Investigation of a Prolonged Group A Streptococcal Outbreak Among Residents of a Skilled Nursing Facility, Georgia, 2009-2012

Dooling, Kathleen; Crist, Matthew B.; Nguyen, Duc B.; Bass, Jennifer; Lorentzson, Lauren; Toews, Karrie-Ann; Pondo, Tracy; Stone, Nimalie D.; Beall, Bernard; Beneden, Chris Van

doi:10.1093/cid/cit558

Cited by 30 publications

(39 citation statements)

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“…Whereas the presence of “any skin condition” was not significantly associated with increased risk of death, this variable includes both chronic and acute skin conditions, which may obscure risks that attend specific skin conditions. Although most invasive GAS infections are sporadic, wounds (eg, surgical wounds and decubiti) have been recognized as a common risk factor for GAS infection in nosocomial outbreaks and outbreaks among persons living in nursing homes and other group settings [36–38]. Many severe infections have also been found to occur within 24–72 hours of nonpenetrating trauma that results in a deep hematoma [39].…”

Section: Discussionmentioning

confidence: 99%

Epidemiology of Invasive Group A Streptococcal Infections in the United States, 2005–2012

et al. 2016

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Background Invasive group A Streptococcus (GAS) infections are associated with significant morbidity and mortality rates. We report the epidemiology and trends of invasive GAS over 8 years of surveillance. Methods From January 2005 through December 2012, we collected data from the Centers for Disease Control and Prevention’s Active Bacterial Core surveillance, a population-based network of 10 geographically diverse US sites (2012 population, 32.8 million). We defined invasive GAS as isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis (NF) or streptococcal toxic shock syndrome (STSS). Available isolates were emm typed. We calculated rates and made age- and race-adjusted national projections using census data. Results We identified 9557 cases (3.8 cases per 100 000 persons per year) with 1116 deaths (case-fatality rate, 11.7%). The case-fatality rates for septic shock, STSS, and NF were 45%, 38%, and 29%, respectively. The annual incidence was highest among persons aged ≥65 years (9.4/100 000) or <1 year (5.3) and among blacks (4.7/100 000). National rates remained steady over 8 years of surveillance. Factors independently associated with death included increasing age, residence in a nursing home, recent surgery, septic shock, NF, meningitis, isolated bacteremia, pneumonia, emm type 1 or 3, and underlying chronic illness or immunosuppression. An estimated 10 649–13 434 cases of invasive GAS infections occur in the United States annually, resulting in 1136–1607 deaths. In a 30-valent M-protein vaccine, emm types accounted for 91% of isolates. Conclusions The burden of invasive GAS infection in the United States remains substantial. Vaccines under development could have a considerable public health impact.

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Section: Discussionmentioning

confidence: 99%

Epidemiology of Invasive Group A Streptococcal Infections in the United States, 2005–2012

et al. 2016

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“…Other notable features of GAS epidemiology include the propensity for long-term fluctuations in disease rates, such as the recent substantial increase in scarlet fever in the United Kingdom in 2013/2014 (4), and the association with outbreaks. GAS outbreaks are strongly associated with long-term-care or institutional facilities (5–8) and occur less often within whole communities (9–11). The introduction of new emm genotypes (12, 13) or the acquisition of prophages harboring virulence genes by previously circulating GAS are the primary mechanisms underpinning these outbreaks (14–16).…”

Section: Introductionmentioning

confidence: 99%

“…In addition to the M protein, virulence is determined by adhesion proteins, by toxin production, and by the absence or presence of a capsule, and is influenced by host factors (5). GAS is also typed based on multilocus sequence typing (MLST); 651 MLST variants have been reported to date (17).…”

Section: Introductionmentioning

confidence: 99%

Epidemiological and Molecular Characterization of an Invasive Group A Streptococcus emm 32.2 Outbreak

et al. 2017

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An emm32.2 invasive group A streptococcus (iGAS) outbreak occurred in Liverpool from January 2010 to September 2012. This genotype had not previously been identified in Liverpool, but was responsible for 32% (14/44) of all iGAS cases reported during this time period. We performed a case-case comparison of emm32.2 iGAS cases with non-emm32.2 control iGAS cases identified in the Liverpool population over the same time period to assess patient risk factors for emm32.2 iGAS infection. The emm32.2 iGAS cases were confined to the adult population. We show that homelessness, intravenous drug use, and alcohol abuse predisposed patients to emm32.2 iGAS disease; however, no obvious epidemiological linkage between the patients with emm32.2 iGAS could be identified. Comparative whole-genome sequencing analysis of emm32.2 iGAS and non-emm32.2 control isolates was also performed to identify pathogen factors which might have driven the outbreak. We identified 19 genes, five of which had previously been implicated in virulence, which were present in all of the emm32.2 iGAS isolates but not present in any of the non-emm32.2 control isolates. We report that a novel emm32.2 genotype emerged in Liverpool in 2010 and identified a specific subset of genes, which could have allowed this novel emm32.2 genotype to persist in a disadvantaged population in the region over a 3-year period.

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“…It is interesting to find that 87.5% (7/8) of GAS patients were at ages between 18 and 20 years old; by contrast, the GAS carriage was low in this age group (0/120) outside the industrial zone. Taking into account that the workers were non-indigenous and seldom go outside, they could be considered to be closed populations, just like soldiers on military bases, patients in long-term care facilities, and students in schools, who were reported to be particularly vulnerable to GAS infection outbreaks (Wasserzug et al, 2009; Chen et al, 2012; Dooling et al, 2013). The factory had an intensive workload, poor-hygiene, and crowded conditions that might facilitate GAS outbreaks.…”

Section: Discussionmentioning

confidence: 99%

“…Group A Streptococcus is well established as a cause of outbreaks, which can occur not only in a school, a military camp or a hospital but also throughout a city or even a country (Wasserzug et al, 2009; Chen et al, 2012; Dooling et al, 2013; Ben Zakour et al, 2015; Cornick et al, 2017). Small-scale GAS outbreaks can be caused by transmission of a GAS strain to vulnerable individuals, whether by person-to-person contact in crowded settings or from a common source (Walker et al, 2014).…”

Section: Introductionmentioning

confidence: 99%

An emm5 Group A Streptococcal Outbreak Among Workers in a Factory Manufacturing Telephone Accessories

Chen

Wang

et al. 2017

Front. Microbiol.

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Ranked among the top10 infectious causes of death worldwide, group A Streptococcus (GAS) causes small- and large-scale outbreaks, depending on the trigger as transmission of a GAS strain or expansion of predominant clones. In China, GAS infections other than scarlet fever are not notifiable. In Shanghai, an epidemiological investigation was initiated after two successive severe pneumonia cases with one death in a digital factory, from where outbreaks are less widely reported. The investigation was performed using emm typing, pulsed-field gel electrophoresis (PFGE) typing, superantigen profiling, and genome analysis. This enabled characterization of relatedness among the outbreak isolates and identification of the mobile genetic elements present. Among 57 patients with respiratory symptoms investigated in the factory, emm5 GAS strains were isolated from 8 patients. The eight GAS infection cases comprising one fatal severe pneumonia case, six influenza-like illness cases, and one pharyngitis case. Two risk factors were identified: adult with an age of 18–20 years and close contact with a GAS patient or carrier. GAS attack rate was 14.0% (8/57), and GAS carriage rate was probably around 2.7% (14/521) based on surveys in two nearby districts. All the 10 outbreak associated isolates were assigned to emm5 and sequence type ST-99 (emm5/ST-99), harbored superantigen genes speC, speG, and smeZ, and were assigned to two similar PFGE patterns (clones). Among the outbreak associated isolates, all carried ermA with resistance to erythromycin and inducible resistance to clindamycin, and eight (80%) carried a tetM gene with resistance to tetracycline. Among the 14 carriage isolates, 12 were emm12/ST-36, and 2 were emm1/ST-28, all with superantigen genes speC, speG, ssa, and smeZ. All the carriage isolates harbored ermB and tetM with resistance to erythromycin, clindamycin, and tetracycline. Genome analysis showed the two outbreak clones were closely related and possessed new prophages carrying virulence gene sdc and antibiotic resistance genes of ermA and tetM, which were not found in the emm5 reference strain Manfredo. This is the first report of a GAS outbreak in this type of workplace. The outbreak was caused by two closely related emm5 clones that differed from the predominant emm types circulating in China.

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Investigation of a Prolonged Group A Streptococcal Outbreak Among Residents of a Skilled Nursing Facility, Georgia, 2009-2012

Cited by 30 publications

References 10 publications

Epidemiology of Invasive Group A Streptococcal Infections in the United States, 2005–2012

Epidemiology of Invasive Group A Streptococcal Infections in the United States, 2005–2012

Epidemiological and Molecular Characterization of an Invasive Group A Streptococcus emm 32.2 Outbreak

An emm5 Group A Streptococcal Outbreak Among Workers in a Factory Manufacturing Telephone Accessories

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