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Armitage EP, de Crombrugghe G, Keeley AJ, Senghore E, Camara FE, Jammeh M, Bittaye A, Ceesay H, Ceesay I, Samateh B, Manneh M, Kampmann B, Turner CE, Kucharski A, Botteaux A, Smeesters PR, de Silva TI, Marks M. Streptococcus pyogenes carriage and infection within households in The Gambia: a longitudinal cohort study. THE LANCET. MICROBE 2024; 5:679-688. [PMID: 38735305 DOI: 10.1016/s2666-5247(24)00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Streptococcus pyogenes causes more than 500 000 deaths per year globally, which occur disproportionately in low-income and middle-income countries. The roles of S pyogenes skin and pharyngeal carriage in transmission are unclear. We aimed to investigate the clinical epidemiology and household transmission dynamics of both S pyogenes asymptomatic carriage and infection in a high-burden setting. METHODS We did a 1-year prospective, longitudinal, household cohort study, recruiting healthy participants from households in Sukuta, The Gambia. Households were eligible if they comprised at least three members, including one child younger than 18 years, and were excluded if more than half of household members declined to participate. Households were identified by random GPS coordinates derived from census data. At monthly visits, pharyngeal and normal skin swabs were collected for S pyogenes culture, and sociodemographic data were recorded by interview. Incident pharyngitis and pyoderma infections were captured. Cultured isolates underwent emm genotyping. The primary outcome measures were incidence of S pyogenes carriage and disease. Additional outcomes were prevalence of S pyogenes skin and pharyngeal carriage, S pyogenes skin and pharyngeal clearance time, S pyogenes emm type, risk factors for carriage and disease events, household secondary attack rate, and emm-linked household transmission events. The study is registered on ClinicalTrials.gov, NCT05117528. FINDINGS Between July 27, 2021, and Sept 28, 2022, 442 participants were enrolled from 44 households. The median age was 15 years (IQR 6-28) and 233 (53%) were female. We identified 17 pharyngitis and 99 pyoderma events and 49 pharyngeal and 39 skin S pyogenes carriage acquisition events. Mean monthly prevalence was 1·4% (95% CI 1·1-1·9) for S pyogenes pharyngeal carriage and 1·2% (0·9-1·6) for S pyogenes skin carriage. Incidence was 120 per 1000 person-years (95% CI 87-166) for S pyogenes pharyngeal carriage, 124 per 1000 person-years (90-170) for S pyogenes skin carriage, 51 per 1000 person-years (31-84) for S pyogenes pharyngitis, and 263 per 1000 person-years (212-327) for S pyogenes pyoderma. Pharyngeal carriage risk was higher during the rainy season (HR 5·67, 95% CI 2·19-14·69) and in larger households (per additional person: 1·03, 1·00-1·05), as was pharyngitis risk (rainy season: 3·00, 1·10-8·22; household size: 1·04, 1·02-1·07). Skin carriage risk was not affected by season or household size, but was lower in female than in male participants (0·45, 0·22-0·92) and highest in children younger than 5 years compared with adults (22·69, 3·08-167·21), with similar findings for pyoderma (female sex: 0·34, 0·19-0·61; age <5 years: 7·00, 2·78-17·64). Median clearance time after carriage acquisition was 4·0 days for both skin (IQR 3·5-7·0) and pharynx (3·5-7·3). The mean household secondary attack rate was 4·9 (95% CI 3·5-6·3) for epidemiologically linked S pyogenes events and 0·74 (0·3-1·2) for emm-linked S pyogenes events. Of the 204 carriage and disease events, emm types were available for 179 (88%). Only 18 emm-linked between-visit household transmission events were identified. Pyoderma was the most common source of S pyogenes household transmissions in 11 (61%) of 18 emm-linked transmissions. Both pharynx to skin and skin to pharynx transmission events were observed. INTERPRETATION S pyogenes carriage and infection are common in The Gambia, particularly in children. Most events are non-household acquisitions, but skin carriage and pyoderma have an important role in S pyogenes household transmission and bidirectional transmission between skin and pharynx occurs. FUNDING Wellcome Trust, Chadwick Trust, Fonds National de la Recherche Scientifique (Belgium), European Society for Paediatric Infectious Diseases, and Medical Research Council (UK).
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Affiliation(s)
- Edwin P Armitage
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Gabrielle de Crombrugghe
- Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université libre de Bruxelles, Brussels, Belgium; Department of Paediatrics, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles, Brussels, Belgium
| | - Alexander J Keeley
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; The Florey Institute of Infection, University of Sheffield, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Elina Senghore
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Fatoumata E Camara
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Musukoi Jammeh
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Amat Bittaye
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Haddy Ceesay
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Isatou Ceesay
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Bunja Samateh
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Muhammed Manneh
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Centre for Global Health and Institut für Internationale Gesundheit, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Claire E Turner
- The Florey Institute of Infection, University of Sheffield, Sheffield, UK; School of Biosciences, University of Sheffield, Sheffield, UK
| | - Adam Kucharski
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Anne Botteaux
- Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université libre de Bruxelles, Brussels, Belgium
| | - Pierre R Smeesters
- Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université libre de Bruxelles, Brussels, Belgium; Department of Paediatrics, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles, Brussels, Belgium; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Thushan I de Silva
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; The Florey Institute of Infection, University of Sheffield, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Michael Marks
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Hospital for Tropical Diseases, University College London Hospital, London, UK; Division of Infection and Immunity, University College London, London, UK
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Ali Sulafa KM, Karrar ZA, Elkurdufani N, Ibrahim N. Sudan's rheumatic fever and rheumatic heart disease guidelines: a simplified approach in an endemic country. Front Cardiovasc Med 2024; 11:1403131. [PMID: 38798925 PMCID: PMC11116708 DOI: 10.3389/fcvm.2024.1403131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
Background Rheumatic heart disease (RHD) is a preventable sequelae of group A beta hemolytic streptococcal infection leading to an immune reaction: acute rheumatic fever (ARF) and progressive heart valve dysfunction. RHD is the leading cause of acquired heart disease in children and young adults in Sudan and many low/middle-income countries. In 2018, the World Health Organization (WHO) issued a resolution for RHD mandating that each country adopt updated guidelines for ARF and RHD management. These current guidelines are mainly directed to primary healthcare workers. Methods Sudan's Federal Ministry of Health (FMOH) in collaboration with the WHO East Mediterranean Regional Office (EMRO) assembled a committee for updating RHD guidelines. We conducted a systematic literature search from 2000 to 2022 in National Institute of Health Database (PubMed) under the following titles: streptococcal pharyngitis, acute rheumatic fever, rheumatic heart disease, benzathine penicillin. Best available, evidence-based practices for diagnosis and management of ARF/RHD were selected and adapted to Sudan's situation. The guidelines were critically appraised by the committee then endorsed to the FMOH and WHO EMRO Noncommunicable Disease Departments in January 2023. This paper describes the updated guidelines. Results Simplified algorithms are provided for diagnosis of bacterial pharyngitis including two clinical criteria: sore throat and the absence of viral symptoms in the target age group. A simplified algorithm for diagnosis and management of ARF is adopted using two levels of diagnosis: suspected case at primary level where penicillin prophylaxis is started and secondary/tertiary care where echocardiography is performed and diagnosis confirmed or excluded. Echocardiography screening is recognized as the standard method for early diagnosis of RHD; however, due to the anticipated limitations, its implementation was not adopted at this time. Streptococcal skin infection is included as a precursor of ARF and a detailed protocol for benzathine penicillin administration is described. Conclusion The Sudan guidelines for ARF/RHD management were updated. Endorsement of these guidelines to FMOH and WHO EMRO is expected to improve control of RHD in the region.
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Affiliation(s)
| | | | | | - Nazik Ibrahim
- Federal Ministry of Health and World Health Organization, Khartoum, Sudan
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Mullane MJ, Thomas HM, Carapetis JR, Lizama C, Billingham W, Cooper MN, Everest C, Sampson CR, Newall N, Pearce S, Lannigan F, McNulty E, Cresp R, Mace AO, Barrow T, Bowen AC. Tonsils at Telethon: developing a standardised collection of tonsil photographs for group A streptococcal (GAS) research. Front Pediatr 2024; 12:1367060. [PMID: 38725980 PMCID: PMC11079290 DOI: 10.3389/fped.2024.1367060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Group A streptococcus (GAS) infections, such as pharyngitis and impetigo, can lead to rheumatic fever and rheumatic heart disease (RHD). Australian Aboriginal and Torres Strait Islander populations experience high rates of RHD and GAS skin infection, yet rates of GAS pharyngitis are unclear. Anecdotally, clinical presentations of pharyngitis, including tonsillar hypertrophy and sore throat, are uncommon. This study aimed to develop a standardised set of tonsil photographs and determine tonsil size distribution from an urban paediatric population. Methods A prospective cohort of children aged 3-15 years were recruited at the public events "Discover Day" and "Telethon Weekend" (October 2017) in Perth, Western Australia, Australia. Tonsil photographs, symptomatology, and GAS rapid antigen detection tests (RADT) were collected. Tonsil size was graded from the photographs using the Brodsky Grading Scale of tonsillar hypertrophy (Brodsky) by two independent clinicians, and inter-rater reliability calculated. Pharyngitis symptoms and GAS RADT were correlated, and immediate results provided. Results Four hundred and twenty-six healthy children participated in the study over three days. The median age was seven years [interquartile range (IQR) 5.9-9.7 years]. Tonsil photographs were collected for 92% of participants, of which 62% were rated as good-quality photographs and 79% were deemed of adequate quality for assessment by both clinicians. When scored by two independent clinicians, 57% received the same grade. Average Brodsky grades (between clinicians) were 11%, 35%, 28%, 22% and 5% of grades 0,1,2,3 and 4, respectively. There was moderate agreement in grading using photographs, and minimal to weak agreement for signs of infection. Of 394 participants, 8% reported a sore throat. Of 334 GAS RADT performed, <1% were positive. Discussion We report the first standardised use of paediatric tonsil photographs to assess tonsil size in urban-living Australian children. This provides a proof of concept from an urban-living cohort that could be compared with children in other settings with high risk of GAS pharyngitis or rheumatic fever such as remote-living Australian Indigenous populations.
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Affiliation(s)
- Marianne J. Mullane
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Hannah M. Thomas
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Jonathan R. Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Catalina Lizama
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Wesley Billingham
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Matthew N. Cooper
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Christine Everest
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Claudia R. Sampson
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Nelly Newall
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Sarah Pearce
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Francis Lannigan
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Eamonn McNulty
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Rebecca Cresp
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Ariel O. Mace
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Tina Barrow
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Asha C. Bowen
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia
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郭 孟, 姚 开. [Research progress on the mechanism of -lactam resistance in group A Streptococci in vivo]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:92-97. [PMID: 38269466 PMCID: PMC10817742 DOI: 10.7499/j.issn.1008-8830.2306157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/11/2023] [Indexed: 01/26/2024]
Abstract
-lactams, including penicillin, have been used for over 80 years in the treatment of group A Streptococcus (GAS) infections. Although -lactam-resistant GAS strains have not been identified in vitro tests, clinical treatment failures have been reported since the 1950s. The mechanism underlying the clinical failure of -lactam treatment in GAS infections remains unclear. Previous research has suggested that -lactam resistance in GAS in vivo is associated with reduced drug susceptibility of strains, bacterial inoculation effects, biofilm formation, the effect of coexisting bacteria, bacterial persistence, and bacterial internalization into host cells. This article reviews the main reports on -lactam treatment failure in GAS infections and analyzes the possible mechanisms of -lactam resistance in vivo. The findings aim to contribute to future research and clinical approaches in the field.
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Lacey JA, Bennett J, James TB, Hines BS, Chen T, Lee D, Sika-Paotonu D, Anderson A, Harwood M, Tong SY, Baker MG, Williamson DA, Moreland NJ. A worldwide population of Streptococcus pyogenes strains circulating among school-aged children in Auckland, New Zealand: a genomic epidemiology analysis. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 42:100964. [PMID: 38035130 PMCID: PMC10684382 DOI: 10.1016/j.lanwpc.2023.100964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/20/2023] [Accepted: 10/29/2023] [Indexed: 12/02/2023]
Abstract
Background Acute rheumatic fever (ARF) is a serious post-infectious sequala of Group A Streptococcus (GAS, Streptococcus pyogenes). In New Zealand (NZ) ARF is a major cause of health inequity. This study describes the genomic analysis of GAS isolates associated with childhood skin and throat infections in Auckland NZ. Methods Isolates (n = 469) collected between March 2018 and October 2019 from the throats and skin of children (5-14 years) underwent whole genomic sequencing. Equal representation across three ethnic groups was ensured through sample quotas with isolates obtained from Indigenous Māori (n = 157, 33%), NZ European/Other (n = 149, 32%) and Pacific Peoples children (n = 163, 35%). Using in silico techniques isolates were classified, assessed for diversity, and examined for distribution differences between groups. Comparisons were also made with GAS strains identified globally. Findings Genomic analysis revealed a diverse population consisting of 65 distinct sequence clusters. These sequence clusters spanned 49 emm-types, with 11 emm-types comprised of several, distinct sequence clusters. There is evidence of multiple global introductions of different lineages into the population, as well as local clonal expansion. The M1UK lineage comprised 35% of all emm1 isolates. Interpretation The GAS population was characterized by a high diversity of strains, resembling patterns observed in low- and middle-income countries. However, strains associated with outbreaks and antimicrobial resistance commonly found in high-income countries were also observed. This unique combination poses challenges for vaccine development, disease management and control. Funding The work was supported by the Health Research Council of New Zealand (HRC), award number 16/005.
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Affiliation(s)
- Jake A. Lacey
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Julie Bennett
- The Department of Public Health, University of Otago, Wellington, New Zealand
- The Maurice Wilkins Centre for Biodiscovery, The University of Auckland, Auckland, New Zealand
| | - Taylah B. James
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin S. Hines
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Victoria, Australia
| | - Tiffany Chen
- Department of Molecular Medicine and Pathology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | - Darren Lee
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Anneka Anderson
- Te Kupenga Hauora Māori, The University of Auckland, New Zealand
| | - Matire Harwood
- Department of General Practice and Primary Healthcare, The University of Auckland, Auckland, New Zealand
| | - Steven Y.C. Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael G. Baker
- The Department of Public Health, University of Otago, Wellington, New Zealand
- The Maurice Wilkins Centre for Biodiscovery, The University of Auckland, Auckland, New Zealand
| | - Deborah A. Williamson
- Department of Infectious Diseases at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Nicole J. Moreland
- The Maurice Wilkins Centre for Biodiscovery, The University of Auckland, Auckland, New Zealand
- Department of Molecular Medicine and Pathology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand
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Kado J, Salman S, Hla TK, Enkel S, Henderson R, Hand RM, Hort A, Page-Sharp M, Batty K, Moore BR, Bennett J, Anderson A, Carapetis J, Manning L. Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study. Antimicrob Agents Chemother 2023; 67:e0096223. [PMID: 37971244 PMCID: PMC10720493 DOI: 10.1128/aac.00962-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023] Open
Abstract
Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.
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Affiliation(s)
- Joseph Kado
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Sam Salman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Clinical Pharmacology and Toxicology Unit, PathWest, Western Australia, Australia
| | - Thel K. Hla
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Stephanie Enkel
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Henderson
- Medical Imaging Department, Perth Children’s Hospital, Nedlands, Western Australia, Australia
| | - Robert M. Hand
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Adam Hort
- Western Australian Country Health Service, Perth, Western Australia, Australia
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Kevin Batty
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Brioni R. Moore
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Anneka Anderson
- Te Kupenga Hauora Maori, University of Auckland, Auckland, New Zealand
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Baker MG, Masterson MY, Shung-King M, Beaton A, Bowen AC, Bansal GP, Carapetis JR. Research priorities for the primordial prevention of acute rheumatic fever and rheumatic heart disease by modifying the social determinants of health. BMJ Glob Health 2023; 8:e012467. [PMID: 37914185 PMCID: PMC10619085 DOI: 10.1136/bmjgh-2023-012467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/09/2023] [Indexed: 11/03/2023] Open
Abstract
The social determinants of health (SDH), such as access to income, education, housing and healthcare, strongly shape the occurrence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) at the household, community and national levels. The SDH are systemic factors that privilege some more than others and result in poverty and inequitable access to resources to support health and well-being. Primordial prevention is the modification of SDH to improve health and reduce the risk of disease acquisition and the subsequent progression to RHD. Modifying these determinants using primordial prevention strategies can reduce the risk of exposure to Group A Streptococcus, a causative agent of throat and skin infections, thereby lowering the risk of initiating ARF and its subsequent progression to RHD.This report summarises the findings of the Primordial Prevention Working Group-SDH, which was convened in November 2021 by the National Heart, Lung, and Blood Institute to assess how SDH influence the risk of developing RHD. Working group members identified a series of knowledge gaps and proposed research priorities, while recognising that community engagement and partnerships with those with lived experience will be integral to the success of these activities. Specifically, members emphasised the need for: (1) global analysis of disease incidence, prevalence and SDH characteristics concurrently to inform policy and interventions, (2) global assessment of legacy primordial prevention programmes to help inform the co-design of interventions alongside affected communities, (3) research to develop, implement and evaluate scalable primordial prevention interventions in diverse settings and (4) research to improve access to and equity of services across the RHD continuum. Addressing SDH, through the implementation of primordial prevention strategies, could have broader implications, not only improving RHD-related health outcomes but also impacting other neglected diseases in low-resource settings.
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Affiliation(s)
- Michael G Baker
- Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Mary Y Masterson
- Center for Translation Research and Implementation Science (CTRIS), National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Maylene Shung-King
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Andrea Beaton
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Geetha P Bansal
- HIV Research and Training Program, John E Fogarty International Center, Bethesda, Maryland, USA
| | - Jonathan R Carapetis
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
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8
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Rwebembera J, Cannon JW, Sanyahumbi A, Sotoodehnia N, Taubert K, Yilgwan CS, Bukhman G, Masterson M, Bruno FP, Bowen A, Dale JB, Engel ME, Beaton A, Van Beneden C. Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report. BMJ Glob Health 2023; 8:e012356. [PMID: 37914184 PMCID: PMC10619102 DOI: 10.1136/bmjgh-2023-012356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/24/2023] [Indexed: 11/03/2023] Open
Abstract
Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) encompasses the timely diagnosis and adequate treatment of the superficial group A Streptococcus (GAS) infections pharyngitis and impetigo. GAS is the only known inciting agent in the pathophysiology of the disease. However, sufficient evidence indicates that the uptake and delivery of primary prevention approaches in RHD-endemic regions are significantly suboptimal. This report presents expert deliberations on priority research and implementation opportunities for primary prevention of ARF/RHD that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. The opportunities identified by the Primary Prevention Working Group encompass epidemiological, laboratory, clinical, implementation and dissemination research domains and are anchored on five pillars including: (A) to gain a better understanding of superficial GAS infection epidemiology to guide programmes and policies; (B) to improve diagnosis of superficial GAS infections in RHD endemic settings; (C) to develop scalable and sustainable models for delivery of primary prevention; (D) to understand potential downstream effects of the scale-up of primary prevention and (E) to develop and conduct economic evaluations of primary prevention strategies in RHD endemic settings. In view of the multisectoral stakeholders in primary prevention strategies, we emphasise the need for community co-design and government engagement, especially in the implementation and dissemination research arena. We present these opportunities as a reference point for research organisations and sponsors who aim to contribute to the increasing momentum towards the global control and prevention of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Division of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Jeffrey W Cannon
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Amy Sanyahumbi
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Nona Sotoodehnia
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathryn Taubert
- American Heart Association International, Basel, Switzerland
- Department of Physiology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher Sabo Yilgwan
- Departments of Paediatrics and West African Center for Emerging Infectious Diseases, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Gene Bukhman
- Center for Integration Science in Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Fernando P Bruno
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Asha Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - James B Dale
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mark E Engel
- AFROStrep Research Initiative, Cape Heart Institute, Department of Medicine, University of Cape Town, Rondebosch, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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9
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Willis GA, Kearns T, Mayfield HJ, Sheridan S, Thomsen R, Naseri T, David MC, Engelman D, Steer AC, Graves PM, Lau CL. Scabies prevalence after ivermectin-based mass drug administration for lymphatic filariasis, Samoa 2018-2019. PLoS Negl Trop Dis 2023; 17:e0011549. [PMID: 37607196 PMCID: PMC10497159 DOI: 10.1371/journal.pntd.0011549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 09/12/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Scabies is a common skin infestation caused by the Sarcoptes scabei mite. Ivermectin, one of three drugs used in mass drug administration (MDA) for lymphatic filariasis, is also effective for treating scabies. Ivermectin-based MDA was first conducted in Samoa in August 2018, with ivermectin being offered to those aged ≥5 years. Here, we report scabies prevalence in Samoa after MDA. METHODS We conducted household surveys 1.5-3.5 months (Survey 1) and 6-8 months (Survey 2) after the 2018 MDA in 35 primary sampling units. We conducted clinical examination for scabies-like rash and used International Alliance for the Control of Scabies classification criteria. We estimated scabies prevalence by age, gender and region. Multivariable logistic regression was used to assess factors associated with prevalence. RESULTS We surveyed 2868 people (499 households) and 2796 people (544 households) aged 0-75 years in Surveys 1 and 2, respectively. Scabies prevalence increased from 2.4% (95% CI 2.1-2.7%) to 4.4% (95% CI 4.0-4.9%) between surveys. Scabies was associated with younger age (0-4 years: aOR 3.5 [2.9-4.2]; 5-15 years: aOR 1.6 [1.4-1.8] compared to ≥16 years), female gender (aOR 1.2 [95% CI 1.1-1.4]; region (aOR range from 1.4 [1.1-1.7] to 2.5 [2.1-3.1] between regions), large households (aOR 2.6 [2.0-3.4] households ≥13), and not taking MDA in 2018 (aOR 1.3 [95% CI 1.1-1.6]). CONCLUSIONS We found moderate prevalence of scabies in two population-representative surveys conducted within 8 months of the 2018 MDA for lymphatic filariasis. Prevalence appeared to increase between the surveys, and ongoing surveillance is recommended, particularly in young children.
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Affiliation(s)
- Gabriela A. Willis
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Therese Kearns
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Helen J. Mayfield
- Research School of Population Health, Australian National University, Canberra, Australia
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Sarah Sheridan
- National Centre for Immunisation Research and Surveillance, Sydney, Australia
| | | | | | - Michael C. David
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Daniel Engelman
- Tropical Diseases, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Andrew C. Steer
- Tropical Diseases, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Patricia M. Graves
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Australia
| | - Colleen L. Lau
- Research School of Population Health, Australian National University, Canberra, Australia
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
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10
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Brouwer S, Rivera-Hernandez T, Curren BF, Harbison-Price N, De Oliveira DMP, Jespersen MG, Davies MR, Walker MJ. Pathogenesis, epidemiology and control of Group A Streptococcus infection. Nat Rev Microbiol 2023; 21:431-447. [PMID: 36894668 PMCID: PMC9998027 DOI: 10.1038/s41579-023-00865-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
Streptococcus pyogenes (Group A Streptococcus; GAS) is exquisitely adapted to the human host, resulting in asymptomatic infection, pharyngitis, pyoderma, scarlet fever or invasive diseases, with potential for triggering post-infection immune sequelae. GAS deploys a range of virulence determinants to allow colonization, dissemination within the host and transmission, disrupting both innate and adaptive immune responses to infection. Fluctuating global GAS epidemiology is characterized by the emergence of new GAS clones, often associated with the acquisition of new virulence or antimicrobial determinants that are better adapted to the infection niche or averting host immunity. The recent identification of clinical GAS isolates with reduced penicillin sensitivity and increasing macrolide resistance threatens both frontline and penicillin-adjunctive antibiotic treatment. The World Health Organization (WHO) has developed a GAS research and technology road map and has outlined preferred vaccine characteristics, stimulating renewed interest in the development of safe and effective GAS vaccines.
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Affiliation(s)
- Stephan Brouwer
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Bodie F Curren
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Nichaela Harbison-Price
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - David M P De Oliveira
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Magnus G Jespersen
- Department of Microbiology and Immunology, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Mark R Davies
- Department of Microbiology and Immunology, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia.
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia.
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11
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Liang Y, Yu D, Lu Q, Zheng Y, Yang Y. The rise and fall of acute rheumatic fever and rheumatic heart disease: a mini review. Front Cardiovasc Med 2023; 10:1183606. [PMID: 37288267 PMCID: PMC10242100 DOI: 10.3389/fcvm.2023.1183606] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction The incidences of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), which were leading causes of death in children in the 1920s, have decreased substantially. Considering the recent resurgence of scarlet fever and increased incidence of streptococcal pharyngitis in children, an investigation of the current status of ARF and RHD may be worthwhile. Objective To summarize the prevalence trends, pathogenic factors, and prevention strategies for ARF and RHD in children. Methods A selective search of literature published between January 1920 and February 2023 was done in PubMed, using the terms "acute rheumatic fever", "rheumatic heart disease", "group A Streptococcus", "pharyngitis", "pharyngeal tonsillitis", "scarlet fever", "impetigo", "obstructive sleep apnea syndrome" and "child". Results Overcrowded homes and inadequate sanitation led to recurrent group A streptococcal infection, and the causal relationship between group A streptococcal infection and ARF/RHD was well established. Streptococcal infectious diseases, such as group A streptococcal pharyngeal tonsillitis, SF, impetigo, and obstructive sleep apnea syndrome, were associated with the occurrence of ARF and RHD. ARF and RHD were still prevalent in young people of developing countries and economically poor populations of high-income countries. Universal disease registration systems were critical to locating disease outbreaks, tracking disease transmission, and identifying high-risk populations. Four-level prevention strategies were effective in reducing the incidence and mortality of ARF and RHD. Conclusions Registry and preventive measures for ARF and RHD should be strengthened in areas of dense population; poor sanitation; resurgence of SF; and high incidence of streptococcal pharyngitis, impetigo, and obstructive sleep apnea syndrome.
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Affiliation(s)
- Yunmei Liang
- Department of Pediatrics, Beijing Chaoyang Hospital Affiliated to the Capital Medical University, Beijing, China
| | - Dingle Yu
- Department of Respiratory Medicine, Shenzhen Children’s Hospital, Shenzhen, China
| | - Qinghua Lu
- Department of Respiratory Medicine, Shenzhen Children’s Hospital, Shenzhen, China
- Microbiology Laboratory, National Center for Children’s Health, Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Yuejie Zheng
- Department of Respiratory Medicine, Shenzhen Children’s Hospital, Shenzhen, China
| | - Yonghong Yang
- Department of Respiratory Medicine, Shenzhen Children’s Hospital, Shenzhen, China
- Microbiology Laboratory, National Center for Children’s Health, Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University, Beijing, China
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12
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Pickering J, Sampson C, Mullane M, Sheel M, Barth DD, Lane M, Walker R, Atkinson D, Carapetis JR, Bowen AC. A pilot study to develop assessment tools for Group A Streptococcus surveillance studies. PeerJ 2023; 11:e14945. [PMID: 36935916 PMCID: PMC10022509 DOI: 10.7717/peerj.14945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/02/2023] [Indexed: 03/15/2023] Open
Abstract
Introduction Group A Streptococcus (GAS) causes pharyngitis (sore throat) and impetigo (skin sores) GAS pharyngitis triggers rheumatic fever (RF) with epidemiological evidence supporting that GAS impetigo may also trigger RF in Australian Aboriginal children. Understanding the concurrent burden of these superficial GAS infections is critical to RF prevention. This pilot study aimed to trial tools for concurrent surveillance of sore throats and skins sore for contemporary studies of RF pathogenesis including development of a sore throat checklist for Aboriginal families and pharynx photography. Methods Yarning circle conversations and semi-structured interviews were performed with Aboriginal caregivers and used to develop the language and composition of a sore throat checklist. The sore throat story checklist was combined with established methods of GAS pharyngitis and impetigo surveillance (examination, bacteriological culture, rapid antigen detection and serological tests) and new technologies (photography) and used for a pilot cross-sectional surveillance study of Aboriginal children attending their health clinic for a routine appointment. Feasibility, acceptability, and study costs were compiled. Results Ten Aboriginal caregivers participated in the sore-throat yarning circles; a checklist was derived from predominant symptoms and their common descriptors. Over two days, 21 Aboriginal children were approached for the pilot surveillance study, of whom 17 were recruited; median age was 9 years [IQR 5.5-13.5], 65% were female. One child declined throat swabbing and three declined finger pricks; all other surveillance elements were completed by each child indicating high acceptability of surveillance assessments. Mean time for screening assessment was 19 minutes per child. Transport of clinical specimens enabled gold standard microbiological and serological testing for GAS. Retrospective examination of sore throat photography concorded with assessments performed on the day. Conclusion Yarning circle conversations were effective in deriving culturally appropriate sore throat questionnaires for GAS pharyngitis surveillance. New and established tools were feasible, practical and acceptable to participants and enable surveillance to determine the burden of superficial GAS infections in communities at high risk of RF. Surveillance of GAS pharyngitis and impetgio in remote Australia informs primary RF prevention with potential global translation.
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Affiliation(s)
- Janessa Pickering
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
| | - Claudia Sampson
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
| | - Marianne Mullane
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
| | - Meru Sheel
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Acton, ACT, Canberra, Australia
| | - Dylan D. Barth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Perth, Western Australia
| | - Mary Lane
- Broome Regional Aboriginal Medical Service, Broome, Australia
| | - Roz Walker
- School of Population and Global Health, University of Western Australia, Perth, Australia
- Ngank Yira Institute for Change, Murdoch University, Perth, Australia
| | - David Atkinson
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
| | - Jonathan R. Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Nedlands, Perth, Australia
| | - Asha C. Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Nedlands, Perth, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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13
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Cytokine imbalance in acute rheumatic fever and rheumatic heart disease: Mechanisms and therapeutic implications. Autoimmun Rev 2022; 21:103209. [PMID: 36228998 DOI: 10.1016/j.autrev.2022.103209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/04/2022] [Indexed: 12/15/2022]
Abstract
Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD) are autoimmune sequelae of Group A Streptococcus infection with significant global disease burden. The pathogenesis of these diseases is poorly understood, and no immune modulating therapies are available to stop progression from ARF to RHD. Cytokines and chemokines are immune signaling molecules critical to the development of autoimmune diseases. An increasing number of studies point to a central role for pro-inflammatory cytokines and chemokines in ARF and RHD pathogenesis, in particular IL-6, IL-8/CXCL8, and TNFα, which are elevated in circulation in both ARF and RHD patients. Histological studies of RHD valve tissue implicates Th1 and Th17 associated pro-inflammatory cytokines, chemokine CXCL9, and the fibrosis-associated cytokine TGF-β in progressive cycles of inflammatory damage and fibrotic repair. Taken together, this suggests immune molecules contribute to both the acute inflammatory disease stage of ARF, as well as cardiac remodeling and valve dysfunction in RHD. Monoclonal antibody blockade of pro-inflammatory cytokines IL-6 and TNFα are approved therapies for many autoimmune diseases and the most successful immunomodulating therapies for rheumatoid arthritis. Current evidence suggests possible benefit for ARF patients from IL-6 and TNFα blockade, in particular to interrupt progression to RHD, and warrants immediate investigation.
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14
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The effects of sugar in drinking water on Streptococcus pyogenes colonisation in a murine nasopharyngeal infection model. Sci Rep 2022; 12:17716. [PMID: 36271250 PMCID: PMC9587037 DOI: 10.1038/s41598-022-22648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/18/2022] [Indexed: 01/18/2023] Open
Abstract
The number of sugar-sweetened beverages consumed per day has been associated with an increased risk of acute rheumatic fever, an autoimmune disease triggered by superficial Streptococcus pyogenes infection. To explore if there could be a biological basis for this association, we used a mouse model of S. pyogenes nasopharyngeal colonisation combined with a dietary intervention. We observed an increased bacterial load in the nasopharynx of mice receiving sucrose drinking water post-infection, suggesting that high sucrose intake promotes S. pyogenes growth and/or survival. This provides new insight into the potential biological basis behind the association seen in humans.
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15
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Scheel A, Miller KM, Beaton A, Katzenellenbogen J, Parks T, Cherian T, Van Beneden CA, Cannon JW, Moore HC, Bowen AC, Carapetis JR. Standardization of Epidemiological Surveillance of Rheumatic Heart Disease. Open Forum Infect Dis 2022; 9:S50-S56. [PMID: 36128407 PMCID: PMC9474940 DOI: 10.1093/ofid/ofac250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rheumatic heart disease (RHD) is a long-term sequela of acute rheumatic fever (ARF), which classically begins after an untreated or undertreated infection caused by Streptococcus pyogenes (Strep A). RHD develops after the heart valves are permanently damaged due to ARF. RHD remains a leading cause of morbidity and mortality in young adults in resource-limited and low- and middle-income countries. This article presents case definitions for latent, suspected, and clinical RHD for persons with and without a history of ARF, and details case classifications, including differentiating between definite or borderline according to the 2012 World Heart Federation echocardiographic diagnostic criteria. This article also covers considerations specific to RHD surveillance methodology, including discussions on echocardiographic screening, where and how to conduct active or passive surveillance (eg, early childhood centers/schools, households, primary healthcare), participant eligibility, and the surveillance population. Additional considerations for RHD surveillance, including implications for secondary prophylaxis and follow-up, RHD registers, community engagement, and the negative impact of surveillance, are addressed. Finally, the core elements of case report forms for RHD, monitoring and audit requirements, quality control and assurance, and the ethics of conducting surveillance are discussed.
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Affiliation(s)
- Amy Scheel
- Emory University School of Medicine , Atlanta, Georgia , USA
| | - Kate M Miller
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Perth Children’s Hospital , Nedlands, Western Australia , Australia
| | - Andrea Beaton
- The Heart Institute, Cincinnati Children’s Hospital Medical Center , Cincinnati, Ohio , USA
- Department of Pediatrics, University of Cincinnati College of Medicine , Cincinnati, Ohio , USA
| | - Judith Katzenellenbogen
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- School of Population and Global Health, University of Western Australia , Nedlands, Western Australia , Australia
| | - Tom Parks
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital , London , United Kingdom
| | | | - Chris A Van Beneden
- CDC Foundation, Centers for Disease Control and Prevention , Atlanta, Georgia , USA
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health , Boston, Massachusetts , USA
| | - Hannah C Moore
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
| | - Asha C Bowen
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Perth Children’s Hospital , Nedlands, Western Australia , Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Perth Children’s Hospital , Nedlands, Western Australia , Australia
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16
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Baker MG, Gurney J, Moreland NJ, Bennett J, Oliver J, Williamson DA, Pierse N, Wilson N, Merriman TR, Percival T, Jackson C, Edwards R, Mow FC, Thomson WM, Zhang J, Lennon D. Risk factors for acute rheumatic fever: A case-control study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 26:100508. [PMID: 36213134 PMCID: PMC9535428 DOI: 10.1016/j.lanwpc.2022.100508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain an inequitable cause of avoidable suffering and early death in many countries, including among Indigenous Māori and Pacific populations in New Zealand. There is a lack of robust evidence on interventions to prevent ARF. This study aimed to identify modifiable risk factors, with the goal of producing evidence to support policies and programs to decrease rates of ARF. METHODS A case-control study was undertaken in New Zealand using hospitalised, first episode ARF cases meeting a standard case-definition. Population controls (ratio of 3:1) were matched by age, ethnicity, socioeconomic deprivation, location, sex, and recruitment month. A comprehensive, pre-tested questionnaire was administered face-to-face by trained interviewers. FINDINGS The study included 124 cases and 372 controls. Multivariable analysis identified strong associations between ARF and household crowding (OR 3·88; 95%CI 1·68-8·98) and barriers to accessing primary health care (OR 2·07; 95% CI 1·08-4·00), as well as a high intake of sugar-sweetened beverages (OR 2·00; 1·13-3·54). There was a marked five-fold higher ARF risk for those with a family history of ARF (OR 4·97; 95% CI 2·53-9·77). ARF risk was elevated following self-reported skin infection (aOR 2·53; 1·44-4·42) and sore throat (aOR 2·33; 1·49-3·62). INTERPRETATION These globally relevant findings direct attention to the critical importance of household crowding and access to primary health care as strong modifiable causal factors in the development of ARF. They also support a greater focus on the role of managing skin infections in ARF prevention. FUNDING This research was funded by the Health Research Council of New Zealand (HRC) Rheumatic Fever Research Partnership (supported by the New Zealand Ministry of Health, Te Puni Kōkiri, Cure Kids, Heart Foundation, and HRC) award number 13/959.
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Affiliation(s)
- Michael G. Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
- Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Jason Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nicole J. Moreland
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jane Oliver
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Victoria, Australia
| | - Deborah A. Williamson
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Nevil Pierse
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nigel Wilson
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Starship Children's Hospital, Auckland, New Zealand
- Green Lane Paediatric and Congenital Cardiac Services, Auckland, New Zealand
| | - Tony R. Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, United States of America
| | - Teuila Percival
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Moana Research, Auckland, New Zealand
| | | | - Richard Edwards
- Department of Public Health, University of Otago, Wellington, New Zealand
| | | | | | - Jane Zhang
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Diana Lennon
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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17
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Bennett J, Moreland NJ, Zhang J, Crane J, Sika-Paotonu D, Carapetis J, Williamson DA, Baker MG. Risk factors for group A streptococcal pharyngitis and skin infections: A case control study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 26:100507. [PMID: 35789826 PMCID: PMC9250036 DOI: 10.1016/j.lanwpc.2022.100507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Group A streptococcal (GAS) infections can trigger an immune-mediated response resulting in acute rheumatic fever (ARF). The role of social and environmental risk factors for GAS pharyngitis and skin infections are not well understood. This study aimed to identify factors associated with GAS pharyngitis and skin infections, and to determine if these are the same as those for ARF. METHODS A case-control study, including 733 children aged 5-14 years, was undertaken between March 2018 and October 2019 in Auckland, New Zealand. Healthy controls (n = 190) and symptomatic cases including GAS pharyngitis (n = 210), GAS seronegative carriers (n = 182), and GAS skin infections (n = 151) were recruited. Trained interviewers administered a comprehensive, pre-tested, face-to-face questionnaire. FINDINGS Multivariable analysis identified strong associations between barriers to accessing primary healthcare and having GAS pharyngitis (adjusted OR 3·3; 95% CI 1·8-6·0), GAS carriage (aOR 2·9; 95% CI 1·5-6·0) or a GAS skin infection (aOR 3·5; 95% CI 1·6-7·6). Children who had GAS skin infections were more likely than all other groups to report living in a crowded home (aOR 1·9; 95% CI 1·0-3·4), have Māori or Pacific grandparents (aOR 3·0; 95% CI 1·2-7·6), a family history of ARF (aOR 2·2; 95% CI 1·1-4·3), or having a previous diagnosis of eczema (aOR 3·9; 95% CI 2·2-6·9). INTERPRETATION Reducing barriers to accessing primary healthcare (including financial restrictions, the inability to book an appointment, lack of transport, and lack of childcare for other children) to treat GAS pharyngitis and skin infections could potentially reduce these infections and lead to a reduction in their sequelae, including ARF. These strategies should be co-designed and culturally appropriate for the communities being served and carefully evaluated. FUNDING This work was supported by the Health Research Council of New Zealand (HRC), award number 16/005.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Nicole J. Moreland
- School of Medical Sciences, the University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
- Maurice Wilkins Centre, the University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Jane Zhang
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Julian Crane
- Department of Medicine, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Dianne Sika-Paotonu
- Department of Pathology and Molecular Medicine, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Jonathan Carapetis
- Telethon Kids Institute, 15 Hospital Ave, Nedlands, Perth, 6009, Western Australia
- Centre for Child Health and Research, University of Western Australia, 35 Stirling Hwy, Crawley, Perth 6009, Western Australia
- Perth Children's Hospital, 15 Hospital Ave, Nedlands, Perth, 6009, Western Australia
| | - Deborah A. Williamson
- Department of Infectious Disease, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3004, Australia
| | - Michael G. Baker
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
- Maurice Wilkins Centre, the University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
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Williams AN, Tyrrell GJ. ARF risk factors: Beyond a sore throat. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 26:100545. [PMID: 35875692 PMCID: PMC9301566 DOI: 10.1016/j.lanwpc.2022.100545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Ashley N. Williams
- Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Gregory J. Tyrrell
- Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
- Alberta Precision Laboratories, Public Health-Alberta Health Services, Edmonton, AB, Canada
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB, Canada
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19
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Oben G, Duncanson M, Adams J, Satyanand T. State of child health: acute rheumatic fever in Aotearoa New Zealand. J R Soc N Z 2022. [DOI: 10.1080/03036758.2022.2113102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- Glenda Oben
- Te Ratonga Mātai Tahumaero Taitamariki o Aotearoa—New Zealand Child and Youth Epidemiology Service, Department of Women’s and Children’s Health, University of Otago, Dunedin, New Zealand
| | - Mavis Duncanson
- Te Ratonga Mātai Tahumaero Taitamariki o Aotearoa—New Zealand Child and Youth Epidemiology Service, Department of Women’s and Children’s Health, University of Otago, Dunedin, New Zealand
| | - Judith Adams
- Te Ratonga Mātai Tahumaero Taitamariki o Aotearoa—New Zealand Child and Youth Epidemiology Service, Department of Women’s and Children’s Health, University of Otago, Dunedin, New Zealand
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20
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Ralph AP, Kelly A, Lee AM, Mungatopi VL, Babui SR, Budhathoki NK, Wade V, de Dassel JL, Wyber R. Evaluation of a Community-Led Program for Primordial and Primary Prevention of Rheumatic Fever in Remote Northern Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191610215. [PMID: 36011846 PMCID: PMC9407981 DOI: 10.3390/ijerph191610215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/02/2022] [Accepted: 08/14/2022] [Indexed: 06/09/2023]
Abstract
Environmental factors including household crowding and inadequate washing facilities underpin recurrent streptococcal infections in childhood that cause acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD). No community-based 'primordial'-level interventions to reduce streptococcal infection and ARF rates have been reported from Australia previously. We conducted a study at three Australian Aboriginal communities aiming to reduce infections including skin sores and sore throats, usually caused by Group A Streptococci, and ARF. Data were collected for primary care diagnoses consistent with likely or potential streptococcal infection, relating to ARF or RHD or related to environmental living conditions. Rates of these diagnoses during a one-year Baseline Phase were compared with a three-year Activity Phase. Participants were children or adults receiving penicillin prophylaxis for ARF. Aboriginal community members were trained and employed to share knowledge about ARF prevention, support reporting and repairs of faulty health-hardware including showers and provide healthcare navigation for families focusing on skin sores, sore throat and ARF. We hypothesized that infection-related diagnoses would increase through greater recognition, then decrease. We enrolled 29 participants and their families. Overall infection-related diagnosis rates increased from Baseline (mean rate per-person-year 1.69 [95% CI 1.10-2.28]) to Year One (2.12 [95% CI 1.17-3.07]) then decreased (Year Three: 0.72 [95% CI 0.29-1.15]) but this was not statistically significant (p = 0.064). Annual numbers of first-known ARF decreased, but numbers were small: there were six cases of first-known ARF during Baseline, then five, 1, 0 over the next three years respectively. There was a relationship between household occupancy and numbers (p = 0.018), but not rates (p = 0.447) of infections. This first Australian ARF primordial prevention study provides a feasible model with encouraging findings.
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Affiliation(s)
- Anna P. Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin 0810, Australia
- Rheumatic Heart Disease Australia, Menzies School of Health Research, Darwin 0810, Australia
| | - Angela Kelly
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Anne-Marie Lee
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
- Sunrise Health Corporation, Katherine 0850, Australia
| | - Valerina L. Mungatopi
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Segora R. Babui
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Nanda Kaji Budhathoki
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Vicki Wade
- Rheumatic Heart Disease Australia, Menzies School of Health Research, Darwin 0810, Australia
| | | | - Rosemary Wyber
- Telethon Kids Institute, Perth 6000, Australia
- George Institute for Global Health, Sydney 2000, Australia
- Australian National University, Canberra 2610, Australia
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21
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Whitcombe AL, McGregor R, Bennett J, Gurney JK, Williamson DA, Baker MG, Moreland NJ. OUP accepted manuscript. J Infect Dis 2022; 226:167-176. [PMID: 35134931 PMCID: PMC9373162 DOI: 10.1093/infdis/jiac043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background Group A Streptococcus (GAS) causes superficial pharyngitis and skin infections as well as serious autoimmune sequelae such as acute rheumatic fever (ARF) and subsequent rheumatic heart disease. ARF pathogenesis remains poorly understood. Immune priming by repeated GAS infections is thought to trigger ARF, and there is growing evidence for the role of skin infections in this process. Methods We utilized our recently developed 8-plex immunoassay, comprising antigens used in clinical serology for diagnosis of ARF (SLO, DNase B, SpnA), and 5 conserved putative GAS vaccine antigens (Spy0843, SCPA, SpyCEP, SpyAD, Group A carbohydrate), to characterize antibody responses in sera from New Zealand children with a range of clinically diagnosed GAS disease: ARF (n = 79), GAS-positive pharyngitis (n = 94), GAS-positive skin infection (n = 51), and matched healthy controls (n = 90). Results The magnitude and breadth of antibodies in ARF was very high, giving rise to a distinct serological profile. An average of 6.5 antigen-specific reactivities per individual was observed in ARF, compared to 4.2 in skin infections and 3.3 in pharyngitis. Conclusions ARF patients have a unique serological profile, which may be the result of repeated precursor pharyngitis and skin infections that progressively boost antibody breadth and magnitude.
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Affiliation(s)
- Alana L Whitcombe
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Reuben McGregor
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jason K Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Deborah A Williamson
- University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nicole J Moreland
- Correspondence: Nicole J. Moreland, BSc, PhD, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand ()
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