Early Detection: Echocardiographic Screening The clinical diagnosis of ARF remains challenging As a consequence, the majority of the patients even with advanced RHD do not have a previously documented history of ARF and hence miss out on lifesaving secondary prophylaxis.15 The regions of the world that are crippled by the human and socioeconomic cost of severe RHD are currently carefully evaluating the role of early detection of RHD via echocardiographic screening, which would allow for detection of disease before symptomatic heart failure develops and expensive cardiac surgery or percutaneous intervention are the only lifesaving options The optimum approach for early detection of RHD is yet to be defined but potentially involves population-based or alternatively opportunistic echocardiographic screening of the young In 2012, the World Heart Federation developed echocardiographic diagnostic criteria for RHD to facilitate early case detection (see Box 55.1).22 It has proved to be both sensitive21,84 and specific.85,86 However, unanswered questions remain, including the natural history of subclinical (definite and borderline) RHD Even patients with borderline RHD are at substantial risk of ARF and disease progression.87–89 Longitudinal evaluation of echocardiographic screening programs is needed to define the absolute benefit/cost ratio because two factors restrict its widespread use in resource-poor settings: the expense of portable equipment and the shortage of highly specialized health care workforces Initial studies show promising findings for echocardiographic screening programs led by nurses/nonexperts, although further evaluation and refinements are needed.90,91 Establishing Centers for Rheumatic Heart Disease One of the unmet needs in the fight against ARF and RHD is the gross shortage or virtual nonexistence of strategically located specialized centers of excellence to deal, in a comprehensive manner, with different aspects of the disease.72,92–94 This has been clearly emphasized in the Addis Ababa communique95 and Cairo Accord recommendations94 (Box 55.5) along with other important strategies for the eradication of RHD The scope of these centers would ideally include prevention, treatment, and research at population, basic science, translational, and clinical levels Attempts at enhancing the quality of the services offered in these centers are being made by establishing dedicated consortia in the developing countries.96 Box 55.5 Recommendations to the African Union Commission and Member States From the Third All-Africa Workshop on ARF and RHD: “Addis Ababa Communiqué” Providing Seven Key Actions to Eradicate Rheumatic Heart Disease in Africa Establish prospective RHD registers at sentinel sites in affected member states in order to monitor RHD-related health outcomes, including the achievement of a 25% reduction in mortality from RHD by the year 2025 Ensure adequate supplies of high-quality benzathine penicillin that can be administered in the most effective manner, in order to achieve primary and secondary prevention of RHD Guarantee universal access to reproductive health services for women with RHD and other NCDs, in whom pregnancy carries specific and often fatal risks, and for whom contraception can reduce maternal and fetal mortality Decentralize appropriate technical expertise to the primary and district levels in order to improve the diagnosis of ARF (which is underdiagnosed in Africa) and early detection, diagnosis, secondary prevention and treatment of RHD using cross-cutting point-of-care technologies such as cardiac ultrasound, anticoagulation testing and rapid antigen tests for group A streptococcal pharyngitis Establish centers of excellence for cardiac surgery, which will sustainably deliver state-of-the-art surgical care, train the next generation of African cardiac practitioners, and conduct research on endemic cardiovascular diseases, including RHD Foster multisectoral and integrated national RHD control programs led by the Ministry of Health, which will oversee the implementation of national RHD action plans in order to achieve the goal of reducing mortality from RHD and other NCDs by 25% by the year 2025 Cultivate, through a strong communication framework, partnerships between the AUC, ministries responsible for health, international agencies, governments, industry, academia, civil society and other relevant stakeholders, in order to ensure the implementation of the above actions, and the connection of African RHD control measures with the emerging global movement towards RHD control ARF, Acute rheumatic fever; NCDs, noncommunicable diseases; RHD, rheumatic heart disease From Roberts K, Maguire G, Brown A, et al Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening Med J Aust 2015;203(5):219; and Watkins, D, Zuhlke L, Engel M, et al Seven key actions to eradicate rheumatic heart disease in Africa: the Addis Ababa communique Cardiovasc J Afr 2016;27(3):184–187 Importantly, these centers should guarantee sustainability and accessibility to the surrounding affected communities Funding of the centers of excellence can be achieved by nongovernment organizations, harnessing the efforts of the local and international communities, to be followed gradually by the establishment of