Rheumatic heart disease in low-income countries: a mirror of poverty - the case of the Democratic Republic of Congo

¹Department of Pediatrics, Pediatric Cardiology Unit, University Clinics of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo, ²Department of Internal Medicine, University Clinics of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo, ³Department of Anesthesia and Intensive Care, University Clinics of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo

^&Corresponding author
Arriel Makembi Bunkete, Department of Internal Medicine, University Clinics of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo

Commentary    

A disease of inequalities

Rheumatic heart disease (RHD) strongly illustrates the persistence of health inequalities worldwide. This condition, a preventable sequela of acute rheumatic fever (ARF), results from poorly treated or untreated streptococcal infections [1]. In high-income countries, it practically disappeared from the second half of the 20^th century, due to the combined effect of improved living conditions, hygiene, housing, and rapid access to antibiotics [2]. In contrast, in many low- and middle-income countries (LMICs), RHD remains a major cause of heart failure and premature death, often affecting children and young adults in the prime of life. The natural history of the disease is well known: untreated group A beta-hemolytic streptococcal pharyngitis can trigger an autoimmune reaction leading to ARF, whose recurrences progressively cause irreversible valvular lesions [3]. Rheumatic heart disease (RHD) is therefore an emblematic disease linking poverty, limited access to care, and social vulnerability. It reminds us that medicine is not only a matter of scientific progress but also of social justice.

Global burden

Current figures are alarming. According to the WHO, more than 55 million people live with RHD worldwide, with approximately 360,000 deaths each year [1]. The burden is particularly heavy in sub-Saharan Africa, South Asia, and the Pacific islands, where RHD remains the leading cause of acquired heart disease in children and adolescents [2,3]. The geographic distribution of the disease is revealing: almost absent in industrialized countries, it persists in areas where social inequalities and health system fragilities are most pronounced. In Africa, a recent meta-analysis including 21 studies and more than 100,000 children reports an average prevalence of 25.5 per 1,000 inhabitants [4]. These figures, based on echocardiography, contrast strongly with older estimates (1 to 5 per 1,000) from clinical surveys, which massively underestimated the disease burden. Rheumatic heart disease (RHD) is not only a health issue: it causes major economic and social costs. Deaths often occur between 25 and 29 years [3], that is, at an age when individuals should contribute to family life and the economy. Consequences include school dropout, loss of productivity, and family impoverishment.

The Congo example: a mirror for DRC

Local data are severely lacking in the Democratic Republic of Congo (DRC), but experiences in neighboring countries shed light on the situation. In Brazzaville, a cross-sectional survey conducted in 2005 in four schools revealed a clinical prevalence of 3.5‰ among schoolchildren aged 5 to 17 years [5]. Most affected children lived in overcrowded housing and reported histories of untreated sore throats. Secondary prophylaxis with benzathine penicillin, although initiated, quickly suffered from poor adherence: 75% of children were still followed at one month, but only 37.5% at the third month. Compared to the previous estimate of 1.4% in 1996 [5], this progression suggests a worsening situation, probably linked to socio-political crises and population impoverishment. These results align with those reported elsewhere in Africa: prevalence of 12% in Lusaka (Zambia) [6], and strong correlation between RHD and socio-economic status in Senegal and Guinea [2]. Democratic Republic of Congo (DRC) shares with Congo-Brazzaville a similar history, geography, and socio-economic context. The absence of updated national data is therefore particularly concerning. It suggests a high but invisible burden of the disease. This invisibility justifies the urgent organization of school-based screening in DRC using the modernized 2023 WHF criteria.

2023 WHF echocardiographic criteria: a turning point

The echocardiographic criteria of the World Heart Federation (WHF) published in 2012 represented a major advance, allowing international standardization of diagnosis, including subclinical forms [7]. However, their application remained limited to centers with echocardiography experts. In 2023, the WHF published new criteria constituting a true revolution [8]: a dual diagnostic pathway: simplified screening criteria usable by non-specialists, and confirmatory criteria reserved for experts; staging classification: reflecting the disease continuum (latent, definite, advanced), allowing adapted management; integration of early morphological abnormalities: detectable only by echocardiography, permitting identification of at-risk patients before complications appear (Table 1). These innovations aim to broaden diagnostic access, strengthen screening sensitivity, and allow earlier intervention. They open the way to school-based screening programs relying on trained but non-expert operators, an approach adapted to low-income countries.

Obstacles in low-income countries

Despite these advances, implementation in contexts like DRC remains hindered by numerous obstacles: 1) limited technological access: echocardiography remains expensive, dependent on stable technical and energy infrastructure, rarely available in rural areas. Portable echocardiographs offer a promising solution, but their distribution remains marginal. 2) Insufficient training: even simplified criteria require learning. Training, monitoring, and evaluation of non-expert operators require investments that few countries can afford [5]. 3) Benzathine penicillin shortages: WHO highlights recurrent stock-outs of this essential drug, compromising primary and secondary prophylaxis [1]. 4) Structural weaknesses: long distances to healthcare facilities, family poverty, low adherence to follow-up, and population mobility. 5) Absence of registries and political prioritization: lacking solid data, RHD is often ignored in public health agendas [2,9].

A disease as a barometer of poverty

Rheumatic heart disease is not only a cardiovascular pathology. It condenses social determinants of health: poverty, overcrowding, and limited access to education and care. Every preventable murmur reflects a failure of the health system. Every premature death signals structural inequality. Its eradication would represent much more than a medical victory: it would testify to progress in social justice. History in industrialized countries shows that RHD declined even before the advent of antibiotics, thanks to fighting overcrowding and improving living conditions. The experience can be reproduced today in LMICs, provided there is strong political will.

Perspectives: breaking the cycle

Eradication of RHD is possible with existing tools [9]. It requires an integrated approach: Primary prevention: systematic diagnosis and treatment of streptococcal pharyngitis, even on clinical criteria when tests are unavailable; secondary prevention: establishment of regular benzathine penicillin prophylaxis programs with structured follow-up; school-based screening: using the new 2023 WHF criteria to identify affected children early; training and innovation: developing task-sharing programs with mid-level healthcare workers, supported by telemedicine; social action: reducing overcrowding, improving housing, educating families, empowering mothers; integration into national policies: creation of registries, inclusion of RHD in strategies against non-communicable diseases, sustainable funding. This integrated strategy has been described in detail by Carapetis et al. who emphasized that eradication of RHD is feasible with current medical and social tools [10].

Conclusion     

Rheumatic heart disease (RHD) remains an emblematic pathology of social and health inequalities in DRC. It mainly affects children and young adults, reflecting insufficient care, poverty, and overcrowding. Recent advances, notably the 2023 WHF echocardiographic criteria, offer unprecedented opportunities for early screening and prevention, but their implementation remains limited by structural and logistical obstacles. Eradication of RHD is conceivable, provided an integrated approach combining medical prevention, political commitment, and targeted social actions is implemented.

Recommendations

Political and economic actors: integrate RHD into national health strategies, ensure sustainable financing for screening and prophylaxis programs, and improve living conditions to reduce social determinants of disease. Public health actors: establish standardized school-based screening according to WHF 2023 criteria, guarantee regular supply of benzathine penicillin, and create national registries for epidemiological monitoring. Healthcare providers: train mid-level health workers in simplified screening, ensure regular follow-up of affected patients, and promote telemedicine in rural areas. Population and communities: participate in screening programs, promptly treat streptococcal pharyngitis, improve hygiene and housing conditions, and engage actively in family health education. This multidimensional approach would not only reduce RHD-related morbidity and mortality but also tackle the social inequalities at its root, making prevention a true indicator of social justice.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and approved the final version of this manuscript.

Table     

Table 1: evolution of WHF echocardiographic criteria (2012 vs 2023)

References