Scarlet Fever: A Razorback House Divided

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A case-patient is defined as a child having sore throat, fever, skin rash, or strawberry tongue with or without laboratory confirmation of GAS infection between March 28 and April 28, The index case-patients developed symptoms on March 28, , and this outbreak persisted over a period of 16 days. The outbreak affected 21 out of children The common symptoms reported were fever The epidemiologic analysis showed that children attending one of the classrooms in the kindergarten were Our results suggest that the outbreak likely affected from the index case-patients who attended to one of the classrooms in the kindergarten.

This highlights the importance of immediate notification of outbreak to prevent large number of patients. Scarlet fever is an infection caused by group A streptococcus GAS , Streptococcus pyogenes , which produces a pyrogenic exotoxin [ 1 ]. GAS causes diverse clinical symptoms associated with sudden onset of fever The incubation period ranges from 2 to 10 days and the transmission usually persist from 10 to 21 days without appropriate treatment [ 2 , 3 ]. Antibiotic penicillin administration for 10 days is the treatment of choice with the loss of transmissibility within a day following proper antibiotic treatment [ 2 ].

Scarlet fever was known to be highly fatal in the early s; however, it only causes mild illness recently due to the development of antibiotics and improvement of hygiene and living environment [ 3 ]. Nevertheless, the annual number of scarlet fever reported has greatly increased from 0. On April 3, , an outbreak of scarlet fever among children at a kindergarten was reported to the local public health department by the local pediatric clinic.


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A field epidemiologist from Gyeonggi Provincial Government conducted an investigation and implemented control measures. Here, an epidemiological analysis was conducted to identify the possible route of transmission and to recommend appropriate control measures to prevent future outbreaks of scarlet fever.

The need for ethical approval for this study was waived, based on the Korean Infectious Disease Control and Prevention Act. Scarlet fever has been designated as a notifiable disease with a case defined by the Korean Centers for Disease Control and Prevention [ 5 ]. Probable case is defined as the person who has symptoms such as sore throat, fever, skin rash, or strawberry tongue without laboratory confirmation of GAS infection.

Confirmed case is defined as the person with identified GAS in his or her pharynx or blood among probable cases. Carriers are those who have GAS in their pharynx without presenting any symptoms during the study period. All cases were based on the notification from the physician and staff in a kindergarten during the period between March 28 and April 28, A retrospective cohort study was conducted to identify the possible transmission route.

RAZORBACK - Definition and synonyms of razorback in the English dictionary

A total of 19 confirmed and 2 probable cases were enrolled as a case group. Eight carriers and children without infection were enrolled as a non-case group. Data including age, sex, the classroom attended at a kindergarten, underlying disease, date and type of symptoms developed, and presence of illness from their household were collected during the investigation. A screening was performed in the kindergarten on April 4, Forty-four children diagnosed cases, 21; refusal, 6; absence, 17 were excluded from the screening test among the children and 9 staff.

The provincial field epidemiologist and a physician from the city public health department performed the screening by swabbing the posterior pharynx and tonsils. Five swab samples collected from the local clinics and specimens collected for screening carriers from the kindergarten were sent to the provincial public health laboratory for GAS identification using the Vitek II system bioMerieux, Marcy l'Etoile, France.

Overall attack rate was calculated using the number of cases divided by the total number of children in the kindergarten. Secondary attack rate was calculated using the number of cases divided by the total number of siblings. The statistical package R version 3.

Scarlet Fever (Scarlatina)

The kindergarten has seven classrooms with two floors. Each floor has a toilet and was connected with a stair. During investigation, a total of children and 9 teachers were present.

Environment

No large-sized group activity among classrooms was found in the recent months, and meals were provided in each classroom. The outbreak affected 21 out of children in the kindergarten with 19 confirmed and 2 probable cases: The median age was 4. Antibiotics amoxicillin were introduced to all cases from the local primary care clinic without hospitalization, and complication of infection was not identified.

The index cases, attendees at the same class named Leaf A , had symptoms such as fever, sore throat, and skin rash since March 28, , and were quarantined and administered with antibiotics the day after the symptom developed according to the physician's recommendation. This outbreak was reported on April 3, and persisted over a period of 16 days Figure 2. The most common symptoms reported were sudden onset of fever and sore throat 15 cases, Reddened tonsil and scarlatinoid rash were reported in 12 Two household transmissions were found from two cases, which started on March 28 and March 29, They were all siblings of the patients, and appropriate antibiotic treatment with quarantine was administered.

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The overall attack rate was The RR of the children attending class Leaf A was GAS was not isolated from the staffs in the kindergarten. However, it colonized in six 5. Among them, four were on the first floor and two were on the second floor, which were not significantly different. On April 4, , the first day of investigation, cases were recommended to stay away from the kindergarten and social activities for 24 hours after starting appropriate antibiotic treatment.

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Furthermore, environmental disinfection in the bookshelves, doorknobs, and toys in all classrooms in the kindergarten was performed, and personal hygiene education to kindergarteners including hand washing was conducted. In addition, to immediately identify the cases, daily health check-up was conducted by the staffs of the kindergarten by asking kindergarteners any abnormal symptoms such as sore throat and fever until April 30, The results suggest that this infection likely originated in the children who attended class Leaf A and then spread to other nearby classrooms.


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The reasons are the following: Person-to-person transmission with respiratory droplet or direct contact with other persons is the most common route of GAS transmission [ 2 ]. A previous study supports our results that the duration of exposure and the distance from the index case are the major risk factors of GAS transmission [ 6 ]. Furthermore, two siblings of the cases developed the symptoms on the first and second day of this outbreak. GAS can be environmentally transmitted, such as in the surface of the furniture and the floor [ 7 ].

Thus, environmental cleaning with disinfectants such as alcohol or chlorine was included as a control measure for this outbreak.

Scarlet Fever (Scarlatina)

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