Hints of much worse to come as Strep A and RSV hit children and flu cases start to rise

Concerns about respiratory bugs and viruses moved up a gear this week, with the confirmation that a four-year-old in the northeast had died from an invasive form of the bacterial infection, Strep A. A five-year-old girl had died from the same infection earlier in the week in Belfast, the ninth such death in the UK in recent months.

Children’s hospitals say they are at “critical capacity” due to high numbers of people attending emergency departments (ED) and the number of sick children already occupying beds. Adult hospitals are experiencing record ED attendances and extremely high trolley numbers for the time of year.

So just how bad are things, and how much worse are they likely to become?

Overall, the figures reveal a mixed picture – it definitely isn’t all bad news, but there are hints of much worse to come.

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“If we want to get a realistic look at whether we’re truly seeing spikes in infection, we have to look pre-pandemic,” says virologist Dr Gerald Barry of University College Dublin.

The Covid-19 pandemic changed everything for a time in terms of infection control. Measures such as mask-wearing and social distancing did not just halt Covid; they put the brakes on a wide variety of other pathogens. And now that these measures have been dispensed with, most of the bugs are back.

[  What is strep A and what are the symptoms? ]

Making inroads

This winter, we have already seen a wave of RSV (respiratory syncytial virus) cases, and high numbers of hospitalisations among children. The wave has peaked, but children’s hospitals are still dealing with the aftermath.

Flu is also circulating – early – and numerous other viruses are making inroads on the population. Of the infectious diseases tracked by the HSE, 44 are showing increased case numbers this year while 11 have lower numbers.

“There is definitely a jump in these kind of respiratory infections, just as there was in Australia in its summer,” says Barry. “Something a little bit different is happening this year compared to previous years, before the pandemic.”

As he points out, the Covid measures affected other bugs. “For the first time ever, we had a winter where very few kids were coughing and spluttering and had runny noses and things like that. That creates a herd of people who are less exposed to a whole host of different pathogens.

“When you release the brakes, as we’ve done by going back to normal, you suddenly have a pool of people, particularly younger people, who are relatively naive to a whole host of infections.”

Instead of smaller populations experiencing infection in successive winters, a much larger group is being infected this winter. “We’re seeing a bigger rise in infections because now, suddenly, a flood of people are getting infected, all at the same time.”

Reduced immunity largely explains the rise in many respiratory bugs among small children. Those aged one or two have never been exposed to these viruses, circulation of which was suppressed during the pandemic, and neither were their mothers during the Covid era.

Another factor is at play in the rise of invasive Strep A. It usually peaks in the late winter and early spring. This year, cases have surged early in the UK.

Many of the serious cases in Britain are the result of co-infection, often where Strep A bacteria opportunistically take advantage of an immune system weakened by viral infection.

[ Strep A: When do normal symptoms become an emergency? ]

‘Immunity debt’

The resurgence of viruses after the pandemic has sparked much debate internationally about the wider impact of Covid and the measures taken to control it. The term “immunity debt” has gained popularity, and some blame the current wave of infections on a weakening of immunity caused by Covid measures.

But talk of a post-pandemic “immunity debt”, a kind of infectious disease “payback time”, is misconstrued, according to Barry. “There’s no evidence that our immune system works like a muscle, or that we need to constantly infect ourselves to keep it in tip-top form, or to say that because we had a reduced number of infections over 2020/21, our immune system is suddenly weaker.”

The signs for the coming months are ominous. Flu, while not yet surging, is at higher levels for the time of year than any recent winter. The US last week recorded a record number of positive flu tests as cases there rise exponentially.

Covid has been mercifully quiet, but that may change soon. Case numbers are rising and so is test positivity. The number of people with Covid in hospital on Thursday was the highest for a month, and the number of new cases was the highest for six weeks.

With Belfast hospitals recording surging numbers of children attending with Strep A, it is likely that case numbers south of the Border will continue to rise. EDs will also fill up with less seriously ill children brought there by understandably worried parents.

“Things are hard to predict, but we are likely to see a pretty steep wave of influenza, and Covid may increase in January and February because that’s when coronaviruses tend to rise,” says Barry.

What can people do? In the short term, the experts advise people to get vaccinated where this is possible, and to stay at home if they have symptoms.

In the longer term, Barry asks whether it is time to stop passively accepting these winter waves of infection. “Why are we not doing as much as possible to limit these infections? Why don’t we have a vaccine for Strep A, for example? Why don’t we vaccinate every child with meningitis? Why don’t we give a Covid booster to everyone who wants one?”

“Life is probably better if your child doesn’t have a snotty nose and a cough for three or four months every year or struggles to breathe when they go to sleep. I think everyone probably would prefer that.”