Bacteria Wars

In the run up to Christmas, Covid was knocked off the headlines by a far older threat to human health – one that’s bedevilled us for centuries. UK doctors reported an increase in the number of cases of serious Group A streptococcus (Group A Strep) infections, mostly among children, deeply troubling a public only just recovering from the effects of a global pandemic. At the same time, many were successfully treated as a result of discoveries and treatments that have evolved thanks to doctors and scientists metaphorically passing the torch to each other down the centuries.

Between five and fifteen per cent of healthy children have Strep A on their throats at any given time

Group A Strep is, of course, a bacterium rather than a virus, one of a great many variants from the family of streptococci. They are round bacteria that travel around in chains (hence the name: from Greek strep meaning chain and kokkos meaning berry). The Group A tag comes from how it’s identified from its cousins in the laboratory. Group A Strep commonly lives and grows on us without causing problems or anyone knowing it’s even there; it’s generally thought between five and fifteen per cent of healthy children have it on their throats at any given time without ever noticing. However, the bacteria occasionally cause active infection including infected tonsils, skin infections (especially after burns), a more generalised infection causing fever and dry red skin in children (scarlet fever) and, more lethally, it can lead to infections in deeper reaches of the body like the lungs or the bloodstream. Long-term consequences can also include rheumatic heart disease, which globally claims nearly 290,000 lives a year – mostly in low-income countries, according to the WHO. So the history of Strep A is necessarily intertwined with the story of human frailty.

There is still international debate over who identified Group A strep infection first, with familiar descriptions appearing in writings from Ancient Greece and Rome, and later across Europe in the sixteenth century. It seems likely that the Europeans took it with them to the New Worlds, part of a cocktail of bacteria that ravaged native populations. But it wasn’t until the seventeenth century that there was a more recognisable description, by a physician known as the “British Hippocrates”, Thomas Sydenham. He was a rare medic for his age in that he systematically recorded the specific features of different diseases. In his seminal texts Methodis Curandis Febres (1666) and Observationes Medicae (1676) Sydenham sets down the first description of “scarletina”, which we know as scarlet fever.

Thomas Sydenham set down the first description of “scarletina”, which we know as scarlet fever

Sydenham was revolutionary in more ways than one, abandoning his studies in Royalist Oxford during the English Civil War to do battle as a Roundhead, in the process sustaining injuries that would plague him for life, leading Cromwell to award him a gratuity. The money allowed Sydenham to marry and quit Oxford, where he’d gained medical qualification, and move to “marshy” Westminster. Despite being a great categoriser, Sydenham’s treatments weren’t innovative, nor were they in keeping with the prevailing theories of the causes of illness at the time. Shockingly, he recommended that children with scarlatina should have their necks blistered with a hot iron, with opium to relieve the pain.

It wasn’t until the nineteenth century that the idea of an actual bacteria behind Group A Strep disease was accepted by the medical profession, and it’s impossible to overstate how seismic that recognition was. The genius of that “eureka!” moment, and the dogged determination required to change prevailing beliefs and treatments in its wake, was the result of careful observation and experimentation, involving entities which nobody could physically see at the time. It was the Austrian surgeon, Theodor Billroth, who looked down a microscope at pus from a wound and who described, and for the first time named, the tiny round chains of bacteria he saw.

These discoveries were urgently needed. Throughout the nineteenth century there were huge global pandemics of Group A Strep, especially scarlet fever, causing widespread death. In 1860, the year of his presidential election campaign, even Abraham Lincoln took to his bed with a sore throat and fever, while his son, Willie became severely unwell with scarlet fever (and though he survived, later died aged eleven, probably of typhoid fever).

The discovery of antibiotics was of course the true game changer in battling the ravages of Group A Strep

A remarkable American scientist called Rebecca Lancefield made further progress in the early twentieth century, despite facing huge barriers due to her sex. Slights included being refused posts by senior scientists, who refused to work with a woman. Yet her perseverance and the brilliance of her research eventually led to the identification of proteins in the wall of Group A Strep, which enabled it’s identification and classification through the system subsequently named after her. (Or as a medical student could tell you, it’s Group A in the Lancefield system, which runs its way through the gamut of the alphabet to Group R&S Strep.)

While identification and description are the first part of the story, we have subsequent medical revolutionaries to thank for the second chapter: advances in treatment. The Chicago-based husband-and-wife team, George and Gladys Dick (physician equivalents of economists Sydney and Beatrice Webb), were the first, spurred on by serious investment from billionaire John D Rockefeller, whose grandson had died of scarlet fever. The medical duo developed both an antitoxin for scarlet fever and also the “Dick test” to improve earlier diagnosis – which led to a joint nomination for the Nobel Prize.

The discovery of antibiotics was of course the true game changer in battling the ravages of Group A Strep. By 1941, Howard Florey’s Oxford team had developed and purified a penicillin compound which had been safely tried and tested on animals, but not humans. That is, until a local police constable, Albert Alexander, accidentally cut himself pruning roses and rapidly became unwell with what was almost certainly a streptococcal skin infection. When Alexander was close to death in hospital, Florey’s team was ready to spring into action and he became the first ever patient to receive penicillin. It was a challenging process, not because of safety, but because the quantity of penicillin available was so tiny that they had to catch Alexander’s urine to filter it for penicillin and then recycle the drug. Although the patient showed clinical improvement, it was sadly insufficient to save his life. However, rapid improvements in the manufacturing process soon followed and larger and more effective quantities of penicillin soon became available. The world had entered the antibiotic age and to this day penicillin remains the first line treatment for Group A Strep throat infections and scarlet fever.

Group A Strep has remained with us, but thanks to access to antibiotics, improved living conditions and public health measures (Group A Strep is a mandatory reportable disease in the UK) it’s mercifully a rare cause of serious disease in children in high-income countries. However, the story is still very different in poorer countries, as well as in indigenous populations within affluent countries, where Group A Strep is still a larger, more common killer and cause of illness.

The challenge for the future is in tackling improved healthcare for the poorer and more deprived members of our race, and the hope of finding a vaccine. While those of us living in the UK can be grateful that, despite this winter’s sobering outbreak, we have the means to battle this bacterium, we should strive to ensure that the next chapter in fighting Group A Strep will be the last.

Lee Hudson is a clinical associate professor in child health at the Great Ormond Street UCL Institute of Child Health and Consultant Paediatrician