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early in August. No cases had occurred among the patrons of this boarding house prior to this. According to the landlady, this woman was sick when she began her employment, complaining of headache, backache and chills but continued to work despite her indisposition.
This boarding house serves from forty to fifty and as high as eighty boarders at meals, some of them steady boarders but most of them transients. The only water served was bottled water and this likewise was used in cooking.
From the dates of onset of cases not known to have used city or Second avenue and Thirteenth street water, it is probable that Mrs. B. was a carrier discharging typhoid organisms for a week or two at least prior to taking to her bed and that she was the primary source of infection for five of the cases and probably an auxiliary source for the remaining two. No cases came down from this boarding house after October 9, three weeks subsequent to Mrs. B.'s departure.
In conclusion, it may be stated that the fundamental source of Watervliet's typhoid is the present city water supply, which is not only from a highly polluted source but contains at times so much suspended matter that people will not use it for drinking. Their only recourse is to purchase bottled water or to resort to wells of questionable sanitary quality. The latter is the usual procedure among people with less than moderate incomes. Enjoinders to boil the water fail to reach the class of people most likely to use the wells for drinking and for other purposes and fail here as cverywhere else to prevent a high endemic rate. The first requisite, therefore, to reduce the typhoid morbidity of this city is the displacement of the present supply with the filtered and chlorinated water from Normanskill and until this is done the efforts of the Health Department can have but slight effect upon the typhoid rate unless such efforts are continuously and intensively applied
Subsequent to the introduction of a safe supply, all of the wells in the city should be closed and the residual typhoid will then remain the problem of the local board of health. As Watervliet has had typhoid during practically its whole existence, it is highly
probable that the number of carriers is very great, probably numbering as many as fifty in the entire community. We may expect that their rate for some years will remain higher than the average state rate unless vigorous measures are taken to see that cases are reported promptly and thoroughly investigated, and that minor sources of infection such as contact, flies and milk are properly guarded against.
The privies at present existing in the city should be made fly proof or abolished and the houses connected with the sewer system.
Another method of infection is by swimming in the Hudson river, since the river receives the untreated sewage of Watervliet, Troy and other more distant localities.
An effort should also be made to increase the percentage of pasteurized milk sold in the city and steps taken to guard against its production, sale or delivery by typhoid carriers.
This work means a considerable attention to detail and the health officer should be provided with assistance to carry it out.
During the year there occurred several interesting but fortunately smaller typhoid outbreaks, accounts of some of which follow.
In July, attention was called to the sudden appearance of several cases of typical typhoid fever in and near Millbrook, N. Y. The situation was complicated by the fact that the local health officer was one of the victims, while the other active practising physician in the locality was subject to call as an officer in the M. R. C., U. S. Army. Dr. Halsey J. Ball Jr., sanitary supervisor, was assigned to investigate the outbreak and assume charge of its control, and incidentally was given carte blanche to render medical service in emergencies, when circumstances would permit. Dr. Ball's report follows:
TYPHOID FEVER OUTBREAK, MILLBROOK, DUTCHIESS COUNTY,
July, 1917 Nineteen primary cases with one death and three secondary cases from a single can of milk.
Between the 15th and 27th of July, there occurred in the
village of Millbrook and the town of Washington, Dutchess county, 19 cases of typhoid fever. An investigation of the outbreak showed that all of the cases occurred among persons taking milk from one of the two milkmen serving the community, there being no cases on the other milkman's route.
It was found that the owner of the milk route under suspicion, was distributing about four hundred quarts of milk and cream daily and that all of the milk was being bottled.
The milk was obtained from five farms and delivered at the bottling plant daily, where it was bottled under good conditions as soon as delivered, and cooled immediately.
The fact that only one can contained the infective organism, the bacillus typhosus, and that the infection occurred on the 6th, 7th or 8th of July, is shown by the following facts: Three of the cases occurred in two families that procured milk from the suspected milk route only on the dates given, and all of the primary cases had an onset between the 15th and 27th of July, which would be between the minimum and maximum incubation period after infection, either on the 6th, 7th or 8th of July. As the milkman was distributing about 400 quarts of milk daily, it is reasonable to assume that there would have been a larger number of primary cases had any considerable amount of the milk contained the infective material, and that only one can was probably infected, is a reasonable assumption based upon the number of cases. sonable explanation of this assumption is based on the fact that the farmer who delivered the milk from the farm on which it was shown there were two carriers of the typhoid bacilli, was usually the first producer to arrive at the bottling station, but occasionally the last to arrive; that he was delivering between three and four cans of milk daily; that the bottling machine had a capacity of only three cans; that the milk from three cans was bottled, and that the milk from the fourth can was frequently bottled before another producer arrived at the bottling station, or was the last can bottled, thus making it possible that if this fourth can alone contained the typhoid bacilli, that the forty quarts or less of the milk contained in the infected can might have been delivered to the households in which the cases occurred.
In order to determine the source of the infection, specimens of blood and feces were procured from the people on the farms supplying the milk route under investigation, samples of water were also procured from the wells and springs on the several farms. It was found that a woman, 72 years of age, who had typhoid fever when a girl 12 years of age, and her daughter, 37 years of age, who apparently had never had typhoid fever were discharging the typhoid baccilli. The water from the well on the same farm also showed an excess of chlorine for the locality and was polluted with intestinal organisms.
There were three ways in which the typhoid bacilli might have reached the milk: First, directly by the woman or her daughter taking milk from the can; second, by flies going from the privy to the milk house, which were fifty feet apart and unscreened; third, by the water from the well which was used in the cooling vat in which the cans werep laced overnight.
The outbreak was suppressed by the pasteurization of all of the milk sold in the village and vicinity, the milk from the farm implicated being sold with the other milk until the probable source of the infection was discovered. Another fact tending to prove that the conditions on the farm under suspicion were responsible for the outbreak, is shown by the fact that although none of the milk sold from the other farms had been pasteurized for the five months after the probable source of the infection was discovered and the sale of milk from that farm stopped, there have been no more cases of typhoid fever (with possibly one exception) in the village of Millbrook and town of Washington.
The question naturally arises why there should have been this single outbreak on the milk route involved. The explanation seems to be that previous to April 1, 1917, the milk from the farm having the carriers was sold to a condensery and cheese factory where it was heated before being used.
* It was impossible to determine the date of onset in this case for the reason that the child had whooping cough, and the father who is a physician did not come to the conclusion that the child had typhoid fever until late in August, but undoubtedly the date of onset was between the 15th and 27th of July.
It is interesting to note that while the primary cases are evenly distributed between males and females, there being ten and nine, respectively, the secondary cases are all female, and resulted from the nursing care given primary cases.
The lesson taught by this outbreak seems very clear, namely, that there is always a possibility of infection from raw milk.
Another small outbreak traced to infection through milk occurred during October at and near Delmar, Albany county. Delmar is one of several small unincorporated villages situated a few miles from the city of Albany.
When three cases, all school children, were reported, the writer was more than ordinarily interested, inasmuch as he resides in Delmar and has a child in school. Dr. William B. May was assigned to investigate.