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Volume 31, Number 8—August 2025
Research
Group A Streptococcus among American Indian Persons, White Mountain Apache Tribal Lands, United States, 2016–20191
, Ryan Close2, Laura B. Brown, Dennie Parker, Jayshree Patel, Eugene Romancito, Robert Weatherholtz, James McAuley3, and Laura L. Hammitt3
Table 1
Demographic and clinical characteristics of invasive and severe group A Streptococcus infections among American Indian persons in the White Mountain Apache Tribal lands, Arizona, USA, 2017–2019*
| Characteristic | Total, n = 161† | Invasive, n = 48 | Severe, n = 113 | p value‡ |
|---|---|---|---|---|
| Sex | 0.33 | |||
| F | 58 (36.0) | 20 (41.7) | 38 (33.6) | |
| M |
103 (64.0) |
28 (58.3) |
75 (66.4) |
|
| Median age, y (IQR) |
40.7 (30.5–55.8) |
51.3 (39.3–65.4) |
39.4 (28.6–49.6) |
<0.001 |
| Age, y | 0.01 | |||
| <1 | 4 (2.5) | 1 (2.1) | 3 (2.7) | |
| 1–4 | 3 (1.9) | 0 | 3 (2.7) | |
| 5–17 | 11 (6.8) | 0 | 11 (9.7) | |
| 18–34 | 36 (22.4) | 6 (12.5) | 30 (26.6) | |
| 35–49 | 54 (33.5) | 16 (33.3) | 38 (33.6) | |
| 50–64 | 32 (19.9) | 12 (25.0) | 20 (17.7) | |
| 65–74 | 12 (7.5) | 8 (16.7) | 4 (3.5) | |
| >75 |
9 (5.6) |
5 (10.4) |
4 (3.5) |
|
| Residence before culture | 0.43 | |||
| Private residence | 151 (93.8) | 45 (93.8) | 106 (93.8) | |
| Long-term care facility | 2 (1.2) | 1 (2.1) | 1 (0.9) | |
| Unhoused | 5 (3.1) | 1 (2.1) | 4 (3.5) | |
| Incarcerated | 1 (0.6) | 1 (2.1) | 0 | |
| Unknown |
2 (1.2) |
0 |
2 (1.8) |
|
| Body mass index§ | 0.18 | |||
| <25 | 33 (23.4) | 9 (20.0) | 24 (25.0) | |
| 25–29 | 39 (26.7) | 9 (20.0) | 30 (31.3) | |
| >30 |
69 (48.9) |
27 (60.0) |
42 (43.8) |
|
| Underlying conditions¶ | ||||
| Alcoholism | 90 (55.9) | 20 (41.7) | 70 (62.0) | 0.02 |
| Hypertension | 61 (37.9) | 25 (52.1) | 36 (31.9) | 0.02 |
| Diabetes | 54 (33.5) | 21 (43.8) | 33 (29.2) | 0.07 |
| Chronic skin breakdown | 33 (20.5) | 8 (16.7) | 25 (22.1) | 0.43 |
| Smoker | 16 (9.9) | 2 (4.2) | 14 (12.4) | 0.15 |
| Cirrhosis | 14 (8.7) | 4 (8.3) | 10 (8.9) | 1.00 |
| Asthma | 14 (8.7) | 4 (8.3) | 10 (8.9) | 1.00 |
| Renal failure/dialysis | 14 (8.7) | 6 (12.5) | 8 (7.1) | 0.26 |
| Peripheral vascular disease | 12 (7.5) | 5 (10.4) | 7 (6.3) | 0.36 |
| Abscess | 12 (7.5) | 4 (8.3) | 8 (7.1) | 0.75 |
| Heart failure | 11 (6.8) | 7 (14.6) | 4 (3.5) | 0.02 |
| Immunosuppression | 8 (5.0) | 1 (2.1) | 7 (6.2) | 0.44 |
| Atherosclerosis | 6 (3.7) | 1 (2.1) | 5 (4.4) | 0.67 |
| Transplant | 5 (3.1) | 1 (2.1) | 4 (3.5) | 0.63 |
| Chronic obstructive pulmonary disease | 4 (2.5) | 2 (4.2) | 2 (1.8) | 0.58 |
| Cognitive deficit | 4 (2.5) | 2 (4.2) | 2 (1.8) | 0.58 |
| Myocardial infarction | 4 (2.5) | 1 (2.1) | 3 (2.7) | 1.00 |
| Dementia | 3 (1.9) | 1 (2.1) | 2 (1.8) | 1.00 |
| Burns | 3 (1.9) | 0 | 3 (2.7) | 0.56 |
| Hemiplegia | 2 (1.2) | 0 | 2 (1.8) | 1.00 |
| Connective tissue disorder | 2 (1.2) | 0 | 2 (1.8) | 1.00 |
| Stroke | 2 (1.2) | 2 (4.2) | 0 | 0.09 |
| Malignancy | 1 (0.6) | 1 (2.1) | 0 | 0.30 |
| Peptic ulcer | 1 (0.6) | 0 | 1 (0.9) | 1.00 |
| HIV | 0 | 0 | 0 | NA |
| Injection drug use | 0 | 0 | 0 | NA |
| Any |
161 (100.0) |
48 (100.0) |
113 (100.0) |
NA |
| Severe GAS infection within previous 5 y# |
23 (14.6) |
9 (19.2) |
14 (12.6) |
0.45 |
| Disease syndromes associated with GAS infection¶ | ||||
| Pneumonia | 6 (3.7) | 5 (10.4) | 1 (0.9) | 0.009 |
| Meningitis | 2 (1.2) | 1 (2.1) | 1 (0.9) | 0.51 |
| Cellulitis | 142 (88.2) | 34 (70.8) | 108 (95.5) | <0.0001 |
| Osteomyelitis | 17 (10.6) | 5 (10.4) | 12 (10.6) | 0.97 |
| Sepsis | 41 (25.5) | 24 (50.0) | 17 (15.0) | <0.0001 |
| Arthritis | 4 (2.5) | 1 (2.1) | 3 (2.7) | 1.00 |
| Endometritis** | 1 (1.7) | 1 (5.0) | 0 | 0.34 |
| Otitis media | 1 (0.6) | 0 | 1 (0.9) | 1.00 |
| Streptococcal toxic shock syndrome | 8 (5.0) | 8 (16.7) | 0 | <0.0001 |
| Necrotizing soft tissue infection | 14 (8.7) | 14 (29.2) | 0 | <0.0001 |
| Necrotizing fasciitis |
11 (6.8) |
11 (22.9) |
0 |
<0.0001 |
| Recent triggers within previous 14 d¶ | ||||
| Surgery or skin incision | 5 (3.1) | 1 (2.1) | 4 (3.5) | 1.00 |
| Delivery** | 1 (1.7) | 1 (5.0) | 0 | 0.34 |
| Postpartum** | 1 (1.7) | 1 (2.6) | 0 | 0.27 |
| Penetrating trauma | 51 (31.7) | 12 (25.0) | 39 (34.5) | 0.23 |
| Blunt force trauma | 23 (14.3) | 7 (14.6) | 16 (14.2) | 0.94 |
| Surgical wound (postoperative) | 3 (1.9) | 2 (4.2) | 1 (0.9) | 0.21 |
| Burns | 3 (1.9) | 1 (2.1) | 2 (1.8) | 1.00 |
| None | 84 (52.2) | 26 (54.2) | 58 (51.3) | 0.74 |
| Unknown |
4 (2.5) |
0 |
4 (3.5) |
0.39 |
| Admitted to the hospital†† | 157 (97.5) | 45 (93.8) | 112 (99.1) | 0.05 |
| Median length of hospitalization, d (IQR, total range) | 4 (3–7, 0–27) | 5.5 (4–12, 2–27) | 4 (3–6, 0–24) | 0.004 |
*Values are no. (%) except as indicated. GAS, group A Streptococcus; IQR, interquartile range; NA, not applicable. †Twenty-five cases were identified from the private medical facility, including 22 through retrospective review for which isolates were not collected. ‡p value comparing invasive and severe cases from χ2 test or Fisher exact test for categorical variables and Wilcox rank sum tests for continuous variables. §Among patients >18 years of age; missing for 2 persons. ¶Multiple conditions or syndromes or triggers per case. #Includes 4 recurrent cases during the study period. **Among women only (n = 58); postpartum defined as <30 days postdelivery. ††One severe case was offered admission but refused.
1Preliminary results from this study were presented at IDWeek, October 2–6, 2019, Washington, DC, USA
2These first authors contributed equally to this article.
3These senior authors contributed equally to this article.