The increase in cases of scarlet fever throughout Europe is causing some concern. But the bacterial disease, which is typical of childhood, is easily curable with antibiotic therapy, thanks to which the child is no longer infectious two days after being treated

Scarlet fever, it is important to contact your paediatrician as soon as the first symptoms appear

In Europe, as in Italy, there has been an increase in cases of scarlet fever, especially in children under the age of 15, since January 2023.

The United Kingdom is the country most affected by this sudden increase.

As of 7 December 2022, England alone has reported more than 6,600 cases of scarlet fever in a period of only 12 weeks (with an average of about 550 new cases per week) along with another 652 cases of invasive Streptococcus A infection (GAS), the bacterium also responsible for the infectious paediatric disease.

Staying closer to home, in Veneto, 1,506 cases were recorded in the first four months of 2023, compared to 116 in the whole of 2022.

To find a higher number of infections, one has to go back to 2012 (1,943) and 2013 (1,733).

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Why this increase in scarlet fever cases in a short period of time?

The causes, as always, can be more than one.

The Covid-19 pandemic and the subsequent measures taken to limit the spread of the virus certainly play a role.

Restrictions on the movement of people (globally) and the adoption of non-pharmaceutical interventions – hand hygiene, mask wearing and others – helped to keep the burden of many paediatric viral and bacterial infections low during the peak of SARS-CoV2 circulation.

Now that the restrictions have been lifted, the return of free circulation and confinement to enclosed spaces due to winter may be a plausible explanation for this sudden increase in scarlet fever cases.

All this in conjunction with the increase in reports of other respiratory infections including influenza and RSV (respiratory syncytial virus)

Another theory that could easily coexist with the previous one indicates that COVID-19 infections (both in symptomatic and asymptomatic cases) could have led to immune dysregulation in children (so-called ‘immune theft’), thus leaving them susceptible to subsequent infections.

However, personal protective measures for the prevention of viral and bacterial illnesses should be maintained and encouraged even now that the end of the COVID 19 emergency has been declared, including good hand hygiene, and opportunities for overcrowding should be avoided.

Limiting the sharing of personal items such as water bottles, glasses, bed linen, toiletries… Disinfection of surfaces should also be encouraged.

What is scarlet fever

Scarlet fever is one of the most common infections caused by Streptococcus pyogenes, also called Group A beta-haemolytic Streptococcus (GAS).

It is a Gram-positive bacterium, resident in the normal microflora of the human skin, nasopharyngeal and anogenital tract.

The rate of asymptomatic carriers of the bacterium is generally higher among school-age children (5-15 years), ranging from 8.4-12.9% in high-income countries to 15-20% in developing countries

How Group A beta-hemolytic streptococcus (GAS) is transmitted

It is traditionally believed that the bacterium is spread through large respiratory droplets (when coughing, sneezing or talking) from infected individuals, including asymptomatic carriers.

However, with advances in methodological approaches, additional modes of transmission have been discovered.

It has been shown that nasal secretions, sputum or saliva, dust particles, direct skin-to-skin contact, indirect contact with surfaces or bedding/textiles, food and biological vectors such as insects promote transmission of bacteria, although to a lesser extent.

Diseases that cause streptococcal infection

Clinically, streptococcal infection can cause not only scarlet fever, but tonsillitis, pharyngitis, impetigo (a skin infection ed.), up to pneumonia.

Invasive forms of scarlet fever infection

Bacteria can be responsible for more serious forms of disease, known as invasive infections: autoimmune post-infection reactions that cause kidney disease, such as acute post-streptococcal glomerulonephritis.

Streptococcus can also cause acute rheumatic fever and/or rheumatic heart disease: what used to be called rheumatism or ‘high blood count’, a popular way of referring to TAS the Anti Streptolysin titre.

Rarely, invasive disease may manifest as necrotising fasciitis, septic arthritis, pneumonia, meningitis, abscess, osteomyelitis and other focal infections, endocarditis and peritonitis.

In 2005, using conservative estimation methodologies, WHO reported that globally more than 18 million people are affected by GAS infections, with an annual increase of more than 1.7 million new reported cases and 500,000 deaths. This makes GAS infections the ninth leading cause of human mortality.

Scarlet fever diagnosis

Scarlet fever presents with fever and reddening of the throat (‘scarlet fever’).

In many cases there is a full-body rash, with the characteristic sign of the ‘yellow hand’, i.e. the visible relief of the hand after pressing it on an extended surface of the trunk for a few seconds.

The clinical diagnosis must be confirmed with a pharyngeal swab.

There are currently very reliable rapid antigenic and molecular tests that give the answer within minutes, which are also available in the paediatrician’s surgery.

It is important to pay attention to the first symptoms and to trust the paediatrician, without falling into misinformation.

Treatment

The management of streptococcus requires antibiotic therapy with penicillins and derivatives (e.g. amoxicillin) as the first choice.

Alternatively, in cases of allergy or intolerance to penicillin, macrolides and clindamycin are good though not optimal alternatives.

If treated, children are no longer infectious 24-48 hours after starting antibiotics, after which, if well, they can return to school.

If untreated, infectiousness lasts for 10-21 days.

Is there a vaccine?

There is currently no vaccine available for GAS prophylaxis although several candidates are in various stages of development.

The main challenge stems from the constant emergence of new and more resistant strains.

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