Seeing red
Why scarlet fever is back
When Sarah Allen took her sickly, feverish toddler to the doctor, his red rash, high temperature and strangely coated tongue were dismissed as a virus that happened to coincide with a fungal infection in his mouth.
In fact, her son, Jasper, who was then 18 months old, had scarlet fever, a killer disease that made regular appearances in Victorian literature and wiped out untold thousands of children before the arrival of antibiotics in the middle of the 20th century. It is now making a sinister comeback in Britain, with more than 19,000 infections reported in 2016, the highest annual caseload in 50 years.
In the last week of last month, there were another 735 cases of infection in England and Wales. The average age of the infected patients was four.
Scarlet fever is highly contagious and in the 19th century, when the disease killed up to 20,000 children a year, it was normal to burn all bedding, clothing and toys after the death of a child, in a tragic ritual that almost eliminated all evidence of their short existence. Although it is no longer fatal, it can cause severe illness, including pneumonia, blood poisoning or long-term damage to the heart, liver and kidneys.
The modern version of the disease is also harder to predict. Sarah’s older child, Poppy, who is now seven, was stricken with scarlet fever aged four when Jasper was less than a year old. Strangely, he was unaffected, and she also remained well when he got the disease a year later.
For Sarah, a 37-year-old children’s nursery manager with 20 years of experience, from St Neots, Cambridgeshire, the biggest issue is making sure doctors know what they are dealing with.
“It is only worrying if the symptoms go unrecognised and children don’t get the antibiotics,” she says. “Before Poppy had it, I don’t think I had ever really heard of it.
“Luckily, that time, the doctor picked it up straight away, but when Jasper caught it he was seen first by a young locum doctor who said it was a virus that would clear up. He got worse and I ended up having to take him to hospital,” she says. “I think it is only older doctors and nurses who remember when it was a fairly common condition.”
Outbreaks simultaneously affecting a dozen or more children in primary schools around the country in recent years have led to complete shutdowns.
Although Poppy and Jasper were attending nurseries when they contracted the disease, each of them was the only child affected. “I know it is airborne, but you can catch it from saliva or touching anything that is carrying the bacteria,” says Sarah. “It is strange that no one else around them got it.
“I bought both of the children new toothbrushes, and made sure they didn’t share towels or food, but whatever precautions you take
with hygiene I think if a child is going to catch it, they probably still would do.”
The reasons for the reappearance of the disease are not understood.
It is caused by streptococcus A,a ubiquitous type of bacteria that is carried harmlessly by up to one in five of the population at any time, but which can also cause anything from a mild sore throat to fatal blood poisoning. It is, however, readily treatable with antibiotics, which can clear symptoms within as little as two days.
Results from a population surveillance study published last year in The Lancet show Britain is the only European country to be affected by what is, at least, a seven-fold rise in cases in only the past five years. A total of 620 infection clusters were reported in 2016 in England alone, and there have been similar unconnected surges in infection rates among children in the Far East, including Hong Kong, South Korea and parts of China.
Experts have speculated that there may be some other infectious agent working with the streptococcus in the new outbreak which has given it an extra turbo-charged infectious boost – or that new strains of the bacteria
could have emerged, infecting a child population lacking immunity.
Genetic analysis of the infectious bacteria in different areas of the country, however, has shown there were no new strains, and the ones that had affected Asian victims were also well-known, but different from the infectious strains seen here.
Theresa Lamagni, the head of streptococcal surveillance at Public Health England, who led the Lancet study, says the recent rise in cases is bigger than any seen in the past century. “We are investigating what might be causing the increase, but no definitive reasons have come to light,” she says. “Infectious diseases do rise and fall from time to time for reasons that are not always understood.”
However, Beate Kampmann, professor of paediatric infectious diseases at Imperial College, London pointed out that the real cause for the outbreak could be quite simple. “Because of fears about antibiotic resistance, we are much more reluctant to use antibiotics for sore throats,” she said. “GPS are instructed not to prescribe them. Sometimes, people don’t go back to the doctor and there’s a delay while bacteria get into the bloodstream and that’s when you get patients being hospitalised.”
By comparison, doctors in the US are encouraged to use a simple dipstick test that detects streptococcus A.
Studies of 19th-century epidemics have connected the disease with spikes in wheat prices, which led to malnutrition, dietary protein deficiency, in particular, and then scarlet fever. While there are no such obvious associations for the recent outbreaks, there is evidence of a resurgence of other Victorian diseases associated with poor nutrition in childhood. Malnutrition has now
become a consequence of wrong nutrition rather than an overall lack of food. Cases of rickets, the bone deformity and bow-leggedness caused by vitamin D deficiency, have risen steadily since the mid-nineties.
Meanwhile, cases of scurvy caused by vitamin C deficiency have shown a similar upward trend. There were 147 hospital admissions for scurvy in 2016, compared with 94 two years earlier – a rise of more than 50per cent. In 2016, an inquiry into the death from scurvy of eight-year-old Dylan Seabridge, who was home-educated in Pembrokeshire, South Wales, called for greater supervision of children not attending regular school, to ensure they receive appropriate nutrition. Parents have been warned to be alert for chronic bone pain as a symptom of vitamin D deficiency and unexplained bleeding gums as a sign of a lack of vitamin C.
“Malnutrition is an issue in children,” said Professor Alan Maryon-davis, former president of the Faculty of Public Health. “It is not just poverty that means some children don’t get their five servings of fruit and vegetables a day, there is also a risk associated with the restrictions of fad diets.
“Simply making sure that children go to school without missing breakfast can make all the difference.”