Outbreaks Open Access
Like 0


We observed an increase in notifications of puerperal group A (GAS) infections in July and August 2018 throughout the Netherlands without evidence for common sources. General practitioners reported a simultaneous increase in impetigo. We hypothesised that the outbreak of puerperal GAS infections resulted from increased exposure via impetigo in the community.

We conducted a case–control study to assess peripartum exposure to possible, non-invasive GAS infections using an online questionnaire. Confirmed cases were recruited through public health services while probable cases and controls were recruited through social media. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) with logistic regression analysis.

We enrolled 22 confirmed and 23 probable cases, and 2,400 controls. Contact with persons with impetigo were reported by 8% of cases and 2% of controls (OR: 3.26, 95% CI: 0.98–10.88) and contact with possible GAS infections (impetigo, pharyngitis or scarlet fever) by 28% and 9%, respectively (OR: 4.12, 95% CI: 1.95–8.68). In multivariable analysis, contact with possible GAS infections remained an independent risk factor (aOR: 4.28, 95% CI: 2.02–9.09).

We found an increased risk of puerperal fever after community contact with possible non-invasive GAS infections. Further study of this association is warranted.


Article metrics loading...

Loading full text...

Full text loading...



  1. Walker MJ, Barnett TC, McArthur JD, Cole JN, Gillen CM, Henningham A, et al. Disease manifestations and pathogenic mechanisms of Group A Streptococcus. Clin Microbiol Rev. 2014;27(2):264-301.  https://doi.org/10.1128/CMR.00101-13  PMID: 24696436 
  2. Oliver J, Malliya Wadu E, Pierse N, Moreland NJ, Williamson DA, Baker MG. Group A Streptococcus pharyngitis and pharyngeal carriage: A meta-analysis. PLoS Negl Trop Dis. 2018;12(3):e0006335.  https://doi.org/10.1371/journal.pntd.0006335  PMID: 29554121 
  3. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5(11):685-94.  https://doi.org/10.1016/S1473-3099(05)70267-X  PMID: 16253886 
  4. Efstratiou A, Lamagni T. Epidemiology of Streptococcus pyogenes. In: Ferretti JJ, Stevens DL, Fischeretti VA, editors. Streptococcus pyogenes: basic biology to clinical manifestations. Oklahoma City: University of Oklahoma Health Sciences Center; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK343616/#top
  5. Lamagni TL, Efstratiou A, Dennis J, Nair P, Kearney J, George R, et al. , national incident management team. Increase in invasive group A streptococcal infections in England, Wales and Northern Ireland, 2008-9. Euro Surveill. 2009;14(5):19110.  https://doi.org/10.2807/ese.14.05.19110-en  PMID: 19215717 
  6. Meehan M, Murchan S, Bergin S, O’Flanagan D, Cunney R. Increased incidence of invasive group A streptococcal disease in Ireland, 2012 to 2013. Euro Surveill. 2013;18(33):20556.  https://doi.org/10.2807/1560-7917.ES2013.18.33.20556  PMID: 23968875 
  7. Teatero S, McGeer A, Tyrrell GJ, Hoang L, Smadi H, Domingo MC, et al. Canada-wide epidemic of emm74 group A streptococcus invasive disease. Open Forum Infect Dis. 2018;5(5):ofy085.  https://doi.org/10.1093/ofid/ofy085  PMID: 29780850 
  8. Deutscher M, Lewis M, Zell ER, Taylor TH Jr, Van Beneden C, Schrag S, Active Bacterial Core Surveillance Team. Incidence and severity of invasive Streptococcus pneumoniae, group A Streptococcus, and group B Streptococcus infections among pregnant and postpartum women. Clin Infect Dis. 2011;53(2):114-23.  https://doi.org/10.1093/cid/cir325  PMID: 21690617 
  9. Leonard A, Wright A, Saavedra-Campos M, Lamagni T, Cordery R, Nicholls M, et al. Severe group A streptococcal infections in mothers and their newborns in London and the South East, 2010-2016: assessment of risk and audit of public health management. BJOG. 2019;126(1):44-53.  https://doi.org/10.1111/1471-0528.15415  PMID: 30070056 
  10. Sriskandan S. Severe peripartum sepsis. J R Coll Physicians Edinb. 2011;41(4):339-46.  https://doi.org/10.4997/JRCPE.2011.411  PMID: 22184573 
  11. Mason KL, Aronoff DM. Postpartum group a Streptococcus sepsis and maternal immunology. Am J Reprod Immunol. 2012;67(2):91-100.  https://doi.org/10.1111/j.1600-0897.2011.01083.x  PMID: 22023345 
  12. van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. 2010;23(3):249-54.  https://doi.org/10.1097/QCO.0b013e328339257c  PMID: 20375891 
  13. Lamagni TL, Darenberg J, Luca-Harari B, Siljander T, Efstratiou A, Henriques-Normark B, et al. , Strep-EURO Study Group. Epidemiology of severe Streptococcus pyogenes disease in Europe. J Clin Microbiol. 2008;46(7):2359-67.  https://doi.org/10.1128/JCM.00422-08  PMID: 18463210 
  14. Jasir A, Schalén C, Strep-ERUO study group. Strep-EURO: progress in analysis and research into severe streptococcal disease in Europe, 2003-2004. Euro Surveill. 2005;10(2):E050203.3. PMID: 16685103 
  15. National Institute for Public Health and the Environment (RIVM), Department of Infectious Disease Control. Groep A-streptokokkeninfectie richtlijn. [National guideline for Group A Streptococcal Infections]. Bilthoven: RIVM. [Accessed: 20 Sep 2019]. Dutch. Available from: https://lci.rivm.nl/richtlijnen/groep-streptokokkeninfectie
  16. Netherlands Institute for Health Services Research (Nivel). Meer kinderen met krentenbaard dit najaar, oorzaak onbekend. [More children with impetigo this autumn. Cause unknown] Utrecht; Nivel; 20 Sep 2018. Dutch. Available from: https://www.nivel.nl/nl/nieuws/meer-kinderen-met-krentenbaard-dit-najaar-oorzaak-onbekend
  17. Cole P, MacMahon B. Attributable risk percent in case-control studies. Br J Prev Soc Med. 1971;25(4):242-4.  https://doi.org/10.1136/jech.25.4.242  PMID: 5160433 
  18. Cole P, MacMahon B. Attributable risk percent in case-control studies. Br J Prev Soc Med. 1971;25(4):242-4. PMID: 5160433 
  19. Mearkle R, Saavedra-Campos M, Lamagni T, Usdin M, Coelho J, Chalker V, et al. Household transmission of invasive group A Streptococcus infections in England: a population-based study, 2009, 2011 to 2013. Euro Surveill. 2017;22(19):30532.  https://doi.org/10.2807/1560-7917.ES.2017.22.19.30532  PMID: 28537550 
  20. Watts V, Balasegaram S, Brown CS, Mathew S, Mearkle R, Ready D, et al. Increased risk for invasive group A Streptococcus disease for household contacts of scarlet fever cases, England, 2011-2016. Emerg Infect Dis. 2019;25(3):529-37.  https://doi.org/10.3201/eid2503.181518  PMID: 30602121 
  21. Bowen AC, Tong SYC, Chatfield MD, Carapetis JR. The microbiology of impetigo in indigenous children: associations between Streptococcus pyogenes, Staphylococcus aureus, scabies, and nasal carriage. BMC Infect Dis. 2014;14(1):727.  https://doi.org/10.1186/s12879-014-0727-5  PMID: 25551178 
  22. Hervás D, Hervás-Masip J, Ferrés L, Ramírez A, Pérez JL, Hervás JA. Effects of meteorologic factors and schooling on the seasonality of group A streptococcal pharyngitis. Int J Biometeorol. 2016;60(5):763-9.  https://doi.org/10.1007/s00484-015-1072-0  PMID: 26446674 
  23. Royal Netherlands Meteorological Institute. Weerstatistieken De Bilt 2018. [Weather statistics De Bilt 2018]. De Bilt: Koninklijk Nederlands Meteorologisch Instituut (KNMI). [Accessed 20 Sep 2019]. Dutch. Available from: https://weerstatistieken.nl/de-bilt/2018
  24. Liu Y, Chan TC, Yap LW, Luo Y, Xu W, Qin S, et al. Resurgence of scarlet fever in China: a 13-year population-based surveillance study. Lancet Infect Dis. 2018;18(8):903-12.  https://doi.org/10.1016/S1473-3099(18)30231-7  PMID: 29858148 
  25. Lamagni T, Guy R, Chand M, Henderson KL, Chalker V, Lewis J, et al. Resurgence of scarlet fever in England, 2014-16: a population-based surveillance study. Lancet Infect Dis. 2018;18(2):180-7.  https://doi.org/10.1016/S1473-3099(17)30693-X  PMID: 29191628 
  26. Lynskey NN, Jauneikaite E, Li HK, Zhi X, Turner CE, Mosavie M, et al. Emergence of dominant toxigenic M1T1 Streptococcus pyogenes clone during increased scarlet fever activity in England: a population-based molecular epidemiological study. Lancet Infect Dis. 2019;19(11):1209-18.  https://doi.org/10.1016/S1473-3099(19)30446-3  PMID: 31519541 
  27. Statistics Netherlands (CBS). Bevolkingsontwikkeling; maand en jaar. [Population development; month and year]. The Hague: CBS. Accessed [20 Sep 2019]. Dutch. Available from: https://opendata.cbs.nl/statline/#/CBS/nl/dataset/83474ned/table?ts=1549578173545

Data & Media loading...

Supplementary data

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error