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Note.—These six cases are well distributed throughout a department of 400 children, and point to several
sources of infection, probably outside the school. Such an outbreak requires investigation, but there is nothing
to suggest school closure or any cause for alarm.
The connection between cases is considered and, if necessary, a special visit to the school is made
for further enquiries. But, without regarding epidemics, information is also obtained by following up
series of consecutive cases. In these investigations the school work is supplemented by further
enquiries out of school made by the Medical Officers of Health.
Methods of Infection.—Scarlet fever spread in schools appears to be through close personal
contact with:—
A previously known case either in its early or later stages.
A mild unrecognised case, not excluded from school.
An apparently simple sore throat, without other symptoms.
Rarely a carrier case not suffering.
Sometimes it is impossible to differentiate between the last three varieties of infector. The
incubation period is usually three to five days, but appears to vary between 12 hours and three weeks and
sometimes possibly longer. Slight sanitary defects in the school and its surroundings, bad drains, smells,
unsatisfactory w.c.'s and water supplies, however unhygienic in themselves, are not primary causes of
scarlet fever in London schools, and must not be suffered to lead us astray from the real channels. Infected
books, pencils or drinking cups, cannot account for more than an infinitesimal number of the cases.
Origin of outbreak is traced by the following method :—
(a) The registers must be examined for at least a month previously to see if any child
has returned to school after scarlatina or after exclusion for infection in the home. All such
cases should be carefully investigated, the parents, if necessary, being seen. It does not suffice
to rely on the teacher's memory for these details.
(b) The names of all other absentee children must be written down with their absences in
chronological order. Absence for a single day, especially Friday or Monday, may be sufficient
for mild scarlatina. Enquiries should be made from the child, the class teacher, the returns of
the attendance officer and the head teacher. All cases should be regarded as suspicious until
proved innocent.
(c) In the classes in the various standards, questions as to sore throats may be asked
from the children generally, or as to their knowledge of anyone with sore throats for a considerable
time back, to some fixed date such as Easter, etc.
(d) Having exhausted the enquiries from registers and teachers, the seats of all suspicious
and affected children should be noted, also other associations, on the way to or from school, for
instance.
(e) The mixing in classrooms for particular lessons or hours has also to be enquired into
and the possibility of contact with previous cases in other rooms or departments.
These enquiries, even if there be seven or eight cases in a department, can easily be conducted in
a school session. Without them, any more superficial examination, such as the examination of the
children class by class for signs of desquamation or of aural or nasal suppuration is for practical or scientific
purposes comparatively useless. Nor is it fair to exclude the school as a probable or possible source of
infection till such an enquiry has been made.