Hemolytic Streptococci with Measles at Camp Pike
Between September 15 and December 15, 1918, 867 cases of measles, admitted to the wards of the base hospital, were studied and handled according to the system outlined above. About one half of these cases appeared during the first month of the study. During this month hemolytic streptococci played a very insignificant rôle. This microorganism did not appear with alarming prevalence until after the wards had been thoroughly overcrowded. After the emergency, when better ward conditions were provided, S. hemolyticus carriers continued to develop in the wards and were removed when identified. The first S. hemolyticus carriers to develop in the wards were identified on October 8. The first case of streptococcus pneumonia developed on October 17, while streptococcus otitis as a complication of measles did not begin until a little later. During the latter two months of the study, S. hemolyticus became rampant in the wards. The streptococcus complications date their onset at some time during these two months.
Table LXI shows the number of admissions to the measles wards by weeks and the patients among them found to be carrying hemolytic streptococci. It also shows the number of S. hemolyticus carriers developing each week among patients under treatment in the “clean” wards, as identified by throat cultures repeated at weekly intervals. For purposes of orientation, the number of cases developing streptococcus pneumonia and otitis media with its subsequent mastoiditis are given for each week during the period of observation.
An admission to the measles ward can generally be regarded as an acute case of measles. There are a few exceptions to this statement and these are cases of measles treated in barracks and afterwards transferred to the base hospital. A relatively small number of such cases furnished 16 of the cases positive for hemolytic streptococci on admission to the measles ward.
| Table LXI | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| S. Hemolyticus Carriers Identified by Throat Culture Among Admissions; Those Developing Among Patients Under Treatment in the Streptococcus “Clean” Measles Wards; S. Hemolyticus Complications According to Their Dates of Onset | |||||||||||
| GROUPING OF CASES BY WEEKS | ADMISSION CASES | HEMOLYTIC STREPTOCOCCI HOSPITAL CASES DEVELOPING | PRINCIPAL COMPLICATIONS DUE TO HEM. STREP. | ||||||||
| NO. CASES CULTURED | NO. POS. HEM. STREP. | PER CENT POS. HEM. STREP. | NO. CASES CULTURED | NO. POS. HEM. STREP. | PER CENT POS. HEM. STREP. | PNEUM. | OTITIS | MASTOIDITIS | |||
| Sept. 15 to Sept. 21 | 23 | 252 | 1 | 3 | 1.2 | 0 | 0 | 0 | 0 | 0 | 0 |
| Sept. 22 to Sept. 29 | 25 | 1 | 23 | 0 | 0 | 0 | 0 | 0 | |||
| Sept. 30 to Oct. 6 | 95 | 0 | 24 | 0 | 0 | [[91]]1 | 0 | 0 | |||
| Oct. 7 to Oct. 13 | 109 | 1 | 121 | 4 | 3.3 | 0 | 0 | 0 | |||
| Oct. 14 to Oct. 20 | 223 | 494 | 7 | 19 | 3.8 | 175 | 8 | 4.6 | 1 | 0 | 0 |
| Oct. 21 to Oct. 27 | 156 | 5 | 451 | 35 | 7.7 | 2 | 3 | 0 | |||
| Oct. 28 to Nov. 3 | 71 | 6 | 333 | 29 | 8.7 | 1 | 12 | 1 | |||
| Nov. 4 to Nov. 10 | 44 | 1 | 263 | 45 | 17.1 | 3 | 8 | 11 | |||
| Nov. 11 to Nov. 17 | 31 | 117 | 4 | 13 | 11.1 | 149 | 46 | 30.8 | 0 | 5 | 5 |
| Nov. 18 to Nov. 24 | 41 | 4 | 93 | 7 | 7.5 | 0 | 2 | 2 | |||
| Nov. 25 to Dec. 1 | 19 | 0 | 48 | 7 | 14.6 | 0 | 3 | 2 | |||
| Dec. 2 to Dec. 8 | 26 | 5 | 52 | 12 | 23.1 | 0 | 3 | 0 | |||
| Dec. 9 to Dec. 15 | 4 | 2 | 47 | 12 | 25.5 | 1 | 0 | 0 | |||
An admission to the measles ward does not indicate admission to the hospital, because a considerable number of cases of measles developed from time to time among patients under treatment in the hospital for other conditions. Since these patients remained in other wards not subject to the same ward management and with no distinction between those positive and those negative for hemolytic streptococci, they cannot be included in figures to show the incidence of hemolytic streptococci in patients with measles at the time of admission to hospital from the camp. Two classifications of the 37 cases, positive when first observed, are necessary.
1. Division of cases according to days in the hospital before first culture was taken:
| Days in Hospital | No. of cases |
|---|---|
| 0–1 (admission) | 15 (2 not acute) |
| 2–7 | 10 |
| More than 7 | 12 |
2. Classification according to stage of the disease:
| During acute stage | 21 cases |
| After acute stage | 16 cases |
The first classification shows only 13 cases positive when cultured on admission to the hospital and also during the acute stage of the disease; the incidence of S. hemolyticus in patients on admission is very low (1.76 per cent).
The second classification shows a slightly higher incidence for cases during the acute stage of the disease, regardless of whether they were admitted to the measles service from camp or from another service of the hospital (2.4 per cent). These findings conform with those at Fort Riley in a smaller series of cases and support the opinion that the hemolytic streptococci temporarily disappear from the throat during the acute onset of measles. Unfortunately controls among normal men in Camp Pike were not taken at intervals throughout the period of three months represented by this study of measles, but all controls taken show a higher incidence than that found among measles patients on admissions over a period of time comparable to that of the control series.
The gradual increase in the percentage of patients developing hemolytic streptococci in their throats in wards receiving only streptococcus free cases demonstrates that the admission culture and the subsequent weekly cultures, with the separation of all patients identified as carriers, did not suffice to control the spread of streptococcus in this group of cases. It is interesting to note that the greatest incidence of streptococcus carriers among these patients occurred three weeks after the height of the measles epidemic, when it became about four times that observed at the height of the measles epidemic.
When we consider the time relations of the streptococcus complications, it is noteworthy that they begin to appear somewhat after the appearance of streptococcus carriers and then increase parallel with the increase in the numbers of carriers. The relative number of complications developing among the first carriers which were identified is less than that among the carriers appearing later. This suggests an increase in virulence of hemolytic streptococci attending their wider dissemination.
Tables LXII and LXIII are introduced for the purpose of showing to what extent duration of stay in the hospital increases the individual’s chances of acquiring hemolytic streptococci. Table LXII includes all cases admitted to and treated in the measles wards. On repeated cultures, previous positives and negatives were cultured alike and the total positives reported for each week.
Table LXIII includes only those cases treated in the “clean” wards and known to be negative on previous culture.
| Table LXII | |||
|---|---|---|---|
| Incidence of Hemolytic Streptococci in Throats of Measles Cases with Reference to Period in Hospital | |||
| (All cases treated in the wards) | |||
| PERIOD IN MEASLES WARD | NO. CASES CULTURED | NO. POSITIVE FOR HEMOLYTIC STREPTOCOCCI | PER CENT POSITIVE FOR HEMOLYTIC STREPTOCOCCI |
| (Admission) | 867 | 37 | 4.2 |
| 1 week | 768 | 84 | 10.9 |
| 2 weeks | 479 | 109 | 22.8 |
| 3 weeks | 240 | 63 | 26.2 |
| 4 weeks | 133 | 44 | 33.1 |
| 5 weeks | 82 | 26 | 31.7 |
| 6 weeks | 53 | 14 | 26.4 |
| 7 weeks | 25 | 8 | 32.0 |
| 8 weeks | 13 | 1 | 7.7 |
| 9 weeks | 9 | 1 | 11.1 |
| 10 weeks | 6 | 0 | 0 |
| 11 weeks | 5 | 0 | 0 |
| Table LXIII | |||
| Weekly Development of Hemolytic Streptococci in Throats of Patients Treated in “Clean” Wards | |||
| PERIOD IN MEASLES WARD | NO. CASES CULTURED | NO. POSITIVE FOR HEMOLYTIC STREPTOCOCCI | PER CENT POSITIVE FOR HEMOLYTIC STREPTOCOCCI |
| 1 week | 738 | 67 | 9.1 |
| 2 weeks | 424 | 74 | 17.4 |
| 3 weeks | 195 | 34 | 17.4 |
| 4 weeks | 92 | 16 | 17.4 |
| 5 weeks | 46 | 7 | 15.2 |
| 6 weeks | 26 | 4 | 15.4 |
| 7 weeks | 14 | 3 | 21.4 |
| 8 weeks | 8 | 0 | |
| 9 weeks | 5 | 0 | |
| 10 weeks | 4 | 0 | |
| 11 weeks | 3 | 0 | |
A comparison of Tables LXII and LXIII gives some indication of what might have been expected if the carriers had not been removed from the treatment wards at weekly intervals. With the carriers removed from the “clean” cases and segregated in a separate ward so as to be removed effectively as sources of spread of the S. hemolyticus infection to clean cases, the percentage incidence with all cases considered rose to a point nearly twice as high as that ever reached in the wards where clean cases alone were allowed to remain. Had these carriers not been separated, and remained in contact with cases free from hemolytic streptococci, they would have served as just so many more sources of infection, and an incidence of at least twice that recorded for all cases combined, or four times that of the treatment wards, might have been expected. These results indicate that the weekly separation of carriers from clean cases did, to a considerable extent, lower the individual’s danger of acquiring S. hemolyticus infection while in the hospital.