INTRODUCTION:Peripartum cardiomyopathy (PPCM) affects previously healthy women commonly of African ancestry resulting into elevated morbidity and mortality rates. The clinical characteristics of PPCM are diverse but there is yet limited data on outcomes for women with PPCM in Uganda. We sought to elucidate the clinical presentation, echocardiographic findings, and 6-month outcomes among women with PPCM in Uganda. METHODS:A prospective cohort study of 80 PPCM women matched for age were monitored over a 6-month period while on goal-directed medical therapy (GDMT) was conducted. All participants underwent a physical examination, 12-lead electrocardiography, echocardiography and biomarkers including NT-pro BNP and Prolactin at baseline and at 6-month follow-up visit. Additionally, 80 matched controls were recruited at baseline as comparison for the biomarkers. RESULTS:The mean age of cases and controls was 33.6 ± 6.6 and 30.2 ± 5.9 years respectively. Clinical data for cases were as follows: mean left ventricular ejection fraction (LVEF) was 35.7 ± 11.0%, mean LV global longitudinal strain (GLS) was -11.9 ± 4.7%, mean right ventricular GLS was -14.7 ± 10.9%. A total of 22 (27.5%) participants had a LVEF <35% while 6 (7.5%) participants had severe RV systolic dysfunction. 20 (25%) participants were in NYHA IV. 54 (68%) participants received bromocriptine therapy in addition to other GDMT. Clinical data for controls were as follows: mean LVEF was 67.2 ± 4.5%, mean LV GLS was -17.1 ± 4.9%, all controls had normal RV systolic function parameters. After 6-months of follow-up, 6 (7.5%) of the cases had died. Atrial fibrillation occurred in 2 (2.5%) participants and intracardiac thrombus was documented among 8 (10%) participants. 52 (65%) participants were in NYHA I. LV recovery (LVEF ≥ 50%) was observed in 37 (46.3%) cases. CONCLUSION:This study shows a high mortality rate of 7.5% aligning with global studies, the observed high thrombus burden and stroke occurred in 10% and 2.5%, respectively which may indicate severity of LV systolic dysfunction at presentation. Two-thirds of patients received Bromocriptine in addition to GDMT which may explain the high rate of LV recovery in this cohort.

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.

Research teams undertaking randomized clinical trials in low-and middle-income countries frequently encounter significant challenges, including limited infrastructure, cultural barriers to trust, and limited resources. Rheumatic heart disease (RHD) trials can be especially difficult because early stages of RHD often show no symptoms, there is low disease awareness among healthcare workers and the public, pediatric heart disease is often stigmatized, and disease management requires burdensome secondary antibiotic prophylaxis. To address these challenges, the RHD Research Collaborative in Uganda (RRCU) partnered with community members to establish a community-centered framework for trial design and implementation that incorporates group-based consent, frequent and personalized communication, and convenient, family-friendly participation structures. These components have been successfully adapted and applied across a series of RRCU studies, contributing to exceptionally high rates of consent, retention, and prophylaxis adherence. The RRCU's community-informed approach to trial design and implementation challenges assumptions about research feasibility in low-resource settings and demonstrates that high-quality, ethical pediatric research can be successfully conducted by engaging communities and integrating their values into all aspects of study design and execution.

Rheumatic heart disease (RHD) requires long-term secondary antibiotic prophylaxis to prevent disease progression, yet sustained patient engagement remains challenging in many low- and middle-income countries. Within Uganda’s first integrated decentralized RHD control program, Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Uganda (ADUNU), we applied a human-centered design (HCD) approach to co-develop strategies for improving engagement in care. Using two Group Level Assessment sessions (with n = 43 stakeholders) and three design focus group discussions (n = 23 stakeholders), participants identified and prioritized feasible implementation strategies. Strategies were synthesized into four domains: community integrated follow-up, structured patient health education and counselling, provider capacity and service delivery improvement, and strengthening stock planning for medicine availability. These co-developed strategies directly address barriers related to missed appointments, limited understanding of RHD, provider-patient interactions, and medicine stockouts within decentralized primary care settings. This participatory approach generated contextually grounded strategies, ready for prospective testing within decentralized RHD programs.

Cardiovascular disease (CVD) morbidity and mortality are increasing globally, including among patients living with human immunodeficiency virus (HIV). We aimed to determine the risk of all-cause mortality and morbidity in patients with CVD, comparing those with and without HIV infection, and whether mortality differed by HIV status during hospitalization for Major Adverse Cardiovascular Events (MACE) components (stroke, acute myocardial infarction (AMI), and heart failure) in northern Uganda. We conducted a retrospective cohort study at two hospitals in northern Uganda, comparing outcomes in CVD patients with and without HIV hospitalized from January 2015 to June 2023. We utilized a logistic regression model for crude, adjusted, and stratified analyses of MACE components and mortality by HIV status. Among 2,127 CVD patient records analyzed, 292 (13.7

BACKGROUND:Recently under the European Society of Cardiology (ESC) EURObservational Research Programme (EORP) PPCM registry the first predictive score was derived. This study sought to test the validity of this predictive score in a cohort of women with PPCM in Uganda. METHODS:80 PPCM cases enrolled had a 12-lead electrocardiography, echocardiography at baseline and at 6-months follow-up. Core clinical data included LVEF, LVEDD, duration of symptoms, QRS duration and pre-eclampsia were captured. RESULTS:Recovered participants' scores included one case who scored ≤ 1 and one of 2, six cases had a score of 3, fifteen cases had a score of 4, six cases had a score of 5, two cases had a score of 6 and only five cases had the highest score of 7. The discrimination analysis achieved a c-statistic of 0.67. CONCLUSION:The ESC EORP PPCM LV predictive recovery score under performed in predicting LV recovery in our Ugandan PPCM cohort.

Background Rheumatic heart disease (RHD) interventions are currently being rolled out in Northern Uganda. We recently evaluated a programme to decentralise secondary antibiotic prophylaxis (SAP) from regional hospitals to primary clinics in Lira and Gulu districts, finding equivalent adherence and high acceptability. The present study evaluated the cost implications of the programme. Methods We prospectively assessed costs from the purchaser, patient, and societal perspectives, comparing unit and total costs before and after programme implementation. We used a mixed costing approach, including ingredients-based and step-down costing for direct and indirect costs (respectively) to the purchaser. We assessed patient costs through exit surveys. Cost data were analysed using descriptive statistics and t-tests for changes after implementation. A sensitivity analyses was done around indirect costs. Results The programme reduced purchaser costs for clinical services (overheads, personnel and medications) by over 50% in both districts. Likewise, it significantly reduced patient costs, by lowering transport costs and productivity losses. To enable this, substantial investments were needed for implementation strategies (“programme costs”) to support SAP delivery, especially for equipment and training. Our findings were robust in the sensitivity analysis. Conclusion Compared to current practice, an RHD decentralisation programme reduced the unit cost of SAP to the purchaser, though this was attenuated by higher programme costs. The programme provided financial benefit to low-income households and reduced the volume of RHD care at hospitals. Future projects could seek to reduce programme costs, by streamlining training activities. Our findings can inform the design of RHD programmes in the region.

BACKGROUND:Early echocardiographic detection improves rheumatic heart disease (RHD) outcomes, but screening in endemic, resource-limited settings remains a challenge. The Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Northern Uganda program was developed to integrate task-shifted RHD screening into the existing health system in Kitgum, Uganda. We evaluated the program's impact on RHD case detection and assessed screening performance during its first year. METHODS:We conducted a programmatic evaluation of all individuals screened via the program from May 2023 to April 2024, describing demographic and echocardiographic findings. We assessed sensitivity, specificity, predictive values, and accuracy of screenings performed by health care workers who had completed the full training, using expert-confirmed diagnoses as the gold standard. RESULTS:Of 11 793 individuals screened, 806 (6.8%) screened positive, with 544 receiving confirmatory testing. A total of 126 new RHD cases were diagnosed (74 mild, 52 moderate/severe). Among 3243 screenings by fully trained health care workers, sensitivity was 55% (95% CI, 47%-63%), specificity 97% (95% CI, 97%-98%), positive predictive value 52% (95% CI, 45%-60%), negative predictive value 98% (95% CI, 97%-98%), and accuracy 95% (95% CI, 95%-96%). Accuracy varied with age, sex, and health care worker screening volume: older age (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]) and female sex (OR, 0.46 [95% CI, 0.22-0.91]) were associated with decreased accuracy, whereas higher screening volume improved accuracy (OR, 5.24 [95% CI, 2.52-10.65]). CONCLUSIONS:Task-shifted echocardiographic screening can be effectively integrated into low-resource health systems. Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Northern Uganda trained a local screening workforce and identified 126 new RHD cases in its first year. Moderate sensitivity and subgroup variability indicate opportunities for improvement through targeted training and supportive technologies.

Acute rheumatic fever (ARF), the acute autoimmune sequela of group A Streptococcus infection, and its chronic life-threatening manifestation, rheumatic heart disease (RHD), which causes permanent heart valve damage, remain major drivers of preventable cardiovascular mortality and disability in low-income and middle-income countries. Since the mid-1990s, multidisciplinary and international collaborative research has yielded new insights into the role of superficial skin infections such as impetigo in ARF pathogenesis and the disease mechanisms that underlie the progression from ARF to RHD, and has explored novel treatments and delivery mechanisms in clinical trials and progressed the development of Strep A vaccines. Early detection and patient care have advanced, with revised echocardiographic screening criteria and the 2024 WHO guidelines, which provide a framework for evidence-based management and therapeutic strategies. Notwithstanding these advancements, considerable disparity persists in the care, control and treatment of advanced disease, necessitating coordinated programmes, prioritization by global agencies and local governments, and substantial involvement of those with RHD. Of note, few to no cardiac surgery programmes exist in some countries most burdened by RHD. Future research must encompass implementation studies for validated evidence-based therapies, translational technologies and applications, together with a definitive pathway to direct patient effect, to achieve the WHO target of eliminating RHD as a public health problem.

Rheumatic heart disease (RHD) represents a significant global health challenge, disproportionately affecting over 40 million people in low- and middle-income countries. Early detection through color Doppler echocardiography is crucial for treating RHD, but it requires specialized physicians who are often scarce in resource-limited settings. To address this disparity, artificial intelligence (AI)-driven tools for RHD screening can provide scalable, autonomous solutions to improve access to critical healthcare services in underserved regions. This paper introduces RADAR (Rapid AI-Assisted Echocardiography Detection and Analysis of RHD), a novel and generalizable AI approach for end-to-end spatiotemporal analysis of color Doppler echocardiograms, aimed at detecting early RHD in resource-limited settings. RADAR identifies key imaging views and employs convolutional neural networks to analyze diagnostically relevant phases of the cardiac cycle. It also localizes essential anatomical regions and examines blood flow patterns. It then integrates all findings into a cohesive analytical framework. RADAR was trained and validated on 1,022 echocardiogram videos from 511 Ugandan children, acquired using standard portable ultrasound devices. An independent set of 318 cases, acquired using a handheld ultrasound device with diverse imaging characteristics, was also tested. On the validation set, RADAR outperformed existing methods, achieving an average accuracy of 0.92, sensitivity of 0.94, and specificity of 0.90. In independent testing, it maintained high, clinically acceptable performance, with an average accuracy of 0.79, sensitivity of 0.87, and specificity of 0.70. These results highlight RADAR’s potential to improve RHD detection and promote health equity for vulnerable children by enhancing timely, accurate diagnoses in underserved regions.

OBJECTIVE:To evaluate the impact of maternal postpartum body mass index on cardiovascular health at 12 months postpartum in a low-resource urban Black African population. STUDY DESIGN:Ugandan women (n = 653) were recruited from 20 weeks until labour onset at a national maternity hospital in urban Kampala. At 12 months postpartum, participants underwent cardiovascular assessment including echocardiography, pulse wave velocity, and blood pressure measurement. Multivariable regression models were used to assess associations between postnatal maternal body mass index and 12-month cardiovascular risk markers. RESULTS:Women with body mass index ≥ 30 kg/m2 were more likely than women with body mass index < 30 kg/m2 to have ≥1 cardiovascular marker above the 95th cohort-derived centile at 12 months postpartum (OR 1.69, 95% CI: 1.23-2.32, p = 0.001). Women with body mass index ≥30 kg/m2 had increased left ventricular mass (p < 0.001), left ventricular (p < 0.001) and atrial (p < 0.001) diameters, and wall thickness (p = 0.02) compared to women with body mass index <30 kg/m2. Postnatal pulse wave velocity (p < 0.001) and blood pressure (p = 0.03) were higher in women with body mass index ≥30 kg/m2, although this was not associated with an increase in overt cardiovascular complications including reduced left ventricular ejection fraction (p = 0.08) or increased rates of hypertension (p = 0.91). CONCLUSIONS:Elevated postnatal maternal body mass index is associated with increased cardiovascular risk markers at 12 months postpartum, even after adjustment for relevant pregnancy complications, socioeconomic status, and maternal age. These findings suggest that postnatal weight management strategies merit exploration as interventions aimed at reducing the high risk of cardiovascular disease affecting Black African women in low-resource urban populations.

BACKGROUND:The World Health Organization recommends echocardiographic screening and secondary prophylaxis for rheumatic heart disease (RHD), but evidence on how to implement these interventions within healthcare systems is limited. We report early implementation and clinical outcomes of an RHD program in northern Uganda. METHODS:From May 2023, the District Health Office in Kitgum trained primary healthcare workers in RHD screening and implemented registry-based secondary antibiotic prophylaxis in public facilities. We analyzed program and registry data through December 31, 2024. Data were obtained from aggregated program reports and individual-level records from the national RHD registry. We developed an RHD care cascade to examine screening uptake and outcomes, including adherence to secondary antibiotic prophylaxis. Adherence was categorized as perfect (100%), near perfect (90%-99%), acceptable (80%-89%), suboptimal (60% to 79%), or poor (<60%). Differences in mean adherence across subgroups were evaluated using 1-way ANOVA and χ2 tests. Time-to-event analysis was conducted to assess the probability of receiving an injection over time since enrollment. RESULTS:Health workers screened about 1% of the district's target population each month. Over 18 months, 25 358 people were screened, including 1213 (4.8%) positive screens and 333 (1.3%) confirmed RHD cases. Among those screened, 16 406 (64%) were female, and 10 746 (42%) and 7333 (28%) were children (aged 5 years-14 years) and adolescents (aged 15 years-24 years), respectively. Of those with positive screens, 972 (80%) received confirmatory echocardiograms. Confirmed cases were relatively young (mean age 28 years), and 224 (67%) were female. Overall, 220 (75%) individuals achieved at least acceptable adherence. Among those who defaulted, 79% did so within 6 months of enrollment. CONCLUSIONS:An integrated RHD program in Uganda achieved successful delivery of echocardiographic screening within primary healthcare and acceptable early outcomes. The care cascade framework can be used to monitor similar RHD programs and identify opportunities for improvement.

IntroductionEchocardiography screening for rheumatic heart disease (RHD) has gained support as a public health approach, but scale up of RHD screening services is complex. We sought to evaluate the effectiveness of a novel training program to build non-expert competency for RHD echocardiography screening within the Uganda public health system and to describe the human and material resources required to support it.MethodsGuided by a logic model, we evaluated the Accelerating Delivery of Rheumatic Heart Disease Prevention in Northern Uganda (ADUNU) Program, a novel RHD control program, 15 months after its implementation within the Ugandan public health care system.ResultsSixty-one healthcare workers (HCW) across 10 public health facilities started in training under the program, of which 58 (95%) advanced past the initial stage of training and earned conditional certification to screen for RHD with ongoing remote and in-person feedback and oversight. Of these, 17 (29%) completed all stages of training and earned full certification to independently screen for RHD with no ongoing oversight. A total of 17,927 community members were screened through ADUNU during the program's first 15 months. After receiving final certification, 14 HCWs (93%) continued to perform screening echocardiograms (≥20/month) at median follow-up of 8 months [IQR 8-10]. HCW sensitivity and specificity were 61% and 96%, respectively.ConclusionDevelopment and deployment of a large scale RHD screening echocardiography training program within an existing public health system is feasible. Future program iterations are needed to improve HCW screening sensitivity and decrease the reliance on human resources.

Introduction Detection and treatment of streptococcal pharyngitis in children reduces acute rheumatic fever by 70–80%. However, investment in primary prevention is limited in rheumatic heart disease (RHD) endemic countries due to lack of diagnostic capacity. We conducted a pragmatic public health trial (Rheumatic Heart Disease Community Streptococcal Treatment Program (RESET)) to determine the effect of an integrated group A streptococcal (GAS) education and treatment programme on the echocardiographic burden of RHD among children aged 5–15 years in Uganda.Methods We implemented our interventions within the primary healthcare system of Tororo district, Eastern Uganda, over 2 years. The primary outcome was a reduction in RHD prevalence. Secondary outcomes included improved provider and community knowledge and increased health-seeking behaviour for sore throat. Interventions targeted three key barriers to primary prevention: limited provider expertise in diagnosing and treating GAS pharyngitis, poor uptake of guideline-based treatment and low public awareness of the link between sore throat and RHD.Results There was no significant change in RHD prevalence from baseline (0.66%, 95% CI 0.58% to 0.73%) to 2 years post-implementation (0.61%, 95% CI 0.51% to 0.71%). Primary training was completed by 101 healthcare workers with knowledge scores improving from 55% pre-training to 75% post-training. Secondary training reached 470 providers across 81 facilities. Facility assessments found only one-third met nearly all readiness metrics. Over 2000 community education events reached an estimated 380 000 people. Recognition of sore throat as a serious issue improved with 89% post-campaign identifying its link to heart disease. Health centre logs showed no increase in sore throat presentations over 22 months.Conclusion As the first large-scale integrated primary prevention programme for RHD in sub-Saharan Africa, RESET demonstrated both feasibility of scaling up patient and provider education and implementation challenges in translating education into action. Ongoing research aims to identify care-seeking barriers and co-design a sore throat treatment model tailored to the community’s cultural and contextual needs.Trial registration number NCT05276999.

The co-occurrence of HIV and non-communicable diseases (NCDs), particularly hypertension, is a growing global health issue. As people living with HIV (PLHIV) live longer due to antiretroviral therapy (ART), they become more susceptible to NCDs like hypertension due to chronic inflammation, long-term drug side effects, and metabolic factors that compound their risk. The integrated HIV/HTN project implemented a feasible and cost-effective multi-component intervention in several public health facilities in Uganda. In this study, we sought to evaluate the program sustainability of the intervention by the public health delivery system. A mixed-methods cross-sectional study was conducted across 26 public health facilities in 13 intervention districts of southwestern Uganda. Quantitative data were collected using the Program Sustainability Assessment Tool (PSAT) from District Health Officers (N = 15), HIV focal persons (N = 10), and Facility/Clinic in-charges (N = 25). Qualitative data were gathered through in-depth interviews with healthcare managers and analyzed using Stata and Dedoose software. The PSAT Partnerships domain scored high (5.68), reflecting strong stakeholder engagement, communication, and leadership involvement. The Organizational Capacity domain also performed well (5.66), with strong integration of hypertension screening and data management, resource management and staff training rated at 4.24 and 4.9 respectively. Integration of HTN into HIV Care Evaluation scored (5.54), excelling in public communication but needing improvement in reporting and evaluation capacity. The Communications domain (5.51) showed moderate effectiveness, with room to enhance public engagement and feedback strategies. Environmental Support was the weakest domain (4.73), highlighting the need for better resource mobilization and training adequacy. The sustainability of a multi-component care model was strongly influenced by strong partnerships and leadership. To ensure long-term success, environmental support, resource management, and sustainability planning is essential. Addressing these gaps will strengthen ongoing integration efforts in resource-limited settings. ClinicalTrials.gov, TRN: NCT04624061, Registration date: 04 November 2022.

Prompt diagnosis of group A streptococcal pharyngitis is essential for primary prevention of acute rheumatic fever and rheumatic heart disease, yet affordable point-of-care diagnostics remain limited in low-resource settings. We conducted a prospective study among Ugandan children 5-15 years of age presenting with sore throat, comparing smartphone-acquired oropharyngeal videos analyzed using an artificial intelligence-based image recognition model-trained and validated using combined data from Ugandan and US-based cohorts-with microbiologic culture as the reference standard. Among 82 children evaluated with the optimized model, 12 (15%) had culture-confirmed group A streptococcal pharyngitis. The smartphone-based approach demonstrated 100% sensitivity (95% confidence interval [CI]: 73.5%-100%), 95.7% specificity (95% CI: 88.0%-99.1%) and an overall accuracy of 96.6% (95% CI: 90.0%-99.3%), with an area under the receiver operating curve of 0.93 (95% CI 0.83-1.00). These findings support the potential of smartphone-based artificial intelligence as a rapid, noninvasive diagnostic tool for primary prevention in rheumatic heart disease-endemic settings.

BACKGROUND:Secondary antibiotic prophylaxis is the only intervention known to prevent rheumatic heart disease progression, yet delivery of prophylaxis at scale in low-resource settings has proven challenging, undermining many global programmes. We sought to assess whether enhanced prophylaxis support for rheumatic heart disease, administered through community health workers in the public health system, was feasible and a scalable model. METHODS:The CAMPS trial was a pragmatic randomised trial of prophylaxis supports integrated into routine care in Eastern Uganda. Children and adolescents with rheumatic heart disease who were aged 5-17 years were randomly assigned (1:1) using permuted block randomisation to either usual care or enhanced support. Enhanced support consisted of case managers and peer groups. Participants and providers were not masked to treatment assignment due to the study design. Children were followed up for 12 months to compare the primary outcome of prophylaxis adherence, measured as a continuous variable of days covered, using a modified intention-to-treat analysis principle. Secondary outcomes were treatment satisfaction, and patient and caregiver health-related quality of life scores. This trial is registered at ClinicalTrials.gov, NCT05502042, and has been completed. FINDINGS:Between Aug 9, 2022, and Aug 9, 2023, 208 individuals were enrolled in the study and included in the analysis. 104 (50%) individuals were randomly assigned to the usual care group and 105 (50%) to the enhanced support group; one participant in the usual care group was excluded from the primary analysis as they died before the first injection, meaning that 103 participants were analysed in the usual care group. 121 (58%) participants were female and 87 (42%) were male. After 12 months, mean adherence was 80·0% (SD 19·0) for those receiving usual care, compared with 98·2% (7·1) for those receiving enhanced support (estimated mean difference in adherence of 18·2%, 95% CI 14·4-22·1; p<0·0001). No significant differences were found between groups in treatment satisfaction (mean between-group difference of 0·1 points [95% CI -1·9 to 2·1] at 12 months) or quality of life (2·3 [-1·1 to 5·8] for patient score; 1·3 [-1·6 to 4·1] for caregiver score). INTERPRETATION:The integration of community health workers into rheumatic heart disease supports within the public health system provides an effective and likely scalable model to improve outcomes for children with rheumatic heart disease in low-resource settings. Further research should examine scale-up and scale-out of these strategies, formally explore cost, and rigorously partner with diverse groups of patients to shape adaptations to this design and ensure appropriateness for all groups affected by rheumatic heart disease. FUNDING:Thrasher Research Fund Early Career Award and Edwards LifeSciences Foundation.