CHAPTER XIII
Hemolytic Streptococcal Infections
Lowell A. Rantz, M. D.
THE MILITARY PROBLEM
Period before World War II- Infection by hemolytic streptococcihas been a major problem tothe United States Army in all of its wars for which informativehistorical data are available.However, for a number of reasons, disease caused by these organisms wasnot recognized as animportant military problem before World War II. The nature of infectionby the hemolyticstreptococcus, the essentials of its epidemiology, and particularly theintimacy of the relationshipbetween it and the development of rheumatic fever have become, wellestablished only in thelast 20 years. Furthermore, in all wars prior to World Wars I and II,the enormous incidenceof enteric infection and malaria so overshadowed that of otherinfectious diseases that theseattained relatively little prominence in the minds of medical officersresponsible for thehealth of the Army.
Inspection of the recordedexperience of the United States Army in the Civil War 1demonstrates that hemolytic streptococcal disease occurred veryfrequently, and themagnitude of the problem was such that, had it been present in the Armyduring World WarII, it would have been regarded as of the very greatest importance.During the Civil War,scarlet fever was an uncommon disease, only 696 cases having beenreported. Approximately25,000 cases of erysipelas, another form of streptococcal infection,were reported with a notethat it was known that this was only a part of the total problem. Oneof every two hundredand twenty-five wounded developed the disease, which occurredessentially as primary facialerysipelas in epidemic form and also as a complication of battleinjuries. It had a verydefinite geographic distribution in that the infection was much morecommon in troopsstationed in the western areas, particularly in the States of Michigan,Ohio, Indiana, Illinois,Wisconsin, Iowa, Minnesota, Nebraska, and the Dakotas.
In addition to thewidespread occurrence of erysipelas, there was also oil enormousincidenceof acute rheumatism in the Civil War.2 In 5.2 years, 145,000cases occurred among whitetroops at a rate of 65 per 1,000 per annum.
1 (1) Medical and Surgical Historyof the War of the Rebellion. Medical History. Washington: GovernmentPrinting Office, 1888, pt. III, vol. I, pp.624, 662-675. (2) Medicaland Surgical History of the War of theRebellion. Surgical History. Washington: Government Printing Office,1883, pt. III, vol.II, p.851.
2 Medical and Surgical History ofthe War of the Rebellion. Medical History. Washington: GovernmentPrintingOffice, 1870, pt. I, vol. I, pp.637-639.
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Not all of these may be regarded as examples ofrheumatic fever, but examination of thecase records which have been preserved in the Medical and SurgicalHistory of the War ofthe Rebellion indicates that a substantial number of them werecertainly this disease. Thisimpression is substantiated by 642 deaths reported to have been causedby rheumatism,endocarditis, and pericarditis. In retrospect, it is impossible todefine in absolute terms themagnitude of the problem of rheumatic fever in the Civil War, but it isobvious that it wasgreat. An attempt to determine the geographic distribution of acutearthritis on the basis ofavailable data was unsatisfactory.
The hemolyticstreptococcus was a common cause of bacterial pneumonia complicatinginfluenza during the pandemic of 1918. Primary infection by theseorganisms was notrecognized as an important problem. There were 11,675 admissions forscarlet fever, but themortality was extremely low, and the disease caused little concern.3Similarly, littleinterest was aroused by 2,598 admissions for erysipelas. Thesignificance of 24,770admissions for acute articular rheumatism was entirely overlooked. Thisdisorder was notconsidered to be probable rheumatic fever, and no attempt was made todetermine thefrequency of occurrence of chronic valvular heart disease as acomplication.
Rheumatic fever is notmentioned in the official history of the Medical Department of theUnited States Army in the World War. Acute articular rheumatism appearsonly in thestatistical reports, and this disease was not deemed worthy of specialcomment elsewherealthough the number of cases was very great. The available data do notpermit a definition ofthe geographic incidence, but inspection of the statistical informationreveals that disease inthis category was very common in the same areas in which outbreaks ofrheumatic feverwere observed during World War It. On the basis of these data coveringonly 2 years ofactive mobilization, streptococcal respiratory infection and thefrequently associatedrheumatic fever must have occurred in epidemics comparable to thoseobserved duringWorld War II.
Advances in understandingand accumulation of information about hemolytic streptococcalinfection had been continuous and of far-reaching importance in thedecade before the onsetof World War II. In spite of this fact, the Medical Department of theUnited States Armyfound itself poorly prepared to cope with the problem of infection bythese organisms.Several well-defined factors were responsible for this lack ofpreparation. Of primeimportance was the failure of the Medical Department and of thecivilian physiciansassociated with it to recognize the extreme importance of hemolyticstreptococcalrespiratory infection occurring without a skin rash. Emphasis waslargely on the control ofscarlet fever. Also, medical officers were not trained to distinguishclinically betweenhemolytic streptococcal and nonbacterial respiratory infections anddiagnostic bacteriologic
3 The medical Department of theUnited States Army in the World War. Statistics. Washington: GovernmentPrinting Office, 1925, vol. XV, pt 2, p.86.
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methods were not readily available to them. Lastly, the Army and itsconsultants had notfamiliarized themselves with available civilian and military data onthe basis of which itwould have been possible to predict with considerable accuracy thosegeographic areas inwhich outbreaks of hemolytic streptococcal disease and rheumatic fevermight be expectedto occur.
Little information isavailable as to the situation during the prewar expansion of the ArmedForces. During 1941, outbreaks of scarlet fever followed by rheumaticfever occurred atChanute Field, Ill., Scott Field, Ill., and Fort Knox, Ky. Theincidence of these diseaseselsewhere In the Army during this year was low. Drs. James D. Trask,Francis F.Schwentker, and M. Henry Dawson, of the Commission on HemolyticStreptococcalInfections, visited each of these camps in November 1941. They notedthat medical officersdid not recognize the association of scarlet fever and streptococcaldisease occurring withouta rash nor did they connect either of them with rheumatic fever.4
World War II period.- Plans were made to investigate outbreaksof hemolytic streptococcalinfections during the coming year. Between December 1941 and April1942, Dr. Schwentkermade bacteriologic studies at the camps mentioned at Fort Francis E.Warren, Wyo., wheremany cases of scarlet fever were occurring.5
Available records do notreveal that streptococcal disease was viewed with alarm during1941 and 1942, although the frequency of scarlet fever in the totalArmy during these yearswas comparable to that in 1943 and 1944 when interest in infection bystreptococcalorganisms was very great. The absence of concern in the earlier periodwas the direct resultof the lack of accurate reports 6 on the occurrence ofrheumatic feverprior to 1943 and tothe mildness of acute streptococcal disease.
The first detailedinformation in regard to the problem of rheumatic fever was obtainedwhen a survey early in February 1943 of the continuing scarlet feverepidemic at FortWarren revealed that more than 100 cases of streptococcal disease hadbeen hospitalized butneither correctly diagnosed nor reported to The Surgeon General.7Subsequently, the rapidincrease in size of installations in areas of high incidence of thisdisease in Colorado andUtah was associated with epidemics of streptococcal infection andrheumatic fever andadditional surveys were made which again delineated the deficiencies inbackground andinformation on the part of medical officers in regard to streptococcalrespiratory disease andits complications, but no control measures
4 Report, M.Henry Dawson, M.D.,Director, Commission on Hemolytic Streptococcal Infections, ArmyEpidemiological Board, 24 Nov. 1941, subject: Report on ReconnaissanceTrip to the Fifth and Sixth CorpsAreas by Dr. James D. Trask, Dr. Francis F. Schwentker, and Dr. M.Henry Dawson, Members of theCommission on Hemolytic Streptococcal Infections, November 11-19, 1941,
5 Schwentker, F.F. Survey ofHemolytic Streptococci in Certain Army Camps. Army M. Bull. No. 65:94-104,January 1943.
6 Rheumatic fever was firstincluded in the weekly statistical summary in February 1942.
7 Report, Lowell A. Rantz, M.D.,Member, Commission on Hemolytic Streptococcal Infections, ArmyEpidemiological Board, to Col. S., Bayne-Jones, Office of the SurgeonGeneral, 23 Feb. 1943, subject: Reportof Epidemic of Scarlet Fever and Septic Sore Throat, at Fort Francis E.Warren.
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were recommended.8 Principal interest of this investigationcentered in the large numberof cases of rheumatic fever and the varying clinical patterns ofstreptococcal infection.Scarlet fever was common in certain stations; in others, tonsillitiswithout rash was the rule.In one post, suppurative complications were exceedingly common.
During 1943, 6,710 admissions for rheumatic feverwere reported from the Army in theUnited States. According to summaries of the statistical healthreports, about 74 percent ofthese were in the Seventh and Ninth Service Commands. About 43 percentof all casesoccurred in the States of Colorado, Utah, Idaho, Montana, and Wyoming.The 10 stationshaving more than 100 cases of rheumatic fever and an annual rate ofgreater than 5 per 1,000in 1943 are presented in table 39.Their geographic proximity isapparent. There is thepresumption that the incidence of rheumatic fever has been underreported on the statisticalhealth report.
TABLE 39-Incidence of rheumatic feverin the U.S. Army, selected installations, 1943
This large number of cases of a serious disease requiring prolonged hospital care and resulting in many separations from service attracted very considerable interest in the Offices of the Surgeon General of the Army and the Air Surgeon. Three programs aimed at the acquisition of new knowledge about hemolytic streptococcal disease with special reference to its relationship to rheumatic fever and to control methods were instituted toward the end of this year. One of these programs was under the auspices of the Commission on Hemolytic Streptococcal Infections of the Army Epidemiological Board. Its purpose was the intimate investigation of a large number of cases of hemolytic streptococcal respiratory infection for the purpose of defining the natural history,
8 Report, Chester S. Keefer, M.D., Director,and Lowell A. Rantz, M.D., Member, Commission on HemolyticStreptococcal Infections, Army Epidemiological Board, April 1943,subject: Report of Investigation ofRheumatic Fever at Fort Francis E. Warren, Cheyenne, Wyo, Lowry Field,Denver Colol, Buckley Field,Denver, Colo., and Camp Carson, Colorado Springs, Colo.
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bacteriology, and immunology, of these disorders. Associated with thisgroup was theCommission on Air-Borne Infections whose main interest lay in theinvestigation ofmethods for control of airborne infection with particular reference tothe hemolyticstreptococcus. The third was the Army Air Forces Rheumatic FeverControl Program, whichwill be the subject of a later section of this chapter.
These three programs werein active operation throughout 1944. Much new knowledge wasacquired, but effective methods for the control of streptococcaldisease were notforthcoming. Dust control and air sterilization with glycol vapors wereproved not to be ofgreat value and were not applied in other than experimental fieldstudies.
The Air Forcesinvestigated intensively the role of sulfonamide prophylaxis during theearlymonths of 1944. Impressive results were obtained in the reduction ofstreptococcal infectionand rheumatic fever, and the, use of this technique in certain definedsituations, primarily forthe prevention of these diseases, became established Army policy on 1November 1944 withthe publication of TB MED 112. Unfortunately, by this time highlysulfonamide resistantstrains of streptococci had emerged and were causing disease amongnaval personnel wherechemoprophylaxis had been widely used on a mass basis since December1943.
Streptococcal infectioncontinued to be epidemic throughout 1944, and 4,877 cases ofrheumatic fever were reported in the United States. The highestincidence was in the Sixthand Seventh Service Commands where 37 percent of the cases occurred.Twenty-fourpercent occurred in the States of Colorado, Utah, Wyoming, and Nevada,where relativelyfew troops were stationed. The widespread movement of troops throughoutthe country mayhave been responsible for larger numbers of cases in other areas thanduring the previousrear. By this time, highly communicable strains of hemolyticstreptococcus were doubtlessseeded throughout the Army and its numerous establishments.
In 1944, streptococcalinfection and rheumatic fever became an important problem amongtroops overseas for the first time, 4,639 cases being reported. Thisrepresented a rate of only1.21 per 1,000 per annum or approximately one-third of that amongtroops in the UnitedStates.
As the winter of 1945began, it became apparent that sulfonamide prophylaxis, the only toolof value for the prevention of streptococcal infection and rheumaticfever, had becomeineffective. Disease caused by resistant streptococci was epidemic inthe United StatesNavy, and an outbreak of infection caused by similar strains hadoccurred in an Army AirForces station. The problem was considered at a National ResearchCouncil conference on28 February 1945. The failure of sulfonamide prophylaxis was discussedin detail, and thehazards involved in its continued use were described. As a result ofthese experiences in theNavy, this technique was applied only selectively in the Army AirForces and practically notat all in the Army Ground Forces. The possible value of penicillinprophylaxis was exploredat another National
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Research Council conference on 20 March 1945, and certain studies forits evaluation underfield conditions by the Army Air Forces were outlined but were notundertaken.
Although the incidence ofscarlet fever and rheumatic fever declined sharply in the Zone ofInterior during 1945, in spite of the absence of effective controlmeasures, the incidence ofstreptococcal sore throat rose from 0.82 per 1,000 in 1944 to 3.64 in1945 (table 40). Thecombined effect was an increase in incidence from 3.98 in 1944 to 5.21in 1945. Only 1,675cases of rheumatic fever were reported. Two thousand and fiftyadditional cases occurred inthe Army overseas.
An important NationalResearch Council conference on streptococcal disease was held on 7July 1945, and recommendations were made which will be the subject oflater comment. Thewar ended in the fall of that year, and information on the occurrenceof these diseases duringdemobilization is not available.
STATISTICALINFORMATION
The previous section hasindicated that hemolytic streptococcal respiratory infection and itscomplications were an important problem during World War II.
During 1942 through 1945,26,063 cases of scarlet fever were reported in the Army in theUnited States and 3,449 additional cases from the Army overseas (table41).During the 2years, 1944 and 1945, when streptococcal sore throat was codedseparately, 20,471 caseswere diagnosed (table 42). This figure was entirely too low asstreptococcal respiratoryinfection occurring without a rash was recognized in only its mosttypical clinical form.
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The author believes that not less than 5 cases ofstreptococcal sore throat were hospitalizedfor every case of scarlet fever. If this approximation be accepted, atleast 150,000 mensuffered infection by hemolytic streptococci of this degree of severityduring 1942-45,inclusive. A minimum of 5 days of hospitalization was required by each,a loss of 750,000man-days during the war. These statistics do not include a group atleast equally large inwhom infection occurred which was not sufficiently severe to requirehospital care, butwhich reduced efficiency for several days.
The data pertaining torheumatic fever are even more significant: there were 18,339 casesreported (table 43). Average hospitalization was not less than 3 monthsand usually more. Atleast 2 million man-days were lost. Many of these men were separatedfrom service and mayvery well have later received service-connected disability compensationand care under theVeterans' Administration.
TABLE 41.-Incidence of scarlet fever inthe U. S. Arnty, by area and year, 1942-45
The cost to the UnitedStates Army in terms of dollars and effectiveness as the result ofhemolytic streptococcal infection and its complications cannot beassessed. The loss ofabout 900,000 man-days per year presented a problem of considerablemagnitude.
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TABLE 42.-Incidence ofstreptococcal sore throat in the U. S.Army, by area and year,1944-45
During 1942-45, the numberof deaths due to the three streptococcal diseases was as follows:
Scarlet fever | 61 |
Rheumatic fever | 28 |
Streptococcal sore throat (1944-45) | 12 |
There were 689 cases of streptococcal pneumonia in 1944-45, 524 cases in continental United States, and 165 cases overseas. There were 20 deaths (13 in the United States and 7 overseas) attributed to streptococcal pneumonia. The disease was notably uncommon even in areas in which streptococcal infection was epidemic. At Chanute Field, only 16 cases with 1 death were observed between 1 January 1942 and 21 April 1945. 9 Pulmonary invol
vement was anot infrequent complication of the type 17 sulfonamide-resistantoutbreak of streptococcaldisease that occurred at Keesler Field and Amarillo Army Air Fieldduring late 1944 and early1945. At the latter station, 312 cases of streptococcal respiratoryinfection were recognized, ofwhich 19 were compli-
9 Countryman, H. D.: The Treatmentof Pneumonias and Their Complications. News Letters, Army Air ForcesRheumatic Fever Control Program, vol.2, No.9, September 1945, pp.6-12.
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cated by pneumonia.There was one death.Prompttreatment with penicillin was highlyefficacious in controlling the illness.l0
During 1942-45, 2,398cases of erysipelas were reported, 1,627 in the continental UnitedStates and 771 overseas.
TABLE 43.-Admissions for rheumaticfever in the U. S. Army, by area and year 1942-45 1
EPIDEMIOLOGY
GeographicIncidence
The geographicdistribution of streptococcal infection in the continental UnitedStates hasbeen emphasized. Table 40 demonstrates that rates for disease caused bythese organismswere high in the Sixth and Seventh and very low in the Fourth ServiceCommands. Thesefacts are further presented in tables 44 and 45, which show theoccurrence of scarlet feverand rheumatic fever during 1943 and 1944 when the most widespreadepidemics were inprogress.
Inspection of thesefigures, particularly the incidence by States, reveals thatstreptococcalinfection was most common in belts lying to the east and
10 Report, Maj. Norman B. Roberg,MC, subject: A Survey of an Epidemic Caused by a Virulent SulfadiazineResistant Strain of the Streptococcus Hemolyticus (Group A,Type 17) at Amarillo Army Air Field.
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west of the Rocky Mountains, in the area of the Great Plains, andaround the Great Lakes.The experience was worst in Colorado, Utah, and Wyoming. The Navy alsoencounteredvery severe outbreaks of these diseases in their installations in thesesame general areas.
Civilian experience wouldhave suggested that the Northeastern States should haveexperienced a high incidence of these disorders. That it did not isdoubtless the result of thefact that few troops were trained there. It was used principally as astaging area for well-seasoned men.
Equally noteworthy was theinfrequent occurrence of hemolytic streptococcal infectionamong troops stationed in the Southern United States. Epidemics didoccur there,particularly during 1944 and 1945, but they were short lived and oflittle consequence.
Additional pertinentinformation was obtained by the Army Air Forces Rheumatic FeverControl Program in a study of group A hemolytic streptococcal carriersat several Army AirForces installations. The data for the period 1 January to 21 April1944 are summarized asfollows: 11
Location | Percent |
Buckley Field, Colo | 30.3 |
Amarillo Field, Tex | 13.1 |
Lincoln Army Air Field, Nebr | 9.7 |
Kearns Field, Utah | 9.2 |
San Antonio Aviation Cadet Center, Tex | .3 |
Drew Field, Fla | 1.4 |
Davis-Monthan Field, Ariz | .7 |
The higher carrier ratesamong troops stationed in the Rocky Mountain area, the MiddleWest, and northern Texas are to be contrasted with the very
11 Van Ravenswaay, A. C.: TheGeographic Distribution of Hemolytic Streptococci. Relationship to theIncidence of Rheumatic Fever. J. A. M. A. 126: 486-490, 21 Oct. 1944.
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low rates in the South. This study doubtlessreflects the previously emphasized geographicvariations in the occurrence of streptococcal disease.
The results of the twostudies by the Commission on Acute Respiratory Disease, ArmyEpidemiological Board, were equally striking. These studies wereconducted at Fort Bragg,N. C., one from April to June 1943 and the other from March to May 1944.12In each year,approximately 900 successive admissions to the hospital because ofrespiratory disease wereinvestigated. About 4 percent in both years were proved by appropriatebacteriologic andimmunologic procedures to be of group A hemolytic streptococcal origin.The
12 (1) Commission on AcuteRespiratory Diseases: Endemic Exudative Pharyngitis and Tonsillitis.Etiologyand Clinical Characteristics. J. A. M. A. 125: 1163-1169, 26 Aug. 1944.(2) Commission on Acute RespiratoryDiseases: Role of B-Hemolytic Streptococci in Common RespiratoryDisease. Am. J. Pub. Health 35:675-682,July 1945.
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troops involved were unseasoned during both periods and highlysusceptible toundifferentiated respiratory infection.
Another study, fromJanuary to April 1944, was carried out at Camp Carson.13Fifteenhundred cases of hospitalized respiratory disease were examined andabout 350, or 23percent, were proved to be caused by hemolytic streptococci.
A contrasting situationwithin the author's experience at Fort Francis E. Warren is ofinterest.This post of about 20,000 men was experiencing a severe outbreak ofstreptococcal disease inFebruary 1943. Forty cases of scarlet fever per week were entering thehospital. On 8 February1943, a special barracks hospital was opened. Three days later, 100 newcases of acutestreptococcal respiratory disease occurring without skin rash,sufficiently severe to deservebed care, had been admitted to the hospital. All were personallyexamined and studiedbacteriologically by the author. This represented a streptococcaldisease rate at that time ofaround 650 per 1,000 per annum.
The causes of thesestriking geographic relationships in the frequency of occurrence ofhemolytic streptococcal infection and its complications have been thesubject of muchspeculation, but no satisfactory explanation has been offered. Theimplications in regard to theestablishment of camps for future training of troops are obvious.
Approximately 12 percentof all scarlet fever admissions and 23 percent of all rheumatic feveradmissions (tables 41 and 43) occurred in the Army overseas. The ratesfor the former diseasewere about one-fifth and for the latter about two-fifths of those inthe continental UnitedStates. The worst experiences were encountered in the European,Mediterranean, and MiddleEast theaters, and the North American area. Streptococcal infection wasa much less importantproblem in the Pacific Ocean, Southwest Pacific, and Latin Americanareas. This distributionis in accord with the available information regarding the occurrence ofthese disorders amongcivilian populations in the several areas.
There were 77 cases ofscarlet fever and 75 admissions for rheumatic fever on transports,during the years 1942-45, according to individual medical recordtabulations.
Seasonalincidence.- Hemolytic streptococcal infection has been regardedas a disease of thewinter months. This was true, to a certain extent, in the Army in thecontinental United States.Inspection of chart 21 reveals, however, that whereas the incidence ofscarlet fever began toincrease in December and January 1942-43, 1943-44, and 1944-45,respectively, peak levelswere not attained until March or April, and rates remained high untilthe end of May and thenfell sharply through the summer. This was particularly true in theSixth and Seventh ServiceCommands where epidemics were in progress.
13 Rantz, L. A., Rantz, H. H.,Boisvert, P. J., and Spink, W. W.: Streptococcic and NonstreptococcicDisease ofthe. Respiratory Tract; Epidemiologic Observations. Arch. Int. Med. 77:121-131, February 1946.
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CHART 21.-Seasonal incidence ofscarlet fever in the Army in thecontinental United States,1942-45
The highest incidence ofrheumatic fever always lags about 1 month behind the streptococcalrespiratory infection. A comparison of charts 21 and 22 shows that thiswas the case in thetotal Army in 1943 and 1945, the highest level being attained each yearin May. However,many cases appeared throughout the summer. In 1944, the peak occurredin April. Satisfactoryexplanations for these seasonal relationships have not been forthcoming.
Seasoning ofPersonnel
Epidemics of nonbacterialrespiratory infection are very likely to occur when raw recruits areassembled in basic training centers. Throughout the last war, it wastacitly assumed that thiswas also the case in regard to hemolytic streptococcal disease. Thisopinion emerged since themost serious outbreaks in both the Army and the Navy occurred instations in which men freshfrom civilian life were undergoing basic training.
It is curious to learnthat, in spite of the great importance of the problem, a critical studywasnever made, by the Army or the Navy for the purpose of determining therelative susceptibilityto streptococcal disease of personnel of various degrees of seasoning.
Experience in the Navy, asdescribed by Coburn,14 indicates that well-seasoned men werehighly susceptible to streptococcal disease when brought together incenters in high-incidenceareas. One study was conducted in an Army camp in such an area in whichnearly all of thepersonnel had had from 7 to 24 months of service. Annual rates ofhospitalization forstreptococcal infection of 200 per 1,000 were attained.15
Another pertinentinvestigation suggested that the rates might have been much higher hadasimilar number of raw recruits been assembled.
14 Coburn, Alvin F., and Young,Donald C.: The Epidemiology of Hemolytic Streptococcus During World WarII in the United States Navy. Baltimore: Williams and Wilkins, 1949.
15 See footnote 13, p. 240.
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CHART 22.-Seasonal incidence ofrheumatic fever in the Army inthe continental UnitedStates, 1942-45
Approximately 300 cases ofsulfonamide-resistant type 17 hemolytic streptococcal infectionwere hospitalized at Amarillo Army Air Field during February and March1945. An annualrate of 105 per 1,000 was observed among 7,000 well-seasoned men. Abasic trainingsquadron of about 1,000 men experienced an annual rate of 864 per1,000, 8 times that in theseasoned troops.16
In summary, the meagerevidence indicates that all types of troops brought together in areaswhere streptococcal infection is common will experience outbreaks ofdisease caused by theseorganisms. One study suggests that the epidemic will be more intenseamong new recruits.
16 See footnote 10, p.237.
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Movement of Troops
During one investigation,it was clearly shown that the transfer of troops from a low- to ahigh-incidence area was accompanied by an outbreak of streptococcaldisease even amongseasoned troops.17 Inconclusive evidence was obtainedwhich suggested that men who had beenstationed for 6 months in the latter area were relatively immune toinfection. Annual ratesamong such troops were about 50 per 1,000 as contrasted with previouslymentioned rates of200 per 1,000 among fresh troops, but seasoned men moved into the studypost from a low-incidence area.
The severity andpersistence of certain epidemics of streptococcal infection whichoccurred inbasic training establishments in high-incidence areas were probablyspecifically related to theconstant movement into such posts of men in small groups from otherparts of the country.This constant influx of susceptibles doubtless served to maintain theepidemic situation andmay have been of greater importance than the lack of seasoning. Thepractice of distributingthese new arrivals throughout the post, rather than maintaining them inseparate units, insuredthe exposure of all to the epidemic streptococcus.
Movement of troops fromhigh- to low-incidence areas must have been associated with theestablishment of outbreaks of varying degrees of severity in stationswhich had previouslybeen relatively free of streptococcal illness. This definitely occurredon several occasions inthe Navy.18 The Amarillo Army Air Field epidemic in 1945 wasinitiated by troopstransferred from Keesler Field.l19 No other documentedepisodes of this type in the Army areknown to the author.
If such spread fromhigh-incidence areas occurred frequently with the establishment of newand prolonged epidemics, there should have been a leveling off of therelative frequency ofscarlet fever and rheumatic fever be tween various areas during1942-44. Such a comparativestudy is possible at present only on a service command basis.Inspection of table 46 revealsthat the rates for scarlet fever in each service command were quitestable throughout thecritical period when men who had received their basic training inhigh-incidence areas werebeing distributed throughout the country.
The seven service commands(excluding the Sixth and Seventh) in which rheumatic fever rateshad been low during 1942 and 1943 all showed very definite increasesduring 1944. This maywell have reflected a spread of streptococcus into these areas bytroops from the Sixth andSeventh Service Commands. Rates for rheumatic fever remained notablylow throughout thewar for the Second Service Command as well as the Eighth. Epidemicsoccurred in theseareas, as has been previously noted, but were explosive and short lived.
17 See footnote 13, p. 240.
18 See footnote 14, p. 241.
19 See footnote 10, p. 237.
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TABLE 46.-Incidence rates ofscarlet fever and rheumatic fever, byyear and servicecommand, 1942-45
Housing
Overcrowding in barracksand classrooms was often considered to be a contributing factor toepidemics of streptococcal infection in the Army. Critical evaluationwas impossible sincevirtually all Army establishments were over crowded from 1942 to 1944when disease causedby these organisms was most prevalent. Many exceedingly crowded postsin low-incidenceareas escaped epidemic; streptococcal disease entirely. The congestionin barracks doubtlessaggravated the spread of hemolytic streptococci, but its eliminationwould not have been aneffective prophylaxis if other conditions had been favorable to theorganism.
Relationshipto Virus Infection
The experience of World War I hadalerted physicians in the Army to the potentialities ofinfluenza as a precursor of hemolytic streptococcal pneumonia. It wasalso believed thatinfection by this and other respiratory viruses might predispose toupper respiratory infectionby streptococci. Evidence supporting this possibility was notforthcoming. The increase inrates for scarlet fever during and after the pandemic of influenza A inNovember andDecember 1943 was no greater than the usual seasonal increment. Onecritical study in a postin an area of high incidence at this time failed to demonstrate anyincrease at all in thestreptococcal disease rate.20 It is of considerableinterest, that this epidemic was not associatedwith the appearance of hemolytic streptococcal pneumonia even in areaswhere streptococcalrespiratory infection was common.
20 See footnote 13, p.240.
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Information is not available to the author whichwould indicate that rubella, rubeola, ormumps significantly enhanced the susceptibility of troops tostreptococcal infection.Doubtless, an occasional case of these disorders was complicated bystreptococcal pneumonia.
HemolyticStreptococcus Grouping and Typing
It was well known in 1940that the hemolytic streptococci could be divided into groups andtypes by serologic techniques. Nearly all primary human infections ofthe respiratory tract hadbeen shown to be caused by strains be longing to group A. The membersof this group couldbe subdivided into types by agglutination or precipitin methods. It wasthe perfection of thelatter technique which permitted the widespread application ofstreptococcal typing duringWorld War II. The agglutinative method, although a valuable tool,cannot be standardized foruse by laboratories without personnel with a great deal of specialtraining.
The first application ofserologic typing in the Army was by Schwentker, who studied a smallnumber of cases of scarlet fever and tonsillitis at Chanute Field,Scott Field, Fort Knox, andFort Warren, between 18 December 1941 and 25 March 1942. A large numberof differenttypes were recovered from scarlet fever contacts and from healthycarriers. Only 11 types wereshown to be causing disease. At Fort Warren, type 19 was responsiblefor nearly allinfections.21
Another study made betweenMarch and June 1942 at Chanute Field by the Commission onAir-Borne Infections revealed that 85.5 percent of all infections weredue to types 18, 19, 1,6, 17, and 26 in that order. Between November 1942 and August 1943,86.7 percent werecaused by types 19, 1, 3, 6, 17, 36, 18, and 5.22 InFebruary 1943, a survey showed that type19 was still the only important type responsible for disease at FortWarren. The frequency ofvarious types was determined at Camp Carson between December 1943 andMay 1944 bythe Commission on Hemolytic Streptococcal Infection. A somewhat broaderspectrum wasencountered here but 13 were responsible for 94.5 percent and 7, types36, 19, 3, 17, 30, 46,and 6, for 66.1 percent of all infections.23
After April 1944, completedata are available on type distributions in Army Air Forcesinstallations from the Rheumatic Fever Control Program. Between Apriland August 1944,85.2 percent of 2,021 presumed cases of group A streptococcalrespiratory infection werecaused by types 19, 30, 3, 1, 17, 14, 6, 36, 5, 26, and 12. The first 6were responsible for 77percent of all illness.24
21 See footnote 5, p.231.
22 Hamburger, M ., Jr., Hilles, C.H., Hamburger, v. G., Johnson, M. A., and Wallin, J. G.: Ability ofDifferentTypes of Hemolytic Streptococci to Produce Scarlet Fever. J. A. M. A.124: 564-566, 26 Feb. 1944.
23 See footnote 13, p.240.
24 News Letter, Army Air ForcesRheumatic Fever Control Program, vol. 1, Nos.1-5; vol.2, Nos.1-9,August1944 September 1945.
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After this date, the type incidence is expressedonly on the basis of rates which makesepidemiologic calculation and comparison more difficult. An analysishas been made basedon reports of 10 months of study in which each type has been scored onthe basis of itshaving caused a significantly large number of cases (2.58 X standarderror) in any month inany post or, if this value was not calculated, a rate of 10 per 1,000per annum.
Only nine types causedsignificant amounts of disease: Type 17 in 11 months, type 19 in 7,type 30 in 2, and types l, 3, 5, 6, 26, and 36 each in 1 month. Thesame nine types in 27additional months were responsible for rates of 5 per 1,000 per annum.Only four others, 11,10-12, 14, and 22 attained these levels and then only in single postmonths.
In summary, the results of streptococcal typingpresented here demonstrate that the samesmall group of types caused the bulk of studied respiratory infectionby these organismsbetween the spring of 1942 and the fall of 1945. During the period 1942to the summer of1944, types 1, 3, 6, 17, 19, and 36 were most frequently recovered.During late 1944 and1945, types 3, 17, 19, and 30 were of the greatest importance.
It is apparent from theseobservations that the Army functioned for several years as a closedepidemiologic unit in which streptococci were serially transmitted.Strains of a certain smallgroup of types retained their high degree of communicability over along period of time. Thedominance of types 3, 17, and 19 during the last year was very largelydue to the fact thatthey had become sulfonamide resistant and were thus able to spread inpopulations protectedby these drugs.
An additional feature ofthe typing program was the establishmentof a relationship betweentype and the ability of the streptococcus to produce a skin rash. Theobservation was firstmade by Hamburger and his associates of the Commission on Air-BorneInfections. Theseworkers noted that between November 1942 and August 1943, types 1, 3,17, 19, and 29were frequently associated with scarlet fever. Sufficient observationswere available toindicate strongly that types 5, 6, 18, and 36 were not able tostimulate the development of arash.
These observations wereextended by the Commission on Hemolytic StreptococcalInfections at Camp Carson between December 1943 and May 1944. Duringthis period onlytypes 3, 17, 19, and 30 were rash formers. Nonscarlatinogenic typeswere 1, 5, 6, 24, 26, 36,44, and 46. Critical study revealed that strains of the latter typeswere erythrogeneticallyineffective even in Dick-positive persons. 25
Considerable additionaland related information was obtained by the Army Air ForcesRheumatic Fever Control Program. Between April and August 1944, 89.4percent of 229cases of scarlet fever were caused by types 1, 3, 17, 19, and 30.Strains of only types 6 and18 of those previously shown by the commissions to benonscarlatinogenic were recoveredfrom 2 cases of
25 Rantz, L. A., Boisvert, P. J.,and Clark, W. H.: The Relationship of Serological Types of Group AHemolyticStreptococci to Toxin Formation and Antibody Response. Stanford M.Bull. 6: 55-65, February 1948.
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scarlet fever during this period although they were responsible formore than 70 cases ofrespiratory infection occurring without rash. It is possible that thestreptococci from thesetwo cases were incorrectly classified.
At any event, certainstrains remained highly scarlatinogenic for 2 years and others wereunable to stimulate rash production. After October 1944, all data arepresented in the form ofrates per 1,000 per annum, and no strain is recorded unless a frequencyof 1 per 1,000 wasattained in some month in a post under study. Over an 11-month period,only disease causedby types 3, 17, 19, and 30 attained these levels, although during 1post-month types 6, 24,and 26 were recorded as etiologically responsible for scarlet fever.
The relationship of thevarious serologic types in the causation of rheumatic fever was ofinterest, but little information was obtained which can be reviewedprofitably. Streptococciof type 126 and an unidentified type 27 werethe cause of extensive foodborne outbreaksthat were not followed by the development of rheumatic fever.Similarly, the type 17Streptococcus responsible forthe epidemic at heesler Field and Amarillo Army Air Fieldwas not capable of inciting the rheumatic state.28 Theimpression is gained that certainstrains were rheumato-genetically more potent than others and that thisproperty was notrelated specifically to the numerical type.
An attempt was made todefine the geographic distribution of the several types of group Ahemolytic streptococcus by the typing laboratory at the Santa Ana ArmyAir Base.29 Thisstudy was carried out between 25 April and 1 July 1944. Throat cultureswere obtained from5,828 men within 48 hours after their arrival at this post from thevarious college trainingdetachments of the Army Air Forces Western Flying Training Command. Thetotal group Acarrier rate was circa 200 per 1,000, but this varied from 490 per1,000 to 1 per 1,000depending on the establishment from which the troops lead come. Thepredominant typeswere similar to those noted, 1, 3, 6, 14, 17, 19, 30, and 36, and theywere found to be widelydistributed throughout the country. Space does not permit a furtherdetailed analysis of thisinteresting study.
FoodborneStreptococcal Infection
Food contaminated byhemolytic streptococci is well able to transmit these organisms tosusceptible persons. When this occurs, an explosive outbreak ofstreptococcal respiratorydisease occurs which reaches its peak in from 48 to 72 hours and thendeclines rapidly. Thedisease process is not different from that seen in more usualcircumstances, and rheumaticfever is a frequent complication.
26 Rantz, L. A., Spink, W. W., andBoisvert, P. J.: IIemolytic Streptococcus Sore Throat; Detailed StudyofSimutaneous Infection of a Large Number of Men by a Single Type. Arch.Int. Med. 76: 278-283, November-December 1945.
27 Bloomfield, A. L., and Rantz,L. A.: An Outbreak of Streptococcic Sore Throat in an Army Camp;Clinical andEpidemiologic Observations. J. A. M. A. 121: 315-319, 30 Jan.1943.
28 See footnote 10, p. 237.
29 Mitchell, R. B.: GeographicalDistribution of the Serological Groups and Types of Beta HemolyticStreptococci.Report from Streptococcus Typing Laboratory, Army Air Forces RegionalHospital, Santa Ana Army Air Base. 21Oct. 1944. [Official record.]
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There were 19 recorded epidemics of streptococcalinfection during 1942-45, involving 2,879cases, and others doubtless occurred but were not recognized orreported. Three were studied bycommissions of the Army Epidemiological Board, and the results werepublished in scientificjournals.30
Of greatest interest to this history is the factthat, careful bacteriologic investigation offoodhandlers was made in five of these outbreaks, and a hemolyticstreptococcal carrier wasdiscovered among the kitchen staff in four of them. The serologic typeof streptococcusrecovered from two of these individuals was the same as that isolatedfrom infected cases. Theother two strains were not typed. Messworkers with acute tonsillitiswere discovered during theinvestigation of two other epidemics, but, no bacteriologic studieswere made.
Traditional epidemiologicstudy of such outbreaks includes elaborate survey of food and watersupplies with particular reference to milk. The observations justrecorded indicate that the usualsource of the infectious agent is a hemolytic streptococcal carrieramong the foodhandlers whocontaminates certain articles of food after they are cooked. Simplebacteriologic methods,readily applicable by almost any military establishment, should permitthe detection and controlof such individuals and the elimination of foodborne streptococcaldisease as a health hazard inthe Armed Forces.
DIAGNOSIS
At the onset of World WarII, medical officers were inadequately trained in the recognition ofhemolytic streptococcal infection. The author, during 1943, repeatedlyexamined large numbersof patients in epidemic areas in whom the presumptive diagnosis ofstreptococcal respiratoryinfection could be made on inspection of the nasopharynx. The correctetiology of these caseshad usually not been suspected by the officers in charge, even thoughconcurrent epidemics ofscarlet fever were in progress. This situation was partly the result ofinsufficient previousexperience and partly because of the failure to appreciate theimportance and significance ofstreptococcal infection occurring without a skin rash.
An additional factor wasthe inability of the usual station hospital laboratory to isolate andidentify adequately the hemolytic streptococcus. Bacteriologic controlof clinical diagnoses wasessentially impossible in most installations during the early years ofthe war.
Similarly, rheumatic feverwas not regularly recognized clinically, even in epidemic areas, untilearly in 1943 and was not reported to The Surgeon General. Facilitiesfor the adequate study ofthis disease were usually available but were not regularly utilized.This situation changed rapidlyduring
30 (1) See footnote 26, p. 247.(2) See footnote 27, p. 247. (3) Commission on Acute RespiratoryDiseases: Study ofa Foodborne Epidemic of Tonsillitis and Pharyngitis Due to B-HemolyticStreptococcus, Type 5. Bull. JohnsHopkins Hosp. 77: 143-210, September 1945.
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1943, and by 1944 most medical officers had been alerted to the factthat rheumatic feverwas occurring frequently in the Army, and they were able to diagnoseand treat the disease,with considerable precision.
CONTROL OFSTREPTOCOCCAL INFECTION
The control of hemolyticstreptococcalinfection was a problem which engaged the attentionof all branches of the Armed Forces during World War II. Extensivestudies were carried outby the Commission on Hemolytic Strepto coccal Infection and theCommission on Air-Borne Infections of the Army Epidemiological Boardwhich are described elsewhere in therecords of that board. The Army Air Forces established its ownrheumatic fever controlprogram in the fall of 1943 under orders from Maj. Gen. (later Generalof the Army) HenryH. Arnold. Its objectives were (1) recommendations for the use ofsulfonamide prophylaxisfor the control of respiratory infections and rheumatic fever, (2)adoption of uniformstandards for the diagnosis of rheumatic fever, (3) coordination andstandardization ofbacteriologic techniques in the study of the hemolytic streptococcus,(4) establishment of auniform convalescent program and followup studies on positive andsuspected cases ofrheumatic fever, and (5) consideration of special projects andinvestigations at various ArmyAir Forces posts.
Only objectives 1, 3, and5 are germane tothis chapter. The other two were accomplishedunder the direction of Ruth Pauli Callender. Uniform techniques for theisolation andserologic classification of the hemolytic streptococci were adopted foruse throughout ArmyAir Forces streptococcal laboratories. Forty hospitals were members ofthe initialcooperating group and a chief of the streptococcal laboratory wasdesignated in each.Laterreports presenting detailed epidemiologic information were derivedentirely from 10stations: Amarillo Army Air Field, Buckley Field, Davis-Monthan Field,Drew Field,Hamilton Field, Calif., Keesler Field, Lincoln Army Air Field, LowryField, San AntonioAviation Cadet Center, and Santa Ana Army Air Base. At each of theseposts acomprehensive prograin was undertaken in January 1944 and continueduntil September1945. The work was divided into three phases, proceeding concurrently:(1) Determinationof incidence of hemolytic streptococcal infection by systematic studyof nasopharyngealflora of all hospital admissions with respiratory illness, (2)determination of hemolyticstreptococcal carrier rates by regular bacteriologic samplings ofnasopharyngeal flora oftroops, and (3) determination of serologic groups and types of allisolated hemolyticstreptococci.
A very large amount ofinformation in regardto certain aspects of the epidemiology ofhemolytic streptococcal respiratory infection was obtained during the21 months in whichthis program was in operation.
It is probable that noother infectiousdisease has been studied on a nationwide basis by sucha well-coordinated group applying uniform techniques.
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Methods ofControl
Methods applied duringWorld War II for thecontrol of hemolytic streptococcal infectionmay be considered in two categories: (1) General hygienic measures and(2)chemoprophylaxis. Any possible value of the former, which included suchteellniques asisolation of infected personnel, elimination of overcrowding, and thelike, was largelynullified early in the war by the failure to recognize the importanceof streptococcalinfection occurring without a rash. For this reason, cases of scarletfever were isolated andtheir contacts intensively examined, but a huge reservoir of potentialtransmitters of diseasein the nonrash cases was ignored. Later, this situation was rectifiedsomewhat, but suchnonspecific measures failed to terminate the serious outbreaks ofstreptococcal infection,and chemoprophylaxis was given very serious consideration by the Army.
Sulfonamideprophylaxis
Sulfonamide prophylaxis ofhemolyticstreptococcal respiratory infection was usedinfrequently in the Army during World War II, but a more detailedreview of thedevelopment of this technique, its applications, and subsequentfailures is appropriate to thishistory.
The first reports of thepossible value ofthe continuous administration of sulfonamides overlong periods of time for the prevention of streptococcal disease werepresented from twocivilian clinics in 1939. This experience was rapidly expanded byothers with uniformlygood results and low toxicity. A panel of experts in the summer of 1943was able torecommend the widespread application of this method for the preventionof recrudescencesin rheumatic subjects.31
Early in 1942, it wasdiscovered by theCommission on Meningococcal Meningitis that theadministration of 2 gm. of sulfadiazine in a single dose was highlyeffective in eliminatingmeningococci from the nasopharynx of carriers and in terminatingepidemics of meningitiscaused by these organisms. The earliest known deliberate use of thesedrugs in the ArmedForces for the prevention of streptococcal infection was that of Maj.(later Col.) Russel V.A. Lee, MC, at the Santa Ana Army Air Base in 1942. The study was notcontrolled. At aboutthis time, Watson and his associates conclusively demonstrated thevalue of sulfonamideprophylaxis in the control of an epidemic of scarlet fever on a Navypier in New York.32
In spite of thisinformation and in the faceof the gravely high incidence of streptococcalinfection and rheumatic fever in the Army and the Navy, sulfonamideprophylaxis was notundertaken by either service during the winter of 1942-43. It isdifficult for the author, whowas in constant touch
31 Proceedings of conference onRheumaticFever, Washington, D. C., October 5-7,1943. U. S. Department ofLabor, Children's Bureau Publication 308. Washington: U. S. GovernmentPrinting Office, 1945.
32 Watson, R. F., Schwentker, F.F.,Fetherston, J. E., and Rothbard, S.: Sulfadiazine Prophylaxis in anEpidemicof Scarlet Fever. J. A. M. A. 122: 730-733, 10 July 1943.
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with the situation in the Army through thisperiod, to be certain why this delay occurred.Presumably, the constant fear of reactions to the prolongedadministration to large numbersof troops of these potentially highly toxic drugs was a principaldeterring factor.
At a conference on 7September 1943, the,Navy decided to employ sulfadiazineprophylactically, and the program was well established by mid-December.The results of thisextraordinary experiment in preventive medicine have been described intwo monographs.33More than 600,000 men received either 0.5 or 1.0 gm. of sulfadiazinedaily for varyingperiods of time throughout the winter and spring of 1943-44. For thefirst few months,controlled studies were done and brilliant results obtained in that theincidence ofstreptococcal respiratory infection and rheumatic fever was strikinglyreduced. By March1943, controlled work had been abandoned, and the drug was given to allnaval personnel intraining in the continental United States.
During 1943, the Army wasdeeply interestedin this technique, and plans were laid for itsstudy during the winter of 1943-44 by the Commission on HemolyticStreptococcalInfections and by the Army Air Forces Rheumatic Fever Control Program.Only one orderfrom The Surgeon General permitting chlemo-prophylaxis in the Armyduring 1943 has beendiscovered.34 No record of its implementation isavailable. On another occasion,Headquarters, New York Port of Embarkation, recommended theadministration ofsulfonamides to the scarlet fever contacts. It is not known whether thedrug was used in thissituation.35
The Commission onHemolytic StreptococcalInfections failed to institute its proposedinvestigation of sulfonamide prophylaxis during 1943-44, but the ArmyAir Forces proceededwith an extensive program. Several careful studies were done at SiouxFalls Army Air Field,Truax Field, Wis., and Lowry Field. Various schedules were employed,and it was learnedthat a daily 0.5 gm. dose of sulfadiazine was adequate. Toxicity wasamazingly uncommon.Only 47 men of 36,500 receiving the drug experienced any untowardeffects, and in 33 thereactions were mild. The usual impressive reduction in streptococcaldisease and rheumaticfever was obtained.36 These controlled investigations werenotcompleted until May 1944,at which time the streptococcal disease rates were declining rapidly.Chemoprophylaxis wasnot employed widely through the remainder of the Army Air Forcesinstallations and not atall by Army Ground Forces during this season.
33 (1) See footnote 14, p. 241.(2) ThePrevention of Respiratory Tract Bacterial Infections by SulfadiazineProphylaxis in the United States Navy. NAVMED 284, Bureau of Medicineand Surgery, Navy Department,Washington: U. S. Government Printing Office, 1944.
34 Letter, Lt. Col. R. V. Lee, MC,to AirSurgeon, Headquarters, Army Air Forces, 19 Mar. 1943, subject:Prophylactic Use of Sulfadiazine in Prevention of Scarlet Fever, withendorsements thereto.
35 Memorandum, Commanding General,Headquarters, New York Port of Embarkation, for Surgeon, StagingArea, 20 May 1943, subject: Disposition and Prophylaxis Treatment ofContacts With Scarlet Fever in TaskForces and Station Complement Units.
36 Professional Division, Officeof the AirSurgeon: Prophylactic Use of the Sulfonamides. Air Surgeon's Bull.I No. 9: 5-7, September 1944.
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The Army Air Forces was greatly impressedwith its studies during early 1944 and wentahead rapidly with the development of a program for general applicationduring 1944-45.This culminated with the issuance of Army Air Forces Letter 25-20 fromthe CommandingGeneral, Army Air Forces, authorizing chemoprophylaxis as a commandfunction and thepublication of the details of the method in the Air Surgeon'sBulletin, September 1944. Aconference was held on 3 September 1944 attended by representatives ofThe SurgeonGeneral, the Army Epidemiological Board, the Air Surgeon, and theBureau of Medicine andSurgery (United States Navy) for the purpose of discussing this programwhich lead alreadybeen authorized by the Air Surgeon.
Although some evidence hadalready beenobtained that prophylaxis was breaking down inthe Navy, this group endorsed the Army Air Forces program for usethroughout the Army.Mass administration of the sulfadiazine was not approved. The drug wasto be given onlywhen acute respiratory disease, scarlet fever, or meningococcalmeningitis reached a certainprescribed minimum rate and was to be continued for only 3 weeks unlessspecialcircumstances indicated a more prolonged use of this technique. On 1November 1944, TBMED 112 was issued, authorizing the use of sulfonamide prophylaxisthroughout the Armywhen proper indications were found to exist. Approval of theappropriate higher medicalechelon was required.
During this same month, anepidemic of type17 sulfonamide-resistant streptococcalinfection, which continued for several weeks, began at Keesler Field.Outbreaks of diseasecaused by this same organism occurred later at Amarillo Army Air Fieldand at Lowry Fieldand were traced to troops moved into the two posts from Keesler Field.Several similarepidemics were observed during the winter of 1945, although the totalstreptococcal diseaserate remained low.
Sulfonamide prophylaxiswas, therefore,ineffective in terminating the more seriousepidemics and not needed under other circumstances in 1945. It isbelieved that it wasapplied only rarely during that year although actual data as to thenumber of men treated arenot available.
The appearance ofsulfonamide-resistantstreptococci as a cause of disease among menreceiving mass chemoprophylaxis was believed to be the result of theappearance of drug-fast mutants during the rapid multiplication andtransfer of these organisms in a populationaltered by the administration of these drugs in such a way as to favorthe survival of resistantvariants and the disappearance of sensitive ones.
Althoughsulfonamide-resistant hemolyticstreptococci have not become a common cause ofdisease in the civilian population since the war, there is every reasonto suppose that theywould again appear if mass prophylaxis with these drugs were undertakenin the ArmedForces. There is no reason why the method should not be applied in morelimited groups ona short-term basis in an attempt to terminate an epidemic ofstreptococcal infection.
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Othercontrol methods
The continuing epidemic ofhemolyticstreptococcal infection in many Navy installationsafter the breakdown of sulfonamide prophylaxis led to aci exhaustivediscussion of theproblem at a National Research Council conference held in Washington,D. C., on 6 and 7July 1945. The techniques of potential value that were considered aredescribed as follows:
Control ofcarries.-The Commissionon Air-Borne Infections demonstrated that theindividual convalescent from streptococcal infection who harboredorganisms in the nosedisseminated them much more freely than (lid simple tonsillar andpharyngeal carriers. Suchpersons were regarded as "dangerous" carriers. Detection bybacteriologic methods andisolation of these potentially infectious men was considered but neverattempted duringWorld War II. Their number would have been great in certain camps andthe administrativeproblem enormous. There was general agreement that detection ofcarriers by masspharyngeal swabbing was not a valuable procedure since many of thesemen would not be"dangerous."
Oiling offloors and bedding.- The Commission on Air-Borne Infectionsdemonstrated thatmany hemolytic streptococci could be recovered from the air of barracksin which"dangerous" carriers were housed and that their numbers increasedsharply during periods ofactivity such as dressing, bedmaking, and, particularly, floorsweeping.The possibilityexisted that these extrahuman reservoirs might be potent sources ofinfection.
Simple and entirelyapplicable methods weredevised for their control including oiling offloors (fig. 4) and bedding. These techniques were shown experimentallyto reduce greatlythe contamination of the air of barracks by bacteria and were fieldtested for their ability toreduce the incidence of streptococcal disease. The results weredisappointing since, at a timewhen these infections were not actually epidemic and in a populationcomposed largely ofseasoned men, the reduction of streptococcal illness was only about 40percent. Whenapplied during an epidemic of undifferentiated respiratory disease, nodecrease in rateoccurred. A similar test during a severe outbreak of streptococcalinfection was not,attempted by the Army.
The available resultsclearly indicate thatextrahuman reservoirs are potentially important inthe spread of streptococcal disease and that their control isdesirable. Unfortunately, dropletinfection during direct contact of carrier and susceptible seems to bethe most importantmode of transmission of these organisms. This is probably particularlytrue during theperiods of intimate physical association connected with basic trainingin the Armed Forces.
Glycolvapors. - The vaporization of glycols into the air of hospitalwards containing"dangerous" streptococcal carriers was shown by the Commission onAir-Borne Infectionsto be effective in lowering the number of hemolytic streptococci in theair. Theeffectwas most marked when floors and blankets had been oiled.
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FIGURE 4.-Soldiers of a sanitary companyoiling the floor of a barrack. The soldier on theleft sprinkles oil from a can while the two on the right spread the oilwith brushes.
Methods were never devisedby the Commissionwhich would permit the accurate control ofthe concentration of glycol vapor in the air. This difficulty, inaddition to others involvingthe relative humidity at which these substances are bactericidal, madeit most unlikely thatthey would be of value in the control of streptococcal or otherrespiratory infection in theArmed Forces. A controlled field study of this method was neverattempted by the Army.
Ultravioletirradiation.- The Armydid not make use of or study extensively ultravioletirradiation in the control of airborne streptococcal disease. It wasnot found to be of value ina limited investigation by the Navy and will probably not be applicablein the future by theArmed Forces.
Activeimmunization.- Active immunization,leading to the enhancement of resistance toinfection by the tissues of the susceptible host, was theoretically themost desirable way tocontrol the spread of infectious disease when general public healthmeasures proved to beineffective. This technique had not been extensively explored inrelation to hemolyticstreptococcal disease, but certain considerations suggested that itmight not be feasible.Immunity to infection
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by group A Streptococci was believedto be type specific, and many different types wereendemic in the Armed Forces. A polyvalent vaccine would have beenrequired containingrepresentatives of a large number of types. Probably none could havebeen administered insuch a mixture in sufficient quantities to stimulate the production ofeffective quantities ofantibody.
Two groups investigatedstreptococcalvaccination during World War II. The Navy carriedout an important field study in which a monotype epidemic was notinterrupted byimmunization under the most favorable circumstances. The Commission onHemolyticStreptococcal Infections demonstrated that measurable type-specificantibodies appeared inthe serum only when relatively huge amounts of streptococcus wereadministered over aperiod of several weeks. Both of these, studies also showed that groupA streptococcalvaccines were very toxic substances, and the latter indicated thattheir use was associatedwith the development of increased sensitivity.
The use of Dickimmunization for theprevention of scarlet fever was repeatedly consideredduring the war but, insofar as is known, never undertaken. Thisprocedure was discardedsince it conferred no antibacterial immunity and could not be expectedto reduce the totalincidence of streptococcal infection. It would merely have lowered thefrequency ofoccurrence of cases with a skin rash. This result could be of no value,particularly in thelight of the toxicity inherent in this form of immunization and thelarge number of injectionsrequired.
Generalsanitary measures.- No typeof special sanitary measures over and above thosegenerally recommended for the control of respiratory disease wereemployed by the Army tocombat the spread of streptococcal infection. In 1945, the Navy didpropose an intensiveprogram including a number of such techniques because epidemics ofinfection caused bythese organisms continued to be an important problem. These proposalsincluded (1)maintenance of 50 square feet of floor space and 450 cubic feet of roomspace per man andavoidance of overcrowding of all other facilities; (2) dust-controlmeasures, including oilingof floors and bedding, in barracks, classrooms, and all other indoorareas where mencongregated; (3) airing and cleaning of barracks and bedding betweeneach filling withrecruits; (4) adequate ventilation; (5) adequate refrigeration,improvement of milkdispensers, and inspection of foodhandlers; (6) changes in dispensarypractice to preventovercrowding and spread of disease among men on sick call; and (7)changes in hospitalpractice designed to prevent cross-infection.
These seven proposalscould not have beenexpected to affect materially the course of aserious outbreak of streptococcal disease, although each was desirablein its own right andall should have been part of standard military practice.Certain otherphases of the programmight well have been of great value although administrativelyexceedingly difficult to apply;namely, (1) reduction of size of training regiments, (2) segregation ofeach regiment, (3)placement of groups of new arrivals together rather than spreadthroughout
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the installation, (4) screening of newlyarrived and departing men for presence of respiratoryinfection, and (5) division of barracks into cubicles.
The effects of thisprogram on an epidemic ofstreptococcal disease was probably neverdetermined since the war ended in 1945. Because it failed to come, togrips with yssentialproblems in the epidemiology of streptococcal infection, it wouldprobably not have beenmore than partially effective.
SUMMARY
The previous sections ofthis chapter haveindicated that hemolytic streptococcal infectionand rheumatic fever are most likely to become major problems to thehealth of the Armywhen large numbers of recruits are brought together for training incertain geographic areas.Among Army personnel, more than one-third of all cases of rheumaticfever in thecontinental United States during World War II occurred in the Sixth andSeventh ServiceCommands, although the total number of troops trained there wasrelatively small. Forinstance, according to a special sample tabulation of individualmedical records during1944-45, 17 percent were derived from installations in Colorado,Wyoming, and Utah,where the streptococcal disease rates were appallingly high.
A simple measure for thepartial control ofhemolytic streptococcal disease and itscomplications would be a change in policy so that basic training is notundertaken in high-incidence areas. Seasoned men will also be at riskbut to a lesser degree, partly because theyare seasoned and partly because their training is more likely to beaccomplished in largeunits with relatively little replacement of fresh men in small groups.
A second goal of thisprogram would be theprevention of seeding of many widely scatteredinstallations of the Army by men who received their basic training inareas in whichstreptococcal disease is epidemic and who have become carriers ofhighly communicableorganisms. Wide dispersement of men at the end of periods of basictraining is inevitable. Itis much less likely to occur among troops at later stages of theirtraining program.
Certain evidence, notablyincomplete, hasbeen presented to show that this was an importantfactor in the spread of streptococcal infection throughout the Armybetween 1942 and 1944.Information obtained by study of the epidemiology of these diseasesamong navalinstallations convincingly demonstrates dissemination by men movingfrom boot camps tomore advanced training centers.
Administrative problemsmay well make suchchanges in training programs difficult duringperiods of rapid mobilization. Other control measures will undoubtedlybe necessary, andnone of those suggested and investigated during the last war, with thepossible exception ofchemoprophylaxis, is likely to be of value.
Chemoprophylaxis with sulfonamides, althoughof no value in mass application, may beuseful in the control of localized outbreaks caused by
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sulfonamide-sensitive streptococci.Penicillin and the newer antibiotics, Aureomycin,Terramycin, and chloramphenicol, may also have a place in prophylaxis,particularly sinceresistance to these agents develops less readily than do sulfonamides.
Additional new techniquesinvolve thetermination of the carrier state by administration ofpenicillin and the prevention of rheumatic fever by treatment ofestablished hemolyticstreptococcal infection with this agent.
Evaluation of thesemethods and their properapplication will require the accuraterecognition of hemolytic streptococcal respiratory disease. It isbelieved that thedevelopments in recent years have made physicians more aware of theimportance of theseinfections and the clinical signs permitting their diagnosis.
Satisfactory bacteriologicexamination of therespiratory flora is essential to the study ofrespiratory illness and was available in only a few Army hospitalsduring World War II. It isclear that this situation must be rectified. Every Army hospital shouldbe prepared to carryout these exceedingly simple bacteriologic procedures usingstandardized methods andmaterials. Individual station hospitals need not maintain facilitiesfor grouping and typing.Several laboratories throughout the country should be able to identifystreptococci in thisway and to test the sensitivity of the organisms to variousantimicrobial agents. Samplingand study of strains isolated in the field should be a continuousoperation.
Laboratory control of thecharacter justdescribed will permit the rational application ofprophylactic and therapeutic regimes presently available and willpermit the application ofnew ones. In addition, accurate information as to the incidence ofhemolytic streptococcaldisease would be constantly available to The Surgeon General,permitting vigorous action atthe earliest sign of an epidemic. A few teams of qualified officers orcivilian consultantsshould be available to go into the field and apply special methods whenexcessively largenumbers of cases appear in any establishment.
It is not known whetherthese measures can beexpected to diminish the frequency ofstreptococcal infection in the Army. The availability of new toolsraises the hope that theirrational and vigorous application may be at least partly successful inreducing the hazard ofstreptococcal disease and its important complications.
