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December 2022, Volume 72, Issue 12

KAP Study

Knowledge, attitude, and practice regarding treatment of group a beta haemolytic tonsillo pharyngitis and prevention of rheumatic fever among doctors in Karachi, Pakistan: A perspective study

Arshad Ali Shah  ( Department of Cardiology, Dow University of Health Sciences, Karachi, )
Dil Bahar Shah Asad  ( Department of Cardiology, Dow University of Health Sciences, Karachi, )
Syed Saboor Hasan  ( Department of Psychiatry, )
Rohan Kumar Ochani  ( Department of Internal Medicine, Civil Hospital, Karachi )
Asim Shaikh  ( Department of Internal Medicine, Civil Hospital, Karachi )
Mukesh Kumar  ( Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan. )
Dileep Kumar  ( Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan. )


Objective: To assess knowledge and practices associated with rheumatic fever among medical practitioners in an urban setting.


Method: The cross-sectional study was conducted at five major hospitals in Karachi from August to November 2019, and comprised house officers, postgraduate trainees, and general physicians of either gender. The subjects were given a questionnaire assessing their knowledge and perception regarding acute rheumatic fever as well as prophylaxis. Data was analysed using SPSS 25.


Results: Of the 247 respondents, 173(70%) were house officers, 31(13%) were postgraduate trainees and 43(17%) were general physicians. Overall, 202(82%) subjects were associated with some teaching hospital. Significantly more postgraduate trainees and general physicians answered correctly when asked to identify clinical and laboratory findings suggestive of Group A streptococcal throat infection than house officers (p<0.001). Among the house officers 49(28.3%), and among the postgraduate trainees 11(35.4%) knew the correct way to prescribe penicillin to prevent rheumatic fever. Among the general physicians, 20(46.5%) had accurate knowledge regarding the prescription.


Conclusion: Knowledge and practices of medical practitioners regarding rheumatic fever were less than ideal and may play a part in misdiagnoses of Group A streptococcal infections and, hence, prophylaxis.


Keywords: Rheumatic fever, Preventive medicine, Rheumatic heart disease, Pakistan. (JPMA 72: 2477; 2022)






Acute rheumatic fever (ARF) is an autoimmune reaction causing widespread nonsuppurative inflammation focussing on several organs of the body, primarily the heart, joints, skin, and the central nervous system (CNS).1 ARF is a delayed complication of various rheumatogenic Group A Streptococcus (GAS) Pyogenes strains, infecting the pharynx and, in some rare cases, the skin.2 ARF and its more serious sequalae, the rheumatic heart disease (RHD), is responsible for millions of children and adolescents suffering from heart conditions. The main target are the valves of the heart, most commonly affecting the mitral valve, followed by the tricuspid valve, eventually leading to severe heart failure due to compensatory ventricular hypertrophy, in absence of any medical or surgical intervention.3 The prevalence of ARF and RHD has decreased in the past decades in the developed world due to better living conditions, access to modern medicine and easy availability of antibiotics.4 More importantly, the use of penicillin for the prompt treatment of GAS throat infections have been shown to reduce the incidence of ARF following a GAS infection.5 However, developing nations, such as Pakistan, are yet to curb this endemic as RHD is one of the most common causes of acquired heart disease in adolescents and the Indian subcontinent falls under the most affected areas of the world.6 This high infiltration of RHD in the population is not just a burden on the economy and the health sector, but causes overall lower quality of life (QOL) in the young population afflicted with it, especially a disease that is highly preventable by proper identification of GAS infections and their prompt treatment.7

Ensuring proper prophylaxis in patients and the initial treatment of GAS infection is key and general knowledge regarding the disease and its different treatment modalities should be essential for general physicians (GPs), especially in a country with a higher frequency. Treatment of acute GAS infections is considered to be primary prophylaxis for ARF/RHD while a patient with positive findings of ARF/RHD is given secondary prophylaxis which has to be managed according to the patients' respective heart status and any associated valvular pathology. The prophylaxis comprising antimicrobials, tends to be for a longer duration. ranging 5-10 years, and may even be lifelong in some cases.8 Thus, it is essential to assess the awareness of doctors about this disease as a child presenting with sore throat will be directed to a GP rather than a cardiologist. The current study was planned to assess knowledge and practices associated with RF among medical practitioners at various tiers in an urban setting.


Subjects and Methods


The cross-sectional study was conducted at five major public hospitals in Karachi from August to November 2019 after approval from the institutional ethics review board of the Dow University of Health Sciences (DUHS), Karachi. The sample population consisted of doctors associated with Jinnah Postgraduate Medical Centre (JPMC), National Institute of Cardiovascular Diseases (NICVD), Liaquat University Hospital, Abbasi Shaheed Hospital, and Civil Hospital Karachi (CHK). Doctors of either gender who agreed to participate were included and informed consent was obtained.

Doctors working in the departments of Surgery and Obstetrics and Gynaecology were excluded, as ARF patients are not referred to these departments. The sample was categorised into three groups; house officers (HOs), postgraduates (PGs), and general physicians (GPs). The sample size was calculated using OpenEpi9 with an anticipated frequency of 50% and 95% confidence interval (CI).

Data was collected using a questionnaire having three sections. The first section recorded basic demographic details, while the second section assessed the participants' knowledge and perceptions regarding RF, its signs and symptoms, clinical and laboratory findings, and treatment modalities concerning primary prophylaxis and RF recurrence. The third section assessed secondary prophylaxis with regards to penicillin and its allergy. Each correct option was scored 1, while each incorrect option was given a score of 0.

The interviewers used standard protocol with all subjects. The participants were given time to fill the questionnaire privately to ensure accurate results by avoiding interviewer bias. The incomplete questionnaires were discarded, and no imputation method was used to maintain an accurate representation of the views of the sample population.

Data were analysed using SPSS 25. Categorical variables were expressed as frequencies and percentages, while continuous variables were expressed as mean and standard deviation. Chi-square test was used to check for disparity among the three groups. In the case of ordinal data, Mann-Whitney U test was used. P<0.05 was considered statistically significant in all cases.




Of the 265 individuals approached, 247(93.2%) completed the questionnaire; 173(70%) HOs, 31(13%) PGs and 43(17%) GPs. Overall, 202(82%) subjects were associated with some teaching hospital (Table-1).

Regarding the definition of rheumatic fever, more HOs identified the correct definition compared to both PGs and GPs (p<0.001). More PGs and GPs answered correctly when asked to identify clinical and laboratory findings suggestive of GAS infection than HOs (p<0.001). Most participants 217(87.8%) knew how to treat patients with primary prophylaxis.

Most GPs 30(69.7%) and PGs 18(58.1%) knew the next best choice to prescribe when their patient was found to be allergic to penicillin. Only 68 (39%) HOs answered correctly (p=0.002).

Further, 38(22%) HOs and 17(39.5%) GPs correctly identified the ways how penicillin is prescribed to prevent RF in a patient with a history of previous RF, and with a residual valvular lesion. Half of the participants 123(49.8%) knew how to prescribe penicillin as secondary prophylaxis.



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