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Rheumatic heart disease in Namibia: evaluating the burden and the cost-effectiveness of a preventive strategy
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.ORCID iD: 0000-0002-0899-2185
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Rheumatic Heart Disease (RHD) is a neglected public health problem, which is most prevalent in low-and middle-income countries. It affects over 460 million people and causes about 390,000 deaths annually, predominantly children, young adults, and women. This thesis aimed to assess the burden of Rheumatic Heart Disease in Namibia and to evaluate the cost-effectiveness of a preventive strategy.

Methods: Data was obtained from primary and secondary sources in four distinct studies. The first study analysed the RHD outpatient and inpatient data from 2010-2020. The second employed a cross-sectional survey, incorporating a questionnaire with the EQ-5D-5L tool, to assess the health-related quality of life and healthcare usage pre- and post-RHD diagnosis. A systematic review was conducted in the third study synthesising preventive interventions, while the fourth study used a Markov model to evaluate the cost-effectiveness of a secondary prevention strategy in Namibia.

Results: The clinical RHD prevalence was estimated at 28 per 100,000 cases. From the survey, 83 RHD patients participated, predominantly women (77%) and primarily young adults aged 20-29 (41%). The majority (84%) had received surgical treatment. Notably, there was a significant increase in mean QALY from 0.773 pre-diagnosis to 0.941 post-diagnosis (p<0.001). The systematic review underscored the effectiveness of school and nurse-led prevention programmes. The health economic evaluation demonstrated that echocardiographic RHD screening was cost-effective, with an Incremental Cost-Effectiveness Ratio of N$ 28,516.75 per QALY gained, which falls below Namibia’s GDP per capita.

Conclusions: The findings highlight a significant gap in RHD data, particularly in high-endemic regions like Sub-Saharan Africa, emphasising the need for enhanced data quality and surveillance. The effectiveness of school-based and community-led programmes is apparent, but the scarcity of data from diverse regions limits a comprehensive understanding of optimal prevention strategies. Echocardiographic screening is identified as a feasible component of RHD secondary prevention in Africa, pointing towards a policy need for improved surveillance and data quality. Future research should investigate the impact of various interventions on RHD incidence and prevalence.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2024. , p. 49
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2292
Keywords [en]
Rheumatic Heart Disease, Prevention, Cost-effectiveness, Namibia
National Category
Cardiac and Cardiovascular Systems Public Health, Global Health, Social Medicine and Epidemiology
Research subject
cardiovascular disease; Public health; Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-222916ISBN: 978-91-8070-330-7 (print)ISBN: 978-91-8070-331-4 (electronic)OAI: oai:DiVA.org:umu-222916DiVA, id: diva2:1848098
Public defence
2024-04-26, Universitetsledningshuset (ULED), Triple Helix, Umeå, 09:00 (English)
Opponent
Supervisors
Funder
Familjen Erling-Perssons StiftelseAvailable from: 2024-04-05 Created: 2024-04-02 Last updated: 2024-04-08Bibliographically approved
List of papers
1. Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers
Open this publication in new window or tab >>Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers
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2022 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 22, no 1, article id 266Article in journal (Refereed) Published
Abstract [en]

 Background:  Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understanding of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess the RHD-related health care systems in Namibia.

 Methods:  Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement in the systems.

 Results:  The outpatient register covered 0.032% of the adult Namibian population and combined with the cumulative incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05% and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-eastern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.

Conclusion:  The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investigate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the "Awareness Surveillance Advocacy Prevention" framework supported by relevant resolutions by the WHO.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2022
Keywords
Acute rheumatic fever; Namibia; RF; RHD; Rheumatic heart disease
National Category
Cardiac and Cardiovascular Systems
Research subject
cardiovascular disease
Identifiers
urn:nbn:se:umu:diva-196779 (URN)10.1186/s12872-022-02699-2 (DOI)000811207600001 ()2-s2.0-85132144539 (Scopus ID)
Funder
Familjen Erling-Perssons StiftelseFamiljen Erling-Perssons Stiftelse
Available from: 2022-06-17 Created: 2022-06-17 Last updated: 2024-04-02Bibliographically approved
2. Health-related quality of life and healthcare consultations among adult patients before and after diagnosis with rheumatic heart disease in Namibia
Open this publication in new window or tab >>Health-related quality of life and healthcare consultations among adult patients before and after diagnosis with rheumatic heart disease in Namibia
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2023 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 23, no 1, article id 456Article in journal (Refereed) Published
Abstract [en]

Background: Rheumatic Heart Disease (RHD) causes high morbidity and mortality rates among children and young adults, impacting negatively on their health-related quality of life (HRQoL). This study aimed to evaluate the HRQoL and healthcare consultations of adult patients with RHD in Namibia.

Methods: From June 2019 to March 2020, a questionnaire was administered to 83 RHD patients during routine follow-ups. The EQ-5D-5L instrument was used to assess the health-related quality of life before diagnosis and at the time of the survey. The Ethiopian value set for EQ-5D-5L was used to calculate Quality-Adjusted Life Years (QALY).

Results: Most respondents were women (77%), young adults below the age of 30 years (42%), and individuals who grew up in rural areas (87%). The mean QALY statistically significantly improved from 0.773 pre-diagnosis to 0.942 in the last 12 months (p < 0.001). Sixty-six patients who had surgery reported a better QALY. Healthcare visits statistically significantly increased from on average 1.6 pre-diagnosis to 2.7 days in the last 12 months (p < 0.001). The mean distance to the nearest facility was 55 km, mean cost of transport was N$65, and mean time spent at the clinic was 3.6 h. The median time from diagnosis to the survey was 7 years (quartiles 4 and 14 years).

Conclusion: Treatment and surgery can improve HRQoL substantially among RHD patients. Being diagnosed with RHD affects patients living in socioeconomically disadvantaged rural areas through cost and time for healthcare visits. It would be valuable with further research to understand differences between disease severities.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023
Keywords
Health-related quality of life, RHD, QALY, EQ-5D-5L, Namibia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-214434 (URN)10.1186/s12872-023-03504-4 (DOI)2-s2.0-85171150062 (Scopus ID)
Funder
Familjen Erling-Perssons Stiftelse
Available from: 2023-09-14 Created: 2023-09-14 Last updated: 2024-04-02Bibliographically approved
3. Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review protocol
Open this publication in new window or tab >>Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review protocol
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2021 (English)In: Systematic Reviews, E-ISSN 2046-4053, Vol. 10, no 1, article id 200Article in journal (Refereed) Published
Abstract [en]

Background: Rheumatic heart disease is preventable, yet associated with significant health burden, mostly in low-resourced settings. It is prevalent among children and young adults living in impoverished areas. Primordial, primary, and secondary preventive measures have been recommended through health interventions and comprehensive programmes, although most implemented interventions are the high-resourced settings. The proposed review aims to synthesise the evidence of prevention effectiveness of implemented health interventions for the prevention of rheumatic heart disease.

Methods and design: This article describes a protocol for a systematic review. A predefined search strategy will be used to search for relevant literature published from the year 2000 to present. Electronic databases Medline, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials will be searched for the studies, as well as reference lists of relevant studies included. Risk of bias and quality appraisal will be done for the included studies using ROBINS-I tool and Cochrane tool for assessing risk of bias in randomised control trials. Findings will be analysed in subgroups based on the level of intervention and prevention strategy implemented. We will present the findings in descriptive formats with tables and flow diagrams.

Discussion: This review will provide evidence on the prevention effectiveness of interventions or strategies implemented for the prevention of RHD. The findings of this will be significant for policy, practice, and research in countries planning to implement interventions.

Registration: PROSPERO ID: CRD42020170503.

Place, publisher, year, edition, pages
BioMed Central, 2021
Keywords
Acute Rheumatic Fever, Rheumatic Heart Disease, Intervention, Prevention, Systematic Review
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health; cardiovascular disease
Identifiers
urn:nbn:se:umu:diva-185872 (URN)10.1186/s13643-021-01748-9 (DOI)000674358500003 ()34238388 (PubMedID)2-s2.0-85110511031 (Scopus ID)
Available from: 2021-07-09 Created: 2021-07-09 Last updated: 2024-04-02Bibliographically approved
4. Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review
Open this publication in new window or tab >>Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review
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2024 (English)In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, E-ISSN 2047-9980, Vol. 13, no 5, article id e032442Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Rheumatic heart disease (RHD) is a devastating yet preventable condition that disproportionately affects low-middle-income countries and indigenous populations in some high-income countries. Various preventive interventions have been implemented across the globe, but evidence for the effectiveness of these measures in reducing the incidence or prevalence of acute rheumatic fever and RHD is scattered. This systematic review aims to assess the effectiveness of preventive interventions and identify the strategies used to reduce the burden of RHD.

METHODS AND RESULTS: A comprehensive search was conducted to identify relevant studies on RHD prevention interventions including interventions for primordial, primary, and secondary prevention. Effectiveness measures for the interventions were gathered when available. The findings indicate that school-based primary prevention services targeting the early detection and treatment of Group A Streptococcus pharyngitis infection with penicillin have the potential to reduce the incidence of Group A Streptococcus pharyngitis and acute rheumatic fever. Community-based programs using various prevention strategies also reduced the burden of RHD. However, there is limited evidence from low-middle-income countries and a lack of rigorous evaluations reporting the true impact of the interventions. Narrative synthesis was performed, and the methodological quality appraisal was done using the Joanna Briggs Institute critical appraisal tools.

CONCLUSIONS: This systematic review underscores the importance of various preventive interventions in reducing the incidence and burden of Group A Streptococcus pharyngitis, acute rheumatic fever, and RHD. Rigorous evaluations and comprehensive analyses of interventions are necessary for guiding effective strategies and informing public health policies to prevent and reduce the burden of these diseases in diverse populations.

REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020170503.

Place, publisher, year, edition, pages
American Heart Association, 2024
Keywords
RHD prevention, acute rheumatic fever, rheumatic heart disease, systematic review
National Category
Health Sciences Public Health, Global Health, Social Medicine and Epidemiology
Research subject
cardiovascular disease; Public health; Epidemiology
Identifiers
urn:nbn:se:umu:diva-221473 (URN)10.1161/JAHA.123.032442 (DOI)38390809 (PubMedID)2-s2.0-85187199895 (Scopus ID)
Funder
Familjen Erling-Perssons Stiftelse
Available from: 2024-02-23 Created: 2024-02-23 Last updated: 2024-07-04Bibliographically approved
5. Rheumatic heart disease school-based echocardiographic screening: A cost-effectiveness markov model
Open this publication in new window or tab >>Rheumatic heart disease school-based echocardiographic screening: A cost-effectiveness markov model
(English)Manuscript (preprint) (Other academic)
National Category
Cardiac and Cardiovascular Systems Rheumatology and Autoimmunity
Identifiers
urn:nbn:se:umu:diva-222926 (URN)
Available from: 2024-04-02 Created: 2024-04-02 Last updated: 2024-04-02

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Shimanda, Panduleni Penipawa

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  • modern-language-association-8th-edition
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  • en-GB
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  • Other locale
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Output format
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