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The occurrence of the Streptococcus hemolyticus in the throats of children on hospital wards
T H E OCCUI%P~ENCE O F T H E STREPTOCOCCUS HEMOLYTtCUS I N T H E T H R O A T S OF C H I L D R E N ON H O S P I T A L W A R D S LEO ~B. BURGIN, M.D:, AND HAROLD L . HIGGINS, M.D. BOSTON, MASS. THE PROBLEM
H E object of this investigation has been to assemble data pertainof carTiers of the Streptococcus hemolyticus a m o n g the patients and nursing staff of hospital wards for children.
T Jng to the incidence
F r o m clinical observations, the following statements r e g a r d i n g streptococci seem to us to be correct and to present a background f o r evaluating data regarding carriers of this organism. 1. The streptococcus is d a n g e r o u s in p r o p o r t i o n to its virulence. 2. I n f e c t i o n begins w h e n the streptococcus comes in contact with diseased or i n j u r e d tissue. 3. Carriers of the Streptococcus hemolytieus are responsible for m a n y streptococcus infections, including scarlet fever, both in themselves and
others. 4. Streptococci arc spread'from throat carriers by droplet infection especially when the carrier is coughing, sneezing', or crying. 5. I n most years 95 p e r cent of cases of severe sinusitis, including mastoiditis are due to streptococci, and at least 75 p e r cent to the Strep-
tococcus hemolyticus. Therefore, on a children's w a r d the streptococcus carrier raises a problem. There are on such w a r d s : (1) children with, or exposed to, ov recovering from the p r e v a l e n t epidemic r e s p i r a t o r y infection; (2) children with chronic infections of the nose or ears; and (3) children who h a v e h a d acute tonsillitis and h a v e cryptic tonsils. M a n y of these children c a r r y in t h e i r t h r o a t s h e m o l y t i c streptococci of g r e a t e r or less virulence. The nurses t a k i n g cai~e of such children m a y become carriers and in t u r n aid in t h e dissemination of hemolytic streptococci. I t was to obtain i n f o r m a t i o n r e g a r d i n g the actual and v a r y i n g incidence of carriers t h a t the present s t u d y was carried out. LITERATURE
War Camps and Hospitals.--The first intensive studies on carriers were done in the camps and the hospital wards d u r i n g the W o r l d War. Read' before the American Pediatric Society, Asheville, N. C., May 4, 1934. 156
BURGIN r AND
HIGGINS:
STREPTOCOCCUS
ttEMOLYTICUS
157
A t this time it was found that many of the complications arising in the course of pneumonia, influenza, and measles were due to invasion by the hemolytic streptococcus. Cole and MacCallum 1 found the incidence of hemolytic streptococci in the throats of patients entering a measles ward at an army camp to be 11.4 per cent. Within from three: to five days the rate rose to 38.6 per cent. Sixteen days later the rate was 56.8 per cent. A coincident survey in a "tuberculosis suspect" ward showed an average rate of 21.4 per cent. L e v y and Alexander 2 found an incidence of 77.1 per cent among 388 patients with measles. Examination of healthy men from a brigade, which had supplied 89 per cent of all measles cases, revealed a car~'ier rate of 83.2 per cent; of 489 new arrivals into camp, 14.8 per cent were carriers; it was apparent that hemolytic streptococci were readily and easily spread. In another series of measles eases, Cumming, Spruit, and Lynch 3 found 35 per cent carriers. D u r i n g the months of March and April, Nichols 4 f o u n d the rate r a n g i n g from 50 to 90' per cent among the patients and a t t e n d a n t s at the W a l t e r Reed Ilospital. Blanton and Irons 5 r e p o r t e d 34 per cent carriers in a g r o u p of influenza patients. W a l k e r 6 examined successive groups of recruits entering a training camp. The a v e r a g e incidence was 17 p e r cent. The personnel of this camp showed a consistent rate of 20 per cent. These men were all p r e s u m a b l y well.
Civilian Population.--In 10.0 normal appearing throats from the population at large, Smillie ~ f o u n d a carrier rate of 50 per cent. Ruediger s reports 59 per cent in a series of normal individuals, and Otteraaen, 9 57 per cent. A r n o l d ~~ examined 134 t h r o a t s and found hemolytic streptococci in 50.7 per cent. Tonsils a,nd Carriers.--Nichols and B r y a n ~ directed their attention t o w a r d localizing the focus of infection in carriers. A comparative s t u d y was made of cultures from nasal, p h a r y n g e a l , salivary, and tonsillar swabbings. Tonsillar swabs were f o u n d positive for the hemolytic streptococcus more f r e q u e n t l y than a n y of the others. In a group of fifty cases, 28 per cent were positive b y tonsil swab. A f t e r tonsillectomy, eulture examination of the crypts gave positive results in 50 per cent. I n another group of 100 pairs of excised tonsils, 75 per cent were positive when the crypts were cultured. In twenty-five eases of follicular tonsillitis t w e n t y - f o u r were positive for hemolytic streptococci. These authors concluded that the site of infection in carriers was m a i n l y the tonsil and especially the crypts of the tonsils, A similar s t u d y was made by Pilot and DavisY' I n a group of 100 children, f r o m five t+ sixteen years of age, about to have their tonsils removed, swab cultures from the p h a r y n g e a l wall were positive in
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43 p e r cent. I n these cases tonsil-swab cultures were positive in 61 per cent. A f t e r excision, cultures o~f the crypts of these tonsils were positive in 97 per cent. I n a control series 58 per cent of all cases with tonsils were positive while 15.8 per cent were positive in those cases without tonsils. Blanton, Burhans, and t t u n t e r 13 r e p o r t e d a carrier rate of 80 per cent in patients with tonsils. Cultures f r o m the crypts a f t e r excision were positive in 90 per cent. Walke~ 14 made cultures from the throats of 896 healthy recruits, All but twenty-eight still had their tonsils. I n the group with tonsils 20 per cent were carriers. I n the g r o u p without tonsils the incidence of carriers was 7 per cent. One h u n d r e d and f o r t y of the men h a d h y p e r t r o p h i e d tonsils; this group, showed a rate of 35 per cent. Pilot and Tumpeer 15 d e t e r m i n e d the rate as 89.3 per cent in a group of children u n d e r six with h y p e r t r o p h i e d tonsils. A control series of seventy-five children contained 47.7 per cent carriers. Tongs 16 studied the problem of Carriers with special reference to the persistence of that state a f t e r tonsillectomy. I n 125 cases with tonsils 60' per cent were positive by t h r o a t culture; 83 per cent a f t e r the crypts were cultured. I n a similar g r o u p of 342 persons whose tonsils had been removed only seventeen, o r 4.9 per cent, were positive. Nichols and B r y a n 11 f o u n d that in thirty-one positive cases streptococci could not be detected in twenty-seven of the cases eleven d a y s a f t e r tonsillectomy. Me]eney ~7 in s t u d y i n g a surgical operating room staff over a period of a year f o u n d the incidence of carriers greatest in April and May and lowest in the winter. Helmholz, is in 486 cultures of the n a s o p h a r y n x of children, f o u n d an average of 44 per cent positive cultures for hemolytic streptococci. I n a group of eighteen patients in p r i v a t e practice, he took cultures at a p p r o x i m a t e l y eighteen-day intervals for two y e a r s ; all the children at one time or another had positive cultures; the percentage of positive cultures for individual children varied from 18 p e r cent to 65 per cent. There was a variation f r o m m o n t h to month, the incidence at times being as low as zero and at others as high as 100 per cent positive. These latter findings were in J u l y and in September. THE
WARDS
The present s t u d y was made of patients and nurses on the children's w a r d of the Massachusetts E y e and E a r InfirmaIT~. There are three rooms in this w a r d ; the children in one room are not changed to another room, a n d t h e y do not mingle with the children of the other rooms. The same group of nurses care for the patients in all the rooms. Two of the rooms, of twelve and five beds each, all in glass cubicles, are for ear and t h r o a t cases; routine ton-
BURGIN AND HIGGINS:
STREPTOCO,CCUS
H/~MOLYTICUS
159
sillectomy cases are not on this ward. The ear cases are mostly of otitis media and mastoiditis, usually operative and occasionally recurrent; there are occasional cases of secondary lateral sinns thrombosis or brain abscess; there are also a few n o n s u p p u r a t i v e cases. The t h r o a t c a s e s are of sinusitis, foreign body a,spirations, l a r y n g e a l stenosis with tracheotomy, esophageal stenosis, dacryoeystitis. In these rooms a high percentage of the patients have infections. In the third room, which is f o r the children with eye troubles, there are thirteen beds, with five cubicles. They do not include the patients with acute p u r u l e n t conjunctivitis or keratitis. The m a j o r i t y of the eases have had an eye injury, or have strabismus, interstitial Or p h l y c t e n u ] a r keratitis, cataract, or buphthalmos. Thus the ear-throat rooms are occupied largely b y children who have or have had p r i m a r y streptococcus infections while in the eye room there are almost no such cases. The eye cases m a y be said to serve as a control group. PROCEDUEE
Throat cultures were t a k e n every M o n d a y m o r n i n g for twenty-seven c o n s e c u t i v e weeks on each patient and nurse then on the ward. I n all, 386 cultures were t a k e n on 178 children; on some children, who were on the w a r d only one Monday, only one culture was taken. Other children h a d as m a n y as six or seven cultures. The. cultures were t a k e n by p a s s i n g a swab f r o m one tonsil across the soft palate to the other tonM1. I n the absence of tonsils, the fossae were swabbed. The swab immedia.tely was immersed in 1.5 c.e .of low-meat infusion broth to which Na.2CQ had been added as recommended b y Mueller and Whitman. 1~ The cultures were incubated for two hours and then smeared on a blood agar plate as described in detail by Mueller and Klise? ~ I n the mastoid cases cultures were obtained at operation of the same patients and examined ~or the presence of hemolytic streptococci. OBSEICVATIONS M A D E Notes were made on the a p p e a r a n c e of the t h r o a t at the time each culture was taken. Comparing the culture findings with the appearance of t h e throat, we were not able to tell if a noninfected t h r o a t would give a positive culture. I n f e c t e d h y p e r t r o p h i c tonsils usually were positive f o r streptococci. I n Table I are given t h e r e s u l t s of the cultures for hemolytic streptococci in each of the twenty-seven weeks of the study. The percentage of carriers among the children varied f r o m time to time from as low as 9 per cent to as high as 75 per cent. W h e n the n u r s i n g staff was included, similar percentage variations were found.
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160
TARLE INCIDENCE
O1~ TIIROAT
WEEK OF STUD'Y
MONT~
PATIENTS
1
September
6 7 9 7 12 18 24 19 16 15 13 12 9 11 16 21 19 11 9 12 22 17 13 17 18 18 15
2
3 4 5
October
6
7 8
November
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
CULTURE POSITIVE EOl~ ~EMOLYTIC CHILI)REN~S WAR]), 1931-1932
December
Janaar,y
February
March
STICEPTOCOCCI
NU3s 1 2 1 2 3 7 7 2 12 8 4 2 2 4 7 6 5 1 2 5 6 5 5 7 7 13 6
PERCENTAGE 17 29 11 29 25 39 29 11 75 53 31 17 22 37 44 29 26 9 22 42 27 29 38 41 39 72 40
There seemed to be a high peak in the percentage tures
about
patients
once a month;
this was
independent
A
PERCENTAGE INCLUDING STAFF' 7.7 25.0 6.3 13.3 21.1 34.6 21.8 7.4 50.0 39.1 19.0 10.5 13.3 22.2 34.8 21.4 23.1 12.5
CULTURES
POSIT'IVE
ON
14.3 33.3 22.2 21.7
25.0 36.4 28.0 68.0 42.9
of p o s i t i v e cul-
of t h e
number
of
on the ward.
Chaz"c 1 is a g r a p h i c
representation
cultures in the children; ing staff are given. gartner
did not
Several
became
0nly
become carriers
of the percentage
of p o s i t i v e
also t h e f i n d i n g s in t h e c u l t u r e s of t h e n u r s one regular a
carrier
near
at
nurse
and a substitute
some
time
during
the
tile end of the observations
kinderstudy.
in March,
TABLE I I ANALYSIS OF PATIENTS AS TO CARRIEP~ FREQUENCY AND PREVIOUS TONSIIJLECTOMY BOTII ROOMS
Total patients Carriers
Total patients With tonsils Total with tonsils Carriers Total without tonsils Carriers Total carriers r Carriers with tonsils
178 78
178 1.25 125 65 53 13 78 65
EAIr ROO,M
103 i43.8%)
(70.2%) (52.0%) (24.5%) (83.3%)
46
103 68 68 37 35 9 46 37
EYE
ROOM
75 (44.6%)
(66.0%) (54,4%) (27.1%) .(80.4%)
32
75 57 57 28 18 4 32 28
(42.6%)
(76.0%) (49.1%) (22.2%) (87 5 % ) .
BURGIN AND I-IIGGINS:
STREPTOCOCCUS H E 2 v I O L Y T I C U S
16]
w h e n the p e r c e n t a g e of carriers was high. E i g h t of the ten nurses h a d h a d t h e i r tonsils removed. Only N u r s e 4 a n d N u r s e 5 r e t a i n e d their tonsils. A m o n g the children the c a r r i e r p e r c e n t a g e was p r a c t i c a l l y as high in the eye r o o m as in the ear rooms. A higher p e r c e n t a g e of children with tonsils was f o u n d in the eye room. This is p r o b a b l y because m a n y mastoiditis cases had h a d a tonsillectomy p e r f o r m e d . A m o n g the childrert w i t h tonsils a h i g h e r p e r c e n t a g e of carriers was f o u n d t h a n a m o n g the children w i t h o u t tonsils. Of the total n u m b e r of carriers, 83.3 p e r cent still h a d their tonsils. F u r t h e r d a t a showed t h a t of the 114 children who showed negative cultures at first, fifty h a d cultures t a k e n again f r o m t h e i r t h r o a t s some subsequent week, and f o u r t e e n became positive.
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E i g h t of the f o u r t e e n were in the ear' r o o m ; t h r e e h a d positive cultures at o p e r a t i o n ; f o u r changed to positive on the " p e a k " " w~eks; three showed signs of a more injected t h r o a t with the positive culture, and five showed no change in the throat. Six of the children were in the eye r o o m ; none h a d infection or increased redness of the. t h r o a t ; three changed on " p e a k " weeks. F o u r t e e n children who at first h a d a positive culture h a d a n e g a t i v e culture at a l a t e r week. Of the eighteen o p e r a t i v e cultures obtained, twelve showed hemolytic streptococci; nine of these patients h a d positive t h r o a t cultures. Of the six w i t h n e g a t i v e operative cultures, f o u r showed positive t h r o a t cultures. I n the ear w a r d there were t h i r t e e n eases i n which some f o r m of i n s t r u m e n t a t i o n w a s p e r f o r m e d , such as the passing of a laryngoscope, a bronchoscope, or an esophagoseope. There were five p a t i e n t s positive
]62
THE JOURNAL OF PEDIATRICS
in this group before any i n s t r u m e n t a t i o n was done. No others b e c a m e carriers a l t h o u g h m a n y of these p a t i e n t s r e t u r n e d for f u r t h e r treatm e n t t h r o u g h o u t the period of t h e investigation. SUMMARY
1. There is considerable variation in the incidence of streptococcus bemolyticus carriers on the w a r d of a hospital from week to week during the fall and winter season. 2. There a p p e a r s to be a m o n t h l y p e a k in the incidence of carriers. I n these observations two peaks of grea~er magnitude t h a n the others occurred in November and March. This m a y be an indication of an epidemic r e s p i r a t o r y infection in the whole community at t h a t time. 3. IV[embers os the n u r s i n g staff t e n d to become carriers at the "peak" periods. 4. The incidence of carriers a m o n g 178 children was 43.8 p e r cent a n d was p r a c t i c a l l y as common in a r o o m of noninfectious eye cases as in rooms w i t h m a n y o p e r a t i v e mastoiditis cases. 5. The c a r r i e r rate a m o n g p a t i e n t s w i t h tonsils was h i g h e r t h a n a m o n g those w i t h o u t tonsils. 6. There is no characteristic a p p e a r a n c e of the c a r r i e r ' s t h r o a t t h a t m a k e s diagnosis possible w i t h o u t culture. CONCLUSION
The epidemic r e s p i r a t o r y infections in the c o m m u n i t y seem to p l a y a b i g g e r rSle in the c a r r i e r state of a w a r d t h a n the p r i m a r y conditions of the patient. Tonsillectomy c e r t a i n l y tends to reduce the n u m b e r of carriers. I n s t r u m e n t a t i o n did not t e n d to m a k e a p a t i e n t a carrier. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17, 18. 19. 20.
Cole, Rufus, and !V[acCallum, W. G,: J. A. M. A. 70: 1146, 1918. Levy, Robert L., and Alexander, H . L . : J. A. M. A. 70: 1827, 1918. Cumming, J. G.; Sprult, C. B.; and Lynch, C.: J . A . :~. A. 70: 1066, 1918. Nichols, H. J. : Ann. Otol. l~hin., & Laryng. 28: 344, 1919. Blanton, W. B., and Irons, E . E . : J . A . 1~[. A. 71: 1988, 1918. Walker, J . E . : J. Infect. Dis. 27: 618, 1920. Smillie, W. G.: J. Infect. Dis. 20: 45, 1917. Ruediger, G. F.: J. Infect. Dis. 3: 755, 1906. Otteraaen, Andrew: J. Infect. Dis. 26: 23, 1920. Arnold, Lloyd: J. Lab. & Clin. Med. 5: 587, 1920. Nichols, H. J., and Bryan, J . H . : J. A. M. A. 71: 1813, 1918. Pilot, L, and Davis, D . J . : 3. Infect. Dis. 24: 386, 1919. Blanton, W. B., Burhans, C. W., and Hunter, O . W . : J. A. M. A. 72: 1520, 1919. Walker, J. E. : i~vlil. Surgeon 48: 561, 192i. Pilot, L, and Tnmpeer, L H.: Am. J. Dis. Child. 31: 22, 1926. Tongs, !VL S.: J . A . M . A . 73: 1050, 1919. Meleney, ~. L.: J. A. 1VL A. ~8: 1392, 1927. Helmholz, t t e n r y F.: Am. J. Dis. Child. 42: 328, 1931. Mueller, J . H., und Whitman, L.: J. Baet. 21: 219, 1931. ~r J. I~I., and Klise, K. S.: J. Immunol. 22: 53, 1932.
H E object of this investigation has been to assemble data pertainof carTiers of the Streptococcus hemolyticus a m o n g the patients and nursing staff of hospital wards for children.
T Jng to the incidence
F r o m clinical observations, the following statements r e g a r d i n g streptococci seem to us to be correct and to present a background f o r evaluating data regarding carriers of this organism. 1. The streptococcus is d a n g e r o u s in p r o p o r t i o n to its virulence. 2. I n f e c t i o n begins w h e n the streptococcus comes in contact with diseased or i n j u r e d tissue. 3. Carriers of the Streptococcus hemolytieus are responsible for m a n y streptococcus infections, including scarlet fever, both in themselves and
others. 4. Streptococci arc spread'from throat carriers by droplet infection especially when the carrier is coughing, sneezing', or crying. 5. I n most years 95 p e r cent of cases of severe sinusitis, including mastoiditis are due to streptococci, and at least 75 p e r cent to the Strep-
tococcus hemolyticus. Therefore, on a children's w a r d the streptococcus carrier raises a problem. There are on such w a r d s : (1) children with, or exposed to, ov recovering from the p r e v a l e n t epidemic r e s p i r a t o r y infection; (2) children with chronic infections of the nose or ears; and (3) children who h a v e h a d acute tonsillitis and h a v e cryptic tonsils. M a n y of these children c a r r y in t h e i r t h r o a t s h e m o l y t i c streptococci of g r e a t e r or less virulence. The nurses t a k i n g cai~e of such children m a y become carriers and in t u r n aid in t h e dissemination of hemolytic streptococci. I t was to obtain i n f o r m a t i o n r e g a r d i n g the actual and v a r y i n g incidence of carriers t h a t the present s t u d y was carried out. LITERATURE
War Camps and Hospitals.--The first intensive studies on carriers were done in the camps and the hospital wards d u r i n g the W o r l d War. Read' before the American Pediatric Society, Asheville, N. C., May 4, 1934. 156
BURGIN r AND
HIGGINS:
STREPTOCOCCUS
ttEMOLYTICUS
157
A t this time it was found that many of the complications arising in the course of pneumonia, influenza, and measles were due to invasion by the hemolytic streptococcus. Cole and MacCallum 1 found the incidence of hemolytic streptococci in the throats of patients entering a measles ward at an army camp to be 11.4 per cent. Within from three: to five days the rate rose to 38.6 per cent. Sixteen days later the rate was 56.8 per cent. A coincident survey in a "tuberculosis suspect" ward showed an average rate of 21.4 per cent. L e v y and Alexander 2 found an incidence of 77.1 per cent among 388 patients with measles. Examination of healthy men from a brigade, which had supplied 89 per cent of all measles cases, revealed a car~'ier rate of 83.2 per cent; of 489 new arrivals into camp, 14.8 per cent were carriers; it was apparent that hemolytic streptococci were readily and easily spread. In another series of measles eases, Cumming, Spruit, and Lynch 3 found 35 per cent carriers. D u r i n g the months of March and April, Nichols 4 f o u n d the rate r a n g i n g from 50 to 90' per cent among the patients and a t t e n d a n t s at the W a l t e r Reed Ilospital. Blanton and Irons 5 r e p o r t e d 34 per cent carriers in a g r o u p of influenza patients. W a l k e r 6 examined successive groups of recruits entering a training camp. The a v e r a g e incidence was 17 p e r cent. The personnel of this camp showed a consistent rate of 20 per cent. These men were all p r e s u m a b l y well.
Civilian Population.--In 10.0 normal appearing throats from the population at large, Smillie ~ f o u n d a carrier rate of 50 per cent. Ruediger s reports 59 per cent in a series of normal individuals, and Otteraaen, 9 57 per cent. A r n o l d ~~ examined 134 t h r o a t s and found hemolytic streptococci in 50.7 per cent. Tonsils a,nd Carriers.--Nichols and B r y a n ~ directed their attention t o w a r d localizing the focus of infection in carriers. A comparative s t u d y was made of cultures from nasal, p h a r y n g e a l , salivary, and tonsillar swabbings. Tonsillar swabs were f o u n d positive for the hemolytic streptococcus more f r e q u e n t l y than a n y of the others. In a group of fifty cases, 28 per cent were positive b y tonsil swab. A f t e r tonsillectomy, eulture examination of the crypts gave positive results in 50 per cent. I n another group of 100 pairs of excised tonsils, 75 per cent were positive when the crypts were cultured. In twenty-five eases of follicular tonsillitis t w e n t y - f o u r were positive for hemolytic streptococci. These authors concluded that the site of infection in carriers was m a i n l y the tonsil and especially the crypts of the tonsils, A similar s t u d y was made by Pilot and DavisY' I n a group of 100 children, f r o m five t+ sixteen years of age, about to have their tonsils removed, swab cultures from the p h a r y n g e a l wall were positive in
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TtIE
JOUIr
OF P E D I A T R I C S
43 p e r cent. I n these cases tonsil-swab cultures were positive in 61 per cent. A f t e r excision, cultures o~f the crypts of these tonsils were positive in 97 per cent. I n a control series 58 per cent of all cases with tonsils were positive while 15.8 per cent were positive in those cases without tonsils. Blanton, Burhans, and t t u n t e r 13 r e p o r t e d a carrier rate of 80 per cent in patients with tonsils. Cultures f r o m the crypts a f t e r excision were positive in 90 per cent. Walke~ 14 made cultures from the throats of 896 healthy recruits, All but twenty-eight still had their tonsils. I n the group with tonsils 20 per cent were carriers. I n the g r o u p without tonsils the incidence of carriers was 7 per cent. One h u n d r e d and f o r t y of the men h a d h y p e r t r o p h i e d tonsils; this group, showed a rate of 35 per cent. Pilot and Tumpeer 15 d e t e r m i n e d the rate as 89.3 per cent in a group of children u n d e r six with h y p e r t r o p h i e d tonsils. A control series of seventy-five children contained 47.7 per cent carriers. Tongs 16 studied the problem of Carriers with special reference to the persistence of that state a f t e r tonsillectomy. I n 125 cases with tonsils 60' per cent were positive by t h r o a t culture; 83 per cent a f t e r the crypts were cultured. I n a similar g r o u p of 342 persons whose tonsils had been removed only seventeen, o r 4.9 per cent, were positive. Nichols and B r y a n 11 f o u n d that in thirty-one positive cases streptococci could not be detected in twenty-seven of the cases eleven d a y s a f t e r tonsillectomy. Me]eney ~7 in s t u d y i n g a surgical operating room staff over a period of a year f o u n d the incidence of carriers greatest in April and May and lowest in the winter. Helmholz, is in 486 cultures of the n a s o p h a r y n x of children, f o u n d an average of 44 per cent positive cultures for hemolytic streptococci. I n a group of eighteen patients in p r i v a t e practice, he took cultures at a p p r o x i m a t e l y eighteen-day intervals for two y e a r s ; all the children at one time or another had positive cultures; the percentage of positive cultures for individual children varied from 18 p e r cent to 65 per cent. There was a variation f r o m m o n t h to month, the incidence at times being as low as zero and at others as high as 100 per cent positive. These latter findings were in J u l y and in September. THE
WARDS
The present s t u d y was made of patients and nurses on the children's w a r d of the Massachusetts E y e and E a r InfirmaIT~. There are three rooms in this w a r d ; the children in one room are not changed to another room, a n d t h e y do not mingle with the children of the other rooms. The same group of nurses care for the patients in all the rooms. Two of the rooms, of twelve and five beds each, all in glass cubicles, are for ear and t h r o a t cases; routine ton-
BURGIN AND HIGGINS:
STREPTOCO,CCUS
H/~MOLYTICUS
159
sillectomy cases are not on this ward. The ear cases are mostly of otitis media and mastoiditis, usually operative and occasionally recurrent; there are occasional cases of secondary lateral sinns thrombosis or brain abscess; there are also a few n o n s u p p u r a t i v e cases. The t h r o a t c a s e s are of sinusitis, foreign body a,spirations, l a r y n g e a l stenosis with tracheotomy, esophageal stenosis, dacryoeystitis. In these rooms a high percentage of the patients have infections. In the third room, which is f o r the children with eye troubles, there are thirteen beds, with five cubicles. They do not include the patients with acute p u r u l e n t conjunctivitis or keratitis. The m a j o r i t y of the eases have had an eye injury, or have strabismus, interstitial Or p h l y c t e n u ] a r keratitis, cataract, or buphthalmos. Thus the ear-throat rooms are occupied largely b y children who have or have had p r i m a r y streptococcus infections while in the eye room there are almost no such cases. The eye cases m a y be said to serve as a control group. PROCEDUEE
Throat cultures were t a k e n every M o n d a y m o r n i n g for twenty-seven c o n s e c u t i v e weeks on each patient and nurse then on the ward. I n all, 386 cultures were t a k e n on 178 children; on some children, who were on the w a r d only one Monday, only one culture was taken. Other children h a d as m a n y as six or seven cultures. The. cultures were t a k e n by p a s s i n g a swab f r o m one tonsil across the soft palate to the other tonM1. I n the absence of tonsils, the fossae were swabbed. The swab immedia.tely was immersed in 1.5 c.e .of low-meat infusion broth to which Na.2CQ had been added as recommended b y Mueller and Whitman. 1~ The cultures were incubated for two hours and then smeared on a blood agar plate as described in detail by Mueller and Klise? ~ I n the mastoid cases cultures were obtained at operation of the same patients and examined ~or the presence of hemolytic streptococci. OBSEICVATIONS M A D E Notes were made on the a p p e a r a n c e of the t h r o a t at the time each culture was taken. Comparing the culture findings with the appearance of t h e throat, we were not able to tell if a noninfected t h r o a t would give a positive culture. I n f e c t e d h y p e r t r o p h i c tonsils usually were positive f o r streptococci. I n Table I are given t h e r e s u l t s of the cultures for hemolytic streptococci in each of the twenty-seven weeks of the study. The percentage of carriers among the children varied f r o m time to time from as low as 9 per cent to as high as 75 per cent. W h e n the n u r s i n g staff was included, similar percentage variations were found.
THE JOURNAL OF PEDIATI~ICS
160
TARLE INCIDENCE
O1~ TIIROAT
WEEK OF STUD'Y
MONT~
PATIENTS
1
September
6 7 9 7 12 18 24 19 16 15 13 12 9 11 16 21 19 11 9 12 22 17 13 17 18 18 15
2
3 4 5
October
6
7 8
November
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
CULTURE POSITIVE EOl~ ~EMOLYTIC CHILI)REN~S WAR]), 1931-1932
December
Janaar,y
February
March
STICEPTOCOCCI
NU3s 1 2 1 2 3 7 7 2 12 8 4 2 2 4 7 6 5 1 2 5 6 5 5 7 7 13 6
PERCENTAGE 17 29 11 29 25 39 29 11 75 53 31 17 22 37 44 29 26 9 22 42 27 29 38 41 39 72 40
There seemed to be a high peak in the percentage tures
about
patients
once a month;
this was
independent
A
PERCENTAGE INCLUDING STAFF' 7.7 25.0 6.3 13.3 21.1 34.6 21.8 7.4 50.0 39.1 19.0 10.5 13.3 22.2 34.8 21.4 23.1 12.5
CULTURES
POSIT'IVE
ON
14.3 33.3 22.2 21.7
25.0 36.4 28.0 68.0 42.9
of p o s i t i v e cul-
of t h e
number
of
on the ward.
Chaz"c 1 is a g r a p h i c
representation
cultures in the children; ing staff are given. gartner
did not
Several
became
0nly
become carriers
of the percentage
of p o s i t i v e
also t h e f i n d i n g s in t h e c u l t u r e s of t h e n u r s one regular a
carrier
near
at
nurse
and a substitute
some
time
during
the
tile end of the observations
kinderstudy.
in March,
TABLE I I ANALYSIS OF PATIENTS AS TO CARRIEP~ FREQUENCY AND PREVIOUS TONSIIJLECTOMY BOTII ROOMS
Total patients Carriers
Total patients With tonsils Total with tonsils Carriers Total without tonsils Carriers Total carriers r Carriers with tonsils
178 78
178 1.25 125 65 53 13 78 65
EAIr ROO,M
103 i43.8%)
(70.2%) (52.0%) (24.5%) (83.3%)
46
103 68 68 37 35 9 46 37
EYE
ROOM
75 (44.6%)
(66.0%) (54,4%) (27.1%) .(80.4%)
32
75 57 57 28 18 4 32 28
(42.6%)
(76.0%) (49.1%) (22.2%) (87 5 % ) .
BURGIN AND I-IIGGINS:
STREPTOCOCCUS H E 2 v I O L Y T I C U S
16]
w h e n the p e r c e n t a g e of carriers was high. E i g h t of the ten nurses h a d h a d t h e i r tonsils removed. Only N u r s e 4 a n d N u r s e 5 r e t a i n e d their tonsils. A m o n g the children the c a r r i e r p e r c e n t a g e was p r a c t i c a l l y as high in the eye r o o m as in the ear rooms. A higher p e r c e n t a g e of children with tonsils was f o u n d in the eye room. This is p r o b a b l y because m a n y mastoiditis cases had h a d a tonsillectomy p e r f o r m e d . A m o n g the childrert w i t h tonsils a h i g h e r p e r c e n t a g e of carriers was f o u n d t h a n a m o n g the children w i t h o u t tonsils. Of the total n u m b e r of carriers, 83.3 p e r cent still h a d their tonsils. F u r t h e r d a t a showed t h a t of the 114 children who showed negative cultures at first, fifty h a d cultures t a k e n again f r o m t h e i r t h r o a t s some subsequent week, and f o u r t e e n became positive.
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I t I I |
M'I M1 I NI I I I"1 I I I I ]x/( I I I I I I I I I |1 I f I I I I I t I I I I I I I I I'1 I I I I I I I I I C h a r t 1 . - - T h r o a t eult'ures of n u r s i n g s t a f f : "+" i n d i c a t e s t h a t h e m o l y t i c s t r e p t o c o c c i w e r e f o u n d , a n d " - " I n d i c a t e s t h a t no h e m o l y t i c s t r e p t o c o c c i w e r e f o u n d .
E i g h t of the f o u r t e e n were in the ear' r o o m ; t h r e e h a d positive cultures at o p e r a t i o n ; f o u r changed to positive on the " p e a k " " w~eks; three showed signs of a more injected t h r o a t with the positive culture, and five showed no change in the throat. Six of the children were in the eye r o o m ; none h a d infection or increased redness of the. t h r o a t ; three changed on " p e a k " weeks. F o u r t e e n children who at first h a d a positive culture h a d a n e g a t i v e culture at a l a t e r week. Of the eighteen o p e r a t i v e cultures obtained, twelve showed hemolytic streptococci; nine of these patients h a d positive t h r o a t cultures. Of the six w i t h n e g a t i v e operative cultures, f o u r showed positive t h r o a t cultures. I n the ear w a r d there were t h i r t e e n eases i n which some f o r m of i n s t r u m e n t a t i o n w a s p e r f o r m e d , such as the passing of a laryngoscope, a bronchoscope, or an esophagoseope. There were five p a t i e n t s positive
]62
THE JOURNAL OF PEDIATRICS
in this group before any i n s t r u m e n t a t i o n was done. No others b e c a m e carriers a l t h o u g h m a n y of these p a t i e n t s r e t u r n e d for f u r t h e r treatm e n t t h r o u g h o u t the period of t h e investigation. SUMMARY
1. There is considerable variation in the incidence of streptococcus bemolyticus carriers on the w a r d of a hospital from week to week during the fall and winter season. 2. There a p p e a r s to be a m o n t h l y p e a k in the incidence of carriers. I n these observations two peaks of grea~er magnitude t h a n the others occurred in November and March. This m a y be an indication of an epidemic r e s p i r a t o r y infection in the whole community at t h a t time. 3. IV[embers os the n u r s i n g staff t e n d to become carriers at the "peak" periods. 4. The incidence of carriers a m o n g 178 children was 43.8 p e r cent a n d was p r a c t i c a l l y as common in a r o o m of noninfectious eye cases as in rooms w i t h m a n y o p e r a t i v e mastoiditis cases. 5. The c a r r i e r rate a m o n g p a t i e n t s w i t h tonsils was h i g h e r t h a n a m o n g those w i t h o u t tonsils. 6. There is no characteristic a p p e a r a n c e of the c a r r i e r ' s t h r o a t t h a t m a k e s diagnosis possible w i t h o u t culture. CONCLUSION
The epidemic r e s p i r a t o r y infections in the c o m m u n i t y seem to p l a y a b i g g e r rSle in the c a r r i e r state of a w a r d t h a n the p r i m a r y conditions of the patient. Tonsillectomy c e r t a i n l y tends to reduce the n u m b e r of carriers. I n s t r u m e n t a t i o n did not t e n d to m a k e a p a t i e n t a carrier. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17, 18. 19. 20.
Cole, Rufus, and !V[acCallum, W. G,: J. A. M. A. 70: 1146, 1918. Levy, Robert L., and Alexander, H . L . : J. A. M. A. 70: 1827, 1918. Cumming, J. G.; Sprult, C. B.; and Lynch, C.: J . A . :~. A. 70: 1066, 1918. Nichols, H. J. : Ann. Otol. l~hin., & Laryng. 28: 344, 1919. Blanton, W. B., and Irons, E . E . : J . A . 1~[. A. 71: 1988, 1918. Walker, J . E . : J. Infect. Dis. 27: 618, 1920. Smillie, W. G.: J. Infect. Dis. 20: 45, 1917. Ruediger, G. F.: J. Infect. Dis. 3: 755, 1906. Otteraaen, Andrew: J. Infect. Dis. 26: 23, 1920. Arnold, Lloyd: J. Lab. & Clin. Med. 5: 587, 1920. Nichols, H. J., and Bryan, J . H . : J. A. M. A. 71: 1813, 1918. Pilot, L, and Davis, D . J . : 3. Infect. Dis. 24: 386, 1919. Blanton, W. B., Burhans, C. W., and Hunter, O . W . : J. A. M. A. 72: 1520, 1919. Walker, J. E. : i~vlil. Surgeon 48: 561, 192i. Pilot, L, and Tnmpeer, L H.: Am. J. Dis. Child. 31: 22, 1926. Tongs, !VL S.: J . A . M . A . 73: 1050, 1919. Meleney, ~. L.: J. A. 1VL A. ~8: 1392, 1927. Helmholz, t t e n r y F.: Am. J. Dis. Child. 42: 328, 1931. Mueller, J . H., und Whitman, L.: J. Baet. 21: 219, 1931. ~r J. I~I., and Klise, K. S.: J. Immunol. 22: 53, 1932.