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: 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.

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.