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First Presentation Acute Rheumatic Fever is Preventable in a Community Setting: A School-based Intervention

Lennon, Diana, MB ChB*†‡; Anderson, Philippa, MB ChB§; Kerdemilidis, Melissa, MB ChB; Farrell, Elizabeth, MHSc; Crengle Mahi, Suzanne, MB ChB; Percival, Teuila, FRACP; Jansen, David, MB ChB**; Stewart, Joanna, MSc††

The Pediatric Infectious Disease Journal: December 2017 - Volume 36 - Issue 12 - p 1113–1118
doi: 10.1097/INF.0000000000001581
Original Studies

Background: Robust evidence is lacking for community initiatives to prevent first presentation acute rheumatic fever (ARF) by group A streptococcal (GAS) pharyngitis treatment.

Methods: We measured the effect of introducing a sore throat clinic program on first presentation ARF into 61-year 1–8 schools with students 5–13 years of age (population ≈25,000) in Auckland, New Zealand. The study period was 2010–2016. A generalized linear mixed model investigated ARF rate changes before and after the staggered introduction of school clinics. Nurses and lay workers treated culture-proven GAS sore throats (including siblings) with 10 days of amoxicillin. ARF cases were identified from a population-based secondary prophylaxis register. Annual pharyngeal GAS prevalence was assessed in a subset.

Results: ARF rates in 5–13 year olds dropped from 88 [95% confidence interval (CI): 79–111] per 100,000 preclinics to 37 (95% CI: 15–83) per 100,000 after 2 years of clinic availability, a 58% reduction. No change in rate was demonstrated before the introduction of clinics [P = 0.88; incidence risk ratio for a 1-year change: 0.98 (95% CI: 0.63–1.52)], but there was a significant decrease of first presentation ARF rates with time after the introduction of the sore throat program [P = 0.008; incidence risk ratio: 0.61 (95% CI: 0.43–0.88)]. Pharyngeal GAS cross-sectional prevalence fell from 22.4% (16.5–30.5) preintervention to 11.9% (8.6–16.5) and 11.4% (8.2–15.7) 1 or 2 years later (P = 0.005).

Conclusions: ARF declined significantly after school-based GAS pharyngitis management using oral amoxicillin paralleled by a decline in pharyngeal GAS prevalence.

From the *Department of Pediatrics, University of Auckland, Division of Pediatric Infectious Diseases, Starship Children’s Hospital, Auckland District Health Board, Division of Child Health, Kids First Public Health Nursing, Kidz First Community, and §Division of Population Health, Counties Manukau District Health Board, Auckland, New Zealand; Division of Funding and Planning, Canterbury and West Coast District Health Board, Christchurch, New Zealand; Invercargill Medical Centre, Invercargill, New Zealand; **National Hauora Coalition, and ††Division of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand.

Accepted for publication January 12, 2017.

D.L. had full access to all of the data in the study and took full responsibility for the integrity of the data and the accuracy of the data analysis. D.L. and M.K. contributed to the literature search. D.L., P.A., E.F., S.C.M., T.P., D.J. and J.S. contributed to the study concept and design. D.L., P.A., M.K., E.F., D.J. and J.S. contributed in the collection of data. D.L., M.K. and J.S. contributed to data analysis. D.L., P.A., M.K., D.J. and J.S. contributed to the interpretation of data. D.L., P.A. and J.S. contributed to the drafting of the manuscript. D.L., P.A., M.K., E.F., S.C.M., T.P., D.J. and J.S. contributed to the critical revision of the manuscript for important intellectual content. D.L., P.A. and J.S. contributed to the figures. D.L. obtained funding for this study. Administrative, technical or material support was provided by D.L., P.A., E.F., D.J. and J.S., and D.L., P.A. and E.F. supervised the study.

This study was supported by a grant (13–969) from the Health Research Council of New Zealand in partnership with the New Zealand Ministry of Health and the Heart Foundation of New Zealand and Cure Kids.

The authors have no conflicts of interest to disclose.

The funder had no role in the design and concept of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

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Address for correspondence: Diana Lennon, MB ChB, University of Auckland, Tamaki Campus, 261 Morrin Road, Auckland 1072, New Zealand. E-mail:

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