Table 4.

Adaptable Strategies for Successful Active RHD Surveillance

PROVAR Design Feature	Challenge Addressed	Translational Strategy for LMIC
Diagonal integration
Screening for RHD within primary healthcare clinics	Vertical (RHD‐specific) vs diagonal (integration into existing systems) program	Identification of platforms for accessing at‐risk populations (women and children) Integration with other disease‐specific programs or primary care (when available)
Follow‐up of screen‐positive cases at the primary healthcare center	Low rates of follow‐up for screen+examinations, patient barriers to travel for care	Consider outreach strategies to bring follow‐up locally, task shifting to lower providers after initial confirmatory diagnosis
Use of handheld echocardiography machines	Equipment costs, multifunctional uses	Consider point‐of‐care (not fully functional) echocardiographic equipment to reduce costs, and equipment that can be multipurpose (obstetrical and vascular imaging)
Use of equipment for all cardiac concerns and all ages	Single focus (RHD) vs assessment for other common cardiac conditions Improved overall care delivery	Explore expansion of indications for screening echocardiography to address other cardiac conditions
Educational programs for community awareness (house‐to‐house education by community health workers already visiting homes)	Suboptimal participation in screening. Low community knowledge of RHD	Identification of existing educational resources (village health teams, schools, and community organizations) to add RHD education
Task shifting
Use of nonspecialty physicians and nonphysicians for image acquisition	Constrained human resources	Identify a workforce available for continuous training of nonexperts, task shift as appropriate
Web‐based initial training	Trainer and trainee time, need for ongoing training of new staff	Consider asynchronous learning platforms
Telemedicine/web‐based applications
Telemedicine for diagnosis	Constrained human resources, large geographic areas	Consider best staffing for final diagnosis in your setting Can experts be virtually accessed thorough telemedicine
Continuous competency assessment	Maintenance of high standards and competency	Consider remote monitoring and retraining of staff through telemedicine
Web‐based RHD registry	Case tracking and provision of secondary prophylaxis	Consider centralized registers, making RHD a reportable condition

LMIC indicates low‐ and middle‐income countries; PROVAR, Rheumatic Valve Disease Screening Program; and RHD, rheumatic heart disease.