Queensland Health Guidelines for Public Health Units

• Infectious Agent
• Case definitions and notification criteria
• Notification Procedure
• Reporting to NOCS
• Objectives of Surveillance
• Public Health Significance and Occurrence
• Clinical Features
• Management
• References

Infectious agent

Acute post-streptococcal glomerulonephritis (APSGN) is an inflammatory disease of the kidneys following a skin (impetigo/cellulitis) or throat infection (pharyngitis) with Streptococcus pyogenes, known as group A streptococcus (GAS), or occasionally groups C or G streptococcus.

Case definitions and notification criteria

Public health units to report confirmed and probable cases to NoCS.

Confirmed case

A confirmed case requires laboratory definitive evidence

OR

Laboratory suggestive evidence AND clinical evidence

Laboratory definitive evidence
Renal biopsy suggestive of APSGN

Laboratory suggestive evidence

1. Microscopic haematuria (RBC > 10/ul)

AND

2. Evidence of recent streptococcal infection (Isolation or detection of GAS by culture^{^}, NAAT or rapid antigen detection test from skin or throat or elevated/rising ASO or Anti-DNase B titre, as shown below in Table 1.)

AND

3. Reduced C3 complement level  (< 0.7g/L)^#

Table 1. Upper limit of normal (80th centile) values for serum streptococcal antibody titres by age group in tropical settings where Strep A is endemic¹

Clinical evidence

At least 2 of the following:

• facial and/or peripheral oedema
• macroscopic and/or moderate haematuria⁺
• hypertension, according to age/sex/height percentiles (refer to appendix A).

^{^Case confirmation with Isolation of group C or G streptococci to be discussed with local PHU.
#C3 should be tested within 4 weeks of APSGN symptom onset
+On visual inspection or moderate haematuria on urine dipstick (≥ 2+ red blood cells).}

Probable case

A probable case requires clinical evidence only and APSGN is considered the most likely cause by a treating clinician*

*It is recommended that probable cases are diagnosed in consultation with the treating paediatrician/nephrologist.

Possible (subclinical case)

A possible case requires laboratory suggestive evidence only.

Notification procedure

Attending Medical Practitioners/Medical Superintendents (or Delegates):
Notify public health units on clinical suspicion or confirmation within 48 hours by email, fax or phone.

Objectives of surveillance

1. Timely contact tracing to prevent further cases and disease transmission
2. Outbreak identification and response
3. Surveillance to monitor the need for and effectiveness of preventative activities.

Public health significance and occurrence

Globally APSGN is the most common cause of acute nephritis in children with more than 95% of cases occurring in developing countries. The highest risk of disease occurs among children between the ages of 5–12, it is also seen among older adults over the age of 60 with chronic medical conditions. The global incidence rate is estimated to range between 9.5–28.5 per 100,000 individuals per year.²

In Australia, Aboriginal and/or Torres Strait Islander children have amongst the highest incidence of APSGN reported worldwide.³ Research from the Northern Territory estimates the incidence of confirmed cases in Aboriginal children <15 years at 124 cases/100,000 person-years. The median age of all cases was 8 years (range 0–62 years).⁴ APSGN typically affects children residing in the top end between the ages of 12 months and 17 years.⁵ The incidence in children aged younger than 15 years has increased significantly over 25 years with consistently rising numbers of notifications annually and reduced frequency of outbreaks. This could be partly due to increased awareness of APSGN in the health system [reporting bias].⁴

The incidence and consequences of subclinical APSGN have yet to be established in North Queensland or other regions of tropical Australia. APSGN occurs sporadically and as intermittent outbreaks in association with virulent skin strains of GAS. As of 2023, there is limited data available for the North Queensland region, due to the recent listing as a notifiable condition.

APSGN is an indicator of social disadvantage, poverty, remoteness and household overcrowding.⁴ Treatment of GAS infection with penicillin may reduce the spread of nephritogenic strains and prevent recurrences.^6,7 Improving environmental conditions such as reducing household overcrowding and enhancing access to functional washing facilities, and early identification and treatment of GAS infections remain important control strategies.^7,8

Clinical features

APSGN is an immune-mediated inflammatory disease of the kidney glomerulus following infection by “nephritogenic” M-type strains of Streptococcus pyogenes or GAS, or occasionally groups C or G streptococcus.⁹ Skin sores or breaks in skin integrity due to scabies or fungal skin infections are common sources of GAS infection.

The pathophysiology of APSGN is complex and features the reduction in glomerulus filtration rate (GFR) and disrupted glomerular permeability associated with streptococci beta-haemolysis activity (red blood cell destruction), build-up of trapped antigen-antibody immune complexes, and inflammatory hypersensitivity.²

APSGN can be asymptomatic, and diagnosis relies on the identification of clinical manifestations following a GAS infection latent period. Clinical manifestations of APSGN may include electrolyte imbalance, hypertension, peripheral oedema and acute nephritis syndrome characterised by haematuria, proteinuria and oliguria or anuria. The degree of renal impairment or acute kidney injury (AKI) can vary from self-limiting to life-threatening hypertensive encephalopathy, cardiac failure or sepsis.^2,9

APSGN is generally associated with complete recovery following syndromic management. Development of chronic kidney disease (CKD) in adults following infection related glomerulonephritis is reported among individuals with pre-existing risk factors such as immunocompromise, diabetes, malignancies or excess alcohol consumption.¹⁰

Childhood APSGN is a risk factor for CKD or end stage renal disease in adulthood, particularly in communities with high GAS disease burden. This disease progression is poorly understood. Subclinical APSGN in children may present a risk of under diagnosis and long-term complications.^2,9–11

Reservoir

Humans are the sole reservoir for GAS.

Mode of transmission

GAS is spread through direct person to person transmission via droplet spread or direct contact. Typically, transmission occurs through respiratory droplets but can also occur through contact with secretions (such as saliva, wound discharge or nasal secretions) from an infected person or through skin to skin contact. People with GAS disease (e.g. impetigo or pharyngitis) are more likely to transmit the bacteria to others than asymptomatic carriers. GAS infection is rarely transmitted by indirect contact through objects.¹²

Incubation period

The incubation period for GAS pharyngitis (or carriage) is usually 1–3 days and GAS impetigo/pyoderma is 7–10 days. GAS can be isolated from the throat in absence of clinical evidence of infection late in the course of a skin infection.⁹

The latent period between GAS infection and onset of APSGN varies depending on whether the glomerulonephritis follows pharyngitis or impetigo. For pharyngitis the latent period may be 1–2 weeks, whereas for impetigo it may be 3–6 weeks.²

Period of communicability

Whilst APSGN is not considered a communicable disease it is a complication of GAS infection. GAS cases may be infectious from 7 days before the onset of acute GAS symptoms until 24 hours post appropriate antibiotic treatment.^9,12

The infectious period for an untreated and uncomplicated GAS skin infection extends to 10–21 days, with extended communicability for weeks or months associated with untreated conditions and purulent discharge. Pharyngeal carriage in an untreated individual may persist for weeks to months with declining communicability thought to occur after 2–3 weeks.⁹

Susceptibility

Susceptibility to streptococcus is universal, although the distribution of GAS disease in childhood suggests a degree of immune protection into adulthood.¹³

Diseases that may predispose persons to APSGN include systemic inflammatory disorders such as systemic lupus erythematosus, haemolytic uraemic syndrome, rheumatoid arthritis, metabolic disorders such as diabetes or thyroiditis, or hereditary disorders like basement membrane disease.²

Management

Suspected case

Any clinician reported case of suspected APSGN to a PHU should be discussed with a paediatrician (or nephrologist/physician if an adult).

Confirmed and probable case

All cases of confirmed or probable APSGN should be:

• notified to the local PHU and NoCS notification completed
• referred for specialist (paediatrician/nephrologist) advice regarding admission and/or treatment
• given benzathine penicillin (Bicillin) IM injection or, if allergic to penicillin given oral trimethoprim + sulfamethoxazole as per Primary Care Clinical Manual (PCCM), eTG or appropriate guideline.

Investigations to confirm or exclude APSGN may include:

• urine dipstick and urine microscopy, culture and sensitivity (MCS) and albumin/creatinine ratio
• swabs from 2 separate sites if skin sores present, and throat swab if indicated. Write ‘APSGN case’ on the pathology request form and request emm typing if GAS isolated
• bloods for ASOT, anti-DNAse B titres, C3, C4, FBC, film, CHEM20.

Possible (subclinical) cases

Possible (subclinical) cases are often found when screening individuals for APSGN during an outbreak response or where a case that didn’t meet clinical criteria has been investigated and found to meet laboratory criteria. Sub-clinical cases do not have oedema or hypertension but on laboratory investigation are found to have haematuria, evidence of GAS infection and reduced C3. The significance of these laboratory diagnosed cases is uncertain and currently there are no recommendations to actively find or manage these cases.

Contact tracing is not required. Clinical management is at the discretion of a paediatrician (or nephrologist/physician if an adult). Where possible cases are detected the PHU could be made aware of them to facilitate evaluation, but they are not notifiable.

Counselling

The case should be advised of the nature of the infection and the mode of transmission of GAS.

A Queensland Health fact sheet for APSGN should be provided.

Contacts

Contact tracing

Early contact tracing for confirmed and probable cases is recommended to detect and prevent additional cases of APSGN and ongoing transmission of GAS. Contact tracing should be commenced as soon as possible, ideally within 5 working days of notification. There is limited benefit in investigation and treatment of asymptomatic household contacts of a sporadic case more than 2 weeks after onset of APSGN, however information should still be provided to the household.

Definition

Persons sleeping overnight in the house at any time in the 2 weeks preceding the onset of APSGN in the primary case.

PHUs may also, at their discretion, investigate household-like contacts.

Management

All contacts should be asked about any recent sore throat or skin sores and managed accordingly (see PCCM or eTG for further details).

Children aged 12 months to less than 17 years of age should in addition be examined for:

• skin sores and scabies
• facial or peripheral oedema
• blood pressure to determine if hypertensive
• urine dipstick for blood, anything more that 1+ blood should be sent for urine MCS.

Any contact identified by a health care worker to have ONE of the clinical signs of APSGN should be referred to a medical officer for further assessment for APSGN and managed accordingly.

If any contact has scabies the entire household should be treated. Use either Ivermectin (for those >15kg weight) or topical 5% permethrin cream as appropriate to the setting and availability.

All contacts should be given information and advice that includes:

• strategies for the prevention of skin infections; especially regular hand washing, bathing and keeping broken skin covered
• signs and symptoms of APSGN
• seeking treatment early from their primary care clinic if they develop skin sores, sore throat or APSGN symptoms
• recommendations on maximising distance between beds in sleeping areas.

Early childhood education and care and school settings

• Attendees are not considered close contacts in this context.
• Staff and parents/caregivers should be notified that a case of APSGN has occurred and be provided with information regarding APSGN including signs and symptoms.
• Routine screening of other children attending that school or day care is not necessary.

Public health response

Broader public health action will be determined at a local PHU level in response to increased APSGN notifications in a defined community or geographical location. The risk of ongoing transmission within relevant areas or target community should be assessed with consideration of local epidemiological data, and local knowledge of the region and population. A stepped approach informed by APSGN prevalence can be considered according to Table 2.

Community outbreaks

An outbreak is defined by:

Three reported cases either probable or confirmed (at least one confirmed case) from a defined community or geographical area

AND

• all cases with an onset within a 4 week period

AND

• the cases are not household-like contacts of each other.

The PHU could consider cases in neighbouring HHSs if there is significant movement of people between the two.

Outbreak response

The objectives of an outbreak response should be clearly identified and may include:

• interruption of GAS transmission
• prevention of additional cases of APSGN
• detection and treatment of APSGN cases
• analysis to inform subsequent responses.

An outbreak management team (OMT) should be established early with representation from key stakeholders and the target community for effective decision-making and response. The OMT should define and allocate roles according to available resources.

Outbreak response may consist of:

• Public health alerts confirming the presence of an outbreak.
• Increased awareness of APSGN, through appropriate channels (consider councils, religious groups, health care providers, parents, teachers and prominent community members plus media).
• Outbreak responses may include population based screening and physical examination of children within a population, for APSGN and / or GAS infection. This can place a significant burden on the general community, families and health care providers.
• Mass drug administration (MDA) with IM Bicillin has limited evidence for effectiveness.⁷ Careful consultation and co-design principles should be employed considering the latency between infection and disease, burden, and community support levels.
• MDA for scabies with ivermectin or topical 5% permethrin, if population prevalence of scabies is a contributing factor and individual case management capacity is exceeded. MDA is the administration of treatment to an entire community regardless of whether individuals currently have signs or symptoms of infestation.^14,15
• The outbreak response can be wound back, in consultation with the public health physician, if there are no further cases after 6 weeks.

Table 2. Possible public health actions according to APSGN prevalence and local circumstances

^{*population based screening or MDA based on likely effectiveness}

Population based screening

Objectives

• to reduce ongoing GAS transmission
• to prevent additional cases of APSGN occurring
• to identify and treat people with undiagnosed APSGN.

Principles for effective screening

• clear identification of the community to be targeted
• clear justification and objective for an intervention
• timely implementation of a response (commenced within 5 days of decision by OMT, completed within 2 weeks of commencement)
• high acceptability with 85% of target population screened and treated
• clear strategy including consent, referral and management processes
• appropriate monitoring and reporting of effectiveness at a population level
• adequate resourcing.

Implementation of screening

• Endorsement and support from the community to conduct screening.
• Effective and appropriate engagement to design the strategy and inform the target population and stakeholders of the proposed intervention, methodology and time frame (eg Councils, businesses, local health care teams including Aboriginal Medical Services/ Queensland Aboriginal and Islander Health Council, schools, Royal Flying Doctors Service, and community leaders).
• Identification of health and environmental health surge capacity and resources. Include health and environmental responses together if possible.
• Clarification of consent and referral processes.
• Where available, generation of lists of the population aged 12 months to 16 years (inclusive).
• Screening of the population aged 12 months to 16 years (inclusive) with history and examination for oedema, skin sores, fungal infections and scabies. Only check blood pressure and urinalysis if indicated by the screening objective.
• Follow up children identified with possible haematuria or oedema to assess for APSGN.
• For children with skin sores take swabs (send a representative selection of GAS isolates for emm typing) and treat with IM Bicillin or oral trimethoprim + sulfamethoxazole as per eTG.
• For anyone with scabies treat the whole household and provide advice on environmental interventions. Also treat the person with scabies for GAS if infected.
• Opportunistic education to the community about early detection and treatment of skin infections and sore throats and prevention through skin health and hand hygiene.
• Nomination of an appropriate specialist e.g. paediatrician to be available for direct phone advice.
• Develop mechanisms for regular updates during the screening implementation including on site feedback and ensure a short report summarising the implementation is distributed to stakeholders within one week of completion.
• All outbreak responses at a population level should include a full evaluation to aid in understanding the effectiveness of interventions. This would include short term and long term assessment of feasibility, acceptability, and impact.

Environmental health considerations

• Provide wide-spread community messaging about healthy environments and healthy skin hygiene.
• Aim to refer households (with consent) at high risk due to clinical/epidemiological features for risk assessment of the house and living environment.
• Support access to housing repairs and maintenance if required.

Post outbreak

• A public health physician or the OMT lead should hold a debrief with all key staff within 6 weeks of outbreak response completion.
• The OMT should provide a final report of the overall response. This should document any contributing environmental and economic factors and lessons learnt.
• Reports should be distributed to all stakeholders involved in the response.
• If publication of any interventions is being proposed ensure that co-authorship and permission from the population is central to the process.
• Consider opportunistic skin checks and continued APSGN surveillance within health care services.
• All regional health services should maintain advocacy to support health literacy on healthy skin and address the social determinants that contribute to poor skin health.
• Continue advocacy work and liaison on the implementation of preventative measures as listed below.

Preventative measures

Prevention of APSGN must recognise impetigo, scabies, and fungal skin infections (such as tinea, ringworm) as priority conditions for prevention, treatment, and public health control.

Routine prevention activities may include:

• Community health promotion regarding the importance of skin health and sore throats and subsequent complications.
• Promotion of regular washing of people, clothes and bedding.
• Advocacy and support for initiatives that may improve housing and reduce the negative impacts of overcrowding (appropriate health hardware within households, availability of washing machines, supply of hot water, sufficient sleeping space). Activities to improve the environmental health could consider Healthhabitat’s Healthy Living Practices as a framework.
• Encouragement of regular skin checks e.g. by parents and primary health care to enhance early presentation to primary care services for treatment of throat and skin infections including scabies, impetigo and fungal conditions.
• Epidemiological audit or surveillance of throat and skin disease including pharyngitis, impetigo, scabies and fungal skin infections where available.

Addressing social determinants

• APSGN has been eliminated in most of Australia however it remains in locations where environmental and primordial factors have not been addressed.
• Strategies to improve health service delivery, housing and overall socioeconomic and environmental conditions are likely to be the most effective at addressing the incidence of APSGN and other GAS related disease.
• Socioeconomic disadvantage contributes to access issues for health hardware services like plumbing, electrical and other trades, disadvantage may be further exacerbated by the impact of distance in remote settings.
• It is important for health staff to engage in advocacy and support initiatives that may ensure households have access to functioning hardware for health such as bathing and laundry services, as well as reducing negative impacts of overcrowding.

References

1.     Steer AC, Vidmar S, Ritika R, Kado J, Batzloff M, Jenney AWJ, et al. Normal Ranges of Streptococcal Antibody Titers Are Similar Whether Streptococci Are Endemic to the Setting or Not. Clin Vaccine Immunol. 2009 Feb;16(2):172–5.

2.       Alhamoud M, Salloot I, Mohiuddin S, AlHarbi T, Batouq F, Alfrayyan N, et al. A Comprehensive Review Study on Glomerulonephritis Associated With Post-streptococcal Infection. Cureus [Internet]. 2021 Dec 6;13. Available from: A Comprehensive Review Study on Glomerulonephritis Associated With Post-streptococcal Infection - PubMed (nih.gov)

3.       Dowler J, Wilson A. Acute post-streptococcal glomerulonephritis in Central Australia. Aust J Rural Health. 2020 Feb;28(1):74–80.

4.       Chaturvedi S, Boyd R, Krause V. Acute Post-Streptococcal Glomerulonephritis in the Northern Territory of Australia: A Review of Data from 2009 to 2016 and Comparison with the Literature. Am J Trop Med Hyg. 2018 Dec;99(6):1643–8.

5.       Krause V, Johnston F, Kearns T, Marshall C, Scott L, Kilburn C, et al. Northern Territory Guidelines for Acute Post-Streptoccocal Glomerulonephritis [Internet]. 2010. Available from: NT guidelines for control of APSGN.pdf

6.       Becquet O, Pasche J, Gatti H, Chenel C, Abély M, Morville P, et al. Acute post-streptococcal glomerulonephritis in children of French Polynesia: a 3-year retrospective study. Pediatr Nephrol Berl Ger. 2010 Feb;25(2):275–80.

7.       Johnston F, Carapetis J, Patel MS, Wallace T, Spillane P. Evaluating the use of penicillin to control outbreaks of acute poststreptococcal glomerulonephritis. Pediatr Infect Dis J. 1999 Apr;18(4):327–32.

8.       McDonald M, Brown A, Edwards T, Hope A, Amu M, Morey F, et al. Apparent contrasting rates of pharyngitis and pyoderma in regions where rheumatic heart disease is highly prevalent. Heart Lung Circ. 2007 Aug;16(4):254–9.

9.       Yeoh D, Carapetis JR, Bowen A. Streptoccocal Diseases. In: Control of Communicable Diseases Manual [Internet]. 2021 [cited 2023 Aug 22]. Available from: AJPH (aphapublications.org)

10.     Oda T, Yoshizawa N. Factors Affecting the Progression of Infection-Related Glomerulonephritis to Chronic Kidney Disease. Int J Mol Sci. 2021 Jan;22(2):905.

11.     Hoy WE, White AV, Dowling A, Sharma SK, Bloomfield H, Tipiloura BT, et al. Post-streptococcal glomerulonephritis is a strong risk factor for chronic kidney disease in later life. Kidney Int. 2012 May;81(10):1026–32.

12.     Department of Health and Aged Care. Invasive Group A Streptococcal (iGAS) Disease CDNA Series of National Guidelines. Communicable Diseases Network Australia; 2023.

13.     Frost H, Excler JL, Sriskandan S, Fulurija A. Correlates of immunity to Group A Streptococcus: a pathway to vaccine development. Npj Vaccines. 2023 Jan 17;8(1):1–7.

14.     The Australian Healthy Skin Consortium. National Healthy Skin Guideline: for the prevention, treatment and Public Health control of Impetigo, Scabies, Crusted Scabies and Tinea for Indigenous Populations and Communities in Australia [Internet]. 2018. Available from: national-healthy-skin-guideline---1st-ed.-2018.pdf (telethonkids.org.au)

15.     Engelman D, Marks M, Steer AC, Beshah A, Biswas G, Chosidow O, et al. A framework for scabies control. PLoS Negl Trop Dis. 2021 Sep 2;15(9):e0009661.

16.     Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017 Sep 1;140(3):e20171904.

Further reading

1. Queensland Health. Primary Clinical Care Manual, 11th edition 2022
2. Northern Territory Centre for Disease Control, Department of Health and Families. Northern Territory Guidelines for Acute Post-Streptococcal Glomerulonephritis, 2010
3. Government of Western Australia, Department of Health, Public Health and Clinical Services. Public Health Management of Acute Post-Streptococcal Glomerulonephritis Guideline, 2019
4. Rinaldi, G and Porter, K. Mass drug administration for endemic scabies: a systematic review. Tropical Diseases, Travel Medicine and Vaccines 2021; 7, 21, available from https://doi.org/10.1186/s40794-021-00143-5
5. The Australian Healthy Skin Consortium. National Healthy Skin Guideline: for the Diagnosis, Treatment and Prevention of Skin Infections for Aboriginal and Torres Strait Islander Children and Communities in Australia (2nd edition), 2023.

Appendix A: Screening and diagnostic blook pressure values in children (16)

Diagnosing hypertension in children requires screening (see below screening values) followed by referral for diagnosis.

Screening values for elevated blood pressure requiring further evaluation (as per American Academy of Pediatrics).

Best practice principles of hypertension diagnosis:

• 3 different measures averaged
• use of appropriately sized cuffs
• correct patient positioning
• use of auscultation for at least one measure
• determined against tables based on age/weight/height to be above 95^th centile.

Refer to American Academy of paediatrics clinical practice guidelines for screening and management of high blood pressure in children 2017:

• Blood pressure levels for males by age and height percentile: Table 4 American Academy of Pediatrics (aap.org)
• Blood pressure levels for females by age and height percentile: Table 5, American Academy of Pediatrics (aap.org).