U.S. NAVY: 1918 PREVENTIVE MEASURES
January 7th, 2009First and last, all preventive measures which seemed logical, either from a priori reasoning or because of seemingly good effects claimed for them elsewhere during the year or in previous epidemics, were tried in the Navy.
These included quarantine, daily inspection of personnel and the taking of temperatures, early isolation of the sick, the wearing of face masks and gowns and rigid aseptic technic by attendants upon the sick; the early transfer of patients to a base hospital; the retention and isolation of patients in dispensaries where they could be segregated in small groups instead of being brought into immediate or indirect contact with large numbers of other patients; strict attention to ventilation, relief of overcrowding, use of muslin screens between bunks or hammocks in barracks; prevention of gatherings indoors as much as possible; restrictions on travel, particularly by common carrier;
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the application of nose and throat sprays to those not yet attacked; the use of prophylactic vaccines, the very general and intensive use of educational measures, and the rigid enforcement of sanitary rules and regulations with particular regard to personal hygiene, cleanliness, care of floors and decks, windows, and other ventilating inlets and outlets, mess gear, drinking utensils, drinking fountains and other articles liable to contamination with mouth and nose discharges of patients or carriers. The protection of influenza patients during convalescence, even those having mild attacks, was generally regarded as an important preventive measure. The therapeutic use of serum donated by patients convalescing from influenzal pneumonia was given a somewhat extensive trial in attempts to reduce influenzal pneumonia case-fatality rates.
Speaking in general terms, the history of influenza in the autumn of 1918 shows that the disease spread rapidly and progressively, attacking communities of all sizes regardless of preventive measures put into effect, and regardless of geographical location, climate, weather, nature of the industries, race, density of population, habits of the people, character of housing, habits of diet, social and economic conditions, sanitation, soil conditions, flora and fauna, or routes and modes of travel.
Naval stations varied greatly in size and density of population as well as with regard to geographical location, environment, and the nature of activities carried on. Strong efforts were made at all stations and on board all vessels to prevent the introduction of the disease and to limit its spread by the enforcement of all preventive measures which were practicable under war conditions. Attention was paid universally to sanitation, education of the naval personnel, ventilation, proper care of mess gear, and early treatment of the sick. Relief of overcrowding was possible in some places; in others, not. Under the necessity of fighting the war it was usually deemed impracticable to establish quarantine of any degree or to prevent intercommunication with civil communities and other naval stations. At different stations various special preventive measures were tried, such as vaccines, use of face masks, daily or twice daily use of prophylactic nose and throat sprays, and putting the men into tents.
Epidemic incidence rates, epidemic death rates, and case-fatality rates varied considerably at different shore stations and among different forces afloat, as the statistical data show. Not infrequently certain specific measures which were credited at one station with having prevented the spread of influenza or with having reduced the complications or with having kept case-fatality rates low failed to prove of any value at another station. So many epidemiological factors were or might have been involved in every instance that it is quite impossible to judge what factors were operative at a given station or to what preventive measures low rates could be definitely attributed when they occurred. It may be said, however, that each of the preventive measures enumerated was thoroughly tried, in conjunction with other measures of course, at some one or more stations where the incidence of influenza was high and the epidemic severe. In other words, each particular preventive measure failed in some instances to accomplish recognizable results.
It should be remarked that influenza was regarded as a disease of the respiratory type disseminated by moist discharges from the
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mouth and nose, and the preventive measures applied were those which have come to be looked upon as valuable in preventing the spread of any acute communicable disease of the respiratory type. With the exception of absolute quarantine at the United States Naval Training Station, San Francisco, these measures proved of little or no appreciable value in the presence of epidemic influenza.
The experience of 1918 would indicate that a very important preventive measure when confronted with an outbreak of influenza consists in rapidly enlarging existing medical and nursing facilities for the proper care and treatment of the large numbers of persons who will inevitably be attacked regardless of measures planned to prevent the occurrence or spread of the disease.
Quarantine.--Absolute quarantine was imposed at the United States Naval Training Station, San Francisco, on September 23, before the introduction of influenza. All officers, enlisted men, and civilian were recalled and required to remain on the island. All communication with San Francisco and Oakland was discontinued, except to receive supplies and recruits or other men who reported and necessarily had to be received. Precautions were taken to prevent the crews of tugs from approaching persons on the dock closer than 20 feet. All recruits and others who had to be received from the mainland had the pharynx and nasal passages thoroughly sprayed with a 10 per cent solution of silvol and were required to put on gauze face masks before they were allowed to board the tug bound for the island. Upon arrival they were placed in a quarantine camp for several days, during which they wore masks, were sprayed three times a day with silvol, and were required to keep at a distance of 20 feet from each other.
The entire personnel of the station--officers, enlisted men, and civilians were required to have the pharynx and nasal passages sprayed once daily with a 10 per cent solution of silvol. All drinking fountains were flamed with a gasoline torch, and all telephone transmitters were disinfected twice daily. In barracks each cot was provided with a muslin screen extending around the head and along one side, 30 inches above the level of the cot. A part of the personnel was quartered in tents. Outdoor recreation was provided.
This was not a pure quarantine experiment. The entire personnel was inoculated with three successive doses of a mixed bacterial vaccine administered October 12, 15, and 18, respectively. This vaccine contained per c.c.:
Pfeiffer bacillus, Rockefeller strain ..........5,000,000,000
Pneumococcus type I, various strains..... 3,000,000,000
Pneumococcus type II, various strains ....3,000,000,000
Pneumococcus type III, one strain .........1,000,000,000
Streptococcus hemolyticus, two strains .....100,000,000
The three doses were 0.5 c.c., 0.8 c.c., and 1 c.c. respectively.
While quarantine was in effect no case of influenza occurred on the station, although all other naval stations on the Pacific coast, as well as civilian communities, experienced epidemics during this period. The disease made its first appearance at the station on December 6, 16 days after quarantine was raised.
In the city of San Francisco the primary epidemic began during the week ending September 21, reached its height during the week ending October 5, and subsided rapidly. The epidemic, as indicated
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by epidemic death rates, was of about the same duration and severity as those which occurred in Boston, Mass., and Washington, D.C., in spite of the fact that somewhat drastic ordinances and regulations, which included the compulsory wearing of face masks on the street, were adopted; measures which the cities in the East did not see fit to undertake. A rather sharp recurrent epidemic began in the city during the week ending December 14, and the weekly death rate did not reach an approximately normal level until after the week ending March 8, 1919.
At the United States Navy Yard, Mare Island, Cal., very practical precautions were taken as early as September 23, against the introduction and spread of the disease. Absolute quarantine was not feasible but a modified quarantine was ordered. The epidemic in the Mare Island navy yard began October 4, and reached its height in the latter part of the month. The incidence diminished one half in November, but the epidemic period lasted until November 30.
To the absolute quarantine efficiently maintained on Goat Island must be attributed the entire absence of influenza from this training station while all communities in the vicinity were suffering. After free communication was resumed with San Francisco and Oakland on November 21 the disease was introduced, and during the month of December 148 cases of acute bronchitis, 13 of broncho-pneumonia, 4 of lobar pneumonia, and 25 cases of influenza were reported. Doubtless some at least of the cases reported as broncho-pneumonia were true cases of influenza, and judging from the incidence of pneumonic complications at other stations it is altogether probable that at least 100 cases of influenza occurred. The experience at this station seems to show that under exceptional conditions quarantine can be made effective against the introduction of influenza, but that after quarantine is raised the disease will make its appearance with an incidence proportionate to that obtaining at the time in the surrounding territory. Beyond question, life was saved there by the absolute quarantine.
Deaths from influenza and all forms of pneumonia, during the year 1918, occurred at the United States Naval Training Station, San Francisco, as follows:
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