There is currently a higher rate of infection of strep A (and scarlet fever) in the UK compared to previous years.
Scarlet fever is a contagious infection that mostly affects young children. It is caused by strep A, also known as group strep A.
We spoke to Dr Alexandra Streeter de Diego, paediatric clinical fellow at Frimley Park Hospital and clinical lead for Frimley Healthier Together, a website set up provide health advice to the public served by Frimley hospitals, including Wexham Park and Heatherwood.
Below is a guide to what parents and guardians need to know about strep A – how to spot it, how to treat it and when to go to the doctor or A&E.
How serious are strep A and scarlet fever?
Most strep A infections are not serious and can be treated with antibiotics. In very rare occasions, the bacteria can get into the bloodstream and cause an illness called invasive group A strep.
So far, 15 children in the UK are reported to have died as a result of these rare complications of the infection strep A.
However, Dr Streeter de Diego said that, though it may appear that there is a spike in serious cases, this only reflects a proportional rise in the number of cases in general, including the many mild cases.
The risk of invasive strep A remains low and strep A-related deaths in children are still rare in the UK.
Invasive strep A is usually more common in people over 75 than in children, yet no older people are known to have died from the condition in the current outbreak so far.
Why might case numbers be higher?
Scarlet fever is ‘highly infectious’, so it’s no surprise that the infection is going around. Nonetheless, there are higher rates of infection compared to previous years – this could be for several reasons.
A key one is what’s called ‘immunity debt’, caused by lack of exposure to common infections.
During COVID-19, infections that children would normally catch were not caught so much, because of the lockdowns and other pandemic guidance that kept them at home or socially distanced.
Now that things have got more back to normal with ‘increased mixing’, those children are now effectively catching up on these common infections, getting them now rather than in 2019-2021.
There was a similar outbreak in 2017 and 2018. Four children aged under 10 died of invasive strep A.
“I’m a parent myself and it can be quite worrying when you see the news headlines,” said Dr Streeter de Diego.
“[But] group A strep is a bug we see every year – it’s a bug that lives on our skin and in our throats. We’re seeing a lot more cases at the moment but we do see it throughout the year.”
What are the symptoms I need to look out for? What should I do if I spot them?
The most common symptom is a very sore throat, known as strep throat.
But, Frimley says, if your child only has a runny nose, cough or diarrhoea, they are less likely to have scarlet fever.
“The most important thing for parents to remember is that the majority of runny noses, coughs and colds will still be caused by viral infections, which we see more of this time of year,” said Dr Streeter de Diego.
More telling symptoms include a fever (temperature of 38 degrees Celsius or above) and painful, swollen glands in the neck.
The biggest symptom is a rash that often begins with small spots on the body. It then spreads to the neck, arms and legs over the next one-two days. The rash is often like ‘sandpaper’ to touch but is not itchy.
The rash does not appear on the face, but the cheeks can look red.
Redness may be harder to see on brown and black skin – but any rash on the body will still have that sandpaper feel.
The most distinctive symptom (though less common than the rash) is probably so-called ‘strawberry tongue’ – a red tongue with a white coating which peels, leaving the tongue red, swollen and covered in little bumps.
“If a child has any of those symptoms we would be saying they should see a GP,” said Dr Streeter de Diego.
The doctor will diagnose and then prescribe antibiotics they discover the infection.
Top left - what the rash may look like on dark skin. Top right - appearance on pale skin. Bottom left - red cheeks. Bottom right - 'strawberry tongue'.
When should I go to A&E?
On the whole it will not be necessary to go to hospital but there are circumstances when a child should.
To help people navigate the symptoms, Frimley has set up a website, which includes a ‘red box’ of symptoms to look out for, where children should be taken to A&E.
This includes:
“If the child doesn’t have the symptoms in the red box, we recommend they contact their GP in-hours – when the GP is closed, we would advise calling 111 or visiting 111 online,” said Dr Streeter de Diego.
How long will children with strep A need to be off school? What care should I provide?
If a child has a strep A infection, they should stay away from nursery, school or work for 24 hours after they start taking antibiotics. A person is no longer contagious after 24 hours of starting antibiotics.
After that, when the child goes back to school is a matter for parents or guardians to decide.
“Everyone knows their children the best – it would be deciding whether they’re well enough to go back to school,” said Dr Streeter de Diego.
A child with strep A will have a high temperature. The advice is that if a child with a fever shouldn’t be going to school anyway.
“They should stay at home and be treated with paracetamol and plenty of fluids. The same rules apply as they would at any other time [for other infections],” said Dr Streeter de Diego.
“We don’t recommend sponging children [with a fever] any more, as it can cause them to shiver and feel more unwell.”
If the child is still feeling very unwell despite being on antibiotics, parents/guardians should monitor if the child is becoming more unwell, and if so, go back to the doctor.
“If anything changes, look at the Frimley Health Together site to see if you need to see someone [a doctor],” said Dr Streeter de Diego.
The antibiotics don’t agree with my child, or they won’t take them. What should I do?
It is important that any course of antibiotics is completed – i.e., taken exactly as directed by the doctor, for as long as instructed. Stopping an antibiotic too soon leaves bacteria that may start to multiply again and may cause another infection.
Worse yet, the remaining bacteria can adapt to cope with being blasted with antibiotics, breeding a new strain of antibiotic resistant bacteria. These are responsible for so-called ‘superbugs’ like MRSA which can be very serious.
Dr Streeter de Diego recommends encouraging children to take their antibiotics with the promise of something that tastes nice afterwards.
If the child finds it difficult to swallow tablets and capsules, putting them in a spoonful of soft food may help, such as yoghurt.
Taking medicine should be made ‘as much fun as possible.’ Role playing can be helpful – pretending to give a favourite doll or teddy bear some medicine too.
If a child is unwell as a result of antibiotics, you might have to speak to the doctor again.
“Children can get slightly loose stools with an antibiotic, but anything else besides that, speak to a clinician,” said Dr Streeter de Diego.
What is the risk to teachers/parents? What should adults do if they catch strep A?
If an adult catches strep A and they’re otherwise fit and healthy, they are likely to become less unwell from the infection than a child would.
“The infection more common in under 10s and it can be more severe in the under-fives,” said Dr Streeter de Diego. “The elderly and those with weakened immune systems are more likely to get severe infections.”
If any adult starts to develop the key symptoms described above, the advice is the same – contact the doctor to confirm or rule out strep A.
Then, if confirmed, stay away from any school or work for 24 hours after starting antibiotics, and treat at home.
“As with all illnesses, prevention is the key. It would be sensible to be at home, for your wellbeing as well,” said Dr Streeter de Diego.
What can schools do to stop the spread?
As with COVID-19, good hand hygiene practice is a must in schools, says Dr Streeter de Diego, and teaching the ‘Catch it, bin it, kill it,’ rule when using tissues for coughs and sneezes.
For the most part, it is not expected whole classes, school years or the entire schools would have to close if a strep A infection breaks out.
Any school with an outbreak would be guided individually by the UK Health Security Agency (formerly Public Health England).
Dr Streeter de Diego does not recommend parents choosing to keep healthy children home from schools just because there are cases of strep A in their child’s school.
“We all worry about our children – but in the vast majority of cases, group A strep and scarlet fever will be mild illnesses,” she said.
“We would encourage children to be going to school if they are well. As we’ve seen with COVID, it is important for children to be at school to have an education and all the other things that come with schooling.”
To see Frimley’s guide on Strep A and Scarlet fever, visit: frimley-healthiertogether.nhs.uk/parentscarers/worried-your-child-unwell/scarlet-fever
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