OF THE Department of Health of the City of New York All communications relating to the publications of the Department of Health should be addressed to the Commissioner of Health, 149 Centre St., N. Y. Entered as second class matter May 7, 1913, at the post office at New York, N. Y., under the Act of August 24, 1912. Vol. V. NEW YORK, APRIL, 1915. No. 4 TYPHOID FEVER IN NEW YORK CITY. With Some Special Studies Made During the Last Three Years. By DR. M. L. OGAN, Chief Division of Epidemiology, Bureau of Preventable Diseases. Prevalence and Report. It is generally known by physicians throughout the city that each case of typhoid fever must be reported as soon as the diagnosis is made. The difficulties of early diagnosis in so insidious a disease are fully comprehended by the clinicians of the Department of Health and physicians are not censured for delay in reporting of this disease when the explanation makes it apparent that obscure symptoms were solely responsible for such delay. It is the practice of the Department, however, to call the attention of the reporting physician to each and every case where the elapsed time from onset to date of report is as much as two weeks. The officers of the Department believe that any continued fever, not otherwise definitely accounted for, should arouse suspicion of this disease, and inasmuch as the agglutinins are present in the blood at about the end of the first week, the Widal test is available for settling the matter. Of course, even in the second week, or later, of typhoid fever, this reaction is sometimes negative and any practitioner may be excused for not having decided upon his diagnosis when the laboratory findings have not been conclusive. Failure, however, to resort to this helpful measure as an aid is almost inexcusable in view of the im portance of the disease and the danger to those about the patient. A great many of the cases are reported indirectly by means of specimens sent to the Department Laboratories for examination. In the year 1914, as heretofore, threefourths of the cases were reported by this means, a positive Widal specimen being considered as a proper notification. The following table shows the number of Widal examinations, and the total number of cases reported in 1914: How Reported— One of the worst outbreaks the city has ever experienced was due in part to the failure of certain institutions to report a number of cases under treatment. These were the very early cases of the outbreak and, had they been promptly reported, a study of the food habits of the persons involved would have revealed the source of the infection in time to have prevented many other cases. The importance of early notification cannot be too much impressed upon medical practitioners both private and institutional. In order to insure prompt notification of all these infections, it would be even well to have a number of cases incorrectly reported on the mere suspicion that they might be typhoid fever. The authoritatively estimated case fatality of this disease is about 11%, whereas the average fatality for the past five years of the cases reported in New York City has been nearly 15%. The following table, arranged by boroughs, therefore shows the probable approximate number of cases unreported for the year 1914: Nearly 800 cases, therefore, were probably never reported. New York City does not stand alone in this respect and, for this reason, all careful studies of typhoid fever prevalence have been based upon the death rate per unit of population, rather than on the case incidence. The Department is not satisfied, however, to have the shortcomings of New York City excused by those of other communities and will continue its practice of inquiring carefully into each delayed report and especially into those cases reported as typhoid fever for the first time upon the death certificate. Where necessary, physicians will be summoned to give an accounting for this breach of duty. The Sanitary Code requires that each case be reported within twenty-four hours of the time it is first seen. This is interpreted, liberally, to mean within twenty-four hours of the time a diagnosis might reasonably have been made. It is good practice always to submit a specimen for the Widal test in suspected cases. This affords the Department an opportunity, if the specimen proves negative, to call up the physician at the end of the week to inquire as to the outcome of the case; meanwhile he has shown his good intention, though he may be still in doubt. Standard Case Incidence.-The Department has comprehensive data as to the occurrence and distribution of cases of typhoid fever by boroughs and by wards, according to the date reported, for a period of many years. Exclusive of epidemics, it is therefore known just how many cases may be expected in a given time from one of these units (borough or ward). A table from Monograph No. 3, *Richmond having had a case fatality of only 10.3 on a small number of cases, the actual number reported exceeds the estimated number, on an eleven per cent. basis, by three. Health Dept. Series, is subjoined to illustrate the manner of tabulation of such 0.41 0.42 0.4 0.21 0.8 0.4 7 8.0 0.21 0.8 5 7.0 1 30.4 4 6.0 7 22 6 15 0.2 0.2 0.2 0.21 0.8 1.0 23.. .4 29 11 22 26 20 18 0.6 0.2 0.2 0.6 3 0.8 24. 21 21 16 19 25 44 18 0.4 0.2 0.2 0.2 0.220.2 10.6 25. 15 88 19 12 11 37 19 0.2 0.2 0.2 0.2 0.6 10.2 0.6 0.6 0.6 2 5.0 0.2 0.21 0.3 2 7.0 10.4 0.210.6 9 4.0 0.3 10.41 0.6 0.8 8 6.0 0.4 10.4 0.2 8 8.01 0.25 0.2 10.4 7 5.0 0.4 28. 27 27 35 6 21 47 23 0.41 0.2 0.2 15 8.0 0.21 0.21 0.2 0 2 0.4 ....11.2 0.4 0.6 10.8 0.4 1.4 0.2 0.8 0.43 0.61 0.4 1.8 1.4 1 0.23 0.8 0.2.... 1.6 10.8 2 2.5 0.6 0.4 12.01 1.01 1.5 2 0.8 2 2.4 1.0 23.3 0.4 3 0.4 2 2.4 1 0.8 1 3.5 1.0 2 2.8 0.41 0.2 0.2 0.8 10.6 2 0.8 0.42 0.82 0.6 2 C.2 2 1.2 0.62 0.0 11 2.0 0.22 0.42 0.63 5 3.4 0.21 0.21 2.0.6 1.4 0.4 0.4 1.2 0.8 2 2.4 0.64 0.25 0.6 0.42 0.2 4 4.0 1.01 1.6 20 12.0 0.4 0.6 2 0.65 1.0 2 1.8 1 0.8 6 3.2 0.22 1.0 18 10.01 0.6 1 0.21 0.84 1.0 11.0 11.2 13 4.0 0.22 1.4 26 11.0 1 0.41 0.6 0.63 0.61 .871.2 7 5.4 11.2 22 12.01 0.2 0.8 1.2 4 1.6 3 1.6 3 0.4 13 5.0 2.02 1.6 23 17.01 0.6 1.0 10.6 2 1.8 2 1.8 4 3.0 7 4.0 0.8 1 3.0 23 24.0 1.2 1.0 0.8 11.8 18 12.2 10 2 2.8 1 1.2 3 2.4 21 24.01 1.6 10.8 1.2 20.6 1.6 2.6 13 11.5 0.2 13.6 0.4 1 0.8 2 0.8 1 2.0 32 29.0 1 2.6 0.6 0.8 1 1.2 23.8 12.6 4 10.5 4 0.5 1 0.8 1 2.3 1.0 13.1 38 31.0 1.81 0.4 1 0.8 2 1.0 14.4 2 3.8 15 10.0 0.43 0.21 0.2 0.8 23.02 0.6 6 2.0 2.1 4 2.4 24 27.0 11.3 0.6 0.64 1.4 24.63 3.4 6 8.5 0.4 0.6 10.4 1 2.6 1 1.25 1.8 1.6 1.2 16 22.02 0.8 0.61 1.01 1.4 4 2.8 2 2.0 6 9.0 0.2 0.6 0.4 2 0.8 1 1.03 2.8 1 0.8 2 3.0 13 19.01 1.8 0.4 0.8 1 0.8 1 2.0 12.5 611.5 0.22 1.21 0.64 2.21 0.8 4.0 22 18.0 0.8 0.2 1.3 1.8 3 1.8 33.0 9 5.0 .... 12.0 0.8 6 2.0 1.2 1 1.4 21 15.0 1.2 0.6 11.6 1 1.4 2 1.4 2 1.8 9 7.0 0.23 1.8 0.62 2.0 2 1:24 1.4 20 14.0 2 0.8 0.62 1.01 1.6 2.01 1.4 3 5.4 20.2 23.01 0.63 0.8.1 1.2 2 1.6 12 15.0 10.5 1 1.0 1 2.3 3 1.42 0.6 2 7.0 0.6 10.41 1.8 10.4 0.82 0.47 0.6 16 12.05 0.8 1.0 1.2 1 1.2 1 2.2 0.8 6 6.0 0.2 0.2 0.6 11.2 10.2 11.6 10.8 1 1.8 18 11.0 0.4 0.3 0.6 10.85 1.0 1.0 12 4.0 0.2 0.2 0.2 1.0 0.22 0.6 0.4 10.4 17 7.0 0.4 0.6 0.2 0.27 0.4 0.8 6 4.0 10.2 0.2 1.0 2 1.0 0.22 1.0 0.5 1.2 20 8.0 10.21 0.2 0.6 10.8 3 1.0 11.0 1 5.0 0.4 0.81 1.4 10.4 0.8 12 5.0 11.0 0.4 0.81 1.07 0.2 1.4 5 3.4 10.82 0.2 0.2.12 8.0 10.2 0.2... 0.8 10.4 0.2 4 5.6 30.6 10.42 0.81 0.210.4 6 5.5 0.0 10.21 0.4 10.4 10.8 2 3.6 0.6 0.2 0.4 0.4 0.8 30.210.6 2 1.4 0.2 11.01 0.62 0.2 10.4 1 0.4. 0.3 11.21 1.0 4 0.8 2 2.5 1.21 0.6 1 2.0 2.8 0.6 1.0 5 2.8 1 1.8 32 10.0 43.0 1.6 31 5.8 14 2.02 1.526 3 4.0 2 2.0 29 34.4 12.3 9 6.6 3.4 7 2.3 15 6.1 43.22 5.0 7 9.2 14.0 14.8 9 9.8 33.4 13.0 11 6.3 43.223.5 11 7.3 6.4 6.2 73.83 2.3 6 10.0 13.8 1.5 7 8.4 53.0 2.5 11 6.0 3 1.64 4.0 12 6.2 12.03 3.0 9 6.0 32.02 3.4 14 5.0 This chart shows the distribution for the Borough of Manhattan by wards together with the total borough experience for a period of five successive years. The averages are found for each ward and for the borough for each week. Any week showing an abnormally high number of cases is eliminated in calculating the averages. This is termed "normalizing" them. Thus a basis is provided for comparison of present with past experiences. This method has proved very useful and has recently been improved so as to show the number of cases within the 40-acre census areas. Future analyses will observe these boundary lines, thus affording an opportunity for closer observation of local conditions. Pending the coming census, which will also observe the 40-acre boundaries, the populations of 1910 are available for these sections. It is serviceable at times to divide these into smaller population units, and for practical purposes the latest voters' registration lists make it possible to have these sub-divisions just as small as may be desired, since a fairly defined relation of the voting registration to the total population calculated on the census basis makes it feasible to estimate the population for any one of these small voting precincts. When a number of years have been tabulated according to the small areas any of them habitually subject to more than the average number of cases in relation to the population will stand out plainly, indicating fields for intensive work. Such fields are even now becoming apparent and special sanitary supervision is being exercised therein. Inspection Work. Each borough is divided into several sections, in each of which is located a branch office in charge of a physician and having attached thereto district diagnosticians and nurses. There are in all 19 branch offices in the City of New York. When a report of a case is forwarded to the borough office, it is telephoned to the Branch Office of the district in which the case is located, and assigned to a district nurse, who calls at the home of the patient and interviews a responsible member of the family for the purpose of obtaining, among other things, the age, the business address, the date of onset, the beginning of prodromal symptoms and all of the food habits which may be of service in tracing the infection, including the milk supply, water supply, use of raw oysters or green vegetables or other raw foods and, in special cases, particular articles of diet, such as ice-cream, etc. Other things are important in tracing the source of infections, as the whereabouts of the patient for a period of one month preceding the onset, including even an occasional or week-end trip during this period; whether there has been any suspicious illness among any of the friends or relatives of the patient or in the house in which the patient lives, or among the servants; and even as to whether there has been any typhoid fever in the family during the past few years. It is not necessary to annoy the patient with these questions, as almost invariably this information can be better obtained from another member of the household. As no placard is put upon the door and as the patient is not in any way disturbed, this intimate investigation should not annoy any well-meaning family or practitioner. The nurse makes inquiry as to what measures are taken to prevent other persons from contracting the disease; whether the patient has a separate room and bed; who nurses patient; whether the dishes are sterilized; and whether every effort is made to prevent the dissemination of infective material. Special cards of instruction are provided for the convenience of the family informing them as to how best to prevent the infection of other people. Special attention is given to food handlers. If the patient has been engaged in the manufacture or sale of food material, he or she may not return to such previous occupation until several faecal examinations |