Increase in group A Streptococcus and Staphylococcus aureus infections in prisons, people who use drugs, and those who are homeless or live in hostels, England, 2018-2019



Staphylococcus aureus and group A Streptococcus (GAS) infections in prison and homeless populations have been associated with poor general hygiene and in people who inject drugs (PWID) these infections may be related to unsterile injection practices. Morbidity can be severe and compounded by delays in seeking healthcare. In 2018-2019, increased reports of GAS infections were observed in England in prison inmates, PWID and the homeless, with co-infection with S. aureus reported in some cases. We report the results from an ongoing national investigation to quantify the burden of these infections and characterise risk factors in order to direct prevention measures.


National case reporting and laboratory surveillance systems were searched using the following case definition: ‘people in prison (including staff) and/or people who use or have a history of using drugs (injecting or not) and/or live in a hostel and/or are homeless with invasive or skin and soft tissue GAS infection from 1 January 2018’. For prison settings, cases of Staphylococcus aureus (MRSA and MSSA) bacteraemia and skin and soft tissue infections were also included. Isolates received at the national reference laboratory were typed using emm gene sequencing for GAS or multilocus sequence typing (MLST) for S. aureus.


Between 1 January 2018 and 14 June 2019, 841 cases were identified; 794 with GAS infection and 57 with S. aureus infections (10 had co-infection). In total, 223 cases were associated with prisons, 61 with hostels and 233 with homelessness. Injecting drug use was reported by 600 cases (71%). Twelve prisons geographically distributed across England reported two or more cases. Of 794 GAS infections, 513 were invasive, 173 non-invasive or unspecified (108 unknown); 388 were admitted to hospital and 11 deaths (all-cause) were reported. Three predominant emm types were identified amongst GAS cases; 108.1 (n=95), 66.0 (n=81) and 94.0 (n=36). S. aureus MLST typing information was available for 39 cases; predominant MLST types were 8 (n=6), 5 (n=5) and 398 (n=4).


A persistent increase in GAS infections has been observed in England in people in prison, PWID and those who are homeless. Services that work with homeless, prison and PWID populations should: encourage people with any skin lesions or other signs of infection to seek prompt medical attention; report any clusters of cases to allow for prompt identification and control of outbreaks; emphasize safe and hygienic injection practices; and ensure easy access to needle and syringe programmes. Specific guidance has been published for prisons to recommend: health assessment on first entry; isolation and restriction of prison transfers for cases until 48 hours of compliance with antibiotic treatment; thorough and regular cleaning in communal areas and deep cleaning for cells of cases; implementation of laundry protocols.


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