Reprinted from THE AMERICAN JOURNAL OF HYGIENE, Vol. 45, No. 3, 305-334, May, 1947 Printed in U.S. A. TYPHUS FEVER IN ITALY, 1943-1945, AND ITS CONTROL WITH LOUSE POWDER By F. L. SOPER, W. A. DAVIS, F. S. MARKHAM anp L, A. RIEHL1 (Received for publication January 3rd, 1947) INTRODUCTION A suggestion from the Office of The Surgeon General of the United States Army to the National Research Council led, in 1942, to the development of an effective pyrethrum-containing louse powder, MYL, by a United States De- partment of Agriculture group working in Orlando, Fla. Field tests of this powder in artificial louse infestations during the summer of 1942 gave such promising results (Davis and Wheeler, 1944) that similar studies on natural in- festations were planned for Mexico (Davis et al., 1944) and the Middle East. Early in 1943 it was demonstrated in Egypt by the United States of America Typhus Commission that two applica- tions of MYL powder with a 14-day in- terval between treatments would re- duce the louse infestation of an indi- vidual to a low level, and that with an adequate staff large numbers of persons could be deloused at central powder sta- tions in spite of the time consumed in removing the clothing of each individual for dusting. Furthermore, in a village where typhus was epidemic the spread of the disease ceased following the de- lousing treatment. Later in 1943, in Algeria, a technique was evolved for blowing louse powder on the inner surfaces of garments, especially those next the skin, without undressing the person treated (Soper et al., 1945). Tests of MYL and the 1 Members of the typhus team of The Rocke- feller Foundation Health Commission. 305 then new DDT powders, carried out in the absence of typhus infection but con- trolled by louse counts before and for a considerable period after hand or me- chanical application of the powders, indicated that either should be efficacious in arresting transmission of epidemic typhus. Since a resumé of the Naples epidemie with an account of the measures insti- tuted for its arrest has appeared (Wheeler, 1946), the present report will not attempt to relate the particular ac- tivity of each of the organizations which collaborated in the fight against typhus in Naples. Rather, it will describe the evolution of the epidemic and the per- sons affected thereby; it will discuss the measures instituted for the control of the outbreak and evaluate their merits; and it will describe in some detail the techniques and procedures recommended for applying louse powder in the event of subsequent typhus outbreaks. The typhus team of The Rockefeller Foundation Health Commission organ- ized and administered the delousing service in Naples under Col. W. H. Crichton (British}, Public Health Off-, eer, Allied Military Government (AMG), Region III, 15th Army Group, from December 9th, 1948, to January 2nd, 1944; continued in charge of the mass delousing section of the typhus control service under Brig. Gen. Leon A. Fox and Col. Harry A. Bishop, United States of America Typhus Commission, Janu- ary 3rd to February 19th, 1944; and resumed full responsibility for all de- A.J.H., 1947, Vou. 45: Pe. 305-834 306 lousing under Brig. G. 8. Parkinson and Lt. Cols. W. C. Williams and Gordon Frizelle, director and deputy directors of the Public Health Sub-Commission for Italy, from February 20th, 1944, to July 31st, 1945. Administrative personnel were drawn from both military and civilian sources including: Allied Military Government agencies; the Municipal Health Service, Naples; the Public Health Sub-Commis- sion of the Allied Control Commission for Italy; the Peninsular Base Section, United States Army; the North African Theater of Operations of the United States Army (NATOUSA); malaria control units from North Africa, Iran and Iraq; the Royal Army Medical Corps (British); the United States of America Typhus Commission, the United States Navy, and the Italian Red Cross and civilian medical profes- sion. Evolution of the epidemic The earliest incursion of typhus in the mainland of Italy during World War II apparently occurred in late February of 1943 when a hospital train bringing soldiers from the Russian front arrived at Foggia, where 281 soldiers and officers were hospitalized. The train then proceeded to Bari, where 226 others were discharged to hospitals. On the 12th and 13th of March, 80 eases of typhus appeared among these repatri- ated soldiers. Two additional cases were reported from the crew of the hospital train, a third in the staff of the Red Cross Hospital in Foggia and another in a soldier who had gone to Messina on leave from one of the military hos- pitals. The first cases of typhus in Naples were reported in March among patients in the military hospital, one in a soldier returned by train from the Russian F. L, SOPER, W. A. DAVIS, F. S. MARKHAM AND L, A. RIEHL front and 3 others in men brought by hospital ship from North Africa. The initial ease of typhus in civilians was re- ported at Aversa, some 12 miles from Naples, where the first of 8 cases, all in the same family, had its onset on April 24th. The diagnosis was confirmed sero- logically at the Cotugno San Giorgio municipal contagious disease hospital in Naples. This patient had traveled to Foggia province twice during the week preceding onset, making portions of the trip in military vehicles operating to and from the military hospital. The commandant of this hospital at Aversa claimed that there was no typhus among his patients; however, his records of wounded and sick included several ty- phus convalescents who were brought from North Africa directly to Aversa. In July two cases were reported among patrons of a bathing establish- ment in Naples and a third case (Giu- seppe Grassi) with onset on the 16th of the month, occurred at the Poggio- reale prison, a large provincial institu- tion located in the industrial area of Naples. Grassi was released on July 21st. On the 28th he was taken to the Cotugno Hospital where a diagnosis of typhus was confirmed serologically. Poggioreale prison, the most impor- tant in the area, was surrounded by military barracks, airplane and locomo- tive works and soap and textile plants. Several direct hits during the Allied air raids of 1943 rendered some of its pavilions uninhabitable. The bathing plant was demolished, and hygiene in the prison sank accordingly. There were no shelters, and while raids were in progress the prisoners were herded together in the basement. The inmates were almost all louse infested, so that conditions for the transmission of typhus were ideal once the causal agent had been introduced. TYPHUS FEVER CONTROL IN ITALY There were many opportunities for the introduction of typhus into Pog- gioreale durmg the winter and spring of 1942-1943. The disease was unusu- ally prevalent in North Africa at this time, and there are records of large numbers of prisoners, both French and Italian, who were evacuated from Tu- nisian prisons, some by way of Sicily and others directly to Naples. Dr. Sa- porito, Medical Inspector General for: Italian prisons, admitted that there was typhus among the prisoners in Sicily ? and that louse control there consisted of burning and replacing clothing be- cause there were neither chemicals nor equipment for delousing. Large num- bers of Yugoslav prisoners also passed through Poggioreale as late as April, 1943, and the names of some of these appear in the infirmary reports. The records at Poggioreale are re- stricted largely to the infirmary registers which escaped destruction when the riot- ing prisoners burned the personnel rec- ords in the late summer of 1943, but a number of the inmates were traced through transfer records at branch pris- ons. Following the case of Grassi, men- tioned above, Vincenzo Petriccione, who apparently contracted the disease in the prison infirmary, became ill on, July 19th. On the 23rd he went to C¥tugno Hospital, where the diagnosis of typhus was made. De Luea, a clerk in the prison, became ill with the disease on August 13th and Guerrino, one of the earabinieri, contracted it on August 2The first outbreak was at Milazzo, Sicily, where 37 cases with 9 deaths occurred among Libyan prisoners between January and April, 1943. Twenty cases occurred among 130 Libyans at Nicosia in July, 1943, just before the Allied invasion. No civilian cases had been registered up to the prison break which came in August during the invasion, but escaping prisoners may have been responsible for scat- tering the infection in Sicily. 307 15th. How many other cases oceurred among the prisoners and staff between this time and December, when the first cases were actually reported from the prison, is not known, but inspection of the infirmary records reveals a long list of suspicious diagnoses, and one is im- pressed by the frequency with which acutely ill prisoners were liberated or transferred to branch prisons. Typhus appeared in men transferred from Poggioreale in at least 4 branch institutions. One prisoner with a fully developed infection was transferred to Casoria on July 17th. In July and August the Poggioreale infirmary was filed to capacity so that patients from the prisons at Gragnano, Casoria and Aversa, in whom typhus was diagnosed serologically, were refused admission. Some of these patients returned to branch prisons while others were liber- ated. The Pozzuoli prison, a reformatory for boys and mental delinquents which was evacuated in July to receive the over- flow from Poggioreale, is the most in- teresting of the 4 branch prisons where typhus occurred during the summer of 1943. Large numbers of prisoners were transferred to Pozzuoli on July 12th, 26th, and 27th, and shortly after their arrival some 25 cases of typhus de- veloped. One patient died only 6 days after admission, and-onsets among the others began on August 5th. When the disease was finally diagnosed the prison was quarantined, and the patients were sent to Cotugno Hospital. Of no little significance is the fact that during Au- gust, when at least 25 typhus patients were present, no less than 100 prisoners were liberated, 40 or more were trans- ferred to other institutions and some 25 escaped. In the mounting confusion of August and September in Naples these potential carriers of the disease were 308 lost to sight. Many probably sought refuge in the air-raid shelters, locally called ricoveros, which were as ad- mirably designed to protect runaway prisoners from the law as honest citizens from bombs. The ricovero in ‘‘Tunnel 9th of May,’’ a main traffic artery be- tween Naples and Pozzuoli, began to yield cases of typhus in August and September. Although Naples is a city of nearly a million inhabitants it is relatively small and compact. The tenement dis- tricts about the port and industrial areas suffered extensive damage during the Allied raids in the spring and summer of 1948, so that large numbers of fami- lies were forced to reside in air-raid ‘shelters. These were large underground chambers, most of them old quarries for tufa, the chief building material of the region. Many of the ricoveros were equipped with lights, some had water and toilet facilities and a few afforded some measure of privacy in cubicles built of wood or stone, but in general the shelters were draughty, damp and almost always dirty. Most of their permanent dwellers came from the poor- est sections of Naples. There are no official or reliable esti- mates of the usual population of the air-raid shelters in the summer of 1943, but their estimated capacity of 220,000 must have been severely taxed during the heavy raids of July, August and September. On September 28rd the Germans ordered the evacuation of a zone 300 meters deep about the port and coastal area, and some 300,000 persons were obliged to leave their dwellings on that day, which resulted in further crowding of the air-raid shelters. Among the evacuees were thousands who lived in the ‘‘Tunnel 9th of May.’’ Typhus had been incubating in this shelter for weeks, F, L. SOPER, W. A. DAVIS, F. 8. MARKHAM AND L. A. RIEHL and its occupants were now dispersed to the shelters beyond the 300-meter zone. With characteristic thoroughness the Germans, before leaving Naples on September 30th, opened the doors of Poggioreale and Pozzuoli prisons and emptied their infested occupants into the already overcrowded shelters of the city. Owing to the disorganization caused by the German evacuation and the Allied occupation of Naples this serious situa- tion went unchallenged. Transportation and communication facilities were in- adequate for the needs of the civilian health authorities, with the result that the investigation of reported cases, iso- lation of known cases and even the preparation of reports were all delayed. Persons affected by the epidemic The final record of cases of typhus in Naples and the vicinity from July 1st, 19438, to June Ist, 1944, may be classified as follows: Cases Deaths Civilian cases in Naples 1,403 318 Civilian cases outside Naples 511 82 Italian military personnel 23 3 Italian civilian prisoners 37 ll Unverified civilian cases 46 15 2,020 429 The unverified cases were those not hospitalized nor seen by the control service staff, and the diagnoses were not eonfirmed by laboratory tests. These data and the data presented in table 1 differ from those reported during the epidemic, when lists of cases were be- ing received from various sources. Duplications have been eliminated by careful checking of the names and identifying information regarding cases reported in municipal and provincial health department lists, death certifi- cates, hospital admission records and laboratory reports, and the daily re- ports of the case-finding section. TYPHUS FEVER CONTROL IN ITALY Only the 1,914 civilian cases in and TasBLe 1—Continued 309 outside Naples are included in the analy- sis in table 1, since soldiers and prison- ; Naples quaide Total ers constitute specially selected groups. eek Of the 1,914 patients, 91 per cent were get | port | set | port | set | pert hospitalized; and serological confirma- tion of diagnosis, based on Weil-Felix, Jan. 2 , 189/ 199] .18) 11 | 207} 210 Castenada or complement-fixation test, 9 | 187) 237 | 23) 24) 160) 261 ich 16 143/| 153; 385) 181 178] 171 was recorded for 61 per cent. Hig teen 23 | 117| 116! 571 25 | 1741 141 of the patients were nurses or hospital 30 64/ 130) 31! 68 ai 193 16 attendants and two were physicians. V4] ‘ Feb. 6 43 75| 387} 32 80| 107 Tanue 1 13 | 33] 38] 35) 34} 68| 72 ae _ 20 | 16) 38) 28) 37| 44] 75 Distribution of typhus cases among civilians 27 9| 20] 26] 24 3 44, AO in Naples and vicinity, by weeks, Ll 4 July, 1948, through May, 1944 Mar. 5| 10] 12| 38] 22) 48| 34 12 5 9; 17| 42 22 51 Naples Quiside Total 19 1] 3] 17] 32] 18] 35 Week 26 3| 2] 13] 18| 164 20, ending oul 7 | yO On- | Re- | On-| Re- On- | Re- set | port | set | port | set | port Apr. 2 4 3/ 16; 21 20 24 9 2 4 9 2 11 6 July 4 0; oO; O; 0 Oo; oO 16 Oo} 1) 10] 21] 10}| 22 11 1 Oo; oO; 0 1 0 23 1 0} 10; 3] It 3 18 2 0; oO 0 2 0 30 0 2| 4 5 A LT 25 1} 38] 1] O 2 CBS ob b | FF May 7 o| o; 2] 11 2t 1 Aug. 1 0 1 0 1 0 2 14 0 0! Oo 3 0 3 8 2! o| 2 0 4 0 21 0] o| 1] 0 1} oO} 15 3 2 1 . 28 0 0 0 3 1” 22 1 3 0 2 1 5 xX fl 29 4 1] o| Oo AT 1 ( 1,403 |1,403 | 500 | 500 |1,903 1,903 B A i . Before . 12 6 8| 1 0 7 8 Uncertain 3 3 3 3 19 & 4 1 0 9 4 26 11 7 0 2 lly 39 3s Kt Totals [1,403 |1,403 | 511 | 511 11,914 /1,914 Oct. 3 8 11 1 0 9 11 7 3 ; 5 3 io 3 Table 1 contains the distribution of al -6 6! 1 2 7 g these 1,914 cases, by week of onset and 31 1 6} Oo} 1) Le % of report, for Naples and outlying com- # munities from July Ist, 1943, through Nov. 7; 9} 5) 2) O| 11). 5 May 28th, 1944. Between July Ist, and 14 12 5 3 2 15 7 o1 | 32| 12} 5| 31 37) 45 September 26th (13 weeks), 32 cases 23 | 46| 26| 61 3 Sa- agg were reported in Naples and only 6 yl outside. During the next 5 weeks the Dec. 5 | 40) 42) 11; 7) 51! 49 georresponding figures were 34 and 4. io bo “ i 1 ar In the following 5 weeks (to December . 26 | 2041 115| 211 4 24%) 119,4 Oth), 90 cases were reported in Naples : ot +] and 15 outside, bringing the totals of 310 240¢ ® Inside Naples goo h K———-x Outside Naples 160} Munber of cases w wy o 80 - F. L. SOPER, W. A. DAVIS, F. 8S. MARKHAM AND L. A. RIEHL e ° 40> N \ J pt “NX \ ° eee ~ ‘ee ae 4 18 20645) 06 629°0:«2120C2Ksids2 7 21 § 19 2 16 #30 $3 27 12 26 9 23 7 21 duly Aug. Sent. Ost. Nov. Deos Jans Feb. Mar. Apr. May 1943 1944 Week ending Fieure 1. Typhus cases, by date of onset, in Naples and vicinity, July, 1943, through May, 1944. reported cases to that date up to 156 for Naples and 25 outside. During this interval, however, 209 cases had their onset in Naples and 37. outside. The date of onset was that given by the patient or his family, and there was a tendency for these dates to cluster about days readily recalled; eg., 45 cases with onset on New Year’s Day. Likewise the date of report is not always epidemiologically significant, since it did not necessarily coincide with the date of hospitalization or of dusting with in- secticide. Although one or more cases occurred in Naples each week after the middle of August, the epidemic rise did not actually begin until the week ending November 7th, when there were 9 cases. It reached its peak with 224 cases in the week ending December 26th. The recession was not quite so rapid, but by March 5th, 1944, the number of cases in Naples by date of onset had dropped to 10. Figure 1 shows the gradual rise of the epidemic in November, a sharp sky- rocketing in December, followed by a reversal in the form of the curve in late December and a rapid decline in the following months. When incidence in Naples is compared with that outside the city it is apparent that both ac- celeration and deceleration of the epi- demic were more rapid in the city than outside. The median date of onset for the 1,403 cases in Naples was December 29th and that of reporting January 6th, giving an average lag of about 8 days. The distribution of families or house- holds with two or more cases is shown below: TYPHUS FEVER CONTROL IN ITALY Cases in families No. of families 130 49 42 28 16 9 8 6 10 , 2 11, 12, 16, 18, 20 1 each No. of cases COND or & to Although louse-borne typhus is essenti- ally a contact disease, only 1,089 of the 1,914 patients came from households having more than one case. The break- ing up of families due to conditions prevailing in the city may have been partly responsible for this, but it is also probable that many cases were never reported. The application of louse powder to persons in the incubation pe- riod may also have prevented the spread of the disease within the family. The distribution of typhus cases and deaths by age and sex are contained in table 2, and in figure 2 the histograms showing the age distributions of cases among males and females are compared. The large number of persons between the ages of 10 and 24 years in each sex group is a conspicuous feature of figure 2 and may be a reflection of the break- down of the normal discipline and order of family life in this war-torn area. Young people, when homeless, probably frequented the shelters, where the risk of exposure was greatest. Thus 9 of 14 cases recorded for one of the shelters were in boys from 18 to 20 years of age. No less interesting is the greater num- ber of cases in females between the ages of 35 and 44 years. Greater exposure may have been a factor here, and since women at these ages are usually mothers with numerous children, their illness disrupts the life of the family and they 311 Tasne 2 Age and sex distribution of typhus cases and deaths, Naples and vicinity, 1943-1944 Cases Deaths Age (years) Male} Female| Total | Male} Female] Total 0- 4 40 33 73 5 5 10 5- 9 70. 64| 134] 2 3 5 10-14 124] 112; 236 2 3 5 15-19 175| 134] 309; 16 13 | 29 20-24 94} 121) 215 6 il 17 25-29 57 75} 132) 9 6 | 15 30-34 55 77{ 1382] 16) 13 | 29 35-39 50} 109) 159] 22; 19) 41 40-44 51 97| 148| 24} 27 | 51 45-49 59 70} 129) 31} 21 | 52 50-54 35 64 99; 20); 27 | 47 55-59 24 35 59; 14; 18 | 32 60-64 15 24 39 9 15 24 65-69 12 Il 23; I1 9 20 70-74 4 9 13| 4 9] 13 75-79 2 2 4 2 2 4 80-84 3 2 5 3 2 5 85 0 1 1 0 1 1 Unknown 1 3 4! 0 0 0 Totals 871 | 1,043 | 1,914} 196; 204 | 400 are more likely to receive medical aid and to be reported. It is probable that cases of typhus were less well reported among young children in whom the disease may be mistaken for a childhood exanthema. The low frequency of cases among men of middle age may have been due partly to their employment on night shifts, which reduced their risk of exposure in the shelters, and to a large number of missed cases, Owing to the uncertainty regarding the completeness of these data, attack or fatality rates derived from them would have little significance. . For practical purposes an assumption of universal susceptibility is believed 312 F, L. SOPER, W. A. DAVIS, F. §. MARKHAM AND L, A, RIEHL FEMALES ‘Fieure 2. Typhus cases by age and sex, Naples and vicinity, 1943-1944. TYPHUS FEVER CONTROL IN ITALY justified. The only recent account of typhus in Naples was that of a group of 42 cases described in a bulletin of the Commune of Naples in 1927, originat- ing in the winter of 1925-1926 from two small ships from North Africa, which entered the port without the formality of quarantine inspection. Vig- orous measures appear to have sup- pressed the spread of the disease at this time. Prior to the epidemic, murine typhus was not reported from Italy. It is now known to be. present in the area, but it seems unlikely that the disease is sufficiently widespread to af- fect appreciably the susceptibility of the population as a whole. Although exposure to infection was by no means universal, the distribution of cases shown in figure 3 indicates that typhus permeated most of the 24 alpha- betically designated districts of the 313 city. Districts T, U, and W to the east were industrial areas with few habita- tions, and few cases were reported from them. The evolution of the epidemic also varied within the districts. In area A, for example, half the cases occurred by mid-December, while in area V this stage was not reached until January 8th. Areas A, C, G, M, N, P, and Q ac- counted for more than 50 per cent of the cases. Outside the city 511 civilian cases were reported from 60 different com- munities of which 495 occurred within 25 miles of Naples (figure 4). This limited dispersion was probably due to difficulties in civilian travel as well as to less complete reporting of eases. The most remote point reached was Lecce and the greatest number in any one locality was 46 cases in Torre del Greco, a small, but busy, port at the ) N af \ Tt \ ) @ >) pp x » be a r - nS SA (09 B = © x= o @\ © 7 Cc N @) \ @) al Ke ye N é @ T oO” a \ (@) ; " | Cc FicurE 3. Distribution of typhus cases in Naples by administrative district, November 1st, 1943, to April 30th, 1944. 314 foot of Vesuvius. This town like many others is really an extension of the city of Naples. Epidemic potential The question of when a typhus patient becomes a menace to the community is not easy to answer. A person harbor- ing a, single infected louse is not a likely focus of disease spread during the period of survival of that particu- lar louse. The individual and his own lice may remain well for 10 or 12 days or until the febrile period begins. The febrile period may last from 16 to 18 days, during which time the patient’s lice may become infected and remain so until their death some 10 to 15 days after their first infective meal. During this period the risk of transmission of typhus organisms from the patient to his associates will be greatest. Later F, L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL in the attack when fewer rickettsiae are present in the blood stream, the lice develop their infections more slowly and the risk of transmission will lessen. In view of the intermediate character of the period of potential transmission, it was necessary to make an arbitrary assumption regarding its length, and it was decided to define this period as one of 18 days following onset unless in the meantime the patient had died, or had been dusted or isolated. For each case reported in. Naples, therefore, with onset between November 1st, 1943, and April 30th, 1944, the number of days (up to 18) elapsing between onset and isolation, dusting or death was counted. These periods of infectiousness, when accumulated on a chronological basis, may be said to con- stitute the epidemic potential of typhus with respect to the uninfected popula- ® Fieurz 4, Distribution of typhus cases in and around Naples, July Ist, 1943, to May 3ist, 1944. TYPHUS FEVER CONTROL IN IT4’:Y¥ 315 1000 r . . = 100,000 r Epidemic Potential —— 4 . nN (Unisolated cases) 4 r i ‘s Contact Dusting eee 4 y rv Station Dusting <---- 4 } , \ a . j \n 4 _ 4 Ss od = 2 § 00} 4 10,000 2 oO r 7 dt oe 4 Pp ° r 7 a 3 F | g oO i 6 z 1 3 a . 8 ~s “a a 3 @ 7 8 > ® »P g 3 + : 10 + 4 1,000 8 bf ; 16 2-1, evident 1 4. ry ry 1 4 Dl 100 1 14 28 12 26 9 23 6 20 5 19 2 16 30 Nove Dec. Jane Feb. Mer. Apr. 1943 1944 Figure 5. Typhus epidemic potential compared with the dusting activities, Naples, November 1st, 1943, to April 30th, 1944. tion of Naples. Figure 5 shows the trend of these data when plotted on a semilogarithmie seale, compared with the trends of persons treated daily by the contact and station dusting serv- ices. The dramatic evolution, progress and decline of the epidemic and the relation of the control measures to its various phases are clearly depicted here. The organization and accomplishments of delousing activities Headquarters for typhus control ae- tivities were established at the Pro- vincial Laboratory on December 14th, and delousing with insecticidal powder began on December 15th with the com- pulsory dusting of 700 passengers leav- ing Naples on the first passenger train to depart after Allied oceupation. The first dusting crews were composed of nurses and inspectors from the Munic- ipal Health Department. These proved to be intelligent, faithful workers and formed the nucleus around which the greatly expanded service developed later. Subsequently, recourse was had to personnel hired through the AMG Labor Office. The delousing activities fell naturally into the following categories for ad- ministrative purposes and were initiated on the dates indicated: 1. Contact delousing (December 16th, 1943) 316 2. Air-raid shelter delousing (Decem- ber 27th, 1943) 3. Mass delousing: cember 28th, 1943); (February 6th, 1944) 4. Flying squadron for work outside Naples (January 8th, 1944) 5. Institutional delousing (January 9th, 1944) 6. Military and military labor delousing (December, 1943) 7. Refugee delousing (December, 1943) (a) Station (De- (b) Block There will be no discussion of institu- tional, military or refugee delousing, and no account of the isolation and treatment of the sick. Casual refer- ence only will be made to vaccination as a method of combating the disease. Insecticide and dusting equipment. The Surgeon’s Office of the Peninsular Base Section made 20,000 two-ounce tins of MYL available immediately. The Surgeon’s Office, NATOUSA, sent 400 pounds of DDT concentrate by air and authorized the use of such amounts of MYL powder, up to 500,000 two-ounce tins, as were required until the Allied Control Commission stocks began to ar- rive in January. The relative amounts of MYL and DDT used in Naples cannot be accurately determined, but since most of the early work was done with MYL, to this insecticide must go the credit for the early results of the delousing campaign. Hand dust-guns were used in the ap- plieation of the powder and the work- ers were trained to follow a definite procedure in dusting each person, for which written instructions (reproduced below) were issued, so that the chance of omitting certain points might be lessened when dusters were working under pressure. Most. of the work in Naples had to be done with the small “*Cadet’’ type of Hudson duster, which F. L, SOPhR, W. A. DAVIS, F. 8. MARKHAM AND L, A. RIEHL is the least satisfactory of the three pumps eventually used because it re- quires refilling after each two or 3 dustings, and its delivery of powder tends to be in masses rather than in clouds of dust (Soper et al. 1945). There were a few Dobbins ‘‘Super- built’’ no. 133 guns on hand, and later the Hudson ‘‘ Admiral’’ no. 765 gun be- came available, both of which were found to be equally satisfactory and far superior to the ‘‘Cadet’’ duster (see figures 10-16). “~Contact or spot delousing. The names and addresses of all typhus patients re- ported after November Ist were as- sembled on December 12th so that the homes could be visited and the contacts of the patients discovered and deloused. An immediate result of this work was the finding of additional cases hitherto unreported, and, subsequently, this dis- covery of new cases became an impor- tant function of the contact-delousing squads. , The careful records of names and ad- dresses of families dusted and new pa- tients found, which were kept by the squads, provided the data for group- ing the cases by families. They also facilitated the preparation of block his- tories for certain areas, so that what families had been dusted and when, in relation to primary and subsequent ty- phus cases, could be determined. Such information has aided materially in evaluating the spot-dusting measures, which were those first. employed. In practice, all members of a patient’s family were dusted at the time of the squad’s visit but absent members were not sought out. The family was urged to see that such persons attended the nearest mass-delousing station. The squad also powdered those other per- sons wishing to be dusted who lived in the same or contiguous buildings. Thus TYPHUS FEVER CONTROL IN ITALY the term ‘‘spot dusting’’ more adequately deseribes its work. The crew usually worked in the courtyard or street in front of the building in which the pa- tient lived. On January 12th this spot delousing by persons accompanying the case-find- ing units was reduced to the immediate family and household contacts. Later in the month, however, the units re- verted to a more extensive coverage and shortly afterward collaborated with the mass-delousing service in dusting resi- dents of certain blocks in areas where typhus persisted or where surveys re- vealed an appreciable amount of louse infestation. Aw-raid shelter delousing. The im- portance of the air-raid Shelter as a focus of typhus transmission was recog- nized at once, but the organization and conduct of delousing activities there presented certain problems since the work had to be done between 6 P.M. and midnight, when the shelter held its maximum population. The service was organized to care for the dusting of ap- proximately 10,000 persons weekly. Six teams, each consisting of a physician and 12 dusters, made the rounds of some 80 to 90 shelters, at first every 7 days and later once in 2 weeks, as the num- ber of cases reported from the shelters declined. ae aousing: (1) Station _ When contact delousing was operating satis- factorily and adequate transportation and stocks of insecticide became avail- able, plans were ready for opening 50 publie delousing stations with an esti- mated capacity of 100,000 persons daily. Sites in hospitals, schools, churches, railway and streetcar waiting rooms, ete., were chosen with consideration for population density and the known dis- tribution of typhus. Each station was under the direction of a foreman and an 317 assistant, who were responsible for the conduct of the work and the keeping of the daily records. The first two stations opened on De- cember 28th. The one at the Ascalesi . Hospital began by bringing children in from the street to be dusted. Its record jumped from 107 persons dusted the first day to 577 on the third and 1,625 persons on the seventh day. The other station at the Anguilli School had the advantage of a large pediatric dispen- sary in the same building and its clientele was sent to be dusted. This station de- loused 837 persons on the first day, 2,200 on the third and 3,585 on the seventh day. The delousing stations be- came popular overnight, so that soon the sight of persons on the street with powdered hair and clothing was too common to cause comment. The supervision of the stations was carried out by Italian civilian inspec- tors, most of them physicians, who had a varying number of stations to visit twice daily. They issued powder and pumps, checked the work of the stations and eollected the daily reports of oper- ating personnel, supplies received and used, and the number of persons pow- dered. When received at headquarters these reports were summarized each day to provide the supervisors and adminis- trators with current data on the opera- tion of every station. In a summary of the work of 33 stations operating in Naples on January 15th, 1944, there were, on the average, 13 persons working in each station, and an average of 1,611 persons were dusted per station. Some 2,500 pounds of powder were used in the 33 stations, with an average of 21 persons dusted per pound. It was only by daily checking of the activity of the stations that a proper level of efficiency could be maintained. A problem involved in the operation ours. Mass Afass_delousing: (2) Block. work of the stations ae Te ea it be- us 318 of the stations was the hourly variation in the volume of work to be done. Visit- ing hours at hospitals, arrival and de- parture of trains and the opening and closing of business affected attendance at the stations. The staff provided had to be sufficient to deal with persons coming to be dusted at rush hours, which meant an overstaffing in slack 2) Block. As the came evident that a certain portion of the population was not being reached, since typhus continued to occur in cer- tain blocks within walking distance of busy dusting stations. It was decided, therefore, to survey different sections of the city with a view to answering the following questions: (@) were per- sons living near the stations being dusted repeatedly while those at a distance were missed; (b) was the dusting of men, women and children of equal pro- portion; (c) what proportion of those dusted still had lice? For this survey, groups of blocks rep- resenting different sections of a given district were chosen and detailed maps and census forms prepared. By the middle of February the canvass had covered over 100,000 persons, of whom 77 per cent claimed to have been dusted one or more times. The percentage varied from 65 around the Poggioreale prison to 93 in Fuorigrotta. Approxi- mately 20 per cent had been dusted once, 28 per cent twice and 29 per cent more frequently. Of some 13,000 children who had been powdered, 11.6 per cent were found to be louse infested, as compared with 20 per cent of 2,500 undusted children. As a result of these surveys, squads were organized on February 6th to work blocks having more than 5 per cent of louse infestation, less than 70 per cent F, L. SOPEX, W. A. DAVIS, F. S. MARKHAM AND L, A, RIEHL of persons with a record of previous dusting, or both. Where typhus was being reported dusting was carried out if less than 90 per cent had been pre- viously dusted. Block dusting was be- gun when the epidemic in Naples was definitely on the decline, so that, the crews were augmented by persons re- leased from the contact-delousing sec- tion. After February 14th the residents of each block where a case was reported were dusted, as well as residents of blocks contiguous to the one containing the infected house. Block-dusting crews always started at the same point in each block, say the northeast corner, and proceeded to the right, calling at every door, entrance or courtyard, moving from floor to floor in the same manner, until they returned to their starting point ready to begin the next block. The squad kept a record of the dusted and undusted persons living in each household and those who were away from home were reached at school or at their place of employment. Flying squadron delousing outside Naples. The fiying squadron began work on January 8th, 1944, investigat- ing typhus suspects outside Naples and operating in much the same manner as did the contact delousing squads in the city. Household and neighborhood con- tacts of infected persons were dusted, and a search was made for new cases. The squadron also vaccinated contacts as well as others in infected areas. Al- though 97 per cent of the cases of typhus outside Naples occurred within a 25- mile radius (figure 4), investigations had to be carried out at greater dis- tances, at times even in the zone of military operations. Some of the infected suburbs of Naples were heavily populated areas, and for these a special mobile unit was TYPHUS FEVER CONTROL IN ITALY organized to carry on more extensive house-to-house delousing than could be done by the squadron. A report of de- lousing and vaccination activities per- formed by the flying squadron is given, by weeks, in table 3 with reference to the probable cases of typhus seen from January Ist through May 28th, 1944. Approximately 630 persons were dusted per case seen. TaBLe 3 Weekly block dusting and vaccination of contacts performed by the flying squadron outside Naples, January to May, 1944 Week Probable Persons Persons ending cases seen dusted vaccinated Jan. 9 1 13 13 16 6 402 44 23 17 8,484 16 30 48 13,480 226 Feb. 6 24 12,150 193 13 21 11,075 77 20 32 20,457 130 27 27 13,758 26 Mar. 5 17 11,720 38 12 37 20,336 63 19 26 12,023 139 26 17 10,066 47 Apr. 2 20 9,636 65 9 4 9,967 28 16 22 7,675 9 23 5 11,284 21 30 8 11,143 5 May 7 8 6,640 17 14 5 7,697 7 21 0 6,888 8 28 3 6,360 18 Totals 348 211,204 1,190 It is diffieult to appraise the work of the flying squadron because of the like- lihood of reinfection from Naples, and because many persons residing in these sareas may have been dusted in the city. In 7 of the 60 places outside 319 Naples where cases occurred no delous- ing was undertaken and in 26 places where measures were taken no subse- quent cases occurred during a 12- to 14- day post-treatment period, so the typhus potential in these communities must be regarded as minimal. Summary of delousing activities. From the middle of December, when dusting operations began, until the epi- demic subsided, over 3,000,000 applica- tions of powder were made in Naples and the surrounding towns. Table 4 contains a day-by-day report of dustings by the services in Naples between De- cember 15th, 1943, and January 15th, 1944, while the work was being organ- ized and developed. Table 5 contains the weekly report of all dustings through May 31st, 1944. From the standpoint of economy of effort and material, it is now important to decide whether con- tact or spot dusting alone is sufficient for typhus control or whether this method plus station delousing should be employed in future programs. An appraisal of typhus control by louse powder For evaluating the effect of dusting with louse powder upon the spread of typhus, the outbreak in Fuorigrotta, which was epidemiologically a part of Naples, has been chosen for considera- tion. This community, with its 11,000 inhabitants, is the area designated ‘‘M”’’ in figure 3. Various tunnels through a narrow, high land barrier connect it with western Naples, but for the most part epidemiological factors appear to have operated locally. The eastern half of Fuorigrotta, lying west of the Naples tunnels, is characterized by narrow streets, bad sanitation and housing con- ditions like those of Naples. The west- ern half contains two municipal housing projects, one of which consists of a 320 TaBLe 4 Daily dusting totals, Naples, December 15th, 1943, to January 15th, 1944 Service Date - Contact| Ri taste t dusting dusting dusting dusting, Totals etc. Dec. 15 700 700 16 } 485 435 17 576 576 18 1,060 1,060 19 | 1,387 1,387 20 1,311 1,311 21 1,569 1,569 22 1,391 1,391 23 713 713 24 1,345 1,345 25 1,131 1,131 26 1,404 1,404 27 1,767| 600 2,367 28 944 | 2,042 600 3,586 29} 1,765] 3,078} 180 5,023 380 | 3,683] 3,386 500 7,569 31 | 4,041} 1,675 447 6,163 Jan. 1 2,568 | 1,808 446 4,822 2/ 5,158] 3,311 492 8,961 3 | 11,495| 4,231] 488 16,214 4 | 19,581 | 2,463 | 1,055 23,099 5 | 22,935 | 3,838 | 1,761 28,534 6 | 28,658} 3,344| 1,041 33,043 7 | 37,960 | 3,360; 1,275 42,595 8 | 38,971 | 3,405! 1,224 43,600 9 | 37,750; 1,911] 1,228) 200] 41,089 10 | 66,126 | 2,994] 2,092] 1,410 | 72,622 11 | 63,210} 3,533 | 2,321; — 69,064 12 | 66,476 147 | 1,588} 1,215 | 69,426 13 | 60,862 112 954 667 | 62,595 14 | 59,995 149} 1,414] 1,304 | 62,862 15 | 53,153] 71! 1,648] 1,966 | 56,838 Totals |585,331 |59,647 |21,354 | 6,762 | 673,094 collection of 4-family cottages, each with a garden plot, and the other of a group of large 5-story apartment buildings. The town suffered relatively slight F. L. SOPE,, W. A. DAVIS, F. 8. MARKHAM AND L. A, RIEHL damage during the Allied air raids of 1943 so that its two shelters did not have a large resident population, but the German air attacks in the late fall and winter caused many people to re- sort to shelters at night. Since the com- bined capacity of the two shelters did not exceed 5,000 they were extremely crowded during the raids. The first typhus case in east Fuori- grotta had its onset on_December Ist, 1943, but was not reported until Janu- TaBie 5 Weekly dusting totals, Naples, December 15th, 1943, to May 81st, 1944 Week ending Station* Other Total Dec. 19 —_ 4,158 4,158 26 _ 8,864 8,864 Jan, 2 18,159 20,332 38,491 9 197,350 30,824 228,174 16 408,163 27,558 435,721 23 334,785 19,085 353,870 30 188,346 29,052 217,398 Feb. 6 174,000 24,829 198,829 13 165,493 18,815 184,308 20 147,701 16,742 164,443 27 144,200 20,534 164,734 Mar. 5 139,355 20,664 160,019 12 130,829 18,046 148,875 19 102,421 20,986 123,407 26 83,564 11,931 95,495 Apr. 2 80,902 13,197 94,099 9 66,887 8,914 75,801 16 61,883 16,954 78,837 23 64,442 7,675 72,117 - 80 52,455 5,933 58,388 May 7 29,732 15,606 45,338 14 24,281 11,215 35,496 | 21 6,408 3,206 9,609 28 4,550 3,367 7,917 29-31 2,307 1,762 4,069 Totals 2,628,208 | 380,249 | 3,008,457 *Includes mass delousing in out-of-town stations, TYPHUS FEVER CONTROL IN ITALY ary 6th. The second ease in this section occurred December 10th and was re- ported on the 18th. This patient had slept in the shelter and was the probable source of many of the subsequent cases there and in the Via Grotta Vecchia. At the other end of the town two, cases of typhus had their onset in the munic- ipal housing developments. on Decem- ber 2nd. The people in this section used the shelter in Rione Duca d’Aosta. Contact_and_spot_dusting with louse, powder began in Fuorigrotta on_De-' cember 2 and, as elsewhere, disin- —testation was welcomed by the people. In the western end of the community more persons per case were dusted owing to the greater density of population, with the result that here only one case had its onset more than 15 days after - spot dusting began. In the eastern sec- tion of the community where the popu- lation was more scattered and nearer . to Naples the final case had its onset on January 29th, which was 6 weeks after contact dusting was started in Fuori- grotta. Because of the alarm. created by the discovery of 59 cases during the first week of January, a mass-delousing sta- tion was opened on January 7th and nearly 20,000 dustings were done in the first 5 days. Beginning with Janu- ary 24th, applicants were refused dust- ing if they had been powdered during the previous 2 weeks. In the subse- quent survey of Fuorigrotta 9 t of the people said _the I5 per cent once, 32 per cent twice, and~ “46 per cent more than twice. When the station was closed at the end of April over 58,000 dustings had been done, representing an expenditure of 1.5 tons of louse powder in addition to the 7 cost of labor and supervision. Could / the job in Fuorigrotta have been accom- plished with less money and material? 321 A criterion for determining the effec- tiveness of dusting operations must now be considered. Obviously delousing an individual during the incubation stage of typhus will not prevent infection from developing, so that cases may be expected to appear over a period of from 10 to 12 days after dusting begins, but when such persons are thoroughly duisted before onset the chances will be materially lessened that they will infect lice and so be likely to transmit the disease to others. Hence if cases de- cline in number as r after an interval of from 12 to 15 days, the presumption is that the treatment has reduced transmission of the disease. It is also obvious that with an average. lag of from 8 to 10 days between onset and report, the effectiveness of control measures will be reduced. For maxi- mum efficiency, therefore, the dusting service must be accompanied by an ade- quate and skilled case-finding service. Figure 6 shows the individual cases in Fuorigrotta plotted in order of onset above the horizontal line and the same eases plotted below the line when re- ported. On the 20th of December when spot dusting began in Fuorigrotta, only 18 of the 106 onsets had occurred and of these only 5 had been reported. Twelve days later, on January Ist, 87 cases had had their onset with the proba- bility that none could have been pre- vented by the dusting. During the next 3 days 6 more cases occurred, but by January 5th the epidemic was virtually over although 13 eases had their onset between that date and January 29th. Figure 7 shows the rise and fall of the epidemic potential curve in Fuori-_ grotta plotted to a semilogarithmic ale. Between December 1 _ Le, 10 Le. 10 days prior _and subsequent to rior_and ie pepinning af gotact ant fo the beginning of contact dusting, the _ Sumber of undeclared eases in the aren of undeclared cases in the area EUORIGROTTA DATE _OF ONSET J 1944. December 1943 anuar Februar Le pe tg tt SY g0 gg ag pebruagy 2 8 a g = 5 3 beet tt : 70 20 3 T 70 35 December January February W943 ATE OF REPORT 1944. Fraure 6. Fuorigrotta: individual typhus cases by date of onset and report, with reference to dusting activities. GGE THOIY *V “I GNY WVHMYVA ‘8S ‘d ‘SIAVG ‘V "A “UadOS “IT “a TYPHUS FEVER CONTROL IN ITALY rose steadily. The straight line fitted to the logarithms of the numbers of cases indicates a rate of increase of 17.2 per cent daily. If the curve_had i et continued to rise at this rate durin another ays, on January 9th there cases in the community. Actually there were only 17. While one cannot prove that dusting was wholly responsible for the subsidence of the outbreak, one can confidently assert that it was an im- portant contributing factor, particu- larly in view of the fact that no vacei- nations were done. Figure 7 also reveals that the fall of the epidemic potential 323 was not accelerated by the mass dusting activities begun on January 7th. A study of individual block histories in the city of Naples further strengthens the impression that prompt coverage ane en) by the contact-dusting and _case-finding would have been some 368 undeclared __ services resulted in early suppression of: transmission, A single block in area P, for example, had 48 of the 195 cases oceurring in this district. Twenty of these had onset after spot dusting be- gan, but 13 of them occurred within 12 days of the first dusting. Of the remain- ing 7, four had been dusted before on- set. How many patients in the Naples epidemic were actually dusted before on- 500 - Y / 368 100 F / 2 (OE / s . 3 . o%, e z OF . 8 . 3 . es . 3 b ® & ee, 4 e Z "e 1O- C ee s eS @ ee 5 & ee . a Z e ee . e a S eco ee . ecce oo Ve 3 ae ee 2 = 5 e e 3 ® ee 4 3 8 a + + 1 4 1 i Ls 2 1 i 1 4 z. i 1. 2. 2 § 10 15 20 25 30 § 1a 15 20. 26 $0 December 1943 January 1944 Fievure 7. Fuorigrotta: rise and fall of the typhus epidemic potential with reference to dusting activities, December Ist, 1943, to January 31st, 1944, ‘\ 324 set is unknown, for the case histories are commonly incomplete on this point. From information available, however, it was ascertained that at least 10 per cent of the patients or their families were dusted prior to the onset of ill- ness. For Naples as a whole (figure 5) the peak of the epidemic potential curve was attained approximately 15 days after contact and spot delousing began. On December 10th there were fewer than 60 undeclared cases in the city, and by the end of the month there were over 300. With the exception of the work at the railway station, dusting in Naples between December 15th and 28th was done around typhus cases in homes, hospitals and shelters, yet within 15 days after dusting was initiated the upward trend of the potential curve was arrested and reversed. Thus spot dusting by itself was ap- parently an effective method of control- ling transmission of the disease. The dusting stations probably also rendered certain infected persons innocuous by destroying the potential vectors, and the reduction in the lousiness of the population unquestionably decreased the likelihood of transniission by per- sons unfortunate enough to contract the disease. Station versus block delousing The mass delousing station probably offers the most practicable method of reaching great numbers of people in a large metropolitan area quickly, but for smaller populations block dusting is preferable because it affords more uniform and extensive coverage. The relative efficiency of the two methods was tested in two small com- munities in the metropolitan area: Arzano, with a population of about 8,500, and Casoria with one of about F. L., SOPER, W. A. DAVIS, F. 8S. MARKHAM AND L, A. RIEHL 10,000. Relatively little dusting had been done in either community before the beginning of the experiment. A mass delousing station was established in Arzano after the town had been sur- veyed and each family given a ticket admitting its members to the station for dusting. Of more than 800 children examined before the station was opened, 33 per cent were found to be louse in- fested. A similar degree of infestation was revealed in Casoria. Squads with carefully prepared maps and family ree- ords then dusted all blocks in Casoria between April 3rd and 12th, with an expenditure of 107 man-days of labor. The station in Arzano operated from April 2nd to 29th, requiring 229 man- days of labor. Both communities were immediately resurveyed. Block dusting in Casoria had reached 86.6 per cent of the inhabitants and the residual louse infestation in approximately 3,000 chil- dren was 5.4 per cent, while in Arzano only 53.9 per cent of the population had been dusted and 9 per cent of 2,537 children were found infested. Block dusting was, therefore, more extensive and effective and became the method of choice for most of the work outside Naples. Its effectiveness, how- ever, depends on the availability of trained personnel and adequate trans- port, while the stations are more easily supervised and better suited to the training of new personnel for an ex- panding project. Finally, had an epi- demie been present in Arzano, a greater proportion of its population would doubtless have applied for dusting. Residual lousiness A survey in late April at 4 delousing stations in Naples revealed the distri- bution of residual louse infestation by age and sex of the applicants. Of ap- proximately 9,000 persons, 9.7 per cent TYPHUS FEVER CONTROL IN ITALY were lousy and 66 per cent of those mfested were males. There was less lousiness among both males and females between the ages of 10 and 44 ‘years than among persons over 45. In the latter group, infestation inereased with age, especially among females. In July, 1944, new surveys were made in those districts of Naples where the greatest number of typhus cases had oc- curred and the most intensive powder- ing had been done. The results indicated that the epidemic and dusting had not in- spired any ‘‘louse-consciousness.’’ Some 35,000 persons, including more than 9,000 children, were examined. Of the latter, 641 (7 per cent) had never been pow- dered and had an infestation rate of 28 per cent, while 34 per cent of those who had been powdered were found to be infested at the time of the survey. In the Pallonetto Santa Lucia district, one of those most affected by typhus, 53 per cent of the children were louse in- fested at a time when practically every- one lived within a 10- or 15-minute walk from a free delousing station open 8 hours a day. In late April and early May, 1944, 14,584 persons were examined in 81 shelters, where among 5,300 children, 8.5 per cent were infested. Routine dusting in the shelters stopped in June and another survey in late August re- vealed about 5,000 still living there, with almost 50 per cent of the children infested. It should not be inferred from the results of these surveys that DDT is not all that its champions claim it to be, an almost perfect insecticide. Mass dust- ing in Naples was not a louse eradication project, it was a typhus control measure for reducing the louse population to a point where typhus transmission would cease. Unless all the clothing possessed by all the people is dusted at about the 325 same time, no more than a temporary \reduetion in lousiness can be achieved in crowded metropolitan districts. “Vaccination Vaccination was not a part of the initial program in Naples and was used on a small seale for only a few weeks following the peak of the epidemic. From January through March, 1944, some 26,000 persons were vaccinated by a 3-dose technique and another 10,000 by a one-dose method, but nothing can be deduced regarding the effect of this measure upon the course of the epi- demic. The 1,190 vaccinations adminis- tered by the flying squadron outside Naples are reported in table 3. Postepidemic organization of typhus control teams The civilian doctors who were re- leased when the dusting stations in Naples were discontinued were em- ployed to keep the public health officials and practicing physicians in the area alert to the possibility that typhus might remain undetected during the summer and reappear in epidemic form with the return of cold weather. The towns within a radius of 20 miles were re- peatedly visited, with special attention paid to those communities where cases had oceurred. The contagious disease hospital, as well as the infirmary of the Poggioreale prison, which had been one of the primary points of dissemination during the previous winter, was kept under observation. During the fall of 1944 arrangements were made through the Ministry of the Interior for a series of meetings with the provincial health officers and their representatives throughout liberated Italy. At these gatherings the epidemio- logical and clinical features of both louse-borne and murine typhus were dis- 326 cussed, the importance of early diag- nosis and reporting was emphasized and the technique of dusting demonstrated. Each provincial representative was re- quired to dust at least 15 or 20 individu- als under expert supervision. An emer- gency supply of powder and of dust guns was left in each province so that the local officers could do immediate spot dusting should typhus or suspected typhus patients appear within their jurisdiction. These meetings began in October, 1944, and extended to all but two of the southern provinces, both in Sicily. In December a similar instruction tour was undertaken in the liberated prov- inces to the north. Delegates from the 3 Sardinian provinces met in Cagliari. Also in December, the typhus control service, in cooperation with the Office of Hygiene of the Commune of Rome, supplied and supervised a dusting squad at the Prenestina railway station, where large numbers of refugees from the north were being discharged. This work was discontinued in June, 1945, after dusting operations in the northern camps had been adequately organized. Postepidemic typhus Between June Ist, 1944, and March 31st, 1945, when the Naples headquarters were closed, 24 cases of typhus with two deaths were investigated; only one of these cases occurred in Naples. The pa- tient, a baker, had arrived from Sicily only 10 days before onset, and his serum gave a positive complement-fixation reac- tion for murine typhus. The epidemio- logical and serological evidence is strong- ly suggestive that 17 of the 24 cases were of the murine type. All were either food handlers or closely associated with ra- tion dumps where rats were numerous. In addition to the one case in Naples, 10 of the 24 cases were in the vicinity F. L. SOPER, W. A. DAVIS, F. 8S. MARKHAM AND L. A. RIEHL ’ of that city, 6 were in Brindisi, 3 in Sardinia, two in Calabria and one each in Sicily and Leghorn. During the months of April through July, 1945, scattered cases were observed in north- ern Italy in connection with the move- ment of displaced persons from Ger- many, Austria and Yugoslavia. Spot dusting about these imported cases was done by the local authorities who had previously been provided with powder and guns. At Cappizi, Sicily, a series of 39 cases with 9 deaths occurred between March 12th and May 11th, but typhus was not suspected until 26 cases had occurred, when the local authorities initiated con- tact delousing. As usual, much powder was used after the epidemic was over. At Palermo typhus was recognized in May after 10 or 12 eases had occurred and, in spite of the local activities, some 25 cases and 3 deaths had occurred be- fore the outbreak ended. Figure 8 shows the distribution of cases during this period. RECOMMENDATIONS Materials required for dusting. A motor compressed-air unit with multiple guns is a valuable apparatus for dusting large groups of people quickly, such as those in institutions, travel centers, de- mobilization points, ports, and hospitals, as well as in labor, refugee and prison camps, where such an apparatus may be installed. With this implement the worker can dust more people with greater efficiency, since he is not fa- tigued by the operation of the gun. The simple hand-operated gun, however, is inexpensive, portable and enables many workers to operate in a limited space. Dusting units with hand guns can be of any size, and additional dusters can be trained in a few moments from COMONTEMESCI th EP * = seeds PAR ULAPee ee eeRe rere Petts SCALE 4/7000000 Figure 8. Postepidemic distribution of typhus cases in southern Italy, duly, 1944, to Fane, 1945. A - a end, dy ATVLII NI IO0ULNOD WHAT SHHdAL LGB 328 among the persons to be deloused. One person can easily carry a hand gun and enough powder to dust from 200 to 300 persons, and a pack mule can transport guns and powder sufficient for several thousand dustings. The most satisfac- tory hand pump used is one with ex- centric entry and discharge air tubes to and from the dust chamber, exempli- fied by the Dobbins ‘‘Superbuilt”’ no. 133 and the Hudson ‘‘Admiral’’ no. 765 (Soper et al., 1945). The 10 per cent DDT louse powder can be readily blown from the dust guns. It does not kill nits but remains active and kills lice as they hatch for a considerable period, varying with the amount of insecticide used and the thoroughness of its application. In the Naples campaign a pound of powder was sufficient for dusting 20 persons, but in colder countries where more clothing is worn, a conservative estimate would be one pound for 15 persons. No evi- dence of sensitization or intoxication due to the DDT louse powder was observed during the Naples control activities. Instructions for dusting. Members of dusting squads should be trained to follow a definite routine in dusting so as to reduce the likelihood of missing one or more important points. The op- erator should bear in mind that the powder should be distributed on the inner surfaces of the inner garments and on the skin itself. Clothing should be removed from the first persons dusted so that the distribution may be observed. If properly done, the inner surface of garments should be covered and powder should be visible on the hairs of the chest, back, thighs, armpits and of the pubie and perineal regions. Since body lice are most. often found in the seams of the clothes, those about the neck (figure 9), armpits, waist, shirt tail, and F, L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A, RIEHL crotch of the pants should receive par- ticular attention. A definite routine for dusting is as follows: 1. Dust inside the hat (figure 10). 2. Dust the head, pumping the powder against the scalp especially above the back part of the ears (figure 11). 3. With the arms of the treated person extended at shoulder height at the side (not in front) of the body, insert de- livery tube first up the right and then up the left sleeve and pump powder in between the skin and the innermost garment (figure 12). Powder should reach the armpit and the gun should be shifted to eject the powder about the shoulder. 4. The delivery tube is next inserted at the back of the neck and a liberal charge of powder shot down the back, care being taken to dust the neckband (figure 13). 5. The tube is next inserted inside the clothing from in front and powder sprayed first on the right side, then on the chest and finally on the left side, special care being taken to reach the armpits again (figure 14). 6. (a) For men: The trousers are loosened and the tube inserted in front next the skin and a good dose of powder delivered to the crotch and pubie area (figure 15). With the tube still in con- taet with the skin, the underclothing is powdered, with special attention to the waist and side seams. (6) For women: The skirt is lifted in front and the body and the inside of the underclothing are powdered as with men. 7. (a) For men: With the trousers still loose, the tube is inserted at the rear of the garment next the skin and the powder distributed over the buttocks and rear of the crotch (figure 16). (8) For women: The skirt is lifted TYPHUS FEVER CONTROL IN ITALY behind and the body and underwear are powdered.® Administrative procedures. Contact or spot delousing is of primary import- ance im the event of a typhus outbreak. By the time a case is discovered, which may be several days after onset, infec- tion may have been transmitted to the contacts, and these, when dusted during the incubation period, may be rendered innocuous at onset. Dusting only the immediate family contacts may not be sufficient to arrest the spread of the disease; hence all persons in the build- ing where the patient’s onset occurred as well as others in the neighborhood should be dusted by the spot-delousing squads. Station delousing can be organized on a large scale with a minimum of trained personnel. Persons missed by the mobile units ean be referred to a station for treatment. Also, the large-scale dusting reduces the louse burden of the com- munity and for the time being protects those treated both from infestation by infected lice and from uninfected lice. Long continued work at a given station, however, is not economical because it is difficult to avoid redusting applicants, while an appreciable proportion of per- sons never applies for treatment. When trained workers are available more efficient work can be done by block- dusting squads, which follow a syste- matic plan that insures more uniform distribution and coverage. Institutional delousing. A minimum of trained personnel is required for this work since persons in the institution ean be instructed and pressed into serv- ice as dusters. Quarantine. It is virtually impossible to enforce quarantine in circumstances 3 If more than one layer of clothing is worn; steps 3 to 7 must be repeated for the second layer from the skin. 333 under which typhus flourishes, since in- fected persons can always find ways of avoiding barriers on fixed travel routes. On the other hand, infested and panicky citizens welcome dusting and when treated are relatively innocuous as trav- elers. All wearing apparel carried out of the epidemic area should, however, be dusted. Isolation. Adequate care and hospital- ization of the sick is practically impos-. sible during a large typhus epidemie, and the public aversion to isolation hos- pitals is the chief cause of the conceal- ment of cases. A thorough application of 10 per cent DDT louse powder to the patient, his clothing and bedding, and to the members of his household will greatly reduce the spread of typhus in the community. The patient should be hospitalized only if he requires and can obtain better care there than he would receive at home. Vaccination. In the presence of an epidemic, mass vaccination should be undertaken only if personnel and trans- portation required cannot be used more profitably for case-finding, and eontact- or mass-delousing operations. Vaccina- tion should be available to doctors, nurses, assistants, dusters and others who may be exposed by reason of their occupation to serious risk of infection. SUMMARY A well-seeded epidemic of typhus fever was revealed in Naples in No- vember, 1943, following the German evacuation and the Allied occupation of that city. The peak of the outbreak was reached in December and the trend reversed in January, 1944. In Naples 1,403 civilian cases were reported with an additional 511 cases from 60 points outside the city. Final cases in Naples occurred in April, 1944, while those in 334 outlying towns ceased in May, 1944. None of the sporadic cases or small out- breaks observed in other parts of Italy in the following year could be traced to the Naples epidemic. Delousing services were established in December, 1943, so that an opportunity was afforded to test the efficacy of large- scale dusting with louse powders (MYL and DDT), applied with hand dust-guns without the removal of elothing. De- lousing was welcomed by the people and more than 3,000,000 applications of powder were made during the outbreak. Examination of results revealed that the epidemic potential, i.e., the number of undeclared eases in the population each day, reached its peak 15 days after contact or spot delousing began and be- fore the effect of mass dusting at sta- tions could have become operative. This was true of Naples as a whole and of the F, L, SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL community of Fuorigrotta where a more exact appraisal of the efficacy of dust- ing was possible. Spot dusting of the patient’s family and of persons otherwise associated with him is believed to have been an im- portant factor in arresting and revers- ing the trend of the epidemic. Delousing in fixed stations and air-raid shelters and the systematic dusting in areas block by block, through reducing the louse bur- den of the community, supplemented the work of the spot-dusting squads. During the winter of 1944 provincial health officers and their representatives were equipped with powder and dust guns to be used should cases of typhus appear in their jurisdictions. Instructions for dusting with hand guns are given with recommendations as to dusting procedures in the event of an epidemic of louse-borne typhus. REFERENCES Davis, W. A., and Wheeler, C. M. The use of insecticides on men artificially infested with body lice. Amer. Jour. Hyg., 1944, 39: 163-176. Davis, W. A., Juvera, F., and Lira, P. H. Studies on louse control in a civilian population. Amer. Jour. Hyg., 1944, 39: 177-188. Soper, F. L., Davis, W. A., Markham, F. 8., Riehl, L. A., and Buck, P. Louse powder studies in North Africa (1943). Arch. de 1’Institut Pasteur d’Algerie, 1945, 23: 183-223. Wheeler, C. M. Control of typhus in Italy, 1943-1944, by use of DDT. Amer. Jour. Pub. Health, 1946, 86: 119-129.