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Liu Y, Chan TC, Yap LW, Luo Y, Xu W, Qin S, Zhao N, Yu Z, Geng X, Liu SL. Resurgence of scarlet fever in China: a 13-year population-based surveillance study. THE LANCET. INFECTIOUS DISEASES 2018; 18:903-912. [PMID: 29858148 PMCID: PMC7185785 DOI: 10.1016/s1473-3099(18)30231-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/09/2018] [Accepted: 03/27/2018] [Indexed: 12/25/2022]
Abstract
Background A re-emergence of scarlet fever has been noted in Hong Kong, South Korea, and England, UK, since 2008. China also had a sudden increase in the incidence of the disease in 2011. In this study, we aimed to assess the epidemiological changes before and after the upsurge. We also aimed to explore the reasons for the upsurge in disease in 2011, the epidemiological factors that contributed to it, and assess how these could be managed to prevent future epidemics. Methods In this observational study, we extracted the epidemiological data for all cases of scarlet fever between 2004 and 2016 in China from the Chinese Public Health Science Data Center, the official website of National Health Commission of the People's Republic of China, and the National Notifiable Infectious Disease Surveillance System. These data had been collected from 31 provinces and regions in China and included geographical, seasonal, and patient demographic information. We used descriptive statistical methods and joinpoint regression to examine the spatiotemporal patterns and annual percentage change in incidence of the upsurge of disease across China. Findings Between Jan 1, 2004, and Dec 31, 2016, 502 723 cases of scarlet fever, with ten fatalities, were reported in China, resulting in an annualised average incidence of 2·8807 per 100 000 people. The annual average incidence increased from 1·457 per 100 000 people in 2004 to 4·7638 per 100 000 people in 2011 (incidence rate ratio [IRR] 3·27, 95% CI 3·22–3·32; p<0·0001), peaking in 2015 (5·0092 per 100 000 people). The annual incidence after the 2011 upsurge of scarlet fever, between 2011 and 2016, was twice the average annual incidence reported between 2004 and 2010 (4·0125 vs 1·9105 per 100 000 people; IRR 2·07, 95% CI 2·06–2·09; p<0·0001). Most cases were distributed in the north, northeast, and northwest of the country. Semi-annual patterns were observed in May–June and November–December. The median age at onset of disease was 6 years, with the annual highest incidence observed in children aged 6 years (49·4675 per 100 000 people). The incidence among boys and men was 1·54 greater than that among girls and women before the upsurge, and 1·51 times greater after the upsurge (p<0·0001 for both). The median time from disease onset to reporting of the disease was shorter after the upsurge in disease than before (3 days vs 4 days; p=0·001). Interpretation To our knowledge, this is the largest epidemiological study of scarlet fever worldwide. The patterns of infection across the country were similar before and after the 2011 upsurge, but the incidence of disease was substantially higher after 2011. Prevention and control strategies being implemented in response to this threat include improving disease surveillance and emergency response systems. In particular, the school absenteeism and symptom monitoring and early-warning system will contribute to the early diagnosis and report of the scarlet fever. This approach will help combat scarlet fever and other childhood infectious diseases in China. Funding National Key R&D Plan of China Science and key epidemiological disciplines of Zhejiang Provincial Health of China.
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Affiliation(s)
- Yonghong Liu
- School of Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Provincial Key Laboratory of Intelligent Transport System, Guangzhou, Guangdong Province, China
| | - Ta-Chien Chan
- Research Center for Humanities and Social Sciences, Academia Sinica, Taipei, Taiwan
| | - Li-Wei Yap
- Research Center for Humanities and Social Sciences, Academia Sinica, Taipei, Taiwan
| | - Yinping Luo
- School of Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Provincial Key Laboratory of Intelligent Transport System, Guangzhou, Guangdong Province, China
| | - Weijia Xu
- School of Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Provincial Key Laboratory of Intelligent Transport System, Guangzhou, Guangdong Province, China
| | - Shuwen Qin
- Department of Infectious Diseases, Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, Zhejiang Province, China
| | - Na Zhao
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Zhao Yu
- Department of Infectious Diseases, Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, Zhejiang Province, China
| | - Xingyi Geng
- Emergency Offices, Jinan Centre for Disease Control and Prevention, Jinan, Shandong Province, China
| | - She-Lan Liu
- Department of Infectious Diseases, Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, Zhejiang Province, China.
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Affiliation(s)
- Diego O Andrey
- a Service of Infectious Diseases, Department of Medical Specialties , Geneva University Hospitals & University of Geneva Medical School , Geneva , Switzerland
| | - Klara M Posfay-Barbe
- b Pediatric Infectious Diseases Unit, Department of Pediatrics , Geneva University Hospitals & University of Geneva Medical School , Geneva , Switzerland
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Zaman M, Chandrudu S, Giddam AK, Reiman J, Skwarczynski M, McPhun V, Moyle PM, Batzloff MR, Good MF, Toth I. Group A Streptococcal vaccine candidate: contribution of epitope to size, antigen presenting cell interaction and immunogenicity. Nanomedicine (Lond) 2014; 9:2613-24. [DOI: 10.2217/nnm.14.190] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: Utilize lipopeptide vaccine delivery system to develop a vaccine candidate against Group A Streptococcus. Materials & methods: Lipopeptides synthesized by solid-phase peptide synthesis-bearing carboxyl (C)-terminal and amino (N)-terminal Group A Streptococcus peptide epitopes. Nanoparticles formed were evaluated in vivo. Results: Immune responses were induced in mice without additional adjuvant. We demonstrated for the first time that incorporation of the C-terminal epitope significantly enhanced the N-terminal epitope-specific antibody response and correlated with forming smaller nanoparticles. Antigen-presenting cells had increased uptake and maturation by smaller, more immunogenic nanoparticles. Antibodies raised by vaccination recognized isolates. Conclusion: Demonstrated the lipopeptidic nanoparticles to induce an immune response which can be influenced by the combined effect of epitope choice and size.
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Affiliation(s)
- Mehfuz Zaman
- School of Chemistry & Molecular Biosciences, The University of Queensland, St. Lucia, Australia
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Saranya Chandrudu
- School of Chemistry & Molecular Biosciences, The University of Queensland, St. Lucia, Australia
| | - Ashwini K Giddam
- School of Chemistry & Molecular Biosciences, The University of Queensland, St. Lucia, Australia
| | - Jennifer Reiman
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Mariusz Skwarczynski
- School of Chemistry & Molecular Biosciences, The University of Queensland, St. Lucia, Australia
| | - Virginia McPhun
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Peter M Moyle
- School of Chemistry & Molecular Biosciences, The University of Queensland, St. Lucia, Australia
- School of Pharmacy, The University of Queensland, Woolloongabba, Australia
| | | | - Michael F Good
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Istvan Toth
- School of Chemistry & Molecular Biosciences, The University of Queensland, St. Lucia, Australia
- School of Pharmacy, The University of Queensland, Woolloongabba, Australia
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Wong SS, Yuen KY. Streptococcus pyogenes and re-emergence of scarlet fever as a public health problem. Emerg Microbes Infect 2012; 1:e2. [PMID: 26038416 PMCID: PMC3630912 DOI: 10.1038/emi.2012.9] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 04/16/2012] [Indexed: 11/09/2022]
Abstract
Explosive outbreaks of infectious diseases occasionally occur without immediately obvious epidemiological or microbiological explanations. Plague, cholera and Streptococcus pyogenes infection are some of the epidemic-prone bacterial infections. Besides epidemiological and conventional microbiological methods, the next-generation gene sequencing technology permits prompt detection of genomic and transcriptomic profiles associated with invasive phenotypes. Horizontal gene transfer due to mobile genetic elements carrying virulence factors and antimicrobial resistance, or mutations associated with the two component CovRS operon are important bacterial factors conferring survival advantage or invasiveness. The high incidence of scarlet fever in children less than 10 years old suggests that the lack of protective immunity is an important host factor. A high population density, overcrowded living environment and a low yearly rainfall are environmental factors contributing to outbreak development. Inappropriate antibiotic use is not only ineffective for treatment, but may actually drive an epidemic caused by drug-resistant strains and worsen patient outcomes by increasing the bacterial density at the site of infection and inducing toxin production. Surveillance of severe S. pyogenes infection is important because it can complicate concurrent chickenpox and influenza. Concomitant outbreaks of these two latter infections with a highly virulent and drug-resistant S. pyogenes strain can be disastrous.
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Affiliation(s)
- Samson Sy Wong
- Department of Microbiology, Research Centre for Infection and Immunology, Faculty of Medicine, The University of Hong Kong , Hong Kong, China
| | - Kwok-Yung Yuen
- Department of Microbiology, Research Centre for Infection and Immunology, Faculty of Medicine, The University of Hong Kong , Hong Kong, China
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Smeesters PR, McMillan DJ, Sriprakash KS, Georgousakis MM. Differences among group A streptococcus epidemiological landscapes: consequences for M protein-based vaccines? Expert Rev Vaccines 2010; 8:1705-20. [PMID: 19905872 DOI: 10.1586/erv.09.133] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Group A streptococcus (GAS) is a bacterial pathogen responsible for a wide array of disease pathologies in humans. GAS surface M protein plays multiple key roles in pathogenesis, and serves as a target for typing and vaccine development. In this review, we have compiled GAS epidemiological studies from several countries around the world to highlight the consequences on the theoretical efficacy of two different M protein-based vaccine strategies.
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Affiliation(s)
- Pierre R Smeesters
- Bacterial Pathogenesis Laboratory, Queensland Institute of Medical Research, Brisbane, Queensland 4029, Australia.
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Bessen DE. Population biology of the human restricted pathogen, Streptococcus pyogenes. INFECTION GENETICS AND EVOLUTION 2009; 9:581-93. [PMID: 19460325 DOI: 10.1016/j.meegid.2009.03.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Revised: 02/24/2009] [Accepted: 03/04/2009] [Indexed: 12/31/2022]
Abstract
Streptococcus pyogenes, also referred to as beta-hemolytic group A streptococci, are strictly human pathogens with a global distribution and high prevalence of infection. The organisms are characterized by high levels of genetic recombination, extensive strain diversity, and a narrow habitat. This review highlights many key features of the population genetics and molecular epidemiology of this biologically diverse bacterial species, with special emphasis on ecological subdivisions and tissue-specific infections, strain diversity and population dynamics in communities, selection pressures arising from the specific host immune response and antibiotic exposure, and within-host selection during the course of invasive disease.
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Affiliation(s)
- Debra E Bessen
- Department of Microbiology & Immunology, New York Medical College, Valhalla, NY 10595, USA.
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Bessen DE, McGregor KF, Whatmore AM. Relationships between emm and multilocus sequence types within a global collection of Streptococcus pyogenes. BMC Microbiol 2008; 8:59. [PMID: 18405369 PMCID: PMC2359762 DOI: 10.1186/1471-2180-8-59] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2007] [Accepted: 04/11/2008] [Indexed: 12/02/2022] Open
Abstract
Background The M type-specific surface protein antigens encoded by the 5' end of emm genes are targets of protective host immunity and attractive vaccine candidates against infection by Streptococcus pyogenes, a global human pathogen. A history of genetic change in emm was evaluated for a worldwide collection of > 500 S. pyogenes isolates that were defined for genetic background by multilocus sequence typing of housekeeping genes. Results Organisms were categorized by genotypes that roughly correspond to throat specialists, skin specialists, and generalists often recovered from infections at either tissue site. Recovery of distant clones sharing the same emm type was ~4-fold higher for skin specialists and generalists, as compared to throat specialists. Importantly, emm type was often a poor marker for clone. Recovery of clones that underwent recombinational replacement with a new emm type was most evident for the throat and skin specialists. The average ratio of nonsynonymous substitutions per nonsynonymous site (Ka) and synonymous substitutions per synonymous site (Ks) was 4.9, 1.5 and 1.3 for emm types of the throat specialist, skin specialist and generalist groups, respectively. Conclusion Data indicate that the relationships between emm type and genetic background differ among the three host tissue-related groups, and that the selection pressures acting on emm appear to be strongest for the throat specialists. Since positive selection is likely due in part to a protective host immune response, the findings may have important implications for vaccine design and vaccination strategies.
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Affiliation(s)
- Debra E Bessen
- Department of Microbiology and Immunology, New York Medical College, Valhalla, NY 10595, USA.
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Ekelund K, Darenberg J, Norrby-Teglund A, Hoffmann S, Bang D, Skinhøj P, Konradsen HB. Variations in emm type among group A streptococcal isolates causing invasive or noninvasive infections in a nationwide study. J Clin Microbiol 2005; 43:3101-9. [PMID: 16000420 PMCID: PMC1169105 DOI: 10.1128/jcm.43.7.3101-3109.2005] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Since the late 1980s several studies have described the increased incidence and severity of invasive group A streptococcal (GAS) infections. However, most studies on GAS pathogenesis have focused on information obtained during outbreaks. We analyzed isolate distribution and host susceptibility as part of a nationwide prospective surveillance study performed between January 2001 and August 2002. GAS isolates collected from 201 patients with invasive infections, 335 patients with noninvasive infections, and 17 asymptomatic carriers were characterized with respect to their emm types and superantigen genotypes. The superantigen-neutralizing capacity and levels of antibodies against streptolysin O and DNAse B were determined for isolates from the sera from 36 invasive cases and 91 noninvasive cases. emm type 1 (emm-1) isolates were significantly more common among invasive cases, whereas emm-4, emm-6, and emm-12 dominated among the noninvasive cases. The distributions of the phage-associated superantigen genes (speA, speC, speH, speI, ssa) differed among invasive and noninvasive isolates, mainly due to their linkage to certain emm types. No significant differences in serum superantigen-neutralizing capacities were observed. The levels of anti-streptolysin O and anti-DNAse B antibodies were highest in the sera from invasive cases. Our study emphasizes the importance of obtaining data during years with stable incidences, which will enable evaluation of future outbreak data.
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Affiliation(s)
- Kim Ekelund
- Department of Bacteriology, Mycology and Parasitology, Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark.
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Ekelund K, Skinhøj P, Madsen J, Konradsen HB. Reemergence of emm1 and a changed superantigen profile for group A streptococci causing invasive infections: results from a nationwide study. J Clin Microbiol 2005; 43:1789-96. [PMID: 15815000 PMCID: PMC1081333 DOI: 10.1128/jcm.43.4.1789-1796.2005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Between 1999 and 2002, 496 invasive group A streptococcal (GAS) isolates from clinical microbiological departments in Denmark and subsequently 487 (98%) questionnaires from the clinicians treating the patients were received as part of a national surveillance. emm types and streptococcal superantigen (SAg) genes were determined. The incidence of invasive GAS infections was on average 2.3 per 100,000 per year. Bacteremia with no focal symptoms (27%) was together with erysipelas (20%) the most prevalent clinical diagnoses. Streptococcal toxic shock syndrome occurred in 10% of patients, of which 56% died. The overall case fatality rate within 30 days was 23%. In total, 47 different emm types were identified, of which emm1, emm3, emm4, emm12, emm28, and emm89 were identified in 72% of the 493 available isolates. During the 4-year period the presence of emm1 increased from 16% in 1999 to 40% in 2002. Concurrently, the presence of emm3 decreased from 23% in 1999 to 2% in 2002. The emm1 isolates predominantly carried speA, although the frequency decreased from 94% in 1999 to 71% in 2002, whereas the emm1-specific prevalence of speC increased from 25 to 53%. In a historical perspective, this could be interpreted as a reemergence of emm1 and could indicate a possible introduction of a new emm1 subclone. However, this reemergence did not result in any significant changes in the clinical manifestations during the study period. Our results show the complexity of invasive GAS infections, with time-dependent variations in the incidence and distribution of emm and SAg genes, which emphasizes the need for continuous epidemiological and molecular investigations.
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Affiliation(s)
- Kim Ekelund
- Streptococcus Unit, Department of Bacteriology, Mycology and Parasitology, Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S., Denmark.
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Beres SB, Sylva GL, Sturdevant DE, Granville CN, Liu M, Ricklefs SM, Whitney AR, Parkins LD, Hoe NP, Adams GJ, Low DE, DeLeo FR, McGeer A, Musser JM. Genome-wide molecular dissection of serotype M3 group A Streptococcus strains causing two epidemics of invasive infections. Proc Natl Acad Sci U S A 2004; 101:11833-8. [PMID: 15282372 PMCID: PMC511060 DOI: 10.1073/pnas.0404163101] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2004] [Indexed: 11/18/2022] Open
Abstract
Molecular factors that contribute to the emergence of new virulent bacterial subclones and epidemics are poorly understood. We hypothesized that analysis of a population-based strain sample of serotype M3 group A Streptococcus (GAS) recovered from patients with invasive infection by using genome-wide investigative methods would provide new insight into this fundamental infectious disease problem. Serotype M3 GAS strains (n = 255) cultured from patients in Ontario, Canada, over 11 years and representing two distinct infection peaks were studied. Genetic diversity was indexed by pulsed-field gel electrophoresis, DNA-DNA microarray, whole-genome PCR scanning, prophage genotyping, targeted gene sequencing, and single-nucleotide polymorphism genotyping. All variation in gene content was attributable to acquisition or loss of prophages, a molecular process that generated unique combinations of proven or putative virulence genes. Distinct serotype M3 genotypes experienced rapid population expansion and caused infections that differed significantly in character and severity. Molecular genetic analysis, combined with immunologic studies, implicated a 4-aa duplication in the extreme N terminus of M protein as a factor contributing to an epidemic wave of serotype M3 invasive infections. This finding has implications for GAS vaccine research. Genome-wide analysis of population-based strain samples cultured from clinically well defined patients is crucial for understanding the molecular events underlying bacterial epidemics.
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Affiliation(s)
- Stephen B Beres
- Laboratory of Human Bacterial Pathogenesis, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT 59840, USA
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Brandt CM, Haase G, Spellerberg B, Holland R, Lütticken R. drs (Distantly related sic) gene polymorphisms among emm12-type Streptococcus pyogenes isolates. J Clin Microbiol 2003; 41:1794-7. [PMID: 12682191 PMCID: PMC153900 DOI: 10.1128/jcm.41.4.1794-1797.2003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Twenty-eight emm12-type Streptococcus pyogenes isolates from patients with invasive and noninvasive infections or from asymptomatic carriers were genetically typed. Sequencing of drs (distantly related sic [streptococcal inhibitor of complement]) genes identified two novel alleles and revealed a polymorphism for drs similar to that of sic. No association was observed between the five different drs alleles and the five restriction patterns of the vir regulon for the isolates studied. These data suggest that drs sequencing may be useful for further differentiation of S. pyogenes isolates with emm12 and identical vir regulon restriction patterns.
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Affiliation(s)
- Claudia M Brandt
- Institute of Medical Microbiology and National Reference Center for Streptococci, University Hospital Aachen, 52057 Aachen, Germany.
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