P2.B037: Keeping up with the JONES: Assessing changes in incidences of Streptococcal related diseases during the COVID era

Background: The incidence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) has significantly declined in developed nations due to improved hygiene, enhanced access to medical care, and socioeconomic changes. During the COVID-19 pandemic, global efforts to avoid crowding and increase mask use altered the rates and seasonality of common infections. Concurrently, inconsistent access to medical care and delayed health-seeking behavior during the pandemic led to delayed presentations of serious illnesses. The aim of our study was to compare the incidence of streptococcal pharyngitis, ARF, and RHD in the United States in the pre-COVID-19 and pandemic era.

Methods: Leveraging the Epic Cosmos database – a community collaboration representing over 240,000,000 patient records from over 1,400 hospitals and 32,000 clinics in the United States – we performed a descriptive study of streptococcal pharyngitis, ARF, and RHD rates in patients less than 21 years of age from longitudinal health data from 2016 to 2023. We calculated annual diagnosis rates for ARF, RHD, and the number of positive streptococcal tests per 100,000 patients under 21 years of age with encounters at the queried institutions. We also examined the positivity rate of streptococcal tests. Statistical analysis analyzed in R included two-sample t-tests to compare average incidence rates across pre-pandemic (2016-2019), pandemic (2020-2022), and post-pandemic (2023) periods with a significance level set at α=0.05.

Results: We identified relevant data at 99 healthcare organizations during the study period. From the pre-pandemic years to the pandemic years, there were significant reductions in the diagnosis rates of both ARF (3.28 to 1.62 cases/100,000 patients, p=0.0065) and RHD (1.45 to 1.03 cases/100,000 patients, p=0.0163). In 2023, there was a recovery in ARF to 2.20 per 100,000 and a slight decrease in RHD to 0.99 per 100,000, but these changes were not statistically significant. For streptococcal tests in the pre-pandemic vs pandemic period, we found a non-statistically significant decrease in the number of positive streptococcal tests per 100,000 patients (p=0.084) and streptococcal positivity rates (p=0.384) (Figure 2). However, in 2023, there were substantial rebounds in positive streptococcal tests and streptococcal positivity rates compared to pre-pandemic years, with a 205% increase in positive streptococcal tests and a 170% increase in streptococcal positivity rate.

Conclusion: These findings highlight the substantial impact of the COVID-19 pandemic on the incidence of streptococcal infections, ARF, and RHD, with changes in incidence likely influenced by masking protocols and decreased exposure. The significant post-pandemic increase in positive streptococcal tests may reflect a rebound in general infectious disease incidence as public health measures relax; the rates of ARF and RHD appear to be slowly returning as well. Ongoing surveillance and responsive healthcare strategies will be crucial to address the continuing variability in strep, ARF, and RHD incidences in the post-COVID era.