The Turkish Journal of Pediatrics
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Group A Streptococcal Tonsillopharyngitis Burden in a Tertiary Turkish Hospital
Aslınur Özkaya-Parlakay1, Mutlu Uysal2, Ateş Kara1
Departments of 1Pediatric Infectious Diseases, and 2Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.
|Acute tonsillopharyngitis is a very common upper respiratory tract infection
and might cause serious morbidity and even mortality if not handled
properly. Although the etiologic agent is mostly viral, group A beta hemolytic
streptococcus is the most important bacterial agent, with a frequency of
15-30% in the pediatric age group. In this article, as the social burden for
this infection is notable and almost one-third of costs are estimated to be
non-medical, we applied a questionnaire to the parents of 100 proven group
A tonsillopharyngitis patients to describe the social cost of this infection.|
group A beta hemolytic streptococcus, burden, tonsillopharyngitis, child.
|Acute tonsillopharyngitis is one of the most
common reasons for doctor visits and medical
care demands, especially in the pediatric age
group. According to United States (US) data,
approximately 7.3 million outpatient physician
visits attributable to sore throat occur each
year among children in the United States, and
group A streptococcus (GAS) is responsible for
15% to 36% of cases. Group A streptococcus
is an important pathogen responsible not just
for suppurative complications, necrotizing
fasciitis and streptococcal toxic shock syndrome,
but also nonsuppurative ones such as acute
rheumatic fever (ARF), post-streptococcal
glomerulonephritis (PSGN), and reactive
arthritis. It is estimated that around 9700
invasive diseases and 1300 deaths can be
attributed to GAS each year in the US.
Considerable similarity between GAS strains
causing pharyngitis in school-aged children and
isolates from cases associated with invasive
disease in the community indicates this age
group serves as a reservoir of infection,.
Nonsuppurative complications of GAS, ARF
and PSGN, are also important aspects of
streptococcus infection. The incidence of ARF
varies according to geographic area, and the
overall mean incidence rate of first attack of
ARF ranges from 5 to 51/100,000, with a
higher incidence (>10/100,000) documented
in Eastern Europe, Middle East (highest), Asia,
and Australasia. PSGN is the most common
form of postinfectious glomerular injury. The
disease occurs in 5% of those infected with
streptococcal sore throat and may occur in
25% of infections with nephritogenic strains
of beta-hemolytic streptococci. It is estimated
that over 470,000 cases of acute PSGN occur
annually. The incidence rate in children in less
developed countries was found to be 24.3 cases
per 100,000 person-years.
In human and animal experiments, it has been
demonstrated that recombinant multivalent
vaccines containing aminoterminal M protein
fragments from as many as 26 different
serotypes of GAS evoked opsonic antibodies
in animals and humans,, and the same group
also demonstrated that a new 30-valent vaccine
containing M protein elicited significant levels
of bactericidal antibodies against 24 of 40
non-vaccine serotypes of GAS. If these phase
I/II trials prove the vaccine as efficacious, a
common reason for antibiotic prescriptions and
antibiotic resistance will be diminished, and
hopefully invasive diseases due to GAS will be
prevented. The more commonly encountered
GAS tonsillopharyngitis cases are also expected
to decrease in number.
Before the debates start, including regarding the
advantages and disadvantages of vaccination,
the burden of GAS tonsillopharyngitis should
be weighed. Unfortunately, there is no well- coordinated data input demonstrating the
burden of GAS in our country. We thus aimed
to describe the medical and non-medical costs
in proven GAS tonsillopharyngitis patients.
|Material and Methods |
|Parents of children proven to have GAS
tonsillopharyngitis admitting to Hacettepe
University Pediatric Hospital between January
2007 and December 2008 were enrolled. Parents
of the patients were considered eligible if the
patient had, in addition to fever, any complaint
such as sore throat, headache, abdominal pain,
or rash, and a proven GAS tonsillopharyngitis
with a throat culture but not considered to
be carrier. A telephone survey was completed
with parents within 2-4 weeks after the initial
visit. Name, surname, age, gender, visit type
(emergency department or outpatient clinic),
month of admittance, symptoms and duration,
infection in last month and last six months,
sibling number, antibiotic, parental forgetfulness
in giving medications, child’s willingness to
take medicine, side effect of the medication
(diarrhea, vomiting, allergy, etc.), antipyretic
usage, means of obtaining medication (with
insurance, personal resources, etc.), means of
transportation, school day loss, and work day
loss of mother and father, if employed, were
noted. Work day loss was calculated according
to the Turkish Statistics Institute work day
cost research reports, and transportation
costs were obtained by questioning the parents
and calculated according to data gathered
from families and also data supported by the
|Of 187 potentially eligible cases, 100 parents
could be enrolled in our study (exclusions were
due to wrong contact information or incomplete
survey). The mean age of the patients was
8.1±3.18 years (range: 1-19) (Fig. 1), and 56%
of the patients were male. Of 100 patients,
19 attended a daycare center, 71 attended
primary school, and 7 were not in school. Of
the patients, 73.4% admitted in winter, 14.3%
in fall and 12.2% in spring (Fig. 2). Fever was
present in all of the patients, sore throat in
74%, abdominal pain in 38%, headache in 30%,
and rash in 14%. Children experienced fever
with a mean of 2.28 ±1.72 days, sore throat
with a mean of 2.20±1.81 days, abdominal pain
with a mean of 0.9 ±0.49 days, and headache
with a mean of 0.7 ±0.41 days. Antibiotic was
prescribed in 64% of patients due to throat
culture and in 22% at admittance, and no
antibiotic was prescribed in 14%. In 42% of the
patients, intramuscular therapy was preferred.
The emergency department was the place of
admittance in 56% of patients, and 44 of them
admitted to the general clinic. Sixty patients
admitted only once, whereas 11 had 2 visits
and 2 had 3 visits. Seventy-three patients had
a sibling, and 33% of them were also sick.
| ||Fig 1. Age distribution of GAS cases.|
| ||Fig 2. Monthly distribution of GAS cases.|
Parents used their own resources to obtain
medication in 25% of the cases. Personal
vehicles were preferred by 40% of the parents,
40% used public transportation, 17% used taxi,
and 3% came on foot. Of 90 patients either
attending daycare center or primary school,
10 did not have any school day loss, and 80
had school day loss ranging between 1-10 days
Ninety-three percent of the fathers were
employed; 13% of them had work day loss,
ranging between 1-3 days (mean: 0.3±0.89
days). Thirty-six percent of mothers were
employed and had work day loss ranging
between 1-2 days (mean: 0.09±0.35).
| ||Fig 3. Distribution of cost of GAS.|
Expenditure for transportation was determined
as 22.8 Turkish lira (TL) (12.26 USD) per child,
cost of work day loss per child was 12.98 TL
(6.98 USD), drug expense per child was 7.18
TL (3.86 USD), and visit cost per patient was
66.9 TL (35.93 USD) (including throat culture),
bringing the total cost per patient to 109.86
TL (59.03 USD)(Fig. 3).
|The economic burden of GAS tonsillopharyngitis
is high according to studies in the literature.
Pfoh et al. found cost per case as over $200,
almost one-half attributable to non-medical
costs. It was calculated as 109.86 TL (59.03
USD). We estimate the difference is high
due to medical costs (doctor, hospital, tests)
being far less expensive in our country; salary
differences between the US and our country
could also explain this difference. Other studies
of vaccine-preventable diseases have declared
that non-medical costs accounted for 39-83% of
the total costs-. In our study, non-medical
cost was 45.7% of the total cost.
Societal cost per case of viral respiratory
infections was $80 and $262 for otitis media
and $397 in previous studies-. However,
while the cost per case of GAS pharyngitis is
lower than these costs, it is more frequent,
which causes an economic burden of $224
million to $539 annually in the US. In this
aspect, it is obvious that the burden of
GAS pharyngitis would be far more than we
In previous studies, it was stated that children
experienced symptoms for 4.5 days on
average, whereas children in our study had
fever for 2.28, sore throat for 2.2, abdominal
pain for 0.49, and headache for 0.7 days on
average. In our study, children had a 2.56
school days loss, which was higher than 1.9
days loss on average in the literature. The
bedrest of children in our study might have
caused a shorter symptomatic period. Mothers
of children in our study had 0.09 work day
loss, and fathers had 0.09 work day loss, which
is less than the 1.8 days in literature. This
might be due to the fact that in our country,
parents have other available relatives to care
for their children.
Tonsillopharyngitis due to GAS has different
aspects of importance, primarily its frequency,
transmission and societal costs. While we
calculated a societal cost of 109.86 TL (59.03
USD) per case, it should be kept in mind that
GAS tonsillopharyngitis has a greater economic
burden than calculated in this study, in that the
attack rate in school and among relatives also
cause far more damage. As our study group
does not represent primary and secondary
health-care centers, further studies are needed
to gather data about the real burden of GAS
in our country.
Rates of invasive disease and pharyngitis
attributable to GAS infection in unvaccinated
adults may decrease if transmission is
interrupted, similar to results observed with the
7-valent pneumococcal conjugate vaccine-.
Thus, current ongoing studies about a candidate
GAS vaccine would be important in decreasing
the frequency of pharyngitis, invasive disease
and acute rheumatic fever. It might also
decrease unnecessary prescription of antibiotics
both in children and adults, hopefully yielding
lower antibiotic resistance.
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