Part 3

2. There should be proper ventilation laws, which laws should be enforced.

Since the disease is probably largely a group or crowd problem, the three following sub-heads are especially important.

3. CLOSING.—Since the spread of influenza is recognized as due to the transmission of mouth and nasal discharges from persons infected with influenza, some of whom may be aware of their condition but others unaware of it, to the mouths and noses of other persons, gatherings of all kinds must be looked upon as potential agencies for the transmission of the disease. The limitation of gatherings with respect to size and frequency, and the regulation of the conditions under which they may be held must be regarded, therefore, as an essential administrative procedure.

Non-essential gatherings should be prohibited. Necessary gatherings should be held under such conditions as will insure the greatest possible amount of floor space to each individual present, and a maximum of fresh air, and precautions should be taken to prevent unguarded sneezing, coughing, cheering, etc.

Where the necessary activities of the population, such as the performance of daily work and earning of a living, compel considerable crowding and contact, but little is gained by closing certain types of meeting places. If, on the other hand, the community can function without much of contact between individual members thereof, relatively much is gained by closing or preventing assemblages.

SCHOOLS: As to the closing of schools there are many questions to be considered.

(a) Theoretically, schools increase the number and degree of contacts between children. If the schools are closed, many of the contacts which the children will make are likely to be out of doors. Whether or not closing will decrease or increase contacts must be determined locally. Obviously, rural and urban conditions differ radically in this regard.

(b) Are the children in coming to and going from school exposed to inclement weather or long rides in overcrowded cars?

(c) Is there an adequate nursing and inspection system in the schools?

(d) Is it likely that teachers, physicians and nurses can really identify and segregate the infected school child before it has an opportunity to make a number of contacts in halls, yards, rooms, etc.? We suggest that children suspected of having influenza and held in school buildings for inspection should be provided with and required to wear face masks.

(e) Will the closing of schools release personnel or facilities to aid in fighting the epidemic?

(f) If schools are kept open, will the absence of many teachers lower the educational standards?

(g) If a number of pupils stay at home because of illness or fear, will they not constitute a heavy drag upon their classes when they return?

(h) If schools are closed, is there likely to be an outbreak in any case when they are reopened?

CHURCHES: If churches are to remain open, services should be reduced to the lowest number consistent with the adequate discharge of necessary religious offices, and such services as are held should be conducted in such a way as to reduce to a minimum intimacy and frequency of personal contact.

THEATRES: As regards theatres, movies, and meetings for amusement in general, it seems unwise to rely solely or in great part upon the ejection of careless coughers. In the first place it is difficult to determine who is a careless cougher, and after each cough, danger has already resulted. It seems, too, that the closing of theatres may have as much educational value as their use for direct educational purposes, etc. Discrimination as to closing among theatres, movies, etc., on the basis of efficiency of ventilation and general sanitation, may be feasible.

SALOONS, ETC.: The closing of saloons and other drinking places should be decided upon the basis of the probability of spread of the disease through drinking utensils and the conditions of crowding.

DANCE HALLS, ETC.: The closing of dance halls, bowling rooms, billiard parlors and slot-machine parlors, etc., should be made effective in all cases where their operation causes considerable personal contact and crowding.

STREET CARS, ETC.: Ventilation and cleanliness should be insisted upon in all transportation facilities. Over-crowding should be discouraged. A staggering of opening and closing hours in stores and factories to prevent overcrowding of transportation facilities may be cautiously experimented with. In small communities where it is feasible for persons to walk to their work it is better to discontinue the service of local transportation facilities.

FUNERALS: Public funerals and accessory funeral functions should be prohibited, being unnecessary assemblies in limited quarters, increasing contacts and possible sources of infection.

4. MASKS.—The wearing of proper masks in a proper manner should be made compulsory in hospitals and for all who are directly exposed to infection. It should be made compulsory for barbers, dentists, etc. The evidence before the committee as to beneficial results consequent upon the enforced wearing of masks by the entire population at all times was contradictory, and it has not encouraged the committee to suggest the general adoption of the practice. Persons who desire to wear masks, however, in their own interest, should be instructed as to how to make and wear proper masks, and encouraged to do so.

5. ISOLATION.—The isolation of patients suffering from influenza should be practised. In cases of unreasonable carelessness, it should be legally enforced most rigidly.

6. PLACARDING.—In cases of unreasonable carelessness and disregard of the public interests placarding should be enforced.

7. HOSPITALIZATION.—The theory of complete hospitalization is that, if all the sick were hospitalized the disease would be controlled. In certain somewhat small communities where hospitalization of all cases was promptly inaugurated the disease did come quickly under control. It must be recognized, however, that unless every infective person can be detected and identified as such and removed to the hospital before he has infected others, hospitalization cannot be depended upon to eliminate the disease.

In general, home treatment is to be advocated where medical, nursing and other necessary facilities are adequate, and where home treatment is not directly contra-indicated by the danger of infecting others. The hospitalization in any case, mild or severe, should be undertaken only when facilities for home treatment are inadequate with respect to medical and nursing care or otherwise. The objection to routine hospitalization of mild cases lies in the fact that patients not already suffering from secondary infections may acquire them by exposure to hospital cases already so infected. The objection to the routine hospitalization of severe cases lies in the danger to the patient necessarily incident in the transfer from home to hospital.

8. COUGHING AND SNEEZING.—Laws regulating coughing and sneezing seem to be desirable for educational and practical results.

9. TERMINAL DISINFECTION.—Terminal disinfection for influenza has no advantage over cleaning, sunning and airing.

10. ALCOHOL.—The use of alcohol serves no preventive purpose.