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Group A Streptococcus can be easily transmitted within and between long-term care facilities

What you need to know
  • Group A Streptococcus (GAS) spread easily in long-term care facilities (LTCFs) once it has been introduced.
  • There are many opportunities for introduction of GAS into LTCFs because GAS colonization and infection are commonly present in the community.
  • Strong infection prevention and control practices are critical to stopping GAS transmission and preventing outbreaks in LTCFs.

Colonization rates differ by age

Colonization with GAS is common among children. Up to 20% of asymptomatic school-aged children and 25% of asymptomatic household contacts of children with streptococcal pharyngitis (i.e., strep throat) are colonized with GAS. However, among healthy adults, fewer than 5% are colonized with GAS in their throat.

Multiple routes of transmission are common in LTCFs

Once introduced into a facility, GAS can easily spread through multiple routes.

GAS is transmitted from an infected or colonized person through

  • Respiratory droplets
  • Contact with saliva or nasal secretions
  • Contact with open sores or wounds

GAS can be transmitted to others in a LTCF by1

  • Residents
  • Visitors
  • Healthcare personnel (HCP)

Spread of GAS among residents in LTCFs has been associated with the following:

  • Having a roommate who is infected or colonized with GAS
  • Being cared for by the same HCP as a resident who is infected or colonized with GAS
  • Residing on the same unit as a resident who is infected or colonized with GAS

GAS outbreaks are rarely point source

Point-source foodborne outbreaks of GAS have occurred in healthcare settings2 but are rare. GAS outbreaks in LTCFs frequently involve multiple routes of transmission and are rarely point source or common source. A common-source outbreak is an outbreak in which all persons are exposed to infectious agents from the same source.

Additionally, multiple outbreaks have occurred in which transmission was linked to HCP with GAS pharyngitis who cared for patients while ill.1,3 Furthermore, asymptomatically colonized residents and healthcare personnel can also serve as sources of GAS transmission during outbreaks.

A nurse uses a hand sanitizing dispenser in the clinic

Pay special attention to hand hygiene and wound care.

Infection prevention and control is key

Importantly, lapses in infection prevention and control practices, including lapses in hand hygiene, have been identified in multiple GAS outbreak investigations in LTCFs.1,4-6 Lapses in infection control practices during wound care have also been frequently documented in GAS outbreaks in LTCFs.1,5-6 Wound care can lead to shedding or spray of GAS into the environment or onto HCP performing wound care.5

Infection prevention and control is critical for preventing GAS outbreaks in LTCFs. Strengthening of infection control practices, with special attention to good hand hygiene and wound care, is key to interrupting transmission of GAS in ongoing outbreaks.

See Related: CDC’s Infection Control website

GAS outbreaks can involve multiple facilities

LTCFs, especially those in close geographic proximity, may share HCP. Shared HCP may be a GAS transmission link between facilities. If public health officials identify cases in multiple nearby LTCFs, they should consider the possibility of a single, multi-facility outbreak.

In LTCFs experiencing cases of invasive GAS, it’s especially important for public health to inquire about wound care service providers and other external consultants. External consultants often work in multiple LTCFs.

Whenever possible, LTCFs with shared HCP should seek to

  • Align policies and procedures (e.g., flexible sick leave policies) to ensure that HCP do not report to work when ill
  • Establish procedures for communication when any shared HCP are placed on work restrictions
  1. Jordan HT, Richards CL, Burton DC, et al. Group A streptococcal disease in long-term care facilities: Descriptive epidemiology and potential control measures. Clin Infect Dis. 2007;45(6):742–52.
  2. Ertugrul BM, Erol N, Emek M, et al. Food-borne tonsillopharyngitis outbreak in a hospital cafeteria. Infection. 2012;40(1):49–55.
  3. Kobayashi M, Lyman MM, Francois Watkins LK, et al. A cluster of group A streptococcal infections in a skilled nursing facility: The potential role of healthcare worker presenteeism. J Am Geriatr Soc. 2016;64(12):e279–84.
  4. Dooling KL, Crist MB, Nguyen DB, et al. Investigation of a prolonged group A streptococcal outbreak among residents of a skilled nursing facility, Georgia, 2009–2012. Clin Infect Dis. 2013;57(11):1562–7.
  5. Ahmed SS, Diebold KE, Brandvold JM, et al. The role of wound care in 2 group A streptococcal outbreaks in a Chicago skilled nursing facility, 2015–2016. Open Forum Infect Dis. 2018;5(7):ofy145.
  6. Nanduri SA, Metcalf BJ, Arwady MA, et al. Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: Repeated intrafacility transmission of a single strain. Clin Microbiol Infect. 2019;25(2):248.e241–247.