Title: Influenza
Author: Provincial Board of Health of Ontario
Language: English
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                 Department of the Provincial Secretary

[Illustration: ONTARIO]

                       PROVINCIAL BOARD OF HEALTH



                               INFLUENZA


                                TORONTO:

  Printed and Published by A. T. WILGRESS, Printer to the King’s Most
                           Excellent Majesty
                                  1919



                               INFLUENZA


The Provincial Board of Health deems it advisable that the statement
issued by the American Public Health Association, following the recent
meeting in Chicago should be in the hands of the medical profession of
Ontario. Consequently this statement is herein given in full.

As there is considerable difference of opinion among health officers,
the profession and the public, with reference to the value of measures
of prevention, such as the placarding and quarantine of premises where
the disease exists, the Board has deemed it of sufficient importance to
add some remarks giving the views of provincial and state officers of
health in this respect as well as upon other points of interest.

With the view of learning the experience of the state and provincial
health officers of the United States and Canada the Board addressed the
following inquiry to all such officers, viz.:—“Does your province (or
state) require the reporting, placarding and quarantine of influenza,
and, if so, do you consider placarding and quarantine of such,
practicable?”

Replies were received from the health officers of the nine Canadian
provinces and from 43 state health officers. Four of the provinces of
Canada reported that placarding and quarantine of influenza was
impracticable. One states that “modified quarantine was working fairly
well,” another said that “the law was not well obeyed,” a third stated
“almost impossible in rural places,” and a fourth “many infractions but
believe good effect,” a single officer only declared it practicable.

Of the reports from United States’ health officers, 29 out of the 43 or
67 per cent. state that placarding and quarantine in influenza are
impracticable. Of the remainder of the replies nine report the law
practicable, and five qualify their statement by such expressions as
“seems to be of value,” “enforcement depends on local sentiment,” “law
fairly obeyed,” “beneficial,” “believe quarantine should be included.”

Thus it will be seen that out of 52 health officers of the states and
provinces of North America, 9 frankly state, as the result of their
experience, that placarding and quarantine are practicable, 10 qualify
their approval, and _33 frankly state that these measures are
impracticable_.

The real facts, considering the views of the American Public Health
Association as well as of the public health authorities of the two
countries, seem to be, as Sir Arthur Newsholme, Chief Medical Officer of
the Local Government Board of England, says, “I know of no public health
measures which can resist the progress of pandemic influenza.” And, as
remarked by Dr. Victor Vaughan at the recent meeting, “I say that, in
the face of the greatest pestilence that ever struck this country, we
are just as ignorant as the Florentines were with the plague described
in history.”

The Chairman of the Provincial Board says: “If our patients are put to
bed immediately they feel the first symptoms of the disease and kept
there for 5 days after the temperature falls, they will, in the large
percentage of cases, recover.”



                        INTRODUCTORY STATEMENT.


The present epidemic is the result of a disease of extreme
communicability. So far as information available to the committee shows,
the disease is limited to human beings.

The micro-organism of virus primarily responsible for this disease has
not yet been identified. There is, however, no reason whatsoever for
doubting that such an agency is responsible for it. Mental conditions
may cause one to believe he has influenza when he has not, and may make
the patient who has the disease suffer more severely than he otherwise
would. No mental state alone, however, will cause the disease in one who
is not infected by the organism or virus that underlies the malady.

While the prevailing disease is generally known as influenza, and while
it will be so referred to in this statement, it has not yet been
satisfactorily established that it is the identical disease heretofore
known by that name, nor has it been definitely established that all
preceding outbreaks of disease styled at the time “influenza” have been
outbreaks of one and the same malady.

There is no known laboratory method by which an attack of influenza can
be differentiated from an ordinary cold or bronchitis or other
inflammation of the mucous membranes of the nose, pharynx, or throat.

There is no known laboratory method by which it can be determined when a
person who has suffered from influenza ceases to be capable of
transmitting the disease to others.

Laboratories are necessary agencies for the supervision and ultimate
control of the disease. The research laboratory is necessary for the
discovery of the causative micro-organism or virus, and for the
discovery of some practicable method for the propagation of a specific
vaccine and a curative serum. Clinical laboratories are necessary for
the supervision and control of such vaccines and sera as may be used
from time to time for the prevention of the disease and for therapeutic
purposes, and for the information such laboratories can give to health
officers and physicians as to such variations in the types of infective
micro-organisms, as occur during the progress of an epidemic.

Deaths resulting from influenza are commonly due to pneumonias resulting
from an invasion of the lungs by one or more forms of streptococci, or
by one or more forms of pneumococci, or by the so-called influenza
bacillus, or bacillus of Pfeiffer. This invasion is apparently secondary
to the initial attack.

Evidence seems conclusive that the infective micro-organism or virus of
influenza is given off from the nose and mouth of infected persons. It
seems equally conclusive that it is taken in through the mouth or nose
of the person who contracts the disease, and in no other way, except as
a bare possibility through the eyes, by way of the conjunctivæ or tear
ducts.



                              PREVENTION.


If it be admitted that influenza is spread solely through discharges
from the noses and throats of infected persons finding their way into
the noses and throats of other persons susceptible to the disease, then
no matter what the causative organism or virus may ultimately be
determined to be, preventive action logically follows the principles
named below and, therefore, it is not necessary to wait for the
discovery of the specific micro-organism or virus before taking such
action.

    I. Break the channels of communication by which the infective agent
  passes from one person to another.

   II. Render persons exposed to infection immune, or at least more
  resistant, by the use of vaccines.

  III. Increase the natural resistance of persons exposed to the
  disease, by augmented healthfulness.


_I. Breaking the channels of communication._

  (a) By preventing droplet infection. The evidence offered indicates
  that this is of prime importance.

  (b) By sputum control. The evidence offered indicates that the danger
  here is due chiefly to contamination of the hands and common eating
  and drinking utensils.

  (c) By supervision of food and drink. Evidence offered does not
  indicate much danger of infection through these channels.

Details and practical methods possible for the limitation of infection
through droplets, sputum, and food and drink are discussed later under
special preventive methods.


_II. Immunization and vaccines._

  (See the report of the laboratory committee appended.)

  In the present epidemic vaccines have been used to accomplish:

  1. The prevention or mitigation of influenza _per se_.

  2. The prevention or mitigation of complications recognized as due to
  the influenza bacillus or to various strains of streptococci and
  pneumococci.

In relation to the use of vaccines for the prevention of influenza, the
evidence which has come to the attention of the committee as to the
success or lack of success of the practice is contradictory and
irreconcilable. In view of the fact that the causative organism is
unknown, there is no scientific basis for the use of any particular
vaccine against the primary disease. If used, any vaccine must be
employed on the chance that it bears a relation to the unknown organism
causing the disease.

The use of vaccines for the complicating infections rests on more
logical grounds, and yet the committee has not sufficient evidence to
indicate that they can be used with any confident assurance of success.
In the use of these vaccines the patient should realize that the
practice is still in a developmental stage.

The committee believes that when vaccines are used experimentally for
the purpose of determining their preventive or curative value, the
following conditions should be complied with:

  1. The groups of vaccinated and unvaccinated persons should be the
  same in number.

  2. The relative susceptibilities of the two groups should be equal, as
  measured by age and sex distribution, previous exposure to infection
  without development of influenza and a previous history as to recent
  attacks of the disease.

  3. The degree of exposure in each group should be practically the same
  in duration and intensity.

  4. The groups should be exposed concurrently during the same stage of
  the epidemic curve.


III. _Increased natural resistance of persons exposed to infection._

Physical and nervous exhaustion should be avoided by paying due regard
to rest, exercise, physical and mental labor, and hours of sleep. The
evidence is conclusive, however, that youth and bodily vigor do not
guarantee immunity to the disease.

The nature of the preventive measures practicable and necessary in any
given community depends in a large part upon the nature of the community
itself, as to population characteristics, industries, and so on, and
upon the stage and type of the epidemic curve. For example, the measures
to be adopted in a purely rural community would not be practicable or
desirable in a large metropolitan area, nor would the measures desirable
and feasible at the beginning or end of an epidemic be found those best
adapted for the intervening period. The committee has found it
impossible, therefore, to lay down any rules for the guidance of all
health officials alike in preventive measures. The most it has been able
to do has been to state certain general principles that in its judgment
should underlie administrative measures for the prevention of influenza.
The application of these principles to the needs of any particular
community must be left for determination by the officers of that
community who are responsible for the protection of its public health.

The preventive measures recommended by the committee are as follows:

A. Efficient organization to meet the emergency, providing for a
centralized co-ordination and control of all resources.

B. Machinery for ascertaining all facts regarding the epidemic:

  1. Compulsory reporting.

  2. A lay or professional canvass for cases, etc.

C. Widespread publicity and education with respect to respiratory
hygiene, covering such facts as the dangers from coughing, sneezing,
spitting, and the careless disposal of nasal discharges; the
advisability of keeping the fingers and foreign bodies out of the mouth
and nose; the necessity of hand-washing before eating; the dangers from
exchanging handkerchiefs; and the advantages of fresh air and general
hygiene. Warnings should be given regarding the danger of the common
cold, and possibly cold should be made reportable so as to permit the
sending of follow up literature to persons suffering from them. The
public should be made acquainted with the danger of possible carriers
among both the sick and the well and the resultant necessity for the
exercise of unusual care on the part of everybody with respect to the
dangers of mouth and nasal discharges.

D. Administrative procedures:

1. There should be laws against the use of common cups, and improperly
washed glasses at soda fountains and other public drinking places, which
laws should be enforced.

2. There should be proper ventilation laws, which laws should be
enforced.

Since the disease is probably largely a group or crowd problem, the
three following sub-heads are especially important.

3. CLOSING.—Since the spread of influenza is recognized as due to the
transmission of mouth and nasal discharges from persons infected with
influenza, some of whom may be aware of their condition but others
unaware of it, to the mouths and noses of other persons, gatherings of
all kinds must be looked upon as potential agencies for the transmission
of the disease. The limitation of gatherings with respect to size and
frequency, and the regulation of the conditions under which they may be
held must be regarded, therefore, as an essential administrative
procedure.

Non-essential gatherings should be prohibited. Necessary gatherings
should be held under such conditions as will insure the greatest
possible amount of floor space to each individual present, and a maximum
of fresh air, and precautions should be taken to prevent unguarded
sneezing, coughing, cheering, etc.

Where the necessary activities of the population, such as the
performance of daily work and earning of a living, compel considerable
crowding and contact, but little is gained by closing certain types of
meeting places. If, on the other hand, the community can function
without much of contact between individual members thereof, relatively
much is gained by closing or preventing assemblages.

SCHOOLS: As to the closing of schools there are many questions to be
considered.

  (a) Theoretically, schools increase the number and degree of contacts
  between children. If the schools are closed, many of the contacts
  which the children will make are likely to be out of doors. Whether or
  not closing will decrease or increase contacts must be determined
  locally. Obviously, rural and urban conditions differ radically in
  this regard.

  (b) Are the children in coming to and going from school exposed to
  inclement weather or long rides in overcrowded cars?

  (c) Is there an adequate nursing and inspection system in the schools?

  (d) Is it likely that teachers, physicians and nurses can really
  identify and segregate the infected school child before it has an
  opportunity to make a number of contacts in halls, yards, rooms, etc.?
  We suggest that children suspected of having influenza and held in
  school buildings for inspection should be provided with and required
  to wear face masks.

  (e) Will the closing of schools release personnel or facilities to aid
  in fighting the epidemic?

  (f) If schools are kept open, will the absence of many teachers lower
  the educational standards?

  (g) If a number of pupils stay at home because of illness or fear,
  will they not constitute a heavy drag upon their classes when they
  return?

  (h) If schools are closed, is there likely to be an outbreak in any
  case when they are reopened?

CHURCHES: If churches are to remain open, services should be reduced to
the lowest number consistent with the adequate discharge of necessary
religious offices, and such services as are held should be conducted in
such a way as to reduce to a minimum intimacy and frequency of personal
contact.

THEATRES: As regards theatres, movies, and meetings for amusement in
general, it seems unwise to rely solely or in great part upon the
ejection of careless coughers. In the first place it is difficult to
determine who is a careless cougher, and after each cough, danger has
already resulted. It seems, too, that the closing of theatres may have
as much educational value as their use for direct educational purposes,
etc. Discrimination as to closing among theatres, movies, etc., on the
basis of efficiency of ventilation and general sanitation, may be
feasible.

SALOONS, ETC.: The closing of saloons and other drinking places should
be decided upon the basis of the probability of spread of the disease
through drinking utensils and the conditions of crowding.

DANCE HALLS, ETC.: The closing of dance halls, bowling rooms, billiard
parlors and slot-machine parlors, etc., should be made effective in all
cases where their operation causes considerable personal contact and
crowding.

STREET CARS, ETC.: Ventilation and cleanliness should be insisted upon
in all transportation facilities. Over-crowding should be discouraged. A
staggering of opening and closing hours in stores and factories to
prevent overcrowding of transportation facilities may be cautiously
experimented with. In small communities where it is feasible for persons
to walk to their work it is better to discontinue the service of local
transportation facilities.

FUNERALS: Public funerals and accessory funeral functions should be
prohibited, being unnecessary assemblies in limited quarters, increasing
contacts and possible sources of infection.

4. MASKS.—The wearing of proper masks in a proper manner should be made
compulsory in hospitals and for all who are directly exposed to
infection. It should be made compulsory for barbers, dentists, etc. The
evidence before the committee as to beneficial results consequent upon
the enforced wearing of masks by the entire population at all times was
contradictory, and it has not encouraged the committee to suggest the
general adoption of the practice. Persons who desire to wear masks,
however, in their own interest, should be instructed as to how to make
and wear proper masks, and encouraged to do so.

5. ISOLATION.—The isolation of patients suffering from influenza should
be practised. In cases of unreasonable carelessness, it should be
legally enforced most rigidly.

6. PLACARDING.—In cases of unreasonable carelessness and disregard of
the public interests placarding should be enforced.

7. HOSPITALIZATION.—The theory of complete hospitalization is that, if
all the sick were hospitalized the disease would be controlled. In
certain somewhat small communities where hospitalization of all cases
was promptly inaugurated the disease did come quickly under control. It
must be recognized, however, that unless every infective person can be
detected and identified as such and removed to the hospital before he
has infected others, hospitalization cannot be depended upon to
eliminate the disease.

In general, home treatment is to be advocated where medical, nursing and
other necessary facilities are adequate, and where home treatment is not
directly contra-indicated by the danger of infecting others. The
hospitalization in any case, mild or severe, should be undertaken only
when facilities for home treatment are inadequate with respect to
medical and nursing care or otherwise. The objection to routine
hospitalization of mild cases lies in the fact that patients not already
suffering from secondary infections may acquire them by exposure to
hospital cases already so infected. The objection to the routine
hospitalization of severe cases lies in the danger to the patient
necessarily incident in the transfer from home to hospital.

8. COUGHING AND SNEEZING.—Laws regulating coughing and sneezing seem to
be desirable for educational and practical results.

9. TERMINAL DISINFECTION.—Terminal disinfection for influenza has no
advantage over cleaning, sunning and airing.

10. ALCOHOL.—The use of alcohol serves no preventive purpose.

11. SPRAYS AND GARGLES.—Sprays and gargles do not protect the nose and
throat from infection, for the following reasons:

  (a) So far as the knowledge of the committee extends, no germicide
  strong enough to destroy infective organisms can be applied to the
  nose and throat without at the same time injuring the mucous
  membranes.

  (b) Irrigation of the nose and throat to accomplish the complete
  mechanical removal of the infective organism is impracticable.

  (c) Their use tends to remove the protective mucus, to spread the
  infection and to increase the liability of actual entrance of the
  infective organisms.

  (d) Their domestic use is liable to lead in families to a common
  employment of the same utensils.

  (e) The futility of sprays and gargles has been demonstrated with
  respect to certain known organisms such as the diphtheria bacillus and
  the meningococcus.



                     MISCELLANEOUS CONSIDERATIONS.


1. Colleges, asylums and similar establishments may with advantage
enforce rigid institutional quarantine against the outside world, if
they begin in the early stage of an epidemic, provided they are so
located and conducted as to render the procedure reasonably likely to be
effective, even temporarily; for even temporary success will postpone
the appearance of the disease, if it appears at all, to a time when the
patients will be more likely to be able to have adequate medical and
nursing care.

2. The recommended measures for control, even if they do not accomplish
the desired end, should at least be instrumental in distributing the
epidemic over a longer period of time, which in itself is highly
desirable.

3. The statistics of the disease and the keeping of proper records are
extremely important. The lack of knowledge regarding innumerable factors
in reference to the disease makes all the more desirable complete case
records, etc.

4. The committee wishes to emphasize the need for the complete
statistical study of the collected data on the mortality, morbidity,
case fatality, duration, economic aspects, and therapeutics of the
disease. Through the collection of the facts in a uniform manner, and
through the analysis of such tabulated data, especially mathematical
graduation, and testing and study of the figures, important
contributions to the natural history and typical characters of the
disease may be expected. General principles as to the etiology, fatality
and practical management of influenza may follow from the extensive
survey of the epidemic in the statistical laboratory as well as from the
intensive bedside observation of single cases of the disease.

5. The measures recommended are calculated to be effective in the
promotion of respiratory hygiene in general and particularly in the
control of pneumonia and other respiratory infections.



                  ADMINISTRATIVE MEASURES FOR RELIEF.


The committee on administrative measures for relief would submit the
following considerations as constituting a summary of the important
measures for meeting epidemic conditions:


_I. General Rules._

1. Compulsory reporting.

2. Isolation by co-operation and education, to a point where it does not
diminish the willingness of the physician to report.

3. Placarding would seem to be subject to the same limitations as is
isolation.

4. The closing of schools, prohibition of funerals, etc., being
preventive measures, are not touched upon in this report, except to
mention that the closing of many agencies will release medical, nursing,
and volunteer services for special influenza work.

5. It may be necessary to grant authority and power to the health
authorities to administer relief.


_II. Preliminary Measures._

1. The listing and distribution of resources, including physicians,
nurses, social workers, nurses’ aids, clerks, domestics, laundresses,
automobiles, chauffeurs, mask makers, and volunteers of all kinds.

All available publicity channels should be used to promote volunteer
service.

An appeal should be made for voluntary donors of human blood serum from
convalescent influenza patients, to be held in readiness for use in
treatment.

2. The centralization of resources, under one control, with central and
branch headquarters, the city being districted for medical, nursing and
other work.

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_.





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