The increase in both simple strep infections and invasive infections, seen as early as last September in northern European countries such as the UK and France, has put the scientific community on alert. The specialists in our country did the same, although it is documented that cases with serious symptoms remain rare, report Theodora Psaltopoulou, professor of Epidemiology-Preventive Medicine, EKPA School of Medicine, and Anna Pardali, pediatrician, vice president of the Union of Independent Pediatricians of Attica.

Nevertheless, the death last week of the 7-year-old boy from Imathia reignited the concern of (mainly) parents. In total, six children have died from streptococcus in our country.

APE-MPE addressed Ms. Psaltopoulou and Pardalis, to explain whether there is an increase in streptococcus cases compared to previous years, how streptococcus is diagnosed, who should carry out the tests, what parents should be aware of and at the same time, they give useful advice on the transmission of the disease and the precautionary measures.

Streptococcus growth in European countries

Some European countries (Ireland, France, Netherlands, Sweden, United Kingdom) recorded an increase in the number of cases of invasive group A streptococcal disease (iGAS) in children under ten years of age within the year 2022, particularly from September onwards .

In France and the UK, the increase in iGAS cases in children was several times higher than pre-pandemic levels for the corresponding time period, Theodora Psaltopoulou reports.

During the same period, he continues, several deaths from iGAS in children under the age of 10 were also reported (UK, France, Ireland). The US Centers for Disease Control and Prevention (CDC) reports similar data. In fact, some areas of the US continue to have high rates of iGAS in children, even though respiratory viral infections have generally declined.

In addition, cases have also been recorded in adults, mainly in the elderly aged 65 and over. “The recorded increase in cases followed a period of reduced frequency of group A strep infections observed during the COVID-19 pandemic,” notes Ms. Psaltopoulou.

Are strep cases up this season?

Anna Pardali gives the answer.

Throughout time, streptococcus is a microbe that you encounter all year round, but it is at its peak from the end of winter and spring to the beginning of summer.

This pattern also appeared this year, while during the pandemic like many other germs and viruses, which were almost non-existent due to protective measures that prevented their infection and spread, we did not see widespread or almost no cases of strep. Due to the immune inactivity during the pandemic, which “lazy” the children’s immunity and made them less ready to fight against microbial invaders, in the post-COVID era, germs and viruses such as influenza, RSV, Adenoviruses, etc. their appearance, and a similar behavior may be observed for streptococcus as well.

He explains that there is no data to prove this, as the presence of the microbe in our country is not subject to any surveillance regime in order to record the real numbers and to have a comparison with past years.

Laboratory diagnosis with test, how and when

A key issue is the laboratory diagnosis of the disease with a strep-test, with Mrs. Pardali underlining that this should only be carried out by trained health professionals. This can be done in two ways:

A) the strep-test: it is a quick and simple test that uses a smear from the pharynx and tonsils. The answer is given in 10 minutes

B) the culture of the pharyngeal tonsil smear is necessary not only to confirm the pathogenic microbe but also to check its sensitivity to the antibiotics to be used.

“However, be careful: a child can test positive for these two tests not only when he is sick, but also if he is a carrier of the disease, i.e. carries it around his neck without getting sick and without having symptoms. In this case, with a small probability it can further transmit the germ”, explains Ms. Pardali. Regarding who can do a strep-test on children, Ms. Pardali is categorical.

“Although strep tests have recently been available from pharmacies, these tests should not be carried out by untrained health professionals who have no experience with children. These are the doctors and trained nurses and diagnostic microbiology laboratory staff. A positive test does not mean disease and a negative test does not mean that someone with suspected symptoms is not sick. It is up to the pediatrician to evaluate and consider the child’s clinical and laboratory picture and make the appropriate decisions.”

Instructions for parents

“In children, the highest incidence of strep throat is seen between the ages of 3-10 years. Streptococcus “does not like babies” under the age of 2, who are rarely affected. It has been estimated that 10% of school-aged children visit the pediatrician every year due to pharyngitis and in 25%-50% streptococcus is the responsible cause”, says Mrs. Pardali.

Ms Psaltopoulou explains that strep infections cause tonsillitis, fever and a skin rash known as scurvy, skin infections such as ringworm.

In some cases it can lead to serious complications such as kidney disease (poststreptococcal glomerulonephritis) or heart disease (rheumatic fever). The symptoms that the patient will present depend on the type of infection caused by the bacteria.

Pharyngotonsillitis is manifested by fever, angina (sore throat), dysphagia, swollen tonsils with a whitish coating, swollen lymph nodes and hemorrhagic spots (petechiae) on the palate.

Group A streptococcal infection should be treated promptly with appropriate antibiotics, depending on the severity of the infection.

The non-improvement of the symptoms or the worsening under antibiotic treatment in a reasonable period of time are criteria for immediate communication with the attending physician, in order to evaluate the situation, says Ms. Pardali. “Invasive streptococcal infection progresses rapidly, so any suspected disease requires immediate medical evaluation.”

In any case, he continues, “we never underestimate any sore throat. Many times, the only symptom can be a fever without a severe sore throat and this is because the frequent administration of antipyretics to children also acts as a painkiller and thus they stop complaining.

Vomiting and manifestations from the gastrointestinal tract are often misleading symptoms that may initially be attributed to gastroenteritis, and as these symptoms subside along with the fever, a streptococcal pharyngotonsillitis may remain undiagnosed.”

Case management of invasive streptococcal infection (iGAS) in the home setting

According to the instructions of the EODY, in the event of a case of invasive streptococcal infection in the home environment, the close contacts of the case and especially the close contacts who are at high risk of contracting invasive streptococcal infection, such as people aged 75 and over, newborns , pregnant and lactating. As Ms. Psaltopoulou mentions, in high-risk close contacts, the administration of chemoprophylaxis is recommended, which must begin immediately after the diagnosis of the positive case, ideally within 24 hours and no more than 10 days after the diagnosis of the reference case.

For close contacts of an iGAS case in the household environment who are not at high risk for disease, it is recommended that close contacts be monitored for suspected symptoms for 30 days after contact with the case. Contacts with more than 24 hours of continuous exposure to a case are at the highest risk of infection and colonization.

If 2 or more confirmed cases of iGAS are identified in the household, chemoprophylaxis is recommended for all household members within 10 days of diagnosis of iGAS infection. If any close contacts with signs and symptoms of GAS or iGAS infection are identified they should be immediately evaluated clinically and treated with antimicrobial therapy according to guidelines.

Why is the term GAS sometimes used and IGAS sometimes?

Group A streptococcus is also known as pyogenic streptococcus or GAS (Group A Streptococcus). Group A streptococcus (GAS) is considered the most common cause of bacterial pharyngitis in school-age children, which is noted to be easily treated with antibiotics, the ECDC explains.

Group A interspecific streptococcal (iGAS) infections are those that occur when GAS infects a part of the body where the bacteria don’t normally live, but these are rare cases, explains Ms. Pardalis.

Forms of invasive disease include necrotizing peritonitis and streptococcal toxic shock syndrome. Persistent fever, severe angina, severe dysphagia, fever combined with a rash, severe diarrhea are symptoms that need medical help and special treatment, notes Ms. Psaltopoulou.

Precautions

For the prevention of streptococcal infection from pyogenic streptococcus, the daily and correct application of hygiene and hand hygiene rules, as well as the application of personal protection measures, is important. Avoiding close contact, especially with symptomatic people who present with fever, sore throat and other symptoms, and proper ventilation of closed spaces are important measures, as well as social distancing of sick people to contain the spread of infection as much as possible.