April
Full chapter update to new format following a significant update to the 2024 Acute Rheumatic Fever Guidelines. Includes changes to the following sections:
For an overview of all updates made to the Communicable Disease Control Manual, see Updates to the Communicable Disease Control Manual – Health New Zealand | Te Whatu Ora.
Group A Streptococcus (GAS) infection ranks in the top 10 infectious causes of global mortality and results in at least half a million deaths per year [1]. Along with invasive GAS infections, acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD) in low- and middle- income countries account for most of the burden of disease [1-3]. In high-income countries rates of ARF and RHD are lower overall, but in Indigenous communities and those experiencing socioeconomic deprivation, higher rates persist [4].
The annual global incidence of ARF in children and young people has been estimated to be between 5 and 51 per 100,000 [5,6]. The peak incidence occurs between the ages of 9 and 14 years, and incidence declines after the age of 20 years.
The incidence of ARF in Aotearoa New Zealand is not evenly distributed throughout the population, with the burden of disease almost exclusively in Pacific and Māori children. Between 2000 and 2018, the rate of initial ARF hospitalisations for Pacific children was 80 per 100,000 and Māori children was 36 per 100,000 [8]. In comparison the rates in New Zealand European and other ethnicities were less than 2 per 100,000 over the same period [8]. Rates of ARF in Pacific and Māori children in Aotearoa are some of the highest in the world [9].
The pattern of ARF incidence in Aotearoa is one of sustained high incidence in Pacific and Māori peoples. In comparison, incidence in non-Pacific, non-Māori people has decreased over time, which has resulted in steadily increasing inequities between these groups. [8,10].
The incidence of ARF also varies by geography with the majority of cases occurring in the upper North Island. Approximately half of all cases live in the Auckland region [11]. Cases are significantly more likely to be from areas of higher socioeconomic deprivation. Cases aged 0 to 14 years are over 20 times more likely to be from a New Zealand Deprivation Index quintile 5 area (most deprived) than a quintile 1 area (least deprived) [10].
Recurrent ARF is associated with progression of RHD. Recurrent ARF occurs mostly in those aged 16 years and over, and occurs in approximately 7% of those who have presented with an initial ARF episode [8,12].
Mortality from RHD is higher in Pacific and Māori peoples and people experiencing socioeconomic deprivation. These groups have a substantially lower mean age at death than New Zealand European and other ethnicities and those that experience less socioeconomic deprivation [8].
A person’s risk of developing acute rheumatic fever (ARF) is influenced by a range of factors, including their access to the social determinants of health. Access to these determinants is highly patterned by ethnicity and socioeconomic status, which creates significant inequities in ARF rates and outcomes for Māori and Pacific Peoples in Aotearoa New Zealand. Working to achieve the health sector principles of the Pae Ora Act is key to overcoming these inequities.
When discussing contributing risk factors for ARF, it is essential to acknowledge the systemic inequities that create and perpetuate these risk factors. Most importantly, we must ensure whānau are not unfairly held responsible for circumstances shaped by these wider determinants, including their exposure to specific risk factors.
Higher rates of ARF are seen in the following demographic groups:
People with the following also have a higher risk of developing ARF:
The link between disability and ARF rates has not been well explored. As households with tamariki whaikaha (disabled children) are more likely to experience socioeconomic deprivation or live in poorer quality housing [16], and Māori and Pacific children have higher rates of disability, it is likely that tamariki whaikaha are at greater risk.
For further information on providing culturally safe and equitable care for a range of population groups, refer to the Equity chapter (external link).
For further information on public health service responsibilities under Te Tiriti o Waitangi, refer to Te Tiriti o Waitangi and Māori health (external link).
Clinical spectrum of Group A Streptococcus disease
Group A Streptococcus (GAS, Streptococcus pyogenes, Strep A) is a species of streptococcal bacteria grouped as ‘A’ in the Lancefield classification system [17]. Infection with GAS bacteria preceeds the development of acute rheumatic fever (ARF) in susceptible people.
The clinical spectrum of GAS-related disease is broad, and includes:
A proportion of the population also carry GAS through asymptomatic colonisation/carriage of the skin and throat.
Acute rheumatic fever
Acute rheumatic fever is a multi-organ inflammatory condition that can follow a GAS infection in susceptible people.
In susceptible people, a GAS infection leads to an immune response which becomes dysregulated and self-reactive [18]. During this unbalanced reaction, the immune system makes antibodies against GAS bacteria which may be damaging to parts of the body.
Exactly why this immune system response occurs is unknown, but possible reasons are [19,20]:
People who develop ARF may experience a range of signs and symptoms including [21]:
Following the initial GAS infection, there is usually a latent period where the person appears well before developing symptoms of ARF. This period averages 19 days but can be as long as 15 weeks. In people with Sydenham chorea or indolent carditis, it may be significantly longer (up to 8 months) [22,23].
Over time, repeated infections with GAS can lead to permanent damage and scarring of the heart valves known as rheumatic heart disease. In severe cases this damage means the heart cannot work properly and may lead to congestive heart failure [24,25].
A strong association exists between GAS throat infections (pharyngitis or sore throat) and ARF [26-30]. However, the pathogenesis of ARF is not completely understood. There is also an association between GAS skin infections and an increased risk of ARF in Aotearoa New Zealand and Australia, but the role of skin infections in ARF has not yet been established [31-36]. The contributions of asymptomatic GAS throat infections and infections with other Streptococci (groups C and G) to the development of ARF is uncertain [1,7,37-40].
This section primarily discusses the infectious agent Group A Streptococcus (GAS). It is important to note that acute rheumatic fever (ARF) is unusual in that the disease is caused by an abnormal immune response that produces cross-reacting antibodies to GAS infection, rather than caused by the GAS bacteria directly. This means that the condition is not infectious, but the GAS bacteria which trigger the infection are. Only a tiny proportion of all GAS infections trigger ARF.
Human reservoir. As a human-adapted pathogen, GAS survival requires an unbroken cycle of human-to-human transmission resulting in adherence to the primary infection site (skin or throat), colonisation/carriage (with or without infection), and onwards transmission to a new human host [41].
The incubation period for a GAS pharyngitis infection generally ranges between 1–3 days [42].
Following the initial GAS infection, there is usually a latent period where the person appears well before developing symptoms of ARF. This period averages 2–4 weeks but can be as long as 15 weeks. In people with Sydenham chorea or indolent carditis, it may be significantly longer (up to 8 months) [22,23].
GAS is generally considered to be spread from person-to-person by direct contact (i.e. contact with infected/colonised skin, body surfaces, or exudates) or by droplet transmission (i.e. contact with exhaled respiratory droplets from a person with GAS pharyngitis). Transmission via indirect contact with contaminated surfaces (fomites) is also a possible, less common route of transmission [42].
There is no relevant infectious period for management of ARF cases.
Standard precautions apply. This includes hand hygiene with alcohol-based hand sanitiser or soap and water, usual cleaning, and both mask-wearing and eye protection when examining the mouth, throat or nose of a patient with an undifferentiated illness.
For more information, refer to Appendix 6: Infection, prevention and control guidance
This section provides a brief overview of primordial, primary and secondary prevention of acute rheumatic fever (ARF). For more information, refer to the relevant chapters in the 2024 ARF Guidelines.
A comprehensive approach is needed for successful ARF prevention. Primordial prevention has been shown to be a vital aspect of preventing ARF and reducing inequities.
Primordial prevention of ARF focusses on addressing inequitable access to the social determinants of health (external link) and the subsequent creation of structural barriers and inequities seen in ARF. Key components of this approach include Māori and Pacific leadership, clinical care, promoting health and wellbeing, ensuring warm dry housing, and social and income support.
In Aotearoa New Zealand, the distribution of the social determinants of health are highly patterned by the history of colonisation and racism [43]. This means that Pākeha are privileged through greater access to these determinants while Māori and Pacific people are systematically disadvantaged through poorer access. Primordial prevention requires addressing these complex issues [44].
The three key social determinants of health that are modifiable risk factors for Group A Streptococcus (GAS) infection, ARF and rheumatic heart disease (RHD) in Aotearoa are [45]:
Although the specific biological mechanisms for how these social determinants of health pattern ARF are not fully understood [45], this should not delay action for ARF prevention. Reduction in ARF rates has been observed within countries in which living conditions were improved through the reduction of household crowding and access to affordable quality healthcare [46].
Scaling up of successful strategies, Pacific and Māori led responses and cross-sectoral response to these challenges is required for addressing ARF rates in Aotearoa. Refer to the Aotearoa Rheumatic Fever Roadmap, 2023–2028 [PDF, 9.3 MB] for further information.
Primary prevention of ARF aims to stop ARF from occurring through the diagnosis and treatment of sore throats caused by GAS. For people at higher risk of ARF, antibiotic treatment of GAS sore throat is recommended to prevent ARF and subsequent RHD. Treatment of sore throats in higher-risk groups for ARF must be balanced with avoiding the overuse of antibiotics in sore throat treatment for lower-risk groups. Refer to the 2024 ARF Guidelines for detailed sore throat management guidance.
Primary prevention occurs through a range of pathways in Aotearoa. These include:
Primary prevention programmes face a range of challenges to overcome including poor access to healthcare, delivering culturally safe and culturally appropriate care, and ensuring health promotion messaging is not stigmatising for Pacific and Māori communities.
Overall, a sustained reduction in ARF has not occurred with the introduction of primary prevention measures, although impacts of the COVID-19 pandemic between 2020 to 2022 made assessment difficult. There are complex contributors to this including post COVID-19 pandemic increases in GAS infections both locally and internationally as well as ongoing primary care access barriers. This highlights the need for primary prevention to be part of a broader strategy to prevent ARF and RHD.
In the future, vaccination is also expected to have a role in primary prevention of ARF and subsequent RHD. However, GAS vaccines are still in early developmental stages [47,48].
Secondary prevention of ARF refers to the provision of long-term antibiotic prophylaxis to prevent recurrence of ARF and RHD processing or recurring. Secondary antibiotic prophylaxis is delivered throughout Aotearoa through a range of providers that differ regionally.
Secondary antibiotic prophylaxis in Aotearoa has been most effectively delivered in the community by trained nurses who are resourced to engage with whānau and coordinate support. Long-acting intramuscular benzathine penicillin G is recommended every 28 days (4 weeks), unless the person has experienced a recurrent episode of ARF, in which case benzathine penicillin G is given every 21 days. In Aotearoa, recurrences are rare in those who fully adhere to a 28-day regimen.
Implementation of a national register of people (Rheumatic Fever Care Coordination System) with RHD receiving secondary antibiotic prophylaxis will support coordinated care for whānau with ARF and RHD.
Health services for secondary prevention of ARF and RHD need to be culturally safe and provide a holistic approach to whānau, acknowledging their mana, autonomy and decision-making. Services also need to recognise the long-term nature of the condition.
Clinical Criteria
Aotearoa New Zealand has specific criteria for the diagnosis of ARF, which are adapted from the 2015 American Heart Association Jones criteria [49]. While the 2015 AHA Jones Criteria are appropriate for use in international settings, they should not be applied in Aotearoa [50].
Clinical criteria are divided into major and minor criteria, which are used in combination (as outlined in case classification) to make a diagnosis of ARF.
Major manifestations
Minor manifestations
a When carditis is present as a major manifestation (clinical and/or echocardiographic), a prolonged P-R interval cannot be considered an additional minor manifestation.
b Advanced AV block (transient second- or third-degree heart block or junctional rhythm) is now included as a major sign of carditis. Among people with other manifestations of ARF, advanced AV block is highly specific for ARF [51].
c History of any joint too sore to walk is considered to be arthritis. Other causes of arthritis/arthralgia should be carefully excluded (refer to differential diagnosis section in the 2024 ARF Guidelines). If polyarthritis or monoarthritis is present as a major manifestation, then polyarthralgia cannot be considered an additional minor manifestation.
Criteria for classification of an initial episode of ARF
Confirmed (Definited)
A person with 2 major manifestations; OR 1 major and 2 minor manifestations AND evidence of a preceding GAS infection (refer to laboratory criteria)
Probable
A person with 1 major and 1 minor manifestationb AND evidence of a preceding GAS infection (refer to laboratory criteria)
Suspect (Possible)
A person for whom there is strong clinical suspicion of ARF, but insufficient signs and symptoms to fulfil diagnosis of definite or probable ARF, and no other alternative explanation for the clinical presentation
Under investigation
A person who has been notified to the medical officer of health, but information is not yet available to classify them further.
Not a case
A person who has been investigated and subsequently found not to meet the case definition.
d Alternative classification names as per 2024 ARF Guidelines and other international guidelines.
e For the purpose of classifying a probable case, evidence of a preceding GAS infection is instead considered a minor manifestation under the list of clinical criteria (as per Jones, 1956 [49]).
Criteria for classification of a recurrent episode of acute rheumatic fever
Recurrent ARF is defined as when a person with a reliable history of previous ARF or RHD presents with clinical features of ARF AND evidence of a preceding GAS infection.
Confirmed (Definitea)
A person with one of the following:
AND evidence of a preceding GAS infection (refer to laboratory criteria) AND a prior confirmed episode of ARF or RHD
Probable
A person with 1 major and 1 minor manifestationb AND evidence of a preceding GAS infection (refer to laboratory criteria) AND a prior confirmed episode of ARF or RHD
Suspect (Possiblea)
A person for who there is strong clinical suspicion of ARF, but insufficient signs and symptoms to fulfil diagnosis of definite or probable ARF, AND no other alternative explanation for the clinical presentation AND a prior confirmed episode of ARF or RHD
Under investigation
A person who has been notified to the medical officer of health, but information is not yet available to classify them further.
Not a case
A person who has been investigated and subsequently found not to meet the case definition.
a Alternative classification names as per 2024 ARF Guidelines and other international guidelines.
b The inclusion of evidence of a preceding GAS infection is counted as a minor manifestation for probable cases (as per Jones, 1956 [49]).
Epidemiological criteria
No epidemiological criteria are associated with case classification for ARF.
Evidence of preceding GAS infection
Rising or elevated antistreptolysin O (ASO) or anti-DNase B titres (refer to Laboratory testing guidelines for serology interpretation guidance) are acceptable evidence of preceding GAS infection for classifying confirmed or probable cases of ARF. This is the preferred laboratory evidence of a preceding GAS infection.
Rising GAS antibody titres OR a single GAS antibody titre above the 2025 Aotearoa New Zealand upper limits of normal (see Table 1 below) are acceptable.
| Antibody | IU/mL for Aotearoa New Zealand in 2025 |
|---|---|
| Anti-Streptolysin-O (ASO) | ≥450 |
| Anti-DNase B | ≥400 |
A positive throat culture or rapid molecular test for GAS alone are also acceptable evidence when the case has carditis). For a case of ARF without the major manifestation of carditis, there is a higher standard of evidence to meet for a preceding GAS infection.
The following are considered acceptable evidence of a preceding GAS infection for any case classification.
For acute rheumatic fever cases who do not have carditis as a major manifestation
When classifying cases as confirmed
The following are considered acceptable evidence of a preceding GAS infection for the purposes of classifying a case as confirmed.
If an ARF case without carditis does not have rising or elevated GAS antibody titres, they do not meet the confirmed case criteria and should be assessed to see if they meet the probable or suspected case criteria.
When classifying cases as probable
The following are considered acceptable evidence of a preceding GAS infection for the purposes of classifying a case as probable.
The case classification algorithm can be found here (external link).
There is no gold standard laboratory test for acute rheumatic fever (ARF). This section outlines a range of laboratory tests that are used to support a ARF diagnosis and key information on their use and interpretation.
The purpose of this section is primarily to enable public health services to accurately apply ARF case definitions. Other clinicians should refer to the 2024 ARF Guidelines for more detail applicable to clinical settings.
The purposes of testing are to:
Laboratory testing only forms part of the evidence required for a diagnosis of ARF, as there is no single confirmatory laboratory test. Diagnosis of ARF is primarily a clinical diagnosis with laboratory testing to provide supporting evidence required for case classification. Refer to case definitions for more information.
Public health services do not have a role in initiating laboratory testing as part of ARF diagnosis.
All people with suspected ARF should be admitted to hospital for assessment and the appropriate diagnostic investigations will be directed by the responsible clinical team.
Evidence of preceding group A streptococcal infection
Evidence of a preceding GAS pharyngitis (and/or immune response to pharyngitis) is an important adjunct to the diagnosis of ARF (except for when a person has Sydenham chorea, which means that evidence of preceding GAS pharyngitis is not required as a diagnostic criterion).
Identifying recent GAS infection may be imprecise. Currently, acceptable evidence of a preceding GAS infection for most casesa includes:
a the exception to this is for ARF cases without carditis, who require GAS serology evidence to be classified as confirmed. Refer to Laboratory criteria.
The GAS serology tests used in Aotearoa and most of the world are the antistreptolysin O (anti-SLO, ASO) and the anti-deoxyribonuclease B (anti-DNase B) titres.
typically peaks 3–6 weeks following infection and typically peaks 6–8 weeks following infection. Both may vary with the age of a person, alongside season and geography. In the absence of re-infection, the ASO titre usually approaches pre-infection levels between 6 and 12 months after infection, while the titre tends to remain elevated for longer.
The best evidence for a preceding GAS infection is rising antibody titresb. Alternatively, a single ASO or anti-DNase B titre that exceeds the 2025 Aotearoa New Zealand 80% upper limits of normal for diagnosis of ARF (below) is also considered to be sufficient evidence.
b Historically, the best evidence of an immune response to a preceding GAS infection, was said to be a twofold or more increase in titre from acute to convalescence (usually 12 to 28 days apart [50]. However, people with ARF typically present with an established immunological response. Additionally, it is unclear whether a twofold increase in titres is always seen with modern laboratory methods (turbidimetry and nephelometry).
There are a number of factors that are important to consider when interpreting GAS serology:
Updated 2025 Aotearoa New Zealand upper limits of normal for serum streptococcal antibody titres are shown in Table 1. These were derived from a combined cohort of 224 healthy children in the Auckland region who were involved in two case-control studies.
The values shown below represent the ”80% upper limit of normal (ULN)”. This is the level at which 80% of healthy children had a lower antibody value, and 20% had a higher antibody value. There were ethnic differences, with healthy Pacific and Māori children having higher levels. This highlights that ASO titres must be interpreted in context of the clinical signs and symptoms (i.e. pre-test probability) of ARF in the individual.
These values have an uncertainty of at least 5% due to intra-test variability and should be used for diagnosis of ARF only, in place of any lab-specific values provided [52,53].
These were derived from a combined cohort of 224 healthy children in the Auckland region who were involved in two case-control studies.
The values shown below represent the ”80% upper limit of normal (ULN)”. This is the level at which 80% of healthy children had a lower antibody value, and 20% had a higher antibody value. There were ethnic differences, with healthy Pacific and Māori children having higher levels. This highlights that ASO titres must be interpreted in context of the clinical signs and symptoms (i.e. pre-test probability) of ARF in the individual.
These values have an uncertainty of at least 5% due to intra-test variability and should be used for diagnosis of ARF only, in place of any lab-specific values provided [52,53].
Table 1: 2025 Aotearoa New Zealand 80% upper limits of normal for serum streptococcal antibody titres used in Aotearoa for diagnosis of ARF
| Antibody | IU/mL for Aotearoa New Zealand in 2025 |
|---|---|
| Anti-Streptolysin-O (ASO) | ≥450 |
| Anti-DNase B (ADB) | ≥400 |
Group A Streptococcus culture and rapid molecular test for throat swabs
A positive GAS infection identified within the last 4 weeks from a throat swab culture or rapid molecular test for GAS is also accepted as laboratory diagnostic evidence to support a diagnosis of ARF. This evidence alone is considered less reliable as a positive culture in the absence of elevated antibody titres may reflect asymptomatic colonisation or carriage of GAS which is common in children [54].
Rapid molecular testing for GAS is currently considered equal to culture as evidence to support a diagnosis of ARF.
Tests that do not provide sufficient evidence of preceding GAS infection
Group A Streptococcus rapid antigen detection testing
Rapid antigen detection (RAD) tests are not accepted as evidence of preceding GAS infection and are not recommended for use in Aotearoa. Their diagnostic accuracy varies, and sensitivity has been found to be as low as 26% in an Auckland study [55,56]. The primary reasons for this recommendation are concerns about both missing cases of ARF or GAS pharyngitis in high incidence ARF populations, and over testing and overtreatment of ARF in low incidence ARF populations.
Group A Streptococcus skin culture
Bacteriologic culture for GAS from the skin is not accepted as evidence of preceding GAS infection for the diagnosis of ARF in Aotearoa. The role of skin infection and ARF immunopathogenesis at the individual patient level remains uncertain.
Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) as a minor criterion
ARF is a systemic inflammatory process that also raises the serum CRP and/or ESR levels. At least one of these must be raised above set thresholds (Table 2) to meet the minor criterion of raised ESR or CRP. If both ESR and CRP are raised this is only considered as meeting a single minor criterion.
The diagnostic threshold levels for ARF in Aotearoa are shown in Table 2 and should be used in place of any lab-specific threshold provided.
Table 2 Erythrocyte sedimentation rate and C-reactive protein thresholds used in Aotearoa New Zealand for diagnosis of acute rheumatic fever
| Acute phase reactant | Diagnostic threshold for ARF |
|---|---|
| Erythrocyte sedimentation rate (ESR) | ≥50mm/h |
| C-reactive protein (CRP) | ≥30mg/L |
| Test | Sample | Estimated turnaround time | Additional information |
|---|---|---|---|
| GAS serology | Blood in SST tube (gold cap) | Up to 7 days | Serum only accepted. Onset of illness information desirable. Sample transport - samples should be transported to the laboratory as soon as possible after collection. |
| Throat culture | Throat swab in transport medium for routine culture. | 2–3 days | Samples should be collected as soon as possible after the onset of the infection, ideally before the initiation of antimicrobial treatment or as soon after the start of antimicrobial treatment as possible. Sample collection technique - samples should be collected as per the local respiratory swab collection guidelines Sample transport - samples should be transported to the laboratory as soon as possible after collection. |
| Rapid molecular testing | Throat swab | 2 days | |
| ESR | Whole blood in EDTA tube (purple cap) | 4 hours | Transport immediately to the laboratory for testing. |
| CRP | Blood in SST tube (gold cap) | 3 hours |
Group A Streptococcus serology – Antistreptolysin O titre
Antistreptolysin O (ASO) titre is a blood test used to help diagnose a past infection with GAS. It detects antibodies to the ASO.
The ASO test is primarily ordered by itself or along with an anti-DNase B. ASO and anti-DNase B are the most common of several antibodies that are produced by the body's immune system in response to a GAS infection.
Antistreptococcal antibodies have a high sensitivity for the documentation of GAS infection in the setting of ARF. Titres vary with age, season, and geography.
Paired sera should be obtained wherever appropriate: (a) acute sample – as early as possible in the illness, and (b) convalescent sample: 2–3 weeks after onset.
Group A Streptococcus serology – Anti DNase-B
Anti-DNase B is a blood test to look for antibodies to a substance (protein) produced by GAS and will help to diagnose a past infection. High titre indicates recent infection with Streptococcus pyogenes. The titre peaks at 4–6 weeks, but high levels persist for longer than the ASO.
Paired sera should be obtained wherever appropriate: (a) acute sample – as early as possible in the illness, and (b) convalescent sample: 2–3 weeks after onset. When used together with the ASO more than 90% of past streptococcal infections can be identified.
GAS serology is routinely processed in laboratories throughout Aotearoa.
Bacterial throat culture
GAS is generally detected in microbiological throat samples via bacterial culture methods (growth in the laboratory using specialised incubation conditions and bacterial growth media). GAS generally grows in culture after 18–24 hours of incubation, with final bacterial identification results (+/- antimicrobial susceptibility results) generally available within an end-to-end turnaround time of 48 to 72 hours.
Bacterial throat cultures are routinely processed in laboratories throughout Aotearoa.
Rapid molecular testing
There is limited availability of rapid molecular testing for GAS throughout Aotearoa and the estimated end-to-end turnaround time is 48 hours. It has a high sensitivity and is considerably faster than a swab for bacterial culture [57]. The assay is an automated real-time polymerase chain reaction (PCR) targeting the Streptococcus pyogenes speB gene that encodes streptococcal pyrogenic exotoxin B, a virulence factor universally present in GAS.
Erythrocyte sedimentation rate (ESR)
ESR is an indirect measure of the degree of inflammation present in the body. It measures the rate of fall (sedimentation) of erythrocytes. Results are reported as how many millimetres of clear plasma are present at the top of the column after 1 hour. Increased blood levels of certain proteins (such as fibrinogen or immunoglobulins, which are increased in inflammation) cause the red blood cells to fall more rapidly, increasing the ESR.
A normal ESR does not exclude active disease.
The test is routinely available throughout Aotearoa, ESR results should be interpreted with caution for the following situations.
C-reactive protein (CRP)
A CRP test is used to detect inflammation. It measures levels of CRP, a hepatic protein that is produced as part of the acute inflammatory response and is released into the blood in response to inflammation. Levels start to rise soon after the start of inflammation or an infection and indicate the presence of inflammation, but it is not specific for the site.
The laboratory test is routinely available throughout Aotearoa, reference ranges may vary depending on the platform the sample is tested on. Age, gender and ethnicity can also alter CRP levels.
All people who are suspected to have acute rheumatic fever (ARF) must be notified to the local public health service by attending health practitioners. Follow the local pathway for disease notification, including completion of the case report form and referral pathway.
Public health services should ensure complete case information is entered into the appropriate surveillance database for notifiable diseases (i.e. EpiSurv).
A person with ARF should be enrolled on the regional/national register for ARF following written consent from the person or parent/caregiver.
There are no specific situations where cases of ARF should be routinely escalated to the national protection team.
There are no routine international reporting requirements.
Follow up of notified cases of ARF and the relevant public health actions should be initiated on the next working day following notification.
Supporting ARF cases and their whānau
Support for cases and their whānau in the hospital setting will primarily be from the treating team, and Māori and Pacific cultural support teams as appropriate/available.
The role of public health services in supporting people with ARF and their whānau may vary by region and context.
Priorities when engaging people with ARF and their whānau are:
For further information on providing culturally safe and equitable care for a range of population groups, refer to the Equity chapter.
For further information on public health service responsibilities under Te Tiriti o Waitangi, refer to Te Tiriti o Waitangi and Māori health chapter.
For further information on support that is available, refer to Appendix 7: Manaaki and Welfare.
Healthy homes referrals
A healthy homes referral for cases with any housing needs is an important avenue of support to offer whānau. Healthy homes services aim to enable whānau to have warmer, drier, healthier homes to live in. They are also able to provide support that reduces functional crowding (e.g. bedsharing) which reduces the spread of GAS bacteria within households.
Healthy homes referrals will often be made by the responsible clinical team as part of discharge planning, but public health services should make healthy homes referrals for any cases who require one and it has not been completed by the clinical team for any reason.
For information on eligibility and local providers of the Healthy Homes Initiative refer to Health NZ: Healthy Homes (external link).
All people who are suspected to have acute rheumatic fever (ARF) should be admitted to hospital for appropriate assessment and treatment.
All suspected rheumatic fever cases should be notified to the local public health service.
Cases of ARF do not require source investigation.
For all cases of ARF
Ascertain if the case has had sufficient investigation to confirm diagnosis (i.e. throat swab, GAS serology, erythrocyte sedimentation rate (ESR) test and/or an elevated C-reactive protein (CRP), echocardiogram, electrocardiogram (ECG))
For recurrent episodes of ARF
The reason for recurrence should also be investigated. Recurrent episodes of ARF may represent a treatment or systems failure and should be investigated and where possible changes to treatment approaches made to reduce the risk of further recurrences. Common reasons for recurrence include:
People with ARF are not required to isolate.
Initial management of cases
All people who are suspected to have ARF (first episode or recurrence) should be hospitalised as soon as possible after onset of symptoms and should be under the care of a specialist paediatrician or physician.
The main priorities in the first few days after presentation are:
The case’s clinical team are responsible for their treatment. Treatment options for arthritis/arthralgia, fever, carditis/heart failure and chorea are outlined in the 2024 ARF Guidelines: Initial management of Acute Rheumatic Fever.
Note that evolution and/or improvement in carditis may take months.
Follow up of cases
All cases should receive regular primary care review, and outpatient follow-up should be initiated before discharge from hospital and is the responsibility of the treating clinician.
Public health services may have a role in checking that all relevant referrals for follow up have been made.
Follow-up of cases depends on the severity of carditis and case classification, but in general will include:
Refer to additional information for a summary table of recommended follow-up of cases based on their clinical presentation, including duration of secondary antibiotic prophylaxis.
Further details including a discharge checklist can also be found in 2024 ARF Guidelines: Initial management of Acute Rheumatic Fever.
Secondary antibiotic prophylaxis
One episode of rheumatic fever significantly increases the risk of further episodes, often with further cardiac damage. Antibiotic prophylaxis to prevent recurrent attacks of ARF should therefore be started before discharge from hospital. The case should also be referred to the local service providing ongoing secondary antibiotic prophylaxis in the community prior to discharge. Long-acting intramuscular benzathine penicillin (preferred brand preformulated Bicillin-LA) is usually provided by a community nursing service but this differs region to region. Refer to your local community HealthPathways for further information.
The appropriate duration of secondary antibiotic prophylaxis depends on a number of factors, including age, severity of heart involvement, environment and time elapsed since the last episode of ARF (see additional information).
Antibiotic prophylaxis for endocarditis and dental follow-up
Rheumatic heart disease leads to a lifelong increased risk of bacterial endocarditis, and antibiotic prophylaxis may be required at the time of dental, oral, respiratory tract, oesophageal, gastrointestinal and genitourinary procedures. Ongoing dental care is essential, and each case should be notified to and supported to engage with the appropriate school dental service or dentist.
At the time of diagnosis, it is essential to explain the disease process to the case and their whānau in a culturally appropriate way. In most regions this should be covered by the inpatient care team as well as the team providing secondary antibiotic prophylaxis, with public health services supporting as needed.
Ongoing health education should be provided to all cases and their whānau so that they have a good understanding of:
The ARF information sheet can be accessed here (external link).
The following additional resources can be shared be shared with whānau:
As acute rheumatic fever (ARF) is not an infectious condition, there are no contacts created. However, public health services have a role in the follow-up of people who live in the same household as an ARF case who, due to shared risk factors, are at higher risk of ARF and rheumatic heart disease (RHD). For this reason, this section refers to ‘household members’ rather than ‘contacts’.
Initiate follow up within 5 to 10 working days depending on the wider context and pressures on the whānau.
Household members at risk – A household member considered at risk is anyone aged 3 to 35 years who is usually resident in the case’s household/s at the time of follow-up.
For whānau where there is usually significant crossover with another household/other households most days of the week, the public health service may choose to consider members of this extended group aged 3 to 35 years as household members at risk as well.
Key actions:
A manaaki-centred approach to follow-up with household members is crucial to establishing relationships and trust between public health services, cases, and their contacts. For further details on this approach, see Equity chapter.
As ARF is a serious condition with a lifelong impact, whānau are likely to be worried and feeling overwhelmed by the complex diagnostic process, new information, and long-term implications of the diagnosis including monthly antibiotic injections for many years. The following approaches should be considered when following up household members of an ARF case:
Further information on manaakitanga/manaaki in practice (including healthy homes referral) for ARF cases and their whānau can be found in the case management section or as per your local community HealthPathways.
Management of sore throats, skin infections and household throat swabbing
All household members of the index case who have symptoms of pharyngitis or a current skin infection should be advised and supported where possible to see their primary care provider or another community-based provider for assessment and management. Sore throats in household members should be managed as per the 2024 ARF Guidelines: Sore throat management.
If a household member of an ARF case has a sore throat at the time of follow up and swabs cannot be performed, they should be offered empiric treatment in line with the guidelines. Public health services should support this access wherever possible.
Routine throat swabbing of asymptomatic household members is not recommended
Previously, routine swabbing of all household members (including asymptomatic people) was undertaken in some regions of Aotearoa New Zealand.
In general, public health contact tracing for ARF aims to identify additional cases and prevent secondary cases via provision of antibiotic chemoprophylaxis. The logic to undertake contact tracing for an immune-mediated, non-infectious condition, is uncertain and secondary cases remain extremely rare in Aotearoa.
Any theoretical benefit needs to be considered against the resources required and the potential harms. There is uncertain benefit to the routine swabbing of all household members, and it is no longer recommended.
Alerting primary care to risk status of household members
It is recommended that, where possible, public health services send a letter to the primary care provider of household members at risk to inform them that a person in the whānau was recently diagnosed with ARF and to provide recommendations for sore throat management. Consent should be gained from the household member or their caregiver prior to contacting their primary care provider.
A template letter can be found here (external link).
Provision of health education
All household members should be provided with the information outlined in health education.
Referral of siblings for echocardiography
Public health services should support referral of siblings of people with recently diagnosed ARF for opportunistic echocardiography.
This referral should ideally be made by the clinical team looking after the ARF case as they can provide relevant education and counselling for the whānau. There is a role for public health services in supporting this referral to be made and supporting national consistency in referral for sibling screening.
This includes genetic siblings who no longer live in the household/s (where practical). For non-genetic siblings, or other children aged 5 to 20 years living in the same household, if the family is concerned and would like them to be referred for echocardiography screening, the referral should be made. Siblings with an existing diagnosis of RHD do not need to be referred.
The rationale for this recommendation is:
It is not clear whether the increased risk to siblings arises from genetics, the environment or a combination of factors.
See the 2024 ARF Guidelines for further information on opportunistic echocardiographic screening, including recommended care pathways.
There are no quarantine or restriction requirements for household members of people with ARF.
Ensure the below health education information has been provided to the household/s, ensuring communication is provided in an accessible format and is culturally and/or language appropriate. This should include:
An information sheet summary for household members/whānau can be found here (external link).
Acute rheumatic fever (ARF) is not infectious; however, cases of ARF may indicate a high GAS burden in the case’s environment. Therefore, more than one case of ARF in a defined community may warrant control measures aimed at addressing GAS transmission. In most instances, public health action in a potential outbreak will be in the form of reactive communications to address community concerns and increase primary prevention.
In general, clusters of ARF cases are rare.
There is no specific definition for a cluster of ARF, but the following criteria are suggested to trigger consideration of whether any further public health action is warranted.
When to think about a cluster of cases:
Consider the population context including the overall size of the population group and the expected number of cases within that group when deciding to respond to a cluster.
Equity implications should also be considered when responding to a cluster, given the disproportionate impact of ARF to Pacific and Māori populations. Action undertaken as a result of these considerations should address inequities as appropriate.
If a cluster is recognised that should be responded to with local control measures (as per the above criteria), the following actions are suggested:
If any action is taken in response to a cluster of ARF cases, public health services should enter that cluster as an ‘outbreak’ on EpiSurv for surveillance purposes.
Liaising with a community
When liaising with specific community groups, consider who may already hold relationships with that community within the public health service, or other areas of health. Involvement of people with existing trusted relationships in the community will support a culturally appropriate response.
In some instances, it may not be possible to raise awareness without identifying cases within a community. Maintaining the engagement, trust and privacy of ARF cases and their whānau is vital to their treatment, and care should be taken not to identify them through public health action without their explicit consent.
Māori and Pacific communities may wish to take action in response to an ARF cluster. Supporting this could involve actions such as:
For school communities
In areas where they operate, find out whether the school has a throat swabbing service or a school nurse. Communicate any actions to the school throat swabbing service staff and the school nurse if these are identified.
Provide information to the school about the increased GAS burden and importance of responding to sore throats to share with their community and work with them to find an appropriate way to share that information (e.g. school newsletter). The use of appropriate translations or resources designed for Māori communities is encouraged in kura kaupapa and kohanga reo settings.
For medical centres/primary care providers
Several ARF cases associated with the same medical centre may reflect a range of contributing factors, such as challenges associated with accessing timely care, financial barriers to appointments or medications, a high burden of GAS infections in the local population, or systemic difficulties in consistently applying best practice guidelines.
Public health services should consider liaising with the medical centre or local primary care liaison to increase their awareness of the GAS burden among their registered patients as well as best practice sore throat management in the 2024 ARF Guidelines and their local community HealthPathways.
Community antibiotic prophylaxis
There is no evidence-based protocol for managing an ARF cluster through mass antibiotic chemoprophylaxis at a community or setting level (i.e. school, church, suburb).
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This table is a brief overview of follow-up for reference. For further details refer to the 2024 ARF Guidelines: Initial management of ARF.
Initial guidance regarding benzathine penicillin prophylaxis duration should always be reviewed depending on the person’s situation and the progression of echocardiography findings. When inflammatory markers have resolved (typically within 6 months), any residual carditis is termed chronic rheumatic heart disease (RHD).
| Severity | Clinical follow up | Echocardiogram | Antibiotic prophylaxis for endocarditis | Benzathine penicillin prophylaxis (secondary antibiotic prophylaxis – SAP) |
|---|---|---|---|---|
| Definite or probable ARF with normal heart or mild carditis | Annual primary care (GP) and dental review. Specialist (paediatrician/ physician) follow up 1 to 3 yearly (less often if stable) |
2 yearly (less often if stable) | Recommended if carditis | Minimum of 10 years or until age 21, whichever is longer. (consider minimum of 5 years if over 16 years at first episode and minimal carditis) |
| ARF with moderate carditis/RHD | Annual specialist (paediatrician/physician), primary care (GP), dental review. | Annual | Recommended - lifelong | Minimum of 10 years or until age 21, whichever is longer, then reassess. If still moderate RHD or progressed to severe RHD, continue SAP until age 30 and reassess. |
| ARF severe carditis/RHD | 6 to 12 month specialist (paediatrician/physician),primary care (GP), dental review. Refer to chapters 10 and 11 of the 2024 ARF Guidelines (external link) |
6–12 monthly | Recommended - lifelong | Reassess at 30 years, beyond 30 individualised as per patient and physician. Refer to 2024 ARF Guidelines (external link). |
| Possible ARF | Specialist (paediatrician/physician) follow up at 6 and 12 months, then as needed if ARF/RHD confirmed. | At 6 and 12 months | Not recommended | 1 year then review. SAP may stop earlier if another diagnosis (such as juvenile arthritis) is confirmed. If from a higher risk population and no other diagnosis is confirmed, 5 years of SAP is recommended. |