Primary prevention of rheumatic fever in the 21st century: Evaluation of a national programme

Background: Acute rheumatic fever (ARF) has largely disappeared from high-income countries. However, in New Zealand (NZ) rates remain high in indigenous (Maori) and Pacific populations. In 2011, NZ launched an intensive and unparalleled primary Rheumatic Fever Prevention Programme (RFPP). We evaluated the impact of the school-based sore throat service component of the RFPP. Methods: The evaluation used national trends of all-age first episode ARF hospitalisation rates before (2009–11) and after (2012–16) implementation of the RFPP. A retrospective cohort study compared first-episode ARF incidence during time-not-exposed (23 093 207 person-days) and time-exposed (68 465 350 person-days) with a school-based sore throat service among children aged 5–12 years from 2012 to 2016. Results: Following implementation of the RFPP, the national ARF incidence rate declined by 28% from 4.0 per 100 000 [95% confidence interval (CI) 3.5–4.6] at baseline (2009–11) to 2.9 per 100 000 by 2016 (95% CI 2.4–3.4, P <0.01). The school-based sore throat service effectiveness overall was 23% [95% CI -6%–44%; rate ratio (RR) 0.77, 95% CI 0.56–1.06]. Effectiveness was greater in one high-risk region with high coverage (46%, 95% CI 16%–66%; RR 0.54, 95% CI 0.34–0.84). Conclusions: Population-based primary prevention of ARF through sore throat management may be effective in well-resourced settings like NZ where high-risk populations are geographically concentrated. Where high-risk populations are dispersed, a school-based primary prevention approach appears ineffective and is expensive.