Scarlet fever, due to infection with an erythrogenic toxin-producing Group A streptococcus, is an uncommon and generally mild illness, although serious sequelae do occur. In March 2009, 57 of the 126 (45%) pupils in a primary school in Lancashire, UK developed scarlet fever over a 4-week period. Infection was transmitted via direct contact between pupils, particularly among the youngest pupils. A significant degree of transmission also occurred between siblings. The median number of days absent from school was 3 (range 1-10 days). No children were hospitalised. Control measures, including hygiene advice to the school and exclusion of pupils for 24h while initiating penicillin treatment, were ineffective. The outbreak occurred against a background of an unusually high incidence of invasive Group A streptococcal infection. While there are national guidelines for the control of invasive disease, none exist for the control of scarlet fever outbreaks. This prolonged outbreak of scarlet fever highlights the need for an evidence based approach to outbreak management.

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Sir: The 2008 UK national guidelines on HIV testing 1 have highlighted the need for more widespread testing for HIV. It is well recognized that although significant morbidity and mortality arises from missed diagnoses, health-care workers often fail to test for HIV. 2,3 Patients may present to their general practitioner (GP) with symptoms that might not be initially recognized as HIV related. Following a number of patients who presented to our department with previously unrecognized late-stage HIV infection, we decided to increase awareness and encourage HIV testing in general practice by providing all the GPs in our primary care trust (PCT) with testing advice. Our PCT covers a population of 460,000 with 88 GP practices and approximately 225 salaried/principle GPs. We sent a document to all 88 GP practices informing GPs of the need for HIV testing in certain situations, along with the logistics of how to actually perform a test in our area. GPs are inundated with letters, hence it was decided to keep the document as short and simple as possible. It took the form of a double-sided A4 sheet; on one side was a covering letter that explained the need for HIV testing outside of 'traditional' settings and encouraged GPs to test (with consent) if clinically indicated. On the reverse side we gave advice on common clinical indicator diseases, with a summary table of some of the conditions in which HIV should be thought of as a differential diagnosis in adults (from the UK national guidelines on HIV testing 1). We also provided a list of 'at-risk' patients in whom the opportunistic offer of an HIV test might be considered. We initially planned to laminate the document and send it out to every GP surgery, in the hope that it might be pinned up on a notice-board and used as an aid-memoir. For practical reasons it turned out to be easier to simply send the page electronically as an attachment to an email sent to all GP practices, who were then asked to disseminate the document to all their GPs. We viewed this as a public health measure and involved our local Health Protection Unit in the exercise, with our local consultant in Communicable Diseases as a cosignatory on the letter. The document was sent out in December 2008. The analysis took place five months after the letter was sent, hence we decided to compare five-month time-frames. The number of HIV tests requested from GPs was obtained from the local virology laboratory which serves the entire PCT area-no GP HIV tests are processed elsewhere. In the five months following the letter, 126 HIV tests were requested. In the five months before the letter was sent out, there had been 105 tests. The increase represents a 20% increment. To check this was not a spurious result, we looked back a further five months, to 5-10 months before the letter was sent: there had been 108 test requests during this time, comparable to the 105 figure (Table 1). Although the total figures are relatively small and absolute percentages should be interpreted cautiously, we have been heartened that s...

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