Title: Streptococcal pharyngitis
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2Epidemiology 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
3Introduction
4Definition
- - 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. -
5Causes
- - 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
7PPublic 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.
10Magnitude 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.
12GAßHS 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.
14Clinical Pictures
15Diagnosis of streptococcal pharyngitis
16Complications of GAßHS pharyngitis
17Prevention 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.
19Secondary 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.
21B) 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.
23AIM 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.
26SUBJECTS 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).
36Interpretation of results
- Beta haemolytic streptococci strains showing
zone of inhibition around bacitracin disc ,
were considered to be GAßHS.
37Data 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.
38Results
39- Overall prevalence of GAßHS pharyngitis
among primary and preparatory school children
in Alexandria during 2005-2006.
40Prevalence of GAßHS pharyngitis cases
according to educational zones among primary
and preparatory school children in
Alexandria (Egypt) during 2005-2006.
41Prevalence of GA?HS pharyngitis cases
according to sex in Alexandria during
2005-2006
42PPrevalence of GAßHS pharyngitis cases
according to educational stage among primary
and preparatory school children in Alexandria
during 2005-2006.
43Prevalence of GAßHS pharyngitis cases
according to age group among primary and
preparatory school children in Alexandria
during 2005-2006.
44PPrevalence of GAßHS pharyngitis cases
according to Season among primary and
preparatory school children in Alexandria
during 2005-2006.
45Distribution of cases according to history
of family diseases among primary and
preparatory school children in Alexandria
during 2005-2006.
46Distribution of cases according to history of
recent contact with pharyngotonsillitis among
primary and preparatory school children in
Alexandria during 2005-2006.
47Distribution of cases according to number
of sore-throat attacks per year among primary
and preparatory school children in
Alexandria during 2005-2006.
48predictors for GAßHS pharyngitis among
primary and preparatory school children in
Alexandria during 2005-2006
49CONCLUSIONS
50CONCLUSIONS
- 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 52RECOMMENDATIONS
- 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.
54Thank you