Acute Rheumatic Fever: Global Persistence of a Preventable Disease

Francine Bono-Neri, MA, RN, PNP


J Pediatr Health Care. 2017;31(3):275-284. 

In This Article

Abstract and Introduction


The persistence of acute rheumatic fever continues to be seen globally. Once thought to be eradicated in various parts of the world, the disease came back with a vengeance secondary to a lack of diligence on the part of providers. Today, the global burden of group A streptococcal infection, the culprit of the numerous sequelae manifested in acute rheumatic fever, is considerable. Although a completely preventable disease, rheumatic fever continues to exist. It is a devastating disease that involves long-term, multisystem treatment and monitoring for patients who were unsuccessful at eradicating the precipitating group A streptococcal infection. Prevention is the key to resolving the dilemma of the disease's global burden, yet the method to yield its prevention still remains unknown. Thus, meticulous attention to implementing proper treatment is the mainstay and remains a top priority.


Despite the efficacy of antibiotics against group A Streptococcus species in reducing the incidence of acute rheumatic fever (ARF), the global burden and chronic sequelae of the disease continue to exist. Although North America and Europe have seen a reduced frequency in acute rheumatic fever over the past several decades (Bach, 2015), providers must not exclude this diagnosis from their differential. Notwithstanding accessibility to antimicrobials, countries continue to see ARF as a major cause of serious valvular heart disease (Parnaby & Carapetis, 2010). Research and new guidelines continue to evolve because of its persistent prevalence.

In the United States, a decline in ARF was seen in the 30 years after World War II. The annual occurrence dropped by more than 90%, which was believed to reflect ameliorated living conditions, overall improved hygiene, and the use of antibiotics (Congeni, 1992). By the early 1980s, ARF had reached such an all-time low in the United States that some providers began to question their ardency in treating streptococcal pharyngitis. It was not until the major epidemic at the beginning of 1984 that a resurgence was witnessed in various regions of the United States (Congeni, Rizzo, Congeni, & Sreenivasan, 1987; Hosier, Craenen, Teske, & Wheller, 1987; Veasy et al., 1987; Wald, Dashefsky, Fedit, Chiponis, & Byers, 1987).. Unlike the traditional outbreaks found in crowded and impoverished inner-city ghettos, these cases occurred primarily in children of White, middle-class families, many of whom resided in suburban or rural environments (Congeni, 1992). In the present day, although isolated cases of ARF continue to be seen in modernized countries, most are found in countries with limited resources and in poorly represented aboriginal groups (World Health Organization [WHO], 2005). Various regions of South America, the Middle East, India, and Africa are showing particular risk of ARF for children (Casey, Solomon, Gaziano, Miller, & Loscalzo, 2013; Tibazarwa, Volmink, & Mayosi, 2008).

Global burden of disease, up until the early 1990s, was assessed using a narrow criterion. Global studies of population mortality were the main focus. These studies failed to consider morbidity that arose from disorders and injuries that were not fatal but nevertheless affected a person's functioning in an adverse manner (Degenhardt, Whiteford, & Hall, 2014). Measuring the impact of disease and its global burden was radically transformed in 1993, when estimates of causes of global disease burden used a new summary measure. This new measure, known as Disability-Adjusted Life Years, "simultaneously accounted for both premature mortality and the prevalence, duration and severity of the non-fatal consequences of disease and injury" (Lopez, 2005, Abstract, para. 1). The World Health Report (World Health Organization, 2005) states that approximately 18.1 million people were suffering from a serious group A Streptococcus (GAS) disease and that approximately 1.78 million new cases were being seen annually as of 2005. In addition, the report also states that GAS infections were identified as the ninth leading cause of worldwide mortality from a single pathogen. Global burden, defined by the WHO as those afflicted, found an overall burden of 471,000 annual cases of ARF (Zühlke & Steer, 2013). Although prompt diagnosis and treatment are imperative, prevention is pivotal to success.