Clinical management and impact of scarlet fever in the modern era: findings from a cross-sectional study of cases in London, 2018–2019

Abstract

ObjectivesIn response to increasing incidence of scarlet fever and wider outbreaks of group A streptococcal infections in London, we aimed to characterise the epidemiology, symptoms, management and consequences of scarlet fever, and to identify factors associated with delayed diagnosis.Design and settingCross-sectional community-based study of children with scarlet fever notified to London’s three Health Protection Teams, 2018–2019.ParticipantsFrom 2575 directly invited notified cases plus invitations via parental networks at 410 schools/nurseries with notified outbreaks of confirmed/probable scarlet fever, we received 477 responses (19% of those directly invited), of which 412 met the case definition. Median age was 4 years (range <1 to 16), 48% were female, and 70% were of white ethnicity.Outcome measuresPreplanned measures included quantitative description of case demographics, symptoms, care-seeking, and clinical, social, and economic impact on cases and households. After survey completion, secondary analyses of factors associated with delayed diagnosis (by logistic regression) and consequences of delayed diagnosis (by Cox’s regression), and qualitative analysis of free text comments were added.ResultsRash was reported for 89% of cases, but followed onset of other symptoms for 71%, with a median 1-day delay. Pattern of onset varied with age: sore throat was more common at onset among children 5 years and older (OR3.1, 95% CI 1.9 to 5.0). At first consultation, for 28%, scarlet fever was not considered: in these cases, symptoms were frequently attributed to viral infection (60%, 64/106). Delay in diagnosis beyond first consultation occurred more frequently among children aged 5+ who presented with sore throat (OR 2.8 vs 5+without sore throat; 95% CI 1.3 to 5.8). Cases with delayed diagnosis took, on average, 1 day longer to return to baseline activities.ConclusionsScarlet fever may be initially overlooked, especially among older children presenting with sore throat. Raising awareness among carers and practitioners may aid identification and timely treatment.

Toxic Streptococcal Infection in Children: Report on Two Cases with Uncharacteristic Course of Scarlet Fever

“…Usually, the course of scarlet fever is mild, and a return to normal activity occurs after two days with the use of appropriate treatment; very rarely is it a reason for hospitalization [ 2 ].…”

“…Thus, it is an important epidemiological risk factor for death and severe complications [ 1 ]. Scarlet fever is a common infectious disease with a characteristic morphology; however, according to existing data, its diagnosis is often delayed or not considered at all in groups of children over five years of age due to its similarity to streptococcal pharyngitis [ 2 , 3 ]. Distinguishing between viral and bacterial etiologies of acute pharyngitis can be problematic when attempting to make a correct diagnosis.…”

Scarlet Fever: An Exploration Based on Characteristics, History and The Intervention

“…At the beginning of the 20 centuries, major outbreaks were reported in several countries. For example, Vietnam identified more than 23,000 cases in 2009 and mainland China had an outbreak of more than 100,000 cases [9]. Between 2004-2016, 502723 cases were reported by more than ten facilities in China.…”

Progress towards a glycoconjugate vaccine against Group A Streptococcus

“…Invasive infections have high mortality and morbidity, and secondary diseases from autoimmune sequelae such as rheumatic heart disease (RHD) result in significant disease adjusted life years (DALYs), particularly in Low- and Middle-Income Countries (LMICs) 5 . In recent years there has further been a re-emergence of scarlet fever particularly noted in the UK and Europe, with particular concern in the current season with rising rates of sepsis associated with these infections 6 , 7 . There is therefore an urgent need globally to develop a vaccine against Strep A.…”