Little Women, the 19th century coming of age movie directed by Greta Gerwig currently showing in theaters nationwide, has moviegoers searching for information about scarlet fever. Beth, the youngest of the four March sisters, dies of complications of the infection at the climax of the movie.
Scarlet fever is a bacterial infection caused by the group a streptococcus bacteria, the same bacterium that causes “strep throat.”1 As many as 10 percent of the population contracts strep throat, and of this group, as many as ten percent then develop scarlet fever.2 Scarlet fever is transmitted through respiratory droplets by coughing or sneezing, or touching something with the droplets on it. Symptoms usually include fever, sore throat and a typical scarlet rash with a sandpaper quality caused by toxins made by the bacteria. Some people may also experience chills, vomiting or abdominal pain. Although generally considered to be a mild infection that clears within a few days, complications such as swollen lymph nodes and tonsils, and serious conditions that affect the heart, lung, kidneys or joints, can occur if not treated with antibiotics.
Scarlet Fever Mortality Rate Less Than One Percent Today
Scarlet fever is most often contracted by children ages 5-15, and is rare in children younger than three years of age.3 Fifteen to twenty percent of school-aged children are thought to be asymptomatic carriers,4 and by age ten, 80 percent of children are thought to have long lasting, potentially lifelong immunity to the bacteria.2 5 However, a 2017 study6 found that ten percent of scarlet fever patients had more than one episode.
In the pre-antibiotic era, scarlet fever resulted in death in 15 to 20 percent of those affected. With the advent of improved socioeconomic conditions and antibiotic therapy, the mortality rate for scarlet fever is less than one percent.2 However, group a streptococcus is still among the top ten infectious causes of human mortality worldwide, with more than 500,000 deaths annually.7
In 1970, scarlet fever was removed from the list of reportable diseases in the United States. However, since 1999, a total of 9,400 cases have been reported in the U.S. At the same time, there are an estimated three million cases of strep throat per year, which indicates that the infection is still circulating in the U.S.8
Outbreaks Since 2011 In Some Countries Despite Good Hygiene, Antibiotics
With the discovery of penicillin in the 1940’s scarlet fever became an easily treated infection and efforts to manufacture a vaccine largely halted. Penicillin remains the antibiotic of choice, and scarlet fever infections that are resistant to antibiotic treatment has not yet been reported. Hand washing, covering coughs and sneezes, disinfection of shared objects, and avoiding infected persons are the best way to avoid contracting group a streptococcus infections.9
Public health officials do not know exactly why scarlet fever, along with other childhood illnesses like measles, declined throughout the early part of the 20th century, but improved sanitation due to indoor plumbing and other hygiene factors are thought to be likely causes. Although scarlet fever is considered a disease of the past, there has been a resurgence of scarlet fever with notable outbreaks in the United Kingdom, China and Hong Kong.7 10 11 The cause of these outbreaks is unknown, but changes in strains of the bacteria,12 the potentially compromised immune status of people contracting scarlet fever, and environmental factors such as temperature and rainfall have been identified as possible factors.11 13 A 2016 study from China14 provided evidence that pollution may play a key role in the re-emergence of scarlet fever in some parts of the world.
In Louisa May Alcott’s book, Little Women, her sister Lizzie Alcott contracts scarlet fever in 1856 while helping a neighbor family and was “never the same afterward.” She died in her sleep in 1858. In Gerwig’s movie, Beth March, played by actress Eliza Scanlen, apparently survives, but is weakened by a first bout with the fever. Later, Beth seems to be sick again with the same illness, but she also talks about how she feels she has been slowly wasting away, noting, “It’s like the tide, Jo, when it turns, it goes slowly, but it can’t be stopped,” making it unclear if she is experiencing a new infection, a relapse of the old infection, or consequences from the first infection. Beth’s death is further complicated by the juxtaposition of moments when Beth is sick for the first time with moments when she falls ill again.15
Disease-Acquired Immunity Highlighted
Little Women highlights the importance of natural disease-acquired immunity. When the doctor comes to the house to evaluate Beth and confirms the scarlet fever diagnosis, he tells the two sisters who have previously had scarlet fever that they are considered immune as a result and can care for their sister, while their sister Amy, who has not had the illness, is sent away for the duration of the illness.
Typically, childhood viral illnesses like measles, mumps and chickenpox confer robust long lasting, potentially lifelong immunity after contracting the illness. This reservoir of disease-acquired immunity in a population previously exposed to an infectious disease produces true “herd” or “community immunity.”16 17
There are features of naturally acquired herd immunity that serve to protect newborn infants. For example, mothers who have experienced wild type measles as children can pass antibodies to their unborn infants through the placenta during pregnancy and through breast milk after birth that protects them from the disease for the first months of life.18 Women who have not had the infection, including those who have received measles (MMR) vaccinations and have artificial vaccine acquired immunity, are unable to pass natural protective antibodies to their infants.19 20 21 22
A Strep A vaccine is being developed for global use, with the World Health Organization (WHO) listing the development of a Strep A vaccine as one of the top 13 priority vaccines targeted for fast tracking to licensure. 23 24
1 Centers for Disease Control and Prevention. Scarlet Fever: All You Need to Know. Nov. 1, 2018.
2 Sotoodian B, Rao, J. Scarlet Fever Medscape June 21, 2019.
3 CDC. Group A Streptococcal (GAS) Disease: Scarlet Fever. Nov. 1, 2018.
4 Hon A. Scarlet Fever DermNetNZ.org Sept 2015.
5 Davis, CP. Scarlet Fever (Scarlatina) MedicineNet Jan. 11, 2020.
6 Dios Javierre B, Venture MG, et. al. Recurrent scarlet fever: A common entity Anales de Pediatria Oct 1, 2017; 87(4): 232-233.
7 Brouwer S, Lacey JA, et. al. Scarlet fever changes its spots The Lancet 2019; 19(11): 1154-1155.
9 Scarlet Fever and Its Prevalence in the United States. RocketSwag.com Jan.11, 2020.
10 Parado S, Perera TB. Scarlet Fever StatPearls Feb 28, 2019.
11 Adee S. Why are people getting scarlet fever again? Lastwordonnothing.com Apr. 6, 2018.
12 Laurance J. Scarlet Fever, Scourge of the 19th Century, is Coming Back Independent Feb. 16, 2009.
13 Global Biodefense Scarlet Fever Making a Comeback, This Time More Resistant GlobalBiodefense.com Nov. 5, 2015.
14 Mahara G, Wang C. et. al. The Association between Environmental Factors and Scarlet Fever Incidence in Beijing Region: Using GIS and Spatial Regression Models International Journal of Environmental Research and Public Health Nov. 2016; 13(11): 1083.
15 Rawden J. Little Women 2019: Why There’s So Much Confusion Around What Happens To Beth. Cinemablend.com Dec. 25, 2019.
16 Humphries S. Herd Immunity: Flawed Science and Mass Vaccination Failures GreenMedInfo.com July 16, 2012.
17 Leuridan D, Van Damme P. Passive transmission and persistence of naturally acquired or vaccine-induced maternal antibodies against measles in newborns Vaccine Aug. 21, 2007; 25934): 6296-6304.
18 Edwards KM. Maternal antibodies and infants immune response to vaccines. Vaccine 2015; 33: 6469-6472.
19 Albrecht P, Ennis FA, et. al. Persistence of maternal antibody in infants beyond 12 months: Mechanism of measles vaccine failure The Journal of Pediatrics Nov. 1977; 91(5): 715-718.
20 Obukhanych T. Herd Immunity: Can mass vaccination achieve it? Tetyanaobukhanych.com.
21 Waaijenborg S, Hahne SJM, et.al. Waning of Maternal Antibodies Against Measles, Mumps, Rubella, and Varicella in Communities With Contrasting Vaccination Coverage The Journal of Infectious Diseases, July 2013; 208(1): 10-16.
22 Fisher BL. The Science and Politics of Eradicating Measles. NVIC Newsletter May 25, 2019.
23 Wellcome Trust Sanger Institute. Global Strep A vaccine one step closer. AAAA May 27, 2019.
24 World Health Organization. WHO Product Development for Vaccines Advisory Committee (PDVAC) meeting. June 26-27, 2018.