PUBLIC HEALTH REPORTS.

VOL. XXVI.

NOVEMBER 17, 1911.

No. 46

THE CHOLERA SITUATION.

Reports received indicate that the outbreak of cholera in the northern part of Italy has about subsided, and that fewer cases are being reported in the rest of Italy. Otherwise there has been no material change in the cholera situation during the past week.

AN INVESTIGATION OF THE PREVALENCE OF TYPHOID FEVER AT CHARLES TOWN, W. VA.

By J. R. RIDLON, Assistant Surgeon, Public Health and Marine-Hospital Service.

Upon request of the State board of health to the Surgeon General, Public Health and Marine-Hospital Service, to send an officer for the purpose, the writer was detailed to conduct investigations of typhoid fever in Charles Town, W. Va., and vicinity, to determine the cause of the undue prevalence of the disease, the methods of transmission, and the measures necessary for its control. The investigation extended from August 19 to September 13, 1911.

It is a pleasure to make due acknowledgment of the help and courtesies afforded by the board of health, the mayor and city council, the local newspapers, the officials of the water company, and various other citizens of the city. Appreciation is expressed for the cooperation of the local physicians, without which assistance a complete investigation would have been impossible.

A temporary laboratory, supplied from the Hygienic Laboratory, was established in Charles Town at the office of Dr. C. L. Skinner, for whose courtesy appreciation is also expressed.

POSSIBLE CAUSES.

A preliminary survey of the situation showed that the possible causes to be considered were much the same as in other localities at this season of the year, namely, (1) water supply; (2) milk supply; (3) ice supply; (4) uncooked fruits and vegetables; (5) other food supplies, including ice cream, shellfish, and bakery products; (6) infection by personal contact; (7) infection by flies; and (8) infection through faulty disposal of excreta.

SCOPE OF INVESTIGATIONS.

The investigation included (1) a sanitary survey of the source of the town water system; (2) a study of general sanitary conditions in the city, including the milk supply, the food supply, and the disposal of sewage; (3) a bacteriological examination of the town and other waters; (4) the making of Widal tests as an aid in diagnosis; and (5) an epidemiological study of 30 cases occurring since the 1st of June. For the latter a blank form was used and filled out with information furnished by the patient or other reliable person and covering all facts pertinent to the possible source of infection.

EXTENT OF OCCURRENCE OF TYPHOID.

Among a population of 4,000 (estimated), including the cities of Charles Town and Ranson and the people within a radius of about 3 miles, there occurred during June, July, and August, 1911, 30 cases of typhoid fever with 2 deaths.

Ranson may be classed practically as a part of Charles Town, although under a separate city government. It is really an extension of the city and has the same public water supply. Many people living in Charles Town are employed in Ranson and vice versa. The popu lation is estimated at between 500 to 600 and the houses are, for the most part, more widely scattered than in Charles Town. Ranson appears to have been remarkably free from typhoid, no cases having been reported in that community.

The above reports of cases and deaths are taken from personal reports by the physicians, as typhoid fever is not reported officially. The record of deaths is incomplete and unsatisfactory, so that no accurate comparison can be drawn between this year and previous ones. This condition should be remedied by the reporting of cases of typhoid fever to the health officer, as are certain other infectious diseases.

The above figures give a rate of occurrence equal to 1 case of typhoid to every 133 people, and a mortality rate of 50 deaths to 100,000 of population, which rate may be justly considered excessive, regarding typhoid fever as a preventable disease and not a necessary evil. The case mortality rate, being 6.6 per 100, is lower than the average, which is usually regarded as 10.

The general opinion of physicians and others is that there has probably been little, if any, more typhoid fever in Charles Town and vicinity during the present season than for preceding years.

The distribution of the cases between the city and surrounding country shows that in proportion to the population the incidence of the disease is about equal, 22 cases having occurred in the city in a population of 3,000 and 8 in the country in a population of about 1,000. The 30 cases occurred in the following months: 2 in June, 11 in July, and 17 in August. This closely follows the usual seasonal prevalence of the disease, the greater number of cases usually appearing in August and September except in epidemics of an explosive and widespread character, such as may be caused by water or milk borne infection, and frequently appear in the colder months. A tendency to the grouping of cases is shown by a study of their location. Seven occurred in one neighborhood on South George

Street, 2 occurred in a hotel and 2 in the immediate vicinity, 4 occurred on the same farm, 3 in one neighborhood in the southwestern part of the city, 2 near Conrad Spring, 2 in the same house on Washington Street, while only 8 were scattered or isolated cases. Of the 30 cases 12 occurred in 4 houses, distributed as follows: 5 in 1 house, 3 in another, 2 in another, and 2 in still another. These facts suggest that contact and flies were important factors in the spread of infection.

AGE.

The distribution according to age was, under 5 years, 2; 5 to 9 years, 7; 10 to 14 years, 6; 15 to 19 years, 6; 20 to 24 years, 0; 25 to 29 years, 3; 30 to 34 years, 1; 35 to 39 years, 2; 40 to 44 years, 0; 45 to 49 years, 3; total, 30.

The occurrence of 15 cases, or 50 per cent, among children under 15 years of age is a high percentage.

SEX.

The distribution of the cases was nearly equal according to sex, 16 being among males and 14 among females.

COLOR.

Twenty-two cases occurred among the white population and 8 among the colored. Of these 8 cases 4 were probably contact cases, occurring where little, if any, attention was given to sanitary surroundings.

WIDAL TESTS.

As an aid in diagnosis 11 Widal agglutination tests were made of which 5 were positive for Bacillus typhosus, 2 positive for Bacillus paratyphosus A, and 4 negative. Of the 4 negative ones 2 cases were not clinically typhoid, and 2 cases in which the test was made during the first week were clinically typhoid and are so classed.

It is interesting to note that paratyphoid infection was present along with the typhoid infection, 2 cases showing positive agglutination for Bacillus paratyphosus A, but not for Bacillus typhosus. It is regretted that the paratyphoid organism was not isolated.

It is extremely improbable that any errors of diagnosis were made in the 30 reported cases.

DISCUSSION OF EPIDEMIOLOGY.

MILK.

Of the 30 cases 22 gave a history of using raw milk within 30 days of onset of the disease. Eight of these used milk from their own In one instance a boy, during the incubation period, was carrying milk to several customers, and in two instances milk was being supplied from a place where there was a typhoid patient.

The most probable source of infection for one case was from milk. Taking into account the age of the patients, 50 per cent being under

15 years, and the irregular source of supply in several instances, it is probable that milk was a more important factor in the spread of

infection.

A number of patients gave a history of obtaining milk within 30 days from several sources, some of which they could not remember, and this irregularity of supply necessarily made the source of infection much more difficult to trace.

The fact that no license is required to sell milk and that no sanitary supervision is exercised over the sources of supply must be regarded as dangerous to the public health, not only in regard to the spread of typhoid fever, but of other infectious diseases as well.

Much of the milk used in the city comes from places where only a few cows are kept and the surplus beyond home consumption is sold. In but few cases could the sterilization of milk receptacles be called adequate, and pasteurized milk is not sold.

ICE CREAM.

Of the 30 patients, 19 used ice cream occasionally within 30 days at various places, mostly at home. No suspicion was attached to any common supply, and ice cream can be practically eliminated as a source of infection.

UNCOOKED FOODS.

At this season in Charles Town uncooked shellfish can be definitely eliminated.

The use of uncooked fruits and vegetables was quite general among the 30 patients, the supply being obtained from various sources, but no case could be definitely attributed to either of these causes. However, the exposure of these articles, in the markets and elsewhere, to contamination by flies and dust is to be regarded as a possible source.

ICE.

The general use of artificial ice made from distilled water makes it possible to practically eliminate this as a possible factor.

FLIES.

The most probable source of infection in 5 cases was from flies. These cases were located within 200 feet or less of other cases where the disinfection of stools was inefficient, where there were no screens, and where the abundant flies had free access to both dejecta of patients and the food. That flies under the proper conditions can be a prominent factor in the spread of infection is an undisputed fact, as is also the fact that their prevalence can be greatly limited by proper care of their breeding places, including stable manure, household refuse, and garbage.

CONTACT.

The most probable source of infection in 10 cases, or 33 per cent, was from contact. These patients gave a history of living in the same house in intimate association with other patients, either in the febrile or incubation stage of the disease. This is a high percentage and shows that contact becomes a most important factor where the necessary precautions are not taken.