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remained to assist the local Health Department. Probably as a result of a general, relaxation, there has since been an increase in the number of cases to about nine weekly. It is believed that reorganization of local health activities, coming at a time of favorable climatic conditions, will result in the case incidence again, being brought to normal.

Figures. indicating crude death rates. are significant. In 19.15, with 201 cases reported, the death. rate was 12 per cent. In December, 1916, it was 6.3 per cent; in January 1.3 per cent; and in February 1 per cent. While the diminishing rate may have been due in some degree to earlier treatment with antitoxin, it seems to the writer to reflect. chiefly. the increased reporting of mild cases, previously unreported.

In conclusion, a study of this outbreak presents nothing new, but, serves to emphasize certain welli established general observations: (1) Generally speaking, the communicable disease rate in any municipality indicates the degree of organization and effectiveness of health activities.. (2) An. outbreak is difficult to control in direct proportion to the length of time it has been under way and the extent of dissemination. (3) Health activities are thorouglily organized only when there is complete coordination of activities of all agencies interested in health protection, including health department, schools, medical profession and lay organizations. (4) There is serious need of stimulation of civic consciousness and of education, not alone of the laity but of the medical profession, to the need of intelligent cooperation, ifi Health is to be protected.

Diphtheria which in 19:16 for the first time in the history of the state reached a death rate below 15 per 100,000 rose above that mark in 1917. The rate is, however, lower than any year except 1916. The increase was about equally divided Between New York City and the rest of the state though the relative increase was greater up-state. The case and death rates are shown in the table on page 202 and a graph drawn from them is shown opposite this page. While diphtheria no longer claims the large number of victims it did thirty years ago when the rate usually varied from 80–100 per 100,000, and while the rate today is approximately half of the usual rate of ten years ago, yct for the past seven years the rate has shown comparatively little decline. It seems remarkable that the case fatality rate remains as high as it does despite the quite complete knowledge we have of the cause of diphtheria, its mode of transmission and treatment.

As in previous years, the New York City rate is very much higher than the up-state rate, due almost entirely to a higher case

the difference in the case fatality rates is very slight. It is found that the highest case fatality rate is in the group composed of Buffalo and Rochester (175,000 --- 500,000). The rate in the


former city was 10 per cent, in the latter 12.5 per cent, the combined rate 10.8. In Rochester the disease was said to have been of unusual virulence in the later months of the year and there were an unusual number of deaths among adults.

Among the second class cities the disease prevailed extensively in Binghamton and the nearby villages. An outbreak beginning late in 1916 extended over into the early part of 1917 and reappeared in decreased intensity in the fall. The outbreak in 1916 appears really to have been simply the culmination of a condition that had existed for three years previously. The adoption of systematized control brought to light a large number of carriers and resulted in an apparent temporary increase in the number of cases.

A decline rapidly set in as is usual in such circumstances, though it required three months of intensive work to bring the outbreak to a successful conclusion. In November the case incidence again rose to abnormal proportions but was promptly brought under control by the reorganized local health department.

In December the attention of the department was called to the unusual prevalence of the disease in Gloversville. Investigation was begun only two weeks before the close of the year but brought to light the fact that the cases had been unusually numerous for the preceding three months and, although every section of the city had had a case, the disease was unusually prevalent in the sections served by tiro of the public schools. The age incidence showed a large preponderance of school children among those attacked and with but very few exceptions children attending one or other of these two schools were members of families attacked. In a number of instances neighborhood contact was quite as possible as school contact. A study of the individual cases showed that in one school nearly all the cases had been confined to one grade, culturing of which yielded four carriers one of whom proved later to be carrying nonvirulent oragnisms. One of the others was a child who had had clinical diphtheria in September

three months previously — but had been released on two negative cultures.

As cases had occurred quite generally throughout the second school it was decided to culture all those attending it. The chief

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