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respiratory infections that could predispose to iGAS. The drivers of the change in epidemiology remain an area of active research.
While there may be changes in circulating strains and disease incidence, at the bedside, there are no distinguishing features for disease caused by M1UK. The lineage can
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Rates of ARF and RHD in Indigenous people are among the highest globally. |
The median prevalence of impetigo,
driven by strep A, has remained unacceptably
high for more than five decades, with almost one in two remote-living Aboriginal children affected at any one time( median prevalence 45 %). 23-25 The risk of disease is amplified by scabies infection. Although
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NHMRC / MRFF-funded initiatives such as STARFISH( Stopping Acute Rheumatic Fever Infections to Strengthen Health) and ASAVI( Australian Strep A Vaccine Initiative) aim to approach both biomedical and environmental facets of strep A disease in partnership with communities. |
azithromycin or cefalexin) is recommend as soon as possible( preferably within 48 hours of diagnosis of the index case). 5 Other household contacts should be counselled regarding invasive strep A disease and, in some instances, may also be offered antibiotic prophylaxis at the discretion of public health |
only be detected by surveillance genomic sequencing carried out by public health laboratories. We advocate for increased awareness of severe strep A disease and signs of sepsis among the community and clinicians, to ensure treatment as early as possible to prevent severe outcomes including death. |
strep A pharyngitis has been reported to be uncommon in remote communities, data is scarce and could relate to under-presentation. 26 Additionally, a recent genomic and epidemiological study suggested complex transmission dynamics may be a factor in remote communities, including asympto- |
Updates in community management
Community treatment guidance has not
changed with the recent strep A surge, other than the promotion of increased vigilance for signs of severe disease or sepsis. Thera-
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units. An essential part of the management of contacts in the community is early assessment if they develop signs or symptoms of disease such as fever, rash or sore throat.
Conclusion
Strep A continues to cause a large burden of
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Recognising early signs of sepsis
Early recognition relies on an apprecia-
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matic pharyngeal colonisation as a reservoir that could transmit strains causing pharyngitis and impetigo. 27
Rates of ARF and RHD in Aboriginal and
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peutic Guidelines provides a comprehensive clinical overview of sore throat to aid clinical assessment and management. 29
With regard to impetigo, it is important to
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disease, particularly in Aboriginal and Torres Strait Islander communities. The recent changes in epidemiology indicate a complex interaction between the pathogen, environ- |
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tion of the significance of a combination |
Torres Strait Islander people are among the |
highlight the efficacy of trimethoprim-sul- |
ment and host. |
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of clinical features. These include infec- |
highest globally. ARF incidence is estimated |
famethoxazole in endemic remote commu- |
The establishment of invasive strep A dis- |
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tion symptoms, altered mental state, and |
to be more than 100 times higher( particu- |
nities. Traditionally, it has been dogma that |
ease as a nationally notifiable condition and |
|
vital sign abnormalities of rapid breath- |
larly in children aged 5-14 years) than in |
strep A is resistant to trimethoprim-sul- |
ongoing research efforts towards developing |
|
ing, high or low heart rate, and abnormal |
non-Indigenous people; and age-standard- |
famethoxazole. However, the apparent |
a vaccine are important developments in our |
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temperature. Sepsis may be more difficult |
ised RHD prevalence is estimated at over 650 |
resistance reported from older studies related |
progress to better understand and control of |
|
to diagnose in children, and signs may |
per 100,000 population in Indigenous Aus- |
to the bacterial media used for testing, which |
strep A disease. A holistic approach, includ- |
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include reduced activity, listlessness, con- |
tralians, with the greatest burden in north- |
had high levels of thymidine, bypassing the |
ing addressing socioeconomic and cultural |
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fusion, pale appearance, cool and clammy |
ern Australia and the Northern Territory. 28 |
action of trimethoprim-sulfamethoxazole. 30 |
determinants of health, is required to com- |
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skin, non-blanching rash, and unexplained severe pain.
Unequal burden of disease
Although much attention has focused on
the recent surge in invasive strep A cases, Aboriginal and Torres Strait Islander communities in Australia experience a dis-
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Strep A causes a large burden of disease, particularly in Aboriginal and Torres Strait Islander communities. |
Tri methoprim-sulfamethoxazole( 4mg / kg plus 20mg / kg per dose) twice-daily for three days has, in fact, been shown to be as efficacious as benzathine penicillin for impetigo in remote settings. 23
Finally, with the introduction of invasive strep A as a nationally notifiable disease, management of household contacts may be
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bat the disproportionate burden of disease in Australia.
References on request from kate. kelso @ adg. com. au
Online resources
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proportionate burden across almost all manifestations of strep A disease. This has been linked to the social determinants of health, including systemic racism and inequitable access to healthcare and housing. 20 Factors such as household overcrowding, handwashing and hygiene practices that require access to health hardware have been linked with streptococcal disease. 20-22 |
Both impetigo and pharyngitis contribute to the pathways to ARF, so diagnosis, early treatment and community-wide prevention actions are all needed.
Biomedical interventions and research, including progress towards a strep A vaccine, are important elements to disease control. But it is pivotal to address underlying social, economic and cultural determinants of health in order to address disease disparity.
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initiated by public health units, often with the assistance of community providers. Estimates of the risk of developing invasive disease in household contacts is imprecise but may be as high as 2000 times the risk in the general population— although the absolute risk is still low. 31
Birthing-parent neonate pairs are at the highest risk, and prophylaxis( for example, intramuscular benzathine penicillin, oral
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• National Healthy Skin Guideline bit. ly / 4fUuw9Q
• Invasive Group A Streptococcal( iGAS) Disease: CDNA National Guidelines for Public Health Units bit. ly / 3Ao9xfg
• The Royal Children’ s Hospital Melbourne fact sheet: Sepsis bit. ly / 3WJuCrZ
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