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Streptococcal pharyngitis

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Title: Streptococcal pharyngitis


1
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2
Epidemiology and prevention of streptococcal
pharyngitis Prepared by Ghada Mohamed Ahmed
BedairGhada_epi_at_yahoo.comB.Sc, Nursing, Faculty
of Nursing, Alexandria University.Master degree
in Epidemiology, High Institute of Public Health,
Alexandria University, Egypt
3
Introduction
4
Definition
  • - Pharyngitis refers to inflammation of the
    structures of the pharynx.
  • - The tonsils are most often affected.
  • - The term pharyngitis, tonsillitis,
    tonsillopharyngitis and pharyngotonsillitis are
    interchangeable and do not imply an
    etiology.

5
Causes
  • - Up to 85 are caused by viruses.
  • - Pharyngitis caused by Streptococcus pyogenes is
    the most common bacterial pharyngitis diagnosed
    in developed countries.
  • SStreptococcus pyogenes , Group A- Beta
    haemolytic streptococci (GAßHS) is a gram
    positive, catalase negative, facultative
    anaerobe, that occurs in pairs or chains in
    cultures.
  • GAßHS divided into more than 130
    distinct M serotypes.

6
  • GAßHS represent one of the most
    impressive human pathogens, it cause a wide
    array of serious infections including
  • Pharyngitis
  • Respiratory infection
  • Skin infection (impetigo, erysipelas)
  • Endocarditis
  • Meningitis
  • Puerperal sepsis
  • Arthritis
  • Scarlet fever

7
PPublic health importance
  • It is a precursor of two serious non-suppurative
    sequlae
  • acute rheumatic fever, and
  • post streptococcal glomerulonephritis.

8
  • Risk factors
  • All group A streptococcal diseases are most
    common in setting of poverty, overcrowding, and
    low socioeconomic status, where living
    conditions promote transmission of the
    organism.
  • 2. Streptococcal pharyngitis most often occurs
    in the late winter and early spring.
  • 3. It affects schoolage children, particularly
    those 5-11 years old, but children and adults of
    all ages can be infected with group A
    streptococci.

9
of GAßHS Mode of transmission
  • GAßHS spread when a person coughs or
    sneezes infected large droplets that come into
    contact with another persons mucous membrane.
    The highest risk of transmission occurs during
    the acute stage.

10
Magnitude of the Problem
  • GAßHS diseases are highly prevalent in some
    regions, but may be less in others, For
    example, RHD is very common in Sub-Saharan
    Africa and the Pacific, common in
    South-Central Asia and the Middle East/North
    Africa, but less common in many Asian
    countries and Latin America.
  • From 1985 through 2002, the world Health
    Organization (WHO) estimated that over 600
    million cases of symptomatic GAS pharyngitis
    occur annually worldwide.

11
  • GAßHS pharyngitis in some developed countries
  • Acute pharyngitis is one of the most common
    illnesses for which patients seek medical advice
    in the more developed countries. accounting for
    nearly over 7 million visits to pediatricians
    each year in the United States. In this country.
  • Oliver (2000) in England reported that the
    prevalence of GAßHS was 20.
  • In France, Chiadmi et al (2003) stated that the
    prevalence was 33.
  • In Belgium, sore-throat is one of the most
    frequent causes of consultation seen by general
    practitioner, and GAS has been isolated in 20.3
    of cases.
  • In Chile, a study done by Munoz et al
    (2003-2004), streptococcus sore-throats were
    detected in 37 of cases.

12
GAßHS pharyngitis in some developing countries
  • In low income countries, there are few
    prospective studies that provide data on group A
    streptococcal pharyngitis, its epidemiology and
    clinical presentation.

13
  • In India, it is estimated that approximately 7
    sore throat episodes occur per child per year,
    there are as many as 20-30 million cases of
    streptococcal pharyngitis may occur annually in
    that country in Asia.
  • In Iran (2000) Jasir et al reported a
    prevalence of 30.
  • Shrestha et al in Nepal (2001) reported
    prevalence 7.2.
  • Dos Santos and Berezin in Brazil (2004) found the
    prevalence of GAßHS pharyngitis (24.4) .
  • In Taiwan Lin et al (2003) reported s prevalence
    of 21.4
  • A study done in 3 countries from September 2001
    to August 2003, Rio de Janeiro (Brazil), Cairo
    (Egypt), Zagreb (Croatia), the proportion of
    children with a positive GAßHS culture differed
    between countries 24.6 in Brazil, 42.0 in
    Croatia, and 27.7 in Egypt.

14
Clinical Pictures
15
Diagnosis of streptococcal pharyngitis
16
Complications of GAßHS pharyngitis
17
Prevention and control of GAßHS pharyngitis
  • Primary prevention
  • A) Reducing overall exposure to GAS.
  • 1) Improving living standards.
  • 2) Adequate nutrition.
  • 3) Provision of easily accessible laboratory
    facilities for diagnosis of GAßHS.
  • 4) Pasteurization of milk and exclude of
    infected people from handling food.
  • 5) Health education to public and health workers
    about modes of transmission and the relationship
    of streptococcal sore throat to ARF/RHD.

18
  • B) Immunization
  • Although there have been multiple attempts
    to produce a GAßHS vaccine for approximately a
    century, none of the candidate vaccines has
    proceeded beyond preliminary animal or human
    studies until recently.

19
Secondary prevention
  • A- Treatment of GAßHS pharyngitis
  • The gold standard of therapy for GAßHS is
    penicillin.
  • Treatment of GAßHS pharyngitis should,
  • 1) Relieve the symptoms of the acute illness.
  • 2) Eliminate transmissibility.
  • 3) Prevent both suppurative and nonsupporative
    sequelae.

20
  • It has been very well demonstrated that a 10
    days course of an appropriate oral antibiotic
    (usually oral penicillin V) or a single dose of
    long-acting intramuscular penicillin (benzathine
    penicillin BPG) if administered within 9 days of
    the onset of symptoms of GAßHS pharyngitis, will
    prevent most cases of ARF.

21
B) Primary prophylaxis of RF
  • This refers to the prevention of ARF by timely
    and complete antibiotic treatment of
    symptomatic GAßHS pharyngitis.
  • CSurgical approach to recurrent GAßHS
    pharyngitis
  • More clearly defined indicators for surgical
    intervention include patients with peritonsillar
    abscess or severe obstructive symptoms.

22
Tertiary prevention
  • This refers to measures to reduce the severity
    or long-term impact of GAS diseases. In practice,
    it mainly refers to management of patients with
    RF/ RHD.

23
AIM OF THE STUDY
24
  • General objective
  • To study group A-ß haemolytic streptococci
    (GAßHS) among school children with
    Pharyngotonsillitis in Alexandria (Egypt).

25
  • Specific objectives
  • 1- To estimate the prevalence of GAßHS
    infection among school children with
    pharyngotonsillitis .
  • 2- To identify the predictive clinical findings
    of GAßHS pharyngitis.
  • 3- To determine the seasonal variations of
    GAßHS pharyngitis.

26
SUBJECTS AND METHODS
27
  • Study design
  • Cross-sectional approach
  • Study setting
  • School health insurance clinics in six
    educational zones in Alexandria (Egypt).
  • Target population
  • School children aged 6-15 years old with
    pharyngotonsillitis in primary and preparatory
    education in Alexandria.

28
  • Sampling design
  • Based on data from the Medical Affairs for
    School Children, the sample size was calculated
    by using epi-info program, on the assumption that
    the prevalence is 17 according to the last
    study by zaher et al, the calculated sample size
    at 95 confidence interval and at degree of
    precision of 3 was found to be 600
    students.

29
  • To fulfill this sample size multistage sample
    technique was used. One school health insurance
    clinic was randomly chosen from each educational
    zone. Then the total sample size was
    proportionally distributed on chosen health
    clinics.

30
  • Ethical considerations
  • 1- Getting approvals from the Medical Affairs for
    School Children.
  • 2- Informed consent was taken from enrolled child
    and parents or guardian accompanying the child to
    the clinic.

31
  • Study tools
  • 1- A predesigned questionnaire interview with
    child and his/her parent, inquiring about
  • Demographic characteristics( child name, age,
    sex,.......)
  • Co-morbidity and past history of diseases for
    both child and his family.
  • Clinical signs and symptoms predicting GAßHS
    pharyngitis which extracted from the literature.
  • 2- Throat swab was taken from each child to be
    cultured on blood agar plate.

32
  • Inclusion criteria
  • Sore- throat and/or difficult swallowing.
  • Pharyngeal erythema, exudates.
  • Or tonsilar enlargement, redness with or without
    exudates.
  • Fever.
  • Enlarged tender anterior cervical lymph nodes.
  • Exclusion criteria
  • Oral antibiotic use within 3 days or
    intramuscularly administered antibiotics within
    the 20 days prior to the clinic visit.
  • History of previous RF or RHD, or presence of
    another illness requiring hospitalization.

33
  • Implementation phase
  • Selection and examining of cases were done by
    clinic physician.
  • Questionnaire interview, Throat swab sampling
    and cultures were made by the researcher.
  • The cultures were made in Microbiology
    Department of High Institute of Public Health.

34
  • Transport samples to the laboratory
  • The swabs were transported to the laboratory
    within 2 hrs. If there is delay in
    transportation to the laboratory , they were put
    in transport medium (stuarts media)
  • Procedure of cultivation and identification
  • Swabs were streaked onto crystal violet
    blood agar plate and incubated at 37C in
    5-10 CO2 atmosphere using candle jar.
  • After overnight incubation, the plate were
    examined for bacterial growth, colonial
    morphology and haemolytic characteristics.

35
  • Colonies that appeared on blood agar plate
    as pinpoint, transparent, circular colonies
    surrounded by wide zone of ß haemolysis were
    suspected as GAßHS, and subcultured on another
    crystal violet blood agar plate and tested for
    their sensitivity to bacitracin discs
    (0.05units).

36
Interpretation of results
  • Beta haemolytic streptococci strains showing
    zone of inhibition around bacitracin disc ,
    were considered to be GAßHS.

37
Data analysis and interpretations
  • FFrequency distribution and chi-square test
    were calculated for each signs and symptoms.
  • LLogistic regression analysis was used to
    model the probability of GAßHS pharyngitis
    occurrence.

38
Results
39
  • Overall prevalence of GAßHS pharyngitis
    among primary and preparatory school children
    in Alexandria during 2005-2006.

40
Prevalence of GAßHS pharyngitis cases
according to educational zones among primary
and preparatory school children in
Alexandria (Egypt) during 2005-2006.
41
Prevalence of GA?HS pharyngitis cases
according to sex in Alexandria during
2005-2006
42
PPrevalence of GAßHS pharyngitis cases
according to educational stage among primary
and preparatory school children in Alexandria
during 2005-2006.
43
Prevalence of GAßHS pharyngitis cases
according to age group among primary and
preparatory school children in Alexandria
during 2005-2006.
44
PPrevalence of GAßHS pharyngitis cases
according to Season among primary and
preparatory school children in Alexandria
during 2005-2006.
45
Distribution of cases according to history
of family diseases among primary and
preparatory school children in Alexandria
during 2005-2006.
46
Distribution of cases according to history of
recent contact with pharyngotonsillitis among
primary and preparatory school children in
Alexandria during 2005-2006.
47
Distribution of cases according to number
of sore-throat attacks per year among primary
and preparatory school children in
Alexandria during 2005-2006.
48
predictors for GAßHS pharyngitis among
primary and preparatory school children in
Alexandria during 2005-2006
49
CONCLUSIONS
50
CONCLUSIONS
  • From the present study, it could be concluded
    that
  • The prevalence of GAßHS infection among selected
    primary and preparatory school children suffering
    from pharyngotonsillitis in Alexandria during
    2005-2006 was 30.3.
  • The peak prevalence of GAßHS pharyngitis
    occurred in spring and winter.
  • Cases who reported family history of rheumatic
    disease had the highest percent of positive
    culture of GAßHS pharyngitis (37.2).
  • Cases who reported a history of recent
    contact with pharyngotonsillitis had a higher
    prevalence of GAßHS pharyngitis (58.8), compared
    to cases without such history, the prevalence of
    GAßHS among whom was 41.2.
  • The predictors which were found to be highly
    associated with GAßHS pharyngitis were recent
    contact with a pharyngotonsillitis case, tender
    cervical lymph nodes, enlarged cervical lymph
    nodes, enlarged tonsils, joint/limb pain, and
    vomiting.

51
  • RECOMMENDATIONS

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RECOMMENDATIONS
  • To encourage national authorities to include this
    disease and its complications in their public
    health priorities.
  • To develop an educational materials and training
    programs for health care providers and laboratory
    personnel which include standard guidelines
    addressing recognition of GAßHS pharyngitis,
    clinical diagnosis, case management, and
    prevention of group A streptococcal sequelae.

53
  • 3- To Upgrade the skills of school health
    physicians and To train them on early detection
    of GAßHS pharyngitis cases depending on the
    predicting signs and symptoms.
  • 4- To carry out Further research to continually
    re-evaluate continually the clinical signs and
    symptoms associated with GAßHS pharyngitis in
    light of epidemiologic and demographic
    characteristics of such infection in our
    community to reach an accurate clinical
    diagnosis.

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