Epidemiology

Primary episodes of acute rheumatic fever (ARF) occur mainly in children aged 5 to 14 years and are rare in people over 30 years old.[4] Recurrent episodes remain relatively common in adolescents and young adults but uncommon in those over 35 years old.[1] Overall, it is estimated that in 2019, 40.5 million people were affected by rheumatic heart disease (RHD), accounting for 10.7 million disability-adjusted life years lost and leading to 306,000 deaths.[5][6][Figure caption and citation for the preceding image starts]: Global prevalence and mortality rates. Source: data derived from Global Burden of Disease data 2010/2013.Zühlke, L.J., Beaton, A., Engel, M.E. et al. Group A streptococcus, acute rheumatic fever and rheumatic heart disease: epidemiology and clinical considerations. Curr Treat Options Cardio Med 19, 15 (2017). Used with permission. [Citation ends].com.bmj.content.model.Caption@57695436

The greatest burden of ARF and RHD is in people in low- and middle-income countries and in populations of indigenous people living in poverty in high-income countries.[4] The highest prevalence and age-standardised mortality of RHD are in Oceania, South Asia, and central sub-Saharan Africa.[5][6] There is no clear sex predilection for ARF, although RHD tends to be more common in females. ARF is most common in tropical countries with no seasonal variation. The highest rates of ARF have been documented in Aboriginal children in the Northern Territory of Australia and Pacific peoples, including those living in the US and New Zealand.[7][8] However, data from Uganda describe a higher incidence of ARF in populations with co-existing malaria, suggesting under-recognition of ARF and the value of surveillance.[9]

ARF was common in high-income countries including the US until the first half of the 20th century, when the incidence decreased because of improvements in living conditions and hygiene, which in turn led to decreased transmission of group A streptococci.[10] In the 1980s there was a resurgence of ARF in the intermountain regions in the US, thought to be related to the emergence of virulent group A streptococci belonging to M serotypes 1, 3, and 18.[11][12][13] In addition, changing patterns of antibiotic use, in particular the movement away from using antibiotics for treating group A streptococcal pharyngitis in countries with low rates of ARF, may also have affected the epidemiology of group A streptococcal diseases. However, overall the incidence of ARF in the US is unknown, as it is no longer a nationally notifiable disease.[14]

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