Epidemiology and Control of Acute Respiratory Diseases With Emphasis on Group A Beta-Hemolytic Streptococcus: A Decade of U.S. Army Experience

¹ Epidemiology and Disease Surveillance Directorate, U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland
² Preventive Medicine Service, Madigan Army Medical Center, Tacoma, Washington
³ Clinical Investigation Department, Brooke Army Medical Center, Fort Sam Houston, Texas
⁴ Food and Drug Administration, Rockville, Maryland
⁵ Department of Pediatrics and World Health Organization Collaborating Center for Reference and Research on Streptococci, University of Minnesota Medical School, Minneapolis, Minnesota

Address correspondence to: John F. Brundage, MD, MPH, Epidemiology and Disease Surveillance Directorate, U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, MD 21010-5422

Objective. To summarize the experiences of the U.S. Army regarding prevention and control, and frequencies, rates, trends, and determinants of febrile acute respiratory diseases (ARDs), particularly Group A beta-hemolytic streptococcus (GABHS).

Methodology. Since 1966, the U.S. Army has conducted routine surveillance of ARDs among basic trainees. Since 1985, all trainees with fever and respiratory tract symptoms have been cultured for GABHS. Field investigations were conducted when outbreaks of acute respiratory or GABHS-associated illnesses were detected. Mass plus tandem benzathine penicillin prophylaxis were used to interdict and control training center GABHS outbreaks.

Results. During the period 1985 to 1994, there were 65 184 hospitalizations for acute febrile respiratory illnesses among Army trainees. The crude hospitalization rate was 0.45 per 100 trainees per week. The rate consistently declined over the period. Incremental dedines were temporally associated with increased use of adenovirus immunizations and broader use of benzathine penicillin prophylaxis. During the period, 10 789 of 59 818 (18%) pharyngeal cultures were positive for GABHS. GABHS outbreaks were associated with diverse clinical manifestations including streptococcal toxic shock, acute rheumatic fever, and pneumonia. The emergence of mucoid colony morphology in clinical isolates was a consistent indicator of circulating virulent strains with epidemic potential. Outbreak-associated M types were M1, M3, M5, and M18. In response to six GABHS outbreaks, mass plus tandem benzathine penicillin chemoprophylaxis produced rapid and sustained GABHS control. ARD and GABHS recovery rates were lowest when benzathine penicillin prophylaxis was widely used.

Conclusions. ARD rates among Army trainees have consistently declined to unprecedented levels. GABHS has reemerged as an important threat to military trainees.

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