AWARENESS:

Waleed AlNamiri- Controlling and preventing this lethal disease necessitates a complete knowledge of the
general public, medical personnel, and the patient population (Beaton et al., 2012). Consequently, our study
aimed to highlight the baseline level of knowledge and attitude of RHD among health-related students in
Makkah city, Saudi Arabia. The current study shows that participants with higher academic years were
significantly correlated with students’ level of knowledge. Our results utilized for awareness-raising activities
and programmers to minimize RHD risks. Further investigations are required, and health campaigns as well to
educate students about RHD.

David Chelo- This makes it important to assess the aptitude of senior medical students who are doctors-to-be
on RHD. This could thus give a base on which to increase awareness and decrease the burden of the disease.
Therefore, we sort to evaluate the knowledge, attitudes, and practices (KAP) of senior medical students on
rheumatic heart disease. One-quarter of the students had good knowledge, attitudes, and practices on
rheumatic heart disease. Lecture on RHD, history of sore throat and study in faculty of health science (FHS)
was associated with good knowledge, attitudes, and practices on RHD. Conclusion: Despite having most of the
senior medical students (6th and 7th years) in Cameroon with moderate to good knowledge of RHD, only a
third has an above-average knowledge. There is a modest knowledge of RHD that could be used as an
important foundation upon which to build RHD educational programs to expand awareness and
understanding.

Jamunai Bhattarai- only 13.5% said consequence of sore throat may be Rheumatic fever. Majority of the
respondents said that sore throat should be treated but their first choice was home remedies. Few had
knowledge that consequence of sore throat would be RF and RHD but this study found out that parents had
inadequate knowledge regarding primordial and primary prevention regarding RHD.

Saeed- To determine the degree of awareness about the different aspects of rheumatic heart disease in
patients coming to different departments of Faisalabad Institute of Cardiology, Faisalabad. Only 5% of the
patients were aware that sore throat is a precipitating factor for Rheumatic Heart Disease. 23% of the patients
were aware of prolonged antibiotic prophylaxis. After diagnosis of the disease, 77% of the patients were aware
of different treatment options available like valvuloplasty or valve replacement surgery. 58% of the patients
were aware of prolonged oral anticoagulation and antibiotic prophylaxis after undergoing surgery. The study
will help us to plan awareness strategies and their implementation by health department and the other
measures of mass communication.

Parisa Kasmaie- Guilan province, Iran. Among the 443 respondents, good knowledge about treatment was
high (86 per cent); fewer mothers had a good level of knowledge about other aspects of treatment. In our
study 86 per cent of mothers had good knowledge about treatment of rheumatic fever while the least
knowledge was about the symptoms (4 per cent). More educated women had significantly better knowledge
about rheumatic fever. We found a significant relationship between level of knowledge and level of mothers’
education.

Wanzhu Zhang- Mulago, Uganda. A significant proportion of RHD patients present to hospital with severe
disease associated with severe complications of advanced heart failure, pulmonary hypertension, infective
endocarditis and atrial fibrillation. There is a need to improve awareness of the disease among the population,
and clinical suspicion in primary health workers, so that early referral to specialist management can be done
before severe damage to the heart ensues.

INTERVENTION:

Madhab Ray- We examined the level of awareness about Rheumatic Heart Disease (RHD) among school aged
children in a rural district of India and evaluated the effects of a questionnaire-based survey in improving the
level of awareness. The baseline questionnaire survey assessed students’ knowledge and was followed by a
multimedia presentation about RHD and a post-intervention survey using the same questionnaire. After the
school-based presentation, the score improved to a mean of 55% (15.9 points on the 29-point scale), a 31%
relative improvement. Improvement in students' knowledge was noted across all seven domains, individually
and combined. Awareness among children in rural India about RHD is modest. A school-based intervention
could help in improving awareness about this chronic condition and may promote secondary prophylaxis to
reduce the morbidity and mortality from RHD.

Prakash Raj Rejmi-

The aim of this study is to assess the effectiveness of various awareness raising activities on increasing
knowledge about throat infection (TI), acute rheumatic fever (ARF) and RHD and their impact on RHD
prevention.
Methods: Fourteen randomly selected government health facilities in Lalitpur were enrolled in this study. A
baseline study conducted in early 2015 analyzed the level of knowledge about RHD among care seekers
attending health facilities in Lalitpur. An expansive public awareness raising activities on RHD were performed
for 2.5 years starting from February 2015. Data were collected using structured interviews, and review of
health facility records. Data were analyzed to compare the postintervention status with the baseline status.
Results: The mean knowledge about ARF and RHD increased by over 71% (1.82 to 3.12) and 124% (0.37 to
0.83) respectively in post intervention group. There was significant difference in knowledge about TI, ARF and
RHD among baseline and post intervention group (p-value<0.0001). The number of throat infection cases
presented at health facilities increased by 30.39% from fiscal year (FY) 2071/72 to FY 2072/073 and by 4.69% in
the next FY. Conclusions: Awareness raising interventions are effective in increasing knowledge about TI, ARF
and RHD which further can produce positive impact in the primary prevention of ARF and RHD. Public
awareness raising efforts at national level would be an important strategy for the prevention and control of
RHD in Nepal.

Gehan M Osman- The results showed that the overall doctors’ awareness about prevention of rheumatic fever
and rheumatic heart disease was at average level. It was raised by intervention through lectures to good level.
It is recommended to introduce training programs for physicians in order to improve doctors’ awareness about
prevention of RF and RHD. Such activities need to be conducted at regular intervals. The overall awareness of
doctors about prevention of rheumatic fever and RHD was found to be at an average level and it was raised by
a single lecture to good level. Hence we recommend conducting similar interventions to more physicians.
More importantly, these activities need to be more frequent, sustained and rolled to other states where the
disease is more prevalent.

Laura Susan Ramsey- Primary prevention measures have been gaining more attention from researchers
frustrated by the perpetual prevalence of ARF and RHD in developing countries around the globe [6]. Recent
investigations have found that primary prevention is actually more successful and cost-effective [7]. Primary
prevention involves a single injection of benzathine penicillin after confirmation of streptococcal pharyngitis by
microbiological culture of a throat swab specimen. Antibiotic treatment of GAS infection has been shown to
reduce the attack of ARF by 70%, with intramuscular penicillin reducing it by as much as 80% [5].

M.B. Soudarssanane- To measure the economic output/input ratios for the various options of prevention of
rheumatic fever/rheumatic heart disease (RF/RHD) and check the viability of primary prevention vis-à-vis
secondary and tertiary preventions. Primary prevention is the definite viable economic option (1:1.56)
compared to secondary (1: 1.07) and tertiary (1: 0.12) preventions. In fact, the current stress on only
secondary and tertiary preventions is found to be economically unviable. Conclusion. It is postulated that
primary prevention as a practical policy in tackling RF and RHD can be recommended.

Basic symptoms of ARF include fever, joint pain, and a sore throat. The condition of strep throat, if left
untreated, may initiate an immune response which can damage the heart and become RHD. Western Samoa
(Samoa) is a country considered to be among those tropical and resource-poor countries grappling with ARF
and RHD.

Katharine A. French- Rheumatic heart disease (RHD) is a disease of poverty. Following the near eradication of
rheumatic fever and RHD in the developed world and the emergence of competing large global epidemics such
as AIDS, tuberculosis, and malaria, research and investment for the control of rheumatic fever and RHD
worldwide declined.1 However, over the past decade, RHD has reemerged as a priority in global health. The
World Health Organization and the World Heart Federation have called for a 25% reduction in mortality
because of cardiovascular causes, including RHD, by 2025.2 Contemporary studies have begun to shed light on
the enormous burden of RHD that persists in countries with emerging and developing economies. The highest
prevalence of RHD has been reported in India, China, Pakistan, Indonesia, and the Democratic Republic of
Congo—accounting for 73% of global cases. Within 20 countries where RHD remains endemic, the age
standardized prevalence is estimated at >1% and greatest in women of childbearing age.
2 Moran M, Guzman J, Henderson K, Liyanage R, Wu L, Chin E, et al. Neglected disease research and development: a five year review.
Sydney: Policy Cures; 2012. 2. Watkins DA, Johnson CO, Colquhoun SM, Karthikeyan G, Beaton A, Bukhman G, Forouzanfar MH,
Longenecker CT, Mayosi BM, Mensah GA, Nascimento BR, Ribeiro ALP, Sable CA, Steer AC, Naghavi M, Mokdad AH, Murray CJL, Vos T,
Carapetis JR, Roth GA. Global, regional, and national burden of rheumatic heart disease, 1990–2015. N Eng J Med. 2017;37:713–722.

David A Watkins - WHAT IS NEEDED TO ERADICATE RHD WORLDWIDE?

THE GLOBAL AGENDA:

RHD policy targets and statements. In 2013, the WHF called for a 25% reduction in RHD mortality among
individuals aged <25 years by the year 2025 (109). More recently, the United Nations Sustainable Development
Goal 3 (SDG3) proposed a one-third reduction in premature deaths from noncommunicable diseases by 2030
(110).
International collective action on RHD: Ensuring global leadership in RHD has been challenging. RHD has been
neglected by policymakers and civil society because it does not sit in a single department (e.g., at WHO) nor is
it amenable to single-intervention strategies.
THE NATIONAL AGENDA:
Disease control programs: The notion that RF can be eliminated is supported by studies of country control
programs conducted during the 1970s and 1980s. Experience with primary prevention programs has also been
favorable, and the WHO recommends combined primary and secondary prevention efforts delivered in
community settings (43). These programs can achieve the vast majority of their impact within about a decade
or so (42)
Integration of RHD programs into country health systems: There is currently little appetite among health
planners for developing targeted programs, especially for chronic noncommunicable diseases. The global
economic impact of early death from RHD was about $65 billion in 2015 (121). Across a wide range of global
health interventions, primary and secondary prevention of RHD stand out as providing excellent value for
money (122). The integration of RHD into the broader global health agenda will ensure that the future
generations grow up free from the scourge of this eminently preventable disease.

WUBISHET BELAY - Rheumatic heart disease (RHD) is a complication of untreated throat infection by Group A
beta-hemolytic streptococcus with a high prevalence among socioeconomically disadvantaged populations.
Despite its high incidence and prevalence, RHD prevention is not a priority in major global health discussions.
Primary (treating GAS pharyngitis) and secondary (preventing ARF recurrence in a patient with RHD)
preventive measures are available and cost-effective [3, 4]. Despite remarkable success in the developed
world, ARF and RHD continued to contribute significantly to chronic disease burden in Southeast Asia and Sub-
Saharan Africa [13]. Echocardiography-based screening has increased the detection rate of latent RHD in young
children and adults [14]. Surveys conducted in various countries showed echocardiographic-based RHD
screening detects a significant additional number of children with latent RHD, estimated to be from 7.5–51.6
per 1000 children [6, 13, 15]. The lack of widespread use of echocardiographic screening in many LMICs has
considerably underestimated the prevalence, incidence, morbidity, and mortality burden of RHD [16].

Lack of public awareness

The public has an essential role to play in RHD prevention and control [30]. Public awareness of RHD is another
public health issue that is not well addressed. Many patients do not know the relationship between a sore
throat and rheumatic fever and its consequences [31]. Multicenter data on public awareness of ARF and RHD
are lacking currently. More studies are needed to identify knowledge gaps to help design public awareness
methods in areas with a high disease burden. At a 2015 meeting in Addis Ababa, Ethiopia, experts issued seven
priority areas to reduce RHD-related mortality by 25% by 2025 and eliminate ARF and eradicate RHD. While
this is a good first step, there is not enough evidence to suggest if the seven priority areas are embraced by
policymakers, funding agencies, and public health experts [32]. In addition to the expert guidance from the
Addis Ababa meeting, the World Health Assembly (WHA) adopted a resolution dedicated to RHD in 2018. By
advocating for an organized global response to RHD, we hope that this resolution will significantly boost
national prevention efforts [36]. RHD continues to be a significant public health problem in many LMICs.
Multisectoral collaboration by engaging the public, health experts, and policymakers is therefore critical.
Augmenting funding for prophylaxis distribution and research and innovation is crucial to saving millions of
people from preventable morbidity and mortality.