11th August 2017, Volume 130 Number 1460

Diana Lennon, Te Aro Moxon, Philippa Anderson, Alison Leversha, Timothy Jelleyman, Peter Reed, Catherine Jackson

Rheumatic heart disease (RHD), the long-term sequela of acute rheumatic fever (ARF), can persist for life.1 Despite ARF being preventable, the associated morbidity and mortality continue to be a significant…

Subscriber content

The full contents of this page is only available to subscribers.

To view this content please login or subscribe


Rheumatic fever is preventable. It causes long-term heart disease in many and can even cause premature death. It is important to count the cases carefully and accurately as there is an important campaign underway to prevent it by treating strep sore throats. We looked at the different methods for case counting. A register is the best way, well established in the Auckland region for several decades and leading to the current MOH campaign.



To determine the most accurate data source for acute rheumatic fever (ARF) epidemiology in the Auckland region.


To assess coverage of the Auckland Regional Rheumatic Fever Register (ARRFR), (1998–2010) for children <15 years and resident in Auckland at the time of illness, register, hospitalisation and notification data were compared. A consistent definition was applied to determine definite and probable cases of ARF using clinical records. (www.heartfoundation.org.nz)


Of 559 confirmed (definite and probable) RF cases <15 years (median age 10 years), seven were recurrences. Of 552 first episodes, the ARRFR identified 548 (99%), hospitalisations identified 501 (91%) including four not on the register, and public health notifications identified 384 (70%). Of hospitalisation cases, 33% (245/746), and of notifications 20% (94/478) did not meet the case definition and were therefore excluded. Between 1998–2010, eight cases, initially entered as ARF on the ARRFR, were later removed once further clinical detail was available.


The ARRFR produced the most accurate information surrounding new cases of ARF (for children <15 years) for the years 1998–2010 in Auckland. This was significantly more accurate than medical officer of health notification and hospitalisation data.

Author Information

Te Aro Moxon, Clinical Research Fellow, Department of Paediatrics, University of Auckland, Auckland; Peter Reed, Bio-Statistician, Starship Children’s Hospital, Auckland DHB, Auckland;
Timothy Jelleyman, Paediatrician, Waitākere Hospital, Waitematā District Health Board, Auckland; Philippa Anderson, Public Health Physician, Population Health Team, CMDHB, Auckland;
Alison Leversha, Honorary Academic, Department of Paediatrics, University of Auckland, Auckland; Catherine Jackson, Public Health Medicine Specialist, Auckland DHB, Auckland.


The vision of RF control in New Zealand began in Rotorua and Tairāwhiti in the 1960’s and 1970’s. The National RF Working Party was an important step forward. Partnership with Māoridom has been evident from the beginning.


Diana Lennon, Professor of Population Child & Youth Health, Paediatrician in Infectious Diseases, Kidz First and Starship Children’s Hospitals, Community Paediatrics Department of Paediatrics: Child & Youth Health, The University of Auckland, School of Population Health, Private Bag 92019, Auckland 1142.

Correspondence Email


Competing Interests

Dr Jackson reports personal fees from HDEC Northern A Ethics Committee (Dec 2016–present) outside the submitted work.


  1. Lennon DR. Acute Rheumatic Fever. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL, editors. Feigin & Cherry Textbook of Pediatric Infectious Diseases 7th edition. 7 ed. Vol. 1. Philadelphia: Saunders; 2013. p. 401–18.
  2. Seckeler MD HTR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease Clinical Epidemiology 2011; 3(1):17.
  3. Wilson NJ, Neutze JM. Echocardiographic diagnosis of subclinical carditis in acute rheumatic fever. Int J Cardiol. 1995; 50(1):1–6.
  4. Wilson N, Voss L, Morreau J, Stewart J, Lennon D. New Zealand guidelines for the diagnosis of acute rheumatic fever: small increase in the incidence of definite cases compared to the American Heart Association Jones criteria N Z Med J. 2013; 126(1379):50–9.
  5. Lennon D, Martin D, Wong E, Taylor L. Longitudinal study of poststreptococcal disease in Auckland; rheumatic fever, glomerulonephritis, epidemiology and M typing 1981–86. N Z Med J. 1988; 101(847 Pt 2):396–8.
  6. Wabitsch KR, Prior IA, Stanley DG, Pearce N. New Zealand trends in acute rheumatic fever and chronic rheumatic heart disease 1971–1981. N Z Med J. 1984; 97(763):594–7.
  7. Craig L, Anderson P, Jackson C. The health status of children and young people in Counties Manukau. Auckland: Child & Youth Epidemiology Service; 2008.
  8. Lennon D. Rheumatic fever secondary prophylaxis. Department of Health Circular; 1987. Report No.: HP 2/87.
  9. Lennon D, Stewart J, Farrell E, Palmer A, Mason H. School-Based Prevention of Acute Rheumatic Fever: A Group Randomized Trial in New Zealand. Pediatr Infect Dis J. 2009; 28(9):787–94.
  10. Lennon D, Kerdemelidis M, Arroll B. Meta-Analysis of Trials of Streptococcal Throat Treatment Programs to Prevent Rheumatic Fever. Pediatr Infect Dis J. 2009; 28(7):e259–e64.
  11. Jackson C LD. Rheumatic fever register scoping the development of a national web-based rheumatic fever register. Ministry of Health, Auckland. 2009.
  12. Lennon D, Wilson N, Peat B, Atatoa-Carr P, Kerdemelidis M, Arroll B, et al. New Zealand Guidelines for Rheumatic Fever: 1. Diagnosis, Management & Secondary Prophylaxis Auckland: National Heart Foundation of New Zealand; 2006. Available from: http://www.nhf.org.nz/files/Rheumatic%20fever%20guideline%201.pdf
  13. Oliver J, Baker MG, Pierse N, Carapetis J. Comparison of approaches to rheumatic fever surveillance across Organisation for Economic Co-operation and Development countries. J Paediatr Child Health. 2015; 51(11):1071–7.
  14. Wood H, Feinstein A, Taranta A, Epstein J, Simpson R. Rheumatic Fever in Children and Adolescents: A long-term epidemiologic study of subsequent prophylaxis, streptococcal infections, and clinical sequelae III. Comparative effectiveness of three prophylaxis regimens in preventing streptococcal infections and rheumatic recurrences. Ann Intern Med. 1964; 60(suppl):31–45.
  15. Lennon D, Martin D, Wong E, Taylor LR. Longitudinal study of poststreptococcal disease in Auckland; rheumatic fever, glomerulonephritis, epidemiology and M typing 1981–86. N Z Med J. 1988; 101(847 Pt 2):396–8.
  16. Milne RJ, Lennon DR, Stewart JM, Vander Hoorn S, Scuffham PA. Incidence of acute rheumatic fever in New Zealand children and youth. Journal of Paediatrics and Child Health. 2012; 48(8):685–91.
  17. Atatoa-Carr P, Lennon D, Wilson N, New Zealand Rheumatic Fever Guidelines Writing G. Rheumatic fever diagnosis, management, and secondary prevention: a New Zealand guideline. N Z Med J. 2008; 121(1271):59–69.
  18. Markowitz M, Gordis L. Rheumatic Fever. Philadelphia: W.B. Saunders; 1972.
  19. Grayson S, Horsburgh M, Lennon D. An Auckland regional audit of the nurse-led rheumatic fever secondary prophylaxis programme. N Z Med J. 2006; 119(1243):U2255.
  20. Moxon TA , Mills C, Malcolm J, Pennock V, McLean M, Reed P, Cramp G, Poskitt N, Jackson C. New Zealand’s Unique Experiment: Primary prevention of rheumatic fever with a focus on schools. World Congress of Cardiology, Melbourne. 2014. Abstract.
  21. Stanhope JM. New Zealand trends in rheumatic fever 1885–1971. N Z Med J. 1975; 82:297–9.
  22. Pennock V, Bell A, Moxon TA, Reed P, Maxwell F, Lennon D. Retrospective epidemiology of acute rheumatic fever: a 10-year review in the Waikato District Health Board area of New Zealand. N Z Med J. 2014; 127(1393):26–37.
  23. Oliver J, Pierse N, Baker MG. Estimating rheumatic fever incidence in New Zealand using multiple data sources. Epidemiol Infect. 2015; 143(1):167–77.
  24. Health Mo. Communicable Disease Control Manual 2012, RF chapter updated 2014. 2014.
  25. Newman JE, Lennon DR, Wong-Toi W. Patients with rheumatic fever recurrences. N Z Med J. 1984; 97(765):678–80.
  26. Moore R LD, Cramp G, Briant R, Webb R, Crengle S, Stander H. Rheumatic Heart Disease and its sequelae in adulthood: is a documented childhood rheumatic fever episode likely? Abstract Paediatric Society NZ (Annual Scientific meeting 2009). 2015.
  27. Oliver J, Pierse N, Baker MG. Improving rheumatic fever surveillance in New Zealand: results of a surveillance sector review. BMC Public Health. 2014; 14:528.
  28. Gurney J. The incidence of acute rheumatic fever in New Zealand, 2010–2013. N Z Med J. 2015; 128(1417):65–7.
  29. Rossi PG MJ, Ferroni E, Forcina A, Stanghellini E, Curtale F, Borgia P Incidence of bacterial meningitis (2001–2005) in Lazio, Italy: the results of a integrated surveillance system BMC Infect Dis. 2009; 9(13).
  30. Lambo JA, Khahro ZH, Memon MI, Lashari MI. Completeness of reporting and case ascertainment for neonatal tetanus in rural Pakistan. Int J Infect Dis. 2011; 15(8):e564–8.
  31. Trijbels-Smeulders M, de Jonge GA, Pasker-de Jong PC, Gerards LJ, Adriaanse AH, van Lingen RA, et al. Epidemiology of neonatal group B streptococcal disease in the Netherlands before and after introduction of guidelines for prevention. Archives of disease in childhood Fetal and neonatal edition. 2007; 92(4):F271–6.
  32. Rutstein D, Bauer W, Dorfman A, et al. Jones Criteria (modified) for guidance in the diagnosis of rheumatic fever: report of the committee on standards and criteria for programs of care. Circulation. 1956; 13:617–20.
  33. Special Writing Group of the Committee on Rheumatic Fever and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. Guidelines for the Diagnosis of Rheumatic Fever. Jones criteria 1992 update. Journal of the American Medical Association. 1992; 268:2069–2073.


The downloadable PDF version of this article is only available to subscribers.

To view this content please login or subscribe