Screening is a public health strategy that aims to identify asymptomatic individuals with very early-stage disease.1^,2 

Disease screening programs aim to improve patient outcomes by intervening with effective treatment as soon as possible, preferably before symptoms appear. In the case of rheumatic heart disease (RHD), early and effective delivery of antibiotic prophylaxis can reduce the progression of disease by preventing ARF recurrences,3 and may allow for improvement (regression) or resolution of early RHD. In well-resourced settings, early diagnosis of severe RHD also provides the opportunity for earlier surgical intervention and improved surgical outcomes.4^,5

Population-based screening using auscultation is not accurate for detecting undiagnosed RHD. Echocardiography is more accurate in detecting RHD than auscultation alone.6

Several issues need careful consideration before commencing screening activities for RHD. The following benefits and potential risks highlights challenges that have been faced in different settings:

• Individuals diagnosed with early RHD or borderline RHD will have the opportunity to receive secondary prophylaxis which may prevent disease progression.
• Screening activities may be effectively used to estimate disease prevalence, and have the potential to improve community awareness, foster local champions, and stimulate support for better RHD control.
• High-quality, local disease data that is shared with the community is a powerful tool that can be used for local community planning, advocacy, and government engagement.
• Individuals diagnosed with borderline RHD or RHD who are not able to access required secondary prophylaxis and medical or surgical intervention, will have limited benefit.
• Population-based screening programs require infrastructure for the screening activity, as well as sustained resources to support people diagnosed with RHD. In some remote settings, the opportunity costs of screening and the ability to provide ongoing care can be issues to consider.​

Screening models

Screening procedures have evolved over time, using different technologies, and using operators with varying levels of expertise. Historically, screening programs have relied on expert teams led by cardiologists.

Cardiac expert model

Cardiologists and expert Physicians perform screening using portable echocardiography equipment. Abbreviated and comprehensive echocardiograms can be performed, including detection of RHD and congenital heart defects. The Cardiologist can provide immediate diagnosis and management planning, including relevant referral.7^,8

Technical expert model

Trained cardiac sonographers perform screening using portable echocardiography equipment under the direction of a Cardiologist or expert Physician. Abbreviated and comprehensive echocardiograms can be performed, including detection of RHD and congenital heart defects. In cases where the cardiologist or Physician is offsite, scans need to be relayed through a cloud server or other secure platform for reporting, and confirmation of the diagnosis may be delayed.9 

Non-expert model

Briefly trained health care workers perform screening using handheld echocardiography equipment under the direction of a Cardiologist or expert Physician. Abbreviated scans only are possible, with limited detection of RHD and congenital heart defects due to lower sensitivity and specificity. Scans deemed to be abnormal will require repeat by a cardiac sonographer or clinical expert.10^,11

For more information, see Chapter 9 in the RHDAustralia 2020 Australian guidelines for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition).

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• 1. Council of Europe Council of Ministers. Recommendation No. R (94) 11 on Screening as a Tool of Preventive Medicine. 1994.
• 2. Australian Government Department of Health and Aged Care. (2021) Population-based health View Source
• 3. de Dassel JL, de Klerk N, Carapetis JR, Ralph A P. How Many Doses Make a Difference? An Analysis of Secondary Prevention of Rheumatic Fever and Rheumatic Heart Disease. Journal of the American Heart Association 2018; 7(24): e010223 View Source
• 4. Reményi B, Webb R, Gentles T, et al. Improved long-term survival for rheumatic mitral valve repair compared to replacement in the young. World Journal for Pediatric and Congenital Heart Surgery 2013; 4(2): 155-64 View Source
• 5. McGurty D, Reményi B, Cheung M, et al. Outcomes After Rheumatic Mitral Valve Repair in Children. Annals of Thoracic Surgery 2019; 108(3): 792-7 View Source
• 6. Rothenbühler M, O’Sullivan CJ, Stortecky S, et al. Active surveillance for rheumatic heart disease in endemic regions: a systematic review and meta-analysis of prevalence among children and adolescents. The Lancet Global Health 2014; 2(12): e717-e26 View Source
• 7. Francis J, Fairhurst H, Hardefeldt H, et al. Echocardiographic Screening Detects Extremely High Prevalence of RHD in Australia. Heart Lung and Circulation 2019; 28(2): S51 View Source
• 8. Davis K, Reményi B, Draper AD, et al. Rheumatic heart disease in Timor-Leste school students: an echocardiography-based prevalence study. The Medical Journal of Australia 2018; 208(7): 303-7  View Source
• 9. Roberts K, Maguire G, Brown A, et al. Echocardiographic screening for rheumatic heart disease in high and low risk Australian children. Circulation 2014; 129(19): 1953-61 View Source
• 10. Ploutz M, Lu JC, Scheel J, et al. Handheld echocardiographic screening for rheumatic heart disease by non-experts. Heart 2016; 102(1): 35-9 View Source
• 11. Sanyahumbi A, Sable CA, Karlsten M, et al. Task shifting to clinical officer-led echocardiography screening for detecting rheumatic heart disease in Malawi, Africa. Cardiology in the Young 2017; 27(6): 1133-9  View Source