Ongoing Excess Hospitalizations for Severe Pediatric Group A Streptococcal Disease in 2023–2024—A Single-Center Report
, Matthias Horn 1, Andreas Bartenstein 2, Kristina Keitel 3, Matthias V. Kopp 1,4, Philipp K. A. Agyeman 1 and Christoph Aebi 1,*Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsAlthough it is common to use the term “group A streptococci”, it is not scientifically correct. At appropriate places (early) in the manuscript - at least in the introduction, the abstract and in the methods section - the scientific name Streptococcus pyogenes (S. pyogenes) should be used / introduced; the reviewer assumes the laboratory serving their institution diagnosed all these isolates correctly as S. pyogenes. The authors should be aware of the fact that human isolates of Streptococcus dysgalactiae subsp. equisimilis can possess the group A cell wall antigen – see for example the following publication: Chochua S. et al. (2019) Emergent Invasive Group A Streptococcus dysgalactiae subsp. equisimilis, United States, 2015-2018. Emerg Infect Dis 25 (8):1543-1547. https://doi.org/10.3201/eid2508.181758.
Further remarks:
1. The legend of Figure 1 must not be repeated in the text.
2. The Table S1 has to be corrected!
Correct the following (spelling) errors:
Line 15: … pediatric group A streptococcal …
Line 20: … 25 cases …
Line 35: … by the COVID-19 ….
Line 103: omit “returned”!
Line 231 (reference no. 10): … Group A Streptococcal …
Author Response
Comment 1: Although it is common to use the term “group A streptococci”, it is not scientifically correct. At appropriate places (early) in the manuscript - at least in the introduction, the abstract and in the methods section - the scientific name Streptococcus pyogenes (S. pyogenes) should be used / introduced; the reviewer assumes the laboratory serving their institution diagnosed all these isolates correctly as S. pyogenes. The authors should be aware of the fact that human isolates of Streptococcus dysgalactiae subsp. equisimilis can possess the group A cell wall antigen – see for example the following publication: Chochua S. et al. (2019) Emergent Invasive Group A Streptococcus dysgalactiae subsp. equisimilis, United States, 2015-2018. Emerg Infect Dis 25 (8):1543-1547. https://doi.org/10.3201/eid2508.181758.
Response: We now have added term Streptococcus pyogenes in the introduction (line 33) and made a comment mentioning Streptococcus dysgalactiae subsp. equisimilis in table 1 of the supplementary data file.
Comment 2: "The legend of Figure 1 must not be repeated in the text."
Response: This unintended duplication was now deleted.
Comment 3: +The Table S1 has to be corrected!"
Response: As the reviewer does not disclose what needs to be corrected, we assume that the comment refers to comment 1. As noted above, we amended Table S1 accordingly.
Comment 4: +Correct the following (spelling) errors: Line 15: … pediatric group A streptococcal …; Line 20: … 25 cases …; Line 35: … by the COVID-19 ….; Line 103: omit “returned”!;Line 231 (reference no. 10): … Group A Streptococcal …"
Responses: Corrections were made as requested on the lines mentioned above.
Reviewer 2 Report
Comments and Suggestions for AuthorsAuthors are to be congratulated for a nice description of the increase of GAS infections at their institution from 2022-2024 compared to pre-COVID baseline.
My major comment is that I find the Table confusing with the 2 2013-2020 columns, the second of which contains different data to other columns in table. Inclusion of both columns makes it more challenging to interpret and difficult to understand the comparison made for the p value. Would suggest either finding a way to combine the 2 columns or deleting the second column and including any vital data it contains in the text instead
Minor comments:
1) Introduction line 32. "Massive" is non-specific and subjective term which doesn't add meaningful information. Suggest deleting
2) Introduction, line 33: Not sure if there is a limitation to references since only 10 provided but if not would recommend adding this additional reference for the increase in severe GAS infections outside Europe Notes from the Field: Increase in Pediatric Invasive Group A Streptococcus Infections - Colorado and Minnesota, October-December 2022 - PubMed (nih.gov)
3) Intro, line 36. Emergence of M1 clades not limited to only M1UK, suggest rewording - see Increase in invasive group A streptococcal infections and emergence of novel, rapidly expanding sub-lineage of the virulent Streptococcus pyogenes M1 clone, Denmark, 2023 - PubMed (nih.gov)
4)Methods, line 60-61. Did not see supplemental material with definition of iGAS that is referenced. Please either provide definition in body of text or ensure this is readily available to readers, as this is crucial piece of information
5) Results, line 103. Grammar do not need both returned and declined in this sentence, please delete one word
6) Figure 1 is too small to easily read, please provide larger version
7) Abstract, lines 27 and 28. Given the small sample sizes and lack of statistical testing, I suggest it would be more valid to not refer to declines in specific syndromes as for any one this might represent a chance effect and may stretch the conclusion from limited data. Recommend either deleting the end of this sentence of using similar wording as in the last sentence of the paper which looks at these syndromes in aggregate "The decline mainly affected distant body sites and systemic infections, while the classic suppurative complications in the head area remained largely unchanged."
Author Response
Comment 1: "My major comment is that I find the Table confusing with the 2 2013-2020 columns, the second of which contains different data to other columns in table. Inclusion of both columns makes it more challenging to interpret and difficult to understand the comparison made for the p value. Would suggest either finding a way to combine the 2 columns or deleting the second column and including any vital data it contains in the text instead"
Response: We understand the reviewer's concern as it is indeed unusual to place al column with the medians of the preceding column into a table. We originally used this representation as we also use the medians in our result text and discussion. However, we now deleted this entire column in Table 1 as suggested. Numbers to footnotes were adjusted accordingly.
Comment 2: Introduction line 32. "Massive" is non-specific and subjective term which doesn't add meaningful information. Suggest deleting.
Response: changed as suggested.
Comment 3: "Introduction, line 33: Not sure if there is a limitation to references since only 10 provided but if not would recommend adding this additional reference for the increase in severe GAS infections outside Europe Notes from the Field: Increase in Pediatric Invasive Group A Streptococcus Infections - Colorado and Minnesota, October-December 2022 - PubMed (nih.gov)"
Response: We are happy to add this reference. However, technically we cannot insert it in the edited version. It would be reference 3. The paper is: https://doi.org/10.15585/mmwr.mm7210a4.
NOTE: We also provide a revised version of the manuscript in our original format. Here we have updated the references and the list of references at the end of the document.
Comment 4: "Intro, line 36. Emergence of M1 clades not limited to only M1UK, suggest rewording - see Increase in invasive group A streptococcal infections and emergence of novel, rapidly expanding sub-lineage of the virulent Streptococcus pyogenes M1 clone, Denmark, 2023 - PubMed (nih.gov)"
Response: We changed text on lines 38-39 to emphasizes that other M1 clades, e.g. M1DK also were associated with the increase in iGAS cases 2022/23. Again, we cannot insert the respective reference in the already typeset manuscript for technical reasons (Endnote not working in this file), s. comment above.
Comment 5: "Methods, line 60-61. Did not see supplemental material with definition of iGAS that is referenced. Please either provide definition in body of text or ensure this is readily available to readers, as this is crucial piece of information".
Response: we now provide the definition if iGAS(short version) in the main text, still referring to the full definition in the supplementary data file as the latter would be to long for insertion into the manuscript body.
Comment 6: "5) Results, line 103. Grammar do not need both returned and declined in this sentence, please delete one word"
Response: this was corrected, s. responses to reviewer 1.
Comment 7: "Figure 1 is too small to easily read, please provide larger version".
Response: as we now have omitted one entire column (s. response to comment 1 above), it should be possible to typeset in a readable font size. In our impression, however, the version already provided by MDPI is easily readable as is.
Comment 8: "Given the small sample sizes and lack of statistical testing, I suggest it would be more valid to not refer to declines in specific syndromes as for any one this might represent a chance effect and may stretch the conclusion from limited data. Recommend either deleting the end of this sentence of using similar wording as in the last sentence of the paper which looks at these syndromes in aggregate "The decline mainly affected distant body sites and systemic infections, while the classic suppurative complications in the head area remained largely unchanged."
Response: We agree with the reviewer's point and deleted the second part of the last sentence as suggested.
