ORIGINAL ARTICLE

Evaluation of the WHO clinical decision rule for streptococcal pharyngitis

A W Rimoin¹, H S Hamza³, A Vince⁴, R Kumar⁵, C F Walker², R A Chitale², A L A da Cunha⁶, S Qazi⁷, M C Steinhoff²

¹ Department of Epidemiology, School of Public Health, University of California, Los Angeles, CA, USA
² Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
³ Department of Pediatrics, University of Cairo, Egypt
⁴ University Infectious Disease Hospital, Zagreb, Croatia
⁵ Department of Pediatrics, King George Medical College, Lucknow, India
⁶ Department of Pediatrics, Federal University of Rio de Janeiro, Brazil
⁷ Department of Child and Adolescent Health and Development, World Health Organisation, Geneva, Switzerland

Correspondence to:
Dr A W Rimoin
Department of Epidemiology, UCLA School of Public Health, 71-279B CHS, 650 Charles E. Young Drive South, Los Angeles, CA 90095-1772, USA; arimoin{at}ucla.edu

Aims: To prospectively assess the WHO clinical decision rule (CDR) for group A beta haemolytic streptococcal (GABHS) pharyngitis in three countries.

Methods: A prospective, observational cohort study in urban outpatient clinics in Rio de Janeiro, Cairo, and Zagreb. There were 2225 children aged 2–12 years with cough, rhinorrhoea, red or sore throat; 1810 of these with sore throat were included in the analysis.

Results: The proportion of children presenting with sore throat and found to have GABHS pharyngitis ranged from 24.6% (Brazil) to 42.0% (Croatia). WHO CDR sensitivity was low for all sites in both age groups. In children age 5 or older, sensitivity ranged from 3.8% in Egypt to 10.8% in Brazil. In children under 5, sensitivity was low (0.0–4.6%) Specificity was high in both age groups in all countries (93.8–97.4%).

Conclusions: In these populations, the current WHO CDR has high specificity, but low sensitivity; it did not detect up to 96.0% of children who have laboratory confirmed GABHS pharyngitis. A CDR with higher sensitivity should be developed for use in regions where rheumatic fever and rheumatic heart disease are still major health problems.

Abbreviations: ARI, acute respiratory infection; CDR, clinical decision rule; GABHS, group A ß haemolytic streptococcal; GNI, gross national income; NPV, negative predictive value; PPV, positive predictive value; RF, rheumatic fever; RHD, rheumatic heart disease; WHO, World Health Organisation

Keywords: group A beta haemolytic streptococcal pharyngitis; GABHS; streptococcal pharyngitis; developing regions; clinical decision rule; diagnosis

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