Risk factors for acute rheumatic fever: A case-control study

Michael G Baker; Jason Gurney; Nicole J Moreland; Julie Bennett; Jane Oliver; Deborah A Williamson; Nevil Pierse; Nigel Wilson; Tony R Merriman; Teuila Percival; Catherine Jackson; Richard Edwards; Florina Chan Mow; William M Thomson; Jane Zhang; Diana Lennon

doi:10.1016/j.lanwpc.2022.100508

Risk factors for acute rheumatic fever: A case-control study

Lancet Reg Health West Pac. 2022 Jul 4:26:100508. doi: 10.1016/j.lanwpc.2022.100508. eCollection 2022 Sep.

Authors

Michael G Baker^{1

2}, Jason Gurney¹, Nicole J Moreland^{3

2}, Julie Bennett¹, Jane Oliver^{4

5}, Deborah A Williamson^{4

6}, Nevil Pierse¹, Nigel Wilson^{3

7

8}, Tony R Merriman^{9

10}, Teuila Percival^{3

11}, Catherine Jackson¹², Richard Edwards¹, Florina Chan Mow¹³, William M Thomson¹⁴, Jane Zhang¹, Diana Lennon³

Affiliations

¹ Department of Public Health, University of Otago, Wellington, New Zealand.
² Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand.
³ Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
⁴ Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
⁵ Murdoch Children's Research Institute, Victoria, Australia.
⁶ Victorian Infectious Diseases Reference Laboratory at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
⁷ Starship Children's Hospital, Auckland, New Zealand.
⁸ Green Lane Paediatric and Congenital Cardiac Services, Auckland, New Zealand.
⁹ Department of Biochemistry, University of Otago, Dunedin, New Zealand.
¹⁰ Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, United States of America.
¹¹ Moana Research, Auckland, New Zealand.
¹² Northland District Health Board, Whangarei, New Zealand.
¹³ Counties Manukau District Health Board, Auckland, New Zealand.
¹⁴ Department of Oral Sciences, University of Otago, Dunedin, New Zealand.

Abstract

Background: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain an inequitable cause of avoidable suffering and early death in many countries, including among Indigenous Māori and Pacific populations in New Zealand. There is a lack of robust evidence on interventions to prevent ARF. This study aimed to identify modifiable risk factors, with the goal of producing evidence to support policies and programs to decrease rates of ARF.

Methods: A case-control study was undertaken in New Zealand using hospitalised, first episode ARF cases meeting a standard case-definition. Population controls (ratio of 3:1) were matched by age, ethnicity, socioeconomic deprivation, location, sex, and recruitment month. A comprehensive, pre-tested questionnaire was administered face-to-face by trained interviewers.

Findings: The study included 124 cases and 372 controls. Multivariable analysis identified strong associations between ARF and household crowding (OR 3·88; 95%CI 1·68-8·98) and barriers to accessing primary health care (OR 2·07; 95% CI 1·08-4·00), as well as a high intake of sugar-sweetened beverages (OR 2·00; 1·13-3·54). There was a marked five-fold higher ARF risk for those with a family history of ARF (OR 4·97; 95% CI 2·53-9·77). ARF risk was elevated following self-reported skin infection (aOR 2·53; 1·44-4·42) and sore throat (aOR 2·33; 1·49-3·62).

Interpretation: These globally relevant findings direct attention to the critical importance of household crowding and access to primary health care as strong modifiable causal factors in the development of ARF. They also support a greater focus on the role of managing skin infections in ARF prevention.

Funding: This research was funded by the Health Research Council of New Zealand (HRC) Rheumatic Fever Research Partnership (supported by the New Zealand Ministry of Health, Te Puni Kōkiri, Cure Kids, Heart Foundation, and HRC) award number 13/959.

Keywords: Acute rheumatic fever; Case-control study; Crowding; Group A streptococcal infections; Housing; Māori; New Zealand; Pacific peoples; Primary healthcare; Risk factors; Social determinants.