The Medical Unit in London, Ontario, Canada had declared nine people have died from a bacterial infection outbreak.  The outbreak, declared eighteen months ago, has been slowly getting worse.

The Middlesex-London Health Unit says more than 132 cases of infection have been reported since April 1, 2016. Of those cases, 22 percent required treatment in intensive care, 15 percent had Streptococcal Toxic Shock Syndrome and 15 percent had necrotizing fasciitis – also called “flesh-eating” disease.

The bacteria are spread by direct contact with nose and throat secretions from an infected person, or by direct contact with infected wounds or sores on the skin. While the infections can occur year-round, the health unit said Monday that the number of infections tends to increase during the winter.

Associate Medical Officer of Health Dr. Gayane Hovhannisyan said about half of the cases have been among injection drug users and/or people without access to stable housing. However, Hovhannisyan said the alert has been issued because the health unit is seeing an increase in infections among people who have no connection to the outbreak. “We need a better understanding of what’s happening, which is why we’ve issued this alert,” she said Monday in a news release.

For the most part, the majority of streptococcus infections cause relatively mild illnesses like strep throat. But sometimes more serious and potentially life-threatening infections are able to get into muscles, blood, and other organs. The health unit advises regular hand washing, covering the mouth and nose when coughing or sneezing, avoid sharing drinking and eating utensils, and do not share drug paraphernalia in an effort to avoid infection.

Symptoms of a streptococcus A infection depend largely on the site of the infection but still include fever, chills, sore throat, dizziness, confusion, severe pain, and redness or swelling around a wound or injured area.

Provincial health agencies report data on a monthly basis, so there are more recent statistics available, but in an effort to compare the number of infections, for example, there were 91 cases of invasive Strep A reported in January 2017 in Ontario. That was up from 77 cases reported in January 2016 leaving health officials a little concerned.