With Covid-19 dominating the news for almost three years, it’s easy to forget the other infectious diseases that still cause us problems. Strep A has been making news headlines because eight children have died of it in England and Wales, plus one in Northern Ireland. And in Scotland, 437 children were recorded as having strep A in the past two weeks, putting it on par with the 2017/18 season, albeit much earlier in the winter.
Strep A is a common infection in children and most cases are mild or asymptomatic. But on rare occasions, some cases cause scarlet fever and strep throat and bacteria gets into the bloodstream and lungs, causing sepsis. The rising numbers of infections and deaths have understandably caused anxiety among parents. Early signs of strep A can look similar to a range of other infections, and it spreads easily among children via sneezing and coughing, or through touching. This makes it a difficult disease to contain during an indoor mixing and party season, and clinically it is hard to diagnose strep A at an early stage when it is seen in primary care.
Why are we seeing a steep increase in cases, at a different time of year compared with before the pandemic? The scientific process involves waiting for clear data, analysing this data and testing it against various explanations. But sadly, those with political or ideological agendas have been quick to fit this into their pre-existing narrative: some have said it’s a consequence of lockdown and children not being exposed enough to diseases and building up an “immunity debt”, while others have said it’s due to weakened immune systems from prior Covid-19 infection, given that the majority of children have now had Covid-19.
Neither of these hypotheses has enough data to support it yet. And in fact one could also argue that restrictions on social mixing and the reduced transmission of all infectious diseases delayed strep A infection in children, including severe cases. A similar argument can be made for the benefits of delaying RSV infection in infants, which can trigger recurrent wheezing and asthma during childhood.
The myth that “it’s better to get infected early” has also spread widely: it was evident in early 2020 when “Covid-19 parties” took place with a view to getting it over and done with. There are children who died because of this approach. The simple message is that it’s better to avoid getting ill if possible: whether it’s strep A, Covid-19, seasonal flu, RSV or cholera. But with mixing and daily life, we do get infected unintentionally, and there should be no blame on individuals or stigma associated with disease.
How worried should we be about strep A? This is not a repeat of Covid-19: strep A is a disease that is well researched and known by the medical community. The first step is to raise awareness among parents and caregivers of the early signs to look for and when to seek medical care. These are: high fever not coming down with pain medication, rashes on the body (raised bumps like sandpaper), an extremely painful sore throat, and extreme tiredness and lethargy. There is an inexpensive and widely available treatment that works for most unwell children. And there is a good surveillance system with positive throat swabs being recorded by laboratories and sent to health authorities to keep track of the rise in cases.
Strep A is a treatable infection if managed early on. Early use of antibiotics such as penicillin works against the vast majority of infections within 24 hours, and early treatment is vital to better outcomes. With concerns about antibiotic resistance, and given that the vast majority of winter bugs are viruses, GPs usually don’t prescribe medicine for coughs, colds or low-grade fevers. But now guidance has asked GPs to be especially vigilant for strep A, which may mean temporarily lowering the threshold for prescribing antibiotics.
The healthcare challenge is how to include strep A on top of an overloaded and struggling primary care system: for example, to have enough GP appointments for all children who need to be seen, and to find a good way to diagnose strep A without moving to mass distribution of antibiotics. Diagnosis is a challenge in the NHS, given that swabs need to be sent to laboratories and can take days to get back – this creates delays in diagnosis and treatment. The US uses rapid strep A tests, which are throat swabs taken by a medical practitioner, with results within 15 minutes. If the test is positive, antibiotics can be immediately started. If it’s negative, but strep A is still suspected, then the swab is sent to the laboratory for more extensive investigation.
Introducing these rapid strep A tests into primary care would help an overburdened system by allowing nurses and support staff to test children who are unwell, and move quickly to the most appropriate clinical management. It makes sense to introduce these during a surge of cases and pressure on the NHS, and also to help keep children out of hospital.
Every child death is a tragedy, and must be taken seriously. In 2020, 789 child deaths were recorded in England and Wales, which was the lowest on record, with 11 of those caused by Covid-19. Most deaths in children are due to cancer, accidents such as injuries and poisonings, and congenital conditions. We have made major progress in reducing child deaths in Britain, particularly from infectious diseases such as measles and pneumonia. And while strep A is obviously concerning, we have the knowledge and tools to manage the disease and prevent more deaths.