# Implementing the World Health Organization Guidelines for Rheumatic Heart Disease in Highly Endemic Settings: Balancing Evidence with Reality

## TL;DR

This paper discusses the challenges of implementing WHO guidelines for rheumatic heart disease in areas where it is very common.

## Contribution

The paper highlights practical strategies to improve RHD diagnosis and treatment in resource-limited settings.

## Key findings

- Simplified clinical criteria may improve diagnosis by frontline health workers.
- Handheld echocardiography is recommended but faces implementation barriers.
- Benzathine penicillin G availability and administration remain problematic.

## Abstract

In 2024, the World Health Organization (WHO) released rheumatic heart disease (RHD) guidelines; however, implementation in highly endemic countries remains challenging. The severe nature of RHD in such areas necessitates adopting pragmatic approaches to improve diagnostic yield. The WHO continues to recommend the Jones Criteria for the diagnosis of acute rheumatic fever, even though these criteria have been shown to miss up to 10% of cases. Using simplified clinical criteria is expected to have better sensitivity at the level of frontline health workers. The WHO recommendation to use handheld echocardiography for diagnosis of RHD is a crucial asset for secondary and tertiary prevention of RHD; however, implementation of this strategy might be hampered by limited availability and the need for expert training. While benzathine penicillin G remains the cornerstone of RHD treatment, as recommended by the WHO, persistent issues related to its availability and proper administration techniques need to be addressed.