Management of Group A Streptococcal Sore Throat for the Prevention of Acute Rheumatic Fever

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1 Management of Group A Streptococcal Sore Throat for the Prevention of Acute Rheumatic Fever 2011

2 Ministry of Health 2011 Published by: New Zealand Guidelines Group (NZGG) PO Box , The Terrace, Wellington 6145, New Zealand ISBN (Electronic): Copyright The copyright owner of this publication is the Ministry of Health, which is part of the New Zealand Crown. Content may be reproduced in any number of copies and in any format or medium provided that a copyright acknowledgement to the New Zealand Ministry of Health is included and the content is neither changed, sold, nor used to promote or endorse any product or service, or used in any inappropriate or misleading context. For a full copyright statement, go to Funding and independence This work was funded by the Ministry of Health. The work was researched and written by NZGG employees or contractors. Appraisal of the evidence, formulation of recommendations and reporting are independent of the Ministry of Health. Statement of intent NZGG produces evidence-based best practice guidelines to help health care practitioners, policymakers and consumers make decisions about health care in specific clinical circumstances. The evidence is developed from systematic reviews of international literature and placed within the New Zealand context. While NZGG guidelines represent a statement of best practice based on the latest available evidence (at the time of publishing), they are not intended to replace the health practitioner s judgment in each individual case. Citation: New Zealand Guidelines Group. Management of Group A Streptococcal Sore Throat. Wellington: New Zealand Guidelines Group; Copies of the evidence review are available online at

3 Contents Acknowledgments... v About the evidence review... v Purpose... v The need for a guidance... v Scope of the evidence review... v Target audience... v Treaty of Waitangi... vi Key point development process... vi Definitions... vi Summary... 1 Key messages Introduction and context... 2 GAS throat infection...2 Acute rheumatic fever...2 GAS throat infection in New Zealand...3 Acute rheumatic fever in New Zealand...3 Ethnic disparities...9 Signs and symptoms of GAS throat infection Rapid Antigen Diagnostic Tests Rapid Antigen Diagnostic Test in people with a current sore throat Rapid Antigen Diagnostic Test in people with a resolved sore throat Timing of testing Antibiotic treatment Antibiotic type Antibiotic dose Antibiotic duration Asymptomatic GAS infection Prevalence of GAS sore throat Relationship between prevalence of asymptomatic GAS throat infection and rheumatic fever Community swabbing Rheumatic fever outbreaks Swabbing asymptomatic community members and households in areas of outbreak... 77

4 Appendix 1: Methods Contributors Research process Research questions Reviewing the literature Evidence appraisal Appendix 2: Abbreviations and glossary Abbreviations Glossary References... 95

5 Acknowledgments NZGG would like to thank Dr Richard Milne and his co-authors for granting us permission to use their analysed data on incidence of acute rheumatic fever in New Zealand, and Dr Rajesh Khanna, DHB (Paed), MPH; Co-ordinator, National Child Health Research Centre, National Institute for Health and Family Welfare, Delhi, for reviewing the analysis of Rapid Antigen Diagnostic Tests. About the evidence review Purpose The purpose of this evidence review is to provide an evidence-based summary of current New Zealand and overseas evidence to inform best practice in the management of people with Streptococcal A infection of the throat (pharyngitis) especially with the aim of preventing one of the more serious sequalae: Acute rheumatic fever (ARF). The need for a guidance Acute rheumatic fever rates in New Zealand have failed to decrease since the 1980s and remain some of the highest reported in a developed country. 1, 2 In response to this ongoing problem, the Ministry of Health wished to understand whether there were specific strategies for managing Group A beta-hemolytic streptococcal throat infection (GAS) throat infections that could help to lower the rate of ARF and prevent chronic rheumatic heart disease. Scope of the evidence review The evidence review specifically addresses the diagnosis of people with suspected GAS throat infection using Rapid Antigen Diagnostic tests, and the management of people with confirmed GAS throat infection using antibiotics. The review also provides information on asymptomatic GAS throat infection and community swabbing. It should be noted that the management of GAS throat infection in people with confirmed ARF, acute or chronic rheumatic heart disease or in people with recurrent GAS throat infection is beyond the scope of this work and has been excluded. Target audience The evidence review and guidance is intended primarily for the providers of care for New Zealanders with GAS throat infection.

6 Treaty of Waitangi The New Zealand Guidelines Group acknowledges the importance of the Treaty of Waitangi to New Zealand, and considers the Treaty principles of partnership, participation and protection as central to improving Māori health. NZGG s commitment to improving Māori health outcomes means we work as an organisation to identify and address Māori health issues relevant to each piece of guidance. In addition, NZGG works to ensure Māori participation is a key part of the development process. It is important to differentiate between involving Māori in the guidance development process (the aim of which is to encourage participation and partnership), and specifically considering Māori health issues pertinent to the topic at all stages of the development process. While Māori participation in guidance development aims to ensure the consideration of Māori health issues by the expert advisory group, this is no guarantee of such an output; the entrenched barriers Māori may encounter when involved in the health care system (in this case guidance development) need to be addressed. NZGG attempts to challenge such barriers by specifically identifying points in the development process where Māori health must be considered and addressed. In addition, it is expected that Māori health is considered at all points in the guidance in a less explicit manner. Key point development process NZGG convened a multidisciplinary expert advisory group (EAG) comprising members nominated by a diverse range of stakeholder groups. The research questions developed by the Ministry of Health and NZGG were discussed with the EAG and were used to inform the search of the published evidence, from which systematic evidencedbased statements for best practice were derived. A one-day, face-to-face meeting of the full EAG was held, plus additional teleconferences, at which evidence was reviewed and key practice points were developed. Full methodological details are provided in Appendix 1. Definitions Several common terms are currently in use for Group A beta-haemolytic streptococcal pharyngitis. NZGG has elected to use the term GAS throat infection throughout this document in an attempt to keep the document clear and easy to read.

7 Summary Key messages Antibiotics should be initiated as soon as possible as there is no evidence to support current practice of delaying treatment by up to nine days and there is no evidence to support any other recommendation about the timing of treatment. Children at high risk of developing rheumatic fever should continue to receive empiric (immediate) antibiotic treatment and the presence of GAS should continue to be confirmed by laboratory culture. To establish asymptomatic carriage rate in the school population, where an intervention is planned, all consented children should be swabbed before and after the intervention, regardless of symptoms to allow evaluation of programme effectiveness. There is reliable evidence about the efficacy of rapid antigen diagnostic tests, which give a result much faster than swabbing and testing. Once daily amoxicillin is the first choice for antibiotic treatment for a GAS throat infection. Studies comparing amoxicillin with penicillin V report comparable outcomes. Amoxicillin is likely to achieve better compliance because of its daily dosing and ability to be taken with food compared with penicillin V s more frequent dosing and the requirement to take it on an empty stomach. Management of Streptococcal A Sore Throat 1

8 1 Introduction and context GAS throat infection Streptococcal pharyngitis is caused by a Group A beta-haemolytic streptococcal infection and can trigger an inflammatory response in pharyngeal cells that causes many of the signs and symptoms of streptococcal pharyngitis. 3 Group A streptococcus (GAS) is a bacterium often found in the throat and on the skin and can be carried by people who have no symptoms of illness. 4 It affects the pharynx including the tonsils and possibly the larynx. After an incubation period of 2 to 5 days 5, 6 there is an abrupt onset of illness with sore throat and fever. 7 The tonsils and pharynx are inflamed and tonsillar exudate may be present. 3 Throat pain is typically described as severe and is associated with difficulty in swallowing. 3 Symptom severity varies and the presence of classically associated symptoms such as headache, malaise or gastrointestinal symptoms may be present in only 35% to 50% of patients. 3 GAS sore throat is a communicable disease, spread through close contact with an infected individual. A definitive diagnosis is made based on the results of a throat culture. One of the more serious complications is acute rheumatic fever (ARF). Evidence indicates that antibiotic treatment for GAS throat infection in communities where the complication is common can reduce progression to ARF by more than twothirds. 8 Acute rheumatic fever Acute rheumatic fever is an autoimmune response to infection with GAS bacteria. In New Zealand this response is primarily thought to be due to GAS throat infections. Though there has been discussion of the role of GAS skin infections in ARF (skin sepsis), convincing evidence has yet to be found to support this theory. 9 The ensuing generalised inflammatory response to the GAS infection occurs in certain organs; the heart, joints, central nervous system (ie, brain) and skin. Inflammation of the heart (carditis) can cause long-term damage to the heart valves requiring heart valve replacement surgery. The consequence of recurrent exposure to ARF is the development of rheumatic heart disease (RHD) which may include valvular disease and cardiac myopathy and sequlae such as heart failure, atrial fibrillation, systemic embolism, stroke, endocarditis and the requirement for cardiac surgery. 10 In the 1990s RHD was responsible for 120 deaths per year in New Zealand. 1 Management of Streptococcal A Sore Throat 2

9 GAS throat infection in New Zealand While most sore throats are thought to be viral in origin, estimates of the numbers of sore throats due to GAS vary widely. 3 Evidence on rates is slim. A review completed by the World Health Organization 11 investigated the current evidence in relation to the burden of GAS infections on a worldwide scale and estimated that in children in developing countries (New Zealand was included in this group given the high rates of rheumatic fever in specific communities within New Zealand) the number of sore throats due to GAS could be as high as 40%. 11 This estimate was based on the findings from three studies from populations where ARF is common: New Zealand (primarily in Māori and Pacific communities), Kuwait and Northern India. As the authors state, a positive GAS finding was not confirmed with serology and hence the true rate may be lower. New Zealand data is currently being collected in a school-based sore throat swabbing programme in Opotiki. 12 Interim data shows that between October 2009 and December 2010, 8% of children reporting sore throats who were swabbed had a GAS infection (211 positive swabs of 2489 taken). Data collection is ongoing and analysis of trends would currently be premature. 12 This data supports those accepted estimates that between 3% and 36% of sore throats are due to a GAS infection. 3 There is currently no national data collected by ESR (Environmental Science and Research) for GAS infections in New Zealand independent of the notification of rheumatic fever. Acute rheumatic fever in New Zealand Acute rheumatic fever is reported two ways in New Zealand. The most current data, available publically in rate form, is that reported by the ESR as part of its annual surveillance of notifiable diseases. ESR collects this data from the regional public health units. Local District Heath Boards (DHBs) and treating hospital clinicians are required to use a specific ARF reporting process to notify regional public health services of the ARF cases hospitalised within their region; this data is then reported to ESR by each region (who each have their own database to hold this data). This data may be reported from the DHBs to the regional public health units late and in bundles or not at all, given it requires a separate reporting process. The second source of ARF data in NZ comes from the National Minimum Dataset (NMDS). This is a centralised dataset, in which all hospital encounters are coded within the hospitals themselves and entered straight into the database, the direct report nature does mean the NMDS data is viewed as more reliable and valid. However, given the large numbers of data involved in the NMDS, rates for ARF are not calculated on an annual basis. Management of Streptococcal A Sore Throat 3

10 Case Numbers of acute rheumatic fever Acute rheumatic fever appears to have been virtually eradicated from most developed countries yet rates in New Zealand have failed to decrease since the 1980s and remain some of the highest reported in a developed country. 1, 2 The Ministry of Health s ESR Annual Surveillance Report of notifiable disease has reported annually between 100 and 150 cases over the last decade (all ages). 13 In 2010, 155 initial cases and 13 recurrent cases of rheumatic fever were notified (for all ages), 14 while analysis of the hospital admissions and ICD discharge data provided in the NMDS indicated that from 1987 to 2008 there were between 150 and 230 cases per year (all ages). 13 Hospitalisation data indicates that the primary episode of ARF usually occurs in children aged between 5 to 14 years (Figure 1.1) 1, 2 and a recent analysis of the NMDS hospitalisation data (using data up to 2009) reported 115 index cases of ARF in children aged 5 to14 years in 2009 (Table 1.1). 15 In 2010, approximately 75% (117 cases) of initial attack ARF cases notified were in those aged less than 15 years, with the highest age-specific rate in the 10 to 14 years age group (25.4 per population, 75 cases). 14 Figure 1.1 Number of hospitalisations between 2004 and 2010 for acute rheumatic fever by age Source: National Minimum Data Set 1, 2 Management of Streptococcal A Sore Throat 4

11 Table 1.1 Annual index cases by year and ethnicity for children 5 to 14 years of age Cases %change Ratio of 2009 to 1993 Māori % 2.0 Pacific Islands % 2.9 European/Other % 0.3 Total % 1.8 Source: Milne, R., D. Lennon, et al. (2010). Burden and cost of rheumatic fever and rheumatic heart disease in New Zealand: focus on school age children. A report to the Ministry of Health. Auckland, New Zealand, Health Outcomes Associates Limited. Rates of acute rheumatic fever It is reported that rates of ARF in New Zealand since 1980 have remained at about 15 cases per 100,000 children aged 5 to 15 years of age. 13 An analysis of hospitalisation data between 2000 and found a mean incidence rate for New Zealand children (all ethnicities) of 17.2 per 100,000, and distinct inequalities in the rates between different ethnic groups (Table 1.2). Table 1.2 ARF incidence rates for New Zealand children 5 to 14 years of age ( ) Māori Pacific Non- Māori/Pacific Total Māori Rate ratio * Pacific Mean %CI %CI CI = confidence interval * Compared to non-māori/pacific Source: Milne, R., D. Lennon, et al. (2010). Burden and cost of rheumatic fever and rheumatic heart disease in New Zealand: focus on school age children. A report to the Ministry of Health. Auckland, New Zealand, Health Outcomes Associates Limited. Of concern is that the inequality between ethnic groups has been widening over time. In the period studied ( ) incidence rates increased by 79% and 73% for Māori and Pacific children respectively and declined by 71% for non-māori/pacific categories, with an overall increase of 59% 15 (Figure 1.2). Māori and Pacific children 5 to 14 years of age accounted for 92% of new cases of ARF in the period 2000 to 2009 and comprised 30% of children in the 2006 census. 15 Management of Streptococcal A Sore Throat 5

12 Figure 1.2 Annual index cases and incidence rates for acute rheumatic fever in for children 5 to 14 years of age Source: Milne, R., D. Lennon, et al. (2010). Burden and cost of rheumatic fever and rheumatic heart disease in New Zealand: focus on school age children. A report to the Ministry of Health. Auckland, New Zealand, Health Outcomes Associates Limited. Management of Streptococcal A Sore Throat 6

13 The notification rates from ESR since 2000 for all ages and ethnicities are displayed in Figure 1.3 for both initial and recurrent attacks. 14 Figure 1.3 Rates of notified rheumatic fever per 100,000 from 2000 to 2010 Source: ESR, 2011 Acute rheumatic fever in New Zealand by region ESR reports rates for initial ARF attack by DHB, ethnic group, age and sex for the 2010 year. The highest rate of notified cases in 2010 was in Tairawhiti DHB (15.1 per 100,000 population, 7 cases), followed by Counties Manukau (10.6 per 100,000, 52 cases) and Northland (10.2 per 100,000, 16 cases) DHBs. 14 However, given the small numbers, rates by DHB are more meaningful if examined over time. Analysis of the 2000 to 2009 hospitalisation data found that Counties Manukau DHB had the highest mean annual incidence rate for children (93.9 per 100,000) and contributed 298/700 cases (43%). 15 Ninety-nine percent of index cases in Counties Manukau were in children of Māori or Pacific ethnicity. Table 1.3 displays incidence for the 2000 to 2009 years by DHB, ethnicity and decile. Management of Streptococcal A Sore Throat 7

14 Table 1.3 Index ARF cases and incidence rates for deciles 9 and 10 children aged 5 to 14 years, by District Health Board Index ARF cases in Mean annual incidence per 100,000 Non- Māori/ Non- Māori/ DHB a Māori Pacific Pacific Total Māori Pacific Pacific Total Counties Manukau Northland Capital and Coast Auckland b Bay of Plenty Tairawhiti Hawke's Bay Lakes Waikato Midcentral Remaining 11 c Total Top 10 DHBs % total cases d 95% 95% 81% 94% Na Na Na Na % population e 81% 84% 64% 76% Na Na Na Na CCDHB=Capital and Coast DHB; CMDHB=Counties Manukau DHB; DHB=District Health Board; Na=not applicable a Sorted by total incidence rate b Waitemata patients were also hospitalised at Auckland hospital (ADHB) c Includes five North Island and all six South Island DHBs d Percentage of all index cases occurring in the top10 DHBs e Percentage of NZ population 5 14 years of age Source: Milne, R., D. Lennon, et al. (2010). Burden and cost of rheumatic fever and rheumatic heart disease in New Zealand: focus on school age children. A report to the Ministry of Health. Auckland, New Zealand, Health Outcomes Associates Limited. International rates of acute rheumatic fever International comparisons for rates of ARF are problematic (due to global data quality issues) and estimates of the annual number of ARF cases must be considered a very crude estimate. 11, 16 The World Health Organization estimates median incidence of 10 per 100,000 in established market economies; the data was not stratified by initial and recurrent attack. 11 Recent data derived from Aboriginal communities in Australia indicates an incidence of 374 cases per 100,000, 11 which is extremely high. Data on rates of ARF in Aboriginal communities is probably most usefully compared with data on the incidence in Māori and Pacific communities, rather than overall New Zealand incidence. A systematic review which focused only on prospective population-based studies of first incidence of ARF (all ages) computed a mean yearly incidence rate of 10 cases per 100,000 in the USA and Western Europe and less than 10 cases per 100,000 in Eastern Europe, Australia and the Middle East. 18 The only study that met the inclusion Management of Streptococcal A Sore Throat 8

15 criteria for the Australasian area was a New Zealand study from 1984 authored by Talbot. 17 This was assessed by the authors as being of high quality. In that study, overall incidence in New Zealand was reported as being 22 per 100,000 in a population of people aged less than 30 years. A subgroup analysis from the Talbot study showed an incidence of greater than 80 per 100,000 for Māori. Again the authors highlighted the paucity of high quality population-based prospective studies of ARF around the world. Mortality data related to ARF is also problematic. 11 Reliable cause-specific mortality data relating to ARF and RHD are only available from indigenous populations living in relative poverty in wealthy countries (such as New Zealand). However, the New Zealand data cited is relatively old ( ); age standardised mortality for RHD (with or without rheumatic fever) for non-māori were reported at 2.0 per 100,000 per year, and 9.6 per 100,000 per year for Māori. 11 Ethnic disparities As has been highlighted in earlier sections, Māori and Pacific children experience a disproportionally high rate of ARF in New Zealand and rates of disparity are widening 1,15 (Figure 1.2). In the 10 years to 2005, the 5 to 14 year-olds rate for non- Māori and Other children was reported to be 3.0 per 100,000 (lower than the age standardised rate for all people of 3.4 per 100,000), while for Māori and Pacific children rates were 34.1 and 67.1 per 100,000 respectively. 1 More recent analysis has found this disparity to have increased: for the period from 2000 to 2009, Māori children experienced an initial ARF rate of 40.2 per 100,000 (CI 36.8 to 43.8, p=.05), Pacific children 81.2 per 100,000 (CI 73.4 to 89.6, p=.05) and non-māori children 2.1 per 100,000 (CI 1.6 to 2.5, p=.05) (Table 1.2). From 1996 to 2005, the New Zealand European and Others ARF rate decreased significantly while Māori and Pacific peoples rates increased. Compared with New Zealand European and Others, rate ratios were 10.0 for Māori and 20.7 for Pacific peoples. 1 These disparities continued to increase after Incidence rates between 2000 and 2009 for children 5 to 14 years were about 20-fold higher for Māori children and 40-fold higher for Pacific children in this age group compared with non- Māori/Pacific categories. 15 Rate ratios for Māori children were 19.5 and for Pacific children were 39.3, when compared with non-māori children (Table 1.2). During 1993 and 2009 the ethnic disparity for Māori and Pacific children compared with non- Māori/Pacific children widened both in relative terms (the ratio of incidence rates) and in absolute terms (the difference in incidence rates) (Table 1.4). Management of Streptococcal A Sore Throat 9

16 Table 1.4 Changes in ethnic disparity over time for children 5 to 14 years of age during the period a Incidence rate ratio b Incidence rate difference per 100,000 per year c Māori Pacific a Based on linear regression of incidence rates on year b Incidence rate of Māori or Pacific children divided by that for non-māori/pacific children c Difference in incidence rates between Māori or Pacific compared to non-māori/pacific Source: Milne, R., D. Lennon, et al. (2010). Burden and cost of rheumatic fever and rheumatic heart disease in New Zealand: focus on school age children. A report to the Ministry of Health. Auckland, New Zealand, Health Outcomes Associates Limited. Deaths associated with chronic RHD have increased from an average of 123 deaths per annum between 1971 and 1980 to 186 reported deaths in For Māori this equates to a prevalence rate for mortality of 8.5/100,000 population (95%CI 7.0 to 10.3) and for non-māori 1.4/100,000 population (95%CI 1.2 to 1.5). Rheumatic heart disease mortality was over six times greater in Māori than non-māori (relative risk (RR) 6.27 [95%CI 4.95 to 7.94]). 13 Māori experience of rheumatic fever prevention and management It is important to point out that the susceptibility of both Māori and Pacific children to rheumatic fever is most likely attributable to economic deprivation (and associated factors) experienced by Māori and Pacific people in New Zealand (ie, overcrowding, poor housing conditions, rural locations and decreased access to and utilisation of health care services) 13. However, while a World Health Organization report into global burden of GAS-related disease states that The burden of GAS diseases and the association of these diseases with poverty cannot be ignored, 11 the evidence to date has not been designed to reliably indicate which particular factors contribute to the high rates of rheumatic fever in New Zealand. NZGG could not locate any specific data that explored Māori or Pacific people s experiences of, or access to, care for rheumatic fever. However, given that the majority of sore throats are managed in primary care settings, research relating to Māori experiences of primary care and general practice is relevant. 19 In a qualitative investigation into Māori experience of health care in New Zealand, themes to emerge from hui with 86 Māori regarding general practice care is encapsulated in the following statement: Participants experiences of general practice were, in the main, related to how they had been treated by health staff, and their hesitancy about seeking treatment. This hesitancy, or wait and see attitude, described by many participants was associated with their financial concerns and their values and beliefs, as well as with their knowledge of how general practice staff were likely to treat them based on their previous experiences (Jansen et al). 19 Management of Streptococcal A Sore Throat 10

17 Further surveying of a larger group of Māori (n=651), the majority of whom had either school- or pre-school aged children (54.2%), revealed, in general, a satisfaction with health services. However, clustering of the survey results found that that those in the younger age bracket (aged 39 years or less) reported a greater reluctance to use health and disability services, and a greater dissatisfaction with the interactions they had with these services. Of particular concern in relation to the management of sore throats in primary care is that a significantly-higher proportion of the younger respondents agreed that: they had to be quite sick and usually waited until the last minute before going to the doctor it was too expensive to go every time they were sick the doctor was not good value for money they do not like taking drugs for their illnesses. Further reporting on the same study, but comparing Māori and non-māori experiences of access to primary care, 20 found differences in reported access to general practice care. For example, there were significant differences between Māori and non-māori participants in terms of being: seen in the timeframe needed (93% of Māori 96.5% of non-māori); given a suitable time (93.8% of Māori 98.3% of non-māori); given a choice of times (68.3% of Māori 77.8% of non-māori); and being seen on time (64.2% of Māori 75.1% of non-māori). The authors state that there may be a number of issues that explain the discrepancies, including non-medical staff attitudes to Māori patients, Māori cultural beliefs (including the tendency to noho whakaiti to not cause a ruckus), and self-selection bias into the study. However, in relation to treatment of sore throat, timely access to a medical practitioner when required is very important. Once a sore throat is recognised as a serious issue by individuals and whānau living in high risk communities, a responsive primary care service upon presentation is no doubt critical to both treatment success and further developing those individual s and community s confidence in an equitable and responsive healthcare system. 20 In terms of use of and access to treatments specifically relevant to the prevention of rheumatic fever, a study of antibiotic use in Te Tairawhiti between 2005 and 2006, revealed that Māori are dispensed fewer antibiotics than non-māori, and the differences increase for Māori living in rural areas. Forty-eight percent of Māori people and 55% of non-māori received one or more antibiotic prescriptions during the study period. Both Māori and non-māori living in rural areas received fewer prescriptions for antibiotics, but the difference was much larger for Māori than for non-māori. There was very low prevalence for antibiotic prescriptions for rural Māori children (aged <6 years) (43%) compared with that for rural non- Māori (68%) or urban dwellers (80% and 85% for Māori and non- Māori, respectively). Unfortunately no statistical analysis was completed to determine if the differences were significant. However, given that in the Tairawhiti DHB area rates of rheumatic fever in 2010 were the highest in the country at 15.1 per population, the report highlights a serious issue that warrants further exploration and certainly consideration in the context of the prevention of ARF in young Māori. 21 Management of Streptococcal A Sore Throat 11

18 Messages from research with Māori are clear; their experiences with primary healthcare services could be improved. For the New Zealand health systems and individual practitioners within that system it is important to consider how such experiences may impact upon the effective management of sore throats and the prevention of ARF. Indigenous populations experience of rheumatic fever care Given the lack of data identified specific to Māori experiences of ARF prevention and management, research with indigenous Aboriginal Australians may be useful to consider in the context of sore throat management approaches with both Māori and Pacific people, until more specific research is conducted. Qualitative research on patient s experiences of rheumatic fever programmes in Aboriginal communities in the Northern Territories provides useful insight for the implementation of rheumatic fever prevention programmes. In a study of Aboriginal people in the Kimberly region of Australia with a diagnosis of rheumatic fever or rheumatic heart disease there was a varied understanding of either disease or its management. The findings highlighted the need for culturally-appropriate access to information about the disease, and the importance of the relationship between patient and healthcare workers compliance with medication was closely linked with positive patient-staff interactions. 22 Although the study was mainly about secondary prophylaxis, the findings may equally apply in the prevention of rheumatic fever and GAS throat infection prevention. A second qualitative study exploring the experiences of 15 patients with RHD or a history of rheumatic fever, 18 relatives and 18 health care workers in a remote Aboriginal community, found a mix of staff and patient factors influence the success of the programme in terms of compliance to a secondary prophylaxis regime. 23 Staffing factors that influence compliance included: appropriately trained, socially and culturally competent staff, staff willingness to treat patients at home, and an active recall system. Individual and family factors that encouraged uptake of regimes were an enhanced belief that the disease is chronic and serious, confidence in the health service and a feeling of holistic care, and family support for the treatment and belief in the efficacy of the treatment. The same study found that staff factors that inhibited uptake included: negative perception of the secondary prophylaxis programme, conflicting priorities for staff, no effective strategy for dealing with absent patients, staff fatigue and frustration. 23 Individual and family factors inhibiting uptake included: conscientious refusal of treatment, inconvenience to the patient, not belonging to the health service, lack of family support and lack of confidence in the treatment. Management of Streptococcal A Sore Throat 12

19 Specific issues relating to primary care workforce requirements that have been noted during rheumatic fever work with aboriginal communities in Australia may also apply to New Zealand. 24 Examples include: a lack of trained health professionals willing to stay for extended periods of time in remote communities to provide co-ordinated care, and a high turnover of nursing staff (in remote communities). There is also a scarcity of appropriately-trained Aboriginal health workers (these people are often considered the key players of the primary health service in remote settings), who are often pulled in many directions at the community level. This leads to a high burden of work and responsibility, with associated high rates of burnout. 24 Signs and symptoms of GAS throat infection Signs and symptoms of GAS throat Infection Sore throat is one of the common signs and symptoms of streptococcal pharyngitis. 6 Four guidelines were identified that summarised data on signs and symptoms of GAS throat infection; all agree that the cardinal symptoms suggestive of streptococcal pharyngitis include: history of fever tender anterior cervical adenopathy exudative tonsillitis lack of cough. A systematic review found that the most useful findings for evaluating the likelihood of streptococcal pharyngitis are the presence of tonsillar exudate, pharyngeal exudate, or exposure to streptococcal pharyngitis in the previous two weeks (positive likelihood ratios, 3.4, 2.1, and 1.9 respectively) and the absence of tender anterior cervical nodes, tonsillar enlargement or exudate (negative likelihood ratios, 0.60, 0.63, and 0.74, respectively). 3 GAS throat infection: timing, length The Ministry of Health asked the research question below in an attempt to gain a better understanding of the window of opportunity for throat swabbing in people with suspected GAS throat infection. NZGG undertook a literature review to answer the question. Research question: When do sore throats occur in the natural course of streptococcal pharyngitis and how long they tend to last? Management of Streptococcal A Sore Throat 13

20 Body of evidence Two guidelines from the United States agree that patients are more likely to present with GAS throat infection in the colder months of winter and spring. 25, 26 The New Zealand Heart Foundation guideline found that evidence was sparse in relation to other climatic conditions and cite no clear seasonal peak in Auckland over a four-year period. The natural history is for symptoms to subside within 3 to 5 days unless suppurative complications intervene. 7, 25 Children are most infectious during the acute phase of the illness; 5, 7 however, they may remain infectious for more than two weeks. 5 Transmission is by inhalation of large droplets or direct contact with respiratory secretions. Summary of findings No evidence was found to suggest seasonal variation in GAS throat infection in New Zealand. Evidence from narrative reviews reported the incubation period to be 2 to 5 days and for symptoms to subside within 3 to 5 days from onset. Narrative reviews also report that children are most infectious during the acute phase of the illness. However, they may remain infectious for more than two weeks. Management of Streptococcal A Sore Throat 14

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