The group A strep disaster: can we do higher?

We should be taught from the group A strep disaster, writes Alastair Hay

Final month the UK Well being Safety Company (UKHSA) launched a report displaying that from 12 September to twenty November 2022 there was a 4 to fivefold improve within the incidence of scarlet fever and 5 deaths from invasive group A streptococcal (iGAS) an infection.1

The UKHSA gave a transparent description of scarlet fever and the late levels of strep A an infection, advising dad and mom to “belief their judgment” and call NHS 111 or their GP if their baby appeared “critically unwell.” Mother and father of youngsters who had respiratory difficulties or blue pores and skin, tongue, or lips or who had been unresponsive had been suggested to name 999 or go to the emergency division.1 Since then, harrowing tales of youngsters falling unwell and dying from iGAS an infection have appeared within the media.

The outcome has been a dramatic improve in demand as involved dad and mom contact and attend NHS 111, main care, paediatric evaluation models, and emergency departments. Providers have been overwhelmed, with some studies of requests for care from dad and mom of mildly unwell, and even completely nicely, youngsters.

The paradox is that nicely intentioned messaging could have harmed public well being by making the detection of unwell youngsters more durable. Scarlet fever is a nicely recognised an infection of youngsters that’s simply recognized as soon as the cardinal options are current. Nevertheless, early signs equivalent to fever and sore throat are indistinguishable from different, extra widespread, sicknesses attributable to viruses such flu, SARS-CoV-2, and respiratory syncytial virus (RSV). Which means that, regardless of having among the world’s finest skilled frontline clinicians, we can not reliably reply to oldsters of youngsters with undifferentiated signs who, prompted by the media, ask, “Does my baby have strep?” Microbiological testing, utilizing both standard laboratory tradition or speedy antigen testing, is unlikely to assist on condition that commensal carriage is current in as many as 15% of youngsters.2

Messaging and analysis

So, what might be completed in another way? First, timing is vital. The incidence of scarlet fever had been rising for 2 months,1 suggesting that the UKHSA might have given the NHS, antibiotic suppliers, and pharmacies extra time to organize.

Second, messaging content material. Though detailed details about finish stage scarlet fever was offered, no context was given about its chance in relation to different self-limiting febrile sicknesses. Judging by the general public response, a big quantity appear to have concluded that, “if my baby is unwell, I ought to contact my GP, NHS 111, or emergency division.” The UKHSA might have anticipated, and offered detailed solutions to, the general public’s questions equivalent to, “When ought to I search assist?” “When ought to my baby obtain antibiotics?” and “Ought to I ask for or buy a check?”

Third, we should contemplate if, and the way, the NHS can reply. The signs and indicators of prodromal group A streptococcus an infection usually are not delicate or particular sufficient to differentiate it from different febrile sicknesses, and there’s no check to differentiate commensal carriage from an sickness inflicting pathogen. Contemplating this, how are paediatricians, GPs, and nurses supposed to reply? The Wilson screening standards, which needs to be absolutely met earlier than screening programmes are initiated, are solely partially met. Whereas scarlet fever and strep A are necessary well being issues, we don’t absolutely perceive the microbiological pure historical past of group A streptococcus an infection, there’s no absolutely recognisable early symptomatic stage, and we’ve got no check that’s simple to carry out and interpret and is appropriate, correct, dependable, delicate, and particular.

Lastly, analysis is required to analyze the security and effectiveness of public well being messaging, to supply the general public with proof based mostly recommendation on whether or not to hunt medical assist, and to assist folks distinguish between “regular” sicknesses and people who require intervention.3 Frontline clinicians should be outfitted with the instruments to precisely and reliably distinguish between sufferers who will or won’t profit from remedy. The microbiological pure historical past of widespread infections should be researched additional, to make clear how organisms equivalent to Streptococcus pyogenes (and Neisseria meningitidis), that are generally and harmlessly carried in higher respiratory tracts, change into pathogenic. And we should develop and consider speedy, level of care checks that may distinguish when an organism is being harmlessly carried from when it’s inflicting illness.


Alastair D Hay is an NIHR senior investigator. The views and opinions expressed are these of the writer and never essentially these of the NHS, the NIHR (Nationwide Institute for Well being and Care Analysis), or the Division of Well being and Social Care. He thanks his GP colleagues at Harmony Medical Centre, Bristol, for his or her contributions.


  • Competing pursuits: none declared.

  • Provenance and peer overview: commissioned, not externally peer reviewed.