Rheumatic heart disease (RHD) remains the leading cause of cardiac death and disability in children and young adults worldwide

RHD results from cardiac valvular damage caused by an exaggerated immune response to Group A Streptococcus infections (GAS), usually during childhood and adolescence, with global estimates of >34 million people affected and >345,000 deaths with sub-Saharan Africa as the main hotspot

Complications include heart failure, atrial fibrillation, stroke, infective endocarditis and adverse pregnancy outcomes. Though RHD is readily preventable with penicillin, there are numerous misunderstood barriers to effective control programs.

In The Gambia, RHD burden is expected to be high due to the number of children identified with heart failure at Edward Francis Small Teaching Hospital (EFSTH) and MRC Unit The Gambia at LSHTM. However, there is no high-quality data available, and no control activity is currently being implemented.

Dr Annette Erhart, a Clinical Epidemiologist from MRC Unit The Gambia at LSHTM, and her colleague Cardiologist Dr Lamin Jaiteh, from the EFSTH, were able to secure a Wellcome Trust Seed Award for a pilot project aiming to generate baseline data on the burden of RHD among high risk groups (children and pregnant women) in The Gambia.

The study team consists of two Gambian staff (one nurse, one medical officer) in addition to the two above mentioned study Principal Investigators. The first phase of the study started in November 2017 based at the MRC Unit The Gambia at LSHTM Clinical Services Department where all registered RHD cases were reviewed clinically and by standard echocardiography (EC). This allowed for a detailed assessment of the epidemiological, clinical and valvular characteristics of RHD patients presented at referral health facilities and prognosis under penicillin prophylaxis.

The second phase of the project started in January 2018 and consists of a population based screening by EC of children aged 5 to 19 years in Farafenni town (rural town in the North Bank Region at about 135km from the coast) as well as all pregnant women consulting for antenatal care at Farafenni Health Centre (FHC).

The study team is based at FHC and works in close collaboration with the Farafenni Health and Demographic Surveillance System (HDSS) team to identify study participants and later follow up for RHD cases. The study team plans to scan over 3,000 children and about 1,000 pregnant women by the end of June 2018. This will create a gateway to accurately estimate the prevalence of RHD and identify related risk factors among children and pregnant women. All study participants identified with RHD will be invited to undergo secondary prophylaxis and two local nurses will be specially trained to administer safe penicillin injections at monthly intervals. In addition, all newly detected cases will be monitored annually by EC at the MRC Unit The Gambia at LSHTM.

This pilot project, initiated with the close collaboration of The Gambian Health Services, represents a first step on the roadmap for RHD control in The Gambia, and constitutes the evidence-base for the formulation of larger multi-disciplinary studies that will address pending knowledge gaps and bottlenecks for the implementation of an effective RHD control program.