The incidence of sore throat and group A streptococcal pharyngitis in children at high risk of developing acute rheumatic fever: A systematic review and meta-analysis

PLoS One. 2020 Nov 18;15(11):e0242107. doi: 10.1371/journal.pone.0242107. eCollection 2020.


Background: Group A streptococcal (GAS) pharyngitis has traditionally been considered the sole precursor of acute rheumatic fever (ARF). Evidence from Australia, however, suggests that GAS skin infections may contribute to the pathogenesis of ARF. A missing piece of evidence is the incidence of sore throat and GAS pharyngitis in this setting. We conducted a systematic review and meta-analysis of the incidence of sore throat and GAS pharyngitis in all children at risk of developing ARF.

Methods: Databases were systematically searched for studies reporting on the incidence of pharyngitis among children from low to upper-middle income countries, and Indigenous children living in high-income countries. Studies were subjected to data extraction by two independent reviewers. Following an assessment of the methodological quality of the studies, we extracted incidence rates (IRs) and conducted a meta-analysis. This systematic review is registered on PROSPERO (CRD42019113019).

Results: From 607 titles identified by the search, 11 articles met the predetermined inclusion criteria; ten studies reported IRs while for the remaining study, the incidence was calculated. The pooled incidence estimated for sore throat was 82.5 per 100 child-years (95% confidence interval [CI], 6.5 to 1044.4 per 100 child-years, I2 = 100%) and GAS pharyngitis was 10.8 per 100 child-years (95% CI, 2.3 to 50.0 per 100 child-years, I2 = 99.9%).

Conclusions: The pooled IRs for sore throat in children at risk of developing ARF were higher than rates reported in developed nations (32.70-40 per 100 child-years) and similar for GAS pharyngitis (12.8-14 per 100 years). The limited Australian data lend support to the need for further studies to inform the role of GAS pharyngitis in the development of ARF in Australian Indigenous children, so as to inform local primary prevention strategies for ARF and Rheumatic Heart Disease (RHD).

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Female
  • Humans
  • Incidence
  • Infant
  • Male
  • Pharyngitis / complications
  • Pharyngitis / epidemiology*
  • Rheumatic Fever / epidemiology*

Grant support

The authors received no specific funding for this review. SP received a scholarship from the National Health and Medical Research Council (NHMRC) funded through the HOT North initiative. AB is funded by a fellowship from the NHMRC.