Group A Streptococcus: Report


Group A Streptococcus

The plan is to reduce the transmission of Group A Streptococcal bacteria using the transmission rate hypothesis issued forth by Dr. Paul Ewald. While most diseases caused by Group A Streptococcus are relatively benign, some result in a swift death such as necrotizing fasciitis and Streptococcal toxic shock syndrome. The idea is that by reducing the transmission, these bacteria cannot increase in virulence to cause more malignant diseases as seen in the past. For example, in the 1800's, scarlet fever had a high mortality rate, and now it is almost unheard of in the United States. This is through the miracle of antibiotics. However, simply treating diseases caused by Group A Streptococcus with antibiotics may not continue to work. Some strains are showing a tolerance for antibiotics, and while none show outright resistance, there is still a possibility of it occurring in the near future.

The reduction of transmission will be targeted using a multi-pronged approach to reduce the virulence and the infection rate. A large part of this approach is focused on education to teach people how to properly protect themselves from the Streptococcal bacteria and how to properly administer their medication. A smaller portion of this approach is focused on vaccination treatment. A vaccine for six of the most common strains of Group A Streptococcus was developed in 2004 but was never released into the public (Kotloff KL et al 2005; McNeil SA et al 2005). There is still testing being conducted.

Discussion of the issues

Group A Streptococcus is spherical and gram positive and grows in chains (Patterson MJ 1996). This bacterium causes skin problems from relatively benign to life-threatening. Certain strains of Streptococcus produce toxins that determine how devastating the infection is on the human host. These infections occur on the skin or in the throat and mouth. Group A Streptococcus is found world-wide, and the natural hosts are humans. It is a very common bacterial infection. There are other groups of Streptococcus: Group B, C, D, and G.

The virulence factors for Group A Streptococcus are the proteins it releases. Each strain releases a different array of proteins to attach to a host, avoid immune detection, and fan out through the host's tissues. The hyaluronic acid capsule protects the bacterium from phagocytosis of the immune system (Bisno AL, MO Brito, and CM Collins. 2003). Other proteins that affect the virulence are the M-protein, F-protein, and lipoteichoic acid (Chatellier S et al 2000). It is the M-protein that inhibits phagocytosis; however, it is also the M-protein that antibodies use to identify the bacterium, but the M-protein is unique to each strain of Streptococcus (Bisno AL, MO Brito, and CM Collins. 2003; Chatellier S et al 2000; Musser JM et al 1996). There are at least 100 different serotypes of M-protein (Banks, DJ, B Lei, and JM Musser 2003).

Aside from the M-protein, F-protein, and lipoteichoic acid, Streptococcus releases Streptolysin O and S, Streptococcal pyrogenic exotoxins (SPE) A and C, Streptokinase, Hyaluronidase, Streptodornase, C5a peptidase, and Streptococcal chemokine protease (Banks, DJ, B Lei, and JM Musser 2003). Each protein causes a different reaction to the immune system and the host. It is possible to diagnose based on the proteins present.

Group A Streptococcus causes necrotizing fasciitis (NF), Streptococcal toxic shock syndrome (STSS), strep throat, impetigo, scarlet fever, and rheumatic fever. However, NF and STSS are the deadliest of infections caused by Group A Streptococcus (Mehta S et al 2006). Each infection is caused by a different strain of Group A Streptococcus.

Necrotizing fasciitis is commonly known as flesh-eating bacteria. This name is a misnomer. These bacteria do not actually eat flesh. They release a toxin that destroys flesh. There is more than one species of bacteria that cause necrotizing fasciitis: Vibrio vulnificus, Clostridium perfringens, Bacteroides fragilis, and Streptococcus pyogenes, which is the most common (Green RJ, DC Dafoe, and TA Raffin 1996.). These bacteria become harmful when they enter the body, but cause no damage when they settle on epidermal tissue or esophageal. However, when the skin breaks and the bacteria enter the body through the wound, infection occurs. Infection can also occur if the bacteria are ingested.

These bacteria release a toxin that decimates flesh (Green RJ, DC Dafoe, and TA Raffin 1996). The toxin is the virulence factor: the stronger the toxin, the more damage it causes. Therefore, if transmission were reduced among the more virulent strains, the less virulent strains would be left and cause less damage.

The majority of these bacteria enter the body via a site of trauma. The effects of the infection are almost instantaneous unless the bacteria have become deeply embedded in the tissue. The bacteria can also be taken into the body orally. There is a high mortality rate for those infected with necrotizing fasciitis (50%), and the rate is even higher for those who do not receive immediate medical attention (almost 75%), and even those who do receive medical attention do not have a hundred percent chance of survival. Even among t hose who do survive the infection, severe disfigurement can occur. T herefore, it is important that medical attention should be sought out immediately after infection.

Streptococcal toxic shock syndrome is just as deadly as necrotizing fasciitis and enters the body through the throat, skin, or vagina. STSS causes internal bleeding and other serious complications (Cone LA et al 1987). The bacteria spreads much like necrotizing fasciitis, and it is treated similarly. The transmission is different, however. Those at risk are those who have a history of using super-absorbent tampons, a history of using a diaphragm or contraceptive sponge, or a history of childbirth or abortion (Hauser AR et al 1991). Also at risk are those with surgical wounds or a local infection in the skin or deep tissue.

Strep throat is when the bacteria colonize the throat and tonsils (Ebell MH et al 2000). This infection is painful, but relatively benign, especially when compared to necrotizing fasciitis. Scarlet fever and impetigo are infections of the skin, although scarlet fever also infects the throat. All three of these infections can be treated with antibiotics (Brown J et al 2003). Rheumative fever can sometimes occur in people who have had untreated strep throat. This results in heart complications that need to be treated with antibiotics and anti-inflammatories (Catanzaro FJ et al 1954; Dinkla K et al 2003).

Due to the commonness of the bacteria in children, it is important to target children so they understand how to protect themselves. If children can practice good hygiene, the transmission rate of the bacteria (and other human-to-human transmitted pathogens) will decrease.

Call for action

Everyone is at risk for Group A Streptococcus. It is a very common bacteria that is teetering on the verge of antibiotic resistance. If action is not taken now, these bacteria will evolve in a similar way to Staphylococcus as antibiotic resistant and increased in virulence. However, if steps are taken now to prevent transmission, to lower it a significant amount, then the virulence would decrease and fewer children would be infected.

The statistics on prevalence vary from source to source. However, the CDC reports that there were approximately 9,400 cases of invasive Group A Streptococcus reported in 1999, 1,500 result in death, and there are over a million cases of strep throat and impetigo (non-invasive Group A Streptococcus) reported yearly within the United States. There are over 10 million cases a year world-wide.

Budget

The hypothetical $5 million dollars can only go so far. Because a vaccine is already in the process of trial testing, most of this money will be spent on education of the public. The targeted audience for this education will be those who are the most at risk: children to the age of 18-years-old.

Two 30-second television commercials will be made at $350,000 each. One commercial will be live-action and the other will be a cartoon. This will cost a total of $700,000 in production. It will cost $100,000 to disperse it nationally for one month, and therefore $1.2 million will be spent for one year's worth of commercials. This is approximate because certain programs cost more than others: prime spots on prime networks cost upwards toward $1 million (such as the last episode of Seinfeld) and some programs on other networks cost $50.

Magazine advertisements will also be created to go along with the commercials. There will be two different advertisements, one geared for children and one geared for parents. A full page will cost $1,000 to commission a design for, and for two pages that will result in $2,000 worth of commission. It will cost $10,000 a month per a magazine. The advertisements will run in eight magazines for a year: four kid magazines and four parenting magazines resulting in $960,000.

A traveling teacher program will be set up for a trial run. This program will be similar to the DARE drug program, except it will be taught to first graders. The trial will run in five regions of the United States by five people: the four corners of the continental and the Midwest (Connecticut and Rhode Island, Washington, Georgia, New Mexico, and Illinois). These five people will attend a mandatory training seminar that will import pediatrician lecturers (five at $500), require props (CPR dummy and first aid kits at $450 and $50 respectively) books (five at $100), and other expenses ($500) that will cost approximately $4,000. The person teaching the seminar will be paid $1000. These five people will receive a salary of $30,000 a year plus $10,000 for props and travel expenses giving a total of $200,000. A more accurate number cannot be given do to the constant flux of gasoline prices.

If the traveling teacher program is successful, it will continue in each of the fifty states, except there will be one person for Connecticut, Rhode Island, and Massachusetts, one person for New Hampshire, Vermont, and Maine, one person for Maryland and Delaware, two people for Texas, and two people for California. This will result in 49 people across the United States teaching in elementary schools and will cost $1.96 million.

The remaining $179,000 will be directed to vaccination trials. If the traveling teacher program is not successful, there will be $1.933 million that will be directed to the vaccination trials.

Plan of action

The less virulent varieties of Group A Streptococcus usually infect children. Therefore it is important to impress good hygiene to children. Parents should teach their children how to properly take care of their bodies by example and instruction. When the child is out of the parents' jurisdiction at school, teachers should impress good hygiene to the students.

To help the parents, an advertisement campaign will be used to inform the general public of viral and bacterial infections such as Streptococcus. A commercial will be aired on the children's networks such as Cartoon Network, The Disney Channel, and Nickelodeon during the times that children would be watching with their parents such as Saturday mornings and during the summer.

Most antibacterial treatments such as Lysol© wipes are directed at the parents, for the parents to take full responsibility for all the pathogens their children come across. These commercials will put some of the responsibility on the children, because Streptococcus is transmitted skin-to-skin, not inanimate object-to-skin.

There will be two different 30-second commercials: a live-action one and a cartoon one. Both will be targeting children as the main audience. In the live-action commercial the main character will be washing his or her hands and singing "Happy Birthday" using the soap dispenser as a microphone. This will take about 15 seconds, so the remaining time will be spent explaining to the children audience the importance of washing hands, much like the Listerine commercials where the main character uses the mouthwash for the entire commercial. For example, "You just prevented three colds, strep throat, and pink eye."

The cartoon commercial will show children around the age of 8-years-old playing tag in a playground. Their natural flora will be enlarged for the viewer to see the bacteria and other pathogens on each child. One child will have a runny nose and be constantly wiping it on the back of his hand. He is "It" and has green skin. He runs around tagging all of the other children, turning them from their natural color to green so that the viewer can see the pathogen spread through the group of children. The end of the commercial will have the last child to be tagged humming "Happy Birthday" over a sink with running water while washing his hands.

The advertisements in parenting magazines will be along the lines of the live-action commercial. It will remind parents to teach their children good hygiene and remind them that antibiotics should be taken only when there is a bacterial infection and should be taken until the end of the prescription, not until the symptoms disappear. The advertisements in the children's magazine will be along the lines of the cartoon commercial, reminding the child to wash his hands often.

The traveling teacher program will visit elementary schools to reinforce these commercials. These five traveling teachers will lead an assembly to the first grade classes at different elementary schools state-wide. They will educate the children using simplified evolutionary medicine principles; the most important idea to teach is reducing transmission of pathogens. The teacher will use props to encourage hand washing after using the toilet, coughing, sneezing, or blowing one's nose. The teacher will also demonstrate other ways to avoid making other people sick including the importance of staying home when sick. The teacher will leave a chart for each first-grade teacher to monitor how often a child washes his or her hands, with incentive for not being sick. This will not only protect against Streptococcus but also Staphylococcus, the flu, colds, and other pathogens.

The trial teaching programs will be conducted in five very different parts of the United States both economically and environmentally. Connecticut and Rhode Island have a harsh and defined winter and therefore cold and flu season, as well as having predominantly wealthy communities. Georgia has mild winters and hot, wet summers. New Mexico has severe winters in the high altitudes and hot, dry summers. Washington is mild and wet year-round. Illinois has hot summers and cold winters, and Chicago is usually very windy. These different climates lend to different ways for pathogens to avoid a weakened immune system.

If the traveling teacher program does lower the transmission rates of pathogens (as recorded by school secretaries for sick-related absences of teachers and students and compared to neighboring schools and past years), then this will continue in all 50 states. There will be one person for each state with the exception of one person for Connecticut, Rhode Island, and Massachusetts, one person for New Hampshire, Vermont, and Maine, one person for Maryland and Delaware, two people for Texas, and two people for California.

The remaining money will be directed toward the vaccination development trails started three years ago targeting six common strains of Group A Streptococcus. The vaccine development is conducted by Dr Karen Kotloff at the University of Maryland. When it is ready, it will be administered to children with other childhood vaccinations.

All of these programs can contribute to a reduction in transmission of Group A Streptococcus and other pathogens passed skin-to-skin. This reduction in transmission should, according to the transmission rate hypothesis, reduce the virulence of the bacterium. The reduction of transmission should also correlate with a decrease in antibiotic tolerance and no evolutionary movement toward antibiotic resistance, resulting in increasingly benign strains non-invasive of Group A Streptococcus.

Literature Cited

Group A Streptococcus