{
  "abstract": "Background Rheumatic heart disease (RHD) remains a major cause of morbidity and mortality in low-resource settings, underscoring the need for accurate and scalable screening approaches. The 2023 World Heart Federation (WHF) screening criteria were designed to facilitate task-shifting but real-world performance data are limited. We evaluated the diagnostic accuracy and operational performance of the 2023 WHF criteria in a large school-based screening programme in Uganda.Methods We conducted a cross-sectional diagnostic accuracy study among 11 198 children aged 5–17 years screened between September and November 2024 in Lira District, Northern Uganda. All screen-positive children (n=522) and a stratified random sample of screen-negative children (n=3301) underwent confirmatory echocardiography. The index test was nurse-performed handheld echocardiography using a standardised three-view protocol. The reference standard was comprehensive echocardiography interpreted by a blinded expert adjudication panel using full WHF criteria. Diagnostic accuracy metrics included sensitivity, specificity, positive and negative predictive values and likelihood ratios. Partial verification bias was addressed using multiple imputation.Results Among 3802 participants who had the reference standard test and no alternative cardiac diagnosis, 122 cases of RHD were identified. After accounting for partial verification bias, sensitivity was 60.0% (95% CI 46.6 to 73.5%) and specificity 96.3% (95% CI 96.0 to 96.7%). Positive and negative predictive values were 19.5% and 99.4%, respectively. Complete-case analysis overestimated sensitivity (80.3%) and underestimated specificity (89.0%). Missed cases were predominantly early-stage or aortic valve disease, with no advanced cases missed. Exploratory analysis using single-expert interpretation yielded comparable performance.Conclusions In this large real-world evaluation, nurse-performed handheld echocardiographic screening using the 2023 WHF criteria demonstrated high specificity and negative predictive value, supporting its role as a scalable frontline triage strategy for RHD. After accounting for partial verification bias, sensitivity was moderate, with missed cases representing early-stage disease, highlighting opportunities to improve case detection through optimisation of screening workflows, training and technology.",
  "authors": [
    {
      "affiliations": [
        "Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda",
        "Department of Research and Compliance, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda"
      ],
      "name": "Joselyn Rwebembera"
    },
    {
      "affiliations": [
        "Global Health Initiative, Children’s National Hospital, Washington, District of Columbia, USA"
      ],
      "name": "Alison Spaziani"
    },
    {
      "affiliations": [
        "Department of Research and Compliance, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda",
        "Division of Research, Uganda Heart Institute, Kampala, Uganda"
      ],
      "name": "Jenifer Atala"
    },
    {
      "affiliations": [
        "Department of Research and Compliance, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda",
        "Division of Research, Uganda Heart Institute, Kampala, Uganda"
      ],
      "name": "Jane-Liz Nambogo"
    },
    {
      "affiliations": [
        "Department of Research and Compliance, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda",
        "Division of Research, Uganda Heart Institute, Kampala, Uganda"
      ],
      "name": "Jafesi Pulle"
    },
    {
      "affiliations": [
        "Department of Research and Compliance, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda",
        "Division of Paediatrics, Uganda Heart Institute, Kampala, Uganda"
      ],
      "name": "Emma Ndagire"
    },
    {
      "affiliations": [
        "Division of Research, Uganda Heart Institute, Kampala, Uganda",
        "Department of Finance and Administration, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda"
      ],
      "name": "Mucunguzi Atukunda"
    },
    {
      "affiliations": [
        "Global Health Initiative, Children’s National Hospital, Washington, District of Columbia, USA"
      ],
      "name": "Rachel Sarnacki"
    },
    {
      "affiliations": [
        "Division of Adult Cardiology, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil"
      ],
      "name": "Maria Carmo Nunes"
    },
    {
      "affiliations": [
        "Division of Cardiology, Children’s National Hospital, Washington, District of Columbia, USA",
        "School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA"
      ],
      "name": "Jennifer Klein"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA"
      ],
      "name": "Meghan Zimmerman"
    },
    {
      "affiliations": [
        "Division of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda",
        "School of Medicine, Uganda Christian University, Mukono, Uganda"
      ],
      "name": "Twalib Aliku"
    },
    {
      "affiliations": [
        "Division of Adult Cardiology, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil"
      ],
      "name": "Luz Marina Tacuri Chavez"
    },
    {
      "affiliations": [
        "Department of Pediatrics, University of Cape Town, Rondebosch, South Africa"
      ],
      "name": "John Lawrenson"
    },
    {
      "affiliations": [
        "Infection, Immunity and Global Health, Murdoch Children’s Research Institute, Parkville, Victoria, Australia"
      ],
      "name": "Chris Selman"
    },
    {
      "affiliations": [
        "Infection, Immunity and Global Health, Murdoch Children’s Research Institute, Parkville, Victoria, Australia",
        "Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia"
      ],
      "name": "Anneke Grobler"
    },
    {
      "affiliations": [
        "Infection, Immunity and Global Health, Murdoch Children’s Research Institute, Parkville, Victoria, Australia",
        "Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia"
      ],
      "name": "Andrew Craig Steer"
    },
    {
      "affiliations": [
        "Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda",
        "Department of Research and Compliance, Rheumatic Heart Disease Research Collaborative in Uganda, Kampala, Uganda"
      ],
      "name": "Emmy Okello"
    },
    {
      "affiliations": [
        "The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA",
        "School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA"
      ],
      "name": "Andrea Beaton"
    },
    {
      "affiliations": [
        "Division of Cardiology, Ochsner Children’s Hospital, New Orleans, Louisiana, USA"
      ],
      "name": "Craig Sable"
    },
    {
      "affiliations": [
        "Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda"
      ],
      "name": "Damalie Nakanjako"
    }
  ],
  "title": "Operational performance of the 2023 World Heart Federation screening criteria for rheumatic heart disease in a high-risk, resource-limited population",
  "uid": "54b23e12-8c39-5a38-9475-59b9410b617e"
}