Part 7

1. Instructions to physicians as to reporting, facilities available, district arrangements, etc.

2. Advice to physicians regarding treatment standards and suggestions.

3. Instructions for families, to be distributed by nurses, physicians, social workers, druggists, etc., covering the problems of care during the physician’s absence.

4. Instructions to the public as to where aid may be secured, to be printed in various languages, and distributed by druggists, displayed in street cars, used in the press, etc.

5. Instructions for families on “What to do till the doctor comes.”

6. Instructions to physicians, factory managers, school superintendents, etc., urging the necessity for immediate home and bed treatment at the first sign of respiratory disease.

7. Popular literature on the essentials of adequate care, the danger of returning to work too soon, etc. Popular press space is worth paying for, if it cannot be secured otherwise.

8. Popular publicity as to legitimate medical, nursing, undertaker, drug, and other charges, to prevent profiteering.

X. Miscellaneous.

1. The co-operation of pharmaceutical agencies should be secured to ensure an adequate supply of drugs and druggists.

2. Influenza victims and their families should have “first call” on fuel deliveries.

3. While follow up procedures are not legitimately a factor in the epidemic situation, their consideration is essential to an adequate meeting of the entire problem. This means adequate provision for medical examination and nursing care, relief measures, industrial employment problems, the follow up of special sequelæ such as cardiac affections, tuberculosis, etc.

4. It is finally suggested that Health Department draw up a programme based on the above outline, holding it in reserve for future use, if not immediately needed, and modifying the proposal to fit the size and other characteristics of the particular community.

THE BACTERIOLOGY OF THE 1918 EPIDEMIC OF SO-CALLED INFLUENZA.

The epidemic disease known as influenza is believed to be due to an undetermined organism which causes an infection that lowers the resistance of the body as a whole, and of the respiratory organs in particular. This allows the invasion of other pathogenic micro-organisms. The most important complicating infections are due to the influenza bacilli, different strains of pneumococci and different varieties of streptococci. Some careful observers regard certain of these organisms as the primary cause.

In each case, one or several of these micro-organisms may be present. In different portions of the country the dominating variety of organism has been found to differ.

VACCINES.

Assuming that the cause of the epidemic is an unknown virus, it does not seem possible at present to prevent the primary disease by vaccination with known organisms. Against the secondary infections, there would seem to be a theoretical basis for the use of vaccines, and especially for the use of vaccines prepared from organisms responsible for complications which may differ in various localities at various times. This variable bacterial flora may militate against the practical application of vaccination on a large scale, because it would seem to require frequently repeated vaccinations with the flora that may be met with. It is impossible at present to evaluate the reports from the use of these vaccines adjusted to meet local conditions. More data obtained under carefully controlled conditions are needed.

Stock vaccines made from the influenza bacillus alone or from other bacteria, have been used to considerable extent. The injections of stock vaccines have seemed to mitigate to some degree some outbreaks of influenza and also the severity of the complicating infections; but in those instances in which the results of the use of vaccine have been controlled, no appreciable results have been obtained. The fact that the vaccine is usually employed after the epidemic has broken out and is perhaps on a decline, and the fact that an unknown number of people have been exposed, make it very difficult to draw conclusions as to its efficacy.

RECOMMENDATIONS.

Your committee recommends that until such time as the efficacy, or the lack of efficacy, of prophylactic vaccination against influenza is established, vaccine if used, should be employed in a controlled manner, under conditions that will allow a fair comparison of the number of cases and of deaths among the vaccinated and non-vaccinated groups. Particular attention should be directed to securing data as to the period in the epidemic at which vaccinated and non-vaccinated persons developed the disease.

Your committee is of the opinion that the indiscriminate use of stock vaccines against influenza and influenza and pneumonia cannot be recommended.

Nothing in these recommendations should be interpreted as discouraging the use of a pneumococcus stock vaccine against lobar pneumonia.

This epidemic emphasizes the importance of properly equipped laboratories.

HISTORY AND STATISTICS OF THE EPIDEMIC.

Your sub-committee wishes to say that in view of the fact that the historical and other data of the epidemic are still in process of collection, no positive statement can be made at the present time on the precise incidence of the disease in the American population. On the basis of the best data available your sub-committee estimates that there were not less than 400,000 deaths from the disease in the United States during the months of September, October and November, 1918. The major portion of this mortality occurred at ages 20–40, when human life is of the highest economic importance. We would suggest that this sub-committee be authorized to co-operate with the special committee on statistical study of the epidemic of the section on Vital Statistics of this Association, and that the data collected through that latter special committee be reported through the sub-committee on history and statistics of the epidemic to the general reference committee on the influenza epidemic. Standard forms for purposes of statistical tabulation, analysis and graphic presentation will be submitted in a supplementary report at an early date.

SUGGESTIONS.

In view of the probability of recurrences of the disease from time to time during the coming year, health departments are advised to be ready in advance with plans for prevention, which plans shall embody the framework of necessary measures and as much detail as possible. Laws plainly necessary should be enacted and rules passed now. Emergency funds should be held in reserve or placed in special appropriations, which appropriations can be quickly made available for influenza prevention work.