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
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.
• 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.
||Once Daily - 50 mg/kg/dose (max dose 1000 mg)
Weight <30 kg: 750 mg once daily
Weight ≥30 kg: 1000 mg once daily
Twice daily - 25 mg/kg/dose (max dose 1000 mg)
| 10 days
Reference: National Heart Foundation algorithm
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
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.