The impact of sore throats on the economy and the NHS over winter and spring is huge. One in ten will contract a sore throat every year – that means 6million cases every year. A proportion of these will be caused by a bacteria – commonly strep A. This is a contagious infection and easily spread. You may be contagious 2 – 3 days before the symptoms begin and then for a further 14 days- well after the symptoms have cleared. It is also responsible for more serious infections such as scarlet fever in children and invasive disease.
If you were in the US the advice would be simple – pop down to your pharmacy or medical facility and get tested. In fact this advice is fairly common across Europe. The test would be a rapid antigen detection test (RADT) that takes just a few minutes. Sensitivity is 96% and specificity is 98% vs culture. If positive you get an antibiotic and if negative, just symptomatic advice. Following the initiation of an antibiotic and the fall in fever you can go back to work or school in 24 hours.
Their strategy is:
|RADT||Instruction||% who have strep A||Comment|
|Positive||Prescribe antibiotic||96%||4% are needlessly given an antibiotic|
|Negative||No prescription||2%||2% remain contagious for 14 days|
If you have a sore throat – go and get tested. If you are a healthcare worker, carer of the elderly or work in schools it is even more important that you go and get tested.
In the UK we have a rather quaint love of the ‘educated guess’. We send all these patients to the GP who use the Public Health and NICE supported FEVERPAIN score. The strategy is as follows:
|FEVERPAIN score||Instruction||% who have strep A||Comment|
|4 – 5||Prescribe antibiotic||62-65%||35-38% are needlessly given an antibiotic|
|2 – 3||Delayed prescription||34-40%||Patients with infection returned to community untreated for 72 hours|
|0 – 1||No Prescription||13-18%||13-18% remain contagious for 14 days|
We are diverted by concentrating on symptoms rather than infection. If you have an infection and receive an antibiotic then your symptoms may improve quicker, but perhaps only by half a day. Some would suggest that this half a day is not worth the investment without considering the value of reducing transmission. Others reflect on antibiotic resistance, but still to this day there has not been a single strep A isolate found that is penicillin resistant.
Why should we be worried? The dramatic increase in Scarlet Fever notifications seen in the 2013-2014 season has continued at this level, meaning we have the highest levels for 50 years. Can we be complacent because the incidence of severe complications still seems low? The incidence of invasive disease is also increasing and data from the 2015-2016 season suggested that levels were 45% above the average for the previous years. There is no room for complacency as mortality remains at 15% and as high as 55% for some infections.
This season I am hoping for four things:
We create a consistent narrative “have a sore throat – get tested”
Community Pharmacy takes a lead and start offering strep A tests to people with a sore throat.
The Strep A sore throat test and treat service, that was supported by Simon Stevens within the NHS Innovation Accelerator and throughout the innovation network actually gets commissioned somewhere.
We have a different conversation and stop supporting an ‘educated guess’ process where a better objective test is available and widely used. Let’s concentrate on reducing transmission and reducing the use of needless antibiotics.