Outbreaks Of Acute Rheumatic Fever Research Articles

An outbreak of acute rheumatic fever in a remote Aboriginal community

ObjectivesWe describe the public health response to an outbreak of acute rheumatic fever (ARF) in a remote Aboriginal community. MethodsIn August 2021, the Northern Territory Rheumatic Heart Disease Control Program identified an outbreak of acute rheumatic fever in a remote Aboriginal community. A public health response was developed using a modified acute poststreptococcal glomerulonephritis protocol and the National Acute Rheumatic Fever Guideline for Public Health Units. Results12 cases were diagnosed during the outbreak; six-times the average number of cases in the same period in the five years prior (n=1.8). Half (n=6) of the outbreak cases were classified as recurrent episodes with overdue secondary prophylaxis. Contact tracing and screening of 11 households identified 86 close contacts. ConclusionsThis outbreak represented an increase in both first episodes and recurrences of acute rheumatic fever and highlights the critical need for strengthened delivery of acute rheumatic fever secondary prophylaxis, and for improvements to the social determinants of health in the region. Implications for Public HealthOutbreaks of acute rheumatic fever are rare despite continuing high rates of acute rheumatic fever experienced by remote Aboriginal communities. Nevertheless, there can be improvements in the current national public health guidance relating to acute rheumatic fever cluster and outbreak management.

The reemergence of serious group A streptococcal infections and acute rheumatic fever.

Acute rheumatic fever and life-threatening group A streptococcal infections have reemerged during the past 15 years to once again become a serious health threat in the developed countries of the world. Reports of outbreaks of acute rheumatic fever in many parts of this country and others have shattered the complacency that the health-care community had acquired related to this devastating sequela of streptococcal pharyngitis. Invasive streptococcal infections, often associated with loss of limbs of life despite optimal antibiotic therapy, have underscored the potential virulence of these organisms. A new clinical entity, streptococcal toxic shock syndrome, has emerged as a consequence of the new invasive strains of group A streptococci. In this article, the authors summarize the recent changes in the epidemiology of group A streptococcal infections and rheumatic fever and review the potential reasons for the increased virulence of these organisms. In addition, they discuss prospects for a streptococcal M protein vaccine designed to control these infections and their sequelae.

The Reemergence of Serious Group A Streptococcal Infections and Acute Rheumatic Fever

<h2>ABSTRACT</h2> Acute rheumatic fever and life-threatening group A streptococcal infections have reemerged during the past 15 years to once again become a serious health threat in the developed countries of the world. Reports of outbreaks of acute rheumatic fever in many parts of this country and others have shattered the complacency that the health-care community had acquired related to this devastating sequela of streptococcal pharyngitis. Invasive streptococcal infections, often associated with loss of limbs or life despite optimal antibiotic therapy, have underscored the potential virulence of these organisms. A new clinical entity, streptococcal toxic shock syndrome, has emerged as a consequence of the new invasive strains of group A streptococci. In this article, the authors summarize the recent changes in the epidemiology of group A streptococcal infections and rheumatic fever and review the potential reasons for the increased virulence of these organisms. In addition, they discuss prospects for a streptococcal M protein vaccine designed to control these infections and their sequelae.

Discontinuing Rheumatic Fever Prophylaxis in Selected Adolescents and Young Adults: A Prospective Study

To assess the safety of discontinuing prophylaxis with antimicrobial agents in patients judged to be at relatively low risk for recurrence of acute rheumatic fever. Observational cohort study. Public health clinics in the Southeast Health District of Santiago, Chile. Fifty-nine patients (19 men, 40 women) ranging in age at study entry from 15 to 44 years (mean, 24.5 years). Forty-eight had completed their prescribed period of prophylaxis. Eleven refused or were allergic to intramuscular benzathine penicillin G and were non-compliant with oral sulfadiazine. In patients who did not have carditis during their previous attack(s), prophylaxis was discontinued after 5 years or at age 18, whichever was longer. In those with only mild mitral regurgitation or healed carditis, prophylaxis was stopped after 10 years or at age 25. Symptomatic intercurrent streptococcal throat infections were treated with antibiotics. Patients were seen every 3 months during the study (July 1982 to September 1988). For the first 4.25 years, throat cultures as well as sera samples for antistreptolysin O and anti-DNAse B assays were obtained at each visit. During laboratory surveillance, significant increases in antibody titers were detected in 56 instances (28.1 [95% CI, 21.7 to 36.5] per 100 patient-years), and 29 isolations of group A streptococci occurred (14.5 [CI, 10.1 to 20.8] per 100 patient-years). The patients were followed for a total of 3349 patient-months, during which time two acute rheumatic fever recurrences were observed (0.7 [CI, 0.2 to 2.6] per 100 patient-years). No recurrences occurred during an outbreak of acute rheumatic fever in 52 patients in the study area in 1986. These and other data indicate that acute rheumatic fever prophylaxis can safely be discontinued in young adults judged to be at low risk for recurrence and who are maintained under careful prospective surveillance.

The resurgence of acute rheumatic fever in the United States.

Several areas in the United States have experienced significant outbreaks of acute rheumatic fever. Reasons for the reappearance of acute rheumatic fever are incompletely understood but may relate to changes in the organism. Fortunately, however, GABHS has remained exquisitely susceptible to penicillin. Given the resurgence in cases of acute rheumatic fever, the practicing physician needs to be vigilant in diagnosing and ensuring adequate treatment of acute streptococcal pharyngitis. In addition, acute rheumatic fever must be considered in a patient who presents with a new onset murmur, a migratory polyarthritis, chorea, or a rash suggestive of erythema marginatum.

Broad and persistent effects of benzathine penicillin G in the prevention of febrile, acute respiratory disease.

After an outbreak of acute rheumatic fever at a US Army training installation, a benzathine penicillin G prophylaxis program was instituted. Surveillance data were analyzed to measure rates of febrile, acute respiratory disease (ARD) among trainees before and after prophylaxis was begun. Annual admissions for ARD decreased from 1927 to 690 (-64.2%) after benzathine penicillin G prophylaxis was begun. Admissions with throat cultures positive for Streptococcus pyogenes fell from 595 to 63 (-89.4%), a reduction that accounted only for a minority (43%) of the total 1237 "prevented" admissions. Temporal changes in disease rates at other installations where drug was not administered were also analyzed. Only a small decrease in the number of annual ARD admissions (-6.3%) was observed at other training installations. These findings support a hypothesis that benzathine penicillin G has a broad effect in the prevention of ARD that extends beyond the simple elimination of group A streptococcal infection.

Molecular characterization of a locus required for hyaluronic acid capsule production in group A streptococci.

To characterize the production of hyaluronate capsule by the membrane-associated enzyme hyaluronate synthase (HAS), group A streptococci from a recent outbreak of acute rheumatic fever were mutagenized via Tn916 insertion. Acapsular transconjugants harboring multiple, nontandem copies of the transposon were identified and found to lack HAS activity (less than 1% of wild-type levels). Generalized transduction was then performed to determine which Tn916 insertion was responsible for the HAS- phenotype. These marker exchange experiments resulted in the isolation of two distinct classes of acapsular transductants, designated WF61 and WF62. Both transductants also lacked significant HAS activity, and excision of the transposon from WF62 restored capsular hyaluronate production. Southern analysis of WF61 DNA demonstrated a large deletion of genomic DNA adjacent to the Tn916 insertion. This deletion event is presumably responsible for the observed stability of the acapsular phenotype of WF61. Further analyses of transductant whole-cell DNA indicated that the transposon insertions of WF61 and WF62 were separated by 2.5 kb. These studies define a locus required for hyaluronate capsule production in group A streptococci. Further genetic analysis of this locus has identified a gene required for HAS activity which wasd inactivated by TN916 in WF62 and deleted in WF61.

Diagnosis and management of acute rheumatic fever

Acute rheumatic fever (ARF) is a multisystem disease characterised by migratory arthritis (usually affecting the large joints), carditis, chorea, erythema marginatum and subcutaneous nodules (occurring singly or in any combination). It is mainly a disease of childhood and affects children of 5–15 years of age, but no age or race is immune. In the Western European countries the decline in the incidence of ARF became more pronounced after the Second World War, falling to an annual incidence of 12 per 100 000 in Denmark by 1962 and 0.2 per 100 000 in Sweden by 1986. However, ARF remained a significant problem in the United States during this period, with an annual incidence of 26 per 100 000 in Baltimore by 1964. Acceleration of the decline in the United States began in the late 1960 and by 1980, and annual incidence of 0.5 per 100 000 was recorded in Baltimore. Recently, however, several outbreaks of ARF have been reported from different areas in the United States; the recent resurgence of the disease remains unexplained.

Hyaluronic acid capsule is a virulence factor for mucoid group A streptococci.

Mucoid strains of group A Streptococcus have been associated with recent outbreaks of acute rheumatic fever. The mucoid colony morphology of these strains is a result of abundant production of capsular polysaccharide, which is composed of hyaluronic acid. To study the role of the hyaluronic acid capsule in virulence, we derived an acapsular mutant from a mucoid strain of group A Streptococcus by transposon mutagenesis. M protein expression was not altered in the mutant strain. The mucoid wild-type strain grew in fresh human blood and was resistant to phagocytic killing in vitro. In contrast, the acapsular mutant failed to grow in fresh human blood and was sensitive to phagocytic killing in vitro. Loss of capsule was associated with a 100-fold reduction in virulence of the organisms in mice. We conclude that the hyaluronic acid capsule protects mucoid group A streptococci from phagocytosis and has an important role in virulence.

Epidemiology of Acute Rheumatic Fever in a Multiethnic, Multiracial Urban Community: The Miami-Dade County Experience

During the mid-1980s, several US communities experienced outbreaks of acute rheumatic fever (ARF), often involving predominantly white, middle-class individuals living in suburban or rural settings. The medical records of all patients diagnosed with ARF in Miami-Dade County, Florida, between 1984 and 1988 were reviewed. Thirty-five cases met the revised Jones criteria and were considered definite; four additional cases were classified as probable. Carditis was present in 54%. Of the 39 patients, 32 (82%) were black. The annual incidence of ARF among black children aged 5-14 years was 12.25 per 100,000 compared to 0.71 for other (non-Hispanic white plus Hispanic) children (P less than .001). ARF was centered in the inner city, where the incidence among black children reached 15.21. Despite the multiethnic, multiracial character of Miami-Dade County and the rapid influx of immigrants, ARF in this community remains primarily a disease of underprivileged, black inner-city children.

Facts and fallacies about streptococcal infection and rheumatic fever

Recent outbreaks of acute rheumatic fever (ARF) in the United States are drawing attention to a previously declining disease. Authorities agree that penicillin treatment of group A beta-hemolytic streptococcus (GABHS) pharyngitis contributed to the decline in incidence and severity of ARE However, because the pathogenic mechanism that links GABHS and ARF is still a debatable issue, the cause of the recent outbreaks is unknown. A review of the current literature generates interesting questions about the current status of ARF and common GABHS testing and treatment practices. Facts about GABHS and ARF and current recommendations for the diagnosis and treatment of GABHS pharyngitis are presented.

An outbreak of acute rheumatic fever in Tennessee

From January, 1987, until July, 1988, a significant increase in newly diagnosed cases of acute rheumatic fever was noted at our hospital. In sharp contrast to the 3 cases seen in 1986, 14 cases were diagnosed in 1987 (a significant increase from 1985 to 1986, P = 0.001). In the first 6 months of 1988 an additional 12 new cases were diagnosed (a further significant increase from 1987, P = 0.02). No further cases were diagnosed between July, 1988, and September, 1989. The major clinical manifestations were carditis in 73%, polyarthritis in 58% and chorea in 31%. In 15 of 26 patients an antecedent illness which included pharyngitis was noted; the remainder of patients were asymptomatic. Group A beta-hemolytic streptococci were isolated from 13 of 19 children cultured. Isolates from two patients with acute rheumatic fever were submitted for M typing: one isolate was mucoid M18/T18; the other isolate was a mucoid nontypable strain. The demographic characteristics of the 26 patients agree with classic descriptions in that patients were more likely to be urban, to come from large families and to have low incomes; racial breakdown of the group mirrored the Tennessee pediatric population. These characteristics stand in contrast to reports of recent outbreaks which describe suburban high income patients. These data suggest that practitioners should be again aware of acute rheumatic fever and that aggressive identification and treatment of streptococcal pharyngitis should continue to be a relevant public health concern.

Acute Rheumatic Fever: Findings of a Hospital-Based Study and an Overview of Reported Outbreaks

To review the characteristics of reported outbreaks of acute rheumatic fever in the United States, and to determine if there is an increase in the incidence of acute rheumatic fever in the population served by the Hospital for Sick Children, Toronto, Ontario, the authors conducted a literature search and a retrospective review of inpatients and outpatients, satisfying the revised Jones criteria for the diagnosis of acute rheumatic fever, from 1972 to 1988. Patients satisfying the revised Jones criteria for the time period 1972-88 were included in the study. There have been eight articles reporting an increase in acute rheumatic fever in the United States. In three, the majority of children were white and from middle class suburban/rural communities in different geographic locations. Mucoid strains of group A streptococci were implicated but not confirmed as being associated with the outbreaks in three. The results of the chart review at the Hospital for Sick Children revealed that 83 cases satisfied the revised Jones criteria. The number of cases per 100,000 children (aged 18 years or less) per year, decreased progressively over the study period. Polyarthritis was the most frequently seen major criterion occurring in 73% of patients (61 of 83). The most frequently affected ethnic groups were Italians 23%, Afro-Canadians 19% and Orientals 8%. The reported outbreaks in the United States are multifocal and predominantly confined to white middle class children residing in suburban/rural communities. There was no evidence of an increase in the number of cases of acute rheumatic fever seen in the population served by the Hospital for Sick Children; there was a progressive decline in number of cases over the study period. The results facilitate the characterization of acute rheumatic fever within North America into three different patterns of occurrence.

Evidence for two distinct classes of streptococcal M protein and their relationship to rheumatic fever.

The antigenic relatedness of surface-exposed portions of M protein molecules derived from group A streptococcal isolates representing more than 50 distinct serotypes was examined. The data indicate that the majority of serotypes fall into two major classes. Class I M protein molecules share a surface-exposed, antigenic domain comprising the C repeat region defined for M6 protein. The C repeat region of M6 protein is located adjacent to the COOH-terminal side of the pepsin-susceptible site. In contrast, Class I M proteins display considerably less antigenic relatedness to the B repeat region of M6 protein, which lies immediately NH2-terminal to the pepsin site. Surface-exposed portions of Class II M proteins lack antigenic epitopes that define the Class I molecules. Studies in the 1970s demonstrated that M protein serotypes can be divided into two groups based on both immunoreactivity directed to an unknown surface antigen (termed M-associated protein) and production of serum opacity factor. These two groups closely parallel our current definition of Class I and Class II serotypes. Both classes retain the antiphagocytic property characteristic of M protein, and Class II M proteins share some immunodeterminants with Class I M proteins, although the shared determinants do not appear to be exposed on the streptococcal surface. Nearly all streptococcal serotypes associated with outbreaks of acute rheumatic fever express M protein of a Class I serotype. Thus, the surface-exposed, conserved C repeat domain of Class I serotypes may be a virulence determinant for rheumatic fever.

Management of streptococcal pharyngitis: the conundrum of acute rheumatic fever.

The incidence of acute rheumatic fever in the residents of three counties in Ontario (population 507,300) from 1975 to 1986 inclusive was 0.17 hospitalized cases per 100,000 population (0.4 per 100,000 for 5- to 19-year-olds). Indigent patients (0.6 per 100,000) and North American Indians (2 per 100,000) had substantially higher rates. This experience is in marked contrast to recent outbreaks of acute rheumatic fever in areas of the United States, but is similar to experience in the United Kingdom. The implications of this data on the current management of the streptococcal sore throat is reviewed, showing the complexities of real-life prevention of acute rheumatic fever.

Outbreak of acute rheumatic fever in northeast Ohio

An outbreak of acute rheumatic fever in 23 patients was seen in northeastern Ohio in 1986, with polyarthritis (78%) and carditis (30%) the major manifestations. Results of a questionnaire completed by the parents of all 23 patients indicated that they were generally nonindigent, with good access to medical care, and from a nonurban setting. Records of inpatients with acute rheumatic fever were reviewed for the 10 years prior to 1986. The clinical manifestations in inpatients from 1976 to 1985 were not significantly different from those of inpatients seen during 1986. Similar outbreaks have been reported elsewhere, and physicians should be aware of a possible resurgence of classic acute rheumatic fever and ensure compliance with an adequate course of therapy for patients with streptococcal pharyngitis.

Resurgence of acute rheumatic fever in the intermountain area of the United States.

We describe an outbreak of acute rheumatic fever that occurred in the intermountain area centered in Salt Lake City, Utah. Seventy-four children meeting the modified Jones criteria for the diagnosis of acute rheumatic fever were evaluated by the staff at Primary Children's Medical Center, Salt Lake City, from January 1985 through June 1986. This represents an eightfold increase over the average annual incidence at this hospital during the past decade. Carditis, a dominant feature of the outbreak, was confirmed by auscultation in 53 of the patients (72 percent). An additional 14 patients were found to have mitral regurgitation by Doppler ultrasound examination, raising the total incidence of carditis to 91 percent. The children were predominantly from white (96 percent) middle-class families with above-average incomes and with ready access to medical care. There was no apparent increase in the incidence of streptococcal disease or other explanation for the marked increase in acute rheumatic fever. However, mucoid M type 18 and M type 3 group A streptococcal strains were isolated from several siblings of the patients and from schoolchildren (chosen at random) in the area. We conclude that acute rheumatic fever remains an important health problem in the United States.