title: Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren.
abstract: BACKGROUND
  Rheumatic heart disease (RHD) is an important problem in developing countries; however, many cases are detected only when the disease has progressed to cardiac failure. Screening can detect cases earlier, but there are no screening guidelines.
  
  
  METHODS
  We performed a cross-sectional screening study in Tonga among 5,053 primary school children, in whom auscultation followed by echocardiography of those with heart murmurs were used to identify RHD. We also analyzed whether a three-stage screening protocol of auscultation performed by a medical student to detect any heart murmur, second-stage auscultation performed by a local pediatrician to differentiate pathological from innocent murmurs and echocardiography of those with pathological murmurs altered outcomes.
  
  
  RESULTS
  The prevalence of definite RHD was 33.2 per 1,000. The prevalence of RHD increased significantly with age, peaking at 42.6 per 1,000 in children aged 10-12 years. Most valve lesions (91 [54%] of 169) were mild. Auscultation to detect pathological murmurs was poorly sensitive (46.4%), and the finding of any murmur on auscultation did not affect the likelihood of detecting pathology on echocardiography. The finding of a pathological murmur did significantly increase the likelihood of detecting pathology on echocardiography, but still missed 54% of those with pathology (mainly RHD) detected on echocardiography.
  
  
  CONCLUSIONS
  Screening is a useful method for detecting asymptomatic RHD in regions of high prevalence and we report a high echocardiographically confirmed prevalence. The most appropriate screening strategy remains to be confirmed, however, and implementation will depend on the availability of echocardiography and trained staff.
authors.affiliation: Menzies School of Health Research, Charles Darwin University, Darwin, Australia. jonathan.carapetis@menzies.edu.au
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Carapetis
authors.forename: Myra
authors.initials: M
authors.lastname: Hardy
authors.forename: Toakase
authors.initials: T
authors.lastname: Fakakovikaetau
authors.forename: Rohayati
authors.initials: R
authors.lastname: Taib
authors.forename: Lyn
authors.initials: L
authors.lastname: Wilkinson
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Penny
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Steer
mesh_terms: D002648:Child; D003430:Cross-Sectional Studies; D003937:Diagnosis, Differential; D004452:Echocardiography; D005260:Female; D006326:Heart Auscultation; D006337:Heart Murmurs / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D011237:Predictive Value of Tests; D015995:Prevalence; D012214:Rheumatic Heart Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology; D012680:Sensitivity and Specificity; D019023:Stethoscopes; D014058:Tonga / Q000453:epidemiology