Research and analysis

Group A streptococcal infections: first update on seasonal activity in England, 2025 to 2026

Updated 29 January 2026

Applies to England

Main points

Scarlet fever activity for the current 2025 to 2026 group A streptococcal (GAS) season remains in line with normal seasonal patterns, with GP consultations within expected levels for the time of year. Laboratory notifications of invasive group A streptococcal (iGAS) infection are also in line with normally expected levels and patterns, with slight increases over recent weeks being seen in both scarlet fever consultations and iGAS notifications.

Given the potential for severe presentations, scarlet fever cases should be treated promptly with antibiotics to limit further spread and reduce risk of potential complications in cases and their close contacts. Clinicians should continue to be alert to the severe complications of GAS infections and maintain a high degree of clinical suspicion when assessing patients, particularly those with preceding viral infection (including chickenpox) or their close contacts. Tetracycline resistance is being more frequently identified in iGAS isolates at this point in the season; clinicians should continue to consider the full antibiogram when treating patients with reported penicillin allergy.

Updated UK public health guidance on the management of close contacts of iGAS cases in community settings was published on 15 December 2022, with public health action extended to include patients with probable invasive GAS infection and additional close contact groups recommended for antibiotic prophylaxis. The evidence base underpinning the change in risk groups has been published.

National guidance on the management of scarlet fever outbreaks highlights essential tools to limit spread: prompt notification of scarlet fever cases and outbreaks to UK Health Security Agency (UKHSA) Health Protection Teams (HPTs); collection of throat swabs (prior to commencing antibiotics) when there is uncertainty about the diagnosis; and exclusion of cases from school and work until 24 hours of antibiotic treatment has been received.

Numbers presented in this seasonal activity update are based on data available as of 21 January 2026 for diagnoses up to and including 11 January 2026 (end of week 2). Numbers presented may change as updated data becomes available.

Key definitions are available at the end of the report.

Scarlet fever

So far this season (week 37, 2025, to week 2, 2026), typical increases are being observed for GP in-hours consultations for scarlet fever, with activity remaining within expected levels (Figure 1). For the latest week, the rate (0.46 per 100,000 registered population, week 2, 2026) falls within the range (0.08 to 2.0) observed for the same week in the last 6 seasons (2019/20 season to 2024/25 season, excluding the 2022/23 upsurge season). The highest weekly rate of in-hours GP consultations has so far been observed in week 48 at 0.98 per 100,000 registered population..

Figure 1. Weekly Scarlet fever notifications in England, 2017 to 2018 onwards

Note: Data shown for the current season goes up to week 2 (11 January 2026).

Invasive group A streptococcal infection

Laboratory notifications of iGAS infection so far this season (week 37, 2025, up to week 2, 2026) are in line with numbers usually seen at this time of year, though in the most recent two weeks, increases are being observed (Figure 2). A total of 821 notifications of iGAS disease have been received to date this season, with the most recent week (2) seeing the highest weekly total so far this season at 58 notifications (week commencing 5 January 2026). Cumulative numbers of iGAS infections to date this season are higher than average (797) though still fall within the range (778 to 920) for the same period in the prior 5 seasons (2019/20 to 2024/25 seasons, excluding the 2022/23 upsurge season). The first few weeks of this GAS season displayed a similar trend to that seen during the early part of the 2022/23 season; however, total numbers for the current season so far are lower than for the same point during 2022/23, 821 compared to 1,659.

At this pont in the season (up to week 2), the highest notification rates have been seen in the Yorkshire and Humber (2.1 per 100,000 population), followed by the North East (1.8 per 100,000). Lowest rates were seen in London and the East of England (all 1.1 per 100,000).

Figure 2. Weekly laboratory notifications of invasive GAS, England, 2019 to 2020 season onwards

Note: Numbers of notifications in the latest weeks of the 2025 to 2026 season are expected to increase due to a lag in laboratory reporting. The decline in notifications in recent weeks should be interpreted with caution; delayed processing and reporting timeframes are represented by a dashed line between weeks 1 and 2 of 2026.

Rates of iGAS infection to date this season are highest in those aged 75 years and over (5.3 per 100,000). The second highest rate so far is in those individuals under 1 year old (1.9 per 100,000), followed by those aged 65 to 74 years and over (1.8 per 100,000). The lowest notification rate was observed in 10 to 14 year-olds, 0.3 per 100,000.

The median age of notified cases of iGAS infection so far this season is 63 years (range of 0 to 101 years). This is higher than the range of median age reported for this point in the preceding five seasons (49 to 59 years).

Antimicrobial susceptibility results from routine laboratory surveillance for iGAS infection so far this season (week 37, 2025, to week 2, 2026) continue to show elevated levels of tetracycline and erythromycin resistance, higher than the range seen in the previous 6 seasons, with co-resistance to both tetracycline and erythromycin identified in 24% of sterile site isolates. Co-trimoxazole resistance has been reported in 5% of iGAS cases in the 2025/26 season so far (4% iGAS cases in the 2024/25 season). Changes in the resistance rates are likely to reflect dominant emm types currently circulating.

Specifically:

• 12% were resistant to clindamycin (8% in 2024/25; range 4% to 16% in the last 6 seasons)
• 26% were resistant to erythromycin (18% in 2024/25; range 4% to 20% in last 6 seasons)
• 49% were resistant to tetracycline (40% in 2024/25; range 12% to 44% in the last 6 seasons)

Analysis of reference laboratory sterile-site iGAS isolate submissions indicated a diverse range of emm gene sequence types identified to date this season (week 37, 2025, to week 2, 2026), with emm 49.8 remaining the most common type (21.2% of all referrals), followed by emm 8.0 (7.1%) and emm 89.0 (6.5%).

At the same point last season, emm 49.8 (10.2%), emm 89.0 (6.4%) and emm 28.0 (6.1%) were the top three emm types .

Discussion

Following the 2022/23 season, which saw a period of considerable elevation in scarlet fever notifications (1,2) and unusual seasonal patterns, the 2023/24 season saw a return to more usual GAS activity. At this point in the 2025/26 season, scarlet fever rates are in line with expected activity and remain at relatively low levels.

Invasive GAS infection cases are similarly within the usual range for this time of year and showing a typical increase expected during January. Incidence by age group follows the expected pattern with highest rates in the elderly.

Of note this season, the antimicrobial resistance in second line therapeutic agents (like tetracyclines and macrolides) remains elevated. This is likely a result of emm 49.8 being the dominant emm type this season, as more than 95% emm 49.8 isolates are resistant to tetracycline and erythromycin, but predominantly susceptible to clindamycin. GAS remains universally susceptible to penicillin which remains the drug of choice.

Prompt treatment of scarlet fever with antibiotics is recommended to reduce risk of possible complications and limit onward transmission. GPs and other frontline clinical staff are also reminded of the increased risk of invasive disease among household contacts of scarlet fever cases (3,4). Clinicians should continue to maintain a high index of suspicion in relevant patients for invasive disease as early recognition facilitates prompt initiation of specific and supportive therapy for patients with iGAS infection.

Relevant guidelines and FAQs are available on GOV.UK:

• guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings
• scarlet fever: symptoms, diagnosis and treatment
• guidelines for the management of close community contacts of invasive GAS cases
• prevention and control of group A streptococcal infection in acute healthcare and maternity settings
• Report a Notifiable Disease (eNOIDS)

All invasive disease isolates – and also non-invasive isolates – from suspected clusters or outbreaks should be submitted for typing to:

Staphylococcus and Streptococcus Reference Section
Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI)
UK Health Security Agency
61 Colindale Avenue
London
NW9 5HT

Further information on health equity groups is published annually within the annual streptococcal bacteraemia report, describing trends ethnic group and deprivation for GAS bacteraemia.

Data sources and methods

Scarlet fever data is presented as GP in-hours consultation rates per 100,000 registered population. This information is collected from UKHSA’s GP in-hours syndromic surveillance system. This system is sentinel, which means that not all GP practices in England are included, and coverage varies by UKHSA region, so comparison between geographic regions is not recommended. The system currently includes approximately 19 million registered patients across England. The data included is from 2 sources: technology provider TPP and ORCHID (Oxford and Royal College of General Practitioners Clinical Informatics Digital Hub). The indicator for scarlet fever syndromic is based on diagnoses recorded during GP in-hours patient consultations, and diagnoses are based on signs/symptoms and may not be laboratory confirmed. The weekly rates presented differ from the daily rates reported as standard elsewhere (5).

Invasive GAS laboratory notification data was extracted from the UKHSA Second Generation Surveillance System (SGSS) and combined with specimen referrals to the Staphylococcus and Streptococcus Reference Section to produce a total number of episodes for England. Data was extracted on 21 January 2026.

Antimicrobial resistance data is based on phenotypic test results for tetracycline, erythromycin, or clindamycin reported by laboratories to SGSS and are reported as susceptible or resistant. Co-resistance data is based on data where both tetracycline and erythromycin results have been reported for the iGAS episode.

Population rates are calculated per 100,000 using the relevant year’s ONS mid-year population estimate.

The M protein gene (emm) encodes the cell surface M virulence protein. Information for the emm gene was extracted from UKHSA’s reference laboratory and this report contains data covering the period 8 September 2025 to 21 January 2026.

Prior to the COVID-19 pandemic, there were a number of seasons when elevated incidence of scarlet fever and iGAS was seen, in particular the 2017/18 season. During the pandemic there was an unprecedented reduction in the number of scarlet fever and iGAS notifications, affecting the 2019/20 season and the 2021/22 season.

References

1. UKHSA (2023). Group A streptococcal infections: 15th update on seasonal activity in England. Health Protection Report volume 17, number 7.

2. Guy R, Henderson KL, Coelho J, Hughes H, Mason EL, Gerver SM and others (2023). ‘Increase in invasive group A streptococcal infection notifications, England, 2022’. Eurosurveillance: volume 28, number 1.

3. Lamagni T, and others (2018). ‘Resurgence of scarlet fever in England, 2014 to 2016: a population-based surveillance study’. The Lancet Infectious Diseases: volume 18, number 2, pages 180 to 187.

4. Watts V, Balasegaram S, Brown CS, Mathew S, Mearkle R, Ready D, and others (2019) . ‘Increased risk for invasive group A streptococcus disease for household contacts of scarlet fever cases, England, 2011 to 2016’ Emerging Infectious Diseases: volume 25, number 3, pages 529 to 537.

5. UKHSA (2024). Syndromic Surveillance Systems and Analyses.

Acknowledgements

These reports would not be possible without the weekly contributions from microbiology colleagues in laboratories across England, without whom there would be no surveillance data.

This report was prepared by: Eleanor Blakey, Kartyk Moganeradj, Rebecca Guy, and Theresa Lamagni.

Feedback and specific queries about this report are welcome via hcai.amrdepartment@ukhsa.gov.uk.