Epidemiology and prevention

of streptococcal pharyngitis
Prepared by:
Ghada Mohamed Ahmed Bedair
Ghada_epi@yahoo.com
B.Sc, Nursing, Faculty of Nursing,
Alexandria University.
Master degree in Epidemiology, High
Institute of Public Health, Alexandria
University, Egypt

Introduction

: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.

: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 (GAHS) is a gram
positive, catalase negative, facultative
anaerobe, that occurs in pairs or chains in
cultures.
GAHS divided into more than 130 distinct
M serotypes.

GAHS 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

:PPublic health importance

It is a precursor of two serious
non-suppurative sequlae;
acute rheumatic fever, and

post
streptococcal
glomerulonephritis.

Risk factors:
1. 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.

of GAHS: Mode of
transmission
GAHS 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.

Magnitude of the Problem

GAHS 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.

GAHS 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 GAHS 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 (20032004), streptococcus sore-throats were detected
in 37% of cases.

GAHS 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.

 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 GAHS 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 GAHS culture differed between countries: 24.6%
in Brazil, 42.0% in Croatia, and 27.7% in Egypt.

Clinical Pictures

Diagnosis of streptococcal pharyngitis

Complications of GAHS pharyngitis

Prevention and control of GAHS

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
GAHS.
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.

B) Immunization:
Although
multiple

there

attempts

have
to

been

produce

GAHS vaccine for approximately a

century,

none

of

the

vaccines has proceeded

preliminary

animal

or

studies until recently.

candidate
beyond
human

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

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
GAHS
pharyngitis, will prevent most cases
of ARF.

:B) Primary prophylaxis of RF

This refers to the prevention of ARF
by timely and complete antibiotic
treatment of symptomatic GAHS
pharyngitis.
CSurgical approach to recurrent GAHS

pharyngitis:
More clearly defined indicators for
surgical
intervention
include
patients with peritonsillar abscess
or severe obstructive symptoms.

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.

AIM OF THE
STUDY

General objective:
To study group A- haemolytic
streptococci (GAHS) among school
children with Pharyngotonsillitis in
Alexandria (Egypt).

Specific objectives:
1- To
estimate
the
prevalence of
GAHS infection among
school
children with pharyngotonsillitis .
2- To identify the predictive
findings of GAHS pharyngitis.

clinical

3- To determine
the
seasonal
variations of GAHS pharyngitis.

SUBJECTS AND
METHODS

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.

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.

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.

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.

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

GAHS pharyngitis which extracted from

the literature.

2- Throat swab was taken from each child

to be cultured on blood agar plate.

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

requiring hospitalization.

another illness

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.

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.

Colonies that appeared on blood

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

:Interpretation of results
Beta haemolytic streptococci
strains showing zone of inhibition
around bacitracin disc , were
considered to be GAHS.

Data analysis and

:interpretations

FFrequency distribution and chisquare test were calculated for

each signs and symptoms.

LLogistic regression analysis was

used to model the probability
of GAHS pharyngitis occurrence.

Results

Overall prevalence of GAHS pharyngitis

among primary and preparatory school
children in Alexandria during 2005-2006.

Prevalence of GAHS pharyngitis cases

according to educational zones among primary
and preparatory school children in Alexandria
.(Egypt) during 2005-2006

Prevalence of GAHS pharyngitis cases

according to sex in Alexandria during
2005-2006

PPrevalence of GAHS pharyngitis cases

according to educational stage among primary
and preparatory school children in Alexandria
during 2005-2006. *

Prevalence of GAHS pharyngitis cases

according to age group among primary and
preparatory school children in Alexandria
during 2005-2006. *

PPrevalence of GAHS pharyngitis cases

according to Season among primary and
preparatory school children in Alexandria *
during 2005-2006.

Distribution of cases according to history of

family diseases among primary and
preparatory school children in Alexandria
during
2005-2006.*

Distribution of cases according to history of recent

contact with pharyngotonsillitis among primary and
preparatory school children in Alexandria during
2005-2006.*

Distribution of cases according to number of sorethroat attacks per year among primary
and
preparatory school children in Alexandria during
2005-2006.*

predictors for GAHS pharyngitis among

primary and preparatory school children in
Alexandria during 2005-2006
Model

coefficient

Odds
ratio

Confidence interval
Lower

Upper

Tender cervical
lymph nodes

1.303

3.681

2.080

6.516

Recent contact
with
pharyngotonsilliti
s

1.441

4.226

2.762

6.467

Enlarged cervical
lymph nodes

0.841

2.320

1.243

4.329

Joint/Limb pain

0.529

1.697

1.107

2.603

Vomiting

0.461

1.586

1.045

2.405

Enlarged tonsils

0.758

2.153

1.042

4.375

CONCLUSIONS

CONCLUSIONS
From the present study, it could be concluded that:
The prevalence of GAHS infection among selected primary and
preparatory school children suffering from pharyngotonsillitis
.in Alexandria during 2005-2006 was 30.3%
The peak prevalence of GAHS pharyngitis occurred in spring
.and winter
Cases who reported family history of rheumatic disease had the
highest percent of positive culture of GAHS pharyngitis
.(37.2%)
Cases who reported a history of recent contact with
pharyngotonsillitis had a higher prevalence of GAHS
pharyngitis (58.8%), compared to cases without such history,
. the prevalence of GAHS among whom was 41.2%
The predictors which were found to be highly associated with
GAHS pharyngitis were: recent contact with a
pharyngotonsillitis case, tender cervical lymph nodes,
enlarged cervical lymph nodes, enlarged tonsils, joint/limb
.pain, and vomiting

RECOMMENDATIONS

1. To

RECOMMENDATIONS

encourage national authorities to

include this disease and its complications
in their public health priorities.

2. To develop an educational materials and

training programs for health care providers

and laboratory personnel which include
standard
guidelines
addressing:
recognition of GAHS pharyngitis, clinical
diagnosis,
case
management,
and
prevention of group A streptococcal
sequelae.

3-

To
Upgrade the skills of school health
physicians and To train them on early
detection of GAHS 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
GAHS
pharyngitis in light of epidemiologic and
demographic characteristics of such infection
in our community to reach an accurate
clinical diagnosis.

Thank you