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While the upstate rate has shown a continuous decline since 1913, New York City had shown such a decline since 1910 and had contributed materially to the declining typhoid death rate of the State as a whole. Since little could be deduced from the study of county death rates or of city death rates as compared with “rural” rates as the latter term is used in the monthly bulletin and the previous reports of the Department, it has seemed desirable to resort to a classification dependent upon the actual size of the population groups. Accordingly the upstate municipalities have been aggregated into eight classes as shown in the accompanying chart and table, the populations as of June, 1915, being taken as the base. The population of the same areas in 1910 was then determined and the mid-year estimates made in the usual way using the group totals for the calculation. The reported cases and deaths from the various classes were then assembled from the previous annual reports and the records of the Department. The deaths and cases from State institutions have not been included in the municipalities in which they are located but have been separately grouped although no rates have been calculated for them. The populations of these institutions were not included in the 1915 census.

As may be seen by looking at chart No. 15, although all classes show a lower death rate in 1917 than in 1913, minor fluctuations are found in all classes except the 10,000 – 20,000 class and the unincorporated towns. Case rates, based as they are on less dependable reporting, show larger fluctuations and these are to be found in all classes. Taking up the different groups seriatim, it is found that the first group, consisting of Rochester and Buffalo, shows an increase in case and death rates in' 1914 over 1913, a very marked drop in 1915 and a slightly declining rate since. The preponderance of Buffalo's population masks the remarkably good showing of Rochester, whose death rate has declined from 11 per 100,000 in 1914 to 3 per 100,000 in 1917. This death rate was the lowest recorded in any city in the State of 50,000 or more population. Three of the eight recorded deaths were among patients sent in from Wayne County Home (near Lyons) for treatment and one other came from a village in Monroe county. The reduction of the past two years has been ascribed

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by the health officer to the improvement of water supplies and sanitary conditions in nearby pleasure resorts largely patronized by Rochester people. Antityphoid vaccination has been extensively advertised but it is not possible to estimate the influence of this measure from the data at hand.

The persistence of Buffalo's rate at or above 10 per 100,000 is only in a slight degree explicable by the deaths of patients sent in for treatment. Only six of the 47 deaths were among such patients and it has been noted too that Buffalo has been mentioned rather prominently in the itinerary of cases investigated elsewhere in the State. The city water supply is derived from Lake Erie, without filtration, and is disinfected with liquid chlorine. The somewhat erratic monthly incidence of the cases gives rise to a suspicion that the water supply is in part to blame. Buffalo is under the disadvantage, however, of having in its vicinity the small city of Tonawanda where the water supply is notoriously polluted and whose typhoid case rate is one of the highest in the State. The monthly bulletins of the Buffalo city health department ascribe 35 cases among residents to out of town infection and give 16 as the number of cases brought into the city for treatment. Among the latter there were six deaths. Even deducting these the death rate of the city remains 8.8 per 100,000 which should hardly be accounted satisfactory for the second city of the State.

A further criticism of Buffalo's typhoid should be made of the abnormally high case fatality rate — 22 per cent - twice as high as Rochester's and nearly double that of the State outside New York City. The inference to be drawn is that cases are very incompletely reported. It would seem that by insisting upon complete reporting and by intensive investigation of all cases the probable sources could be ascertained and the proper remedial measures applied, with a material reduction in the typhoid rate as a result.

The cities of the second class (population from 50,000 to 175,000) showed as a group an increase in 1917 over 1916 and 1915, both in case and mortality rates. Albany, Troy and Yonkers contributed most to the increase in the death rate though the latter's mortality rate was well below that of upstate New York as a whole and but little more than half that of the combined rate for cities of this class. Yonkers' case fatality rate of 37.5 per cent is indicative of lax reporting of cases and as a corollary of incomplete investigations. It would seem that with but little effort Yonkers should be able to maintain a rate very near its low record of 1916.

Yonkers, Syracuse and Schenectady all had mortality rates below that of the group as a whole but Schenectady is the only one of these three showing a case fatality rate indicative of good reporting, and it is perhaps significant that it has the lowest mortality rate of this group and has maintained its low rate for two successive years. Syracuse has a case fatality rate of ridiculous proportions (38.5 per cent) and the marked fluctuations in its rate from year to year strengthen the suspicion that its rate for the past year has been fortuitous rather than the result of control.

The highest rate for any city in the group is Troy's which is more than twice that of the group as a whole or that of any single member of it. However, two factors for which Troy is not wholly responsible enter as mitigating circumstances. First, Troy is the hospital center for Watervliet and Mechanicville and their environs, places subject to very high typhoid rates. Second, these places, more especially Watervliet, serve to infect residents of Troy who work or visit in those communities. As regards the first point an examination of the Troy death certificates shows 7 deaths to have been nonresidents of Troy leaving 14 deaths among residents and giving a death rate (18.7) which is still more than 50 per cent higher than that of the group as a whole.

The influence of the second point is more difficult to estimate. During the course of an investigation of the outbreak in Watervliet in September and October a number of Troy residents were found to have been infected in the former city but the relatively small number of such cases does not indicate that Troy's typhoid rate should be satisfactory to her citizens even if such outside sources were eliminated. In other words, there is some inherent defect which should be sought out and remedied. A localized outbreak investigated by the local health department was found to be due to an infected well extensively used in the affected neighborhood. While this accounted for a large proportion of the cases reported in Troy for the year it failed to account for a corresponding proportion of the deaths (exclusive of deaths among imported cases). The disproportion of deaths to cases was especially marked in the first half of the year during which period 8 deaths and but 16 cases were reported, only one of the deaths being that of a nonresident.

Unquestionably a very considerable reduction in Troy's typhoid rate can be effected with comparatively small effort. The menace of the neighboring cities might be mitigated by proper publicity of their danger and the encouragement of antityphoid vaccination for those whose business requires them to visit those places. Second, it is stated that a considerable number of wells of doubtful safety exist in the city. Should the municipal supply be shown to be safe beyond reasonable doubt their elimination would be an obvious duty. It seems hardly tenable, as some contend, that a mere warning to desist from the use of an unsafe water constitutes the full duty of a health department having power to abate such a menace. If only those drinking from such a source were attacked by the disease there would be more reason for this contention, but when it is considered that each case constitutes a focus of infection throughout the febrile period and for a varying length of time afterward, it is apparent that having typhoid is not merely a matter of personal concern.

Other things being equal, the more seed the bigger the crop.

Albany's typhoid rate increased somewhat over its low record for 1916 and the case rate was materially increased by the occurrence of an unusually large number of cases in November and December. Some difficulty was experienced about this time with the operation of the filter plant and during the early part of this period an unusual number of typhoid cases and convalescents existed in Troy and Watervliet. A sharp decline followed the resumption of adequate treatment of the water supply. Four of Albany's typhoid deaths were among nonresidents.

Utica experienced a sharp outbreak during February, over twothirds of all cases reported during the year occurring in that month. The case and mortality incidence for the last half of the year indicates lax reporting, a condition which the records for the preceding four years indicate is a chronic one. Under such cir


cumstances an outbreak can easily reach large proportions before discovery, with resulting loss from the lack of prompt application of proper remedial measures. The January-February outbreak was due to a defective valve in a cross connection between the city's main and an industrial plant's private supply happening which still occurs despite numerous bitter experiences.

This group of cities as a whole seems not to have made the progress which might have been expected of it. It is the only group of the series whose death rate remains above 10 per 100,000 and, despite the importation of cases for treatment, a material reduction should follow if adequate reporting were insisted upon and a moderate amount of intensive work instituted.

The group of cities of from 20,000 – 50,000 population attained a reduction of nearly 25 per cent over its death rate for the previous year and as indicated by its lowered case fatality rate, reporting of cases has shown considerable improvement. No remarkable outbreaks occurred during the year although limited outbreaks occurred in Niagara Falls and Kingston — the former confined to a locality using a private well, the latter due to a suspension of the filtration plant during repairs. Amsterdam and Newburgh came through the year without a typhoid death. The one death in Oswego was a case sent in for treatment as were four of the five deaths in Elmira and two of the three occurring in Poughkeepsie.

Newburgh until 1916 had had a high rate, though it had been enormously reduced from the excessive rate which prevailed prior to the sterilization of its water supply. Most of the residual typhoid was found in 1915 to be due to a typhoid carrier supplying milk to the city. This carrier had been supplying milk for ten years and undoubtedly had been responsible for a large proportion of the city's typhoid,- a good illustration of how a polluted water supply can mask other sources of typhoid. The populations of the cities in this class are not sufficiently large to provide stable individual rates, a slight increase in morbidity or mortality causing a much larger fluctuation in the rate. The health officers of these and smaller municipalities have peculiar need of prompt reports from physicians followed by prompt investigation if the gains already made are to be held or further

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