The Dissemination of Hemolytic Streptococci in Wards

Beginning October 24 cultures for the identification of carriers of hemolytic streptococci were made from all patients in a ward and repeated at intervals of one week. Prior to this time individual patients had been examined at intervals of one week, so that an entire ward was never studied on any particular day. This system did not identify and remove all “carriers” in a ward at a given time and was abandoned because it failed to show the conditions present. Investigation of wards as units proved much more satisfactory.

The studies made in four of the double wards used for the care of patients with measles are presented in Table LXV. During the time of this study hemolytic streptococci were more prevalent than at an earlier period.

Cultures from the throats of all patients entering these wards were negative for S. hemolyticus on admission. The table showing the incidence of “carriers” of hemolytic streptococci each week in these wards demonstrates:

1. The separation of “carriers” and “noncarriers” by throat culture made on admission does not prevent the increase of streptococcus “carriers” in wards.

2. Removal of all “carriers” found by cultures on admission and at weekly intervals is inadequate.

Table LXV


Ward Conditions with Reference to Hemolytic Streptococcus Infection

DATE OF CULTURE	NO. PATIENTS CULTURED	NO. POSITIVE HEM. STREP.	PER CENT POSITIVE HEM. STREP.	COMPLICATIONS ASSOCIATED WITH HEM. STREP. WITH DATES OF ONSET	REMARKS
Ward 57
11–3	35	1	2.8
11–10	13	2	15.5	None
11–17	16	6	37.5
Ward 58					Wards 57 and 58 served by same ward staff.
11–3	38	7	18.4	Otitis media:	Wards 57 and 58 served by same ward staff.
11–10	11	4	36.4	11–8 1 case	Members of staff cultured on 11–5, 11–12 and 11–19. No positives
11–17	6	2	33.0	11–7 1 case
Ward 49
				Otitis media:
10–25	37	7	18.9	10–25 2 cases
11–1	31	3	9.7	10–26 1 case
11–8	35	9	25.7	10–28 1 case
11–15	32	18	56.3	11–15 1 case
11–22	16	7	43.8	11–18 1 case
				11–27 1 case
Ward 50					Wards 49 and 50 served by same ward staff.
10–25	29	2	3.4	Otitis media:	Wards 49 and 50 served by same ward staff.
11–1	43	2	4.6	11–8 1 case	Ward staff cultured: 11–5 1 positive 11–12 1 positive 11–26 2 positives
11–8	32	3	9.4	11–13 1 case
11–15	20	11	55.0	11–22 1 case
11–22	11	0	0.0
Ward 41					Case of pneumonia developing on 11–9 was transferred to the “clean” pneumonia ward without a throat culture to warrant its transfer; last culture 11–4 negative; culture 11–12 in pneumonia ward positive
10–28	45	4	8.9	Streptococcus pneumonia:
11–4	34	9	26.5	(11–9 1 case)
11–11	12	8	66.6	11–10 1 case
Ward closed—No patients.				Otitis media:
11–21	13	0	0.0	10–29 1 case
11–28	8	4	50.0	11–4 1 case
12–5	12	4	33.3	11–5 1 case
12–12	4	3	75.0	11–11 1 case
				11–27 1 case
				12–3 1 case
Ward 42					Wards 41 and 42 served by same ward staff.
				Streptococcus pneumonia:
10–28	32	0	0	11–10 1 case
11–4	43	7	16.3	12–11 1 case
Ward closed—No patients.				Otitis media:	Ward staff cultured: 11–5 2 positive 11–12 2 positive 11–26 2 positive 12–2 1 positive
10–21	16	4	25.0	10–29 1 case
11–28	12	1	12.5	12–3 1 case
12–5	20	10	50.0	12–6 1 case
12–12	14	7	50.0
Ward 59					The 3 cases of streptococcus pneumonia acquired S. hemolyticus infection while patients in the 16 bed south section of this ward
				Streptococcus pneumonia:
10–24	37	6	16.2	10–17 1 case
10–31	27	5	18.5	10–21 1 case
11–7	9	3	33.3	10–29 1 case	Case developing 10–29 was removed from section a few days before onset of pneumonia
11–12	7	1	14.3	Otitis media:
				11–1 1 case
Ward 60					Wards 59 and 60 served by same ward staff.
				Streptococcus pneumonia:	Wards 59 and 60 served by same ward staff.
10–24	22	1	4.5	10–21 1 case	Ward staff cultured: 11–5 0 positive 11–12 1 positive 11–19 0 positive
10–31	17	2	11.7	Otitis media:
11–7	8	1	12.5	10–31 1 case
11–12	6	1	16.6

When the streptococcus complications are traced back to the wards in which the streptococcus infection of the throat was acquired, it is found that with the exception of Case 141 (already cited) all the streptococcus pneumonias arose from two double wards. Wards 41 and 42 furnished 4 cases at times when streptococcus was rampant in them and 3 of these cases arose within a period of a few days. Wards 59 and 60 furnished 4 cases, very closely associated. In 3 cases the streptococcus infection was acquired in a section of Ward 59 containing 16 beds. These patients were in beds, of which the positions are represented by numbers 2, 5, and 7, along one side of the ward. The fourth instance of pneumonia appeared at the same time in Ward 60, which was attended by the same ward personnel, but no other connection can be established between this case and the other three.

The otitis media appeared in patients scattered throughout those wards for measles in which the weekly incidence of “carriers” was rising rapidly. This relation is illustrated by Wards 58, 50, and 41. The same observation applies to streptococcus pneumonia arising in Wards 41 and 42. In Ward 41 the weekly percentage of carriers are October 28, 8.9, November 4, 26.5 and November 11, 66.6. On November 9 and 10 the first 2 cases of streptococcus pneumonia arising from this ward developed. At the same time, November 10, a third case appeared in another part of this same ward unit (Ward 42) where the spread of hemolytic streptococci had been very active. These observations suggest that hemolytic streptococci may build up its virulence as the result of rapid dissemination to such a degree that it is capable of causing grave complications.

The relation of complications to “carriers” in Wards 59 and 60 is different from that in the wards just cited. Wards 59 and 60 were opened on October 9 and before October 17; when the first case of fulminating streptococcus pneumonia occurred, only three “carriers” had been found in them. From October 17 to 24 when the record in Table LXV begins eight “carriers” were removed. The appearance of a case of severe streptococcus pneumonia in an unusually clean ward was followed by the rapid development of “carriers,” and the appearance within twelve days of 3 other cases of streptococcus pneumonia, 2 of which were in beds close to the first case. This sequence suggests focal dissemination of a streptococcus from a case in which it had suddenly assumed high virulence.

An outbreak of infection with S. hemolyticus was recognized on November 12 in a measles-pneumonia ward which had been opened for several weeks and had continued free from streptococcus. In three patients hemolytic streptococci were found by throat cultures. Inquiry revealed that a nurse in this ward, recognized as a streptococcus “carrier” the week before, had been retained on duty. Two patients well advanced in the course of their pneumonias, had acquired S. hemolyticus demonstrated by throat examination. Both patients developed otitis media with mastoid extension requiring operations. Cultures from both at operation showed hemolytic streptococci.

The third patient, with acute pneumonia, had been sent into the ward on November 11 from Ward 42, which at the time was a highly infected ward; no culture of the throat was made before transfer. This patient developed streptococcus pneumonia with empyema requiring subsequent operation.

Discussion.—At Camp Funston, where the prevalence of S. hemolyticus in the measles wards did not rise above that among normal men in the camp at large, 112 consecutive cases of measles were treated without a single complication due to hemolytic streptococci.

At Camp Pike, the investigation began at the onset of a small epidemic of measles at a time when hemolytic streptococci were an almost negligible factor. The epidemic of measles was followed throughout its course; and, with the passing of the epidemic, there was an increase in the prevalence of hemolytic streptococci which assumed alarming importance in the production of complications.

The epidemic of measles was in part superimposed upon the epidemic of influenza, so that deductions concerning complications strictly due to measles became impossible. It is evident that influenza played a considerable part in producing the complications of measles at Camp Pike.

The dissemination of hemolytic streptococci through measles wards was controlled only in part by the methods used. This partial control may have served to limit the incidence of streptococcus pneumonia, nine instances occurring among 867 cases of measles.

In the ward treatment of measles effort should be directed to prevent the exposure of patients free from hemolytic streptococci to S. hemolyticus “carriers.” By this means the rate of development of S. hemolyticus “carriers” may be reduced.

Measures which should be adopted are as follows:

1. Adequate wards should be prepared in advance for the treatment of measles. The rather gradual onset of epidemics of measles makes this provision possible.

2. The separation of S. hemolyticus “carriers” from other patients should be enforced. Observation wards, where strict technic to prevent transfer of infection is practiced and where throat cultures are made on admission, are essential. Those wards should be promptly evacuated to wards for the care of S. hemolytic “carriers” on the one hand and for “noncarriers” on the other. As far as possible patients should be admitted to a ward until it is filled and then another ward should receive consecutive cases in the same manner. It is desirable to have all cases in each treatment ward in the same stage of the disease. With this system of ward rotation convalescent wards are necessary, so that cases requiring a period of hospitalization longer than the average may be segregated, thus rendering treatment wards available for another levy of acute cases.

3. Strict ward technic elaborated to prevent transfer of bacterial infection from one patient to another must be employed.

4. Throat culture for identification of “carriers” is laborious but essential. An accurate method for identifying and reporting “carriers” as speedily as possible must be employed. A competent bacteriologist is essential. A twenty-four hour interval between culture and its report is desirable. The following scheme is recommended:

(a) A culture from the throat made on admission to the observation ward (first day in hospital).

(b) A culture made on the first day in the treatment ward (third day in hospital).

If the ward incidence of hemolytic streptococci reaches 10 per cent, especially in a filled ward, the cultures should be repeated on the thirteenth day in the hospital. If the incidence of “carriers” of hemolytic streptococci increase rapidly, cultures on alternate days should be made so that “carriers” may be removed from the ward. Wherever possible, culturing of the treatment wards as units should be practiced.

5. Patients developing acute symptoms in any way suggestive of infection with S. hemolyticus should be immediately isolated; culture from the throat should be made at once and final disposal of the patient should depend upon its result.