Viewpoint

Rheumatic heart disease remains one of the most devastating and neglected forms of acquired cardiovascular disease in young people in Sub-Saharan Africa. Despite decades of global screening initiatives and advances in portable echocardiography, the region continues to bear a disproportionate burden of heart failure, atrial fibrillation, stroke, and premature death associated with rheumatic heart disease. ^{Reference Rwebembera, Marangou and Mwita1–Reference Zühlke, Engel and Karthikeyan4} Contemporary estimates from the Global Burden of Disease demonstrate that Sub-Saharan Africa remains among the regions with the highest mortality and disability related to rheumatic heart disease, particularly in young, economically active populations. ^{Reference Watkins, Johnson and Colquhoun5} The expansion of echocardiographic screening has revealed a vast reservoir of previously invisible subclinical disease, with prevalence exceeding 25 cases/1000 individuals observed in African studies. ^{Reference Rwebembera, Marangou and Mwita1,Reference Marijon, Mirabel, Celermajer and Jouven2} However, a critical question often overlooked remains: are we truly changing the clinical course of the disease or merely increasing our epidemiological counting capacity?

During the last decade, echocardiographic screening for rheumatic heart disease has evolved from a research tool to a global health priority. The standardised World Heart Federation criteria have allowed for a substantial increase in early detection and have standardised the classification of subclinical disease. ^{Reference Rwebembera, Marangou and Mwita1} In parallel, ultra-portable devices and task-sharing models have expanded the operational feasibility of screening in low-resource settings. ^{Reference Meel and Kaswa6} However, increasing diagnostic capacity, although essential, does not necessarily translate into improved population-level outcomes.

Although observational studies demonstrate that children with subclinical rheumatic heart disease are at a higher risk of valvular progression over time, ^{Reference Beaton, Aliku and Dewyer7} there is still little robust data demonstrating that population-based screening programmes, in isolation, reduce mortality, advanced heart failure, or the need for surgery on a large scale. ^{Reference Marijon, Mirabel, Celermajer and Jouven2,8} The GOAL Trial represented an important milestone by demonstrating that secondary prophylaxis with benzathine penicillin significantly reduced the echocardiographic progression of latent rheumatic heart disease in Ugandan children. ^{Reference Beaton, Okello and Rwebembera9} However, even this trial predominantly evaluated subclinical valvular progression and not long-term hard cardiovascular outcomes such as mortality, heart failure hospitalisation, or the need for valvular surgery. This distinction is fundamental. Early detection represents only the first link in a care chain that is often interrupted before producing real clinical benefit.

Despite these limitations, it would be an error to conclude that the available evidence diminishes the relevance of echocardiographic screening. On the contrary, screening allows for the identification of children with latent disease who would otherwise only be diagnosed at more advanced stages of rheumatic heart disease. Furthermore, the GOAL Trial demonstrated that secondary prophylaxis with benzathine penicillin significantly reduces the echocardiographic progression of subclinical disease, reinforcing the value of early detection. The central question, therefore, is not whether screening should be performed, but how to ensure that each diagnosis is integrated into a continuum of care capable of translating into long-term clinical benefit.

While underdiagnosis remains a major challenge, growing evidence suggests that the greatest limitation lies in the structural inability of health systems to ensure long-term continuity of care. In many African countries, recurrent shortages in the supply of benzathine penicillin, the absence of integrated clinical records, shortages of follow-up programmes, and geographical and socioeconomic barriers compromise adherence to secondary prophylaxis and perpetuate the progression of rheumatic disease. ^{8,Reference Topçu and Uçar10} Consequently, many programmes end up generating an ethical paradox: diagnosing asymptomatic children early without the sustainable capacity to ensure continuous treatment or future access to cardiac surgery.

Successful national programmes in Cuba, Costa Rica, New Zealand, and indigenous Australian communities have consistently demonstrated that long-term success depends not only on screening but also on integrated systems capable of guaranteeing continuous prophylaxis, structured follow-up, and access to specialised care. ^{Reference Nordet, Lopez, Dueñas and Sarmiento11–14}

In Sub-Saharan Africa itself, potentially transformative experiences are also beginning to emerge, such as in South Africa, with the introduction of models centred on primary health care, using point-of-care ultrasound devices and task-sharing strategies to decentralise echocardiographic screening and bring cardiovascular care closer to communities. ^{Reference Meel and Kaswa6,Reference Peters, Karthikeyan, Abrams, Muhwava and Zühlke15} Beyond screening, additional initiatives across Sub-Saharan Africa illustrate emerging efforts to strengthen the continuum of rheumatic heart disease care. In Rwanda, a national postoperative rheumatic heart disease registry has been established to support longitudinal follow-up and monitoring of patients after cardiac surgery. ^{Reference Ntaganda, Rusingiza and Rukundo16} In Zambia, efforts to improve access to and appropriate use of benzathine penicillin have sought to strengthen primary and secondary prevention. ^{Reference Long, Lungu and Machila17} In Uganda, the ADUNU programme has explored decentralised approaches to integrating rheumatic heart disease prevention and care into community and primary healthcare services. ^{Reference Nakagaayi, Pulle and Otim18} Together, these experiences demonstrate that efforts to improve rheumatic heart disease outcomes in Sub-Saharan Africa are extending beyond case detection towards prevention, longitudinal follow-up, and decentralised care, although their sustainability and impact on long-term cardiovascular outcomes remain to be established. Collectively, these initiatives, together with the REMEDY Registry, highlight that the major challenge lies not only in identifying rheumatic heart disease but also in ensuring that diagnosis translates into continuous therapy, adequate anticoagulation, structured follow-up, and timely referral for cardiac surgery. ^{Reference Zühlke, Engel and Karthikeyan4}

Thus, perhaps it is time to redefine the very concept of success in rheumatic heart disease screening programmes. The endpoint should not be simply the number of abnormal valves identified but how many patients remain linked to longitudinal care, free from heart failure, atrial fibrillation, stroke, or early surgery. Screening without adequate systems risks becoming epidemiological surveillance without cardiovascular impact. The future of rheumatic heart disease in Sub-Saharan Africa will not be determined solely by the quality of echocardiographic images or the expansion of portable screening, but rather, determined by the capacity of health systems to build resilient networks of care continuity, sustained access to secondary prophylaxis, timely surgical referral, and longitudinal monitoring based on real clinical outcomes. The era of success measured exclusively by detection must end. In rheumatic heart disease, survival depends less on the number of valves we can visualise and more on the number of patients we can keep alive within the care system.

Take-home message

1. 1. In Sub-Saharan Africa, the main challenge of rheumatic heart disease is no longer just early diagnosis but ensuring care continuity, sustained prophylaxis, and effective longitudinal follow-up.

2. 2. Isolated echocardiographic screening has limited impact if it is not integrated into systems capable of ensuring therapeutic retention, access to penicillin, and timely referral for specialised care.

3. 3. True success in rheumatic heart disease control must be measured by real clinical outcomes such as the reduction of heart failure, stroke, valve surgery, and premature death and not just by the increase in echocardiographic detection.

Priorities for the next phase of rheumatic heart disease control in Sub-Saharan Africa

1. 1. Move beyond detection-centred screening towards care-centred rheumatic heart disease programmes.

2. 2. Link every screening strategy to a sustainable continuum of care, from diagnosis to long-term follow-up.

3. 3. Redefine programme success using clinical outcomes rather than screening yield alone.