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.