Sore Throats and Acute Rheumatic Fever: advice for GPs and Practice Nurses

Tuesday, 17 November 2009

Key Messages

  • Think differently about sore throats in different population groups.
  • Acute rheumatic fever and rheumatic heart disease are a serious and worsening problem in Maori and Pacific populations (especially children) in the Auckland region.
  • Maori and Pacific children in Auckland presenting with sore throats are at high risk of group A streptococcal infection which, if left untreated, can lead to acute rheumatic fever and chronic rheumatic heart disease.

Map

Hotspots: Rheumatic Fever Notifications Jan 2000 – Aug 2009

Recommended action

  • All Maori and Pacific children in Auckland aged 3 years and over presenting with a sore throat should have a throat swab taken. In addition, antibiotics should be given empirically if any of the following are present:
    • T >38°C
    • No cough
    • Anterior cervical lymphadenopathy
    • Tonsillar swelling or exudate.
  • If none of these features are present wait for a positive group A streptococcal throat swab result before starting antibiotics.
  • Suitable antibiotics include pencillin V or amoxycillin. Use erythromycin (EES) if penicillin allergic.
  • Antibiotics must be given for 10 days.

Algorithm

An excellent National Heart foundation guideline/algorithm providing more detailed information, including dosages, on managing sore throats can be found here.

Refer to hospital

  • Suspect acute rheumatic fever if a Maori or Pacific child (highest risk at 5-14 years of age) presents with fever and arthritis/arthralgia and/or a murmur, particularly if there is a history of a recent sore throat. Other rarer features may include chorea, erythema marginatum or subcutaneous nodules.
  • Refer suspected cases to hospital early.

Background

Acute rheumatic fever and rheumatic heart disease remain serious preventable causes of morbidity and mortality in NZ, with rates for Maori and Pacific in many areas similar to those in developing countries and continuing to increase.

Recent cases of acute rheumatic fever have occurred in Auckland in patients who had presented to primary care with a sore throat but did not receive antibiotics. This highlights that doctors need to think differently about sore throats in different population groups.

Acute rheumatic fever is still all too common in certain populations (Maori and Pacific children living in relatively deprived areas at highest risk) and can be prevented by appropriate sore throat management. While sore throats are commonly viral in children of European descent, and in adults, group A streptococcus is still a very important cause in Maori and Pacific children. Auckland sees up to 100 preventable cases per year (and many more are likely to go undiagnosed). Twice as many deaths occur from rheumatic heart disease as from cervical cancer each year in NZ.

60% of acute rheumatic fever cases in NZ occur in the Auckland region. While South Auckland has the highest rates and numbers of any DHB in NZ, other areas in Auckland also have relatively high rates.

Particular geographic ‘hotspots’ in the Auckland region include Ranui, Glen Innes/Tamaki, Mt Roskill, Mangere/Favona, Otahuhu/Otara, Clendon/Manurewa and Papakura (see map below). However, Maori or Pacific children living anywhere in Auckland are at relatively high risk.

For further information on rheumatic fever please download the recently published National Heart Foundation Guidelines here.