Part Six (of Don’t Count Your Children Until They’ve Had the POX!) Scarlet Fever Returns: but it is a lot less deadly!

Scarlet Fever Returns: but it is a lot less deadly

We don’t know much about Scarlet Fever from the earlier era (pre-1800s), but we do, however, understand that it was fairly widespread and existed in some form as it relates to another fairly similar disease – Diphtheria, as documented in the excerpt below taken from Charles Creighton’s 1894 history of epidemics.

A History of Epidemics in Britain

CHAPTER VII.

SCARLATINA AND DIPHTHERIA.

Scarlatina and diphtheria have to be taken together in a historical work for the reason that certain important epidemics of the 18th century, both in Britain and in the American colonies, which were indeed the first of the kind in modern English experience, cannot now be placed definitely under the one head or the other, nor divided between the two.

Creighton, C.  (1894, 678)
[1]
https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693

Creighton also documents regular and widespread outbreaks of throat infections that often led to fatalities throughout Ireland, Britain and in parts of the U.S. over the course of the 18th Century (the 1700s) that were akin to what we would call Scarlet Fever. However, it wasn’t really until the 19th Century (the 1800s) that we begin to see specific epidemics erupt around the same time within Ireland, Scotland, England and Wales that Scarlet Fever becomes understood as a more distinct disease as indicated in the excerpt that follows.

A History of Epidemics in Britain

Vol. II.

SCARLATINA

… The general prevalence of malignant scarlet fever in the first years of the 19th century is farther shown by the accounts from Ireland, which were recalled by Graves in a clinical lecture of the session 1834-35, during the prevalence of a scarlet fever as malignant as that of thirty years before…

“In the year 1801,” he says, “in the months of September, October, November and December, scarlet fever committed great ravages in Dublin, and continued its destructive progress during the spring of 1802. It ceased in summer, but returned at intervals during the years 1803-4, when the disease changed its character; and although scarlatina epidemics recurred very frequently during the next twenty-seven years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution.

The epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes terminating in death (as appears by the notes of Dr Percival kindly communicated to me) so early as the second day. It thinned many families in the middle and upper classes of society, and even left not a few parents childless. Its characters seem to have answered to the definition of the scarlatina maligna of authors.”

The long immunity from malignant scarlatina which Graves asserts for Ireland after 1804, is made probable also for England and Scotland after 1805…

It is not until 1831 that we begin to hear much of malignant scarlatina again. But it is clear that scarlet fever was common enough all through that interval, probably in its milder form. It was now the usual epidemic trouble of schools.

Creighton, C.  (1894, 722-3)
[2]
https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693

Supporting this observation of Scarlet Fever taking a turn for the worse to become a much more lethal contagion of pandemic proportions throughout many of our developing nations, and bearing in mind that we also had to contend with other fairly consistently deadly contagions of the era such as, Measles, Diphtheria and Whooping Cough (Pertussis) alongside Scarlet Fever, as indicated below,  Scarlet Fever became so deadly that it began to supersede all of these  other contagions. Scarlet fever–past and present

AETIOLOGY 

In the early nineteenth century, the clinical presentation of the disease appears to have changed for the worse. Lethal epidemics were seen in Tours, France, in 1824; in Dublin, Ireland, in 1831; and in Augusta, Georgia, during 1832-33. Similarly, in Great Britain, the fatality rate from scarlet fever increased from between 1 and 2 % to more than 15% in 1834. From 1840 until 1883, scarlet fever became one of the most common infectious childhood disease to cause death in most of the major metropolitan centers of Europe and the United States, with case fatality rates that reached or exceeded 30% in some areas–eclipsing even measles, diphtheria, and pertussis.
Smith, T.C.(2011)
[3]
http://aetiologyblog.com/2011/07/06/scarlet-fever-in-hong-kong/

 In other words, you can imagine how parents felt as they not only were losing their children to all the other highly lethal contagions of childhood, but now they had to contend with the lesser of these killers rising to prominence as an even greater plague of destruction in the form of a particularly virulent increase of Scarlet Fever.

Scarlet Fever knew no social boundaries. When Scarlatina came to visit, it didn’t matter how poor or well off you were, she could still knock on your family’s door. For instance, as highlighted earlier in Creighton’s (1884) [4] discussion of the devastation of Scarlet Fever in Ireland of the beginning of the 1800s, he highlights the fact that even some of the more affluent families had been thinned by its impact. And indeed, the devastation often included some of our best-known figures of historical renown as highlighted in the following excerpt:

Scarlet fever–past and present 

AETIOLOGY

Children were always the worst affected, and proved to be highly susceptible. Charles Darwin lost two children to scarlet fever in the 1850s. Scarlet fever is also believed to have caused the 19-month old Helen Keller to lose her hearing and sight. John Rockefeller lost a two-year old grandson to scarlet fever, which is why Rockefeller University remains one of the world’s leading biomedical research centers in the world today.

Smith, T,C, (2011)
[5]
http://aetiologyblog.com/2011/07/06/scarlet-fever-in-hong-kong/

Scarlet Fever was so common and dreaded in childhood that it worked its way into children’s literature such as Little Women and  ‘Velveteen Rabbit’. Below is a short excerpt from the latter.

SYNOPSIS

The Velveteen Rabbit, or How Toys Become Real tells the story of a stuffed rabbit made of velveteen…

And then, one day, the Boy was ill.
His face grew very flushed, and he talked in his sleep, and his little body was so hot that it burned the Rabbit when he held him close.  Strange people came and went in the nursery, and a light burned all night and through it all the little Velveteen Rabbit lay there, hidden from sight under the bedclothes, and he never stirred, for he was afraid that if they found him some one might take him away, and he knew that the Boy needed him…
Presently the fever turned, and the Boy got better.  He was able to sit up in bed and look at picture books, while the little Rabbit cuddled close at his side.  And one day, they let him get up and dress
The Boy was going to the seaside tomorrow.  Everything was arranged, and now it only remained to carry out the doctor’s orders.  They talked about it all, while the little Rabbit lay under the bedclothes, with just his head peeping out, and listened.  The room was to be disinfected, and all the books and toys that the Boy had played with in bed must be burnt.
“Hurrah!” thought the little Rabbit.  “Tomorrow we shall go to the seaside!”
…Just then Nana caught sight of him.
“How about this old Bunny?” she asked.
“That?” said the doctor.  “Why, it’s a mass of scarlet fever germs!– Burn it at once.  

Williams, M., (1922, 33-36)

[6]

https://archive.org/stream/thevelveteenrabb11757gut/11757.txt

Thankfully, the boy (and seemingly the rabbit) survive the ordeal with Scarlet Fever – thus, leaving the reader with some hope that the disease could be gotten over without any bad effects. And most certainly, they needed hope, as you might imagine, at the coal face so to speak, there was a great deal of pessimism as we felt wholly helpless and unable to prevent this slaughter of innocence. Below are some quotes from the period which reveal this bewilderment and hope that our medical advances will hold the key to such senseless destruction of life sometime in the not too distant future.

Chapter 5

The Historiography of Social Medical Improvement

… the situation in February 1885 remained bleak:

The prevention of scarlet fever is as yet an unsolved problem. I trust such men as Pasteur and Koch will turn their attention to it; my only hopes of a satisfactory answer lie in that direction…

Davies was not alone in his pessimism…:

Yet, as knowledge and administrative resources now stand, official powers of preventing this murderous disease are, practically speaking, insignificant; and such general advice as may be given for individual preventive purposes has so little likelihood of being applied except in select cases, that, as regards the main mass of sufferers, it may seem almost insincere and derisory…

Bristol Historical Resource (2000)
[7]
http://humanities.uwe.ac.uk/bhr/Main/abstract_health/Health_5.htm

Creighton draws our attention to the remarkable pattern of  this disease as it rose from being so meek to such lethal virulent proportions for a number of decades from the mid-19th Century, and he also describes how it began to return to its milder form by the 1880s within England and Wales, but bear in mind that Ireland, Scotland and many other regions follow this pattern of peaks and troughs for the same period.

A History of Epidemics in Britain

Vol. II

The enormous number of deaths from scarlatina during some thirty or forty years in the middle of the 19th century will appear in the history as one of the most remarkable things in our epidemiology. There can be no reasonable doubt that this scarlatinal period was preceded by a whole generation with moderate or small mortality from that disease, just as it is now being followed by annual death-rates which are less than a half, perhaps not more than a third, of the average during forty years before 1880.

Creighton, C.  (1894, 72)
[8]
https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693

As tabulated by Creighton (1894), although Scarlet Fever’s reign of terror is shown to continue ebbing, the statistics also demonstrate that Measles, and to some extent, Diphtheria, began to pick up the reins where Scarlet Fever left off up to the time of Creighton’s review published in the last decade of the 19th Century. This pattern is illustrated in the following graph for the era under discussion (Figure 1).

Scarlet Fever, Measles, Diphtheria Eng and Wales

Fig. 1 Graph generated using tabulations for individual annual death statistics in England and Wales from 1837 to 1880 compiled by Creighton, C. (1894) A History of Epidemics in Britain, Volume II, From the Extinction of Plague to the Present Time, p. 722-3, Cambridge University Press, Cambridge.https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693

As we move into the 20th Century, we discover something that the earlier statisticians could not have foreseen. Scarlet Fever ceases to be a major threat to children and becomes a relatively benign disease of childhood.

Scarlet Fever Deaths Ireland

Fig. 2: Chart of the annual individual number of deaths in Ireland from Scarlet Fever since records began going beyond the period when deaths from this disease were no longer registered. Source: Chart generated using this tumultuous statistics reports since records began – “Annual Reports on Marriages, Births and Deaths in Ireland, from 1864 to 2000” courtesy of: An Phríomh-Oifig Staidrimh, Central Statics Office CSO, link. © Copyright dig-press.com

Scarlet fever–past and present 

AETIOLOGY

Historical data suggest at least three epidemiologic phases for scarlet fever. In the first, which appears to have begun in ancient times and lasted until the late eighteenth century, scarlet fever was either endemic (always present at a low level) or occurred in relatively benign outbreaks separated by long intervals.

In the second phase (~1825-1885), scarlet fever suddenly began to recur in cyclic and often highly fatal urban epidemics. In the third phase (~1885 to the present), scarlet fever began to manifest as a milder disease in developed countries, with fatalities becoming quite rare by the middle of the 20th century.

In both England and the United States, mortality from scarlet fever decreased beginning in the mid-1880s. By the middle of the twentieth century, the mortality rate from scarlet fever again fell to around 1%.

Smith, T,C, (2011)
[9]
http://aetiologyblog.com/2011/07/06/scarlet-fever-in-hong-kong/

A drop to c. 1 per cent by the middle of the 20th Century in the death rate from Scarlet Fever is fairly spectacular.

The pattern seen in the above graph for deaths from Scarlet Fever in Ireland (Fig. 2) corresponds very closely with the historical documentation for the same timeframe as those charted for England and Wales and elsewhere.  Moreover, the fact that Scarlet Fever cases (infections) were very prevalent at the time when deaths from the disease was very rare in our more modern era (the 1950s and 60s) is clearly illustrated by the steep decline in deaths from Scarlet Fever and correspondingly high incidence of cases of the disease recorded from official statistics in England and Wales for infants and children even up to the 1940s (given in Figure 14) in: ‘A Century of Changes in the Mortality and Incidence of the Principal Infections of Childhood’ (Gale, A.H, Medical Officer, Ministry of Education, 1945) http://adc.bmj.com/content/archdischild/20/101/2.full.pdf [10].

Bearing in mind the fact that Scarlet Fever childhood outbreaks (epidemics) in our more modern era did not produce corresponding mortality and morbidity, it is not until we review the death statistics over the course of the earlier part of the 20th Century throughout our developed nations that we really grasp just how dramatic the decline in deaths from Scarlet Fever throughout this timeframe truly was.

For instance, this is clearly seen within graphs presented in Figure 4.15: Scarlet Fever from the turn of the 20th Century until modern times, with the overwhelming majority (over 99 per cent) decline in deaths occurring in the period 1901-45 (See ‘Atlas of Epidemic Britain: A Twentieth Century Picture’  Smallman-Raynor, M., and Cliff, A (2012) [11] https://books.google.ca/books?id=iMnN4fZrj70C&pg=PA48#v=onepage&q&f=false

This dramatic decline of Scarlet Fever as a major killer – also within England and Wales – is clearly seen in the graphs generated in Thomas McKeown’s research as illustrated in ‘The Role of Medicine’ (1979) http://peaceworkspartners.org/vault/Oxford/DPHPC/Health%20and%20Development%20Course/Int%20Dev%20Readings%20HT10/1a.%20Main%20Theories/McKeown%20The%20Role%20of%20Medicine%201979.pdf  [12].

This near-simultaneous decline in deaths from Scarlet Fever (but not its cases of infection) is also illustrated by the graphs generated for the United States for a similar timeframe here: Figure 1: Deaths per 100,000 from Rheumatic Fever and Scarlet Fever …Link https://www.econ.ucla.edu/costa/figureschicago.pdf ‘Health at Older Ages: The Causes and Consequences of Declining Disability among the Elderly’ (Costa,  D.L., 2009) [13]. 

Also see the graphs  ‘Mortality in the United States 1900 – 1950’ (Gordon, T., 1968, figure. 3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2024011/ [14], and ‘Vital Statistics Rates in the United States, 1940 -1960’, (Grove, R.D. and Hetzel, A., 1968) https://www.cdc.gov/nchs/data/vsus/vsrates1940_60.pdf [15] for very similar patterns of decline in deaths from Scarlet Fever and essentially the same endpoint for this disease ceasing to be a major killer – again, within the United States.

Anyway,  everyone it seems began to sigh a great breath of relief as they were now counting more of their children with increasing confidence, from having had Scarlet Fever. But, it just so happened that Scarlet Fever returned and it would seem that we had forgotten just how tame this pathogen had become and we simply equated the return of the disease in our modern world with a return to the type of fatalities of the 19th and earlier 20th Century. It was a global comeback out of seemingly nowhere, and its impact left everyone scratching their heads.

THE ONCE-DEADLY SCARLET FEVER IS MAKING A WEIRD COMEBACK AROUND THE WORLD

What is happening!

After decades of decline, scarlet fever is once again on the rise in the UK and other places around the world, and doctors are scrambling to figure out why.

Beginning in 2014, the infection started to steadily rise, and in 2016, over 19,000 cases from 620 outbreaks were reported, mostly in schools and nurseries. This represents a seven-fold increase since 2011.

Starr, M., (2017)
[16]
https://www.irishtimes.com/life-and-style/health-family/scarlet-fever-is-back-in-the-21st-century-1.3291330

You can begin to imagine the fear as we began to realise that this was the very same disease and symptoms of Scarlet Fever of old. Would our children start dying from the disease in their thousands as emblazoned in our imaginations of the tragic stories of the dark days of the Victorian era?

 Scarlet fever: the disease in the UK

The Pharmaceutical Journal

…it may not sound terrible based on those symptoms, but it was responsible for 36,000 registered deaths in the first decade of the 20th century in England and Wales, and was a leading cause of child mortality.

There’s no vaccine for scarlet fever. Once contracted, it’s treated quite easily with a course of antibiotics, which – at least partially – contributed to the disease’s decline in developed countries after about 1945.

Marshall, S.  (2006)
https://www.pharmaceutical-journal.com/opinion/comment/scarlet-fever-the-disease-in-the-uk/10001690.fullarticle
[17]

This was a true pandemic as it almost went worldwide. It was horrifying for the poor parents of infants and children who got the disease as they had remembered stories of the massive death toll of the dreaded strawberry tongue.

Scarlet Fever, a Disease of Yore, Is Making a Comeback

The reason for the sudden surge remains a mystery,

Scientific America

Scarlet fever, a disease that struck fear into the heart of parents when cases surged in the days of yore, appears to be making an unexpected and puzzling comeback in parts of the world. England and Wales have seen a substantial rise in scarlet fever cases starting in 2014.

The number of cases tripled from 2013 and continued to increase in 2015 and 2016, with England and Wales last year recording the highest number of cases there in a half-century, British scientists reported Monday in the journal Lancet Infectious Diseases.

Similar and in some cases even larger surges of scarlet fever have been reported in recent years in South Korea, Vietnam, China, and Hong Kong. Hong Kong, which saw a tenfold rise in cases, continues to report increased annual counts five years after the resurgence was first noticed.

The reason for the sudden and surprising increase is a mystery. And the authors of a commentary that accompanied the article urge other countries to be on the lookout for similar spikes in cases.

Branswell, H. (2017)
[18]
https://www.scientificamerican.com/article/scarlet-fever-a-disease-of-yore-is-making-a-comeback/

However, the pandemic continued to sweep throughout our now developed nations, and its impact was nowhere near as devastating as we were beginning to anticipate. Different causes for the mildness of the modern pandemic were considered as seen in the following.

 Scarlet fever: the disease in the UK

The Pharmaceutical Journal

…The most obvious reason for a resurgence in a bacterial infection would be a new strain of the disease that spreads more easily and is possibly antibiotic-resistant – but molecular genetic testing has ruled this out.

Instead, tests showed a range of already established strains of the bacteria, leaving researchers still looking for a possible cause.

Meanwhile, the 2016 statistics put incidence at 33.2 cases per 100,000 people, with 1 in 40 cases being admitted to hospital (although around half of those get discharged the same day).

Marshall, S. (2006)
https://www.pharmaceutical-journal.com/opinion/comment/scarlet-fever-the-disease-in-the-uk/10001690.fullarticle
[19]

This posed the obvious question: if it was not the Scarlet Fever strain of old – the pathogen that killed so many – then,  what on earth was going on? The fact that it was essentially the same disease and amazingly, no deaths and rather brief and typically uneventful hospital visits, left them even more puzzled than before as indicated in the following excerpt:

Scarlet Fever, a Disease of Yore, Is Making a Comeback

The reason for the sudden surge remains a mystery,

Scientific America

“The strains didn’t give us the answer. We were really pinning our hopes on those, because that’s the most obvious answer,” she noted. “We’re left thinking what on earth it could be. We don’t have an answer at the moment.” Even though scarlet fever does not have to be reported to the CDC, Lamagni said a surge in the United States would be hard to miss. “If they were seeing what we’re seeing, they would know about it. It is unusual,” she said.

Branswell, H. (2017)
[20]
https://www.scientificamerican.com/article/scarlet-fever-a-disease-of-yore-is-making-a-comeback/

We now know that the pathogen didn’t change genetically – it’s still the same pathogen that killed thousands annually back in the day. And perhaps the answer to this quandary regarding Scarlet Fever’s return in our fully modern era points to another cause. It looks very likely that our immune systems have become highly educated regarding this particular pathogen. Our genes didn’t change to accommodate, it as it would take too long to make such a genetic change as discussed earlier – perhaps then, our fairly rapid adaptation is more indicative of an epigenetic phenomenon – leaving a long-term impression upon our existing genes that can be transmitted across generations.

Could it be that like the great plagues (Typhus, Typhoid, Dysentery and Cholera) discussed previously, that it was our familiarity and resistance to the pathogen that had changed over many generations and this memory was imprinted in our ancestor’s epigenome? This would provide us with very longterm resilience to the pathogen and it would be perfectly natural if the disease returned in our modern era, that it would behave in the way that it did – giving us all a much-needed booster, lest our immune systems forgot. See it as a type of fire drill and a way of keeping our systems up to date. After all, as the excerpt below indicates:

Scarlet fever: the disease in the UK

The Pharmaceutical Journal

Figures suggest that up to 40 per cent of the population are asymptomatic carriers, with low infectivity and little risk of developing complications.

Marshall, S. (2006)
https://www.pharmaceutical-journal.com/opinion/comment/scarlet-fever-the-disease-in-the-uk/10001690.fullarticle
[21]

With that number of asymptomatic carries (or silent carriers of Scarlatina), it seems that it is always circulating away in the background – but simply not generally expressing itself to any great degree.

It would appear that we just became more resilient to its attacks via exposure over the generations akin to what would seem to be the case with all the other – once more deadly contagions discussed thus far. Fortunately, with all the generations of exposure prior to this pandemic event, we were ready for Scarlatina’s return, even if we didn’t know it at the time. With no vaccine at hand, everyone assumed that deaths and horrors of the Victorian era would descend upon our children.

I suppose nobody knew to look back at the death statistics and watch in real-time, as, across all our developing nations, even by the mid-1940s,  this disease was already becoming a relatively benign and natural rite of passage in childhood and do also bear in mind that Measles went the same way shortly after.

Next Episode: Part Seven: (Don’t Count Your Children ’til they’ve had the POX) Killer Plagues of Our Modern Era – Plummet from Natural Causes..?

References to Part Six
[1]  Creighton, C. (1894) A History of Epidemics in Britain, Volume II, From the Extinction of Plague to the Present Time, Vol. II, p. 678, Cambridge University Press, Cambridge.https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693
[2]  Creighton, C. (1894) A History of Epidemics in Britain, Volume II, From the Extinction of Plague to the Present Time, Vol. II, p. 722-3, Cambridge University Press, Cambridge.https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693
[3] Smith, T.C. (2011) Scarlet fever–past and present, Aetiology Blog (July 6yh 2011) [Available online at aetiologyblog.com] http://aetiologyblog.com/2011/07/06/scarlet-fever-in-hong-kong/
[4] Creighton, C. (1894) A History of Epidemics in Britain, Volume II, From the Extinction of Plague to the Present Time, Vol II. Cambridge University Press, Cambridge.https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693
[5] Smith, T.C. (2011) Scarlet fever–past and present, Aetiology Blog (July 6yh 2011) [Available online at aetiologyblog.com] http://aetiologyblog.com/2011/07/06/scarlet-fever-in-hong-kong/
[6] Williams, M., (1922) Velveteen Rabbit or How Toys Become Real, Doubleday & Company , Inc., New York. [Available on Project Gutenberg] https://archive.org/stream/thevelveteenrabb11757gut/11757.txt
[7] Bristol Historical Resource (2000) Chapter 5: The Historiography of Social Medical Improvement, in, (eds) ByIan Archer, Spencer Jordan, Keith Ramsey, Peter Wardley and Matthew Woollard [Available online website BHR] http://humanities.uwe.ac.uk/bhr/Main/abstract_health/Health_5.htm
[8] Creighton, C. (1894) A History of Epidemics in Britain, Volume II, From the Extinction of Plague to the Present Time, Vol. II, p. 72, Cambridge University Press, Cambridge.https://www.gutenberg.org/files/43671/43671-h/43671-h.htm#Page_693
[9] Smith, T.C. (2011) Scarlet fever–past and present, Aetiology Blog (July 6yh 2011) [Available online at aetiologyblog.com] http://aetiologyblog.com/2011/07/06/scarlet-fever-in-hong-kong/
[10] Gale, A. H. (1945). A Century of Changes in the Mortality and Incidence of the Principal Infections of Childhood. Archives of Disease in Childhood, Vol. 20, [101], pp. 2–21. http://adc.bmj.com/content/archdischild/20/101/2.full.pdf
[11] Smallman-Raynor, M, and Cliff, A (2012), Atlas of Epidemic Britain: A Twentieth Century Picture, Oxford University Press, Oxford. p.50, figure 4:18 (Measles); p. 52, figure 4:24 (Whooping Cough); p.49, figure 4:15 (Scarlet Fever). https://books.google.ie/books
[12] Mc Keown, T (1979) The Role of Medicine: Dream, Mirage, or Nemesis? Basil Blackwell, Oxford [Available online as PDF] http://peaceworkspartners.org/vault/Oxford/DPHPC/Health%20and%20Development%20Course/Int%20Dev%20Readings%20HT10/1a.%20Main%20Theories/McKeown%20The%20Role%20of%20Medicine%201979.pdf
[13] Costa, D. L., (2009) Health at Older Ages: The Causes and Consequences of Declining Disability among the Elderly in, (eds.,) David M. Cutler and David A. Wise, Selection from a published volume from the National Bureau of Economic Research, University of Chicago Press [Available online at the National Bureau of Economic Research NBER] http://www.nber.org/chapters/c11109.pdf
[14] Gordon, T. (1953) Mortality in the United States, 1900-1950. Public Health Reports, Vol. 68 [4], pp. 441–444. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2024011/
[15] Grove, R.D., and Hezel, A.M (1968) Vital Statistics Rates in the United States, 1940 – 1960, Department of Health, Education and Welfare Public Health Service, National Center for Health Statistics. [Available online cdc.gov] https://www.cdc.gov/nchs/data/vsus/vsrates
[16] Starr, M., (2017) The Once-Deadly Scarlet Fever is making a Weird Comeback around the World – What is happening! Irish Times, (November 29th 2017) https://www.irishtimes.com/life-and-style/health-family/scarlet-fever-is-back-in-the-21st-century-1.3291330
[17] Marshall, S., (2006) Scarlet fever: the disease in the UK, The Pharmaceutical Journal (July Issue 2006). https://www.pharmaceutical-journal.com/opinion/comment/scarlet-fever-the-disease-in-the-uk/10001690.fullarticle
[18] Branswell, H., (2017) Scarlet Fever, a Disease of Yore, Is Making a Comeback – The reason for the sudden surge remains a mystery, Scientific America (November 28th 2017). https://www.scientificamerican.com/article/scarlet-fever-a-disease-of-yore-is-making-a-comeback/
[19] Marshall, S., (2006) Scarlet fever: the disease in the UK, The Pharmaceutical Journal (July Issue 2006). https://www.pharmaceutical-journal.com/opinion/comment/scarlet-fever-the-disease-in-the-uk/10001690.fullarticle
[20] Branswell, H., (2017) Scarlet Fever, a Disease of Yore, Is Making a Comeback – The reason for the sudden surge remains a mystery, Scientific America (November 28th 2017). https://www.scientificamerican.com/article/scarlet-fever-a-disease-of-yore-is-making-a-comeback/
[21]  Marshall, S., (2006) Scarlet fever: the disease in the UK, The Pharmaceutical Journal (July Issue 2006). https://www.pharmaceutical-journal.com/opinion/comment/scarlet-fever-the-disease-in-the-uk/10001690.fullartic

 

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