Part 29
In the United States the vaccines employed have often contained a greater variety of organisms. It is unnecessary to enumerate the results obtained by various investigators. Some have been mildly enthusiastic, while others have obtained no demonstrable benefit. It will suffice to say that there has been no clear evidence that vaccination has been beneficial, but that the procedure has not been given a thorough trial. If the causative organism of the disease is eventually determined, vaccination will probably be attempted with it as antigen. For the success of vaccination it is important that practically entire communities be inoculated, and that they be so inoculated before the development of epidemic prevalence.
_Palliative measures in the presence of an epidemic._—An epidemic, once having obtained a start will run its course. Our attempts will be to lessen its extent and diminish its explosiveness. Or, more probably, we will best succeed by _extending_ the duration and making the invasion less explosive. We must know of its earliest appearance. _Notification_ must be made by physicians to the health authorities in order that the earliest increase may be detected. This again renders the reporting of the disease at all times an essential feature. The _administrative control_ and the _publicity_ to be given have already been discussed.
What general measures should be taken against the disease? Should the _public schools_ be closed? Winslow and Rogers found that the orthodox methods of combating epidemics applied in Connecticut exerted no appreciable influence on the spread of influenza. Bridgeport, Hartford and New Haven _did not close_ their schools and suffered from death rates near the average for the State, lower than the rates which prevailed in cities like New London and Waterbury, which closed their schools. No deductions can be drawn from this fact, however, because the closing of the schools in most cases was forced because of the severity of the outbreak.
The data obtained by Jordan indicate that schools were not important distributing centers for the infection. No explosive outbreak occurred in any one grade, and the four days of the Thanksgiving holiday evidently afforded more favorable opportunities for infection than did the days of regular school attendance.
Carnwath believes that in view mainly of the marked prevalence of the disease amongst school children, the balance of opinion is in favor of closure, even in densely populated urban districts. In the author’s investigation there was a slightly higher incidence of the disease among children attending school than among those younger children who were not at school. The spread is probably not facilitated so much in the class room as it is on the play ground. In the school room the children are constrained to remain at a certain distance from each other. Probably they would come into as close contact with cases if they were not at school. Certainly it has not been demonstrated that the school room is a factor of great importance in the spread of influenza. It would, perhaps, be better not to close the schools in the presence of an epidemic, but to discontinue any congregation on the play grounds, and to discourage the grouping of children in play on the streets.
With children and with all individuals, large or small, a great factor in exposure and probably in the transmission of the disease is the necessary _crowding on street cars and in public buildings_. Here is a potent source which requires deep study and new treatment. Some cities have with partial success attempted lessening the congestion in public conveyances at the beginning and closing of business hours by arranging with the various offices, stores, etc., that the opening and closing times occur at different hours. In order that this procedure may work it is important that the employees of a factory or store which closes early must ride to their destination at the time of closing and not remain in the congested business districts. Here again it is a problem of educating the public to a point where they will co-operate intelligently.
It has been amply demonstrated that _crowd gatherings_ markedly facilitate the spread of the disease. Mass meetings should be prohibited and gatherings in and out of doors should be discouraged. The public should be taught that the safest place is at home.
What _instructions_ can we give _to the individual_ for his own protection? There are at least six precautions based on scientific knowledge. They are:
First: Avoid crowds.
Second: Avoid crowding in the family.
Third: Sleep alone.
Fourth: Pay particular attention to personal hygiene.
Fifth: Boil all dishes, etc., after meals.
Sixth: Do not eat in insanitary restaurants. Eat at home.
Should cases be _isolated_? Should they be quarantined until no longer infective? The experience of the last epidemic has rendered us pessimistic. We have found that isolation and quarantine does little or no good. Institutions which were held under rigid quarantine for the first months of the epidemic were later invaded when discipline became lax. The disease thereafter spread often as extensively as it would have, had there been no delay. But, on the other hand, there is record of some institutions in which the quarantine lasted throughout the epidemic and in which the inmates never became ill. All of our past experience with infectious diseases leads us to believe that isolation of cases should be enforced. The experience of 1918 should not cause us to change from this point of view. Up until now the procedure has been without results. It has been nearly impossible to enforce it. Further study must be made before any definite conclusion can be reached.
The same in general may be said regarding _disinfection_ after recovery of a case of influenza. Today most people believe that disinfection is unnecessary. The work of Lynch and Cumming, if correct, would indicate the contrary. The possibility of transmission through inanimate objects has not as yet been completely eliminated.
The _efficacy of face masks_ is still open to question. Certainly the face mask as extensively used during the 1918 epidemic was of little benefit and in many cases was, without doubt, a decided detriment. The same mask was worn until it was filthy. It was not worn in such a way as to be a protection. Even had the nose and mouth been efficiently protected, the conjunctivae remained unprotected. The work of Maxcy and of Vincent and others has demonstrated the importance of the naso-lachrymal duct as a possible portal of entry into the respiratory tract proper. After cultures of Bacillus prodigiosus were sprayed upon the ocular conjunctivae these organisms have been recovered from the nose within five minutes, from the nasopharynx within fifteen minutes and from the feces within twenty-four hours. One difficulty in the use of the face mask is the failure of co-operation on the part of the public. When, in pneumonia and influenza wards, it has been nearly impossible to force the orderlies or even some of the physicians and nurses to wear their masks as prescribed, it is difficult to see how a general measure of this nature could be enforced in the community at large. If masks are to be used they should be employed in the same manner as for protection against the plague. They should be made to cover the entire head. This procedure has been recommended particularly by Vincent and by Thorne.
It is safe to say that the face mask as used was a failure.
_Problems for the future._ _Constructive research._—While pure epidemiologic study of influenza will not demonstrate the causative agent, it is the chief procedure upon which we can at present rely for improvement in our methods of combat. Many important laboratory contributions have been made during the last two years. The majority have been without immediate value to the health officer. The author suggests in the following paragraphs a plan of study, based upon past epidemics and the experiences of the last pandemic, as epitomized in the preceding chapters. During the exposition of this subject we have drawn certain conclusions and have developed some theories. We believe that they explain the facts correctly, but should the hypotheses prove not entirely correct the value of the following outline for study will be in no way impaired.
To become thoroughly acquainted with epidemic influenza in all its manifestations would require a life time of study. Knowledge of the disease would be greatly furthered if competent epidemiologists should see fit to devote their entire time to a study of the disease in its various ramifications. The author suggests a research organization of individuals whose function it would be to become completely acquainted with influenza. The organization should be under the direction of a competent board of epidemiologists. Under them would work several groups composed of epidemiologists, bacteriologists and others. There should be sufficient groups so that they might be distributed to diverse regions of the earth. They should be equipped for travel, with mobile bacteriologic laboratories and all the necessary equipment for epidemiologic surveys, so that at a moment’s notice they could proceed to wherever an epidemic of any disease simulating influenza is reported to be prevalent. The working groups would be under the administrative control of the central directors and would make their reports to them. All groups should be so distributed geographically as to have easy and rapid access to any community in which an epidemic might occur. They would keep themselves informed concerning the disease prevalence in all communities under their jurisdiction. This would be done through the co-operation of the civil health authorities and through the utilization of all other available sources of information. The central board should be constantly in touch with the groups, so that the infectious disease prevalence in all parts of the world would be known at all times.
Had such an organization been in existence during the last thirty years, every one of the so-called influenza epidemics reported in one place or another would have been investigated. Detailed epidemiologic, statistical, demographic and bacteriologic reports would have been made. It matters little how small or insignificant the outbreak appears to be. Even the smallest have their characteristic features and are worthy of study. If we study epidemic influenza but once in thirty years, we will never become well acquainted with the disease. We must see it repeatedly and frequently. If it does not exist during the intervals we must study the diseases simulating it. It is surprising how much of the knowledge acquired in 1889 was forgotten by 1918. Even some of the more important features had passed from memory. Thus we find statements in 1918 that the age morbidity was quite different from that in all preceding epidemics. Research into the literature of the past does not corroborate this impression.
If influenza is scattered throughout the earth in mild form, it would avail us but little to send a commission to Bokhara to study the endemic focus supposed by some to exist in Turkestan. Even though the disease were endemic in that country, one would not expect to discover epidemics there. The general immunity of the population in the endemic area is probably increased. Nevertheless one unit might well be stationed in Turkestan, there to study the existing conditions regarding infectious diseases.
There would be ample work for all groups at all times. The study would not be limited to a consideration of infectious diseases. Sociologic conditions may be of importance. We have recorded instances of this. Wherever there is an unusual concentration of large masses of individuals the investigators should study the results of such concentration.
An advantage of this organization would be that the groups through their central bureau would establish an information bureau of infectious disease prevalence analogous to the popular weather bureau of today. They would report the presence of a cloud before it had appeared on the local horizon.
In the absence of any epidemics resembling influenza, there would be abundant opportunity for correlated work. We have mentioned the epidemiologic resemblances between influenza and certain other infectious diseases. Comparative study of any or all of them is of importance. The bacteriologist and the immunologist would find plenty of material in the study of measles prevalences. The two diseases are so similar in their manner of spread, in the probable mode of transmission, in their clinical characteristics and in the results of laboratory attempts at transmission, that one must assume that the causative viruses are not dissimilar. Any new facts that we may gain concerning measles will be of value in the study of influenza.
Many years could be well devoted merely to a study of immunity in influenza.
The results obtained by this proposed organization for the investigation of influenza would be slow in achievement. The study is not of a type calculated to appeal to the popular imagination. Communities in which the dread of an imminent pestilence is not present would subscribe with some hesitation to appeals for pecuniary assistance. Fortunately, however, there are in existence several organizations already well developed along these lines, organizations chiefly interested in certain other diseases. There can be no doubt but that at the present time the financing of such a broad project could be arranged, and that the groups could be efficiently organized on the basis of experience already gained in similar projects.
Crookshank well remarks that our present epidemiologic intelligence service is hardly superior to that of a Meteorologic Office which only gives warning of rain when unfurled umbrellas pass along the street. Influenza will surely return. There will be mild epidemics within the next few years. In time another pandemic will arrive, and after it will come pandemic after pandemic. In 1918 as in 1889 we were caught unprepared. Let us do our utmost to prevent the recurrence of this tragedy. To delay is to loose the valuable information gained during the last two years. The future is not without well grounded hope, but success will not be achieved until we have attained a much deeper understanding of the epidemiology of influenza.
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