UK Health Authorities Issue Warnings About Rare Invasive Strep A Infection Outbreak After Six Children Died And More Than 851 Infected


Health Security Agency issues rare alert over rise in cases, urging people to seek immediate medical help if they see symptoms

Parents across the UK are being urged to look out for symptoms of strep A infection in their children after health officials revealed a rise in cases had led to the death of six youngsters.

The UK Health Security Agency (UKHSA) issued a rare alert on Friday evening after a rise in cases across the country, telling parents to seek medical help as soon as possible if they detect signs in their children, in order to stop the infection becoming serious.

Symptoms include a sore throat, fever and minor skin infections. In most cases, people can be treated with antibiotics and make a full recovery. In rare cases, however, strep A can become a serious illness, and anyone with high fever, severe muscle aches, pain in one area of the body and unexplained vomiting or diarrhoea should seek urgent medical help.

One or two children under the age of 10 die as a result of strep A in typical winter, but five children in England and one in Wales have already lost their lives this season.

Public health officials said there was currently no evidence of a new strain was circulating. The rise in cases and deaths was most likely to be related to high amounts of circulating bacteria and increased social mixing, they said.

Strep A can cause a range of different health issues, including the skin infection impetigo, strep throat and scarlet fever.

The vast majority of infections are relatively mild, but the bacteria can also cause a life-threatening illness called invasive group A streptococcal (iGAS) disease.

The UKHSA said on Friday evening that there has been a significant rise in scarlet fever cases recently. There were 851 cases reported in the week of 14 to 20 November, compared with an average of 186 for the same period in previous years.

There have also been 2.3 cases of iGAS per 100,000 children aged one to four in England this year, compared with an average of 0.5 in the pre-pandemic seasons from 2017 to 2019, the agency said. There have also been 1.1 cases per 100,000 children aged five to nine, compared with the pre-pandemic average of 0.3.

During the last high season for strep A infection, in 2017/18, there were four deaths in children under 10 in England at this point of the season. This year the figure is five.

“We are seeing a higher number of cases of group A strep this year than usual,” Dr Colin Brown, the deputy director of UKHSA, said in a statement.

“The bacteria usually cause a mild infection producing sore throats or scarlet fever that can be easily treated with antibiotics. In very rare circumstances, this bacteria can get into the bloodstream and cause serious illness called invasive group A strep (iGAS).

“This is still uncommon. However, it is important that parents are on the lookout for symptoms and see a doctor as quickly as possible so that their child can be treated and we can stop the infection becoming serious.

“Make sure you talk to a health professional if your child is showing signs of deteriorating after a bout of scarlet fever, a sore throat, or a respiratory infection.”

The UKHSA said investigations were also under way after reports of an increase in lower respiratory tract strep A infections in children that have caused severe illness over the past few weeks.

The agency confirmed earlier on Friday that a child who attended St John’s primary school in Ealing, west London, had died of strep A, and it also emerged that the parents of a four-year-old boy from Buckinghamshire said he had died of it too.

Streptococcus pyogenes (group A Streptococcus; GAS) is a common community-acquired pathogen, predominantly affecting skin, soft tissues, and the respiratory tract. Invasive GAS (iGAS) infection, characterized by entry of the bacterium into sterile body fluids, including blood, has a mortality rate of 8%–16% (1–4).

Person-to-person iGAS transmission is thought to occur through direct skin contact or via respiratory droplets from symptomatic infections and asymptomatic carriers. Throat, nose, skin, and anogenital carriage have been linked to healthcare-associated outbreaks (5–8), which have been recorded in hospital, long-term care, and outpatient facilities worldwide (9–11). Environmental and fomite transmission are less well characterized.

In England, most community nursing care is performed by practitioners traveling between patients to deliver healthcare in the patients’ homes, termed home healthcare (HHC). HHC is administered by a variety of healthcare workers, including district nurses, community nurses, healthcare assistants, general practitioners, podiatrists, hospital outreach teams, and palliative care staff.

A substantial part of HHC is wound care, but HHC workers (HHCWs) also administer medication, assist with rehabilitation, and perform catheter and end of life care. During a single working week, an HHCW could perform many of these duties for different patients.

The home environment is not designed for healthcare and has unique infection control challenges. HHCWs and their equipment could become contaminated directly from the patient or the patient’s home, and the patient risks infection from practitioners or their equipment (12,13).

In England, iGAS cases are notifiable to local health protection teams (HPTs) under the Health Protection (Notification) Regulations 2010 (14) as a means of beginning immediate public health actions as needed, including contact tracing, according to national guidelines (15). Guidance also requests that all sterile site GAS isolates be sent for typing to the Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU) of Public Health England (PHE).

All isolates, including GAS isolates from possible healthcare-associated infections, should be referred for typing or stored locally for future outbreak investigations. RVPBRU returns results to the referring hospital and local HPT within 6 days. RVPBRU also provides whole-genome sequencing (WGS) to support outbreak investigations.

In 2013, PHE identified the first HHC-associated iGAS outbreak in England (16). PHE has regularly recorded outbreaks since then, and HPTs managed outbreaks with advice from national leads for streptococcal surveillance and reference microbiology units. We describe HHC-associated iGAS outbreaks reported during January 2018–August 2019, including identification, investigation, and management, to inform public health response in England and elsewhere.

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