Seizing opportunities for prevention of group A streptococcal infection
Authors: Theresa Lamagni, Calum McGregor, Rebecca L Guy, James Whitworth, Androulla Efstratiou
Journal: The Lancet Microbe (2024)

We read with interest the Comment by Dingle Yu and colleagues1Yu D Liang Y Lu Q et al.Thoughts on group A streptococci.Lancet Microbe. 2023; 4: e484-e485Summary Full Text Full Text PDF PubMed Google Scholar and strongly agree that group A streptococcal (GAS) infections have been neglected and warrant increased attention. Global deaths due to GAS infection rank among the highest for any infectious disease, with a disproportionate impact on the poorest nations and most susceptible subpopulations; however, research and development funding allocated for GAS diseases is remarkably low.2Macleod CK Bright P Steer AC Kim J Mabey D Parks T Neglecting the neglected: the objective evidence of underfunding in rheumatic heart disease.Trans R Soc Trop Med Hyg. 2019; 113: 287-290Crossref PubMed Scopus (27) Google Scholar In the absence of a licensed vaccine, tools to combat the spread of GAS infections are scarce and improvements in diagnosis and surveillance are required. Providing effective treatment for GAS infections is key to reducing the risk of complications and the spread of this pathogen, with more than one in ten individuals no longer infectious within 24 h of starting antibiotics.3McGuire E Li A Collin SM et al.Time to negative throat culture following initiation of antibiotics for pharyngeal group A streptococcus: a systematic review and meta-analysis up to October 2021 to inform public health control measures.Euro Surveill. 2023; 282200573Crossref Scopus (2) Google Scholar Reducing transmission from patients with superficial infections, such as pharyngitis, reduces the risk of life-threatening invasive infection in close contacts, given the crossover of strains causing both mild and severe presentations.4Watts V Balasegaram S Brown CS et al.Increased risk for invasive group A streptococcus disease for household contacts of scarlet fever cases, England, 2011-2016.Emerg Infect Dis. 2019; 25: 529-537Crossref PubMed Scopus (19) Google Scholar,5Chalker V Jironkin A Coelho J et al.Genome analysis following a national increase in scarlet fever in England 2014.BMC Genomics. 2017; 18: 224Crossref PubMed Scopus (46) Google Scholar As noted by Yu and colleagues, GAS infections should be treated. In the UK, point-of-care tests are not used in routine practice, thus making the country an outlier among high-income countries. This approach creates challenges in identifying individuals who can benefit from antibiotic treatment. A re-assessment of the use of these tests in primary care and emergency departments is long overdue. Yu and colleagues noted inter-country and within-country variations in the statutory requirements to notify manifestations of GAS infection. In England and Wales, a review of notification legislation in 2010 added invasive GAS (iGAS) infection to the schedule as a means of facilitating rapid identification and assessment of iGAS contacts, as per national guidance.6UK Health Security AgencyInvasive group A streptococcal disease: managing close contacts in community settings, 2023.https://www.gov.uk/government/publications/invasive-group-a-streptococcal-disease-managing-community-contactsDate accessed: December 4, 2023Google Scholar Scarlet fever, notifiable since 1899, was retained in the schedule and continues to provide a marker for population levels of GAS infection, showing close synchrony with iGAS infection (appendix p 1). A survey of national public health leads for streptococcal disease in countries in the WHO European region (n=53) in 2018 revealed that 14 of 32 responding countries included scarlet fever in the schedule of notifiable diseases (appendix p 2). Surveillance through notification or other means provides opportunities for detection and control of scarlet fever outbreaks. During the marked increase in GAS cases seen in the UK in December, 2022, more than 700 outbreaks were recorded by local health protection teams in England, representing a major disruption to children's education. Public health measures to control such outbreaks are important not only to protect children's education but also to reduce the spread of life-threatening infections.4Watts V Balasegaram S Brown CS et al.Increased risk for invasive group A streptococcus disease for household contacts of scarlet fever cases, England, 2011-2016.Emerg Infect Dis. 2019; 25: 529-537Crossref PubMed Scopus (19) Google Scholar We declare no competing interests. Download .pdf (.1 MB) Help with pdf files Supplementary appendix