Introduction

Despite being in existence for hundreds of years, Streptococcus pyogenes (group A streptococci) remains a significant cause of global morbidity and mortality, with a particular impact in resource-limited settings. The vast majority of cases of acute rheumatic fever (ARF), rheumatic heart disease (RHD), acute post-streptococcal glomerulonephritis (APSGN), and invasive S. pyogenes cases occur in low-resource settings (Carapetis, 2005) (Figure 1).

Figure 1.

(a) Map of RHD prevalence, 1970–1990; (b) Map of rheumatic heart disease prevalence, 1999–2011. Reproduced from (Seckeler & Hoke, 2011).

Accurate estimates of the global disease burden are important in planning for disease control, allocating resources, advocating for interventions, and prioritizing new strategies and research. This is particularly relevant in light of the potential to invest in the development of a vaccine to control S. pyogenes disease (Moreland, et al., 2014) (for more information, see the chapter on vaccine development in this book). However, overall disease burden estimates are difficult, mainly because of the scarcity of comprehensive disease registries, the reliance on passive surveillance systems, and the underreporting of both acute and chronic cases. This is true in all regions, and particularly in countries where S. pyogenes diseases occur most frequently (Marijon, Mirabel, Celermajer, & Jouven, 2012).

Clinical manifestations of S. pyogenes are among the most diverse of any human pathogen (Ralph & Carapetis, 2013). S. pyogenes has a varied presentation that ranges from seemingly benign pharyngitis and skin infections to more severe glomerulonephritis and sepsis, as well as devastating rheumatic heart disease (RHD), toxic shock syndrome, and necrotizing fasciitis.

In 2005, a review of the global burden of group A streptococcal diseases was published, using conservative methodologies that were deliberately designed to under-estimate the burden (Carapetis, 2005; Carapetis, Steer, Mulholland, & Weber, 2005b). At that time, it was estimated that a minimum of 18.1 million people were suffering from invasive S. pyogenes diseases, with an additional 1.78 million incident cases occurring each year. These estimates did not include over 111 million cases of streptococcal pyoderma and 616 million cases of S. pyogenes pharyngitis each year (Carapetis, Steer, Mulholland, & Weber, 2005b). A subsequent review published in 2008 provided updated data on the RHD burden from Asia, which estimated between 1.96 and 2.21 million cases of RHD in Asian children 5 to 14 years of age (Carapetis, 2008). These studies also highlighted the dramatic gaps in reliable recent disease burden data from many regions, particularly Asia, Eastern Europe, and Latin America.

In this chapter, we will build on the 2005 review by including the considerable amount of studies that have been performed since that review. Improved capacity for case detection that includes the use of echocardiography, as well as an increase in notification, have been associated with increases in reported rates of S. pyogenes–related diseases in low-resource settings.

Methods

We conducted a systematic review with the goal of including population-based data published between 2005 and October 2014. Information on post-streptococcal glomerulonephritis (Table 3) was expanded to include older studies, because of the lack of recent studies in this area. We searched the PubMed database for the following terms. The number of publications returned is in parentheses.

Table 3:

Population-based studies of the incidence of acute post-streptococcal glomerulonephritis (APSGN)

1.

Rheumatic fever or rheumatic heart disease AND incidence or prevalence (1120)

2.

Rheumatic fever or rheumatic heart disease AND mortality or cause of death or burden of disease (685)

3.

Glomerulonephritis AND (streptococcus or streptococcal or post-streptococcal or post-streptococcal or streptococcus) AND incidence or prevalence (89)

4.

Invasive or bacteremia or bacteremia or toxic shock syndrome or necrotizing fasciitis or necrotizing fasciitis AND incidence or prevalence AND group A Streptococcus or group A streptococcal or Streptococcus pyogenes (345)

5.

Stroke AND Rheumatic fever or rheumatic heart disease (147)

6.

Endocarditis AND Rheumatic fever or rheumatic heart disease (298)

7.

Impetigo or pyoderma or scabies AND incidence or prevalence (603)

8.

Bacteremia or bacteraemia and developing country (101)

9.

Pharyngitis AND incidence or prevalence (>9,000)

Because of the large number of publications on pharyngitis, and because other summarized sources of information were available for this endpoint, we chose not to review those abstracts for this chapter. For all other S. pyogenes diseases, we reviewed abstracts, and those that seemed to offer population-based incidence or prevalence data were selected for inclusion in the tables at the end of this chapter. Our analysis of the burden of S. pyogenes–related diseases is organized as follows:

1.

Superficial and locally invasive disease (pharyngitis, impetigo, pyoderma, cellulitis, erysipelas).

2.

Immune-mediated disease (acute rheumatic fever and acute post-streptococcal glomerulonephritis).

3.

Disease with direct sequelae (rheumatic heart disease).

4.

Invasive and toxin mediated disease (bacteremia, streptococcal toxic shock syndrome, scarlet fever, necrotizing fasciitis, meningitis, osteomyelitis, pneumonia, puerperal sepsis).

Superficial and Locally Invasive Disease: Pharyngitis and S. pyogenes skin infections

The absolute numbers of cases of superficial S. pyogenes skin infections (impetigo, pyoderma and “skin sores”) and pharyngitis are much greater than those of more serious S. pyogenes diseases. Although superficial S. pyogenes diseases may seem relatively benign, their economic, social, and health utilization burdens can be considerable. Their direct costs can include use of antibiotics and other medication for symptomatic relief, while their indirect costs can include time away from school and parental time off work. Superficial S. pyogenes diseases also have clinical and public health implications, because of their causal association with invasive S. pyogenes infections and post-streptococcal diseases (Carapetis, Steer, Mulholland, & Weber, 2005b) (Table 1).

Table 1:

Studies since 2005 that document the prevalence of scabies or pyoderma

The burden of S. pyogenes skin infection is associated with scabies infection through co-infection and shared risk factors. The 2010 Global Burden of Disease study estimated that there are 140,495,000 cases of impetigo and 100,625,000 cases of scabies globally each year. This infectious burden ranks impetigo and scabies among the 50 most common diseases worldwide (Hay, et al., 2014). S. pyogenes skin infections and scabies are more prevalent, and are a larger cause of morbidity in resource-limited settings. Scabies can affect more than 60% of people who live in overcrowded communities with poor sanitation (Hay, et al., 2014).

Variations in the prevalence of S. pyogenes skin infections are related to accessibility to appropriate housing and hygiene. S. pyogenes also shows seasonal variation, being more common in dry than wet seasons in monsoonal climates (McDonald, et al., 2008). Communities with high scabies rates have been shown to have an elevated prevalence of pyoderma (Andrews, McCarthy, Carapetis, & Currie, 2009a). In 2005, pyoderma prevalence was found to range from 1 to 20% among children in less-developed countries, but was found to be as high as 40–90% in some areas of Pacific (Carapetis, Steer, Mulholland, & Weber, 2005b; Steer, Adams, Carlin, Nolan, & Shann, 1999) and Indigenous Australian children (Ralph & Carapetis, 2013; Shelby-James, Leach, Carapetis, Currie, & Mathews, 2002).

The incidence of cellulitis and erysipelas reported from Minnesota in 2007 was 200 cases per 100,000 patient-years (McNamara, et al., 2007). At San Francisco General Hospital, skin and soft tissue infections, including cellulitis, were the leading cause of admission for medical or surgical treatment (The Centers for Disease Control and Prevention, 2001). Almost all erysipelas episodes and many cellulitis episodes are attributable to S. pyogenes. However, microbiological confirmation is uncommon unless there is associated bacteremia (Ralph & Carapetis, 2013; Bisno & Stevens, 1996).

S. pyogenes pharyngitis is generally self-limiting, but can lead to a number of complications, which can include retropharyngeal abscess, ARF, and APSGN (Jackson, Steer, & Campbell, 2011). Prevalence rates of S. pyogenes pharyngitis are difficult to determine because there is a high rate of S. pyogenes throat colonization, which is reported to be as high as 15–20% in some studies (Henningham, Barnett, Maamary, & Walker, 2012).

Pharyngitis is a common cause of presentation to general practitioners in high-income settings. In a prospective, cohort-based study in Melbourne, Australia, the incidence of acute sore throat, group A streptococcal swab–positive pharyngitis, and serologically confirmed group A streptococcal pharyngitis was 33, 13, and 8 per 100 child-years, respectively, for school-aged children (5–12 years) and 60, 20, and 15 per 100 family-years, respectively (Danchin, et al., 2007).

Infection rates are best determined from studies that use serological testing to avoid the issue of misclassification of pharyngeal carriage as infection. It has been previously estimated that in high-resource settings, about 15% of school children and 4–10% of adults suffer an episode of symptomatic S. pyogenes pharyngitis per year, based on a number of population studies. In some low-resource settings, these rates may be 5–10 times higher (Carapetis, 2005; Ralph & Carapetis, 2013; Danchin, et al., 2004; Nandi, Kumar, Ray, Vohra, & Ganguly, 2001).

Immune mediated: acute rheumatic fever, and acute post-streptococcal glomerulonephritis

Incidence of Acute Rheumatic Fever

Acute rheumatic fever (ARF) is the most common cause of acquired heart disease in children worldwide (Carapetis, Steer, Mulholland, & Weber, 2005b; Jackson, Steer, & Campbell, 2011). ARF has become considerably less common in middle and high-income settings over the last half-century (Land & Bisno, 1983; Gordis, 1985). Studies in low-resource settings show that ARF rates remain high, and the resultant RHD is a source of substantial morbidity and mortality (Carapetis, Steer, Mulholland, & Weber, 2005b; Ahmed, Mostafa Zaman, & Monzur Hassan, 2005). However, accurate estimations of ARF incidence are difficult. There is no diagnostic test for ARF, its clinical presentation may be subtle and overlooked, and few countries, particularly among low and middle-income countries, have robust ARF notification programs (Table 2).

Table 2:

Recent studies (since 2005) that document the incidence of acute rheumatic fever (ARF) in children and adolescents

In 2005, the global incidence of ARF in children aged 5–14 years was estimated to be roughly 300,000–350,000 cases per year in the global population (Carapetis, Steer, Mulholland, & Weber, 2005b; Carapetis, McDonald, & Wilson, 2005a; Tibazarwa, Volmink, & Mayosi, 2008). Most of the studies published since 2005 come from Australia and New Zealand, and continue to demonstrate very high incidences in Indigenous populations in those countries (Table 2). New studies from the Northern Mariana Islands, Fiji, and Samoa confirm that high rates of ARF persist throughout Pacific Island nations (Seckeler, Barton, & Brownstein, 2010; Viali, Saena, & Futi, 2011; Parks, Kado, Colquhoun, Carapetis, & Steer, 2009). Interestingly, two studies have shown that ARF still frequently occurs in Italy (Breda, et al., 2012; Pastore, et al., 2011), and a study from Israel shows a relatively low rate overall, but one that is still higher than in most affluent nations (Vinker, Zohar, Hoffman, & Elhayany, 2010).

Overall, ARF incidence estimates vary widely, from a low of 0.1 per 100,000 in Greece (Jackson, Steer, & Campbell, 2011) and 0.7 per 100,000 children per year in Slovenia in 1990–1991 (Cernay, Rusnák, & Raisová, 1993) to 120 per 100,000 in Bangladesh (Ahmed, Mostafa Zaman, & Monzur Hassan, 2005), 374–508/100,000 in selected Australian Aboriginal populations in the 1980s–1990s (Ralph & Carapetis, 2013; Carapetis, Currie, & Mathews, 2000; Richmond & Harris, 1998) and 826 per 100,000 in Sudan (Jackson, Steer, & Campbell, 2011). However, it should be noted that these studies were based on various age ranges.

A systematic review in 2008 aimed to summarize population-based studies of ARF incidence, but restricted the analysis to only the first ARF episode (Tibazarwa, Volmink, & Mayosi, 2008). Studies from 10 countries on all continents (except Africa) were reviewed. The mean incidence rate of first attack of ARF was 19 per 100,000 per population per year (95% confidence interval; 9–30/100,000), lowest rates (< 10/100,000) documented in America and Western Europe, and higher incidences (> 10/100,000) documented in Eastern Europe, Middle East, Asia, and Australasia (Omar, 1995).

ARF incidence rates reported from each country would be expected to correlate with that country’s RHD prevalence, but such correlation is not always evident. In particular, although South Africa has some of the highest global prevalence of RHD (Carapetis, Steer, Mulholland, & Weber, 2005b), ARF incidence is only reported there at a rate of 13.4/100,000. This suggests either a substantial under-diagnosis of ARF (Ralph & Carapetis, 2013) or a lack of classical ARF manifestations in this population.

Aside from RHD, consequences of recurrent ARF include chorea which sometimes lasts up to 6 months, with rare cases lasting 2–3 years, and the need for 10 years or longer of secondary prophylaxis with monthly benzathine penicillin injections. In high-resource settings, where ARF rates can be high in Indigenous people, access to secondary- and tertiary-level care may result in lower mortality rates.

Direct sequelae: rheumatic heart disease

Prevalence of Rheumatic Heart Disease

(Tables 3a and 3b)

The most serious sequela of ARF is established RHD, which occurs in 42–60% of people with a history of prior ARF (Ralph & Carapetis, 2013; Carapetis, Currie, & Mathews, 2000; The Rheumatic Fever Working Party of the Medical Council of Great Britain; The Subcommittee of Principal Investigators of the American Council on Rheumatic Fever and Congenital Heart Disease, 1960). In 2005, it was estimated to cause at least 250,000 premature deaths per year (Carapetis, Steer, Mulholland, & Weber, 2005b). Recent estimates suggest that the disability burden associated with RHD is equivalent to one-quarter of disability from all forms of cancer combined (Mirabel, Narayanan, Jouven, & Marijon, 2014). RHD rates are the best documented of S. pyogenes-related diseases (Ralph & Carapetis, 2013). In 2005, 15.6 to 19. 6 million people worldwide were estimated to have RHD (Carapetis, Steer, Mulholland, & Weber, 2005b).

In 1990 the Global Burden of Disease (GBD) study published global population-based data that showed estimates of RHD prevalence, incidence, and mortality (Carapetis, Steer, Mulholland, & Weber, 2005b). The GBD 2010 study was undertaken to provide an updated estimate of global epidemiology with the objective of updating the estimates of RHD burden of disease using vital statistics data in 187 countries and 21 regions of the world from 1990 to 2010. Inclusion criteria were population-based studies published from 1990–2009. Data on RHD incidence, prevalence, and mortality were included. Incidence, prevalence, number of deaths, and Disability Adjusted Life Years (DALYs), were calculated using epidemiological modeling tools. The results showed that, in 1990, there were an estimated 29,172,383 cases of RHD globally, which increased to 34,232,795 in 2010 (Figure 2); the areas with the highest prevalence were Oceania (Pacific Islands region) and Eastern Europe (both 9.8 per 1,000). The estimated global number of incident RHD cases for 1990 and 2005 were 2,146,273 and 1,542,454 cases respectively. The estimates presented in the GBD 2010 Study suggest a higher burden of RHD than previously reported.

Figure 2.

RHD rates, as estimated by the 2010 Global Burden of Disease Study.

Historic studies of RHD prevalence from the 1950s onwards were based on population-based screening of school children through cardiac auscultation. Evidence from the echocardiographic era suggests that auscultation is insufficiently sensitive to detect early valvular lesions of subclinical RHD. Estimates of RHD prevalence based on clinical surveillance methods alone, without echocardiography, have been shown to result in gross underestimates and detect less than 1 in 10 cases of latent disease (Marijon, et al., 2007; Roberts, Colquhoun, Steer, Reményi, & Carapetis, 2013).

Within the last decade, many studies have used echocardiography alone to screen for RHD in asymptomatic children. Data using echocardiography to primarily screen for RHD has led to a marked increase in the prevalence of reported RHD (Seckeler & Hoke, 2011). In 2012, the World Heart Federation (WHF) released guidelines for characterizing RHD lesions, which has now helped to standardize their diagnosis (Reményi, et al., 2012). Since these guidelines are relatively recent, most studies reported in this chapter do not adhere to these guidelines. The inclusion or exclusion of asymptomatic disease represents millions of patients and creates a broad range of plausible estimates of the global prevalence of RHD. Therefore, Table 4 provides separate estimates of the prevalence of RHD. Supplementary Table 1 is based on studies that employed auscultation, then echocardiographic confirmation of clinical disease, and Supplementary Table 2 summarizes studies that diagnosed RHD based on echocardiographic screening only (without prior auscultation).

Table 4:

Hospital-based and cause of death Studies that relate to rheumatic heart disease (RHD)

The distribution of RHD varies between continents, within countries, and by neighborhood. The highest RHD rates are reported in slum dwellers, followed by rural, then urban populations (Carapetis, 2005). Sub-Saharan Africa and Indigenous populations in Australia have the highest documented prevalence (Carapetis, Steer, Mulholland, & Weber, 2005b; Tibazarwa, Volmink, & Mayosi, 2008; Nkomo, 2007; Longo-Mbenza, et al., 1998), with high rates also documented in North Africa (Ba-Saddik, et al., 2011; Rossi, Felici, & Banteyrga, 2014), Latin America (Paar, et al., 2010; Miranda, Camargos, Torres, & Meira, 2014), the Indian subcontinent (Sadiq, et al., 2009; Saxena, et al., 2011; Shrestha, et al., 2012), and Asia (Marijon, et al., 2007). The highest national rates recorded were in South Africa, with recorded RHD prevalence of 5.7 per 1,000 in the 5–14 year population. This South African rate was derived from 14 studies that used clinical or echocardiographic confirmation of RHD (Carapetis, 2005; Carapetis, Steer, Mulholland, & Weber, 2005b). However, it is likely that an even greater prevalence exists in areas of sub Saharan Africa that do not have active surveillance programs. There are also high rates documented in Pacific Island nations, as well as in Indigenous Australians and New Zealanders (Carapetis, 2005; Carapetis, Steer, Mulholland, & Weber, 2005b; Carapetis, Currie, & Mathews, 2000).

Uncertainty about the prognostic significance of subclinical RHD has complicated efforts to extrapolate prevalence from screening of school children to adult populations. The prevalence of clinical RHD in 20-50 year olds is known to be greater than in the adolescent period, which reflects the natural history of progressive symptomatic valve disease (Carapetis, Steer, Mulholland, & Weber, 2005b; Carapetis, McDonald, & Wilson, 2005a; Sliwa, Carrington, Mayosi, Zigiriadis, Myungi, & Stewart, 2010b). As expected, there are much higher estimated rates of prevalence if asymptomatic disease diagnosed by echocardiographic screening is included.

Other RHD Complications—Cardiac failure, infective endocarditis, and stroke

Cardiac failure, infective endocarditis (IE), and stroke are devastating sequelae that add to the burden of RHD and ARF. In Australia, 28% of those diagnosed with RHD developed heart failure at some stage between diagnosis and the end of their 13-year study period (Lawrence, Carapetis, Griffiths, Edwards, & Condon, 2013).

A review of eight studies of stroke from resource-limited settings concluded that between 3 and 7.5% of all strokes are directly attributable to RHD (Carapetis, Steer, Mulholland, & Weber, 2005b). The Global Burden of Disease Study estimated that, during 2010, 11.5 million people suffered their first stroke in less developed countries (Krishnamurthi, et al., 2013). Based on the estimated percentage of strokes attributable to RHD in less developed countries, this would equate to 345,000 to 862,500 strokes per year that can be attributed to RHD.

RHD is the most common underlying heart lesion in IE in resource-limited settings (Yew & Murdoch, 2012) (Table 5). In a systematic review of 11 studies, RHD was the underlying cause of valve disease in 63% of cases of IE, and the endocarditis mortality rate in low-resource countries was 25% (Carapetis, Steer, Mulholland, & Weber, 2005b). A study performed in Brazil found the mortality rate to be even higher, at 31% (Nunes, Gelape, & Ferrari, 2010). Thus, RHD is a significant cause of IE-related morbidity and mortality in resource-limited settings.

Table 5:

Studies published since 2005 that document the association of rheumatic heart disease (RHD) and infective endocarditis

The 2010 Global Burden of Disease study reported the incidence of IE to be between 1.5 to 11.6 cases per 100,000 people (Bin Abdulhak, et al., 2014). The only low or middle-income country that reported an IE incidence was Tunisia, with an incidence of 5.5 cases per 100,000 people. If we assume this incidence, with the median proportion of cases due to RHD (37.5%) and IE mortality (19%) from resource-limited countries, with an estimated population of 3,798,429,000 people over 5 years in resource-limited settings (The United Nations, 2012), this infers that there are 14,885 RHD-related IE deaths annually.

Invasive Disease

S. pyogenes has the ability to penetrate epithelial surfaces and cause a wide array of invasive diseases, including bacteremia, cellulitis, and necrotizing fasciitis, all of which may also involve streptococcal toxic shock syndrome (STTS). Other, less common invasive S. pyogenes diseases include septic arthritis, puerperal sepsis, meningitis, abscess, osteomyelitis, endocarditis, and peritonitis. Globally, in 2005 it was estimated that at least 663,000 cases of invasive S. pyogenes disease occurred each year, which resulted in 163,000 deaths (Carapetis, Steer, Mulholland, & Weber, 2005b) (Table 6).

Table 6:

Population-based studies of the incidence of invasive group A streptococcal infections

It appears that the incidence of invasive S. pyogenes disease is increasing (Henningham, Barnett, Maamary, & Walker, 2012; Cleary, et al., 1992; Cole, Barnett, Nizet, & Walker, 2011). In 2005, the reported incidence of invasive S. pyogenes infections was 1.5–3.9 cases per 100,000 population per year in high-income countries (Carapetis, 2005); 6.4–10.2 per 100,000 in Australian non-Indigenous populations (Carapetis & Currie, 1999; Norton, et al., 2004); 13 per 100,000 in Kenyan children (Berkley, et al., 2005), and up to 82.5 per 100,000 in Australian Indigenous populations (Norton, et al., 2004). In Fiji, the incidence of S. pyogenes bacteremia in people over 5 years of age was found to be 11.6 per 100,000, with Indigenous Fijians disproportionately affected (Steer, et al., 2008).

The proportion of S. pyogenes positive blood cultures is highest in infants, and progressively falls during the first years of life. A WHO Young Infants Study found that S. pyogenes accounted for 29% of all bacteremia isolates in children under 90 days of age in four less developed countries (Papua New Guinea, Ethiopia, The Gambia, and the Philippines) (The WHO Young Infants Study Group, 1999). In Kenya, S. pyogenes is the fifth most common cause of community-acquired bacteremia in children less than 5 years of age, with a case fatality of 25% among all children (Berkley, et al., 2005).

Resource-limited environments have higher incidences of invasive S. pyogenes, but it carries a high mortality rate, no matter the setting. Overall, about 20% of patients with invasive S. pyogenes disease die within 7 days of infection (Henningham, Barnett, Maamary, & Walker, 2012; Lamagni, et al., 2008; O'Grady, et al., 2007; O'Loughlin, et al., 2007). Our literature review of population-based and multicenter hospital-based studies after 2005 revealed mortality rates of 4%–32% (Table 6), with high mortality rates in both resource-rich and resource-poor settings.

Challenges and the Way Forward

Even a decade after the first comprehensive review in 2005, quantifying the burden of S. pyogenes disease remains a global challenge. Although more data are emerging, our ability to confidently estimate the incidence and mortality from S. pyogenes remains limited because of the lack of high quality data from large parts of the world, particularly from low-resource settings that appear to bear the greatest burden of disease. However, the REMEDY study is a recently published registry that has employed the systematic collection of RHD data from low and middle-income countries. This prospective registry enrolled 3343 patients (with a median age 28 years and that were 66.2% female) who presented with RHD at 25 hospitals in 12 African countries, India, and Yemen between January 2010 and November 2012. The study found that RHD patients were young, predominantly female, and had a high prevalence of major cardiovascular complications (Zühlke, et al., 2015). However, the available data on incidence and mortality from RHD, APSGN, and invasive disease, especially in children and young adults, support the conclusion that these diseases are significant causes of premature morbidity and mortality.

Establishing the true burden of S. pyogenes diseases is critically important as efforts to reduce morbidity and mortality progress. In particular, understanding the burden of S. pyogenes is an economic, public health, and advocacy prerequisite for further investment and development of an S. pyogenes vaccine. High-quality epidemiologic data will help assign an appropriate priority to these efforts and identify appropriate settings in which vaccine and other trials could be conducted (Jackson, Steer, & Campbell, 2011).

Non-vaccine strategies to reduce the burden of some S. pyogenes manifestations continue to progress. Developments in health systems and care delivery may provide opportunities to optimize primary and secondary prevention of ARF. In particular, secondary prevention with long-term antibiotics can prevent disease progression from ARF to RHD. Emerging data from developing countries indicate that clinical presentations with RHD occur only at a very advanced stage of diseases. Early echocardiography-based identification of asymptomatic RHD through active surveillance programs and the subsequent use of prophylactic antibiotics may help to prevent the devastating complications of RHD. It is critical that individuals with RHD that has been detected on echocardiographic screening are followed in rigorous research projects to identify the natural history of these lesions. Improved understanding of the natural history of RHD will determine which children identified through echocardiography screening are most appropriately included in burden of disease estimates. Finally, burden of disease estimates remain important for informing and monitoring essential efforts in primordial prevention. Understanding and addressing S. pyogenes disease risk factors including poverty, overcrowding, malnutrition, and maternal educational level and employment are essential elements of disease control programs (Marijon, Mirabel, Celermajer, & Jouven, 2012).

S. pyogenes is an important global pathogen with diverse clinical manifestations and limited epidemiologic data. Despite the paucity of high-quality studies, it is evident that resource-limited settings shoulder the majority of the burden of morbidity and mortality from S. pyogenes. As a result, there should be a focus on improving reporting systems and strengthening prevention and treatment programs in these parts of the world.

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