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53
not have contracted the infection. On the other hand, it is most exceptional
for any child suffering from scarlet fever to be removed to hospital
on the day of onset of illness. Last year, the third day was the commonest,
slightly fewer being rerroved on the second day, and the same
number again on the fourth or later day. As of the eight cases, the
onset in half was the fifth day from the onset in the primary case, it
is quite likely that had it been decided that the primary case should be
nursed in hospital, removal would not have been carried out sufficiently
early in a number of these cases to have prevented the development of
the infection in the secondary case.
Return Cases.
Sometimes an inmate of the household to which has returned a
patient who has been nursed in a hospital while suffering from scarlet
fever develops the disease. If the onset is within the arbitrary period
of 28 days from the return home of the patient, this is classed as a return
case. Such cases might occur in about 5 per cent. of the households
to which patients return, though the incidence is quite variable. Most
of these cases are thought to be associated with the return home of the
primary case who, though most often apparently clinically well, does in
many cases exhibit abnormal signs such as a running of the nose, an
abnormality not present at the time the patient leaves hospital, but
developing on his return home. Not all these cases are the result of
an infection contracted from the returning patient. In a number of
instances the second patient has fallen ill even before the first has returned.
It is presumed in these instances that infection has been spread by some
inanimate object, or it might be due to the presence of a persistent carrier
of the causative organism.
When the influence of removal of a patient to hospital in limiting
the spread of infection in the household is being considered, it is necessary
to take account of the extent to which these return cases occur. Although
persons in the same household have been known to develop scarlet fever
after freeing from isolation of a child nursed at home throughout the
course of the illness, these occurrences are quite exceptional as contrasted
with the not unusual development of the return case.
The incidence of the return cases is probably related in some degree
to the general invasiveness of the organism. Insofar as the occurrence
of secondary infection may be due to the same cause, their frequency
might be related. In 1949, however, by contrast with the higher
incidence of secondary infection there were no return cases.
Schools and Infection.
Although so many of the patients who succumb to an attack of
scarlet fever are children of school age, in this district it has rarelv been
found in recent years that an attack of scarlet fever in a child is the result
of his contact with another recognised case at his school. This year,
mostly during the summer term, there was a markedly higher incidence
of infection amongst those attending some schools. These schools were
infected at the same time by a throat infection which was quite probably
the result of infection by the same organism which caused a reaction