Recruit Streptococcal Infection Prevention Program

 

RECRUIT STREPTOCOCCAL INFECTION PREVENTION PROGRAM

Group A Streptococcal (GAS) infections and their sequelae have long caused illness, training disruptions, and preventable deaths among Navy and Marine Corps recruit and trainee populations. Since the 1960's, a program of streptococcal disease surveillance and penicillin prophylaxis has been the cornerstone of efforts to control GAS at Navy training centers and Marine Corps Recruit Depots (MCRDs).  Despite these efforts, GAS outbreaks still occur periodically, resulting in lost training time, invasive streptococcal infections (iGAS) and their sequelae among recruits. These outbreaks are nearly always associated with lapses in control measures. Routine chemoprophylaxis, continuous surveillance for GAS disease, and rapid outbreak intervention are essential for minimizing morbidity and training disruption due to streptococcal disease.

BUMEDINST 6220.8C provides policy and guidelines for streptococcal disease surveillance and the use of antibiotic prophylaxis to control GAS infections among recruits at Recruit Training Command (RTC) and MCRD, MCRD graduates attending Marine Corps Schools of Infantry (SOIs), and personnel in other Navy and Marine Corps training environments with historically high incidences of streptococcal disease.
 

Policy and Guidance

BUMEDINST 6220.8C Recruit Streptococcal Infection Prevention Program
BUMEDINST 6220.12D Medical Surveillance and Response
 

Clinicians

GAS in high-intensity training settings is often more severe than in the routine outpatient setting, and can lead to outbreaks of pneumonia, rheumatic fever and necrotizing fasciitis if GAS cases are not identified, isolated and treated. Incidence can be effectively reduced through chemoprophylaxis, with details in Enclosure 1 of BUMEDINST 6220.8C. The preferred regimen for chemoprophylaxis is the long-acting formulation of benzathine penicillin G, Bicillin L-A. Oral azithromycin is the preferred drug when penicillin (PCN) allergy is reported. Repeated shortages of Bicillin L-A have led to extended periods where azithromycin is used as the primary drug for chemoprophylaxis.

A large, well-documented GAS outbreak in 2002 was found to be associated with high levels of self-reported PCN allergy (30%) in conjunction with very poor compliance with the oral erythromycin used as the PCN alternative. More careful allergy screening and directly observed therapy (DOT) for oral medications were key elements to resolving this outbreak. Several smaller outbreaks have also been attributable to poor compliance with oral chemoprophylaxis, and are behind the requirement for DOT when Bicillin L-A alternatives are used. Poor compliance with oral medications is the most common reason for “breakthrough” GAS infections when chemoprophylaxis is being used.

An emerging concern with azithromycin chemoprophylaxis is antibiotic resistance. Resistance to macrolide antibiotics is increasing nationally, with 1 in 3 invasive GAS infections now caused by resistant strains (CDC Active Bacterial Core Surveillance). While the level of macrolide resistance that will directly affect the success of chemoprophylaxis in preventing GAS outbreaks in military training environments is unknown, it is reasonable to expect that the effectiveness of an azithromycin-based prevention strategy may be compromised in the near future.  It is essential that microbiological monitoring for macrolide resistance is performed when azithromycin is being used for chemoprophylaxis. This requires that GAS cultures are performed in addition to relying on rapid diagnostic testing.
 

Reporting

GAS outbreaks are required to be reported  to Preventive Medicine authorities through Disease Reporting System internet (DRSi) within 24 hours per BUMEDINST 6220.12D.  Navy Environmental and Preventive Medicine Unit (NEPMU) staff can advise on and/or assist with outbreak investigation and risk communication. Individual cases of GAS are not reportable. The NMCFHPC Medical Surveillance and Reporting webpage contains in-depth information to facilitate surveillance and reporting.

Additionally, Toxic Shock Syndrome (either Streptococcal or Non-streptococcal) is reportable through DRSi. Case Classification details may be found in the Armed Forces Medical Reportable Events Guide.
 

Surveillance

NMRTCs should actively seek out and track GAS infections in training commands with a history of streptococcal-related outbreaks or hospitalizations. This includes RTC GL, MCRD SD, MCRD PI and SOI West. Other training commands with high density living and/or training activities should also consider active GAS surveillance, to include BUD/S, OCS and Naval Academy.

In addition to outpatient GAS infection tracking, hospitalizations due to invasive GAS should also be carefully monitored as part of routine GAS surveillance. It is highly recommended that wound and respiratory infections be tracked separately to better tailor response efforts.

Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) can be used to supplement routine GAS surveillance in recruit populations to understand baseline rates of disease and to monitor for concerning increases that may indicate an outbreak. Strep dashboards for all three recruit training sites can be obtained from the nearest NEPMU. For more information on ESSENCE, visit NMCFHPC’s Medical Surveillance and Reporting page.

NMCFHPC has developed Enhanced Surveillance Guidelines (*CAC Required*) for use with azithromycin chemoprophylaxis to more closely monitor macrolide resistance and identify potential chemoprophylaxis failures.
 

Outbreak Response

Outbreaks in accessions or training environments have the potential to grow rapidly, with resultant training disruptions and high levels of illness.  Ensure local Preventive Medicine assets are engaged for support.  The cognizant  Navy Environmental and Preventive Medicine Unit (NEPMU) can advise on and/or assist with outbreak investigation activities.
 

Resources

NMCFHPC GAS Info Paper (*CAC required*)
Enhanced Surveillance Guidelines (*CAC Required*)
 

Epidemiology and Selected Publications

Centers for Disease Control (CDC). Acute rheumatic fever at a Navy training center--San Diego, California. MMWR Morb Mortal Wkly Rep. 1988;37(7):101-104.

Crum NF, Russell KL, Kaplan EL, et al. Pneumonia outbreak associated with group a Streptococcus species at a military training facility. Clin Infect Dis. 2005;40(4):511-518. doi:10.1086/427502  (*CAC required for full text link*)

Frank PF, Stollerman GH, Miller LF. Protection of a military population from rheumatic fever: routine administration of benzathine penicillin G to healthy individuals. JAMA 1965; 193:775-83  (*CAC required for full text link*)

Gray GC, McPhate DC, Leinonen M, et al. Weekly oral azithromycin as prophylaxis for agents causing acute respiratory disease. Clin Infect Dis. 1998;26(1):103-110. doi:10.1086/516275  (*CAC required for full text link*)

Sanchez JL, Cooper MJ, Myers CA, Cummings JF, Vest KG, Russell KL, Sanchez JL, Hiser MJ, Gaydos CA. 17 June 2015. Respiratory infections in the U.S. military: recent experience and control. Clin Microbiol Rev doi:10.1128/CMR.00039-14. (*CAC required for full text link*)

Webber BJ, Kieffer JW, White BK, Hawksworth AW, Graf PCF, Yun HC. Chemoprophylaxis against group A streptococcus during military training. Prev Med. 2019;118:142-149. doi:10.1016/j.ypmed.2018.10.023