Rates 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.

P909 Diagnostic evaluation of rheumatic heart disease in aborigonal population

Abstract Background Among Indigenous Australians, rates of Acute Rheumatic Fever (ARF) continue to be among the highest in the world. Diagnosis remains a clinical decision based on identification of major and minor manifestations of the illness. Treatment involves lengthy prophylaxis and should continue for a minimum of 10 years. ARF can cause permanent damage to the heart known as rheumatic heart disease (RHD). We therefore utilised echocardiography as a diagnostic tool incorporating Tissue Quantification Backscatter expressed in decibels (dB) and global LV work efficiency estimated from left ventricle (LV) pressure-strain loops to identify rheumatic changes of the Mitral Valve and help improve early diagnosis of RHD. Method Data from patients with suspected RHD (n = 14), and age matched controls (n = 10) underwent Mitral Valve Backscatter Analysis (MVBS). MVBS was expressed as a ratio % (MVBS ratio %) by dividing the average MVBS and the average blood pool value expressed in decibels (dB). Furthermore LV function was utilised via 2D longitudinal strain and indices of myocardial work were derived. Result MVBS ratio % was significantly higher in the control group as compared to the RHD group (p = 0.001) (fig1). Of the RHD group echocardiography parameters showed there were no significant mitral valve stenosis or regurgitation. Correlates of LV function included: Global work Index (GWI), Global longitudinal Strain (GLS) and Global work efficiency (GWE). Of the above correlates the control group showed Backscatter vs GLS (r= -0.89, p = 0.001), the RHD group: Backscatter vs GLS (r = 0.52. p = 0.12). Within the RHD group the ratio vs GWE (r= 0.57, p = 0.09) these results showed a trend to significance. Conclusions Currently diagnosis of RHD remains a clinical decision based on the identification of major and minor manifestations. In addition treatment involves prophylaxis injections for a minimum of ten years. Of this group there were no significant echocardiography changes, rather clinical manifestation to derive RHD. This study shows that calibrated MVBS ratio % and determinants of myocardial work may be a promising quantitative tool to detect early manifestation of RHD potentially aiding an early treatment plan and thus reducing the clinical burden of monthly penicillin injections for a ten year period. Abstract P909 Figure. RHD and Myocardial correlates

“That Heart Sickness”: Young Aboriginal People’s Understanding of Rheumatic Fever

ABSTRACTHigh rates of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australia predominate in young Aboriginal people highlighting underlying racial and equity issues. This article focuses on the perceptions of the disease among young Aboriginal people living in remote Australia. Participant understanding was constrained by clinicians’ use of language rooted in biomedicine and delivered through English, a second language for all participants. Clinicians’ communicative competency is a social determinant of Aboriginal health. We recommend that the use of Aboriginal languages be prioritized in health services caring for Aboriginal people and that biomedical dominance in the services be relinquished.

Effect of Oral Probiotic Streptococcus salivarius K12 on Group A Streptococcus Pharyngitis: A Pragmatic Trial in Schools.

The aim of this study was to examine effectiveness of oral probiotic Streptococcus salivarius K12 in preventing group A streptococcus pharyngitis in 5- to 14-year-old children at high risk of acute rheumatic fever. New Zealand has high rates of acute rheumatic fever among Māori and Pacific children. Children were already enrolled in a school-based Ministry of Health throat swabbing and treatment program. Children self-identified and reported sore throats daily and were swabbed twice weekly. A total of 1314 children were quasirandomized (based on odd or even birthdates) to receive either K12 (2.5 × 10(9) cfu per lozenge) or placebo lozenges and continued observed daily treatment (in the school week, during school time) for one school year. A total of 801 children (61.0%) reported a sore throat on one or more occasions resulting in 2927 pharyngeal swabs. Of these swabs, 1525 (52.1%) were taken from 411 children receiving K12 and 119 (7.8%) of these were positive for group A streptococcus on routine culture. In addition, 1402 (47.8%) swabs were taken from 390 children receiving placebo and 124 (8.8%) were positive. Overall there was a nonsignificant 11.2% relative reduction in positive swabs among children receiving K12. This relative reduction was greater for older children, 7-9 years of age, 15.6%, and for children 10 years and older, 30.2%. S. salivarius K12 had modest nonsignificant effects on culture-positive sore throats when given at school, during the school day. Based on our pragmatic trial, the routine use of this probiotic in the prevention of pharyngitis associated with GAS detection is not supported.

A repeat audit of primary care management of group A streptococcal pharyngitis in Northland, New Zealand 2016

INTRODUCTION One of the New Zealand Government's Better Public Services targets was to reduce the rate of acute rheumatic fever (ARF) nationally by two-thirds by 2017. Māori children and young people are disproportionately affected by ARF in the Northland District Health Board region. General practice contributes to ARF prevention in detecting and appropriately treating group A streptococcal (GAS) pharyngitis. An audit in 2012 suggested improvements in adherence to national guidelines were needed. AIM The aim was to reassess general practice adherence to national guidelines for the management of GAS pharyngitis in Northland, New Zealand, following implementation of the national Rheumatic Fever Prevention Programme. METHODS Throat swab and dispensing data were obtained and analysed for children and young people aged 3-20 years who attended general practice in Northland between 1 April and 31 July 2016 and had laboratory-proven GAS pharyngitis. RESULTS Between 2012 and 2016, the number of throat swabs carried out in general practice more than doubled, and amoxicillin was more commonly prescribed. The proportion of GAS pharyngitis patients in general practice not receiving recommended antibiotics, or receiving an inadequate length of treatment or no prescription, has not reduced. There are significant differences in the management of care for Māori and non-Māori patients, with much higher risk of ARF for Māori. Discussion The management of GAS pharyngitis by general practice in Northland remains substandard. Implicit bias may contribute to inequity. Focused engagement with identified subgroups of general practices and practitioners who disproportionately contribute to non-guideline prescribing should be further investigated.

Using preceding hospital admissions to identify children at risk of developing acute rheumatic fever

New Zealand (NZ) Māori and Pacific children have high rates of acute rheumatic fever (ARF). Around 150 new cases arise each year. As part of the national ARF prevention programme, funding is available to improve housing. To obtain maximum benefit from interventions, an effective tool is needed for targeting high-risk children. This study aimed to assess the effectiveness of using hospitalisations for identifying children at risk of subsequent ARF. Three potentially avoidable hospitalisation (PAH) groups were investigated, including diseases thought to be influenced by housing. All were developed using expert opinion or systematic reviews. These were: (i) the PAH conditions associated with the housing environment (PAHHE) group; (ii) the Crowding group; and (iii) the Ministry of Health (MoH) group. We analysed NZ public hospital discharge data (2000-2014). The prevalence of ARF among patients hospitalised in each group was calculated to estimate sensitivity and potential effectiveness. The number needed to screen (NNS) to identify one ARF case was estimated as a measure of efficiency. Nearly one-third of ARF patients experienced a PAH as children (before developing ARF). Sensitivity for detecting future ARF ranged from <5% (MoH group) to 27% (PAHHE group). NNS ranged from 502.4 (PAHHE) to 707.5 (MoH). Because ARF is relatively rare, observing hospitalisations is not particularly efficient for targeting prevention activities for this condition alone. However, housing interventions are likely to improve multiple outcomes; thus, the hospital setting is still useful for identifying at-risk children who could benefit from such programmes.

Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data

Indigenous populations have high rates of disease and premature mortality. Most Indigenous communities are young, and adolescence (age 10-24 years) provides great opportunities for population health gain. However, the absence of a comprehensive account of Indigenous adolescents' health has been a barrier to effective policy. We aimed to report a national health profile for Indigenous adolescents in Australia. We undertook a systematic synthesis of population data to report the health and wellbeing of Indigenous adolescents in Australia. A reporting framework for Indigenous adolescent health in Australia was defined to measure health outcomes, health risks, and sociocultural determinants. Available data (primary data from national surveys and administrative datasets, and available published data) were mapped against the defined reporting framework, and the quality graded, with the highest quality data selected to report a health profile for Indigenous adolescents. Comparison with non-Indigenous adolescents was made where possible, and estimates (disaggregated by age, sex, and remoteness) were reported as relative risks. A national advisory group (six Indigenous young people, three Indigenous adult community members, three researchers, three policy makers, and two service providers, all aged ≥16 years) provided input about the reporting framework, interpretation of findings, and policy recommendations. Data were available for 184 (79%) of 234 elements of the reporting framework. All-cause mortality for Indigenous adolescents (70 per 100 000) was more than twice that of non-Indigenous adolescents, with about 60% of deaths due to intentional self-harm and road traffic injury. 80% of all deaths among Indigenous adolescents were considered as potentially avoidable in the current health system. Communicable diseases (particularly sexually transmitted infections) were leading contributors to morbidity. Almost a third of Indigenous adolescents aged 18-24 years reported high levels of psychological distress (twice the non-Indigenous rate). There was an excess burden of mental disorders and substance use, alongside emerging type 2 diabetes and ischaemic heart disease. Additionally, there were excess intentional and unintentional injuries. Many aspects of this health profile differed markedly from that of non-Indigenous adolescents: rates of acute rheumatic fever, pneumococcal infection, gonorrhoea, and type 2 diabetes resulting in admission to hospital were ten times higher; rates of assault and childbirth in those aged 15-19 years were five times higher; whereas rates of eating disorders, melanoma and other skin cancers, and anaphylaxis were significantly lower. Risks for future ill-health were common; 43% of 15-24 year olds were current tobacco smokers and about 45% had high body mass (overweight or obese). Disadvantage across sociocultural health determinants also emerged, particularly around education. Despite Australia's adolescents having one of the best health profiles globally, Indigenous adolescents have largely been left behind. Adequate responses will require intersectoral actions, including a health system responsive to the needs of Indigenous adolescents. Without a specific focus on adolescents, Australia will not redress Indigenous health inequalities. Australia's National Health and Medical Research Council, Sidney Myer Foundation, and the Murdoch Children's Research Institute.

Update on rheumatic fever in New Zealand

Despite being a relatively affluent nation, New Zealand (NZ) has persistently high rates of acute rheumatic fever (ARF) disproportionally affecting Māori and Pacific people. In 2011 the NZ government launched the Rheumatic Fever Prevention Programme (RFPP) with the stated aims of achieving equity of incidence and outcomes of ARF between Māori/Pacific and other NZ children, and to achieve a reduction in the national incidence of ARF by two-thirds, from 4.0 per 100,000 people in 2011 to 1.4 per 100,000 people by 2017. The three interventions of the RFPP are: (1) improve access to timely diagnosis and treatment for group A streptococcal pharyngitis; (2) increase awareness of ARF; and (3) reduce household crowding and transmission of group A streptococcus. The presentation will cover the epidemiology of ARF in NZ, and discuss issues arising from the RFPP and outcomes.

Incidence and clinical features of acute rheumatic fever in Kayseri, Central Anatolia, 1998–2011

In developing countries, acute rheumatic fever is the most common cause of acquired heart disease in the paediatric and adolescent population. It is believed that vulnerability to developing acute rheumatic fever is associated with several factors such as socio-economic and living conditions. Aim Determine the incidence and clinical characteristics of acute rheumatic fever in the Central Anatolia region of Kayseri within the last 14 years, and to make a comparison of two 7-year periods. Material and methods We performed a retrospective analysis of 624 patients who were diagnosed with acute rheumatic fever at the Department of Pediatric Cardiology in the Medical Faculty of Erciyes University between January, 1998 and December, 2011. The mean age of patients was 10.9±2.7 years. The female/male ratio was 1.4. When patients were categorised according to age groups, the largest group represented 376 patients (60.3%) aged between 10 and 14 years. The estimated incidence rate of acute rheumatic fever was 7.4/100,000 in the Central Anatolia region of Kayseri. Among the major findings, the most common included carditis at 54%, arthritis at 35%, Sydenham's chorea at 25%, and subcutaneous nodules at 0.5%, respectively. No significant difference was found between the first 7-year period and second 7-year period in distributions of age, gender, and major findings. Although there has been socio-economic development in Turkey in the recent years, the incidence of acute rheumatic fever is still high in the Central Anatolia region of Kayseri.

Primary care management of group A streptococcal pharyngitis in Northland

Reducing the rate of acute rheumatic fever nationally by two-thirds by 2017 is a New Zealand Ministry of Health priority. Northland District Health Board (DHB) has high rates of rheumatic fever, disproportionately impacting on Maori children and young people. School-based programmes and general practice both contribute to rheumatic fever prevention in detecting and appropriately treating group A streptococcal (GAS) pharyngitis. The aim of this study was to assess adherence by general practitioners and school-based sore throat programmes to national guidelines for the management of GAS pharyngitis in Northland. Laboratory and pharmaceutical data were obtained for children and young people aged 3-20 years who had GAS positive throat swabs in Northland laboratory services between 1 April and 31 July 2012. Data were analysed separately for general practice and the school programmes for rheumatic fever prevention. One in five of those children presenting to general practice with a positive throat swab and complete prescription data did not receive treatment according to national guidelines, while appropriate treatment was offered to more than 98% of children accessing school-based programmes. A significant proportion of those seen in general practice received antibiotics not recommended by guidelines, an inadequate length of treatment or no prescription. There were no significant differences in the management of Maori and non-Maori children. There is room for improvement in general practice management of GAS pharyngitis in Northland. School-based management of sore throat provides high-quality management for children at high risk of rheumatic fever.

The Cochrane Library and the Treatment of Sore Throat in Children and Adolescents: An Overview of Reviews

AbstractBackgroundSore throat is a common respiratory tract symptom responsible for 6% of children's visits to pediatricians or family physicians. Even though sore throat is usually self‐limiting, antibiotics are often prescribed in hopes of decreasing symptom length and the risk of developing sequelae. However, antibiotic over‐prescription could lead to adverse events in individuals and bacterial resistance in the community, so the efficacy and safety of antibiotics must first be established, and alternative treatment options should also be investigated.ObjectivesThis overview of reviews aims to synthesize evidence from the Cochrane Database of Systematic Reviews (CDSR) on the efficacy and safety of different antibiotic treatment strategies (standard antibiotics, delayed antibiotics, short‐duration antibiotics and different types of antibiotics) to improve symptoms of sore throat in children and adolescents. The efficacy and safety of two other treatments, steroids and Chinese herbal medicine, are also investigated.MethodsIssue 1, 2011 of the CDSR was searched for all reviews examining the treatment of sore throat and disorders which commonly have sore throat as part of their clinical presentation. We also searched for reviews examining the prevention of important sequelae of sore throat. All systematic reviews examining pharmacologic or non‐pharmacologic treatments in children were identified, and data were extracted, compiled into tables and synthesized using quantitative and qualitative methods.Main resultsData pertaining to sore throat in children and adolescents were extracted from seven Cochrane reviews. Antibiotics provided only modest benefit over placebo for symptoms of sore throat and fever. Immediate versus delayed prescription of antibiotics resulted in a 58% decrease in severity of pain due to sore throat on day three (RR: 0.42; 95% CI: 0.33, 0.54), and a significant, moderate decrease in fever on day three (SMD: − 0.53; 95% CI: − 0.74, − 0.31). Most studies of macrolides, cephalosporins and carbacephem showed no significant benefit over oral penicillin for resolution of symptoms, but in two trials a short course of a cephalosporin compared to oral penicillin led to modest decreases in both sore throat (half a day; MD: − 0.50; 95% CI: − 0.78, − 0.22) and fever (seven hours; MD: − 0.30; 95% CI: − 0.45, − 0.14). Steroids compared to placebo decreased symptoms of sore throat in children with infectious mononucleosis at 12 hours (RR: 0.54; 95% CI: 0.30, 0.99) but not at any other measured time points. A higher rate of vomiting was associated with delayed antibiotics (RR: 0.07; 95% CI: 0.03, 0.20); vomiting, diarrhea and abdominal pain were associated with short‐duration antibiotics (RR: 1.74; 95% CI: 1.31, 2.32); and overall adverse effects were associated with macrolides (RR: 2.19; 95% CI: 1.04, 4.61). Trials involving Chinese herbal medications for sore throat were of low quality and no good evidence for the use of these agents was available.Antibiotics compared to placebo were associated with lower rates of acute rheumatic fever, but the difference was not statistically significant when only pediatric data were included (RR: 0.20: 95% CI: 0.01, 4.18). One review examining the secondary prevention of rheumatic fever found that intramuscular versus oral penicillin reduced the recurrence of rheumatic fever by 92% (RR: 0.08; 95% CI: 0.04, 0.18) and significantly reduced the number of participants who developed streptococcal throat infections (RR: 0.22; 95% CI: 0.17, 0.27; I2: 81%).Authors' ConclusionsEvidence from the CDSR suggests that antibiotics provide only modest improvements in symptoms of sore throat in children and adolescents. If antibiotics are prescribed, macrolides are less ideal compared to other agents, and there is some evidence that a short course of a newer cephalosporin may be slightly better than a standard course of penicillin. Any potential benefit of antibiotic treatment must be weighed against the cost of treatment and the possibility of adverse effects. Children with a past history of rheumatic fever or those living in a region with a high prevalence of this condition are more likely to benefit from antibiotics than those without these risk factors. Oral corticosteroids can decrease sore throat symptoms within the first day and may be helpful for children with severe symptoms of infectious mononucleosis. There is no compelling evidence that any Chinese herbal medicine has beneficial effects for the relief of sore throat symptoms or prevention of sequelae. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. The Cochrane Collaboration

Acute rheumatic fever in Indigenous people in North Queensland: some good news at last?

To ascertain whether changing from enhanced to routine surveillance had any deleterious impact on notification rates of acute rheumatic fever (ARF) among Indigenous people in north Queensland; and to determine whether initiatives to raise awareness about ARF among medical practitioners during the routine surveillance period were associated with any changes in the numbers of recurrences of the disease among Indigenous people in the region. Routine surveillance of all cases of ARF, and (to identify unrecognised prior episodes) retrospective checking of the medical records of Indigenous people with notified first cases of ARF from mid 2004 to mid 2009 in north Queensland, which has an estimated resident Indigenous population of about 68 400. Rate of notifications of ARF during the routine surveillance period (mid 2004 to mid 2009) compared with that in the previous 5 years of enhanced surveillance; proportion of recurrent episodes of ARF that occurred from mid 2004 to the end of 2006 compared with the proportion in the following 2.5 years. There were 203 notifications of ARF in 194 Indigenous people in north Queensland from mid 2004 to mid 2009, and this was a 23% increase in the average annual incidence compared with that in the preceding 5 years. Of the 54 recurrences, 34 (63%) occurred between mid 2004 and the end of 2006 and 20 occurred between the beginning of 2007 and mid 2009 (P < 0.01). Of the 148 episodes that were not recurrences, 69 (47%) occurred in the first 2.5 years and 79 in the more recent 2.5 years (P > 0.05). Changing from enhanced to routine surveillance in 2004 did not have a negative impact on notifications of ARF. The initiatives to raise awareness about ARF probably contributed to fewer missed cases and therefore to the considerable increase in the number of notifications, and ultimately to fewer recurrences.

Higher rates of streptococcal colonization among children in the Pacific Rim Region correlates with higher rates of group A streptococcal disease and sequelae

AbstractGroup A streptococcal (GAS) pharyngeal colonization rates were determined among 1061 asymptomatic students in Hawaii and American Samoa where acute rheumatic fever rates are high. All GAS isolates were emm sequence typed. Although pharyngeal colonization rates were low in Hawaii (3.4%), Pacific Islander children had significantly higher colonization rates (5.7% vs. 1.2% in other ethnic groups, p <0.05). The colonization rate was higher in American Samoa (13%). Few emm types that were infrequently observed in symptomatic infections in Hawaii were repeatedly identified in both sites. These emm types were previously described among asymptomatic children suggesting a type-specific association with pharyngeal colonization.

Rheumatic Heart Disease in Indigenous Populations

Rates of acute rheumatic fever and chronic rheumatic heart disease in Aboriginal people, Torres Strait Islanders and Māori continue to be unacceptably high. The impact of rheumatic heart disease is inequitable on these populations as compared with other Australians and New Zealanders. The associated cardiac morbidity, including the development of rheumatic valve disease, and cardiomyopathy, with possible sequelae of heart failure, development of atrial fibrillation, systemic embolism, transient ischaemic attacks, strokes, endocarditis, the need for interventions including cardiac surgery, and impaired quality of life, and shortened life expectancy, has major implications for the individual. The adverse health and social effects may significantly limit education and employment opportunities and increase dependency on welfare. Additionally there may be major adverse impacts on family and community life. The costs in financial terms and missed opportunities, including wasted young lives, are substantial. Prevention of acute rheumatic fever is dependent on the timely diagnosis and treatment of sore throats and skin infections in high-risk groups. Both Australia and New Zealand have registries for acute rheumatic fever but paradoxically neither includes all cases of chronic rheumatic heart disease many of whom would benefit from close surveillance and follow-up. In New Zealand and some Australian States there are programs to give secondary prophylaxis with penicillin, but these are not universal. Surgical outcomes for patients with rheumatic valvular disease are better for valve repair than for valve replacement. Special attention to the selection of the appropriate valve surgery and valve choice is required in pregnant women. It may be necessary to have designated surgical units managing Indigenous patients to ensure high rates of surgical repair rather than valve replacement. Surgical guidelines may be helpful. Long-term follow-up of the outcomes of surgery in Indigenous patients with rheumatic heart disease is required. Underpinning these strategies is the need to improve poverty, housing, education and employment. Cultural empathy with mutual trust and respect is essential. Involvement of Indigenous people in decision making, design, and implementation of primary and secondary prevention programs, is mandatory to reduce the unacceptably high rates of rheumatic heart disease.

Group A streptococcal pharyngitis and immune-mediated complications: from diagnosis to management

Group A streptococcal pharyngitis remains the most important bacterial pharyngitis because of its frequency and potential complications. Group A streptococcal pharyngitis is most common in children 5–11 years of age in winter–spring, and a rapid test or culture is necessary for accurate diagnosis. We propose a management strategy for those geographic areas with very low acute rheumatic fever rates, emphasizing selective testing that avoids testing those patients with viral-like features (e.g., rhinorrhea and cough). Acute rheumatic fever is the most important immune-mediated sequela and has become rare in most areas of the USA and Western Europe, most probably due to decreased circulation of highly rheumatogenic group A streptococcal strains.

Streptococcal emm types in Hawaii: a region with high incidence of acute rheumatic fever.

The clinical epidemiology of group A streptococcal (GAS) infections in Hawaii seems different from that in the continental United States with frequent skin infections and endemically high rates of acute rheumatic fever (ARF). GAS emm types in Hawaii were determined to identify any possible association between the emm types and specific clinical manifestations. A convenience sample of 1482 Hawaii GAS isolates collected between February 2000 and December 2005 was used. All isolates were characterized by emm sequence typing. The distribution of emm types in Hawaii was compared with the published continental US data for pharyngeal and invasive GAS strains, the CDC database from similar time periods, as well as with emm types present in a candidate GAS vaccine. Ninety-three distinct emm types were recognized among the 1482 GAS isolates. The most frequently identified emm types in order of decreasing frequency were 12, 1, 28, 4, 22, 77, 81, 58, 65/69, 49, 74, 85, 92, 75, 101 and 2. Of this study sample, 27 of the 50 invasive GAS isolates belonged to uncommon continental US emm types (54% in Hawaii cultures vs. 10% reported from the continental US). Of the 1179 pharyngeal isolates, 509 belonged uncommon continental US emm types (43% in Hawaii cultures vs. 27% reported from the continental US). The prevalent emm types in Hawaii differ from those in the continental US. The prevalence of these unusual emm types might limit the effectiveness of any proposed multivalent type-specific GAS vaccine in Hawaii.

Acute rheumatic fever: an important differential diagnosis of septic arthritis

We present three cases of suspected septic arthritis in which the joint fluid was sterile. Subsequently all three patients were diagnosed with established moderate-severe rheumatic heart disease. In retrospect it is likely that the earlier presentations were in fact episodes of acute rheumatic fever but were not recognized as such. These cases underline the importance of acute rheumatic fever as a differential diagnosis of septic arthritis when the joint fluid is sterile, particularly in regions where there are high rates of acute rheumatic fever and rheumatic heart disease.

Low Rates of Streptococcal Pharyngitis and High Rates of Pyoderma in Australian Aboriginal Communities Where Acute Rheumatic Fever Is Hyperendemic

Acute rheumatic fever is a major cause of heart disease in Aboriginal Australians. The epidemiology differs from that observed in regions with temperate climates; streptococcal pharyngitis is reportedly rare, and pyoderma is highly prevalent. A link between pyoderma and acute rheumatic fever has been proposed but is yet to be proven. Group C beta-hemolytic streptococci and group G beta-hemolytic streptococci have also been also implicated in the pathogenesis. Monthly, prospective surveillance of selected households was conducted in 3 remote Aboriginal communities. People were questioned about sore throat and pyoderma; swab specimens were obtained from all throats and any pyoderma lesions. Household population density was determined. From data collected during 531 household visits, the childhood incidence of sore throat was calculated to be 8 cases per 100 person-years, with no cases of symptomatic group A beta-hemolytic streptococci pharyngitis. The median point prevalence for throat carriage was 3.7% for group A beta-hemolytic streptococci, 0.7% for group C beta-hemolytic streptococci, and 5.1% for group G beta-hemolytic streptococci. Group A beta-hemolytic streptococci were recovered from the throats of 19.5% of children at some time during the study. There was no seasonal trend or correlation with overcrowding. Almost 40% of children had pyoderma at least once, and the prevalence was greatest during the dry season. In community 1, the prevalence of pyoderma correlated with household crowding. Group C and G beta-hemolytic streptococci were rarely recovered from pyoderma lesions. These data are consistent with the hypothesis that recurrent skin infections immunize against throat colonization and infection. High rates of acute rheumatic fever were not driven by symptomatic group A beta-hemolytic streptococci throat infection. Group G and C beta-hemolytic streptococci were found in the throat but rarely in pyoderma lesions.

Impact of single dose azithromycin on group A streptococci in the upper respiratory tract and skin of Aboriginal children.

Aboriginal children living in remote Australia experience high rates of bacterial infection such as trachoma, otitis media and streptococcal skin infection, which often progress to associated chronic diseases in later life. In February, 1995, single dose azithromycin was given to 130 Aboriginal children with trachoma and their contacts. The impact of this program on respiratory and skin group A Streptococcus pyogenes carriage and infection was also monitored. Immediately before treatment 90% of children had skin sores, 38% of sores had pus and 74% of sores with pus had group A Streptococcus (GAS). Overall 57% of children had GAS skin infections. At 2 to 3 weeks and 2 and 6 months after treatment, this proportion was 10, 32 and 51%, respectively. For the upper respiratory tract GAS recovery rates were 8% before treatment and 0, 11 and 15% at the 2- to 3-week, 2-month and 6-month posttreatment visits, respectively. Multiple types occurred concurrently in individuals, particularly after treatment. Identical types were sometimes recovered simultaneously from the upper respiratory tract and skin, suggesting that the high rates of acute rheumatic fever in this population in the absence of high rates of detectable throat GAS carriage could be related to high rates of skin GAS infection. There is an urgent need for education, adequate housing, scabies eradication and improved hygiene to reduce skin trauma and subsequent GAS infection in this population. Clinical trials are needed to determine how these measures can best be integrated with the trachoma eradication program to maximize health outcomes.

Childhood infections in the tropical north of Australia.

In the tropical north of Australia there are high rates of infections in Aboriginal children living in remote communities. In addition to the burden of respiratory infections, diarrhoeal disease and skin sepsis, there are high rates of acute rheumatic fever, outbreaks of poststreptococcal glomerulonephritis and gonococcal conjunctivitis, endemic trachoma and various intestinal parasites. A number of infections generally restricted to the tropics are also present and can cause disease in both indigenous and non-indigenous children. These include melioidosis, Murray Valley encephalitis and dengue on the east coast. With global warming, these infections may become more common and more widespread within Australia and the potential for establishment of introduced infections such as Japanese encephalitis and malaria may increase.