Implementation and evaluation of a pragmatic community streptococcal treatment programme to improve rheumatic heart disease primary prevention in Uganda

Detection and treatment of streptococcal pharyngitis in children reduces acute rheumatic fever by 70-80%. However, investment in primary prevention is limited in rheumatic heart disease (RHD) endemic countries due to lack of diagnostic capacity. We conducted a pragmatic public health trial (Rheumatic Heart Disease Community Streptococcal Treatment Program (RESET)) to determine the effect of an integrated group A streptococcal (GAS) education and treatment programme on the echocardiographic burden of RHD among children aged 5-15 years in Uganda.

We implemented our interventions within the primary healthcare system of Tororo district, Eastern Uganda, over 2 years. The primary outcome was a reduction in RHD prevalence. Secondary outcomes included improved provider and community knowledge and increased health-seeking behaviour for sore throat. Interventions targeted three key barriers to primary prevention: limited provider expertise in diagnosing and treating GAS pharyngitis, poor uptake of guideline-based treatment and low public awareness of the link between sore throat and RHD.

There was no significant change in RHD prevalence from baseline (0.66%, 95% CI 0.58% to 0.73%) to 2 years post-implementation (0.61%, 95% CI 0.51% to 0.71%). Primary training was completed by 101 healthcare workers with knowledge scores improving from 55% pre-training to 75% post-training. Secondary training reached 470 providers across 81 facilities. Facility assessments found only one-third met nearly all readiness metrics. Over 2000 community education events reached an estimated 380 000 people. Recognition of sore throat as a serious issue improved with 89% post-campaign identifying its link to heart disease. Health centre logs showed no increase in sore throat presentations over 22 months.

As the first large-scale integrated primary prevention programme for RHD in sub-Saharan Africa, RESET demonstrated both feasibility of scaling up patient and provider education and implementation challenges in translating education into action. Ongoing research aims to identify care-seeking barriers and co-design a sore throat treatment model tailored to the community's cultural and contextual needs.

NCT05276999.