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

Acute Rheumatic Fever (ARF) is an autoimmune disease caused by an abnormal immune response to a group A streptococcal (GAS) pharyngitis. It occurs in 1-3% of people 1–5 weeks (mean 19 days) after a GAS throat infection.

ARF can affect:

• Joints → arthritis or arthralgia
• Heart → murmur, prolonged PR interval, or heart failure
• Central nervous system → chorea (fidgety or abnormal movements
• Skin → rash (erythema marginatum)
• Subcutaneous tissue → nodules
• Acute inflammation → Fever, raised ESR/CRP, raised Strep Titres

Only heart involvement can cause permanent damage to the mitral and/or aortic valves (rheumatic heart disease - RHD). People with ARF or RHD are started on monthly IM benzathine penicillin to prevent recurrent ARF and worsening RHD, and remain on this for 10-15 years.

2015 New Zealand Diagnostic Guidelines: Available from the National Health Foundation (PDF).

Refer to Hospital

Discuss all possible cases with a Paediatric or Adult Infectious Disease Consultant and refer for hospital admission.

High index of suspicion
• Maori or Pacific children and young people (highest risk at 5-14 years of age)
• With fever and arthritis/arthralgia (joint pain) and/or a murmur
• Recent sore throat a history
• Rarer presentations include chorea, erythema marginatum, or subcutaneous nodules.

Notify to Public Health

• ARF is notifiable to Public Health under the Health Act 1956 on suspicion.
• Find the Acute Rheumatic Fever notification form here.
• Time to notification is included in the Ministry of Health's expectations of DHBs as follows: Ensure that all cases of acute rheumatic fever are notified to the Medical Officer of Health within 7 days of hospital admission.

ARPHS' Role

• Collection of national surveillance data
• Contact tracing household contacts of patients with ARF, throat swab for GAS and treat if positive (antibiotics are provided free of charge by ARPHS)
• Facilitating M/emm typing of GAS isolates associated with a case of ARF to inform vaccine development and evaluation.
• Supporting the national Rheumatic Fever Prevention Programme and regional DHBs to meet national targets including:
    o Collating risk factor data on the national surveillance database
    o Facilitating timely notification


Auckland Regional Rheumatic Fever Register

• The Regional Rheumatic Fever Register supports delivery of monthly benzathine penicillin to patients with ARF and rheumatic heart disease and is run by Paediatric ID at Starship Children’s Hospital.
    o Paediatrician Oversight – Professor Diana Lennon, Starship Children’s Hospital
    o Administration – Robyn Buchanan, Starship Children’s Hospital, 09 307 4949 extn 22559
    o Referral Form available here

NOTE: Notification to public health does not facilitate referral to the Rheumatic Fever Register and delivery of IM penicillin.

 Rheumatic Fever Prevention Programme

In 2011 the Ministry of Health launched a Rheumatic Fever Prevention Programme with three key strategies:
• Improve access to timely and effective treatment for strep throat infections in priority communities.
• Increase awareness of rheumatic fever, what causes it and how to prevent it
• Reduce household crowding and household transmission of strep throat bacteria

For more information see http://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever

Primary Prevention through Treating Sore Throats

Treating group A Streptococcal sore throats (pharyngitis) prevents rheumatic fever. Not all sore throats are caused by strep A and clinical signs and symptoms are poor predictors, therefore a high risk approach is recommended:

High Risk Priority Populations

High risk if personal, family or household history of rheumatic fever or have 2 or more criteria:
• Māori or Pacific
• Aged 3–35 years
• Living in crowded circumstances or lower socioeconomic area

Sore Throat Management in High Risk Priority Populations

• Throat swab if follow up possible
• Start 10 days of amoxicillin. If the throat swab comes back negative for group A strep this should be stopped.
Erythromycin should be used if allergic to penicillins.

Antibiotic Route
Dose
Duration
 Amoxicillin  PO Once Daily - 50 mg/kg/dose (max dose 1000 mg)
                         Weight <30 kg: 750 mg once daily
                         Weight ≥30 kg: 1000 mg once daily

OR

Twice daily - 25 mg/kg/dose (max dose 1000 mg)
 10 days
Reference: National Heart Foundation algorithm and guidelines.

Checking your child's sore throat

• In Auckland if your child is Māori or Pacific and aged 4 to 19 years they can have their throat checked at a free sore throat clinic. You can call Healthline on 0800 611 116 to find a clinic near you
• Your child's school may have a sore throat checking programme in place (contact the school to find out) – this service is free
• You can go to your normal doctor or nurse (GP). You may have to pay a fee, you can phone ahead to check

Rheumatic Fever Resources

Guidelines

Ministry of Health
Communicable Disease Manual - guidelines for public health units
National Heart Foundation
Diagnosis, Management and Secondary Prevention of Acute Rheumatic Fever and Rheumatic Heart Disease guideline   

Group A Strep Sore Throat Management guideline and algorithm

For Patients and Whanau

National Heart Foundation
Know the facts webpage
What is Rheumatic Fever booklet 
Kids Health website for parents and whanau
This website is a joint initiative between the Paediatric Society of New Zealand and Starship Foundation providing child health information for NZ parents and whanau.

Rheumatic Fever page

Sore throat page
 Health Promotion Agency
 Awareness Raising campaign 2016 – videos, posters, etc.
© Copyright 2007 - 2011 Auckland Regional Public Health Service, ADHB. All rights reserved. Disclaimer

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Phone 09 623 4600 Fax 09 630 7431
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