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Introduction:Active case detection using screening echocardiography (echo) has high sensitivity for rheumatic heart disease (RHD). Most children with echo-detected RHD have mild disease, offering a chance to limit progression through secondary prophylaxis. However, implementation of screening programs in RHD endemic areas presents challenges given limited resources. Timing of screening remains an unexplored question. Here, we begin to address screening intervals by assessing risk of RHD among previous screen-negative children in Northern Uganda.Methods:Between June and October 2018, a large school-based echo screening was conducted in Gulu, Uganda and surrounding districts. Prior echo screenings had occurred in the same region in 2013 and 2014. A short 4-question interview was conducted, allowing children to self-identify as having prior screening. All children who self-reported were verified by checking the class and school they reported attending at the prior screening. Additionally, a subset (33%) of the sample was manually cross-checked by name, age, school and grade, to ensure adequacy of recall. Relative risk of RHD was calculated for those with a prior negative screening compared to those undergoing first screening.Results:Echo screening was completed in 102,400 children with 1,608 reporting a previous screening (44-61 months prior). Of the 528 children manually cross-checked, all were confirmed to have participated in a prior program. RHD was diagnosed in 1,099 children (1.1%), 10 (10/1608, 0.6%) of whom were previously screen-negative. The relative risk of RHD in children who have had a negative screening echo compared to those who were never previously screened was 0.58 (95% CI 0.3-1).Conclusions:Children who have a screen-negative echo have a low likelihood of developing RHD over a 4-5 year timeframe. While not reaching significance, prior screen-negative children in our cohort had a nearly 50% lower risk of RHD, indicating a strategy focused on a single screening may be practical. While verification is needed with larger sample sizes, these data provide the first information about a child?s risk of RHD following a negative echo screen and add to the growing implementation literature around this public health approach.