deaths from scarlet fever in the twentieth century

Deaths from Scarlet Fever in the Twentieth CenturyAuthor(s): HUGH PAULSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 46, No.9 (SEPTEMBER 1955), pp. 363-367Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41980681 .

Accessed: 14/06/2014 01:29

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

.

Canadian Public Health Association is collaborating with JSTOR to digitize, preserve and extend access toCanadian Journal of Public Health / Revue Canadienne de Sante'e Publique.

http://www.jstor.org

This content downloaded from 195.34.79.223 on Sat, 14 Jun 2014 01:29:30 AMAll use subject to JSTOR Terms and Conditions

http://www.jstor.org/action/showPublisher?publisherCode=cpha

http://www.jstor.org/stable/41980681?origin=JSTOR-pdf

http://www.jstor.org/page/info/about/policies/terms.jsp


Deaths from Scarlet Fever in the

Twentieth Century

HUGH PAUL, M.D., B.Ch., D.P.H.1 Medical Officer of Health

County Borough of Smethwick Staffs , England

CCARLET FEVER is a disease with a moderately long history and was described in some detail by Ingrassias in the 16th and Döring in the 17th

centuries. The term scarlatina was first used by Sydenham in 1678 to denote the mild disease associated with a rash but with no other signs. Indeed there is considerable evidence that this disease, two or three hundred years ago, did not display the acute toxic pharyngeal symptoms which later became a much more important feature of the disease than the actual rash. From the 17th century onwards, however, the disease changed in character and became more severe, reaching a climax about the end of the 18th century with deva- stating death-dealing epidemics occurring all over continental Europe and Great Britain.

In the 19th century in Europe (though not in America) the disease reverted abruptly to its mild form and continued to be a relatively trivial disease for about a generation. In 1830, however, the virulent type of the disease once again returned and the death rate continued to be very high until about 1870. During the past 80 years the severity of the disease has gradually but steadily declined and the death rate has been reduced to almost negligible proportions. In 1870 scarlet fever killed 720 persons per million population at all ages in England and Wales, but at the turn of the century these had been reduced to 110 per million.

The vagaries in the rates of mortality from scarlet fever have long been a puzzle to epidemiologists and make one wonder whether the alterations in other diseases which apparently have been brought about by improvements in living conditions, by immunizations or by specific treatment have not been influenced also by some unknown factors affecting the ecology of the organism itself. It must be pointed out, however, that in many countries of the world at the present time, the incidence of scarlet fever is as great as it ever has been and the alteration is only in its fatality.

In many countries scarlet fever is a notifiable infectious disease but the value of this notification is influenced both by the completeness or otherwise of notification and by the fact that scarlet fever is only one manifestation of a

^on. Consultant in Epidemiology, Birmingham Regional Hospital Board, England. Lecturer and Examiner in Public Health, University of Birmingham. Sometime Examiner in Public Health, University of London. Author, "The Control of Communicable Diseases", 1952, Harvey & Blythe, London.

363



364 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 46

more general infection by the hemolytic streptococcus. It is therefore obvious that any comparisons should be made not between scarlet fever in one country as compared with scarlet fever in another country but with the total of streptococcal infections in each country. With this reservation, it is interesting to compare both the incidence and the mortality from scarlet fever in different countries and the following table taken from a WHO Epidemiologic and Vital Statistics Report shows the notifications and deaths from scarlet fever in seven countries during the ten years from 1939-1949.

Scarlet Fever in Various Countries 1939-1949

Notifications (N) and Deaths (D)

England United Union of New Zealand and Wales Canada States South Africa Australia (Whites) Scotland

1939 N 78,101 15,157 162,897 1,945 7,562 480 12,023 D 181 167 853 29 2 47

1940 65,303 13,712 155,464 2,040 8,252 357 8,353 154 125 668 34 1 35

1941 59,433 16,966 128,928 1,991 9,934 338 8,760 133 117 454 25 2 26

1942 85,084 20,648 128,194 7,941 6,509 457 13,792 104 129 447 22 1 24

1943 116,034 18,639 142,622 2,779 14,985 1,196 14,722 134 100 451 52 2 22

1944 92,671 20,945 192,661 2,237 16,292 7,612 12,057 107 115 422 27 27 18

1945 73,687 11,982 175,398 3,565 11,492 5,033 11,654 84 79 303 5 11 13 15

1946 56,730 9,308 116,042 3,255 7,787 1,454 9,774 43 58 198 6 7 1 5

1947 58,046 7,492 84,379 2,824 4,561 866 9,800 42 42 107 3 9 0 8

1948 74,831 7,545 78,662 2,368 4,138 1,106 13,866 37 38 68 5 6 3 7

1949 70,667 8,508 74,913 2,481 3,842 1,038 9,648 18 13 39 6 3 0 5

This table shows that the incidence of scarlet fever has fallen appreciably in Canada, the United States and Australia but not in England and Wales, South Africa and New Zealand. This last named country showed a steep upward surge in 1943, reaching its maximum in 1944, and the pre-epidemic level has not yet been regained. It is rather strange that though the incidence is declining in Canada, the case-fatality rate is very much higher than in the United States or England and Wales.

A more recent WHO report (1), gives a resume of the deaths from scarlet fever from the beginning of the present century and shows some surprising vagaries in different countries. In the United States the mortality was high at the beginning of this century amounting to about 40 deaths per million population at its peak and during the first twenty-five years the variations in the number of deaths occurred only within relatively narrow limits, the highest peak being reached in 1910 when there were 6,255 deaths and the lowest figure in 1905 with 2,284. During this time the deaths averaged about 4,000. From 1925 until 1936 there was a substantial though not a spectacular reduction, the yearly deaths averaging 2,300 to 2,700. The advent of the



Sept. 1955 DEATHS FROM SCARLET FEVER 365

sulphonamides apparently was responsible for the steady reduction which then occurred and from 1939 onwards the deaths never numbered as many as 1,000, the lowest figure being 68 in 1948.

A somewhat similar picture is shown in the figures for England and Wales. The deaths at the beginning of the century were between 4,000 and 5,000 but they fell more steadily than in the United States, and by 1923 had fallen to under 1,000. The fall during this period was fairly steady. It is difficult to account for the considerably lower incidence for the period between the two wars in England and Wales when the decline continued at a steady rate. The influence of the sulphonamides was possibly less marked in England and Wales than in the United States and the curve of incidence of mortality from scarlet fever in England and Wales shows a fairly steady and even drop from 1901 to 1949. In the last named year the deaths numbered 20.

Much the same pattern is shown in Scotland but the mortality in Northern Ireland shows fairly extreme variations ranging from 43 at the beginning of the century to 284 in 1914, falling to 42 once again in 1917, reaching 206 in 1920 and falling as low as 24 in 1932. During the war the deaths in Northern Ireland fell to negligible proportions.

A close study of the table given in the report referred to above (1) shows a fairly substantial decline in many parts of the world in the incidence after 1936, i.e., after the period when the sulphonamides came into common use. This reduction is marked in the case of Canada, Chile, the United States, Belgium, France, Spain, Italy, Scotland and Northern Ireland and to a lesser extent, England and Wales. Sulphonamides appear to have had no effect on the death rate in Mexico, in the Netherlands and in Portugal. The mortality was not affected by the sulphonamides until the end of the war in Japan, Germany, Austria and Switzerland.

It is interesting to compare France and Germany. From 1940 onwards the deaths in France from scarlet fever steadily decreased (with the exception of the year 1945) and the deaths per million fell from 2.6 in 1939 to 0.35 in 1952. In Germany on the other hand the incidence increased substantially during the war years. From 1931 to 1933 the average number of deaths in Germany was 676. The deaths rose in 1934 to 1,171, and from then until the outbreak of war, yearly deaths averaged 1,233. During the war years, 1940 to 1944 the deaths numbered 1,363, 2,874, 3,892, 2,938 and 2,388 respectively. The difference between Germany and France could hardly have been due to the lack of sulphonamides as France during all this period was under German occupation and it is difficult to believe that the Germans denied themselves the use of sulphonamides to assist the French. The story from 1946 onwards in Germany is more satisfying and for the quinquennial period 1946-1950 the deaths numbered from 180 to 258 and in 1951 had fallen to 121. The post-war figures exclude East Germany.

The picture in Mexico is unusual. Figures are not available for the first 21 years of the century but from 1922 onwards the variations in the number of deaths could reasonably be ascribed to chance. The average number varied from about 400 to 600, the largest number of deaths occurring in 1925 when



366 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 46

801 persons died and the fewest in 1947 (150 deaths). The figure in 1949 was 536 and in 1952,617 persons died; this latter figure includes deaths from streptococcal sore throat.

In South Africa with a population of about 11§ millions scarlet fever has never been a serious problem and the deaths have been consistently low throughout the whole century. The largest number of deaths was in 1928 when 47 died but only one person died in each of the years 1946 and 1947. In Belgium the death rate was fairly high for the first 11 years but later declined considerably and within the last decade the fall has been very substantial.

Canada has had a relatively high incidence for many years. Figures are only available from 1921 but in that year 410 persons died. The peak figure was 440 deaths in 1929 and from the end of the war the deaths fell to very small proportions.

In the beginning of the century the country which appears to have suffered the largest relative mortality from scarlet fever was undoubtedly Germany when the mortality varied from 300 to 400 per million population. In the first four years of the century no fewer than 54,717 persons died in Germany from scarlet fever. In 1952 the number of deaths in the Western section of Germany had fallen to 94 and this figure included deaths from streptococcal sore throat.

From 1949 deaths in most countries have been classified according to the International Abridged List 1948 (6th Revision) and include deaths from streptococcal sore throat, and in the WHO report the tables for the last four years include for most countries deaths not only from scarlet fever but from streptococcal sore throat. It is interesting to note that in a few cases this alteration has not shown a spectacular increase in the number of deaths recorded, although generally the numbers dying were substantially higher.

In South Africa there were 4 deaths from scarlet fever during the three years from 1946-1948 and 14 from scarlet fever plus streptococcal sore throat in the next three years but these figures are too small to justify any statistical conclusions. In Canada the number of deaths from scarlet fever from 1947- 1949 was 31 and the number of deaths from scarlet fever plus streptococcal sore throat from 1950-1952 was 49. In Chile the new classification resulted in a trebling of the death rate but the figures again were small. In the United States the new classification showed a very substantial increase in mortality. In 1946, 1947 and 1948 the deaths were 189, 98 and 63 whereas from 1949-1952 the combined deaths amounted to 486, 347 and 360 respectively.

In Mexico the new classification showed an increase from an average of 324 in the previous three years to an average of 450 for 1950-1952. In Japan where the number of deaths from scarlet fever from the beginning of the century has been negligible, the new classification shows a lower number of deaths (yearly average 38) from the combined diseases than was shown in the previous three years from scarlet fever alone (yearly average 57). It is interesting to note that in 1901 only six persons were recorded as having died from scarlet fever in Japan and the highest number ever recorded in that country was 505 in 1934. Either scarlet fever is a very mild disease in Japan or the deaths in the early years have not been fully recorded.



Sept. 1955 DEATHS FROM SCARLET FEVER 367

In Germany the new classification was only adopted in 1952 and the total number of deaths in that year from scarlet fever and streptococcal sore throat was lower than the number of deaths from scarlet fever alone in any previous year. In Belgium the new classification showed 30 deaths from all streptococcal infections in 1952, a figure rather more than double the average for scarlet fever for the previous three years. In Ireland the incidence of scarlet fever has never been high and during the past decade the number of deaths has never been greater than 35; there were 12 deaths in 1949. From 1950-1952 the new classification showed an average each year of 13 deaths for scarlet fever and other streptococcal infections. In Italy the new classification showed no increase over preceding years. In England and Wales the number of deaths from scarlet fever alone amounted to 99 for the three years 1947-1949 whereas the deaths from scarlet fever and other streptococcal infections from 1950-1952 numbered 224; of these, 93 were from scarlet fever.

The treatment of scarlet fever under modern conditions has been made relatively easy by the discovery of the sulphonamides in the middle '30s and by modern antibiotics during the past decade. In most countries of the world therefore scarlet fever has ceased to be a major scourge. Together with other streptococcal infections it continues, however, to be a source of considerable invalidity and fairly substantial numbers of the population harbor the hemolytic streptococcus in their throats. At periods of greatest incidence these carriers may amount to as many as 1 in 3 of the total population. It is therefore impossible to prevent the disease by the isolation or treatment of carriers.

Treatment of patients in hospital during the past half century has not served to reduce the incidence of the disease in any country to a measurable extent and has largely been abandoned. Streptococcal infections now are treated in hospital only when the disease is of such severity that it cannot be suitably treated at home or where the home conditions are entirely unsatis- factory. It seems therefore that scarlet fever and streptococcal sore throat will remain for many years a source of illness and invalidity in most countries but that as the years go by this disease will kill fewer and fewer persons.

REFERENCE 1. Epidemiologic and Vital Statistics Report, Volume 7, No. 8, 301-303.



deaths from scarlet fever in the twentieth century

Documents