title: Screening for Rheumatic Heart Disease among Peruvian Children: A Two-Stage Sampling Observational Study.
abstract: BACKGROUND
  The objective of the study was to evaluate the implications of different classifications of rheumatic heart disease on estimated prevalence, and to systematically assess the importance of incidental findings from echocardiographic screening among schoolchildren in Peru.
  
  
  METHODS
  We performed a cluster randomized observational survey using portable echocardiography among schoolchildren aged 5 to 16 years from randomly selected public and private schools in Arequipa, Peru. Rheumatic heart disease was defined according to the modified World Health Organization (WHO) criteria and the World Heart Federation (WHF) criteria.
  
  
  RESULTS
  Among 1395 eligible students from 40 classes and 20 schools, 1023 (73%) participated in the present survey. The median age of the children was 11 years (interquartile range [IQR] 8-13 years) and 50% were girls. Prevalence of possible, probable and definite rheumatic heart disease according to the modified WHO criteria amounted to 19.7/1000 children and ranged from 10.2/1000 among children 5 to 8 years of age to 39.8/1000 among children 13 to 16 years of age; the prevalence of borderline/definite rheumatic heart disease according to the WHF criteria was 3.9/1000 children. 21 children (2.1%) were found to have congenital heart disease, 8 of which were referred for percutaneous or surgical intervention.
  
  
  CONCLUSIONS
  Prevalence of RHD in Peru was considerably lower compared to endemic regions in sub-Saharan Africa, southeast Asia, and Oceania; and paralleled by a comparable number of undetected congenital heart disease. Strategies to address collateral findings from echocardiographic screening are necessary in the setup of active surveillance programs for RHD.
  
  
  BACKGROUND
  ClinicalTrials.gov identifier: NCT02353663.
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Ernest
authors.initials: E
authors.lastname: Spitzer
authors.affiliation: Institute of Cardiology CardioSalud, Arequipa, Peru.
authors.forename: Jorge
authors.initials: J
authors.lastname: Mercado
authors.affiliation: University Hospital San Carlos, Madrid, Spain.
authors.forename: Fabian
authors.initials: F
authors.lastname: Islas
authors.affiliation: Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland.
authors.forename: Martina
authors.initials: M
authors.lastname: Rothenbühler
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Reto
authors.initials: R
authors.lastname: Kurmann
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Fabian
authors.initials: F
authors.lastname: Zürcher
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Krähenmann
authors.affiliation: National Hospital Carlos Alberto Seguín Escobedo, Arequipa, Peru.
authors.forename: Nassip
authors.initials: N
authors.lastname: Llerena
authors.affiliation: Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
authors.affiliation: Institute of Cardiology CardioSalud, Arequipa, Peru; National Hospital Carlos Alberto Seguín Escobedo, Arequipa, Peru.
authors.forename: Pedro
authors.initials: P
authors.lastname: Torres
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Pilgrim
mesh_terms: D000293:Adolescent; D000886:Anthropometry; D019072:Antibiotic Prophylaxis; D002648:Child; D002675:Child, Preschool; D005260:Female; D006306:Health Surveys; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging / Q000453:epidemiology; D006801:Humans; D033162:Incidental Findings; D008297:Male; D008403:Mass Screening; D015588:Observer Variation; D010568:Peru / Q000453:epidemiology; D010808:Physical Examination; D015995:Prevalence; D012214:Rheumatic Heart Disease / Q000000981:diagnostic imaging / Q000453:epidemiology*; D012494:Sampling Studies; D012959:Socioeconomic Factors; D014463:Ultrasonography