This guideline is based on the Invasive Group A Streptococcal (iGAS) Disease – Communicable Diseases Network Australia (CDNA) National Guidelines for Public Health Units. NSW specific guidance and recent updates to the CDNA Series of National Guidelines (SoNG) are included within these call-out boxes throughout the document. The content of the CDNA SoNG has not been modified.
These guidelines outline Australia's national minimum standard for surveillance, laboratory testing, case management and contact management for Invasive Group A Streptococcal (iGAS) disease. The intention of these guidelines is to reflect the current available evidence base, with pragmatic guidance provided where evidence is still evolving. Jurisdictions may implement policies that exceed the national minimum standard based on local epidemiological context. CDNA will continue to review and update these guidelines as new information becomes available on iGAS and the situation in Australia.
Readers should not rely solely on the information contained within these guidelines. Guideline information is not intended to be a substitute for advice from other relevant sources including, but not limited to, the advice from a public health specialist or other health professional. Clinical judgement and discretion may be required in the interpretation and application of these guidelines.
The membership of the CDNA and the Australian Health Principal Protection Principal Committee (AHPPC), and the Australian Government as represented by the Department of Health (Health) do not warrant or represent that the information contained in these guidelines is accurate, current or complete. The CDNA, the AHPPC and Health do not accept any legal liability or responsibility for any loss, damages, costs or expenses incurred by the use of, or reliance on, or interpretation of, the information contained in these guidelines.
1Birthing-person" refers to someone who gives birth, regardless of their gender identity, which may be female, male, nonbinary, or other, and regardless of their relationship with the neonate (e.g., surrogate pregnancy).
Initiate public health response within 1 working day of notification for birthing person-neonate pairs, and within 3 working days of notification for all other cases, both probable2 and confirmed. Isolate case and practice standard and droplet precautions until 24 hours after initiation of appropriate and effective antibiotic treatment. Exclude case from child-care, school, other educational institutions, or work, until 24 hours after initiation of effective antibiotic treatment.
2Probable cases should be notified to the NNDSS from 1 January 2024 onwards.
Provide information to all identified close contacts of both probable and confirmed cases and liaise with treating clinical teams for antibiotics for chemoprophylaxis to be given to eligible close contacts.
The infectious agent is Streptococcus pyogenes,also known as Group A Streptococcus(GAS), a Gram positive, ß-haemolytic bacterium.
Humans.
GAS is spread through direct person-to-person transmission, via droplet spread or direct contact with patients or carriers. Typically, transmission occurs through respiratory droplets but can also occur through contact with secretions (such as saliva, wound discharge, or nasal secretions) from an infected person, or through skin-to-skin contact.
People with GAS disease (e.g., pharyngitis or impetigo) are much more likely to transmit the bacteria to others than asymptomatic carriers. GAS infection is rarely transmitted by indirect contact through objects.
The incubation period for iGAS is not well defined (1,2). Cases of iGAS may be preceded by superficial non-invasive GAS infections, such as GAS pharyngitis (incubation period is usually 1 to 3 days) or GAS impetigo (estimated incubation period is 7 to 10 days).
Secondary cases of iGAS infection have been identified up to 30 days after the identification of the initial case, though this is rare (3,4).
For contact tracing purposes, iGAS cases are considered infectious from 7 days before onset of GAS-related symptoms until 24 hours after commencement of appropriate antibiotic treatment. The 7 days prior to onset is included to account for a potential period of communicability related to asymptomatic carriage and to capture the source.
There are a range of clinical presentations related to GAS infections. These include common mild illnesses such as scarlet fever, tonsilitis or pharyngitis (also known as “strep throat") and skin or soft tissue infections such as impetigo or cellulitis. In rare instances, GAS infections can lead to invasive GAS (iGAS).
Invasive GAS disease is defined by the isolation of GAS from a normally sterile site, such as blood, cerebrospinal fluid, or bone marrow. GAS can enter these sites through a break in the skin (e.g. a cut, puncture, or surgical wound), or via exposure to respiratory or wound secretions from a person carrying the bacteria.
Presentations may include bacteraemia, sepsis, empyema, osteomyelitis, septic arthritis, meningitis, puerperal sepsis, and life-threatening conditions such as streptococcal toxic shock syndrome (STSS) and necrotising fasciitis. Necrotising fasciitis (NF) can lead to life-long complications such as limb-loss and severe scarring, and in approximately 20-30% of cases, death (5). STSS can have similar complications to NF and the case fatality rate is approximately 30% (6). In cases where patients have NF and STSS concurrently, a case-fatality rate of up to 30% has been observed (7).
Birthing person-neonate pairs are considered to be the highest risk group for secondary iGAS infection. Though evidence is limited, the relative risk of secondary infections in birthing person-neonate pairs has been estimated at 12-times higher than other close contacts of a case (3).
While the available evidence is limited and variable, a range of small studies have found increased risk of secondary iGAS cases in household contacts of cases, ranging from 19 times higher than the general population to over 2,000 times higher (3,8,9).
While an increased risk of infection has been noted in all household contacts of iGAS cases compared to the general population, secondary cases among household contacts are rare (10).
Elderly contacts of a single case in a household or household-like setting have been identified as at higher risk for secondary iGAS infection than other household contacts (3,11).
Institutions can refer to a range of settings outside the home where people may reside (short-term or long-term) or attend for care or schooling, including, but not limited to:
Outbreaks of iGAS infection in aged care facilities, hospitals, and childcare facilities are well-documented in the literature both in Australia and internationally, with aged care facilities being the most frequently reported setting of iGAS outbreaks (12–31).
Other institutional settings where there is likely to be close contact between residents and attendees, high density living with potential for overcrowding, and poor hygiene (such as prisons, military barracks, hostels, and schools) are generally understood to have a higher baseline risk for communicable disease transmission (32–34). However, evidence specific to the increased risk of iGAS transmission in these institutions is not well documented in the literature.
Communities of people experiencing homelessness or utilising safe-injecting rooms or other community-based harm-reduction facilities, can experience increased risk of iGAS infection, and whole genome sequencing has identified connections between apparently sporadic cases in these communities (35–37). However, as these cases are often linked to risk behaviours (such as shared needle use) and environmental exposures rather than facilities, they are referred to in these Guidelines as 'community outbreaks.'
There are a number of environmental, sociodemographic and health risk factors that can lead groups of people to experience increased risk of iGAS infection, such as:
Groups who may experience some of these risk factors at a higher rate than the general population include Aboriginal and Torres Strait Islander people, the elderly, people experiencing homelessness, people experiencing poverty, people who inject drugs, and children aged <5 years (15,17,20,27,32,37–44).
Post-surgical, postpartum, and burns patients are also at increased risk of infection; as broken cutaneous or mucosal barriers may facilitate invasive infection after exposure to GAS (8, 10). Acute viral respiratory infections, particularly influenza, are risk factors for developing iGAS (45), and in children, varicella (chickenpox) infection has been noted as a risk factor (46,47).
Internationally, the reported incidence in high-resource countries is estimated to be between 2 and 4 cases per 100,00 population, per year (8). At the time of writing, the national incidence of iGAS in Australia is unclear. iGAS became nationally notifiable in Australia from 01 July 2021, and while some jurisdictions had been collecting data on iGAS for up to a decade prior to this time, iGAS did not become notifiable in all jurisdictions until September 2022 (see Table 1).
Several cohort studies, linked data studies and analyses of data collected by jurisdictions provide some insight into the estimated incidence of iGAS in Australia:
Seasonality of iGAS disease at the national level in Australia has not been well-established, though some evidence from Victorian studies suggests cases may increase during periods of increased influenza circulation (53). Internationally, studies from other high-resource countries have found seasonal peaks in winter to early spring (54–57) and, in some instances, differing seasonal peaks depending on emm type (58).
Public health management of iGAS and associated conditions can be complex and demanding. This is related to the potential for serious complications and death, the fact that incidence is highest among certain populations, including those with potentially complex sociodemographic factors (such as birthing person-neonate pairs, Aboriginal and Torres Strait Islander people, infants, and the elderly) and that clusters of cases may occur.
In accordance with the assigned public health priority levels, confirmed and probable cases of iGAS disease should be entered onto the notifiable diseases database within:
Ensure that data on Aboriginal and Torres Strait Islander status is collected and entered into the jurisdictional database. Typing results and case outcome should be added to the database when available.
Symptoms of illness field should be completed in NCIMS if possible.
Both confirmed cases and probable cases3 should be notified.
Pathology laboratories should notify confirmed cases of iGAS to public health.
Diagnosing clinicians, including clinical microbiologists, should notify probable cases of iGAS to public health.
3Probable cases will be notified to the NNDSS from 1 January 2024
A confirmed case requires laboratory definitive evidence only.
A probable case requires laboratory suggestiveand clinical suggestive evidence.
Isolation or detection of Streptococcus pyogenes by culture or molecular methods (such as polymerase chain reaction [PCR]), from a normally sterile site (such as blood, cerebrospinal fluid, pleural-peritoneal-pericardial fluids, joint aspirate, or bone [see Appendix 3 for the complete list]).
Isolation or detection of Streptococcus pyogenes by culture or molecular methods (such as PCR), from a non-sterile site including deep tissue or abscess at operation or post-mortem.
Clinical presentation consistent with severe invasive GAS infection such as:
Bacterial culture is the current gold standard for GAS confirmation, however NAAT assays are also available for blood and sterile tissues and fluids.
Traditional agar plate culture methods (combined with Gram stain which is suggestive but non-specific) rely on incubation in a carbon dioxide added atmosphere to enhance growth.
Identification relies on a combination of traditional methods (no single method is perfect) and includes: (i) Gram stain morphology, (ii) beta-haemolysis on blood agar plates, (iii) Latex agglutination (Lancefield) grouping, differentiating from other species, (iv) bacitracin sensitivity, and (v) PYR testing assay, is used for the detection of pyrrolidonyl arylamidase enzyme (also called pyrrolidonyl aminopeptidase) activity in GAS. MALDI-TOF is also a validated method of identification, as are commercial biochemical panels.
NAAT testing can include commercial molecular panels or in-house detections. One molecular target amplified is the highly conserved sdaB gene, which encodes for DNase B, an extracellular antigen of GAS, and the basis for the anti-DNase B antibody test used to substantiate a likely GAS infection. An alternative target is speB, also highly conserved, and it encodes for streptococcal pyrogenic exotoxin B or SPEB, a cysteine protease, major virulence factor, and superantigen whose expression mediates toxic shock, seen with various syndromes of severe acute pyogenic infections due to GAS.
Both of these target genes are specific for GAS, and both are single gene copies in the Streptococcuspyo geneschromosome.
Serology (ASOT and Anti-DNAase b) is available and may be useful in assisting diagnosis of GAS immune mediated syndromes such as acute rheumatic fever but is not sufficient for iGAS diagnosis.
Blood culture (sterile procedure), cerebrospinal fluid (CSF), body fluid from a normally sterile site (such as syringe aspirate), surgical biopsy material (i.e., fasciitis), pus and swabs (with transport media).
Post-mortem specimens may be collected but interpretation requires consideration of specimen type, disease causing death, and time from death to specimen collection, due to the effects of post-mortem bacterial translocation.
Keep specimens moist and collect into sterile containers. Use sterile saline wrapped gauze if necessary to avoid surgical specimens drying out.
Nucleic acid testing offers an alternative way to improve speed and accuracy in GAS diagnosis and has been shown to have superior sensitivity and specificity compared to conventional throat cultures and pharyngitis and clinical diagnosis. Similar studies have not been conducted for iGAS and culture positivity rates can be influenced by specimen collection, handling during transport and time to processing.
Various typing systems are available for epidemiological purposes. GAS has been classically subdivided based upon serotyping of surface-expressed M and major pilus subunit protein T typing. M-typing using specific antisera has been largely replaced by emm-typing, by DNA sequencing the variable region of the emm gene. While useful it may not be specific enough when common emm types occur geographically, hence multi-locus sequence typing (MLST) and the even more specific whole genome sequencing (WGS) are also used. Emm type of GAS strains can also be determined from the WGS results.
GAS remains universally penicillin sensitive. However alternative agents are also tested due to patient allergies and include vancomycin, macrolides, trimethoprim/sulfamethoxazole, and clindamycin. Though usually susceptible antimicrobials develop resistance, such as clindamycin which may develop constitutional or inducible reduced susceptibility.
Testing is classically done by phenotypic disc-based methods, but Minimum Inhibitory Concentration (MIC) testing and broth microdilution are also available. Breakpoints and standardised methods are protocol based on either EUCAST (European Committee on Antimicrobial Susceptibility Testing) or CLSI (Clinical and Laboratory Standards Institute).
Mutations in GAS penicillin binding protein genes have been noted in many countries but have not yet caused penicillin resistance but do confer some reduced susceptibility to other beta lactam antibiotics.
Case investigation and appropriate public health action for probable and confirmed cases should commence within:
The response to a notification will usually be carried out in collaboration with the case's treating clinical team. As such, public health response procedures for both confirmed and probable cases should include the following actions:
Treatment is the responsibility of the treating clinician. For antibiotic treatment recommendations refer to the current edition of Therapeutic Guidelines: Antibiotic.
Cases should be managed using appropriate standard and droplet transmission-based precautions until completion of 24 hours of treatment with appropriate antibiotics, as per the Australian Guidelines for the Prevention and Control of Infection in Healthcare. This is applicable to any setting where the case is being treated, including healthcare facilities and residential care facilities.
None routinely required.
For management of iGAS in Aboriginal communities, see Section 11: Special Situations
The aim of identifying contacts is to:
For a single case of iGAS, public health follow-up focuses on identifying the subsets of close contacts who require information only, and those who may also require antibiotics for chemoprophylaxis.
Contact groups for which information and antibiotics for chemoprophylaxis should be routinely provided:
Birthing person-neonate pairs: where either the birthing person or neonate develop iGAS disease during the first 28 days after birth.
Contact groups for which information should be routinely provided:
These categories have been developed based on the limited evidence available regarding the public health management of close contacts of a single case of iGAS.
For institution contacts (as described above), contact during the case's infectious period is considered cumulative. Where cases are hospitalised in a shared ward, risk to other patients should be considered in relation to the timing and degree of exposure. Unless there is close interaction with the case for a cumulative period of at least 24hrs during the case's infectious period, other patients are not considered contacts.
Contact information for childcare and aged care facilities is included in Appendix 4 and Appendix 5 respectively.
Some people who fall into the above close contact categories may have additional risk factors that contribute to iGAS infection risk. According to the limited evidence available (as outlined in Section 2: Other priority groups and Section 2: Disease occurrence and public health significance) the following groups may be at higher risk at baseline for iGAS infection:
These risk factors may be considered by PHUs and treating clinical teams when determining most appropriate management for contacts of a single case. PHUs may also wish to consider severity of disease in these determinations.
When close contacts of a case are identified, provide an information fact sheet to these contacts about the disease and how it is spread as soon as possible, noting this may occur via the treating clinician, case or next of kin. Where the PHU is relying on a clinician, case or next of kin to identify and disseminate information to contacts, they should provide advice on close contact identification. It is acknowledged that depending on the method adopted to disseminate information to contacts, there may be variability in completeness of contact identification.
Information in the fact sheet in Appendix 2 can be adapted for the cultural and literacy needs of recipients, but all fact sheets provided to contacts should include the following information and advice:
In instances where a single case has occurred in an institutional setting, appropriate fact sheets should be provided to facility management for circulation as appropriate to staff, residents or, in the case of a childcare centre, to parents of attendee children.
Routine provision of antibiotics for chemoprophylaxis to all close contacts of a single case is generally not recommended, as evidence of the efficacy of this strategy in preventing secondary cases is limited (3).
Based on this limited evidence, these Guidelines suggest routine provision of antibiotics for chemoprophylaxis by PHUs for birthing parent-neonate pairs only (Table 2).PHUs may wish to adopt a risk-assessment based approach for all other contact types on a case-by-case basis in cooperation with the treating clinical team, taking into account factors outlined in the Other priority groups and Populations at increased risk sections of this document.
Decisions to provide antibiotics for chemoprophylaxis to any close contacts of a single case should take into account the benefits and risks including:
Antibiotics for chemoprophylaxis should be given to eligible contacts of a single case of iGAS as soon as possible after the contact is identified, preferably within 48 hours of exposure to the original case or, at least, within 48 hours of the case being notified, noting that the utility of administering antibiotics for chemoprophylaxis beyond 10 days of iGAS diagnosis in the initial case is limited. As of August 2023, Therapeutic Guidelines: Antibiotic – Prophylaxis regimens for invasive iGAS infection indicates that the optimal antibiotic prophylaxis regimen for iGAS infection has not been determined but suitable regimens include:
or
* The ventrogluteal site is preferred for administration of intramuscular benzathine benzylpenicillin because of reduced pain and risk of nerve injury.
For instructions on intramuscular injection at the ventrogluteal site, see Figure 2.57
# It is unclear if eradication of pharyngeal group A streptococcuscarriage is required to prevent secondary cases. Limited evidence suggests the addition of rifampicin to benzathine benzylpenicillin increases the rate of pharyngeal carriage eradication.
However, the role of rifampicin in the prevention of secondary invasive group A streptococcal infection is uncertain, and routine combination prophylaxis is not recommended.
For close contacts with delayed non-severe hypersensitivity to penicillins, cefalexin can be used in most cases^.
For close contacts with immediate (non-severe or severe) or delayed severe hypersensitivity to penicillins, antibiotic choice depends on the susceptibility of the isolate from the index case (as rates of resistance to non–beta-lactam antibiotics are higher). If susceptibility results are not available, a reasonable regimen is azithromycin 500 mg (child: 12 mg/kg up to 500 mg) orally, daily for 5 days.
^ It is safe to use cefalexin in patients who had a delayed non-severe reaction to a penicillin in the distant past. It is also safe to use cefalexin in patients who have had a delayed non-severe reaction recently, unless the reaction involved amoxicillin or ampicillin, because cross-reactivity between these drugs is possible. For patients who have had a recent delayed non-severe reaction to amoxicillin or ampicillin, use the drug recommended for patients with immediate (non-severe or severe) or delayed severe hypersensitivity.
Recommendations in these Guidelines regarding the provision of antibiotics for chemoprophylaxis to close contacts of a single case are not intended as a substitute for the expert knowledge of treating clinical teams, nor are they intended to override jurisdictional best practice in accordance with their specific populations and contexts. Decisions about antibiotics for chemoprophylaxis must always take into account the individual and population risks and benefits of this intervention.
*PHUs should be aware of and implement public health jurisdictional guidelines, where these may be different from the CDNA guidelines. It is not the responsibility of Public Health Units (PHUs) to undertake contact management based on guidelines of individual hospitals if these differ from public health jurisdictional or CDNA guidelines.
# Chemoprophylaxis may be considered by PHU and treating clinicians for contacts with additional individual risk factors on a case-by-case basis.
^Fact sheets may be provided by PHUs for distribution to contacts to the following groups: cases, treating clinical teams of a case, family members/next of kin of a case and facility management for distribution to institutional residents or attendees.
~Where these occur in a hospital setting, contact management of airway-exposed healthcare workers should be undertaken by the hospital, however PHUs should ensure appropriate management has been undertaken.
Where two or more cases of iGAS infection occur in the same household or household-like setting within 30 days of symptom onset in the initial case.
In the event of a household cluster, the entire household should be offered antibiotics for chemoprophylaxis as per Therapeutic Guidelines: Antibiotic – Prevention of invasive group A streptococcal infection and provided with the appropriate fact sheet. This includes all persons ordinarily resident in the affected household regardless of whether they were identified as a contact of a case.
Where a secondary case is identified after the initial case has completed a course of antibiotics, the initial case does not require additional antibiotics for chemoprophylaxis.
Specimens from household clusters should be sent to a reference laboratory for molecular typing. The administration of antibiotics for chemoprophylaxis to the household should not be delayed while waiting for molecular typing results.
For Aboriginal people, decisions around contact tracing in the event of a household cluster should be made in collaboration with the family, or family champion, for a tailored and individual response that is realistic and achievable for the family/household. See Aboriginal and Torres Strait Islander people below for further information.
Where two or more cases of iGAS infection occur in an institution within 3 months of onset in the initial case. Institutions can include, but are not limited to:
For clusters in hospitals, utilise the below guidance in conjunction with hospital guidance or applicable jurisdictional guidance for special risk groups in healthcare (i.e., dialysis patients in the Northern Territory).
Confirmed cluster: 2 or more cases that are epidemiologically linked within an institution that occur within a 3-month period and are identical on molecular typing where cases are not household contacts of each other.
Possible/suspected cluster: 2 or more cases that are epidemiologically linked within an institution that occur within a 3-month period where cases are not household contacts of each other.
Epidemiological link: Where cases occur in a physical or geographical context and a plausible mode of transmission accounts for infection spreading between people.
For the purposes of initiating public health management, it is preferable that a cluster be confirmed via molecular typing prior to response. However, if there is strong epidemiological evidence of a cluster or, if staff members, residents or other attendees of an institution belong to a group at increased risk of disease (see People at increased risk of disease), a public health response may be initiated prior to receiving results for a suspected cluster or outbreak.
Coordinating the provision of antibiotics for chemoprophylaxis, in a both confirmed and suspected institutional cluster other than in a healthcare facility, is the responsibility of PHUs. PHUs may engage the assistance of any clinicians working within an institution for provision and dissemination of antibiotics. Whilst the PHUs coordinate the overall contact management strategy, PHUs should liaise with staff health or infection control teams (where they exist).
Hospitals should take primary responsibility for implementing prevention and control measures for their facility, including identification of acquisition, and follow-up of staff, patients, and visitors. Depending on respective workloads and resources, PHUs may be able to assist hospitals with follow-up of patients discharged to the community.
In initiating a public health response to a cluster or outbreak, PHUs should:
PHUs should engage institutional facility management to:
Screening asymptomatic people for GAS carriage through testing is not routinely recommended but may be considered as part of a cluster investigation in an institutional setting depending on the risk factors for residents, staff, or attendees.
Restriction of asymptomatic contacts and screening for GAS carriage is not routinely recommended, including in institutional settings. If a staff member working in an institutional setting has been screened and identified as a GAS carrier during a cluster investigation, the staff member should be excluded from work until 24 hours after initiation of appropriate and effective antibiotic treatment.
Clustering of iGAS cases in community settings outside institutions and healthcare settings present distinct challenges for public health response. Community clusters can occur in a range of settings and contexts, including universities, sports clubs (where the sport involves close contact), among people who inject drugs (PWID) and among people experiencing homelessness (PEH).
Stigma, marginalisation, and criminalisation of injecting drug use and homelessness are a challenge to effective engagement with PWID and/or PEH. It is important to keep this in mind when responding to any increase in cases among this population.
Contacts within PEH and PWID populations who have open wounds or lesions are at higher risk for transmission. Contact tracing may be challenging among some PWID as individuals may not be willing to provide contact information for their peers. PHUs are encouraged to engage with any community services used by PWID and/or PEH cases to identify and provide appropriate treatment and information to contacts. This engagement also serves the purpose of determining whether a case has been linked to sheltered accommodation, a drug service or specific injecting network, prison setting, healthcare setting or other institution in the 7 days prior to onset of symptoms.
Where high-risk close contacts of cluster cases are identified in PWID of PEH populations (e.g., close contacts with chronic conditions, current open wounds or with whom the case has shared needles), liaise with community services to organise provision of antibiotics for chemoprophylaxis.
Each state and territory should monitor rates of iGAS and compare against a relevant baseline to determine if iGAS rates are increasing. These rates may be different for different regions, and tolerable thresholds for increase may be lower for populations at increased risk of disease (see People at increased risk of disease). The baseline rates can be drawn from jurisdictional surveillance data or research (as per Section 2: Disease occurrence and public health significance). PHUs should, after considering available data, establish a threshold for increase from baseline rates appropriate for their population at which public health action should be triggered. If this threshold is met, the following actions should be considered by the PHU:
All alerts and messaging should serve to both inform the public of the increase in rates but also to alleviate excess anxiety.
Aboriginal people are considered a priority group for preventing Strep A infections and their sequelae (including iGAS).
NSW Health is committed to working in partnership with Aboriginal people and communities to improve the health outcomes of Aboriginal people as outlined in documents such as NSW Aboriginal Health Plan 2013-2023, NSW Aboriginal Health Partnership Agreement 2015 – 2025 and NSW Implementation Plan for Closing the Gap.
As such, a lower threshold, appropriate to the needs and circumstances of Aboriginal and Torres Strait Islander populations in each jurisdiction, should be used to initiate disease control measures if a cluster is suspected in an Aboriginal and/or Torres Strait Islander household, household-like setting, or community.
For Aboriginal and Torres Strait Islander people, disease risk needs to be communicated in a culturally safe manner so individuals and families understand the recommended management plan and contribute to how this, and contact tracing, can be actioned appropriately.
Consider referring household and household-like contacts to their Aboriginal Community Controlled Health Service, Aboriginal Medical Service or local health providers for ongoing assessment and follow up if GAS symptoms develop for culturally appropriate follow-up. If iGAS symptoms develop in a household contact of a case, culturally appropriate medical attention should be sought immediately.
Culturally appropriate educational resources should be used where needed.
Further investigation should be undertaken by the local PHU if increases in notification numbers and/or rates are identified for a Aboriginal and/or Torres Strait Islander community. The trigger for investigation should be guided by the community size, composition, and underlying risk factors. The nature of any action will depend on a number of factors, including the size of the community.
Local Aboriginal Health Workers and Practitioners and local Aboriginal Community Controlled Health Organisations are key stakeholders and should be included in the development of community cluster responses.
Environmental health and health education programs should be planned, developed, implemented and disseminated with Aboriginal peoples within a culturally appropriate governance structure, where Aboriginal people actively participate in decisions about public health strategies and actions.
