England's Scarlet Fever Cases Highest in 36 Years

Tim Locke

April 09, 2018

An outbreak of scarlet fever in England and Wales has seen the highest number of cases reported in the first quarter of a year since Public Health England (PHE) began collecting data in 1982.

Cases of scarlet fever are always more common in the spring, but 15,549 cases were reported in the first 3 months of this year — more than twice as many as last year.

However, cases are showing signs of falling, with 1624 cases reported in the week ending April 1 compared with 2105 in the previous week.

The highest number of cases in the latest week of data have been seen in the South East of England (348), North West (277), Yorkshire and the Humber (191), East Midlands (175), and London (171).

Health officials are urging parents to be aware of the symptoms of scarlet fever and to contact their general practitioner (GP) as soon as possible if they think their child has the bacterial illness in order to reduce the spread of infection.

Latest Guidance

PHE updated its public health guidelines for managing scarlet fever outbreaks in schools, nurseries, and childcare in October 2017.

The guidance stresses that until the rash appears, scarlet fever symptoms are nonspecific and may include sore throat, headache, fever, nausea, and vomiting.

After 12 to 48 hours, a pinhead rash typically appears on the chest and stomach first before rapidly spreading to other parts of the body. The guidelines say the rash may be harder to detect on darker skin. The rash gives skin a sandpaper-like texture.

Other symptoms may include flushed cheeks, pallor around the mouth, and "strawberry tongue." Areas of skin peeling may develop during recovery.

Diagnosis will usually be through assessment of symptoms and may be confirmed with a group A Streptococcus throat swab if necessary.

Treatment guidance recommends oral antibiotics, paracetamol (acetaminophen) or ibuprofen to relieve symptoms, rest, and fluids. Clinicians should advise parents or carers to keep a child with scarlet fever away from nursery, childcare, or school for at least 24 hours after antibiotics are started. Home hygiene measures should be advised to help prevent the infection spreading to other family members, especially those at risk for complications.

Although the infection is generally mild and self-limiting, with symptoms lasting around a week, hospital admission may be appropriate if a patient has valvular heart disease, a weakened immune system, or severe symptoms or complications.

Scarlet fever is a notifiable infection to allow for surveillance of case outbreaks.General practitioners, nurseries, schools, and school nurses should be advised of outbreaks in their area by Health Protection Teams.

Close Monitoring

In a statement, Dr Nick Phin, deputy director of national infection service at PHE, said, "While it is not uncommon to see a rise in cases of scarlet fever at this time of year, the numbers we have seen this year have not been seen since 1982 when PHE took over responsibility for collecting data on notifiable diseases.  It is important to be aware that, with treatment, scarlet fever is not usually a serious illness. The antibiotics used to treat the infection also reduce the risk of spread to others.

"We are monitoring the situation closely and have worked with NHS Choices [NHS England's public-facing information health website] to raise awareness of the signs and symptoms of scarlet fever, the importance of good hand hygiene, and also to encourage parents to contact their GP for assessment if they think their child might have scarlet fever."

Commenting on the figures in an emailed statement, Professor Helen Stokes-Lampard, MD, chair of the Royal College of GPs, said, "Scarlet fever used to be a lot more common than it is now, but GPs are noticing more cases than in previous years at the moment. If a patient thinks that they, or their child, might have symptoms, they should seek medical assistance."

Recent Study

In November 2017, PHE scientists writing in The Lancet Infectious Diseases said they were unable to explain the recent large increase in cases of scarlet fever in England.

The disease reached a 50-year high in England in 2016 with 19,206 cases, they reported.

Official data show that after decades of declining rates, the number of cases more than tripled between 2013 and 2014 from 4700 to 15,637.

The rise in cases was accompanied by an almost doubling of hospital admissions, from 703 cases in 2013 to 1300 cases in 2016.

All areas of England saw a surge in cases in 2014, with 87% in children under age 10 years.

Infection rates in 2015 and 2016 were highest in the East Midlands, Yorkshire and Humber, and the North East.

The scientists said the reason why scarlet fever rates rose remains a mystery. But they ruled out any new, more virulent strains with the ability to spread more effectively.

"Although most cases of scarlet fever are not severe, the rate of hospital admission during this upsurge is high and the impact on public health has been substantial, particularly with regards to the management of outbreaks," they wrote. "As such, uncovering the drivers behind this rise in scarlet fever outbreaks remains a priority."

In a news release at the time, Dr Theresa Lamagni, head of streptococcal surveillance at PHE, who led the study, said, "Whilst current rates are nowhere near those seen in the early 1900s, the magnitude of the recent upsurge is greater than any documented in the last century."

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