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Chapter 13 - Hemolytic Streptococcal Infections

Contents

CHAPTER XIII

Hemolytic Streptococcal Infections

Lowell A. Rantz, M. D.

THE MILITARY PROBLEM

Period before World War II- Infection by hemolytic streptococci has been a major problem to the United States Army in all of its wars for which informative historical data are available. However, for a number of reasons, disease caused by these organisms was not recognized as an important military problem before World War II. The nature of infection by the hemolytic streptococcus, the essentials of its epidemiology, and particularly the intimacy of the relationship between it and the development of rheumatic fever have become, well established only in the last 20 years. Furthermore, in all wars prior to World Wars I and II, the enormous incidence of enteric infection and malaria so overshadowed that of other infectious diseases that these attained relatively little prominence in the minds of medical officers responsible for the health of the Army.

Inspection of the recorded experience of the United States Army in the Civil War 1 demonstrates that hemolytic streptococcal disease occurred very frequently, and the magnitude of the problem was such that, had it been present in the Army during World War II, 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 been reported. Approximately 25,000 cases of erysipelas, another form of streptococcal infection, were reported with a note that it was known that this was only a part of the total problem. One of every two hundred and twenty-five wounded developed the disease, which occurred essentially as primary facial erysipelas in epidemic form and also as a complication of battle injuries. It had a very definite geographic distribution in that the infection was much more common in troops stationed in the western areas, particularly in the States of Michigan, Ohio, Indiana, Illinois, Wisconsin, Iowa, Minnesota, Nebraska, and the Dakotas.

In addition to the widespread occurrence of erysipelas, there was also oil enormous incidence of acute rheumatism in the Civil War.2 In 5.2 years, 145,000 cases occurred among white troops at a rate of 65 per 1,000 per annum.

1 (1) Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Government Printing Office, 1888, pt. III, vol. I, pp.624, 662-675. (2) Medical and Surgical History of the War of the Rebellion. Surgical History. Washington: Government Printing Office, 1883, pt. III, vol.II, p.851.

2 Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Government Printing Office, 1870, pt. I, vol. I, pp.637-639.


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Not all of these may be regarded as examples of rheumatic fever, but examination of the case records which have been preserved in the Medical and Surgical History of the War of the Rebellion indicates that a substantial number of them were certainly this disease. This impression is substantiated by 642 deaths reported to have been caused by rheumatism, endocarditis, and pericarditis. In retrospect, it is impossible to define in absolute terms the magnitude of the problem of rheumatic fever in the Civil War, but it is obvious that it was great. An attempt to determine the geographic distribution of acute arthritis on the basis of available data was unsatisfactory.

The hemolytic streptococcus was a common cause of bacterial pneumonia complicating influenza during the pandemic of 1918. Primary infection by these organisms was not recognized as an important problem. There were 11,675 admissions for scarlet fever, but the mortality was extremely low, and the disease caused little concern.3 Similarly, little interest was aroused by 2,598 admissions for erysipelas. The significance of 24,770 admissions for acute articular rheumatism was entirely overlooked. This disorder was not considered to be probable rheumatic fever, and no attempt was made to determine the frequency of occurrence of chronic valvular heart disease as a complication.

Rheumatic fever is not mentioned in the official history of the Medical Department of the United States Army in the World War. Acute articular rheumatism appears only in the statistical reports, and this disease was not deemed worthy of special comment elsewhere although the number of cases was very great. The available data do not permit a definition of the geographic incidence, but inspection of the statistical information reveals that disease in this category was very common in the same areas in which outbreaks of rheumatic fever were observed during World War It. On the basis of these data covering only 2 years of active mobilization, streptococcal respiratory infection and the frequently associated rheumatic fever must have occurred in epidemics comparable to those observed during World War II.

Advances in understanding and accumulation of information about hemolytic streptococcal infection had been continuous and of far-reaching importance in the decade before the onset of World War II. In spite of this fact, the Medical Department of the United States Army found itself poorly prepared to cope with the problem of infection by these organisms. Several well-defined factors were responsible for this lack of preparation. Of prime importance was the failure of the Medical Department and of the civilian physicians associated with it to recognize the extreme importance of hemolytic streptococcal respiratory infection occurring without a skin rash. Emphasis was largely on the control of scarlet fever. Also, medical officers were not trained to distinguish clinically between hemolytic streptococcal and nonbacterial respiratory infections and diagnostic bacteriologic

3 The medical Department of the United States Army in the World War. Statistics. Washington: Government Printing Office, 1925, vol. XV, pt 2, p.86.


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methods were not readily available to them. Lastly, the Army and its consultants had not familiarized themselves with available civilian and military data on the basis of which it would have been possible to predict with considerable accuracy those geographic areas in which outbreaks of hemolytic streptococcal disease and rheumatic fever might be expected to occur.

Little information is available as to the situation during the prewar expansion of the Armed Forces. During 1941, outbreaks of scarlet fever followed by rheumatic fever occurred at Chanute Field, Ill., Scott Field, Ill., and Fort Knox, Ky. The incidence of these diseases elsewhere In the Army during this year was low. Drs. James D. Trask, Francis F. Schwentker, and M. Henry Dawson, of the Commission on Hemolytic Streptococcal Infections, visited each of these camps in November 1941. They noted that medical officers did not recognize the association of scarlet fever and streptococcal disease occurring without a rash nor did they connect either of them with rheumatic fever.4

World War II period.- Plans were made to investigate outbreaks of hemolytic streptococcal infections during the coming year. Between December 1941 and April 1942, Dr. Schwentker made bacteriologic studies at the camps mentioned at Fort Francis E. Warren, Wyo., where many cases of scarlet fever were occurring.5

Available records do not reveal that streptococcal disease was viewed with alarm during 1941 and 1942, although the frequency of scarlet fever in the total Army during these years was comparable to that in 1943 and 1944 when interest in infection by streptococcal organisms was very great. The absence of concern in the earlier period was the direct result of the lack of accurate reports 6 on the occurrence of rheumatic fever prior to 1943 and to the mildness of acute streptococcal disease.

The first detailed information in regard to the problem of rheumatic fever was obtained when a survey early in February 1943 of the continuing scarlet fever epidemic at Fort Warren revealed that more than 100 cases of streptococcal disease had been hospitalized but neither correctly diagnosed nor reported to The Surgeon General.7 Subsequently, the rapid increase in size of installations in areas of high incidence of this disease in Colorado and Utah was associated with epidemics of streptococcal infection and rheumatic fever and additional surveys were made which again delineated the deficiencies in background and information on the part of medical officers in regard to streptococcal respiratory disease and its complications, but no control measures

4 Report, M.Henry Dawson, M.D., Director, Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board, 24 Nov. 1941, subject: Report on Reconnaissance Trip to the Fifth and Sixth Corps Areas by Dr. James D. Trask, Dr. Francis F. Schwentker, and Dr. M. Henry Dawson, Members of the Commission on Hemolytic Streptococcal Infections, November 11-19, 1941,

5 Schwentker, F.F. Survey of Hemolytic Streptococci in Certain Army Camps. Army M. Bull. No. 65: 94-104, January 1943.

6 Rheumatic fever was first included in the weekly statistical summary in February 1942.

7 Report, Lowell A. Rantz, M.D., Member, Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board, to Col. S., Bayne-Jones, Office of the Surgeon General, 23 Feb. 1943, subject: Report of Epidemic of Scarlet Fever and Septic Sore Throat, at Fort Francis E. Warren.


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were recommended.8 Principal interest of this investigation centered in the large number of cases of rheumatic fever and the varying clinical patterns of streptococcal infection. Scarlet fever was common in certain stations; in others, tonsillitis without rash was the rule. In one post, suppurative complications were exceedingly common.

During 1943, 6,710 admissions for rheumatic fever were reported from the Army in the United States. According to summaries of the statistical health reports, about 74 percent of these were in the Seventh and Ninth Service Commands. About 43 percent of all cases occurred in the States of Colorado, Utah, Idaho, Montana, and Wyoming. The 10 stations having more than 100 cases of rheumatic fever and an annual rate of greater than 5 per 1,000 in 1943 are presented in table 39.Their geographic proximity is apparent. There is the presumption that the incidence of rheumatic fever has been under reported on the statistical health report.

TABLE 39-Incidence of rheumatic fever in 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 Hemolytic Streptococcal Infections, Army Epidemiological Board, April 1943, subject: Report of Investigation of Rheumatic 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 this group was the Commission on Air-Borne Infections whose main interest lay in the investigation of methods for control of airborne infection with particular reference to the hemolytic streptococcus. The third was the Army Air Forces Rheumatic Fever Control Program, which will be the subject of a later section of this chapter.

These three programs were in active operation throughout 1944. Much new knowledge was acquired, but effective methods for the control of streptococcal disease were not forthcoming. Dust control and air sterilization with glycol vapors were proved not to be of great value and were not applied in other than experimental field studies.

The Air Forces investigated intensively the role of sulfonamide prophylaxis during the early months of 1944. Impressive results were obtained in the reduction of streptococcal infection and rheumatic fever, and the, use of this technique in certain defined situations, primarily for the prevention of these diseases, became established Army policy on 1 November 1944 with the publication of TB MED 112. Unfortunately, by this time highly sulfonamide resistant strains of streptococci had emerged and were causing disease among naval personnel where chemoprophylaxis had been widely used on a mass basis since December 1943.

Streptococcal infection continued to be epidemic throughout 1944, and 4,877 cases of rheumatic fever were reported in the United States. The highest incidence was in the Sixth and Seventh Service Commands where 37 percent of the cases occurred. Twenty-four percent occurred in the States of Colorado, Utah, Wyoming, and Nevada, where relatively few troops were stationed. The widespread movement of troops throughout the country may have been responsible for larger numbers of cases in other areas than during the previous rear. By this time, highly communicable strains of hemolytic streptococcus were doubtless seeded throughout the Army and its numerous establishments.

In 1944, streptococcal infection and rheumatic fever became an important problem among troops overseas for the first time, 4,639 cases being reported. This represented a rate of only 1.21 per 1,000 per annum or approximately one-third of that among troops in the United States.

As the winter of 1945 began, it became apparent that sulfonamide prophylaxis, the only tool of value for the prevention of streptococcal infection and rheumatic fever, had become ineffective. Disease caused by resistant streptococci was epidemic in the United States Navy, and an outbreak of infection caused by similar strains had occurred in an Army Air Forces station. The problem was considered at a National Research Council conference on 28 February 1945. The failure of sulfonamide prophylaxis was discussed in detail, and the hazards involved in its continued use were described. As a result of these experiences in the Navy, this technique was applied only selectively in the Army Air Forces and practically not at all in the Army Ground Forces. The possible value of penicillin prophylaxis was explored at another National


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Research Council conference on 20 March 1945, and certain studies for its evaluation under field conditions by the Army Air Forces were outlined but were not undertaken.

Although the incidence of scarlet fever and rheumatic fever declined sharply in the Zone of Interior during 1945, in spite of the absence of effective control measures, the incidence of streptococcal sore throat rose from 0.82 per 1,000 in 1944 to 3.64 in 1945 (table 40). The combined effect was an increase in incidence from 3.98 in 1944 to 5.21 in 1945. Only 1,675 cases of rheumatic fever were reported. Two thousand and fifty additional cases occurred in the Army overseas.

An important National Research Council conference on streptococcal disease was held on 7 July 1945, and recommendations were made which will be the subject of later comment. The war ended in the fall of that year, and information on the occurrence of these diseases during demobilization is not available.

STATISTICAL INFORMATION

The previous section has indicated that hemolytic streptococcal respiratory infection and its complications were an important problem during World War II.

TABLE 40.-Incidence rates of scarlet fever, streptococcal sore throat, and rheumatic fever in the U. S. Army, continental United States, by service command and year, 1944-45

During 1942 through 1945, 26,063 cases of scarlet fever were reported in the Army in the United States and 3,449 additional cases from the Army overseas (table 41).During the 2 years, 1944 and 1945, when streptococcal sore throat was coded separately, 20,471 cases were diagnosed (table 42). This figure was entirely too low as streptococcal respiratory infection occurring without a rash was recognized in only its most typical clinical form.


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The author believes that not less than 5 cases of streptococcal sore throat were hospitalized for every case of scarlet fever. If this approximation be accepted, at least 150,000 men suffered infection by hemolytic streptococci of this degree of severity during 1942-45, inclusive. A minimum of 5 days of hospitalization was required by each, a loss of 750,000 man-days during the war. These statistics do not include a group at least equally large in whom infection occurred which was not sufficiently severe to require hospital care, but which reduced efficiency for several days.

The data pertaining to rheumatic fever are even more significant: there were 18,339 cases reported (table 43). Average hospitalization was not less than 3 months and usually more. At least 2 million man-days were lost. Many of these men were separated from service and may very well have later received service-connected disability compensation and care under the Veterans' Administration.

TABLE 41.-Incidence of scarlet fever in the U. S. Arnty, by area and year, 1942-45

The cost to the United States Army in terms of dollars and effectiveness as the result of hemolytic streptococcal infection and its complications cannot be assessed. The loss of about 900,000 man-days per year presented a problem of considerable magnitude.


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TABLE 42.-Incidence of streptococcal sore throat in the U. S. Army, by area and year, 1944-45

During 1942-45, the number of 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 a not infrequent complication of the type 17 sulfonamide-resistant outbreak of streptococcal disease that occurred at Keesler Field and Amarillo Army Air Field during late 1944 and early 1945. At the latter station, 312 cases of streptococcal respiratory infection were recognized, of which 19 were compli-

9 Countryman, H. D.: The Treatment of Pneumonias and Their Complications. News Letters, Army Air Forces Rheumatic Fever Control Program, vol.2, No.9, September 1945, pp.6-12.


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cated by pneumonia.There was one death.Prompt treatment with penicillin was highly efficacious in controlling the illness.l0

During 1942-45, 2,398 cases of erysipelas were reported, 1,627 in the continental United States and 771 overseas.

TABLE 43.-Admissions for rheumatic fever in the U. S. Army, by area and year 1942-45 1

EPIDEMIOLOGY

Geographic Incidence

The geographic distribution of streptococcal infection in the continental United States has been emphasized. Table 40 demonstrates that rates for disease caused by these organisms were high in the Sixth and Seventh and very low in the Fourth Service Commands. These facts are further presented in tables 44 and 45, which show the occurrence of scarlet fever and rheumatic fever during 1943 and 1944 when the most widespread epidemics were in progress.

Inspection of these figures, particularly the incidence by States, reveals that streptococcal infection 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 Sulfadiazine Resistant 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, and around the Great Lakes. The experience was worst in Colorado, Utah, and Wyoming. The Navy also encountered very severe outbreaks of these diseases in their installations in these same general areas.

Civilian experience would have suggested that the Northeastern States should have experienced a high incidence of these disorders. That it did not is doubtless the result of the fact that few troops were trained there. It was used principally as a staging area for well-seasoned men.

TABLE 44.-Incidence rates of scarlet fever and rheumatic fever in the continental United States, by service commands, 1943-44

Equally noteworthy was the infrequent occurrence of hemolytic streptococcal infection among troops stationed in the Southern United States. Epidemics did occur there, particularly during 1944 and 1945, but they were short lived and of little consequence.

Additional pertinent information was obtained by the Army Air Forces Rheumatic Fever Control Program in a study of group A hemolytic streptococcal carriers at several Army Air Forces installations. The data for the period 1 January to 21 April 1944 are summarized as follows: 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 rates among troops stationed in the Rocky Mountain area, the Middle West, and northern Texas are to be contrasted with the very

11 Van Ravenswaay, A. C.: The Geographic Distribution of Hemolytic Streptococci. Relationship to the Incidence of Rheumatic Fever. J. A. M. A. 126: 486-490, 21 Oct. 1944.


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TABLE 45.-Incidence rates of scarlet fever and rheumatic fever in the continental United States, by State, 1944

low rates in the South. This study doubtless reflects the previously emphasized geographic variations in the occurrence of streptococcal disease.

The results of the two studies by the Commission on Acute Respiratory Disease, Army Epidemiological Board, were equally striking. These studies were conducted at Fort Bragg, N. C., one from April to June 1943 and the other from March to May 1944.12 In each year, approximately 900 successive admissions to the hospital because of respiratory disease were investigated. About 4 percent in both years were proved by appropriate bacteriologic and immunologic procedures to be of group A hemolytic streptococcal origin. The

12 (1) Commission on Acute Respiratory Diseases: Endemic Exudative Pharyngitis and Tonsillitis. Etiology and Clinical Characteristics. J. A. M. A. 125: 1163-1169, 26 Aug. 1944. (2) Commission on Acute Respiratory Diseases: Role of B-Hemolytic Streptococci in Common Respiratory Disease. Am. J. Pub. Health 35:675-682, July 1945.

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troops involved were unseasoned during both periods and highly susceptible to undifferentiated respiratory infection.

Another study, from January to April 1944, was carried out at Camp Carson.13 Fifteen hundred cases of hospitalized respiratory disease were examined and about 350, or 23 percent, were proved to be caused by hemolytic streptococci.

A contrasting situation within the author's experience at Fort Francis E. Warren is of interest. This post of about 20,000 men was experiencing a severe outbreak of streptococcal disease in February 1943. Forty cases of scarlet fever per week were entering the hospital. On 8 February 1943, a special barracks hospital was opened. Three days later, 100 new cases of acute streptococcal respiratory disease occurring without skin rash, sufficiently severe to deserve bed care, had been admitted to the hospital. All were personally examined and studied bacteriologically by the author. This represented a streptococcal disease rate at that time of around 650 per 1,000 per annum.

The causes of these striking geographic relationships in the frequency of occurrence of hemolytic streptococcal infection and its complications have been the subject of much speculation, but no satisfactory explanation has been offered. The implications in regard to the establishment of camps for future training of troops are obvious.

Approximately 12 percent of all scarlet fever admissions and 23 percent of all rheumatic fever admissions (tables 41 and 43) occurred in the Army overseas. The rates for the former disease were about one-fifth and for the latter about two-fifths of those in the continental United States. The worst experiences were encountered in the European, Mediterranean, and Middle East theaters, and the North American area. Streptococcal infection was a much less important problem in the Pacific Ocean, Southwest Pacific, and Latin American areas. This distribution is in accord with the available information regarding the occurrence of these disorders among civilian populations in the several areas.

There were 77 cases of scarlet fever and 75 admissions for rheumatic fever on transports, during the years 1942-45, according to individual medical record tabulations.

Seasonal incidence.- Hemolytic streptococcal infection has been regarded as a disease of the winter months. This was true, to a certain extent, in the Army in the continental United States. Inspection of chart 21 reveals, however, that whereas the incidence of scarlet fever began to increase in December and January 1942-43, 1943-44, and 1944-45, respectively, peak levels were not attained until March or April, and rates remained high until the end of May and then fell sharply through the summer. This was particularly true in the Sixth and Seventh Service Commands where epidemics were in progress.

13 Rantz, L. A., Rantz, H. H., Boisvert, P. J., and Spink, W. W.: Streptococcic and Nonstreptococcic Disease of the. Respiratory Tract; Epidemiologic Observations. Arch. Int. Med. 77: 121-131, February 1946.


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CHART 21.-Seasonal incidence of scarlet fever in the Army in the continental United States, 1942-45

The highest incidence of rheumatic fever always lags about 1 month behind the streptococcal respiratory infection. A comparison of charts 21 and 22 shows that this was the case in the total Army in 1943 and 1945, the highest level being attained each year in May. However, many cases appeared throughout the summer. In 1944, the peak occurred in April. Satisfactory explanations for these seasonal relationships have not been forthcoming.

Seasoning of Personnel

Epidemics of nonbacterial respiratory infection are very likely to occur when raw recruits are assembled in basic training centers. Throughout the last war, it was tacitly assumed that this was also the case in regard to hemolytic streptococcal disease. This opinion emerged since the most serious outbreaks in both the Army and the Navy occurred in stations in which men fresh from civilian life were undergoing basic training.

It is curious to learn that, in spite of the great importance of the problem, a critical study was never made, by the Army or the Navy for the purpose of determining the relative susceptibility to streptococcal disease of personnel of various degrees of seasoning.

Experience in the Navy, as described by Coburn,14 indicates that well-seasoned men were highly susceptible to streptococcal disease when brought together in centers in high-incidence areas. One study was conducted in an Army camp in such an area in which nearly all of the personnel had had from 7 to 24 months of service. Annual rates of hospitalization for streptococcal infection of 200 per 1,000 were attained.15

Another pertinent investigation suggested that the rates might have been much higher had a similar number of raw recruits been assembled.

14 Coburn, Alvin F., and Young, Donald C.: The Epidemiology of Hemolytic Streptococcus During World War II in the United States Navy. Baltimore: Williams and Wilkins, 1949.

15 See footnote 13, p. 240.


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CHART 22.-Seasonal incidence of rheumatic fever in the Army in the continental United States, 1942-45

Approximately 300 cases of sulfonamide-resistant type 17 hemolytic streptococcal infection were hospitalized at Amarillo Army Air Field during February and March 1945. An annual rate of 105 per 1,000 was observed among 7,000 well-seasoned men. A basic training squadron of about 1,000 men experienced an annual rate of 864 per 1,000, 8 times that in the seasoned troops.16

In summary, the meager evidence indicates that all types of troops brought together in areas where streptococcal infection is common will experience outbreaks of disease caused by these organisms. One study suggests that the epidemic will be more intense among 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 a high-incidence area was accompanied by an outbreak of streptococcal disease even among seasoned troops.17 Inconclusive evidence was obtained which suggested that men who had been stationed for 6 months in the latter area were relatively immune to infection. Annual rates among such troops were about 50 per 1,000 as contrasted with previously mentioned rates of 200 per 1,000 among fresh troops, but seasoned men moved into the study post from a low-incidence area.

The severity and persistence of certain epidemics of streptococcal infection which occurred in basic training establishments in high-incidence areas were probably specifically related to the constant movement into such posts of men in small groups from other parts of the country. This constant influx of susceptibles doubtless served to maintain the epidemic situation and may have been of greater importance than the lack of seasoning. The practice of distributing these new arrivals throughout the post, rather than maintaining them in separate units, insured the exposure of all to the epidemic streptococcus.

Movement of troops from high- to low-incidence areas must have been associated with the establishment of outbreaks of varying degrees of severity in stations which had previously been relatively free of streptococcal illness. This definitely occurred on several occasions in the Navy.18 The Amarillo Army Air Field epidemic in 1945 was initiated by troops transferred from Keesler Field.l19 No other documented episodes of this type in the Army are known to the author.

If such spread from high-incidence areas occurred frequently with the establishment of new and prolonged epidemics, there should have been a leveling off of the relative frequency of scarlet fever and rheumatic fever be tween various areas during 1942-44. Such a comparative study is possible at present only on a service command basis. Inspection of table 46 reveals that the rates for scarlet fever in each service command were quite stable throughout the critical period when men who had received their basic training in high-incidence areas were being distributed throughout the country.

The seven service commands (excluding the Sixth and Seventh) in which rheumatic fever rates had been low during 1942 and 1943 all showed very definite increases during 1944. This may well have reflected a spread of streptococcus into these areas by troops from the Sixth and Seventh Service Commands. Rates for rheumatic fever remained notably low throughout the war for the Second Service Command as well as the Eighth. Epidemics occurred in these areas, 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 of scarlet fever and rheumatic fever, by year and service command, 1942-45

Housing

Overcrowding in barracks and classrooms was often considered to be a contributing factor to epidemics of streptococcal infection in the Army. Critical evaluation was impossible since virtually all Army establishments were over crowded from 1942 to 1944 when disease caused by these organisms was most prevalent. Many exceedingly crowded posts in low-incidence areas escaped epidemic; streptococcal disease entirely. The congestion in barracks doubtless aggravated the spread of hemolytic streptococci, but its elimination would not have been an effective prophylaxis if other conditions had been favorable to the organism.

Relationship to Virus Infection

The experience of World War I had alerted physicians in the Army to the potentialities of influenza as a precursor of hemolytic streptococcal pneumonia. It was also believed that infection by this and other respiratory viruses might predispose to upper respiratory infection by streptococci. Evidence supporting this possibility was not forthcoming. The increase in rates for scarlet fever during and after the pandemic of influenza A in November and December 1943 was no greater than the usual seasonal increment. One critical study in a post in an area of high incidence at this time failed to demonstrate any increase at all in the streptococcal disease rate.20 It is of considerable interest, that this epidemic was not associated with the appearance of hemolytic streptococcal pneumonia even in areas where streptococcal respiratory infection was common.

20 See footnote 13, p.240.


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Information is not available to the author which would indicate that rubella, rubeola, or mumps significantly enhanced the susceptibility of troops to streptococcal infection. Doubtless, an occasional case of these disorders was complicated by streptococcal pneumonia.

Hemolytic Streptococcus Grouping and Typing

It was well known in 1940 that the hemolytic streptococci could be divided into groups and types by serologic techniques. Nearly all primary human infections of the respiratory tract had been shown to be caused by strains be longing to group A. The members of this group could be subdivided into types by agglutination or precipitin methods. It was the perfection of the latter technique which permitted the widespread application of streptococcal typing during World War II. The agglutinative method, although a valuable tool, cannot be standardized for use by laboratories without personnel with a great deal of special training.

The first application of serologic typing in the Army was by Schwentker, who studied a small number of cases of scarlet fever and tonsillitis at Chanute Field, Scott Field, Fort Knox, and Fort Warren, between 18 December 1941 and 25 March 1942. A large number of different types were recovered from scarlet fever contacts and from healthy carriers. Only 11 types were shown to be causing disease. At Fort Warren, type 19 was responsible for nearly all infections.21

Another study made between March and June 1942 at Chanute Field by the Commission on Air-Borne Infections revealed that 85.5 percent of all infections were due to types 18, 19, 1, 6, 17, and 26 in that order. Between November 1942 and August 1943, 86.7 percent were caused by types 19, 1, 3, 6, 17, 36, 18, and 5.22 In February 1943, a survey showed that type 19 was still the only important type responsible for disease at Fort Warren. The frequency of various types was determined at Camp Carson between December 1943 and May 1944 by the Commission on Hemolytic Streptococcal Infection. A somewhat broader spectrum was encountered here but 13 were responsible for 94.5 percent and 7, types 36, 19, 3, 17, 30, 46, and 6, for 66.1 percent of all infections.23

After April 1944, complete data are available on type distributions in Army Air Forces installations from the Rheumatic Fever Control Program. Between April and August 1944, 85.2 percent of 2,021 presumed cases of group A streptococcal respiratory infection were caused by types 19, 30, 3, 1, 17, 14, 6, 36, 5, 26, and 12. The first 6 were responsible for 77 percent 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 of Different Types 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 Forces Rheumatic Fever Control Program, vol. 1, Nos.1-5; vol.2, Nos.1-9, August 1944 September 1945.


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After this date, the type incidence is expressed only on the basis of rates which makes epidemiologic calculation and comparison more difficult. An analysis has been made based on reports of 10 months of study in which each type has been scored on the basis of its having caused a significantly large number of cases (2.58 X standard error) in any month in any post or, if this value was not calculated, a rate of 10 per 1,000 per annum.

Only nine types caused significant 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. The same nine types in 27 additional 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 post months.

In summary, the results of streptococcal typing presented here demonstrate that the same small group of types caused the bulk of studied respiratory infection by these organisms between the spring of 1942 and the fall of 1945. During the period 1942 to the summer of 1944, types 1, 3, 6, 17, 19, and 36 were most frequently recovered. During late 1944 and 1945, types 3, 17, 19, and 30 were of the greatest importance.

It is apparent from these observations that the Army functioned for several years as a closed epidemiologic unit in which streptococci were serially transmitted. Strains of a certain small group of types retained their high degree of communicability over a long period of time. The dominance of types 3, 17, and 19 during the last year was very largely due to the fact that they had become sulfonamide resistant and were thus able to spread in populations protected by these drugs.

An additional feature of the typing program was the establishmentof a relationship between type and the ability of the streptococcus to produce a skin rash. The observation was first made by Hamburger and his associates of the Commission on Air-Borne Infections. These workers noted that between November 1942 and August 1943, types 1, 3, 17, 19, and 29 were frequently associated with scarlet fever. Sufficient observations were available to indicate strongly that types 5, 6, 18, and 36 were not able to stimulate the development of a rash.

These observations were extended by the Commission on Hemolytic Streptococcal Infections at Camp Carson between December 1943 and May 1944. During this period only types 3, 17, 19, and 30 were rash formers. Nonscarlatinogenic types were 1, 5, 6, 24, 26, 36, 44, and 46. Critical study revealed that strains of the latter types were erythrogenetically ineffective even in Dick-positive persons. 25

Considerable additional and related information was obtained by the Army Air Forces Rheumatic Fever Control Program. Between April and August 1944, 89.4 percent of 229 cases of scarlet fever were caused by types 1, 3, 17, 19, and 30. Strains of only types 6 and 18 of those previously shown by the commissions to be nonscarlatinogenic were recovered from 2 cases of

25 Rantz, L. A., Boisvert, P. J., and Clark, W. H.: The Relationship of Serological Types of Group A Hemolytic Streptococci 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 for more than 70 cases of respiratory infection occurring without rash. It is possible that the streptococci from these two cases were incorrectly classified.

At any event, certain strains remained highly scarlatinogenic for 2 years and others were unable to stimulate rash production. After October 1944, all data are presented in the form of rates per 1,000 per annum, and no strain is recorded unless a frequency of 1 per 1,000 was attained in some month in a post under study. Over an 11-month period, only disease caused by types 3, 17, 19, and 30 attained these levels, although during 1 post-month types 6, 24, and 26 were recorded as etiologically responsible for scarlet fever.

The relationship of the various serologic types in the causation of rheumatic fever was of interest, but little information was obtained which can be reviewed profitably. Streptococci of type 126 and an unidentified type 27 were the cause of extensive foodborne outbreaks that were not followed by the development of rheumatic fever. Similarly, the type 17 Streptococcus responsible for the epidemic at heesler Field and Amarillo Army Air Field was not capable of inciting the rheumatic state.28 The impression is gained that certain strains were rheumato-genetically more potent than others and that this property was not related specifically to the numerical type.

An attempt was made to define the geographic distribution of the several types of group A hemolytic streptococcus by the typing laboratory at the Santa Ana Army Air Base.29 This study was carried out between 25 April and 1 July 1944. Throat cultures were obtained from 5,828 men within 48 hours after their arrival at this post from the various college training detachments of the Army Air Forces Western Flying Training Command. The total group A carrier rate was circa 200 per 1,000, but this varied from 490 per 1,000 to 1 per 1,000 depending on the establishment from which the troops lead come. The predominant types were similar to those noted, 1, 3, 6, 14, 17, 19, 30, and 36, and they were found to be widely distributed throughout the country. Space does not permit a further detailed analysis of this interesting study.

Foodborne Streptococcal Infection

Food contaminated by hemolytic streptococci is well able to transmit these organisms to susceptible persons. When this occurs, an explosive outbreak of streptococcal respiratory disease occurs which reaches its peak in from 48 to 72 hours and then declines rapidly. The disease process is not different from that seen in more usual circumstances, and rheumatic fever is a frequent complication.

26 Rantz, L. A., Spink, W. W., and Boisvert, P. J.: IIemolytic Streptococcus Sore Throat; Detailed Study of Simutaneous 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 and Epidemiologic Observations. J. A. M. A. 121: 315-319, 30 Jan.1943.

28 See footnote 10, p. 237.

29 Mitchell, R. B.: Geographical Distribution of the Serological Groups and Types of Beta Hemolytic Streptococci. Report from Streptococcus Typing Laboratory, Army Air Forces Regional Hospital, Santa Ana Army Air Base. 21 Oct. 1944. [Official record.]


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There were 19 recorded epidemics of streptococcal infection during 1942-45, involving 2,879 cases, and others doubtless occurred but were not recognized or reported. Three were studied by commissions of the Army Epidemiological Board, and the results were published in scientific journals.30

Of greatest interest to this history is the fact that, careful bacteriologic investigation of foodhandlers was made in five of these outbreaks, and a hemolytic streptococcal carrier was discovered among the kitchen staff in four of them. The serologic type of streptococcus recovered from two of these individuals was the same as that isolated from infected cases. The other two strains were not typed. Messworkers with acute tonsillitis were discovered during the investigation of two other epidemics, but, no bacteriologic studies were made.

Traditional epidemiologic study of such outbreaks includes elaborate survey of food and water supplies with particular reference to milk. The observations just recorded indicate that the usual source of the infectious agent is a hemolytic streptococcal carrier among the foodhandlers who contaminates certain articles of food after they are cooked. Simple bacteriologic methods, readily applicable by almost any military establishment, should permit the detection and control of such individuals and the elimination of foodborne streptococcal disease as a health hazard in the Armed Forces.

DIAGNOSIS

At the onset of World War II, medical officers were inadequately trained in the recognition of hemolytic streptococcal infection. The author, during 1943, repeatedly examined large numbers of patients in epidemic areas in whom the presumptive diagnosis of streptococcal respiratory infection could be made on inspection of the nasopharynx. The correct etiology of these cases had usually not been suspected by the officers in charge, even though concurrent epidemics of scarlet fever were in progress. This situation was partly the result of insufficient previous experience and partly because of the failure to appreciate the importance and significance of streptococcal infection occurring without a skin rash.

An additional factor was the inability of the usual station hospital laboratory to isolate and identify adequately the hemolytic streptococcus. Bacteriologic control of clinical diagnoses was essentially impossible in most installations during the early years of the war.

Similarly, rheumatic fever was not regularly recognized clinically, even in epidemic areas, until early in 1943 and was not reported to The Surgeon General. Facilities for the adequate study of this disease were usually available but were not regularly utilized. This situation changed rapidly during

30 (1) See footnote 26, p. 247. (2) See footnote 27, p. 247. (3) Commission on Acute Respiratory Diseases: Study of a Foodborne Epidemic of Tonsillitis and Pharyngitis Due to B-Hemolytic Streptococcus, Type 5. Bull. Johns Hopkins Hosp. 77: 143-210, September 1945.


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1943, and by 1944 most medical officers had been alerted to the fact that rheumatic fever was occurring frequently in the Army, and they were able to diagnose and treat the disease, with considerable precision.

CONTROL OF STREPTOCOCCAL INFECTION

The control of hemolytic streptococcal infection was a problem which engaged the attention of all branches of the Armed Forces during World War II. Extensive studies were carried out by the Commission on Hemolytic Strepto coccal Infection and the Commission on Air-Borne Infections of the Army Epidemiological Board which are described elsewhere in the records of that board. The Army Air Forces established its own rheumatic fever control program in the fall of 1943 under orders from Maj. Gen. (later General of the Army) Henry H. Arnold. Its objectives were (1) recommendations for the use of sulfonamide prophylaxis for the control of respiratory infections and rheumatic fever, (2) adoption of uniform standards for the diagnosis of rheumatic fever, (3) coordination and standardization of bacteriologic techniques in the study of the hemolytic streptococcus, (4) establishment of a uniform convalescent program and followup studies on positive and suspected cases of rheumatic fever, and (5) consideration of special projects and investigations at various Army Air Forces posts.

Only objectives 1, 3, and 5 are germane to this chapter. The other two were accomplished under the direction of Ruth Pauli Callender. Uniform techniques for the isolation and serologic classification of the hemolytic streptococci were adopted for use throughout Army Air Forces streptococcal laboratories. Forty hospitals were members of the initial cooperating group and a chief of the streptococcal laboratory was designated in each.Later reports presenting detailed epidemiologic information were derived entirely from 10 stations: Amarillo Army Air Field, Buckley Field, Davis-Monthan Field, Drew Field, Hamilton Field, Calif., Keesler Field, Lincoln Army Air Field, Lowry Field, San Antonio Aviation Cadet Center, and Santa Ana Army Air Base. At each of these posts a comprehensive prograin was undertaken in January 1944 and continued until September 1945. The work was divided into three phases, proceeding concurrently: (1) Determination of incidence of hemolytic streptococcal infection by systematic study of nasopharyngeal flora of all hospital admissions with respiratory illness, (2) determination of hemolytic streptococcal carrier rates by regular bacteriologic samplings of nasopharyngeal flora of troops, and (3) determination of serologic groups and types of all isolated hemolytic streptococci.

A very large amount of information in regard to certain aspects of the epidemiology of hemolytic streptococcal respiratory infection was obtained during the 21 months in which this program was in operation.

It is probable that no other infectious disease has been studied on a nationwide basis by such a well-coordinated group applying uniform techniques.


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Methods of Control

Methods applied during World War II for the control of hemolytic streptococcal infection may be considered in two categories: (1) General hygienic measures and (2) chemoprophylaxis. Any possible value of the former, which included such teellniques as isolation of infected personnel, elimination of overcrowding, and the like, was largely nullified early in the war by the failure to recognize the importance of streptococcal infection occurring without a rash. For this reason, cases of scarlet fever were isolated and their contacts intensively examined, but a huge reservoir of potential transmitters of disease in the nonrash cases was ignored. Later, this situation was rectified somewhat, but such nonspecific measures failed to terminate the serious outbreaks of streptococcal infection, and chemoprophylaxis was given very serious consideration by the Army.

Sulfonamide prophylaxis

Sulfonamide prophylaxis of hemolytic streptococcal respiratory infection was used infrequently in the Army during World War II, but a more detailed review of the development of this technique, its applications, and subsequent failures is appropriate to this history.

The first reports of the possible value of the continuous administration of sulfonamides over long periods of time for the prevention of streptococcal disease were presented from two civilian clinics in 1939. This experience was rapidly expanded by others with uniformly good results and low toxicity. A panel of experts in the summer of 1943 was able to recommend the widespread application of this method for the prevention of recrudescences in rheumatic subjects.31

Early in 1942, it was discovered by the Commission on Meningococcal Meningitis that the administration of 2 gm. of sulfadiazine in a single dose was highly effective in eliminating meningococci from the nasopharynx of carriers and in terminating epidemics of meningitis caused by these organisms. The earliest known deliberate use of these drugs in the Armed Forces 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 not controlled. At about this time, Watson and his associates conclusively demonstrated the value of sulfonamide prophylaxis in the control of an epidemic of scarlet fever on a Navy pier in New York.32

In spite of this information and in the face of the gravely high incidence of streptococcal infection and rheumatic fever in the Army and the Navy, sulfonamide prophylaxis was not undertaken by either service during the winter of 1942-43. It is difficult for the author, who was in constant touch

31 Proceedings of conference on Rheumatic Fever, Washington, D. C., October 5-7,1943. U. S. Department of Labor, Children's Bureau Publication 308. Washington: U. S. Government Printing Office, 1945.

32 Watson, R. F., Schwentker, F. F., Fetherston, J. E., and Rothbard, S.: Sulfadiazine Prophylaxis in an Epidemic of Scarlet Fever. J. A. M. A. 122: 730-733, 10 July 1943.


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with the situation in the Army through this period, to be certain why this delay occurred. Presumably, the constant fear of reactions to the prolonged administration to large numbers of troops of these potentially highly toxic drugs was a principal deterring factor.

At a conference on 7 September 1943, the, Navy decided to employ sulfadiazine prophylactically, and the program was well established by mid-December. The results of this extraordinary experiment in preventive medicine have been described in two monographs.33 More than 600,000 men received either 0.5 or 1.0 gm. of sulfadiazine daily for varying periods of time throughout the winter and spring of 1943-44. For the first few months, controlled studies were done and brilliant results obtained in that the incidence of streptococcal respiratory infection and rheumatic fever was strikingly reduced. By March 1943, controlled work had been abandoned, and the drug was given to all naval personnel in training in the continental United States.

During 1943, the Army was deeply interested in this technique, and plans were laid for its study during the winter of 1943-44 by the Commission on Hemolytic Streptococcal Infections and by the Army Air Forces Rheumatic Fever Control Program. Only one order from The Surgeon General permitting chlemo-prophylaxis in the Army during 1943 has been discovered.34 No record of its implementation is available. On another occasion, Headquarters, New York Port of Embarkation, recommended the administration of sulfonamides to the scarlet fever contacts. It is not known whether the drug was used in this situation.35

The Commission on Hemolytic Streptococcal Infections failed to institute its proposed investigation of sulfonamide prophylaxis during 1943-44, but the Army Air Forces proceeded with an extensive program. Several careful studies were done at Sioux Falls Army Air Field, Truax Field, Wis., and Lowry Field. Various schedules were employed, and it was learned that a daily 0.5 gm. dose of sulfadiazine was adequate. Toxicity was amazingly uncommon. Only 47 men of 36,500 receiving the drug experienced any untoward effects, and in 33 the reactions were mild. The usual impressive reduction in streptococcal disease and rheumatic fever was obtained.36 These controlled investigations were not completed until May 1944, at which time the streptococcal disease rates were declining rapidly. Chemoprophylaxis was not employed widely through the remainder of the Army Air Forces installations and not at all by Army Ground Forces during this season.

33 (1) See footnote 14, p. 241. (2) The Prevention of Respiratory Tract Bacterial Infections by Sulfadiazine Prophylaxis in the United States Navy. NAVMED 284, Bureau of Medicine and Surgery, Navy Department, Washington: U. S. Government Printing Office, 1944.

34 Letter, Lt. Col. R. V. Lee, MC, to Air Surgeon, Headquarters, Army Air Forces, 19 Mar. 1943, subject: Prophylactic Use of Sulfadiazine in Prevention of Scarlet Fever, with endorsements thereto.

35 Memorandum, Commanding General, Headquarters, New York Port of Embarkation, for Surgeon, Staging Area, 20 May 1943, subject: Disposition and Prophylaxis Treatment of Contacts With Scarlet Fever in Task Forces and Station Complement Units.

36 Professional Division, Office of the Air Surgeon: 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 impressed with its studies during early 1944 and went ahead rapidly with the development of a program for general application during 1944-45. This culminated with the issuance of Army Air Forces Letter 25-20 from the Commanding General, Army Air Forces, authorizing chemoprophylaxis as a command function and the publication of the details of the method in the Air Surgeon's Bulletin, September 1944. A conference was held on 3 September 1944 attended by representatives of The Surgeon General, the Army Epidemiological Board, the Air Surgeon, and the Bureau of Medicine and Surgery (United States Navy) for the purpose of discussing this program which lead already been authorized by the Air Surgeon.

Although some evidence had already been obtained that prophylaxis was breaking down in the Navy, this group endorsed the Army Air Forces program for use throughout the Army. Mass administration of the sulfadiazine was not approved. The drug was to be given only when acute respiratory disease, scarlet fever, or meningococcal meningitis reached a certain prescribed minimum rate and was to be continued for only 3 weeks unless special circumstances indicated a more prolonged use of this technique. On 1 November 1944, TB MED 112 was issued, authorizing the use of sulfonamide prophylaxis throughout the Army when proper indications were found to exist. Approval of the appropriate higher medical echelon was required.

During this same month, an epidemic of type 17 sulfonamide-resistant streptococcal infection, which continued for several weeks, began at Keesler Field. Outbreaks of disease caused by this same organism occurred later at Amarillo Army Air Field and at Lowry Field and were traced to troops moved into the two posts from Keesler Field. Several similar epidemics were observed during the winter of 1945, although the total streptococcal disease rate remained low.

Sulfonamide prophylaxis was, therefore, ineffective in terminating the more serious epidemics and not needed under other circumstances in 1945. It is believed that it was applied only rarely during that year although actual data as to the number of men treated are not available.

The appearance of sulfonamide-resistant streptococci as a cause of disease among men receiving mass chemoprophylaxis was believed to be the result of the appearance of drug-fast mutants during the rapid multiplication and transfer of these organisms in a population altered by the administration of these drugs in such a way as to favor the survival of resistant variants and the disappearance of sensitive ones.

Although sulfonamide-resistant hemolytic streptococci have not become a common cause of disease in the civilian population since the war, there is every reason to suppose that they would again appear if mass prophylaxis with these drugs were undertaken in the Armed Forces. There is no reason why the method should not be applied in more limited groups on a short-term basis in an attempt to terminate an epidemic of streptococcal infection.


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Other control methods

The continuing epidemic of hemolytic streptococcal infection in many Navy installations after the breakdown of sulfonamide prophylaxis led to aci exhaustive discussion of the problem at a National Research Council conference held in Washington, D. C., on 6 and 7 July 1945. The techniques of potential value that were considered are described as follows:

Control of carries.-The Commission on Air-Borne Infections demonstrated that the individual convalescent from streptococcal infection who harbored organisms in the nose disseminated them much more freely than (lid simple tonsillar and pharyngeal carriers. Such persons were regarded as "dangerous" carriers. Detection by bacteriologic methods and isolation of these potentially infectious men was considered but never attempted during World War II. Their number would have been great in certain camps and the administrative problem enormous. There was general agreement that detection of carriers by mass pharyngeal swabbing was not a valuable procedure since many of these men would not be "dangerous."

Oiling of floors and bedding.- The Commission on Air-Borne Infections demonstrated that many hemolytic streptococci could be recovered from the air of barracks in which "dangerous" carriers were housed and that their numbers increased sharply during periods of activity such as dressing, bedmaking, and, particularly, floorsweeping. The possibility existed that these extrahuman reservoirs might be potent sources of infection.

Simple and entirely applicable methods were devised for their control including oiling of floors (fig. 4) and bedding. These techniques were shown experimentally to reduce greatly the contamination of the air of barracks by bacteria and were field tested for their ability to reduce the incidence of streptococcal disease. The results were disappointing since, at a time when these infections were not actually epidemic and in a population composed largely of seasoned men, the reduction of streptococcal illness was only about 40 percent. When applied during an epidemic of undifferentiated respiratory disease, no decrease in rate occurred. A similar test during a severe outbreak of streptococcal infection was not, attempted by the Army.

The available results clearly indicate that extrahuman reservoirs are potentially important in the spread of streptococcal disease and that their control is desirable. Unfortunately, droplet infection during direct contact of carrier and susceptible seems to be the most important mode of transmission of these organisms. This is probably particularly true during the periods of intimate physical association connected with basic training in the Armed Forces.

Glycol vapors. - The vaporization of glycols into the air of hospital wards containing "dangerous" streptococcal carriers was shown by the Commission on Air-Borne Infections to be effective in lowering the number of hemolytic streptococci in the air. The effect was most marked when floors and blankets had been oiled.


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FIGURE 4.-Soldiers of a sanitary company oiling the floor of a barrack. The soldier on the left sprinkles oil from a can while the two on the right spread the oil with brushes.

Methods were never devised by the Commission which would permit the accurate control of the concentration of glycol vapor in the air. This difficulty, in addition to others involving the relative humidity at which these substances are bactericidal, made it most unlikely that they would be of value in the control of streptococcal or other respiratory infection in the Armed Forces. A controlled field study of this method was never attempted by the Army.

Ultraviolet irradiation.- The Army did not make use of or study extensively ultraviolet irradiation in the control of airborne streptococcal disease. It was not found to be of value in a limited investigation by the Navy and will probably not be applicable in the future by the Armed Forces.

Active immunization.- Active immunization, leading to the enhancement of resistance to infection by the tissues of the susceptible host, was theoretically the most desirable way to control the spread of infectious disease when general public health measures proved to be ineffective. This technique had not been extensively explored in relation to hemolytic streptococcal disease, but certain considerations suggested that it might not be feasible. Immunity to infection


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by group A Streptococci was believed to be type specific, and many different types were endemic in the Armed Forces. A polyvalent vaccine would have been required containing representatives of a large number of types. Probably none could have been administered in such a mixture in sufficient quantities to stimulate the production of effective quantities of antibody.

Two groups investigated streptococcal vaccination during World War II. The Navy carried out an important field study in which a monotype epidemic was not interrupted by immunization under the most favorable circumstances. The Commission on Hemolytic Streptococcal Infections demonstrated that measurable type-specific antibodies appeared in the serum only when relatively huge amounts of streptococcus were administered over a period of several weeks. Both of these, studies also showed that group A streptococcal vaccines were very toxic substances, and the latter indicated that their use was associated with the development of increased sensitivity.

The use of Dick immunization for the prevention of scarlet fever was repeatedly considered during the war but, insofar as is known, never undertaken. This procedure was discarded since it conferred no antibacterial immunity and could not be expected to reduce the total incidence of streptococcal infection. It would merely have lowered the frequency of occurrence of cases with a skin rash. This result could be of no value, particularly in the light of the toxicity inherent in this form of immunization and the large number of injections required.

General sanitary measures.- No type of special sanitary measures over and above those generally recommended for the control of respiratory disease were employed by the Army to combat the spread of streptococcal infection. In 1945, the Navy did propose an intensive program including a number of such techniques because epidemics of infection caused by these organisms continued to be an important problem. These proposals included (1) maintenance of 50 square feet of floor space and 450 cubic feet of room space per man and avoidance of overcrowding of all other facilities; (2) dust-control measures, including oiling of floors and bedding, in barracks, classrooms, and all other indoor areas where men congregated; (3) airing and cleaning of barracks and bedding between each filling with recruits; (4) adequate ventilation; (5) adequate refrigeration, improvement of milk dispensers, and inspection of foodhandlers; (6) changes in dispensary practice to prevent overcrowding and spread of disease among men on sick call; and (7) changes in hospital practice designed to prevent cross-infection.

These seven proposals could not have been expected to affect materially the course of a serious outbreak of streptococcal disease, although each was desirable in its own right and all should have been part of standard military practice.Certain other phases of the program might well have been of great value although administratively exceedingly difficult to apply; namely, (1) reduction of size of training regiments, (2) segregation of each regiment, (3) placement of groups of new arrivals together rather than spread throughout


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the installation, (4) screening of newly arrived and departing men for presence of respiratory infection, and (5) division of barracks into cubicles.

The effects of this program on an epidemic of streptococcal disease was probably never determined since the war ended in 1945. Because it failed to come, to grips with yssential problems in the epidemiology of streptococcal infection, it would probably not have been more than partially effective.

SUMMARY

The previous sections of this chapter have indicated that hemolytic streptococcal infection and rheumatic fever are most likely to become major problems to the health of the Army when large numbers of recruits are brought together for training in certain geographic areas. Among Army personnel, more than one-third of all cases of rheumatic fever in the continental United States during World War II occurred in the Sixth and Seventh Service Commands, although the total number of troops trained there was relatively small. For instance, according to a special sample tabulation of individual medical records during 1944-45, 17 percent were derived from installations in Colorado, Wyoming, and Utah, where the streptococcal disease rates were appallingly high.

A simple measure for the partial control of hemolytic streptococcal disease and its complications would be a change in policy so that basic training is not undertaken in high-incidence areas. Seasoned men will also be at risk but to a lesser degree, partly because they are seasoned and partly because their training is more likely to be accomplished in large units with relatively little replacement of fresh men in small groups.

A second goal of this program would be the prevention of seeding of many widely scattered installations of the Army by men who received their basic training in areas in which streptococcal disease is epidemic and who have become carriers of highly communicable organisms. Wide dispersement of men at the end of periods of basic training is inevitable. It is much less likely to occur among troops at later stages of their training program.

Certain evidence, notably incomplete, has been presented to show that this was an important factor in the spread of streptococcal infection throughout the Army between 1942 and 1944. Information obtained by study of the epidemiology of these diseases among naval installations convincingly demonstrates dissemination by men moving from boot camps to more advanced training centers.

Administrative problems may well make such changes in training programs difficult during periods of rapid mobilization. Other control measures will undoubtedly be necessary, and none of those suggested and investigated during the last war, with the possible exception of chemoprophylaxis, is likely to be of value.

Chemoprophylaxis with sulfonamides, although of no value in mass application, may be useful 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 since resistance to these agents develops less readily than do sulfonamides.

Additional new techniques involve the termination of the carrier state by administration of penicillin and the prevention of rheumatic fever by treatment of established hemolytic streptococcal infection with this agent.

Evaluation of these methods and their proper application will require the accurate recognition of hemolytic streptococcal respiratory disease. It is believed that the developments in recent years have made physicians more aware of the importance of these infections and the clinical signs permitting their diagnosis.

Satisfactory bacteriologic examination of the respiratory flora is essential to the study of respiratory illness and was available in only a few Army hospitals during World War II. It is clear that this situation must be rectified. Every Army hospital should be prepared to carry out these exceedingly simple bacteriologic procedures using standardized methods and materials. Individual station hospitals need not maintain facilities for grouping and typing. Several laboratories throughout the country should be able to identify streptococci in this way and to test the sensitivity of the organisms to various antimicrobial agents. Sampling and study of strains isolated in the field should be a continuous operation.

Laboratory control of the character just described will permit the rational application of prophylactic and therapeutic regimes presently available and will permit the application of new ones. In addition, accurate information as to the incidence of hemolytic streptococcal disease would be constantly available to The Surgeon General, permitting vigorous action at the earliest sign of an epidemic. A few teams of qualified officers or civilian consultants should be available to go into the field and apply special methods when excessively large numbers of cases appear in any establishment.

It is not known whether these measures can be expected to diminish the frequency of streptococcal infection in the Army. The availability of new tools raises the hope that their rational and vigorous application may be at least partly successful in reducing the hazard of streptococcal disease and its important complications.