Shimanda et al.

BMC Cardiovascular Disorders (2022) 22:266

[Link]

RESEARCH Open Access

Rheumatic heart disease prevalence

in Namibia: a retrospective review
of surveillance registers
Panduleni Penipawa Shimanda1,2* , Stefan Söderberg3, Scholastika Ndatinda Iipinge2,
Ebba Mwalundouta Neliwa4, Fenny Fiindje Shidhika5 and Fredrik Norström1

Abstract
Background: Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young
people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understand-
ing of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess
the RHD-related health care systems in Namibia.
Methods: Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD
between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key
observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement
in the systems.
Results: The outpatient register covered 0.032% of the adult Namibian population and combined with the cumula-
tive incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05%
and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-east-
ern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in
care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.
Conclusion: The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investi-
gate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs
improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the “Aware-
ness Surveillance Advocacy Prevention” framework supported by relevant resolutions by the WHO.
Keywords: Rheumatic heart disease, Acute rheumatic fever, RHD, RF, Namibia

Background million people globally and caused over 300,000 deaths

Rheumatic heart disease (RHD) continues to cause pre- annually, mostly in low and middle-income countries
mature death and poor quality of life among young popu- (LMICs) [1, 3].
lations, with a greater burden on children and women of RHD is an inflammatory heart valve condition, a
reproductive age [1, 2]. In 2019, RHD affected about 40.5 chronic sequel of Acute Rheumatic Fever (ARF), which
is a multisystem disease resulting from an autoimmune
reaction presumed to ‘antigenic mimicry’ to certain
*Correspondence: [Link]@[Link] Group A Streptococcus (GAS) antigenic proteins. ARF
1
Department of Epidemiology and Global Health, Umeå University, 901 develops in about three percent of untreated GAS phar-
87 Umeå, Sweden yngitis cases [4–6]. Inflammation in heart valves cause
Full list of author information is available at the end of the article

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit [Link] The Creative Commons Public Domain Dedication waiver ([Link]
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 2 of 10

progressive damage with fibrotic changes due to avascu- Prevention and surveillance activities, i.e., outpatient
larised valvular tissues, leading to chronic RHD disease. register, comprehensive prevention programme, and car-
The Mitral valve is most commonly affected, as compared diac surgery, have been established since 2010 along with
to Aortic valve, while mixed valvular involvement is also the Global Rheumatic Heart Disease Registry (REM-
common [7, 8]. The left sided valves are mostly affected EDY), a two-year longitudinal study across 14 countries
because of the high haemodynamic shear forces, rela- from 2010 to 2012 [15, 16].
tive to the right sided valves (Tricuspid and Pulmonary). Basic RHD care is offered across all healthcare levels,
The Tricuspid valve is less structurally involved, however but specialised cardiac care is concentrated at the tertiary
more commonly functionally involved as a haemody- national referral centre. Referrals are done with a bot-
namic consequence of the left heart disease. Presentation tom-up approach from the primary, secondary, and ter-
ranges from ‘forme fruste’ to severe clinical disease with tiary levels (3-tier system). Cost for public care is heavily
heart failure, atrial fibrillation, subacute bacterial endo- subsidised by the government, although out-of-pocket
carditis, stroke/cerebrovascular accident, poor maternal expenditures remains at about 8.2% [17].
outcomes, progressive morbidity/disability with reduced Heart surgery is performed for both heart valve
quality of life, and premature mortality [9]. replacement using biological and mechanical artifi-
It is a socio-economic disease, and social determinants cial prostheses, as well as valve preservation strategies
of health e.g., overcrowding, poor sanitation, and inequi- (repair). Due to the general paucity of human and infra-
table access to healthcare in poor and socially disadvan- structural resources capacity, surgery waiting times can
taged settings partially attributable to the aetiology of be lengthy, ranging between weeks, months, and even
ARF and RHD, in addition to the genetic predisposition years [14]. Equity-based prioritisation is given to patients
[10, 11]. grounded on clinical severity and prognosis.
RHD is preventable, by multi-modal interventions i.e., Penicillin remains the primary antibiotic for treating
reducing risk factors through improved living conditions, ARF and as secondary prophylaxis for patients with RHD
equitable access to health care, and primary prophylaxis. [18]. Lifelong post-surgical treatment includes Aspirin
Subsequently, timely diagnosis and secondary prophy- for patients with biological prostheses, and Warfarin for
laxis of GAS pharyngitis with Benzathine penicillin are patients with mechanical prostheses. Continuous moni-
crucial to preventing ARF and its sequalae RHD. Cardiac toring of the prothrombin time/international normal-
surgery to repair and replace damaged valves, together ised ratio (INR) and appropriate dosage adjustments for
with lifelong chronic medication, is used to manage the patients on Warfarin are done at the cardiac Warfarin
symptoms and prevent severe complications. Benzathine clinic [19]. Routinely, progesterone derived transdermal
penicillin intramuscular injection has been proven to patches have been introduced for women of reproduc-
have superior preventative serum levels compared to oral tive age on life-long anti-coagulation therapy. Equally, for
Penicillin VK, besides improved compliance [12]. Access these cohort of women, should they opt to start a family,
to the former is however a problem in LMICs. there is tailored package for their needs, in collaboration
Limited cardiac expertise, weak surveillance systems, with the Obstetrics and Gynaecology department.
and lack of diagnostic equipment remain a challenge for A gap was identified in data and official reports of
the RHD prevention and control interventions in LMICs. the burden of RHD in Namibia, causing uncertainty on
This contributes to people living with silent RHD for long the sources of information supporting the GBD report.
times until it manifests as severe disease. Another chal- Therefore, this study aimed to estimate the prevalence of
lenge is the lack of true burden of disease estimates on RHD and to assess the RHD-related health care systems
local, national, and international levels to guide evidence- in Namibia.
based interventions for the prevention and control of
RHD. Methodology
Namibia has two sources of data for people with clinical
Rheumatic heart disease in the context of Namibia’s health RHD, a register at the public outpatient cardiac clinic,
care system and an inpatient register from the health information sys-
The prevalence of RHD in Namibia has been estimated tem database for public hospital admission records. The
by a Global Burden of Disease (GBD) study at 1.09% outpatient register contains all patients treated for ARF
(about 25,200 prevalent cases) [13]. In addition to Con- or RHD at the cardiac department, with data captured
genital Heart Disease (CHD), RHD is ranked among the upon their first visit to the clinic. In the inpatient regis-
three most common causes of cardiovascular death in ter, contains all patients admitted due to ARF or RHD in
children in the ages 5–14 years in the country [14]. public hospitals.
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 3 of 10

We conducted a retrospective descriptive study review-

ing data from the two registers from January 2010 to
December 2020. The outpatient register recorded 812
patients, of which 20 patients were Angolan citizens, and
74 patients recorded deaths. The inpatient register had
1 463 hospital admissions, which are events rather than
the number of patients. Like the outpatient register, it is
expected to have a small proportion of foreign citizens,
mainly Angolans admitted to public hospitals. Sociode-
mographic (age, gender, region, hospital of admission)
and clinical (valve disease/diagnosis, comorbidities)
Fig. 1 Yearly number of new RHD cases (n = 810). source: outpatient
characteristics were collected and analysed from both
register
sources.
In the outpatient register, heart valve diseases were
classified as either (i) Mitral, (ii) Aortic, (iii) Tricuspid,
or (iv) a mix. Mitral valve disease was defined as hav- cases, accounting for 49% of them. Data from the out-
ing mitral regurgitation, and or mitral stenosis, or any patient register presented in Table 2 show that most
of these mixed with a tricuspid regurgitation or stenosis. patients were young adults less than 30 years old at the
A similar definition was applied for Aortic valve disease. time of registration (72%), and a majority were women
Tricuspid valve disease is defined as having tricuspid (65%). Only 467 of the registered patients had data on
regurgitation or stenosis alone. Mixed valve disease heart valve impairment recorded, of whom 58% had a
applies to a person with both Aortic and Mitral, or the mitral valve disease, 19% with mixed valve disease, and
two plus Tricuspid valve disease. 13% with aortic valve disease.
Similarly, valvular diseases in the inpatient register Information from the inpatient register is presented in
were classified as per the 2016 fifth edition of the Inter- Table 3 and Figs. 2 and 3. Most individuals admitted dur-
national Statistical Classification of Disease and Related ing this period were young people and, predominantly
Health Problems (ICD-10) manual [20]. Acute Rheumatic women. ARF was attributed to 51% of hospital admis-
Fever was defined as ICD-10 codes I00-I02, codes I05 for sions, 24 deaths, and 15 surgeries in this 11-year period.
Rheumatic Mitral valve disease, codes I06 for Rheumatic The 724 admissions due to RHD were classified as “other
Aortic valve disease, codes I07 for Rheumatic Tricuspid Rheumatic heart disease” (33%), “Rheumatic Mitral valve
valve disease, codes I08 for multiple Rheumatic valve dis- disease” (5%), “Rheumatic Aortic valve disease” (2%),
ease, codes I09 for other Rheumatic valve disease, and “Rheumatic Tricuspid valve disease (0.7%), “multiple
codes I34-I38 for non-rheumatic valve disease. valve disease (1.1%), and “non-rheumatic valve disease”
Descriptive statistics were performed in STATA 14.2 (8%). The length of hospital admissions ranged between 0
and Microsoft Excel, which are presented as frequencies and 335 days (median 4 days). Most of the patients (78%)
and percentages. stayed in hospital between 0 and 9 days.
Prior to acquiring the data, ethical approval was Several key areas were identified that could limit the
granted by the Namibian Ministry of Health and Social quality of the current RHD surveillance systems.
Services research ethical committee (Reference: 17/3/3
PPS). No individual consent was required from patients Discussion
to use the secondary data, as there was no direct harm to The study aimed to estimate the prevalence of RHD from
the patient. The identities of all patients were kept confi- the outpatient and inpatient registers between 2010 and
dential and not revealed in the study. 2020 and describe RHD-related healthcare practices in
Namibia. Of the total population, we estimated an RHD
Results prevalence of 0.032% from the outpatient register, while
We found 718 patients regarded as active, which corre- the cumulative incidence of RHD was 0.058% in the inpa-
sponds to a prevalence of 28 cases per 100,000. The high- tient register, respectively.
est number of RHD cases (n = 110) were registered in The inpatient register can include two or more posts
2011, and the fewest (n = 27) in 2020 (Fig. 1). i.e., hospitalised twice or more during the covered
Table 1 presents an overview of the distribution of the time period, and a few of those have died without it
RHD burden per region from the outpatient register. being reported and updated in the outpatient register
The highly densely populated north-eastern regions of which usually happens if the patients die in the periph-
the country had the highest proportion of the registered eral regions. According to the routines of RHD care in
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 4 of 10

Table 1 Number of Rheumatic Heart Disease patients per region

Population (2016) RHD cases RHD deaths Prevalence/100
000

Namibia 2,550,226 718 74 28

North-Eastern Regions
Kavango 237,779 32 1 13
Kunene 97,865 31 3 32
Ohangwena 255,510 23 1 9.0
Omusati 249,885 6 1 2.4
Oshana 189,237 235 34 124
Oshikoto 195,165 13 1 6.7
Zambezi 98,849 20 0 20
Central-Western Regions
Khomas 415,780 213 21 51
Otjozondjupa 154,342 32 2 21
Omaheke 74,629 11 0 15
Erongo 182 402 27 3 15
Southern Regions
!Karas 85,759 13 0 15
Hardap 87,186 19 5 22

Namibia, all patients should be seen at the clinic as they is that prevalence of RHD in Namibia lies in the interval
are recommended to visit the clinic regularly. We there- 0.3–0.9%. We cannot confirm though that the GBD num-
fore expect there to be only a limited number of diag- ber are representative of people with RHD in Namibia,
nosed patients that are not covered in our registers. Thus, also considering the possibility of false positive in screen-
based on the two registers, and patients not covered in ing studies. To understand the true burden of disease in
the register we expect the prevalence to lie within the Namibia, population-based screening studies are needed.
interval of 0.05% to 0.10%. Additionally, understanding the specific local sources of
An important piece in understanding the burden of RHD data reported in the GBD study for Namibia will
RHD and the true prevalence of RHD in Namibia is the make it easier to understand the validity of the GBD
undiagnosed cases. The only screening study that has report.
been published from Namibia was among 112 school Consistent with the existing literature, we found rheu-
children where two RHD cases were detected, suggest- matic mitral valve disease to be the most common com-
ing an age-related prevalence of 1.8% [21]. This would pared to mixed or aortic valve diseases [7, 27, 28]. This
be higher than the age-related GBD estimate (0.53% for is notable for the mitral valve disease related complica-
ages 0–14 and 1.51% for ages 15–19) [13]. Echocardio- tions i.e., atrial fibrillation and congestive heart failure,
graphic screening studies among school children in other that increase the risk of premature deaths, and prolonged
sub-Saharan Africa countries reported varying results of years living with disability among the young populations.
silent RHD. For instance, 1.18% among 1 102 school chil- Furthermore, a similar finding to the existing literature
dren in Zambia [22], and 0.26% among 4 107 school chil- is that RHD affects mostly young people below the age of
dren in Nigeria [23], had undiagnosed RHD. Systematic 30 years, predominantly women of reproductive age [16,
reviews have presented a prevalence of latent RHD to be 19]. With the adverse impact of RHD on maternal health,
2.1%, seven to eight times higher than the prevalence of it will be valuable to prioritise investments in interven-
clinically diagnosed RHD [24, 25]. tions for the management of RHD in women [26].
Our interpretation is that the GBD study has included The occurrence of RHD is common in the northern
a prediction of the RHD prevalence in Namibia based on regions dominated by rural areas with limited socioeco-
both diagnosed and undiagnosed cases. Even if account- nomic resources. The findings concur with the reported
ing for undiagnosed RHD, we expect, based on results association between social determinants of health and
from our two registers and results from screening stud- RHD in LMICs, mainly poor sanitation, overcrowd-
ies that the prevalence of RHD in Namibia should be ing, and inequitable access to healthcare [11, 29, 30].
lower than the 1.09% presented in GBD [13]. Our guess Improving living conditions and access to health care in
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 5 of 10

Table 2 Characteristics of patients with rheumatic heart disease The lowest cases were registered in 2020 possibly due to
in the outpatient register (n = 812) the effect of the Covid-19 pandemic.
n %
Challenges and future recommendations for RHD‑related
Sex (n = 808) healthcare systems
Women 523 65 Frail surveillance systems persist to challenge the under-
Men 285 35 standing of the true burden of disease in LMICs. In
Age at Registration (n = 802) Namibia, we identified key areas that will benefit from
0–9 years 181 23 systemic and structural changes to strengthen data col-
10–19 years 250 31 lection methods. Future recommendations are outlined
20–29 years 143 18 below to inform planning and changes in Namibia and
30–39 years 115 14 similar settings.
40–49 years 36 4.5 Assessing the RHD-related healthcare practices, we
≥ 50 years 77 10 found that the coordination and integration of the reg-
Death over 11 years (n = 74) isters is minimal, challenging verification and monitor-
Women 35 6.7 ing. This is a well-known challenge for the surveillance
Men 39 14 systems in LMICs affecting the data quality and control
NYHA Classification* (n = 335) of RHD [32]. It would have been valuable if we could
NYHA I 254 76 combine the registers to get a better understanding
NYHA II 45 13 of the total number of people diagnosed with RHD in
NYHA III 2 6.9 Namibia for a more accurate prevalence estimate. The
NYHA IV 13 3.9 registers lack patient unique identifiers, which would be
Valve Affected (n = 467) valuable for combining the registers, and also for better
Aortic Valve Disease 59 13 monitoring patients. Introducing patient unique iden-
Mitral Valve Disease 269 58 tifiers into the systems and possibly electronic registers
Tricuspid Valve Disease 23 4.9 is recommended to strengthen them, as well as overall
Mixed Valve Disease 90 19 surveillance systems. Findings from a pilot of using RHD
Unclassified Valve Disease 26 5.6 electronic registers in Zambia suggested that they are
Treatment & Surgery (n = 791) practical and feasible in LMICs [33].
Warfarin 164 21 We further recommend continuous professional devel-
Penicillin prophylaxis 339 43 opment training for nurses and doctors at all levels of
Surgery 288 36 care and also expanding RHD content in health-related
Co-morbidities & Complications curriculums. In addition, it will be significant to stand-
Acute Rheumatic Fever/Rheumatic Fever 19 2.3 ardise laboratory confirmatory tests for GAS in routine
Atrial Fibrillation 35 4.3 care when treating throat infections. This will improve
Congenital Heart Disease 5 0.6 diagnosis and classification of RHD to improve surveil-
Hypertension 22 2.7 lance of the disease. We suspected possible misreporting
Stroke 14 1.7 in the inpatient register as all the admissions between
Others 15 1.8 2010 and 2017 were classified under ARF, causing 24
*
New York Heart Association Classification
deaths and five surgeries. ARF is not likely to be a single
indication of surgery. The findings could be related to the
limited cardiac expertise in the country and the difficul-
the primordial prevention approach is recommended to ties in identifying ARF by clinical features [4]. According
reduce regional inequities [14]. Namibia remains one of to the local cardiology experts, the real numbers of RHD
the most unequal countries in the world with a Gini coef- patients i.e., surgery cases, could be high than otherwise
ficient of 59.1, and the inequalities are greater in rural presented in our study and GBD. Therefore, there is a
areas compared to urban areas [31]. need to review the clinical records and update the regis-
A declining pattern was found in the yearly number of ters for better estimates of the burden of disease.
registered RHD cases in the outpatient register, but the An expansion of current RHD preventive initiatives
cause of the pattern is unclear. A decline in the reporting to the community level will be significant. Activities
at the outpatient level could be speculated, as the number are mainly clinic-based with minimal engagement with
of hospital admissions were high in the same time period. the community. Financial constraints limit the distribu-
tion of printed materials at the clinic, which should be
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 6 of 10

Table 3 Characteristics of patients hospitalised between 2010 and 2021 due to ARF/RF and RHD from the inpatient register (n = 1463)
n (%) RF (n= 739) VHD (n= 724)

Sex
Women 883 (60) 452 431
Men 580 (40) 287 293
Age during Hospitalisation
0–9 years 266 (18) 149 117
10–19 years 289 (20) 152 137
20–29 years 276 (19) 116 160
30–39 years 219 (15) 97 122
40–49 years 128 (8.8) 60 68
≥ 50 years 285 (19) 165 120
Outcome of Hospital Stay
Deceased 44 (3.0) 24 20
Discharged 1,358 (93) 677 681
Referred to other hospitals 61 (4.2) 38 23
Diagnosesa
Acute Rheumatic Fever/Rheumatic Fever 739 (51) – –
Rheumatic Aortic Valve Disease 31 (2.1) – –
Rheumatic Mitral Valve Disease 72 (4.9) – –
Rheumatic Tricuspid Valve Disease 10 (0.7) – –
Multiple Valve Disease 16 (1.1) – –
Other Rheumatic Heart Disease 481 (33) – –
Non-rheumatic Valve Disease 114 (7.8) – –
Surgery
None 1 388 (95) 724 664
Surgery 75 (5.0) 15 60
Days spent in Hospital
0–9 days 1,144 (78) 610 534
10–19 days 219 (15) 87 132
20–29 days 54 (3.7) 23 31
30–above days 46 (3.1) 19 27
a
Categories defined according to the 2016 fifth edition International Statistical Classification of Disease and Related Health Problems (ICD-10) guideline

improved to achieve wide awareness. On the other hand, Advocacy

the ministry of health and social services remain com- Relevant organisations i.e., high learning institutions,
mitted to improve public RHD-related clinical care with public health organisations, and social groups must col-
an increasing recruitment of cardiologists and surgeons laborate with the clinicians to advocate and mobilise for
to support. Our findings add to the renowned challenges much-needed investments to expand current interven-
experienced in LMICs i.e., policy will towards prevention tions to the community-level. Action-oriented research
interventions, delayed implementation, and low financial is required to identify key areas and feasible strategies to
support [7, 34, 35]. ensure evidence-based advocacy.

Surveillance
A.S.A.P. framework for future interventions
This will be valuable to introduce ARF and RHD sur-
We urge the health care system to adopt and apply the
veillance forms at primary healthcare facilities as part
universal “Awareness Surveillance Advocacy Prevention
of the current routine health information systems. Fur-
(A.S.A.P.)” principles in the planning and implementa-
ther, it is recommendable to establish collaboration
tion of interventions to achieve the resolutions set by
with Information and Technology experts to explore
WHO and other bodies [36–38].
the feasibility of developing and maintaining e-registers
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 7 of 10

Fig. 2 Cause of hospital admission per year (n = 1463). source: inpatient register

600

500
Number of Admissions

400

300

200

100

0
Otjozondjup
!Karas Erongo Hardap Kavango Khomas Kunene Ohangwena Omaheke Omusati Oshana Oshikoto Zambezi
a
RF 20 36 28 133 244 9 54 19 46 34 57 42 17
VHD 6 11 10 29 479 1 37 8 13 79 26 21 4

Fig. 3 Yearly number of hospital admissions per regions (n = 1463). source: inpatient register

at regional levels. Patient unique identifiers must be Awareness

introduced in the surveillance systems to strengthen This will be beneficial to appoint focal persons for the
data quality and allow for monitoring of patients across awareness component to maintain continuous health
different levels of care. This will contribute to a bet- education sessions via different media platforms and to
ter understanding of the referral systems, follow-up of keep monitoring and evaluation of all activities related to
patients, and overall burden of disease at both patient RHD. It may be cost-effective to incorporate awareness
and healthcare system levels. strategies into the existing community health outreach
and school health services. Another recommendable
option is to involve the community healthcare workers
in awareness activities [39]. Namibia has a number of
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 8 of 10

community healthcare workers that are mostly are under Conclusion

and or unutilised. Using national representative registers with patients
diagnosed and hospitalised for RF and RHD over
Prevention 11 years, we estimate the prevalence of clinically
The commitment to the treatment and management confirmed RHD to be between 0.05% and 0.10% in
of RHD e.g., cardiac surgery in Namibia is commend- Namibia, and we expect the prevalence of RHD in
able. However, it will be valuable to prioritise efforts at Namibia to be lower than previous estimates. Identified
the primordial and primary prevention levels. Address- shortcomings demonstrates the need to improve and
ing inequities in access to health care will be integral to strengthen the surveillance and data collection systems.
achieving the prevention targets. Routine care at the pri- Recommendations can thus be considered to make the
mary and secondary healthcare levels must include labo- necessary improvements to enhance quality and valid-
ratory testing for group A streptococcal (GAS) bacteria ity of the registers. Future epidemiological and clinical
among people with pharyngitis, especially children. Posi- studies i.e., population-based echocardiogram screen-
tive cases must receive Benzathine Penicillin intramuscu- ing studies, are recommendable to understand the true
lar injection, as it is proven to have superior preventative burden of disease.
serum levels compared to oral Penicillin VK [12]. Inves-
tigations of the barriers to the supply chains, access, and
Abbreviations
suboptimal compliance will be crucial to the prevention ARF: Acute rheumatic fever; A.S.A.P.: Awareness surveillance advocacy preven-
of avoidable complications for individuals with RHD at tion; GAS: Group A streptococcus; ICD-10: International statistical classification
a lower cost compared to surgical interventions [30, 40, of disease and related health problems version 10; RF: Rheumatic fever; RHD:
Rheumatic heart disease.
41]. Another essential part in the prevention efforts will
be continuous education, and task-shifting to use cardiac Acknowledgements
non-expert practitioners for time detection, treatment, Not applicable.
and referral of ARF and RHD. These have been reported Author contributions
to be effective LMICs with limited cardiac expertise [22, PPS and FN designed the study in collaboration with SS, SNI, FFS, and EMN.
42, 43]. PPS performed the analyses with support of FN. All co-authors supported PPS
in interpretations of the results. PPS drafted the paper, and FN, SS, SNI, FFS, and
EMN contributed actively. All authors read and approved the final manuscript.
Limitations
Our study has several important limitations. Our regis- Authors’ Information
Panduleni Penipawa Shimanda is a Registered Nurse, holds a Master of
ters should give an accurate understanding of patients Science in Public Health with a specialisation in Health Economics, and is a
within inpatient care and receiving follow-up care. A lecturer of Nursing Management.
weakness of our study is that we have not got infor- Stefan Söderberg is a Professor and Senior Cardiologist consultant.
Scholastika Ndatinda Iipinge is a Professor in Community Health Nursing
mation from other clinics than the inpatient and out- Sciences.
patient clinic. However, according to the routines in Ebba Mwalundouta Neliwa is a Registered Nurse, a survivor and advocate
Namibia, all patients should be seen at the clinic and of RHD.
Fenny Fiindje Shidhika is a Paediatric Cardiologist and head of Paediatric
they are recommended to regularly visit the outpatient and Congenital Cardiology department at Windhoek Central Hospital.
clinic for follow-up care. We therefore expect at most Fredrik Norström is an Associate Professor in Health Economics and Docent
a limited number of patients to not have visited either in Epidemiology and Biostatistics.
of the clinics during our coverage time. We also expect Funding
the validity of the registers to be very high, even if there Open access funding provided by Umea University. The work was funded by
could be patients that have not attended follow-up the Erling Persson foundation. The funder had no role in the design of the
study, data collection, analysis, and interpretation of the data and in writing
since 2010. While latent RHD is believed to be high in the manuscript.
high-risk populations, our study was limited by the lack
of data on latent/silent RHD in Namibia and we there- Availability of data and materials
Secondary data used in the analyses was collected retrospectively from health
fore are limited to guesses when making estimates of datasets after ethical approval was granted. The datasets are not publicly avail-
the prevalence of RHD in Namibia. Data validity is an able, as a separate ethical permission is required to share the data with a third
issue in regard to missing data and possible errors for part. The ethical permission is to be obtained from the Namibian Ministry of
Health and Social Services research ethical committee by the corresponding
information on patient level for other issues than the author with a reasonable request.
diagnosis itself. For instance, in the outpatient register
we found 65% of the patients with missing information Declarations
on the heart valve disease, while the inpatient register
recorded a patient admitted for 335 days. Ethics approval and consent to participate
Prior to acquiring the retrospective secondary data, ethical approval was
granted by the Namibian Ministry of Health and Social Services research
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 9 of 10

ethical committee (Reference: 17/3/3 PPS) with a waiver for individual consent 15. National Advisory Committee for Prevention and Control of Rheumatic
of the patients. The study was carried out in accordance with ethical principles Fever and Rheumatic Heart Disease in Namibia | RHD Action [Internet].
as outlined in the World Medical Association Helsinki Declaration. [cited 2021 Mar 1]. Available from: [Link]
nal-​advis​ory-​commi​ttee-​preve​ntion-​and-​contr​ol-​rheum​atic-​fever-​and-​
Consent for publication rheum​atic-​heart
Not applicable. 16. Zühlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Cupido-Katya
Mauff B, et al. Clinical outcomes in 3343 children and adults with rheu-
Competing interests matic heart disease from 14 low-and middle-income countries: two-year
Authors declare no competing interests. follow-up of the global rheumatic heart disease registry (the REMEDY
Study). Circulation. 2016;134(19):1456–66.
Author details 17. Global Health Expenditure Database [Internet]. [cited 2022 Mar 28]. Avail-
1
Department of Epidemiology and Global Health, Umeå University, 901 able from: [Link]
87 Umeå, Sweden. 2 Clara Barton School of Nursing, Welwitchia Health 18. Republic of Namibia Ministry of Health and Social Services. Namibia
Training Centre, Pelican Square, Windhoek, P. o. Box 1835, Namibia. 3 Depart- Standard Treatment Guidelines, First Edition. 2011. p. 891
ment of Public Health and Clinical Medicine, Umeå University, Umeå 901 87, 19. Jonkman LJ, Gwanyanya MP, Kakololo MN, Verbeeck RK, Singu BS. Assess-
Sweden. 4 Cardiac Outpatient Clinic, Intermediate Hospital Oshakati, Oshakati, ment of anticoagulation management in outpatients attending a warfa-
Namibia. 5 Department of Paediatric and Congenital Cardiology, Windhoek rin clinic in Windhoek, Namibia. Drugs Ther Perspect. 2019;35(7):341–6.
Central Hospital, Windhoek, Namibia. 20. ICD-10 Version:2019 [Internet]. [cited 2021 May 13]. Available from:
[Link]
Received: 17 January 2022 Accepted: 2 June 2022 21. Manolakos JJ, Salehian O, Kraeker C, Manolakos L, Hunter CJ. Rheumatic
heart disease screening in windhoek Namibia using portable echocardi-
ography: a pilot project. Can J Cardiol. 2015;31(10):S129.
22. Schwaninger S, Musuku J, Engel ME, Musonda P, Lungu JC, Machila E,
et al. Prevalence of rheumatic heart disease in Zambian school children.
References BMC Cardiovasc Disord. 2018;18(1):135. [Link]
1. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour s12872-​018-​0871-8.
LM, et al. Global burden of cardiovascular diseases and risk factors, 23. Ekure EN, Amadi C, Sokunbi O, Kalu N, Olusegun-Joseph A, Kushimo O,
1990–2019: update from the GBD 2019 study. J Am College Cardiol. et al. Echocardiographic screening of 4107 Nigerian school children for
2020;76:2982–3021. rheumatic heart disease. Trop Med Int Health. 2019;24(6):757–65.
2. Zühlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Cupido-Katya 24. Noubiap JJ, Agbor VN, Bigna JJ, Kaze AD, Nyaga UF, Mayosi BM. Preva-
Mauff B, et al. Clinical outcomes in 3343 children and adults with rheu- lence and progression of rheumatic heart disease: a global systematic
matic heart disease from 14 low- and middle-income countries clinical review and meta-analysis of population-based echocardiographic stud-
perspective. Circulation. 2016;134(19):1456–66. ies. Sci Rep 2019;9(1). Available from: [Link]
3. Dougherty S, Beaton A, Nascimento B, Zühlke L, Khorsandi M, Wilson 31745​178/
N. Prevention and control of rheumatic heart disease: overcoming 25. Rothenbühler M, O’Sullivan CJ, Stortecky S, Stefanini GG, Spitzer E, Estill J,
core challenges in resource-poor environments. Ann Pediatr Cardiol. et al. Active surveillance for rheumatic heart disease in endemic regions:
2018;11(1):68–78. a systematic review and meta-analysis of prevalence among children and
4. Karthikeyan G, Guilherme L. Acute rheumatic fever. Lancet. adolescents. Lancet Glob Health. 2014;2(12):e717–26.
2018;392:161–74. 26. Rwebembera J, Beaton AZ, de Loizaga SR, Rocha RTL, Doreen N, Ssinab-
5. Carapetis JR, Beaton A, Cunningham MW, Guilherme L, Karthikeyan G, ulya I, et al. The Global Impact of Rheumatic Heart Disease. Curr Cardiol
Mayosi BM, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rep. 2021;23(11):1–10.
Rev Dis Primers. 2016;2:15084. 27. Davis K, de Oliveira LNL, da Silva AI, Noronha M, Martins J, dos Santos
6. Zühlke LJ, Beaton A, Engel ME, Hugo-Hamman CT, Karthikeyan G, M, et al. Morbidity and mortality of rheumatic heart disease and acute
Katzenellenbogen JM, et al. Group A streptococcus, acute rheumatic rheumatic fever in the inpatient setting in Timor-Leste. J Paediatr Child
fever and rheumatic heart disease: epidemiology and clinical considera- Health. 2021;57(9):1391–6.
tions. Curr Treat Options Cardiovasc Med. 2017;19(2):15. 28. Shakya S, Gajurel RM, Poudel CM, Shrestha H, Devkota S, Thapa S. echo-
7. Leal MTBC, Passos LSA, Guarçoni FV, Aguiar JM de S, Silva RBR da, Paula cardiographic findings in patients with atrial fibrillation in a tertiary care
TMN de, et al. Rheumatic heart disease in the modern era: recent devel- center of Nepal: a descriptive cross-sectional study. JNMA J Nepal Med
opments and current challenges. Rev Soc Bras Med Trop. 2019;52. Assoc. 2021;59(233):46–50.
8. Peters F, Karthikeyan G, Abrams J, Muhwava L, Zühlke L. Rheumatic heart 29. Bennett J, Zhang J, Leung W, Jack S, Oliver J, Webb R, et al. Rising ethnic
disease: current status of diagnosis and therapy. Cardiovasc Diagn Ther. inequalities in acute rheumatic fever and rheumatic heart disease, New
2020;10(2):305–15. Zealand, 2000–2018. Emerg Infect Dis. 2021;27(1):36.
9. Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. 30. Morberg DP, Alzate López YA, Moreira S, Prata N, Riley LW, Burroughs Peña
Lancet. 2012;379:953–64. MS. The rheumatic heart disease healthcare paradox: disease persistence
10. Muhamed B, Parks T, Sliwa K. Genetics of rheumatic fever and rheumatic in slums despite universal healthcare coverage—a provider perspective
heart disease. Nat Rev Cardiol. 2020;17:145–54. qualitative study. Public Health. 2019;1(171):15–23.
11. Coffey PM, Ralph AP, Krause VL. The role of social determinants of health 31. Sulla V, Zikhali P, Cuevas PF. Inequality in Southern Africa : An Assessment
in the risk and prevention of group A streptococcal infection, acute rheu- of the Southern African Customs Union (English) [Internet]. Washington,
matic fever and rheumatic heart disease: a systematic review. McCarthy D.C; 2022 Mar [cited 2022 Mar 17]. Available from: [Link]
JS, editor. PLOS Neglected Tropical Diseases. 2018;12(6):e0006577. Avail- world​bank.​org/​curat​ed/​en/​09912​53030​72236​903/​P1649​270c0​2a1f0​
able from: [Link] 6b0a3​ae02e​57ead​d7a82
12. Manyemba J, Mayosi BM. Intramuscular penicillin is more effective than 32. Kapepo MI, Yashik S. A process analysis of the Namibian Health System:
oral penicillin in secondary prevention of rheumatic fever–a systematic an exploratory case study. Ethiop J Health Dev. 2018;32(4):200–9.
review. S Afr Med J. 2003;93(3):212–8. 33. van Dam J, Musuku J, Zühlke LJ, Engel ME, Nestle N, Tadmor B, et al. An
13. GBD Compare | IHME Viz Hub [Internet]. [cited 2021 Mar 1]. Available open-access, mobile compatible, electronic patient register for rheumatic
from: [Link] heart disease (’eRegister’) based on the World Heart Federation’s frame-
14. Forcillo J, Watkins DA, Brooks A, Hugo-Hamman C, Chikoya L, Oketcho work for patient registers. Cardiovasc J Afr. 2015;26(6):227–33.
M, et al. Making cardiac surgery feasible in African countries: experi- 34. Ali S, Subahi S. A multi-sectoral, non-governmental program for control
ence from Namibia, Uganda, and Zambia. J Thorac Cardiovasc Surg. of rheumatic heart disease: SUR I CAAN: A model for developing coun-
2019;158(5):1384–93. tries. Int J Cardiol. 2020;15(307):195–9.
Shimanda et al. BMC Cardiovascular Disorders (2022) 22:266 Page 10 of 10

35. Shawar YR, Shiffman J. Generating global priority for addressing

rheumatic heart disease: a qualitative policy analysis. J Am Heart Assoc.
2020;9(8): e014800.
36. Robertson KA, Volmink JA, Mayosi BM. Towards a uniform plan for the
control of rheumatic fever and rheumatic heart disease in Africa—the
awareness surveillance advocacy prevention (A.S.A.P.) programme. South
Afr Med J. 2006;96(3 II):241–5.
37. World Health Organization. Rheumatic fever and rheumatic heart disease:
Report by the Director-General [Internet]. Vol. A71/25, World Health
Organization. 2018. Available from: [Link]
files/​WHA71/​A71_​25-​en.​pdf?​ua=1
38. Watkins D, Zuhlke L, Engel M, Daniels R, Francis V, Shaboodien G, et al.
Seven key actions to eradicate rheumatic heart disease in Africa: the
Addis Ababa communiqué. Cardiovasc J Africa. 2016;27(3):184–1847.
39. Kerrigan V, Kelly A, Lee AM, Mungatopi V, Mitchell AG, Wyber R, et al.
A community-based program to reduce acute rheumatic fever and
rheumatic heart disease in northern Australia. BMC Health Serv Res.
2021;21(1):1–15.
40. Chamberlain-Salaun J, Mills J, Kevat PM, Rémond MGW, Maguire GP.
Sharing success—understanding barriers and enablers to secondary
prophylaxis delivery for rheumatic fever and rheumatic heart disease.
BMC Cardiovasc Disord. 2016;16(1):1–10.
41. Edwards JG, Barry M, Essam D, Elsayed M, Abdulkarim M, Elhossein BMA,
et al. Health system and patient-level factors serving as facilitators and
barriers to rheumatic heart disease care in Sudan. Global Health Res
Policy. 2021;6(1):1–12.
42. Francis JR, Whalley GA, Kaethner A, Fairhurst H, Hardefeldt H, Reeves B,
et al. Single-view echocardiography by nonexpert practitioners to detect
rheumatic heart disease: a prospective study of diagnostic accuracy. Circ
Cardiovasc Imaging. 2021;14(8):801–10.
43. Bhatt N, Karki A, Shrestha B, Singh A, Rawal LB, Sharma SK. Effectiveness
of an educational intervention in improving healthcare workers’ knowl-
edge of early recognition, diagnosis and management of rheumatic fever
and rheumatic heart disease in rural far-western Nepal: a pre/post-inter-
vention study. BMJ Open. 2022;12(4):e059942.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more [Link]/submissions