The above table was based on the measurements of 3,448 normal babies in 23 states, and was prepared by Mr. F. S. Crum, of Newark, N. J., for the American Medical Association.

THE MANAGEMENT OF AN OUTBREAK OF TYPHOID

FEVER

F. M. MEADER, M.D.

Director, Division of Communicable Diseases

Typhoid fever is a communicable disease caused by a germ known as the bacillus typhosus or Eberth's bacillus. This bacillus enters the body through the mouth and always comes either directly or indirectly from another individual who has typhoid fever or who harbors typhoid bacilli in his system.

The bacilli after entering the body begin to grow chiefly in the lower end of the small intestine and also in the gall bladder and bile passages. They are also usually found in the circulating blood.

While growing in the intestinal wall an inflammation is caused in the intestine which may later in the disease develop into an ulcer. This ulcer may cause hemorrhage by destroying the wall of a blood vessel, or peritonitis by ulcerating through the wall of the intestine.

The typhoid bacilli grow in large numbers in the blood and in the intestinal tract, for these provide the proper temperature and nutriment for their multiplication. With every discharge of excreta millions of them leave the body. Indeed, nearly a million of these germs may be found in one drop of the excreta. They continue to be discharged for a variable period of time during convalescence and certain individuals continue to discharge bacilli for many years. In these cases the bacilli usually continue to live in the gall bladder or bile passages and not generally in the intestinal tract.

The prevention of secondary cases is therefore easy if the diagnosis is promptly made and if proper disinfectants are immediately added to the discharges of the patient or carrier. It is evident that the most particular care must be taken to see that discharges from the patient do not contaminate water supplies or the hands of persons coming into contact with the patient. Nurses or other persons who are caring for a case of typhoid fever should carry out the following general plan so as to prevent infection of the nurse or attendant and to prevent the infection of others.

The discharges must be thoroughly disinfected with chloride of lime before being emptied into the sewer system. If there is no sewer system or watertight cesspool or privy for disposal, the discharges should be disposed of by burying in a trench and covering with earth. After the discharges have been emptied the receptacle should be carefully disinfected in a solution of bichloride of mercury of 1 to 5000. The nurse or attend

ant should then wash her hands carefully with soap and water and then immerse them in a solution of bichloride of mercury (I to 5000), or lysol (1 teaspoonful to a pint of water). The clothing and bed linen and other articles which have come in contact with the patient must be soaked in a solution of bichloride of mercury (I to 5000) or boiled in a soapsuds solution for at least twenty minutes before being washed in the usual manner.

Public health nurses should be entirely familiar with the methods of controlling an outbreak of typhoid fever as well as the method of caring for the discharges of the individual case. They should know that typhoid fever usually occurs as the result of an individual drinking water from a water supply that has been infected with typhoid fever; by the use of milk or other food products which have been handled by a typhoid patient or carrier; or by direct contact with a patient or carrier of the disease, and occasionally by means of food products which have been infected. by flies. It is of importance to know the characteristics of an outbreak of typhoid fever from the above causes.

Water-borne outbreaks

Public water supplies

1 General distribution of cases throughout the area supplied by a particular water

2 Seasonal prevalence, spring or late winter

3 Beginning or ending of outbreak following a change of the water supply

4 A large percentage of cases among adults

5 Evidence of pollution shown by bacteriological and chemical examinations

6 Evident sources of infection shown by inspection of watershed 7 Comparative freedom from typhoid fever of persons not using

the suspected water

8 The exclusion of all other probable causes

Milk-borne outbreaks

1 Appearance of an unusual number of cases among customers of

a certain dairy

2 Sudden outbreak of cases followed usually by a rapid decline

3 Usual incidence women and children more than men

4 Occurrence of relatively more cases among well-to-do classes than among the poor

5 Finding of a typhoid case or "carrier" in the dairy or on the

farm.

The sanitary authorities will promptly investigate the type and cause of an outbreak of typhoid fever and endeavor to ascertain the cause as soon as possible. This is oftentimes difficult and several days may elapse before the definite source of the outbreak is determined. During this period of time every effort will be made by the sanitary authorities to prevent the further spread of the disease. It must be assumed that any of the possible sources of infection may be present. Consequently, the authorities will issue warning statements, in the press and by handbills and other methods of publicity, advising the inhabitants of that locality to see that all the water for drinking purposes and kitchen use is boiled; that milk is pasteurized or boiled; and that unusual care is taken in the preparation of food. In the event of the representative of the State Department of Health or the local health officer determining that the outbreak has been due to infected water, they will at once endeavor to secure a purification of the water supply by the municipal authorities. This is done by several methods:

1 By installing a chlorinating plant, which will disinfect the water supply so that it will be promptly rendered safe. (Such a chlorinating plant may be installed within twenty-four hours, and the State Department of Health at Albany always has one available for immediate use.) 2 By using a water from a different source.

3 By passing the water through a storage reservoir.

If it has been ascertained that milk is the medium of infection it will be found that some dairy farm has a case of typhoid fever or a typhoid carrier on the premises and until such patient or carrier is removed or until Regulations 8 and 37 of Chapter II of the Sanitary Code of New York State have been absolutely complied with in every detail the health officer will forbid the sale or use of the milk from that farm. If after study it has been found that the epidemic is neither water nor milk-borne, further detailed investigation will probably reveal the existence of a carrier or of cases that have returned to the vicinity after having contracted the disease in some other part of the country. In these instances every effort should be made to see that the discharges are properly disposed of and that suitable hospital and nursing care is provided and that the other members of the family are protected.

Duty of the public health nurse

In the control of an outbreak of typhoid fever public health nurses are of greatest assistance in the investigation of the cause and also in the prevention of the spread of the disease.

In the investigation the nurse should visit the house of every patient and give detailed instructions as to the method of disposal of the dis

charges as outlined above. She should leave a circular on typhoid fever issued by the State Department of Health, which gives the sanitary duties of the health officer and physician and of the household. She should also distribute any additional handbill or circular which may have been printed especially for the occasion. She should recommend hospital care where that is available. She should also recommend that other members of the family be vaccinated against typhoid fever. Vaccine will be supplied by the State Department of Health to the local health officer and may be obtained from him by any physician. It may be administered either by the family physician or by the health officer.

The nurse will also be of great assistance in making a complete house to house canvass to inquire whether there are other cases of illness which have not as yet been diagnosed. In many instances during the early stage of typhoid fever a physician is not summoned and many cases remain undiscovered and unreported to the health authorities while they are a constant source of danger to other members of the community. In nearly every outbreak of typhoid fever that has been investigated in New York State additional unreported cases have been discovered by public health nurses.

In investigating a case of typhoid fever or a case suspected of having typhoid fever the following items should be noted: History of typhoid fever in the family of relatives or friends with whom they are in immediate contact; inquiry as to history of typhoid fever in the neighborhood or in places recently visited by the family.

Important information should also be obtained from the individual. The exact date of onset - that is, the date on which the patient first began to feel ill or even a little uncomfortable should be noted. A complete study should also be made of the period of seven to twenty-one days prior to the onset, to ascertain whether the patient was associated with another case, had visited neighbors or places out of town; the kind of food eaten, whether meals had been taken at restaurants within or outside of the municipality; the occupation not only of the patient but other members of the family; the kind of water that is used, whether the public supply, private well or bottled water; whether milk or cream or ice cream had been used; whether there have been any visitors in the family and if they had had illness in their home and the same in regard to employes or domestics in the household. Inquiry should also be made as to the source of the milk supply, from whom purchased and the dates upon which milk was taken by the patient. It is of utmost importance that these inquiries should be strictly limited to the period above mentioned.

If a nurse suspects or discovers a case of typhoid fever for the first time she should take the following action: Advise the family that a