Rheumatic heart disease (RHD) constitutes a leading cause of premature death and incapacity in Africa, where it is encountered in younger people, and shows a much faster and more serious course than that seen in Europe or North America.

According to the World Health Organization, rheumatic heart disease is the most commonly acquired heart disease in people under age 25. Rheumatic heart disease claims about 288,348 lives each year — the large majority in low- or middle-income countries. The disease results from damage to heart valves caused by one or several episodes of rheumatic fever also called Bouillaud’s disease, an autoimmune inflammatory reaction to throat infection with group A streptococci (streptococcal pharyngitis or strep throat) that can develop within two to three weeks after strep throat isn’t properly treated. It most commonly occurs in childhood and can lead to death or life-long disability.

Group A strep bacteria are very contagious. Generally, people spread the bacteria to others through respiratory droplets and direct contact. In some rare instances, it can be contracted from food that isn’t properly handled. It usually takes two to five days after exposure to become ill with strep throat.

Group A strep bacteria often live in the nose and throat. People who are infected spread the bacteria by talking, coughing, or sneezing. This creates respiratory droplets that contain the bacteria. People can get sick if they breathe in respiratory droplets that contain the bacteria, touch their mouth or nose after touching something with those droplets on it, or use the same plate, utensil, or glass as a person infected with the bacteria.

RHD remains the most common cardiovascular disease and is the leading cause of valve disease in developing countries. The African continent has the highest prevalence in the world, and RHD represents the most common form of acquired cardiovascular disease in children and adolescents. RHD affects between 15.6 and 19.6 million people worldwide, imposing a substantial burden on families, health systems, and communities in many low-income settings.

Despite being a major public health concern, RHD has been neglected in the past, primarily because of the reduction of RHD in high‐income countries of the West. In November 2006, the Rwandan government began to decentralise chronic care for non-communicable diseases, including cardiovascular conditions, placing RHD eradication as a national priority.

According to the World Heart Federation and Pan African Society of Cardiology, in Rwanda, the prevalence of rheumatic heart disease was estimated at 1.0 per cent. However, in 2013, 0.68 per cent of school children, with a mean age of 12.2 years, were identified with RHD and the total RHD mortality rate was 0.17 per cent of all deaths in 2017.

In many resource-limited settings, at least two barriers exist to effective evaluation and treatment of sore throats. The first is clinical, which involves the difficulty in distinguishing streptococcal pharyngitis or strep throat from other, more common causes of throat infections that are mostly viral.

Rheumatic heart disease can be prevented by effective management of streptococcal sore throat, however, treatment at this early stage is often not achieved. In addition to this, many parents may not take their children to healthcare providers opting for more traditional methods.

Environmental factors play a significant role in the spread and prevalence of streptococcal infections, thereby heightening the risk of rheumatic fever. Overcrowded living conditions, inadequate sanitation facilities, and other environmental challenges create ideal breeding grounds for the rapid transmission of strep bacteria among populations. In such settings, individuals are more likely to encounter carriers of the bacteria, increasing their susceptibility to infection.

Strep throat is a treatable illness that precedes both rheumatic fever and rheumatic heart disease and most commonly affects children. Preventing RHD requires a multifaceted approach of primordial, primary, secondary, and tertiary interventions.

Primordial prevention focuses on mitigating social determinants of health to reduce the risk of Group A strep transmission. Primary prevention involves timely diagnosis and treatment of Group A strep infections with penicillin antibiotic treatment to prevent rheumatic fever.

Secondary prevention entails continuous benzathine penicillin prophylaxis to prevent the recurrence of rheumatic fever, as well as early detection and management of RHD to prevent complications. Tertiary interventions involve heart surgery and chronic medical treatment for the management of chronic RHD. Preventing rheumatic heart disease hinges on thwarting the precursor, rheumatic fever.

Key to this strategy is the timely treatment of strep throat with appropriate antibiotics. By swiftly addressing streptococcal infections, particularly in children and adolescents, the risk of developing rheumatic fever significantly diminishes.

This proactive approach not only curtails the immediate symptoms of strep throat but also acts as a vital preventative measure against the potentially severe and long-term complications of rheumatic heart disease. Thus, ensuring access to and adherence to antibiotic treatment for strep throat emerges as a cornerstone in the broader endeavour to combat RHD.

Dr Vincent Mutabazi is an applied epidemiologist.

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