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Table 1.  

Term Definition
Invasive group A Streptococcus (iGAS) infection Isolation of GAS from a normally sterile site, either by PCR or culture. For this study, iGAS also includes GAS infections in which GAS was isolated from a normally nonsterile site in combination with a severe clinical presentation, such as streptococcal toxic shock syndrome or necrotizing fasciitis
Group A Streptococcus (GAS) infection Isolation of GAS from a non-sterile site in combination with clinical symptoms attributable to bacterial infection including fever (temperature ≥38°C), sore throat, wound infection, or cellulitis
Group A Streptococcus carriage Isolation of GAS from a nonsterile site but no symptoms attributable to infection with this microorganism
Home healthcare (HHC) Community health services, including district nursing teams, general practitioners, podiatry (chiropody), community midwifery, hospital outreach, and palliative care, which provide medical or nursing care within a patient’s home
Residential care Live-in accommodation that provides 24-hour care and support to its residents

Table 1. Definitions used in a study of invasive group A Streptococcus infection associated with home healthcare, England, 2018–2019

Table 2.  

Outbreak no. No. iGAS cases No. GAS cases† No. deaths No. days from first to last case No. cases without identified HHC input emm type WGS
1 14 2 2 136 1 87 N
2 7 1 2 148 0 94 N
3 6 0 3 222 0 94 Y
4 7 0 2 388 0 89 Y
5 5 5 2 179 2 89 N
6 3 0 0 75 0 1 Y
7 4 0 0 219 0 1 Y
8 2 0 1 3 0 89 Y
9 9 1 1 507 0 89 Y
10 39 95 15 487 1 44 Y
Total 96 104 28 NA 4 NA NA

Table 2. Summary of home healthcare–associated invasive group A Streptococcus infection outbreaks, England, 2018–2019*

*GAS, group A Streptococcus; HHC, home healthcare; iGAS, invasive group A Streptococcus; NA, not applicable; WGS, whole-genome sequencing. †Noninvasive GAS was not systematically investigated or recorded in all outbreaks. Available data did not enable distinction between carriage and noninvasive infection.

Table 3.  

Characteristics No. (%) IQR (range)
All outbreaks, n = 10
Total cases 96 (100) NA
Total deaths 28 (29) NA
Median cases 7 4–9 (2–39)
Median outbreak duration, d 199 139–347 (3–507)
Outbreaks with case data, n = 9
Case-patient characteristics, n = 57
Median age, y 83 77–90 (42–100)
Sex
F 39 (68) NA
M 18 (32) NA
Median days between cases 21 6–46 (1–225)
Type of residence, n = 48
Residential care 17 (35) NA
Own home 31 (65) NA
HHCW exposure, n = 96
Patient receiving care 92 (96) NA
Household contact of recipient 2 (4) NA
None identified† 2 (4) NA

Table 3. Characteristics of home healthcare–associated invasive group A Streptococcus infection outbreaks, England, 2018–2019*

*HHCW, home healthcare worker; NA, not applicable.
†Cases linked to outbreaks through whole-genome sequencing but without any identified connection to home healthcare services.

CME / ABIM MOC

Invasive Group A Streptococcus Outbreaks Associated With Home Healthcare, England, 2018–2019

  • Authors: Laura E. Nabarro, FRCPath; Colin S. Brown, MD, FRCPath; Sooria Balasegaram, MBChB; Valérie Decraene, PhD; James Elston, FFPH; Smita Kapadia, MBBS; Pauline Harrington, MSc; Peter Hoffman, BSc; Rachel Mearkle, MBBS; Bharat Patel, MD, FRCPath; Derren Ready, PhD; Esther Robinson, MD, FRCPath; Theresa Lamagni, PhD
  • CME / ABIM MOC Released: 4/18/2022
  • Valid for credit through: 4/18/2023
Start Activity

  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, and other physicians who treat and manage frail patients at risk for invasive group A Streptococcus.

The goal of this activity is to evaluate the source, outcomes, and infection control measures in outbreaks of invasive group A Streptococcus.

Upon completion of this activity, participants will:

  • Analyze characteristics of invasive group A Streptococcus
  • Evaluate demographics and outcomes of the current study of invasive group A Streptococcus outbreaks
  • Assess the source of invasive group A Streptococcus outbreaks based on investigations
  • Distinguish infection control measures employed during invasive group A Streptococcus outbreaks


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Faculty

  • Laura E. Nabarro, FRCPath

    Public Health England, London, United Kingdom

  • Colin S. Brown, MD, FRCPath

    Public Health England, London, United Kingdom

  • Sooria Balasegaram, MBChB

    Public Health England, London, United Kingdom

  • Valérie Decraene, PhD

    Public Health England, London, United Kingdom

  • James Elston, FFPH

    Public Health England, London, United Kingdom

  • Smita Kapadia, MBBS

    Public Health England, London, United Kingdom

  • Pauline Harrington, MSc

    Public Health England, London, United Kingdom

  • Peter Hoffman, BSc

    Public Health England, London, United Kingdom

  • Rachel Mearkle, MBBS

    Public Health England, London, United Kingdom

  • Bharat Patel, MD, FRCPath

    Public Health England, London, United Kingdom

  • Derren Ready, PhD

    Public Health England, London, United Kingdom

  • Esther Robinson, MD, FRCPath

    Public Health England, London, United Kingdom

  • Theresa Lamagni, PhD

    Public Health England, London, United Kingdom

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

Editor

  • Amy J. Guinn, BA, MA

    Copyeditor
    Emerging Infectious Diseases

    Disclosures

    Disclosure: Amy J. Guinn, BA, MA, has disclosed no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.


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CME / ABIM MOC

Invasive Group A Streptococcus Outbreaks Associated With Home Healthcare, England, 2018–2019

Authors: Laura E. Nabarro, FRCPath; Colin S. Brown, MD, FRCPath; Sooria Balasegaram, MBChB; Valérie Decraene, PhD; James Elston, FFPH; Smita Kapadia, MBBS; Pauline Harrington, MSc; Peter Hoffman, BSc; Rachel Mearkle, MBBS; Bharat Patel, MD, FRCPath; Derren Ready, PhD; Esther Robinson, MD, FRCPath; Theresa Lamagni, PhDFaculty and Disclosures

CME / ABIM MOC Released: 4/18/2022

Valid for credit through: 4/18/2023

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Abstract and Introduction

Abstract

Healthcare-associated invasive group A Streptococcus (iGAS) outbreaks are common worldwide, but only England has reported outbreaks associated with home healthcare (HHC). We describe 10 outbreaks during 2018–2019 in England. A total of 96 iGAS cases (range 2–39 per outbreak) and 28 deaths (case-fatality rate 29%) occurred. Outbreak duration ranged from 3–517 days; median time between sequential cases was 20.5 days (range 1–225 days). Outbreak identification was difficult, but emm typing and whole-genome sequencing improved detection. Network analyses indicated multiple potential transmission routes. Screening of 366 HHC workers from 9 outbreaks identified group A Streptococcus carriage in just 1 worker. Outbreak control required multiple interventions, including improved infection control, equipment decontamination, and antimicrobial prophylaxis for staff. Transmission routes and effective interventions are not yet clear, and iGAS outbreaks likely are underrecognized. To improve patient safety and reduce deaths, public health agencies should be aware of HHC-associated iGAS.

Introduction

Streptococcus pyogenes (group A Streptococcus; GAS) is a common community-acquired pathogen, predominantly affecting skin, soft tissues, and the respiratory tract. Invasive GAS (iGAS) infection, characterized by entry of the bacterium into sterile body fluids, including blood, has a mortality rate of 8%–16%[1–4]. Person-to-person iGAS transmission is thought to occur through direct skin contact or via respiratory droplets from symptomatic infections and asymptomatic carriers. Throat, nose, skin, and anogenital carriage have been linked to healthcare-associated outbreaks[5–8], which have been recorded in hospital, long-term care, and outpatient facilities worldwide[9–11]. Environmental and fomite transmission are less well characterized.

In England, most community nursing care is performed by practitioners traveling between patients to deliver healthcare in the patients’ homes, termed home healthcare (HHC). HHC is administered by a variety of healthcare workers, including district nurses, community nurses, healthcare assistants, general practitioners, podiatrists, hospital outreach teams, and palliative care staff. A substantial part of HHC is wound care, but HHC workers (HHCWs) also administer medication, assist with rehabilitation, and perform catheter and end of life care. During a single working week, an HHCW could perform many of these duties for different patients.

The home environment is not designed for healthcare and has unique infection control challenges. HHCWs and their equipment could become contaminated directly from the patient or the patient’s home, and the patient risks infection from practitioners or their equipment[12,13].

In England, iGAS cases are notifiable to local health protection teams (HPTs) under the Health Protection (Notification) Regulations 2010[14] as a means of beginning immediate public health actions as needed, including contact tracing, according to national guidelines[15]. Guidance also requests that all sterile site GAS isolates be sent for typing to the Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU) of Public Health England (PHE). All isolates, including GAS isolates from possible healthcare-associated infections, should be referred for typing or stored locally for future outbreak investigations. RVPBRU returns results to the referring hospital and local HPT within 6 days. RVPBRU also provides whole-genome sequencing (WGS) to support outbreak investigations.

In 2013, PHE identified the first HHC-associated iGAS outbreak in England[16]. PHE has regularly recorded outbreaks since then, and HPTs managed outbreaks with advice from national leads for streptococcal surveillance and reference microbiology units. We describe HHC-associated iGAS outbreaks reported during January 2018–August 2019, including identification, investigation, and management, to inform public health response in England and elsewhere.