Scarlet fever

Good hand hygiene and respiratory etiquette can reduce the spread of all types of group A streptococcal infections, including scarlet fever.[13]Centers for Disease Control and Prevention. Scarlet fever: information for clinicians. Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/scarlet-fever.html [23]UK Health Security Agency. Scarlet fever: symptoms, diagnosis and treatment. Mar 2019 [internet publication]. https://www.gov.uk/government/publications/scarlet-fever-symptoms-diagnosis-treatment/scarlet-fever-factsheet#scarlet-fever There is increasing evidence that the bacteria are spread via respiratory particles.[24]Cordery R, Purba AK, Begum L, et al. Frequency of transmission, asymptomatic shedding, and airborne spread of Streptococcus pyogenes in schoolchildren exposed to scarlet fever: a prospective, longitudinal, multicohort, molecular epidemiological, contact-tracing study in England, UK. Lancet Microbe. 2022 May;3(5):e366-75. https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(21)00332-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/35544097?tool=bestpractice.com

• Good hand hygiene includes washing hands with soap and water for at least 20 seconds or using alcohol-based hand gel consistently, particularly after coughing and sneezing and before preparing foods or eating.

• Respiratory etiquette includes covering coughs and sneezes and washing handkerchiefs or disposing of contaminated tissues.

Advice on isolation of cases varies between countries. Refer to local protocols for specific guidance in your local area.

• In the UK, people with scarlet fever should stay home from nursery, school, or work for at least 24 hours after the initiation of appropriate antibiotic treatment, or until symptoms have resolved if they do not wish to take antibiotics.[25]UK Health Security Agency. Guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings. Jan 2023 [internet publication]. https://www.gov.uk/government/publications/scarlet-fever-managing-outbreaks-in-schools-and-nurseries There is evidence that most patients who are being treated with an antibiotic for 24 hours or longer are generally no longer infectious after this time.[26]McGuire E, Li A, Collin SM, et al. Time to negative throat culture following initiation of antibiotics for pharyngeal group A streptococcus: a systematic review and meta-analysis to inform public health control measures [preprint]. medRxiv. 2022 Nov 8 [Epub ahead of print]. https://www.medrxiv.org/content/10.1101/2022.11.08.22282068v1

• In the US, the Centers for Disease Control and Prevention recommends that patients with scarlet fever stay at home until they are afebrile AND at least 12 hours have passed after starting appropriate antibiotic therapy.[13]Centers for Disease Control and Prevention. Scarlet fever: information for clinicians. Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/scarlet-fever.html ​ 

The incubation period for scarlet fever is approximately 2 to 5 days.[3]American Academy of Pediatrics. Group A streptococcal infections. In: Kimberlin DW, Barnett ED, Lynfield R, et al, eds. Red book: 2021-2024 report of the Committee on Infectious Diseases, 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021. https://publications.aap.org/redbook [13]Centers for Disease Control and Prevention. Scarlet fever: information for clinicians. Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/scarlet-fever.html ​​[23]UK Health Security Agency. Scarlet fever: symptoms, diagnosis and treatment. Mar 2019 [internet publication]. https://www.gov.uk/government/publications/scarlet-fever-symptoms-diagnosis-treatment/scarlet-fever-factsheet#scarlet-fever

Antibiotic prophylaxis against group A streptococcal infection is recommended routinely only in patients with scarlet fever or group A streptococcus (GAS) pharyngitis with a previous diagnosis of acute rheumatic fever.[68]Centers for Disease Control and Prevention. Acute rheumatic fever: information for clinicians.​ Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html ​ This is to prevent progression to rheumatic heart disease with subsequent re-infection. The US Centers for Disease Control and Prevention (CDC) and the American Heart Association (AHA) recommend long-term prophylaxis with an intramuscular injection of benzathine benzylpenicillin (benzathine penicillin G) every 3-4 weeks or oral phenoxymethylpenicillin twice daily.[48]Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009 Mar 24;119(11):1541-51. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.191959 http://www.ncbi.nlm.nih.gov/pubmed/19246689?tool=bestpractice.com [68]Centers for Disease Control and Prevention. Acute rheumatic fever: information for clinicians.​ Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html [69]Kumar RK, Antunes MJ, Beaton A, et al. Contemporary diagnosis and management of rheumatic heart disease: implications for closing the gap: a scientific statement from the American Heart Association. Circulation. 2020 Nov 17;142(20):e337-57. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000921 http://www.ncbi.nlm.nih.gov/pubmed/33073615?tool=bestpractice.com ​​​ The CDC recommends oral sulfadiazine or an oral macrolide for patients who are allergic to penicillin.[68]Centers for Disease Control and Prevention. Acute rheumatic fever: information for clinicians.​ Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html

Antibiotic prophylaxis may be indicated in the context of an outbreak of scarlet fever with co-circulations of varicella (chickenpox) or respiratory viral infection to reduce the risk of invasive GAS disease.[70]UK Health Security Agency. UK guidelines for the management of contacts of invasive group A streptococcus (iGAS) infection in community settings. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/invasive-group-a-streptococcal-disease-managing-community-contacts ​ Other measures that may be considered in this setting include post-exposure prophylaxis with varicella vaccine.[25]UK Health Security Agency. Guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings. Jan 2023 [internet publication]. https://www.gov.uk/government/publications/scarlet-fever-managing-outbreaks-in-schools-and-nurseries ​ Follow your national public health guidance for specific recommendations in your local area.​

Scarlet fever is a notifiable disease in China, South Korea, and many European countries including England, Wales, Northern Ireland, Austria, and Poland.