THE PREVENTION AND CONTROL OF INFLUENZA.
Dr. Hamer has visualized the present state of our knowledge of epidemic
influenza in a manner which can scarcely be improved upon. We,
therefore, quote him at length: “It seems to me that, during the last
thirty years or more, we have been making fairly steady uphill progress
along the road which constitutes the boundary between the county of
epidemiology and the county of bacteriology, and that we have at length
reached, at a height considerably above sea level, the foot of the
mountain, on the very top of which lies hidden the secret of an
‘epidemic constitution,’ and now we are face to face with a parting of
ways. Straight ahead is the frowning height, its summit in cloud. On the
right hand stretches away a fine road skirting the base of the mountain.
Along this road we have recently seen Dr. Brownlee whirled away in his
new car ‘periodogram.’ We are all hoping to hear more from him, but as
he is still insisting upon the primary, if not the exclusive, importance
of continuous variation in the virulence of the germ, we have to realize
that for the time Dr. Brownlee’s road is going down-hill. On the other
hand, on the left, there swerves away, through the territory of the old
epidemiology, another fine road, which has been explored more
particularly by believers in ‘skiey influences.’ So far as it has been
traced this road is as flat as flat can be, but of course there is
always the possibility that after a while it will begin to rise, as it
skirts round the mountain, and leads to a good vantage point from which
to start climbing. At the risk, however, of being laughed at, I venture
to bring under notice the very rough and at first sight unpromising
ground directly in front of us. Along this can be seen two obscurely
marked sheep tracks proceeding at any rate onwards and upwards. One
diverges slightly towards the left hand and it has been followed at
various times by De Schweinitz and others, naturalists bent on
collecting ‘ultravisible viruses;’ the second track, directed rather
more to the right, has been explored by Reiner, Müller, Massini,
Penfold, and others, workers at the problem of discontinuous variation
by ‘mutation.’ As a matter of fact I have reason to believe that two
travellers, each of whom follows one of these tracks, will keep in sight
of and after a while will find that they are approaching one another,
and will ultimately meet at a small and retired upland farm; then after
passing some dogs and following the track until clear of all stone
walls, they will come right out in open ground on the face of the
mountain and can start straight up the steep. But it must here be
pointed out that there remains to be considered a fourth method of
approach to the mountain, the most direct of all; but that is by
aeroplane and is of course only open to those trained in metaphysics and
statistical methods. Investigators thus equipped are able to rise in the
air, to survey with careful scrutiny the whole of the ground beneath
them and to make the best use of details of information obtained by
scouting parties below. It is to be hoped that at no very distant date a
survey of the top of the mountain will thus become an accomplished fact.
Meantime, those who cannot fly may find useful employment in examining
the track beyond the farm. There is the chance there of picking up facts
relating to such questions as the ‘parasites associated with a
parasite,’ symbiosis, and the like; take, for example, a suggestion made
fourteen or fifteen years ago that the influenza organism may at one
time live in association with Pfeiffer’s bacillus, at another with the
Micrococcus catarrhalis, and so on; or the throat distemper organism may
be yoked now with the diphtheria bacillus and now with the Streptococcus
conglomeratus. (Is that, I wonder, now to be regarded as a concept or as
an occurrence or happening?)”
At best our knowledge of the cause and manner of spread of influenza is
fragmentary and insufficient. Attempts to outline a system of control
and prevention based upon present concepts are met with many
discouragements. The next pandemic will not be prevented. The disease
will surely return. If the interval be sufficiently long it may find us
quite as unprepared as we were in 1918. Discouraging as the outlook is
there are many bright points upon which we must base our hopes for
future results.
The difficulties are many: First the _diagnosis_ of influenza is
difficult either in the individual case or in the form of a mild
epidemic. Even in 1918 the identification was often not definitely made
until after weeks had elapsed. Second, we know little concerning the
_mode of transmission_ of the disease. We speak of “respiratory
infection.” We believe that the transmission is by a mechanism similar
to that for measles, but we have never experimentally transmitted either
disease. The _short incubation period_ places us at a great
disadvantage. Were the interval between the occurrence of the first case
and the development of additional cases as long as it is in measles, the
problem of isolation and quarantine would be simplified. As in measles
the disease is probably _very early infectious_, presumably before acute
symptoms develop. The majority of cases of influenza are _ambulatory_.
Many individuals do not take to their beds, but continue about their
work, spreading the disease wherever they go.
Again, we are ignorant of the _period of infectiousness_. Dr. Meredith
Davies has made observations indicating that a patient becomes
non-infectious within one week after the temperature has become normal.
How many influenza patients remain isolated throughout this period?
A _carrier state_ probably exists and plays a most significant part in
the spread.
Yet another drawback is the _apparent wide susceptibility_ to the
disease. Were individuals definitely immunized by one attack the
proportion of susceptibles would be lessened, their concentration in a
population would be decreased, and the probability of their being
exposed would be proportionately diminished.
An additional difficulty is that after an epidemic has once become
prevalent, we must combat not only the virus causing the disease but
also the _secondary invaders_.
Epidemiologic work has shown that _crowd gatherings_ are instrumental in
the spread of influenza. The density of population has not been as
definitely proven to be a factor. Crowding, however, does play a part.
Close crowding in communities must facilitate the spread, but pandemics
of influenza were known before the great metropoleis existed. _Hygienic
conditions_ play their part in the etiology. Finally, in the presence of
every serious epidemic we must also combat the _tendency to panic_ in
the population.
_Anticipatory or preventive measures._—It is erroneous today to speak of
measures for the prevention of influenza in a community. We cannot
prevent the disease. At most, we can anticipate the occurrence of an
epidemic and take precautionary measures by which the spread and the
severity of the disease may be minimized.
First and foremost comes _education_. Education of the public, of the
medical profession and of health authorities. “Scare headlines” in the
newspapers during epidemics should be discouraged. Health cartoons are
of value, but when they express only partial truths they cannot but do
some harm. General education in hygienic methods and in a knowledge of
the spread of contagious diseases has already been most productive. Many
methods by which the public intelligence could be reached are as yet
untried. A daily paper in Boston devotes two columns a week to a
discussion of public health problems, under the title of “The Clinic.”
The statements appearing in these columns are nearly always the truth
and are not exaggerations. There are discussions of recent scientific
work of interest to the reading public. As has been emphasized by
Carnwath, a page devoted to methods of maintaining the health of the
community would probably be of more immediate value than are the many
pages devoted to financial statements, “such as the price of Mexican
Eagles or of Peruvian Corporation Preference.”
The _organization of health services_ to combat unexpected epidemics
would be of great assistance. In times of peace, prepare for war. In all
but the largest cities the health authorities are generally so free from
contact with epidemics and are so pressed with routine that they do not
organize in readiness for an epidemic which may not come. There should
be a closer co-operative organization between health officials and
practising physicians, so that the latter may aid to a greater extent in
the public health work. The physician co-operates in furnishing
information required by the health officer, but too frequently takes
little interest in what further is done with this information. The
medical profession should be made to understand the importance of public
health work, should have a general comprehension of the methods used in
its execution and should particularly develop a sympathetic and
co-operative mental attitude.
The medical societies of the country should be so organized that at a
moment’s notice their membership can be mobilized for the defense of the
community. There is much that the practising physician does not know
about influenza. One of the leading internists in one of our largest
cities, during the 1920 epidemic, refused to call his cases influenza
and treated them as mild “grip.” It is stated that he lost an unusually
large number of his patients. There are still many who believe that the
two diseases are not identical. Not only is this detrimental to the
patient, but as it results in failure to isolate the sick, it is
detrimental to the community.
Nursing groups should be organized to aid at a moment’s notice.
Much work has been done and great experience gained by both the
physicians and the nursing organizations during the last epidemic. Now
is the time to prepare for the next epidemic or pandemic. With the
remembrance of 1918 fresh in our minds we can establish a working
system, while if we delay until the expected arrival of another epidemic
much of our painfully acquired knowledge will have been forgotten.
Opinion differs as to whether influenza should be made a _reportable
disease_. The added expense would be not insignificant. This particular
malady presents the additional complication of being difficult of
diagnosis. The records would at best be inaccurate. The author believes
that certain experiments in reporting the disease even in interepidemic
times should be carried out. This should be done by competent
epidemiologists who could later formulate plans for the permanent
reporting of the disease. We will discuss this further under the
heading, “Constructive Research.”
The use of _vaccines_ has been tried. In 1918 it was almost universally
begun too late—after the epidemic had become prevalent. Prophylactic
vaccination should be inaugurated before the disease actually becomes
epidemic. Vaccination, particularly against the secondary invaders, is
entirely rational. It may not prevent influenza, but it may protect
against the serious complications in individuals and may prevent to an
extent the spread of secondary invaders in the community.
Greenwood aptly remarks that, “In estimating the total effects produced
upon morbidity and mortality by disease, the non-specific secondary
invaders are as important as the specific causes. The camp followers of
an army may do more damage than the regular soldiers, and the same camp
followers may ravage in the wake of different armies.”
At a conference held at the London War Office, October 14, 1918, the
subject of vaccination for influenza was discussed. It was decided that
only three organisms should be employed in each case in the preparation
of the vaccine; that these races should be recently isolated from cases
of the disease developing during the course of the epidemic and that the
microorganisms should be submitted to a rigorous study as to race and
type. The first dose should include 30,000,000 of Bacillus influenzae,
100,000,000 pneumococcus, 40,000,000 streptococcus; the second dose
60,000,000 Bacillus influenzae, 200,000,000 pneumonococcus, 50,000,000
streptococcus. The vaccine should be sterilized at 55° C. and one-half
per cent. phenol should be added. The administration should be at ten
days’ intervals.
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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A most comprehensive bibliography of the literature covering the
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APPENDIX
[Illustration:
FORM A.—Household record, used in Boston influenza census. (See page
127.)
]
[Illustration:
FORM A.—(_Continued._)
]
[Illustration:
FORM B.—Individual Record obtained for each person in every family
canvassed, whether the individual gave a history of influenza (1918
or 1920) or not. (See page 127.)
]
[Illustration:
FORM B.—(_Continued._)
]
------------------------------------------------------------------------
TRANSCRIBER’S NOTES
1. Silently corrected obvious typographical errors and variations in
spelling.
2. Retained archaic, non-standard, and uncertain spellings as printed.
3. Enclosed italics font in _underscores_.
4. Denoted superscripts by a caret before a single superscript
character or a series of superscripted characters enclosed in
curly braces, e.g. M^r. or M^{ister}.
5. Denoted subscripts by an underscore before a series of subscripted
characters enclosed in curly braces, e.g. H_{2}O.