Increase in invasive Group A streptococcal infections among children in Europe, including deaths | Popgen Tech

A number of European countries (including France, Ireland, the Netherlands, Sweden and the United Kingdom) have indicated an increase in 2022, particularly since September, in the number of cases of invasive Group A streptococcal (iGAS) disease among children under 10 years of age age.

During the same period, several deaths related to iGAS disease in children under 10 were also reported, including from France, Ireland and the United Kingdom. In France and the United Kingdom, the number of iGAS cases observed in children was several times higher than the pre-pandemic levels for the equivalent period.

The observed increases reported to WHO/Europe and the European Center for Disease Prevention and Control (ECDC) followed a period of reduced incidence of Group A Streptococcus (GAS) infections during the COVID-19 pandemic.

It is likely that the increase in cases of iGAS disease in children is also associated with the recent increased circulation of respiratory viruses, including seasonal influenza and respiratory syncytial virus, as co-infection of viruses with GAS may increase the risk of iGAS disease.

Disease symptoms

GAS bacteria are the most common cause of bacterial pharyngitis in school-aged children. Gas infections usually cause mild illness, including sore throat, headache and fever, along with a fine, red rash (scarlet fever). The incidence of GAS pharyngitis usually peaks during winter months and early spring in Europe. Outbreaks in kindergartens and schools are frequently reported. GAS pharyngitis is diagnosed by a rapid antigen detection test and/or bacterial culture, and is treated with antibiotics and supportive care.

In rare cases, GAS bacteria can also cause a serious, life-threatening infection known as iGAS disease, which can manifest as bacteremia, pneumonia, or skin and bone infection (cellulitis, osteomyelitis, necrotizing fasciitis). Children with viral infections such as varicella (chicken pox) or influenza are at greater risk of developing iGAS disease.

Risk assessment

GAS and iGAS infections are notifiable diseases in only a limited number of European countries. It is therefore difficult to assess the overall level of circulation in the WHO European Region at this stage.

Although investigations are ongoing, early typing data suggest that the surge in cases is not related to a specific or new strain, nor is it an increase in antibiotic resistance of GAS.

Given that the current increase in cases of iGAS disease is generally relatively low, that the reported cases are not caused by a new strain, and that the disease is easily treatable with antibiotics, the WHO/Europe and ECDC are currently assessing the risk to the general population from iGAS infection is so low. This will be reviewed as investigations continue.

Reaction

All European countries should be alert for a similar increase in cases among children, especially considering the increase in respiratory virus circulation now occurring in Europe.

Reducing the transmission of GAS will help reduce the risk of severe iGAS infection. Early recognition of iGAS disease and prompt initiation of specific and supportive therapy for patients can be life-saving. Public health authorities should therefore consider activities to raise awareness among clinicians and the general public, and encourage rapid testing and treatment of GAS infections according to national guidelines.

GAS infections should be included in the differential diagnosis of children presenting with severe respiratory syndromes and those with prior viral infection (including chickenpox), as well as those who have been in close contact with scarlet fever patients. Close contacts of iGAS cases should be identified, assessed and managed according to national guidelines.

WHO Regional Director for Europe, Dr Hans Henri P. Kluge, is calling on countries to “increase vigilance for iGAS cases, especially when respiratory viruses are widely circulating in children”. ECDC Director Dr Andrea Ammon notes that “iGAS cases can be easily managed if detected in time”.

WHO/Europe and ECDC encourage countries to undertake public health messages to parents and guardians of young children. iGAS infections may initially present with non-specific symptoms (fever, general fatigue, loss of appetite) but, especially in children, may rapidly progress to severe disease. Parents and guardians should therefore be aware of worrying symptoms and seek clinical advice and assessment if their child’s health does not improve.

Public health authorities are encouraged to coordinate with laboratories to obtain specimens for and/or data regarding molecular testing and antibiotic susceptibility testing.

As prevention of viral diseases is likely to be important in reducing the risk of iGAS disease, vaccination against seasonal influenza and COVID-19 should also be promoted.

Adequate hand and respiratory hygiene, as well as good indoor ventilation, should continue to be emphasized as important protective measures during this winter season. Schools and other educational facilities where GAS infections are reported should follow cleaning and disinfection guidelines for toys and frequently touched surfaces.

ECDC and WHO/Europe will continue to work with countries to gain a better understanding of the epidemiological situation in the region, and to provide practical recommendations to the public and guidance for countries’ responses.

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*This article was amended on 13 December 2022. An earlier version of this web article identified Spain among the countries reporting an increase in cases. Although several cases have been reported in Spain, an increase compared to previous years has not been detected.