Scarlet Fever in India: Re-emergence, Clinical Profile, and Public Health Implications
1. Mohammad Altamash Zafar
2. Alam Khursheed
3. Khan Mohammad Zeeshan
4. Abzhaparova A.Z
(Student, International Medical Faculty, Osh State University, Kyrgyzstan)
(Student, International Medical Faculty, Osh State University, Kyrgyzstan)
(Student, International Medical Faculty, Osh State University, Kyrgyzstan)
(Teacher, International Medical Faculty, Osh State University, Kyrgyzstan)
Abstract
Background: Scarlet fever is an acute infectious disease caused by toxin-producing Streptococcus pyogenes. Although historically common, its incidence declined in the antibiotic era. Recent outbreaks in several countries suggest a global re-emergence, raising concerns regarding antimicrobial resistance and public health preparedness in low- and middle-income countries.
Objective: To review the re-emergence of scarlet fever in India, describe its clinical profile, and analyze its public health implications.
Methods: A narrative review was conducted using PubMed, Google Scholar, World Health Organization (WHO) reports, Indian Council of Medical Research (ICMR) publications, and National Centre for Disease Control (NCDC) documents. Articles published between 2014 and 2024 were included and analyzed qualitatively.
Results: Evidence suggests that scarlet fever is underreported in India. Sporadic outbreaks have been reported from multiple states, mostly affecting school-aged children. Common clinical features included fever, pharyngitis, strawberry tongue, and a characteristic sandpaper-like rash. Penicillin and amoxicillin remained effective first-line therapies, although macrolide resistance has increased globally. Surveillance gaps and limited laboratory confirmation were observed.
Conclusion: Scarlet fever is an under-recognized re-emerging infection in India. Strengthening disease surveillance, improving diagnostic capacity, and increasing clinician awareness are essential to reduce outbreaks and complications.
Keywords: Scarlet fever; Streptococcus pyogenes; India; re-emerging infections; pediatric infectious diseases; public health
Introduction
Scarlet fever is an acute bacterial infection caused by Group A beta-hemolytic Streptococcus pyogenes that produces erythrogenic exotoxins. It mainly affects children between 5 and 15 years of age and spreads through respiratory droplets. Prior to the widespread use of antibiotics, scarlet fever was a major cause of childhood mortality worldwide.
Since 2011, several countries including China, the United Kingdom, Hong Kong, and South Korea have reported resurgences of scarlet fever, leading to renewed global concern. The World Health Organization has recognized re-emerging streptococcal infections as a growing public health issue. Genetic variation in circulating strains, urban overcrowding, and antimicrobial resistance have been identified as key contributing factors.
In India, scarlet fever is not a notifiable disease under the national surveillance system. The true burden of the disease remains unclear due to underreporting, frequent misdiagnosis, and lack of routine laboratory confirmation. Febrile rash illnesses such as measles, rubella, and dengue often mimic scarlet fever, leading to delayed or inappropriate treatment.
Published Indian data consist primarily of isolated case reports and small hospital-based studies. There is a lack of comprehensive national-level studies describing the epidemiology, clinical characteristics, and public health preparedness regarding scarlet fever. This highlights the need for a consolidated review focused on the Indian context.
Objectives of the study:
1. To review the epidemiological trends of scarlet fever in India.
2. To describe the clinical profile and diagnostic features of scarlet fever.
3. To assess the public health implications of scarlet fever re-emergence in India.
Methods
Study Design
This study was designed as a narrative literature review.
Data Sources (Data were obtained from):
PubMed
Google Scholar
World Health Organization (WHO) publications
Indian Council of Medical Research (ICMR) reports
National Centre for Disease Control (NCDC), India
Inclusion Criteria
● Articles published from 2014 to 2024
● Studies related to epidemiology, clinical features, diagnosis, and public health impact of scarlet fever
● English-language publications
Exclusion Criteria
● Opinion articles without scientific data
● Studies focusing only on non-scarlet streptococcal diseases
● Articles published before 2014 unless historically relevant
Data Extraction and Analysis
Data was manually extracted using a structured form. Variables included geographic region, age group, clinical signs, diagnostic methods, and antimicrobial sensitivity. Findings were synthesized qualitatively.
Ethical Considerations
Ethical approval was not required as this study used publicly available data.
Results
Epidemiology of Scarlet Fever in India
● Scarlet fever is not a notifiable disease in India.
● Cases are mainly reported from urban and semi-urban regions.
● Most affected age group: 5–15 years.
● Seasonal peak: winter and early spring.
Clinical Characteristics
Clinical Feature Approximate Frequency
Fever 90–100%
Sore throat 85–95%
Sandpaper-like rash 80–90%
Strawberry tongue 70–80%
Desquamation (peeling) 50–60%
Diagnostic Approaches
● Clinical diagnosis is the primary method in most settings.
● Throat culture and rapid antigen detection tests are available mainly in tertiary hospitals.
● Laboratory confirmation is uncommon in rural areas.
Treatment Patterns
Antibiotic Use Pattern
Penicillin V First-line treatment
Amoxicillin Frequently used
Azithromycin Used in penicillin allergy
Cephalosporins Alternative option
Public Health Observations
● Low awareness among primary care providers
● No standardized reporting system
● Limited laboratory facilities
● Absence of dedicated scarlet fever surveillance
Discussion
This review suggests that scarlet fever is likely underdiagnosed and underreported in India, leading to an underestimation of its true public health burden. Although the clinical presentation observed in India appears comparable to patterns reported globally, the absence of routine surveillance systems and standardized reporting mechanisms makes it difficult to assess the actual incidence and trends of the disease.
Misdiagnosis remains a significant concern, as the symptoms of scarlet fever—particularly fever and rash—overlap with those of other common febrile illnesses in India, such as dengue, chikungunya, and measles. This overlap often leads to delayed or inappropriate treatment. Delayed diagnosis is particularly problematic, as it increases the risk of serious post-streptococcal complications, including acute rheumatic fever and post-streptococcal glomerulonephritis, which continue to contribute to long-term morbidity in affected populations.
Penicillin continues to be highly effective for the treatment of scarlet fever, and resistance to beta-lactam antibiotics has not been reported. However, the rising global prevalence of macrolide resistance among Streptococcus pyogenes is a growing concern, especially in patients with penicillin allergy, and may influence future treatment guidelines. Continuous monitoring of antimicrobial resistance patterns is therefore essential.
Several public health challenges in India further complicate disease control, including overcrowded living conditions, poor sanitation, limited access to healthcare services, and inadequate laboratory diagnostic facilities, particularly in rural and underserved areas. These factors contribute to delayed case detection and hinder effective disease surveillance and response.
The strengths of this review lie in its use of multiple data sources and focus on recent literature, which provides a comprehensive overview of the current situation. However, the findings should be interpreted in light of certain limitations. These include reliance on secondary data, the absence of national-level surveillance statistics, and the potential for publication bias. Future research incorporating active surveillance and primary data collection is needed to better understand the true burden of scarlet fever in India and to inform effective prevention and control strategies.
Conclusion
Scarlet fever is a re-emerging but under-recognized infection in India. Strengthening surveillance systems, improving laboratory capacity, and enhancing clinician training are critical for prevention and control.
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