Research and analysis

Group A streptococcal infections: ninth update on seasonal activity in England

Updated 29 June 2023

Applies to England

Data to 14 February 2023.

Main points

Notifications and GP consultations of scarlet fever in England identified exceptional levels of activity in the early phase of the season. Whilst rapid declines were seen in the second half of December, numbers of notifications remained above usual seasonal levels and are now fluctuating. Notifications of invasive group A streptococcus (iGAS) disease remain at the top end of the range expected for this time of year. Relatively high rates of iGAS infection in children are observed with increases in adults occurring in recent weeks.

Medical practitioners were alerted to this early increase in incidence and elevated iGAS infection in children on 2 December 2022. Given the potential for severe presentations, scarlet fever cases should be treated promptly with antibiotics to limit further spread and reduce potential complications in cases and their close contacts. Clinicians should continue to be alert to the severe complications of GAS and maintain a high degree of clinical suspicion when assessing patients, particularly those with preceding viral infection (including chickenpox) or who are close contacts of someone with scarlet fever.

Updated UK public health guidance on the management of close contacts of iGAS cases in community settings was published on 15 December 2022, with additional close contact groups now recommended for antibiotic prophylaxis.

Interim clinical guidance on management of GAS infection was issued on 9 December 2022 to optimise diagnosis and treatment during this current increase in infection. Following recent decreases in GAS activity, this guidance was rescinded on 16 February 2023 with the agreement of relevant organisations and sore throat guidance has reverted to NICE guidance.

National guidance on the management of scarlet fever outbreaks highlights essential tools to limit spread: prompt notification of scarlet fever cases and outbreaks to UK Health Security Agency (UKHSA) Health Protection Teams (HPTs), collection of throat swabs (prior to commencing antibiotics) when there is uncertainty about the diagnosis and exclusion of cases from school or work until 24 hours of antibiotic treatment has been received.

Data presented within this seasonal activity update is based on data available as of 14 February 2023 (the end of week 6). Numbers presented in this report may change when updated data becomes available. A seasonal update report will be published in early March. Weekly notifiable disease reports are published each week throughout the year to provide a regular update of scarlet fever notifications.

Key definitions are available at the end of the report.

Scarlet fever

Higher than expected scarlet fever activity was noted during the early part of summer 2022 in England and notifications during the early part of the current 2022 to 2023 season increased to exceptional levels (Figure 1).

A total of 44,478 notifications of scarlet fever were received from week 37 to week 6 of this season (2022 to 2023) in England, with a pre-Christmas peak of 10,020 notifications in week 49. This compares with an average of 4,907 (range 645 to 8,570) for this same period (weeks 37 to 6) in the previous 5 years. Increased health seeking behaviour as a result of national alerts is likely to have contributed to the increased reports. The last peak season for scarlet fever notifications was 2017 to 2018 when 30,768 reports were received across the entire season.

Notifications in the early weeks of 2023 remain lower than those reported in December 2022, but remain slightly higher than would be expected at this point in the season.

Figure 1. Weekly scarlet fever notifications in England, by season, 2017 to 2018 onwards (weeks 37 to 6)

Note: Data for the current season goes up to week 6 (12 February 2023); data for the most recent weeks may change as further notifications are received and processed, represented by a dotted line between weeks 47 2022 and 6 2023.

Scarlet fever notifications to date this season showed considerable variation across England, ranging between 62.3 (West Midlands) and 114.3 (East Midlands) per 100,000 population (table 1).

Table 1. Number and rate per 100,000 population of scarlet fever and iGAS notifications in England: week 37 to week 6 of the 2022 to 2023 season

Week 37 to week 6 covers the period 12 September 2022 to 13 February 2023.

Region	Number of cases of scarlet fever	Rate of scarlet fever	Number of cases of iGAS	Rate of iGAS
East of England	4,454	67.1	194	2.9
East Midlands	5,576	114.3	188	3.9
London	5,883	66.9	263	3.0
North East	1,828	69.1	124	4.7
North West	7,350	99.0	246	3.3
South East	6,587	73.1	357	4.0
South West	4,093	71.6	260	4.6
West Midlands	3,708	62.3	185	3.1
Yorkshire and the Humber	4,994	91.1	264	4.8
England	44,473	78.7	2,081	3.7

Invasive group A streptococcal infection

Laboratory notifications of iGAS infection so far this season (weeks 37 to 6, 2022 to 2023) remain considerably higher than expected (Figure 2). A total of 2,081 notifications of iGAS disease were reported through laboratory surveillance in England, with a weekly high of 226 notifications in week 52 (26 December 2022 to 1 January 2023). Laboratory notifications of iGAS infection are higher than recorded over the last 5 seasons for the same weeks (average 736, range 347 to 1,043 notifications; Figure 2).

Figure 2. Weekly laboratory notifications of invasive GAS, England, by season, 2017 to 2018 onwards (weeks 37 to 6)

Note: In this graph, the most recent weeks of the 2022 to 2023 season are expected to increase due to lags in reporting timelines from laboratories. The decline in recent weeks should be interpreted with caution, normal processing and reporting timeframes mean that increases in laboratory reports are expected – represented by a dashed line between weeks 4 and 6.

Whilst a decline in weekly laboratory notifications has been seen since week 52, high levels of activity at such an early point in the season remain a concern, with further increases possible in the coming weeks as we move towards the usual time of year for peak activity, typically occurring between weeks 6 and 18

During the current season to date, the highest rates were reported in the Yorkshire and Humber region (4.8 per 100,000 population), followed by the North East (4.7 per 100,000) and South West (4.6 per 100,000; see Table 1.

The highest rate was in the 1 to 4 years age group (9.4 per 100,000), followed by those aged 75 years and over (9.1 per 100,000) and the under-1-year age group (6.7 per 100,000); see Table 2.

Table 2. Rate per 100,000 population of iGAS notifications in England by age group, week 37 to week 6 in the 2022 to 2023 season versus the 2017 to 2018 season

Note: In this table the current 2022 to 2023 season covers weeks 37 to 6, whereas the 2017 to 2018 season data covers the full season, weeks 37 to 36.

Age group (years)	2022 to 2023 season (weeks 37 to 6): number of cases	2022 to 2023 season (weeks 37 to 6): rate per 100,000 population	2017 to 2018 (full season): number of cases	2017 to 2018 (full season): rate per 100,000 population
Aged 1 year and under	39	6.7	80	12.5
1 to 4	233	9.4	194	7.2
5 to 9	156	4.7	117	3.3
10 to 14	50	1.5	40	1.2
15 to 44	433	2.0	633	3.0
45 to 64	419	2.9	625	4.4
65 to 74	303	5.4	480	8.7
75 and over	448	9.1	792	17.0
Total	2,081	3.7	2,967	5.3

The median age of patients with iGAS infection so far this season was 51 years (range 1 year and under, to 102 years), slightly lower than the range seen at this point in the preceding 5 seasons (age 53 to 58 years); 21% of iGAS infections reported so far this season are in children (aged 15 years and under), higher than the range seen for the past 5 seasons (5% to 14%). The slight increase in median age compared to earlier in the season, and the percentage of iGAS that are in children (under 15 years of age), continued to indicate a slight change towards more cases occurring in the older adult age groups (65 years and over).

So far this season 262 deaths have been recorded within 7 days of an iGAS infection diagnosis (from any cause), with 64% (n=168) of the recorded deaths being in those aged 65 years and over, and 10% (n=26) in children aged 10 years and under (Table 3). The case fatality rate (CFR) to date is higher than in recent seasons, although it does vary by age group with the CFR being more elevated in elderly people. Elevations in rates of iGAS infection in children in this early part of this season have resulted in an increased number of deaths over a relatively short period, with 31 deaths in children aged under 15 identified to date for weeks 37 to 6.

There have been 466 iGAS reports in children under 18 years in the season to date (24% of iGAS reports), with 32 deaths being recorded in this age group (CFR of 7.2%).

Antimicrobial susceptibility results obtained from routine laboratory surveillance so far this season indicate tetracycline resistance in 12% of GAS sterile site isolates; this is lower than at this point last season (44%). Susceptibility testing of iGAS isolates against erythromycin indicated 4% were found resistant (compared with 17% last season) and, for clindamycin, 4% were resistant at this point in the season (14% last season). Isolates remained universally susceptible to penicillin.

Analysis of iGAS isolate typing data continues to indicate a diverse range of emm gene sequence types identified this season. The results indicate emm 1 remains the most common (48% of referrals), followed by emm 12 (14%) and emm 89 (4%), compared with 20%, 6% and 10% at the same point in the 2017 to 2018 season, respectively. In children (aged under 15 years) emm 1 and emm 12 have dominated this season, accounting for 58% and 23% respectively (compared with 17% and 10% at this point in the 2017 to 2018 season).

Table 3. Case fatality rate (%) for deaths (all causes) within 7 days of an iGAS specimen, by age group in England for the current season and the previous 5 seasons

Notes: The total may include notifications where the age was unknown. The case fatality rate is the percentage of deaths within 7 days of iGAS infection diagnosis for cases where follow-up has been possible. CFR should be interpreted with caution given the small numbers involved. The current season data (2022 to 2023) covers week 37 to week 6 (12 September 2022 to 12 February 2023). The prior seasons cover the whole season (weeks 37 to 36). ‘Pandemic seasons’ presents data for the 2019 to 2020 and 2020 to 2021 seasons combined.

Age group (years)	2017 to 2018 season % CFR	2018 to 2019 season % CFR	Pandemic seasons (2019/2020 and 2020/2021) % CFR	2021 to 2022 season % CFR	2022 to 2023 season (weeks 37 to 6) % CFR	2022 to 2023 season: number of deaths (all causes) within 7 days of iGAS
Aged 1 year and under	5.6%	2.1%	7.7%	3.8%	5.1%	2
1 to 4	4.7%	6.1%	9.0%	5.9%	7.0%	15
5 to 9	9.9%	4.6%	2.7%	10.6%	6.5%	9
10 to 14	7.9%	8.7%	23.8%	0.0%	12.8%	5
15 to 44	4.1%	1.7%	2.5%	2.3%	6.7%	26
45 to 64	8.4%	8.6%	9.3%	9.7%	9.7%	37
65 to 74	13.5%	8.8%	13.8%	13.1%	18.3%	50
75 and over	24.4%	16.8%	19.9%	18.1%	29.0%	118
Total	12.4%	9.1%	11.3%	10.0%	14.0%	262

Discussion

While a recent downturn in scarlet fever notifications has been reported, it is unclear whether the reduction will be sustained, particularly as weekly rates of scarlet fever notification GP consultations remain above expected levels at this point of the season. While decreases are often seen over the Christmas school break, this decline pre-dated the end of the school term. Public and healthcare professional alerts issued in week 48 (2 December 2022) may have succeeded in bringing people forward for clinical assessment and treatment, inducing the sharp increase in notifications in week 49 and reducing onward transmission. Ongoing monitoring will continue in the weeks following the start of the school term to assess the impact on transmission.

The rate of iGAS infection notifications across the season showed a similar pattern of elevation, with weekly incidence trending above what would be expected during the first part of the season, particularly during December 2022.

While the rate of iGAS infection is elevated in all age groups, incidence in children aged under 10 years is particularly elevated compared to levels reported in the last peak season, and substantially higher than in the past 2 years. However, there continue to be indications of an increase of iGAS notifications in the older age groups in recent weeks; further epidemiological analysis will monitor this trend.

Investigations are underway following reports of an increase in lower respiratory tract GAS infections, particularly empyema, in children over the past few weeks (1). The current emm types have been circulating for many years. Whilst a new strain of emm1 (M1UK) was documented as having emerged and expanded in the last decade, its role (if any) in driving the current high levels of iGAS in children remains uncertain. At present, the weekly rate of iGAS in individuals over 75 years is higher than has been seen at this point in the season in pre-pandemic periods; the CFR at this point in the season is slightly higher than for previous years, with emm1 dominant in this age group. Detailed genomic and biological investigations are underway to investigate any differences in the pathogen being seen this season.

The elevated iGAS levels in children compared to the period when pandemic control measures were in place is likely to be a consequence of the heightened scarlet fever activity given the crossover of strains associated in both presentations (2, 3). Reduced exposure to GAS infections during the pandemic is also likely to have led to increased susceptibility to these infections in children, in view of the very low levels seen during pandemic. Prompt treatment of scarlet fever with antibiotics is recommended to reduce risk of possible complications and limit onward transmission.

Public health messaging to encourage contact with NHS 111 or GP practices for clinical assessment of patients with specific symptoms suggestive of scarlet fever has been issued along with reminders to provide ‘safety netting’ advice for parents indicating signs and symptoms of deterioration, particularly for children with respiratory viral infection. GPs and other frontline clinical staff are also reminded of the increased risk of invasive disease among household contacts of scarlet fever cases (4, 5).

Clinicians should continue to maintain a high index of suspicion in relevant patients for invasive disease as early recognition facilitates prompt initiation of specific and supportive therapy for patients with iGAS infection.

Relevant guidelines and information can be found on GOV.UK as follows:

• Guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings

• Scarlet fever: symptoms, diagnosis and treatment

• Guidelines for the management of close community contacts of invasive GAS cases

• Prevention and control of group A streptococcal infection in acute healthcare and maternity settings)

• Weekly notifiable disease reports are published for a timelier update
• Group A Strep – What you need to know (blog post)

Invasive disease isolates and also non-invasive isolates from suspected clusters or outbreaks should be submitted to:

Staphylococcus and Streptococcus Reference Section
Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI)
UK Health Security Agency
61 Colindale Avenue
London
NW9 5HT

Data sources and methods

Scarlet fever notification data was extracted from the notifications of infectious diseases (NOIDs) reports. Data for England was extracted on 14 February 2023. Weekly totals include a few scarlet fever notifications identified in port health authorities; this will mean that the regional totals will not equal the season total for England.

Invasive GAS laboratory notification data was extracted from the UKHSA Second Generation Surveillance System (SGSS) and combined with specimen referrals to the Staphylococcus and Streptococcus Reference Section to produce a total number of episodes for England. Data was extracted on 14 February 2023.

The sharp increase in scarlet fever and other group A strep infections alongside increased awareness and vigilance amongst clinicians has led to a significant rise in scarlet fever notifications in recent weeks. This has resulted in a backlog of notifications of scarlet fever cases being entered into the national database after being processed.

A season runs from week 37 in one year to week 36 in the following year (mid-September to mid-September). The 2022 to 2023 season data within this report covers 12 September 2022 to 12 February 2023.

All-cause deaths within +/- 7 days: reported date of death (obtained from tracing against the NHS SPINE where patient information is available) is compared to the date of iGAS specimen in a patient. This includes those where the difference between the 2 dates is ≤ 7 days, or ≥ minus 7 days (to include those potentially diagnosed via post mortem). Follow-up was not possible for all reported iGAS cases, primarily due to poor identifier (NHS number and date of birth) completion. In addition, not all iGAS cases have the full 7-day follow-up period for case fatality assessment. CFR should be interpreted with caution given the small numbers involved.

An improved method of patient de-duplication was implemented for the eighth seasonal update report and subsequent reports. This corrected an error which resulted in a small number of records being counted more than once in the mortality analyses in previous reports. The improved data cleaning process has been applied to current and previous seasons data presented in Table 3.

Population rates are calculated per 100,000 using the relevant year ONS mid-year population estimate. Rates have been updated to reflect the recent release of the 2021 mid-year population estimates.

The M protein gene (emm) encodes the cell surface M virulence protein.

Prior to the coronavirus (COVID-19) pandemic, there were a number of seasons with elevated incidence of scarlet fever and iGAS, in particular, the 2017 to 2018 season; this has been used as comparison point to the trends in the current season. During the pandemic there was an unprecedented reduction in the number of scarlet fever and iGAS notifications, affecting the 2019 to 2020 season, and the 2021 to 2022 season.

References

1. Guy R, Henderson KL, Coelho J, Hughes H, Mason EL, Gerver SM and others (2023). Increase in invasive group A streptococcal infection notifications, England, 2022. Eurosurveillance: volume 28, issue 1.

2. Chalker V, Jironkin A, Coelho J, Al-Shahib A, Platt S, Kapatai G, and others (2017). ‘Genome analysis following a national increase in scarlet fever in England 2014’. BMC Genomics: volume 18 number 1, page 224

3. Al-Shahib A, Underwood A, Afshar B, Turner CE, Lamagni T, Sriskandan S, and others (2016). Emergence of a novel lineage containing a prophage in emm/M3 group A Streptococcus associated with upsurge in invasive disease in the UK’. mGen; volume 2 number 11

4. Lamagni T, and others (2018). ‘Resurgence of scarlet fever in England, 2014–16: a population based surveillance study’. The Lancet Infectious Diseases: volume 18, number 2, pages 180 to 187

5. Watts V, and others (2019). ‘Increased risk for Invasive Group A Streptococcus disease for household contacts of scarlet fever cases, England, 2011–2016’. Emerging Infectious Diseases: volume 25, number 3, pages 529 to 537

Acknowledgements

These reports would not be possible without the weekly contributions from microbiology colleagues in laboratories across England, without whom there would be no surveillance data.

The support from colleagues within UKHSA, and the AMRHAI Reference Unit in particular, is valued in the preparation of the report.

Feedback and specific queries about this report are welcome via hcai.amrdepartment@ukhsa.gov.uk