UK: Scarlet Fever On The Ascendant (Again)

Group A streptococcal infections: update on seasonal activity, 2014 to 2015

Ref: HPR 9(5)

 

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In 2014 the UK saw a huge increase in the number of Scarlet Fever cases (blue line in chart above), after a decade of declining or flat numbers.  We looked at that rising tide of cases last March in UK : Sharp Rise In Scarlet Fever Cases In 2014, but the peak in cases didn’t occur until April.

 

Before the year ended, more than 14,000 Scarlet fever cases were diagnosed in the UK, the highest number since the 1960s.

 

Once again this year  Scarlet Fever notifications are up, averaging more than 200 cases a week for the past 6 weeks (n=1265).  As the chart above shows (red line), the number of cases is running nearly double that of last year, with the expected peak of the season still weeks (or months) away.

 

Scarlet Fever primarily affects children under the age of 12. It is highly contagious, there is no vaccine, but antibiotics are generally effective when treated early.

 

Scarlet fever (Group A Streptococcus or GAS) is caused by the bacterium 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.

 

Although less common, a more serious yet related illness is called iGAS (invasive Group A Strep), which indicates infection of the bloodstream, deep tissues, or lungs, and may result in severe (and frequently fatal) cases of necrotizing fasciitis and streptococcal toxic shock syndrome.

 

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. 

 

Last November a 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).

 

On Friday the UK’s PHE released the following statement about this year’s increased activity:

 

 

Scarlet fever notifications continue to increase

From: Public Health England

First published: 13 February 2015

Latest PHE report shows a high number of scarlet fever notifications across England, with 1265 new cases reported in the first 6 weeks of 2015.

Steep increases in scarlet fever activity are being seen across the country, with over 300 cases reported last week (2 to 9 February 2015).

Increases in scarlet fever are normal at this time of year as we approach high season between March and April. However, the numbers of cases currently being reported are above what is typical for this time of the year. Whilst this might reflect heightened awareness and improved diagnosis and/or notification practices, the high number of cases currently being notified are of concern. Last year in England, over 14,000 cases of scarlet fever were notified, the highest total since the late 1960s.

Dr Theresa Lamagni, PHE’s head of streptococcal infection surveillance, said:

As we enter into high season for scarlet fever, we ask GPs and other frontline medical staff to be mindful of the current high levels of scarlet fever activity when assessing patients. Prompt notification of cases to local health protection teams is critical to enable local monitoring and rapid response to outbreaks. Schools and nurseries should similarly be mindful of the current elevated levels of scarlet fever and promptly inform local health protection teams at an early stage if they become aware of cases, especially if more than 1 child is affected. 

(Continue . . . )

In March of 2014, during last year’s dramatic spike in cases, the Eurosurveillance Journal ran a Rapid Communications Report that described the UK outbreak, and discussed possible causes for the recent increase in cases.

 

Eurosurveillance, Volume 19, Issue 12, 27 March 2014

Rapid communications

Increase in scarlet fever notifications in the United Kingdom, 2013/2014

R Guy¹, C Williams², N Irvine³, A Reynolds⁴, J Coelho¹, V Saliba¹, D Thomas², L Doherty³, V Chalker¹, B von Wissmann⁴, M Chand¹, A Efstratiou¹, M Ramsay¹, T Lamagni ()¹

<SNIP>

Discussion

Scarlet fever incidence has shown a remarkable increase this season. Previous analysis of scarlet fever notifications in England over the last century suggest cyclical patterns of incidence, with resurgences occurring on average every four years [3]. The last peak year for scarlet fever was 2008/09, with incidence of invasive disease tending to mirror those of superficial manifestations of GAS infection in many but not all years [4]. While the enhanced media coverage and public health alerts may have increased case ascertainment during this season, the escalation prior to this suggests a genuine increase in disease incidence. The reasons behind this increase are unclear but may be attributable to a natural cycle in disease incidence.

It remains possible that the increase or part of the increase is attributable to changes in virulence of circulating strains or increased incidence in particular risk groups. An exceptional increase in scarlet fever incidence in Hong Kong during 2011 and 2012 was attributed to the introduction of a new emm12 strain [5]. Continued vigilance for the emergence of a novel strain or changes in pattern of clinical disease is essential.

At present, antimicrobial susceptibility results are not indicating any change in antibiotic susceptibility [6]. Analysis of isolates originating from normally sterile sites, which were submitted to the national reference laboratory, has not identified any unusual types circulating, although a slight increase in the proportion of due to emm3 is currently being observed. Strains harbouring this emm type were implicated in the UK rise in incidence in scarlet fever and iGAS infection during 2008/09 [7], and also implicated in population increases in iGAS infection incidence in Ireland in 2013 [8]. While the current rise in emm3 is slight, it raises some concern given its association with a higher case fatality rate than other emm types [9;10]. Rapid assessment of changes in case fatality rate will assist in monitoring any such changes during the current season.

As a result of the current rise in scarlet fever notifications, clinicians, microbiologists and health protection specialists across Europe should continue to be mindful of potential increases in invasive disease and maintain a high index of suspicion in relevant patients, as early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be life-saving. Alerts have been issued by local health protection staff to frontline medical staff in the UK. An unusual pattern of outbreaks of scarlet fever has also been noted in Belgium during this season (K Loens, personal communication, March 2014). Comparison of strains across the two countries would be beneficial in understanding the current situation in the UK. 

 

I’ll update this story later in the spring, as the size of this year’s outbreak becomes more apparent.

UK : Sharp Rise In Scarlet Fever Cases In 2014

Photo Credit CDC

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Although not as common as it was in our great-grandparent's day, Scarlet Fever (aka scarlatina) remains a seasonal threat, affecting a small percentage of people who contract strep throat. It’s incidence usually peaks during the winter and spring.

 

Scarlet fever is caused by the same bacteria that causes `strep throat’ (Group  A Streptococcus), and is characterized by fever, a very sore throat, a whitish coating or sometimes `strawberry’  (red & bumpy) tongue, and a rough feeling  `scarlet rash’ that first appears on the neck and chest.

 

It primarily affects children under the age of 12.  Adults generally develop immunity as they grow older. Untreated, this bacterial infection can lead to:

• Rheumatic fever
• Kidney disease
• Ear infections
• Skin infections
• Abscesses of the throat
• Pneumonia
• Sepsis
• Arthritis

For more on the disease, here is the CDC’s Scarlet Fever: A Group A Streptococcal Infection information page.

 

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 sadly, resulted in a small number of fatalities. 

 

While less common, a more serious yet related illness is call iGAS (invasive Group A Strep), which indicates infection of the bloodstream, deep tissues, or lungs, and may result in severe (and frequently fatal) cases of necrotizing fasciitis and streptococcal toxic shock syndrome.

 

This year, Public Health England is reporting a sharp rise in scarlet fever cases, with the highest number of cases reported in the first two months of the year since 1990; a number roughly double that seen in recent years.   Scarlet fever outbreaks tend to be cyclical, with peaks occurring roughly every 4 years.

 

Infection report : Volume 8 Number 9 

Advance Access report published on: 4 March 2014

Group A streptococcal infections: seasonal activity, 2013/14

Surveillance data for group A streptococcal (Streptococcus pyogenes; GAS) infections are indicating higher levels of scarlet fever incidence so far this season (2013/14) than seen in recent years. Increased levels of invasive and non-invasive GAS infection typically occur between December and April, with peak season usually in March/April.  An update on the current seasonal activity for group A streptococcal infections is given below.

Scarlet fever

Routine monitoring of surveillance data has identified widespread increases in scarlet fever notifications in February 2014, beyond those seasonally expected. A total of 868 notifications of scarlet fever with onset dates during weeks 5 to 8 of 2014 were made to Public Health England (PHE) compared to an average of 444 for the same period over the past four years (range: 365 to 591; figure 1). These are the highest notification totals for this time of year since 1990.

The increase has been seen across England with regional totals for weeks 5 to 8 of 2014 (compared to 2013) as follows: 99 in the East of England (81 for same period in 2013), 74 in East Midlands (30), 92 in London (45), 67 in the North East (53), 179 in the South East (101), 109 in the South West (46), 62 in the West Midlands (32) and 108 in Yorkshire and Humber (95). The only region where fewer notifications have been made in weeks 5 to 8 in 2014 is the North West region with 78 notifications compared with 108 in weeks 5 to 8 of 2013.

Invasive Group A streptococcus

A total of 106 invasive GAS (iGAS) isolates, defined as isolation of GAS from a normally sterile site, were referred to the Respiratory and Vaccine Preventable Bacteria Reference Unit at Colindale PHE from laboratories in England, Wales and Northern Ireland for specimens taken between weeks 5 and 8 2014, a slight reduction on the average (125 reports) but with the range (101-160 reports) for the same period in the previous five years (figure 2). 

Three English regions have referred slightly higher than average (2009 to 2013) iGAS isolates for February 2014, North East (12 isolates), London (18 isolates) and the North West (21 isolates). All other regions in England are referring lower numbers of isolates than normal for this time of year.

Antimicrobial susceptibility results from routine iGAS laboratory reports for January indicate erythromycin non-susceptibility is at 5%, which is within the usual range.  The susceptibility testing of iGAS isolates against other key antimicrobials (tetracycline, clindamycin and penicillin) indicate no changes in resistance being observed. There have been no reports of penicillin resistance in iGAS isolates in England to date.

(Continue . . . )

The good news here is that, unlike in Hong Kong in 2012, only about 5% of the strep cases tested have shown resistance to erythromycin.

The PHE recommends:

Clinicians, microbiologists and HPTs should be mindful of potential increases in invasive disease and maintain a high index of suspicion in relevant patients as early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be life-saving.

 

If history is any guide, we should begin to see the number of scarlet fever/iGAS cases in England begin to decline over the next 6 to 8 weeks.

 

 

Hong Kong: Scarlet Fever In 2012

Photo Credit – CDC 

 

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Over the past two years Hong Kong has experienced  a dramatic increase in the number of Scarlet Fever cases, while at the same time, cases in Mainland China have been reportedly surged as well.

 

The chart below illustrates Hong Kong’s  7-to-9 fold increase over 2005-2010.

 

Credit Hong Kong CHP

 

Scarlet fever is caused by the same bacteria that causes `strep throat’ (Group  A Streptococcus), and is characterized by fever, a very sore throat, a whitish coating or sometimes `strawberry’ tongue, and a `scarlet rash’ that first appears on the neck and chest.

 

It primarily affects children under the age of 10.  Adults generally develop immunity as they grow older. Untreated, this bacterial infection can lead to:

 

• Rheumatic fever
• Kidney disease
• Ear infections
• Skin infections
• Abscesses of the throat
• Pneumonia
• Sepsis
• Arthritis

 

For more on the disease, here is the CDC’s Scarlet Fever: A Group A Streptococcal Infection information page.

 

In the summer of 2011, we saw reports that many of these recent Hong Kong infections were resistant to erythromycin, but still responded to Penicillin. 

 

The CHP also reported:

 

A new genome fragment was discovered by the Department of Microbiology of the University of Hong Kong (HKU) upon sequencingthe whole genome of a GAS isolate from a child suffering from SF and invasive GAS infection admitted to QMH.

 

Subsequent testing by the PHLSB on other GAS isolates found that 70-80% of emm type 12 strains and 50-60% of emm type 1 strains carried this new genomefragment. The contribution of new GAS clone(s) with altered genetic characteristics (such as the new genome fragment) causing the current upsurge of SF remains to be investigated.

 

 

Today, Hong Kong’s Centre For Health Protection  released their latest Communicable Disease Watch, which includes a detailed epidemiological look the past year’s Scarlet Fever activity.

 

 

Scarlet fever – local epidemiology and severe cases in 2012

Reported by Miss Amy Li, Scientific Officer, Respiratory Disease Office, Surveillance and Epidemiology Branch, CHP.

Scarlet fever (SF) is a bacterial infection caused by Group A Streptococcus (GAS) and is a statutorily notifiable disease in Hong Kong. The main symptoms are fever, sore throat and erythematous rash with sand-paper texture. The tongue may have a distinctive "strawberry"-like (red and bumpy) appearance. SF can be treated by antibiotics effectively. Although the illness is usually mild, severe cases can occur and complications may include middle ear infection, throat abscess, pneumonia, sepsis, shock, septicaemia, meningitis, and toxic shock syndrome.This article reviews the local epidemiology and severe cases of SF in 2012.

From 2006 to 2010, the annual number of SF cases ranged between 128 and 235. In 2011, there was an upsurge in SF cases resulting in an annual total of 1526 cases. During the same period of time, there was a simultaneous increase of SF cases in Mainland China and Macao, suggesting the rise of SF cases in Hong Kong was likely a regional phenomenon.

 

The related details were reported in June and July 2011 (http://www.chp.gov.hk/files/pdf/cdw_v8_13.pdf and http://www.chp.gov.hk/files/pdf/cdw_v8_14.pdf). In 2012, the number of SF cases reported to CHP reached 1508* cases which was comparable to that of 2011 (Figure 1). In Hong Kong, relatively more cases occur from December to May though this seasonal pattern was not consistently observed every year (Figure 2). The local activity of SF has been high recently, with cases gradually increased from 65 in October to 132 in November and 119 in December 2012*.

(SNIP)

In view of the high activity of SF recently, people who are suspected to have SF should consult their doctor promptly. Patients who are suffering from SF should not go to schools or child care centres until they fully recover.To prevent SF,people should:

• Maintain good personal and environmental hygiene;
• Keep hands clean and wash hands properly;
• Wash hands when they are dirtied by respiratory secretions, e.g., after sneezing;
• Cover nose and mouth while sneezing or coughing and dispose of nasal and mouth discharge properly; and
• Maintain good ventilation.

 

As we saw in 2011, this report states that :`60 percent of GAS isolated in 2012 were resistant to erythromycin (which also predicts resistance to azithromycin and clarithromycin).’

While Penicillin and first generation cephalosporins are still effective, this is another example of a serious bacterial infection - once easily treated – evolving to evade our antibiotic arsenal.

 

The list of resistant bacteria continues to expand, with names like  MRSA, NDM-1, KPC, EHEC, Neisseria gonorrhoeae, and now Scarlet Fever making headlines around the world.

 

So while the end of the antibiotic era is not yet at hand, many experts fear we may be drawing closer to that day (see World Faces A `Post-Antibiotic Era’).

 

Short of seeing a hugely virulent pandemic – the problem of growing antimicrobial resistance may be the greatest threat to global public health that our species faces over the next couple of decades.

HK: Drop In Scarlet Fever Cases

 

 

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While new scarlet fever cases continue to show up in Hong Kong (and presumably in mainland China, where surveillance numbers are vague at best), the rate of new cases has dropped markedly over the past 3 weeks.

 

Less than a month ago, it wasn’t unusual to see 25 to 30 new cases every 24 hours (see Hong Kong: Scarlet Fever Update). 

 

The latest surveillance report from the Centre for Health Protection shows just 28 cases have been detected over the past 72 hours.

 

 

Most public schools in Hong Kong closed at the end of June for their 6-week summer vacation break, after which we began to see a gradual reduction in new cases.

 

Schools are currently scheduled to reopen the 3rd week of August.  Earlier this month Dr. York Chow – in a media interview – indicated that this outbreak might persist into September.

 

While several strains of Group A Streptococcus (GAS) have been found to be circulating in Hong Kong, two mutated strains have been identified that show signs of increased resistance to erythromycin and clindamycin, long considered the standard treatment for the illness.

 

Fortunately, they remain susceptible to penicillin and some newer drugs of last resort.

 

According to Kwok-yung Yuen - head of Hong Kong University's microbiology department -  the more dominant of the two strains has undergone a genetic mutation that appears to make it more contagious as well.

Hong Kong: Scarlet Fever Cases High, But Stabilized

 

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The number of new scarlet fever cases being reported in Hong Kong remains high, but has slowly decreased over the past several weeks, and today the Centre for Health Protection is calling it `High, but stabilized’.

 

You can see the trend in this graphic from today’s (Jul 14th) edition of Hong Kong’s Communicable Disease Watch.

 

 

A couple of excerpts from today’s report:

 

As of July 9, a total of 831 SF cases have been recorded so far this year, compared to 187 and 128 cases in the whole year of 2009 and 2010, respectively. The weekly number of newly reported cases seems to have peaked at week 26 (week ending June 25) and has decreased for 2 consecutive weeks since then. In the week ending July 9, 120 reports of new cases were received.  There were no new fatal cases since the two deaths reported on May 30 and June 19,  2011, respectively. The case fatality rate stood at 0.2% to 0.3%, which is comparable with literature findings.

 

Continued vigilance against SF is vital because even though the daily number of newly reported cases seems to have stabilized, it remains almost ten times above the normal baseline.

Hong Kong: Same Pathogen, Different Disease

 

Photo Credit – Wikipedia

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Over the past couple of months Hong Kong has experienced an unusually large outbreak of Scarlet Fever caused by the bacterium Streptococcus pyogenes; some strains of which have reportedly `mutated’, picking up greater transmissibility and increased antibiotic resistance.

 

For earlier reports see here, here, and here.

 

The latest report from the Centre for Health Protection lists 35 new cases over the 72-hour weekend reporting period; an increase of 113 over a week ago.

 

 

But S. pyogenes may be the cause of a number of different disease processes, among them pharyngitis ("strep throat"), scarlet Fever, localized skin infections ("impetigo"), and even deep tissue infections resulting in necrotizing fasciitis.

 

Infection with certain strains of S. pyogenes can lead to the release of bacterial toxins, and in rare cases can result in Toxic Shock Syndrome.

 

Yesterday the CHP released the following brief announcement of a Group A Strep-related pediatric TSS (Toxic Shock Syndrome) case.

 

10 July 2011

A paediatric case of Group A Streptococcal Toxic Shock Syndrome 

The Centre for Health Protection (CHP) of the Department of Health today (July 10) is investigating a critical case of Group A Streptococcal infection involving a 10-year-old boy with chronic illness.

 

The patient presented with fever and vomiting and attended the Accident and Emergency Department (AED) of Pok Oi Hospital (POH) on July 8. The clinical diagnosis was gastroenteritis. No hospitalization is required.

 

His condition however deteriorated with cough and shortness of breath the next day. He reattended AED of POH, and was transferred to Tuen Mun Hospital for management.

 

His condition further deteriorated and he developed toxic shock syndrome. He is now in critical condition.

 

Culture of his gastric lavage grew Group A Streptococcus.

 

The boy had no recent travel history. His home contacts were asymptomatic.

CHP’s investigation continued.
Ends/Sunday, July 10 2011

 

 

According to this report in the Hong Kong Standard, government authorities state that this case "is not related to scarlet fever".

 

While the type of infection isn’t characterized in the CHP report, the child is referred to has having `chronic illness’, which can sometimes be a factor in developing an invasive Strep infection.

 

Also unknown at this time is whether child’s infection is due to one of the antibiotic-resistant strains currently being seen in the scarlet fever outbreak.

 

The CDC describes Streptococcal Toxic Shock Syndrome (STSS) this way.

 

Streptococcal toxic shock syndrome (STSS), causes blood pressure to drop rapidly and organs (e.g., kidney, liver, lungs) to fail. STSS is not the same as the "toxic shock syndrome" frequently associated with tampon usage. About 20% of patients with necrotizing fasciitis and more than half with STSS die. About 10%-15% of patients with other forms of invasive group A streptococcal disease die.

 

 

The Toxic Shock Syndrome associated with Tampon use in the early 1980s was caused by Staphylococcus aureus, not Streptococcus pyogenes.

 

Lastly, the CDC has some advice on how to prevent the spread of Group A Strep bacteria:

 

What can be done to help prevent group A streptococcal infections?

The spread of all types of GAS infection can be reduced by good hand washing, especially after coughing and sneezing and before preparing foods or eating. Persons with sore throats should be seen by a doctor who can perform tests to find out whether the illness is strep throat. If the test result shows strep throat, the person should stay home from work, school, or day care until 24 hours after taking an antibiotic.

 

All wounds should be kept clean and watched for possible signs of infection such as redness, swelling, drainage, and pain at the wound site. A person with signs of an infected wound, especially if fever occurs, should immediately seek medical care.

 

It is not necessary for all persons exposed to someone with an invasive group A strep infection (i.e. necrotizing fasciitis or strep toxic shock syndrome) to receive antibiotic therapy to prevent infection. However, in certain circumstances, antibiotic therapy may be appropriate. That decision should be made after consulting with your doctor.

Hong Kong: Scarlet Fever Update

 

 

 

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Hong Kong’s Centre for Health Protection has updated their Scarlet Fever page this morning with new totals gathered from over the weekend.

 

With 65 new cases recorded in the past 96 hours, the outbreak continues at roughly the same pace we’ve seen for the past couple of weeks.

 

 

The good news is that there have been no new fatalities reported. 

 

Last week Dr. York Chow - Secretary for Food and Health -  conceded that the current outbreak is likely a`regional phenomenon’. The Hong Kong Centre for Health Protection (CHP) reported that they are in  contact with other health departments in the region and are aware of `a simultaneous increase of SF cases in Mainland China and Macao’. 

 

But unlike from Hong Kong, we don’t seem to be getting any detailed numbers.

 

In a brief news item today from RTHK news, Dr. Chow indicated that he expected this outbreak to continue until September.

 

While several strains of Group A Streptococcus (GAS) have been found to be circulating in Hong Kong, two mutated strains have been identified that show signs of increased resistance to erythromycin and clindamycin, long considered the standard treatment for the illness.

 

Fortunately, they remain susceptible to penicillin and some newer drugs of last resort. 

 

According to Kwok-yung Yuen - head of Hong Kong University's microbiology department -  the more dominant of the two strains has undergone a genetic mutation that appears to make it more contagious as well.

Dr. York Chow Questioned On HK Scarlet Fever Outbreak

 

 

 

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Dr. York Chow, who is an orthopedic surgeon by profession, has been the Secretary for Food and Health in Hong Kong since 2007.  

 

Today (June 29th), the Health Secretary has responded at some length to two urgent questions posed by members of Hong Kong’s LC (Legislative Council) on the ongoing Scarlet Fever outbreak.

 

Under normal rules of procedure, members of the LC must give notice of a question 7 `clear days’ in advance of a public meeting, but under Rule 24(4) a member may ask permission to pose a question if it is `of an urgent character and relates to a matter of public importance’.

 

Both questions, submitted by Hon Chan Hak-kan and Hon Cheung Man-kwong, had some overlap – particularly in regards to the level of SF (Scarlet Fever) activity being reported on the Chinese mainland and in neighboring countries.

 

York Chow conceded that the current outbreak is likely a`regional phenomenon’ - and that the Hong Kong Centre for Health Protection (CHP) is in contact with other health departments in the region and is aware of `a simultaneous increase of SF cases in Mainland China and Macao’. 

 

But beyond that, he was unable to offer any specifics, noting that scarlet fever is not a notifiable disease in many neighboring countries.

 

When asked to characterize the genetic changes to the bacterium, along with changes to treatment due to antibiotic resistance, he replied:

 

As of June 28, there have been four SF cases with complications and two fatal cases of SF in Hong Kong. Details are set out in the Annex.

 

Laboratory investigation of the two fatal cases showed that two different strains of Group A Streptococcus were involved (emm type 1 and emm type 12).

 

CHP, the Hospital Authority and the University of Hong Kong (HKU) have been working in collaboration on laboratory testing for the bacterium causing SF, including tests on antimicrobial resistance, serotypes, virulence genes and the new gene fragment reported by HKU. Further studies will be done to characterise the role and prevalence of the new genetic change and to project the outlook of the outbreak over time.

 

So far, all the Group A Streptococcus isolates detected are sensitive to penicillin, meaning that all antibiotics belonging to the penicillin group or first generation cephalosporins can effectively treat SF.

 

Local antibiotic resistance surveillance data showed that around 50-60% of Group A Streptococcus isolated in 2011 are resistant to erythromycin (which also predicts resistance to azithromycin and clarithromycin). As a result, antibiotics belonging to the macrolide group (e.g. erythromycin) should not be used as empirical treatment for SF. 

 

 

The health secretary warned that this outbreak was expected to persist into the summer, and that the CHP has stepped up publicity and health education efforts.

 

The complete Q&A’s may be viewed in press releases from the Hong Kong government.

 

LC Urgent Q1: Scarlet fever

LC Urgent Q2: Scarlet fever in Hong Kong and neighbouring areas

 

 

In his remarks, York Chow stated that:

 

Health authorities of Guangdong, Hong Kong and Macao have exchanged the surveillance data and the analysis of SF in view of the rising number of cases this year.

 

Unlike Hong Kong, mainland Chinese officials have a history of holding infectious disease information close to the vest. 

 

So it is disappointing, but not entirely unexpected, that we are not getting any specific numbers from the mainland.

 

Hong Kong, meanwhile, has released their latest daily update, indicating 17 new cases and 1 new outbreak in the last 24 hours.

 

CHP: Scientific Committee Statement On Scarlet Fever

 

 

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Photo Credit – CDC PHIL : Photomicrograph of Streptococcus pyogenes bacteria, 900x Mag.

 

From their Centre For Health Protection we have a consensus view statement issued by the Scientific Committee (SC) on Emerging and Zoonotic Diseases and Scientific Committee on Advanced Data Analysis and Disease Modelling on the ongoing Scarlet Fever outbreak in Hong Kong.

 

You can find previous reports on this outbreak at:

Updating Hong Kong’s Scarlet Fever Outbreak

More On Hong Kong's Scarlet Fever Outbreak

When Old Bacteria Learns New Tricks

 

 

This latest statement, dated 6/27/2011 can be found at:

 

Statement of the Scientific Committee on Emerging and Zoonotic Diseases and the Scientific Committee of Advanced Data Analysis and Disease Modelling on Scarlet Fever

 

Excerpts:

• The rise of scarlet fever (SF) cases in Hong Kong is likely a regional phenomenon.

 

• The overall epidemiologic and clinical characteristics of SF cases  in this outbreak  resemble  those  in  the past, although  infrequently some cases may have atypical clinical presentation.

 

• The case fatality rate so far  is not significantly higher than historical or international figures.

 

• A number of different Group A Streptococcus (GAS) strains causing SF are circulating in the community.

 

• The  underlying  reasons  for  the  SF  upsurge  are  being  further investigated,  including  a  new  genetic  fragment  inserted  in  the bacterial genome, clone shuffling effects and others.

 

• The  contribution  of  new  GAS  clone(s)  with  altered  genetic characteristics  causing  this  outbreak  remains  to  be  further investigated.

• For patients with  suspected SF,  the penicillin group of  antibiotics  is the treatment of choice and should be given for at least 10 days.

• Judicious  use  of  antibiotics  is  important  in  preventing  the development  of  bacterial  resistance.    Microbiological  testing  by antigen  testing  and  culture  should  be  considered  to  guide antimicrobial  therapy.    Patients with  only  runny  nose without  fever should not be considered for antimicrobial therapy unless the clinical condition changes or the microbiological test is positive for GAS.

• High  SF  activity will  probably  persist  for  a  period  of  time  into  the summer.  The situation needs to be closely monitored to guide public health measures.  

The Committee recommends:

• studies  be  done  to  characterize  the  role  and  prevalence  of  new genetic  changes  and  to  project  the  outlook  of  the  outbreak  over time

• continued  intensive  surveillance  for  SF  and  invasive  GAS infections including acute rheumatic fever and glomerulonephritis

• strengthening  publicity  and  education  on  the  appropriate  use  of antibiotics 

• close  communications  with  healthcare  professionals  on  the progression of  the outbreak and  information pertaining  to clinical diagnosis and management of SF patients

 

 

These views are also summarized in a press release issued today (6/28) from the Centre For Health Protection (CHP):

 

Update on scarlet fever in Hong Kong 

The Scientific Committee (SC) on Emerging and Zoonotic Diseases and Scientific Committee on Advanced Data Analysis and Disease Modelling under the Centre for Health Protection (CHP) of the Department of Health (DH) held a joint meeting today (June 27) to review and discuss the upsurge of scarlet fever (SF) in Hong Kong.

(Continue . . . )

 

As of this writing (0530 EST), the CHP website had not updated their daily tally of Scarlet Fever Cases.  As of yesterday, more than 600 cases had been reported in Hong Kong, and there are reports of thousands more on the mainland.

Updating Hong Kong’s Scarlet Fever Outbreak

 

 

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From Hong Kong’s Centre For Health Protection (CHP) this morning, we’ve updated numbers as of mid-day Monday on their Scarlet Fever outbreak.

 

Over the 72 hours of the weekend, 71 new cases have been reported. The number of fatalities (2) remains unchanged from last week.

 

 

While accurate numbers have been impossible to come by, local reporting indicates that scarlet fever is spreading on the mainland of China as well.

 

The number being reported in the media today (9,000 cases) is the same as we heard early last week, suggesting that surveillance and reporting from the mainland is less than robust.

 

In a long and informative Associated Press report by Margie Mason, we learn some new details regarding the two antibiotic resistant strains circulating in this outbreak.

 

Mutated scarlet fever fuels Hong Kong outbreak

By MARGIE MASON , 06.27.11, 03:30 AM EDT

 

 

The gist being that two mutated strains of group A Streptococcus that are causing this outbreak both show signs of increased resistance to erythromycin and clindamycin, long considered the standard treatment for the illness. 

 

Fortunately, they remain susceptible to penicillin and some newer drugs of last resort. 

 

Once a common scourge of children, scarlet fever has been largely controlled by the use of modern antibiotics. What happens should this new strain develop penicillin resistance as well is a major concern of scientists.

 

 

According to Kwok-yung Yuen - head of Hong Kong University's microbiology department -  the more dominant of the two strains has undergone a genetic mutation that appears to make it more contagious as well.

 

(Source CDC Scarlet Fever Webpage)

For some background on Scarlet Fever this morning, we’ve a 5 minute CDC Podcast on the illness from last February.

 

Scarlet Fever

Katherine Fleming-Dutra, pediatrician, discusses scarlet fever, its cause, how to treat it, and how to prevent its spread. Created: 6/9/2011 by National Center for Immunization and Respiratory Diseases (NCIRD). Date Released: 6/9/2011. Series Name: CDC Featured Podcasts.

More info on this topic

(click image to load page)

Running time = 5:09

To save the Podcast, right click the "Save this file" link below and select the "Save Target As..." option.

Save This File (5MB) [right click]

 

For now, even with the availability of antibiotics, prevention of the disease is the best course of action.  To that end, the CDC recommends:

 

Preventing Infection: Wash Those Hands

The best way to keep from getting infected is to wash your hands often and avoid sharing eating utensils, linens, towels or other personal items. It is especially important for anyone with a sore throat to wash his or her hands often. There is no vaccine to prevent strep throat or scarlet fever.

Hong Kong: Scarlet Fever Update

 

 

# 5646

 

 

From Hong Kong’s Centre For Health Protection we’ve the latest daily update on Scarlet Fever cases.  Over the past 48 hours a total of 60 new cases have been reported.

 

 

Although a great deal has been made over the detection of a `new, more contagious strain’ of Scarlet Fever (see When Old Bacteria Learns New Tricks), it would appear that more than one strain is contributing to the current outbreak in the region.

According to the latest update:

 

“Laboratory investigation showed that the isolates from the two fatal cases belong to different strains. emm typing of the isolate from 7 year-old girl and 5
year-old boy are Type 12 and Type 1 respectively.”

 

While the number of cases in Hong Kong has just passed the 500 mark, in mainland China more than 9,000 cases have been reported; double the rate seen most years.

More On Hong Kong's Scarlet Fever Outbreak

.

# 5640


Yesterday in When Old Bacteria Learns New Tricks I wrote about the outbreak of what appears to be a new strain of Scarlet Fever in Hong Kong.   Starting today, and until this outbreak is brought under control, Hong Kong's Centre for Health Protection has announced their intention to publish daily updates on new cases.

Hong Kong CHP 

Today, a link to the first of these updates,  an alert issued on the investigation of another child's death, and links to several media reports that provide more detail on the new characteristics of this mutated bacterial strain.

Dr. Thomas Tsang, director of the Centre for Health Protection, is quoted in the media today as saying:

"The situation is rather serious at the moment. We are facing an epidemic because the bacteria that is causing scarlet fever is widely circulating in this region -- not only in Hong Kong but in mainland China and Macau."

Today's report lists 26 new cases in the past 24 hours. The following notice, was issued by the CHP today.

Suspected fatal case of scarlet fever under investigation

The Centre for Health Protection (CHP) of the Department of Health is investigating a suspected fatal case of scarlet fever involving a 5-year-old boy.


The boy presented with fever from June 15. He was admitted to Princess Margaret Hospital on June 19 after sudden deterioration in his condition. The boy developed toxic shock syndrome and passed away today (June 21). According to his parent, the child had consulted a general practitioner for chickenpox earlier.

The patient's clinical diagnosis was scarlet fever and toxic shock syndrome. A laboratory test on his blood specimen revealed gram positive cocci. Further tests are being conducted by the hospital to confirm diagnosis.

The Public Health Laboratory Centre under the CHP will also carry out tests on any positive isolate obtained. Further investigation is ongoing to collect more complete clinical information from the parents and doctors who have seen the child.


The kindergarten that the boy attended, SA Tin Ka Ping Kindergarten in Sha Tin, had no other scarlet fever cases, but an ongoing chickenpox outbreak since May 4 has affected 11 other students aged between 3 and 5. As a precautionary measure, the CHP advised the kindergarten to suspend classes for seven days starting tomorrow (June 22). (Continue . .  )

And lastly, several media reports that identify Erythromycin as the antibiotic that this new strain has developed resistance to, along with other details.


First, from China Daily:

Scarlet fever strain more virulent

By Carmen Zhang (HK Edition)

Next the transcript of a press conference by Dr Thomas Tsang presented by Radio Australia.

Outbreak of scarlet fever in Hong Kong

Updated June 21, 2011 21:45:03

And finally, This from Channel News Asia.

Hong Kong declares scarlet fever outbreak
Posted: 21 June 2011 1940 hrs 

As Dr. Tsang points out, while this outbreak is not as serious as SARS or Bird Flu, with thousands of cases reported on the mainland, increased virulence, and signs of antibiotic resistance -  this outbreak is worthy of our attention.

When Old Bacteria Learns New Tricks

 

 

 

 

# 5638

 

 

Even as Europe continues to deal with their declining EHEC outbreak - caused by what appears to be a new, more virulent, and antibiotic resistant form of E. Coli -we are getting word of another bacterial foe (this time in Hong Kong) that appears to have learned a few new tricks as well.

 

While once greatly feared and the cause of numerous epidemics up until the early 20th century, Scarlet Fever -  caused by a bacteria called group A Streptococcus – can be successfully treated by modern antibiotics and today is usually a mild illness.

 

[Credit: National Library of Medicine]  circa 1918

 

The illness is caused by the same bacteria that causes `strep throat’, and is characterized by fever, a very sore throat, a whitish coating or sometimes `strawberry’ tongue, and a `scarlet rash’ that first appears on the neck and chest.

 

It primarily affects children under the age of 10.  Adults generally develop immunity as they grow older. Untreated, this bacterial infection can lead to:

• Rheumatic fever
• Kidney disease
• Ear infections
• Skin infections
• Abscesses of the throat
• Pneumonia
• Arthritis

 

For more on the disease, here is the CDC’s Scarlet Fever: A Group A Streptococcal Infection information page.

 

Today we are getting word of an unusually large outbreak of scarlet fever in Hong Kong (and presumably parts of mainland China as well) that is being described as having `mutated’ to become more contagious and resistant to some antibiotics.

 

First the alert issued by Hong Kong’s Centre for Health Protection.

 

Alert issued on scarlet fever

June 20, 2011

Centre for Health Protection Controller Dr Thomas Tsang urges the public to guard against scarlet fever, forecasting more infections during the summer.

 

He said 419 cases have been recorded so far this year, well above the historic baseline. He said the high activity is a regional phenomenon, with many cases recorded on the Mainland and in Macau.

 

The bacterial infection is caused by Group A streptococcus. Dr Tsang said the serotype M12 of the bacteria is dominant in this year’s cases.

 

“Over 90% of cases this year affected children aged under 10, with the majority in the age group of four to seven years.”

 

A new gene segment has been found in one of the isolates that gives the bacteria an increased ability to spread among humans.

 

“It may explain why there are higher number of cases this year,” Dr Tsang said, adding the centre will analyse test results and notify doctors, and Mainland and Macau authorities, of the findings.

 

He urged people to watch their personal hygiene. Parents of children with fever and sore throat should seek medical advice immediately.

 

A second report, this time from RTHK News states that the University of Hong Kong has tested this bacteria, and found it to be resistant to some of the antibiotics used to treat strep throat.

 

Mutated scarlet fever more infectious

20-06-2011

Wendy Wong reports

Tests by the University of Hong Kong have found that the bacteria which causes scarlet fever has mutated and become more contagious.

 

Health officials say this explains why there's been a recent surge in the number of cases of the potentially fatal disease, which mainly affects children. Experts warn that infections will remain at a high level for several months.

 

They also say the disease has become resistant to certain antibiotics.

(Continue . . .)

 

 

Although the chart below is only current through the 11th of June, it clearly shows the spike in Scarlet Fever cases reported in Hong Kong in 2011.

 

Credit Hong Kong CDC Communicable Disease Watch.

 

Media outlets are reporting that two children have died from this illness (a 7-year old girl and a 15-year old boy) over the past 3 weeks – the first such deaths in Hong Kong in 10 years.

 

Hong Kong’s Medical Association is recommending that doctors move to using alternative antibiotics to treat the disease.

 

Hong Kong, with excellent surveillance, top notch medical facilities, and plentiful access to a wide range of antibiotics is particularly well equipped to deal with the emergence of this disease.

 

Less certain is how well this outbreak can be managed on the Chinese Mainland.

 

Whether this `mutated’ strep A has `legs’, and this outbreak persists or even spreads, is something we’ll have to wait to see.

 

But regardless of how this particular outbreak plays out, anytime we see an old bacterial foe picking up new tricks – particularly involving transmissibility, virulence, resistance – it is worth our paying attention.

 

Bacterial evolution proceeds at an astonishing rate driven by the misuse of antimicrobials, horizontal gene transfers, recombination, and simple mutation.

 

Despite our arsenal of antibiotics, the list of resistant bacteria continues to expand, with names like  MRSA, NDM-1, KPC, EHEC, and now even Scarlet Fever making headlines around the world.

 

So while the end of the antibiotic era is not yet at hand, the fear is, we may be drawing closer to that day.

 

Short of seeing a hugely virulent pandemic – growing antimicrobial resistance is probably the greatest threat to public health on the horizon.

 

A few of my recent blogs on the subject include:

 

UK: `New MRSA’ Strain Spreading

CMAJ: Local Acquisition Of NDM-1 In Ontario

India Looks For (And Finds) NDM-1

Carbapenemases Rising

WHO: The Threat Of Antimicrobial Resistance

NDM-1: A New Acronym To Memorize

 

 

And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

 

Maryn’s SUPERBUG Blog, now part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.