Results

In 2024, we identified 38 GAS pharyngitis cases in our BHUs—33 in pediatric patients and 5 in adults (Figure 1). There were 9 distinct GAS outbreaks in 2024: 8 occurred in pediatric/adolescent BHUs and 1 in an adult BHU. All four pediatric/adolescent BHUs and one of five adult BHUs were affected. The average age was 10 years for pediatric cases and 33 years for adults. Most infections occurred in males (61% of pediatric and 80% of adult cases). The mean time from admission to diagnosis was 29 days for pediatric/adolescent patients (range: 2–83 d) and 36 days for adults (range: 2–142 d).

Our literature review revealed a predominant focus on COVID-19, with limited data on managing other infectious outbreaks in these settings. Few studies addressed IPC strategies for GAS, particularly in behavioral health settings. ^{Reference Fukuta and Muder2,Reference Younis, Johnstone and Armstrong3} Our review identified limited research addressing GAS in geriatric and long-term care facilities. ^{Reference Bisno and Baracco6–Reference Reid, Briggs, Seal and Pearson8} Common themes we identified included the need for IPC practices focused on early case detection, staff and patient education, active surveillance, and environmental controls that consider the unique needs and constrains of the treatment setting and patient population when managing outbreaks in behavioral health settings. ^{Reference Barnett, Esper and Foster1–Reference Schweon10}

Using insights from our literature review and feedback from our IPC team, we developed standard workflow and mitigation documents for managing GAS outbreaks (Supplemental Figure 1). The workflow document includes key definitions (eg, confirmed and probable GAS cases, outbreak and exposed population definitions), isolation guidance, the infectious period of GAS, and notification protocols for positive cases and potential outbreaks. The GAS exposure standard workflow emphasizes the importance of timely implementation and consistent adherence to contact and droplet isolation precautions for infectious individuals. The mitigation plan provides specific guidance regarding isolation precautions, contact tracing, staffing strategies, employee illness reporting, patient and staff testing, hand hygiene promotion, enhanced cleaning procedures, patient cohort isolation, visitation policies, and ultimately containing the outbreak. Decisions regarding active surveillance (patient screening for GAS carriage), enhanced cleaning procedures, and visitation policies are made in collaboration with the IPC team and BHU staff, based on the specific context of the outbreak.

These documents are shared electronically during outbreaks and serve as practical resources for the IPC team and frontline staff during GAS outbreaks. Since their development, these tools have been adopted as standard practice for managing GAS outbreaks at our organization. They have been utilized in several subsequent outbreaks within our BHUs and have received positive feedback from both IPC and frontline BHU staff.