Scarlet Fever and Strep Have Been on the Rise: What Should You Know — and Do — About It?

We’ve come a long way in treating scarlet fever. Thanks to the discovery of antibiotics, a disease that for centuries was the terror of childhood has been transformed into just another routine childhood illness.

Yet in the past year, parents’ sense of safety has been shaken by reports showing that scarlet fever, and other strep infections, have been on the rise around the globe. Even more worrisome, the biggest increases have been in the more severe “invasive” forms of strep, which can lead to serious illness and rapid death.

While it’s still too early to say if the surge is over, pediatrician Heather Sever, DO, talks us through what parents and caregivers should know — and do — about the current uptick in scarlet fever and other forms of strep.

What should you know about scarlet fever?

Scarlet fever and other strep infections are common diseases, capable of infecting people of every age and health status. But strep infections are especially common in children. “The risk is largest for the younger population,” Dr. Sever confirms, “especially around kindergarten age.” In children younger than 3, infection is relatively rare. And among adults, the highest risk usually has been among parents of school-aged children or adults who are often in contact with school-aged children.

The common symptoms of scarlet fever can include:

• Fever.
• A very red sore throat.
• A red and bumpy “strawberry” tongue.
• Swollen lymph nodes in the front of your neck.
• On lighter skin, a red rash that feels rough, like sandpaper. On darker skin, the color can be harder to detect but you can still feel the rash.

Scarlet fever, and other strep infections, are caused by bacteria called group A streptococci, or group A strep (GAS). While considered a relatively mild type of strep infection, scarlet fever is highly contagious. A healthcare provider can diagnose it in their office by using a rapid strep test or a throat culture. If the tests are positive for strep bacteria, they’ll prescribe antibiotics to treat it.

While pediatric doses of amoxicillin have been in short supply since last fall, there are several alternative antibiotics that your child’s healthcare provider can prescribe instead.

What other illnesses can group A strep cause?

Scarlet fever is only one of many infections caused by GAS. Others include:

• Tonsillitis.
• Strep throat (pharyngitis).
• Cellulitis.
• Impetigo.

Like scarlet fever, these are considered mild strep infections, and antibiotics are used to treat them.

But in rare instances, people with a strep infection may develop post-strep complications, such as:

• Acute rheumatic fever, which is an inflammation of the heart valves.
• Glomerulonephritis, which affects the kidneys.
• Pneumonia.
• Arthritis.

If your child has been treated for a strep infection and suddenly takes a turn for the worse, contact your healthcare provider immediately.

What is invasive group A streptococci?

Unfortunately, there are more serious forms of group A strep out there. Often called invasive group A streptococci, or iGAS, the two main types of severe strep infection are:

• Necrotizing fasciitis, sometimes called the “flesh-eating” infection, caused when strep bacteria enter your body through a break in your skin or by blunt trauma.
• Toxic shock syndrome, caused by strep bacteria releasing toxins into your bloodstream.

In rare instances, a GAS infection can lead to invasive GAS. An iGAS infection can worsen very quickly and can be life-threatening. Prompt medical attention is essential in those cases.

What should parents know about the recent strep surge?

Reports from Europe, Canada and the U.S. show that the recent surge in strep infections has been mainly in the more severe iGAS infections.

But don’t panic. “Invasive strep cases remain relatively rare,” reassures Dr. Sever. “The CDC still considers the risk of contracting them very low.” The World Health Organization (WHO) also says the risk to the general population remains low.

That said, WHO also tells us that as of December 2022, at least five European nations — France, Ireland, the Netherlands, Sweden and the United Kingdom, including Great Britain and Northern Ireland — reported an increase in cases of iGAS and scarlet fever, mostly affecting children under 10 years of age. Some of the pediatric cases have resulted in deaths.

The surge was particularly marked during the second half of the year, which Dr. Sever says is unusual. “Most often, strep cases rise during the winter and spring months,” she notes, “not the summer and fall.”

Even as recently as May 2023, the UK Health Security Agency reported that scarlet fever cases in the U.K. remain higher than normal. And cases of iGAS infections are slightly higher than expected for this time of year.

In Canada, healthcare providers are also reporting a rise in serious strep infections. In Quebec, for instance, the number of iGAS infections was up by 56% compared to the pre-pandemic average for the same time period, and there have been multiple deaths among both children and seniors.

In the U.S., the U.S. Centers for Disease Control and Prevention (CDC) has also reported an increase in iGAS infection levels among children.

CDC information from 2022 shows that iGAS infections in children:

• Increased earlier in the season than in a typical year.
• Happened at the same time as increases in respiratory viruses like the flu and respiratory syncytial virus (RSV).
• In some areas of the country, there were more cases than had been seen before the COVID-19 pandemic.

So far for 2023 in the U.S., the CDC data shows:

• That iGAS infections have remained high in some areas of the country even after respiratory viruses decreased.
• Some areas of the country have seen an increase in iGAS infections in adults, particularly those over the age of 65.
• GAS infections in children remain as high, or higher, than what was seen in pre-pandemic years.

Why are strep infections on the rise?

Although nothing has been proven at this point, says Dr. Sever, there are several theories for why strep infections have been on the rise.

“We started seeing strep increases at the same time that viral respiratory infections like RSV were on the rise in 2023,” she says. “So, there is some thought that there might be a link there.”

Also, the CDC reports that severe iGAS infections fell by 25% during the COVID-19 pandemic. “So, another thought is that there might have been a decrease in natural immunity during those years because we were all wearing masks and avoiding crowds,” she adds.

Reluctance to seek treatment for GAS infections also may be contributing to the rise in iGAS infections, according to a 2018 study. Untreated GAS cases can worsen very quickly, even leading to death. In fact, the CDC estimates that, in the most recent five years, approximately 14,000 to 25,000 cases of group A strep disease occurred annually in the United States, with 1,500 to 2,300 annual deaths.

There is some good news, though. According to the WHO, there’s no sign that the bacteria have become more resistant to antibiotics. Nor is there evidence of newly emerging genetic variants. So, antibiotic treatment should continue to be effective.

What parents and caregivers can do

Dr. Sever says that parents can take a two-step approach to dealing with the surge in strep.

“First, help your child take steps to reduce their risk of catching, or spreading, the illness,” she advises. Because kids usually catch strep through close contact with an infected person — by coughing, sneezing, saliva (sharing food) or direct transmission from a wound — teaching your youngster to take the following precautions can help:

• Wash your hands before eating, drinking or touching your face.
• Cover coughs or sneezes with your elbow or a tissue.
• Don’t share drinking glasses or eating utensils.
• Wear a mask around people who are ill.
• If you are ill, stay home.

Second, be sure to see your healthcare provider if your child has symptoms of a strep infection, including:

• Fever.
• Sudden sore throat.
• Red and bumpy rash.
• Headache.
• Loss of appetite.

“Parents need to be alert about bringing in their children to be evaluated if they see those symptoms,” stresses Dr. Sever. Testing and treatment with antibiotics, if needed, will not only prevent complications, but will also help put your child on the road to recovery.

But if your youngster is already being treated for strep, and suddenly takes a turn for the worse — especially if they seem confused or show a reduced level of consciousness — immediately seek medical attention. While it remains relatively rare, an iGAS infection is serious business and recovery hinges on early recognition of the disease and prompt (often intensive care) treatment.

While panic won’t help, being alert can be your family’s best defense. “If you are suspicious, or have any questions about what’s going on with your child, that child probably needs to be seen by a healthcare provider,” Dr. Sever states. “And if a child tests positive for strep, the infection always needs to be treated to prevent possible complications.”