The burden of rheumatic heart disease and issues affecting the provision of care in Malawi: A scoping review

Abstract

Background Rheumatic heart disease (RHD) is an autoimmune sequela of group A streptococcal (GAS) pharyngitis. Acute rheumatic fever (ARF), a complication arising 2–3 weeks after GAS infection, can cause damage to the valves of the heart and, ultimately, RHD. This trajectory towards severe disease is now rare in high-income countries. In Malawi, as in many low-income countries, RHD continues to pose a significant challenge. Limited access to healthcare and poor education likely contribute to the disease burden. This scoping review aims to determine the present burden of GAS, ARF and RHD in Malawi, the issues affecting the provision of care and the solutions that have been proposed. Method A search was conducted of ‘PubMed’, ‘EMBASE’, ‘Cochrane Library’ and ‘Clinicaltrials.gov’ to identify research published between 1995 and 2024 according to the Arksey and O’Malley framework. The PRISMA extension for Scoping Review (PRISMA-ScR) Checklist guided the search (Supplementary File 3). Results Data were extracted from thirty articles. RHD prevalence among Malawian children ranges between 3.4% and 5.3%, with high rates of late presentation (62%-82.5% presenting with severe disease). Inadequate health system infrastructure, limited RHD-specific education for healthcare providers, and inconsistent availability of benzathine penicillin G for secondary prophylaxis were identified as key challenges. Rural areas, comprising 84% of Malawi’s population, are particularly underserved. Task-shifting to non-physician healthcare workers in primary care has shown promise. Much less research was available on ARF and GAS infections. Conclusion The significant morbidity and mortality associated with RHD is a major concern in the communities and healthcare systems of Malawi. Primary care resourcing and improved education are areas requiring attention. To address the high burden of disease in the country, ongoing research is largely focused on establishing a sufficiently large and appropriately trained workforce to diagnose and monitor RHD using the resources available within the constraints of the country’s socioeconomic context.