INSTITUTIONAL OUTBREAK of HEMOLYTIC STREPTOCOCCI (Scarlet Fever) INVESTIGATION and REPORT FROM THE BUREAU OF COMMUNICABLE DISEASES LOS ANGELES CITY HEALTH DEPARTMENT by O HYMAN I. VENER, M.D. , C.P.H. , Assistant Epidemiologist GEORGE M. STEVENS, M.D., Epidemiologist GEORGE PARRISH, M.D., Health Officer LOS ANGELES CITY BOARD OF HEALTH COMMISSIONERS BULLETIN NO. 63 1939 INSTITUTIONAL OUTBREAK OK HEMOLYTIC STREPTOCOCCI (Scarlet Fever) Investigation and Report* Hyman I. Yener, M.D., C.P.H,, Assistant Epidemiologist. George M. Stevens, M.D., Epidemiologist. The Bureau of Epidemiology was notified on March IU, 1939 that a num- ber of cases of scarlet fever had been admitted from the Los Angeles County Juvenile Hall to the Communicable Disease Division of the Los Angeles County Hospital. An immediate investigation was launched by George M. Stevens, M.D., Epidemiologist, and Hyman I. Yener, M.D*, Assistant Epidemiologist. Interviews were obtained from Dr. Herman W. Covey, Medical Director, Miss Rhea C. Ackerman, Superintendent, and Mrs. George P. Payne, Assistant Superintendent. A preliminary tour of inspection was made, and plans insti- tuted for a complete survey of the institution. In this investigation we were assisted by Mr. Conrad Peterson, R.N., of the Bureau of Quarantine. Each of the children, ages 6 to 19 years was interrogated and from data thus obtained, tables and graphs were formulated, constituting part of this report. The reliability of some of the replies obtained from the chil- dren may be questioned. In the majority of instances, however, we felt that the replies were sincere and to the children’s best ability. The fullest cooperation and courtesy was extended by the entire person- nel of the institution, which made it possible to conduct the survey with a minimum of confusion and loss of time. GENERAL DESCRIPTION OF INSTITUTION The Los Angeles County Juvenile Hall Institution is located at 1369 Henry Street, Los Angeles, California, approximately one block north of the northern boundary of the Los Angeles County Hospital. (MAP) It was created by law and prior to the court appearance of the children, serves as their *Erom the Bureau of Communicable Diseases, Los Angeles City Health Department. (2 STORES Fl.lJWnWca)) .22. Beds(3'df>a»-t) i 2 washfa X, B tellers SlabVo.s(Playroom; „ 4 Oel'fcni’)fc»r> Rooms (v 68.) Z 2 Beas(VapjKKovi/\«( 2. wvindts SLIDING HOUS»N& MAiN KITCHEN Pqnf*ry C«"5"TJ,«wfry ' 2 StRVIMt T«HS JN- / JH-2 JH. CcTTWi SHOP SC /-/C O-L 9 U U. O: ,VQ Jh~/3 Ay/ 3 5 / O /V O O Hw / r OHy Qou. O/fVG CO/I Girl s JH- // detention home and as a means for studying their mental hygiene status. The Institution is under the control of Los Angeles County and is sup- ported by county taxes. The governing body of the Institution consists of a Probation Commit- tee, a superintendent, an assistant superintendent, a medical director and assistants. The entire personnel numbers approximately 110 and their func- tions are many and varied. The medical staff consists of Dr. H. W. Covey, Medical Director and Psychiatrist; Dr* M« P. Prior, Assistant; Dr. Etta Gray, part-time physi- cian; and Dr. W. H. Burrell, dentist. Dr. Covey examines all the boys and prepares psychiatric reports dealing with cases that are to appear in court. A similar service is extended to cases coming from other institutions through the Out-patient Division. Dr. Marion Prior assists in these psychi- atric studies. Dr. Etta Gray, a part-time physician, examines all the girls, conducts daily ward rounds as needed; renders special treatments to the girls; administers diphtheria toxoid and performs tuberculin skin tests as indicated. Dr. Wilford H. Burrell, conducts a part-time dental clinic twice weekly. The present group of thirteen buildings were completed about 1929* The buildings include dormitories for the male and female children, a hospital, a public school undef the direct supervision of the Los Angeles City School Department, a main kitchen for preparing and distributing foods, and other miscellaneous buildings. Assigned to each dormitory are a variable number of boys and girls, segregated into companies according to age and sex. Intermingling between dormitory groups is forbidden; segregation of each company is enforced both in play activities and living quarters. Approximately 17 days is the average stay of a child in the institu- tion, during which time they attend school. The daily average population is approximately 250 cases; the annual average population is approximately I+soo cases. Despite the large child population, no resident physician is available on the grounds to render 2U hour medical service. The large and rapid population turnover does not permit individual or group isolation, and with present facilities is not practicable or possible. During 193&» there were 5*265 children detained in the institution for study and disposition. In addition, 1,396 children were brought to the clinics for study from various other county institutions. Consequently, the two groups undoubtedly intermingled rather freely and could serve as a possible source in the spread of the various infectious diseases. The usual routine of a new admission and the subsequent stay is as follows; A history is obtained and a preliminary examination made. If the child is found to have a temperature, cough or rash, it is sent to the hospital isolation unit for further observation. Members of the younger age groups, assigned to living quarters in Junior Cottage and Company C., are sent direct to these units. The boys of the older age groups usually are detained overnight in the hospital unit, end the following morning as- signed to their respective companies. The older girls are detained for 3 several days in the hospital isolation unit until special reports of smears and blood tests are received, then they are assigned to various living quarters. In the assigned company the child is -under constant supervision hy a specially trained attendant. The children take daily showers, and are ob- served for evidence of any skin eruptions. If a child appears to be ailing or a rash noted, the case is reported. A clinic nurse makes rounds twice daily of the various companies, and supervises the children requiring special treatments, or makes preliminary inspections of new patients. Daily temperature recordings are not ma.de and no sustained search enforced for evidence of desquamation of the hands or feet. Consequently, a child ill for several days but who for some reason fails to report his condi- tion may, unless detected by the nurse or attendant, continues his normal activities. Therefore, a missed case of scarlet fever either during the clinical phase or in the subsequent stages, may cause an outbreak of the character herein described. Especially is it probable, if the ill child is suffering from th» complications of scarlet fever, such as sinusitis, otitis media or paronychia, while employed as a food handler. IMMEDIATE MEASURES INSTITUTED 1. Dispensing of bulk milk was discontinued, except for cook- ing purposes. 2. Bottled milk was to be used exclusively for drinking and served preferably with straws through the cap opening. 3. Discontinuance of boys as kitchen helpers until the epidemic had subsided, (a procedure instituted on March ll). All children found to be desquamating were isolated in a separate unit. All children with a recent history of sore throat, and confirmed by positive throat cultures for hemo- lytic streptococci were isolated in a separate unit. 5. All clinical and suspicious cases were transferred to the Communicable Disease Unit of the Los Angeles County Hospital. 6. A strict quarantine was established, and no new cases were admitted to the institution. 7. An immediate survey was instituted to investigate the milk supply, as well as various other foods suspected as respon- sible agents. S. A clinical and epidemiological investigation was instituted, correlation of data eventually made, and recommendations for the future management submitted. 1+ EPIDEMIOLOGICAL INVESTIGATION CONDUCT OF SURVEY A complete survey of the institution was made, particular attention was given to the housing facilities, the kitchens and the manner of handling food. Every child was interviewed and, if indicated, briefly examined for evidence of desquamation of the hands or feet. Whenever warranted, this examination was supplemented with throat cultures for hemolytic streptococci. Every child was questioned regarding age, company residence, history of recent sore throat, past history of scarlet fever, work assignment dur- ing the first ten days of March, and also as to likes or dislikes of certain foods which appeared on the menus, which might have served as possible vehicles for the outbreak. Each company was considered a complete and separate unit. An effort was made to correlate the case incidence by age, sex, color, work assign- ments during the first week of March, the amount of milk consumed, the foods that might have served as a favorable culture media for the hemolytic strep- tococci, the source of the milk and ice cream, and the manner of storing and handling the various foods. KITCHEN The main kitchen was used as the focal distributing unit for the other buildings of the institution. Food was prepared in the main kitchen and served directly to the several adjoining dining rooms, which were used by Companies A, B, C, Girl’s Department and the Junior Cottage. The boys seg- regation group and the Nightingale unit, both in the hospital building were serviced by food carts from the main kitchen to the hospital kitchen, thence to two separate dining rooms, adjoining or on individual trays direct to those held on the isolation wards. Eood served to Company C was handled in the main kitchen only by the hired personnel. Their food was placed on trays near one of the exits and picked up and carried by a member of Company C to his fellow companions. This messenger did not contact members of any other unit during the course of his duties. The girls’ dining room was served by different girls who acted as wait- resses, and the food was given them directly by the hired kitchen personnel. The girls were not allowed to cone into the kitchen- The boy’s dining rooms were served by boy waiters, and others who worked as helpers in the kitchen. Each company had its individual dining room and did not contact other units. All sterilization procedures were performed by the hired personnel and not entrusted to the inmate kitchen helpers. The latter however, did wipe and stack the dishes on the shelves. KITCHEN PERSONNEL The hired personnel did not eat in the institution. With one or two exceptions, none of the institution personnel ate any meals prepared in the kitchen. All either brought their lunches or ate out at nearby restaurants. 5 At the time of the investigation, March 25, 1939» not one of the employees had been ill with scarlet fever, or gave a history of recent sore throat. Several members of the staff were ill at home due to apparent colds, but they were not examined for hemolytic streptococci. The boys from Company A and B were assigned for kitchen detail as follows; At 6;00 A.M. six boys were detailed to the main kitchen, but two of this number left for school at 9:00 A.M. Bor the noon meal, five boys helped in the kitchen. Two boys each from Company A and B remained in the different dining rooms to clean up. At the hospital dining room, a similar plan was followed. No definite time limit was assigned to any boy. The turnover was very great and the boys intermingled freely. Therefore, the possibility of con- stant exposure to a contagious disease, such as scarlet fever, cannot be overlooked. The boys detailed as kitchen helpers washed dishes, assisted in making salads, poured milk, and frequently served food from the pans onto the large serving dishes to be distributed to the various adjoining dining rooms. MILK The entire bulk milk supply was pasteurized and furnished by the Los Angeles County Pam. The bulk milk was shipped in 10 gallon cans to the main kitchen. Daily shipments averaged approximately ~(G gallons and the supply was used for cooking and drinking. The average daily consumption of milk per child was 1.2 quarts per day. Examination of the milch herd and of conditions at the County Pam was made by Dr. P. B. Wilcox, Chief Dairy and Milk Inspector of the Los Angeles County Health Department. He reported no evidence of mastitis or udder trouble in any of the cows. Pasteurization records were found to be accurate and the phosphatase test indicated proper pastcurization. No cases of scarlet fever had occurred at the County Pam. The daily disposal of 700 gallons of milk from the County Pam had been traced, but no canes of scarlet fever had occurred. At Juvenile Hall the milk was found to be stored in the refrigerators in 10 gallon cans. The thermometers were working satisfactorily. For im- mediate consumption, the milk was poured from the large cans into three or five gallon granite crocks, and thence again poured into smaller pitchers for table consumption. The larger pitchers were also used to transport milk to other units of the institution. The pouring of the milk from one container to another was performed by the boys assigned to work in the kitchen* The women working in the kitchen were unable to move the heavy contain- ers very readily. A few, however, did pour the milk from the three gallon granite crocks into the pitchers. The hired personnel after each meal washed for 1-L to 2 hours all gran- ite crocks, pitchers, dishes and utensils with soap and hot water and 6 sterilized them. The sterilizers functioned properly. The crocks and pitchers were allowed to dry and were placed "bottoms up on the nearby pantry shelves. A great deal of dust was revealed on the exposed portion of the cupboard where the granite crocks were stored. The crocks were clean, but some were chipped exposing the underlying surface. The milk pitchers were stored on shelves in an enclosed cupboard, mouths up, un- covered and easily could become contaminated with dust. The refrigerator in the hospital kitchen on several visits revealed quantities of left-over milk, standing for two or three hours from the previous meal, stored in an uncovered granite crock on the floor. The opportunities for contamination were most excellent and similar situations could have existed in the past of which we were unaware. The milk thus stored was used as a reserve supply for the various adjoining dining rooms in case of shortage during meal tine. A summary of answers received from some of the boys who had worked in the kitchen at various times were compiled. To avoid the possibility of eavesdropping each boy was questioned sejjarately. Too much credence should not be given to the replies of many of those questioned, owing to the type of individual and the opportunity of such person to become fanciful. On the whole, due consideration must be given to the uniformity of the answers received, which in brief were as follows. The milk was poured from the 10 gallon cans into the three and five gallon granite basins by the boys assigned to the kitchen detail. Frequent ly, the milk was allowed to stand uncovered at room temperature, until the following meal, the time interval of which varied from one to four hours, depending on instructions when to pour the fresh milk for the next meal. At times the crocks were cleaned only with hot water and not sterilized, but kept out in the open and refilled with fresh milk the next day* Some of the hired kitchen personnel occasionally woold be in a harry to complete their duties and would not take time to sterilize the various utensils. Instead they would order the boys on the kitchen detail to per- form this duty. Milk that remained in the smaller pitchers was poured into larger pitchers and later used for cooking, and occasionally for drinking. The boys working in the kitchen detail admitted that if unob- served, they would drink milk out of the pitchers. They thought nothing of this 11 stunt" and considered this ant one of the just rewands for their duties. OTHER FOODS On the days when custards or puddings were to be served, it was pre- pared during the early part of the morning, and allowed to cool in a large basin on a shelf at room temperature. If the dessert was to be served for lunch, it wa.s thus exposed for about five hours, and if served for dinner, eight to ten hours would elapse from the time of preparation to the time of consumption. At all times, the product was only covered with a muslin cloth. 7 A supply of custard was observed cooling during one of our inspections. It was very appetitizing, and one was sorely tempted to revert to an old boyhood habit of sticking the fingers into the dessert and sampling. The same thought might not only liave been entertained by boys working in the kitchen, but actually performed, particularly if they felt they were unob- served, A very likely source of contamination was thus possibly detected. It could not have been at all improbable for one of the kitchen helpers who might have been a clinical case or a missed case of scarlet fever to contaminate the product, which serves well as a culture media and conveyor for the streptococci* Gelatin served on March 8, had been prepared several days earlier, but had been kept in refrigeration until just prior to serving. CLINICAL CONSIDERATIONS All clinical cases, immediately upon detection, were transferred for the period of quarantine to the Communicable Disease Division of the County Hospital for active management. At the termination of the quarantine, the patient was transferred to the institution and kept in isolation an addi- tional week. In the simple uncomplicated case, this additional period of quarantine results only in overcrowding of the valuable and limited isola- tion facilities. Such a procedure should not be routine, but instituted only if a complicating drainage occurs after dismissal from the Comnunicable Disease Hospital. Missed cases were classified as patients with a history of recent sore throat, fever, or a feeling of “being indisposed,u and evidence of desquama- tion of the fingers, hands, toes or feet. These patients were isolated for the regular quarantine period. Patients with a history of sore throat of recent origin were examined, and if acute inflammation observed, they were isolated and cultures were taken for hemolytic streptococci. If these cul- tures were negative, the patients were released; but if positive, they were isolated until repeated throat cultures were negative. Culture examinations for hemolytic streptococci were performed by Dr, L. V. Dieter, Director of the City Health Department Laboratories, and by Dr. Hoy Fisk, Director of the Communicable Disease Laboratories of the County Hospital. Twenty-seven cases of clinical scarlet fever, sixteen missed cases of scarlet fever and thirty-five cases of positive hemolytic streptococci cul- tures occurred. Approximately 32$ of 'the total population of the institu- tion had some type of a streptococcal infection. The annual incidence for the period 1930-1939 (March 25 inclusive), revealed that outbreaks had occurred in 1930, 1933» and the current one. (Graph A) During the past nine years, the highest monthly incidence occurred during the winter months, namely, November, December, January and February.(Graph B) s In January, 1939* wo cases of scarlet fever occurred. In February, two additional cases occurred* The first case was in a girl on February 20; and the second was a missed case in a boy on February 25. During the survey this boy was discovered to have a marked cervical adenitis, a mod- erately sore throat which subsequently upon culture was positive for hemolytic streptococci. His duties consisted of serving, washing and assisting in preparing some of the salads and food for the other children* During the first week of March, a missed case of scarlet with an ap- proximate onset on March 2 occurred in a boy. On March 3» a- clinical case occurred in a male kitchen helper. On March 6, another clinical case occurred in a kitchen helper. The same day, another kitchen helper became ill from whose throat, on subsequent culturing, positive hemolytic strep- tococci was reported. It is very probable that the explosive outbreak that occurred US hours later, namely, March 8, could have been due to these two cases. The onset of the epidemic began March 8, reached the peak on March 9 and 10th, and as the emergency measures mentioned we re instituted, subsided approximately one week later. (Graph C) 9 SCARLET FEVER IN JUVENILE HALL Showing INCIDENCE BY YEARS (1930—1939 Inclusive)* Graph A. Number of cases 1930 Years *To March 25, 1939* (Clinical Cases only considered,) 10 SCARLET FEVER IK JUVENILE HALL SHOEING INCIDENCE BY MONTHS (1931-1939 Inclusive) * Graph B. Jan. Eeo. Mar. Apr. May Jun. Jul. Aug. Sep. Oct, Nov. Dec- Months *To March 25, 1939» (Clinical cases only considered) 11 SCARLET FEVER IE JUVENILE HALL Showing DAILY INCIDENCE FEBRUARY 15 to MARCH 20, 1939- GRAPH C Male, case of positive culture for hemolytic streptococci, showing approx, date of onset. Male, missed case, date of onset unknown. Showing date case was first detected. Male, clinical case. Female, Clinical case. Male, missed case, showing approx, date of onset. Female, missed case, showing approx, date of onset. Female, case of positive culture for hemolytic streptocci, showing approx, date of onset. Fumber of Cases February March 12 POPULATION The population of the institution at time of the investigation was 2U55 155 or 63$ were males and 90 or 37% were females. (Table I.) Dis- tribution by race revealed that 68$ were whites, 22$ Mexicans and 10$ negroes. Ta B L E I. POPULATION JUVEITILE HALL As of March 14, 1939* Showing DISTRIBUTION BY AGE GROUPS AND SEX. AGS IN YEARS MALE POPU- LATION DISTRIBUTION OF MALE POPULATION PERCENT FEMALE POPULATION DISTRIBUTION OF FEMALE POPULATION PERCENT TOTAL POPULATION PERCENTAGE DISTRIBUTION - S 2.6 9 10.0 13 5.3 8 2 1.3 k k.k 6 2.5 9 5 3-4 2 2.2 7 2.9 10 k 2.6 3 3.3 7 2.9 11 7 4.5 1 1.1 8 30 12 5 3.* 1 1.1 6 2.5 13 17 10.9 5 5.5 22 8.2 ik 28 18.0 16 17.7 18.0 15 55 35.5 16 17.7 71 29.0 16 19 12.2 19 21.1 32 16.0 17 7 U.5 11 12;2 18 1-k 18/ 2 1-3 3 3.3 5 2.0 rOTALS 155 100.2^ 90 99 •($ 2U5 100. -- - ■■■ ■ — Employed in various capacities were 109 persons, men, 75 women) , none of whom to our knowledge developed scarlet fever. 13 CLINICAL CASES?-- DISTRIBUTION Using the classical symptoms and sign? of scarlet fever, as a guide, 11$ of the population developed clinical manifestations. (Table II.) TABLE 11. SCARLET FEVER CLINICAL CASES Showing INCIDENCE DISTRIBUTION BY AGE GROUPS. AGE IN YEARS POPULATION NUMBER OP Cases CASE incidence DISTRIBUTION PERCENT PERCENT DISTRIBUTION OF TOTAL CASES - g 13 i 7*7 4.0 g 6 i 16.6 4.0 9 7 0 - - 10 7 2 2g.5 7.4 11 g 0 - - 12 6 0 - - 13 22 0 - - l4 44 6 13.6 22.2 15 71 12 17.0 44.4 l6 3S 2 5.3 7.4 17 IS 2 11.1 ?.* IS/ 5 1 20.0 3-2 TOTALS 2*4-5 27 11.0$ 100.0$ Males end females were equally attacked, each with a rate of 11$. Based on racial immunity, the negro males had the highest case incidence of approximately 19$, then the white males with a case incidence of approxi- mately 13$. The Mexican male population showed a case incidence of 2.55• (Table III.) Ik TAB LEIII. MALE POPULATION OF JUVENILE HALL As of March IU, 1939* Showing DISTRIBUTION OF CLINICAL CASES BY RaCE AND INCIDENCE RACE POPULATION DISTRIBUTION OF TOTAL MALE POPULATION INCIDENCE PERCENT NUMBER OF CLINICAL CASES DISTRIBUTION OF CASE INCIDENCE AS TO RACE .PERCENT WHITE 101 65.I 13 12. 8 MEXICAN 3S 2U.5 1 2.6 NEGRO & OTHERS 16 ... 10.3 _ 3 18.8 TOTALS 155. 99.9^ 17 11.0$ Among the females, the white girls had the highest case rate of 13.65, then the negroes with an incidence distribution of llfo. No cases occurred among the Mexicans. (Table IV.) TABLE IV. ITEtiALE POPULATION OF JUVENILE HaLu As of March. IU, 1939* Showing DISTRIBUTION OF CLINICAL CASES BY RACE AND INCIDENCE RAGE POPULATION DISTRIBUTION OE TOTAL FEMALE POPULATION INCIDENCE PERCENT NUMBER OF CLINICAL CASES DISTRIBUTION OF CASE INCIDENCE aS TO RACE PERCENT WHITE 66 73-3 9 13,6 MEXICAN 15 16.7 0 - negro & OTHERS 9 10.0 1 11.1 »TOTALS VD o 100. o$ 10 11.1$ 15 HISSED CASES; —* DISTRIBUTION The criterion for the diagnosis of missed cases has been previously described. Patients so discovered gave a history of residence in the in- stitution of at least 10 days, and in most instances, much longer. 6.5cp of the institution population were diagnosed as missed cases. (Table V.) TABLE V. SCARLET FEVER MISSED CASES Showing INCIDENCE DISTRIBUTION BY ACE GROUPS AC-E IN YEARS POPULATION NUMBER OP CASES CASE INCIDENCE DISTRIBUTION PERCENT PERCENT DISTRIBUTION OF TOTAL C^SES - g 13 1 7.7 6.3 g 6 0 - - 9 7 0 - •4 10 7 0 - - 11 S 0 - - 12 6 0 - - 13 22 3 13.6 IS.g ik UU k 9*1 25.0 15 71 k 5.6 25.0 16 3S 3 s.o 1S.S 17 IS 0 - - lg/ 5 1 20.0 6.3 TOTALS 2U5 16 6.5% 100.2# The case incidence was four times higher amongst the male as contracted to that of the females (2.25) . A possible explanation would be that the boys complained less or perhaps did not care to be bothered in reporting their mild illnesses. 16 POSITIVE CULTURES FOR HEMOLYTIC STREPTOCOCCI;— DISTRIBUTION A culture for hemolytic streptococcus was taken in any child who had a history of recent sore throat, exposure to a clinical or missed case of scarlet, and who at time of examination showed either some injection or a punctate rash of the palate, or a tonsillitis. Approximately lU$ of the population thus segregated had positive throat cultures. (Table VI.) TABLE VI. POSITIVE THROAT CULTURES FOR HEMOLYTIC STREPTOCOCCI CASES WITH RECENT HISTORY OF SORE THROAT AND SCARLET CONTACT Showing INCIDENCE DISTRIBUTION BY AGE GROUPS AGE IN ■"YEARS POPULATION NUMBER OE CASES CaSE incidence DISTRIBUTION PERCENT PERCENT DISTRIBUTION OP TOTAL CASES - 8 13 0 8 6 0 — 9 7 1 1U.3 2.8 10 7 0 - — 11 8 0 _ — 12 6 1 16.2 2.8 13 22 6 27.2 17.0 Ik 6 13.6 17.0 15 71 10 1U.0 28.5 16 3S 8 21.0 22.8 17 18 2 11.0 5.7 18/ 5 1 20.0 2,8 TOTALS 2U5 35 iu.;$ 99- ¥ The case incidence among the females was 11$ as contrasted to that of approximately 16$ among the males. Sixty-five children were cul- tured, of which thirty-five cases, or s*+s were reported positive for hemolytic streptococci. A summary of the various types of hemolytic streptococci infections showing the incidence distribution by individual years and five year age groups, are shown graphically. (Graphs D and S) 17 Graph. ,JD. INCIDENCE DISTRIBUTION OF JUVENILE HALL POPULATION BY YEARS OF AGE AMD SHOWING WITHIN EACH AGE THE NUMBER OF CASES OF CLINICAL SCARLET.FEVER NUMBER OF CASES OF MISSED SCARLET FEVER NUMBER OF CASES WITH POSITIVE CULTURES FOR HEMOLYTIC STREPTOCOCCI LEGEND: POPULATION INCIDENCE NIMEER OF CASES OF SCARLET FEVER mmM §mitKs§c?osi"ive caLTUR2s k)r MJMIER OF MISSED CASES OF SCARLET FEVER Age in Years (Less than) Population and Umber of Cases TOTAL INCIDENCE OF HEMOLYTIC STREPTOCOCCI INFECTIONS Showing- DISTRIBUTION BY 5 YEAR AGE GROUPS OF; CLIITICAL CASES MISSED CASES POSITIVE CULTURES LEGEND: CLINICAL CASES POSITIVE CULTURES KISSED CASES Graph E ITuEiber of Cases Age Groups in Years 19 RE SI DSN OS IN POPU- LATION PER Ux'j i T PERCENT OF TOTAL DISTRI- BUTICN NUMBER OF CASES CLINICAL S.F. PERCENT OF TOTAL DISTRI- BUTION CASE INCI- DENCE DIS- TRIBUTION PERCENT N UMBER OF CASES MISSED SCARLET PERCENT OF TOTAL DISTRI- BUTION CASS INCI- DENCE DIS- TRIBUTION PERCENT NUMBER OF CASES OF POSITIVE CULTURE PERCENT OF TOTAL DISTRI- BUTION CASE INCI- DENCE DIS- TRIBUTION PERCENT NO. CASES ALL TYPES HEMOLYTIC STREPT. INFECTION PERCENT OF TOTAL DISTRI- BUTION CASE INCI- DENCE DIS- TRIBUTION PERCENT 16 «£.. k 1o P ..... i _ P