School-based prevention of acute rheumatic fever: a group randomized trial in New Zealand

Pediatr Infect Dis J. 2009 Sep;28(9):787-94. doi: 10.1097/INF.0b013e3181a282be.


Background: Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease is the commonest cause of childhood cardiac morbidity globally. The current approach to the prevention of a primary attack of rheumatic fever in children using oral medication for streptococcal pharyngitis is poorly supported. The efficacy of injectable penicillin, in high rheumatic fever incidence military environments is indisputable.

Objective: To evaluate school-based control of rheumatic fever in an endemic area.

Methods: Fifty-three schools ( approximately 22,000 students) from a rheumatic fever high incidence setting ( approximately 60/100,000) in Auckland, New Zealand were randomized. The control group received routine general practice care. The intervention was a school-based sore throat clinic program with free nurse-observed oral penicillin treatment of group A streptococcal pharyngitis. The outcome measure was ARF in any child attending a study school. Analysis A defined ARF cases using criteria derived from Jones Criteria 1965 (definite) and 1956 (probable) with more precise definitions. Analysis B was based on 1992 Jones criteria but also included echocardiography to determine definite cases.

Results: In Analysis A, 24 (55/100,000) cases occurred in clinic schools and 29 (67/100,000) in nonclinic schools, a 21% reduction when adjusted for demography and study design (P = 0.47). Analysis B revealed a 28% reduction 26 (59/100,000) and 33 (77/100,000) cases, respectively (P = 0.27).

Conclusion: This study involving 86,874 person-years showed a nonsignificant reduction in the school-based sore throat clinic programs.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Oral
  • Adolescent
  • Anti-Bacterial Agents / administration & dosage
  • Anti-Bacterial Agents / therapeutic use*
  • Child
  • Child, Preschool
  • Endemic Diseases / prevention & control*
  • Endemic Diseases / statistics & numerical data
  • Female
  • Humans
  • Male
  • New Zealand / epidemiology
  • Penicillins / administration & dosage
  • Penicillins / therapeutic use*
  • Pharyngitis / drug therapy*
  • Pharyngitis / microbiology
  • Rheumatic Fever / epidemiology
  • Rheumatic Fever / prevention & control*
  • Schools*
  • Streptococcal Infections / drug therapy*
  • Streptococcal Infections / microbiology
  • Streptococcus pyogenes / isolation & purification
  • Treatment Outcome


  • Anti-Bacterial Agents
  • Penicillins