Part 2

The central headquarters should be ordinarily under the supervision of a board representative of the most important agencies concerned, the board’s work to be administered through a manager (presumably the health officer) selected for his fitness.

3. The service should be maintained on a 24–hour basis, and a system of outgoing and incoming telephone service is essential.

4. The local authorities should get and keep in touch with state and national agencies.

_III. Current and Continuous Analysis of Case Situation._

1. In the smaller communities a canvass should be made of all physicians, soliciting information as follows:

(a) Number of cases under care.

(b) Number of cases needing hospital treatment.

(c) Number of cases needing home nursing care.

(d) Number of cases requesting medical service but not reached.

This information will indicate the situation as regarding the need for emergency nursing and medical service, and should be acquired as fully as possible in larger communities, through various agencies such as a current lay or police canvass of homes, etc. The continuous classification of cases according to these groupings is of practical value.

_IV. Analysis, Augmentation and Organization of Principal Facilities._

(A) _Field Nursing._

1. Ordinarily nursing facilities utilized in general public health work should be diverted to meet the epidemic situation, and should be used on a district basis, with all other available facilities, under one supervision.

2. Nursing assistants, volunteers, etc., should be used wherever possible in homes and institutions, under expert supervision, after classification and assignment on a basis of minimum standards as to fitness, and such intensive training in the care of influenza and pneumonia patients as may be feasible.

3. From the standpoint of the patient, home treatment is to be advocated, if medical, nursing, disease preventive and other facilities are adequate.

4. Restriction so far as possible through the pressure of public opinion should be brought against the unnecessary use of private nurses.

5. Automobile transportation should be provided, and the nursing service used to encourage isolation and education.

6. Special record forms are essential for this and the medical work, and a special sub-committee is proposed to meet this problem.

7. Provision as to housing and care should be made for out of town nurses.

8. We recommend further training with reference to influenza for all graduates of Red Cross Home nursing courses and more extensive use of their services. This would necessitate frequent and careful registration (names, addresses and telephone numbers) and further information regarding personal health, age and ability and willingness to serve.

(B) _Emergency Medical Service._

1. The medical service should be handled through the central office, the physicians being responsible to the central office, though perhaps assigned to district offices.

2. In this emergency service there should be utilized all available physicians such as school and factory physicians, volunteers, practitioners on a paid basis, fourth year medical students, etc. This service should cover all calls reported as unreached by private physicians or received through other channels, and should be co-ordinated with the special nursing service, being provided with automobile transportation, machines being hired if necessary.

3. The emergency medical service should be used to select cases needing hospital care.

4. It may be feasible to institute a central clearing house in certain districts for private physicians’ calls.

5. An arrangement should be made through the medical licensing board for granting of temporary permits to practise to reputable physicians from out of the state, at the request of the Central Influenza Committee.

6. In some localities it may be feasible to district the local practitioner and to have him meet special calls on a part time basis for adequate compensation.

7. Certain of the relatively non-essential specialties should be discouraged, and the physician in those specialties urged to volunteer for emergency district work. This type of service may be operated on a pay or free basis.

8. Presumably some effort should be made, through an authoritative medical commission, to suggest standard methods of treatment, and wise limitations as to therapeutic procedure.

(C) _Hospital Facilities._

1. It is essential that the facilities, if possible, be kept ahead of the demand. A daily canvass should be made and data collected regarding available beds, medical and nursing needs, domestics, food, cots, supplies, etc. A regular visit by an inspector will probably prove more effective than an attempt at telephone communication.

2. Under most conditions a central clearing house, covering most if not all of the hospitals, is advisable for the admission of cases. Through this channel the severer cases may receive first consideration. Owing to constant changes in the hospital bed situation, the daily canvass of facilities may not be wholly depended upon; on the contrary, it may usually be necessary to telephone the hospital in order to make sure regarding the admission of a particular case. In any event the hospitals, if facilities are inadequate, should be impressed with the necessity for admitting only the most severe or needy cases, pay or free. Special hospital arrangements should be provided for pregnant women.

3. It is advisable to add wards or tents or new equipment to existing institutions rather than to establish entirely new emergency hospitals. If practicable, certain hospitals may be urged to handle influenza cases exclusively.

4. Non-emergency surgical and chronic medical cases amenable to home treatment should be de-hospitalized.

5. A convalescent home, if adjacent to the hospital, may serve for the care of mild and convalescent cases, thereby increasing the space in the hospital for acute cases, obviously involving an increase in the nursing facilities.

6. A canvass of ambulance facilities should be made, ambulances being requisitioned with payment, or hired by contract, if necessary. Automobiles and motor trucks should be potentially mobilized for this purpose. Frequently military equipment may be used if accessible.

_V. Social and Relief Measures._

1. The central office should keep the family advised regarding the patient, thereby saving telephone calls, trolley fares and worry on the part of the family, and thereby increasing the willingness for hospitalization.

2. Volunteer workers such as Red Cross volunteers, teachers, relatives, etc., should be placed in care of families where the responsible members are dead or hospitalized, this service being under expert social supervision, and the families in touch with the supply system. Supervision of placed-out children is also necessary.

3. Homes should be investigated before patients are discharged into them, when destitution or other untoward circumstances are apparent.

4. Precaution should be taken that institutions and families too busy with the influenza situation to look after their own needs, are covered by the general relief measures.

5. Ordinary charitable relief should be handled through the routine agencies, the service co-ordinated with the other epidemiological measures. Churches, lodges, etc., should be urged to handle their own cases, in order to relieve the pressure on the central agency. Aid should be immediate, without protracted investigation.

6. Recreation facilities (motoring, etc.) should be provided for the physicians and nurses while off duty.

_VI. Food._

1. Available central cooking facilities should be used so far as is necessary, such as the dietetic equipment in high schools, normal schools, colleges, etc., with a delivery system to families and institutions in need.

2. Individual families should be encouraged to cook additional amounts, the same to be delivered to central diet kitchens for distribution, a standard list of prepared foods needed being devised and advertised, with recognition of racial customs and preferences.

3. It may be necessary to establish canteens in sections of the city.

_VII. Laundry._

1. A special collection and distribution system may be essential both for homes and institutions.

2. It may be necessary to take over a public laundry with compensation, or a private non-medical institution laundry.

_VIII. Provision for Fatalities._

1. Death reporting should be prompt (24 hours) and a record kept so as to ensure prompt disposal of bodies.

2. A daily canvass of available coffins should be made, labor assured for construction, and possibly no coffins sold without the permit of the Influenza Administration Office.

3. If morgue facilities are inadequate a central place should be provided, with embalming facilities, for the temporary disposal of bodies.

4. A canvass of hearses should be made and regulations issued prohibiting unnecessarily long hauls, insisting on maximum capacity loads, etc. A central control will prevent unnecessary duplication as to routes, etc.

5. A reserve supply of trucks and automobiles should be at hand for use in various ways in connection with the handling of fatal cases.

6. The number of graves required should be estimated and labor released from public works or secured through other channels (possibly military) for digging. Possibly temporary trench interment may be necessary.

_IX. Education, Instruction and Publicity._

Literature and special instructions will be necessary on many phases, including the following:

1. Instructions to physicians as to reporting, facilities available, district arrangements, etc.

2. Advice to physicians regarding treatment standards and suggestions.

3. Instructions for families, to be distributed by nurses, physicians, social workers, druggists, etc., covering the problems of care during the physician’s absence.

4. Instructions to the public as to where aid may be secured, to be printed in various languages, and distributed by druggists, displayed in street cars, used in the press, etc.

5. Instructions for families on “What to do till the doctor comes.”

6. Instructions to physicians, factory managers, school superintendents, etc., urging the necessity for immediate home and bed treatment at the first sign of respiratory disease.

7. Popular literature on the essentials of adequate care, the danger of returning to work too soon, etc. Popular press space is worth paying for, if it cannot be secured otherwise.

8. Popular publicity as to legitimate medical, nursing, undertaker, drug, and other charges, to prevent profiteering.

_X. Miscellaneous._

1. The co-operation of pharmaceutical agencies should be secured to ensure an adequate supply of drugs and druggists.

2. Influenza victims and their families should have “first call” on fuel deliveries.

3. While follow up procedures are not legitimately a factor in the epidemic situation, their consideration is essential to an adequate meeting of the entire problem. This means adequate provision for medical examination and nursing care, relief measures, industrial employment problems, the follow up of special sequelæ such as cardiac affections, tuberculosis, etc.

4. It is finally suggested that Health Department draw up a programme based on the above outline, holding it in reserve for future use, if not immediately needed, and modifying the proposal to fit the size and other characteristics of the particular community.

THE BACTERIOLOGY OF THE 1918 EPIDEMIC OF SO-CALLED INFLUENZA.

The epidemic disease known as influenza is believed to be due to an undetermined organism which causes an infection that lowers the resistance of the body as a whole, and of the respiratory organs in particular. This allows the invasion of other pathogenic micro-organisms. The most important complicating infections are due to the influenza bacilli, different strains of pneumococci and different varieties of streptococci. Some careful observers regard certain of these organisms as the primary cause.

In each case, one or several of these micro-organisms may be present. In different portions of the country the dominating variety of organism has been found to differ.

VACCINES.

Assuming that the cause of the epidemic is an unknown virus, it does not seem possible at present to prevent the primary disease by vaccination with known organisms. Against the secondary infections, there would seem to be a theoretical basis for the use of vaccines, and especially for the use of vaccines prepared from organisms responsible for complications which may differ in various localities at various times. This variable bacterial flora may militate against the practical application of vaccination on a large scale, because it would seem to require frequently repeated vaccinations with the flora that may be met with. It is impossible at present to evaluate the reports from the use of these vaccines adjusted to meet local conditions. More data obtained under carefully controlled conditions are needed.

Stock vaccines made from the influenza bacillus alone or from other bacteria, have been used to considerable extent. The injections of stock vaccines have seemed to mitigate to some degree some outbreaks of influenza and also the severity of the complicating infections; but in those instances in which the results of the use of vaccine have been controlled, no appreciable results have been obtained. The fact that the vaccine is usually employed after the epidemic has broken out and is perhaps on a decline, and the fact that an unknown number of people have been exposed, make it very difficult to draw conclusions as to its efficacy.

RECOMMENDATIONS.

Your committee recommends that until such time as the efficacy, or the lack of efficacy, of prophylactic vaccination against influenza is established, vaccine if used, should be employed in a controlled manner, under conditions that will allow a fair comparison of the number of cases and of deaths among the vaccinated and non-vaccinated groups. Particular attention should be directed to securing data as to the period in the epidemic at which vaccinated and non-vaccinated persons developed the disease.

Your committee is of the opinion that the indiscriminate use of stock vaccines against influenza and influenza and pneumonia cannot be recommended.

Nothing in these recommendations should be interpreted as discouraging the use of a pneumococcus stock vaccine against lobar pneumonia.

This epidemic emphasizes the importance of properly equipped laboratories.

HISTORY AND STATISTICS OF THE EPIDEMIC.

Your sub-committee wishes to say that in view of the fact that the historical and other data of the epidemic are still in process of collection, no positive statement can be made at the present time on the precise incidence of the disease in the American population. On the basis of the best data available your sub-committee estimates that there were not less than 400,000 deaths from the disease in the United States during the months of September, October and November, 1918. The major portion of this mortality occurred at ages 20–40, when human life is of the highest economic importance. We would suggest that this sub-committee be authorized to co-operate with the special committee on statistical study of the epidemic of the section on Vital Statistics of this Association, and that the data collected through that latter special committee be reported through the sub-committee on history and statistics of the epidemic to the general reference committee on the influenza epidemic. Standard forms for purposes of statistical tabulation, analysis and graphic presentation will be submitted in a supplementary report at an early date.

SUGGESTIONS.

In view of the probability of recurrences of the disease from time to time during the coming year, health departments are advised to be ready in advance with plans for prevention, which plans shall embody the framework of necessary measures and as much detail as possible. Laws plainly necessary should be enacted and rules passed now. Emergency funds should be held in reserve or placed in special appropriations, which appropriations can be quickly made available for influenza prevention work.

The probability that as an after effect of the influenza epidemic there will be an unusually high pneumonia rate for several years should be taken into consideration.

Of measures for the control of the disease, bacteriologic studies as to the nature of the organisms causing the primary infection and as to bacteria associations, new and improved procedures leading to the production and use of effective vaccines and curative sera, and the fresh air treatment of the infected, appear to offer most promise.

TRANSCRIBER’S NOTES

1. Silently corrected typographical errors and variations in spelling. 2. Retained anachronistic, non-standard, and uncertain spellings as printed. 3. Enclosed italics font in _underscores_.

End of Project Gutenberg's Influenza, by Provincial Board of Health Ontario