experimental arm (OR 0.34, 95% CI 0.11 to 1.07, p=0.064). In the experimental group, the odds ratio of definite or borderline rheumatic heart disease at follow-up versus baseline was 0.29 (95% CI 0.13-0.65). This cluster randomized trial spanning over 9 years provides for the first time some evidence that systematic school-based echocardiographic screening in combination with secondary antibiotic prophylaxis in children found to have evidence of latent rheumatic heart disease may be an effective strategy to reduce the prevalence of rheumatic heart disease in endemic regions.