Delivering Rheumatic Heart Disease Diagnosis at Scale: Performance of an Integrated Public Health Screening Program in Northern Uganda

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BACKGROUND: Early echocardiographic detection improves rheumatic heart disease (RHD) outcomes, but screening in endemic, resource-limited settings remains a challenge. The Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Northern Uganda program was developed to integrate task-shifted RHD screening into the existing health system in Kitgum, Uganda. We evaluated the program's impact on RHD case detection and assessed screening performance during its first year. METHODS: We conducted a programmatic evaluation of all individuals screened via the program from May 2023 to April 2024, describing demographic and echocardiographic findings. We assessed sensitivity, specificity, predictive values, and accuracy of screenings performed by health care workers who had completed the full training, using expert-confirmed diagnoses as the gold standard. RESULTS: Of 11 793 individuals screened, 806 (6.8%) screened positive, with 544 receiving confirmatory testing. A total of 126 new RHD cases were diagnosed (74 mild, 52 moderate/severe). Among 3243 screenings by fully trained health care workers, sensitivity was 55% (95% CI, 47%-63%), specificity 97% (95% CI, 97%-98%), positive predictive value 52% (95% CI, 45%-60%), negative predictive value 98% (95% CI, 97%-98%), and accuracy 95% (95% CI, 95%-96%). Accuracy varied with age, sex, and health care worker screening volume: older age (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]) and female sex (OR, 0.46 [95% CI, 0.22-0.91]) were associated with decreased accuracy, whereas higher screening volume improved accuracy (OR, 5.24 [95% CI, 2.52-10.65]). CONCLUSIONS: Task-shifted echocardiographic screening can be effectively integrated into low-resource health systems. Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Northern Uganda trained a local screening workforce and identified 126 new RHD cases in its first year. Moderate sensitivity and subgroup variability indicate opportunities for improvement through targeted training and supportive technologies.

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