Epidemiologic Notes and Reports Acute Rheumatic Fever at a Navy Training Center -- San Diego, California

Between December 15, 1986, and July 15, 1987, 10 cases of acute rheumatic fever (ARF) were identified among recruits at the Naval Training Center (NTC) in San Diego, California. This outbreak was the first at the San Diego NTC in over 2 decades.

All patients were male and ranged from 19 to 31 years of age. Five were white, four were black, and one was an Asian/Pacific Islander. All had polyarthritis and fever and met the modified Jones criteria (1). Three patients had carditis confirmed by Doppler echocardiography, and one had subcutaneous nodules. Antistreptolysin O titers ranged from 500-2,500 Todd units, and corrected erythrocyte sedimentation rates were 55-129 mm. Five of the 10 patients indicated that they had had a sore throat within 1 month of admission to the hospital. One patient had sought treatment for sore throat and was diagnosed as having group A Beta-hemolytic streptococcal (GABHS) pharyngitis but did not complete an oral penicillin regimen. Throat cultures for four of the patients were positive for GABHS when they were hospitalized for ARF. No M- or T-serotyping was performed on these isolates. Paired sera from seven of the first nine cases are being tested for M-type-specific antibody.

The attack rate for ARF was 0.75/100,000 recruits from January 1, 1982, to December 1, 1986. In 1987, it was 80/100,000. No clustering of ARF had occurred at the San Diego NTC since at least the mid-1960s.

Six cases of GABHS pneumonia also occurred among NTC recruits during the ARF outbreak. All six patients had positive sputum cultures, radiographic evidence of pneumonia, elevated white blood cell counts, and elevated antistreptolysin O titers. Two had empyemas in the left lower lobe of the lungs, which required drainage. For both patients, GABHS was confirmed by culture of the empyema. All patients responded to penicillin. One case of GABHS septic arthritis was also identified. Only two cases of GABHS pneumonia had occurred among active duty personnel in the San Diego area from 1982-1986.

Recruits at NTC receive primary medical care only at recruit sick call or the base emergency room. A single laboratory serves both facilities. From February 2, 1987, to April 13, 1987, recruit sick call used only rapid diagnostic tests for diagnosing GABHS disease. Tests were positive for 25% (328/1,298) of the recruits seen for respiratory tract symptoms. The emergency room at NTC continued to use throat cultures to diagnose GABHS pharyngitis. During the same time period, 44% (66/149) of the throat cultures taken in the emergency room were positive for GABHS. None of the 91 cultures taken during the same time period in 1986 were positive. The number of patient visits did not differ significantly between 1986 and 1987.

Attack rates for laboratory-confirmed GABHS pharyngitis exceeded 10 cases per 1,000 recruits per week for 8 consecutive weeks beginning February 9, 1987. While this rate has not been documented at NTC in over 10 years, smaller peaks of illness were noted at other times (Figure 1). The Armed Forces Epidemiological Board has suggested that rates of streptococcal disease in excess of 10/1,000 recruits per week may result in epidemics of ARF (2).

For approximately 15 years, intramuscular benzathine penicillin G was given to all incoming recruits at NTC as prophylaxis against streptococcal infection. However, the practice was discontinued in 1980 because of a perceived decrease in the risk for ARF and related streptococcal sequelae. The Marine Corps Recruit Depot adjacent to NTC has used benzathine penicillin G prophylaxis continuously since the mid-1960s. No cases of ARF were reported at the Marine depot during the time of the outbreak at NTC, although GABHS pharyngitis was epidemic.

During this outbreak, the mean time from entering training to diagnosis and hospitalization was 44 days. This finding is consistent with past experience and with current Navy streptococcal infection control directives, which suggest that medical departments be especially aware of the potential occurrence of ARF about 42 days after training begins. Mass prophylaxis with benzathine penicillin G has been reinstituted at NTC (3). All incoming recruits except those allergic to penicillin receive 1.2 million units intramuscularly. Weekly streptococcal disease surveillance rates are being scrutinized. The prophylaxis program will be reevaluated in the spring of 1988. Reported by: LCDR T Papadimos, MC, USN, CDR, J Escamilla, MSC, USN, Navy Environmental and Preventive Medicine Unit No. 5; LCDR P Garst, MC, USN, CDR E Oldfield, MC, USN, LT C Counihan, MC, USNR, Naval Hospital; LT S Schiffer, NC, USN, CAPT T Gross, MC, USN Br Clinic, Naval Training Center, San Diego; KH Acree, MDCM, MPH, JD, Acting State Epidemiologist, California Dept of Health Svcs. Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Apparent increases in ARF have been reported recently from Utah, Pennsylvania, and Ohio, and a recent CDC survey identified a twofold or greater increase in ARF in several other states (4-8). The increase in ARF at the San Diego NTC after a period of time with little or no ARF is similar to the experience in these states. Although the incidence of ARF has not returned to levels observed in the early 1970s, the resurgence of this disease in several different areas raises many important issues regarding prevention and control. It reemphasizes the need for accurate diagnosis and adequate treatment of GABHS pharyngitis, and it underlines the need to learn more about the complex geographic, host, and microbial factors that influence the distribution of ARF in this country and throughout the world. The need for carefully designed epidemiologic studies to different areas raises many important issues regarding prevention and control. It reemphasizes the need for accurate diagnosis and adequate treatment of GABHS pharyngitis, and it underlines the need to learn more about the complex geographic, host, and microbial factors that influence the distribution of ARF in this country and throughout the world. The need for carefully designed epidemiologic studies to evaluate these issues has been emphasized (9).

The NTC epidemic offers a unique opportunity to reexamine ARF among military populations, which are recognized to be at increased risk for streptococcal infections and their sequelae (10-12). Collection of standardized clinical and demographic information from recruits with upper respiratory infections is needed to clarify risk factors for acquiring GABHS pharyngitis and subsequently developing ARF. The use of throat cultures to diagnose GABHS pharyngitis at NTC and the retention of GABHS isolates will permit serotyping of isolates from patients with ARF and may help determine whether certain strains or serotypes of GABHS are more likely to cause rheumatic fever among this population (9). Rapid diagnostic tests for GABHS could be used at NTC once acceptable levels of sensitivity and specificity have been documented. The high rates of GABHS pharyngitis and ARF at NTC offer an opportunity to reevaluate treatment regimens for GABHS pharyngitis and to compare methods of mass prophylaxis. Questions regarding year-round versus seasonal prophylaxis, routine prophylaxis of all new recruits versus prophylaxis only when the incidence of GABHS pharyngitis increases above a preset level, and the timing and number of penicillin doses given each recruit could be studied.

Despite recent increases in some areas, ARF continues to occur sporadically at low levels in this country. In the past decade, surveillance of ARF through notifiable disease reporting has received relatively little attention, and many states have recently dropped ARF from their list of notifiable diseases (13). Alternative methods, such as periodic hospital discharge surveys or reviews of outpatient records at sentinel clinics may help identify regions to target for more intensive surveillance and prevention efforts. State health departments are requested to notify the Respiratory Diseases Branch (RDB), Division of Bacterial Diseases, Center for Infectious Diseases, CDC, of other clusters of cases of ARF. The Streptococcal Laboratory of RDB serves as the reference laboratory for serotyping GABHS isolates from patients with known or suspected ARF. Information on ARF in the United States can be obtained by calling RDB at (404) 639-3021.

References

1. American Heart Association. Jones criteria (revised) for guidance in the diagnosis of rheumatic fever. Circulation 1965;32:664-8.

2. Armed Forces Epidemiological Board. Recommendations of the ad hoc committee on prophylaxis of streptococcal infections of the commission on streptococcal disease. Washington, DC: Armed Forces Epidemiological Board, 1959.

3. Frank PF, Stollerman GH, Miller LF. Protection of a military population from rheumatic fever: routine administration of benzathine penicillin G to healthy individuals. JAMA 1965; 193:775-83.

4. Veasy LG, Wiedmeier SE, Orsmond GS, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med 1987;316:421-7.

5. Wald ER, Dashefsky B, Feidt C, Chiponis D, Byers C. Acute rheumatic fever in western Pennsylvania and the tristate area. Pediatrics 1987;80:371-4.

6. Hosier DM, Craenen JM, Teske DW, Wheller JJ. Resurgence of acute rheumatic fever. Am J Dis Child 1987;141:730-3.

7. Congeni B, Rizzo C, Congeni J, Sreenivasan VV. Outbreak of acute rheumatic fever in northeast Ohio. J Pediatr 1987;111:176-9.

8. Centers for Disease Control. Acute rheumatic fever--Utah. MMWR 1987;36:108-10,115.

9. Kaplan EL. Epidemiological approaches to understanding the pathogenesis of rheumatic fever. Int J Epidemiol 1985;14:499-501.

10. Rammelkamp CH, Denny FW, Wannamaker LW. Studies on the epidemiology of rheumatic fever in the Armed Services. In: Thomas L, ed. Rheumatic fever. Minneapolis: University of Minnesota Press, 1952.

11. James L, McFarland RB. An epidemic of pharyngitis due to nonhemolytic group A streptococcus at Lowry Air Force Base. N Engl J Med 1971;284:750-2.

12. Basilier JL, Bistrong HW, Spence WF. Streptococcal pneumonia: recent outbreaks in military recruit populations. Am J Med 1968;44:580-9.

13. Kaplan EL. Current status of rheumatic fever control programs in the United States. Public Health Rep 1981;96:267-8.

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