We learned recently that one of our region’s most popular camps had an outbreak of streptococcal pharyngitis, AKA, strep throat.
This came as no surprise to us, we have seen a growing number of cases of strep throat over the last few summers, a real change from the not so distant days when strep throat was seen mainly in cold months. What happened, how did a winter illness start showing up in summer?
It all has to do with how germs travel. So here is a quick review of strep and how its travel plans have changed.
What is Strep?
Everyone has heard of strep, but no everyone knows what it is. The word strep refers to a bacteria whose formal name is Streptococcus pyogenes. In the letter-defined system of classifying strep germs (the most famous is the one seen at the end of pregnancy, Group B strep), the germ that causes strep throat is in the A group, and so is also called Group A streptococcus. In the great worlds of germs, the four main domains are viruses, fungi, parasites, and bacteria. As noted strep is a bacteria.
Strep causes trouble by getting into our tissue and quite literally eating it. This tends to deeply anger our immune system which then destroys these bacteria, and in the process, making a ton of pus, and loads of antibodies to rid us of the invader. The pus and inflammation happen, of course, wherever the strep germ is feasting on our cells. Now, this germ can feast just about anywhere, but we tend to see strep infections showing up in two major locations- the throat and the skin.
If you have a bite or cut and strep gets into the break, that area will get quite hot, red, sore, and generate lots of pus. We call that cellulitis, but a better term for it would be, a bacterial infection of the skin. These red skin infections are nearly all caused by staph, and the strep we have been talking about.
But most of the strep infections we see are in the throat. Strep throat is very, very common. If you look for a strep throat infection in any American classroom, on any day, you will find 10% of the children in every classroom, every day, will have strep throat.
That’s why we gently smile when schools send home notices to all families when one of their children is identified as having strep throat. If it was actually important to know when a child appears in a school, or even classroom, with strep, the school would have to send those notices home every day.
Some kids get strep many times, some never get it, and many get it a handful of times. There seems to be some strong genetic force at work determining who will fall into which group. It may have to do with how well the genetic code of our throat cells allows, or disallows, strep germs to stay attached to one’s throat. Although many people have seen episode after episode of strep end when someone removes their tonsils, the data suggest surgery has minimal actual impact on the chances of getting strep. This makes sense,after all, even if you remove your tonsils, there is still a throat present to allow strep throat to occur.
Symptoms of Strep
This is a very interesting story. Many kids with strep throat have no symptoms, but most kids who feel fine do not have strep throat.
Here are the numbers. If we look at a typical group of 100 kids with a strep throat infection, then:
- 33 will have a fever and sore throat, symptoms of strep throat
- 33 will have a cold without a sore throat
- 34 will feel perfectly fine
All 100 will recover just fine, typically.
Now, here is where it gets even more interesting. Take 100 kids who feel fine, and not many will have strep throat, less than 10. Take 100 kids with a cold and that number rises a bit. But take 100 kids with a fever and sore throat, and about 30 will have strep throat.
Treating Strep Throat
There was a time, about 30 years ago and longer, that about 3% of kids who got strep throat, if not treated would develop rheumatic fever. It’s still happens in poor countries. But not so much in the US. Since 1980, the chance of getting rheumatic fever from a strep throat has, effectively, vanished.
Rheumatic fever happens if your immune system makes antibodies to strep that also attack your heart, brain, and joints. It is an awful, dangerous, life-altering event. When it affected 3% of untreated children, there was an urgency to treat strep throat. The data proved that if you gave a child with strep throat an antibiotic within 10 days of the first symptom, they would no longer be at risk for rheumatic fever.
But now rheumatic fever has nearly disappeared, the whole rationale for treating strep has nearly vanished with it. So why treat? The main reason is to feel better. Treatment of strep does shorten the course, and will prevent the bacteria from traveling around the body any further.
Why Strep in the Summer?
It turns out that strep loves a crowd. That makes sense. To spread, the strep has to travel from one person to another. If no one else is around, no spread. Pack kids into a crowd and,voila, the highway to spread opens up.
We have seen the rise of summer strep follow the wonderful popularity of summer camps. A time not so long ago, kids went to school from September to May, and played around the neighborhood in the summer. That ended the easy rides from person-to-person for strep, and summer was a time of only rare strep throats.
Now kids congregate in the summer. There are pre-school camps, and drama camps, and sleep-away camps, and travel sports teams, a camp for every interest. Many children now leave for camp a few days after school ends. And so summertime is a time of many kids gathering, much as is school. This allows strep to travel from person-to-person in the summer. And so it does.
- Strep throat is a bacterial infection of the throat that can be very painful, but no longer is considered a dangerous infection.
- Strep throat is incredibly common, and constant, about 10% of any classroom’s children will have strep throat on any day.
- Two thirds of kids with strep throat have no sore throat or fever, but the vast majority of kids who feel fine or have a cold do not have strep throat.
- The main scourge of strep throat infections was once rheumatic fever, but that phenomenon is now quite rare in the US, so the reason we treat today is for comfort.
- The rise of organized activities in the summer has extended the time kids are in large groups all day quite dramatically, this has opened the door to strep going year round.
To your health,
Dr. Arthur Lavin