High morbidity and mortality in children with invasive lower respiratory tract group A streptococcal infection in England, winter 2022

Objectives:

To describe the epidemiological and clinical characteristics of children with invasive group A Streptococcus (iGAS) infection and severe GAS-associated lower respiratory tract infections (including empyema) [LRTIs] identified in England in late 2022, supporting earlier recognition and informing pre-hospital admission clinical decision and public health response.

Study design:

Case series analysis.

Methods:

LRTI iGAS cases in children aged <15y in England reported between October 01 and December 21, 2022, were identified using laboratory data (GAS detected in LRT specimens) and notifications by clinicians. Symptoms, diagnoses, healthcare interactions, and outcomes were described based on case management notes, the National Child Mortality Database, and the national Emergency Care Dataset (ECDS).

Results:

Across England, 147 paediatric cases of LRTI iGAS were reported, 52% male and with a median age of four (IQR 2-6) years. Most reported symptoms were fever (75%; n = 90) and cough (50%; n = 60). Half (50%, n = 74) had a confirmed respiratory viral coinfection. Over three-quarters (77%, n = 113) attended an emergency department and 25% died (n = 37/147), with a median of four days from symptom onset to death. Over half of these deaths (n = 21/37) occurred in the community, with several (n = 6) cases having rapid deterioration recorded. Of cases who died, 81% (n = 21/26) had their GAS-positive sample taken shortly before death or post-mortem.

Conclusions:

Viral-like symptoms, and the presence or suspicion of viral co-infection, combined with rapid deterioration made prompt identification of iGAS infection challenging, despite high healthcare engagement. Early recognition and timely treatment remain critical to reducing morbidity and mortality in these cases.