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| Essex County - Credit Wikipedia |
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For nearly a decade we've been watching the pronounced rise in the number of Scarlet fever (Group A Streptococcus or GAS) cases in the UK (see 2018's UK: `Exceptional' Scarlet Fever Season Continues).
Scarlet Fever primarily affects children under the age of 12, although adults can be affected. It is highly contagious, and while there is no vaccine, antibiotics are generally effective when treated early.Far less common - albeit considerably more serious - is a related illness called iGAS (invasive Group A Strep), which indicates infection of the bloodstream, deep tissues, or lungs, and may result in severe (and often fatal) cases of necrotizing fasciitis and streptococcal toxic shock syndrome.
While caused by the same Streptococcus pyogenes bacteria, iGAS can strike any age, with those over 65 most commonly affected.The most recent PHE (Public Health England) report on Scarlet Fever and iGas - released 6 weeks ago - suggested a less severe year than 2018 was winding down.
Group A streptococcal infections: third report on seasonal activity in England, 2018/19
Health Protection Report Volume 13 Number 16
Group A streptococcal infections:
third report on seasonal activity in England, 2018/19
Surveillance of scarlet fever indicates the start of a seasonal decline in notifications. Weekly numbers remained below those seen during the last few seasons (weeks 37 to 18) [1]. The number of laboratory notifications of invasive group A streptococcal (iGAS) disease are within the range of what is normally reported at this time of year.As you can see by the NHS Chart below, iGas notifications as of early May were down considerably over 2018's numbers.
Today, however, UK papers are filled with reports of 12 deaths in the County of Essex, from iGas (h/t Shiloh at FluTrackers), which sent me in search of a more official statement. The news report below comes from the Mid-Essex NHS office, which is followed by the NHS FAQ on iGAS.
I'll return with more after the break.
News
Streptococcus outbreak in mid Essex
The NHS in the mid Essex area is responding to a number of local cases of bacterial infections among elderly people receiving treatment for wounds in care homes and in their own homes.
To date there have been 32 cases of invasive Group A streptococcus (iGAS) in Braintree District, Chelmsford City and Maldon District and sadly 12 patients have died. An incident management team has been set up, led by NHS Mid Essex CCG, with input also from Provide Community Interest Company, Public Health England and support from NHS England and NHS Improvement.
Group A streptococcus (GAS) is a bacteria that can be found in the throat and on the skin and for many people will not cause any illness. Most Group A streptococcus infections cause relatively mild illnesses such as ‘strep throat’ (a sore throat), scarlet fever or a skin infection. There is an extremely low risk of serious infection to healthy people but on rare occasions, these bacteria can enter the body and cause severe and even life-threatening conditions. This infection is called Invasive Group A streptococcal disease (IGAS).
Additional infection control measures have been put in place to prevent the infection spreading.
Rachel Hearn, Director of Nursing and Quality, Mid Essex Clinical Commissioning Group said: “Our thoughts are with the families of those patients who have died.
“The NHS in Essex is working closely with Public Health England and other partners to manage this local incident, and extra infection control measures have been put in place to prevent the infection spreading in the area.
“The risk of contracting iGAS is very low for the vast majority of people and treatment with antibiotics is very effective if started early. We will continue to work with our partners in Public Health England to investigate how this outbreak occurred and take every possible step to ensure our local community is protected.”
Anyone who is worried can call a Freephone helpline on 03000 032124. Lines are open Monday to Friday, 9am to 5pm. Further updates will be shared on our website.
The causative bacterium is Streptococcus pyogenes - which like viruses, can evolve over time – sometimes resulting in
increased virulence, greater transmissibility, and/or antibiotic
resistance.
Strains are identified by changes in their M-protein gene sequence (emm types) – which often determines virulence - and within these types new variants can emerge.In 2011 and 2012 we followed an unusual erythromycin resistant (but still sensitive to Penicillin & other 1st generation cephalosporins) scarlet fever outbreak in Hong Kong (see Hong Kong: Scarlet Fever In 2012), which resulted in a small number of pediatric fatalities.
A 2014 Nature Genetics journal article attributed Hong Kong’s severe outbreak to the emergence of a new emm12 variant (see Emergence of scarlet fever Streptococcus pyogenes emm12 clones in Hong Kong is associated with toxin acquisition and multidrug resistance).While the reasons remain unclear (see The Lancet's Nov 2017 report Resurgence of scarlet fever in England, 2014–16: a population-based surveillance study), Scarlet Fever has been on the ascendant since 2009 across much of Asia, and more recently in the UK.
They wrote:
Analysis of strains (n=303) identified a diversity of emm types with emm3 (43%), emm12 (15%), emm1 (11%), and emm4 (9%) being the most common.
Lastly, the 2019 March Edition of the CDC's EID Journal carried this research report on the increased risks of iGas infection in household contacts of Scarlet Fever cases.
Volume 25, Number 3—March 2019
Research
Increased Risk for Invasive Group A Streptococcus Disease for Household Contacts of Scarlet Fever Cases, England, 2011–2016
Vicky Watts, Sooria Balasegaram, Colin S. Brown, Suzanna Mathew, Rachel Mearkle, Derren Ready, Vanessa Saliba, and Theresa Lamagni
Author affiliations: Public Health England, Liverpool, UK (V. Watts); Public Health England, London, UK (S. Balasegaram, C.S. Brown, D. Reddy, V. Saliba, T. Lamagni); Public Health England, Leeds, UK (S. Mathew); Public Health England, Chilton, UK (R. Mearkle)
Abstract
The incidence of scarlet fever in England and Wales is at its highest in 50 years. We estimated secondary household risk for invasive group A Streptococcus (iGAS) disease within 60 days after onset of scarlet fever.
Reports of scarlet fever in England during 2011–2016 were matched by residential address to persons with laboratory-confirmed iGAS infections. We identified 11 iGAS cases in ≈189,684 household contacts and a 60-day incidence rate of 35.3 cases/100,000 person-years, which was 12.2-fold higher than the background rate (2.89).
Infants and contacts >75 years of age were at highest risk. Three cases were fatal; sepsis and cellulitis were the most common manifestations. Typing for 6 iGAS cases identified emm 1.0 (n = 4), emm 4.0 (n = 1), and emm 12.0 (n = 1). Although absolute risk in household contacts was low, clinicians assessing household contacts should be aware of the risk to expedite diagnosis and initiate life-saving treatment.
Given the clustering in Essex county, and coming rather late into summer, this Gas outbreak in the UK is a bit unusual, and bears watching. It will be interesting to see what emm types are involved, and whether they show any significant changes.
Stay tuned.
