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Health: The red rash of romantics

Scarlet fever used to be a killer. Today it is easily treated, but a recent outbreak surprised one family.
A few weeks before Christmas my two-year-old daughter and I were both struck down with what I thought was a particularly nasty bout of flu. Alarmed by Christina's temperature and the fact that she was refusing to eat or drink, my husband called the doctor. She was suitably impressed by the child's declining health and, since she was in the house, agreed to have a quick look at me. I was fully expecting to be told to get up and tend to my ailing daughter (like a proper mother), but instead was told to stay put as I was suffering from scarlet fever.

I must admit to having been secretly pleased that I had a genuine reason for feeling utterly lousy, though somewhat alarmed to have succumbed to a disease which, as far as I was concerned, had all but died out and affected only small children. While we stayed in bed and watched the Christmas schedule of black-and-white movies (in which the heroines tended to die of scarlet fever), I learnt that there had been an outbreak of the disease in Sussex, with 14 cases reported in the Brighton and Hove area within a month, compared to just one case in the previous year.

Dr Angela Iversen, the area's consultant in communicable disease control, says that such a rise is not unusual but does give some cause for concern. "The disease is cyclical so numbers tend to go up and down. The danger with scarlet fever is that, because its early symptoms are similar to a sore throat, doctors may not prescribe antibiotics immediately, and if it isn't treated there can be severe complications."

The earliest historical record of a scarlet fever outbreak was made in 1543 in Sicily. A century later, on 10 November 1664, Samuel Pepys wrote in his diary: "my little girlie Susan is fallen sick of the meazles, we fear, or, at least, of a scarlett fever." Whether there had been earlier outbreaks of the disease is not known, but it continued to occur in Europe and North America, cropping up frequently in literature.

One of my childhood heroines, Beth in Little Women, caught scarlet fever and, though she survived the incident, she was so weakened by the disease that she never fully recovered. As a rather bookish child I always quite liked the idea of being struck down with what I considered to be a "romantic" disease but, having suffered an apparently mild dose of scarlet fever, it's an experience I'm not anxious to repeat.

Characterised by a sore throat, a high temperature and a rough red rash, scarlet fever is far less common and less threatening than it used to be. In the 19th century it was still widespread and dangerous, especially among small children. In the 1860s, the mortality rate from scarlet fever was 972 per million of population. Nowadays there are virtually no fatal cases, but about 4,000 to 5,000 people a year contract the disease in England and Wales.

It is caused by a type of streptococcus (bacterium) that also causes sore throats, swollen glands, ear infections and tonsillitis. Scarlet fever is just one form that a streptococcus infection can take. According to Dr Julius Weinberg, consultant epidemiologist for the Public Health Laboratory, the bacteria are common and many people carry them in their throats with no ill-effects whatsoever. "What causes some people to get scarlet fever and not others is not completely understood. It may be that the hosts become more susceptible because they have flu or are run down, for example."

My initial symptoms were apparently typical; a sore throat, accompanied by fever and headache. Small children often also suffer from vomiting and nausea. The characteristic rash usually appears within two days on the neck, chest and back, and may spread to the rest of the body. It results from a reaction to a toxin, produced by certain strains of the streptococcus, which is absorbed by the blood and, if not treated, can ultimately lead to blood poisoning.

The face also becomes flushed and the tongue swollen and red - doctors charmingly describe it as a "strawberry" tongue. As the fever subsides there is frequently peeling of the skin, especially on the hands and feet.

My father backed away in some alarm on hearing that our home was infected with scarlet fever. He had spent six weeks in isolation in the school sanatorium after getting the disease in the Thirties. At that time, scarlet fever was dreaded because cases developed far away, in time and distance, from others. Thinking that one must come from another, people would blame the contamination on a toy that had been played with by another scarlet fever patient a year before. Now, it is understood that a child who develops scarlet fever probably picked up a germ from someone who just had a sore throat, or was carrying the streptococcus without feeling its effect at all.

Our household copy of Dr Spock, published in 1957, advised that scarlet fever could be treated with "one of the modern drugs that shorten the disease and greatly lessen the chances of complications". It still went on, however, to list frightening-sounding complications such as rheumatic fever, and urged parents to check with the local authority about quarantine regulations. When I asked my doctor about this, she shot me and the tattered health manual a withering look, and put the record straight.

Before the advent of antibiotics, scarlet fever did pose a considerable risk to health, because of the danger of the bacteria spreading from the throat to other parts of the body. This can still result in ear infections, sinusitis, necrotising fasciitis (the famous flesh-eating bug) septicaemia, meningitis, pneumonia and toxic shock syndrome. In the past, it also caused rheumatic fever and kidney infections. Nowadays scarlet fever can be diagnosed by a throat swab test, and treatment with an antibiotic, usually penicillin or erythromycin, usually leads to rapid recovery.

There may also be other reasons for scarlet fever having ceased to be a killer disease. People are obviously healthier and living in less crowded conditions, but Dr Weinberg believes the bug itself may have become less virulent. "A bug that kills its host is badly designed. It in fact wants to live with its host. So it is probable that the streptococcus that causes scarlet fever has adapted, so that the discomfort it causes is less severe."

Our immune systems, too, are constantly shifting,which explains why some people may come into contact with the streptococci but suffer no ill-effects, whereas children, whose immune systems are not fully developed, are more prone to the disease.

Although scarlet fever is no longer a killer, it remains on the list of notifiable diseases, "more for historical reasons than for anything else", says Dr Weinberg. However, he and his colleagues do not wish to see it removed from the list because of the danger that the bug could become virulent again. "It is important to maintain surveillance of a disease that has the potential to be life-threatening, and monitor its level of occurrence. At the moment the bacterium that causes scarlet fever is highly sensitive to penicillin, but it is possible that new strains could develop which are resistant."

Both I and my daughter are now fully recovered, and, having researched this piece, I am truly thankful for the availability of penicillin. No longer do I harbour daft romantic notions about 19th-century diseases, though I admit I got a lot more sympathy from friends and family than my husband, who was also pretty ill over Christmas - but he only had a nasty bout of flu!