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Evaluating the use of penicillin to control outbreaks of acute poststreptococcal glomerulonephritis
F Johnston1, J Carapetis, M S Patel
1Territory Health Services, Northern Territory, Australia.
Insights
Benzathine penicillin G (BPG) can help prevent acute poststreptococcal glomerulonephritis (APSGN) outbreaks in Australian Aboriginal communities. Targeted BPG treatment for children with skin sores and contacts of cases is effective.
Area of Science:
- Infectious Disease Epidemiology
- Public Health Interventions
- Pediatric Nephrology
Background:
- Acute poststreptococcal glomerulonephritis (APSGN) outbreaks are recurrent in remote Australian Aboriginal communities.
- Benzathine penicillin G (BPG) reduces streptococcal carriage but its role in preventing APSGN outbreaks is unproven.
Purpose of the Study:
- To investigate nine recent APSGN outbreaks in Australia's Northern Territory.
- To evaluate the impact of BPG interventions on APSGN outbreaks compared to literature data.
Main Methods:
- Observational study of published data and Northern Territory (NT) experiences.
- Prospective assessment of eight NT outbreaks; outbreak defined as ≥2 cases within 1 week.
- Intervention strategies included community-wide BPG, BPG for children with skin lesions, or BPG for contacts of cases.
Main Results:
- Literature review showed limited evidence for BPG effectiveness in APSGN outbreaks.
- Community-wide BPG with low uptake showed prolonged cases; higher uptake led to cessation of new cases within 3-4 weeks.
- Targeted BPG for skin lesions or contacts resulted in rapid cessation of new APSGN cases.
Conclusions:
- Observational data support community BPG use for preventing APSGN.
- Targeted BPG for children with skin sores and household contacts may be an effective intervention strategy, potentially more so than community-wide treatment.
Introduction:
Outbreaks of acute poststreptococcal glomerulonephritis (APSGN), occur every few years in remote Australian Aboriginal communities. Intervention with benzathine penicillin G (BPG) to all children is effective in reducing streptococcal carriage in a community, but its effectiveness in arresting outbreaks of APSGN has not been established.
Objective:
To study nine recent community outbreaks of APSGN in Australia's Northern Territory and compare them with outbreaks reported in the literature to assess the impact of intervention with BPG.
Methods:
Because randomized controlled trials have not been conducted for this purpose, we assessed data from published observational studies and relevant experiences in the Northern Territory (NT). Eight of the nine outbreaks in the NT were studied prospectively. An outbreak was defined as two or more clinical cases of APSGN occurring within 1 week in a single community. Three intervention methods were used: intramuscular BPG to all children ages 3 to 15 years; BPG only to children with skin lesions; and BPG only to child contacts of clinical cases. The attack rates, number of clinical cases before and after the interventions were documented and the coverage of children with penicillin were estimated.
Results:
A review of the literature found very little evidence either for or against the effectiveness of intervention with BPG. In our study four communities used the first method of intervention. The community with the lowest uptake of penicillin continued to have cases in untreated children for 9 further weeks, two communities had no new cases from 3 weeks after the intervention and the fourth had a single further case after 4 weeks. The one community that used the second method had a high initial attack rate but no further cases from 1 week after the intervention. Three communities used the third method and in one community no intervention was attempted.
Conclusion:
Our observational study supports the use of BPG in the community to prevent new cases of APSGN. It suggests that targeted treatment of children with skin sores and household contacts of cases, rather than attempted treatment of all children in the community, could be an effective method of intervention.