Jpn. J. Infect. Dis., 52, 208‑213, 1999

Original Article

PediatriC Admission for Vaccine Preventable Diseases:
a 5‑year Survey from 1994 to 1998 in Aichi Prefecture
Takao Ozaki* , Tsuneo Morishimal , Takahisa Hirota2, Kouhachiro Suglyama3●

and Yoshizo Asano4
Department of Pediatrics, Showa Hospital,
Nobaku 46, Nobaku, Kohnan 483‑8703,

1Department of Hygiene, Nagoya UniversitySchool of Medicine,
Higashi‑ku, Nagoya 461 10047,{

2Department of Pediatrics, Aichi Medical UniJersity,
Nagakute, Aichi 480‑ll 95,
3Department of Pediatrics, Nagoya CityUniversity,

Mizuho‑ku, Nagoya 467‑0001 and4Department of Pediatrics, Fujita Health University, Kutsukake,Toyoake 470‑1101, Aichi, Japan(Received September 10, 1999. Accepted October 25, 1999)

SUMMARY: Several infectious childhood diseases can be prevented by vaccination･ A survey of hospital
admissions for such diseases was conducted in Aichi Prefecture over 5 years beglnnlng in 1994･ A questionnaire●●

was sent annually to hospitals with 100 or more beds to obtain information on pediatric patients requlnng hospl‑●●●

talization for 10 vaccine preventable diseases･ Information was obtained on 3,953 patients･ Most admissions
were for measles (49%), followed by mumps, chickenpox, pertussis, rubella, and tuberculosis. Over half of thepatients were under 3 years old, with 20% aged under 12 months, 25% aged from 12 months to 2 years, and lo啄
aged from 2 to 3 years･ The average hospital stay was longest fわr tuberculosis and pertussis, and was around 1

week for the other diseases･ Familial transmission was the most common source of infection identified･ The only

deathwas an unvaccinated patient with measles pneumonia･ Sequelae were reported at the time of discharge in
15 patients (0･4%), and were permanent in some cases. Some 96% of the patients surveyed were unvaccinated●agalnSt the disease causlng hospitalization･ The fact that there were 14 patients with sequelae and the one patient
who died were unvaccinated, emphasizes the need to promote vaccination･

nation on patients aged 15 years or younger who required

INTRODUCTION

hospitalization between January and December. Ten diseases

In order to implement effective measures for the preven‑

were surveyed: tuberculosis, measles, rubella, chickenpox,

tion of infectious diseases in children throughvaccination,

mumps, pertussis, diphtheria, Japanese encephalitis, polio一●

the Aichi Prefecture Council For Viral Infectious Disease
Policy was set up in Aichi Prefecture in 1994, the same year
amendments were made to the Japanese Preventive Vaccina‑

myelitis, and tetanus. The toplCS COVered included patienttion IAW･ This was partly prompted by the growlng Importancetion history. The cost of admission for each of the various●

background data, details of the disease (diagnosis, sourcF of
infection, reason for admission, and outcome), and vacclna‑●of, and more presslng need for, a safe environment for the

diseases was also investigated at 1 5 0f the hospitals. Althoughhealthy growth and development of infants, preschoolers, andthe investigation of influenza was also considered to be●important, this disease was excluded from the 5‑year survey

school‑age children due to the declining birth rate･

due to the dimculty of making a definitive diagnosis in daily

One of the Council's tasks was to conduct a fact‑finding

clinical practice.

survey over a 5‑year period beglnnlng ln 1994, targeting●●●

pediatriC patients in Aichi Prefecture who required hospitaliza‑tion for diseases that could have tN3en Prevented by vaccination･

RESULTS
Number or reported cases:

MATERIALS AND METHODS

Table I shows the number of reported cases of the 10 diseases

during the 51year Surveyperiod. Questionnaires were retumed

The 5‑year survey targeted 112 hospitals (1 1 I from 1997)
With pediatric patients and 100 or more beds which had been

by 42‑51 hospitals each year, with a total of 3,953 patientsselected from the medical institutions in Aichi Prefecture,

being reported over the 5‑year period. The majority of●admissionswere for measles (49%), followed by mumps (24%),

which is located in the center of Japan ltotal population of

6,986,289 (5･5% of the total Japanese population) and a popu‑
lation aged under 16 years of 1,178,120 (16.9%) as ofOctoberchickenpox (17%), pertussis (lo啄), rubella, andthen tuber‑culosis. No patients were admitted with diphtheria, Japanese
encephalitis, poliomyelitis, or tetanus. The number of cases

1998】･ The participating hospitals were sent a questionnaire

reported each year varied 5‑fold, ranglng from 248 to I ,288.

each year for the 5 years from 1994 to 1998 to obtain infor‑

This was due mainly to variation in the number of admissions*Corresponding author: Fax: +8 1 1587‑5610340

fわr measles.

208'

Table l･ Number of reported cases of each disease
Disc‑e Tuberculosis Measles Rubella Chckenpox Mu‑ps Pe血ssis Diphtheria Ei::pThei;ietis Polio‑yelitis Tetwus Tohl

1 994

2238tt97tq
oJ oJ 仲 oJ 仲

809

Number 1995
0r

Reported 1996
CaSeS(%) 1997

nrh一 円■ ､■‑u Ei

106(13.9)(68. 2)91(8. 9)

73

119

61

(18.6)(30. 4)(15.6)

285

128

328

(34. 0)(15.3)(39.1)

763

151

314

(59. 2)(24.4)

6(ll.7)
91(2.4)(36.7)(50.0)

1 998･obl (.I.2)

165

1 L 1 0.10.4240tt087 O
iZE nr■Ju qJu ノー■u∩■Jhu nrhu n■.r■nu M■1 u

I

93

6

29

0

0

0

1,187

132

0

0

0

0

392

0

0

0

0

838

0

0

0

0

1 ,288

0

0

0

0

248

(33.7)
95(ll.3)
41(3. 2)

1 24

654

0

(7.7)

26

(10.5)

933

385
0(49.0)

(0.7)

(

16.5)

0

(23.6)

(9.7)

0

v

v

0

3

,953

o

Age and sex:

years.Aswith measles, a high proportion of children hospital‑

Figure 1 shows the age range of the patients forall diseases

ized for chickenpox was in th芭younger age groups･ Children

combined and fわr each individual disease. Children under 3

under 12 months old accounted for 25% of admissions, theyears old accounted fわr 56% of admissions, with 20% aged

second highest rate of infants after pertussis･ In contrast with

under 12 months, 25% aged from 12 months to 2 years, andmeasles, chickenpox, and pertussis, the older age groupslo啄 aged from 2 to 3 years. In other words, over half of theaccounted for the majority of patients with mumps (the second
most common disease), and 86% of the patients were aged 3

patients admitted were infants and young children.
The l6 patients･ with tuberculosis (the least common disease)

years or older･ Pertussis had the highest rate of infant admis‑

were relatively evenly distributed across each age group. In

sions, with 68% of its patients being younger than 12 months

contrast, 67% of the patients with measles (the most common

and more than half of them being younger than 6 months old

disease) were aged 2 years or younger, while I 8% were schoolage (18% were 6 years or older and 10% were ll years or(not shown in Fig. 1).
The survey lnCluded 2,199 boys and 1,721 girls, while theolder)･ For the small number of patients hospitalized forsex of the remalnlng 33 patients was not specified･ There were

●

●

●

●

rubella, the two common age groups were preschoolers aged

no slgnificant sex differences for overall admissions or for

between 3 and 5 years as well as school children aged 6‑10

the individual diseases.

Au Diseases

TtJ berculosis

Chickenpox

Mumps(3,953 Patients)(16 Patients)(654 Patients)(933 Patients)

Measles

RubellaPertussis( I ,936 Patients)(29 PatierltS)(385 Patients)､､12moto<2yr■<12mo三二6‑10yr

rW 3‑5 yr
ロUnknown

Figure l･ Age distribution

209

裁く3yr
帯1日5yrTable 2･Length of hospital stay

Length of HospitalStay
Di s cas e Total

Mean± SD
≦l wk

≦2 wk

≦3 wk

≦4 wk

>4 wk U血own/lU ′b Oノ

1932

Tuberculosi 〜

Measles

4

229
1

l 9

縄1 9卿甥1

12 8125耶砧

430903407

Rubel la68.2 ± 42.7000431

5 ∠U 1 2 5 1

1

6.2±3.9

2

1 1 1

8

6.1 ±3.9654

117

7.7 ±7.5

Mumps

933 5

315

7.6±9.8

Pertussi s

3 8

178

10.8± 10.8

Chi ckenpox

Total

3

,953

2,629

1

,029

Length of hospital stay･.

933) of mumps patients were admitted because of complica‑

Table 2 shows the length of hospitalization for each disease･

tions, with aseptic meni.nglqtis being diagnosed in 83% (586/The longest average hospital stay was for tuberculosis (68705)･ Patientswitht chickenpox were hospitalized for F varietydays), followed by pertussis (I I days). For the other diseasesof reasons. Those admitted because of complications lnCluded(measles, rubella, chickenpox, and mumps), the average hos‑

15 with encephalitis or menlngitisand 40 with febrile convul‑

pital stay was approximately 1 week, although some patientssions. The reason for the admission ofpertussis patients was
the severity of the original disease in 71% (273/385)and●

were hospitalized for a long period･ Of the 3,953 patientssurveyed, 2,629 (67%) Were hospitalized for 1 week or less.

complications in only 17% (64/385).
Outcome :Source of infection and reason for admission:
The source of infection was unknown in 66% (2,594/3,953)

Table 3 shows the patient outcome at the time of discharge.

of the patients. When the source was identified, familial trans‑

In the 5‑year period surveyed, there was only one death. The

mission was the most common, followed by transmission atpatient was a 1‑yeaト01d male child with measles who deve1‑●

0ped pneumonia and had not been vaccinated agalnSt the

public facilities such as preschools or schools and at medical
institutions such as hospitals, in that order. Identification of

disease. Sequelae were reported at discharge in 15 patientsthe source of infection was most common for tuberculosis(0.4%), and were persistent in ll of them. The outcome was(81%, 13/16), followed by chickenpox (41%, 271/654) andmumps (41%, 380/933), while it was least common fortherefore good in the vast majority of patients.

pertussis (20%, 77/385)･ Family or relatives were reported tobethe source of infection in ll patients with tuberculosis,
accounting for 85% of patients in whom the source was iden‑discharge were as fわllows: among 5 patients with measles,●

The sequelae reported in the 15 patients at the time ofthere was liver dysfunction, an abnomal electroencephalo‑gram (EEG), and an abnormal chest X‑ray film in 1 case each,tified･ Medical institution,s were identified as the source ofas well as blindness in 2 patients (one in the left eye and theinfection in many patients with measles (279, or 46% of theother bilateral); 5 patients with mumps had hearing loss in 3

608 patients fわr whom the source was specified). This wascases and idiopathic thrombocytopenic.purpura (ITP) in 2

followed by familial transmission, which wasthe reported

cases; 3 patients with tuberculous menlngitis had cerebral

source for 158 measles patients･ The disease was transmitted

palsy in 2 cases and hydr∝ephalus in 1 case, 1 patient withfrom the parents in 15 cases･ Further investigation is required

chickenpox had amputation of the left leg due to fulminant

to determine whether the parents were unvaccinated, Orgroup A streptococcal (GAS) infection, and l patient withwhether they contracted the disease after being vaccinated･

rubella had muscle weakness in the lower limbs (Table 4).

●

●

●

The severity of the onglnal disease itself or complications

Tuberculous menlngitis occurred only in these 3 patients who

accounted for 86% (3,385/3,953) of the admissions･ Amoヮgwere unvaccinated. Follow‑up showed that 4 cases of thepatients with measles, chickenpox, and pertussis, the seventyof the ordinal disease was the reason for admission more often

abnormal chest X‑ray caused by measles, as well as muscle

sequelae resolved (liver dysfunction, EEC abnomalities, andthan the ∝cu汀enCe Of complications･ In contrast, complica‑

weakness in the lower limbs caused by mbella). However,tions were the reason fわr hospitalization in 76% (705/933) of

the blindness caused by measles, cerebral palsy and hydro‑

patients with mumps. Some 7% (259/3,953) of admissions

cephalus caused by tuberculosis, hearlng loss caused bywere requested for family relief.

mumps, and leg amputation associated with chickenpox were●Some 38% (737/1 ,936) of measles patients wでre hospital‑

all pemanent. The two patients with mumps who developed

ized due to complications･ Although lower resplratOry tract

ITP had the chronic form, and it remained present more than 2

infections such as pneumonia and bronchitis were the mostyears later. Fourteen of the patients with sequelae (excludingcommon complication, febrile convulsions were also reported

the measles patient with transient EEC abnomalities in 1 994)

in 46 patients and encephalitis in 14. A total of 76% (705/

and the other measles patient who died were unvaccinated･

Table 3. Outcome
Di sease

Resolved lmproved

Tubercul osi s

Measles

2ー̲301 6㌶13

1 6跳29封3 8l 91‖70̲ 23 275知7 232

Rubel 1 a/lU Oノ 3

Chi eke npox

Mumps
Pertussi s
Tota1

3 ,953*Unv accinated.

210

lHH

sequelaeDea h

Not Entered3511500100000 0 0 q/ 3 2*

Table 4･ Sequelae
Year
1994

1995

DiseaseSequelaMeaslesAbnomal EEC

Muscle weakness in the lower limbs

Vaccination

History

Cerebral palsy
Heanng loss

Measles

Blindness in the left eye

Measles
Mumps

Abnormal chest X‑ray film
Heanng loss

Mumps

ITP

Hydrocephal us

Tuberculosis

Measles
Mumps
1998

Patients

Rubel la

Mumps

1997

of

Liver dysfunction

Tuberculosis

1996

No･

Measles

Bilateral blindness

Heanng loss
Amputation of the left leg

Chickenpox

Table 5･ Vaccination history
Vaccination

Di sease

History"

Unknow n

Total

No. of･Pati e nts

Tubercul osi s

43.8

7 ′0 1 0 0 5

Measles

Faotieonfts

7

5

3.9

1

,744

No. or%Pati ents

31.3

90.

Rubel la3.4

Chi ckenpox

1.2

618

94.5

5.4

812

87.0

Mumps

5

Pertus si s

26

4 /b 2 0 1 4

1

1 1 27

89.7

1.3

376

97.7

3.7

3,581

90.6

Table 6･ Medicalcosts (Point systema)Av era ge

Disease Faot･ieOnfts

No. of Points (I Point=Yb10)〜5,000 ‑10,000 ‑20,000 ‑40,000

80,000‑160,000 ‑320,000 320,000‑

Total Av e rage
No. orTotal No.

No. of

OfPoints

Days inMeasles

1 2 91 1細414m

001010｡脚47｡仰0 0 2 AV 4

l O^

8 12

2知41 614350292 1叫

30 00 24

1,791,624

767

20,436,383

7,263

220121l10311

2 11

RubellaChi c ke npox

1 2

Mumps

67

2,76 1

9,654,337

Pertussi s
Total

216,484

9,263 ,593

5

2,016

2

127

56

1,124

6,839,532

96

590

133

25

7

8

48,201,953

perPatient

per Day

149,3022,336
2,8 14

19,6803,23 1

23 ,320

2,41 2perPati ent

1 9,860

27,008

3 ,322

16,592

Poi nts

Poi nts

Hospital

Tubercul osi s

No. or

33,041

23,9103 ,355
2,906

2,836
2,905

aThis isthe system used bythe NationalHealthInsurance Scheme in Japan to reimburse hospitalSand doctors･b¥=Japanese yen

Vaccination history:

after being vaccinated and one of the 10 measles patients

The vaccination history of the patients surveyed is shown

developed encephalitis. It was not possible to investigate thein Table 5･ The majority of the patients (96%, 3,806/3,953)

vaccine used, as this information was unavailable for thewere either unvaccinated or had an unknown vaccination

maJOrityof patients.
Medicalcosts:●

history and only 147 (3.7%) had definitely been vaccinated.
The proportion of patients that required hospitalization despite

The cost of hosp血l admission was investigated at 15 0f thebeing vaccinated was highest for tuberculosis (44%), followedfacilities surveyed (Table 6), which handled 2,016 patients orby muPps (5･4%), and measles (3･9%)･ Patients w.ere deflned

5 1 % of the total(2,016/3,953). The average hospital admission

as havlng been vaccinated even if they had been Immunized

cost･ per patient was lowest forrubella (Y197,000) and highest

only once.

for tuberculosis畔1.493 million), reflecting the length of hospi‑

The length of time between vaccination and the onset oftal stay. The average cost per patient was Y239,000 (US$the disease was unknown in over half of the patients･ In several

2,100) forall diseases combined and the totalhospital admis‑

patients with measles, mumps, and chickenpox, vaccination
was performed immediately before onset, since the patient

over the 5‑year period. Since these 15 facilities accountedsion cost for the 15 facilities surveyed was Y482.02 million

developed symptoms several days later (i.e., the patient had
been vaccinated during叫e incubation period of the naturalfor 51% of the 3,953 patients surveyed, the total cost for allof the facilities was estimated at over Y900 million (US$ 8

infection)･ Ten patients with measles and I with mumps weremillion).

reported to have contracted the disease more than 10 years

211

●

transmission from infected individuals without the typical

DISCUSSIOON

cough seemed to have occu汀ed in a considerable number of

The effect of amendments tothe Japanese Preventive Vacci‑patients withpertussis, the source of which was often di爪cultnation hw in October 1994 has been followed with interest,

to identify. Medical institutions werethe source of infection

since vaccination is encouraged rather than being compulsory

in 46% of measles patients for whom the source was identifled,

under the amended Law･ In particular, there was concem thathighlighting the need for strategies to prevent the in‑hospital

the vaccination rate would fall, leading to epidemics and antransmission of this disease. Interestingly, I 5 measles patients

increase of admissions･ The 5‑year survey of the Aichi Prefec‑
ture Council For Viral Infectious Disease Policy was started inwere infected from their parents. Further investlgatiOn isrequired to determine whether the parents were unvaccinatedthe year that the new Preventive Vaccination bw was enacted,

or whether they contracted the disease despite vaccination.

●in order to provide an indication of the effects of the newSome 86% of all patients were hospitalized because of the

Law･ A total of 1,187 admissions were reported in the 1994

severity of the orlglnal disease itself or fわr complications.

●survey･ This decreased to approximately one‑third (392) in●

However, 7% of admissions were requested for family relief,in part reflecting the trendd in Japan toward fewer children･ A●

the followlng year. The number of admissions increased to

838 in 1996, and rose agaln tO 1,288 in 1997, the fourthyear

slgnificant number of measles patients were admitted fわrof the survey･ This was fわllowed by a dramatic fall to 248 incentral nervous system complications such as febrile convul‑●●

1998･ One of the major Causes Of these marked changes was thesions and encephalitis, as well as for lower resplratOry tract

variation in the number of patients with measles, for which a

infections such as pneumomiaand bronchitis, demonstrating oncehigh proportion of patients seemed to hB hospitalized･ Althoughagaln that measles is a potentially serious disease. Complica‑

the survey was initiated because of concem that the number oftions were the reason for admission in 76% of mumps patients,

patients with vaccine preventable diseases increase followlng

withviralmenlngitis accounting for 83% of them. This finding

amendment of the Vaccination hw, the results did not show

reconfirms the highincidence of menlngltlS aS a complication

●

●

●

●

●

●

●

a nslng trend in admissions for the diseases surveyed･ Effortsof mumps. In contrast with mumps, most pertussis patientsby health professionals to encourage vaccination are thought

were hospitalized because of the severityof the originaldisease

to be the reason that patient numbers remained fairly constant･itself, with 71 % being admitted fわr this reason. The fact that

Overall, more than half of the admissions occurred during

many of these patients were very young demonstrates that

infancy or early childhood･ Some 67% of the patients hospl‑

pertussis is a severe disease in infancy (1). The other reasons

talized for measles, which was the most common cause offor hospitalization varied, but included referral from medical

admission, were aged 2 years or younger, again highlighting

practitioners and emergency departments.

the importance of early vaccination･ School‑age children also

One patient with measles died during the 5‑year survey●

comprlSed a considerable proportion of admissions forperiod. Apart from this patient, the outcome was generally gd,

measles, with 18% of the patients being aged 6 years or older

With sequelae being reported in only 15 patients. Pemanent
sequelae included blindness caused by measles (2), cerebral

and lo啄 being aged 1 1 years or older, indicating the need for●more widespread vaccination･ Like measles, many patientspalsy and hydr∝ephalus caused by tuberculosis, hearlng loss

admitted for chickenpox were very young, withchildren aged

Caused by mumps, and leg amputation due to fulminant GAS

infection associated with chickenpox. Chickenpox is thought

2 years or younger accounting for 65%. The numbr of admis‑

sions for chickenpox was third highest, after measles andto be a particularly important risk factor for severe invasive

mumps, also demonstrating the need for early vaccination･

GAS infections in previously healthy children (3‑5). Another

Unlike measles, chickenpox, and pertussis, the majority of

two patients with mumps developed ITP as reported by otherchildren hospitalized for mumps (the second most common

investigators (6‑8) and were still being monitored 2 years later.

disease) were older･ This reflects the epidemiologicalcharac‑

Fourteen of the patients with sequelae were unvaccinated●teristics of the disease, which is more common in school age(excluding the patient with measles who exhibited transientchildren･ Most admissions for pertussis occurred durlng

EEC abnomalities), as was and the measles patient who died.

infancy, with 68% of the patients being under 12 months old･Over half of them were under 6 months old, at which age theThis fact emphasizes the importance of vaccination.

disease is more likely to become severe (1).

illnesses were either unvaccinated or hadanunknown vaccina‑●

The finding that 96% of the patients admitted with these

The average hospital stay was longest for tuberculosis (68tion history also indicates theusefulness of vaccination. Althoughdays)･ This was because some tuberculosis patients required

thepercentage of patientsthat required hospitalization despite●

long‑term treatment, thereby increaslng the average hospitalstay

being vaccinated was highest for tuberculosis (44%), thefor the whole group･ Tuberculosis was followed by pertussis,

effectiveness of the BCG vaccine cannot be evaluated fromfor which the average hospital stay was ll days, probably

these results. The hospital cost of admission was generally

because of the severity of this disease in infants, who made up

around Y200,000 (US$ I,800) per patient and the total costthe majority of admissions･ Although some patients with otherof hospitalization for all of the patients over the 5‑yearperiod

diseases required long‑term admission, most were hospitalized

was estimated to be in excess of ¥900 million (US$ 8 million).

for 1 week or less.

Thus, this survey provides slgnificant data for investigating●

The source of infection was unknown in the majority of

the cost‑effectiveness of vaccination.
In conclusion, this Aichi Prefecture survey has provided

patients. When it could be identified, familial transmission
was the most common source, followed by public facilities

some indication of the current situation in Japan regarding

such as preschools or schools, and medical institutions suchdiseases that can be prevented by vaccination. It is hoped

as hospitals. Identification of the source of infection was mostthat the findings of this survey will be used for promoting

common for tuberculosis and least common for pertussis･As

vaccination policy in Japan.

has been reported previously, family members and relatives

were the major source of infection (85% of cases) in tuber‑culosis patients for whom the source was identified. In contrast,

212

series of fourteen patients. Pediatr･ Infect･ Dis･ J･, 14,

REFERENCES

588‑594.

5. Doctor, A., Harper, M. B. and Fleisher, G･ R･ (1995):l･ Cherry, J. D. and Heininger, U. (1998): Textbook ofPediatric Infectious Diseases, vol. 2, p. 1426‑1428. The

Group A beta‑hemolytic strept∝∝Calbacteremia: histori‑

WB.Saunders Co., Philadelphia.

●

2. Foster, A. and Sommer, A. (1986): Childhood blindness
from corneal ulceration in Africa: Causes, prevention,with varicella. Pediatrics, 96, 428‑433.

6. Kolars, C. P.and Spink, W. W. (1958): Thrombocytopenic

and treatment. Bull. WHO, 64, 619‑623.
3. Wilson, G. J., Talkington, D. F., Gruber, W., Edwards,

pu叩ura aS a COmplication of mumps･ JAMA, 168, 2213‑

2215.

7. Hyatt, H. W, Sr. (1961): Thrombocytopenic purpura

K･ and Dermody, T. S. (1995): Group A streptococcal●●

cal overview, changlng Incidence, and recent association●

necrotlZlng fasciitis followlng Varicella in children: casecomplicating epidemic parotitis in a child･ Arch･ Pediatr･,

reports and review. Clin. Infect. Dis., 20, 1333‑1338.

78, 143‑150.

4. Brogan, T. V., Nizet, V., Waldhausen, J. H., Rubens, C.

8. Graham, D. Y, Brown, C. H., ⅠⅠⅠ, Benrey, ∫. and Butel, ∫.

S. ( 1 974): Thrombocytopenia; a complication of mumps･E･ and Clarke, W 良. (1995): Group A streptococcal

JAMA, 227, 1162‑I 164.

■

nectrotizing fasciitis complicatlng Prlmary Varicella: a

号t213