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\title{Prevelance Survey for Assessing Intensity of Group a Beta Hemolytic Streptococci (GABHS) Subclinical Infection Rate in School Children: A Cross Sectional Study}
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             \author[1]{Dr. Farheen  Fatima}

             \author[2]{Dr Shubha  DS}

             \affil[1]{  Basaweshwara Medical College}

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\date{\small \em Received: 11 February 2013 Accepted: 28 February 2013 Published: 15 March 2013}

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\begin{abstract}
        


Background: GABHS infections and their sequelae Rheumatic fever and rheumatic heart disease have a worldwide distribution and pose an important health problem. In developing countries it remains as an endemic disease.Objectives: The study is aimed to estimate prevalence and factors associated with the same among school children aged 6-12years.Materials and Methods: This cross-sectional survey was carried out from February to July 2010, in the diagnostic laboratory of Microbiology department. The study group was divided into four groups, namely, Group A; Group B; Group C; and Group D. A total of 1769 eligible children were enrolled for sampling of these schools. For each enrolled child in the study, a standard culture and antibiogram test with the Lancefield grouping technique was done in the assessment of the outcome.Results: Among 1769 participants, 1029 (58.2%) were boys and 740 (41.8%) were girls. The overall prevalence of GABHS was estimated 27.9%.

\end{abstract}


\keywords{antibiogram, factors associated, GABHS, prevalence, school children.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
he prevalence of GABHS carriage in throat of normal asymptomatic school children varies from 13-15\% depending upon the population studied, season and other factors. \hyperref[b0]{1} The GABHS has remained a significant human pathogen for centuries. This organism causes a wide variety of infections in humans, ranging from mild upper respiratory tract and skin infections to severe suppurative and invasive conditions like necrotising fasciitis and toxic shock syndrome. \hyperref[b1]{2} of major concern is that post infectious sequelae like acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis continue to occur worldwide despite efforts of clinicians, scientists and public health officials to comprehend their pathogenesis and devise ways of disease control. \hyperref[b1]{2} It is estimated that approximately 7 sore throat episodes per year, with 13.5\% of these being caused by GABHS. \hyperref[b1]{2} Although ARF and rheumatic heart disease (RHD) have declined in many parts of the world, they continue to be a major cause of cardiovascular morbidity and mortality in India. \hyperref[b1]{2} Sore throat caused by GABHS is one of the most common diseases during adolescence and early adulthood which makes a lot of problems and consumes a great budget for its treatment and complications, all over the world. \hyperref[b2]{3,}\hyperref[b3]{4,}\hyperref[b4]{5,}\hyperref[b5]{6} II. 
\section[{Materials And Methods}]{Materials And Methods} 
\section[{a) Study design and setting}]{a) Study design and setting}\par
This cross-sectional survey was carried out from February to July 2010, in the diagnostic laboratory of microbiology department. 
\section[{b) Study population, sample size and sampling strategy}]{b) Study population, sample size and sampling strategy}\par
The study population consisted of school children from 6 to 12 years of age enrolled in various schools of Chitradurga. The sample size was calculated for the primary objective taking the prevalence to be 50\% that gives the maximum sample size, with a 95\% level of confidence and 5\% bound on the error of estimation. The minimum sample size required was 400 children.\par
A list of all schools (the sampling frame) in the locality was prepared. They were divided into four groups, Namely, Group A (orphanage); Group B (residential schools); Group C (government schools); and Group D (private schools). The simple random sampling method was employed to select 1 school from each group of schools. A total of 1769 eligible children were enrolled for sampling of these schools. All of them were sampled, giving the response rate of 100\%. The outcome variable was culture status of the received sample, whether positive or negative for GABHS parasite, which was determined from a throat swab. Data on the independent variable of sociodemographic characteristics were collected by trained research officers on a pretested and structured questionnaire addressed to the student. d) Throat swab collection and laboratory testing Apparently healthy children 6-12 years of age were studied. A team of doctors, technician and interns visited the school twice a week. A detailed history as per recommendation of the WHO for identification of streptococcal sore throat such as fever, soreness of throat, cough and watery nasal discharge were excluded.\par
For each enrolled child in the study, for the assessment of the outcome 7 the test was conducted at the diagnostic microbiology laboratory, by the principal investigator and co-investigator with the help of an experienced laboratory technician. The diagnosis of GABHS disease still relies on isolation of GABHS strains on sheep blood agar followed by presumptive identification based on bacitracin sensitivity on the results of more precise serogrouping methods such as the Lancefield grouping.\par
From the selected subjects the tonsillar and the pharyngeal mucosa were rubbed vigorously with sterile cotton swab applicator avoiding the surrounding tissues. Throat swabs were transported to the microbiology laboratory by using Todd Hewitt broth. Then swabs were plated onto crystal violet sheep blood agar, chocolate agar and MacConkey's agar. It was then incubated in a candle jar at 35®C for 18-24 hours, examined for the presence of GABHS and sub cultured onto blood agar for bacitracin sensitivity to differentiate GABHS from non GABHS. The isolates of GABHS were subjected for Lancefield grouping as per the manufacturer's instructions with the kit.\par
After diagnosis of GABHS was confirmed, antibiogram test was done for the isolates according to recommendations of the National Committee for Clinical Laboratory standards (NCCLS) using Cephalothin, erythromycin, tobramycin, tetracycline, amoxicillin, cotrimoxazole, vancomycin, Cloxacillin and penicillin antibiotic discs from HiMedia Laboratories Pvt. Ltd. Mumbai. 
\section[{III.}]{III.} 
\section[{Ethical clearance}]{Ethical clearance}\par
The protocol for this study was approved by the Chairman, and the secretary, institutional ethical committee (IEC). The approval was in the agreement that patient anonymity must be maintained, good laboratory practice quality control ensured, and that every finding would be treated with utmost confidentiality and for the purpose of this research only, all work was performed according to the international guidelines for human experimentation in biomedical research. \hyperref[b7]{8} Approval was obtained from the Head Master of each school studied and informed consent was obtained from each of the participating pupils. The participating students were given chocolates as an incentive. Culture positive subjects were referred to the primary health center in the area for immediate treatment. a) Data management and statistical analysis During data collection completed questionnaires were checked regularly to rectify any discrepancy, logical errors, or missing values. The data entry was carried out using Microsoft Office Excel worksheet and then the data were exported to statistical analysis software WINK SDA for further analysis. Variables were categorized in a biologically meaningful way where applicable. To the analyzed data, mean and standard deviation for continuous variables and proportion for categorical variables were computed. Crude associations of the binary outcome variable with each independent variable were assessed by the Chi -square test. The level of statistical significance was set as P?0.\par
05 and for each statistically significant factor.\par
Results: The results represent information collected from 1769 Throat swabs. b) Descriptive Characteristics Among 1769 participants, 1029 (58.2\%) were boys and 740 (41.8\%) were girls. 
\section[{c) Prevalence of GABHS}]{c) Prevalence of GABHS}\par
The overall prevalence of GABHS was estimated as 493/1769 (27.9\%) [Table \hyperref[tab_0]{1}]. Group A 35.62\% (26/73), Group B 37.5\% (51/136), Group C 34.8\% (187/588), and Group D 23.7\% (230/972). Higher prevalence was found in 6-10 years aged; the prevalence percentage declined with increase in age and showed lowest prevalence in subjects above 10 years of age. The prevalence was higher in boys as compared with girls. [Tables \hyperref[tab_1]{2-5}]. 
\section[{d) The resistance pattern of GABHS}]{d) The resistance pattern of GABHS}\par
The sensitivity was highest for vancomycin (100\%) followed by tobramycin 77.1\%, Cephalothin 74\% and erythromycin 69.6\%. The resistance was highest for amoxicillin 79.1\% followed by penicillin 76.4\%, Cloxacillin 74.6\% and Gentamicin 70\%. [Table-7]  The factors associated with the GABHS prevalence and carrier rate were estimated as in [Table \hyperref[tab_4]{8}].  We observed that the prevalence of GABHS in the throat of asymptomatic school children was 27.9\% which is in correlation with Koshi G et al \hyperref[b18]{11} , Prakash K et al. \hyperref[b18]{11} However, the prevalence of asymptomatic carriage of GABHS has been reported (11,12,13,  14,15,16,17,18) between 11-47\% from various countries this could be attributed to various demographic factors.\par
In this study none of the school children showed the characteristic picture of streptococcal pharyngitis. This is not unusual, as in a 3 year study from Egypt. \hyperref[b14]{19} none of the children had streptococcal exudative tonsillitis out of 1041 children examined.\par
The clinical picture alone is not reliable, as subclinical throat infection caused by GABHS is not uncommon. Also isolation of GABHS alone is not enough to suggest infection in asymptomatic children. Thus the demonstration of a rise in titer of antibodies against extracellular antigens of GABHS is essential for diagnosis of infection. \hyperref[b15]{20}  
\section[{a) Strength and Limitations}]{a) Strength and Limitations}\par
As per our knowledge this study is first of its kind in our locality focusing on school children of different living conditions. The throat swab testing by routine culture and Lancefield grouping method increased the validity of estimates.\par
Our study has certain limitations that need to be single throat swab examination for detection of GABHS, which could have underestimated the prevalence, as optimal laboratory diagnosis of GABHS requires the examination of at least two throat swabs collected over several days.\par
More recent studies have suggested throat culture is still considered as the 'gold standard' method for GABHS detection, giving results in about 90-95\% of the cases and we have done the same.\par
However, Antibody studies are microbiologically important both for demonstration of GABHS pharyngitis as well as the clinical diagnosis of (RF/RHD).We were unable to perform antibody studies on subjects as we could not to get the written consent. This is one of the first few school survey studies carried out in this region and therefore, we wanted to develop a good rapport with the children before we could do intensive studies on them.\par
V. 
\section[{Conclusion}]{Conclusion}\par
According to the present study, the streptococcal carrier rate in this area is comparable to the other studies in surrounding areas. Prevalence of GABHS from the throat of asymptomatic school children has been reported for the first time from this locality. Further epidemiological studies on this aspect are needed to substantiate the findings of our study.\par
In India, the streptococcal reference system has already been established and primary prevention method for RF and RHD, namely control of streptococcal infections is also going on. \hyperref[b16]{21} To conclude, as methods of the streptococcal control program have now become cost effective, we strongly recommend such prevalence studies should be actively employed to prevent the high prevalence of GABHS pharyngitis and their sequelae, with special concern for children below 11 years of age.\par
IV. 
\section[{Discussion}]{Discussion}\par
Healthy carriers of GABHS are sources for bacterial dissemination and are able to communicate the disease and even lead to severe epidemics.\par
There is evidence that asymptomatic throat infection caused by GABHS may lead to ARF. \hyperref[b8]{9} \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}T}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.09205776173285198\textwidth}P{0.07364620938628158\textwidth}P{0.09052346570397111\textwidth}P{0.13194945848375453\textwidth}P{0.062138989169675085\textwidth}P{0.08131768953068592\textwidth}P{0.05753610108303249\textwidth}P{0.09896209386281589\textwidth}P{0.07671480144404333\textwidth}P{0.0759476534296029\textwidth}P{0.009205776173285198\textwidth}}
SEX\tabcellsep \multicolumn{5}{l}{TOTAL NO.OF SPECIMENS PROCESSED}\tabcellsep \tabcellsep \multicolumn{3}{l}{CULTURE POSITIVE No. \%}\tabcellsep \\
Boys\tabcellsep \tabcellsep \tabcellsep \tabcellsep 1029\tabcellsep \tabcellsep \tabcellsep 291\tabcellsep \tabcellsep 28.3\tabcellsep \\
Girls\tabcellsep \tabcellsep \tabcellsep \tabcellsep 740\tabcellsep \tabcellsep \tabcellsep 202\tabcellsep \tabcellsep 27.3\tabcellsep \\
Total\tabcellsep \tabcellsep \tabcellsep \tabcellsep 1769\tabcellsep \tabcellsep \tabcellsep 493\tabcellsep \tabcellsep 27.9\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \multicolumn{5}{l}{Table 2 : Group A (Basawamakkalu)}\tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep \tabcellsep BOYS\tabcellsep \tabcellsep \multicolumn{2}{l}{GIRLS}\tabcellsep \tabcellsep \multicolumn{3}{l}{TOTAL SAMPLED}\tabcellsep \\
AGE\tabcellsep TOTAL\tabcellsep \multicolumn{2}{l}{POSITIVE NO. \%}\tabcellsep TOTAL\tabcellsep \multicolumn{2}{l}{POSITIVE NO. \%}\tabcellsep TOTAL\tabcellsep \multicolumn{2}{l}{POSITIVE NO. \%}\tabcellsep \\
6-7\tabcellsep 05\tabcellsep 04\tabcellsep 80\tabcellsep 01\tabcellsep 01\tabcellsep 100\tabcellsep 06\tabcellsep 05\tabcellsep 83.3\tabcellsep \\
7-8\tabcellsep 08\tabcellsep 06\tabcellsep 75\tabcellsep 02\tabcellsep 02\tabcellsep 100\tabcellsep 10\tabcellsep 08\tabcellsep 80\tabcellsep \\
8-9\tabcellsep 00\tabcellsep 00\tabcellsep 00\tabcellsep 02\tabcellsep 01\tabcellsep 50\tabcellsep 02\tabcellsep 01\tabcellsep 50\tabcellsep \\
9-10\tabcellsep 08\tabcellsep 03\tabcellsep 37.5\tabcellsep 00\tabcellsep 00\tabcellsep 00\tabcellsep 08\tabcellsep 03\tabcellsep 37.5\tabcellsep \\
10-11\tabcellsep 07\tabcellsep 03\tabcellsep 42.8\tabcellsep 08\tabcellsep 01\tabcellsep 12.5\tabcellsep 15\tabcellsep 04\tabcellsep 26.7\tabcellsep \\
11-12\tabcellsep 10\tabcellsep 02\tabcellsep 20\tabcellsep 00\tabcellsep 00\tabcellsep 00\tabcellsep 10\tabcellsep 02\tabcellsep 20\tabcellsep \\
>12\tabcellsep 16\tabcellsep 02\tabcellsep 12.5\tabcellsep 06\tabcellsep 01\tabcellsep 16.7\tabcellsep 22\tabcellsep 03\tabcellsep 13.6\tabcellsep \\
TOTAL\tabcellsep 54\tabcellsep 20\tabcellsep 37.03\tabcellsep 19\tabcellsep 06\tabcellsep 31.6\tabcellsep 73\tabcellsep 26\tabcellsep 35.6\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \multicolumn{5}{l}{Table 3 : Group-B (Orphanage)}\tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep \tabcellsep BOYS\tabcellsep \tabcellsep \multicolumn{2}{l}{GIRLS}\tabcellsep \tabcellsep \multicolumn{3}{l}{TOTAL SAMPLED}\tabcellsep \\
AGE\tabcellsep TOTAL\tabcellsep \multicolumn{3}{l}{POSITIVE TOTAL NO. \%}\tabcellsep \multicolumn{3}{l}{POSITIVE TOTAL NO. \%}\tabcellsep \multicolumn{2}{l}{POSITIVE NO. \%}\tabcellsep \\
6-7\tabcellsep 15\tabcellsep 12\tabcellsep 80\tabcellsep 07\tabcellsep 05\tabcellsep 71.4\tabcellsep 22\tabcellsep 17\tabcellsep 77.3\tabcellsep \\
7-8\tabcellsep 10\tabcellsep 06\tabcellsep 60\tabcellsep 08\tabcellsep 04\tabcellsep 50\tabcellsep 18\tabcellsep 10\tabcellsep 55.5\tabcellsep \\
8-9\tabcellsep 12\tabcellsep 06\tabcellsep 50\tabcellsep 10\tabcellsep 03\tabcellsep 30\tabcellsep 22\tabcellsep 09\tabcellsep 40.9\tabcellsep \\
9-10\tabcellsep 12\tabcellsep 04\tabcellsep 33.3\tabcellsep 07\tabcellsep 03\tabcellsep 42.8\tabcellsep 19\tabcellsep 07\tabcellsep 36.8\tabcellsep \\
10-11 11-12\tabcellsep 14 11\tabcellsep 04 01\tabcellsep 28.6 9.1\tabcellsep 05 03\tabcellsep 01 00\tabcellsep 20 00\tabcellsep 19 14\tabcellsep 05 01\tabcellsep 26.3 07.1\tabcellsep D D D D ) F\\
>12\tabcellsep 20\tabcellsep 02\tabcellsep 10\tabcellsep 02\tabcellsep 00\tabcellsep 00\tabcellsep 22\tabcellsep 02\tabcellsep 09.1\tabcellsep (\\
TOTAL\tabcellsep 94\tabcellsep 35\tabcellsep 37.23\tabcellsep 42\tabcellsep 16\tabcellsep 38.1\tabcellsep 136\tabcellsep 51\tabcellsep 37.5\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \multicolumn{5}{l}{Table 4 : Group-C (Govt. School)}\tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep \tabcellsep BOYS\tabcellsep \tabcellsep \multicolumn{2}{l}{GIRLS}\tabcellsep \tabcellsep \multicolumn{3}{l}{TOTAL SAMPLED}\tabcellsep \\
AGE\tabcellsep TOTAL\tabcellsep \multicolumn{3}{l}{POSITIVE TOTAL NO. \%}\tabcellsep \multicolumn{3}{l}{POSITIVE TOTAL NO. \%}\tabcellsep \multicolumn{2}{l}{POSITIVE NO. \%}\tabcellsep \\
6-7\tabcellsep 41\tabcellsep 14\tabcellsep 34.1\tabcellsep 33\tabcellsep 24\tabcellsep 72.7\tabcellsep 74\tabcellsep 38\tabcellsep 51.3\tabcellsep \\
7-8\tabcellsep 74\tabcellsep 24\tabcellsep 32.4\tabcellsep 25\tabcellsep 13\tabcellsep 52\tabcellsep 99\tabcellsep 37\tabcellsep 57.4\tabcellsep \\
8-9\tabcellsep 45\tabcellsep 14\tabcellsep 31.1\tabcellsep 44\tabcellsep 16\tabcellsep 36.4\tabcellsep 89\tabcellsep 30\tabcellsep 33.7\tabcellsep \\
9-10\tabcellsep 45\tabcellsep 15\tabcellsep 33.3\tabcellsep 69\tabcellsep 23\tabcellsep 33.3\tabcellsep 114\tabcellsep 38\tabcellsep 33.3\tabcellsep \\
10-11\tabcellsep 45\tabcellsep 15\tabcellsep 33.3\tabcellsep 56\tabcellsep 12\tabcellsep 21.4\tabcellsep 101\tabcellsep 27\tabcellsep 26.7\tabcellsep \\
11-12\tabcellsep 25\tabcellsep 07\tabcellsep 28\tabcellsep 35\tabcellsep 01\tabcellsep 02.8\tabcellsep 60\tabcellsep 08\tabcellsep 13.3\tabcellsep \\
>12\tabcellsep 29\tabcellsep 09\tabcellsep 31\tabcellsep 22\tabcellsep 00\tabcellsep 00\tabcellsep 51\tabcellsep 09\tabcellsep 17.6\tabcellsep \\
TOTAL\tabcellsep 304\tabcellsep 98\tabcellsep 32.2\tabcellsep 284\tabcellsep 89\tabcellsep 31.3\tabcellsep 588\tabcellsep \multicolumn{2}{l}{187 31.8}\tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.08975155279503105\textwidth}P{0.058074534161490686\textwidth}P{0.12406832298136646\textwidth}P{0.07391304347826086\textwidth}P{0.058074534161490686\textwidth}P{0.09767080745341614\textwidth}P{0.08447204968944098\textwidth}P{0.09767080745341614\textwidth}P{0.09767080745341614\textwidth}P{0.0686335403726708\textwidth}}
\tabcellsep \tabcellsep BOYS\tabcellsep \tabcellsep \multicolumn{2}{l}{GIRLS}\tabcellsep \tabcellsep \multicolumn{3}{l}{TOTAL SAMPLED}\\
AGE\tabcellsep TOTAL\tabcellsep \multicolumn{3}{l}{POSITIVE TOTAL NO. \%}\tabcellsep \multicolumn{3}{l}{POSITIVE TOTAL NO. \%}\tabcellsep \multicolumn{2}{l}{POSITIVE NO. \%}\\
6-7\tabcellsep 88\tabcellsep 24\tabcellsep 27.3\tabcellsep 59\tabcellsep 14\tabcellsep 23.7\tabcellsep 147\tabcellsep 38\tabcellsep 25.8\\
7-8\tabcellsep 85\tabcellsep 24\tabcellsep 28.2\tabcellsep 58\tabcellsep 16\tabcellsep 27.6\tabcellsep 143\tabcellsep 40\tabcellsep 27.9\\
8-9\tabcellsep 84\tabcellsep 23\tabcellsep 27.4\tabcellsep 58\tabcellsep 16\tabcellsep 27.6\tabcellsep 142\tabcellsep 39\tabcellsep 27.5\\
9-10\tabcellsep 86\tabcellsep 21\tabcellsep 24.4\tabcellsep 60\tabcellsep 14\tabcellsep 23.3\tabcellsep 146\tabcellsep 35\tabcellsep 24\\
10-11\tabcellsep 82\tabcellsep 19\tabcellsep 23.2\tabcellsep 56\tabcellsep 13\tabcellsep 23.2\tabcellsep 138\tabcellsep 32\tabcellsep 23.2\\
11-12\tabcellsep 77\tabcellsep 17\tabcellsep 22.1\tabcellsep 53\tabcellsep 11\tabcellsep 20.7\tabcellsep 130\tabcellsep 29\tabcellsep 22.3\\
>12\tabcellsep 75\tabcellsep 10\tabcellsep 13.3\tabcellsep 51\tabcellsep 07\tabcellsep 13.7\tabcellsep 126\tabcellsep 17\tabcellsep 13.5\\
TOTAL\tabcellsep 577\tabcellsep \multicolumn{2}{l}{138 23.9}\tabcellsep 395\tabcellsep 91\tabcellsep 23.0\tabcellsep 972\tabcellsep \multicolumn{2}{l}{230 23.7}\end{longtable} \par
 
\caption{\label{tab_1}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.20549450549450549\textwidth}P{0.16346153846153846\textwidth}P{0.21483516483516482\textwidth}P{0.2662087912087912\textwidth}}
013\tabcellsep \tabcellsep \tabcellsep \\
2\tabcellsep \tabcellsep \tabcellsep \\
Year\tabcellsep \tabcellsep \tabcellsep \\
Volume XIII Issue III Version I\tabcellsep SEX GROUP-A GROUP-B GROUP-C GROUP-D\tabcellsep TOTAL NO.OF SPECIMENS PROCESSED 73 136 588 972\tabcellsep CULTURE POSITIVE No. \% 26 35.6 51 37.5 187 31.8 230 23.7\\
( ) F\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 6 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7} \par 
\begin{longtable}{P{0.5871485943775101\textwidth}P{0.1433734939759036\textwidth}P{0.11947791164658635\textwidth}}
ANTIBIOTICS\tabcellsep RESISTANCE No.\tabcellsep \%\\
Cephalothin (CF)\tabcellsep 128\tabcellsep 26\\
Erythromycin (E)\tabcellsep 144\tabcellsep 29.4\\
Tobramycin (T)\tabcellsep 113\tabcellsep 22.9\\
Tetracycline (Te)\tabcellsep 241\tabcellsep 48.9\\
Amoxicillin (Amx)\tabcellsep 390\tabcellsep 79.1\\
Co-Trimoxazole (S\&T)\tabcellsep 289\tabcellsep 58.8\\
Vancomycin (Va)\tabcellsep 0\tabcellsep 0\\
Cloxacillin (Cx)\tabcellsep 368\tabcellsep 74.6\\
Gentamicin (Gm)\tabcellsep 345\tabcellsep 70\\
Penicillin (P)\tabcellsep 376\tabcellsep 76.4\end{longtable} \par
 
\caption{\label{tab_3}Table 7 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{8} \par 
\begin{longtable}{P{0.1421602787456446\textwidth}P{0.2754355400696864\textwidth}P{0.11550522648083623\textwidth}P{0.29320557491289195\textwidth}P{0.023693379790940765\textwidth}}
Variable\tabcellsep \multicolumn{2}{l}{Determiner Total no.}\tabcellsep \multicolumn{2}{l}{Positive No. \%}\\
Age\tabcellsep 6-10\tabcellsep 1061\tabcellsep \multicolumn{2}{l}{355 33.5}\\
\tabcellsep >10\tabcellsep 708\tabcellsep \multicolumn{2}{l}{139 19.6}\\
Gender\tabcellsep Male\tabcellsep 1029\tabcellsep \multicolumn{2}{l}{291 28.3}\\
\tabcellsep Female\tabcellsep 740\tabcellsep \multicolumn{2}{l}{202 27.3}\\
Residence\tabcellsep Orphanage\tabcellsep 73\tabcellsep 26\tabcellsep 35.6\\
\tabcellsep Minority\tabcellsep 136\tabcellsep 51\tabcellsep 37.5\\
\tabcellsep Sub-urban\tabcellsep 588\tabcellsep \multicolumn{2}{l}{187 31.8}\\
\tabcellsep Urban\tabcellsep 972\tabcellsep \multicolumn{2}{l}{230 23.7}\\
Oral hygiene\tabcellsep Good\tabcellsep 1263\tabcellsep \multicolumn{2}{l}{216 17.1}\\
\tabcellsep Bad\tabcellsep 506\tabcellsep \multicolumn{2}{l}{413 81.6}\\
Care taker\tabcellsep Literate\tabcellsep 1222\tabcellsep \multicolumn{2}{l}{183 14.9}\\
\tabcellsep Illiterate\tabcellsep 547\tabcellsep \multicolumn{2}{l}{246 44.9}\end{longtable} \par
 
\caption{\label{tab_4}Table 8 :}\end{figure}
 			\footnote{© 2013 Global Journals Inc. (US)} 			\footnote{   ( )   } 			\footnote{Prevelance Survey for Assessing Intensity of Group a Beta Hemolytic Streptococci (Gabhs) Subclinical Infection Rate in School Children: A Cross Sectional Study} 			\footnote{   ( )   } 		 		\backmatter  			  				\begin{bibitemlist}{1}
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