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BCCA Statement on Scarlet Fever and Invasive Group A Streptococcus 06 December 2022
Current invasive Group A
streptococcus (iGAS) infection notifications remain unusually high for this
time of year, particularly in children. Marked increases in scarlet fever
notifications are also being seen. Important links from the UK Health Security
Agency are available at:
The advice and guidance is
likely to change as more data becomes available and updates will be provides
through NHSE and the health security agency.
There has been an
increase in lower respiratory tract GAS infections in children over the past
few weeks in some cases causing severe illness. A high burden of co-circulating
viral infections may be contributing to the increased severity and
complications through co-infection. Clinicians 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.
notification to UKHSA Health Protection Teams of iGAS infection is essential to
facilitate immediate public health actions including assessment of contacts.
There are no specific recommendations for children and adults with congenital heart disease. Although an autoimmune inflammatory reaction to group A streptococcus can lead in very rare cases to rheumatic fever, to our knowledge, group A streptococcus does not cause a more severe illness in children with congenital heart disease.
Given the unusually high level of GAS, and viral co-circulation in
the community, health care professionals are asked to have a low threshold to
consider and empirically prescribe antibiotics to children presenting with features
of GAS infection, including where secondary to viral respiratory illness.
Consider taking a throat swab to assist with differential
diagnosis or if the patient is thought to be part of an outbreak (to confirm
aetiology), allergic to penicillin (to determine antimicrobial susceptibility)
or in regular contact with vulnerable individuals
Parents of children with presumed respiratory viral infection
should be made aware of features suggestive of secondary bacterial infection,
such as clinical deterioration, and when and how to seek further help. Safety
netting advice for parents can be found here.
GPs should maintain a low threshold for prompt referral to secondary
care of any children presenting with persistent or worsening symptoms.
for secondary care:
Maintain a low threshold for considering pulmonary complications
of GAS, especially if presenting with: an illness compatible with bacterial pneumonia,
scarlet fever, GAS infection, or if GAS was recently isolated, or the patient
was recently in contact with a case of scarlet fever/ GAS infection. Prompt
initiation of appropriate antibiotics remains key.
In the case of culture-negative fluid specimens, use molecular
diagnostics such as GAS-specific PCR or 16S rDNA PCR, as guided by microbiology
Clinicians are further reminded of the importance of rapid
notification of all cases of severe GAS infection (including pneumonic complications/
empyema) to Health Protection Teams to facilitate rapid assessment of contacts
and identification of epidemiological links with other cases, as per national
public health guidelines.
Severe GAS cases encompass cases of invasive disease (iGAS) defined
through the isolation of GAS from a normally sterile site, plus additional
cases where GAS is isolated from a non-sterile site in combination with
clinical signs consistent with a severe infection (streptococcal toxic shock
syndrome, pneumonia, necrotising fasciitis, puerperal sepsis, meningitis,
septic arthritis). This includes cases diagnosed via culture or molecular
Advice for parents:
Scarlet fever is caused by bacteria called group A streptococci.
These bacteria also cause other respiratory and skin infections such as strep
throat and impetigo.
Scarlet fever is usually a mild illness, but it is highly
infectious. Therefore, look out for symptoms in your child, which include a
sore throat, headache, and fever, along with a fine, pinkish or red body rash
with a sandpapery feel. On darker skin, the rash can be more difficult to
detect visually but will have a sandpapery feel. Contact NHS 111 or your
GP if you suspect your child has scarlet fever, because early treatment of
scarlet fever with antibiotics is important to reduce the risk of complications
such as pneumonia or a bloodstream infection. If your child has scarlet fever,
keep them at home until at least 24 hours after the start of antibiotic
treatment to avoid spreading the infection to others.
In very rare occasions, the bacteria can get into the bloodstream
and cause an illness called invasive Group A strep (iGAS).
There are lots of viruses that cause sore throats, colds and
coughs circulating. These should resolve without medical intervention. However,
children can on occasion develop a bacterial infection on top of a virus and
that can make them more unwell.
As a parent, if you feel that your child seems seriously unwell,
you should trust your own judgement. Contact NHS 111 or your GP if:
your child is getting worse
your child is feeding or eating much less than normal
your child has had a dry nappy for 12 hours or more or shows
other signs of dehydration
your baby is under 3 months and has a temperature of 38°C, or is
older than 3 months and has a temperature of 39°C or higher
your baby feels hotter than usual when you touch their back or
chest, or feels sweaty
your child is very tired or irritable
Call 999 or go to A&E if:
your child is having difficulty breathing – you may notice
grunting noises or their tummy sucking under their ribs
there are pauses when your child breathes
your child’s skin, tongue
or lips are blue
your child is floppy and will not wake up or stay awake
Healthier Together website: This includes an excellent traffic light guideline and graphics of strep A infection
Health Security Agency website.