Background: Decades of research have shown that Strep A transmission is driven by overcrowded and poorly maintained living environments, which may lead to immune priming and subsequent acute rheumatic fever (ARF). Improved socio-economic conditions and better living standards are associated with reduced Strep A transmission. To eliminate rheumatic heart disease (RHD) by 2031, Australian recommendations emphasise primordial prevention—household and community-level interventions that disrupt disease transmission while awaiting broader economic investment. Understanding Strep A transmission within the home is critical to inform effective prevention strategies.
Methods: A systematic review was conducted to identify mechanisms of Strep A transmission within households and uncover opportunities for prevention. Studies published between January 2000 and March 2023 investigating outbreaks or transmission of Strep A in households were included. After screening 2,167 articles, 28 studies met the inclusion criteria.
Results: A third of studies were case reports, primarily describing outbreaks in Europe and North America. Most studies reported multiple disease manifestations, with invasive group A streptococcal (iGAS) infections identified in 70% of cases. However, only 7 studies detailed transmission mechanisms, including skin-to-skin contact, fabric, medical equipment, and animals. No studies examined post-infectious immune-mediated sequelae.
Conclusions: Household transmission of Strep A is poorly described, highlighting the need for further epidemiological studies and asymptomatic surveillance in high-burden areas. Future research must incorporate culturally sensitive approaches, community involvement, co-design, and co-reporting to address the challenges of studying transmission in household environments and to inform prevention strategies effectively.