Sixty seconds on . . . scarlet fever

Recently we performed an epidemiological study regarding scarlet fever distribution in Beijing region, China. During our study the results we found were very astonishing [1], a rapid increase in scarlet fever incidence was found during the recent years, which is similar in context of overall country China. 15234 cases of Scarlet fever was reported in 2002 followed by 22050 in 2005, 19376 in 2010 and 62830 in 2015 which is almost equal to the epidemic in 2011 [2]. In 2011, scarlet fever broke out (67358 cases) and became epidemic in school children in different cities of mainland China, including Honk Kong, Macao, Taiwan and The Republic Korea [3].
The highest peaks of scarlet fever incidence have been noted in May to June (early spring to early summer), followed by a comparatively small incidence peaks in November to early January (mid-autumn to mid-winter) [1]. The incidence peaks differed by location which could be due to climate change, geographical distribution and other meteorological factors etc [4].
Although, the government of China has been making greater efforts to improve health care and control infectious disease in the country and achievements have also been made, but still there is a long way to go.

References:
1. Mahara G, Wang C, Wang, D H, Xu Q, Huang F, Tao L, Guo J, Cao K, Long L, Chhetri J K, Gao Q, Wang W, Wang Q, and Guo X. Spatiotemporal Pattern Analysis of Scarlet Fever Incidence in Beijing, China, 2005 to 2014. International Journal of Environmental Research and Public Health, 2016, 1(13):131. doi;10.3390.
2. National Health and Family Planning Commission of the People’s Republic of the China, Available online: http://www.nhfpc.gov.cn/zhuzhan/yqxx/lists.shtml (accessed on 17 April 2016).

3. World Health Organization. Western Pacific Region. Scarlet Fever: Factsheet of Scarlet Fever in China. Available online: http://www.wpro.who.int/china/mediacentre/factsheets/scarlet_fever/en/ (accessed on 5 June 2015).

4. Yu Duan, Xiao-lei Huang, Yu-jie Wang, Jun-qing Zhang, Qi Zhang, Yue-wen Dang. Impact of meteorological changes on the incidence of scarlet fever in Hefei city China. International Journal of Biometeorology. 1st March, 2016.PP: 1-8

Corresponding to: guoxiuh@ccmu.edu.cn and gbmahara@gmail.com

Dr Cave wonders if every case of scarlet fever deserves antibiotics. Dr Hopkins asks if the current fashion (NICE and the Department of Health orchestrating the anti-antibiotic campaign) to avoid antibiotics has anything to do with the rise in cases of scarlet fever.

But let us remember that scarlet fever is streptococcal in origin and so is rheumatic heart disease. In my youth there was plenty of scarlet fever. And so was rheumatic fever and rheumatic heart disease. Many with rheumatic heart disease remembered having had scarlet fever but, again, many did not.

It stands to reason that EVERY case of scarlet fever should be treated with penicillin after a swab has been taken. And epidemiological thoroughness demands that the child and siblings should be followed up for evidence of rheumatic heart disease. A counsel of perfection? Perhaps. But there is plenty of appetite for "evidence".

Just one more sugestion (unless it is already the rule): all school age children moving in to the country should be examined by the school doctor - if not an extinct species - for cardiac disease; it certainly was the rule in the 1960s and 1970s, in the London boroughs.

The sixty seconds on scarlet fever is very helpful and succinct. But wish to add the following;
• Streptococcus pyogenes or Group A Beta-haemolytic streptococcus, the infective agent of scarlet fever, apart from its other virulence factors also possesses a certain a genetic material that is responsible for the production of the erythrogenic toxin which is responsible for the scarlatiniform rash and strawberry tongue appearance and probably contributes to the virulence of this organism.
• Another reason why it has dropped off and mortality is rare is not only because of the availability of antibiotics namely beta-lactams or penicillins but also to the fact that Streptococcus pyogenes and all other Beta-haemolytic streptococci are always sensitive to penicillin and all other antibiotics belonging to the penicillin (or Beta-lactam) group of antibiotics.
• We believe it can be avoided within the context of family and close contact of infected cases by taking throat swabs from the contacts and when positive a course of penicillin antibiotic is administered to eradicate the carrier status and prevent potential evolution to scarlet fever infection.
• We couldn’t stress more the importance of taking throat swabs to confirm the presence of this organism furthermore, apart from doing sensitivity testing; there is the opportunity of typing the strains in order to establish whether we are dealing with cross-infection or a cluster in a particular geographical area.
Finally in the presence of ‘strawberry tongue’ appearance Kawasaki disease which produces a similar tongue appearance must be excluded.
The Rotherham NHS Foundation Trust

Susceptibility to streptococcal disease is related to social circumstances. This was well understood by Ryle, the first professor of social medicine in the1940s, whose textbook my father passed on to me. More recently Carapetis has clearly demonstrated this for rheumatic fever in Australia and elsewhere. Is anyone tracking the social conditions of these patients to understand who they are?

Osler: It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.