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Cost-benefit of a streptococcal surveillance program among Navajo Indians
Insights
A school-based streptococcal surveillance program for group A beta-hemolytic streptococci among Navajo children showed limited effectiveness in preventing acute rheumatic fever (ARF). The study suggests focusing surveillance on symptomatic children to improve efficiency.
Area of Science:
- Epidemiology
- Infectious Diseases
- Public Health
Background:
- Group A beta-hemolytic streptococci (GABHS) infections are a significant public health concern, particularly for acute rheumatic fever (ARF) in school-aged children.
- School-based surveillance programs aim to detect and treat GABHS carriers to prevent ARF.
- Previous efforts have focused on routine monthly throat culturing in elementary schools.
Purpose of the Study:
- To evaluate the effectiveness and cost-efficiency of a school-based GABHS surveillance program among Navajo Indians.
- To determine the optimal strategy for ARF prevention through streptococcal surveillance.
Main Methods:
- A 4-year school-based surveillance program involving monthly throat cultures for GABHS.
- Analysis of ARF case distribution in relation to program coverage and participation.
- Cost-benefit analysis comparing program expenses to estimated prevented ARF cases.
Main Results:
- Schools with consistent monthly surveys had lower ARF incidence, but only 24% of ARF cases occurred in these schools.
- Most ARF cases in covered schools happened when surveillance participation lapsed or children were not cultured prior to ARF onset.
- The program's cost was five times the estimated cost of prevented ARF cases, excluding penicillin allergy risks.
Conclusions:
- Routine monthly streptococcal surveillance in schools is not cost-effective for preventing ARF.
- Asymptomatic carriers appear to have a low risk of developing ARF.
- Streptococcal surveillance should primarily target children presenting with pharyngitis symptoms.
Abstract:
A school-based streptococcal surveillance program has been in effect among Navajo Indians for more than 4 years. Throat cultures of symptomatic children are obtained when indicated, and routine throat cultures are performed monthly. Children whose cultures are positive for group A beta-hemolytic streptococci are treated. During 4 academic years, between 48 percent and 56 percent of elementary school children attended the schools that had 4 or more monthly surveys in each year, but only 24 percent (7 of 29) of the acute rheumatic fever (ARF) cases occurred in children at those schools. Six of seven children attending covered schools were not cultured before their ARF episodes. Five cases occurred in children attending previously covered schools, during years in which participation lapse. Three or four ARF cases per year appeared to have been prevented, but the program's costs were five times the estimated costs of the prevented cases, even excluding risks of allergic reactions to penicillin. There is little evidence that most asymptomatic carriers are at risk to develop ARF. The authors recommend that streptococcal surveillance efforts be confined largely to culturing throat swabs of children with pharyngitis.