A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 VOLUME I by Colonel John E« Gordon, M0C0 Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO This monograph is being made available in manuscript form pending the completion of the official History of the Medical Department in World War II, and must be considered as a draft subject to final editing and revision0 Persons finding errors in facts or important omissions should communicate with the Historical Division, Army Medical Library, Washington 25, D„C. It is emphasized that all statistical data in this monograph are tentative and subject to revision when tabulation of individual sick and wounded report cards has been completed. This document it reproduced froa unedited, unreTiowed material on file la the Hit tor leal X> iris ion, SQO, and etat ononis of opinion, any comeatef or criticism contained herein de not necessarily represent the views ef the Surgeon Oeaoral, Beo&rtnent of the dray, er official policy or doctrine. Therefore, this docuanat is not to he reproduced in any part er la ite entirety* FOREWORD This History of Preventive Medicine in the European Theater of Operations has had the advantage of being written in large part by the men who did the things that are described* The four principal parts of the program in Preventive Medicine were in epid- emiology, nutrition, venereal disease control and sanitation. The Chiefs of those branches during opera- tions in Europe subsequently served on temporary duty with the Historical Division of the Office of The Surgeon General where this history was written* The section on nutrition is wholly the contribution of Colonel Wendell H* Griffith* Lt. Colonel Paul padget wrote the section on the control of the venereal dis- eases, and Lt. Colonel Ralph R* Cleland that on sani- tation. They brought to the presentation an author- ity and a familiarity with detail and policy not possible in a history compiled from records by the most? capable of historians* The section on epidem- iology was contributed by the Chief of the Division of Preventive Medicine, who by reason of personal in- terest and often of necessity, was the continuing director of activities in that field* The remaining chapters on administrative and technical features of the work in Preventive Medicine were likewise written by the chief of the division* The thorough documentation and illustra- tion of events by pictures, charts, tables and epidemiological case reports was done by Captain Edna M. cree> who In her long association with the Division of Preventive Medicine had the foresight to accumulate material and effect analyses which could not have been accomplished in retrospect. BIBLIOGRAPHICAL NOTE# The major source of the material in Part XI* aside from the personal observation of the author* is the Diary of the Division of Preventive Medicinea Office of the Chief Surgeon* European Theater of Operations» (300o6)o Also consulted were Annual Reports of the Division* 1942=44* inclusive* and its Periodic Reports Jan~Jun 1945# (both in 3l9ol=2)o With regard to the relationships of the Preventive Medicine Division and the Professional Services Division in the theater* see William So Middleton* "Medicine in the European Theater of Operations*" Annals of Internal Medicine XXVI (February 1947) 191“200 and Annual Reports of the Division of Professional Services» Office of the Chief Surgeon* European Theater of Operations* for 1943 and 1944 (3l9ol~2)o Cooperative activities in the field of preventive medicine for civilians are reported in monthly statements submitted by the Preventive Medicine Division to Civil Affairs Branch* Operations Division* Office of the Chief Surgeon* European Theater of Operations* Jun-Dct 1944* (014 (Reports* Civil Affairs* Prev0 Med0 Division))o Illustrations of the relationship between the Preventive Medicine Division and the United States Public Health Service are provided in "Ltr„* SGO (Prevo Medo) to Chief Surgeon* ETO (Prev0 Med„)* 31 Dec 1942* Subg [introduction of Dr0 Hamilton Southworth]" (729 (Medical Intelligence Section Correpondence)) and "Ltr0* National Institute of Public Health* to Chief Surgeon* ETO (Gordon)* 9 November 1942* Subs [Work of Dr„ Mooser upon typhus vaccines]" (710~(Typhus Immunization)}0 Correspondence (Sept-Dec 1942) covering various aspects of British-American liaison in the field of preventive medicine is filed in 337 (British-OGS Liaison)o For the relations of Dr0 John E0 Gordon with the British Ministry of Health in the period prior to the entrance of the United States into the war* see The American Red Cross Harvard Field Hospital Unit (Cambridge* Mass,,* 1943)<> Among the sources for the cooperation of British agencies with the Preventive Medicine Division in the field of research are Annual Reports, Medical Department Activities* Eighth Air Force in Europe* 1943# and History of the 1st General Medical Labora- (both in 319ol~2)o Cooperative activities with British military and civilian organizations in the handling of venereal disease are documented in correspondence and minutes of meetings filed in 337 (Conferences«=Command Venereologists)* Oct 1942 - Apr 1943# and 080 (Medical Society for Control of Venereal Diseases)* Dec 1942 - Feb 1944o The relations between the preventive medicine service and the American Red Cross are covered in correspondence, Jul 1942 - Jun 1945> of the Office of the Chief Surgeon, with and concerning that body, on file in 080 (Red Cross)# See particularly "Synopsis of Ltr0, Chief Surgo, ETO, to Liaison Officer with the American Red Cross in Great Britain, 17 March 1943> Sub: Letter of Instructions#" A copy of "Sanitary Code for American Red Cross Service Clubs"—Club Department Circular No# 2, B November 1943, is on file together with related correspondence in 080 (Red Cross Miscellaneous Information)# Attention also is called to the other sections of this work, particularly, Part V - Venereal Disease Controls wherein more detailed discussions of cooperative activities in individual fields of preventive medicine appear© Mil file numbers mentioned in this note refer to materials in the ETO files. Historical Division, Array Medical Library* A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNI TED STATES ARMY 1941 - 1945 VOLUME I Part I The Progression of Events in Preventive Medicine, ETO. Part II Organization of Preventive Medicine Service in ETO. Part III Epidemiology Section 1 Introduction Section 2 Intestinal Infections Number 1 The Diarrheas and Dysenteries Number 2 Food Poisoning Number 3 Typhoid and Paratyphoid Fevers Control of Intestinal Infections Section 3 Acute Respiratory Infections Number 1 Common Upper Respiratory Infection Number 2 Influenza Number 3 The Pneumonias Section 4 Infections Transmitted by Discharges - from the Respiratory Tract Section 5 Arthropod Borne Diseases Number 1 Typhus Fever Number 2 Malaria and Others VOLUME II Section 6 Miscellaneous Infections Section 7 Specific Immunization Section 8 Foreign Quarantine Part IV Nutrition Part V Venereal Disease Control Part VI Medical Intelligence Part VII Laboratory Service Part VIII Gas Casualties Part IX Sanitation Part X Military Occupational Hygiene Part XI Integration of Preventive Medicine into Military Medical Practice Part XII The Health of the Command A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19-41 - 1945 Part I - The Progression of Events in Preventive Medicine9 ETO by Colonel John Ed Gordon9 MoCo Chief of the Division of Preventive Office of the Chief Surgeon$ ETO TABLE OF CONTENTS PART I The Progression of Events in Preventive Medicine, ETO Page Initial American Activities in Wartime Preventive Medicine in Europe, 1940 0 „ „ 0 <, <, 0 1 European Activities of the United States Army before .7 December 1941 „ » <. <> 0 • <, • « . . „ • 2 Preventive Medicine in United States Army Forces, Dritisii Isles ooooooooooo&oooooo 3 The ETO and Preventive Medicine--June 1942 0 » „ • • . 6 Preventive Medicine under SOS, ETOUSA 0 « . . <, , . 0 „ 7 Laboratory Service Established 0 . 0 0 • . s 0 . 9 Early Activities, 1942 0 0 0 « 0 » • « . « „ . <> » . . 9 Later Activities, 1942 - 1943 . c „ <> » . „ . 0 o „ • . H Preventive Medicine in 1944 c . . . 0 . . * 0 0 . » . • 13 Preventive Medicine in the* Ground Forces 0 0 0 0 » „ „ 13 Preventive Medicine in the Air Forces 0 , 0 « , 0 • * « 14 Preventive Medicine and Civil Affairs 0 0 e <> 0 • . « « 14 Marshalling and Mounting of Operation OVERLORD 0 0 0 0 15 Preventive Medicine on the Continent, 6 June 1944— 8 May OOOOOOOOOOOOOOOOOOO 17 Development of the Plan in Practice 0 0 • „ e . • • <> . 18 Theater Headquarters in Paris 0 0 « o o • , „ « • . • « 20 Invasion of 'Germany 0 <, o o o . „ » « 0 « » • <> <, <> o • 22 Aftermath of the Campaign 0 „ 0 0 0 „ , 0 • o * . » * • 23 List of Figures ooooooooooooooo © o © © o 25 AppendiX ooooooooooooooooooooooo 26 PART I The Progression of Events in Preventive Medi j.ne, ETO American interest and effort in military preventive medicine in the European war zone originated long before the European Theater of Operations came into being, and indeed measurably before war was declared by the united States* On the military side, this was a logical development of the long-term planning of the Office of The Surgeon General, United States Army* As the probability of war became increasingly evident, civilian authorities in preventive medicine and public health organizations in America gave increasing at- tention to the necessary correlation of civilian and military effort; and to the means by which civilian staffs, equipment, and experience could be converted to a war-time military organization* Beginning shortly after war broke out in Europe in September of 1959# various groups of American observers visited The United Kingdom to gain first hand knowledge of health conditions® After America declared war on 7 December 194-1# and as ihe numbers of United States troops coming to the United Kingdom became greater and greater, the degree of attention devoted to the preventive aspects of medical practice increased progressively* The medical service of the Array began to take shape, and officers were assigned specifically to duty in preventive medicine* Eventually a regularly- constituted Division of Preventive Medicine was es- tablished in the Office of the Chief Surgeon, European Theater of Operations, 26 August 194-2<> Initial American Activities in Wartime preventive Medicine in Europe, 194^ v«s 6T the Bureau of Medicine and Surgery of the United States Navy were among the first American medical men to arrive in the United Kingdom for observation of medical features of the war® Lieutenant Commander Irwin Lo V* Norman and Lieutenant (j«g®) Simon B« Eyer established headquarters and were attached to the American Embassy In July 1914.0. They collected inf or- motion about current medical practices and problems* and brought together factual data relating to military medicine* much of which was in the field of preventive medicine. This material was forward to the United States for general use by civilian and military agen- cies concerned with preventive medicine and public health. At the invitation of the British Ministry of Health* the National American Red Cross and Harvard University joined in establishing the American Red Cross—Harvard Field Hospital Unit to woik throughout the British Isles in preventive medicine and epidem- iology. Headquarters were established in London during late July 19)4.0« Subsequently* in 19)4-!, the base of operations was transferred to Salisbury, Wiltshire„ Provision had been made in this city of southwest Eng- land for a 100 bed hospital for study and observation of communicable disease; for a well-equipped labora- tory; and additionally a group repidemiological workers to conduct field studies of epidemic disease in civilian and military populations* The director of the unit. Dr* John E. Gordon, Professor of preventive Medicine and Epidemiology at Harvard University, was also attached to the Ministry of Health as liaison officer, charged with the responsibility of collecting and transmitting medical information of military in- terest to British and American public health author- ities o European Activities of the United States Army before““7 December T9Ip-.~-ln April of 19I4.I, Colonel ft hen Ma j or)' A * BWe 1 sh of the U.S. Amy Med- ical Corps arrived in London to be attached to the United States Embassy, and to establish an office re- lated to Army medical affairs. He was one of a group of officers and men from many arms and branches known as the Special Observers Group, They had headquarters at 20 Grosvenor Square in London, and comprised expert observers whose general responsibility was to serve the best interests of the United States, as a nation tech- nically at peace but nevertheless vitally concerned in the war effort of the United Nations* These observers kept the War Department informed and prepared the way 2 for prompt action one© war was declared® The principal interest of Major Welsh was in the collection of available information on the medical faculties of Iceland, this being incident then under way for American occupation of that island® With the assistance of officers of the Ministry of Health, of the British Colonial Office and of Dra John Gordon of the American Red Cross, several weeks were devoted to assembling information about Iceland, in re- lation to communicable diseases, water and food supply, sanitation, provision of medical care, available hos- pitable beds, general health conditions and a wide variety of other affairs, many of which had a direct relation to preventive medicine® in the early summer of 19i+l* a similar sur- vey was made of health conditions In West Africa, in- cluding Gambia, sierra Leone, Liberia and French West Africa® It is evident that much of Major Welsh* s time was devoted to medical intelligence, an active field in preventive medicine. Colonel (later Major General) Paul R. Hawley succeeded Major Welsh on 22 September 19i+lo He set up offices in Plat llj., 20 Grosvenor Square, and began to build the firm foundation of the future Office of the Chief Surgeon, ETC, at Headquarters Special Observers Group® Because of his training in public health and his long experience in preventive medicine, those in- terests entered prominently into the work of his office. preventive Medicine in United States Army Forces, BrltTsh isles.--With declaration of war by the United States on 7 December > the work of the med- ical department of the United States Army took on many new interests and experienced greatly enhanced activity® Nevertheless, Colonel Hawley continued for some time to be a one-man medical department® On 7 January V$\\Z, 1st Lieutenant Dean S. Fleming, a member of the Medical Officers Reserve Corps, was called to active duty from the Harvard Field Hospital Unit, to be the first assist- ant attached to Colonel Hawley*s office. Lieutenant Fleming had been trained in public health and had al- ready had some seven months experience in war-time pre- ventive medicine in England® In his new capacity, he 3 initiated policies and made plans for work in preventive medicine in what was to be the future European Theater of Operationso Early in January of 19hZ9 the United States Army established itself as the United States Army Forces in the British Isles (USAPBI)* The medical sec- tion of the Special Observers Group became part of the headquarters of this force0 On 10 March 19h2, the sec- tion became known as the Office of the Chief Surgeon, USAPBI, v/ith a staff of four officers and a separation of interests which included assignment of 1st Lieuten- ant Fleming to affairs concerned with preventive medi- cine, personnel matters, physical standards, and medi- cal reportso This constituted the first official rec- ognition of preventive medicine as one of the primary functions of the Medical Department under field con- ditions in Europe* The program in preventive medicine developed gradually and informally0 In January much time was spent in liaison work with the Royal Axmy Medical Corps and with British civilian health authorities, prin- cipally the Ministry of Healths The first large con- tingent of American troops arrived in North Ireland 26 January 19ij-2<> Early in February, Lto Fleming made an inspection of housing conditionsand general sanit- ary provisions in the Ulster reglon0 Activities of early March included a survey of insect pests in North Ireland with recommendations for their control* During the subsequent spring months, some few cases of epidemic meningitis occurred among troops in North Ireland, in- cident to a moderate general prevalence of this commun- icable disease in the British Isles* By April, the first sanitary reports from American military organiza- tions were received at the Office of The Chief Surgeon and measures were taken for their review and for action on the recommendations they contained* An organization gradually took form at USAFBI Headquarters for adequate attention to affairs concerned with preventive medicine* The Army still lacked the technical help which enters so pertinently into a pro- gram for prevention of communicable disease, and for provision of an adequate health service* No laboratory facilities were available, nor were there trained field investigators. The sponsors of the American Red Cross- Harvard Field Hospital Unit had directed, however, that the facilities of this organization be placed at the dis- posal of the United States Army, a policy endorsed by the British Ministry of Health under whom the unit was work- ing. After mature consideration, it was agreed that for the present, the Harvard Unit had best maintain its civ- ilian status with the unit contributing voluntary tech- nical assistance to the amy in epidemiology and prevent- ive medicine. At this early date, however, it was ap- preciated that the full facilities of the unit would eventually be required by the Army: and the decision was taken that ultimately it would be Incorporated into the Medical Department of the United States Army. Under this arrangement the Harvard Unit contributed technical advice and help to the Office of The Chief Surgeon during the next several months. The most important professional activity in preventive medicine during this first year of the thea- existence was in relation to an extensive out- break of homologous serum jaundice in May, IJL&o Oc- curing first anong troops stationed in North Ireland, it subsequently involved a number of units arriving in Great Britain. The cause was promptly determined to lie in the administration of yellow fever vaccine and to be concerned primarily with an icterogenlc agent present in the supposedly nomal human serum used in preparation of the product.# Several members of the Harvard Field Hos- pital Unit were engaged in the control and management of this outbreak, including the entire epidemiological staff, a group of four public health nurses, and the facilities of the laboratory. They cooperated closely with the staff of the 5th General Hospital, then located near Bel- fast, Ireland, where most of the patients were In hos- pital. Furthermore, a number of the hospital staff par- ticipated in field studies which extended through most of the units then stationed in North Ireland. #AIthough the cause of this outbreak of jaundice was already known in the United States, such information had not yet reached U.So Forces in Great Britain, where the cause was ascertained independently. 5 Tiie increasing activities in preventive med- icine were, of course, only a part of the general de- velopment at this time within the Office of the Chief Surgeono The program expanded to such an extent that it became necessary to have more space for the medical sect!ono Accordingly, on 7 May 1942, the Office of The Chief Surgeon moved to the second floor of an apartment building at 9 North Audley Street, London, where twelve rooms became available* The office organization as of 15 May 1942, included a division responsible solely for preventive medicine, and under the direction of 1st Lieutenant D* S» Fleming* • ' The gradual expansion of other arms and ser- vices of the Army and the increasing number of troops arriving In the theater, presented greater demands on the Division of Preventive Medicine and defined the need for its own technical organization and staff* As a consequence. Colonel Hawley decided in the later part of May to activate the American Red Cross--Harvard Field Hospital Unit as Medical General Laboratory A, to become an integral part ©f the Medical Department and to be responsible to the Division of Preventive Medicine in the Office ef the Chief Surgeon* As a part of this plan. Dr* John So Gordon, director of the unit, was to accept commission in the Army of the United States, and to become chief of the Division of Preventive Medicine* The tentative date of 15 July 1942 was set as the time for transfer of the unit facilities* The ET 0 jmd P reventlve Medi ci ne - - June 1942 * The progressivaTy expanafng organlzatloh IcrfowiTTs ~tli@ Office of The Chief Surgeon, USAFBI, was now the top ranking medical headquarters in the theater, and was charged with the coordination of all United States Army Medical Department activities in the British Isles* On 8 June 1942, the USAFBI was terminated through process of conversion into th© European Theater of Operations, United States Army (ETOUSA)* United States Army forces in Iceland wore included in the new organisation* With the increasing responsibilities which came with the arrival of more and more troops, the work of th© Division of Preventive Medicine was greatly ex- tended* Prominent among interests at this time were the housing of troops, mess sanitation, and the general 6 problem of nutrition* As the scope of duties in pre- ventive medicine became better defined, plans were made for an augmented staff* A request was made to the War Department for assignment of a venereal disease spec- ialist, a nutritionist, and a sanitary engineer* The increasing complexity of the ETC led to a basic reorganization of United States Army forces in the theater* A Ground Force, an Air Force and the Services of Supply were established* They began to operate in clearing up the confusion arising from the presence in England of many advanced echelons of all arms and branches, now landing almost dally* The several supply and technical services of the Army were assigned to the Services of Supply, an arrangement which gave them a definite organization and a channel of authority, and on lb June the Office of The Chief Surgeon was re- lieved of assignment to Headquarters ETOUSA and reas- signed to Headquarters, Services of Supply* Thereafter, the Office of The Chief Surgeon functioned as a part of this newly~established headquarters, although maintain- ing through the dual function of The Chief Surgeon in both Services of Supply and in the Theater, an overall Interest and authority in supervisi on of activities in preventive medicine for all troops of the command * On 7 July 19Ij.2, Dr* John E* Gordon was com- missioned in the Medical Corps and became the Chief of the Preventive Medicine Division* Oh 25 July 191\2., the office of the Chief Surgeon moved to the newly estab- lished headquarters of the Services of Supply at Benhall Farm, Cheltenham, Gloucestershire* The staff of the Division of Preventive Medicine then included Lt* Colonel John E* Gordon, Major John W* R* Norton, Major Emory C <>' Cushing and 1st Lieutenant Do So Fleming* The first two enlisted men joined the staff* Preventive Medicine under SOS, ETOUSA*—An actively functioning and organized effort iri~preventive medicine can be said to date from about this time,, mid- summer of 19^1-2* The plan of organization for the Division of preventive Medicine provided for five principal branches dealing, respectively, with epidemiology, sanitation, nutrition, medical intelligence, and laboratories* A 7 memorandum of the Office of The Chief Surgeon dated 26 August I9I4-2 formally activated the division and defined its duties* to include intelligence relating to commun- icable diseases* nutrition* supervision of the central laboratory* sanitation of camps and billets* sanitary Inspections and reports* and liaison with British agen- cies in preventive medicine,, Problems associated with nutrition had entered prominently into the activities in preventive medicine from the beginning,. Organized effort dates from the arrival of Major (later Colonel) Wendell Ho Griffith on ij. September 19I42 to become chief of that brancho With the arrival of Major (later Lt0 Colonel) Paul padget* M0G0* a venereal disease control branch was added to the preventive medicine division as of 26 Sep- tember 19i42o Its duties were limited to the preventive aspects of the venereal diseases © Matters pertaining to the care of patients remained a function of the Division of Prof es siona1 Servi ce s 0 As would normally be anticipated* the develop- ment of this new theater of operations was associated with many problems relating to environmental hygiene„ Affairs of sanitation were a general function of the div- ision until the work was organized as a special branch under an experienced sanitary engineer* Lt„ Colonel Ralph Eo Sweeney* SnCo* who reported for duty on 12 Oct- ober 19420 Colonel Sweeney?s association with the Div- ision of Preventive Medicine was short-lived* because of the need for assigning him to other duties in the North African Theater0 He was succeede1' on 29 October 19I|2 by Major (later Lt colonel) Ralph Ro Cleland* SnG* a itary engineer with appreciable experience in Great Brit- ain through his preceding connection with the Hospital- ization Divisiono The Epidemiology Branch during the early days was under the direction of Major (later Lto Colonel) Jo Wo Ro Norton,, He was the first of the staff to be transferred on 15 September to Allied Forces Head- quarters for duty in preventive medicine in the coming African campaign,, Thereafter and for the next year or more* primary direction of epidemiological affairs was an obligation of the chief of the division,, 8 Laboratory Service Established.—On 15 July the former harvard Field hospital became Medical General Laboratory A, (prov„) closely associated with the Division of Preventive Medicine and furnishing technical aid to it. in the course of the next six weeks, plans were made to enlarge the original laboratory plant to a size sufficient to provide adequate central lab- oratory service for a theater of operations. Laboratory supplies and equipment were obtained to match this ex- pansion. Authorization was obtained for the necessary increase in laboratory staff to bring Medical General Laboratory A to a strength approximating that of a gen- eral laboratory. After an initial three months of tem- porary arrangements, the unit came under the permanent command of Major (later Colonel) Ralph S« Muckensufss, MG., who developed a comprehensive and efficient lab- oratory service. Early Activities, I9I42.—The first year of the Division of preventive Medicine falls into three rather well-defined phases. In the beginning, the work in pre- ventive medicine was organized on a very general basis, with the varied activities shared by the limited staff. % There followed then a second stage of develop- ment in which the several features of work in preventive medicine, such as epidemiology, nutrition, venereal dis- ease control and sanitation became centered about a qualified expert who took more or less complete respon- sibility for his particular specialty. During the autumn months of 191+2, the time of staff members in preventive medicine was directed in large part toward two principal objectives. The first was in aid of TORCH, destined for assault on North Africa.,---The second was to assure sat- isfactory sanitary provisions for newly arrived troops, scattered widely throughout southern Englando Units representing most of the arms and branches of the Army were arriving almost daily in Great Britain, (pig. 1) They moved into unorganized camps or into old quarters vacated by the British Army. They were unifo;nnly unfamiliar with living and sanitary conditions in this new country in which they found them- selves. There was loose coordination with secondary 9 echelons of command. Units were commonly unfamiliar with theater directives. It was therefore decided that a team of experienced experts In sanitation should visit all camps and installations of the theater, to bring definit- ive advice and information on sanitary procedures and to aid units in their own Immediate and particular problems. Actually, this project was Illustrative of a policy which was to guide all future operations In preventive medicine in the European Theater—an appreciation of the contin- uing necessity for active field work; the need to carry preventive medicine policies and methods directly to those who were to use and apply them. It gave headquarters an appreciation of problems In the fiel5 not otherwise pos- sible. For the individual unit, help was furnished of a kind which cannot be brought about through directives or formal recommendations, nor accomplished by requisitions. The officers engaged In this work found an en- thusiastic reception by medical officers of individual units. They provided the intimate and practical infor- mation most needed at this time. It was not unusual to find camps and military organizations not noted on any station list. This activity was started on 29 August 1942, and continued until February 1943, during which time United States military installations of the south, the west and the east of England were visited in turn. The mounting of Operation TORCH began in early September, continued through October, and was completed in November. Three members of the limited staff in pre- ventive medicine were furnished to this project. The specific plans for the operation in respect to preventive medicine were developed almost wholly by Major Norton at Headquarters, Allied Forces. In the course of the autumn, however, numerous conferences were held with surgeons of units designated for the operation, numerous inspections were made of alerted organizations, and advice and aid were given on many special interests in preventive med- icine. In the final analysis, the mounting of this operation was decidedly makeshift, compared with the major effort which went into preparations for the subsequent landing in Normandy. When TORCH task force finally left England, the theater that remained had miich the appear- ance of a plucked fowl, since staff and equipment had been contributed most freely to the organization of this essential military effort. Thereafter, the theater settled down to the work of the day, with scant idea of what the future held forth. 10 Figure 1. Men of the infantry pack the rails of a tender bringing them to British shores from their convoy, 1942. Later Activities, 1942 - 1945*--The strength of the command and the number of camps and installations had, however, increased to such extent by the latter days of 1942, that general administrative procedure in the Services of Supply was decentralized into five base sections* In accordance with this general policy, work in preventive medicine underwent a similar decentraliza- tion* This marked the third general phase into which activities for 1942 were separated* Under this arrange- ment, each base section had its own division of prevent- ive medicine* The typical unit consisted of an epidem- iologist, a veneral disease control officer, a nutrition officer, and a sanitary engineer* Because of limited personnel, the plan scarcely got under way in 1942, but came to full realization in the early months of 1943* As qualified officers became available, practice in preventive medicine thus changed from a responsibility vested in a centralized program, to a decentralized system with primary operational responsibility a function of base sections. The Division of Preventive Medicine at theater headquarters became essentially a supervisory group, although as an integral part of the Services of Supply, its relations to the several base sections were close, continuing and inclusive* During the first half of 1943, the lack of precise and permanent decision about the place that the European Theater of Operations was to occupy in the world tactical plan, served to inhibit straight-line planning in theater activities* There was decision for rapid and extensive build-up in troop strength* It was counter- manded* Again came directions for augmented activities and increased manpower, and again progress slowed down* Not until early summer of 1943, was a policy definitely formulated for an ultimate assault on the west coast of Europe and an Invasion of France* Thereafter the con- certed effort of all parts of the service was directed to that end* In respect to preventive medicine, the early period of 1943 was devoted to building up a strong and integrated program for the future base of operations in the United Kingdom* As the year progressed, new troops arrived in continually increasing numbers, not only from America but from Iceland, from the North African Theater of Operations, and by plane over the south Atlantic route* 11 This served to introduce new problems in preventive med- icine, including those of tropical and subtropical climate• when the year 1943 ended, activities in pre- ventive medicine had broadened both in scope and in kind, incident to the more than five-fold increase in theater strengtho Of the professional problems presented during this period, perhaps the most outstanding was an epidemic of influenza in October, November and December of 1943» Although the attack rate was substantial, the clinical form of the disease was relatively mild and no deaths directly attributable to this cause occurred among American soldierso Epidemic hepatitis had been an infection of fairly frequent occurrence in the British population throughout the war years» It spread to United States troopso The small outbreaks which had been of frequent report for a year or more, increased perceptibly when American troops from Africa arrived in the autumn of 1943o The disease had been unusually prevalent there« Attack rates continued high until the usual seasonal in- fluence led to improved conditions in the summer of 1944o Malaria, a disease of such rarity in Great Britain as to be almost a curiosity, became one of the more important health problems as troops seeded with this infection returned from Africa, Italy, and particu- larly Sicilyo They frequently experienced relapse or recurrence of previous clinical manifestations, and sometimes developed primary clinical attack after pre- vious suppressive action of atabrino The number of cases reported during late 1943 and early 1944 was of such magnitude as to require special measures to prepare these troops for continental operations• The increasing importance of planning opera- tions for the Normandy invasion made necessary the re- turn of the Office of The Chief Surgeon to the old quarters in North Audley Street, Londono After estab- lishment. there, on 7 February 1944, all other ac- tivities of the Division of Preventive Medicine were submerged in the primary objective of assuring satis- factory preparation for this major military objective<. 12 Preventive Medicine In ~~As 19J|J| came into being, the situation in preventive medicine in respect to administrative practice, was essentially the following* The Division of Preventive Medicine in the Office of The Chief Surgeon, ETC* exercised an overall theater supervisory function* This relation- ship, in respect to general medical organization— and thereby Including preventive medicine--had been clari- fied and redefined by administrative order of the Commanding General, ETO, early in January* The Ground Forces through all major echelons had well-organized staffs for preventive medicine* The Air Forces had a solid comprehensive program* Base section organiza- tion had reached full fruition, with adequate staffs in all principal units of the Services of Supply* Actual plans in preventive medicine for the Operation OVERLORD were developed at theater head- quarters, but throughout the period of constructive effort, which extended through the first five months of 19i|i|., the closest cooperation was practiced with those units of the three major services primarily concerned. Preventive Medicine In the Ground Forces G — Until late in 19U3V the number of Ground Force troops in the European Theater was relatively small* Divi- sions and the single existing corps had the usual provisions for preventive medicine, under direction of appropriate medical inspectors* The First UoS* Army was established late in 19^4-3> principally from troops returned to Great Britain,from Africa and Sicily* In the spring of 19W-J-* Third Army, Headquarters was established in northern England* In the subsequent organization and training of these forces, close cooperation developed in matters con- cerned with preventive medicine, between the staffs of base sections in which ground forces were located, and with the several branches of the Division of Preventive Medicine in the Office of The Chief Surgeon* Both Armies had well-organized divisions of preventive medicine, that of the First Army under Ltv Colonel Edward So Murphy, and that of the Third under Major W* P* Killingsworth* Preventive Medicine in the Air Forces>•—From the date of iis' activation, the Eighth Air Force had a firmly conceived program of preventive medicine, a cir~ cumstance which arose largely from the strong personal interest of the Surgeon in that field of medical prac- tice «, Special stress was placed on the personal health problems of the Individual flyer. Outstanding accom- plishments Included the production of protective body armour and useful improvements in types of clothing and personal equipment* In matters of Interrelated theater interest there was much common effort-among preventive medicine officers of the Air Force and those at theater level* Programs in nutrition and in venereal disease control in the Air Forces were integrated with those of the theater* Measures for the control of the communicable diseases were neeessarlly of mutual concern and interest, prominent among which was a long continued cooperation leading to promulgation of improved regulations for the sanitary control of airports and of air traffic* Much dependence was placed on staffs in sanitary engineering at base sections, with the base sections exercising essentially area control in matters of water supply and waste disposal* Nevertheless, contacts were less close, and common interests were fewer between the Air Force and other preventive medicine services of the theater— both at base section and at theater level—than with the Ground Forces* This was true for a variety of reasons* The Air Forces had greater independence and identity of medical organization, compared with the Services of Supply and the Ground Forces* A smoothly functioning program in preventive medicine suited to the needs of the Air Force was established at an early date* Finally, many of the problems were peculiar to the Air Forces, such as those related to the physiolo- gieal hygiene of flying* preventive Medicine and Civil Affairs preparation for the f’uture invasion' of the continent, a general staff section of theater and Army headquart- ers to deal with civil affairs, was set up in late 19ij.5. Its activities Increased measurably in so that by June a comprehensive organization had been effected to cope with civilian affairs in liberated territory, and to establish military government in oc- cupied enemy areas„ One of the principle subdivlions within the civil affairs staff section was that con- cerned with public health and welfareo This particular activity was represented both at theater headquarters and in civil affairs G~5 sections of Armies„ As pre- parations for the Invasion became more nearly con- summated,, numerous conferences and consultations were held to coordinate public health activities among civ- ilian populations with preventive medicine interests of the army<> Cooperation was particularly close with the public health sections of civil affairs divisions in the two armies that were preparing for the invasion,, Marshalling and Mounting of Operation OVERLORD.-“A comprehensive plan in preventive med- Icine for Operation OVERLORD, the Invasion of Normandy, was completed early in 191+1+7 Individual contributions by the several technical specialists at headquarters were worked into an inclusive and unified plan« (Ap~ pendix A, Part 1)„ This formed the basis and furnished the material for the final mounting plans of the gen- eral operation itself, and that of the Communications Zoneo These two documents were known as Mounting Plan Medical Corps, Annex Number 8, Section and the Medical plan. Annex 9* Sections 7 and 8* Communications Zoneo They dealt with essentials in simple terms, for example the introductory statement* f,proper sanitation is a command responsibility** ,—no more, no less0 In- dividual directions were given on matters concerned with food, water, waste disposal, the control of respiratory, intestinal and venereal diseases, for the management; of insects *and rodents, immunization and for geperaX hygienic requirements0 In preparation for the operation, a program of re-immunization against certain specific infectious diseases was instituted in February, In March, field surveys of various ground and air force units gave assurance that troops to be involved in the opera- tion were almost without exception satisfactorily pro- tected against typhoid, smallpox, typhus fever and tetanus 0 Reports through medical intelligence channels had established the presence of typhus fever in German 15 concentration and forced labor camps in France since as early as 1943o Typhus had been reported in the spring of 1944 from the Normandy invasion areao Arrangements were made with the Office of the Chief Quartermaster for or- ganization and instruction of special teams within Ster- ilization and Bath Units destined for the continent* to be available for disinfestation whenever outbreaks of typhus fever occurredo Detailed plans were developed for a cordon sanitalre along the Rhine River* to be estab- lished promptly"in case of need* once military opera- tions had extended to that areao Lectures on insect prob- lems* and on improved methods for louse control were given to classes of medical officers* who came from paratroop* airborne* infantry and numerous other units to the Med- ical Field Service Schoolo As time for the invasion neared* a more popular and yet decidedly practical in- struction was given to all officers and enlisted men of the invasion forceso The use of insecticide powder and other methods for destruction of lice were demonstratedo In anticipation of increased demand for trained epidemiologists during the early days of the forthcoming operations* a number of medical officers were given spec- ialized training in the control of epidemic diseases through short-term service with the central division of preventive medicine at headquarters«. Preparatory to the invasion of the continent* a large number of temporary camps had been established In marshalling areas near embarkation ports« Since the messes were by necessity largely staffed by inexperienced personnel* brief instruction in mess operation was given in numerous hospitals and camps before men were assigned to this dutyo A special ration was authorized combat troops passing through the marshalling camps« In order to assure that the food was nutritious a special sanitary guide was prepared* and nutrition officers functioned as Instructing supervisors throughout the areas« It was found necessary to establish feeding points at the ports* and nutrition officers were largely responsible for the development of central kitchens which assured hot food for embarking troops» (Figo 2) Because of certainty that the venereal diseases would have far greater significance In continental opera- tions than in the static training period of the United 16 Figure 2. Last hot meal in the marshalling areas before boarding an L.C.I. (Landing Craft Infantry) 3 June 1944. Kingdom, existing regulations for the control of these infections were revised, and adapted to the particular needs and conditions in France* The practical and personal aspects of venereal disease prevention were incorporated in an educational approach designed to be something more than just another sex lecture* Rather* it dealt with the contraction of disease as a loss of fighting effectiveness, not only of the Individual soldier but of other members of his organization upon whom his life might depend* Social customs and prac- tices of the civilians whom they could expect to find* and the effect of the German occupation, were pre- sented in a concise and dramatic manner* The mounting plan included a final briefing shortly before departure, on general preventive meas- ures conducive to the preservation of good health in the forthcoming operation, with emphasis on the ration and on venereal disease* It dealt also with disposal of wastes, the control of body lice, and with mess sanitation* Preventive Medicine on the Continent, 6 June 1944—8 May 1&45*--In projecting the probable develops ment of the preventive medicine program in tne course of continental operations, it was assumed that during the early days of the assault the exigencies of the military situation would be such as to preclude any serious consideration of disease prevention* What- ever might be done would be limited to the simple measures of environmental sanitation-the essentials of water supply, food supply, and waste disposal* These were matters of unit responsibility and pro~ vision existed for attention at that level* According to plan. Advance Section of the Communications Zone would reach the beachheads at about D plus 8* As the first service organization to land, the Advance Section would be responsible for initiating activities in preventive medicine* At such time as the Army declared a rear boundary they would assume area responsibility for all territory between that boundary and the sea* Within actual Army areas, preventive medicine and its attendant problems would continue to be an Army responsibility* since the Advance Section was in direct support of the field 17 armies and functioned in areas immediately contiguous to them and recently over-run, they would be conceivably the first to encounter the fresh problems of unsurveyed terrltory» This assignment required the staff in pre- ventive medicine within Advance Section to be particularly strong.. To accomplish this purpose, the best available junior members of the staff of The Chief Surgeon were transferred to this duty, prom April, when Advance Section was activated, this group acted in developing plans in preventive medicine for their particular mission, being aided by various members of the theater headquarters division® In anticipation of the time that the work of the Office of The Chief Surgeon would be divided between the base of operations in the United Kingdom and forward ac- tivities on the continent, a forward echelon of the com- munications Zone (FECOMZ) was activated in April® This was actually accomplished by division of the Office of The Chief surgeon into two parts® Lt® Colonel Arthur p® Long took up duties as chief of the preventive medicine part of the office and tentative assignment was made of six other members of the parent division® The plans for continental operations in respect to preventive medicine were largely developed by this group® Development of the plan in Practice®--Qrdin- arily no military plan proceeds precisely in the manner designed nor at the anticipated tempo® This was true in this instance® The Advance Section of the Communications Zone left as scheduled, but its Division of Preventive Medicine was not included® PECOMZ was likewise delayed, and as a matter of fact, never did come into active operations® For these reasons, a preliminary exploration of the situation in preventive medicine on the continent was made by Colonel Gordon, chief of preventive medicine who left London on D plus 30, 6 July 1944, for five days in the Normandy beach head® In the course of these ob- servations two days were spent at the headquarters of the First United States Army, and subsequently practically all of the territory in Normandy then under American control was visited and surveyed. Opportunity was taken to con- fer with all principal representatives of the Medical Department, with civilian health officers, and with a number of practicing French physicians® From these sources it was learned that the last case of typhus 18 fever in the Contentin peninsula had been reported in early May, that there was a serious question of existing indigenous malaria, that diphtheria had been prevalent the preceding winter, but that health conditions in Normandy were generally good* The preventive medicine group of Advance Section arrived while Colonel Gordon was in the areao As a part of general plans to meet the developing sit- uatlon, arrangement was made for temporary assignment of Lt* Colonel Cushing, Entomologist, and Lto colonel Cleland* Sanitary Engineer, to Advance Section.. They were to work with that organization, with the 2lst Anny Group, and with Military Government G“5 in de~ veloplng methods for improved environmental sanita- tion and Insect control» These two officers arrived during the next succeeding days * In addition to their professional duties, they aided greatly in ad~ minlstratlve details connected with the impending establishment of headquarters for the theater Division of Preventive Medicine at Valogneso The First United States Army established a rear boundary 26 July 1944, at which time Advance Section assumed area responsibility for all territory between that boundary and the' coast« The preventive medicine group in Advance Section headquarters there- after had general and theater responsibility on the continent until the middle of Augusto By theater order of 11 July 1944, FECOMZ was recombined with the parent section of ETO headquarters and in substitution of the original plan, the entire Office of The Chief Surgeon—including the Division of Preventive Medicine--was transferred to the continent and arrived in Valognes on 17 August 1944» Pour officers and three men of the division were left in Great Britain to form the nucleus of a staff to serve what now became the United Kingdom Base® The Services of Supply became the Communications Zone, and that part of the organization in France had the designation Head- quarters, ComZ (Forward)« Because of the rapid advances made by troops of the First and Third Annies in the course of the next succeeding days, the Division of Preventive Medicine actually took little part in what was being done in pre ventlve medicine * The headquarters had been left far 19 in the rear by the sudden break-through at St* Lo» with the disruption of communioations which followed* more often than not they were wholly out of contact with the field.ami93 o what was accomplished at this time in re- speet to preventive medicine was largely brought about by independent and individual action by the Armies* by Advance Section and by the recently established Normandy Base (Fig» 3) Theater Headquarters in ParisWhen Paris fell in late it became apparent that the headquarters of the Communications Zone in order to function adequately, must occupy a position closer to the advancing armies and more nearly related to the several base sections that were being formed in liberated territory« A preliminary survey of health conditions in Paris was made by a spec- ial group concerned with medical intelligence, and like- wise contact was made with such members of the municipal and national health departments as were still in the city® On request of the Surgeon of the newly constituted Seine Section, an officer was dispatched to Paris to aid in formulating a program for the control of the venereal diseases, which even in those early days of American occupation, gave evidence of being all the problem that had been anticipated® On 9 September 1944 provisional headquarters for the Division of Preventive Medicine was established in Pariso The Office of The Chief surgeon and its preventive medicine division continued to function here until the European Theater of Operations became European Theater, 50 June 1945o With this central location, and as the mil- itary situation became more stabilized, it was possible to undertake constructive development of the planned program for prevention of disease, and to bring into play the modifications made necessary by the changing character of the theater® The record of what took place in the autumn and winter days that followed, is to be found in the activities and Interests of the several special fields of preventive medicine, as set forth in subsequent sections of this presentation® The satis- factory level of accomplishment came primarily from the contributions of the base sections, and particularly of the several armies® Much for there were no dull moments in preventive medicine during this cam- paign® The more common communicable diseases prevailed 20 Figure 3. Advance guard of the 29th Infantry Division enters St. Lo, July 1944. at anticipated levels of incidence except for epidemic hepatitis which occupied a prominent position. The two outstanding professional problems of the year were trench feet among troops and typhus fever among civ- ilians • Six base sections were organized on the Con- tinent with their attendant problems of staffing and of organization in preventive medicine. No small part of the time of the central staff was devoted to periodic visits to these installations, to the end of develop- ing a unified program and because of the need for ad- vice and consultation in the many new problems which arose. The relations of the headquarters Division of Preventive Medicine with the Armies became much closer when on 1 August 1944 our own 12th Army Group took over weaponsIbilHiy for operations of the United States Ground Forces after the previously existing Allied control under 21st Army Group. In the course of time, conditions in the base sections became rela- tively stable, while in the armies there was contin- uous change, because of new territory acquired and new problems encountered. It was therefore a logical development that more and more of the effort of the various specialists in preventive medicine was direct- ed to the annies, as compared with the base sections. (Fig. 4) The Eighth Air Force continued to maintain its headquarters in Great Britain throughout the course of the European campaign. Consequently, matters of preventive medicine of general military interest and of policy and procedure in respect to special problems, were more often a coordinated effort of officers of that organization and those of United Kingdom Base, than with theater headquarters in France. However, the over-all air force headquarters of USSTAF (United States Strategic Air Forces) which functioned on the continent gave opportunity for frequent and close cor- relation of theater and air force interests. The Ninth Air Force operated on the Continent in forward areas with many resultant common interests with ground force and other troops of the theater. Those in preventive medicine Included among others, insect control, acci- dent prevention measures and numerous problems in 21 communicable disease control * The United States troops that invaded southern France in August were under control of the Mediterranean Theater of Operations® On 1 November 1944* these forces were combined with those of the European Theater® This brought responsibility for the Sixth Amy Group* with its subsidiary Seventh United States Amy® The service troops including Delta Base Section and Continental Ad~ vane© Section* were incorporated into ETO as a subdiv- ision of the Communications Zone, termed the Southern Line of Communications (SOLOC)® Eventually* in Feb- ruary 1944* all of these organizations were absorbed into the primary structure of the European Theater of Opera- tions which became again a unified whole® The !,Battl© of the Bulge” and its antecedent American offensive in November brought about such a critical military situation that relatively little time or opportunity was presented for the ordinary affairs of preventive medicine® Trench foot was the all per- vading issue® This condition first appeared on organ- izational reports on 8 November 1944® It reached a max- imum intensity during December* was a problem of no mean magnitude in January* and continued an active interest through February® invasion ox Germany°~-The creak-through into Garmany iri late February 19457 brought all manner of new far and away the most prominent of -which was typhus fevero That disease constituted a pertinent problem during March/ became more so in Aprils and it was not until the end of May that the epidemic came definitely under controlo As the several armies of the theater forces advanced Into Germany, a change of emphasis in prevent- ive medicine matters took place, so marked that problems of civilian public health tended to dominate those of military preventive medicineo This was by no means either unseemly or illogical, because the health of a command is influenced strongly by the environment in which it finds itself, by the health of the civilian population in areas where it is operatingo The health problems of northwest Europe in the spring of 1945 were among the civilian population They were distressingly acute and 22 Figure 4. Slogging through Germany. Filling cans at a water point near Roetgen, Germany, 10 April 1945. decidedly a threat to the health of the Army, To decide that the best way to protect the enviable health record of the army was by direct attack on the principal source of danger—on civilian public health problems —required no great acumen* As a consequence the relations and interests of medical officers responsible for military preventive medicine and those concerned with civilian health through military government, drew closer and closer. Over shadowing all else were the health prob- lems of the millions of displaced persons wandering over Europe, (Pig, 5) Those of German refugees were of no mean extent. The army had its own particular woe in the care of hundreds of thousands of prisoners of war who came to overcrowded cages; and in the often pitifully destitute members of our own and allied forces who were freed from German prisoner of war camps. The increasing threat of typhus fever became so alaming that something more than cooperation was necessary. Supreme Head- quarters Allied Expeditionary Forces therefore directed that the control of the communicable diseases among both civilians and military personnel was to be a responsib- ility of surgeons at all echelons. Typhus was the prin- cipal consideration. Provision was made for pooling of resources and staff under unified control and direction of the surgeons of Armies, The end ol the war on 8 May brought no respite to those members of the military forces re- sponsible for preventive medicine. The month of May was perhaps the most active of any in the history of the theater, not so much because of the demands of military preventive medicine but because of the need for all medical officers to participate in the reorganiza- tion and stabilization of public health in Germany, Aftermath of the Campaign,—The redeployment of troops directly to the pacific fheater, indirectly to that area through the Zone of the Interior, or to the United States for discharge, got actively under way in June, A staff in preventive medicine was provided the Assembly Area Command, the great center through which most troops passed as they left the theater. These mass movements of troops brought up many health considerations; in respect to transport, staging areas, and ports of debarkation. Newly uncovered foci of typhus fever still came 23 to light during Jun©«, Some of the most energetic efforts against tkat disease were needed before the last smoulder- ing remains of the epidemic was stamped outo However* the success which had been promised in May came to real- ization by the end of Jun©0 June was likewise a month of greatly enhanced activity in tkat part of the preventive medicine program devoted to nutrition0 Returned allied military personnel (RAMPS) had full consideration Numerous surveys of civ- ilian populations were undertaken in association with officers of military governmenment, of UNHRA (United Nations Relief and Rehabilitation Administration) and with the several special commissions originating from the Office of The Surgeon General0 The unprecedented numbers of prisoners of war and the unavoidable crowding into inadequate camps brought about a variety of health problems of which common intes- tinal disorders* dysentery* and diphtheria were the most prominent among communicable diseaseso United States Forces European Theater (USPET) with its subsidiary TSPET (Theater Service Forces Europ- ean Theater) was organized In late June with provision for a Division of Preventive Medicine to function for troops of the occupation zone, and to take over from the Division of preventive Medicine* ETO® The staff was drawn from those at Twelfth Array Group and ETO headquarters* Colonel Tom Fo Whayn© becoming chief of the newly constit- uted sect ion o The European Theater of Operations cam© to an end on JO June 19^-5p leaving to its successor* USFET* the complex problems and interests of an army of occu- pation* whe*% military preventive medicine becomes so ad- mixed with civilian public health that the two can scarcely be distingulshedo 24 Figure 5. The war is over. Romanian displaced persons from Buchenwald concentration camp push their way toward Vienna and rail transport to their homeland. Bavaria, 8 July 1945. FIGURES Fig. 1. Men of the infantry pack the rails of a tender bringing them to British shores from their convoy, 1942“ * ** Fig. 2. Last hot meal in the marshalling areas before boarding an L.C.I. (Landing Craft Infantry) 3 June 1944° • 3 % Fig. 3. Advance guard of the 29th Infantry Division enters St. Lo«, July 194-4° Fig. 4« Slogging through Germany. Filling cans at a water point near Roetgen, Germany, 10 April 1945° Fig. 5» The war is over. Roumanian displaced persons from Buchenwald Concentration camp push their way toward Vienna and rail transport to their homeland. Bavaria, 8 July 1945• 25 APPENDIX A Standard Operating Procedure for Preventive Medicine in Continental Operations "Ao OBJECTIVE lo To conserve military manpower through the application of appropriate disease preventive measureSo wBg RESPONSIBILITY 20 Disease prevention measures must apply equally to the inhabitants of occupied territory as well as military personnel if they are to be effective. For this reason,? close cooperation and collaboration between the public health authorities of occupied areas and the Chief Surgeon is imperative in the application of all preventive medical measureso 51 Co ELEMENTS OF PROGRAM - ■ lo Communicable Disease Control 20 General Sanitations 3o Nutrition 4.0 Venereal Disease Control 9*Do COMMUNICABLE DISEASE CONTROL lo Respiratory Diseases a0 Specific diseases of immediate importance.. (l) Epidemic hepatitis. Third only to scarlet fever and diphtheria in Germany. bo Specific diseases of potential importancec (1) Scarlet fever is most prevalent Incidence rose steadily through 1942 and 43o It is now epidemico (2) Diphtheriao Common in Germany* Netherlands* and Norwayc 26 (3) Meningitis. Reached a ten year peak. Last peak was through 1939* 194-0 and 1941 • It is now on the decline. Co Specific diseases of long term importances (l) TuberculosiSo Most prevalent in occupied Europe and second only to malnutrition in numerical importanceo do General Control Measureeo (l) Particular attention should be directed to standards set forth in AR 40=205* AR 40=210j FM 2l=l0o Notes Quarantine of contacts in general is futile and will not be institutedo Co Specific Control Measures. (1) Sulfonamide prophylaxis. Administration of 2 gms of sulfadiazine or sulfathiazole to contacts of meningococcal infections of the upper respiratory tract* in case of threatened epidemics of these diseases* will control the spread by reducing the number of carriers0 (2) Immunizations Scarlet fever immunization is not recommended under any circumstances. Diphtheria fluid toxoid* when administered according to SGC Circular Letter No. 162. 1942* is of value in controlling spread of diphtheria in ease of threatened outbreak when administered to all contacts. Preliminary Schick testing is not essential. Passive immunization with antitoxin is impractical under ordinary conditions. (3) Routine investigations. As far as possible a routine epidemiological investigation will be made of every outbreak which approximates epidemic proportions. Advice will be given on necessary measures for control. 20 Intestinal Diseases. a. Specific diseases of immediate importance. (l) Common diarrheas. Chiefly in Germany.; 27 (2) Bacillary dysentery* Chiefly in Germanyo (3) Typhoid and paratyphoid feverSo Chiefly in Germanyo bo Specific diseases of potential Importanceo \ , (l) Amebic dysentery. Co Specific diseases of long term importance. (l) Cholera, if imported from an epidemic area* do General Control Measures* (l) As set forth in existing regulations and Field ManualSo e0 Specific control measureso (l) Providing Army standards of sanitation are observed, these diseases should prove to be no problem for troops in combat or garrison* Troops will be ex- posed to a level of unsanitary conditions to which they have not been previously schooled, either in the United States or in the United K5.ngdonio There will be increased need for unit Instruction of troops on essential sanitary conditions and for greater activity in routine inspections* Men on pass or furlough in civilian communities will be exposed and undoubtedly some will become infected unless sanitary control is maintained over free hours* This sanitary control should consist of the follow- ing with liberal application of the "out of bounds" prerogative s (a) Thorough preliminary inspection and subsequent checking of all public water supplies for potability* (b) Frequent sanitary inspections of eating and drinking establishments with an approval system for those suitable for patronage by troops. (c) Prohibiting the use of any local fluid milk and dairy products* 28 (d) Close medical supervision of all civilian personnel employed in a food-handling capacity (Red Cross* YMCA* Salvation Array* etco) (2) Immunization. All personnel will have recently received stimulating doses of typhoid-paratyphoid vaccine* but caution must be exercised that the next typhoid-paratyphoid vaccine dose be admin- istered within the year. (3) Routine investigations. Routine epidemiological investigations will be made of every reported case of cholera* typhoid fever* paratyphoid fever* and the bacillary and protazoal dysenteries to de- termine* if possible* the source and route of in- faction. \ (A) Special epidemiological reports. They will be rendered by the surgeon of organizations or stations which experience an outbreak of gastro- intestinal upset. This report will be rendered to the Commanding Officer of the Base Section* attention the Surgeon* through proper channels* and will include all information pertinent to the probable feause of the outbreak together with recommendations to prevent recurrences. (5) Carrier Control. This will be obtained through repeated stool examinations and cultures of excreta from all probable sources and contacts. A diligent search will be made for carriers in every case of typhoid and paratyphoid fevers* and bacillary and protozoal dysenteries. No patient with one of these infections will be released from isolation until a careful study has been made to determine whether or not he may be a convalescent carrier. Every carrier of enteric infection will be governed by the stipulations of paragraph 17d* AR 4.0-210. 3o Insect-borne Diseases a« Specific diseases by Vector. (l) Mosquitoes. Malaria is only of potential importance. 29 (2) Flies, Only the intestinal infections spread by the common house fly are of importance, (3) Ticks, no diseases of importance, (4) Mites, Other than the nuisance produced by the "harvest mite" and the ftitch mite” these insects are of no importance in the transmission of disease in thisarea, ($) Lice, These are of the greatest military importances (a) Typhus fever is of immediate importance, (b) Trench fever is of potential importance, (6) Fleas, Only endemic (murine) typhus is of im- portance, Plague may become of importance if imported into the existing opportune set-up, b* General control measures, (1) Enforcement of the pertinent sections of AR40-205, AR 40-210, EM B-40, EM 21-10, and such existing directives as are in force or may be put in force, c9 Specific control measures. (1) See Section E 4 Tor insect control, (2) Internment camps, prisoners of war re- patriated workers and soldiers con- stitute the chief reservoir of epidemic typhus, and it is of utmost importance that thorough louse control measures be applied to these groups and all military personnel in contact with them. Careful inspection and disinfestation will be made in the case of all civilians re- turning from infected areas. Frequent subsequent surveys for lice infestation will be made among these groups and all troops in contact with them. 30 (3) Immunization® A general program for the ad- ministration of a stimulating dose of typhus vaccine to all troops should be carried out during August and September to give pro- tection during the ensuing cold weather months. In case of an outbreak of typhus fever, typhus vaccine is to be repeated and given every four months thereafter during the course of the outbreak® (A) Mosquito Control. The chief vector of malaria in this area is a labranchiae stroparvus* a salt water breeder which hibernates in warm houses during the winter months. Any mosquito control plan must be modified to fit the habits of this mosquito if results are to be achieved® (5) Suppressive treatment of malaria® To be used with combat troops during the warm summer months* and then only in regions where the demonstrated presence of malaria so warrants® Not a sig- nificant problem here® (CCS, ETC Circular Letter No® 142, 1943)o (6) Sanitation® Sanitary control of Sea and Air Ports (ETC letters. Subjects "Sanitary Control of Ports" and "Sanitary Control of Air Traffic" dated 9 February 1944)0 (?) Routine investigations. Routine epidemiological investigations will be made of every initially reported ease of typhus, yellow fever and plague, and such recommendations will be mad© as may be necessary to prevent the occurrence of other cases. 4« Miscellaneous Diseases® a® Anthrax. Of little importance® Control is largely a veterinary problem® b. Brucellosis. This disease is endemic but of no mili- tary importance if the use of milk and milk products from local sources is prohibited® 31 Co Leptospiral jaundice (Weil's diseased Of potential importance. Intensive rodent control measures will be instituted in both civilian and military com- munities, as far as practicable* for the prevention of this disease as well as endemic typhus* and as a guard against the possible introduction of plagueo do Tetanus. Of immediate military importance. Immuni- zation* however* should prevent the disease from be- coming any problem. This region is highly contamin- ated with tetanus spores. In active operations with appreciable casualties booster shots every six months are recommended. e. Scabies. Extremely prevalent but will be of little importance* providing general hygienic measures are observed. B. GENERAL SANITATION lo Water. a. Existing and potential problems. (1) In northwest Europe water supplies are unreli- able* and in northwest France treatment plants are almost non-existent. (2) Many existing water supplies can be expected to be contaminated by assault and enemy action. (3) In the event that chemical warfare methods are used this action will lead to further pollu- tion of water. bo Solution of water problems. (l) Treatment of water* in some form* will be re- quired without exception. It will vary from plain chlorination to complete treatment* consisting of sedimentation* coagulation* filtration and chlorination. Water for drink- ing and cooking should never be used without 32 sterilization regardless of whether it is drawn from an existing system or a newly developed source. (See Office of the Chief Engineer Report entitled "Engineer Planning Data for Operations in Northwest Europe, flater SupplyM,dated December 1943* and other existing directives listed in Appendix.) (2) In case of chemical contamination all surgeons will have the responsibility of testing water and advising as to potability and required methods of purification. 2. Sewage Disposal a« Existing and potential problemso (1) Primitive methods of sewage disposal such as night pails, cess pits and cess pools are common* (2) Enemy destruction of existing sewage disposal plants may be anticipated. b. Solution of sewage problems. (1) AEF standards for sanitary waste disposal are completely covered in AEF Construction Standard No. 10, Office of the Chief Engineer, ETOUSA, 11 January 1944* (2) The practice of eating uncooked vegetables grown locally must be discouraged due to wide- spread practice of utilizing night soil for fertilizer® 3. Rodent Control. a® Ex-ffiting and potential problems. (l) Rodents will have increased tremendously and accompanying sanitary problems likewise® Buildings destroyed as a result of warfare will provide numerous rat harborages® b. Solution of rodent problems® 33 (l) Rodent extermination is a function of the Corps of Engineers* hut advice and supervision must be rendered by the Medical Department To be effective all rodent control programs must be coordinated between military and civilian corn- munitj.es * requiring cooperation on the part of the Civil Affairs Division 4-<» Insect Control a- Existing and potential problems* (1) Typhus fever (epidemic and murine)o Exists in certain parts of northwest Europe and the constant danger of widespread and explosive epidemics among civil populations is an ever-present threat to the health of military personnels These and other louse and flea borne diseases require ua~ relaxed diligence in the control of the insect vectorSo (2) Mosquitoeso Important pests in Continental Europeo Along the coast of northwest Germany* Holland* Belgium and France benign tertian malaria* transmitted by the brackish water- breeding species of Anopheles* Ao Labranchiae atrooarvus is likely to be eneounteredc In al- most every locality* certain species of pest mosquitoes such as Aedes vexans and Gulex molestus will occur in sufficient numbers to affect the comfort of troopso (3) Flieso The housefly Musca domestics will be an important insect not only from the stand- point of the dissemination of intestinal dis- eases but as a nuisanceo Some species of biting flies will be abundant enough to cause considerable annoyance in some localltieso (4.) Bedbugs. Must be expected any place on the Continent. Billets selected for troops are al- most certain to be infestedo (5) Cockroacheso They will infest kitchens* mess halls* and food storage placeSo 34 (6) Chiggers and harvest mitese Common pests in the European countries. Infestations will be picked up by troops operating or bivouacked in low lying grassy and bushy areas principally along streams, and from sleeping on infested straw. b. Solution of insect problems. (1) The prevention of epidemic typhus among troops de- pends on a rigid louse-control disciplineo (OCS Cir. Ltr. No. 19, Medical Bulletin Noo 12, OCS, 1 November 1943$ SCO Cir. No. 33, 2 February 1943)• Surveys should continually be made among the civil population in the occupied area to determine the presence of cases of epidemic typhus and the degree of influx of refugees from endemic areas. In the event cases occur, control by a special Typhus Control Unit will be initiated at once. (2) Outbreaks of murine typhus and plague are unlikely but may occur in ports. This will necessitate thorough rat control carapaignso (FM 8=405 0CSo Med. Bulletin No» 9* 1 Sept. 1943 )<> (3) During outbreaks of typhus and plague recom- mendations on the isolation of patients and certain degrees of restriction on the movement of both mil- itary personnel and civilians will be made to the CoGo, CoZo at once. (FM B-4O5 SGO Cir. Noo 33, 2 Feb. 1943)o (4) Mosquito control will be enforced chiefly to control pest mosquitoes, since very little malaria is anticipated. The control measures will consist of the followings (a) Use of repellent, protective clothing, bed nets, screens. (b) Control of mosquitoes by spraying tents, bil- lets or other sleeping quarters with insect- icide, freon aerosol. The breeding habits of the principal malaria vector in northwest Europe are such as to preclude the use of larvicidal measures for the control of the particular Anopheline species. Most of the malaria contracted in the area is due to the biting of mosquitoes in human habitations. Spraying of sleeping quarters should be done twice daily*. (c) Treatment of local breeding places by units within camp area* (d) Treatment of general breeding areas0 Sur- veys to determine location of large breed- ing areas*. Surveys to determine location of large breeding places and recommenda- tions made to the Corps of Engineers re- garding methods of preventing breeding*. (TO Giro Noo 223, 21 Sept*. 1943 5 TO Train- ing Giro No. 108, 2l Sept*. 1943? SGO Giro No. 33* 2 Febo 19431 SGO Cir*> No*> 22, 16 Jano 1943| FM 8-40)0 (e) Hospitalization of malaria patientSo Malaria patients will be hospitalized, insofar as possible, outside the breeding area of Anopheline mosquito vectors*. (5) Fly control. (a) Proper garbage and sewage disposal (See section on these procedures}0 (b) Use of fly ribbons, traps, fly swatters*. (c) Use of insecticide, freon aerosol or In- secticide, liquid, finished sprayc The sprays are most efficiently applied by closing the windows and doors, directing the spray toward the ceiling and leaving the room closed for an hour or two*. The work should be done late at night when the room is least used. Two or three sprayings per week when done properly will affect a good control of flies in build- ings. Food should be covered during spraying operations. (d) Screening. Food preparation and storage rooms, mess halls, and operating theaters of fixed hospitals will be screenedo (SGO Giro No, 33s 2 Feb, 1943s Engr, Bul- letin No, 63j 3 Aug, 1943; Engr, Bulletin 36 71* 21 Aug. 1943; Engro Bulletin No0 76* 11 Septo 1943; Engr. Bulletin No* 114* 17 Jan. 1944; FM 8~40). (6) Bedbug control will be accomplished by spray- ing or dusting beds* bedding* cracks in floors* walls* and ceilings with insecticides* liquid, finished spray or Insecticide* powder* body insect. (FM 8-40)o (7) Cockroach control. (a) Cleanliness in kitchens* mess halls and food storage rooms. (b) Use of Insecticide* powder* rcacho (FM 8~40)» (8) Chigger and Harvest Mite Controlo (a) Through the use of repellent* insect or in- secticide powder* body insecto Troops in areas where chiggers occur can obtain good protection against infestation by applying repellent to all the openings of the cloth- ing such as the shirt collar* the front of the shirt? the fly* waist and cuffs of the trousers* bottom and top of leggings* and along the laces of shoes and leggings0 Dust- ing the drawers especially along waistline* the inside of the trousers* socks and leg- gings with Insecticide* powder* body* in- sect will also protect against chiggers. (b) Straw which is infested with harvest mites can be freed of these pests by spraying with Insecticide, liquid* finished spray or dusting with Insecticide* powder* body insecto Fo FOOD AM) NUTRITION !• Objective a* To make such investigations and recommendations con- cerning the character* adequacy and preparation of food insofar as they have a bearing upon the physical condition of troops. 37 2. Necessary action a» To determine the adequacy of field and hospital rations and to make recommendations designed to maintain the nutritional well-being of troopse bo To assist in the instruction of mess personnel in the attainment of good messing; i.e. the preparation and service of tasty, clean food with a minimum of waste of food and its nutrientso Co To assist in the instruction of officers and enlisted men in food values and in the necessity of individual responsibility for nutritional healtho do To make recommendations, as requested by the Civil Affairs Section, concerning the feeding of civilians in occupied or liberated areaso e« T© advise the Quartermaster on the issue of substitute ration items, and on the proper use ©f foodstuffs which are procured from local sources. fo To make recommendations, as requested by Surgeons of Tactical Forces, concerning the subsistence of combat troops supplied emergency or processed rations, and concerning the feeding of casualties. go To investigate and make recommendations concerning the feeding of troops in rest areas or rehabilitation centers with particular reference to troops previously subsisted on emergency rationso ho To advise medical officers and officers of the Quarter- master Corps in assisting unit commanders to achieve the highest possible standards of mess sanitation and of food service. Go VENEREAL DISEASE CONTROL I. The Venereal Disease Control Program for continental opera- tions will be based on full exploitation of educational methods, provision of prophylactic materials and facilities, epidemiologic methods, command functions and responsibil- ities, and cooperation with other agencies. 38 2o There will be in the offices of the Base Section Surgeons a full time venereal disease control officer who will be provided with the following! a. Such assistant venereal disease control officers as are required to implement the program0 bo Nurses trained in contact investigation to implement the program outlined in paragraph 9o Co Transportation facilities adequate for himself and staff at all times. t 3* A general program of factual education regarding the venereal diseases will be carried on and special emphasis will be given to the followings a« The incidence of the venereal diseases in the con- tiguous civilian population. bo General and special protective measures which may be employed. Co The lack of basis for the ’’last fling attitude11. 4® Provision of prophylactic materials and facilities. a. Administrative orders will be issued for the supply of the followings (1) Condoms will be provided at the rate of 6 per man per montho (2) An approved chemical prophylactic kit (at present the HVW Packette”) will be provided at the rate of 2 per man per month. (3) Prior to embarkation a 15 days1 supply of each of these prophylactics will be issued to each unit, as a unit reserve, and issued under the direction of the unit commander. (4) Hospitals will carry a stock of these prophylac- tics for supplementary issue to individuals. 39 (5) After the assault phase, bulk shipment of these prophylactics will be made to Class II and IV depots, dumps or distribution pointSo (a) Issues will be made from these Class II and IV depots, dumps or distribution points on unit requisition and the supplies to be held as unit reserve will not exceed 15 days<> (b) Prophylactic stations will be estab- lished in locations which will afford maximum availabilityo They will be under the supervision of the Surgeon of the Command concerned and will be op~ erated by enlisted men trained for these dutieso (c) Full utilization of suitable prophylactic facilities offered by other agencies will be authorizedo 5o Recreational facilities, a« The maximum utilization of recreational facil- ities will be made for men in rest and furlough areas and in all other areas where feasibleo 60 Repression of Prostitution. a« The Commanding General and all Commanding Officers will be advised that any program of toleration, supervision, support or encouragement of corn- mercialized prostitution is contrary to the best principles of public health and is a detriment to the health, morale, and efficiency of troops• bo The Commanding General and Commanding Officers are advised to develop a policy of full scale re~ pression of prostitutiono In this respect it is suggested that maximum cooperation be maintained between all available agencies with particular reference to local governments, military and civilian governments and other military serviceSo 40 c. The Commanding General and Commanding Officers will be advised to direct the Provost Marshal to exercise the powers of the military police as much as pos- sible in the repression of prostitution* with par- ticular reference to the following control measures. (1) Houses or areas in which prostitution is knowp or reasonably suspected to occur will be placbd "out-of-bounds" to all military personnel (2) Violations of an "out-of-bounds” order will b£ considered a serious offense. (3) A reasonable curfew hour will be established and enforced. (4.) There will be adequate military police to en- force paragraphs c. (l)* (2) and (3)«> 7* In exercising the command function* unit and higher com- manders will be adviseds a* To ensure sufficient policing of camp and bivouac areas to prevent the entry of unauthorized individuals. b« To control troops in transit so as to prevent clan- destine sexual intercourse. Co To hold bed check in rest areas in order to sub- stantiate the curfew. 8. Cooperation with other agencies. a. Pull cooperation will be given to all agencies engaged in the establishment and maintenance of effective venereal disease control programs both in the civilian population and among the personnel of other military services. bo Where facilities are inadequate for the proper control or treatment of the venereal diseases among the civ- ilian population the use of materials and personnel of the United States Army Medical Department will be authorized. 9» Case Finding a<» Epidemiologic investigation of the sex contacts of soldiers with venereal disease will be established in rest and furlough areas and elsewhere as soon as the military situation permits. This will be done under the direction of a medical officer utilizing the personnel provided for in Section 2bo 10o Punitive Measures a„ The provisions of Section III, Circular Letter No0 2, Hq. ETOUSA, 5 Jan. 19will be strictly observed. Ho DRUGS AND SUPPLIES. lo Communicable Disease Items ISeg Stock Unit Required per.lQ.QQ Availability in relation to D-Day See "Rules" Atabrine tablets, 10T mgni„ 108^5 100 300 D / 30 (a) Cholera vaccine, 20 coo 16015 Vial 75 0 / 30 (b) Diphtheria toxoid, USP plain, 10 cc. 16041 Vial 250 0 / 30 (b) Plague vaccine, cc. 16070 Vial 75 0 / 30 (b) Salfathiazole, USP 7o7 gro tab. 146a 1000 0ol 0 / 30 (c) Small pox vaccine, USP 10 cap tubes in pkgo 16090 Pkg. 100 (d) Tetanus toxoid, plain 30 cc. 16127 Vial 35 D / 15 (e) Typhus vaccine, 20 cc. 16128 Vial 50 0/60 (d) Vaccine, triple typhoid, pro- phylactic 17300 1 cc. 1000 D / 60 (d) 2o HRules" governing communicable disease Items* a0 Atabrine supply sufficient for 10$000 men for one month to be stored in communications zone for use as requiredo b. These hiologicals will be stored for emergency use in an amount sufficient to inoculate 12,000 men. c. Sulfathlazole requirement is based on estimate for pro- phylactic needs only. One hundred package units should be held in reserve in the warehouse to supplement un- expected depletion of ordinary supply, in case this drug must be used as a prophylactic measure against an out- break of meningococcal or streptococcal infection. d. These vaccines will be required in the estimated amounts during the year following D-Day to complete the annual stimulating inoculations. e. The Estimated requirement of tetanus toxoid is based on the anticipated need for casualties and reimmunization ' during the ensuing year. f. Venereal disease control items will be drawn from Quartermaster in accordance with Administrative Circular No. 23,Hq., ETOUSA, dated 9 March 19U. by D / 15. 3» Supplies for water purification, delousing of clothes and equipment, and for the control of insects and pests will be drawn from Quartermaster in accordance with administrative Circular No. 23, Hq., ETOUSA, dated 9 March 19A4-, in such amounts as may be needed according to area by D / 15° 43 A HISTORY OF PREVENTIVE MEDICINE IN THE UNITED STATES ARMY 1941 - 1945 PART II - Organisation of Preventive Medicine Service in ETO by Colonel John E. Gordon, M„Cp Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART II Organization of Preventive Medicine Page The Division of Preventive Mediciney Office of The Chief Surgeon « . . A Preventive Medicine in the Services of Supply 6 Preventive Medicine in the Communications Zone „ 7 United Kingdom Base 8 Base Sections . 8 Advance Section „ ..... 10 Continental Advance Section ...............o 11 Preventive Medicine in the Ground Forces ......... 11 Preventive Medicine in the Air Forces .... . « 14- Eighth Air Force ..... .......... . 15 Ninth Air Force ............ 16 United States Strategic Air Forces 17 Air Transport Command ............ . . 17 List of Figures PART II Organization of Preventive Medicine Service in ETO A general policy intended to guide theatre activities in preventive medicine was set forth at an early date. It defined the principal objective in simple terms - to further all measures designed to improve the health, the physical well-being and the morale of the army0 The Chief Surgeon of the European Theater of Operations had a dual responsibility„ The first was in over-all direction of medical activities in the theater, the second as Surgeon of the Communications Zoneo The Division of Preventive Medicine in the Office of the Chief Surgeon therefore had direct sup- ervisory responsibility for preventive medicine as it related to all sections of the Communications Zone and of the Services of Supply which preceded it <> The Division acted in advisory capacity to the surgeons of field armies and of air forces, through the re- spective Army Groups and the United States Strategic Air Forces, (USSTAF)o The two United States Army Groups, the Twelfth and the Sixth, exercised much the same relationship to the Armies, the First, Third, Seventh, Ninth and Fifteenth United States Armies, as did the Chief Surgeon to bases and base sections of the Communications Zone in the course of his second- ary responsibility as Surgeon of the Communications Zoneo Likewise, (USSTAF) had a similar function in respect to the Eighth and Ninth Air Forces„ Affairs in preventive medicine that re- quired a uniform policy for all Allied Forces, or joint action by any one or more with American Forces, v/ere initiated through SHAEF (Supreme Headquarters Allied Expeditionary Forces) and its Chief Medical Officero Such action came into play in respect to a number of wholly ordinary and usual activities in preventive medicine, such as the control of the venereal diseases0 It found its most useful appli- cation in emergency situations such as the control of typhus fever in Germany, in problems of displaced persons, and in the many other ramifications of civ- ilian health under military government. Headquarters of Field Armies had direct opera**? tional responsibility for the preventive medicine activ- ities of combat divisions and separate units; and division headquarters largely in turn determined what unit surgeons should do in the maintenance of health- The general or- ganizational scheme of the Medical Department provided no lack of advice, of supervision, of direction or of coordin- ation - But to assume that this was what determined the first rate health record, would be a mistake- The vast proportion of routine health service rendered to troops of the command was delivered by the unit surgeon- The pre- ventive medicine organization at theater level may sub- sidize and Indirectly shape the local health service- The Preventive Medicine Division of an army may determine major policies for battalion surgeons, set the standards, promulgate regulations, and even directly supervise his activities; but the final determining factor in the effect- iveness of a preventive medicine program rests with the workers in the locality where the problems are occuring- Belief in this principle dominated practice in preventive medicine in the European Theater- It was stressed at upper command level to the extent that during the period of active operations it was rarely possible to assemble at any one time the complete staff of the Division of Preventive Medicine in the Office of The Chief Surgeon- Some men were inevitably away on field duty; not uncommonly half the staff was so engaged; and in times of stress, as in the course of a typhus epidemic, the central office was almost barren of person- nel- There was nothing but acclaim for the Army prevent- ive medicine officer who regularly each month visited all of his divisions; brought word of new directives, policies and problems; and conferred with regimental and battalion surgeons on the specific difficulties they were having- It reached its ultimate in a squadron surgeon sitting about of an evening with perhaps twenty men of his par- ticular air base, giving no sex lecture but frankly and informally talking about venereal disease. It is es- sential to carry preventive medicine to the consumer; it cannot be successfully transmitted through channels by written directives- Before continuing discussion of the general organizational features of preventive medicine in the 2 various forces of the theater, a word is to be said of personnelo After all, it is men who make an organization, not tables of organization nor directives nor lines of authorityo With no intent of detracting from the accomp- lishments of the men who did the work in preventive med- icine--— two outstanding deficiencies in training and qualifications have come out of this experience® The first is in respect to the physicians who did the work of the day— the unit surgeons 8 A lack of command of the principles of prevent- ive medicine was too generally evident® Too often the actual practice of preventive medicine, sometimes even of the simplest technics such as small pox vaccination, verged on apparent entrance into a new world. This marks a fundamental deficiency in medical education, and the remedy lies with medical educators® The second shortcoming had to do with positions in preventive medicine of high administrative responsibil- ity of requiring specialized skills®* Many were filled by officers with neither professional training in public health, nor experience in public health practice. In the European Theater there may be said to have been at the height of its strength, thirty key positions in prevent- ive medicine. Eleven of the thirty officers had had training in public health or in one of its special dis- ciplines® Five others qualified on the basis of exper- ience® Almost one-half were selected from physicians with good training in internal medicine or pediatrics, who had been accustomed to take leadership and assume re- sponsibility® Consideration should be given this problem by those concerned with future planning for the Medical Reserve Corps and the peace time military structure® The next expeditionary force needs to be assured of sufficient qualified and experienced specialists in preventive medi- cine® In the recent past experience, too many of this rel- atively small group were crowded into a few of the services. The Regular Amy was altogether too small® *This shortcoming has been recognized and is ranidly being correctedo Adequate numbers of Regular Army medical officers have received apd are receiving post-graduate training in civilian schools of public Health and Hygiene. 5 The Division of Preventive Medicine, Office of The Chief SurgeonV“-Activities in' preventive medicine at theater revel'centered in the Division of Preventive Medicine of the Office of The Chief Surgeon* This was one of eleven divisions into which the work of that of- fice was divided* The Division of Preventive Medicine, in turn, was constituted of several branches which var- ied in number with general organizational changes in the Office of The Chief Surgeon* The branches likewise var- ied from time to time in importance and activity, depend- ent upon the nature of the existing problems* The of- ficers who headed the several branches were of such calibre that each branch tended to function independently, each responsible for the work in its particular field of interest whether it was nutrition, veneral disease or in- sect control* It is not to be interpreted, however, that the work of the division was strictly categorized* Pull exchange of aid, as well as of advice, took place when problems involved the interest of more than one branch* The resources of several branches were not infrequently turned to the aid of another to meet the emergency needs of a special situation* Some of the best work in trench foot was done by an entomologist arud the gas casualty of- ficer* Through some special assignment at one time or an- other, the chief of the venereal disease control branch took part in the activities of about every other branch of the division, and to all intent and purpose was the trouble shooter of the division. The branches of the office included at various times organized activity in epidemiology, venereal dis- ease control, medical intelligence, sanitation, military occupational hygiene, laboratories, gas casualties, and nutrition* The bulk of the work centered in four branch- es-“Epidemiology, Venereal Disease Control, Sanitation and Nutrition* The branches of Military Occupational Hygiene and of Laboratories functioned throughout the life of the theater* The work in occupational hygiene consistently overlapped into the interests of ttxi other branches* The supervision of theater laboratory service was strongly supported and reenforced by the aid which came from the commanding officer and the staff of the First Medical General Laboratory* 1* The Medical Intelligence Branch was estab- lished In the early days of the theater. It continued operations until 6 November 1910* at which time the scope of interests in this field was extended beyond its original conception, to include evaluation of scientific.activities in enemy countries, medical edu- cation and other features. The work of the.existing branch in the Division of Preventive Medicine was transferred to the newly constituted Medical Intelli- gence Branch of the Operations Division, except for matters concerned primarily with communicable disease, which were incorporated in the Epidemiology Branch. For administrative reasons the Gas Casualty Division which had long been an independent part of-the Office of The Chief Surgeon was on 15 January 19I4.5* transferred to the Division of'Preventive Medicine as one of its branches. It so continued until 11 June 1910 when work in this field reverted to its previous status of an independent division. An organizational chart of the Division of Preventive Medicine as constituted in 1945 3-s shown in Pig. 1. In contrast to the organizational plan orig- inally holding in The Surgeon General»s Office, work in nutrition in the ETO was incorporated within the Division of Preventive Medicine, rather than in the Division of Professional Services. This has served to emphasize the preventive aspects of nutrition, with no loss of attention to the dietary needs of hospital patients or the management of deficiency diseases. The Division of preventive Medicine thus followed the pat- tern of most good civilian health departments in stres- sing nutrition as a major part of a preventive program, with activities in that field closely integrated into the general program for the maintenance of health. This emphasis on the diet of the healthy soldier led to un- usually close association with the Subsistence Division of the office of the Chief Quartermaster. A second and individual administrative feature was in respect to venereal disease control. Almost without exception, in both civilian and military practice, prevention and treatment of the venereal diseases are com- bined in a single program under a direction. The 5 Chief Surgeon saw fit to delegate the treatment of the venereal diseases to the Division of Professional Ser- vices and the development of a program for prevention and control to the Division of Preventive Medicine. This was logical and potentially promising of a better total effort. With direction of a venereal disease program by a clinician, prevention is likely to suffer; and with a public health man at its head, treatment is rather certain of under-emphasis. Such a division of interests has furthermore characterized the history of most developments in preventive medicine, notably in respect to the common communicable diseases, tubercu- losis, cancer and pneumonia. Without exception the impetus toward prevention originated from the clinic and the bedside. The development of technical methods of prevention came with the interest of trained public health workers. Prevention reached its full potential- ity, however, only when it attained equal standing in effort and importance with the clinical problem. Continuity of service of key personnel con- tributed as much as anything to the accomplishments of the division,, The chief of the division acted informal- ly from the earliest days of the theater, later became Consultant in preventive Medicine, and continued as chief throughout the existence of the theater. A similar sit- uation likewise held for two of the major branches, with Major (later Colonel) Griffith in Nutrition, and Major (later Lt. Colonel) padget in Venereal Disease Control. It was essentially true for the Sanitation Branch. While work in this field was started by Lt. Colonel Sweeney, it was under the direction of Major (later Lt. Colonel) Cleland during the greater part of the theater's existence, with Lt. Colonel Sweeney returning toward the end of operations. To a large extent, the same state of affairs held true in respect to junior members of the staff, except for those who left because of qualifying for more senior positions. The chief of the division was fortunate in~the quality of officers and men assigned to the staff, and still more fortunate in being able to hold them together. Preventive Medicine in the Services of Supply.— Base sections were first formed in the Services of Supply in late 19i|2o While organizational plans were well under 6 GAS CASUALTY BRANCH LT. COL A M. JOHNSON, MC CART F.D. BROWN. MC T/3 M J. FRIEDMAN T/5 J H. PHILLIPS CLERICAL STAFF T/Sg» N E COOK T/4 B L. SUEL PVT A.S. MASUR MISS M HEMING MLLE H FONTAINE VENEREAL DISEASE CONTROL BRANCH LT. COL. P. PADGET, MC MAJ. R HEITZ, MC l*t LT. H.M MALONE, ANC T/4 G. BERGERON MILITARY OCCUPATIONAL HYGIENE BRANCH MAJ E.J. MARZAC, SnC ORGANIZATION CHART DIVISION OF PREVENTIVE MEDICINE OFFICE OF THE CHIEF SURGEON CHIEF OF THE DIVISION COL. J.E. GORDON, M. C. EXECUTIVE OFFICER LT. COL. R P MASON, M C. SANITATION BRANCH LT. COL. R.C. SWEENEY, SnC LT COL. E.C. CUSHING, SnC MAJ. R W BUNN, SnC MAJ E.J. MARZAC, SnC V5 J. HIDALGO, Jr CPL. F F McREE Figure 1 LABORATORY BRANCH MAJ. W.C. SPRING,MC NUTRITION BRANCH LT. COL. W.H. GRIFFITH, SnC CAPT. 6.F. COMBS,SnC 1st LT. M ALDRICH, MDD T/4 A B. FINK EPIDEMIOLOGY BRANCH LT COL. R P. MASON, MC MAJ. W.L. HAWLEY, MC CAPT. W.S BRUMAGE, MC CAPT. E.M. CREE, ANC T/Sgt J.C. RYZAC T/3 R.H. FOOTE P»c N. WHITE , WAC way that autumn, no Instance existed in which a base section had a complete and functioning Division of Pre- ventive Medicine before 19J4.3• As the emphasized policy of decentralization became established and more and more responsibility was delegated by the Chief surgeon to Surgeons of base sections. Divisions of Preventive Medicine at that level increased in size and progress- ively developed comprehensive programs, By the end of 1910 all base sections had complete departments of pre- ventive medicine, organized on the basis of four branches—epidemlology, nutrition, sanitary engineering and venereal disease controlo They were adequately staffed, and functioned more or less independently with- in their areas, directing and supervising all activities in the field„ Perhaps the strongest organization in a base section was that of Southern Base Section, as was proper, since the heaviest concentration of troops was in that region0 The two other base sections. Western and Eastern were adequately staffed and organized. The preventive medicine staff at Central Base Section in the London area was smaller, but sufficient to meet the needs. Epidemiology and venereal disease control were under the direction of a single officer, the medical inspector, A nutrition officer was as- signed later in the history of the organization. The Ireland Base Section was organized late in 19i+5<> It gathered a strong staff, which was necessary because of the variety of problems peculiar to North Ireland and because of its relative isolation. The areas of the United Kingdom included within the several base sections are presented in Figo 2, The base sections were responsible for pre- ventive medicine affairs relating to Services of Supply troops within their respective areas, and in addition had area responsibility for such matters as water sup- ply and waste disposal. Ground forces stationed within a base section had unit responsibility for preventive medicine within their organization, as did the air forces o preventive Medicine in the Communications Zone o~\with the beginning of continental operations, the 7 former Services of Supply became the Communications Zone. As of 19i+5 it included a headquarters in Paris, six base or intermediate sections within continental Europe, two advance sections and a single base, that of the United Kingdom., (Fig. 3) United Kingdom Base.—The original five base sections which had operated "in the United Kingdom under the Services of Supply were contracted into a single unit, the United Kingdom Base. The base was further di- vided administratively into four districts, corresponding in general to the areas previously included within the base sections of Great Britain proper. Operations in North Ireland had by this time practically ceased. A strong staff for preventive medicine, drawn almost entire- ly from the Office of The Chief Surgeon, remained in Great Britain under command of Major Co Mo Eberhart. Its re- sponsibilities were heavy, in that for all practical pur- poses it took over obligations for installations and areas which had previously engaged theater headquarters. The United Kingdom furthermore became the principal center for hospitalization of casualties. The districts had individual representation in preventive medicine in some Instances, usually one officer, but no formal preventive medicine division was established at that levelo The work of the base was directed centrally from its headquarters, London. The districts were later dissolved, and base organization and administration became essentially that of Service Commands in the zone of the Interioro A certain amount of decentralization was:still practiced, however, through assignment of special officers in preventive medicine to hospital centers to work in sur- rounding territory. Base sections0~~The well-organized divisions of preventive~medicine which came into being within the various base sections of the United Kingdom in 19k-3* served as a nucleus for staffs in similar positions in the newly organ- ized base sections of the communications zone on the con- tinent. In addition to Advance Section, there were six such organizations in the original area of the European Theater of Operations5 the Seine, Brittany, Normandy, Chan- nel, Oise, and Loire Base Sections, although the latter was short-lived, eventually being absorbed into Brittany Base Section. 8 BASE SECTIONS AND PORTS IN ETOUSA I JANUARY 1944 •LE4EN0* MM MOTION IOUMO. THEATER BOUNDARY HEAOOOAATEIW Figure 2 ''(T Map of United Kingdom showing boundries of base sections. Services of Supply, 1943. SECTIONS OF THE COMMUNICATIONS ZONE ET 0 U S A-NOV.'44 CSS ffcspontIfc1• for US Activities In British Control I# It so happened that the first fully organized and independently functioning div- ision of preventive medicine in any lower echelon of the theater was that of the Eighth Air Force Composite Com- mand, which arrived in North Ireland in September with a full complement of officers for preventive med- icine O The strongest part of the air force program in preventive medicine was that relating to the per- sonal health of the Individual soldier--those factors which contribute to his efficiency as a fighting man, the every day features of food, clothing, relaxation, rest and recuperation® The soldier, like the worker in industry, encounters certain specific health hazards because of his occupation as a soldier® While this is particularly true of the soldier in the air forces, it is by no means individual to him and certainly no more so than to men serving in the tank corps or to the paratrooperso At any rate, attention to this important consideration saw a higher development in the air force in this theater under field conditions than in any other branch of the service* A special group at air force headquarters was continuously engaged in the study of these problems and in the development of improved equip- ment and preventive measures* The degree to which it was emphasized was- indicated by the existence within the headquarters of the Air Forces and of TJSSTAP (United States Strategic Air Forces) of a special division of the Surgeon’s office called the Division for Care of the Flyer* In further development of this interest, special Industrial Hygiene Control Officers were assigned to duty on the continent and in Great Britain* They were prim- arily concerned with the prevention of accidents and injury, and of occupational hazards peculiar to men of the air forces* It would appear that opportunity for material improvement in the future program of military preventive medicine rests in more intensive study and application of measures directed toward minimizing these occupational and personal health hazards* Eighth Air Force.--The Eighth Air Force was the first major air force "unit established in Great Britain, in early 19i+2* The usual separation of Interests between prevention of disease and care of the sick and wounded did not exist in the organization of the Surgeon—as for in- stance in the Office of The Chief Surgeon,, ETC, with its Division of Preventive Medicine and Division of Profession- al Services* However, there was no lack of emphasis in preventive medicine, and at least four divisions of the office of the Surgeon were concerned with this activity* The Division for the Care of the Flyer has been mentioned* The Division of Professional Services had general responsibility for plans in the control of com- municable disease and for supervision of venereal disease control* The Division of Medical Inspection dealt with problems of sanitation and with administration of the program for control of communicable diseases, including the venereal diseases* An independent Division of Nu- trition indicated the stress given this Important field* Responsibility in lower echelons fell to surgeons of the four separate commands making up the Eighth Air Force, with Composite Command more strongly staffed than others because of its isolated geographic position* In addition 15 to the permanent staff at the Eighth Air Force head- quarters, additional personnel were assigned from time + -> time for special investigations such as the study of aerosols and of chemoprophylaxis in the control of upper respiratory infections,, The organization in 19i|4 remained much the same, with general supervision of preventive medicine affairs under the Chief of Professional Services. Ven- ereal disease control, medical Inspection and the care of the flyer continued as. separate divisions * Ninth Air ForceThe Ninth Air Force came to the European Theater from ‘North Africa with a long, solid experience in field operations. Differing from the Eighth Air Force, whose military mission was’ strategic bombing from a fixed base, the Ninth Air Force was a mobile, tac- tical air force with the definite mission of furnishing support to the Allied invasion of Normandy, and there- after close support to the various Armies of the United States. Its organization for preventive medicine was materially different from that of the Eighth Air Force, as demanded by the different character of its operations. Based largely on its experience in Africa, a Hygiene and Sanitation Team was organized at Ninth Air Force headquarters. It consisted of a medical officer ex- perienced in epidemiology, hygiene, and preventive med- icine; an officer of the Veterinary Corps to be re- sponsible for food inspection; and a Sanitary Corps off- icer trained in sanitary engineering. The duties of the team were nto insure supply and proper maintenance of adequate sanitary installations, disease control as well as insect and rodent control, on all occupied fields, camps, and stations, as well as proposed sites. The Hygiene and Sanitation Team will advise and assist all unit commanders as well as unit surgeons on all matters pertaining to public health. These Include food in re- spect to supply, handling, storage, and preparation; the supply, transport and storage of water; messes and all mess equipment; waste disposal; and disease control.” Similar teams were set up in the six commands which made up the Ninth Air Force, with similarly defined duties and organization except that they consisted of one medical officer and one sanitary engineer. This was preventive medicine in its best tradition of field practice. 16 United States Strategic Air Forees,--USSTAF was activated in 19W as the superior air force headquarters of the theater* It had administrative control of the Ninth Air Force, operative control of the Fifteenth Air Force and administrative and operational control of the Eighth Air Force 9 In the office of the surgeon the Chief of Professional Services had supervision of all affairs concerned with'the prevention of disease, including ven- ereal disease control* A special Projects Officer was responsible for sanitation and review of the monthly san- itary reports* The Division for the Care of the Flyer was independent, as was usual in air force practice* The sur- geon of the Rase Air Depot Area had responsibility for the Division of Nutrition,, The integration of general theater policies and procedures with air force units was accomplished through this headquarters* In the case of the Ninth Air Force, perhaps because of its geographic location on the con- tinent and its close association with the ground forces, there were numerous Informal consultations and brief tours of field duty by officers in preventive medicine from theater headquarters* Air Transport Command.—The Air Transport Com- mand would seem to have greater organic need for prevent- ive medicine than most other branches of the service* The far flung and changing character of its operations brought multiple and complex exposure to communicable disease, its occupational hazards were numerous, and its activities were of necessity often conducted under conditions of ex- temporized and deficient environmental sanitation* In the ETC, its measure of accomplishment in preventive medicine was scarcely that of other parts of the Air Forces* In too many Instances, it had difficulty in meeting minimal requirements * The part which the Air Transport Command took in developing improved measures for control of International air traffic was of importance to the welfare of the theater as a whole* What eventually became the standard operative procedure for control of aircraft entering and departing from the theater was a joint development of surgeons of the Air Transport Command, the Eighth Air Force and the Chief Surgeon, ETC* 17 FIGURES 1. Organizational chart of Division of Preventive Medicine, Office of the Chief Surgeon, ETO, 1945. 2. Map of United Kingdom showing boundaries of base sections. Services of Supply, 1943. ✓ 3. Map of Western Europe showing boundaries of advance and base sections. Communications Zone, 1945. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES AFMY 1941 - 1945 PART III - Epidemiology Section I - Introduction by Colonel John E, Gordon, M.C. Chief of the Division of Preventive Medicine Office of The Chief Surgeon, ETO TABLE OF CONTENTS PART III Epidemiology Section 1 - Introduction Page Policies and Functions 1 Organization for the Control of Epidemics • „ 2 Personnel in Epidemiology, Office Chief Surgeon . . . „ . o 3 Reporting of Communicable Disease 5 Medical Records in the United Kingdom 5 Medical Records in Continental Europe • « 6 Medical Records for Epidemiologic Use « 7 Provisional Health Date 8 Data Included in the History of the Theater 9 List of Figures PART III Epidemiology- Section I - Introduction Organized effort in preventive medicine, whether it be civilian or military, quite apparently extends well beyond the pre- vention and control of the communicable diseases; and yet in the final analysis that is the primary obligation of any health de- partment, of any military organization in preventive medicine. The first health problems encountered in the European theater were in epidemiology. Work in this special field took shape in advance of others, and perhaps first attained formal organization and satisfactory performance. Policies and Functions .—Certain major objectives and aims designed to govern activities in the control of the communicable diseases, were prescribed in a statement of policies formulated shortly after the Epidemiology Branch was established in the Division of Preventive Medicine at theater headquarters. Intended primarily to guide action at this higher level of authority, they were nevertheless applicable throughout the fabric of the Medical Department. In detail, they were as follows? (1) Preparation of comprehensive plans and procedures for the control of the acute communicable diseases commonly existing in the European Theater of Operations; and for those likely to be introduced through military action or other abnormal activities incident to war. (2) Provision to unit, base section, ground force, and air force surgeons of advice, consultation, and specific information on particular problems associated with epidemic or endemic situations. (3) To furnish the technical aid of qualified epidemiologists for the investigation and control of epidemics that had developed or might develop beyond the facilities of a particular unit. Preliminary surveys will be made by a staff member of the Epidemiology Branch at theater headquarters. As circumstances demands, epidemiologic teams* of medical officers, public health nurses, and laboratory tech- nicians will be designated from the staff of the medical general laboratory, (4) To prescribe an adequate program for specific immunization against those communicable diseases for which such measures exist; and to control by inspection, survey, and report, the satisfactory accomplishment of that program. (5) To extend knowledge and to improve methods for the control of epidemic disease, through continuous investigation by all clinical, laboratory, and epidemiologic means available. In unusual circumstances and for unfamiliar diseases, special boards will be constituted to this end. (6) The collection of information and the institution of a system of records, charts, and graphs to permit analysis and interpretation of the current prevalence and incidence of the more important communicable diseases. This will include data on troops of the command, of the civilian population of the area occupied, and of the troops of allied armies. (7) To establish close cooperation and liaison with civilian and allied military authorities, to the end of a full exchange of information on the incidence of the communicable diseases; and on methods and practices for the control of these conditions, (8) To affect periodic interchange of information with the Office of The Surgeon General, Washington, on experiences and on scientific progress in the field of epidemiology. Organization for the Control of Epidemics,—It is to be accepted as principle, that primary responsibility for the control of the communicable diseases rests with the unit surgeon. No one else has equal opportunity to recognize the beginnings of an epidemic and to initiate promptly and effectively the indicated measures for its limitation. The sole function of expert epidemiologists at more exalted levels of command is to furnish general rules for guidance, to keep unit surgeons informed of newly developed technics, to assure satisfactory distribution of current knowledge on the movements of transmissible disease, and finally, to lend a hand when the demands of a given situation are beyond local resources. The unit surgeon serving with troops of the line, ordinarily called upon the division medical inspector for necessary aid in matters concerned with control of the communicable diseases. This principal assistant to the division surgeon had primary responsibility for all matters of health within the division area. He in turn consulted the medical inspector of Corps, who had supervisory action over assigned troops and direct responsibility for units attached to corps. The first organized division of preventive medicine in the ground forces was at Army level. An experienced epidemiologist was invariably a member of the staff. Matters of such interest or importance that other armies were concerned, were cleared through the preventive medi- cine division of the respective Army Group, which also extended a consultation service to armies within its jurisdiction. The air force organization for communicable disease control resembled that of the ground forces. An epidemiologist was stationed at Air Force level, the work of the various Commands corresponded to that of Divisions in the ground forces, and overall authority was vested in the United States Strategic Air Force, The third principal component of the forces comprising the European theater, the Communications Zone, had provision for epidemio- logic consultation and aid through epidemiologists serving as staff members of all base section preventive medicine divisions. This service was available to all units within the base section area. The epidemiologists at higher echelons, whether Base Section, Army or Air Force, brought into full play all services and instal- lations having to do with epidemic control® They were in a position to elicit# the help of the Corps of Engineers, if the problem was related to water supply, or that of the Quartermaster Corps if it chanced 2 to be one of insect control. Coordinated effort with local and theater laboratory services was assured. Epidemiology at these major operational levels was field epidemiology. Epidemiologists gave direct and practical aid in bringing about control of a situation, (Fig, 1) Working with the local medical officers in the area involved, they surveyed the conditions underlying an outbreak. They gathered the history of the outbreak from its beginnings, visited commands and quarters from which cases had come, made spot maps of occurrence, traced contacts, investigated the relations of case to case spread, deter- mined relations to water and food, and instituted laboratory studies to confirm their findings. The particular measures neces- sary to arrest an epidemic could then be formulated intelligently. The division of Preventive Medicine of the office of the Chief Surgeon established epidemiologic policy, circulated information and aided in meeting emergencies. It confirmed technical examina- tions, reviewed reports of epidemiologic studies and the recommen- dations they contained, and gave advice. It contributed the experience and knovfledge gathered by reason of familiarity with conditions throughout the theater generally. But the service provided by the organization at theater headquarters aimed at more than advice, — or consolation or criticism. Provision existed for direct field aid in the investigation of outbreaks of communicable disease by members of the epidemiologic staff. This professional assistance was liberally used by many units, sometimes to accomplish preliminary surveys of a situation, with recommendations for a method of attack; sometimes as a long continued cooperative effort in problems of major concern. Under circumstances where the causes of an epidemic or the reasons for its continued progression were particularly obscure, the special facilities of the First Medical General Labora- tory were utilized. Adequate investigation of some outbreaks re- quired highly specialized laboratory procedures; in other instances, the primary need"was for appreciable numbers of experienced field workers. The benefit deriving from close coordination of laboratory and field studies was commonly evident, and many times imperative. Need for such special studies was in all instances determined by preliminary survey by epidemiologists from the theater office of Preventive Medicine, Request for study of the particular problem was made to the laboratory and they organized staff and equipment, and planned and executed the study. The results were transmitted to the Preventive Medicine division for administrative action, and for necessary recommendations to the Chief Surgeon and to the organization concerned. Personnel in Epidemiology, Office Chief Surgeon,—A long term and continued development of activities under a single directing head characterized the work of most branches of the Division of 3 Preventive Medicine in the Office of the Chief Surgeon. The Epidemiology Branch lacked that advantage. Throughout the several years of the theater, it fell to the lot of the Chief of the Division to maintain a guiding policy in this important feature of preventive medicine and to provide the continuity between frequent changes in administrative responsibility. During the early months of 194-2, the conduct of epidemiologi- cal interests was a responsibility of the subsequent chief of the division, Colonel John E. Gordon, then acting as civilian consultant to the Chief Surgeon. Lt. Dean S. Fleming assisted in field work and was responsible for the general management of the office. From June through August 194-2 the head of the Epidemiology Branch was Major (later Lt. Colonel) John W, R. Norton. With Lt. Fleming he left the theater in the autumn of 194-2 for duty in the Mediterranean Theater. 2nd Lt, (later Captain) Edna M. Cree joined the Epidemiology Branch in September 1942, continued as a member of the staff until operations ceased in June 1945, and through the latter half of 1945, served with the Historical Division, collecting material and planning the content of this present history. The work was continued as a member of the Historical Division, Office of The Surgeon General until June 1946, her services thus extending from the earliest days to the very end. With the departure of Major Norton and Lt. Fleming the supervision of epidemiological interests again came directly under the chief of the division and so continued until Captain (later Major) Claude M. Eberhart joined the staff in December 1943« During the intervening period assistance was furnished by a number of officers, including Captain Joseph T. Marshall, Lt. Lawrence Kilham, and various members of the staff of the First Medical General Laboratory who served on temporary duty from time to time, particularly Captain John Degen and Captain W. 3. Spring. When the Epidemiology Branch was transferred to the continent with the remainder of the division in August 1944, Captain Eberhart remained in Great Britain as Chief of Preventive Medicine for the United Kingdom Base. He continued his responsibilities for epidemiology in that important area until transferred to the Assembly Area Command in June 1945o Captain (later Major) Roger S, Whitney worked in epidemiology from 19 January 1944 until he left in May of that year to becane epidemiologist with the Advance Section, C.Z, Major (later Lt. Colonel) Charles D. May served for a brief period in connection with epidemiological studies on pneumonia. Captain (later Major) W. L. Hawley joined the Epidemiology Branch in May 1944 and remained until May of 1945o Lt. Colonel Arthur P. Long assumed direction of epidemio- logical affairs in the Division in August 1944, having been released from assignment to the forward echelon of the Communications Zone on inactivation of that part of the Office of the Chief Surgeon. He 4 Figure 1. Field Epidemiology in Practice left the theater in October 1944 to resume his previous position in the Preventive Medicine Service of the Office of The Surgeon Generalo During the next several months, work in epidemiology again came under the direct supervision of the Chief of the Division until Lto Colonel Richard To Mason took over in February 1945 after a long and active field service in the Mediterranean Theater and subsequently with Soloc in southern Pranceo He continued in this position until theater activities closed 30 June 1945 and shortly thereafter became acting chief of the Division of Preven- tive Medicine in the newly organized DSFETo Captain William So Brumage served as his principal assistant from May 1945, as did 1st Lto William Go Good® Much of the collection and analysis of records of disease prevalence was done by the enlisted men of the divisiono Con- scientious service was rendered by many individuals0 T/3 Richard Ho Foote brought a sound scientific training to the position of chief clerk of the Branoh0 t/4 Norman Ec Williams and T/3 John Co Ryzak were largely responsible for statistical analyses and the pre- paration of graphs and charts, many of which appear in this history of the work of the Divisiono Reporting of Communicable Disease c—A well-organized system of reporting the communicable diseases is essential to satisfactory epidemiologic work0 The conditions for this did not exist in the early days of the theaterc Even toward the end of 1942, reporting could not be said to be either good of prompto With units moving into the theater and out to North Africa, with information often lacking about the location of units within Great Britain, with indefinite information of total numbers of troops, it is understandable that reliable and current facts about the number and location of patients with communicable disease was often most indefinite0 Medical Records in the Bhited Kingdcanc —Throughout the his- tory of the theater, a close working arrangement was maintained with the Division of Medical Recordso Their routine weekly reports were rendered promptly, and more commonly than not, delivered by hand that they might reach Preventive Medicine at the earliest momento More important than that, informal information about recent developments was exchanged almost daily0 Access was had to their work sheets in advance of formal reports0 Because of the recognized lack of a satisfactorily function- ing system, all sorts of sources of information were developed to increase current knowledge of the communicable diseaseso An occasional bit of information was obtained from the routine sanitary reportso The daily admission and discharge records of hospitals were examined for communicable diseaseso Arrangements were made with the Ministry of Health to obtain information about communicable 5 diseases affecting American military personnel, which came to that agency through reports from local civilian health authorities* British hospitals, not uncommonly advised of American soldiers admitted directly to those institutions* Knowledge of unusual happen- ings often came directly from base section surgeons through request for epidemiologic aid* Thus, from a variety of sources of varying reliability, information.was gathered during this formative period in the theater's history which gave a working command of the fre- quency with which the communicable diseases were occurring* Epidemiological work was greatly benefited during the year 1943 by the development of a better organized system of reporting; with the result that the Division of Preventive Medicine was able to accumulate more nearly complete records* The Division of Medical Seconds furnished weekly consolidated statistical reports of admissions to hospitals and quarters* Perhaps most valuable of all were the direct weekly reports to the Division of Preventive Medicine by base surgeons, a system instituted early in 1943o The health of United States forces in a theater of operations is inevitably associated with that of the civilian and other military populations of the country where it is located* The office of the Chief Surgeon kept abreast of disease trends in the United Kingdom by means of the weekly reports on infectious diseases furnished by the British Ministry of Health, and through the reports of the British war office* Medical Records in Continental Europe *—The many months in the United Kingdom had led to a situation whereby a very satisfactory system of medical records had eventuated* Information came readily to hand, sufficient for the needs of most epidemiologic problems* When operations started on the continent, conditions were materially different. The relatively static sort of existence no longer held* The conditions that presented were those of active military operations, with field armies largely concerned, and with most of the troops on the move* Reliable medical records were much more difficult to obtain, and their assembly and tabulation infinitely more complicated* The probability of such a situation had been appreciated in the preliminary planning for continental operations* Discussions were held early in 1944 between the two divisions concerned, those of preventive medicine and of medical records, with the purpose of determining the minimal requirements for sound epidemiologic practice, and to eliminate all non-essential information* To facilitate the program, the Medical Records Division sent a small detachment to the continent in August 1944, while the main part of the division remained in the United Kingdom* The first con- solidated reports furnished by the detachment were as of 7 September 1944« event will explain a number of the tabulations to follow, in that satisfactory records of continental experience in many instances date from these reports* 6 In the course of continental operations, epidemiologic data were derived from several sources of information* Principal reliance was placed on the weekly consolidations of the Statistical Health Report, WIMD Form 86 ab, 24 January 1944» All infectious disease from units, treated as such in quarters or in hospital was reported on this form* Knowledge of hospital cases also came from Form 310 MDETO, a report peculiar to the European theater* Total cases of a given communicable disease were obtained by the summation of data from these two sources* MDETO Form 323, a report used only by field armies, was of great advantage in epidemic situations involving the ground forces* (Fig* 2) It served in a particularly useful capacity during the outbreak of trenchfoot in November and December of 1944o Special information related to contact tracing, as a measure in venereal disease control, was obtained through MDETO Form 302, a report designed to fill that particular need* Unusual outbreaks of epidemic disease, or the occurrence of uncommon and particularly serious infections were reported by telephone or tele- gram by base sections of the communications zone, by armies and by air forces* Information concerning communicable disease in the French Ministry of Health after the occupation of Paris in September, 1944* At best, the data were fragmentary and unreliable* The French reporting system had been disrupted and the chaotic state of comraunications introduced other difficulties* More valuable information on the state of civilian health was ordinarily obtained from the special reports and the regular monthly summaries issued by the Public Health Section of G-5, SHAEF* Through early contact with the Office International d'Hygiene Publique, information became regularly available about communicable diseases in French ports, and internationally from countries with which that agency continued in contact* Pertinent information on outbreaks of disease in enemy territory and in forward areas under our control was often furnished bv Gk-2 staff sections of armies, through interrogation of prisoners pf war* Medical Records for Epidemiologic Use\—The system of medical records in the U0 S„ Army was designed \o meet a variety of needs. The present comments relate only to the use they were, put in the conduct of epidemiologic affairs in the control of the com- municable diseases, and the extent to which they adequately served that purpose6 Principal reliance was placed on the Form 86 ab, Statistical Health Report,, That it failed to meet the complete need has been brought out by the numerous measures that were taken to supplement the information providedc The Statistical Health Report Is a consolidated report,, The main shortcoming was therefore the inability to identify an individual infection in terms of the name, unit and location of the person affected,. This was essential to case study, and case study is the principal reliance in the control of unusual or particularly serious diseases such as typhus, typhoid and many others„ 7 The delay inherent to submission of a periodic consolidated report, in this instance on a weekly basis, meant that the promptest reporting was a matter of seven to fourteen days after the event occurred. A fast moving epidemic such as influenza could reach critical height before it became evident in statistical reports. Lack of identifying data made it impossible to eliminate dup- licate reporting by unit and by hospital. Prisoners of war, allied military personnel and civilians treated in U0 S. Army hospitals often could not be separated from military personnel; with the result that the estimated current incidence of a given disease was invariably greater than fact, but to an indeterminate extent. The nature of many illnesses was first determined after ad- mission to,hospital and reported by Form 310. No indication was available in such instances as to the unit of origin of the case, which was the critical feature epidemi©logically. Serious consideration should be given to introduction into Army practice of a comprehensive system of individual case reporting. Provisional Health Data.-—Principal attention has thus far been devoted to the difficulties of theater headquarters in obtaining adequate information about health affairs in the various units of the commando These troubles were reciprocal. The existing military situ- ation and the vagaries in communications combined to make trans- mission of epidemiological information to units in the field during continental operations unreliable and unsatisfactory. A great part of the difficulty came from the fact that the Medical Records division was in qreat Britain. Cross channel communications were particularly bad. To remedy the deficiency, the Division of Preventive Medicine at theater.headquarters instituted on 1 January 1945 a brief weekly report containing essential data on disease, battle casualties and non-battle injuries. A second part of the report was devoted to epidemiologic notes arising from interests of the preceding week, and to brief interpretation of the statistical data presented. • This little mineographed bulletin, with the title, Provisional Health Data, was prepared from information submitted each week-end by the continental detachment of the medical records division. The data were those forwarded by units as of the previous week which ended Friday midnight. Effort was made to get the bulletin into the mails on Mondays, with the result that the information reaching surgeons of the theater was not more than ten days old. It was distributed informally to the surgeons of all major commands, where in some instances it was reproduced for unit distribution. The promptness of its appearance compensated for its incompleteness and its provisional nature. 8 Figure 2. Collecting Medical Records in the Field Data Included in the History of the Theater.—Practically all of the data concerned with the analyses presented in this and in subsequent sections of the history of preventive medicine in the European theater are derived from the Statistical Health Report, WEMD Form 86 ab, 24 January 1944- The tentative nature of this information and the inaccuracies it contains are recognized. It is the only information available at this time. The final data to be obtained through tabulation of WDAGO Forms 8-26 and 8-27 (Individual Medical Records) will form, when available, the authorative and final basic record. 9 FIGURES Fig, 1, Field Epidemiology in Practice, Fig, 20 Collecting Medical Records in the Field, A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 PART III - Epidemiology Section 2 - Intestinal Infections Number 1 - The Diarrheas and Dysenteries by Colonel John Ee Gordonf M0Co Chief of the Division of Preventive Medicine Office of The Chief Surgeon} ETO TABLE OF CONTENTS PART III Epidemiology Section 2 - Intestinal Infections Number 1 - The Diarrheas and Dysenteries Page Introduction • . . • . . . , , 1 Glassification of Intestinal Infections, 2 A Basis for Comparison of Experience • • • 4 The Diarrheas and Dysenteries, « * 4 Experience of the Peace-Time Army, ....... .5 Preparations for War 5 The War Years in the United States ,.••••••••••• 5 Diarrheas and Dysenteries in the Several Theaters of Operations * 6 The Experience in the European Theater, 1942 - 1945, • , . • 6 Intestinal Infection During Operations in the United Kingdom. 7 Intestinal Infection During Continental Operations 9 Racial Differences in Rates for Intestinal Infections. • • . 11 Mortality in the European Theater 11 The Wide-spread Epidemic of Diarrhea in Army Areas, Autumn of 1944, 11 Outbreaks on Troop Transports. . . . , 13 Diarrheal Disease Among Prisoners of War 17 The Common Diarrheas in ETO, 20 Classification ... ........ . 20 Modes of Transmission. , 20 Incidence ...... ........ 21 Page Sources of Infection 21 Water-Borne Common Diarrhea ••••••••••••••••• 22 Food—Borne Common Diarrhea* 24 The Dysenteries ...... 24 ■ Amebic Dysentery 25 Bacillary Dysentery 28 List of Figures List of Tables List of Epidemiologic Case Reports PART III Epidemiology Section 2 - Intestinal Infections Number 1 4 The Diarrheas and Dysenteries Despite the catastrophic results that may follow in the wake of an epidemic of influenza, or of typhus fever or cholera, "the plagues of field and camp" have come to signify more than anything else the troubles that arise from diseases associated with infection of the intestinal tract® American military history sub- stantiates this fully® No less than 1,755,889 soldiers of the American Civil War suffered from acute and chronic diarrhea and dysentery® The number who died from these causes was 46,277® The annual attack rate for white troops during the period May 1861 through June 1866, was never less than 494 per thousand per year and for 1863 it was 850 per thousand per year® The annual death rate was likewise inordinately great; in 1865, 21®29 deaths per thousand per year* The overwhelming importance of typhoid fever in the Spanish- American War served to overshadow the importance of the diarrheas and dysenteries® Nevertheless the number of patients with these condition** including gastro-enteritis, was 204,040® The admission rate to hospital was 426.0 per thousand per year and the mortality was 3.3® (Table 1) The greatly improved environmental sanitation which came with the turn of the century paid dividends in World War I® Deaths from diarrhea and dysentery were less than in any previous major conflict of which there is record® The prevailing rates showed the variations characteristic of the alternating conditions under which military operations are conducted, but a direct relation could ordinarily be established between incidence and the efficiency with which sanitary requirements were carried out® The marked improve- ment shown by this experience over all others is best demonstrated by the mortality rate for the period of World War I, which was 0®X3 per thousand per year® The gain in comparison with the Spanish- American War was overwhelmingly greater than that which the Spanish- American War showed over the Civil War® A similar ratio held for reported cases® World War II continued this trend, to the extent that only four deaths from diarrhea and dysentery of all forms were reported for troop* of the European Theater of Operations; and the mortality rate was 0*00126. Attention in subsequent discussion will be given to the identity of those particular intestinal infections exerting the greatest influence in bringing about this general improvement. The causes of decreased rates will be considered in some detail, together with the nature of the preventive measures which conceivably may lead to still greater improve- ments * Glassification of Intestinal Infections,—The consideration of the disease conditions ordinarily included within the group of in- testinal Infections will be in accordance with the separation made by the Statistical Health Report. The following are recognized: 1, Bacterial food poisoning 2, Common diarrheas 3, Dysentery, bacillary 4, Dysentery, amebic 5, Dysentery unclassified 6, Paratyphoid fever 7, Typhoid fever > ■ ' ■ ;-v ’ ‘ • '• • ' ■ . - . . *■■■■' During the first two years of operations in Europe only six categories were distinguished. Bacterial food poisoning was added when the statistical health Form 86ab of 22 August 194-0, was revised in 1944-. This term will be understood to refer to cases of abrupt onset and short duration, characterized by vomiting and diarrhea, and occurring simultaneously in groups of individuals who have all consumed the same suspected food or drink. Cases of bacterial food poisoning previous to 19UU were presumably included under common diarrhea. Undoubtedly a considerable proportion continued to be so reported, be- cause the numbers of cases listed under bacterial food poisoning in the tables to follow can by no means be considered as inclusive, based on first-hand knowledge of what actually took place * The above circumstance is illustrative of the extent to which differences in nomenclature, and styles in diagnostic terminology make difficult a satisfactory comparison of the experiences of one war or of one period of time with another. Medical criteria for diagnosis likewise change with the years. Current statistical information on typhoid fever and paratyphoid fever can be accepted as reliable, since in modern practice diagnosis depends almost universally on satisfactory identification of the specific infectious agent. The same observation applies to amebic and bacillary dysentery in United States Army practice, since identification of the responsible pathogen is by regulation requisite to these diagnoses. But these conditions have not always held, and they do not always hold now. Laboratory confirmation was commonly impossible under combat conditions, with the result that by far the greater 2 number of dysentery reported in the European Theater fell within the group designated as unclassified etiologically, The diagnosis was clinical; and cases may hare been true dysentery or they may hare been instances of severe and prolonged food poisoning or of common diarrhea* The common diarrheas include a variety of gastro-intestinal infections of unknown cause* The use of this single inclusive term is believed to have a material advantage over the practice of previous years in applying a number of inexact anatomic diagnoses to a group of diseases about which too little is known* Disease conditions designated enteritis, colitis, enterocolitis and gastro-enteritis are here classed collectively as the common diarrheas. Also included are instances of diarrhea (cause undetermined) and fermentative diarrhea, intestinal indigestion and intestinal toxemia, when associated with diarrhea* The clinical character of these conditions makes it certain that a proportion of cases included in the category of common diarrhea may well have been dysentery, and conversely that a number of cases reported as dysentery might better have been called common diarrhea, had a strict etiologic classification been possible* However, a broad distinction between the group of common diarrheas and the group of dysenteries, including those registered as unclassified, appears valid on the basis of general clinical differences* A further consideration which complicates attempted comparison of the current experience in the European theater with that of other wars, is the fact that data of this war include all patients reported as suffering from a given condition, irrespective of whether they were sick in quarters of admitted to hospital* Previous information from United States Army sources was often limited to hospital admissions* This is a consideration of little consequence in relation to typhoid fever and to a large extent with the dysenteries, since practically all patients go to hospital* The common diarrheas are wholly another matter* No worthwhile estimate can be made of the porportion of patients in the European Theater who were sick in quarters, and those who were admitted to hospital* The relation would certainly vary according t® the severity of a given outbreak* However, the present data may be exaggerated by inclusion of both hospital and quarters patients* This factor is to be considered in comparing the present experience of the European theater with that of previous wars* The general level of reporting was also undoubtedly much better. In times past, intestinal infection came to be considered as more or less a normal accompaniment of military life* With increased rarity of these conditions, an intestinal infection became a matter of more concern and soldiers were more likely to attend sick call, and to enter hospital* The improved standard of medical care contributes to the same general result. It is not to be concluded, however, that present day reporting of common intestinal complaints is by any means good. It is simply better. 3 The numbers coming to official report still represent a relatively small proportion of actual occurrence. Even if data on hospital admissions for diarrhea and dysentery were available for the European Theater, the comparison with previous experience of the United States Army would not be wholly valid, because of the very different interpretation given in the course of time as to just what was a hospital and just what constituted a hospital admission. For these several and diverse reasons comparisons of eras and even of areas at a given date must be on a broad and very general basis. No more than relative differences can be shown. A Basis for Comparison of Experience0—Comparisons of the be- havior of the intestinal infections would seemingly best be accomplished by consideration of two groups. The first and larger group will include all infections of indeterminate and undetermined cause, the common diarrheas, and it will be treated as a group. The members of the smaller group will be cbniidered individually, since they represent diseases of specific etiology and reliable clinical diagnosis. The general term of diarrheas and dysenteries will be interpreted to include all of the dysen- teries - amebic, bacillary, and unclassified - and the loosely defined aggregate of the common diarrheas. Bacterial food poisoning, which became reportable in 1944, typhoid fever and the paratyphoid fevere are not included. Using this broad generic grouping of all the diarrheas and dysenteries, the relationship between the experience of various major elements of the forces of the European Theater can be determined with relative exactness. The explanation of demonstrated differences in rates can be sought in varying epidemiologic factors. Since systems of reporting and criteria for diagnosis are fairly uniform throughout the United States Array, the differences in rates between theaters may be measured with some certainty. Such a basis of comparison is not necessarily unscientific nor illogical, considering the present situation of etiologic uncertainty for many of these diseases, and the inability under field conditions to determine specific cause where methods are available. All of these diseases are transmitted by the same general means, through ingestion of food or drink. The underlying predisposing causes and the indicated preventive measures are much the same, irrespective of differences in specific etiology of individual cases. This would not hold true in like degree in comparing experiences of American and Allied armies in the same field 6f operations because of differences in classification and variation in standards for diagnosis. The Diarrheas and Dysenteries,—The anticipated frequency of this group of diseases in military practice is measurably greater during active operations in the field than under peace-time conditions, with due consideration given to periods of maneuvers when conditions simulate those of campaigns. The nature-of the terrian, the climate, the habits of civilians within the area of operations , the level of environmental sanitationt the character of military operations, all act in determing the average level of rates for an army in the field0 An army in train- ing in the zone of the interior likewise meets a different situation than that characteristic of seasoned veteran troops in time of peace. As a basis for judging the experience of United States Army forces in the European Theater of Operations in respect to the diarrheas and dysenteries, the rates for troops stationed in the United States are set forth. They represent three different sets of circumstances5 those of the peacetime array at home, of the mobilization of an army for war, and of the training of newly inducted recruits for service abroad. Experience of the Peace-time Army,--The years immediately pre- ceding preparations for war and the war itself may be considered re- presentative of good average accomplishment for the United States Army, It is a record which compares favorably with that of any army, (Table 2) The period includes the years 1935 to 1939, and data are limited to troops stationed within the continental limits of the United States, The rates were remarkably uniform, with annual variations from 2,5 per thousand strength per annum to 3o6, and an average for the period of 3o0. Seasonal variation was consistently emphasized, with low rates in -the winter months and an increase in the spring. The maximum level was attained in summer, August being the chief month. Preparations for rapid aggregation of large numbers of untrained men, the active field training they underwent, and the participation of large units in maneuvers led to a greatly increased overall incidence of diarrhea and dysentery for the pre-war period of 194-0-1941, 13o0 cases per thousand strength per annum, (Table 3) This rate was in excess of that for domestic troops of the actual war period which was 9,5 per thousand per year. The incidence during the North Carolina maneuvers of August and September 1941 was greater by far than that for any single month of operations in Europe, The rates for these two months, 35 and 37 per thousand per annum, are to be compared with the maximum monthly rate in the European Theater of 2£, in May of 1943, The annual ratd for 1941, 15 per thousand per annum, is not far different from the year of greatest incidence in the European Theater - 17 per thousand in 1942, The troop strength in the theater was small and operations were just starting in an unfamiliar country. The War Years in the United States,--The incidence of the diarrheas and dysenteries for troops of continental United States was 5 measurably less during the war years than in the pre-war period* (Table 4) Training and reception of raw recruits continued with increased activity* The large scale maneuvers were lacking. Nevertheless, it would appear that army procedure and army methods in prevention must have stabilized, for the general rate for this period of the war was 9® 5* The usual seasonal fluctuation was evident. Some few months had an excess incidence beyond seasonal expectation, that of 26 per thousand in July 1943 being the greatest. This particular situation also suggests a relation to the un- precedented concentration in August and September of that year of a number of major outbreaks of common diarrhea on board transports bringing troops to Europe* The circumstances are described on page 23®* Of the four years included in this period the rate for 1943 was highest, a time when large number of troops were in course of train- ing and shipments to theaters of operations were frequent. Diarrheas and Dysenteries in the Several Theaterg of Operations.— In the course of the war, the United States Army extended its activities to eight different theaters of operations* They very nearly included the globe* All manner of conditions and climates were encountered* The epidemiologic factors which influenced the incidence of the diarrheas and dysenteries were so variable and so different that alaple comparison of annual rates is without value* The analysis involved itt a fair com- parison is beyond the present interest* The data for the four war years in the various theaters of operations are therefore set forth merely as an index of the relative seriousness of the intestinal infections in these several spheres of activity* (Table 5) The best rates were obtained in the Alaskan Theater, better even than for troops stationed in continental United States* The record of the European Theater was next in order* If comparison be based on troops occupying foreign territories, its record heads the list* The highest recorded rates were those holding for the Asiatic Theater* The striking and progressive improvement demonstrated by the Mediterranean and Middle East Theaters gave proof of the possibilities of preventive medicine* The Experience in the European-TheaterT 1942 - 1945o—The average annual rate for the diarrheas and dysenteries for the United States Army in Europe was 14®0 per thousand strength per annum* This was greater hy about one-half than comparable data for troops stationed in continental United States* The rate for domestic troops was 9®5 per thousand per year* The record that was established in the course of European operations constituted a creditable performance under field conditions,1 and gave evidence of the sound basic training of troops* (Table 6) 6 The lack of variation between annual rates from year to year was an outstanding feature. The rate of 17 during the first year in the United Kingdom was the highest in the history of the theater, but it was not greatly in excess of the average for the war period. The number of troops was small, conditions were unsettled and measures relating to environmental sanitation were in the course of development. The record for 1943 was excellent, almost identical with that for troops of continental United States. The increased rates that occurred when the Army took to the field in the invasion of France were considerably less than had been anticipated. The rate for 1944 was 12.7. For the first six months of 1945 it was 15.6. No outstanding difference existed between the rates experienced by troops serving in the United Kingdom base, and those which pre- sented during the very active war of movement which characterized the European campaign. Much of the credit for the favorable rates on the continent was undoubtedly due to the strict prohibition on eating in civilian establishments. The record of American troops in France in this war compared very favorably with that of the American Expeditionary Force of 1918, (Table 1) when the rate was 28.9. The difference becomes strikingly great when it is recalled that the European Theater data of 1944-45 represent all patients reporting ill, while those of the American Expeditionary Force include in the latter half of 1918 only the more seriously ill who were sent to hospital. The relatively inconsequential part which the intestinal diseases had in relation to the general disease rates for the theater is shown by the fact that the diarrheas and dysenteries were re- sponsible for only 2.6 per cent of total disease from all causes. Intestinal Infection During Operations in the United Kingdom.—■ Material differences in the frequency of intestinal infection could te demonstrated among the three major forces of the command during the period when operations were limited to the United Kingdom. The Services of Supply maintained consistently higher rates than did the Air Forces and Ground Forces, (Figure 1, Table 7). The cases which determine rates for the diarrheas and dysenteries in a military command come from two sources. The first group includes the more or less continuously appearing spor:die and isolated infections which determine the minimum static level of incidence characterizing a military population. The second increment is made up of groupings of cases constituting epidemics of varying size and accounting for the peaks in curves of incidence. The frequency and size of these outbreaks eventually determine whether the complete experience is good or bad. Under conditions existing in Great Britain sporadic intestinal upsets were to a large extent associated with eating and drinking in 7 civilian establishments. Actual outbreaks of diarrhea, on the other hand, were almost always due to faulty messing practice within the unit. The principal factors which operated in causing food-borne out- breaks were the use of left-over foods, preparation of foods too long in advance of serving, and failure to maintain minimum sanitary standards in messes. Other contributing factors influenced these major faults either singly or in combination. They were lack of refrigeration for food storage, inadequate stove space in relation to number of rations prepared, undue use of custards, puddings and creamed foods in mess planning, failure on the part of mess personnel to properly plan meals in regard to amount of food, palatability of the food that was served, and an intensive food conservation program which resulted in wide use of left-over foods. Reference to Figure 1 will show that the fewest peaks (food-borne outbreaks) occurred in the trend line that relates to the Air Forces, where in general the mess management and mess personnel were more adequate, and where less attempt was made to conserve food. The minimum static level of the curve (sporadic cases) was also low, since Air Force stations were relatively isolated and personnel had little opportunity to patronize civilian eating establishments except on pass or furlough. ,• *; i The Ground Forces had a greater number of food-borne outbreaks than did the Air Forces, some of which were of relatively large scale. This was due to all of the listed contributing factors being operative until marshalling exercises began, an actual concentration of troops in marshalling areas took place in the late spring of 1944. As a result of the special emphasis then placed on proper mess management, and the provision of more adequate mess equipment, major food-borne epidemics were largely eliminated. This is reflected in the consistently declining trend of the curve of incidence for Ground Forces after February. Although Services of Supply troops for the most part had the advantage of permanent messes, they were handicapped by a particularly intensive food conservation program and a poorer type of mess personnel. The prevention of food wastage was emphasized in Services of Supply units more than in any of the other forces. The result was that foods which had been prepared in excessive amounts were stored and served again several hours later. If refrigerated storage had been generally available, this practice would have not constituted a special hazard. In the European Theater, where refrigeration was not commonly available, the practice of saving left-over puddings, custards and creamed foods for any appreciable time, and cooked meat dishes for more than six hours, accounted for about one-half of the traceable food-borne outbreaks. ;Mess duty in units of the Services of Supply was not as attractive as in the other forces. In e Ground Force organization, mess personnel did. not engage in the more rigorous phases of training or combat, and in 8 48 8880 Intestinal Infections, Including Common Diarrheas and. Dysenteries, All Forces, and Communications Zone, United Kingdom, Rate per 1000 strength per annum by weeks, 1 January 1943 to 30 June 1944. Figure 1 the Air Force they did not have to participate in the long gruelling periods of work under pressure on the line or take part in extremely hazardous combat missions. Hence, for certain types of men, mess duty in these forces was coveted and they strived to do an excellent job. In the Services of Supply, mess duties entailed more confining work over longer hours than most other assignments, and therefore was less desirable than ward work in a hospital, office clerical work, driving, or even depot supply work. In view of this difference, it was reasonable to believe that Service of Supply mess personnel took less pride in their work and made less effort to adapt themselves, This was observed in many instances. Short cuts in mess practice were common, such as the early preparation of foods during slack periods without regard to the time of serving, and the extensive use of left-over foods parti- cularly when it was known that an admonition would be administered if excess food was discarded. The combination of these factors was reflected in the curve of diarrheal incidence in the Services of Supply, which had more peaks (food-borne outbreaks) than either of the other two forces. It was characteristic of all individual base sections. The minimum static level of the curve of incidence for all Services of Supply troops was influenced by the regularly prevailing high rates of the Central Base Section, That was due to the relatively great number of sporadic cases that occurred among troops in the London area through patronizing civilian eating and drinking establishments, intestinal Infection During Continental Operations,—The transition from a long static existence at a base of operatTbns to a condition of decidedly active operations in the field led to certain alterations in the relationship of the three components of the command in respect to the dysenteries and diarrheas, (Figure 2S Table 8) The general rates of the theater increased somewhat, but not greatly, (Table 5) The increment was due to an increased frequency of these diseases among troops serving on the continent, with contemporary rates for troops stationed in the United Kingdom remaining essentially unchanged. (Figure 3, Table 9) The Air Forces operating on the continent maintained their same relative position (Figure 1, Table 7) in respect to the two other forces, with rates that were materially lower. Air Force troops in Europe were represented principally by the Ninth Air Force, a tactical organization operating under field conditions. Although three fair sized peaks (epidemics) and a number of minor ones were introduced into the curve of incidence in the course of the year on the continent, the mini- mum static level was decidely good and the overall experience compared most favorably with the rate for continental troops as a whole during the same 9 time interval. It is likewise worthy of note that this tactical unit on the continent fared very well in comparison with troops of the Eighth Air Force who remained in Great Britain, By 194-5 the Eighth Air Force had become firmly established in fixed stations with presumably well stabilized living conditions. The mobile wandering Ninth in the course of its support of Armies, accomplished a rate that was equally good. (Figure 4, Table 10) The Ground Forces went through some of the most difficult days of the European campaign with rates for the diarrheas and dysenteries that were almost unbelievably good. The diarrheal disorders were certainly not frequent, in fact their general absence was a matter of comment. As an indication of actual incidence, the recorded rates are likely less reliable than usual, because the reporting of communicable disease in those early days of the operation was decidedly irregular. One important consideration must not be discounted. During the first part of the campaign, troops of the command were on C and K field rations, which is a first-class preventive against food-borne disease. As the diet became more com- plicated through the eventual introduction of Class B and Class A rations, the opportunities for contamination of food were'increased, and the rates for diarrheas and dysenteries were greater,, Beginning the latter part of September, a general wave of epidemic diarrhea involved most of the field Armies (See page 19). This is reflected in the progressively increased rates which reached a peak of 3B per thousand per year for all Ground Forces during the week ending 15 December. 1944* Thereafter conditions were somewhat better except that January and February saw continued high rates, in the neighborhood of 25 per thousand, during the active fighting and the war of movement which* characterized those months. With th break-Uirough nto Germany in late March, the situation was both stabilized and improved, with successive weekly rates being much the same and averaging about 13 per thousand per annum until operations ceased. With the exception of brief periods in December, January, and February, the Communications Zone rather continuously maintained the same leading position in respect to rates for the diarrheas and dysenteries that it had established in the United Kingdom, During the summer months of 1944 presumably the same influences acted as had in the case of the Ground Forces, for the record then was decidedly good. Neither the Ground Forces nor the Communications 40ne troops ever again approached such favorable levels. Only the Air Forces continued to go along on a fairly even keel. The performance of the Communications Zone was most uneven, being punctuated by repeated sharp variations in rates indicative of extensive local epidemics. The contrast with the Ground Forces was well marked. That branch of the service experienced a gradual and well-defined upward 10 Intestinal Infections, Including Common Diarrheas and Dysenteries, All Forces, Ground Forces, Air Forces, European Continent only. Rates per 1000 strength per annum by weeks, 23 June 1944 to 29 June 1945, Figure 2 Figure 3 Intestinal Infections, Including Common Diarrheas end Dysenteries, United Kingdom and Continental Kurcpe, Rates per 1000 strength per annum, by weeks, 23 June 1944 to 29 June 1945. Figure 4 Intestinal one , Including Common Diarrheas said Dysenteries, . Forces, European Continent and United Kingdom, Rates per 1000 strength per annum, by weeks, 23 June 1944 to 29 June 1945. bulge in rates during the course of heavy operations in the autumn and winter, which then was followed by a uniform leveling off to a more or less fixed experience at a commendable level, Racial Differences in Rates for Intestinal Infections„ — Throughout the course of this experience, the rates for the diarrheas and dysenteries among colored troops were consistently lower than those for white troops,, (Figure 5, Table 11) The ratio held true both in the United Kingdom and on the continent where the general rates for the theater were somewhat greater0 This was no novel experience. It had been noted for colored troops in Europe in the last war and is more or less consistently true in American military practice. Mortality in the European Theatere--Only 6 deaths from all of the diseases included within the collective group of dysenteries and diarrheas were recorded during the four years that the European theater was operational. The mortality rate per thousand was 0,00126, an infinitesimal figure in itself, and particularly so in comparison with the rates that held in previous wars. All four of the reported deaths occurred in 194-5 among troops stationed on the continent. One was due to amebic dysentery, one to bacillary dysentery and two were the result of common diarrhea. yhe Wide-spread Epidemic of Diarrhea in Army Areas. Autumn of 1944.-Vunly once in the history of the theater was there a widespread and general outbreak of diarrheal disease, with large numbers of men involved and persisting for an appreciable period of timec Common diarrhea in this military experience was a disease which in its typical epidemiologic manifestations struck irregularly, more frequently in summer than in winter, involved troops of a par- ticular unit and was rather commonly related to some well-defined precipitating event, Epidemics in a particular location or region were ordinarily short-lived. Dysentery was clinically a more severe disease and tended to occur in outbreaks still more limited in size than those of common diarrhea. The epidemic which involved troops of the Army areas in the autumn of 1944 partook of the epidemiologic characteristics of both. The epidemic first appeared among troops of the XIX Corps near Maastricht, Holland, about 1 October 1944. A similar condition existed concurrently in the civilian population of that region,, From Holland, the disease spread gradually southward. Reports of its presence were received from several units of the XIII Corps about the middle of October. It invaded troops of the First United States Army, eventually made its appearance in the Third Army, and in December was widely prevalent in the Seventh Army. (Figure 6, Table 12) 11 From the time that the Seventh Army landed in southern France, it had had a consistently higher rate for the diarrheal diseases than other armies of the theater. Ihese conditions were particularly prevalent during the march across France, A general improvement was noted in November, The recurring increased frequency in December was appreciated to be somethig new, of different clinical character from the ordinary diarrheas that had prevailed up to that time. Outbreaks in a given troop area did not appear explosively as is characteristic of food-borne or water-borne intestinal disease. Spread was more nearly by extension and as a steady progression. The incidence within a given unit was not extremely high at any one time, although the greater part of an individual organization was affected before the epidemic ran its course. The ordinary epidemiologic behavior was for the peak of incidence to build up over a period of four to eight days, and then gradually taper off during the next few weeks. For example, the general dispensary in Luxembourg which cared for a number of units in that area, had 187 patients from 1 November 1944 to 17 December 1944 with 30 the greatest number treated on any one day. Officers and men were involved alike. In its epidemiological and clinical manifestations, the outbreak resembled the situation which existed in France during World War I, where from July through September of 1918 a distinct excess incidence of diarrheal disease was reported among combat troops. In both instances the epidemic of diarrhea was an accompani- ment of the height of a campaign, when general sanitary discipline would be expected to undergo severe strain, * The usual clinical reaction was decidedly mild. Only a small pro- portion of affected persons ever reported to sick call, and relatively few required admission to hospital. The onset was fairly sudden, with abdominal cramps and ordinarily four to eight watery stools within the next 24 hours. In most instances symptoms terminated within 24 to 48 hours, a longer course being exceptional. Nausea and vomiting were rare, although anorexia was more or less constant and often persisted for several days. Blood and mucus were uniformly absent from stools. Only a small fraction of patients had fever, and rarely did it exceed 100° p, Ihe number of leukocytes was within normal limits. The above description was characteristic of the disease in areas where it appeared. In a number of places, however, coryza commonly preceded the diarrhea by about two days. This was true of the disease in the XIX Corps where the oubreak appears to have started, and seems to have been a general observation through- out the Ninth and Seventh Armies, However, the interval between coryza and onset of diarrheal symptoms was not constant. Coryza occasionally 12 Figure 5 Intestinal Infections, Including Common Diarrheas, Colored and White Troops, United Kingdom and European Continent, Rates per 1000 strength per annum, by weeks, 9 July 1943 to 29 June 1945. Intestinal Infections, Including Common Diarrheas, First, Third, Seventh and Ninth Annies. Rate per 1000 strength per annum by weeks, 9 June 1944 to 29 June 1945. Figure 6 appeared with the diarrhea and sometimes shortly afterward. It was nevertheless the opinion of medical authorities of these two organi- zations that diarrhea rarely occurred without concomitant upper respiratory manifestations0 This was not characteristic of the disease as it appeared in the Third Array, where medical officers were strongly of the opinion that upper respiratory infection was not a part of the disease syndrome. Samples of feces and rectal swabs from patients in the acute stage of the illness were examined in the course of study in the XIX Corps in October,, No pathogenic micro-organisms were isolated. No specific etiologic agent could be determined in the course of observations in Luxembourg. Bacteriologic studies in the Third Army, which were related to the more seriously ill patients of a circumscribed outbreak, yielded cultures of Flexner bacilli from samples of feces. This particular outbreak appeared definitely to have been bacillary dysentery. In other outbreaks in the Third Army, dysentery organisms were occasionally isolated but not with sufficient frequency to make certain that they were the cause of the outbreak. The increasing frequency with which dysentery bacilli were isolated from patients of the First Army as the epidemic progressed, gave evidence that this infectious agent was fairly widespread and was responsible for some of the mild infections that were then so common in that command. Of the strains isolated, eight were the Sonne variety, 14- were Flexner type, and one was type ambiguua. The bacteriologic experience of the Seventh Army was similar to that of the Third, with isolation of dysentery bacilli in about fifteen per cent of stool examinations of patients. The type distribution was varied„ (Table 13) The labora- tory making these examinations had had wide experience with this infect- ious agent when more than fifty per cent of cases in a dysentery out- break in North Africa had been confirmed bacteriologically. Bacteria of the Salmonella group were rarely encountered, so infrequently indeed as to discount any significance. Water seemed to bo a factor in only one local outbreak which occurred in the Third Array. No particular foods could be impli- cated, (Figure 7) The general epidemiologic behavior of the out- break would indicate a relation to environmental sanitation. There is good reason to believe that this was probably a collection of epidemics rather than an entity. At least some of the illnesses were mild bacillary dysentery. Outbreaks on Troop Transports,—The outbreaks of diarrheal disease that occurred on board ships bringing troops to the theater were among the most extensive in this experience. The conditions on troops transports favored such epidemics. Crowding was always great and reached extreme proportions during the autumn of 194-3 and the early 13 part of 1944, when troop strength was being built up rapidly for the coming operations in FranceMessing facilities were almost always inadequate for the number of men carried, (Figure 8) Field trained troops often found difficulty in accommodating themselves to the dis- cipline and restriction of a ship. Transport commanders and transport surgeons were frequently inexperienced, and it was furthermore not at all uncommon for a medical officer to be assigned this responsibility with little or no previous notice and with meager instruction as to his duties. Latrine and ablution facilities often left much to be desired, and the men commonly slept in shifts. This not only increased the opportunities for contact infection, but required messes to function almost continuously without proper intervals for policing, * * ‘i ' ■ ■" . •; : ' v. '• •*. . / - The inspection of ships practiced at ports of debarkation gave information on the nature and extent of the epidemics of diarrheal disease that occurred on ships and aided in determining the proba^’10 inci'l.ng factors. The control and improvement of conditions depended upon the cooperative effort of authorities in ports and staging areas of the Zone of the Interior, because that was where the necessary measures for limiting these situations had to be applied. Special reports from port authorities of the theater therefore supplemented the routine reports of surgeons. The absence of laboratories aboard ships capable of dealing with epidemics of the’ size that occurred led to the result that the specific agent in these outbreaks was in no*instance determined. At least one was suggestive x>f bacillary dysentery because of a re- crudescence of diarrheal attacks shortly after the troops disembarked in Britain, with identification of the Sonne type of Shigella para- dysenteriae. The clinical course, and the fact that only a single death occurred among thousands of cases suggested that most infections were of the type of common diarrhea. Minor difficulties had been encountered from time to time in the course of troops movements by sea, but the first major epidemic of intestinal infection involved the USAT Argentina which arrived at Glasgow on 4 September 1943. In fact, this was the largest single outbreak of diarrheal disease in the history of the European theater. The Argentina had sailed from New York shortly after the middle of August with 6,153 Negro troops aboard, together with the usual complement of officers and ship’s company, and the naval gun crew. The ship was grossly overcrowded. Only three medical officers were included in the troop movement. Sleeping accommodation was .such that soldiers slept in shifts, and since the shifts were rotated the three messes were further overloaded by reason of a succession of meals. The inherent potentialities for an outbreak of intestinal 14 Figure 7 An Army Mess under canvas, 95th Evacuation Hospital, Epinal, France, November 1944. Figure 8 Messing on board a Troop Transport, November 1942. disease were early recognized by the transport surgeon* In his first report to the transport commander he described the inade- quacies in bathing and toilet facilities, the multiple sanitary deficiencies in galleys, pantries and the troop mess, and’the lack of proper facilities for washing and sterilization of mess equipment. During the night of 29 August 1943, some 400 patients were treated for acute diarrhea at the ship’s hospital and dispensary. Three subsequent waves of infection occurred during the course of the next week and the number of patients approximated 3,000. The epidemic involved enlisted passengers, officer passengers and the permanent personnel of the ship. In addition to the estimated 3,000 patients who reported for treatment many more mild infections were known to have existed. The attack rate was estimated to have been well in excess of half the ship’s population. One soldier died of acute intestinal infection. The specific infectious agent involved in the epidemic was never determined. Bacteriologic examination of stools from some of the more seriously ill patients who were removed to hospitals after the ship docked, failed to demonstrate any of the pathogenic bacteria commonly involved in such epidemics. The port physician, reporting his observations made on boarding the ship shortly after her arrival, had this to say* "The first impression was of gross overcrowding; the second, of filth and dirt everywhere. A long queue of soldiers waited outside the door of the dispensary, some so weak they had to sit or lie on the deck. The epidemic of dysentery had begun four days out of New York. All galleys, including that of the Navy gun crew and the civilian crew were in a deplorable state of sanitation. The main troop galley was the worst of the lot. The supposedly clean kitchen utensils had dirt, grease, and decaying food stuck to them. The stoves and tables were very dirty with old burnt grease and decayed food particles. The garbage disposal was extremely unsanitary. Garbage cans were coated with decaying organic matter and had not been washed for a long time. They were piled helter-skelter in a corner of the kitchen and their contents were spilled all over the deck. The troops were messing in the main mess hall. Half-eaten food was thrown over the tables and floor. In fact, the floor was so covered with waste food that one had to be careful not to slip and fall. The garbage cans just outside the main mess hall were tiie most nauseating scene I have seen on board a ship. Half a dozen soldiers were standing in garbage two to three inches deep around five or six garbage cans filled to over- flowing with uneaten food. Sterilization and washing of trays was unsatisfactory. There was not enough soap in the water and the water was not hot enough to really clean the 15 trays in the very brief period that they were immersed. Inspection of the rest of the ship — troop quarters, decks, and latrines — revealed conditions just as un- sanitary as in the kitchens. The troop quarters reeked with vomitus and diarrheal fecal latter from those who were ill and could not find a place in the latrines to relieve themselves. The latrines themselves'were beyond description. I can truly say that I have never seen a United States Transport in such deplorable sanitary condition.w The Argentina epidemic was by no means an isolated experience during the month of September 1943. Records were at hand of sanitary con- ditions on all transports arriving in the United Kingdom from 1 January 1943 to 1 October 1943. Only one serious ou break of diarrhea had occurred prior to that month., There were four in September, The USAT Shawnee arrived at Bristol 15 September 1943 with report of an outbreak of 362 cases of diarrhea. The epidemic had first'become manifest on 9 September 1943. It lasted two days, and had completely subsided by the time the ship docked. This transport carried 1,843 military personnel. The history of the outbreak was particularly significant, and the con- trol measures that were put into effect gave evidence of good epidemio- logic sense. An investigation by the transport surgeon showed that the cooks, bakers and butchers of the permanent ship’s personnel ate their food in the galley and had remained unaffected throughout the voyage. This kd to the conclusion that the food was contaminated somewhere be- tween the galley and the mess room. An inspection showed no evident contamination of food. It developed, however, that the kitchen police of the 2190-S Task Force had been relieved by men of the 2190-K Task Force on 9 September 1943, No diarrhea had been reported up to that time. The epidemic began on the 10th of September, the day after 2190-K took over. It was thereby deduced that.a bacterial carrier probably existed among the personnel of that detachment of kitchen police. Clinical histories and physical examination directed suspicion to three members as having had diarrheal disturbances. The whole of the kitchen police of 2190-K were relieved of duty, the old detail of 2190-S was put back to, work, and no further difficulties occurred duflng the remainder of the voyage, A third major outbreak, on board the USAT Cristobalrwas con- sidered to have been due to the fact that only 200 compartment steel trays were available to serve approximately 3,000 troops, while the rate of feeding was from 700 to 900 per hour. The opportunity for proper washing and sterilization of the trays was lacking, and the facilities that were provided were also unsatisfactory. The fourth outbreak in September involved the transport Capetown Castle. An epidonic of 170 cases of diarrhea developed the third day out, with 20 cases reported the following day. The epidemic 16 was thought to be due to an inadequate system for washing mess gear. The outbreak was brought under control when chlorine was added to the final rinse water. This grouping of epidemics within a period of a few weeks served to center attention on the need for added precautions, if freedom from epidemics of common diarrhea was to be insured on board transports. The military situation happily permitted a lesser degree of crowding. Measures were instituted at ports of embarkation to remedy the specific efficiencies brought out by these experiences, with the result that no serious difficulties were encountered throughout the rest of the year. The continued survey of health reports of trans- ports showed only eight instances of excess incidence of diarrhea to have occurred in the course of 378 overseas troop movements to the theater from 1 January 1944 to 10 June 1944. Only three were of any moment and none was of outstanding seriousness until the eastward voyage of the HMT Nieuw Amsterdam in early June. The aid of authori- ties in the Zone of the Interior was again sought. The approaching summer season made repetition of such occurrences more likely, and the existing military situation required more than ever that troops arriving in the theater be in a good state of health and morale. Only one serious epidemic of common diarrhea on board a trans- port was noted thereafter. The SS Mariposa brought 9,326 troops into Liverpool on 13 August 1944. Diarrhea had broken out among the men on the second day of the voyage. It reached a peak on the fourth day, when some 2,300 patients were treated at the dispensary. The total number of persons involved was in excess of 2,000, exclud- ing those who failed to report at sick call'. Clinically, the illness was not severe, although 200 or more patients wore still under treat- ment several days after arrival at their station in Britain. The ship was greatly overcrowded and messing facilities were taxed beyond the limit of their capacity. ,, Diarrheal Disease Among Prisoners of War.y-The really serious pi encount ered Ijy the United States AnS|y in Europe in respect to the diarrheas and dysenteries had to do with prisoners of war. The conditions surrounding prisoners were not those of soldiers in the line. Demoralization was prevalent, and discipline had relaxed in marked degree. This was not characteristic of the enemy soldier alone, for it was noted also with oUr own soldiers recovered from German prisoner of war camps. It was a part of the prisoner of war complex. Add to that the extensive crowding that followed when prisoners of war were herded into cages, the deficiencies in sanitation, the inadequacies ip messing, and the limited housing; and the groundwork was laid for diarrheal disease. The rates for prisoners of war that existed during the early months of the campaign and through the winter were strikingly high 17 in comparison with the experience of soldiers of the American Army. They were essentially ten times as great. (Table 14) The situtation did not, however, get out of hand and for prisoners of war was about what was to be expected. The policy of not retaining prisoners on the continent for any appreciable length of time during the early months of operations was an important factor in determining this relatively favorable situation. The reasons were operational. The matter of security was a consideration, since it was not good to have large numbers of prisoners in our immediate rear. It was wasteful of combat troops to use appreciable numbers in guard duty. Conse- quently prisoners of war were rather promptly evacuated to the United Kingdom or to the Zone of the Interior. Diarrheal disease in the European theater was essentially a problem of prisoner of war en- closures on the continent. It did not enter into serious consideration in the camps of the United Kingdom, nor of the Zone of the Interior. The changing form of operations was constantly reflected in the varying rates for diarrhea and dysentery among prisoners of war. When operations were active, when the numbers of prisoners taken were great, when the care that could be devoted bebame less, when over- crowding was increased, then the rates for diarrheal disease were up. Table 14 illustrates these fluctuations. Beginning in early autumn, con- siderable numbers of prisoners were held for labor and other duties on the continent. The rates for diarrhea were relatively great for September and October. They improved somewhat and then reached a high point in December, in connection with the Battle of the Bulge. Thereafter, a steady improvement took place until a very respectable rate of 75 was reached in April. The deluge came with the end of the war in the first week of Mcy. The breakup of Germany and its armies is an old story now; how everything seemed to tumble like a house of cards once it started. The debacle overwhelmed many services of the A*my in the early days of May, other than those having to do with the care of prisoners of war. Geman soldiers surrendered by armies; hundreds of thousands within days. (Figure 9) The facilities provided for receiving prisoners of war.were wholly insufficient. One camp, built originally to house 30,000 men, had to take care of. 170,000. The enclosures for prisoners of war met their name. They were cages and little more. So great were the numbers that scarcely more than a pretext of proper care could be provided. Water supplies were alright as far as they went, but the anount of water available per man was hopelessly small. Messing equipment did not begin to go around and thousands ate out of tin cans discarded from the ration. Facilities for sterilizing kitchen equipment and mess gear were greatly overtaxed. Some cages were so crowded that the men scarcely had room to lie down and they slept in pup tents, improvised shelters,- fox holes or in the open. The approaching warm weather led to an increase of flies, but never to the extent that would have existed without the aid of DDT spray. 18 Figure 9 Prisoner of War cage in Rheinburg, Germany, March 1945 The situation was further aggravated in areas where some of the most crowded cages were located by a series of unprecedented rains which turned the enclosures into a morass and the prisoners into shivering wretches. Dysentery was inevitable. The first days of May showed huge numbers of cases. Tt was wholly a camp disease, for the conditions surrounding a whipped army had come into play and large numbers of prisoners arrived at the enclosures already suffering with intestinal disease. The condi- tions there favored its ready spread. In some of the larger camps more than a hundred cases were frequently reported in a single day. As many as two or three thousand would be suffering from dysentery at a given time. The problem that faced officers of the line and medical of- ficers at prisoner of war enclosures was so great as to appear almost unsolvable. Typhus was prevalent throughout the region, and the work of delousing was alone a stupendous task. Messing arrangements had to be improvised from little or nothing. Hospitals were moved in to take care of the seriously ill patients, water supplies were en- hanced, and latrine and ablution facilities enlarged. Order was brought out of what was little better than milling chaos. Those days appear rather abstract, as these brief details are set down well in the backwash of a war that is over. They had to be lived, in order to appreciate what the Armies in the field faced at that time with an avalanche of prisoners of war that seemed to pour in endlessly. l/Vhat was accomplished in the week that followed the end of hostilities was no less than remarkable. By the middle of May the situation was under control in most enclosures, and the end of the month saw a most decided improvement. But the rate for the diarrheas and dysenteries that month of May touched 735 per thousand strength per year, and the bulk of it occurred in the first two weeks. The rate for June was half the May figure, and conditions settled down thereafter to about the level that had characterized previous experience. The toll in lives was relatively great. Complete data in respect to deaths are not yet available, but for the prisoner of war camps under the Jurisdiction of Advance Section, Communications Zone, information is available for 403,142 prisoners. There are 833 deaths from diarrhea and dysentery during the six weeks period from 1 May 1945 to 15 June 1945. The greater part of this outbreak was certainly bacillary dysentery. Various strains of Flexner type organisms were isolated from patients, although the examinations represented but a sample of the unusually large number of cases that occurred. The clinical nature of thq disease as observed would also indicate that the great pro- portion of cases were bacillary dysentery; and this is corroberated by the appreciable case fatality. To one who has. seen a good many kinds of epidemics in a good many kinds of places, few situations will measure up to an outbreak of bacillary dysentery. Typhus some- times will, but it tends to occur in the colder months and the smells is not so bad. The squalor and misery of a dysentery epidemic are rarely equaled, Experiences such as those just described for prisoners of war ard the huge outbreaks that occurred on board transports are perhaps good for the soul, although scarcely comforting to the spirit. It is easy to become complacent about the diarrheas and the dystenteries when annual rates of 16 characterize the experience of an army in the field in a decidedly active campaign. It is easy to lose respect for a group of diseases when it is necespary to search through four years of experience to find four deaths. These examples of what can happen when modern sanitary practice is relaxed, serve to justify the stress placed on environmental hygiene in military practice, even to the extent of its becoming almost religion. It pays dividends. The Common Diarrheas in ETO.—The very nixed group of in- fections included within the collective term of the common diarrheas have the common characteristics of sudden onset, brief duration, well evidenced symptoms of diarrhea, a varying degree of abdominal pain and tenesmus, rapid recovery and essentially no death rate. Such excep- tion in respect to deaths as are recorded likely represent failure to recognize some more serious intestinal infection, for exanple, bacillary dysentery. Epidemiologically, they are characterized by groupings of cases related to a particular event and ordinarily coincide with a high attack rate in a given population group. The specific infectious agents, for assuredly this is a mix- ture of diseases, remain unknown. The former tendency to place con- siderable stress on dietary indiscretions as a causative factor seems less'and loss warranted. These conditions give every evidence of being infectious diseases. There is close correlation of their epidemio- logic behavior with that of known specific intestinal infections. The same rigidly applied sanitary discipline acts in reducing the incidence of all intestinal disease, known specific infections and these others as well. (Figure 10) Classification.—A change in the army system of classifica- tion instituted in January of 1944, served to separate food poiBoning as a reportable condition distinct from the common diarrheas. Food poisoning in previous years had been included presumably within the group of common diarrheas. It is certain that a great proportion of food poisoning after 1944 was still so recorded. For purposes of determining a continued trend, the two categories had best be com- bined. Modes of Transmission.—The means of transmission involved in a given outbreak of common diarrhea often remained wholly undeter- mined. Foods were commonly concerned, with contamination taking place either in the course of preparation or during storage of the prepared food. The role of carriers among food handlers received full considera- tion. Reports from the field stressed repeatedly the relationship of those intestinal infections to upper respiratory disease. There is every reason to believe that foods can be contaminated with the 20 Figure 10 Early Sanitary Construction in Normandy, July 1944. discharge from the upper respiratory tract and give rise to food poison- ing. There is no precise evidence to support the existence of an epidemic diarrheal disease of the nature of intestinal influenza, of presumed virus etiology and clinically presenting associated symptoms of the upper respiratory and intestinal tracts. Many outbreaks were attributed to contaminated water. Some few could be established as water-borne. Flies undoubtedly had a part in transmission, although in this experience a relatively small part0 Incidence.—The common diarrheas constitute far and away the great bulk of the intestinal infections. The distributions by year and by month for the European theater are presented in Table 15, Comparison of these data with those of Table 6 shows the annual rates to coincide closely with the annual rates for the general group of diarrheas and dysenteries, since the common diarrheas are the dominant factor in that aggregation. The anticipated seasonal variations were not always evident. The influence of active military operations can be repeatedly demonstrated to bring about an increased frequency of these conditions, of such force as to override in im- portance the expected normal seasonal fluctuation. Operation TORCH was mounted in September, 1942, The rates for the common diarrheas in the succeeding three autumn months, until the task force finally left England in November, were, much greater than in mid-summer. The great ' concentrate on of troops in southern England in preparation for the in- vasion of Normandy led to a nonseasonal increase in rates in the spring of 1944, despite the intense effort placed on mess sanitation in the staging areas. The low rates at the beginning of continental operations did not correspond with predictions. It would appear that attention to such minor distractions as the common diarrheas gave way to more serious interests and that reporting was below par. Furthermore, the time that was required to establish satisfactory facilities for recording disease incidence on the continent, made all records other than those of battle casualties indefinite and un- satisfactory at that time. The November offensive of 1944 and particu- larly the Battle of the Bulge was associated with materially increased rates. This situation held through January and February 1945, with mid-winter showing some of the' highest rates in the history of the theater. The slackening of the bitter winter warfare brought improved performance despite warmer weather and conditions ordinarily favoring increased rather than decreased rates. Sources of Infection.--A sudden outbreak of diarrheal disease involving a considerable proportion of a command almost invariably leads the inexperienced observer to suspect the water supply. The cause is far more likely to reside in food. This may come about through spoilage of the ingredients of food, through contamination in the course of preparation, or through inadequacies in serving or of the utensils in which food is served. 21 A fairly satisfactory idea of the sources of infection for the common diarrheas is derived from an analysis of 70 epidemics re- ported in the European theater during operations in England. These outbreaks occurred within the period January to October, 1943, in- clusive. The interpretations as to source of infection and probable cause were derived in most part from the reports of unit surgeons, although not infrequently they came from epidemiologic studies by preventive medicine officers-of one or other of the major commands. Some reports were forwarded by unit surgeons, because of a special interest in the problem. Many came to hand through the monthly sanitazy reports. Special investigations were sometimes made as a result of inquiry by the Chief Surgecn, because of unusual numbers of reported cases of some peculiarity in the attendant circumstances. The epidemics included in the series are believed representative of military experience in the European theater. All the outstanding epidemics within the stated time are included, and the series represents approximately two thirds of the recorded outbreaks. Five epidemics occurred among troops on board transports coming to the United Kingdom, two were in American Red Cross clubs, and the remainder involved troop units. Of the total 70 epidemics, 32 were ascribed to contaminated foods, 7 to unsatisfactory water supplies, and 13 to various unsanitary conditions in messes, including inadequate facilities for washing mess gear. The causative factor in 18 out- breaks was frankly stated to be unknown. A second similar review of experience for troops serving on the continent during the active campaign, recorded experience for the period 1 September 1944 to 31 December 1944. The distribution of sources of infection, based on epidemiologic study of 84 out- breaks, attributed 35 to food, 6 to contaminated water, and 15 to unsatisfactory mess conditions» The number remaining wholly inde- terminate as to cause was 28. . ' Water-Bprne Common Diarrhea.—As a general rule, the out- breaks that were attributed to polluted water involved a large propor- tion of the affected military population, were almost invariably of sudden onset, and ended promptly. Some unusual circumstance associ- ated with the, water supply was a regular incident in the history. The reports of the epidemics that follow are illustrative of this relatively rare type of outbreak of common diarrhea. EPIDEMIOLOGIC CASE REPORT NO. 1 - A battalion of the 347th Engineer General Service Regiment was engaged in the construction of a large camp in Great Britain. Water was derived at first from the nearby community supply. The permanent supply for the camp was to be from a river for which a filtration and chlorination plant was under construction. Due to a misunderstanding, the water for the new source was turned on before the purification plant was properly working. This resulted in raw water flowing through the 22 pipes of the distribution system,, As luck would have it, lemonade was served that day in the mess halls and was made with this water. Water from this source was turned on for only a few hours during the morning of 26 September 1943, but samples of the water from the distribution system taken the following morning were shown by subsequent laboratory exami- nation to be heavily contaminated with colon bacilli. Prompt use of chlorination through Xyster bags served to limit the outbreak. Bacteriologic examination of feces from patients with diarrhea failed to identify a specific microorganisn. The outbreak was limited essentially to troops in the 2nd Battalion of the regiment, with a strength approximating 900 men. On 27 September 1943, 31 persons reported to sick call with complaints of malaise, nausea, intestinal cramps, vomiting or frequent stools. All patients were afebrile. The following day 102 men of the battalion reported sick; and on 29 September 1943, the number was 29 (Figure 11), These numbers by no means represented the total attack rate, for the unit surgeon reported that essentially one-half of the men of his command suffered similar ccmplaints, although not of sufficient seriousness to warrant report at sick call. The course of the disease was short, with recovery of most patients within 24 to 36 hours. It is Of note that a similar outbreak occurred among men of a single company of British engineers working in the same area. The first illnesses were likewise noted on 26 September 1943. EPIDEMIOLOGIC CASE REPORT NO. 2 - A particular communal Site B of the 127th AAF Station suffered serious contamination when flow of sewage was obstructed through failure of a sewage pump. The epidemic of diarrhea that followed was limited to troops of that site. The drinking water was found to be non- potable by laboratory examination. That from other sites of the post was of good quality. A meticulous investigation of the food served at messes eliminated that possible source of infection. The epidemic ceased promptly with institution of emergency treatment measures. EPIDEMIOLOGIC CASE REPORT NO. 3 - More than a fourth of the command of the 2nd Chemical Mortar Battalion were affected by a sharp outbreak of intestinal infection when they moved into an area in France and drew their water from a French water point. The water was proved non-potable, and evidence of previous chlorination was lacking. The epidemic ceased with institution of proper chlorination. Because of the epidemiological considerations governing out- breaks of common diarrhea due to water, they most often involve Engineer construction units, combat troops in the field, and other similar units making use of emergency and untested water supplies. They occurred more frequently on the continent than in Great Britain, 23 |foocL Borne Common Diarrhea,--The distinction between food-borne common diarrhea and food poisoning is more or less artificial Classi- fication in one category or the other depended as a rule on the inclina- tion of the unit surgeon reporting the circumstance« If a pathogenic bacterium commonly associated with food poisoning was identified by examination of the food or of the discharges of patients, it was common practice to report the outbreak as one of food poisoning. If no pathogenic micro-organism was isolated, the epidemic was more likely tb be recorded as one of common diarrhea. Traditional practice also had a decided influence in determining the decision. Common diarrhea is an old accepted term. The newer terminology of food poisoning was less familiar and implied to some medical officers more careflil study and detection of causes than had perhaps been accomplished. Nevertheless, the same epidemiologic influences operate. Although transmission of infection by food was responsible for more outbreaks of common diarrhea than probably all other agencies combined, dis- cussion of the several mechanisms and of the contributing conditions will be reserved for the subsequent section concerned with food poisoning. The Dysenteries,—The Greeks gave the -name to the diarrheas and the dysenteries but an old sergeant in the Pacific Theater had his own way of differentiating these two conditions. In his briefing of recruits making their first trip to tropical regions, he explained its r,If you've got the GI’s, that’s diarrhea; and if the GI's have got you, that's dysentery”. The dysenteries are the more serious condition. The death hate is greater and the period of disability longer. Of the total 44,479 cases of diarrhea and dysentery reported in the European Theater during four years, (Table 6) 3,529 were dysentery or 7,9$, Two principle forms of dysentery were distinguished, the one protozoal, the other bacterial in origin. For purposes of classification they were recorded as amebic dysentery and bacillary dysentery. Army Regulations required that the specific infectious agent be isolated and identified if a patient with symptoms suggestive of intestinal infection was to be classed as suffering from either bacillary or amebic dysentery. If clinical criteria were alone the basis of diagnosis, the condition was called dysentery, unclassified. The result was that the greater proportion of dysenteries fell unto the unclassified group. The bacillary dysenteries were the next largest and the amebic dysenteries were third. (Table 16) Most bacillary dysentery occurred under conditions of active campaigning, which has been characteristic of dysentery in armies in many wars. The conditions for satisfactory identification by labora- tory examination were scarcely favorable. Stool specimens were delayed on the way to the laboratory and most of the patients had been ill for several days before reaching a hospital at which bacteriologic 24 CASES Figure 11 Epidemic of Water-Borne Common Diarrhea: , 347th Engineer Regiment, United Kingdom, September 1943. work could be initiated. The result was that the disease was called dysentery unclassified or put in the category of the common diarrheas, largely dependent upon the severity of the clinical state. The infectious agent of amebic dysentery is fairly easy to recognize. The patient need not be in the same early stage of the disease, nor the stool recently passed. As a technical procedure, the demonstration of E. histolytica is simpler than the identification of the dysentery bacillus, particularly if type determination is included. Carriers of the araebae producing dysentery were found to be numerous in the American military population. Undoubtedly a number of insecure diagnoses of amebic dysentery came from demonstration of amebic cysts in stools of patients with enteric symptoms but actually suffering frcm bacillary dysentery. These several considerations led to the belief that the number of cases of bacillary dysentery presented in Table 1G was materially understated, that the number of amebic dysentery was not far from fact and if anything overstated, and that most of the patients listed as having suffered from dysentery un- classified, in reality were representative of the bacillary form of the disease. The dysenteries are proverbially diseases of greatest incidence in the summer months and yet that conclusion is difficult to sub- stantiate by inspection of Table 17. The few scattered cases in Great Britain in 1942 fall into that pattern, but those of 1943 do not. The principal frequency was during the muter months of January, February, and December. Relatively little dysentery occurred that summer. Because a great part of the American troops were in France during the latter half of 1944, all normal bases of comparison were disturbed. Dysentery under ordinary circumstances is more prevalent on the continent than in the United Kingdom. It was regularly so in the experience of the United States Army during this war, The rates for the dysenteries increased appreciably during the summer of 1944,' ‘ but the last quarter of the year had far and away the greatest number of cases. This was attributed more to an increased opportunity for exposure than to seasonal influence. r ' • Amebic irequency ol amebic dysenxery during the first two years of thtTsuropean Theater cannot be determined, since differentiation of types was not made available in statistical reports. The dysenteries as a group were never prevalent in Great Britain (Table 17) and that held especially true for amebic dysentery (Table 18). Civilian health information likewise indicated no common prevalence of the condition. The distribution of cases by months for 1944 and 1945 shows as a significant feature a loading toward the ’ end of 1944, with one-half of the cases for the year concentrated in the final three months• Rates increased decidedly after the invasion of 25 France, an experience which continued through 1945 when rates were measurably higher than in the preceding year. The maximum rate for any one month was 0.4 per thousand per annum. The clinical manifestations of amebic dysentery, as observed in this experience, presented no unusual features. The greater pro- portion of patients had been previously stationed in the Mediterranean Theater. The clinical history in many instances showed that the di- sease recognized during service in Europe was actually a relapse of a previous infection. Several small outbreaks occurred among personnel of hospital units previously stationed in Africa. The origin of the first infection was not always apparent. In addition, a goodly number of chronic amebic dysentery infections were recognized among soldiers who had previously not been resident outside continental United States. The following is illustrative:- EPIDEMIOLOGIC CASE REPORT NO. 4 - An officer of the 79th General Hospital, stationed in North Ireland experienced indefinite symptoms of tiredness and listlessnoss for several months, unaccompanied by loss of weight. Mild episodes of diarrhea had been noted in November 1943, and in April, 1944. The past history included an attacjc of dysentery in New Orleans in the spring of 1938, said to have been amebic; and another one year later, thought then to have been bacillary. Specimens of feces taken at the time of a proctoscopic examina- tion, 2 June 1944, revealed numerous cysts and trophozoites of E. histolytica. Histories of the sporadic amebic infections reported during the time troops were stationed in Great Britain were so commonly indicative of relapsing chronic infection that it was believed re- latively little endemic infection existed in the population of the British Isles. Studies failed to reveal a single instance of in- fection resulting from eating fresh fruits and vegetables. This evidence was corroborated through information furnished by British health authorities and through examination of feces from civilians. The incidence of amebic cysts was decidedly low. However, several general surveys of American military populations showed a high level of infestation, in one instance 19% in a. division coming directly from the United states. Similar examinations made by the 1st Medical Laboratory attached to the Seventh Arny on the continent, showed a relatively high incidence among men of that command who had served with the organization in the Mediterranean Theater. The frequency of amebic infestation among French civilians was aid to be low. 26 Greater numbers of cases of amebic dysentery were reported on the continent, compared with the previous experience in Britain. The proportion that were newly acquired, and the number representative of relapse, is unknown. Distinction was not made in medical reports. It is known that the three divisions of infantry that came from the Mediterranean Theater had relatively high carrier rates for E. histo- lytica. This is presumptive evidence that many of the reported in- stances were actually chronic infections. It is reasonable to be- lieve, however, that a far greater number of newly acquired infections were encountered in France than in Great Britain. The typical epidemiologic behavior of amebic dysentery is one of long continued appearance of sporadic cases. Groupings of cases in outspoken epidemics are rare although reported, the Chicago out- break during the Worlds Fair being the classical example. Only once in the history of the theater did consideration of an extended and widespread* outbreak of amebic dysentery come into consideration. EPIDEMIOLOGIC CASE REPORT NQ. 5 - The Fifth Infantry Division had served in Iceland from April1942 until August 1943, when it was transferred to England, and subsequently, October 1943, to North Ireland. No outstanding outbreak of diarrhea had occurred in the history of the division until the disease appeared in December 1943 among men of the ar- tillery camp at Mourne Park, North Ireland. The camp includ- ed the 19th Field Artillery Battalion, the 46th Field Artillery Battalion and the 50th Field Artillery Battalion with a total strength of about 2,200 men. Each battalion had a mess for enlisted men, while a single consolidated mess served all officers. The distribution of diarrhea was universal, A small outbreak of 21 cases involved the 46th Field Artillery Battalion the week ending 10 December 1943. The following week there were 4 cases, the next week 15. The 50th Field Artillery Battalion had 11 cases the week ending 31 December 1943. Subsequent numbers are reflected in Table 19, The difficulties that continued through.January and into April were also universal distribution. During the first two months a series of small outbreaks involved one or other of the battalions and sometimes all three. In mid-March the number of reported cases increased decisively, with all three battalions involved. The cases of Table 19 represent patients reporting for treatment. Attending surgeons estimated that in some instances as many as half the coumand wore affected. Two officers became ill with diarrheal disturbance about 5 March 1944. Examination of their stools showed cysts and motile forms of ©ntameba histolytica. Both officers had eaten away from the organization mess on a number of occasions. Twelve enlisted men with diarrheas at this same time, gave no evidence of amebae nor did stool cultures reveal significant bacterial agents. The recognition 27 of the two cases of amebic dysentery among officers of the unit led to a survey in late March of 1944 of all food handlers in the various messes* Single stool examinations of 162 men - showed 18*5% positive for E. histolytica cysts* One specimen contained a Salmonella, Group C* Shortly thereafter, a second series of examinations by another laboratory, selecting men of the unit without relation to occupation and at random, served to demonstrate a frequency of cysts in the same proportion, 19 percent* ■ .v The water supply at the camp had been demonstrated to be non-potable at the time these units arrived* Throughout the period at the camp all three units had been ordered to use water from lyster bags. Ihe character of the outbreak of diarrhea had repeatedly directed attention to the water supply. Frequent examinations showed the water from the Lyster bags to be potable, while that from the camp source continued to be non-potable* The messes of the camp had certain deficiencies that might conceivably have been responsible for some of the minor outbreaks, but scarcely for the continued prevalence of diarrhea in the amount that existed* The civilian health authorities of the region reported the neighboring population as having much the same experience with diarrhea* Other near- by camps with different water supplies were having no trouble* A central chlorinating plant was eventually put into operation on 3 April 1944* The number of reported cases decreased to such an extent that for the first 14 days of April only 26 were reported for all three organizations, essentially the level of endemic prevalence of common diarrheas to be anticipated in similar regions. All carriers of entamebio cysts among food handlers had been relieved from that duty* The frequency (18.5;%) of E* histolytica cyst carriers in this unit as shown by survey was greater than for American civilian popu- lations generally. However, a survey of troops from a division in England showed a comparable rate of 16*1 percent* The two cases of confirmed amebic dysentery were not related apparently to the out- breaks of common diarrhea in the camp* Water would appear to have been the most probable cause through non-observance of the prescribed water discipline in the. face of a known non-potable supply* Diarrhea decreased markedly following installation of a central chlorinating plant, and a technic of purification which would not have freed water from viable amebic cysts. The frequency of fallacious interpretation of individual cases of diarrhea due to other cause, by reason of find- ing cysts of E* histolytica in the stools, was a matter of repeated experience in the course of fcjedical operations in this theater* This is an Instance of similar erroneous reasoning in respect to an epidemic* Bacillary Dysentery* bacillary dysenteries were the largest element in the general group of dysenteric infections* Of the total 3,529 oases of dysentery of all forms 1,054 were determined to be bacillary 28 dysentery, in the proportion of 30 percent# In ©"VI probability most of the infections listed as dysentery, unclassified, were also of the bacillary type, which together would represent 70 percent of the whole# The distribution of bacillary dysentery by months (Table 80) shows the same irregularity that characterized amebic dysentery. More than 45% of all cases of bacillary dysentery of 1944 were concentrated in the last quarter of the year# The rates that were established then were maintained in 1945, and not until May was there a measurable improvement. The influence of an active campaign Is well brought out, Mienever troops move, whenever established sanitary disciplines are interrupted, the likelihood of a developing outbreak of dysentery is increased. The repeated and extensive outbreaks of diarrheal disease on transports bringing troops to Britain have been described. At least one was in all probability due to the dysentery bacillusj others may well have been. The following circumstance is in point: EPIDEMIOLOGIC CASS REPORT NO, 6 - A shipment of a thousand men arrived at a staging area in England 12 January 1943, directly from the transport which brought them to Europe. No previous outbreak of diarrhea had occurred at the camp to which they reported, nor had dysentery ever been recognized there. After their arrival, the troops were restricted to the camp area. On 24 January 1943, nine days after disembarking, the infectious agent involved in a case of acute intestinal infection was confirmed bacteriologically as shigella paradysentery, -variety sonneio In the course of the next three weeks 54 clinically similar cases were recognized, of which 19 were confirmed bacteriologically as due to the Sonne dysentery bacillus. Epidemiologic in- quiry gave information that one man had had an acute diarrhea aboard ship, so mild that he had not reported sick and had recovered within three days. The camp epidemic was believed to have started on board ship. Outbreaks were common under such circumstances. The same sanitary deficiencies so many times characteristic of transports were known to have existed in this instance. Dysentery had not been present among these men in the camps where they were stationed in the United States, An examination of 36 food handlers made shortly after the epidemic began, demonstrated one to be a carrier of dysentery bacilli of the Sonne type. He was considered the immediate source of the epidemic in the staging area. The outbreak throughout its course was limited to the group in which it started. Many similar instances associated with troop movements were recorded in the history of dysenteric disease during operations on the continent. A unit would move in a shuttle operation across country. 29 and find accommodations in an abandoned building, or bivouac in some isolated field. Sanitary facilities were lacking, the hour was late, provisions for sleeping and cooking were often extemporized, and it was little wonder that the inevitable breaches in good sanitary practice were followed by outbreaks of dysentery. No extensive outbreak of bacillary dysentery is included in the list of confirmed epidemics of this disease which, came to the attention of the theater epidemiologic service. The largest in- volved 183 patients at Camp Northway in the Ashchurch Garrison Area in England. The causative agent was a dysentery bacillus of the Flexner type. Most recorded outbreaks were of decidedly lesser extent, usually with less than 50 persons involved. Many confirmed cases represented sporadic infections or small groupings of three or four cases, rather than outspoken epidemics. Compared with the common diarrheas, more of the frank epidemics could be traced to food handlers, perhaps because of the greater definiteness of the infectious agent and the better available bacteriologio methods, (Figure 12) One outbreak of food handler origin established a permanent place in the dysenteric annals of the theater, not so much because of any unique epidemiologic feature but because of the site this particular Sonne strain chose to invade. EPIDEMIOLOGIC CASE REPORT NO. 7 - The headquarters mess of the Services of Supply at Cheltenham, Ehgland, housed about 40 ranking officers of the theater. The attendants were mainly British civilians. An outbreak of diarrheal disease among the domestic staff began about 1 February 1943 and ultimately in- volved 15 persons, three of whom were resident officers. Bacteri- ologic examination of the stools of 11 food handlers revealed 2 carriers of Shigella paradysentery sonne. Removal of the carriers served to terminate the outbreak. A goodly proportion of outbreaks wore transmitted through the agency of food, in much the same proportion as were epidemics of the common diarrheas. An example of such a localized experience is that of 23 officers and nurses of the First Medical General Labora- tory who developed dysentery due to bacilli of type Boyd 1Q3, as the result of contaminated tomato juice served at breakfast 10 March 1945. Only one epidemic was traced to water with certainty and curiously enough a Sonne type of shigella was stated to have been isolated from the water, an uncommon accomplishment. Several of the recognized types of Shigella were isolated in the course of investigations of various outbreaks of dysentery. The 30 Figure 12 Preparation of salmon croquets in a mess, England, December 1942 Sonne variety was determined most frequently among epidemics in Great Britain. That was also true for outbreaks on the continent, although to a lesser extfant. Other identified types included the Flexner strains, Boyd 103, and type ambiguua. The Shiga dysentery bacillus was not known to have been demonstrated in any outbreak of this series, although the limited laboratory facilities in many instances permitted no more than species differentiation. % y The mortality from bacillary dysentery was exceedingly low, 0.0003 per thousand per annum, with only one death, this occurring in June 1945. For dysentery of all forms, there were 43 deaths among American troops serving in Europe in the previous war. In World War II there were two. 31 Table 1 Admissions and Deaths for Diarrheas and Dysenteries Including Gastroenteritis ' With rates per 1000 per annum in Certain Major Wars of the United States Ue S. Wars 1 Time Cases Deaths Number Hate Nuraber Rate Civil War May 1861- July 1865 1,755, 389a 741,2 46,277b 18,0 Spanish-Araerican 1898-1901 204,040d 426o0 1, 59 5b 3.3 World-War I In Europe (excluding Russia) April 1917- Dec. 1919 48, 202° 28 o9 20 8b 0.13 World-War II in Europe (excluding Iceland) Feb. 1942- June 1945 44,479 14o0 5 0.00157 a. Admissions to field medical installations and all deathso bo All deaths, c0 Hospital admissions only after 15 June 1918o do Hospital and quarters admissionso Source: Division of Medical Statistics, Office War Department, Washington, Do Go of The Surgeon General, Month ■ Total 1935 1936 1937 1938 1939 Cases Rate Gases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 102 2.0 12 1.6 18 2.0 19 1.5 23 2.1 30 2.9 February 63 1*3 7 0.9 9 0.8 12 1.2 20 1.9 15 1.5 March 130 205 22 2.4 14 1.5 15 1*5 52 5.0 27 - 2.1 April 81 lo6 17 2.3 9 1.0 8 0.8 28 2.2 19 1.8 May 90 lo 7 16 2.1 14 1.3 14 1.1 22 2.1 24 2.3 June 136 206 18 2.0 16 1.7 38 3.7 27 2.6 37 2.8 July 200 3.7 14 1.8 16 1.7 51 4.1 39 3 o 0 80 7.3 August 334 6.3 52 5.1 81 7.1 119 12. 40 3.8 42 3.9 September 254 4.6 56 6.6 54 5.7 41 4.0 50 3.8 53 3.9 October 188 3.4 19 2.2 84 7.1 17 1.3 33 3.2 35 3.0 November 186 3.5 16 1.5 10 1.0 104 10. 23 2.2 33 2.7 December 121 2.0 13 1.5 11 1*1 51 4.0 17 1.3 29 1.8 Total 1885 3.0 262 2.5 336 2.8 489 3.6 374 2.8 424 2.9 Source: Division of Medical Statistics, Office of Wn.sKlrifr'fcon, D„ The Surgeon General, War Department, Intestinal Infections Including Common Diarrhea and Dysentery (All Types) Peace Time Army in Continental United States Number of cases and rates per 1000 strength per annum, by months 1935 - 1939 Inclusive Table 2 Table 3 Intestinal Infections Including Common Diarrhea and Dysentery (All Types) Pre-War Army, Compulsory Military Service, in Continental United States Number of cases and rates per 1000 strength per annum, by months 1940 - 1941 Inclusive Month Total 1940 1941 Cases Hate Cases Rate Cases Rate January 156 2o 3 15 lol 141 2,6 February 165 2o 3 18 lo2 145 2,5 March 255 2o9 47 2o6 208 2,9 April 195 2o0 9 0o6 186 2,2 May 447 3o5 27 lo6 420 3,8 June 2212 20 o3 61 4o2 2151 22 o 8 July 1494 13o0 28 lo7 1466 14,6 August 4664 30 oO 205 8o2 4459 34,5 September 3984 32o0 146 605 3838 37,4 October 2207 14o0 185 6ol 2022 15,7 November 1837 12ol 847 19 o 4 990 9 o 2 December 824 5o8 286 7 06 538 5,1 Total 18438 13o0 1874 7 o0 16564 14,5 Source* Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D, Co Table 4 Intestinal Infections Including Common Diarrhea and Dysentery (All Types) War Time Army in Continental United States Number of cases and rates per 1000 strength per annum, by months January 1942 - June 1945 Inclusive Month To- bal 1942 li )43 IS 44 1945 Cases Rate Cases Rate Cases Sate 'Cases Hate Cases Sate January 7772 6o7 663 4o7 2187 5ol 3296 9 o0 1626 7 oO February 7384 6o8 601 4o6 1848 5o0 3220 9 cl 1715 7o7 March 7265 509 526 3o6 1961 5o 1 3120 7o3 1658 6,2 April 7522 6o3 509 3o2 3627 7o3 2131 6o4 1255 5o8 May 8485 7 o3 915 4o3 3767 9 c3 2436 7 o5 1367 6o2 June 15415 12ol 1340 7ol 7433 1802 4611 1106 2031 7 ,1 July 19960 18o8 3003 12ol 13235 26 o 2 3722 12ol August 13018 14o2 2126 10 o0 7664 19 o0 3228 03 o o r-t September 12371 12o5 3133 13o8 5542 13o9 3696 10 o 2 October 10295 9o6 2803 9 o 1 4761 9 07 2731 10o0 November 7134 708 1841 6o7 3274 8o6 2019 7 08 December 8159 7o6 1614 5o5 4212 7 o0 2333 7o6 Total L24780 9 o 5 19074 705 59511 llo6 36543 9 o2 9652 6,7 Source: Divi sion oJ [* Medic al Stati sties. Office o f The £ Surgeon CS sneral War Department, Washington, D » Co The Diarrheas and Dysenteries8 Troops of the United States Army in Theaters of Operations and in Continental United States Cases and Rates per 1000 Strength per Annum, by Monthss January 19U2 to June 19^5 i Theater Total 1942 19^3 1944 191*5 Cases j Eate j 1 Cases 1 Hate | Cases Eate Cases j Hate Gases' Hate Total Army ’ 464292 j 22 j34320 11 X65is£] 25 ri690i5 “j 23 1 95771 25 United States | 10 190 s 595111 12 365U3 9 9772 Overseas 339392 42 15246 30 IO5675 | 66 132472 38 85999 35 ■ China-Burma- India 1*7976 144 699 123 6706 146 28850 I 181 11721 97 Africa-Middle East 17370 133 112^ 196 9069 170 5^27 115 1750 73 Southwest Pacific 88842 74 59 13627 70 to7io 55 40540 io4 Mediterranean 9S762 73 719 57006 132 35798 54 5239 22 Pacific Ocean Area 33001 32 i 496s 34 12580 43 10949 28 4504 22 Latin America 6g6j 20 « 2146 21 2557 21 11*77 17 687 18 European 444?9 l4 1240 17 3082 12 18720 13 214^7 j 16 Alaska 1415 5 240 5 890 8 248 3 37 2 North America 680 4 Lilts 4 158 2 293 7 84 5 Source? Division of M« Washington, D sdical Statistics, Offi C, ce of Th< s Surgeon General , War De' partment, Table 5 Month Total 19^2 19U- 195+5+ 19^5 Cases Rate |Cases Rate Cases Rate Cases Rate Cases Rate January 16,2 1 l6l iM ' 777 12.6 3U1I 17. u February 5096 IT o9 6 19.5 136 16,1 7^7 10.6 5+207 20.5+ March U594 12.2 9 11.5+ 86 10.5+ 1085+ 10,5 3U15 12.9 April 5+685 1U.5 0 0 82 7.8 1221 13.1 3382 !5o5 May 5+835+ lU,5 3 1.5+ 260 27.6 1112 11.1 3U59 15.6 June 5+580 11-3 31 S.7 68 5.6 918 7.2 3563 i3o5 July 1183 8.8 5+1+ 6„9 185 9.7 95b 8.8 August 1506 9-7 93 10.6 198 10 0 2 1215 9.6 September 2632 13.2 31* 2U0 8 2jk 11.7 20UU 12.5 October 2627 13.6 5+27 25.5 518 lUol 1682 12.1 November 2599 12.7 21*+ 19.2 311 7.6 2075+ 13.6 December 579>* 19 0 3 99 10.6 803 12.3 5+892 21.6 Total UUU79 1U0O ! 12U0 -I1*Sl. 7082 I!. 7 18720 12.7 21^37 15.6 Sources Division of Medical Statistics Department, Washington, D. C,, Office of The Surgeon General, War Table 6 Intestinal Infections * Including Common Diarrheas and Dysenteries (All Types) United States Army, European Theater of Operations Cases and rates per 1000 strength per annum, by months February 19*+2 - June Inclusive Intestinal infections, Including Common Diarrheas and Dysenteries (All Types) All Forces, Air Forces, Ground Forces and Communications Zone, United Kingdom ✓ Rate per 1000 strength per annum, by weeks 1 January 1943 to 30 June 1944 Table 7 Week Ending ait E Forces 0 T o 0o Services of Supply Air Forces Ground Forces 1 January 1943 8 9 3 5 8 January 1943 9 8 10 6 15 January 1943 10 16 5 6 22 January 1943 13 20 7 17 29 January 1943 12 25 4 3 5 February 1943 12 20 6 14 12 February 1943 9 17 3 6 19 February 1943 9 13 7 6 26 February 1943 9 9 9 8 5 March 1943 8 * * ♦ 12 March 1943 10 12 2 20 19 March 1943 7 12 1 3 26 March 1943 8 14 1 9 2 April 1943 6 5 0 2 9 April 1943 8 12 5 6 16 April 1943 11 16 5 6 23 April 1943 10 19 4 3 30 April 1943 5 9 0 0 7 May 1943 36 76 6 6 14 May 1943 23 49 5 8 21 May 1943 5 9 2 0 28 May 1943 5 11 2 0 4 June 1943 6 10 5 0 11 June 1943 5 11 2 0 18 June 1943 6 11 5 0 25 June 1943 3 4 1 17 2 July 1943 6 * ★ * 9 July 1943 7 7 9 3 16 July 1943 7 12 2 7 23 July 1943 10 22 3 3 30 July 1943 14 20 10 0 6 August 1943 11 24 2 7 13 August 1943 7 16 1 6 20 August 1943 5 7 1 19 27 August 1943 8 17 4 0 3 September 1943 19 12 10 86 10 September 1943 12 24 6 4 17 September 1943 13 16 4 31 24 September 1943 8 9 5 15 Table 7 Cont’do Intestinal Infections, Including Common Diarrheas and Dysenteries (All Types) AH Forces, Air Forces, Ground Forces and Communications Zone, United Kingdom Rate per 1000 strength per annum, by weeks 1 January 1943 to 30 June 1944 Week Ending All Forces EoToOo Services of Supply Air Forces Ground Forces 1 October 1943 11 18 4 14 8 October 1943 15 ♦ * 53 15 October 1943 5 5 3 10 22 October 1943 6 6 5 7 29 October 1943 5 8 3 2 5 November 1943 7 12 3 3 12 November 1943 5 8 4 4 19 November 1943 8 6 3 20 26 November 1943 10 20 3 8 3 December 1943 7 5 3 13 10 December 1943 10 8 9 15 17 December 1943 10 10 12 7 24 December 1943 15 8 8 31 31 December 1943 8 10 6 9 7 January 1944 17 28 12 8 14 January 1944 10 10 11 10 21 January 1944 8 8 7 7 28 'anuary 1944 15 14 5 28 4 February 1944 18 11 11 5 11 February 1944 11 3 21 4 18 February 1944 10 10 6 5 25 February 1944 10 7 8 7 3 March 1944 16 16 13 6 10 March 1944 10 6 14 4 17 March 1944 11 9 10 6 24 March 1944 8 5 9 7 31 March 1944 7 5 9 2 7 April 1944 12 21 8 12 14 April 1944 26 17 11 5 21 April 1944 14 21 6 3 28 April 1944 16 10 7 2 5 May 1944 10 3 5 3 12 May 1944 14 18 9 10 19 May. 1944 11 20 10 3 26 May 1944 11 14 15 2 2 June 1944 8 11 5 2 9 June 1944 6 5 5 5 16 June 1944 9 10 6 12 23 June 1944 7 6 8 6 30 June 1944 6 3 . 6 3 * Data not available Source: Medical Records Division, Office of the Chief Surgec m9 European Theater of 3perations o Week Continental Ground Air Com® Week Continental Ground v Air Com® Ending ETO Forces Forces Zone ETO Forces Forces Zone 23 June 1944 ♦ 9 * 29 Dec 1944 20 19 20 50 30 June 1944 ♦ 12 > * * 5 Jan 1945 20 18 6 30 7 July 1944 ★ 7 * * 12 Jan 1945 19 23 6 17 14 July 1944 * 4 * 11 19 Jan 1945 19 22 6 • 19 21 July 1944 ♦ 5 * 1 26 Jan 1945 20 21 3 20 28 July 1944 * 5 * 2 2 Feb 1945 20 23 *2 XJ 17 4 Aug 1944 * 3 * 5 9 Feb 1945 30 31 7 25 11 Aug 1944 9 4 * 1 16 Feb 1945 24 26 6 13 18 Aug 1944 16 3 * 10 23 Feb 1945 22 27 C XJ 25 25 Aug 1944 . 16 4 * 8 2 Mar 1945 15 21 5 14 1 Sep 1944 17 7 * 11 9 Mar 1945 17 16 13 10 8 Sep 1944 11 7 * * 22 16 Mar 1945 17 19 6 10 15 Sep 1944 11 8 * 13 23 Mar 1945 14 12 6 15 22 Sep 1944 10 15 14 10 30 Mar 1945 13 10 4 10 29 Sep 1944 18 10 11 25 6 Apr 1945 16 9 5 12 6 Oct 1944 14 12 6 13 13 Apr 1945 17 11 5 12 13 Oct 1944 18 14 8 16 • 20 Apr 1945 21 12 6 12 20 Oct 1944 14 13 8 15 . 27 Apr 1945 15 10 6 18 27 Oct 1944 14 11 12 15 4 May 1945 13 8 * 3 10 3 Nov 1944 17 11 4 29 11 May 1945 19 12 2 25 10 Nov 1944 15 10 9 18 18 May 1945 17 17 7 20 . 17 Nov 1944 17 15 9 24 25 May 1945 19 15 7 21 24 Nov 1944 16 20 17 1.3 1 June 1945 15 14 5 11 1 Dec 1944 22 30 8 11 8 June 1945 16 18 8 13 8 Dec 1944 29 33 72 13 15 June 1945 * 13 10 2 12 15 Dec 1944 31 38 11 22 22 June 1945 17 11 11 21 22 Dec 1944 21 19 7 21 29 June 1945 19 12 10 25 ★ Data not available® Source? Medical Records Division*, Office of the C Jhief Surgeon*, European Theater of Operations® Intestinal Infectionss Including Common Diarrheas and Dysenteries (All Types) All Forces* Ground Forces* Air Forces and Communications Zone* European Continent Only . Rates per thousand strength per annum* by weeks 23 June 1944 - 29 June 1945 Table 8 Table 9 Intestinal Infections, Including Common Diarrheas and Dysenteries (All types) United Kingdom and Continental Europe Hates per thousand strength per annum, by weeks 23 June 1944 - 29 June 1945 Week United Continental Week United Continental Ending Kingdom Europe iSnding Kingdom Europe 23 June 1944 7 ♦ 29 Dec 1944 10 20 30 June 1944 6 * 5 Jan 1945 14 20 7 July 1944 4 . ♦ 12 Jan 1945 7 19 14 July 1944 12 ♦ 19 Jan 1945 5 19 21 July 1944 10 * 26 Jan 1945 7 20 28 July 1944 9 ♦ 2 Feb 1945 7 20 4 Aug 1944 10 ♦ 9 Feb 1945 11 30 11 Aug 1944 10 9 16 Feb 1945 6 24 18 Aug 1944 18 16 23 Feb 1945 27 22 25 Aug 1944 11 16 2 Mar 1945 4 15 1 Sep 1944 18 17 9 Mar 1945 5 17 8 Sep 1944 12 11 16 Mar 1945 24 17 15 Sep 1944 6 11 23 Mar 1945 5 14 22 Sep 1944 11 10 30 Mar 1945 3 13 29 Sep 1944 6 18 6 Apr 1945 6 16 6 Oct 1944 4 14 13 Apr 1945 36 17 13 Oct 1944 8 18 20 Apr 1945 4 21 20 Oct 1944 3 14 i 27 Apr 1945 4 15 27 Oct 1944 11 14 j 4 May 1945 3 13 3 Nov 1944 3 17 1 11 May 1945 3 19 10 Nov 1944 3 15 ; 18 May 1945 6 17 17 Nov 1944 6 17 { 25 May 1945 3 19 24 Nov 1944 5 16 , 1 June 1945 4 15 1 Deo 1944 16 22 | 8 June 1945 4 16 8 Deo 1944 9 29 i 15 June 1945 3 13 15 Dec 1944 19 31 22 June 1945 4 17 22 Dec 1944 11 21 29 June 1945 3 19 ♦Data not available0 . Sources Medical Records Division, Office of the Chief Surgeon, European Theater of Operations0 Table 10 Intestinal Infections* Including Common Diarrheas and Dysenteries (All types) Air Forces* U'o So Army, European Continent and United Kingdom Rates per thousand strength per annum, by weeks 23 June 1944 - 29 June 1945 Weak United Continental Week United Continental Ending Kingdom Europe Ending Kingdom Europe 23 June 1944 8 * 29 Dec 1944 8 20 30 June 1944 6 * 5 Jan 1945 4 6 7 July 1944 4 * 12 Jan 1945 6 6 14 July 1944 8 ♦ 19 Jan 1945 6 6 21 July 1944 4 ♦ 26 Jan 1945 7 3 28 July 1944 7 * 2 Feb 1945 7 3 4 Aug 1944 4 ♦ 9 Feb 1945 14 7 11 Aug 1944 14 * 16 Feb 1945 5 6 18 Aug 1944 13 * 23 Feb 1945 12 5 25 Aug 1944 2 * 2 Mar 1945 5 5 1 Sep 1944 17 * * 9 Mar 1945- 4 13 8 Sep 1944 15 * 16 Mar 1945 6 6 15 Sep 1944 6 ♦ 23 Mar 1945 5 6 22 Sep 1944 9 14 30 Mar 1945 4 4 29 Sep 1944 8 11 6 Apr 1945 5 5 6 Oct 19 44 3 6 13 Apr 1945 4 5 13 Oct 1944 4 8 20 Apr 1945 4 6 20 Oct 1944 5 8 27 Apr 1945 4 6 27 Oct 1944 2 12 4 May 1945 5 3 3 Nov 1944 3 4 11 May 1945 2 2 10 Nov 1944 4 9 18 May 1945 4 7 17 Nov 1944 6 9 25 May 1945 3 7 24 Nov 1944 5 17 1 June 1945 5 5 1 Dec 1944 6 8 8 June 1945 5 8 8 Dec 1944 17 72 ! 15 June 1945 2 2 15 Dec 1944 6 11 22 June 1945 5 11 22 Dec 1944 9 ' 7 29 June 19 45 4 10 ♦Bata not avallable0 Sources Medical Records Division* Office of the Chief Surgeon 9 European Theater of 0perationso Intestinal Infections, Including Common Diarrheas and Dysen- teries (All Types) White and Colored Troops, United Kingdom and European Continent Rates per 1000 strength per annum, by weeks 9 July 1943 to 29 June 1945 Table 11 United Kingdom European Continent Week Ending White Colored Week Ending White Colored 9 July 1943 8 0 1 September 1944 19 2 16 July 1943 7 0 8 September 1944 12 2 23 July 1943 10 5 15 September 1944 12 4 30 July 1943 14 0 22 September 1944 11 4 6 August 1943 12 0 29 September 1944 18 24 13 August 1945 7 6 6 October 1944 15 6 20 August 1943 5 7 13 October 1944 19 7 27 August 1943 9 6 20 October 1944 15 4 3 September 1943 20 6 27 October 1944 15 3 10 September 1943 10 36 3 November 1944 18 7 17 September 1943 13 7 10 November 1944 16 6 24 September 1943 8 2 17 November 1944 19 4 1 October 1943 12 2 24 November 1944 18 5 8 October 1943 * ♦ 1 December 1944 23 6 15 October 1943 6 0 8 December 1944 32 4 22 October 1943 7 6 15 December 1944 33 9 29 October 1943 5 3 22 December 1944 22 10 5 November 1943 6 16 29 December 1944 18 42 12 November 1943 6 1 5 January 1945 20 20 19 November 1943 8 4 12 January 1945 20 8 26 November 1943 11 3 19 January 1945 20 ' 13 3 December 1943 6 0 26 January 1945 22 8 10 December 1943 11 0 2 February 1946 21 7 17 Decamber 1943 11 0 9 February 1945 32 10 24 December 1943 16 0 16 February 1945 24 20 31 December 1943 9 3 23 February 1945 23 12 7 January 1944 18 3 2 March 1945 ♦ ♦ 14 January 1944 11 3 9 March 1945 18 4 21 January 1944 8 3 16 March 1946 18 4 28 January 1944 16 0 23 March 1945 15 5 4 February 1944 19 2 30 March 1945 14 5 11 February 1944 11 6 6 April 1945 17 5 18 February 1944 11 3 13 April 1945 18 3 25 February 1944 10 4 20 April 1945 22 7 3 March 1944 16 3 27 April 1945 16 9 Table 11 Cont’do Intestinal Infections, Including Common Diarrheas and Dysen- teries (All Types) White and Colored Troops, United Kingdom and European Continent Rates per 1000 strength per annum, by weeks 9 July 1943 to 29 June 1945 United Kingdom European Cont inent Week Ending White Colored ?/eek Ending White Colored 10 March 1944 10 5 4 May 1945 ★ ♦ 17 March 1944 11 6 11 May 1945 20 13 24 March 1944 8 4 18 May 1945 18 9 31 March 1944 7 3 2 b May 1945 20 7 7 April 1944 13 4 1 June 1945 15 9 14 April 1944 27 7 8 June 1945 17 7 21 April 1944 14 4 15 June 1945 14 4 28 April 1944 17 3 22 June 1945 17 19 5 May 1944 10 4 29 June 1945 20 7 12 May 1944 14 1 19 May 1944 12 1 26 May 1944 12 2 2 June 1944 9 0 9 June 1944 6 2 16 June 1944 8 13 23 June 1944 7 8 30 June 1944 6 1 ♦Data not availableo Source »: Medical Records Division, Office of the Chief Surgeon, European Theater of Operations * Week First Third Seventh Ninth Week First Third 1 Seventh Ninth Ending Army Army Army Army Ending Army Army Army Army Entered 9 June 1944 Combat 22 Dec 1944 13 20 54 3 16 June 1944 8 29 Dec 1944 13 15 39 5 23 June 1944 5 5 Jan 1945 11 15 35 9 30 June 1944 5 12 Jan 1945 30 16 35 11 7 July 1944 4 19 Jan 1945 26 20 28 8 14 July 1944 5 26 Jan 1945 44 22 32 6 21 July 1944 6 Entered 2 Feb 1945 16 23 41 7 28 July 1944 4 Combat 9 Feb 1945 26 50 37 14 4 Aug 1944 5 2 Entered 16 Feb 1945 25 39 29 11 11 Aug 1944 12 4 Combat 23 Feb 1945 13 49 34 11 18 Aug 1944 15 4 29* Ehtered 2 Mar 1945 16 29 20 15 25 Aug 1944 7 7 39 Combat 9 Mar 1945 11 32 20 6 1 Sep 1944 10 6 54 16 Mar 1945 14 23 16 10 8 Sep 1944 6 7 77 1 23 Mar 1945 15 8 19 9 15 Sep 1944 9 5 50 9 30 Mar 1945 7 6 14 6 22 Sep 1944 16 11 55 6 6 Apr 1945 9 7 14 5 29 Sep 1944 17 7 64 9 13 Apr 1945 10 7 29 13 6 Oct 1944 21 6 65 6 20 Apr 1945 10 7 16 10 13 Oct 1944 20 10 55 3 27 Apr 1945 12 6 14 8 20 Oct 1944 13 7 61 7 4 May 1945 15 6 23 6 27 Oct 1944 13 11 71 9 11 May 1945 6 6 27 " 5 3 Nov 1944 12 8 60 16 18 May 1945 Relieved 9 48 10 10 Nov 1944 12 13 41 5 25 May 1945 15 33 7 17 Nov 1944 14 11 35 5 1 June 1945 8 40 6 24 Nov 1944 20 23 31 12 8 June 1945 8 57 6 1 Dec 1944 26 43 51 13 15 June 1945 15 6 Relieved 8 Dec 1944 23 29 48 3 22 June 1945 11 11 15 Dec 1944 19 26 65 4 29 June 1945 13 11 Southern France 15 August 1944 u inder MTOUSA Commands Assigned ETOUSA 1 November 1944<, j* - ~ "---=••= —■■ m ’—- « f' Operations, j^j Intestinal Infections* Including Common Diarrheas and Dysenteries (All Types) First* Third* Seventh and Ninth Armies* European Theater of Operations Rates per thousand strength per annum by weeks 9 June 1944 - 29 June 1945 Table 12 Table 13 Serologic Types of Dysentery Bacilli from Stool Examinations of 187 Patients Seventh Uc S, Army December 1944 FI exner I 1 Flexner II 4 FIexner IV 2 Flexner V 9 FIexner VI 1 Boyd 274 1 S. ambigua 4 Sonne _2 Total 24 Source: Annual Report of Medical Depart- ment Activities, Seventh Amy, 1944o Table 14 Diarrhea's and Dysenteries Prisoners of War European Theater of Operations, Continent Only Cases and rates per 1000 strength per annum, by months September 1944 to June 1945 I Month Cases Rate 1944 September 360 145o3 October 1,070 18405 November 2,215 142o3 December 2,367 185o4 1945 January 1,923 120*6 February 2,198 123o3 March 3,066 101o8 April 4,713 7406 May 80,952 734<>6 June 60,978 326 o 9 Total 159,842 34902 Source: Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operations0 Month. Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 3979 14,8 122 11,1 721 11,7 3136 16,0 February 4710 16,5 6 19,5 87 10,3 712 10,1 3905 19,0 March 4163 11,0 9 11,4 80 9,7 994 9,6 3080 11,6 April 4219 13,1 0 0 80 7,6 1174 12,6 2965 13,5 May 4518 13,5 3 1,4 258 27,3 1074 10,7 3183 14,4 June 4288 10,6 31 8,7 64 - 5,3 839 6,6 3354 12,7 July 1060 7,9 44 6,9 170 8,9 846 7,8 August 1383 8,9 82 9,3 187 9,7 1114 8,8 September 2363 11.8 295 23,3 270 11,6 1798 11,0 October 2482 120 9 423 25,3 505 13,8 1554 11,2 November 2379 11.6 185 16,6 303 7,4 1891 12,4 December 5406 18.0 94 10,1 764 11.7 4548 20,1 Total 40950 12,9 1172 16,1 2890 10,9 17265 11,7 19623 14,3 Source; Division o Department f Medical Statistics* Office of The Surgeon General* * Washington, D„ C, War The Common Diarrheas The European Theater of Operations*, UQ So Army Cases and rates 1000 strength per annum*, by months February- 1942 - June 1945 Inclusive Table 15 Type Total 1942* 1943* 1944 1945 Cases Rate Cases Rate Cases Rate Gases Rate Cases Rate Dysentery* bacillary 1054 04 500 ©3 554 <>4 Dysentery* amebic 780 o3 336 0o2 444 ' o3 Dysentery* unclassified 1435 o 5 619 o4 816 ®6 Total 3529 1*1 68 09 192 o 7 1455 loO 1814 lo3 ♦Types not recorded* Source: Division of Medical Statistics* Department* Washington* Dc C0 Office of The Surgeon General* War The Dysenteries The European Theater of Operations, U0 So Army Cases and tes per 1000 per annum, by types February 1942 «= June 1945 Inclusive Table 16 Month Total 1942 1943 19^ 14 1945 Cases Rate Cases Rate Cases Rate Cases Rate V Gases Rate J anuary 370 1,4 39 3,6 56 ,9 275 1,4 February 386 1,4 ■ 49 5,8 35 ,5 302 1,4 March 431 lol 6 ,7 90 ,9 335 1,3 April 466 1,4 2 ,2 47 ,5 417 2,0 May 316 ,9 ■>= V 2 ,2 38 ,4 276 1,2 June 392 ,7 ~ 4 ,3 79 ,6 209 ,8 July 123 ,9 = 15 ,8 108 1,0 August 123 * 8 11 1,3 11, ,6 101 ,8 September 269 1,3 19 1,5 4- ,2 246 1,5 October 145 ,8 4 ,2 13 ,4 128 ,9 November 220 1,1 29 2,6 8 ,2 183 1,2 December 388 1,3 5 ,5 39 ,6 344 1,5 Total 3529 1,1 68 ,9 192 ,7 1455 1,0 1814 1,3 Source: Medical Si ,atistics Divisio n, Offic ,e of T1 t-* w crc CD )n Generg l1p War I )epartm( mt* Washington* D, C, The Dysenteries, All Forms Hie European Theater of Operations, U„ So Army Cases and rates per 1000 strength per annum, by months February 1942 = June 1945 Table 17 Table 18 Amebic Dysentery The European Theater of Operations, Uo So Army Cases and rates per 1000 strength per annum, by months January 1944 - June 1945* Month Total 1944 1945 Cases Rato Cases Rate Cases Rate January 86 0o3 14 0.2 72 0.4 February 92 Oo 3 6 Ool 86 0o4 March 119 0o3 17 Oo 2 102 0.4 April 85 0o3 21 0.2 64 Oc 3 May 76 0.2 19 0o2 57 Oo 3 June 109 0o3 46 0.4 63 0o2 July 18 0.2 18 Oo 2 August 13 Ool 13 Ool September 17 Ool 17 Ool October 41 Oo 3 41 0o3 November 27 0.2 27 0c2 December 97 0o4 97 0.4 Total 780 0o3 336 Oo 2 444 Oo 3 ♦Types not recorded until January 1944. Source: Medical Statistics Division, Office of The Surgeon General, War Department , Washington, D. C 0 Table 19 Epidemic Diarrhea in the 5th Infantry Division 19th, 46th, and 50th Field Artillery Battalions 1944 1 Week Ending Total 46th FA 50th FA 3,9 th FA January 7 32 23 5 4 14 55 25 15 15 21 30 18 4 8 28 20 7 6 7 February 4 14 5 6 3 11 23 4 2 17 18 18 4 2 12 25 13 10 0 3 March 3 11 3 2 6 10 53 15 21 17 17 161 39 50 72 24 52 10 12 30 31 31 10 9 12 April 7 14 2 2 10 14 16 5 2 9 Total 543 180 138 225 Source: Division of Preventive Medicine, Office of The Chief Surgeon, ETO o Table 20 Bacillary Dysentery The European Theater of Operations, Uo S0 Army Cases and rates per 1000 strength per annum, by months January 1944 - June 1945* Month Total 1944 1945 Cases Rate Cases Rate Cases Rate January 113 0o4 18 0o3 95 Oo 5 February 80 Oo 3 8 Ool 72 0o3 March 116 0o3 34 0o3 82 to 0 o April 224 0o7 14 0o2 210 lo0 May 41 Ool 4 0o04 37 0o2 June 69 0o2 11 Ool 58 0o2 July 58 0o5 58 Oo 5 August 30 Oo 2 30 0o2 September 97 0o6 97 0o6 October 26 0o2 26 0o2 November 96 0o6 96 0o6 December 104 Oo 5 104 o o cn Total 1054 0c4 500 0o3 554 0o4 ♦Types not recorded until January 1944o Source: Medical Statistics Division, Office of The Surgeon General, War Department, Washington D« Co FIGURES 1. Intestinal Infections, Including Common Diarrheas and Dysenteries, All Forces, Ground Forces, Air Forces, and Communications Zone, United Kingdom, Rate per 1000 strength per annum by weeks, 1 January 194-3 to 30 June 1944® 2. Intestinal Infections, Including Common Diarrheas and Dysenteries, All Forces, Ground Forces, Air Forces, European Continent only. Rates per 1000 strength per annum by weeks, 23 June 1944- to 29 June 1945o 3* Intestinal Infections, Including Common Diarrheas and Dysenteries, United Kingdom and Continental Europe, Rates per 1000 strength per annum, by weeks, 23 June 1944 to 29 June 1945* 4* Intestinal Infections, Including Common Diarrheas and Dysenteries, Air Forces, European Continent and United Kingdom, Rates per 1000 strength per annum, by weeks, 23 June 1944 to 29 June 1945® 5* Intestinal Infections, Including Common Diarrheas, Colored and White Troops, United Kingdom and European Continent, Rates per 1000 strength per annum, by weeks, 9 June 1943 to 29 June 1945® 6. Intestinal Infections, Including Common Diarrheas, First, Third, Seventh and Ninth Armies, Rate per 1000 strength per annum by weeks, 9 June 1944 to 29 June 1945* 7o An Army Mess under canvas, 95th Evacuation Hospital, Epinal, France, November 1944® So Messing on board a Troop Transport, November 1942. 9® Prisoner of War cage in Rheinburg, Germany, March 1945. 10. Early Sanitary Construction in Normandy, July 1944* 11. Epidemic of Water-Borne Common Diarrhea, 347th Engineer Regiment, United Kingdom, September 1943® 12. Preparation of salmon croquettes in a mess, England, December 1942. TABLES 1, , Admissions and Deaths for Diarrheas and Dysenteries, Including Gastroenteritis, With Rates per 1000 per annum in Certain Major Wars of the United States, ■ ✓ A , ... •• * •* 2. Intestinal Infections Including Common Diarrhea and Dysentery (All types). Peace Time Army in Continental United States; Number of Cases and Rates per 1000 strength per annum, by month, 1935-1939, 5, Intestinal Infections Including Common Diarrhea and dysentery (All types), Pre-War Army, Compulsory Military Service, in Continental United States; Number of Cases and Rates per 1000 strength per annum, by months, 1940-1941, 40 Intestinal Infections Including Common Diarrhea and Dysentery ' (All types), War Time Army in Continental United States, Number of Cases and Rates per 1000 strength per annum, by months, January 1942-June 1945, ,,. 5, The Diarrheas and Dysenteries, Troops of the United States Army in Theaters of Operations and in Continental United States, Cases and Rates per 1000 strength per annum by years, January 1942-June 1945. . • 6, Intestinal Infections, Including Common Diarrhea and Dysenteries (All types), European Theater of Operations; Cases and Rates per >■ 1000 strength per annum, by months, February 1942-June 1943, 70 Intestinal Infections, Including Common Diarrheas and Dysenteries (All types), All Forces, Air Forces, Ground Forces and Communi- cations Zone, United Kingdom, Rate per 1000 strength per annum, by weeks, 1 January 1943 to 30 June 1944, 8, Intestinal Infections, Including Common Diarrheas and Dysenteries (All types). All Forces, Ground Forces, Air Forces and Communi- cations Zone, European Continent only; Rates per 1000 strength per annum, by weeks, 23 June 1944 to 29 June 1945, 9, Intestinal Infections, Including Common Diarrheas and Dysenteries (All types). United Kingdom and Continental Europe, Rates per 1000 strength per annum, by weeks, 23 June 1944 to 29 June 1945, 10, Intestinal Infections, Including Common Diarrheas and Dysenteries (All types), Air Forces, European Continent and United Kingdom; Rates per 1000 per annum, by weeks, 23 June 1944 to 29 June 1945, 11, Intestinal Infections Including Common Diarrheas and Dysenteries (All types), Colored and White Troops, United Kingdom and Continent; Rates per 1000 strength per annum by weeks, 9 June 194-3 to 29 June 194-5. 12. Intestinal Infections Including Common Diarrheas and Dysenteries (All types). First, Third, Seventh and Ninth Armies, Rate per 1000 strength per annum, by weeks, 9 June 1944 to 29 June 1945. 13. Serologic Types of Dysentery Bacilli from Stool Examinations of 187 Patients, Seventh U. S. Array, December 1944. 14# Diarrheas and Dysenteries, Prisoners of War, European Theater of Operations, Continent only; Cases and Rates per 1000 strength per annum, by months, September 1944 to June 1945. 15. The Common Diarrheas in the European Theater of Operations, D. S. Army; Cases and Rates per 1000 strength per annum, by months, February 1942 to June 1946. 16. The Dysenteries in the European Theater of Operations, U. S. Army by Types and Year; Gases and Rates per 1000 strength per annum, February 1942 to June 1945 Inclusive. 17. The Dysenteries, All Forms, European Theater of Operations, XI. S. Army; Cases and Rates per 1000 strength per annum, by months, February 1942 to Juno 1945. 18. Amebic Dysentery, European Theater of Operations, U. S. Army- Cases and Rates per 1000 strength, by months, January 1944 to June 1945. 19. Epidemic Diarrhea in the 5th Infantry Division, and 50th Field Artillery Battalions, 1944. 20. Bacillary Dysentery, European Theater of Operations, U. S. Army; Cases and Rates per 1000 strength per annum, by months, January 1944 to June 1945. EPIDEMIOLOGIC CASE REPORTS 1, Water-Borne Epidemic of Common Diarrhea—Construction Camp 2, Water-Borne Epidemic of Common Diarrhea-Sewage Contamination ✓ t 3, Water-Borne Epidemic of Common Diarrhea—Non-potable Field Sorted 4* Chronic Relapsing Amebic Dysentery 5« Supposed Water-Borne Epidemic of Amebic Dysentery 6* Some Dysentery in a Staging Area 7, Bacillary Dysentery of Carrier Origin A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN -THEATER OF OPERATIONS UNITED STATES ARMY 19a - 194-5 PART III - Epidemiology- Section 2 - Intestinal Infections Number 2 - Food Poisoning by Colonel John Ec Gordon, M0C, Chief of the Division of Preventive Medicine Office of The Chief Surgeon, ETO TABLE OF CONTENTS Part III - Epidemiology Section 2 - Intestinal Infections Number 2 - Food Poisoning Food Poisoning.,. . 1 Classification0000000000.0.0.00.0.0.900000000000.0000000000000.0 X Incidenc© of Food Poisonmg00000000000000000000000.0009.00000000 2 StaphyXococcus rood P01sonmg00000.000.000.000000000000000000000 3 1* requency of Gp ld©nilC Sooooooooooooooeooaooooeeoooooooooaooaoooao 3 The Epidemiologic Pattern of Staphylococcus Food Poisoning.«..o• 4 6 O tul 1 Sm oooooooooooooooooooooo.oo.o.oooooooooooooooooooooooooooo 5 Food Poisoning from SaXmoneXXa.ooooooooooo.oooeoooaoaooeooooo.eo 7 Frequency of Epidemicsooooooooooooooaooooeoo.ooooooooooooooo.ooo 8 The Epidemioiogic Pattern of SaXmoneXXa Food Poisoning....oo...o 9 Hoiiday Food Pois onmg 00000000000.000000000000000000000000000000 13 Food Poisonmg from Powdered Eggooooooooooooooooooooooooe.ooeooo 15 Evidence Relating Dried Egg to Food Poisoning...o...0.o...oo...o 16 Prevalence of Food Poisoning from Powdered Egg among British Civillansoeooooooooooooooooooooooooooooooeoooooooooooooooooo 17 Food Poisoning from Powdered Egg in the United States Army...... 18 Prevention of Food Poisoning and Food-borne Infection.....o....o 20 Educational Programo oooooooooooooooooooooaoooooooo.ooooooooooo.e 21 Cleanliness of Messes and Kitchen Equipment..o....oo........... 23 Limitation of Flies and Other Xnsectsoooooooooooooooeoooooooo.oo 25 Inspection of Foodstuffsooooooooooooooooooooooo.oooooo.ooooooooo 25 Protection of Stored Basic loodsooooooooooooooo.oooooo.oeo.ooooo 27 TABLE OF CONTENTS(Contfd.) Improper Mess Management 28 Too Early Preparation.,. .. .......... 28 Long Storage at Hoorn Temperature • • ••• 29 Leftover Foods.... ...... 30 Treatment of Haw Fruits and Vegetables. 31 Serving of Food..... <>.. . ........... 32 Food Handlers o ••••• 32 Mess Kit Laundry.. o... 34 Theater Policy of Food Procurement as a Preventive Measure 36 The Control of Epidemics of Food Poisoning. 36 List of Tables List of Figures List of Epidemiologic Case Reports PART III Epidemiology Section 2 - Intestinal Infections Food PoisoningoV-Food poisoning became a reportable conditioii in the European Theater in February 1944o This new term was introduced into the schedule of the reportable diseases because of the commonly existing interpretation that if an outbreak of intestinal infection was definitely food poisoning, it need not be reported under common diarrheas0 Such outbreaks were often not reported at all* Food poisoning is a collective term including a number of clinical conditions. It may arise from actual poisoning, through heavy metals gaining entrance to food from utensils in the course of preparation, or by direct addition, accidentally or otherwise, of any organic or inorganic poison,, This factor has little or no importance in a general consideration of food poisoning in military practice,, It ranks no higher than a curiosity,, The same holds true for toxic effects resulting from poisonous plants and animals. The bulk of food poisoning comes from contamination of food with pathogenic bac- teria in the course of preparation or serving,, Very little food poisoning arises from basic contamination of food ingredients, or spoilage in the popular sense„ Two principle forms of bacterial food borne disease are to be distinguished, the intoxications and the true infections. Classification,,—Food intoxications arise from ingestion of preformed bacterial poisons,—toxins which have developed in the food through action of contaminating bacteria,, Many of these bacteria are not of themselves injurious when taken into the intestinal tract of man. They do not lead to infection of the host,, Their bacterial toxins, if they gain entrance in sufficient amounts in the preformed state, are capable of producing serious disease processes. The infections depend for their action on the production of an actual infectious disease of the host, having a recognized incu- bation period and a relatively prolonged clinical course. HVhen food is involved in the transmission of typhoid fever, the dysenteries, and other recognized intestinal infections, the mechanism is termed food-borne infection. Food poisoning of the type of an infection is limited essentially to the activities of the various members of the Salmonella group of bacteria. This follows from lack of precise knowledge of how much of the affect produced by these bacteria is due to preformed toxin, and how much to actual invasion of the host. 1 Incidence of Food Poisoning.—Ihe data on food poisoning presented in Table I includes all varieties of that condition, both intoxications and infections, that were reported in the European Theater from February 1944 to the end of hostilities. Separate records of types of food poisoning by clinical difference or by spe- cific etiologic agent were not maintained. Neither was distinction made between cases where identification of the infectious agent was accomplished, and those that were dependent upon epidemiologic information alone for recognition as food poisoning. The seasonal -variations are ill-defined because of the small numbers, but in general show a fairly close parallelism with those of the common diarrheas. A comparison of the data of Table I and those of Table 15, Section 2, Number 1, is not to be taken as an indication of the relative frequency of food poisoning and the common diarrheas in this experience. The differences represent more a matter of custom and practice in reporting than of actual occurrence. It was brought out in the discussion of the common diarrheas that the great propor- tion of those diseases were in all probability food poisoning, The numbers of cases included in Table I are small, and on the basis of knowledge of field conditions fall far short of representing actual incidence. For purposes of comparing the behavior of the common diarrheas with previous experience, the two categories of diarrhea and food poisoning as presented in this discussion should be com- bined. A better understanding of the actual prevalence of food poisoning was obtained by summarizing a series of special epidemi- ologic reports submitted by unit surgeons to the Chief Surgeon of the theater. These reports were requested by the preventive medicine service at theater headquarters for all outbreaks of any significance or importance. It will be appreciated that satis- factory information was not available in all instances, either because the proper investigation had not been made at the time of the incident, or because the circumstances were too obscure to lead to reasonable conclusions. Some 115 epidemics of appreciable extent are presented in Table 2, The series is selected in that it includes only epidemics occurring during the time these special reports were required, and only those instances where data were sufficiently definite to be of value. Seventeen of the outbreaks were confirmed as due to staphy- lococci, either by isolation of the pathogenic agent from the food or from patients, or from both. Sixteen epidemics were established as due to a member of the Salmonella group of intestinal bacteria, sometimes by isolation of the agent from the food, but more commonly from the feces or blood of patients.. The great majority, 82 in all, were unconfirmed bacteriologically; but on the basis of clinical and epidemiologic evidence, 44 were considered to be of the staphylococcus type, and 16 others in all probability due to salmonella« For 22 epidemics the observations were either so indefinite or of conflicting nature as to resemble neither of the two principal recognized types* They are set forth in the table as indeterminate„ Staphylococcus Food Poisoning0\— That an understanding may be- had of the clinical nature ot those forms of food poisoning where staphylococci were isolated, and more particularly of those considered as probably of staphylococcus type in the absence of bacteriological identification, the general clinical aspects are outlined, based on observation of patients in a number of epidemics® The symptoms appeared in about three hours, occasionally in from one to six hours, after ingestion of food containing the entero- toxin® The incubation period was apparently influenced by the amount of enterotoxin consumed and the susceptibility of the individual® Usually the first symptom observed was salivation, which was subse- quently followed by nausea, vomiting, retching, abdominal cramping of varying severity, and diarrhea® In severe cases, blood and mucus were not uncommonly observed in the stools and vcmitus® In mild cases, nausea and vomiting occurred without diarrhea; or there was nausea and diarrhea without vomiting® Headache, muscular cramps and sweating often occurred if symptoms were moderately severe® Marked prostration accompanied the vomiting and diarrhea in severe cases® In such instances, fever was sometimes present, or more commonly the temperature was subnormal® Staphylococcus food poisoning in other- wise normal individuals was not fatal and recovery was usually rapid, in from one to three days® Some patients, however, had not com- pletely recovered after a week or more® Individuals varied consider- ably in their susceptibility to the enterotoxin® Frequency of Epidemics®—Satisfactory records of the clini- cal form of food poisoning became available for 115 outbreaks® Staphylococci were deemed responsible for 60, or 52 percent® If the computation is based on only those outbreaks in which a specific etiologic agent was demonstrated, 33, the proportion due to staphylo- cocci was essentially the same® These distributions are not intended to indicate with any preciseness the relative proportion of staphylococcus food poisoning to all forms of food poisoning in this military experience® In the first place, the data are by no means inclusive nor complete® A great many outbreaks never came to report and their relative distri- bution as to type is wholly unknown® Many of the outbreaks of common diarrhea attributed to faulty mess sanitation and other 3 similar causes may very well have been actual food poisoning® This is aside from those shown epidemiologically to have been transmitted by food and more properly to have been classified as food poisoning* Finally the attendant clinical and epidemiologic circumstances are believed to favor identification of salmonella in comparison with staphylococci® Neither the disease process nor the epidemic are quite so abrupt in onset, nor so short-lived® The Epidemiologic Pattern of Staphylococcus Food Poisoning® —Outbreaks of demonstrated staphylococcus food poisoning are presented in Table 3® The number of persons at risk was invariably an estimate because actual troop strength at the time of an outbreak was rarely available® The number more commonly represented average strength for the period involved and as such is fairly close to fact and more reliable than most estimates of population at risk in similar civilian situations® The number of soldiers becoming ill includes all who reported to sick call, were sick in quarters, or were sent to hospital® Most were admitted to sick call only® The epidemic which involved a Quartermaster battalion stationed in southwest England was typical of such instances® EPIDEMIOLOGIC CASE REPORT NO® 1 - A group of men of the 1512th Quartermaster Battalion messed at irregular intervals from 1330 hours to 2030 hours on 20 October 1943; and for the most part separately, because of the particular nature of their duties® From 2330 hours until 0650 the next morning 29 patients were seen by the medical officer of the organization* They complained of nausea, vomiting, abdominal cramps, and diarrhea® The first symptoms of one patient appeared within fifteen minutes after having eaten, in others after as long as three and one-half hours® Extreme prostration was an out- standing feature® Five patients had hematernesis, in four in- stances with less than one ounce of blood, but one patient vomited 250 cc® of red blood® Twenty-four patients were dis- charged within 18 hours, the remainder after 48 hours® Six patients had an elevation of temperature to 99®2°F® or 99®8°F* the day after the episode, but fever lasted for only a few hours® Physical examination of patients when first seen ordi- narily revealed severe prostration, subnormal temperature, and diffuse abdominal tenderness® The results of white blood cell and differential blood examinations were within normal limits® Staphylococcus aureus was cultured from four speci- mens of stools® No other pathogenic organisms were found® An investigation of the circumstances surrounding this outbreak showed that the mess sergeant had placed a large 4 container of meat above the stove in order to keep it warm. It was not kept sufficiently hot to inhibit bacterial growth, but rather served as a good bacteriologic incubator® Additional meat was added to the container as the supply be- came depleted, and without washing the containor0 The tinned tongue was sliced to size before placing it in the wanning receptacle„ Bacteriological examination of the corned beef and the tongue which had been served gave a good growth of Staphylococcus aureus0 Definite confirmation of the origin of this outbreak came from the medical officer of the unit® He ate a piece of tongue about two inches square and a quarter of an inch thick, taken from the same utensil used to serve the affected enlisted men„ Within two and one- half hours he became nauseated, vomited and experienced the same clinical course as his patients., This outbreak was illustrative of classical food poisoning arising from preparation of food too long in advance, with subsequent storage for appreciable periods under conditions which favored growth of food poisoning bacteria and production of their toxic products® Nine of the outbreaks of food poisoning included within this experi- ence were attributed with relative assurance to staphylococcic Suf- ficiently careful epidemiologic studies wore made to indicate a par- ticular article of food0 The infectious agent was isolated from the food in all instances, and in addition twice from the feces or vomi- tus of patientso The clinical reaction was compatible with that of staphylococcus food poisoning® Many other epidemics of food poisoning were suggestive of staphylococcus origin because of the circumstances surrounding the food that was involved, or more particularly because of the clinical nature of the disease that resulted,, Ihey lacked bacteriologic con- firmation; and are listed in Column 5 of Table 2, Most outbreaks occurred under field conditions, where neither opportunity nor time was often available for the careful studies that might otherwise have been madeQ Laboratory facilities were not always at hand0 Furthermore, the study of a staphylococcus epidemic of food poisoning requires initiative and appreciation of the situation on the part of the unit surgeon, because both the disease and the epidemic were ordinarily over by the time an epidemiologist was calledo Ihese circumstances account for the relatively large number of epidemics indicative of an intoxication, which were classed as cause unknown or unproven0 Botulismo--Botulism from commercially canned products is extremely rare, but outbreaks are reported consistently among con- sumers of home-canned foods® Botulism is due to an exotoxin pro- 5 duced by the growth of Clostridium botulinum in suitable medium,, Under- processed canned meats, vegetables, and fruits are the most common foods involved. Outbreaks have also originated from preserved foods, such as sausage and smoked meat. The cold pack method of processing foods for home canning is entirely inadequate for the prevention of botulism. Most foods in which botulinus organisms have grown show evi- dence of spoilage, characterized by a sharp odor, peculiar acid taste, or the presence of swelling of the container through production of gas. Because of the varying degree of fastidiousness exercised by different individuals in the consumption of spoiled food, evidence of spoilage is not an adequate safeguard against botulism. Furthermore, evidence of spoilage has not been observed in all outbreaks. Because of the peculiar conditions which govern pro- duction of this disease, its occurrence in military practice was even more of a curiosity than in civilian life. Only twice in the history of the European theater was botulism reported among the military population. The first small outbreak in a United States Army camp occurred in England during August of 1944. EPIDEMIOLOGIC CASE REPORT NO. 2 - Three soldiers warmed a jar of home canned ravioli prepared with meat and tomato sauce, which had been sent to one of the men from his home in the United States. Each man ate a portion. The jar was cracked and the contents smelled sour. A fourth soldier merely tasted the ravioli. Thirty-three hours later, one of the soldiers reported ill with a slight sore throat. He complained of dizziness, blurring of vision, difficulty in breathing, voice changes, and inability to expectorate. Despite inconclusive physical findings, the patient appeared toxic and was sent to hospital. At the time of admission he had a slight muscular weakness of the arms and legs. The pharynx was slightly injected and a marked post- nasal discharge was noted. The patient appeared comfort- able during that day. The next morning he awoke, 53 hours after eating the ravioli, with a sore throat and complaint of inability to swallow. Fifteen minutes later he had a generalized convulsion, became cyanotic and lapsed into unconsciousness. Respiration ceased after five minutes. Stomach contents collected at post-mortem examination con- tained toxin of B. botulinum A. One of the remaining two soldiers had eaten approximately as much of the food as the patient who died; the other had taken less, an amount which he described as a spoonful. Fifty-three hours after eating the ravioli, both of these men developed symptoms 6 botulism. The first soldier complained of diplopia, inability to swallow, and aphonia,, The second was less markedly affected, having only slight diplopia and hoarsenesso At this time botulinus food poisoning was suspected and about 40,000 unit of antitoxin was given intramuscularly to each man0 Physical examination of the first patient showed him to bo flushed and appre- hensive o He complained of general weakness0 The pupils were dilated,, There was diplopia with evident weakness of all extrinsic ocular muscles, aphonia, complete inability to swallow, and weakness of the tongue. There was no obvious involvement of the other cranial nerves„ The temperature was normal, the pulse slow and respi- rations unaffectodo Both patients improved progressive- lyQ Che had completely recovered after a few days, while the other still had residual symptoms ten days latero The soldier who had only tasted the ravioli developed no symptoms. The second of the two recorded outbreaks of botulism oc- curred in Germany and involved soldiers of a combat unite The home made delicacies they found did not prove to be as good as they lookedo EPIDEMIOLOGIC CASE REPORT NO. 3 - Three soldiers of A Company, 370th Engineer Combat Battalion gave a history of eating pickles and preserves found in cellars in Goppingeu, Germany on 28 April 1945. Other than for these foods, they had long subsisted on K and C rations. All three became acutely ill and were removed to hospital where a diagnosis of botulism was made0 Anti-botulism serum was administered. Two patients recovered, and one died of respiratory paraly- sis some five hours after serum therapy. Autopsy showed death to have been due to the toxin of Bacillus botulinum. Food Poisoning from Salmonella-The clinical reactions associated with food poisoning by bacteria of the Salmonella group showed certain differences from the disease that resulted after in~ gestion of the enterotoxin of staphylococcic The presumptive identification of certain outbreaks of food poisoning as probably related to the salmonella has depended on the presence of a disease which conformed to that ordinarily resulting from infection with these bacteriao The details are set forth as a means of sub” stantiating the epidemiologic interpretations that were mad©0 The symptoms of Salmonella gastro-intestinal infections were characterized by nausea, vomiting, abdominal pain and diarrhea. The 7 onset was usually sudden* The attack was commonly ushered in with headache and a chill* Abdominal pain was often the first symptom, was griping and severe, and frequently associated with persistent foul smelling diarrhea* Later in the attack the stools were watery and sometimes of a greenish color* Prostration, muscular weakness, faintness and thirst were marked* There was almost always a rise in temperature, with various nervous manifestations of restlessness, muscular twitchings and drowsiness* Oliguria was often present and herpes frequently followed* The severity of the disease differed in different outbreaks and among various individuals in the same outbreak* Dosage or number of organisms ingested appeared to be an important factor, since in some experimental work as well as in outbreaks individuals who had a small dose many times escaped without symptoms* All Salmonella organisms causing gastro-intestinal upsets in man seemed to cause identical symptoms, and to be characterized by the same clinical course regardless of the species involved* In a small proportion of cases the organisms invaded the tissues and in this experience were isolated a number of times from the blood* No deaths were recorded among infections reported from the European Theater, although cases occasionally terminate fatally* One of the most characteristic features of Salmonella gastro- intestinal infections was the time required for symptoms to develop after the ingestion of the food* Also characteristic was the varia- bility in the time within which symptoms appeared* This may have been due in part to varying preponderance of affect from preformed toxin and from actual infection* Short incubation periods were conceivably associated with toxic effect, the longer ones with infection, with intermediate intervals representative of combined action* That a pre- formed toxin enters into consideration with relative frequency would seem borne out by clinical and epidemiologic observation of the disease, despite the long held contention that salmonella food poison- ing is typically an infection* Where symptoms result from infection rather than intoxication, incubation periods may very well vary with the time required for multiplication and invasion by the organisms in individuals with differing degrees of resistance, and subjected to differences in dosage* At any rate, a period of at least seven to eight hours ordinarily elapsed before symptoms developed in the most susceptible individuals, 12 to 24 hours in the majority of cases, and 24 to 30 hours or longer were required in some instances* Frequency of Epidemics*—Almost as many outbreaks of food poisoning were bacteriologically confirmed as due to salmonella as was true of staphylococcus episodes* (Table 2) The number was 16* On the basis of clinical and epidemiologic criteria an additional 16 were 8 were considered to be of that nature, compared with 4-4 unconfirmed out- breaks believed to be staphylococcic<> Despite the lesser number of outbreaks in the series, the proportion of confirmed outbreaks was greater; a circumstance attributed to the more favorable conditions for bacteriologic study ordinarily presented by a salmonella outbreak. In addition to food poisoning outbreaks two sizable epidemics among troops of thq command came about through transmission of salmonella infection by water. Many sporadic intestinal infections were of this nature. Through the typing service provided at the First Medical General Laboratory and by the Emergency Public Health Laboratory Service of Great Britain, it was possible to determine the serologi- cal types of salmonella involved in food poisoning outbreaks in a goodly number of instances. Type Montevideo was most frequently en- countered, four instances. Salmonella aertrycke was determined twice and S, enteritidis, Newport, schottmttlleri and suipestifer, each in a single instance. Four strains of Salmonella determined as such were not subjected to further type differentiation. The Epidemiologic Pattern of Salmonella Food Poisoning,— Pertinent information on those instances of food poisoning where some member of the Salmonella group was established bacteriologically as the infectious agent is set forth in Table 4, It will be noted that almost all confirmed epidemics occurred in the United Kingdom, in the proportion of 14 to 2, Salmonella food poisoning, whether definitely determined as such by bacteriological tests or based on epidemiologic evidence, was far less frequently recognized on the continent. The outbreak of salmonella food poisoning that occurred at the 79th General Hospital in North Ireland, following the supper meal served on 11 April 1944, was classical in its manifestations, Within 24 hours, 267 persons had developed an acute illness marked by in- tense diarrheal disturbance. The distribution of cases in subsequent days is shown in Figure 1, Table 5, In all, 354 persons were affected; of whom 307 were patients of the hospital, 45 were members of the medical detachment and two were nurses. The clinical disease con- formed to recognized descriptions of salmonella infection. The extremes of incubation, dated from the offending meal to the onset of symptoms, were three to sixty-six hours. More than half of the patients became ill within 15 hours or less. The average duration of the acute disease was 3 to 6 days. The initial temperature of patients commonly ranged from 102°F, to 104°F,, but a few exceeded 105°Fc Diarrhea lasted from 3 to 5 days, but in seme instances per- sisted to a mild degree for as long as a week or more. Almost all of the duty personnel affected had to be admitted to hospital. 9 EPIDEMIOLOGIC CASE REPORT NO. 4 - The food served at supper on 11 April 1944 was determined as responsible for the outbreak of food poisoning at the 79th General Hospi- tal. Preceding meals could be excluded by the fact that none of 39 patients transferred to another hospital after lunch of that day subsequently became ill. The hospital operated separate messes for officers, enlisted men, and patients. Of the 354 individuals who became ill, 350 had eaten food from the patients mess and three of the other four had contact with food from that mess either in serving or in cleaning dishes. The menus in the three messes had been identical. Analysis of dietary histories directed suspicion to two foods, hamburger steak and rice pudding. Patients on the ulcer ward of the hospital were served no hamburger, and all nine became ill. Some 200 hamburgers left over from this meal were served that night at 2300 hours after reheating. No one eating these ham- burgers and having no contact with the patients subsequently became ill. Two nurses who ate hamburgers at that time and became ill were taking care of patients with food poisoning, and presumably could have acquired the infection by contact. The attack rate for 360 persons eating rice pudding was 88 per 100, while for the 82 not eating rice pudding the rate was 21. For 424 persons eating hamburgers the rate was 75 per 100, for the 38 who did not eat hamburgers it was 53 per 100. Analysis 0f the histories of persons not eating pudding but becoming ill showed contact with that food either by washing dishes that had pudding on them, or in preparing the meals of the ward,or that pudding had been placed on plates but not eaten, or that they had contact with patients with food poisoning during the height of the outbreak. All of the evidence directed attention to the rice pudding as the probable source of the outbreak. The pudding had been prepared at 0400 hours, April 11. It had been left in flat field range pans at kitchen temperature until served that afternoon at 1600 hours and later. The cook who prepared the rice pudding gave a history of two to four loose stools daily since 1929, A routine stool culture made a month prior to the outbreak had been negative. After an eight-hour incubation period, he developed a perfectly typical attack of food poisoning. Nevertheless, during the first week of illness (April 17) his serum agglutinated Salmonella in dilutions of l:32o« 10 Figure 1 Epidemic of Food Poisoning, Salmonella Kentovideo, 79th General Hospital, North Ireland, Distribution of cases by days, April 1944. Agglutination tests of serums from 24 other patients were negative at that timeo All of six stools from the cook, examined between April 14 and May 20, contained Salmo- nella Montevideoo Samples of food served at the supper meal were not availa- ble the next morningo Ingredients entering into the rice pudding were examined, but unfortunately the same lots used in making the offending food were not available. Powdered and evaporated milk, egg powder and bread were found free from pathogenic bacteria. The stools of more than 100 patients, collected during the acute illness, contained a nonlactose fermenting bacillus which was later identified as Salmonella Montevideo. The same bacterium was isolated from the blood of two patients and once from the sputum of a patient with bronchopneumonia. Stool cultures fran a series of persons who had not been ill were negative. Of stools from 28 patients examined serially over the next seven weeks, 21 contained Salmonella for four weeks or more; but by the end of the seventh week all had become negative. Only the cook gave a positive serological reaction to antigens of Salmonella Montevideo during the first week of the out- break. In the course of the next three to six weeks, agglutinin titers of blood from patients ranged from 1:50 to 1:800, but decreased after the sixth week. A number of individuals who had remained unaffected during the outbreak showed no agglutinins. The immediate source of infection was rice pudding, and the causative agent was Salmonella Montevideo. The cook who pre- pared the pudding was believed by medical officers who studied the epidemic to have been a chronic carrier and to have contaminated the food or the pan containing it. Against this interpretation is the fact that the cook developed the disease, an uncommon circum- stance for a chronic carrier. Speaking for that assumption is the early and high agglutinin titer that he showed. The cook certainly was a carrier after his illness, but so were many other patients. A stool examination one month previously had been negative. It was considered that contamination of the ingredients, inherent or acquired in the course of storage, would have been eliminated in the process of cooking. It is, however, highly suggestive that the offending Salmonella strain was of a particular variety commonly found in egg powder, and that numerous outbreaks of food poisoning have been traced to cooked egg dishes. (See page 15). Powdered egg was used in the preparation of the pudding. At any rate, the practice of preparing such a food long in advance of 11 serving, and of keeping it warm at room temperature, is certainly associated with danger*, Food poisoning due to the Salmonella almost invariably showed a direct relation to the food, either through infection of the ingredients as in outbreaks associated with egg powder or the overwhelmingly more frequent association with food handlers harbor- ing the infectious agent® Only once in this experience was an intermediate host suggested, although the actual mechanism in that instance may well have been through an infected person® EPIDEMIOLOGIC CASE REPORT NO. 5 - The 278th Signal Pigeon Company with 141 enlisted men and 9 officers was assigned to the Ninth United States Army® One of the enlisted men developed an acute intestinal infection on 22 October 1944® Within the next two to three days, 50 others were affected, of whom two were sent to hospital® During the next two weeks, at least one or two men of the company became ill daily and five were affected on 1 November 1944® The illness began suddenly with headache, anorexia, nausea, epigastric cramping pains and severe chills, followed within two hours by five or six profuse, loose, watery stools, containing flecks of blood but no clots. There were extreme tenesmus and urgency® Chills con- tinued during the next several hours, and the fever frequently reached 104°F® Symptoms ordinarily con- tinued in lesser degree for three or four more days. The illness was unassociated with history of respiratory infection or other relevant fact. Recurrence was not uncommon® No similar outbreak had ever been experienced by this unit, although spo- radic diarrhea of various types had occasionally been noted® No defects in sanitation were observed in a care- ful inspection of the unit mess® Of the 2160 pigeons housed in the cages of the unit at the time of the outbreak, 159 had clinical paratyphoid infection, evidenced by diarrhea, anorexia, depression and enlarged joints® Laboratory examination of feces from the infected birds served to demonstrate Salmonella typhi- murium® The feces of human patients were bacteriologically negative, as were cultures from rectal swabs® 12 The history and clinical reaction of the men involved in this epidemic are compatible with salmonella infection* Transmission of the infectious agent from infected birds to the food of the mess was a feasible premise, although unconfirmed bacteriologically. The potential danger had long been appreciated, in that no member of the Pigeon Company had been permitted to handle food or serve as kitchen police at posts where the unit was stationed in America* Under field lwHi nf necessity ran its own mess* Holiday Food Poisoning.,—Repeated experience led to antici- pation lof a series of reported outbreaks of food poisoning with each approaching holiday season,, The festival occasions of Thanksgivings Christmas, and New Years Day were especially significant., No less than 16 different outbreaks of food poisoning were known to have oc- curred following Thanksgiving of 1944* (Figure 2) The clinical disease might be suggestive of staphylococcus or salmonella or an unidentified infection, but the attendant circumstances followed a set pattern,, These were the times of the year when soldiers expected a really good meal, and to the credit of the Quartermaster Corps, they usually got it* These were the particular occasions when the professional pride of the cook was seriously aroused, when he genuinely tried to meet the challenge expressed in no uncertain terms by the men of his company,, The result was that kitchens and equipment were overtaxed„ The menus were often so elaborate that food had to be prepared long in advance of serving, and breaches in good messing procedure followed as a natural consequence* EPIDEMIOLOGIC CASE REPORT NO. 6 - Five hours after Christmas dinner of 1944 was served to the 273rd Company of the 502nd Port Battalion stationed in the Channel Base Section in France, 175 of the total strength of 198 men became acutely ill with nausea, vomiting, and abdominal cramps * Excluding ten men who ate at another company mess and were not ill, the attack rate was almost universal* It was one of the most extensive outbreaks of food poison- ing in this experience* Those admitted to hospital or sent to quarters numbered 131* Fever was low grade and recovery took place in from two to eight hours* Investigation showed that the turkey, which consti- tuted the principal dish, was cooked the night before and carved on 25 December 1944 shortly before serving at 1700 hours* The dressing was prepared by mixing bread, milk, water and seasoning at 0400 hours on 25 December 1944* The mixture was kept on the stove for 12 hours* Giblets were added after soaking in salt water for 18 hours and 13 the whole cooked prior to serving© Food histories of 97 patients showed that the dressing was the only single item eaten by all those affected© The unit was housed under canvas and the kitchen was in a walled tent© The general sanitary situation was particularly good, except for lack of immediate hand- washing facilities© The fault would appear to be one of mess management through too early preparation of the dressing for tho turkey without proper protection against contamination© The clinical nature of the disease sug- gested staphylococcus food poisoning, although bacterio- logical confirmation was lacking© EPIDEMIOLOGIC CASE REPORT NO© 7 - Thanksgiving dinner was served to the enlisted men of various companies of tho 58th Armored Infantry Battalion of the 8th Armored Division at 1500 hours, 24 November 1944, at a conmon mess hall in Tidworth Barracks, Southern England© The meal consisted of roast turkey with dressing, salad, potatoes, peas, dessert, and coffee© The whole meal was eaten by most of the men, except for dessert in some instances and salad in others© Turkey and dressing were the common foods taken by all who became ill© Because of inadequate facilities at the unit mess, the turkey and dressing had been prepared and cooked by a Bakery Unit of a neighboring British Quartermaster organization about fifteen to eighteen hours before serving© During the 24-hour period ending 2100 hours, 26 November 1944, 77 enlisted men were admitted to hospital with acute gastroenteritis© Almost all had fever of 100°Po or more and some as much as 103°F© The common complaint was of abdominal cramps, frequent watery stools, and occasionally of prostration© The early symptoms were headache, chills and fever, followed by nausea, vomiting and diarrhea© The average time of onset was about 24 hours after the offending meal© Salmonella were isolated re- peatedly from the stools of patients sent to hospital© Uie total attack rate remained unknown but it was greatly in excess of the number admitted to hospital© EPIDEMIOLOGIC CASE REPORT NO© 8 - About 45 of the men of the 3111th Signal Service Battalion with Advance Section, Communications Zone, in Prance became ill with acute gastro- enteritis after partaking of New Years Day dinner, 1 January 1945, at the unit mess© Some 100 men were absent from din- ner but did have breakfast and supper at the mess© None 14 Fi gure 2 Thanksgiving Turkey served to combat men. Continental Europe, November 1944. were illo The attack rate for those dining at the unit mess was about 13 per hundred,, The onset varied from 2 to 8 hours after eating the meal and was ordinarily sudden, with sharp intermittent abdominal cramps, moderate watery diarrhea, and considerable prostration and dehydration. Recovery was relatively rapid, Turkey and potato were the two foods common to all patients. The turkey was received in the frozen state two days before serving. It was thawed by soaking in water and roasted approximately 20 hours before serving. The roasted birds had been stored in a cool place until the morning of 1 January when they were carved, the meat placed in pans, and reheated in field ranges one to two hours before serving. The vegetables including the potato, were prepared at this time. The roasted turkey appeared to be definitely the cause of the difficulty, and the condition was evidently staphylococcus food poisoning. Food Poisoning from Powdered Eggy-Fresh shell eggs neither locally procured or imported from the United States were almost a curiosity in the messes of the United States Army in the ETO during the war0 The egg used in custards, cakes, ice cream and a variety of other foods came almost wholly from powdered spray-dried eggs® Scram- bled eggs and omelets likewise originated from powdered egg® Only on rare occasions were fresh fried eggs included in the menus of even the most exclusive messes. Although powdered egg had been produced in America for a number of years, the industry was essentially a war-time development.. Prior to the war, no well established standards had existed in regard to production requirements, moisture and bacterial content of the finished product, or methods of packaging® These standards had to be developed during the expansion of the industry and under the pressure of meeting military requirements® Powdered egg was also used extensively by the British civilian population® The source of supply was from the same American producers who prepared powdered egg for the United States Army® The product was imported into Great Britain on a small scale towards the end of 1941® From then until July 1942, distribution was restricted to bulk supplies furnished bakers, confectioners, and caterers® In July 1942, the first issue of five ounce packages was made through retailers to the general public® The frequency of salmonella infection among poultry of the United States, and the ineffectiveness of the drying process in insuring destruction of even nonsporing pathogenic bacteria in the 15 egg, suggested to British health authorities that it -would not be surprising if bacteria belonging to the Salmonella group were found in the final products The correctness of this surmise was verified in August of 1942 when examination of 43 samples of egg powder showed five to contain viable Salmonella. Between August 1942 and May 1943 a total of 2,085 samples of egg powder were examined in British laboratories,, Of these, 121 or 5.8% were found to be in- fected with organisms of the Salmonella group,, The type distri- bution is presented in Table 6. Food poisoning from duck eggs infected with Salmonella bacilli had been reported a number of years before,, The experience of the war brought out the relative frequency with which eggs of the hen were also a source of the salmonella fora of food poisoning. The problem was thoroughly investigated by the British Ministry of Health, and by health authorities in the Zone of the Interior. In no instance was a bacterial count recorded of over 30 Salmonella bacteria per gram of egg powder, showing that the degree of contamination was relatively light. Of a total of some 1865 samples of powdered egg examined by the laboratories of the British Ministry of Foods and of the Emergency Public Health Laboratory Service, 0*2% of samples contained staphylococcus aureus and 7a6% contained some one of the Salmonella group. Included among the Salmonella were five types never known to have been involved in human infections. Of the types of Salmonella known to produce food poisoning of man, the commonest isolated from commercial samples of egg powder were Bacterium Orienienburg, Montevideo and Bareilly. (Table 6) Evidence Relating Dried Egg to Food Poisoning.—All types of Salmonella isolated from dried egg powder were known to be po- tentially pathogenic for man. Some indication of the frequency of food poisoning due to dried egg was obtained by studying the distri- bution of Salmonella types in cases of food poisoning in the United Kingdom before and after the introduction of that product. For many years before the war the Ministry of Health Laboratory of London had been the center for bacteriologic investi- gation of food poisoning outbreaks. In this way knowledge of the -types of Salmonella responsible for the major outbreaks of food poisoning in that country was collected in a single laboratory and published annually by the Ministry of Health. The data are con- tained in Table 7. 16 There are several points of interest in the table. It will be noticed that during the seventeen years 1923-1939, only fourteen different types of Salmonella were identified as being responsible for food poisoning in Great Britain. Never were more than nine types isolated in any one year. All strains were examples of well- known European Salmonella types, such as Newport, Derby, Eastbourne, Stanley, London and Aberdeen. Examination of the figures of 1940 and 1941 shows the type distribution to have been similar to that of pre-war years. In 1942, a change occurred. The usual types were represented but in addition seven new types made their appearance as shown in the lower half of the table. In all, no fewer than 15 dif- ferent types were recognized in 1942, nearly twice as many as in any single pre-war year. A study of the new types showed that four, namely Orienienburg, Montevideo, Bareilly and anatis represent the commonest types found in spray dried eggs. (Table 6) The distribution of dried egg to the general British public began in July 1942. Of the nineteen strains of the seven new types of Salmonella encountered in cases of food poisoning in 1942, fifteen were isolated in the second half of the year. The possible connection was strongly suggestive. It is true that two strains of Bacterium Montevideo had been isolated in July and September of 1941, and one of Bacterium Oslo in March 1942; but this also was after the dis- tribution of dried egg to wholesalers had begun. Of the ten new types observed in 1941 to 1943, only two—Bacterium Reading and Bacterium Chester—had ever been met within Great Britain before; and these were responsible for only three cases of food poisoning. The possibility that some other food such as pork was the vehicle of these new types was seemingly eliminated by the fact that the common type associated with pork. Bacterium cholerae suis, showed little evidence of serious increase in 1942 or 1943. It is possible that the new types were introduced by Ameri- can and Canadian troops, since the Americans began to arrive in ap- preciable numbers only towards the middle of 1942. The two principal objections to that hypothesis were that most of the food poisoning due to the new types appeared to have been among civilians, and secondly that the new types nearly all corresponded to those found in fowls, or in dried eggs, rather than to those so far found in human beings in North America. Prevalence of Food Poisoning from Powdered Egg among British Civilians.—Not only was the number of individual types of Salmonella greater but more cases of food poisoning occurred compared with pre-war years. During the period from mid-May 1943 until 17 5 September 1943 seventy-eight persons contracted food poisoning traceable to powdered egg* of whom seventy-two lived in seven ad- ministrative districts of Great Britain., The largest outbreak in- volved 26 persons at a hotel0 The rest were made up.of small family outbreaks„ All other foods and cooking substances could be elimi- nated in thes-e outbreaks except powdered dried egg. Food Poisoning from Powdered Egg in the United States Army. —The Oxford Laboratory of the Emergency Public Health Laboratory Service, Great Britain, was responsible for identification of Salmo- nella strains and the investigation of food poisoning outbreaks for the Ministry of Healths The relations of the United States Army forces with this installation were always closeo As a consequence, pathologic materials from patients with food poisoning in hospitals of the United States Army of the neighborhood were invariably ex- amined thereo Strains from more remote sections of the theater were also sent for identification The data included in Table 8 are by courtesy of that laboratory., The examinations recorded are for the first nine months of 1943o Ho specimens were submitted from cases of food poisoning among United States personnel between June 1942 and December 1942o Most of the cases of Table 8 represented sporadic in- fections o The predominance of types of Salmonella commonly con- tained in powdered egg is readily apparent, particularly Salmonella Orienienburg and Salmonella Montevideoo Since dried egg was so universally a part of the diet of American soldiers it was difficult to incriminate it in any given case of food poisoning0 The following instances were suggestive; EPIDEMIOLOGIC CASE REPORT NO® 9 - CoScRo was a United States Army cooko He awoke at 2 aom0 with abdomi- nal cramps, nausea, vomiting and diarrhea0 During the next 24 hours he had eleven bowel movements, but these subsequently dropped to three to five a day, over the next eight days.. Bacterium Orienienburg was isolated from the feces on more than one occasion and the serum aggluti- nated Bacterium Orienienburg H, l:800o No particular food was suspected and there were no other cases in the unit* The patient however, gave a history of drinking daily a milk shake made with uncooked egg powdere EPIDEMIOLOGIC CASE REPORT NOo 10 - Private Jo Mo was * admitted to hospital with a history of diarrhea and vomit- ing of three days duration® He appeared to be suffering 18 from a simple gastro-enteritis of the food poisoning type. Bacterium Orienienburg was isolated from his feces and his serum agglutinated Bacterium Orienienburg in 1:320 di- lution. Inquiry revealed that his diet had consisted mainly of canned meat and egg dishes made from dried egg. Since there is no record of the isolation of Bacterium Orienienburg from domestic animals in the United States it is improbable that infection was derived from the canned meat. EPIDEMIOLOGIC CASE REPORT NO. 11 - Thirteen men of the 535th Quartermaster Service Battalion developed an acute gastro-intestinal upset on 1 November 1943. Food histories gave evidence that only those men who had eaten eggs at the breakfast meal became ill. A sample of the egg powder used in preparation of the scrambled egg was submitted for laboratory examination and reported free from dysentery and other micro-organisms. Stool exami- nations of the patients were likewise negative. On epidemiological grounds this would suggest a small outbreak attributable to powdered egg. In no instance in this appreciable series of recorded out- breaks of food poisoning was it possible to identify the same member of the salmonella group in a suspected batch of egg powder and in the stools or other materials from patients. This rigorous require- ment is not altogether justified by the circumstances. Clinical food poisoning after ingestion of powdered egg was of two types. One form was evidently due to a particular toxin present in the powder, in that symptoms developed less than 8 hours after eating and usually within 2 to 3 hours. All of the 79 cases reported for the Ministry of Health were of this nature. In four instances samples of the particular egg powder that was eaten were proved bacteriologically to have contained Salmonella. However, in no instance was Salmonella of the type found in the egg powder that had been eaten, or of any other type, ever isolated from feces or vomit although examinations were made in at least 21 cases; not always under the most favorable circumstances in respect to time. The second form of food poisoning from egg corresponds to salmonella infection, with an incubation period of at least 8 hours and usually 18 hours. The nature of the toxin contained in certain samples of dried eggs remained unknown, but that it exists has been proved by several experiments on human volunteers. No reliable test animal was found. The evidence would indicate that poisoning by toxin was by far the more common. Salmonella infections would expectedly be obviated by the method of preparation--adequate cooking of the egg powder. 19 The possible relationship of egg powder was suggested in a number of other outbreaks and in some of the major ones0 Particular attention was repeatedly directed to the frequency with which rice pudding was involved* a food commonly prepared with egg powder in army practice. Of the total number of outbreaks of food poisoning included in this series twelve were attributable to rice pudding© An outbreak related to bread pudding and a number of others suggested an origin resident in egg powder© Actual confirmation was lacking. There is no doubt that a number of sporadic cases of food poisoning among American soldiers were due to this cause or at least to micro- organisms commonly demonstrated to be present in egg powder. The evidence contributed by British laboratory and epi- demiological workers* and the experience of the United States Army leads to the belief that egg powder was a far more pertinent factor in food poisoning than would be indicated by the actual record of confirmed outbreaks. The difficulties related to powdered egg presumably could arise from unsatisfactory processing* from an undue proportion of badly infected birds in certain regions* or from con- tamination of the materials in the course of packaging. Much pro- gress was made in the Zone of the Interior in developing standards for egg powder and in accomplishing improved methods of production. Food poisoning due to egg* both from toxin and infection* would ap- pear to be preventable. The problem has sufficient significance to warrant continued study. Prevention of Food Poisoning and Food-borne Infection.— Irrespective of whether an intestinal disorder is related to food poisoning or arises through food-borne infection of a specific infectious agent* preventive measures are based on the same general principles. Preventive programs are rarely directed against any single intestinal disease. Even when the difficulty is an epidemic of an individual member of the group* such as bacillary dysentery* the measures instituted are general in nature; for the conditions predisposing to widespread prevalence of any one of the group com- monly lead to increased incidence of several of the intestinal in- fections. A persisting high rate for intestinal diseases in a military or civilian population is commonly the cumulative effect of more than one. The situation in the field armies of the European Theater in the autumn of 1944 is in point. Furthermore* the measures to be applied either in pre- vention of the disease* or in the control of epidemics* are neces- sarily general in nature and directed toward improvement of the environment. No specific preventive measure exists for food poison- ing; they exist only for the typhoid-paratyphoid group of the food- borne infections. Even with the latter diseases* control of the environment is the principle reliance. 20 The contamination of food which led to episodes of in- testinal infection took place in a variety of ways and at various stages in the process of preparing and serving the finished foods. In rare instances, the fault was in the ingredients from which the food was prepared. Contamination occasionally occurred in the course of storage of the food components. Much more commonly it came in the course of preparation, either from extraneous sources, from dirty utensils, or most common of all from the fecal dis- charges of the cook or his helpers. Contamination that entered in the course of serving was a lesser consideration, because of the lack of time for multiplication of bacteria, the resultant low dosage, and consequent ingestion in nearly innocuous amounts. Since people were primarily involved in the genesis of food poison- ing or of food-borne disease, either through their own carelessness in personal habits, or through lack of information on the sources of food infection, it followed that the first requisite in a program of prevention was education. Educational measures designed to limit transmission of intestinal infection by food were directed toward two groups of individuals. The general military public was the main consideration—the soldier of the army. A second and limited special group included food handlers, cooks and their assistants. Educational Program.—The general educational program for the soldier depended principally on unit training. Methods for limiting intestinal infections formed a part of instruction in general health measures. Details of the lectures and discussion hours are beyond the province of this discussion. In addition to this personalized instruction, emphasis was placed on local poster campaigns; various moving pictures were used; and other methods of visual education employed. From time to time, unusual conditions made desirable a theaterwide approach directly to the soldier. Illustrative of such a circumstance was the impending departure of troops to a life in the field after the long period of training in the island base of Britain. Special discussion hours—briefing in the parlance of this war—were devoted to familiarizing the soldier with the new conditions that he would encounter in a world he knew little of, on continental Europe. All didactic and routine considerations were discarded. This was a straightforward talk about the spe- cific situation to be met. It was assumed that the soldier knew the principles of good field hygiene. He was told of night soil fertilization of fields, of the ubiquitous honey bucket of France, of the vindangeur, and of roadside, curbside and doorstep freedom of the population in meeting the calls of nature. He was ac- 21 quainted with the risks these practices brought to the use of fresh fruits and vegetables, to an extent wholly foreign to most American soldiers. When the line stabilized in northern France and on the Ger- man border in late 1944,, a life in foxholes became the existence of the memento A series of articles was published in the army news- paper, Stars and Stripes, on the general theme of how to keep house in a foxholeo An appropriate division of space was devoted to advice on how to run the foxhole kitchen; in other words, how the soldier could protect himself from food-borne infection under a most difficult kind of life. Discussion groups under the auspices of the publication known as Army Talks used the same material0 The special instruction of food handlers fell to the re- sponsibility of unit mess officers and unit mess sergeantso It was individual and intimate instruction, the most practical approach. This effort was reinforced by more formal training in schools for cooks and bakers, conducted by the Quartermaster Corps at the Ameri- can School Center, and participated in by members of the Preventive Medicine staff. One nutrition officer was assigned to full time duty at the school, both while it was in England and later in France. Another training procedure for food handlers came through the agency of traveling teams from the Subsistence Division of the Quartermaster Corps and the Nutrition Branch of the Preventive Medi- cine Division. No little part of the daily work of nutrition of- ficers in the field was likewise devoted to mess management, with advice and instruction given on a personal basis to mess officers and mess personnel. Direct educational measures in messes made use of signs and posters which dealt with food waste, the inherit dangers of leftovers, the need for handwashing, and other matters of personal hygiene on the part of food handlers. Unit medical officers were reached primarily through the circular letters of the Office of the Chief Surgeon. The technical medical bulletins of the War Department furnished more general types of information. Other professional information was published from time to time in the Medical Bulletin of the Office of the Chief Surgeon, including such subjects as the occurrence of the diarrheal diseases in the European Theater, and the methods that were avail- able for the laboratory diagnosis of the intestinal diseases. One leading article was contributed by the Chief Surgeon himself, when he wrote on "Let's Stop Scrubbing.” He brought out the advantage 22 of getting a kitchen really clean, and then trying to prepare a meal with an honest effort to avoid making any dirt« .Cleanliness of Messes and Kitchen EquipmentjJk-The great number of persons in a military organization responsible for the inspection of messes inevitably led to a situation where many of- ficers and non-commissioned officers of limited experience had of necessity to be entrusted with these duties. There was consequently a need for carefully thought out instructions if they were to bring out the more important considerations. A particularly good order on the subject was issued by one of the base sections of the Communications Zone. It dealt with the protection of foods, the inspection of messes, the precautions to be observed in the preparation of food, and the washing of mess kits and utensils. The cogent directions in respect to general cleanliness and order of kitchens included prohibition of common drinking cups, the observance of orderliness in the placing and hanging of utensils and direction that tables, benches, and blocks were to be scrubbed with hot, soapy water after each meal. Soiled rags were not to be left on work surfaces; ovens and stoves had to be thoroughly cleaned, and flies and other insects eliminated by all means available. Mops were to be cleaned by immersion in boiling, soapy water and neatly arranged, suspended with mopheads down and away from walls and furniture. Kitchen and mess hall floors had to be washed daily, avoiding excessive amounts of water. In the event that the kitchen and mess floors were earthen or gravel, extreme caution was to be exercised in avoiding spillage. If that occurred, three percent borax solution was directed to be sprinkled on the ground to aid in the prevention of fly breeding. In any event, floors were to be raked daily or more often if necessary. Mess advisers of the Quartermaster Corps and the Nutrition officers of Preventive Medicine did much to establish the principle that an inspection must needs be constructive and educational, as well as supervisory and administrative. All sorts of little affairs contributed to the disorder of messes and the potentiality of food infection—the practice of stacking benches on mess tables during scrubbing, failure to keep the surfaces of meat and vegetable cut- ting tables planed smooth, and the use of battered wooden paddles which collected food and dirt. The location of garbage cans and waste baskets often determined the extent to which they are used. People with dirty and wet shoes were not permitted in kitchens. Doughs should be mixed on the center of tables, instead of at the edges. Pots and pans with dirty bottoms were not to be put on clean stoves, and tables and garbage cans were to be immediately at hand when potatoes were peeled or peas shelled. 23 All of these matters involved the prevention of dirt and dis « order., to the end of maintaining clean kitchens and avoiding the final grand clean up* The stress placed on the individual soldier to keep his mess gear clean was not always accompanied by the same degree of attention to kitchen utensils,, pots and pans and other equipment of the kitchen itself* They many times suffered poorly in comparison,. To prove that a dirty mess of itself was the direct cause of an outbreak of food poisoning was never possible* but at least there was no surprise when trouble occurred in instances such as the followings EPIDEMIOLOGIC CASE REPORT NO* 12 - An outbreak of food poisoning involved about 50 men of Depot E-508P, 24 Novem- ber 1944o Inspection of the mess subsequent to this episode showed the io*e cream freezer to be a health hazard since it was so full of cracks and rough seams that it-was impossible to clean it properly0 Due to lack of hot water, kitchen utensils* knives* forks* spoons and dishes were not being properly washed and sterilized,, Compound germicidal rinse had never been used* Dishes wore air dried but greasy® Knives* forks and spoons were greasy and were being wiped with unclean towelso Sinks were dirty and utensils were greasy0 Staphylococcus aureus was isolated in moderate numbers from the turkey which was the principal dish of the meal® Bacillus aerogenes was found in moderate numbers in the dressing* and the gravy contained Staphylococcus citreus* No organisms were isolated from the tea* Condiments con- tained small numbers of Staphylococcus albus and the millf mixture for the ice cream contained a moderate number of Staphylococcus aureus* There was every indication then of contamination of several elements entering into the food* The general state of the mess readily suggested how that could have com© about* The first emphasis in mess management was thus on cleanli- ness* and its accomplishment was sought through education and through intelligent inspection* Some basis might exist for the belief that the severe ritual of cleanliness in kitchens was overdone in military practice—that the effort expended was out of proportion to the rela- tive danger from environmental dirt—were it not for the knowledge that the general state of cleanliness of a mess was about the surest index to the level of mess practice* (Figure 3) If floors and stoves were in a slovenly state* the people in the kitchen were also likely to be so* And it is granted that people are responsible for most food-borne infection* 24 Figure 3 Transient Mess, Lerouville, France, Jure 1945. Limitation of Flies and Other Insects,—The activities of flies and other insects in the spread of intestinal infections are almost wholly concerned with the contamination of food. It was never- theless impossible to single out any given situation where with surety it could be concluded that an outbreak of food poisoning or food-borne infection was directly traceable to flies, Other existing circumstances usually suggested an equal importance; for like general untidiness, an otherwise circumspect mess rarely had the single fault of a fly menace0 It was by no means impossible, however, to determine situations where flies were in all likelihood a major consideration, EPIDEMIOLOGIC CASE REPORT NO, 13 - An outbreak of 26 cases of food poisoning occurred in Bishops Cleve Camp in the United Kingdom, 14 July 1942, Many flies wore found in and near the kitchen. There was an inadequate mess kit laundry. Latrines were not flyproof, and pollution of the ground surrounding the kitchen area with human excreta was by no means uncommon, A manure pit near the kitchen showed the presence of many fly larvae, A bizarre source of difficulty in respect to insects was en- countered in the early days of the Normandy campaign. Field messes were almost universally plagued by an outspoken infestation of bumble bees. The control of these insects gave entomologists more trouble than the fly problem. Considering the situation as a whole, the prevalence of flies in Great Britain was never great, although local problems were not absent. Flies were more of a concern on the continent, but no more than would hold true for most parts of the United States during the summer months. It was not believed that fly-borne transmission entered very pertinently into the frequency of intestinal infections. The control of flies formed a part of the program for prevention, but not a major consideration. Inspection of Foodstuffs,—Inspection and certification of all products entering into the preparation of foods was found to be an important part of a preventive program. This service was provided by officers of the Veterinary Corps for foods of animal origin, and in addition they took an important part in the inspection of food stuffs in general, Actual existing contamination or infection of food ingredients as delivered to unit messes was an unimportant consideration among , causes of food poisoning. Much of the basic food received at army mes- ses came in cans. The modern development of the American food packing industry, and the rigorous control which took place at the source, eliminated any appreciable danger from canned foods. 25 Theater regulations required all personnel employed in receiving or issuing canned goods in storage* particularly meat,, meat foods and dairy products* to he instructed as to what constitutes a sound can* Badly dented cans and those with any odor were to be put aside for ultimate inspection by a veterinary officer0 Warehousing personnel were instructed to make careful daily examinations for the presence of foreign odors or mustiness in the storage rooms* This was done before work began* and while doors and windows remained closed* It was recognized that complete inspection of canned goods was im~ practical and reliance was placed on frequent spot checks* A number of outbreaks of food poisoning were recorded in which suspicion was directed to a presumably improperly sterilized can of food as the source of infection* but the evidence was always such that contamination after opening the can could not be eliminated* Other cans of the same lot were often shown by laboratory examination to be in- nocuous* Only an occasional outbreak in this recorded experience could be considered with any assurance to have arisen from contaminated food ingredients* The instance cited below is suggestive* but the evident faults in mess management may have been more than contributory* EPIDEMIOLOGIC CASE REPORT NO* 14 - Pood poisoning at the Camp Malpas port of embarkation camp on 19 March 1944* in- volved about 80 men of three companies who ate at a single mess* Food histories incriminated chicken* served principal- ly at the noon meal and to a few men at the evening meal* The chicken had arrived at the-* camp in the frozen state on 17 March 1944* Some of the meat appeared spoiled* and a veterinarian who was called condemned a number of chickens* Tiie remainder were thawed in water on 18 Iferch* and the entrails removed* The meat was boiled for two hours in the evening* removed from the carcasses largely by hand* and set aside in roasting pans in the meat room* The following morning a hot cream sauce was added* and the chicken warmed for the noon meal* Some of the creamed chicken that remained was kept on the stove and served for supper* However* the officer on duty ordered it thrown away before many men were served* as it did not appear right* Other than occasional similar instances related to poultry* the difficulties ascribed to infected ingredients were largely limited to powdered egg containing Salmonella bacteria or their toxins* the detection of which was beyond the limitations of field inspection of food materials* Outbreaks due to this cause have been described in a previous section* Fresh vegetables and fruits gave little concern* No great amounts were used because of the theater policy of importing from 26 America the great bulk of food required by the United States Army* Local purchases were essentially limited to potatoes and root vegetables. Food prepared from cereals were a common source of food poisoning outbreaks, but the difficulty was in their prepara- tion, not in an innate fault of the materials themselves. All of milk used in the army was either canned or in powdered form; and what danger existed from this source was related to its reconsti- tution and subsequent storage. Protection of Stored Basic Foods.y-The_American forces in the European theater encountered were foreign to the experience of most, in that there was relatively little provision of refrigeration, even to fixed units of the Services of Supply and of the Air Forces6 Essentially none was available to Ground Force units* This required more than usual attention to proper methods of storage* Construction specifications provided for screening of food storage rooms, kitchens, and mess halls, but the requirement was by no means universally met* Food storage rooms were required to be kept scrupulously clean, with stores arranged in a neat and orderly manner* Food was to be stored in a cool, dry place* In the absence of refrigeration, repeated attention had to be given to the all too common practice of storing foods in places that were too hot, in the corners of kitchens and in heated buildings* There was too often the attitude of no refrigeration, then put it anywhere; instead of a genuine effort to get the coolest possible storage. ■ Flour, sugar, bread, and similar items were required to be kept covered* Bread boxes were directed to be constructed, using mosquito netting to afford proper ventilation. Special instructions had to be issued in respect to the transport of bread, because of particularly bad practices that had become altogether too general. It was required to be protected from the sides and floors of dirty trucks by the use of boxes and cartons* Frozen meats, which were the common source of supply, were left in the original containers, stacked closely together so as to aid in preservation until used* The general recommendation was made that frozen, ground meat was to be used before other meat, even if it involved changes in menus* Greater frequency of meat issue was advised when local conditions made meat storage difficult or unsound. All packages, boxes, and bags were stored at least one foot off the floor. Vegetables were stored in bins that permitted proper ventilation, and were sorted daily to remove rotten or spoiled materials* All perishable items were directed to be rotated in order to insure proper utilization of food stuffs* The continued and stringent attention given to the storage of basic foods in military practice would suggest that contamination after receipt at the unit storeroom in good order, was a common and likely source of food poisoning* And yet this large 27 experience does not contain a single instance in which an epidemic was ascribed to spoilage during storageo Perhaps it was because of the outstanding attention given this feature of food protection that so little difficulty was encountered,, Improper Mess Management0--An analysis of some hundreds of food poisoning epidemics of varying size, and the observations arising from practical experience in the field, gave evidence that the most frequent source of danger of food poisoning epidemics was in the course of preparation of food0 Contaminating bacteria may enter food in so many ways that only general principles can be citedo Food may become a potential source of infection whenever dirt enters it. The first requisite therefor is to keep a clean kitchen,, The emphasis placed on that consideration in military practice is common knowledge, and it is thoroughly justified,. Nevertheless it was most unusual in the course of an investigation to find agreement or acknowledgment among mess personnel that a dirty kitchen was ever the cause of a given out- break,, The tendency was always to attribute the difficulty to some defective food, or to the water supply, or to any condition lying outside the kitchen,. But most causes of food poisoning were within kitchens 0 I The basic training of cooks and bakers was of such quality that little necessity existed for stressing the need of thorough cooking of meats, custards, puddings and filled pastries„ If there was a tendency in army cooking, it was to overcook rather than undercooko Three kinds of bad practice were, however, altogether too commono They required continued effort in correction and prevention,, They were responsible for a large proportion of the outbreaks of food poisoning among the commando Too Early Preparation--The first to be mentioned was the preparation of food too far in advance of the meal at which it was to be servedo To a degree, this was unavoidable„ The preparation of food for large bodies of men who had to be fed within a limited period was a matter of no easy accomplishment, especially with the limited facilities that were too often available in army kitchens„ The direct result was that hours were spent in the preparation of a given meal and that certain items, of necessity or by reason of the cook’s convenience, were prepared long hours in advance,, The important consideration was the proper choice of the foods to be prepared in advanceo Some articles of food conform to such preparation; others do not without introduction of unwarranted hazards„ Altogether too common a practice, which of course obviated reheating, was to prepare foods far in advance of serving and to set them aside in pots or warming pans on the back of the stove where they remained neither hot nor cold, but to all practical purposes maintained the temperature of a good bacteriological incubator« (Figure 4) 28 Figure 4 Kitchen stoves as Storage Places for Cooked Food, 155th General Hospital, England, 1944. EPIDEMIOLOGIC CASE REPORT NOc 15 - A small group of men of the 825th Convalescent Center, 17 in all, developed an acute intestinal illness as a result of eating hot dogs at the unit night mess, 25 February 1945c The frankfurters ar- rived at the mess hall in the frozen state, early Saturday morning 24 February 1945. They were put on the kitchen table and allowed to thaw in the course of the next four hours. They presented no unusual odor or appearanee• They were steamed between 1000 and 1.100 hours and served at the noon meal. Those loft over were reheated at 1700 hours and served for supper« About 40 or 50 frankfurters still remained. They were left standing in the pan on the back of the stove and reserved at the midnight mess, being dispensed from the pan on the stove where they had remained warm since 1700 hours. Only those eating frankfurters at the midnight mess became ill. Given sufficient time, the bacteria contained in foods so treated had ample opportunity to multiply. Large doses of organisms were produced, capable of setting up an infection of the human host, or of providing sufficient toxins to produce violent symptoms shortly after ingestion of the food. Long Storage at Rood TemperatureeV-A similar practice, but greater danger IT©cause of tne type of food to which it was ordinarily related, was the early preparation of desserts and their subsequent storage at room temperature for long periods. A corner of the kitchen was commonly selected, with no attention given to preliminary cooling. The result was that the food remained warm for considerable periods, depending on the room temperature and the size of the container0 Lack of proper covering and protection from flies and other insects sometimes contributed to the danger0 The long holding on the stove in course of preparation was usually no more than carelessness« The latter practice was so palpably dangerous as to present little excuse. EPIDEMIOLOGIC CASE REPORT NO. 16 - An outbreak of food poisoning at the 96th General Hospital in Great Britain involved 652 patients and some few attendants among a hospital population of 976. Food histories served to incriminate pumpkin cobbler as the food concerned. It was served at two meals and only those who ate this food at one or the other meal were ill. The food was served only in the patients mess and only those who ate there were affected. The cobbler was prepared between 1800 and 2400 hours on 5 November 1944, and stored in the pantry at room temperature until served either 12 or 18 hours later. 29 Because of the frequency of such episodes as that described, measures were taken to require special care in the preparation of dishes such as creamed foods, hashes, reconstituted powdered eggs and milk, custards, puddings, and desserts with creamed fillings* These foods were directed to be prepared as close to the time of serving as possible and in quantities no greater than could be used at one time. Egg powder and reconstituted dried milk were to be prepared no more than one hour before use0 Meats including poultry were not to be thawed in water, near hot stoves, nor in the sun, but allowed to thaw by natural process in a cool place* The thawing of poultry in water was appreciated as being a particularly pernicious procedure. The meat was not to be cooked at night for use the following day. With the exception of the canned corned-beef hash which was a substi- tutive part of the ration, hash was not to be served as food unless freshly prepared* Leftover Foods.--Food conservation was a matter of military importance/ since all to be brought long distances by sea. As a result shipping allotments came to have a strong influence on mess management, because food that could be saved affected the re- quired theater allotment of tonnageo A strong emphasis was placed by command on avoidance of waste. (Figure 5) Inspectors gave this matter much attention and the penalties imposed for infractions of regulations were decidedly severe. Food conservation received more emphasis in the Services of Supply than in other major commands, to the extent that it was sometimes overdone# This had a direct affect on the rates for food poisoning which were greater in the Services of Supply than in other branches of the service. EPIDEMIOLOGIC CASE HEPORT NO. 17 - Fresh creamed peas were served at the evening meal on 21 July 1943 to the mess of Headquarters Company, A Company and Idle Officers1 moss of the 850th Engineer Aviation Battalion. Half of the creamed peas were consumed at the evening meal. The remainder was put in one large and one small aluminum con- tainer and stored at room temperature at the end of the mess hall. About 18 hours later both containers were re- heated for the noon meal of 21 July# The small container was placed on the mess line and served to the enlisted men. The officers mess used peas from the large container, which was then delivered to the mess line. There a cook noticed that the peas "smelled sharp" and they were discarded. Thirty-five officers and eight enlisted men were treated for gastro-enteritis in addition to an unknown number too mildly ill to require medical treatment. The large con- tainer obviously cooled more slowly and maintained a more 30 Figure 5 Food Conservation, Oise Section, Gonununicati on Zone, June 1945. favorable incubation temperature for bacterial growth over a longer periods Peas from the smaller container gave rise to no food poisoningo By choice* leftover foods should be conspicuous by their absence0 Effort was made to keep them at a minimum* through careful estimate of the amount of food required for each mealo If leftovers did occur* they were to be stored in shallow containers in a cool place* kept covered* and thoroughly reheated just prior to serving* which should be no later than the next meal0 It was stressed that reserving of overnight leftovers was extremely hazardous. The possibility was emphasized of limiting the amount of leftovers through careful estimate of the amounts of food required for a given mealo Palatability was stressed as a means of holding leftovers to a minimum. With the most careful practices* however* difficulties still occurred. It was one of the difficult problems of mess management. Treatment of Raw Fruits and Vegetablesi~-The management of raw fruity and vegetables was a minor concern for troops stationed in Great Britain* because of the scarcity of supplies and the relative infrequency with which such food materials were purchased on the open market., Moreover* the conditions under which fruits and vegetables were produced were such that no more danger was involved than in American practice» Conditions were otherwise when the troops went to the continent* because of the common practice of using human feces in the cultivation of fruits and vegetables0 In the early days of the campaign a strict prohibition was placed on the purchase of these itemso A later regulation provided that fresh fruits and vegetables could be eaten if first carefully cleaned mechanically and then either cooked or* if eaten raw* were first treated with mikroklene* compound germicidal rinse0 This involved thorough washing and trimming of all portions of the food* and the removal of soiled and damaged parts0 Leafy vegetables were separated into individual leaveso All portions of the vegetables or fruit were placed in clean containers* completely covered with the mikroklene solution* and soaked for 20 minuteSo The mikroklene solution was prepared by adding three to four ounces (one package) of compound germicidal rinse to 15 to 25 gallons of cold* clean water<> This solution was used once and then discarded,. After treatment* the vegetables were thoroughly rinsed in potable water <> Even with these precautions* the use of fresh fruits and vegetables was limited to those obtained through authorized Quartermaster procurement« Purchase by indi- viduals or by individual units remained prohibited.. 31 Experience in the treatment of vegetables and fruits by chlorine solutions indicated that the method had much merit. It is to be admitted, however, that it was not subjected to adequate controlled experiment. This remains to be done. Serving of Food,--Self-service was advocated and practiced to a considerable in the European Theater, principally as a moans of preventing food waste, (Figure 6) The advantages were many, but the method had inherent dangers and required rigid supervision. Particular care had to be taken about men reaching in- to food containers. The danger in respect to food eaten at that meal was likely minimal, because of the short interval between theoretical contamination and actual ingestion of the food. The dosage would necessarily be small. The principal danger came from subsequent serving of the food as leftovers. Food Handlers\-With due consideration of all other factors, the greatest danger offdod poisoning came from the people who handled food* They were the cause of most outbreaks * The attention that was directed to carriers was with good reason, but it was a firm conclusion from this experience that more trouble came from sick persons working in kitchens than from healthy germ carriers« EPIDEMIOLOGIC CASE REPORT NO. 18 - A most extensive outbreak of salmonella food poisoning involved only the enlisted men of the 316th Station Hospital on 2 January 1945, The source of infection could be traced with distinct assurance to the dressing of turkeys served at the evening meal, with strong suggestion of the activity of a carrier. At least one of the two cooks who prepared the dressing was determined to be a carrier of Salmonella Montevideo, and the same organism was found in the stools of no less than 160 patients who had eaten the food. There can be no argument that any cook or any mess at- tendant or any member of the kitchen police who is ill has no business in a mess. And yet there were many considerations in the ordinary day's work of military life which acted against the enforcement of that common sense procedure. Good cooks were few. Any kind of a cook was often hard to get. There was the factor of gold bricking and the usual shortage of mess attendants. The result was a common attitude of the man being well enough to work if he wanted to. Men with acute infectious disease, if no more than simple upper respiratory infection, were required to be excluded from duty concerned with the preparation of food, while the man with a gastro- intestinal upset was recognized as a special hazard. 32 Figure 6 Hot Food for Combat Engineers, Hamby, France, August 1944. EPIDEMIOLOGIC CASS REPORT NO. 19 - An outbreak of 84 cases of food poisoning at Depot G-22, 19 March 1944, brought out that one man became ill at 0900 hours on 14 Marcho He had chills, abdominal cramps, many bowel movements, and vomitted during the morning. This did not deter him from carrying on as KP in the mess. He finally became so ill that he reported to the dispensary, was treated, and told to go back to duty. He vomitted as he left and was too weak to return; he was still ill the following day. The outbreak of food poisoning was traced to the meal served that evening. Subsequent individual histories of 14 cooks gave evidence that six had had diarrhea within the past month, of whom two had been severely ill0 A principal deficiency was in the lack of attention given men with minor infected wounds of the hands where their duties involved preparation of foods. A furuncle or carbuncle on an ex- posed surface was usually understood to be a source of danger; the minor affairs not so much so, although they were frequently the apparent sources of staphylococcus food poisoning. EPIDEMIOLOGIC CASE REPORT NO. 20 - A total of 54 men of the 555th Ordnance HU (TK) Company developed food poisoning in October 1944. The symptoms were those of staphylococcus food poisoning. An inspection of the kitchen and kitchen personnel revealed a food handler with an abscess of the neck. He was removed from this duty. With full appreciation of the activity of carriers in food poisoning, routine stool examination of food handlers was believed to be an over-worked ritual. Theater requirements did provide for an X-ray examination of the chest as a part of the required general physical examination given food handlers, a consideration commonly neglected and believed to bo of principal significance. (Figure 7) The routine serologic test for syphilis was completely eliminated. There is no evidence that venereal disease was ever transmitted by a food handler, male or female, in the rigid practice of their primary profession. Examination of stools was dispensed with except in those instances where history or physical findings suggested an intestinal disorder. With the number of examinations thus limited, opportunity was given for more careful study of those samples as- sociated with real suggestion of trouble; in place of the haphazard attention which routine stool examinations usually have when they are made by the hundreds0 General experience has thoroughly demonstrated the lack of result and the undue cost of such routine examinations. The only exception to this policy was under circumstances of an undue prevalence of some intestinal infection. Bacillary dysentery, for example, became so frequent among German prisoners of war in one particular locality, that none were accepted for mess duty until baoteriologic examination of the feces had been made. The American Red Cross, in the conduct of their snack bars and club restaurants, were entirely dependent on civilian food handlers of the country in which they were located. Civilians were used to no small extent in army messes, even in the headquarters of advanced ground force units. Their control was decidedly difficult. Food handler examinations were not a common practice either in England or on the continent. Much prejudice had to be overcome, and that involved education. A food handler1s examination could not be required as a basis for employment, because help was too scarce and too difficult to obtain. By gradually introducing the simplest rules and then developing an appreciation of the need for such examinations, a fair system of control of this difficult group of workers eventually came into being. The standard examination included a brief medical history of recent and chronic illnesses, with special attention to infections of the gastro-intestinal tract; physical examination of the nose and throat for evidence of infectious disease; examination of the chest for acute or chronic inflammatory conditions of the respiratory tract to include X-ray of the chest; and physical exami- nation of the skin for evidence of communicable disease. Bacterio- logic examination of stools for the infectious agents of intestinal disease was made when the medical history indicated the possibility of a carrier state, and a serologic test for syphilis was performed only when indicated by physical examination or medical history, which was not often. These regulations for civilian employees corresponded in general to those prescribed for military personnel. Mess Kit Laundryo"Military practice has always stressed the propeV washing of dished and other eating utensils used by soldierso Several alternative methods were provided at various installations of the theater, depending on the circumstances associ- ated with messes and the type of operationso In static hospitals cooking and eating utensils were washed and scalded by use of dish washing machines, where the washing period was not less than 40 seconds with the temperature of the wash water held at 140°Fo or highero This was followed by rinsing for 20 seconds with the water at a temperature of not less than 180°Fo Where dish washing machines were not available, dishes and utensils were washed in soapy water and rinsed in hot water at 120° to 140°F. They were then immersed in boiling water for at least 1 34 Figure 7 Examination of Food Handlers, France, November 1944. minute. "When hot water was not available, the utensils and dishes were first thoroughly washed and rinsed, and then immersed for not less than 30 seconds in a chlorine solution containing at least 50 parts per million of free chlorine* All utensils were air dried. Dish towels were not used. Mess kits were rinsed in receptacles of clean, boiling water before using* After messing, the kit was cleaned by passing it through three suitable receptacles on the basis of 3 small (about 12-gallon) containers for 125 men, or 3 large (about 24-gal- lon) containers for 250 men* (Figure 8) The first receptacle con- tained hot, soapy water and the other two clear rinse water. The mess equipment was thoroughly washed in hot, soapy water and then rinsed in the two clear waters which were kept boiling* Where facilities for adequately heating water could not be provided, the last rinse water contained at least 50 parts per million of free chlorine. The solution was made by dissolving the contents of one box of germicidal rinse in not more than 25 gallons of water. An additional container with hot soapy water, to act as a roughing dip prior to using the first container of the mess kit line proper, was often used and found desirable and advantageous. A detergent compound (Gusto) was added to hard waters to facilitate the cleansing of mess kits, utensils, and dishes* It was used in conjunction with soap on the basis of one-half to three-quarter ounces per gallon of water. The procedure outlined above gave satisfactory results when hot water was assured. The main difficulty that arose in the field came from an inadequate source of heat* The Gold Medal Im- mersion heater, which was introduced into the theater by the 1st Armored Division and later came into very general use, solved a great deal of this trouble* Another practical difficulty was in respect to overloading of facilities, through use of a mess kit line by too many men* This always led to heavy contamination of the wash waters and inadequate sterilization of mess kits. The introduction in the European Theater of a pre- boiling treatment of mess gear before entering the mess line, was believed to constitute an addition of considerable merit. (Figure 9) During active operations, mess gear must necessarily be carried on the person during the day, with resultant exposure to dirt and contamination; or if stored, it was too often ac- complished under far from favorable circumstances* Despite the unavoidable deficiencies which of necessity enter into field practice, cleaning of mess gear in the European forces was believed to have been generally good. No precise 35 definition of an outbreak of food poisoning as arising from that source was ever determined, although it was suspected in many instances * EPIDEMIOLOGIC CASE REPORT NO. 21 - At the mess of the 507th Port Battalion, around 950 men normally used four mess gear wash lines composed of three soyer stoves each, with one soapy and two clear water containers. Periodi- cally, additional men were quartered there for varying periods and represented a substantial increase in the number of men to be fed. The washing facilities did not measure up to requirements. Water for washing mess gear at the docks was heated at the mess hall and hauled down in trucks. It cooled off a great deal before being used. As was usually true in such instances, the inadequate facilities for washing mess gear were not the only deficiencies of the mess. A common hand towel was provided in the kitchen for the mess personnel. There was improper attention to garbage cans, an excess supply of perishable food materials, and deficiencies in sewers and drainage. The vegetable storeroom was an open shed in the rear of the kitchen, and also housed the toilet. Theater Policy of Food Procurement as a Preventive Measure. —A most important factor that contriWteci to bKe favorab 1 e rates for the diarrheas and dysenteries was the theater policy that no purchases of meats, fish, poultry, marine and dairy products would be made from commercial sources. Whole milk was not to be purchased except on specific authorization by the Chief Surgeon. Ice cream from British commercial sources was likewise prohibited. Subsequently arrangement was made whereby ice cream could be manufactured in civilian plants for American troops if the ingredients were of Quartermaster issue and of American origin. The same provisions existed on the continent. These regulations served to limit food supplies to carefully prepared products shipped from the United States. The Control of Epidemics of Food Poisoiling0\~Several reasons determined the requirement of an epidemiologic study>of all outbreaks of food poisoning by unit surgeons of organizations in which such incidents occurredo One was the common inclination to take such out- breaks too lightly; to consider them nothing more than an inevitable part of military life* It soon became apparent that units with a severe outbreak of food poisoning commonly tended to have recurring epidemics* The self-limited course of most outbreaks of food poison- ing was appreciated* Rarely can much be accomplished in effective 36 Figure 8 Mess kit laundry in a unit of the XXII Corps, Munchen-Gladback, Germany, May 1945 Figure 9 Field Artillerymen sterilize their ness kits before eating, Lanfroicourt, France, October 1944. control or limitation of a given outbreak*, Much can be done in preventing recurrences, and that was the important consideration in requiring epidemiologic studies® The prevention of disease and the control of epidemics ordinarily constitute separate and individual fields in communicable disease practice; directed to the same end, of course, but involving a difference in view point and in timing® The prevention of disease has the purpose of keeping disease from coming into existence® The control of epidemics has the objective of repairing damage already done, and of limiting losses to the fewest possible cases® The epidemiologic study of food-borne outbreaks of acute intestinal infection, realistically considered, had more to do with prevention than control® The first objective in the study of an outbreak of food poisoning was to determine the clinical nature of the existing disease® Food poisoning is not an entity but a group of diseases® The clinical behavior of the condition often formed the basis for a logical search into sources of infection and modes of transmission® The kind of reaction experienced by patients and the length of incubation commonly suggested the nature of the causative agent® The second step was to obtain careful food histories from all persons at risk, within the military installation® Tabulations were made of foods eaten at the last four meals, of the nature of the items included in the various menus, the presence of leftovers, and the time of serving the meals® From these basic data, the article or articles of food common to all patients were determined® Army menus were characterized by a great similarity, and experience soon indicated which particular foods were to be suspected as the most likely cause of outbreaks® This matter of experience brought other factors of proba- bility into play® A consideration too little appreciated by mess officers and epidemiologists was the relative risk of the several daily meals® Few outbreaks of food poisoning were related to breakfasts® It was a simple meal and usually prepared shortly before serving. The main meal of the day, dinner at noon, accounted for most epidemics, and especially those of any size® As the most pretentious meal, it was often prepared in part considerably in advance of serving® The evening meal was less commonly concerned, with midnight suppers a law unto themselves, depending largely on individual mess practice in respect to leftovers® The likelihood of festival occasions being the source of trouble has been brought out in examples already cited® 37 EPIDEMIOLOGIC CASE REPORT NO. 22 - Breakfast at the en- listed men*s mess. Headquarters, Eighth Air Force, on 9 February 1944 consisted of grapefruit juice, scrambled eggs made from egg powder, reconstituted powdered milk, cereal and coffee. Acute food poisoning involved 33 men at about 1100 hours that morning. The outbreak was attributed to the milk, which all had taken, through its contamination by a dirty utensil or by a food handler. It had been re- constituted that morning. Breakfast outbreaks are uncommon. Few foods served then are open to suspicion. Reconstituted milk of relatively recent preparation is not one. Powdered egg has given rise to many outbreaks similar to that described in the above case report. At ary rate, having settled on the suspected food or foods, there followed a careful investigation of the history of preparation —how long and when was the food cooked, the names of the persons who prepared it, the method of storage and all other pertinent factors. The final step was to determine the source of the infection and the nature of the infectious agent. Identification of the bacterial cause depended upon labora- tory examinations of the food and of materials from patients suffer- ing from the disease. Bacteriologic cultures were made from feces, vomitus, and blood obtained in the acute stages of the disease. Later in the course, the blood was tested for the presence of ag- glutinins, and the titer compared with the level existing at the time of the outbreak or shortly thereafter. Food was examined for the presence of pathogenic bacteria. The ideal aim was to identify the infectious agent common to discharges of patients and to the food. In most instances, however, outbreaks of food poisoning came under investigation too late to obtain samples of the food actually served at the meal. Moreover, many diarrheal outbreaks were not due to infection but to intoxications, and isolation of pathogenic bacteria from the discharges of the patients would not be expected. In the rare instances where death occurred in the course of an outbreak, full information was required through examination of the body at autopsy. Control measures do not include isolation of the ordinary patient suffering with food poisoning. The disease is shortlived and there is little danger of person to person transmission. Patients with known or suspected infection with salmonella or dysentery bacilli were of course isolated. 38 If epidemiologic study indicated a likely origin of the outbreak from a carrier, examination of food handlers was a sig- nificant part of the control program,, In a general outbreak of food poisoning, food handlers were almost invariably among those affected® It was surprising to find how frequently action had been lacking in removing them from their duties during the acute illness and in assuring their freedom from the carrier state before returning,. If the epidemic gave indication of staphylococcus origin, search was made for minor infected lesions of the hands among food handlerso Rigid physical inspection was necessary,, Evidence of recent scars often gave evidence of customary practice„ Remedial measures in respect to the mess depended upon the probable source of the infection, as determined by the epidemiologic study,, Where this was not immediately and promptly evident, milk, water and suspected foods in common use were subjected to investigation and control until the definite cause could be determined,, An outbreak of food poisoning always gave excellent opportunity for a review and evaluation of messing procedures„ It is an old story in epidemiology that an outbreak of any kind gives opportunity for the health officer to bring into play an improvement of general conditions not otherwise possible of accomplishment,, This was one of the decided benefits derived from epidemiologic study of outbreaks of food poisoning„ Final recommendations contained suggestions for eliminating future events of the same order, and for improving the general character of mess management in the unit where the epidemic occurred,, 39 Table 1 FOOD POISONING* European Theater of Operations, U. S. Army Cases and rates per 1000 strength per annum February 1944 - June 1945 Total 1944 1945 Cases Rate Cases Rate Cases Rate January 122 .6 122 .6 February 293 1.1 123 1.7 170 .8 March 96 .3 7 .07 89 .3 April 568 00 • H 452 4.8 116 .5 May 237 .8 84 .8 153 ,7 June 71 .2 22 .2 49 .2 July 103 .9 103 ,9 August 129 1.0 129 1.0 September 12 .1 12 .07 October 204 1.5 204 1.5 November 624 4.1 624 4.1 December 323 1.4 323 1.4 Total 2782 1.0 2083 1.4 699 .5 Data were not available until February 1944. Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D.C. Place Total Epidemics Staphylo- Salmonella Bacteriologically Unknown, Clinically and Epidemic logically coccus Staphylo- coccus Type Salmonella Type Indetermi- nate Total United Kingdom 71 11 14 29 11 6 46 Continental Europe 44 6 2 15 5 16 36 Total 115 17 16 44 16 22 82 Source: Division of Preventive Medicine* Office of The Chief Surgeon, European Theater of Operations, U» S9 Army* 116 Selected Epidemics Occurring in the European Theater of Operations U, Sc Array 1943 - 1945 Inclusive FOOD POISONING Table 2 Outbreak Date Place Food Number Persons Involved No. 111 Percent 111 190th Field Artillery 1 Sept. 1943 United Kingdom Chocolate Pudding 44 \ 1512th Quartermaster Battalion 20 Octo 1943 United Kingdom Canned Tongue and Corned Beef Hash 29 135th General Hospital 29 July 1944 United Kingdom Bread Pudding 74 102nd General Hospital 24 Augc 1944 United Kingdom Rice Pudding Patients and Unit 219 485th (GS) Engineer Regiment 23 Nov. 1944 Continent Turkey and Gravy 118 1930th Ordnance Ammu- nition Co. (AVN) 23 Nov. 1944 Continent Turkey, Dressing, Peas, Ice Cream 182 72 40 Depot E-508 P 24 Nov. 1944 Continent Turkey, Ice Cream 50 AAF Station jf541 3 Dec. 1944 United Kingdom Ice Cream 11 Base Air Depot $2 7 Dec. 1944 United Kingdom Pork Sausage 48 166th General Hospital 4 Jan. 1945 Continent Rice Pudding 240 20 15 Staphylococcus Food Poisoning* European Theater of Operations 1943 - 1945 Table 3 Outbreak Date Place Food Number Persons Involved No. 111 Percent 111 Malpas Court Camp 9 Jan® 1945 United Kingdom Identity Unknown 136 556th Quartermaster Battalion 15 Feb® 1945 Continent Canned Beans 352 88 25 12th Replacement Depot 20 Feb. 1945 United K ingdom Bread Pudding 1003 349 35 825th Convalescent Center 25 Feb. 1945 United kingdom Sausage 17 241st General Hospital 21 Mar. 1945 Continent Bread Pudding 33 192nd General - Hospital 8 Apr. 1945 United Kingdom Ice Cream 399 112th General Hospital 14 Apr. 1945 United Kingdom Rice Pudding Approx. 500 101 20 Staphylococcus Food Poisonings European Theater of Operations 1943-1945 Table 3 Cont’d, Unit ' 4 , Date Place Food Origin Number Persons Involved Noo 111 Per- cent 111 175th Infantry Division 30 Jan® 1943 United Kingdom Salmon So enteritidis { Gaertner) 1200 42 825th Engineer Aviation Battalion May 1943 England Butterscotch Pudding So suipestifer 67 342nd Engineer Regiments G, So 1 Augo 1943 England Faulty washing of mess gear on range So aertrycke 1 Coo 5 101st Airborne Division Oct. 1943 United Kingdom Left-over potatoes Salmonella 61 453rd Amphibious Truck Company 22 Deco 1943 United Kingdom Identity unknown So Montevideo 23 79th General Hospital 11 Apr. 1944 North Ireland Rice Pudding So Montevideo 354 314th Station Hospital 17 Apr0 1944 England Identity unknown S, Montevideo 81 15th Tank Battalion, Camp D-6 15 July 1944 United Kingdom Identity unknown So group 4Q Salmonella Food Poisoning European Theater of Operations, U<, S„ Army 1943 - 1945 Table 4 1943 - 1945 . Unit Date Place Food Origin Number Persons Involved No. Ill Per- cent 111 278th Signal Pigeon Company 22-24 Oct.1944 Continent Identity unknown S. aertrycke 150 50 96th General Hospital 5 Nov. 1944 England Pumpkin Cobbler Salmonella 976 652 58th Armored Infantry Battalion 26 Nov. 1944 England Turkey and Dressing So Fewport 77 302nd Transport Wing 3 Dec<> 1944 United Kingdom Rice Pudding So schottmttlleri Hq & Hq Sqdrn 119 31Gth Station Hospital % 2 Jano 1945 United Kingdom Turkey S, Montevideo 200 10th Station Hospital 14 Feb. 1945 United Kingdom Identity unknown Salmonella 27 486th Ordnance Evacuation Company 16 Feb. 1945 Continent Identi ty unknown S, suipestifer 30 Depot, G-45 8 Apr. 1945 United Kingdom Mashed potatoes Salmonella 29 Salmonella Food Poisoning European Theater of Operations* U0 So Army- Table 4 Cont* do Table 5 Epidemic of Food Poisoning Salmonella Montevideo 79th General Hospital, North Ireland Distribution of cases by days April 1944 Date Number Cases 11 April 1944 28 12 April 1944 257 13 April 1944 63 14 April 1944 6 Total 354 Source: Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operations, Table 6 Salmonella Strains in American Dried Eggs Type Percent Bacto Orienienburg 42 Bacto Montivedeo 18 Bacto Bareilly 8 Bacto anaturn 7 Bacto meleagridis 5 Bacto typhimurium 3 Bacto Worthington 3 Bacto London 2 Bacto Derby 2 Bacto bovis-morbificans ♦Incompletely identified 1 10 *Two strains remain incompletely identifiedo Of the others most were subsequently identified as Bacterium Tennessee0 Other types since identified includb Thompson, gallinerum, Newport, Minnesota, and Bredeneyo Sources Emergency Public Health Laboratory Service, Ministry of Health, Great Britain0 Table 7 Outbreaks of Food Poisoning in England and Wales 1923-19 October 1943 i By Type of Salmonella Isolated Salmonella 1923- 39 1940 1941 1942 1943 Total Bacto typhimurium 228 31 35 24 48 366 Bacte enteritidis 52 16 6 8 10 92 Bacto Thompson 47 25 23 8 10 113 Bacto Newport 28 10 3 8 10 59 Bacto cholerae-suis 14 - 2 3 - 19 Bacto bovis- 8 2 - 2 4 16 morbificans Bacto Dublin 7 9 1 2 1 20 Bacto Potsdam 3 2 2 - - 7 Bacto Senftenberg 3 1 - 1 1 6 (Newcastle) Bacto Derby 2 - - - 2 4 Bact. Stanley 1 - 1 - - 2 Bacto Eastbourne 2 - - - - 2 Bacto London 1 10 - - - 11 Bacto Aberdeen 2 1 2 — 5 Bacto gallinerum - 1 - - - 1 Bacto to©wington - 1 - - - 1 Bacto Orienienturg - - - 11 24 35 Bacto Montevideo - - 2 1 13 16 Bacto anatum-lik© - 1 - 3 2 6 Bacto Bareilly - - - 1 3 4 Bacto Reading - - 2 - - 2 Bacto Braendorup - - - 1 - 1 Bacto Oslo - - - 1 - 1 Bact Virchow - - - 1 - 1 Bacto Chester - - - - 3 3 Bacto Kentucky - - ' - - 2 2 Bacto Muenchen - - - - 1 1 Bacto meleagridis - - - - 4 4 Bacto San Diego - - - - 6 6 Bacto sundsvall - - - - 4 4 Bacto Tennessee - - - - 3 3 Unidentified 12 2 6 1 2 23 To“bal 410 112 85 76 153 836 Note: Except for one strain of gallinerum, one Newington > and one anaturn-like organism, upper half of table shows types met with before, and lower half since importation dried egg into Great Britain0 Source; Ministry of Health, Great Britain® of American Table 8 Strains of Salmonella from Patients with Food Poisoning United States Army in Great Britain 1943 Salmonella Month Source anaturn group May 2nd General Hospital bovis- morbifleans June Cambridge Eo Po Ho Laboratory Kentucky June End General Hospital meleagridis October End General Hospital (2 Cases) Montevideo May June July September October End General Hospital End General Hospital 3rd General Dispensary 3rd General Dispensary 3rd General Dispensary Newport June October End General Hospital End General Hospital Orienienburg February April May May August September End General Hospital End General Hospital End General Hospital (2 Cases) 3rd General Dispensary End General Hospital End General Hospital (2 Cases) Tennessee June End General Hospital typhimurium August End General Hospital (2 Cases) enteritidis February Winchester Eo Po Ho Laboratory (2 Cases) Source: Emergency Public Health Laboratory Service, Oxford, England, 19 October 19430 FIGURES 1c Epidemic of Food Poisoning, Salmonella Montevideo, 79th General Hospital, North Ireland, Distribution of cases by days, April 1944o 2o Thanksgiving Turkey served to combat men. Continental Europe, November 1944. 3. Transient Mess, Lerouville, France, June 1945. 4c. Kitchen stoves as Storage Places for Cooked Food, 155th General Hospital, England, 1944. 5- Food Conservation, Oise Section, Communication Zone, June 1945. 6. Hot Food for Combat Engineers, Hamby, France, August 1944. 7e Examination of food handlers, France, November 1944. 8. Mess kit laundry in a unit of the XXII Corps, Munchen-Gladback, Germany, May 1945. 9, Field Artillerymen sterilize their mess kits before eating, Lanfroicourt, France, October 1944. TABLES 1* Food Poisoning, European Theater of Operations, U. S. Amy, February 1944 - June 1945, Cases and rates per 1000 strength per annumo 2. 116 Selected Epidemics Occurring in the European Theater of Operations, U. S. Army, 1943 - 1946 Inclusive. « 3. Staphylococcus Food Poisoning, European Theater of Operations, U« So Amy, 1943 - 1945 Inclusive- 4. Salmonella Food Poisoning, European Theater of Operations, U. So Army, 1943 - 1945. 5. Food Poisoning, Salmonella Montevideo, 79th General Hospital, North Ireland, April 1944o 6. Salmonella Strains in American Dried Eggs. 7. Outbreaks of Food Poisoning in England and Wales, 1923 - 19 October 1943, By type of Salmonella Isolated. 8. Strains of Salmonella from Patients with Food Poisoning, U0 S. Army in Great Britain, 1943. EPIDEMIOLOGIC CASE REPORTS 1. Staphylococcus epidemic from preparing food too long in advance. 2. Botulism from canned ravioli. 3. Botulism from home canned pickles of German origin. 4. Salmonella epidemic from rice pudding. 5. Salmonella outbreak with pigeons the suggestive source of infection. 6. Food poisoning from Christmas dinner. 7. Food poisoning from Thanksgiving dinner. \ 8. Turkey on New Years Day. 9. Salmonella infection from egg nog. 10. Salmonella infection from cooked powdered egg. 11. Food poisoning from scrambled egg. 12. Food poisoning from unsatisfactory sanitary conditions. 13. Food poisoning epidemic with flies suggestive contributing influence. 14. Food poisoning from contaminated food ingredients. 15. Food poisoning from storing food on stove. 16. Food poisoning from long storage at room temperature, 17. Food poisoning from left-over foods. 18. Food poisoning from salmonella carrier. 19. Food poisoning arising from patients with diarrhea serving as mess attendants. 20. Staphylococcus carrier in food poisoning. 21. Deficiencies in mess kit laundry as a source of food poisoning. 22. Breakfast outbreak of food poisoning. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19a - 1945 PART III - Epidemiology Section 2 - Intestinal Infections Number 3 - Typhoid and Paratyphoid Fevers Control of Intestinal Infections by Colonel John E. Gordon, M«C, Chief of the Division of Preventive Medicine Office of The Chief Surgeon, ETO TABLE OF CONTENTS FART III Epidemiology Section 2 - Intestinal Infections Number 3 - Typhoid and Paratyphoid Fevers Control of Intestinal Infections Page Typhoid Fever 1 Special Epidemiological Studies . . 1 Incidence of Typhoid Fever in the European Theater . . , « , 1 Sources of Infection 0 « 3 Previous Immunization Status . . . ...... . U Laboratory Confirmation of Typhoid Infections . k Typhoid in Civilian Populations of Continental Europe .... 5 Typhoid in Various Theaters of Operation} World War II . , 0 5 Typhoid Fever among Prisoners of ETO . 0 • 5 Paratyphoid Fever . . 0 . . . . 8 Prevention and Control of the Intestinal Infections ..... 9 List of Figures List of Tables List of Epidemiologic Case Reports part hi Epidemiology Section 2 - Intestinal Infections Number 3 -; Typhoid and Paratyphoid Fevers [Control of Intestinal Infections Typhoid Fever 0—It is an odd circumstance, even in a present day account of a military experience with intestinal infections, to find typhoid fever bringing up the rearQ Neverthe- less, it does; and on just about every count — in respect to num- bers of cases and deaths; from a military standpoint in respect to days lost from duty; and in medical interest both clinically and epideraiologically. Many others of the health records established by the European theater were more spectacular, but none was basically more astonishing than that there were in an army which reached a maximum strength of 3S064,562 no more than 46 cases of typhoid fever over a 4-year period0 The attack rate was 0o014 per thousand strength per annum0 For troops of the United States army serving in France during World War I the rate was Oo5300 The distribution of cases by years and by months is set forth in Table 10 The number of cases is sc small as to give no indication of the usual seasonal prevalence of the disease, except in the last year of the experience0 Special Epidemiological StudiesThe source of the data for typhoid fever differs from the general origin of most statis- tical Information presented in this discussion, in that reports and special investigations of the division of Preventive Medicine of the Office of The Chief Surgeon were the basis instead of the Statistical Health Reports0 Typhoid fever ranked high among special interest in epi- demiology o all reports of that disease coming to the Medical Records Division on the usual Form 86ab were submitted specially to the Epidemiology Branch for individual investigation0 The results of these studies were combined with the information gained from all other sources available to the Preventive Medicine Division to give the figures presented in Table lc Incidence of Typhoid Fever in the European Theatero~~The number of cases for the four years as reported by the Statistical Health Report was 63o There are a number of important errors of omission, as well as the inclusion of cases proved not to be typhoid or not chargeable to the American Arnjy, such as infections among civilians or displaced persons0 Considering each year in succession, no case of typhoid fever was included in the reports by Form B6ab in 1942, and yet an individual case record showed one patient with typhoid to have been admitted to a U.S, Army hospital in North Ireland. The case is listed in Table 1. Both series of reports contain one case in 1943. It is to be noted that this patient was not properly chargeable to the European Theater, in that he became ill on board ship in transit from Sicily with his unit and was admitted to hospital on arrival in the United Kingdom. Cases of 1944 included 17 in the Form 86ab series, 23 in that of the authenticated data. Six cases of the first series were eliminated; one because it was a second report of the case included under December, 1943> one a typhoid carrier was not a case; another reported through a clerical error, one a Coldstream Guard admitted to an American hospital, one a displaced person, and the sixth a prisoner of ware Through knowledge of the arrival at Marseilles from Oran of a transport carrying patients with typhoid fever, an additional twelve cases were added to the remaining eleven to make a total for the year 1943 of 23 cases. The group of 12 patients received into this theater should properly be charged against the Mediterranean area; but inasmuch as a general realloca- tion of cases of communicable disease was not practiced, they were received into the European totals. The discrepancy between the two series in 1945 was also well marked. The first series included 45 patients, the second 21, The difference came iboht through inclusion in the 86ab series of 13 prisoners of war with typhoid fever, and two displaced persons. This was in addition to five American soldiers originally suspected of typhoid infection but ultimately found to be suffering from other disease, and two instances of severe reaction to typhoid immunication. The geographic distribution of cases showed one infection to have been contracted in North Ireland, four in Great Britain, 28 on the European continent, and 13 patients to have been received into the theater already ill with typhoid or in the incubationary stage. The 28 continental cases included 7 from France in 1944 and five more in 19455 one from Belgium and one from Luxembourg; and 14 from Germany. The thirteen patients admitted into the theater with typhoid fever were all from the Mediterranean area, 12 from North Africa and one from Sicily. If the typhoid record of the European theater were based on cases properly chargeable against that command, in that infection arose within territory under its control, the number of typhoid cases during the four years would be 33, and the rate per thousand strength per annum 0o010« Two of the 46 patients with typhoid fever died, one in Sep» tember of 1944 and the other in March 1945. Both infections were contracted in the course of operations on the continent0 They were confirmed bacteriologically and in one instance by autopsy» One patient gave a histoiy of drinking water from an unauthorized source two weeks before onset0 No information was available as to the possible source of infection for the second„ The status of vaccination was also undetermined0 The average mortality for typhoid fever over the total period of the European theater was 0o00063 per thousand strength per annum0 Sources of Infection.—The first case of typhoid fever occurred in North Ireland in March 1942® Only five cases of typhoid occurred among troops stationed in Great Britain in the course of four yearso All were sporadic infections of which the following is typicals EPIDEMIOLOGIC CASE REPORT, N0„ 10 Corporal N0, 67th Fighter Wing, AAF, reported to sick call 18 Septem- ber 1944 with symptons of fever, nausea, diarrhea, and pain in the right lower quadrant, of a duration of three to four weeks. The Widal reaction was demonstrated to be positive on 23 September„ The patient was married to an English girl who lived on a farm near his station„ She and other members of her family had e xperieneed an unexplained fever during the time of the soldier’s illness0 During August and September there were five civilian typhoid notifications from the same community0 Corporal No received his initial typhoid vaccination in July 1943 and had had a stimulating dose of vaccine 12 July 1944. Typhoid fever on the European continent followed the same pattern as in the United Kingdom, in that all cases represented sporadic infections0 Case studies were always made, but the results were minimal so far as determining sources of The army was a moving army and by the time a man became ill, he and the medical officer who mad© the epidemiologic study were usually miles away from where infection took place0 A history of drinking water or taking food from unauthorized sources could usually be obtained but the significance of such information usually remained undetermined0 3 The following is illustrative; EPIDEMIOLOGIC CASE REPORT NO, 2. Pfc, L,K,, 143rd Infantry, was AV/OL from his organization from the first week in October until 19 February 1945» During that time he was living with a French civilian and eating and drinking water from civilian sources. His last typhoid vaccination had been received in August 1944, as reirnmu- nization after a preceding series. Becoming ill, he returned to his unit and was admitted to hospital the same day. Three days later,''blood and stool cultures were found to contain Eberthella typhosa. The only grouping of cases in the entire experience was that of the twelve patients who arrived by ship from Oran, Previous Immunization Status,—Satisfactory information on previous immunization status was obtained for 31 patients; with 15 remaining unknown by reason of absent records, inability of the patient to remember, or failure on the part of the medical officer to inquire. All 31 soldiers who gave definite histories had been immunized against typhoid, and only two had failed to meet current requirements of either a stimulating dose or an original series within one year. One instance of typhoid after proper immunization is illustrated, EPIDEMIOLOGIC CASE REPORT NO, 3. 2nd,Lt, J,J. was one of three officers in American Military Government living at Buchen, Germany, He was admitted to hospital 29 June 194-5 with an acute illness of four days duration, which was confirmed as typhoid fever by stool and blood culture. Typhoid was stated by German physicians to be endemic in the area, with 13 cases then existing in a village four miles distant. Displaced persons served as mess attendants. The patient had travelled in Czechoslo** vakia two weeks prior to becoming ill. The source of in- fection remained undertemined. The original series of typhoid inoculations was completed 9 October 1942, a stimulating dose was administered 11 November 1943 and a second on 14 July 1944o Laboratory Confirmation of Typhoid Infections,—The clinical diagonals of typhoid fever was known to have been sub- stantiated by laboratory examination of blood or stools, or by satisfactory serologic reactions, for 40 of the 46 cases. In- formation was lacking for four. Of two others determined as typhoid in the absence of lavoratory confirmation, a review of 4 the clinical histories left frank skepticism as to their -tyyphoidal natureo They were nevertheless included as typhoid in this tabu- lation o Typhoid in Civilian Populations of Continental Europe0—The relative freedom of American troops from typhoid fever did not arise from lack of opportunity for exposure0 The disease was particular- ly prevalent in France, in Belgium and Holland, and in Germany dur- ing military operations in those countries. It was present in many places where large numbers of American troops were stationed. For example, the city of St. Etienne had 570 cases with 27 deaths in the autumn of 1944c The city of Greater Liege, Belgium, had 104 cases, with the commune of Seraing an additional 44 for the period of 1 August 1944 to 18 November 1944 o That a military population cannot continually escape typhoid while operating in a typhoid in- feeted region is attested by the experience of the British forces near Caen where in the period 2 September to 11 September 1944, 68 cases were reported to have occurred in a brigade headquarters, in addition to those of two officers who visited the headquarters on 25 August 1944 and had one or two meals there. All patients had been immunized against typhoid fever. Typhoid in Various Theaters of Operation. World War II.— The rates for typhoid fever attained by the European Theater were by no means exceptional. The experience of the nine theaters of operation of the United States Army was much the same throughout the world. (Table 2). The Alaskan Theater had no typhoid fever. The rates for the North American, Latin American, Pacific Ocean Area and European theaters were on a par. The highest rate for a theater of opera- tions T«as that of the Asiatic Theater. The rate for domestic troops of continental United States was 0.01 per 1000 per year. It is to be noted that the number of cases and the rates recorded in Table 2 for the European Theater are derived from the Statistical Health Report, and are lenown to contain inaccuracies. The correct- ed rate for the European Theater is 0.014 and the number of cases 46. (Compare Table 1). Typhoid Fever among Prisoners of Ware £TQ0 V»The rapid- ly increasing incidence of the diarrheas and dysenteries that began among prisoners of mr in late April and came into full play during May, gave certain indication that difficulties were ahead in respect to the typhoid and paratyphoid fevers„ The record of pris- oners of war in respect to the two latter diseases had been excellent during the early months of the campaign, as good as that of the American Army0 Ahe German Army was well immunized, and as long 5 as an acceptable minimum of environmental sanitation was maintain- ed, prisoners remained free from typhoid infection. Accumulated evidence from many sources has led to the convition that immuni- zation against typhoid fever will not stand up in the face of extreme deficiencies in sanitation.. It didn't in World War I. It has not in other situations. Many epidemiologists have long sup- ported the doctrine that immunization against typhoid fever is to be considered an accessory protective measure of distinct'and very great value, but that the control of the disease is fundamentally dependent on sanitary discipline0 The conditions in May 194-5 that gave rise to such undue and exceptional prevalence of diarrheal disease inevitably had an effect on the typhoid rate. There was some indication of this in April. May brought realization. (Table 3)«. The usual frequency of typhoid fever in the German Army is not yet a matter of record. Medical intelligence indicated that it was decidedly at a low level. The conditions associated with the breakup of the German Army undoubtedly led to an increased frequency of the disease in the latter part of April. At least there were numerous admissions to hospital for typhoid fever among recently taken prisoners. Individual case reports for all patients represented in Table 3 are not available, but the date of admission to hospital was de- termined for 43-5 o The distribution by days, for the months of May and June, is presented in Figure 1, Table 4-o Prisoner of war patients with typhoid fever were admitt- ed to American hospitals every day throughout the first ten days of May. The number was 17 on 2 May 194-5® Prisoners were being received during those days literally by hundreds of thousands. Not all of the patients with typhoid fever were newly captured prisoners, but many were. The number of cases was far greater than had characterized the experience of the preceding month of April or indeed the last week of April. That not many infections had originated from prisoners who had been held for appreciable periods in prisoner of war enclosures, was shown by the appreciable decline in numbers of reported cases in the second week of May. About the twenty-first of May, essentially two weeks after the flurry that marked the early days of the month, the number of new patients began to increase but not to any great extent, although the last week of May saw what under ordinary circumstances would have been considered a fair-sized epidemic of typhoid fever, judged by present day standards. There followed a brief lull and then the full force of the epidemic struck, marking what was essentially the third wave of increased prevalence. The number of admissions mounted steadily through the second week of June, to reach a peak of maximum frequency on 11 June 194-5 6 1. Typhoid r ever 415 Prisoners of V/ar in the European Theater of Operations, Distribution bv day of admission to hosoital. May and June 1945. with 31 reported cases. The distribution b} days tapered off gradually in the succeeding two weeks to a point where the last days of the month saw a daily admission of only two or three patients. This sample of 415 patients is believed representative of the 4&2 reported as typhoid fever in the months of May and June, The two series set forth in Tables 3 and 4 differ in time distri- bution, because the first is by day of report as typhoid fever and the second by day of admission to hospital. In a number of instances the source of infection could be determined as lying within some particular part of the chain of evacuation from the front to the rear. Prisoners were ordinarily held for a few days in forward collecting cages, then moved toward the rear to a collecting point? and eventually evacuated to the larger camps well within a base section. Certain collecting points, gave good evidence of being the point of origin for the numerous cases of typhoid fever which developed in permanent prisoner of war camps some two weeks later, EPIDEMIOLOGIC CaSE REPORT NO, 4« Prisoner of War Enclosure No, 11 was a collecting point in Normandy Base Section for prisoners of war captured in Germany, Three prisoners of war received on 6 June 1943 were ill on arrival with a disease characterized by severe headache, prostration, and high fever. The next day nine more men reported ill, and thereafter daily additions were made to the roster of patients with a similar disease; so that by 25 June 1945 the number was 101, About a third of the patients had a rash of the abdomen, not affecting the extremities, face or back; and the fever was typhoid- al in type; The infectious process was confirmed by lab- oratory examinations as typhoid fever in a significant proportion of patients; and by pathologic examination after death in a number of instances. Most of the pris- oners had been captured in Germany about the first of May, They had been held in various enclosures in Germany and then forwarded to the Normandy concentration point. Those with typhoid fever were in large part from P1TE, A7, near Welgesheira, but a number of different enclosures were represented. In general, they had left Germany in the early days of June and had arrived in Norraany between 4 June 1945 and 8 June 1945» There had been no previous typhoid fever in the Normany camp, and the period of incubation would indicate that in most instances the 7 infection had been acquired after capture and in prisoner of war enclosures near the front lines. In some instances a carrier origin of infection could be determined. The epidemic would seem to have arisen from sources within German troops, and to have been disseminated to the extent that it was, largely because of the conditions incident to the end of the warc The breakup of the German Army, the crowding of prisoner of war enclosures and the loss of sanitary discipline were the import- ant contributing factors. The only available information on deaths from typhoid fever among prisoners of war comes from the records of the Advance Section of the Communications Zone, where among 403,14-2 prisoners there were 30 deaths from typhoid in the six week period from 1 May 194-5 to 1$ June 194-5. As would likewise be anticipated, the incidence of para- typhoid fever increased in parallel fashion with that for typhoid fever$ so that there were 4-16 cases reported for the months of May and June, to give a rate essentially that of typhoid fever. Paratyphoid Fevery—The record of the European theater in respec\, io the paratyphoid fevers was even better than that for typhoid. The data are included in Table 5. No cases occurred in 194-2 o was one case in 194-3 and four in 1944. The experience of paratyphoid paralleled that of typhoid in 1945# when more cases occurred during that year than in all others combined, 11 cases. The total for the four years was 16, and the average rate per thousand strength per annum for the total theater period was 0,00$. The number of cases occurring in Great Britain was two, and on the continent 14. The distribution of the latter included six infect- ions contracted in France, four in Germany, three in Luxembourg and one in Belgium. Like the data presented for typhoid fever, the informa- tion in respect to paratyphoid fever is drawn from special reports to the Division of Preventive Medicine. The number of cases re- ported in the 86ab series was appreciably greater, $6, with many instances where the tentative diagnosis of paratyphoid fever was changed to some other disease condition, There were a number of prisoners of war included. (Table 6) ; All cases of paratyphoid fever represented sporadic infections, except for a single instance where two patients from the same unit developed the disease, the 168th General Hospital. All cases included in this experience were confirmed bacteriolog- ically as paratyphoid fever. Twelve were paratyphoid B, and two 8 paratyphoid fever A. No deaths were noted in medical records of the theatero Prevention and Control of the Intestinal Infections.—Specif- 1C preventive measures exist only for typhoid fever and the para- typhoid fevers A and B. All troops were immunized against these conditions as prescribed by existing regulations, and continued effort was directed toward assuring by report and inspection that full protection was maintained by reiiamunization at the required intervalso The details of methods practiced in the European Theater are given in the section of this account devoted to specific immunization., General preventive measures constituted the main reliance in maintaining rates for intestinal infections at a respect- able levelo This applied to typhoid and paratyphoid fevers as well as to diseases lacking a specific protective agent0 The early diagnosis and isolation of patients with intesti- nal infection was considered as fundamental to good control as to good medical practice. The success of both was largely governed by the promptness with which the disease was recognized. Early diagno- sis was facilitated by publication from time to time in the theater Medical Bulletin of diagnostic criteria for the intestinal infect- ions, and information on laboratory aids to diagnosisc Isolation was regularly practiced for typhoid fever, paratyphoid fever and dysenteries, but not for common diarrhea nor for patients with food poisoningo The relative ease of access of most units of the theater to laboratory facilities permitted satisfactory accomplishment in the search for carriers and in their successful discovery. Car- riers were managed in accordance with the measures prescribed in army regulations0 The necessary precautions to prevent contamination of food have been discussed in connection with food poisoning. The sources and modes of infection, and the methods of interrupting transmission, were recognized there as by no means individual to those conditions. They apply equally to the limitation of food borne infection by members of the intestinal group of pathogenic bacteria. With modern environmental sanitation and the control of water supplies what it is, food is perhaps the single most important consideration, unless it be carriers. The primary con- trol of lapses was the function of unit commanders but unit sur- geons were greatly aided by the activity of the numerous nutrition officers of the theater, who took a great interest in mess manage- ment. The specialized knowledge and emphasis which these experts 9 brought to various units served to broaden and extend the level of accomplishment c. The proper safeguarding of water supplies has reached such a standard in military practice that a tendency exists to relegate its importance to secondary consideration„ It is no less important as a potential source of infection than a re foods0 Foods occupy the place they do only because breaks in technic are more frequent and the methods of assuring satisfactory performance are not as well definedo The general procedures that were employed in the theater are given in detail in the section of this history de- voted to sanitationQ It is only necessary here to mention the special measures instituted in continental operations in areas of particular risk of amebic dysentery. A coagulant was directed to be used by the standard mobile or portable water purification units for the treatment of surface waters in such amount as to give a heavy rapidly settling floc0 A minimum settling period of one hour was required for the batch system, using two sedimenta- tion tankso This involved use of three canvas water tanks, two for treatment and one for storage for each water purification unito Filter output was restricted to ten gallons per minute for portable units0 Chlorination was applied in such way as to maintain a residual of at least one part per million in accord- ance with standard practice0 When using Lyster bags and calcium hypochlorite (Grade A) ampules with surface waters not previously filtered, the chlorine dosages were required to be sufficient to produce one part per million chlorine residual after 10 minutes contact0 In addition, one ampule of calcium hypochlorite was added immediately after the chlorine residual test and an addi- tional contact period of 30 minutes allowed before using the water. The efforts directed toward destruction of flies and the prevention of fly breeding met many difficulties0 Screening of hospitals and camps, to say nothing of private dwellings, was not a regular practice in Great Britain, Construction speci- fications for new units to be provided for the United States Army, required screening of kitchens, mess halls and food storage rooms but the level of accomplishment was not always goodQ The same situation held for conditions on the continent. The addi- tion of DoD.T. to methods of fly control gave a method of great practical value under the existing conditions„ Flies were bad in a number of units from time to time but the problem was ordi- narily one of local nature0 In general the level of fly control was probably as good in the European Theater as it ordinarily is in civilian practice in the United States0 10 The disposal of human wastes constituted the final part of the general program for prevention of the intestinal infections. reference is made to the section on sanitation for the de- tails of the methods employed0 11 Table 1 Typhoid Fever European Theater of Operations, U.S« Army Cases and rates per 1000 strength per annum, by month and year February 1942 - June 1945 Inclusive Month Total 1 1942 1943 1944 1945 January 4 - - 3 1 February 1 - - - 1 March 6 1 - - 5 April. 3 - - - 3 May 3 - - - 3 June 8 - 8 July - - _ August - - - * September 4 - 1 - 4 October - - - November 13 - 13 December 4 - 1 3 Total 46 1 1 23 21 Rate .014 .014 .004 o009 .015 , Source; Division c 1 )f Preventive tfedicin* *9 Office of the Chief Surgeon, ETOUSA, Theater To Cases tal T- — 1943 1944 1945 Elates Cases Rates uases Kates uases Kates uases Kates Total Army 528 ,02 44 ' ,01 157 ,02 216 ,03 111 ,03 United States 89 .01 23 ,01 37 ,01 23 ,01 6 ,004 Overseas 439 0 05 21 ,04 120 ,08 193 ,06 105 ,04 China Burma India 93 ,28 8 1.42 21 ,46 51 ,32 13 ,11 African Middle East 23 .18 2 ,35 12 ,22 8 .17 1 .04 Mediterranean Theater 164 .12 0 0 62 .14 97 .15 5 ,02 Southwest Pacific Area 73 o 06 4 o 06 17 .09 14 ,03 38 ,10 Latin America 9 . 5 ,05 4 ,03 0 0 0 0 European Theater 33 .02 0 0 1 ,00 17 ,01 45 ,03 North America 2 .01 0 0 1 .01 1 ,02 0 0 Pacific Ocean Area 12 0 01 2 o01 2 ,01 5 ,01 3 ,01 . Alaska 0 0 0 0 0 0 0 0 0 0 Source; Division of Medical Statistics, Office of the Surgeon General, War Department, Washington D, C, Typhoid Fever Total Amy, Continental United States and Theaters of Operations Uc S, Amy, Cases and Rates per 1000 Strength per annum, January 1942 to June 1945, inclusive Table 2 Table 3 Typhoid and Paratyphoid Fevers Prisoners of War, European Theater of Operation, U, S, Army September 1944 to June 1945, Inclusive. Month Typho id Fever Paratyphoid Fever Cases Hates Cases Rates 1944 September October 2 o3 1 o2 November ■ - - - - - ----- December I.. — —. - 1945 January February — —— —— —— March 2 cl I,—— April 7 oi 3 ,05 May 29 o3 * 4 .04 June 453 2o4 412 202 TOTAL 493 1.1 420 o9 Source: Division of Preventive Medicine, Office of the Chief Surgeon, ETOUSA. Table 4 Typhoid Fever Among Prisoners of War European Theater of Operations, U,S. army Distribution by day of Admission to Hospital of 415 Patients May and June 1945 Day Number Day Number Day Number May 1 8 May 21 A June 10 A n 2 17 it 22 6 tt 11 11 n 3 A it 23 1 it 12 17 t» A 3 tt 24 0 tt 13 12 ft 5 7 it 25 8 tt u 17 ii 6 2 . tt 26 7 it 15 16 it 7 1 it 27 A tt 16 15 n 8 11 n 28 1 it 17 8 ti 9 1 it 29 A tt 18 6 it 10 11 ti 30 5 n 19 7 it II 1 n 31 1 tt 20 5 ii 12 0 June 1 3 ii 21 13 ti 13 3 it 2 5 it 22 6 tt U 0 it 3 2 tt 23 5 m 13 0 n A 12 it 2A A ti 16 1 n 5 10 tt 25 A it 17 2 it 6 2A tt 26 2 it 18 1 ii 7 25 1 >» 27 2 it 19 2 it 8 16 tt 28 3 it 20 0 it 9 23 it 29 2 Source; Division of Preventive Medicine, Office of Chief Surgeon, ETOUSA the Table 5 Paratyphoid Fever European Theater of Operations, UoS. Army Cases and rates per 1000 strength per annum, by month and year February 1942 to June 1945 Inclusive Month Total . 1942 1943 1944 194$ January - - - - February 3 - - - 3 March 1 - - - 1 April 3 - 1 - 2 May 1 - - - 1 June 4 - - - 4 July - - - - August - - - - September 1 - - 1 October - - - - November - - - December 3 - - 3 Total 16 - 1 4 11 Rates »005 - .004 .003 .008 Sources Division of Prever itive Medicine, Office of the Chief Surgeon European Theater of Operations, U. S. Arraye Total 1942 1943 1944 1945 Theater Gases Rates Case: Rates Cases Rates Cases Rates Cases Rates - . . Total Army 650 o 03 76 *02 165 .02 - 180 *02 229 *06 United States 71 o01 15 ,01 20 *00 29 .01 7 *005 Overseas 579 o 07 61 ,12 145 *09' 151 ,04 222 *09 African Middle East 80 o 61 52 9,06 13 *24 .15 *32 0 0 China Burma India 81 *24 1 *18 11 *24 45 '*28 24 *20 Latin America 68 e 19 6 *06 49 ,41 11 *13 2 *05 Southwest Pacific Area 116 *10 0 0 22 *11 12 ,02 82 *21 Mediterranean Theater 103 o08 0 0 45 *10 49 *07 9 *04 Pacific Ocean Area 74 *07 1 *01 3 *01 6 ,02 64 *31 Alaska 1 *004 0 0 0 0 0 0 1 *04 European Theater 56 *02 1 *01 2 *01 13 *01 40 *03 North America 0 0 0 0 0 0 0 0 0 0 Source: Division of Medical Statisticss Office of the Surgeon General s War Departments Washington s Do C* Total Army* Continental United States and Theaters of Operations Army9 Cases and Rates per 1000 Strength per annum* January 1942 to June 1945, inclusive0 Table 6 FIGURES 1. Typhoid Fever among 415 Prisoners of War in the European Theater of Operations, Distribution by day of admission to hospital, May and June 1945. tables 1. Typhoid Fever, European Theater of Operations, U.S. Army, Cases and rates per 1000 strength per annum, by month and year, February 1942 to June 1945 Inclusive. 2. Typhoid, Total Army, Continental United States and Theaters of Operations, U. S. Army, Cases and Rates per 1000 Strength per annum, January 1942 to June 1945, Inclusive. 3, Typhoid and Paratyphoid Fevers, Prisoners of War, European Theater of Operations, U. S. Army, September 1944 to June 1945, Inclusive. 4, Typhoid Fever among Prisoners of War, European Theater of Operations, U, S, Army, Distribution by day of admission to hospital of 415 patients, May and June 1945. 5. Paratyphoid Fever, European Theater of Operations, U. S. array, Cases and orates per 1000 strength per annum, by month and year, February 1942 to June 1945 Ihclusive, 6, Paratyphoid, Total army, Continental United States and of Operations, U. S..Army, Cases and rates per 1000 strength per annum, January 1942 to June 1945, Inclusive. EPIDEMIOLOGIC CASE REPORTS lo Typhoid Fever contracted from civilian sources • 2„ Typhoid Fever infection originating during a period of absence without leave 3o Clinical Typhoid Fever in a faccinated individual„ 4, Epidemic of Typhoid in Prisoner of War Enclosure. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19a - 1945 PART III - Epidemiology Section 3 - Acute Respiratory Infections Number 1 - Common Upper Respiratory Infection by Colonel John E, Gordon, M.C* Chief of the Division of Preventive Medicine Office of The Chief Surgeon, ETO TABLE OF CONTENTS PART III Epidemiology- Section 3 «= Acute Respiratory Infections Number 1 ~ Common Upper Respiratory Infection Page Introduction • . . . . . o . . 1 Classification of the Respiratory Diseases 2 Incidence of Total Respiratory Disease . . . 3 Deaths from Respiratory Disease. . . o . . 3 Common Respiratory Diseases, Including Influenza . . . 4 Racial Differences in Incidence. • . . • 4 Common Respiratory Infections in Major Components of the European Forces <> ........ 5 Acute Upper Respiratory Infection Among Field Armies • • 6 Comparison with United States Domestic Forces. • • • • • 6 Comparison with Other Theaters. « . • . « 6 Common Respiratory Infections Among Army Troops on Transports. • o • • .... .......... . 7 Control of Common Respiratory Infections. 12 v Administrative Measures • ... ..... 12 Personal Hygiene. .... .............. . 12 Environmental Measures. ..... ...... 13 Medical Measures. ........ 14 Special Measures. ......... • 15 Oiling of floors and Blankets 15 Aerosols in the Control of Respiratory Infection. . . . • 16 Chemoprophylaxis of Respiratory Infections • 16 List of figures List of Tables PART III Epidemiology Section 3 - Acute Respiratory Infection Number 1 -/Common Upper Respiratory Infection Under most circumstances and in most parts of the world the work of the day in epidemiology rests with the acute infections of the respiratory tract© From time to time an epidemic of some other communicable disease may dominate all considerations© Special circumstances may bring another group of infections into parti- cular prominence, or the nature of the environment may demand sus- tained effort on a problem like malaria** But ordinarily the respiratory infections account for greater numbers of infected in- dividuals than'do any other form of communicable disease© The epidemic potential of Influenza can rival that of the five classical quarantinable diseases, which in general cause the epidemics of the world* The death rate for the respiratory infections ranks well up among those from acute infectious disease of all formsj and from the standpoint of disability, in days lost from illness, in non- effectiveness of troops, this group is the leading consideration® In the European Theater of Operations the respiratory diseases were easily the most numerous among the acute infections $ S3 percent were of this nature© About 30 percent of all reported disease of whatever cause, infectious or non-infectious, fell with- in this category© The attack rate for respiratory infections of all forms, over the four years American troops were stationed in Europe was 165 per thousand per annum© This was not far from anticipated experience as determined by usual civilian standards for the age group involved, and by the rates which have endured for other armies in other wars© The death rate was materially less than anticipated© The average mortality per thousand strength per annum was 0©04, which is an enviable record in comparison with that of the American Army in France in 1918, when the rate was 9©75 per thousand per year© It was also a satisfactory record in relation to similar rates for American troops in continental United States during the current war, or by almost any other standard that might be selected© The principal reason for this favorable experience was the absence of any significant epidemic of respiratory disease during the entire course of operations© The single event of any moment was the outbreak of Type A influenza that occurred in the United Kingdom during the autumn months of 1943* In the number of deaths it caused, and in the number of persons -who were ill, it offered scant comparison with the pandemic of 1918 which was the major medical event of World War I* A new interest, not previously associated with military practice in other wars, came through the development of knowledge about primary atypical pneumonia, etiology unknowns The condition was easily the most important in the European Theater among respiratory infections* In attack rates it outdistanced primary lobar -pneumonia to such an extent that reported deaths approached in numbers those from the pneumonias of all other forms, despite primary atypical pneumonia being notably a disease associated with low case fatality* Classification of the Respiratory Pis eases *°— The nomen- clature of the acute respiratory infections is in almost as con- fused a state as that of the intestinal diseases* Again the classification employed by the Statistical Health Report will be followed* All acute infections of the upper respiratory tract to include the common cold, acute catarrhal bronchitis, acute coryza, acute catarrhal pharyngitis, acute catarrhal naso- pharyngitis, and acute catarrhal laryngitis are therefor grouped in these analyses under the general term of the common respiratory infections* Influenza will not be treated separately as its epidemiologic and etiologio identity might seemingly warrant* Due to the confusion and lack of definiteness which arises in the clinical diagnosis of that condition in non-epidemic times, and the tendency to call everything influenza when an epidemic does prevail, it will in all instances be considered and included with the common respiratory diseases* The only separate statistical consideration given influenza will consist of a simple demon- stration of the number of cases reported by years* The pneumonias will be considered under three categories: primary pneumonia, primary atypical pneumonia, etiology unknown, and secondary pneumonia* Primary pneumonia will be understood to include all pneumonias occurring in association with common respiratory diseases but will not include pneumonia secondary to influenza or to measles* Secondary pneumonia will include the pneumonias occurring with or as a complication of other diseases except common respiratory disease, as for example the pneumonias after influenza or measles* The term will also include post- operative pneumonias and pneumonias due to inhalation of chemicals* Primary atypical pneumonia, etiology unknown, will be shown as a separate entity* The pneumonias when spoken of collectively will be understood to include all three of the above categories* 2 If considered singly, the specific form will be designated® Total respiratory disease refers to all of the stated five di*= visions of this group of infections, the pneumonias, influenza and common respiratory disease* Incidence of Total Respiratory Pisease® — Troops in the field have repeatedly been shown to have more favorable rates for the respiratory diseases than when engaged in training with a more or less protected life in camps and barracks* The contrast is often as great as that between recruits and more seasoned troops, which likewise is a noteworthy feature of military experience in respect to the respiratory diseafees® During the first year of the European Theater, Table 1, the average rate for all respiratory diseases, 303 per thousand per annum, was a thoroughly satisfactory experience* taking into consideration that most of the men were newly arrived in a country having a climate that differed appreciably from that to which they were accustomed® Living conditions were often makeshift, and unit provisions and equipment which conduced to satisfactory management of the respiratory infections were often lacking® (Figure l) The rate of 421 per thousand for 1943, the highest for any of the four separate years of the European theater, reflects the effect of the extensive outbreak of influenza in the latter part of that year® The outbreak failed to carry over into 1944, which was indeed the most favorable of any within the experience of American troops in Britain® The Army moved to the European continent in June and operations there saw the best record for respiratory diseases of any second half year of the theater® In spite of a rugged winter campaign, the respiratory rate for 1944 was es= pecially good, with only 151 men per thousand affected® This very satisfactory experience was maintained in 1945, when for the first six months only 124 men per thousand contracted acute infections of the respiratory tract® Deaths from Respiratory Disease®-“The total number of deaths from all respiratory infections numbered 141® (Table 2) The average annual rate of 0®04 was very good, in comparison with the 9®75 per thousand for troops of the American Army serving in France during the last war® As a rate in itself, it constitutes a first class record, with due allowance for the favorable age group involved® Only 9 percent of deaths in the European theater from disease of all forms were due to respiratory infections® Among infectious diseases, the proportion was 31 percent® 3 Common Respiratory Diseases, Including Influenzao—The common upper respiratory diseases, particularly the common cold, are characterized in north temperate regions by two general waves of incidence, The first ordinarily makes its appearance in September and the second in February, This pattern was rather well met in the four years of the European war, except that the autumn wave of 1944 was somewhat delayed and the winter wave in all four years tended to appear rather earlier than February, January invariably marking the month of greatest incidence for these infections, (Table 3) Since the great bulk of respiratory disease is made up of the common simple acute upper respiratory infections, the behavior of these diseases by years was in close accord with that for respiratory diseases as a whole* The year 1942 was an ordinary year with an annual rate of 291, and the usual seasonal distribution. The best record was attained in 1945, while 1943 had the highest rate because of the epidemic of influenza that occurred during the autumn. The last two months of 1943 were heavily weighted by that outbreak. The number of reported cases in December 1943 was the greatest of any single month in this experience, while the months of November and the succeeding January of 1944 were characterized by a large excess of cases over normal expectancy. The rate during the height of the influenza outbreak, however, was actually not quite that of the pre- ceding January, 1943, The freedom from respiratory disease during the autumn of 1944 furnished a clear example of how well troops do in the field. The winter was relatively severe. The troops were engaged in a winter campaign, the first great winter campaign fought in western Europe, and the effects of the rigorous temperatures were evident in the undue frequency of cold injuries during that time. The December rate for common respiratory infections was nevertheless only 122, and the figure for the following January was no more than 166, Racial Differences in Incidence,—The rates for acute .in- fections of the upper respiratory tract including influenza were consistently lower for the colored component of the European forces than for white troops. This was true for troops stationed in the United Kingdom and for those serving on the continent, (Table 4) The ratio held during the course of the 1943 epidemic of influenza as it did during the periods when only common upper respiratory infections were prevalent. Indeed, the differences between attack rates for white and colored populations were more pronounced during the outbreak of influenza than during ordinary times. 4 Figure 1. Missen huts used for quarters at Fugglestone Camp, United Kingdom, 19^2. Common Respiratory Infections in Major Components of the European Forces©—The period of active operations in Europe, from June 1944 to June 1945, was particularly favorable in respect to the common respiratory infections© In fact, no similar period in the history of the theater showed to better advantage* A signi« ficant feature was related to the difference in rates for common respiratory disease shown by troops stationed in Great Britain, compared with those operating on the continent* The level of acute upper respiratory infection in the United Kingdom did not depart greatly from previous experience, although by comparison with other years in the United Kingdom it would be termed a good year© The principal contribution to the very favorable rate of the final year of the war came from the troops serving on the continent© (Figure 2, Table 5) This held true for all three major components of the forces of the theater© Of troops stationed on the continent, only those of the Ground Force Replacement Center had rates for respiratory diseases that compared with those of the troops then stationed in the United Kingdom© Of the three principal components of the army, the Com- munications Zone, the Air Forces, and the Ground Forces, soldiers of the Communications Zone consistently showed the highest rates, both on the continent and in the United Kingdom* but the record for continental Communications Zone forces was measurable better than for troops of the service stationed in Great Britain© (Figure 4, Section 3, Number 2) This was likewise true for the Air Forces in the two localities© (Figure 3, Table 6) No worths while comparison can be made for Ground Forces because the number of troops of the line in the British Isles was decidedly limited and rapidly changing, since the United Kingdom base served princi- pally as a staging area and also in the latter parts of the cam- paign most troops came directly to the continent from the Zone of the Interior© During the period of continental service, the Ground Forces had far and away the most favorable rates for common respiratory infection, the Ground Force Replacement Center being considered an independent command© (Figure 4, Table 7) In order of greatest morbidity from acute upper respiratory disease, the three services ranked in the order of Communications Zone, Air Forces and Ground Forces© This same relative position had characterized the pre- ceding year in Great Britain, when rates for common respiratory disease were at a high level due to the then current outbreak of influenza© (Figure 4, Section 3, Number 2) Throughout the entire course of operations, the highest rates for respiratory disease were generally to be found among Communications Zone units, with the Air Force and Ground Forces showing no great differences in 5 respect to each other, but both ordinarily more favorably placed than the Services of Supply# Acute Upper Respiratory Infection Among; Field Armies, —The 15th United States Army became operational only during the late phases of the European campaign* Its record from the last week in February until the end of hostilities was excellent, although the unit did not participate in operations and was not subjected to the same rigorous field conditions under which the other armies of the United States forces operated® Mo great difference existed between weekly rates (Figure 5, Table 8) for the First and Third Armies, although the full record of the First Army is slightly better® The average incidence of common respiratory infection in the Seventh Army was somewhat greater than that of the first two named, but not significantly so® The Ninth Army had decidedly the best rates of any of the four active armies in the field® It is to be noted that all four experienced sharply rising and equally rapidly falling peaks of incidence during the first week in February of 1945, that of the Seventh Army being the most pronounced and that for the Ninth least well marked, while the epidemic wave was longest maintained in the First Army. Comparison with United States Domestic Forces® —During two of the four years of the war period, 1944 and 1945, the annual rates for common respiratory disease, including influenza, were better in the European Theater than for troops of the United States Army serving in continental United States. For the first two years of military operations, domestic troops had the better rates parti- cularly in the 1943 influenza year, although it is to be recalled that influenza also existed in the United States at that time® (Figure 6, Table 9) The rate for the four-year period was 204 per thousand per annum for troops of the Zone of the Interior and 155 for those serving in the European Theater® The difference was not great and constituted a commendable record for any army operating in the field under climatic conditions not particularly conducive to favorable rates for respiratory disease® Actually the best com- parative showing by troops of the European Theater came when field operations in France were at their height. (Figure 7) Comparison with Other Theaters.—Average rates for the full period of military operations until 1 July 1945 showed the European Theater to occupy a middle position in relation to other theaters of operation® The overall rate of 155 per thousand per annum in Europe was exceeded by the Africa-Middle East Theater and North American, by the China-Burma-India Theater, and the Alaskan. 6 RATE 300 1945 Figure 2. Common respij'atory diseases including influenza. United Kingdom and Continental Europe, European Theater of Operations, II. 3. Army, admission rates per 1000 strength per annum by weeks, 1 3eptember 19a4 to 29 June 19A5 inclusive. RATE 400 RATE 400 RATE 400 ■•■BAT* not available 1944 1945 Figure 3, Common respiratory diseases including influenza. Air Forces and Communications Zone, United Kingdom and Continental Europe, European Theater of Operations, U. S. Army, admission rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945 inclusive. Figure 4. Common respiratory diseases including influenza, by major components on the continent, European Theater of Operations, U. S. Army, admission rate per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945 inclusive. Figure $, Comon respiratory diseases including influenza, by armies, European Theater of Operations, U. 0. Army, admission rate per 1000 strength per annum by weeks, 16 September 1944 to 29 June 1945 inclusive. Figure o. Common respiratory diseases including influenza. Continental United States, and European Theater of Operations, U. S. Army, admission race per 1000 strength per annum, by month, January 19A2 to June 19U5 inclusive. Figure 7 Winter quarters of the 394th Infantry Service Company, 99th Infantry Division, Sourbrodt, Germany, January 1945. The Southwest Pacific Area, Pacific Ocean Area, Mediterranean, and Latin American Theaters had better rates* (Table 10) The, best position ever attained by the European Theater among other theaters of operation was fourth in 1944 and 1945, and the most unfavorable comparative standing was in 1942 and 1943 when the rates ipu Europe were the highest among the nine theaters* kflgmmon Respiratory Infections Among Army Troops on Trans- port SoFrom the time that troop movements to the United Kingdom begaivln early 1942, voyage reports of transport surgeons gave account of a high incidence of acute upper respiratory disease among troops in transit from the Zone of the Interior® Appreciable out- breaks occurred, sometimes on board ship and sometimes shortly after arrival* The condition became so common that it was popularly termed a ship cold® These simple infections of themselves had a certain signi- ficance, in that they interfered with training after the troops arrived and led to an appreciable amount of non-effectiveness® Their principal importance was as an index of the possibility of more serious infections from the same source, such as characterized the movement of troops in the last war® Numerous and rather serious epidemics of pneumonia and meningitis occurred at that time among troops in transit to Europe® An epidemiologic survey of three groups of nurses recently arrived in the theater, was made early September 1942® They had travelled on separate ships of the same convoy and were stationed in the same staging area after arrival® The survey included the period from 1 August 1942 to 5 September 1942, corresponding to four days prior to embarkation, the period of travel, and the sub- sequent three weeks after arrival in the theater staging area® Individual case histories were obtained in respect of the presence or absence of an upper respiratory infection and of the nature of the attack® Of 151 nurses interviewed. 111 reported upper respira- tory infection during the survey period® (Table ll) The attack rate was exceptionally great, 74 percent® The behavior of the outbreaks that involved the three groups was essentially identical, although the nurses travelled on different ships® Essentially the same proportion of individuals were in- volved and the spread of the infection followed the same pattern® (Figure 8, Table 12) Only two nurses contracted upper respiratory infection during the five-day period preceding embarkation® No similar five-day period approached this low number until one week 7 after arrival in the staging area® The outbreak reached a peak toward the end of the travel period and fell off rapidly after arrival at the staging area® The effects of the infection were relatively long continued, more than half lasting longer than 14 days® This preliminary study of shipboard colds was extended to include 592 men of the 16th Medical Regiment (exclusive of 26 officers) and 238 men of the 28th Signal Battalion® Similar study methods were used® All individuals of the survey group were inter- viewed and their colds divided by date of onset into the three main divisions of the survey period® These were a preembarkation in- terval, Period A, corresponding to the last three weeks in the United States prior to embarkation; the time in transit. Period B, extending from the date of embarkation to the date of arrival at their station in England, inclusive; and the period after arrival. Period C, which was 20 days in the first instance and 17 days in the second, since the latter survey was made 17 days after arrival® Before departure for the European Theater, the 16th Medical Regiment had been stationed for several months at Camp Devens, Massa- chusetts® Leaving there, the unit embarked directly without inter- mediate stops at temporary staging areas® The men crossed in a single ship, and although subjected to the usual conditions of over- crowding, all were accommodated below deck® They travelled in the same convoy as the units of nurses included in the preliminary study although on different ships, embarking on 5 August 1943, landing on 17 August and reaching their station in England on 18 August® Subsequent to arrival in England they were reinforced with an addi- tional 55 men who were included in the study group® These men crossed in another ship of the same convoy, 35 sleeping inside and 15 on deck, with no information available for the other five® They originated from Camp Grant, Illinois, and spent three days in Fort Hamilton, New York, prior to embarkation® The 28th Signal Battalion reached England after the 16th Medical Regiment® Before sailing on 31 August, they had spent five to six weeks at Fort Dix, New Jersey® Their crossing was on a fast ship sailing without convoy® They landed on 5 September and proceeded to their assigned station in England on the following day® The incidence of colds in Periods A, B, and C is shown in Table 13, for each unit® The crude rates illustrated are not com- parable, since they take into account neither the varying length of the different periods nor the factor of susceptibility® Know- ledge of the immunologic mechanism involved in colds is too meager to justify or attempt to postulate a period of immunity following 8 Figure 8. Upper respiratory infection among 151 nurses in transit from Zone of Interior to European Theater of Operation, by date of onset, August-September 1942. injection, but it is evident that an individual suffering from a cold cannot contract a subsequent cold that he will recognize as such, until he recovers from the one that he has® During the course of a cold, therefor, a person was not considered as part of the population at risk, and was placed temporarily in the category of non-susceptibles® Since approximately half the colds in these two survey groups had a duration of over three weeks, this consideration was of major importance® To correct for these factors, the total exposure of each group in each of the three periods was reexpressed in terms of person days® Each cold was then considered individually, and when it extended into two or more periods it was divided into individual components falling within each time stage® The total duration of colds in person days for each period thus represented person days of non-susceptibility® TThen each such total was subtracted from the corresponding total exposure previously computed, the remainder represented the total exposure of susceptibles for the period® As the population at risk was expressed in terms of person days, the resulting rates were daily incidence rates and therefore comparable® For purposes of comparison, the findings of the preliminary survey of nursing units were included with the subsequent examinations® Table 14 gives the corrected daily rate for the three groups® It will be seen that the three sets of rates were similar for periods A and B, but that in C the incidence dropped sharply in the first two groups, while continuing to rise in the third® The latter difference in respect to the Signal Corps group between Periods B and C is not significant, (l®7 times its standard deviation) but the decreasing rates for the first two units do show a statistically 'significant difference between B and C® The 26 officers of the 16th Medical Regiment were not included in the tabulations, in that they were not subjected to the same environmental conditions on board ship® There were 15 colds among this group, two in period A, nine in B, and four in C, giving corrected daily rates of 0®4 percent, 2®7 percent and 1»3 percent respectively® Comparisons of the 55 men from Camp Grant with the 537 from Camp Devens, and of the 35 Camp Grant men sleeping in- side with the 15 sleeping on deck, showed a higher but not signi- ficantly higher incidence of colds from Camp Grant and for those sleeping on deck® The dates of onset were seldom given as actual dates, but usually in some such form as "a few days after sailing,” "half way across on the boat," or "a week before we sailed®" The basic data did not justify presenting an actual day by day 9 incidence* For this reason, the times of onset were grouped into subdivisions of one week in period A; two and three days in Bj and three and four days immediately after arrival and one week in C* The various groupings of the numbers of colds origi- nating within each of the two organizations were arranged in Table 15 and shown graphically in Figures 9 and 10* Since the bars of the two graphs are of varying width, the incidence is of necessity expressed in the forms of average daily number of colds* The two curves appeared to be roughly similar but that of Figure 9 showed a much greater part of the curve in period C* Table 16 presents an attempt to classify the severity of 117 colds in the 16th Medical Regiment and all in the 28th Signal Battalion* The relative distribution of mild, moderate and severe colds in each period appeared to be similar* Very few patients were sent to hospital, although a good many others said they would have liked to have been* Of the two later survey groups, only 15 were confined to bed in hospital, dispensary or quarters for periods ranging from one to nine days and for a total of 49 days* The duration of colds for the two survey groups is shown in Table 17* Only about one«third of the colds in the 28th Signal Battalion could be classified, as the remainder were still in progress at the time of the survey, with onset less than three weeks before* Approximately one«half of the colds of known duration lasted longer than three weeks, which probably accounts at least in part for the relatively small number of men with more than one cold (17 had two colds and two had three) during the survey period* The two units differed chiefly in branch of service, size of survey groups, date of embarkation, length of voyage and addition of personnel after arrival* The first was a Medi- cal Regiment of 592 men sailing on 5 August 1943, crossing in 12 days and with 55 of their number added after reaching their station in the theater* The other was a Signal Construction Battalion of 238 men (the strengths of both units are in terms of individual surveys), sailing on 31 August, crossing in 5 days and with no additions after arrival in England* ences in station, both in the United States and in England may well have been important factors but evaluation was beyond the aims of this simple survey* Both units were quartered in apparently satisfactory billets* The rate of incidence for colds in both groups was extremely low prior to embarkation, and greatly increased during the period of travel* July and August on the eastern seaboard of the United States are months with relatively few respiratory 10 OASES A - PRE-EMBARKATION B- TRANSIT C-AFTER ARRIVAL 1942 Figure 9. Upper respiratory infections, !J6th Medical Regiment, U.S. Army transport, average number of cases for periods indicated, by dates of onset, July to September 1942. A-PRE-EMBARKATION B-TRANSIT C-AFTER ARRIVAL 19 4 2 Figure 10. Upper respiratory infections, 28th Signal Battalion, U.S. Army Transport, average number of cases for periods indicated by dates of onset, August to September 1942. infections, while on shipboard the men were suddenly exposed to unfavorable climatic conditions plus the heavy exposure to in- fection associated with overcrowding® During the two to three- week period after arrival, the rate for the Medical Regiment dropped sharply, although still maintained well above its pre- embarkation level, while that of the Signal Battalion remained elevated® The curves of incidence (Figures 9 and 10) provide a reasonable explanation© Both curves started to rise at the time of embarkation, reached their peak fairly rapidly, and then sub- sided more slowly to reach a new and somewhat higher base line, approximately three weeks later© The brief drop for the Signal Battalion on 5 and 6 September is the only major difference and might represent either the interval preceding a superimposed secondary wave or a statistical artefact caused by onset dates not being accurate to the day© Otherwise the general appearance and extent of the two curves was much the same and what would be expected as the result of a sudden and large scale herd aggre- gation® The explanation of the difference in incidence rates in period C would therefore appear to be due to the extremely fast crossing of the ship carrying the Signal Battalion which brought about the intrusion of a considerable portion of the epidemic curve in period C that would have fallen in period B had the crossing been more leisurely® As a result of these studies representations were made to "The Surgeon General by the Chief Surgeon of the European Theater expressing the opinion that the attack rates from upper respiratory infection among troops on transports were sufficiently great to exert a significant effect on physical condition, training, and general effectiveness for a measurable period of time® It was brought out that overcrowding was a major cause of the situation® (Figure 11) Recently advanced methods for the control of respira- tory infections such as the use of aerosols, oiling of floors and blankets, and similar procedures had not been investigated in respect to transports® Existing facilities for washing mess kits aboard ship had been found with few exceptions to be bad® It was suggested that certain administrative factors might play a part, such as alternate nights of sleeping on deck and in cabins® The interest of the Surgeon of the New York Port of Embarkation was elicited through action by The Surgeon General® This in turn led to the appointment of a committee to investigate and evaluate the problem of acute upper respiratory infection among troops on transports, with a view of improved measures of control® 11 The subsequent introduction by the Array Transport Service of administrative changes in methods of dispatching troops to foreign theaters lea t,o greatly improved conditions<, A committee originating from the Board for the Control of Influenza and other Epidemic Diseases in the Army made a comprehensive study of the situation and instituted investigative studies designed to improve methods of prevention on transports Control of Common Respiratory Infections^—The principal Reliance \iycontrol of the acute infections of the upper respiratory Aract as nfey occurred among troops of the theater was of necessity placed on the general measures entering into personal and community hygiene* No specific preventive measure of demonstrated value was available* except in respect to influenza; and that not until late in the final year of operations when the absence of that particular infection obviated its use* Administrative Measures*—Continued stress was placed on the responsibility of unit commanders for the enforcement of all disease preventive measures within their respective commands, a responsibility which could not be delegated to subordinates* To aid in the proper discharge of this duty, the technical measures concerned with the control of respiratory infections were incorpo- rated in directives issued by various organizations of the theater at different levels of command* Those of the theater were ordi- narily general in nature; those of base sections of air forces and of armies gave greater detail* Specific information relating to personal hygiene, to control of the environment, and to the application of special control measures was made available to unit surgeons through the activity of officers in Divisions of Pre- ventive Medicine, in the course of routine visits or by special conference when the frequency of infections of the respiratory tract became a matter of particular concern to a given unit* Personal Hygiene*—In the training of the individual soldier emphasis was placed on available means to avoid as far as practicable the infective agents of acute respiratory infection and on the methods for limiting their transmission to others* The features of personal hygiene especially stressed by unit commanders and medical officers included the importance of avoiding contact with patients who had common colds or other forms of acute upper respiratory infection; the proper methods for disposal of sputum and nasal secretions, with stress on the dangers of promiscuous spitting; the importance of covering the nose and mouth with a handkerchief when coughing or sneezing; the dangers of common drinking cups, canteens, towels and other per- sonal items, and of passing cigarettes and pipes from one man to another* The importance of personal cleanliness, of thorough 12 Figure 11. A small section of one compartment aboard a U. S. Army transport after loading at the New York Port of Embarkation, 19A4. Figure 12. U, S. soldiers introduce a Halloween Ball to English girls, England, October 1942. hand washing, of frequent changes to clean fresh clothing? and the dangers of unnecessary crowding of individuals in poorly ventilated, closed places were other matters that received attention*, (Figure 12) The physical welfare of the individual enlisted man was to be given particular attention in regard to the prevention of excessive fatigue and chilling? the prescribing of apparel in keeping with the weather conditions encountered? and with specific prohibition against patronizing eating and drinking establishments outside the military reservation not approved for military personnel*> In times of excess incidence of respiratory infections officers directed more than usual attention to the maintenance of a proper diet for the command, through maximum utilization of the prescribed ration and with particular emphasis on foods which provided vitamins A and C, such as lemon crystals, fruit and tomato juices, leafy, green and yellow vegetables, milk and cheese, and dehydrated eggs*, Protein foods such as meat, fish, eggs and fat were advised as contributing to body warmth*, Soldiers going on trips and passes were urged to consume the emergency rations providedo Although these rations may not have been particularly palatable, they furnished important heat and nutritive elements„ Environmental Measures o —With the aim of reducing to a minimum the transmission of respiratory disease within organi- zations, constant supervision and inspection was required to prevent overcrowding in barracks, mess halls, class rooms, offices and similar places? to maintain the prescribed air space per individual in barrack buildings? and to assure proper ventilation of barracks during .sleeping hours o Strict adherence of head to foot sleeping arrangements was demanded in times of epidemic prevalence, together with utilization to the fullest possible extent of cubicles improvised from shelter halfs, where an excessive degree of overcrowding was unavoidableo The relative importance of dust in the transmission of respiratory disease has received increasing attention in recent years*, Irrespective of whether or not oiling of floors was practiced, dry sweeping was avoided and the necessity for thorough scrubbing of floors with hot, soapy water at frequent intervals was stressed*. Since poor mess management and insanitary mess equip- ment contribute so pertinently to the spread of respiratory in- fection, all messes were required to be closely supervised, and inspections made with particular diligence in times of excess 13 incidence of acute respiratory disease® Attention was directed toward careful and frequent examination of food handlers for evidence of respiratory infection*, with recommendation that they be promptly removed from duty for report to the unit surgeon® Proper cleansing and sterilization of dishes and mess equipment, and thorough washing of tables and condiment containers with hot soapy water were other ordinatry features that required particular attention in times of epidemic respiratory disease® Officers charged with the operation of service clubs, post exchanges and theaters were held responsible for the observance of such of the outlined disease preventive measures as applied® In the case of post theaters, only the specified seating capacity was to be permitted and a sufficient interval allowed between shows to permit thorough airing of the auditorium® Blackout requirements often interferred with proper venti- lation® Fuel supplies in the European Theater were rarely plenti- ful and this led to the common practice of blocking up ventilators® Freouent inspection of quarters was necessary to insure that proper ventilation was provided, particularly during sleeping hours® Proper humidity of sleeping quarters was aided by keeping cans of water on stoves during the hours when heat was authorized® Barracks were directed to be thoroughly aired during the day® One of the most important of the general provisions for control of respiratory disease related to the provision of adequate facilities for drying clothes® All units were directed to maintain the special drying room provided for in army regulations, on a scale of one square foot per man® Well heated tents served the purpose with field units® For field troops, this measure ranks well up or any priority list of preventive measures® Medical Measures®—Physical inspection of incoming troops, whether by train, motor transport or by marching was especially necessary in time of epidemic® New additions to a force spell trouble® Prompt segregation of all patients with acute infections was accomplished before new troops were assigned to quarters® Contention areas were directed for all units where the influx of new personnel was great, with incoming troops quartered in these detention areas and not permitted to mingle with personnel of the station until all possible sources of infection had been eliminated by proper segregation and hospitalization of infected individuals® If the fullest measures were not taken to insure proper isolation of patients admitted to dispensaries and infirmaries* other patients were subjected to the possibility of contracting a respiratory cross infection not present when they were admitted,* Care was taken that all discharges from patients in infirmaries with respiratory or other communicable disease were burned or otherwise disinfected* Unit and dispensary surgeons were expected to maintain a position of properly advising commanding officers regarding the prevention of respiratory disease* Intensification of the activities of medical inspection and of screening out of infected individuals was essential* Prompt removal of infected individuals was recom- mended as of the greatest aid in the control and prevention of spread of respiratory infection* Officers and enlisted men with acute catarrhal symptoms accompanied by a temperature one degree or more above normal should be promptly hospitalized* There was furthermore an increasing realization that a day or two spent in taking care of a cold in the beginning usually saved several days of non-effectiveness* Informal reports concerning infractions of regulations were advantageously rendered to the commander of the organization concerned, with recommendations for correction* Follow-up inspections were found to be important* Working quarantine was not considered a practical measure for the control of acute upper respiratory infection* There was no method of determining carriers and from the standpoint of the results likely to be obtained, quarantine on any effective scale interferred too greatly with unit activities* Special Measures*—Three recently developed measures were used in varying extent by units of the theater, principally on an experimental basis* These included the oiling of floors and blankets, the use of sulfadiazine as a chemoprophylactic agent, and the attempted control of the atmosphere within barracks and buildings by the use of aerosols, principally propylene glycol* More general use was made of the first of these measures because of its simplicity and because the method had been popularized by British workers* Chemoprophylaxis by sulfadiazine was limited essentially to a major trial by the Air Forces, and a smaller study in a General Hospital* Aerosols were used experimentally in one Air Force station* Oiling of Floors and Blankets*—A comprehensive, thoroughly controlled test of the efficacy of oiling floors and blankets was contributed by the medical staff of the Eighth Air Force* The method was used fairly extensively by a number of units of that organization 15 and by several representative installations of the Communications Zoneo The general opinion as to its usefulness was favorable® It had the advantage of simplicity, and through use of spindle oil was not expensive® It appeared to be a worthwhile addition to the general program of prevention of these diseases® Aerosols in the Control of Respiratory Infection®—The opinion of the Army Epidemiologic Board that technical methods concerned with the use of aerosols had not been developed to the point where wide scale use of the procedure was practical found substantiation in the experimental use of propylene glycol as an aerosol at one of the air force stations® Efforts to control the transmission of air borne disease by sterilizing the air in dwellings occupied by troops was abandoned because of the diffi- culties of producing a high enough concentration of propylene glycol to have a bactericidal effect® There was also difficulty in controlling humidity® It became evident on completion of this experiment that the method in the present state of its development was not feasible under field conditions even though units were essentially static® Chemoprophylaxis of Respiratory Infectionse — Recent in- vestigations conducted by the Army Epidemiological .Board, the headquarters of certain Service Commands in the Zone of the Interior and the office of the Air Surgeon, and by the United States Wavy, indicated that the incidence of meningococcal menin~ gitis and streptococcal sore throat, and of certain upper respira- tory diseases of bacterial origin might be remarkedly reduced by the prophylactic administration of small doses of sulfadizaine® A War Department Technical Bulletin gave indications, procedure, dosage and precautions to be employed in the administration of sulfadiazine prophylactically to large bodies of troops® The method was authorized for use in overseas areas in the manner provided, when recommended by the theater commander® Considering that practically all of the military personnel in the European theater had had at least six months seasoning in the army, and that the prevalence of diseases transmitted through the respiratory tract and susceptible to sulfadiazine prophylaxis was extremely low, it was adopted as the policy of the theater that the method was to be used only when epidemiological, clinical and laboratory investigations performed on a sampling basis indicated that the disease or important complications occurring in an epidemic manner were due to beta hemolytic streptococci or to the meningococcus| or under conditions of a rapidly increasing in- cidence of respiratory infection to which affected individuals were not responding satisfactorily® In all instances prior to 16 initiating a program of sulfadiazine prophylaxis, the surgeon of the theater was to be notified and concurrence obtained. Adequate opportunity for trial of the newly developed method was afforded by a large scale experiment introduced by the Air Force Service Command of the Eighth Air Force and subsequently extended to all Air Force troops of the theater. The personnel of four stations of the Service Command were arbitrarily separated into two groups. Occupants of even numbered barracks formed group A, and occupants of odd numbered barracks constituted group B, Groups A and B from each station were combined to form the respective composite groups A and B referred to subsequently. The two groups A and B numbered approximately 6,000 men each. Sulfadiazine was distributed by the barracks chief and actual ingestion was recorded daily by roster. Unannounced spot urine tests on approximately ten percent of the test group served as a further check of whether or not the drug was being taken® The percentage of individuals in the treated groups recorded as ingesting the drug varied around 77 percent. Prophylactic sulfadiazine was administered first to one group, then to the other and terminally to both groups® During the first seven weeks of the experimental period, 8 October to 24 November 1944, group B received prophylactic sulfadiazine while group A served as the untreated control. During the first four weeks of the seven, 7 October to 3 November, each member of group B received 1 gram dailyi for the remaining 3 weeks, 3 November to 24 November, the dose was reduced to 0,5 grams daily. During the next nine weeks, 23 November to 26 January, the status of the groups was reversed, in that group A received the drug and group B served as the untreated control. Group A received 1,0 gram of sulfadiazine daily for the first week only, 25 November to 1 December, and thereafter 0,5 gram daily. During the next 9 weeks, 27 January to 30 March 1945, group A continued the treatment with group B also receiving prophylactic sulfadiazine. The men of both groups received 0,5 gram of sulfadiazine daily throughout this period, (Figure 13) The general conclusion derived from these investigations was that common respiratory diseases were appreciably reduced by the use of prophylactic sulfadiazine. The effect was apparently even when the rate for respiratory disease was comparatively low 17 (100 to 150 per thousand strength per annum), and the effect was maintained for as long as 18 consecutive weeks* The maximum effect was obtained more quickly with a one gram daily dose than with a one half gram dose; the lowered rate once established was maintained equally well with either* A second course of prophylactic sulfadiazine seemed as efficacious as the initial course* Toxic reactions to sulfadiazine were mild and infrequent0 The majority occurred within the first four weeks of chemoprophylaxis and were dermatological in type* There was no conclusive evidence suggesting that one course of the drug sensitized to subsequent adminis tra ti on * To obtain the maximum protective effect, a high percentage of personnel had to ingest the prescribed daily dose* This required clear forceful indoctrination of all personnel, especially of com- manding o'fficers and medical officers, both initially and at inter- vals throughout the period of observation; rigid supervision of administration; and constant vigilance to dispel false rumors of harmful effects of sulfadiazine* A satisfactory drug coverage con- sistently maintained the admission rate for respiratory diseases at less than one hundred* A certain periods this represented an 80 percent reduction in comparison with existing rates for the control group* Less adequate coverage gave proportionately poorer results* The protective effect of chemoprophylaxis adequately applied was appreciable even with admission rates of 150 to 200* In flying personnel with less adequate coverage, the removal rate was not significantly affected by chemoprophylaxis unless the annual rate exceeded 350 to 400* Prophylactic sulfadiazine not only reduced the incidence of respiratory disease but led to fewer severe cases being admitted to hospital and quarters* Limited data indicated that prophylactic sulfadiazine maintained its protective action for as long as 18 consecutive weeks* Similarly, a second course of chemoprophylaxis was as effective as the first* These controlled observations in the Air Force Service Command were striking* The effect of general use of the method by all air force troops during the first three months of 1945 was not reflected in the rates for the Air Force as a whole, when compared with the general theater rate for common respiratory diseases during that time* The rates for the Ground Forces who were never on sulfadiazine averaged better* The Air Force rates were lower than those for the Communications Zone troops but that had been a constant characteristic throughout the activities of the theater* In the presence of very high infection rates with 18 Figure 13. Sulfadiazine in chemoprophylaxis of acute upper respiratory infection, 8th air Force Service Command, October 1944 to Uarch 19a5 inclusive. streptococcus* meningococcus or other susceptible organisms, this procedure may be immediately and significantly helpful* The secondary factor of an increased sensitivity of individuals to the drug and the development of sulfa-resistant micro- organisms should be carefully weighed against the possible benefits in each situation* A second controlled investigation of sulfadiazine prophylaxis of respiratory disease was undertaken among the enlisted detachment of the 154th General Hospital* These studies began early in November 1944 and lasted until late March 1945, a period of some five months* They consisted of careful clinical and laboratory observations of each man, with the principal object of detemining in detail what might be expected from an accepted method of drug prophylaxis when applied to a small body of men in the United Kingdom living with a minimum of disturbance of environment such as those brought about by troop movements, field exposure or large trasfers of personnel* Useful infor- mation could conceivably be gained regarding the value of in- dividualization as opposed to the mass employment of drug pro- phylaxis, with additional contribution brought about through the possibility of coincident bacteriological observations* The number of men available for study was about 490* They were quartered in 31 huts, sleeping 16 to 18 men in each* Half of the men in each hut received sulfadiazine* In this way the control group was made up from representatives of each hut and the contact experience of both drug-treated and control groups was as nearly the same as it was possible to make it* In half of the barracks the prophylactic dose of sulfadiazine for test subjects was 0*5 gram and for the remainder 1*0 gram* An individual clinical and laboratory record was kept for each man* A history of respiratory and allergic disease and certain other relative items including sulfonamide reactions and throat cultures, were obtained before drug preventive was started* During the period of study each man was seen at least once every two weeks and immediately whenever symptoms of disease developed* The study terminated 15 March 1945* No severe toxic reaction were encountered* Six men showed microscopic hematuria* There were two oases of hemolytic streptococcus sore throat in the treated group* The incidence of mild respiratory infection was about the same for both treated and control groups* 19 Year Combined Total Respiratory Infections and Pneumonias Acute Upper Respiratory Infection The Pneumonias Total Pneumonias Primary Lobar Primary Atypical Secondary Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 1942 21*984 303 21*151 291 629 8o7 184 2<>5 20 0o3 833 11.5 1943 111*263 421 108,133 409 1*447 5o 5 1*611 6a 72 0,3 3,130 11.8 1944 222*140 151 209,281 142 5*182 3t>5 7*458 sa 219 0ol 12*859 8,7 1945 169*303 124 154*117 112 4*788 3<,5 10*224 7,5 174 0ol 15,186 11.1 Total 524,690 165 492*682 155 12*046 3*8 19*477 ea 485 0.2 32,008 ioa Source s Division of Medical Statistics, Office of The Surgeon General* War Department* Washington, D. C. Infections of the Respiratory Tract European Theater of Operations, U* So Army Cases and rates per 1000 strength per annum, per year February 1942 to June 1945 Inclusive Table 1 Disease Total 1942 1943 1944 1945 Deaths Rate Deaths Rate Deaths Rate Deaths Rate Deaths Rate Common Respiratory 6 ,0019 0 - 0 - 1 ,0007 5 ,0036 Influenza 1 .0003 0 - 1 ,0038 0 - 0 - Pneumonia, Primary 64 .0201 0 - 2 ,0076 30 .0204 32 .0234 Pneumonia, Secondary Pneumonia, Primary 29 ,0091 0 - 0 - 6 ,0041 23 .0168 Atypical 41 ,0129 0 - 0 - 8 ,0054 33 .0241 Total 141 ,0443 0 - 3 .0114 45 .0306 93 .0679 Source; Division of Medical Stati Washington, D. C. sties. Office of The Surgeon General, War Department, Infections of the Respiratory Tract European Theater of Operations9 Uo So Army Deaths and rates per 1000 per annum* by years February 1942 to June 1945 Inclusive Table 2 Month Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 65791 245 7705 704 25574 416 32512 166 February 60065 211 228 739 4359 516 23206 330 32272 157 March 69122 183 413 523 3383 408 32212 312 33114 125 April 42939 133 284 324 2777 263 19598 211 20280 93 May 35527 106 268 126 2033 216 13955 139 19271 87 June 29472 73 295 83 2092 173 10417 82 16668 63 July 9982 74 800 125 2212 116 6970 64 August 10532 68 1150 131 2264 117 7118 56 September 16695 84 2158 170 3174 136 11363 69 October 27229 141 4549 272 8628 236 14052 101 November 51591 252 5725 514 28666 700 17200 112 December 73737 245 5281 566 40840 628 27616 122 Total 492682 155 21151 291 108133 409 209281 142 154117 112 Source: Division of Medical Statistics Washington, D„ Co , Office of The Surgeon General, War Department, Common Respiratory Disease, Including Influenza European Theater of Operations, U. S. Army Cases and rates per 1000 strength per annum, by months February 1942 to June 1945 Inclusive Table 3 Table 4 Common Respiratory Diseases Including Influenza White and Colored, European Theater of Operations, U« S. Amy .Admission rates per 1000 strength per annum, by weeks in United Kingdom, 3 September 1943 - 30 June 1944* and in Continental Europe, 1 September 1944 - 29 June 1945 Week Ending White Colored Week Ending White Colored 1943 September 3 120 90 1944 September 1 30 16 10 142 58 8 29 19 17 138 54 15 34 26 24 154 103 22 37 23 October 1 220 338 29 60 28 8 * * October 6 85 46 13 216 60 13 95 56 22 237 69 20 85 54 29 320 116 27 73 69 November $ 378 177 November 3 85 70 12 506 407 10 87 71 ■ 19 746 415 17 118 74 26 1129 477 24 104 53 December 3 890 370 December 1 90 51 10 635 396 8 101 71 17 615 365 15 112 92 24 509 283 22 120 86 31 399 258 29 114 72 1944 January 7 405 199 1945 January 5 140 105 14 384 173 12 151 134 21 396 211 19 154 124 28 396 216 26 167 109 February 4 365 269 February 2 174 104 11 348 242 9 188 116 18 337 202 16 150 106 25 356 236 23 120 97 March 3 354 233 March 2 118 94 10 350 225 9 132 99 17 319 230 16 125 93 24 290 201 23 109 82 31 249 156 30 109 72 April 7 244 212 April 6 99 72 14 220 168 13 96 64 21 201 144 20 88 58 28 166 118 27 84 61 May 5 147 90 May 4 •K * 12 140 119 11 96 58 19 133 103 18 85 56 26 121 1 108 25 77 53 June 2 113 91 June 1 70 48 9 89 73 8 71 50 16 84 61 15 60 53 23 76 45 22 61 45 30 i 80 56 29 ._59 15 *Data not available* Source: Division of Medical Records, Office of the Chief Surgeon, ETO* Table 5 Common Respiratory Diseases Including Influenza United Kingdom and Continental Europe European Theater of Operations, U. S, Army Admission rates per 1000 strength per annum, by weeks 1 September 1944 to 29 June 1945 Inclusive Week Ending Jnited Kingdom Continental Europe Week Ending [Jnited Kingdom Continental Europe 1944 Sept. 1 98 28 1945 Feb. 2 211 i 163 8 106 28 9 208 177 15 134 33 16 212 143 22 148 35 23 218 115 29 162 57 March 2 210 116 Oct. 6 163 81 9 192 126 13 153 91 16 205 120 20 146 82 23 181 104 27 142 73 30 185 103 Nov. 3 145 83 April 6 153 94 10 161 86 13 148 91 17 178 113 20 140 83 24 149 99 27 139 80 Dec. 1 149 86 May 4 131 82 8 147 98 11 129 90 15 176 110 18 128 81 22 184 117 25 103 73 29 200 110 June 1 101 66 1945 Jan. 5 270 137 8 98 68 ' 12 276 149 15 103 58 19 229 151 22 121 58 29 196 158 29 88 55 Source: Division of Medical Records, Office of the Surgeon, European Theater of Operations. Chief Week End:! Air Forces Communications Zone Week Ending Air Forces Communications Zone Lng United Kingdom Continental Europe United Kingdom Continental Europe United Kingdom Continental Europe United Kingdom Continental Europe 1944 Sept 1 109 ♦ 97 11 1945 Feb 2 167 141 242 187 8 117 ♦ 102 41 9 160 133 246 183 15 157 ♦ 129 57 16 157 122 262 177 22 163 52 138 53 23 147 127 236 158 29 180 73 151 88 March 2 159 111 211 157 Oct 6 184 103 139 100 9 151 126 203 157 13 172 116 142 123 16 162 126 180 149 20 165 96 140 108 23 165 116 168 149 27 134 101 170 106 30 161 116 199 134 Nov 3 153 81 151 120 April 6 143 93 140 122 10 174 92 183 134 13 150 89 123 124 17 175 134 202 152 20 143 94 102 98 24 153 121 157 132 27 133 88 145 91 Dec 1 157 109 159 111 May 4 127 ♦ 135 ♦ 8 158 121 193 126 11 130 80 113 60 15 205 123 196 140 18 124 93 119 89 22 199 141 222 169 25 109 75 81 88 29 209 149 243 152 June 1 106 72 75 79 1945 Jan 5 265 163 294 180 8 112 105 76 71 12 272 166 303 223 15 115 73 75 66 19 206 157 277 237 22 134 64 81 68 26 166 146 128 206 29 92 61 71 69 ♦Data not available Sources Division of Medical Statistics* Office of the Chief Surgeon* European Theater of Operations* Common Respiratory Diseases Including Influenza Air Forces and Communications Zone, United Kingdom and Continental Europe European Theater of Operations, U<» S» Army 1 September 1944 to 29 June 1945 Table 6 Table 7 Common Respiratory Diseases Including Influenza By major components for Continental Europe European Theater of Operations, U. S« Amy Admission rates per 1000 strength, by weeks 1 September 1944 to 29 June 1945, inclusive Week Ending Total Combat Ground Forces Air Forces Ground Forces Repl. Command Communica- tions Zone 1944 Sept. 1 28 17 * * 11 8 28 17 * * 41 15 33 25 * * 57 22 35 40 52 * 53 29 57 57 73 * 88 Oct. 6 81 82 103 # 100 13 91 95 116 70 123 20 82 86 96 93 108 29 73 83 101 68 106 Nov. 3 83 89 81 86 120 10 86 83 92 105 134 17 113 122 134 147 152 24 99 100 121 138 132 Dec. 1 86 106 109 125 111 8 98 101 121 112 126 15 110 108 123 144 140 22 117 99 141 146 169 29 110 111 149 159 152 1945 Jan. 5 137 126 163 190 180 12 149 137 166 213 223 19 151 131 157 297 237 26 158 139 146 354 206 Feb. 2 163 188 141 527 187 9 177 184 133 356 183 16 143 144 122 303 177 23 115 102 127 304 158 March 2 116 103 111 291 157 9 126 no 126 308 157 16 120 102 126 257 149 23 104 84 116 225 150 30 103 73 116 189 134 April 6 94 68 93 135 122 13 91 65 89 173 124 20 83 60 84 119 98 27 80 58 88 138 91 May 4 82 64 81 131 111 11 90 63 80 140 100 18 81 61 93 126 89 25 73 58 75 94 88 June 1 66 56 72 77 79 8 68 58 105 84 71 15 58 53 73 73 66 22 58 52 64 81 68 29 55 54 61 57 69 *No data available Source: Division Surgeon, » of Medical Records, Office of the European Theater of Operations Chief Table 8 Common Respiratory Diseases Including Influenza, By Armies European Theater of Operations, U. S. Army Admission rates per 1000 strength per annum, by weeks 16 September 1944 to 29 June 194$ Inclusive Week Ending 1st Amy 3rd Army 7 th Amy 9th Amy l$th Alley 1944 Sept. 16 27 23 25 23 45 34 29 30 67 44 38 Oct. 6 116 61 39 13 112 89 73 20 96 80 79 27 80 92 74 Nov. 3 72 92 101 10 84 93 79 17 130 137 94 24 91 113 139 94 Dec. 1 107 115 124 90 8 97 89 101 88 / 15 85 107 122 94 22 89 86 108 74 29 113 112 117 87 1945 Jan. 5 150 130 127 82 12 170 124 145 84 19 168 108 146 91 26 172 130 153 92 Feb. 2 204 183 22$ 136 9 162 213 222 137 16 126 171 176 103 23 87 109 135 89 67* March 2 93 113 131 71 93 9 90 126 140 88 65 16 90 114 134 64 84 23 83 83 101 61 73 30 71 57 10$ 61 54 April 6 64 62 88 54 82 13 56 58 98 50 71 20 51 55 86 46 71 27 64 51 90 45 48 May 4 65 45 111 48 48 11 54 47 96 76 60 18 51 93 53 57 25 56 80 45 59 June 1 46 98 41 59 8 •n 0 45 97 48 56 15 > (D 60 47 50 22 •H 56 47 56 29 ® Pi 55 45 69 *First Report received on Continent. Source: Division of Medical Records, Office of the Chief Surgeon, European Theater of Operations. Table 9 Common Respiratory Diseases, Including Influenza Continental United States and European Theater of Operations, UoSo Army Cases and rates per 1000 strength per annum, by months January 1942 to June 1945 Inclusive Month Continental U. So European Theater of Operations Cases Rates Cases Rates 1942 January 43385 311 February 56496 434 228 736 March 60106 406 413 323 April 41686 262 284 324 May 41905 196 268 126 June 26731 143 295 83 July 26831 109 800 123 August 24306 113 1130 131 September 31386 139 2138 170 October 48844 139 4349 272 November 71231 260 3725 314 December 144019 492 3281 566 Total 616946 242. 21131 291 1943 January 212337 500 7705 704 February 141980 382 4339 316 March 134772 334 3383 408 April 142136 287 2777 263 May 84361 208 2033 216 June 55705 136 2092 173 July 51294 101 2212 116 August 38438 93 2264 117 September 38842 97 3174 136 October 51096 104 8628 236 November 60829 160 28666 700 December 236176 546 _. 40840 628 Total 1268186 247 108133 409 1944 January 124926 3a 23374 416 February 96377 272 23206 330 March 91230 214 32212 312 April 53034 160 19598 211 May 38781 120 13953 139 June 30749 78 10417 82 July 20381 66 6970 64 August 20233 67 7118 36 September 29375 81 11363 69 October 23241 92 14032 101 November 24377 93 17200 112 December 35341 115 27616 122 Total 599085.. . . 147 209281 142 1945 January 38833 167 32512 166 February 42612 192 32272 137 March 43148 167 33H4 123 April 26476 122 20280 93 May 27281 124 19271 87 June 28392 101 16668 63 Total 208944 145 ... 154117 112 Grand Total 2684161 204 492682 Source: Division of Medical Statistics, Office of The Surgeon General, War Departmer it. Washing jton, D»Co Total 1942 1943 1944 1945 Theater Rate Cases Rate Cases Rate Cases Rate Cases Cases Rate Total Armies 3796648 179 700725 230 1555893 231 1052281 140 487749 126 Continental U0 So 2684161 204 616946 243 1268186 247 590085 147 208944 145 Total Overseas 1112487 138 83779 163 287707 181 462196 132 278805 115 Alaska 57495 212 12239 244 25469 222 15628 188 4159 178 North America 33601 198 10382 256 15834 221 5660 144 1725 111 African-Middle East 25403 195 1161 202 10732 201 10364 219 3146 132 China- India 53080 160 855 150 7321 159 28099 176 16805 139 European 492682 155 21151 291 108133 409 209281 142 154117 112 Mediterranean 202701 150 3232 152 61201 142 106571 162 31697 132 Southwest Pacific 126627 105 9958 149 21134 108 45722 83 49813 128 Latin America 35242 101 11595 133 12478 103 7323 85 3846 99 Pacific Ocean 85656 82 13206 90 25405 86 53548 85 13497 : 65 Sources Division of Medical Statistics Do Ce » Office of The Surgeon General^ War Washingtons Common Respiratory Disease* Including Influenza By Theaters of Operations Cases and rates per 100 strength per annum January 1942 to June 1945 Inclusive Table 10 Table 11 Upper Respiratory Infections Among Troops on Transports European Theater of Operations, U« S« Army Cases and attack rates per 100 August and September 19-42 Unit Number in Unit Number Contacting Respiratory Infections Attack rates per 100 A 60 48 80 B 39 26 67 C 52 37 71 Total 151 111 74 Source: Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operationso Table 12 Upper Respiratory Infection Among 151 Nurses in Transit from Zone of Interior to European Theater of Operations by date of onset August - 3eptember 1942 Date Cases 1944 August 1 1 2 1 3 0 4 0 5 0 Left New York 6 3 7 1 8 2 9 2 10 8 11 1 12 4 13 1 14 7 15 13 16 9 Arrived in U« Ko 17 13 Arrived at Staging Area 18 12 19 4 20 4 21 1 22 7 23 2 24 3 25 0 26 0 ' 27 1 28 1 29 1 30 3 31 1 September 1 2 2 0 3 1 4 1 5 1 Total 111 Sources Division of Preventive Medicine? Office of the Chief Surgeon? European Theater of Operations« Group Surveyed No® of Period A (Pre-embarkation] Period B (Transit) Period C (After arrival) Indi- viduals Dates No® of Colds Rate per 100 Dates No® of Colds Rate per 100 Dates No® of Colds Rate per 100 Army Nurse Corps Units5 Salisbury 151 Aug 1-4 2 lo3 Aug 5- 18 76 50o3 Aug 19- Sept 5 33 21®9 16th Medical Regiment*, Swindon 592 July 15- Aug 4 15 2®5 Aug 5- 18 209 35®3 Aug 19- Sept 7 74 12,5 28th Signal Bat- talions Maidenhead 238 Aug 10- 30 15 6®3 Aug 31- Sept 6 57 23®9 Sept 7- 23 106 44® 5 Sources Division of Preventive Medicine* Office of the Operations® Chief Surgeon* European Theater of Crude Incidence Rates for Upper Respiratory Infections United States Troops Aboard U© S© Army Transports July - September 1942 Table 15 Period A (Pre-embarkation) Period B (Transit) Period C (After arrival) Group Surveyed Noo of Sus- ceptibles* (in persona- days) No» of colds Daily rate per 100 No, of Sus- ceptibles* (in person- days) No, of colds Daily rate per.100 No a of Sus- ceptibles* (in person- days) NOa Of colds Daily rate per 100 Amy Nurse CorpSs Units Salisbury 599 2 0» 3 1886 76 4,0 1767 33 la 9 16th Medical Regiment Swindon 12114 21 0,2 6721 209 3a 1 8385 74 0o9 28th Signal Battalion Maidenhead 4758 15 0,3 1368 57 4o 2 1919 105 5a 5 *Individuals are considered as non-susceptible while actually having a cold* Sources Division of Preventive Medicine5 Office of the Chief European Theater of Operations. Daily Incidence Rates of Upper Respiratory Infections U0 So Army Transports* July ■=• September 1942 (Corrected for length of survey period and for susceptibility) Table 14 Table 15 Upper Respiratory Infection By Date of Onset Uo So Army Transports July - September 1942 16th Medical Reg;3 .ment 28th Signal Battalion Period No, of No, of UoRolo S' o o o No. of U oRoI 0 uax.es days colds per day Dates days colds per day July Aug, A 1$-21 7 4 0o6 10-16 7 2 0,3 (Pre- July Aug, embar- 22-28 7 5 0o7 17-23 7 7 1,0 kation) July Aug, 29 7 12 1,7 24=30 7 6 0,9 Augo 4 Augo Aug, . 5-6 2 17 8,5 31 2 6 3o0 Sept, 1 B Augo Sept, 7-9 3 73 24*3 2-4 3 42 14o0 (Trans- it) Augo Septo 10-12 3 45 15*0 5=6 2 9 4o5 Augo 13-15 3 48 16o0 Augo 16-18 3 26 8,7 Augo Sept * - ■ 19-21 3 30 10o0 7-9 3 48 16,0 n Augo Sept o o 22-25 4 19 4o8 10-16 7 36 5.1 (After * arrival) Augo * Sept, 26 7 9 1.3 17=23 7 21 3*0 Septo 1 Sept* i 2-7 6 13 2,5 1 Source: Division of Preventive Medicine* Office of The Chief Surgeon, European Theater of Operations0 Period l6th Medical Regiment 28th Signal Battalion Ho* of BoHo lo Hi lid j Moderate 1 Severe Bo* of Uololo Mild Moderate Severe Ho* Per- 1 cent Ho* Per« 1 cent | 0 0 Per- cent r — Bo* Per- cent Ho* Per- cent Ho* Per- cent A (Pre-embar- kation 8 .. . 2 25.0 2 25oO U 50*0 15 7 U6.7 6 U0o0 2 13o3 B (Transit) 78 _ . US 6X.5 19 2U*U 11 lU.l 57 32 56.1 20 35oi 5 E.S C (After arrival) 31 19 61.3 8 25oS u 12o9 105 50 U7„6 3^ 32. u 21 20o0 Total 117 69 59oO 29 2U0S 19 16.2 1,7 j 89 50<.3 60 33»9 28 15. s Bata on severity were obtained on only 117 cf the 30U colds in the l6th Medical Begiment„ Sources Division of Preventive Medicinep Office of the Chief Surgeon, European Theater of Operations* Severity of Upper Respiratory Infections Uo So Army Transports9 July - September 1942 Table 16 Table 17 Duration of Upper Respiratory Infection U. S» Army Transports July - September 1942 16th Medical Regiment 28th Signal Battalion Duration Number Percent of Total Number Percent of Total 1-7 days 97 33*0 28 43 ol 8-14 days 29 9*9 4 6.1 15 - 21 days 13 4*4 0 0 Over 21 days 155 52.7 33 50.8 Total, known duration 294 100.0 65 100.0 Note: Ten colds in the 16th Medical Regiment and 112 in the 28th Signal Battalion are not included in the above table, as they were still present at the time of the survey with onsets less than Source: 21 days previous. Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operations. FIGURES lo Nipsen huts used for quarters at Rigglestone Camp, United Kingdom, 1942 o ✓ 2« Common respiratory diseases including influenza. United Kingdom and Continental Europe, European Theater of Opera- tions, U« So Army, admission rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945* in- clusive o 3» Common respiratory diseases including influenza. Air Force and Communications Zone, United Kingdom and Continental Europe, European Theater of Operations, Uo So Army, admis- sion rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945* inclusive» 4o Common respiratory diseases including influenza, by major components on the continent, European Theater of Operations, Uo So Army, admission rate per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945* inclusiveo 5o Common respiratory diseases including influenza, by armies, European Theater of Operations, U» S. Army, admission rate per 1000 strength per annum, by weeks, 16 September 1944 to 29 June 1945* inclusive0 6» Common respiratory diseases including influenza, Continental United States and European Theater of Operations, U» So Army, admission rate per 1000 strength per annum, by month, January 1942 to June 1945* inclusive» i 7* Winter quarters of the 394th Infantry Service Company, 99th Infantry Division, Sourbrodt, Germany, January 1945° 8* Upper respiratory infection among 151 nurses in transit from Zone of Interior to European Theater of Operations, by date of onset, August - September 1942 o 9* Upper respiratory infections, 16th Medical Regiment, Uo So Army Transport, Average number of cases for periods indicated by dates of onset, July - September 1942o 10o Upper respiratory infections, 28th Signal Battalion, Uo So Army Transport, Average number of cases for periods indicated by dates of onset, August - September 1942o 11. A small section of one compartment aboard a U« S« Army Trans- port after loading at the New York Port of Embarkation, 1944# 12# U. S. soldiers introduce a Halloween Ball to English girls, England, October 1942• 13• Sulfadiazine in chemoprophylaxis of acute upper respiratory in faction, 8th Air Force Service Command, October 1944 to March 1945* inclusive* TABLES 1# Infection of the respiratory tract, European Theater of Operations, U. S* Army, Cases and rates per 1000 strength, by years, February 1942 to June 1945 inclusive* 2* Infection of the respiratory tract, European Theater of Operations, U* S* Army, Deaths and rates per 1000 per annum, by years, February 1942 to June 1945 inclusive* 3* Common respiratory disease including influenza, European Theater of Operations, U. S> Amy, Cases and rates per 1000 strength per annum, by months, February 1942 to June 1945 inclusive* 4* Common respiratory disease including influenza, white and colored, European Theater of Operations, D« S* Army, admission rate per 1000 strength per annum by weeks; in United Kingdom, 3 September 1943 to 30 June 1944; and in Continental Europe, 1 September 1944 to 29 June 1945« 5* Common respiratory diseases including influenza, United King- dom and Continental Europe, European Theater of Operations, U* S* Army, Admission rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945 inclusive* 6* Common respiratory diseases including influenza, Air Forces and Communications Zone, United Kingdom and Continental Europe, European Theater of Operations, U* S* Army, Admission ratios per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945 inclusive* 7* Common respiratory diseases including influenza, by major com- ponents on the continent, European Theater of Operations, U« S. Army, Admission rates per 1000 strength, by weeks, 1 September 1944 to 29 June 1945 inclusive# 8* Common respiratory diseases including influenza, by armies, European Theater of Operations, U* S* Army, Admission rate per 1000 strength per annum, by weeks, 16 September 1944 to 29 June 1945 inclusive* 9* Common respiratory diseases including influenza, Continental United States and European Theater of Operations, U* S* Army, Cases and rates per 1000 strength per annum, by month, January 1942 to June 1945 inclusive* 10. Common respiratory disease including influenza, by theater. Cases and rates per 1000 strength per annum, by year, January 1942 to June 1945 inclusive. 11. Upper respiratory infection. Army troops on transports, European Theater of Operations, Care and attack rates per 100, August- September 1942. 12. Upper respiratory infection among 151 nurses in transit from Zone of Interior to European Theater of Operations, by date of onset, August-September 1942. 13* Crude incidence rates for upper respiratory infection, U. S. Army Transports, July-September 1942. 14. Daily incidence rates of upper respiratory infection, U. S. Army Transports, July-6eptember 1942. (Corrected for length of survey period and for susceptibility.) 15* Upper respiratory infection, by date of onset, U. S. Arny Trans- ports, July-September 1942. 16. Severity of upper respiratory infection, U. S. Army Transports, July-September 1942. 17. Duration of upper respiratory infection, U. S. Army Transports, July-September 1942. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY - 19^5 Part III - Epidemiology- Section 3 " Acute Respiratory Infections Number 2 - Influenza “by Colonel John E, Gordon, M,C„ Chief of the Division of Preventive Medicine, Office of the Chief Surgeon, ETO TABLE OF CONTENTS FART III Epidemiology Section 3 - Acute Respiratory Infections Number 2 - Influenza Page The Clinical Disease. ••••• .... 2 The Course of the Epidemic 2 Geographic Distribution. • . ... o , 3 Influenza in the Various Forces of Command A Racial Differences in Attack Rates. 6 Frequency of the Pneumonias During the Epidemic Period. .... 6 Influenza in the British Civilian Population . 7 Epidemic Influenza in Smaller Units of the United States Army . 7 Determination of the Specific Infectious Agent. ••*•... . 10 Influenza on Troop Ships 10 Program of Controls 12 The Post Epidemic Period. «. .............. • 13 Subsequent Behavior of Influenza. . ............. . 1A Specific Prevention of Influenza. . 16 List of Figures List of Tables List of Epidemiologic Case Reports PART III Epidemiology Section 3 - Acute Respiratory Infections Number 2 Influenza The confusion and lack of definiteness which arises in the clinical diagnosis of influenza in nonepidemic times and the tendency to designate most acute infections of the respiratory tract as in- fluenza when an epidemic of that disease prevails, leads to a situa- tion where no clear idea can be derived of how frequently or to what extent influenzal infections occurred in the European Theatero The attitude of the purist that the diagnosis of influenza Should be made only when an influenza virus is identified in the course of an acute respiratory infection is impractical. The complicated na- ture of the laboratory methods make them available only to a few hospitals through specially staffed laboratories. Under that policy, only a fraction of actual cases would be reported. The use of epidemiological criteria in diagnosis served with relative accuracy in times of epidemic, provided the diagnosis of in- fluenza was limited to cases which were clinically typical, occurred in groups, and adequate sampling had demonstrated the frequent and widespread distribution of an influenza virus. The principal error came in nonepidemic periods, due to the frequent interpretation of the seasonal waves of simple upper res- piratory infection as of influenzal nature. The years 1942 and 1943 present a curious paradox, in that influenza was epidemic in 1943 and not in 1942, and yet the reported rates for influenza in 1942 greatly exceeded those of the epidemic year. (Table 1.) Influenza virus had been identified among the civilian population of Great Britain in 19419 and there was some reason to believe that the infection may have carried over into the early months of 1942. The outbreak never reached the proportion of the subsequent epidemic in the winter of 1943-1944* The first American troops did not arrive in the United Kingdom, however, until late January of 1942, and the numbers at risk were never great during the first quarter of the year. The rates for respiratory disease among American soldiers were then relatively great, but could not have exerted sufficient influence through the numbers of actual cases of influenza that might have occurred, to give a rate for the year cf 23.1 per thousand. Fur- thermore, influenza virus was never determined to have existed that year in the American military population. The low rates for influenza during 1944 and 1945 were compatible with existing information from other sources* The Brit- ish Isles were free of the disease during those years* as was the Em-opean continent during the period of military operations; except that the virus of influenza was identified in some few scattered instances in late 1945* and occasional localized outbreaks were be- lieved epidemiologically to have been of that nature. The,Clinical Disease.—The clinical manifestations of influenza in the 1943 epidemic were those of a mild and uncomplicated disease* The incubation period was short* a matter of about 48 hours* The onset was abrupt* occasionally with a slight rigor* and the ini- tial symptoms were predominately constitutional rather than local* They consisted chiefly of prostration* aching pains in the legs and back and anorexia. A moderate cough was common, but was neither paroxysmal nor violent. The fever rarely exceeded 102° F* although occasionally it reached 104° F. It usually lasted but one or two days. During convalescence* which began rapidly about the third day* catarrhal symptoms were often prominent. The Course of the Epidemic.—That influenza appeared in epidemic proportions in the autumn of 1943 was by no means unex- pected. Interepidemic influenza in Great Britain had demonstrated a characteristic two-year cycle. The disease had last been prevalent in the United Kingdom during the winter of 1941”42. The late spring and early summer months of 1943 had furthermore been marked by a series of unusual outbreaks of acute respiratory disease* They were limited in time and space and ap- propriate laboratory examinations determined that almost all were due to influenza virus of type A® These outbreaks continued to appear in June* July* September* and October* Ever since studies of the influenza virus had been initiated in Great 1933* the A type of the virus had never been observed later than April nor earlier than December Similar events to those noted for the British civilian and military populations also occurred among American troops; such as the small, localized epidemic in the Southern Base Section in early August* an outbreak clinically typical of influenza although unconfirmed bacteriologically. St- The first statistical evidence of the beginning wave of increased incidence came in the week ending 12 November 1943* The usual autumnal increase in reported cases of upper respiratory dis- ease had started in accord with usual experience in mid-September (Figure 1* Table 2) but the average rates for the theater were ac- tually somewhat less than for the corresponding period of the pre- ceding year. The last week in October and the first week in Novem- ber showed a suggestive upward surge. 2 Figure 1. Common respiratory diseases including influenza, European heater of Operations, U, S. Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 January 1944 inclusive. The probable nature of the responsible Infectious agent was suggested at this time, and in advance of statistical confirma-* tion of the beginning epidemic# by repeated reports from clinicians in general and other hospitals that the clinical nature of the ex- isting disease was different from the ordinary respiratory disease previously prevalent# and more like influenzal The statistical reports of 12 November 194-3 left no doubt that an epidemic was in the makingo The increase in reported cases# thereafter, was extremely rapid# to reach a maximum rate of 1#079 cases per thousand strength per annum for the week ending 26 Novem- ber 194-3o This was measurably in excess of recorded experience, in the previous year# by more than sixty percent. The decline of the epidemic curve was as sharply marked as its sudden rise. By the last week of December the rate was 387# a satisfactory endemic level for that time of year. The remainder of the winter season continued uneventfully. The course of the epidemic as traced above is presented in terms of common respiratory diseases including influenza# for reasons that have already been brought out. Despite the unpre- dictability in the reporting of influenza Jn ordinary times# it tends to conform to type during the presence of an actual epidemic of that disease. This was true in this instance. The curve of reported influenza during the period of the outbreak rather closely paralleled that of the simple respiratory infections# although the magnitude was measurable less. The shape of the influenza curve also presented certain differences# in that the period of peak incidence was carried over into December# whereas the actual course of the epidemic reached its height in the of 26 November 194-3o This was without doubt a reflection of styles in reporting. Once the reporting of influenza had started# it tended to continue! and while the rates dropped precipitously in January they were still in excess of established annual averages through February# March# and April. It is scarcely necessary to observe that the actual incidence of influenza throughout the course of the epidemic was greatly in excess of the cases recorded as such; and that the great proportion of influenzal infections were reported as common respiratory disease. (Table 1.) Geographic Distribution. The geographical spread is best illustrated by the behavior of the disease in the several base sec- tions. The outbreak was first noted as a series of isolated epi- demics in the Eastern Base Section# to be followed almost concur- rently by a similar series of events in the Central Base Section. The eastern area was largely occupied by the Air Forces# and the central was made up principally of London and its immediately sur- rounding territory. 3 The district of East Anglia in the Eastern Base Section, was first involved. The rates for respiratory infection had been greater in this base section, compared with the rest of the area of the theater, since early September. The epidemic extended promptly to the London area, to the Southern Base Section during the week of 29 October 19A3 and within days to the Western Base Section. From then on, there was a more or less universal sweep over all of Great Britain, with the peak of the outbreak occurring in all four base section areas during the week of 26 November 194-3* The course of the epidemic in the several base sections is illustrated in the composite graphs of Figure 2, Table 3* The outbreak did not become manifest in the relatively isolated North Ireland Base Section until the last week in October, did not attain real headway until the third week in November, and the peak was delayed until the week of 3 December 194-3° In the course of its spread, the entire area occupied by American troops was involved, but the attack rates for other areas were never as great as in the two base sections where the outbreak appears to have started. The epidemic situation as of 3 December 194-3 is shown in Figure 3* The concentration of cases of influenza coincides almost precisely with the concentration of troops. Influenza in the Various Forces of the Command.—The sharp rise in the epidemic curve was reflected in the rates for all three major components of the command, although there were individual variations in magnitude. The rates for the Services of Supply reached the highest level and the Air Forces were next. The shape of the curve for the Ground Forces was neither characteristic of influenza nor of the experience of the other two forces, because of well-marked dif- ferences in the time and extent with which the outbreak struck vari- ous major units. Consequently the epidemic curve never reached a cumulative peak of the height noted for the other services. The to- tal attack rate for the as a whole, was essentially the same, for^while the epidemic was less sharply marked among the ground Forces, it was more prolonged. (Figure 4-j Table 4-°) The Ground Force unit first affected was the 101st Airborne Division during the week of 29 October 194-3, and that organization likewise had a greater number of cases in the course of the out- break than any other major unit of long residence in Great Britain. The peak was great, and the wave relatively long continued. The Second Armored Division arrived in the theater during the latter part of November, just as the epidemic was at its height. The attack rate was greater than for any other division, the peak of incidence was higher and it naturally appeared much later, on 17 De- cember 194-3° The same sharp curve, but of somewhat lesser magnitude, was noted for the Ninth Infantry Division, which also arrived in the United Kingdom late in November. 4 Figure 2. Common respiratory diseases including influenza. Base Sections, European Theater of Operations, U* S. Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 January 1944 inclusive. Figure 3 Geographic distribution of common respiratory diseases, U. S. Army in the United Kingdom, 3 December 1943. RATE RATE 1200 Figure 4 Common respiratory diseases including influenza, major commands, European Theater of Operations, U. S. Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 January 1944 inclusive* The reaction of various other Divisions to the epidemic (Figure 5, Table 5) brings out several epidemiologic factors. No correlation could be shown between the length of service in Great Britain and the incidence of influenza*. The oldest division in point of service in Great Britain was the <9th Infantry Division. The attack rate in that organization was essentially the same as the average for the theater. The 5th Infantry Division, which had long been stationed in Iceland, had transferred to Great Britain in North Ireland in early October, had a rate much like that of the 29th Division which was at the theater average. Other divisions such as the First and Second Infantry Divisions and the Third Armored Division had distinctly low rates. The 1st Infantry was a veteran unit recently arrived in Great Britain from North Africa, which the 2d Infantry was.fresh from the Zone of the Interior with the epidemic just under way. The 3rd Armored Divi- sion had been in the theater since September, well before the outbreak. The rates for the 101st Airborne Division and the 28th In- fantry Division were appreciably in excess of average experience. The Airborne Division had been in England since early September, the 28th Infantry since late October when the epidemic was just get- ting under way. It was evident that the distinct variations in the attack rate were not dependent upon length of residence in the theater, although in all instances influenza attacked seasoned troops to a much greater extent than had the ordinary respiratory infections of the preceding two yearso Many veteran units showed the same lack of resistance to influenza as did units of relatively recent origin, although accumulated experience had repeatedly shown the latter to be more susceptible to common respiratory Infection. The course of the epidemic among ground force troops, considered as a whole, was largely influenced by the arrival of the 2d Armored Division and the 9th Infantry Division at the height of the outbreak. It has long been recognized that the introduction of healthy units into a station where an epidemic is in progress tends to exaggerate and prolong the epidemic® These two divisions did not join other troops, but occupied individual camps. Never- theless, influenza struck sharply and severely, with a peak of in- cidence that was greater than that of most divisions, and a course that was more prolonged. Presumably this was due to more or less simultaneous exposure of all susceptibles to a full-blown epidemic, with no opportunity for such progressive salting of the herd as oc- curs even with an influenzal infection, thereby tending to limit explosiveness and extent. The general effect on the broad aspect of the epidemic as it Involved ground forces of the theater was, therefore, the same exaggeration and prolongation of the process as that which follows introduction of a fresh unit into an in- fected post. 5 Racial Differences in Attack Rates*—The incidence of epidemic influenza among colored troops was measureably less than that for white troops of the theater. (Figure 6) (Table 4* Sec- tion 3* Number 1.) During the week of greatest incidence for the theater as a whole* that of 26 November* the rate for white troops was 1*129* that for colored 4-77. The differences each week throughout the epidemic were obviously statistically significant. They were greater than those demonstrated between white and colored troops during nonepidemic timeso No quantitative measure can be given and no categorical statement can be made which will indicate that the difference be- tween white and colored rates during the epidemic was more signifi- cant or was less significant than such difference in nonepidemic periodso Table 6 shows the epidemic to normal ratio for white* the epidemic to normal ratio for colored* and the ratio of white epidemic- normal differences to colored epidemic-normal differences., It will be noted that the average white ratio of epidemic to normal was 6<>0* whereas the comparable average colored ratio was 4o3o The average ratio of the white epidemic-normal differences to the colored-normal differences was 2.2. The distribution of colored troops was fairly uniform throughout the several base sections and all were members of the Services of Supply., The differences that were noted were not re- lated to white troops having been stationed predominantly in a part of the theater more affected than another. Frequency of the Pneumonias During the Epidemic Period.— The significant epidemiologic feature of an epidemic of influenza is the extent to which it brings about increased rates for the pneumonias. The deaths from influenza are deaths from secondary pneumonia. The 1943 outbreak was almost completely unassociated with an increased prevalence of primary and secondary pneumonia. The greater rates noted for the months of November and December of 1943 and for January of 1944 are no more than would be anticipated in the course of the usual seasonal increase of these infections. The abso- lute level was decidedly less during the presence of the influenzr epidemic than it was for the corresponding period of the previous year of 1942 (Figure 7* Table 7). Pneumonia cases were not only in- frequent during the course of the influenza outbreak but no death from pneumonia secondary to influenza was specifically noted. 6 Figure 5, Common respiratory diseases including influensa, six selected divisions, European Theater of Operations, TJ. S, Army, admission rate per 1000 strength per annum, by weeks, 3 September 1943, RATE 1200 RATE 1200 1200 1200 Figure 6 Common respiratory diseases including influenza, white and colored, European Theater of Operations, U. S. Army, admission rates per annum, by weeks, in United Kingdom, 3 September 1943 to 30 June 1944j and on Continental Europe, 1 September 1944 to 29 June 1945. RATE 1000 RATE 1000 1942 1943 1944 Figure 7 Common respiratory diseases including influenza and the pneumonias (all forms), European Theater of Operations, U. S. Army, comparative rates per 1000 per annum by months, February 1942 to January 1944. Influenza in the British Civilian Population*—The experience of the British civilian population in this influenza epidemic differed from that of the United States Army principally in respect to mor- tality. The outbreak occurred at the same time, the clinical course was similar and the same type of influenza virus was demonstrated. Reliable information on morbidity was lacking but the infection was apparently as widespread and universal among civilians as it was among the military. During September, the number of deaths from influenza for the 126 great towns of the United Kingdom, representing a population of about 21,000,000, was less than 10 per week. (Figure 8, Table 8.) A progressive increase in mortality rates from influenza became ap- parent during the next three weeks, with 106 deaths due to this cause reported for the week ending 20 November 194.3* The maximum number of 114.8 deaths was reached during the week of 11 December, which was two weeks later than the peak for reported cases among the American military forces. As the maximal frequency of deaths naturally follows the height of reported cases, the peak of case incidence among British civilians without doubt occurred at about the same time as that for the United States Army. Deaths from influenzal pneumonia were largely among persons in the older age groups, and differences in population content account for the higher death rates among British civilians as contrasted with the United States Army which had a very favor- able groqp of young adults. Epidemic Influenza in Smaller Units of the U. S. The of this epidemic have been described as they af- fected the military population of the United States Army as a whole. Equally informative information concerning the characteristics and behavior of the epidemic disease was obtained through consideration of the affect it had on individual and relatively small units. No attempt was made to accomplish a general field survey of the outbreak. That is ordinarily productive of little result with influenza* because of the rapidity with which it travels and the short duration of a unit outbreak. Epidemiologic studies were limited to thorough observations of a few unit outbreaks. The pur- pose was conceived as wholly apart from control measures* the in- stitution of which, in a widespread outbreak such as the one at hand had of necessity to fall to unit surgeons. Epidemiologists of the theater were considered to have two obligations. The first was to determine the nature of the epidemic process and* secondly* to transfer this information to the surgeons of major commands with such recommendations for control as field studies indicated. It was believed the limited number of experienced epidemiologists could be most usefully employed in the manner indicated. A distinct regular- ity of epidemiologic pattern was demonstrated for outbreaks of re- spiratory disease in various units. (Figure 9*- Table 9*) 7 Epidemiologic Case Report No* Lr-The outbreak of influenza among the Medical Department personnel of the 77th Station Hospital, located in the Eastern Base Section., began suddenly on 31 October 194-3? reached a rate of "),5B6 per thousand per annum for that week, and subsided rapidly during the following week* The symptoms were those of gen- eral malaise, coryza and congestion of nose and throat and fever of 100° F* for 4-8 to 72 hours* The duration of ill- ness lasted from five to seven days* Two patients devel- oped pneumoniao Epidemiologic Case Report No0 2.°~Twc units of engineers, the 360th Engineer (GS) Regiment and the Sec- ond Battalion of the 35Bth Engineer (GS) Regiment-, were stationed in the Eastern Base Section, lived in tents in the same vicinity, and worked on the same construction projects For all practical purposes they constituted one military population* The influenzal outbreak be- gan on B November 1943, and the two units were equally affectedo The highest level of incidence, 6,111 per thousand per annum was reached during the week of 26 November 1943* The decline of the outbreak was as rapid as had be£n its onset* The incidence was greater and the clinical disease more severe than for most other units of the Eastern Base Section. Symptoms consisted of general malaise to almost cdraplete exhaustion, and temperatures ranged from normal to 104° F. with chills, generalized aching and conjunctivitis. Four to eight days was the average duration of the disease* Epidemiologic Case Report No* 3.--The outbreak involved a newly arrived unit* The 333rd Engineer Regi- ment arrived in the United Kingdom on 21 October 1943, proceeded to the Southern Base Section, and immediately became engaged in construction work* On 30 October, the first cases of respiratory disease were reported* For the week of 19 November the admission rate was 3? 807 per thousand per annum* This fell rapidly during the next three weeks* Ten of the patients were hospitalized for primary pneumonia, a possible contributing factor be- ing a temporary shortage of outer clothing* The clini- cal features of what was called common respiratory dis» sease were temperatures of 101° F* to 103° F*, general malaise, and loss of appetite* Epidemiologic Case Report No* 4.—The 342d Engineer Regiment by contrast with the Engineer unit mentioned just previously had been stationed in the United Kingdom for approximately 17 months and was likewise engaged in outdoor construction work. In- fluenza was first observed 12 November 1943. The a Figure 8 Influensa, 126 Great Towns, England and Wales, number deaths by weeks, 2 October 1943 to 28 January 1944, Figure 9 Common respiratory diseases including influerusa, selected units, European Theater of Operations, U. S. Army, admission rates per 1000 strength per annum, by vreeics, 3 September 1943 to 28 January 1944 inclusive. rate of incidence rose sharply to reach 3*712 per thousand per annum for the week of 26 November,, The clinical features were described as headache* malaise* prostration* occasional vomiting and diarrhea* minor upper respiratory symptoms and temperatures ranging from 100° Fo to 103* P. Epidemiologic Case Report Noe 5*—General Depot G-18 of the Western Base Section had a strength of 5*737 men divided into eight camps. The first five were situated near Sudbury, England* and Nos0 6* 7* and 8 were at Eggerton* several miles away. Cn 3 November* the first probable patient with influenza from C Com- pany* 131st Quartermaster Regiment (TRK)* Camp No. 2* reported to the dispensary with headache* backache* prostration* and an elevated temperature. Within 12 hours, the medical officer developed the same symptoms. The following day 21 men of C Company were ill. On 5 November* cases began to develop in the 445th Engineer Base Company* on 7 November in 608th Engineer Light Equipment Company* and on 8 November in the 887th Ord- nance Ammunition Company. Altogether* Camp No. 2 with 837 men had 121 patients in hospital with influenza* practically all of whom developed the infection between the 4th and 11th of November and belonged to one or other of the four companies noted. Camp No. 1 was located in the same vicinity as Camp No. 2* and shared the same dispensary. The out- break in this camp extended over the same period. Of 849 men* 72 were admitted to hospital with influenza. Camp No. 3>» housing the 534th Quartermaster Service Battalion* a colored labor unit* had no known association with any other camp except for an exchange of labor with the 2d platoon of D Company located at Camp No. 8. The outbreak of influenza began at Camp No. 3 on 14 November with the hospitalization of six men. The following day so many new cases appeared that two empty barracks were converted into a camp infirmary. During the period 14 to 24 November* this unit had 111 cases of respiratory disease. The infection spread to 2d platoon* D Company at Camp No. 8 and 26 cases were reported between the 22d and 25th of November. With the exception of this platoon there were few cases of respiratory infection at Camp No. 8. Camp 4> with 689 men* sent 15 to the hospital between 17 November and 25 November* and the daily sick call averaged about 15 which was only slightly higher than had held in October. Camp 5* an Air Corps Depot having little asso- tion with other camps* had no cases of influenza. Camps 6 and 7* located several miles from the other camps* likewise had very few cases of respiratory disease. 9 It is clearly demonstrated that respiratory disease spread rapidly from one group to another within an incubation period of about 24 to 4.8 bourse Association of groups was a much more impor- tant factor than kind of work or type of quarters. Determination of the Specific Infectious Agent.—The specific etiologic agent involved in the 1943 epidemic was determined to be in- fluenza virus Type A. Examinations of material for identification of the virus were obtained from patients in hospitals where continued observation permitted certain clinical diagnosis. Instructions issued to hospitals stated that influenza viruses A and B were rapidly recognized by demonstrating a signifi- cant rise in specific antibodies in the serum of patients during convalescence. Antibodies which were normally present against these two viruses increased rapidly after infection and reached a maximum within several days. Therefore it was directed that an initial sample of blood serum be obtained promptly after onset of and a second sample after six days. Estimation of in- fluenzal antibodies in single samples of blood was emphasized as being of no diagnostic value. During the course of the epidemic somewhat more than 25 strains of Type A influenza virus were identified from patients of the theater. They were representative of the four base sections in Great Britain. No type B virus was ever found. The cause of the outbreak was thereby established as of uniform origin and of the type A variety. The first confirmation of virus was on 19 November 1943. .Influenza on Troop ShinSoV-Renorts received from the United gave information of-etn existing epidemic in the Zone of the Interior of type B influenza® There was considerable con- cern in Great Britain about the possibility of introducing this second strain of influenza virus, with superimposition of a second outbreak upon the first® The convoy Ut-5 carrying approximately 63,750 troops on 24. transports, 17 from New York and 7 from Boston, departed for the United Kingdom on 5 December 194-3* disease was epidemic in the staging areas where these troops were held prior to sailing® The convoy arrived at four ports in the United Kingdom - Glasgow, Liverpool, Bristol, and Belfast — between 1$ and 17 December 194-3* A member of the Division of Preventive Medicine was sent to each port to investigate conditions on the incoming transports® The two or three days before sailing were spent in the checking of equipment and with matters concerned with embarkation. 10 This involved much waiting around* often in exposed situations and with little sleep. Troops arrived on board physically tired* they were packed below deck under overcrowded conditions* in some in- stances with double loading* and they sailed in early winter after exposure to an epidemic of influenza. Notwithstanding these fac- tors* no unusual incidence of respiratory disease occurred. Ships and port surgeons generally agreed that the cases which did occur did not exceed normal expectation for that season. A high proportion of troops did come on board with a respiratory infection of some sort — according to the varied estimates of transport surgeons* in proportions of 15 percent to 80 percent. Many patients doubtless never bothered to go to sick call and yet figures showing the daily admissions to sick call throw several sidelights on the situation. The greatest numbers of patients with respiratory illness were seen during the first half of the voyage* with the peak of the epidemic on the fourth or fifth day at sea. The num- ber reporting to sick call with respiratory infection was 7*592 of whom 962 were hospitalized en route* and 86 evacuated to hospitals on arrival, for all transports* respiratory dis- ease was less prevalent on debarkation than on embarkation. The actual incidence en route was less than that for most units sta- tioned in the United Kingdom during the same period* and decidedly less than the observed rate for respiratory diseases on transports generally. Three of the transport surgeons on ships leaving New York reported an outbreak of disease with the characteristic symptoms of influenza. Epidemiologic Case Report No. 6.—The transport NY- 613 carried 5*542 troops* an overload of 550. The ship sur- geon reported that an outbreak of respiratory illness clini- cally suggestive of mild influenza occurred during the voy- age. Treatment was given to 785 patients with respiratory disease and 58 were hospitalized* 36 with a diagnosis of nasopharyngitis* the remainder with bronchitis and pharyn- gitis* including three patients with pneumonia. Most cases occurred about five to six days after embarkation* the number decreasing rapidly thereafter. The daily sick call is pre- sented in Figure 10* Table 10. The ship surgeon reported that on the whole the number of patients seen daily was no more than would ordinarily be expected on a transport travel- ing the north Atlantic at that time of the year.' The gen- eral situation improved during the voyage. Four patients were disembarked for further treatment in hospital. 11 A small number of patients with an influenzalike disease was reported on other transports. There was a slightly higher pro- portion of respiratory disease among troops from New York than those from Boston, but the difference was not striking. The largest trans- port of the convoy, the BO-454 came from Boston. According to the ship surgeon there were very few infections from this port sugges- tive of influenza. For the most part symptoms consisted of aching joints and muscles, congestion of mucous membranes and a temperature of 102° F. to 104° Fo A relatively small number developed pneumonia. One transport surgeon, the only medical officer aboard his ship, died of pneumonia. The circumstances under which this large convoy sailed aroused concern on both sides of the Atlantic. Troops left the Zone of the Interior where influenza was epidemic, the incidence among embarking troops was high, the crowded conditions favored a serious outbreak during the course of the voyage. From the stand- point of the theater, there was danger of introducing a new strain of virus into a population where influenza was already epidemic. Essentially nothing happened. The health record of the troops in respect to respiratory disease was better than usually experienced. There was no evidence at the time, nor later, that type B influenza virus was ever introduced into Great Britain by recently arrived United States troops. Program of Control*—The principle was early referred to medical officers of the theater that actual control of epidemic in- fluenza in the sense of inhibiting or arresting its spread was be- yond the capacity of present day methods, but that preventive meas- ures were of decided value in checking the explosiveness of the epidemic spread. Retardation of the rate of spread could be ex- pected to produce results leading to fewer men being incapacitated at any one time*. The work of a unit would consequently be inter- ferred with to a lesser extent, hospitals would not be overloaded* and patients would receive better care. The total number of cases could be expected to be less than otherwise. The program instituted to attain this end included provision for epidemiologic studies of isolated outbreaks, that surgeons of the theater might be informed of the current clinical and epidemiologic nature of the condition, the extent of its ex- istence in the theater and the anticipated future behavior of the epidemic. Sufficient laboratory examinations were instituted to establish the nature of the infectious agent, its presumed unity throughout the theater, and the extent of the distribution of the viruso Actual control measures for units of the theater were designated a responsibility of command, with the assistance of unit surgeons. The functions of the central Division of Preventive 12 Figure 10 Daily siok call of patients with aoute upper respiratory infection on board Transport NY 613 "Britanio", December 1943. Medicine were directed toward collection of information and its distribution to surgeons* Advice was given on control measures* based on accepted general principles0 A general educational pro- gram was instituted through the army newspaper Stars and Stripes and for medical officers through the Medical Bulletin of the Of- fice of the Chief Surgeon* The material directed attention to matters of personal hygiene* of sleeping arrangements* of mess kit washing and the numerous other features of a program for prevention of acute respiratory infections* Special stress was placed on frequent medical inspection to discover the presence of upper respiratory disease among food handlers* with directions that persons so infected were to be as- signed to other duty or isolated as the situation demanded* The existing blackout regulations interfered with proper ventilation* Full advantage was to be taken of all available means of ventila- tion with ventilators kept free of obstruction and windows opened at night* Barracks were directed to be freely aired during the day. Working quarantine was stated to be impractical* No method existed for determining carriers and the results likely to be obtained from quarantine on an effective scale would interfere in too great extent with unit training activities* Troops should be kept fully occupied; the precautions outlined need not interfere with the activity of any unit as a whole* Mild cases were to be recognized as a potent source of spread of respiratory disease* Instructions to medical officers stressed a variety of considerations* Daily medical inspection was emphasized as the only method of detecting early and mild infections* Patients were to be either specially instructed on precautions to be taken or isolated* If the fullest measures were not taken to insure proper isolation* patients admitted to a dispensary or infirmary were likely to contract a respiratory cross infection during their visit which was not present on admission* Care was necessary that all discharges from patients in an infirmary be burned or otherwise disinfected* It was urged that the diagnostic term influenza be used according to epidemiologic criteria and that it be limited to cases which were clinically typical and occurred in groups* The Post Epidemic Period*—There was much speculation at the time of the 194-3 epidemic of the possibility that this mild wave might be the precursor of an outstanding pandemic of influenza. A series of such events had preceded the last great epidemic in 1918* with the first of the preliminary waves in March* another in May and the main event in August* Although no reason existed for belief that the 194-3 epld««tc of type A influenza had any more relation to a future pandemic than any one of numerous others that had preceded it 13 in past years* the military implications of such an event were sb important that full measures were taken to acquaint the command with that possibility* Shortly after the epidemic wave had passed* a letter was sent by the Chief Surgeon to the surgeons of all major commands on the need for reporting subsequent recurrences of influenzalike dis- easeo In February* 1944# the theater commander addressed all prin- cipal components of the American forces on measures to prevent epi- demics of respiratory disease* in which it was brought out that the epidemic of mild influenza*which the army had recently experienced* should serve as a warning of the possible occurrence of a serious pandemico The mildness of the disease in the past two years was not to give rise to a false sense of security since influenza epidemics with high mortality were frequently preceded by waves of mild influ- enza and it was entirely possible that this sequence would occur againo Special stress was placed on the consideration* to be given housing* transportation* and the medical supervision of troops* es- pecially those scheduled for operational raovementso This directive was followed some two months later by a comprehensive circular letter from the Office of the Chief Surgeon to all medical elements of the theatero The epidemiologic features of influenza in military populations were discussed and the possible intrusion of a second wave was again presented* together with the precautions necessary for protection of troops from this infectious diseaseo The unusual concern given the matter originated of course from the serious effect such an event would have had on preparations for the impending invasion of France* Subsequent Behavior of Influenza*—Shortly after the end of the 194.3 epidemic* a special organization was established to fa- cilitate early recognition of a possible return of the diseaseo Through a cooperative effort of the First Medical General Laboratory* of the Division of Professional Services and of Preventive Medicine* a small group of qualified observers was selected* usually the chiefs of medical services in certain general hospitals* who were charged with special watchfulness for an epidemic disease suggestive of in- fluenzal for reporting such possibilities to the Office of the Chief Surgeon; and for the collection and transmission of the necessary blood samples to be examined for the presence of antibodies to in- fluenza virus* These special medical observers were so chosen as to give general coverage of the theater* Nothing occurred throughout 1944. to suggest the presence of influenzal infection in the European Theater* The year was com- pletely uneventful in respect to that disease* and in fact the gen- eral rate for respiratory infections was particularly favorableo The following spring of 194-5 brought more cogent possibilities of influenza* although the early months of 194-5 had been characterized by particularly low rates for diseases of the respiratory tracto The minor outbreaks which had characterized the late spring months of 194-3 might well be repeated in the light of the two-year cycle of type A influenza. In April of 1945> the first positive identification of influenza virus was made in Great Britain and during the same month the virus was also determined among troops stationed in Germany® These were the only two known instances® A limited number of small outbreaks confirmed the activity of the virus. The epidemic that involved the 7%th AAA (AW) Battalion located in Speyer, Germany, was typical. Epidemiologic Case Report No. 7.—A sudden out-* break of an acute febrile disease occurred in the 794-th AAA (AW) Battalion which was encamped on the west bank of the Rhine* 15 miles south of Mannheim. The epidemic extended over a 12-day period, from 29 May 194-5 to 9 June 194-5, during which time 83 men were sent to hospi- tal. The battalion had a strength of 780 men divided into five batteries. Batteries Ap BP Cp and D had a strength of 160 men each, and headquarters battery a strength of 100. The men were living under canvas. The clinical disease was marked by sudden onset of marked prostration followed by headache and pains in the neck, lumbosacral region and chest. This was ac- companied by chills and fever, with temperatures aver- aging about 103° F. White blood counts showed a leuko- penia ranging from 5,000 to 7,000 per ccm. The febrile period lasted about 7 days and continued after clinical improvement was apparent. There were no deaths. The original case, and the majority of those that occurred subsequently, involved men of C Battery. Each battery had its own mess, and association between the men in the several batteries was limited. Only after the fourth day did the epidemic spread to the other bat- teries and that never occurred to any appreciable ex- tent. (Figure 11, Table 11.) The epidemiological behavior of this outbreak of acute febrile disease was characteristic and typical of an outbreak of acute influenza. The clinical disease was of that nature. The e tj.pl ogic agent remained undetermined since blood samples taken at the time never came to report.* Contrary to the experience of 1943s there was no perceptible increase of similar events in the course of the summer, and the autumn of 1945 passed with no indication of an undue preva- lence of epidemic proportions throughout the winter of 1945-1946* although both types A and B influenza were demonstrated in Germany in that timeo 15 Specific Prevention of Influenza., — The newly developed influenza vaccine of the United States Army Medical Department be- came available in late 19A4-* The supplies were so limited at that time that the product was never used to any appreciable extent in the European Theater, either in immediate immunization in the face of a developing epidemic of influenza nor in general protection of the commando Sufficient supplies for the first purpose were ob- tained early in 194-5, but the absence of the disease obviated its use» Consideration of general immunization of the command was postponed until the following autumn, because of the considered inadvisability of a general program of immunization against influ- enza initiated in the spring months of a year when the disease was thus far absentc 16 Figure 11 Acute upper respiratory infection, 794th AAA (AW) Battalion, European Theater of Operations, U, S. Army, number oases hospitalized, 29 May to 9 June 1945* TABLE 1 Influenza ✓ European Theater of Operations U. S. Army Cases and Hates per 1000 strength per annum, by years February 1942 to June 1945* inclusive r 1 Cases Rates ( 1942 1680 23ol 1943 3850 14® 6 1944 3226 2.2 1945 2766 2o0 Total 11522 3.6 Sources Division of Medical Records* Office of The Surgeon General European Theater of Operations TABLE 2 Common Respiratory Disease Including Influenza European Theater of Operations Uo So Army Admission rates per 1000 strength per annum, by weeks 3 September 194.3 to 28 January 1944 inclusive Week Ending Rate J 1943, September 3 f 118 N 10 136 t» 17 132 n 24 151 October 1 231 n .8 204 « 15 203 n 22 205 H 29 286 November 5 360 n 12 494 it 19 725 ti 26 1079 December 3 829 n 10 626 n 17 591 tt 24 493 it 31 387 1944, January 7 389 n 14 370 it 21 383 tt 28 384 Source s Division of Medical Records, Office of the Chief Surgeon, European Theater of Operations TABLE 3 Common Respiratory Disease Including Influenza Base Sections European Theater of Operations D0S« Army Admission rates per 1CCG strength per annum, by weeks, 3 September 194-3 to 28 January 1944, inclusive Base Seai bions Week Ending ETO Cen- tral East- ern South- ern West- ern North Ireland 194-3j Sept 3 118 127 129 98 88 10 136 186 134 101 110 17 132 183 113 111 95 24 151 218 143 137 114 Octo 1 231 372 235 356 147 8 204 312 221 169 130 221 15 203 U6 253 149 158 82 22 205 236 269 160 168 61 29 286 266 265 383 243 167 Nov© 5 360 402 344 389 365 220 12 494 807 593 408 626 289 19 725 1310 881 741 707 273 26 1079 1745 1438 1121 1001 534 Deco 3 829 1086 1110 905 669 765 10 626 819 666 657 455 589 17 591 64.5 505 568 427 504 24 493 672 471 433 359 366 31 387 491 392 374 307 265 1944$ J an© 7 389 515 352 340 291 270 U 370 526 298 335 296 253 21 383 468 335 372 394 483 28 384. 424 340 409 396 306 Source: D Ei Ivisioi iropeai 1 of Medical Records* Ofi 1 Theater of Operations. ?ice of the Chief Surgeon* TABLE L Common Respiratory Diseases Including Influenza Major Commands European Theater of Operations Uo So Army Admission rates per 1000 strength per annum, by weeks 3 September 194-3 to 28 January 19A4-# Inclusive Week ending Ground Air Services of I Forces Forces Supply i 194-3 September 3 137 120 109 10 153 144 118 17 145 139 114 24- 166 14.8 139 October 1 217 204 260 8 201 * * 1$ 207 212 183 22 147 236 197 29 231 298 292 November 5 354 357 358 12 426 513 527 19 679 688 775 26 957 1009 1190 December 3 840 727 890 10 706 545 610 17 785 473 523 24 631 420 437 31 ■406 369 368 1944- January 7 . 401 378 344 14 394 346 332 21 366 360 386 28 374 360 389 * Data not w callableo Sources Division of Medical Records# Office of the Chief Surgeon# European Theater of Operations TABLE 5. Common Respiratory Diseases Including Influenza Six Selected Divisions European Theater of Operations U0 So Array Admission rates per 1CC0 strength per annum, by weeks 3 September 1943 to 28 J anuary 1944, inclusive Week Ending 5th Infan- try 28th Infan- try 29th Inf sin- try 2d Arm- ored 3d Arm- ored 101st Airborne 1943, Sept* 3 91 104 ti 10 208 104 13 n 17 182 156 26 0 n 24 221 164 us 18 Oct* 1 24.7 260 182 39 M 8 273 208 169 39 n 15 273 221 156 143 ii 22 302 11 229 281 178 n 29 228 55 161 337 569 Nov* 5 702 338 97 395 890 it 12 681 499 226 377 600 n 19 779 821 531 654 1549 n 26 950 1643 693 882 1126 Dec* 3 1131 1461 899 379xx 747 490 B 10 921 70S 931 1021 537 420 It 17 655 588 902 2505 412 496 H 24 866 375 509 1825 354 383 It 31 612 284 325 733 382 189 1944, Jan* 7 593 346 362 868 330 305 n 14 759 354 374 658 277 212 n 21 571 304 317 858 231 187 H 28 * 371 222 960 231 246 * Data not available.* xx First Report submitted in U* Sources Division of Medical Recc European Theater of Oper K* rds. Office of the Chief Surgeon, ations. White Negro White Negro Ratio Time Period Epi- demic Normal r Dif- ference Epi- demic Normal Dif~ ference Ratio Epidemic Normal Ratio Epidemic Normal of Difference w/c 1st week 15 Oct, 1943 4,15 1.16 2,3 13 Oct, 1944 1.82 2,33 1.08 ,08 1,1 29.1 2d week 22 Oct, 1943 4,56 1,33 2,8 20 Oct. 1944 1,64 2,92 1.03 .30 1,3 9,7 3rd week 29 Oct. 1943 6,15 2.24 4.4 27 Oct. 1944 1,41 4.74 1,32 ,92 1,7 3,2 4th week 5 Nov. 1943 7,26 3,40 4.5 ‘ 3 Nov, 1944 1,63 5,63 1,55 2,05 2,5 2.7 5th week 12 Nov, 1943 9,73 7.83 5,8 10 Nov. 1944 1,68 8,05 1.36 6,47 5,8 1.2 6th week 19 Nov, 1943 14.35 7,98 6,3 17 Nov, 1944 2.26 12.09 1,42 6,56 5.6 1,8 7th week 26 Nov, 1943 21.71 9.17 10.9 24 Nov, 1944 2.00 19.71 1,02 8,15 9,0 2.4 8th week 3 Deo, 1943 17,12 7,12 9,9 1 Dec, 1944 1,73 15,39 *98 6*14 7,3 9,8 9th week 10 Deo, 1943 12,21 7,62 6,3 8 Dec, 1944 1,94 10,27 1.36 6,26 5,6 1,6 10th week 17 Dec, 1943 11,83 7,02 5.5 15 Dec, 1944 2,16 9,67 1,76 5.26 4.0 1.8 Average 10,91 1,83 9.08 5,49 1,27 4,22 6,0 4.3 2,2 Source: Medical Statistics Divisions Office of The Surgeon Generals Washingtons D , C. Common Respiratory Diseases European Theater of Operations.; United Kingdom and Continent* Uo S0 Army Comparison of admission rates per 1000 strength per annum* hy weeks White and colored in an epidemic and a nonepidemic period 1943=1944 TABLE 6a TABLE 7o Common Respiratory Diseases Including Influenza*, and the Pneumonias (all forms) European Theater of Operations* IL S0 Army Jomparative rates per 1000 per annum by months* February 19A2 to January 19AA inclusive Month Con tc unon Respira- >ry Diseases Pneumonias all forms 1942* February 739 60 5 March 523 5ol April 324 4o6 May 126 208 June 83 3o9 July 125 6,3 August 131 6« 0 September 170 5o3 October 272 I0o 5 November 514 30„2 December 566 14o0 1943* January 704 180 3 February $16 210 5 March 408 lOol April 263 •s t ? -LJL O May 216 5o3 June 173 60 3 July 116 60 0 August 117 60 0 September 136 5o9 October 236 110 4 j November 700 . 14o0 • - December 628 160 3 V • 194-4-5 January 416 17c 5 Sources Medical Statistics Division* Office of The Surgeon General* War Department* Washington* D0G0 TABLE 80 Influenza 126 Great Cities and Towns, England and Wales Deaths by Weeks 2 October 1943 to 29 January 1944 Week ending Deaths 194-3* October 2 12 9 14 16 18 23 13 30 25 November 6 31 13 46 20 c 106 27 375 December 4- 709 11 1148 IS 1115 25 699 1944-5 January 1 464 8 255 15 197 22 143 29 104 TOTAL 5474 —————■ ■ ■- -■ Source s England and Wales* Weekly returns* Births* Deaths* Marriages and Infectious Diseases* Office of the Registrar General* British Ministry of Healths Common Respiratory Diseases Including Influenza Selected Units European Theater of Operations, U„ S0 Army Admission rates per 1000 strength per annum, by weeks 3 September 194-3 to 28 January 1944/ inclusive IfeHULS- , Week ending 77th Sta. Hosp. 33rd Engr. Regt. 342d Engr. Regt. 360th Engr. Regt. General Depot G-18 1943 September 3 85 241 277 10 305 174 121 114 17 * 134 * 85 24 371 22L 243 & October 1 95 266 324 141 8 * * * * 15 93 389 226 145 22 529 115 226 104 ' 29 900 0** 632 302 293 November 5 3586 1098 183 265 1439 12 1954 1374 565 402 3255 19 5n 3807 792 952 1627 26 442 2716 3712 6111 867 December 3 455 2407 1714 533 471 10 182 1185 930 1500 545 17 368 1661 592 394 462 24 6^8 1265 544 1238 501 31 371 989 255 397 595 1944 January 7 558 0 287 339 222 14 64.9 0 425 375 290 21 361 0 199 170 482 28 * 0 411 473 307 * Data not available. ** First report received. Sources Division of Medical Records* Office of the European Theater of Operations. Chief Surgeon* TABLE 10. Daily Sick Call of Patients With Upper Respiratory Infection On Board Transport NY613 "Britanic1' December 194-3 1 " Date Cases December 4- 105 5 119 6 220 7 uz 8 152 9 192 10 105 11 163 12 60 13 62 U 33 15 15 16 30 17 25 H— * The number of individual patients for the period was 785o Source: Division of Preventive Medicine* Office of the Chief Surgeon European Theater of Operations TABLE Ilo Acute Upper Respiratory Infections 794th AAA (AW) Battalion Number of Cases Hospitalized, 29 May to 9 June 1945 European Theater of Operations, U. Sc Army Batteries Cases Hq 3 A 5 B 11 C 64 D 0 Total 83 Source: Division of Preventive Medicine9 Office of the Chief Surgeon European Theater of Operationso FIGURES 1* Common respiratory diseases including influenza, European Theater of Operations, Uo S0 Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 January 1944.? inclusiveo 2. Common respiratory diseases including influenza. Base Sections, European Theater of Operations, Uo S0 Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 Janu- ary 1944* inclusiveo 3« Geographic distribution of common respiratory diseases, Uc S0 Army in the United Kingdom, 3 December 1943o 4<> Common respiratory diseases including influenza, major commands, European Theater of Operations, U0 S0 Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 Janu- ary 1944* inclusiveo 5o Common respiratory diseases including influenza, six selected divisions, European Theater of Operations, Uo S0 Army, admis- sion rate per 1000 strength per annum, by weeks, 3 September 1943° 6o Common respiratory diseases including influenza, white and colored, European Theater of Operations, Uo So Army, admission rates per annum, by weeks, in United Kingdom, 3 September 1943 to 30 June 1944; and on Continental Europe, 1 September 1944 to 29 June 1945o 7o Common respiratory diseases including influenza and the pneumonias (all forms), European Theater of Operations, U0 S0 Army, comparative rates per 1000 per annum, by months, February 1942 to January 1944° 8o Influenza, 126 Great Towns, England and Wales, number deaths by weeks, 2 October 1943 to 29 January 1944° 9° Common respiratory diseases including influenza, selected units, European Theater of Operations, Uo So Array, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 Janu- ary 1944* inclusiveo 10. Daily sick call of patients with acute upper respiratory infection on board Transport NY 613 "Britanic", December 1943* 11c Acute upper respiratory infection, 794th AAA (AW) Battalion, European Theater of Operations, Uo So Army, number cases hospi- talized, 29 May to 9 June 1945o TABLES lo Influenza, European Theater of Operations, U. S. Army, and rates per 1000 strength per annum, by years, February 1942 to June 1945, inclusive, 20 Common respiratory diseases including influenza, European Theater of Operations, Uc S. Army, admission rates per 1000 strength per annum by weeks, 3 September 1943 to 28 January 1944, inclusive. 3o Common respiratory diseases including influenza, Base Sections, European Theater of Operations, U. S0 Army, admission rates per 1000 strength per annum by weeks, 3 September 1943 to 28 Jan- uary 1944, inclusiveo 4o Common respiratory diseases including influenza, major com- mands, European Theater of Operations, U0 S0 Army, admission rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 January 1944, inclusive0 5o Common respiratory diseases including influenza, six selected Divisions, European Theater of Operations, U0 S0 Army, admis- sion rates per 1000 strength per annum, by weeks, 3 September 1943 to 28 January 1944, inclusive0 60 Common respiratory diseases including influenza, United King- dom and continent, European Theater of Operations, U0 SQ Army0 A comparison of admission rates per 1000 strength per annum, by weeks, for white and colored in an epidemic and a nonepi- demic period, 1943 - 1944o 70 Common respiratory diseases including influenza and the pneumonias (all forms), European Theater of Operations, U0 S0 Army, comparative rates per 1000 per annum, by months, Feb- ruary 1942 to January 1944, inclusive. 8. Influenza, 126 Great Towns, England and Wales, deaths by weeks, 2 October 1943 to 29 January 1944o 9o Common respiratory diseases including influenza, selected units, European Theater of Operations, U0 So Army, admission rates per 1000 strength per annum, by weeks, 3 September to 28 January 1944, inclusive. EPIDEMIOLOGIC CASE REPORTS 1. A local outbreak of influenza early in the 194-3 epidemic of influenza involving a hospital staff* ✓ 2, Influenza of 194-3 in an engineer unit. 3» Influenza in a unit newly arrived in the theater* 4-* Epidemic influenza in a seasoned unit* 5o Spread of influenza by continuity. 6o Influenza outbreak on a troop transport* 7* Interepidemic influenza in 194-5* A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19a - 1945 PART III - Epidemiology- Section 3 - Acute Respiratory Infections Number 3 - The Pneumonias by Colonel John E, Gordon, M.C, Chief of the Division of Preventive Medicine Office of The Chief Surgeon, ETO TABLE OF CONTENTS Page Primary Atypical Pneumonia, Etiology Unknown 1 Clinical Features 2 Differential Diagnosis 5 Management of Hospital Cases 6 Pathologic Studies 7 Laboratory Diagnostic Methods 7 Reporting 8 Incidence of Atypical Pneumonia 8 Mortality 9 Increased Prevalence in 194-4- 9 Atypical Pneumonia in the United Kingdom and on the Continent 12 Primary Pneumonia 13 Secondary Pneumonia 14- List of Tables List of Figures PART III Epidemiology Section 3 - Acute Respiratory Infections Number 3 - The Pneumonias Primary Atypical Pneumonia, Etiology Unknowno-y- Interest Arid knowledge"Tn this newly recognized respiratory infection had developed well before the onset of military operations in Europe. The disease had not been reported with great frequency in England, and there was considerable speculation among medical officers as to how great its im- portance would be among American troops stationed thereo It soon became apparent that this infection was about as common in military practice in the United Kingdom as it had been in the United States, and that the disease also existed among the resident civilian-population» The exact frequency of the condition for the first six months of operations cannot be determined, because it was not reported separately until 1 July 1942« Thereafter, atypical pneumonia was recognized with increasing frequency; to such extent that for the last two years of the theater it was more commonly reported than primary lobar pneumonia* It easily constituted the most important problem among respiratory infections. The increasing frequency with which atypical pneumonia was being reported led to a series of special epidem- iological investigations on this subject during October of 1942. Studies of sane fifteen units stationed in England demons!rated the existence of the disease, gave the suggestion that atypical pneumonia was of considerably greater frecp ency than indicated by formal reports, and was of fairly general distribution. Most medical officers were found to be fa~ miliar with the condition, and a goodly proportion of units gave a history of the existence of atypical pneumonia during the training period in the United States» A meeting of theater medical officers on 7 November 1944 was devoted entirely to this subject and a board for its study appointed by the Chief Surgeon<, This board met at ir- regular intervals, always with primary interest in atypical pneumonia but eventually broadening its interests to a considera- tion of all acute communicable diseases of current interest. One of the first activities of the board was to formulate current opinion on atypical pneumonia and to outline methods for control, study and management*, An atypical pneumonia that occurred in sporadic and epidemic outbreaks was being increasingly recognized as a disease entity. Medical officers of the United States Army when con- fronted with patients afflicated with incapacitating respiratory illness had the obligation to differentiate this disease from other kinds of pneumonia. When the clinical evidence clearly warranted a diagnosis of primary atypical pneumonia, etiology un- known, such a diagnosis was to be made. The designation virus pneumonia was discouraged, since a virus had not been demon- strated as the causative agent and moreover the term was not de- scriptive. In all cases, the medical officer was required to make a careful differential diagnosis, utilizing such facilities as wore available, to exclude influenza, acute catarrhal bron- chitis, psittacosis, Q fever, pulmonary coccidiomycosis and bacterial pneumonia. The statement which follows represented the theater attitude toward this communicable disease, and the policy and procedures which governed activity directed towards its control. This information was given wide circulation to medical officers of the theater. Clinical Features.•—Presumptive but not ab- solutely conclusive evidence indicates that the in- cubation period is rather long, 2-3 weeks. The onset of the disease is usually gradual, and when first see#, patients complain of malaise and occasionally mild headache. Chilly sensations may be with moderate elevation of the temperature. Slight soreness of the throat may occur but this is not a feature of the disease. The majority of • patients develop a dry cough early in their course, which usually becomes productive later in the disease. The sputum tends to be mucoid and ten- acious, and if rusty or bloody is probably associat- ed with a pulmonary condition distinct from primary atypical pneumonia. It should be noted that some patients may go through the entire course without producing any sputum and with only slight cough. This is infrequent, and characteristically a fairly severe, irritating cough is present. Sub- 2 sternal discomfort may be present in some cases, but true pleuritic pain is extremely uncommon. Herpes labialis is not a featureo The majority of patients do not appear sick enough for hospitalization until 4-5 days after the onset of the disease. At the time of ad- mission the pulse rate is not markedly accelerat- ed and Is disproportionately slow in comparison with the rise in tamperatureo The respiratory rate is only slightly increased or may be normal. Mary of the patients show moderate prostration, but in general do not appear critically ill„ Coryza is usually absento The soft palate and pharynx show only a slight degree of inflammatory reactiono Edema and hyperemia of the lymphoid tissue of the posterior pharynx may be present, but are not striking. Exudate is not present. The acute inflammatory reaction of the pharynx associated with influenza, is conspicuously absent, nor are generalized edema and hyperemia present as in the case of common cold. As a rule, abnormal physical signs over the lungs are of minor degree during the early stages and this finding is rather characteristic of the disease. In general, those consist of slight im- paired resonance to percussion with a diminution in breath sounds, and occasional fine moist rales. Rarely are the signs of massive consolidation elicited. The process is most commonly localized to one or both lower lobes, although any portion of the lungs may be involved, and in certain cases a diffuse patchy process may be present throughout the lungs. Frequently the real extent of the involve- ment is not apparent until a roentgenogram of the chest is made. As a rule, a more extensive process is revealed than is suspected from clin- ical examination. The involvement tends to be patchy, although in many instances the shadow is more uniform and resembles that seen in lobar pneumonia, except that the density is less. This 3 type of shadow may be due to pleural inflammatory reaction* In general, the process appears to extend outward from the hilum toward the peri- phery of the pulmonary fields, simulating the roentgenographic appearance of the lungs in psittacosis* In other oases the involvement does not extend outward from the hilum but may be diffusely scattered throughout the lungs and resemble the later stages of military tuberculosis* This is not an uncomnon picture* The clinical differentiation, however, should not present any difficulty* Patients showing diffuse patchy involvement generally have a more prolonged clinical course than those in whom a localised process is present* When the cough becomes productive the physical signs may be more marked, with increase in the number of rales and the presence of coarse rhonohi heard over most of the chest* Sonorous and sibilant rales are heard at times* Generally speaking, the white blood count is normal, particularly in the early stages of the disease, both in total number and in the differential count* In some patients, par- ticularly after several days of the disease, there is a slight elevation of the leukocyte count, though rarely above 14,000 per cu* mm* Actual leukopenia may be observed infrequently* Although early in the disease the sputum is mucoid, it may occasionally become purulent later on* Bacteriological examination of the sputum has not revealed pneumococci in sig- nificant numbers, but careful studies of the sputum should be made before ruling out pneu- monia due to the common bacterial incitants* Aside from the abnormal findings described above, the remainder of the physical examina- tion is essentially normal. The course of the disease is variable* The majority of patients run a low grade fever for approximately one week, with defervescence by lysis. Cyanosis may be present, in severely ill patients* The period of convalescence may bo prolonged, with weak- ness and vasomotor instability for as long as 4 3-4 weeks. This delayed convalescence is out of proportion to the apparent severity of the disease. In occasional cases the acute course may last for as long as 2-3 weeks. Clinical relapse has been observed in rare instances shortly after patients first become ambulatory. The etiology of the disease is unknown. Differential Diagnosis.—Difficulty should ordinarily not be experienced in differentiating primary atypical pneumonia of unknown etiology from acute influenza due to influenza virus Type A or Type B. In influenza the onset is acute, with a generalized aching and hyperesthesia, usually severe headache and decided prostration. Catarrhal symptoms are not pronounced although there is marked injection of the conjunctivas and naso- pharynx; in addition, leukopenia is character- istically present. Patients with bronchitis not on an allergic basis or not preceded by influenza or conmon cold, should be examined carefully for evidences of primary atypical pneumonia. In such cases it is advisable to obtain roentgenograms of the chest. It seems likely that a certain propor- tion of cases diagnosed as bronchitis are ac- tually suffering from primary atypical pneumonia. Furthermore, it is by no means clear that the latter infectious process invariably proceeds to involve the parenchyma of the lungs, and certain patients may suffer from bronchitis without pulmonary involvement. The differential diagnosis from psittacosis cannot be made on clinical grounds alone. In this specific disease process the diagnosis may be established by isolation of the infectious agent, or else by the demonstration that specific antibodies to the virus have developed upon re- covery from the disease. Q fever likewise cannot be differentiated on purely clinical grounds. The diagnosis in this case may be established by isolating the rickettsia responsible for the infection or by immunological studies. 5 Differentiation from pulmonary coccidioidomy- cosis can be made by specific clinical and laboratory reactions, if the test material is available* The differentiation from bacterial pneumonia, whether of bronchial or lobar distribution, should cause no difficulty., For example, in primary atypical pneumonia the leukocyte count is normal, the pulse and respiratory rates are only slightly elevated, the physical signs over the lungs and roentgenograms of the chest do not coincide and the atypical pneu- monia does not respond to the sulfonamide drugs0 Management of Hospital Cases*—All of the ex- isting evidence indicates that sulfonamides are not effective in the treatment of atypical pneumonia* Moreover the unrestricted use of sulfonamides in conditions where they are not indicated carries with it the dangers of producing toxic effects, as well as of sensitizing individual patients to a drug which may subsequently be of vital importance.. It follows, therefore, that where the attending physician feels reasonably certain that he is dealing with atypical pneumonia, chemotherapy should be withheld., On the other hand it is extremely important not to withhold sulfonamides in any condition where their use may be of critical importance to the patient, and it is recognized that certain varieties of pneumonia of bacterial origin may at times simulate atypical pneumonia* This is true of some of the secondary pneumococcal bronchopneumonias, together with certain infections due to hemolytic streptococci, Priedlandor*s bacillus, staphylococcus aureus, and H* influenzae* It is further possible that atypical pneumonia may alter its fundamental character and take on a second- ary bacterial component, something which up to this time has not occurred* Lastly, influenzal pneumonia of the type seen in 1918 might reappear, where bacter- ial infection of the lung was an extremely prominent feature. It follows that the bacterial flora of the sputum in oases of atypical pneumonia must be kept under steady surveillance in order that proper treat- ment may be instituted should the occasion warrant* 6 With these considerations in mind, the following guide to therapy of atypical pneumonia was suggested: Sulfonamides will not be given in the ordinary case showing characteristic features, Sulfathiazole or sulfadiazine is to be given in full doses if the onset is very abrupt, if there is a sharp leucocy- tosis or if leuoocytosis develops as the disease progresses, if the sputum contains a preponderance of a pulmonary pathogen, or if the course is pro- longed and unfavorableo Generally speaking, the effect of adequate sulfonamide therapy should be almost immediately apparent, and if none is discern- ible in two to three days, the drug should be dis- continued. Pathologic Studies.—Whenever possible, careful pathologic studies should be made of the lungs in all cases of fatal pneumonia. This is of particular importance in lobar pneumonia, in the influenzal and measles pneumonias and in all primary atypical pneumonias of unknown etiology. One clean incision made through the lateral border of the lung to the hilus will enable the prosector to complete his gross examination, cut blocks for his own histologic examination and insure proper fixation of the whole lung. Laboratory Diagnostic Methods,—Lacking knowledge of the etiological agent, the laboratory cannot make a positive diagnosis of atypical pneumonia, but lab- oratory methods may aid in differentiating other conditions. Significantly increased numbers of leucocytes and an increased proportion of polynuclear cells suggest a pyogenic infection and usually constitute an indication for sulfonamide therapy. Blood cultures should be taken. They are without result in atypical pneumonia, but in conditions such as meningoccoccemia and early typhoid fever a positive result serves in distinguishing diseases clinically similar. If undulant fever is suspected, the lab- oratory should be so informed because special cultural methods must be employed. Sputum cultures are usually not helpful but should be employed if there is suspicion of secondary infection or pneu- mococcal pnegmonia. 7 Attempts to isolate other viruses such as those of influenza or psittacosis, are not practicable as a routine procedure because of the number of animals required and the necessary time for idontificationo Should such viruses be found, notification will be given to medical officers, The same situation exists regarding serological studies for antibodies against viruses. Reporting,—All Medical Officers rendering weekly statis- tical reports were required to report atypical pneumonia, etiology unknown, on the Weekly Statistical Report, Mo Do Form 86 ab, sep- arately from other types of pneumoniao Thus the second section of the weekly statistical report might have cases under one of three headings: pneumonia, primary; pneumonia, secondary; and pneumonia, primary, atypical, etiology unknown• When three or more cases of primary -atypical pneumonia occurred in any company or detachment of similar size in any one week, the surgeon responsible for the medical service reported the fact by telephone to the Office of the Chief Surgeon, Likewise, whenever three or more cases diagnosed as primary atypical pneu- monia were admitted to any hospital in any one week from a company or detachment of like size, the commanding officer of the hospital notified the Office of the Chief Surgeon by telephoneo Incidence of Atypical Pneumonia0--While primary atypical pneumonia, etiology unknown, was a reportable disease in the United States Army from 2 March 1942, no case was included in statistical reports of the European Theater until July of that year (Table 1). The number of cases increased during the autumn months but 'there was good reason to believe that reported cases never approximated the number actually existing, viewed in the light of the average rate that was maintained in subsequent years0 The morbidity rate in 1942 was 2o5 per thousand per annum, in 1943 it was 6,1 and succeeding years had rates of 5,1 and 7,5, The seasonal distribution of atypical pneumonia was regularly marked by rather sharp increases in October, Rates ordinarily continued at an excess level over average annual ex- perience for the next several months, in general through May, The months of maximum prevalence were February and March, The highest incidence for any single month of the theater was in March of 1945, when the rate was 9,7, In number of cases and in attack rates, primary atypical pneumonia exceeded primary pneu- monia (Table 2), The distinguishing feature between these two conditions was the tendency of atypical pneumonia to be well 8 maintained through the summer months, in contrast to the marked summer and winter variations of ordinary primary pneumonia0 Primary atypical pneumonia in the European Theater, like primary lobar pneumonia, was somewhat less frequently ob- served ‘condition than among troops of the United States Army stationed in continental United States (Figure 1), Table 3. Mortality,—Primary atypical pneumonia is recognized as an acute infection associated with a low death rate. Never- theless, during the course of the four years of the European Theater, the number of reported deaths was 41 among 19477 re- corded cases of the disease, a mortality rate of ,013 per thousand per annum for the complete experience. The distribu- tion of deaths by years is shown in Table 4. In general, the distribution of deaths was that of reported cases, in that years with a high case rate were characterized by excess mortality. In a number of instances, supposedly fatal cases of primary atypical pneumonia were known not to have been confirmed at autopsy. The corrected data are not yet available, and the rates cited are based on the usual figures from the Statistical Health Report. Deaths shown in this analysis are believed to be in excess of fact. Increased Prevalence in 1944,—The strongly evidenced increase in admission rates for the pneumonias during the first three months of 1944 led to a special investigation of prob- able attendant causes, to the end of determining whether the increased frequency was primarily due to one or other of the two principal components of the pneumonia group, or whether both atypical and primary pneumonia were involved as the data seemed to indicate. When comparison was made of the incidence of prim- ary pneumonia and primary atypical pneumonia in the European Theater in the spring months of previous years with that of the spring of 1944, a sharp increase in the incidence of both diseases was noted in January, 1944, and becoming more ap- parent in March (Tables 1 and 2). It was further observed that no increased incidence of the common respiratory dis- eases nor of influenza had occurred, such as commonly pre- cedes a greater reported frequency of primary pneumonia. (Table 3. Section 3, Part 1). While the increase in the pneumonias was not alarming, as can be seen by comparing the rates in the European Theater with those then current in continental United States, (Figure 2, Table 5), information was desired on whether or not any unusual factors had been introduced. 9 Since primary atypical pneumonia and primary pneumonia were apparently occurring in greater numbers at the same time, an effort was made to appraise the evidence for each patient, to the end of determining the accuracy of diagnosiso The differentia- tion of primary pneumonia and atypical pneumonia is often dif- ficult as had been brought out in previous discussion0 All clin- ical observations for a given patient were reviewed with the attending medical officer, and usually with the chief of the medical service of the hospital concernedo An agreement was reached as to whether what had been established as the final hospital diagnosis was to be considered confirmed, only probably confirmed, or remaining indefinite® Complete data were obtained for 75 patients* # In attempting to arrive at an accurate diagnosis, all the features exhibited by the patient during the entire course of illness were considered together* On this basis, and with these methods, it was possible to substantiate the hospital diagnosis of atypical pneumonia for 7/2 percent of the patients considered originally to have had that form of infection* In only 35 percent of patients determined by hospital physicians to have had primary pneumonia was the evidence considered adequate to justify the diagnosis. Bacteriologic confirmation was lacking for 66 percent of the cases considered to be primary pneumonia* In those in- stances where sputum cultures had been made, only one-half con- tained an organism which could be considered as the cause of the pneumonia. Attending physicians were of universal agreement that only a small proportion of the pneumonias that they had re- ported as primary pneumonia were of the classical lobar type, and only about ten percent contained typed pneumococci in the sputum. The uncomplicated atypical pneumonias were found to be classical in clinical manifestations and indisputably instances of that disease* A comparison of the incidence of primary pneumonia and of atypical pneumonia in the European Theater revealed a parallel trend, which suggested common influences* Epidemiologic information obtained by interview of patients in the course of visits to hospitals demonstrated that the pneumonias showed no tendency to occur with any special frequency among troops recently arrived in the United Kingdom* The average residence of patients in the United Kingdom was about six months antecedent to the onset of pneumonia* The patients with atypical pneumonia tended to remain longer in quarters or at work (3.8 days) before admission to hospital than those suffering from primary pneumonia (1*5 days). Outdoor 10 RATE RATE Figure 1. Primary Atypical Pneumonia, etiology unknown, European Theater of Operations and Continental United States, U.S, Army, admission rates per 1U00 strength per annum. figure 2. The Pneumoniae, 111 Eeros, European Theater of Operations, U. S. Army, Admission Hates per 1000 Strength Per Annum By Months, January 1942 to June 1945, Inclusive, versus indoor life seemed to be an insignificant factor. Exposure to chilling was claimed by only 40 percent of the patients. Only eight knew of any contact with others with pneumonia before they acquired the disease. Bacteriologic information regarding the sputum of patients with the pneumonias was found to be meager. No culture of the sputum had been made in 41 percent of the primary pneu- monias and none in 70 percent of the atypical pneumonias. Of the sputums cultured in the primary pneumonia group, only one-half gave morphologic evidence of pneumococci and only three were con- firmed by typing. Of the sputums cultured in the atypical pneumonia group one-half had a predominating pathogenic organism, none of which were typed pneumococci. Further information was sought through information of sputums received at the First Med- ical General Laboratory for culture and typing. Pneumococci were primarily of Types 1, 2, and 3. The striking feature was that half of the specimens that were received contained a pneumococcus that could not be typed and only one such sputum had the classical features of being purulent and of rusty color. . The apparently increased incidence of both primary and atypical pneumonia in the absence of a corresponding increase in common respiratory disease could be interpreted as resulting from an actual increase in atypical pneumonia with an associated common confusion in diagnosis leading to many cases being reported as primary pneumonia. A number of considerations supported this hypothesis. Detailed and careful clinical examination of represent- ative patients in hospitals led to a confirmation of the diag- nosis of atypical pneumonia in 72 percent of cases, but only 35 percent of supposed cases of primary pneumonia could be confirmed. The sputum in atypical pneumonia frequently changes in appearance from mucoid to mucopurulent as the disease progresses and the number of leucocytes may exceed 10,000. If the patient was first seen at that stage, or was finally considered in the light of such appearances, the mistaken diagnosis of primary pneumonia could readily be made. The apparently increased numbers of pri- mary pneumonia occurred simultaneously with an undoubted in- crease of atypical pneumonia, and did not follow the upward swing of atypical pneumonia as would be expected if secondary infection was producing an ultimate primary pneumonia in an ap- preciable part of patients with an original primary atypical pneumonia. Bacteriological confirmation of most of the supposed primary pneumonias was lacking. Epidemics of atypical pneumonia occur at all seasons of the year and are not necessarily pre- ceded or associated with an increase in common respiratory 11 diseases. The paradox of no increase in common respiratory disease and an increase in primary pneumonia would thus be dissolved. If it be granted that only 35 percent of diagnoses of primary pneu- monia were correct, the incidence of primary pneumonia would then coincide with the recorded incidence in the European Theater during the preceding two years. Another possible hypothesis was that an actual outbreak of atypical pneumonia occurred, in which contrary to previous ex- perience a considerable number of patients became infected with secondary bacterial invaders. Suggestive evidence supporting that possibility was that 77 percent of the patients diagnosed as primary pneumonia experienced a prompt subsidence of symptoms when sulfo- namides were administered, although only 35 percent of patients had enough features of primary pneumonia to justify the diagnosis. Re- sponse to sulfonamides alone is a poor basis on which to establish a diagnosis, as the temperature in atypical pneumonia falls at such varying periods as to easily permit confusion. The bacteriological data indicate the presence of a considerable ifumber of pneumococci, some of which were non-typable,.in the sputum of both forms of pneumonia. Theoretically, an unusual number of patients with atypical pneumonia could have become secondarily infected through an ex- isting greater prevalence of primary pneumonia, or by reason of a prevailing form of unusual throat pathogen; but reasonable evidence to support either possibility was not at hand. The conclusions derived from these clinical and epidemio- logical studies were that an increased incidence of atypical pneu- monia occurred in the European Theater during the early spring months of 1944. The apparent increase in primary pneumonia coin- cident with the increase in atypical pneumonia was believed most likely related to difficulty in differentiating the two types of pneumonia, with a tendency for many atypical pneumonias to be re- ported as primary pneumonia. The possible existence of an un- usual secondary infection of atypical pneumonia has decidedly less support. The evidence is inadequate to eliminate with absolute conclusiveness an increase in primary pneumonia during the period concerned. The reported incidence of both types of pneumonia re- turned to a level of expected frequency in April. No satisfactory explanation for the outbreak was determined0 Atypical Pneumonia in the United Kingdom and on the Continent.— The increased rates for atypical pneumonia for the year X945 raised the question of whether or not the Increase was due to a greater frequency of that infectious disease on the continent, as 12 compared to the United Kingdom* The relative frequen > of the disease in the two parts of the theater during the perxoi, of active operations is presented in Table 60 The data she* that during the period considered, the level of infection was i.eas- urably higher, 7*1 per thousand per annum in the United Kingdom, than it was on the continent, 5o7 per thousand per annum* The increased theater rates for 1945 were due to a greater level of reported cases from both Continental and United Kingdom areas in the late spring months of that year* Primary Pneumonia*—Primary lobar pneumonia was never the problem in the European Theater that it was in continental United States. The comparative rates for troops of the two localities for pneumonia of all forms, including primary, secondary and atypical, during the four years of operations are shown in Figure 2. Information on primary pneumonia alone to permit direct comparison is not available for the Zone of the Interior* The first year of experience in the theater, 1942, gave the highest rate for primary pneumonia of any of the four years of •nilttary operations in Europe, with 8*7 per thousand per annum. This is believed to have been influenced in part by the in- clusion within reported cases of primary pneumonia, of apprec- iable numbers of primary atypical pneumonia, etiology unknown* Reporting of the latter condition was only practiced for a part of the year, and during that time was below the level that sub- sequent experience showed to be usual* An additional considera- tion was that housing and living conditions did not offer gen- erally the same standards of accommodation as were later at- tained. The rates for diarrheal disease and a number of other infectious processes were higher that year than in subsequent experience< Each year thereafter saw a progressively improved per- formance to primary pneumonia, taking into considera- tion attendant circumstances* ‘Specifically, the essentially equal rates of 1944 and 1945 are judged to qualify in that generalization, since the Armies were then in the field under campaign conditions, taking part in as active a winter operation as a United States Army had ever been called upon to face* The pneumonia rates were never better than they were in the months that followed the invasion of Normandy* (Table 2) Again there is evidence of the health that attends an array in the field, given the advantages of sound environmental hygiene* The record was all the more remarkable in view of the evidence brought out by the special study just presented, which indicated in all likelihood that a goodly proportion of patients considered to 13 have contracted primary pneumonia actually were suffering from primary atypical pneumonia. The seasonal distribution of primary pneumonia met the usual expectancy of major predominance in the months of January, February and March; with January invariably showing the highest rates. The mortality from the pneumonias was likewise low. Figure 3, Table 7 shows the rates for the Zone of the Interior and for the European Theater for primary and secondary pneumonias, and for primary atypical pneumonia. Deaths and death rates for primary pneumonia alone are presented in Table 8, by years, for the European Theater. The average death rate for the four years was .02 per thousand per annum, and for individual years it fol- lowed the number of reported oases. Secondary Pneumonia.—Secondary pneumonia exercised such a minimal influence on theater disease rates as to constitute a truly remarkable phenomenon. The consistent and continued ab- sence of measles, serious influenza, and similar diseases commonly attended by a complicating secondary pneumonia, was the evident explanation. The monthly distribution of cases is set forth in Table 9. Deaths from this cause are included with those from primary pneumonia. 14 RATE 0.06 RATE 0 06 E T 0 US PRIMARY a SECONDARY PNEUMONIA E T 0 US ATYPICAL PNEUMONIA Figure 3. Primary and Secondary and Primary Atypical Pneumonias, European Theater of Operations and Continental United States, U.S* Army, mortality rates per 1000 strength per annum for period January 1942 to June 1945, inclusive. Month Total 19^ 12 1943 1944 1945 Cases Rates Cases Rates Cases Rates Cases Rates Cases Rates January 2062 7®7 * * 80 7*3 439 7*1 1543 7*9 February 2457 8*6 ♦ * 87 10*3 476 6*8 1894 9*2 March 3435 9*1 ♦ * 40 4*8 834 8*1 2561 9*7 April 2700 8*4 * * 50 4© 7 778 8*4 1872 8*6 May 2063 602 ♦ ♦ 27 2*9 656 6*5 1380 6*2 June 1562 3*8 ♦ * 46 3*8 542 4*3 974 3.7 July 376 2*8 3 *5 65 3*4 308 2*8 August 377 2*4 13 1*5 57 2*9 307 2*4 September 463 2*3 0 0 79 3*4 384 2*3 October 804 4*2 38 2*3 221 6*0 545 3*9 November 1238 6*1 85 7*6 337 8*2 816 5*4 December 1940 6*4 45 4*8 522 8*0 1373 6*1 Total 19477 6*1 184 2*5 1611 6*1 7458 5*1 10224 7.5 ♦Data not available Sources Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, Do C* Primary Atypical Pneumonia, Etiology Unknown European Theater of Operations, Uo So Army Cases and rates per 1000 strength per annum, hy months February 1942 - June 1945 inclusive Table I Month Total 194 2 19 43 194 4 194 5 Cases Rates Cases Rates Cases Rates Cases Rates Cases Rates January 1712 6®4 116 10, 6 613 10,0 983 5,0 February 1596 5® 6 0 0 94 11,1 449 6,4 1053 5,1 March 1956 5,2 3 3,8 41 4,9 886 8,6 1026 3,9 April 1392 4,3 4 4,6 67 6,3 612 6,6 709 3,2 May 1165 3,5 6 2,8 23 2,4 490 4,9 646 2,9 June 705 1,7 14 3,9 28 2,3 292 2.3 371 1,4 July 235 1,7 37 5,8 46 2,4 152 1.4 August 252 1,6 37 4,2 57 2,9 158 1,2 September 300 1,5 65 5,1 57 2,4 178 1,1 October 590 3,1 137 8,2 190 5,2 , 263 1.9 November 815 4,0 246 22,1 217 5,3 352 2,3 December 1328 4,4 ' 80 8,6 511 7,9 737 3,3 Total 12046 3,8 629 8,7 1447 5,5 5182; 3,5 4788 3,5 Sources Division of Medical Statis tics9 Office of The Surgeon General, War Department, Washington, D0 C, Primary Pneumonia European Theater of Operations, U»S<> Army Cases and rates per 1000 strength per annum, by months February 1942 - June 1945 inclusive Table 2 Year Month Continental United States ffwsBint-m r-iii-i-g-ta j.-a -rasa European Theater of Operations Year Month Continental United States European Thea, of Operations 1942 February 0 * 1944 January 10*8 7*1 March 1*0 * February 11*3 6*8 April 1*8 ♦ March 9*3 8*1 May 2*3 * April 7*6 8*4 June 2*4 ♦ May 6*5 6*5 July 2*3 *5 June 5*3 4*3 August 2*8 1*5 July ; 4*4 2*8 September 5*5 0 August 4*2 2*4 October 7*0 2*3 September 4*5 2*3 November 8*2 7*6 October 5*6 3*9 December 9*7 4*8 November 6.1 5.4 1943 January 10*1 7*3 December 6.6 6*1 February 9*1 10*3 1945 January 8*7 7*9 March 8*7 4*8 February 9*6 9*2 April 7*2 4.7 March 9*5 9*7 May 6*0 2U 9 April 8*1 8.6 June 5*7 3*8 May 8*2 6*2 July 4*2 3*4 June 7*9 3*7 August 3*8 2*9 . September 4*2 3*4 October 4*4 c n 6*0 Q O Mean 6*4 6*1 riOvofliDt/r December 0OV 7.5 O 6 C 8*0 ★Data not availablec Sources Division of Medical Statistics, Office of the Surgeon General, War Department, Washington, D» C* PRIMARY ATYPICAL PNEUMONIA, ETIOLOGY XMKNOWH European Theater of Operations and Continental United States Co So Army-fl Admission rates per 1000 strength per annurrb by months February 1942 to June 1945 inclusive Table 5 Table 4 Primary Atypical Pneumonia, Etiology Unknown European Theater of Operations, U* S, Army Death and Rates per 1000 strength per annum, by years February 1942 to June 1945 inclusive Year Deaths Rates I 1942 0 0 1943 0 0 1944 8 «0054 1945 Jan® - Jim to to o0241 Total 41 *0129 Sources Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D* Co Year Month Cont* U*S* E* T< > 0* Year Month Conto U* S* E* To 0* Cases Rates Cases Rates Cases Rates Cases Rates 1942 January 1437 10,3 1944 January 8235 22*5 1077 17*5 February 1305 10*0 2 6*5 February 7078 19*9 934 13*3 March 1724 11*6 4 5*1 Idarch 6911 16*2 1748 16*9 Apri* 1314 8*2 4 4*6 April 4482 13*5 1403 15*1 May 1797 8*4 6 2*8 day 3414 10*6 1156 11*5 June 1425 7*6 14 3*9 June 3125 7*9 851 6*7 July 1607 6*5 40 6*3 July 1988 6*5 486 4*5 August 1604 7*6 53 6,0 August 1724 5*7 476 3,8 September 2708 11*9 67 5*3 September 2266 6*3 576 3*5 October 4976 16*2 175 10*5 October 2235 8*1 818 5*9 November 5059 18*5 337 30*2 November 2389 9*2 1191 7*8 December 7153 24*4 131 14*0 December 3127 10*2 2143 9*5 Total 32108 12*7 833 11*5 Total 46974 11*7 12859 8*7 1943 January 11576 27*2 200 18*3 1945 January 2979 12*8 2556 13*0 February 8786 23*6 182 21*5 February 3243 14*6 2988 14*5 March 9418 24*7 84 10*1 March 3765 13*9 3618 13*7 April 10114 20,4 120 lie 4 April 2473 11*4 2623 12*0 May 6733 16*6 52 5*5 May 2541 11*6 2047 9*2 June* 5252 12*9 76 6*3 June 3041 10*7 1354 5*1 July 4846 9*6 115 6*0 Total 18042 12*49 15186 11*1 August 3556 8*8 117 6*0 TOTAL 179195 13*65 32008 10*1 September 3501 8*8 137 5*9 October 4826 9*8 417 11*4 November 4319 11*3 572 14*0 Source ; Division of Medical Statistics Office December 9144 19*5 1058 16*3 of the Surgeon General P War Dept.9 Total 82071 16*0 3130 11*8 THE PNEUMONIAS, ALL FORMS European Theater of Operations and Continental United States, U»So Army Cases and Rates per 1000 strength per annum by months January 1942 to June 1945 inclusive Table 5 United Kingdom Continental Europe Total Month Cases Rates Cases Rates Cases Rates July 1944 267 2*6 41 7,9 308 2,8 August 255 4*0 52 • 8 307 2,4 September 293 4,4 91 ,9 384 2,3 October 322 7,7 223 2,3 545 3,9 November 373 9,1 443 4,0 816 5,4 December 651 10,8 722 4,3 1373 6,1 January 1945 610 12,4 933 6,4 1543 7,9 February 543 11,5 1351 8,5 1894 9,2 March 481 9,5 2080 9,7 2561 9,7 April 361 9,3 1511 8,4 1872 8,6 May 249 8,3 1131 5,9 1380 6,2 June 158 3,4 816 3,8 974 3,7 Total 4563 7,1 9394 5,7 13957 6.1 Sources Division of Medical Statistics, Office of the Surgeon General, War Department, Washington, Do Co PRIMARY ATYPICAL PNEUMONIA* ETIOLOGY UNKNOWN United Kingdom and Continental Europe Cases and rates per 1000 strength per annum* by months July 1944 to June 1945 inclusive Table 6 Table 7 PRIMARY AND SECONDARY PNEUMONIAS, AND PRIMARY ATYPICAL PNEUMONIA European Theater of Operations and Continental United States U. So Army- Deaths and Rates per 1000 strength per annum for period January- 1942 to June 194-5 inclusive Type European of Oneratj [heater Lons Continen1 United S’ bal bates Deaths Rate Deaths Rate Primary and Secondary Pneumonia Primary Atypical Pneumonia 93 A1 ,0292 .0129 660 100 .0503 .0076 Total 13A .0421 r 760 : .0579 Source: Division of Medical Statistics. Office of the Surgeon General, War Department, Washington, D.C0 Table 8 European Theater of Operations, U, S* Army Deaths and rates per 1000 strength per annum by years February 1942 to June 1945 inclusive PRIMARY PNEUMONIA Year Deaths Rates 1942 0 0 1943 2 .0076 1944 30 .0204 194$ 32 • 0234 Total , 64 o0201 Source; Division of Medical Statistics, Office of the Surgeon General, War Department, Washington. D„ Z* Month Total 1942 1943 • 194 4 194 5 Cases Rates Cases Rates Cases Rates Cases Rates Cases Rates January 59 02 4 ®4 25 ,4 30 o2 February 53 o2 2 6o5 1 ol 9 ol 41 ©2 March 63 o2 1 lo3 3 o 4 28 o3 31 ol April 58 *2 0 0 3 <>2 13 o 1 42 o2 May 33 a 0 0 2 o2 10 a 21 ol June 28 a 0 0 2 ®2 17 ol 9 ©03 July 30 o2 0 0 4 O 2 26 ©2 August 17 a 3 *3 3 «2 11 ol September 17 ol 2 o2 1 ,04 14 a October 16 ol 0 0 6 o2 10 ol November 47 o2 6 «5 18 a 23 o2 December 64 ' <>2 6 06 25 ,4 33 ol \ Total 485 <»2 20 ©3 72 ,3 219 ol 174 a Sources Division of Medical Statistics, Office of the Surgeon General, War Department, Washington, Do Co SECONDARY PNEUMONIA European Theater of Operations* U» So Army Cases and rates per 1000 strength per annum* by months February 1942 to June 1945 inclusive Table 9 FIGURES I* Primary Atypical Pneumonia, etiology unknown, European Theater of Operations and Continental United States, U. So Army,Admission rates per 1000 strength per annum, by months, February 19A2 to June 194-5, inclusive. 20 The Pneumonias, All Forms, European Theater of Oper- ations and Continental United States, Uo S0 Army, admission rates per 1000 strength per annum, by months, January 19A2 to June 194-5, inclusive. 3« Primary and Secondary Pneumonias, and Primary Atypical Pneumonia, European Theater of Operations and Contin- ental United States, U. S. Army, mortality rates per 1000 strength per annum for period January 19A2 to June 194-5, inclusive. TABLES 1„ Primary Atypical Pneumonia, etiology unknown, Euro- pean Theater of Operations, Ua So Army, Cases and Rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive0 2e Primary Pneumonia, European Theater of Operations, U0 So Army, Cases and Rates per 1000 strength per annum, by months, February 1942 to June 1945, in- clusive 0 3® Primary Atypical Pneumonia, etiology unknown, Euro- pean Theater of Operations and Continental United States, U0 So Army, admission rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusiveo 4« Primary Atypical Pneumonia, etiology unknown, Euro- pean Theater of Operations, U0 S0 Array, death and rates per 1000 strength per annum, by years, Feb- ruary 1942 to June 1945, inclusive0 5» The Pneumonias, All Forms, European Theater of Operations and Continental United States, U0 S0 Army, Cases and Rates per 1000 strength per annum, by months, January 1942 to June 1945, inclusivec 6« Primary Atypical Pneumonia, etiology unknown, United Kingdom and Continental Europe, Cases and Rates per 1000 strength per annum, by months, July 1944 to June 1945, inclusiveo 7o Primary and Secondary Pneumonias, and Primary Atypical Pneumonia, European Theater of Operations and Contin- ental United States, U0 So Army, deaths and rates per 1000 strength per annum for period January 1942 to June 1945, inclusive0 So Primary Pneumonia, European Theater of Operations, Uo S0 Army, deaths and rates per 1000 strength per annum, by years, February 1942 to June 1945, inclusive0 9o Secondary Pneumonia, European Theater of Operations, Uo So Army, Cases and Rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive0 A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 Part III - Epidemiology Section 4 - Infections Transmitted by Discharges from the Respiratory- Tract by Colonel,John E, Gordon, M.C. Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART III Epidemiology Section 4- - Infections Transmitted by Discharges from the Respiratory Tract Page Streptococcal Infections . ...... . ......... . 1 Scarlet Fever 0 . . . . • . . 1 Rheumatic Fever ... ....... ... ........ . 2 Streptococcal Sore Throat ....... . . 2 Diphtheria . . . 0 .... ........... .... . • 2 Incidence of Diphtheria in the European Theater ..... . 5 Mortality from Diphtheria ........... 6 Chronic Cutaneous Diphtheria ................ 6 Wound Diphtheria . . ............... 7 The Clinical Disease in Germany .............. 8 Diphtheria Among Prisoners of War ... ..... 9 Diphtheria in the Several Theaters of Operations ...... 10 Vincent5s Angina ...................... 10 Meningococcus Meningitis .............'....o 10 Mortality from Meningococcus Infection ...... .... o 11 Meningococcus Meningitis in the Various Theaters of Operations ....oo....©..........©.. 11 Program of Control ...... . 12 Tuberculosis ........ ..... 13 Page Incidence of Tuberculosis among United States Troops 0 . . . 13 Field Survey ...... 0 ... . « o • . • . . 15 survey oi 19>A'3 ».«.... o*.eo»o.oe.oo.o. 15 Survey of British Civilians Employed by the United States Army ...... ..e.o.........«..oooo 15 Siirvey of 7Bth Fighter Group „ ...... . . . « . ... 0 15 Tuberculosis Among Nurses ••••«••••• . . 16 Survey of Officer Candidate School ............. 17 General Survey of the Eighth Air Force ....... ... • 17 American RAMP (Recovered Allied Military Personnel) .... 17 Tuberculosis Among Displaced Persons and Allied RAMP .... IB Tuberculosis in Various Theaters of Operations c • Q 0 o . • 19 Measles .......................... 19 German tvieasles o..o. .......... ........ 20 MUmpS co». ........... ....a....... 21 Incidence ................... 21 Mumps in Other Theaters . ® ...... ......... . 22 Control Measures . .... « . 0 ............. . 22 Smallpox .. o « o « 23 List of Figures List of Tables List of Epidemiologic Case Reports PART III Epidemiology- Section 4 - Infections Transmitted by Discharges from the Respiratory Tract \ Streptococcal Infections^—Scarlet fever and the other streptocogpal infections have always been notably frequent in Europe, and it was therefore not surprising that these conditions were more frequently observed in the European Theater than in any other of the nine Theaters of Operation during the war just past. Nevertheless, the average annual rate for the four years was less than one-third the frequency of these conditions in the Zone of the Interior; and that holds for all principal diseases within the group, scarlet fever, rheumatic fever, and streptococcal sore throat o Scarlet Fever.—A year with anything approaching an epidemic situation was never noted during the time that American Troops were stationed in Europe. The average annual rate for scar- let fever during the four years was 0o62 per 1000 strength per an- num, and the fluctuations from year to year were never great. The best year was in 194-3 and the year with highest incidence, 0,64- per thousand strength per annum, was in 1944-o The year 194-5 judged by the first six months gave indication of being an average yearc (Table l) The experience on the continent was almost identical with that in Great Britain, during the single year that operations were conducted in both parts of Europe, (Table 2) Scarlet fever in common with the other streptococcal diseases was more frequently observed in the European Theater than in other, with the North American group next in order. The disease was least common in the theaters of the far eastern group, in accord ance with the known behavior of the disease0 (Table 3) While the total number of cases that occurred during the history of the theater was relatively large, i987, no appreciable grouping was ever observed and no circumscribed epidemic came within the experience of the theater. No special program of control or epidemiologic study was instituted. Rheumatic Fever.—The frequency of rheumatic fever fol- lowed closely the pattern of scarlet fever. The condition was most commonly observed in 1944* and the rates for 1945 were much the same. The best years of the theater were those of 194-2 and 1943. (Table 4-) The usual seasonal distribution in the months of late winter and early spring was characteristic. In contrast to scarlet fever, rheumatic fever was considerably more frequent in the United Kingdom than on the continent during the period when operations took place in both localities. (Table 5) Among theaters of operation the leading position in respect to rheumatidpfever was held by the European Theater with a total of reported for the four years, and an average attack rate of 0.50 per 1000 strength per year. The rate of itself is good, and probably a reflection of the generally low levels of strepto- coccus infection. This figure is to be compared with the incidence for troops stationed in continental United States during the same period, where the rate was 1,07, essentially twice as great. The high rate noted in the African-Middle East Theater was somewhat surprising but the number of cases was small and too great signifi- cance is not to be attached to the observation. The China-Burma- India Theater ranked third. (Table 6) Streptococcal Sore Throat.—Information on the frequency of streptococcal sore throat in the European Theater was available only for two years, 1944 and 1945 > because the condition became reportable only with the change in the form of the Weekly Statisti- cal Report in February, 1944. The rates cited in Table 7 are in accord with the behavior of other streptococcal diseases during the period noted. Diphtheria.—Periodic waves of increased prevalence associated with enhanced clinical severity have characterized diph- theria in Europe for many years, more on the Continent than in Great Britain,, A highly satisfactory immunizing agent exists for diphtheria, but its use was not obligatory for United States troops. Ifar Department regulations prescribed the methods to b6 used for specific protection, but left the decision as to their use in Theaters of Operation with the responsible Surgeon. Because of these circumstances an early review was made of the existing sit- uation in Great Britain, shortly after the European Theater was established, in order to determine whether or not universal or selective use of a specific diphtheria preventive was essential or desirable. 2 From the Ministry of Health in Great Britain it was learned that the diphtheria situation in the civilian population was of no particular import (Table 8); that it compared favorably with conditions in the Zone of the Interior; and that while a slightly increased frequency of the disease had become manifest during the early war years, the rate had never been alarming and the general trend of diphtheria since 1940 had been downward. Similar inquiries concerning the incidence of diphtheria among soldiers of the British Army stationed in England showed the rates to be decidedly low. Decision was therefore taken that neither general nor selective immunization of troops would be practiced, but that a procedure would be prescribed in directives of the Theater to be used optionally by commanding officers of units that might be especially exposed to the disease, such as the staffs of General and Station Hospitals. Continued statistical records of the fre- quency and character of the disease were maintained, with special field surveys made from time to time in order that early informa- tion might be at hand to permit alteration of this policy should circumstances so demand. That eventuality did not materialize. The low attack rates for diphtheria among American troops station- ed in the Uniteid Kingdom substantiated the soundness of the determined policy. The situation that presented when plans came to be made for the invasion of the continent was measurably different. Diphtheria had regularly been more prevalent there than in the United Kingdom, and the case fatality was greater, a comprehen- sive survey of the more recent experience of countries in western Europe was prepared by the Division of Medical Intelligence, It clearly demonstrated that diphtheria had increased to a decided extent during the war years, and the existing incidence marked the disease as one of appreciable importance among infections likely to be encountered by American troops, (Table 9) Current practice in immunization against diphtheria varied among British troops intended for the European Campaign, Protection was routinely required for the Canadian forces but not for troops of the United Kingdom, The desirability of immunization for American troops was again reviewed. The general immunity status of American soldiers was assayed in order to arrive at a justifiable decision0 A Schick test survey in the European Theater was not made, because the results of a recent study conducted among comparable groups of soldiers from the Ground Forces and Services of Supply in the 3 United States were available. Some 56 percent of troops had been found non-susceptibls to diphtheria. Epidemiologic studies have demonstrated that immunity of fifty per cent of a population is effective in affording community protection against an outbreak of diphtheria. The probabilities were estimated of the extent to which military personnel might bo expected to contract diphtheria from civilian populations in the course of active operations. The critical part of the European campaign was anticipated in late spring and early summer of 1945, a time of the year ordinarily associated with a low incidence of diphtheria. The chance of con- tracting diphtheria from civilians in areas where the major forces of the army strength would be concentrated and under combat con- ditions was considered to be minimal. In view of these circumstances, routine active immuniza- tion against diphtheria was judged unnecessary in planning for operations of the immediate future. Small outbreaks in reserve and rest areas were believed possible. In such instances the original policy of selective immunization for exposed units would apply. The Standard Operating Procedure for the continental campaign provided that preliminary Schick testing of individuals in exposed units was not to bo done? inasmuch as it was time con- suming and impracticable in the course of active operations. In lieu of this, all men were to be given 0.1 cc of diphtheria toxoid (plain) subcutaneously. Experience indicated that about one-fourth of a general military population would react to this dose within 48 hours. These men were to be dropped, with the remainder to receive 0,5 cc of diphtheria toxoid subcutaneously two days after the Initial dose. Again another one-fourth would be expected to have a reaction and these men would likewise receive no more toxoid. Three weeks later non-reactors received 1 cc subcutaneous- ly, followed in another three weeks by a second similar and final dose of toxoid. Reactors to the third injection were not to re- ceive the fourth. would be expected to raise the general level of immunity within the group sufficiently to prevent a serious outbreak, A small dose of toxoid often constitutes an effective antigenic stimulus in individuals possessing some degree of latent immunity. 4 ■ Incidence of Diphtheria in the European Theater!—The admission sates for diphtheria during the first year of settle theater were equivocal, not good and yet not of particular concern, the average being 0.4-7 per thousand strength per annum. The mte was great enough to keep active the question of instituting general immunization of troops. Because of the generally falling rate in the civilian population, it was decided not to institute the procedure during the summer of 1943, the most desirable time of the year for start- ing an immunization program against diphtheria. The frequency of the disease during the following winter of 1943-1944 justified that decision, for diphtheria was less commonly observed than ever be- fore in the experience of the European Theater and indeed the rates were most favorable. The admission rate for 1944 was 0.17 per thousand per year. The increased rates for November and December of 1944, 0.36 per thousand, were in accord with the greater expectancy an- ticipated on the continent compared with Great Britain, Of them- selves, the rates were of no special concern, in fact they were no greater than had held for the first year in Great Britain. Any significance they possessed was as an index of what might prevail during the spring months. It was reasonable to believe that the rates would be somewhat higher than, but certainly not to an extent which would warrant universal immunization, nor even a program restricted to troops of the Ground Forces who would expectedly be more affected than others, because diphtheria in Germany was excessive. The autumn of 1944- saw the beginning of the final cam- paign against Germany. The existing tactical situation required any proposed immunization scheme to be supported by evidence of complete essentiality. The number of casualties and patients evac- uated for illness and injury were of such extent that the demand on hospital beds severely taxed existing facilities. Previous exper- ience with diphtheria immunization of adults indicated that a measurable number of admissions to hospital would follow that pro- cedure. Military necessity required that the full number of ef- fectives be maintained. The indication of a future greater prevalence derived from the experience of November and December was substantiated in January 1945, when the rate for diphtheria was 0.57. It increased progressively to reach a high point during April of 1.05 per thous- and strength per year. Thereafter, the disease was less common and June had a rate of 0.67. 5 The rates cited are relatively great for the age group concerned but not strikingly so. It was also known that they are higher than actual fact. The data were derived from the Statisti- cal Health Report. Actual field survey in the case of this and other diseases had shown that for conditions such as diphtheria, typhus, and typhoid fever, the rates from this source of information were measurably exaggerated. For typhus fever the reported attack rate was four times that determined by actual survey; and in the case of typhoid fever it was twice as great. This came through includ- ing with the records of American soldiers numerous infections among prisoners of war and displaced persons who were cared f or in military hospitals of the United States Army. The 1,377 cases and an average annual case rate of 0.43, Table 10, will be measurably less when determined by the more accurate count of individual case records. Diphtheria in 1944-45 was measurably more frequent on the continent than it was in the United Kingdom. The rates for the period September 1944 to June 1945 are set forth in Table 11. The rate for troops stationed in the United Kingdom was 0.23, compared with Qi69 for those serving on the continent. In only one month, May of 1945, did the rate in Great Britain exceed that on the continent. Mortality from Diphtheria.—No deaths from diphtheria occurred in the years 1942 and 194-3, and none in 1944- until opera- tions started on the continent. The number of deaths during the latter half of 1944 was five; and indeed beginning in September 194A, no month thereafter was free from a death from diphtheria. There were nine in the month of April and eleven in June. Deaths for the first six months of 194$ numbered 28, and for the entire experience of the theater the total was 33, for an average mortal- ity rate of 0.01 per thousand per year. The case fatality rate of 2.40 per hundred cases was favorable for this disease, even in view of the age group involved which generally shows a favorable result. S. Chronic Cutaneous Diphtheria.—Chronic cutaneous diphthe- ria, long Known to be a prevalent condition in North Africa and the Middle East among soldiers, was observed among troops returning to the European Theater from the Mediterranean Theater of war. The increased numbers of similar cases reported from Central Europe gave added interest to this form of the disease from a military- standpoint . 6 Chronic cutaneous diphtheria is to be distinguished from the acute form which occurs in conjunction with faucial diph- theria particuarly among debilitated individuals. The chronic form in most instances was unassociated either with diphtheria of the upper respiratory passages or with the carrier state. The condition commonly resulted from contamination of pre-existing skin lesions with virulant diphtheria bacilli. The disorders most commonly affected were minor or major wounds, either traumat- ic or surgical, insect bites, impetigo, staphylococcus folliculi- tis, and scabies. Because of this pathogenesis chronic diphtherit ic lesions were often multiple. The lesions were usually on the exposed parts of the skin, the face, hands and forearms and over the legs and feet. Hairy surfaces were especially susceptible. The disease was most often encountered during outbreaks of faucial diphtheria when contJa«t with active cases and carriers was frequent. The development of diphtheritic infections of the skin was slow. It was usually two or three weeks after onset that the chronicity of the lesion, the progressive increase in size and failure to respond to ordinary treatment suggested to the medical officer something more than an abrasion or a minor infection, at this time the individual lesion was characteristically a punched- out circular ulcsr whose base was covered with adherent blackish membrane and whose margins were raised, undermined and of an un- healthy appearance. Considerable regional edema was not unusual and the entire lesion tended to be painful. The systemic reaction was minimal and fever if present was low grade. The diagnosis of cutaneous diphtheria could not be made from the appearance of the lesion alone, since tropical ulcer, cutaneous leishmaniasis and other chronic ulcerative dermatitides have a similar appearance. Cutaneous diphtheria is to be consid- ered in differential diagnosis of these conditions and appropriate cultures made. Early recogniation was important because healing occurred only after specific treatment with antitoxin. The patient with cutaneous diphtheria as with faucial diphtheria was a menace to public health as a focus for spread of the infection. Finally, only by early and adequate treatment with antitoxin could the dangerous late complications of diphtheria be avoided. Wound Diphtheria,—Diphtheritic infection of war wounds was encountered with relatively frequency among German prisoners of war but was airsre observation among troops of the United States forces. The commonest clinical manifestation of diphtheritic 7 infection of wounds was the presence of a tough, adherent, grey- yellow membrane over the wound, but all wounds covered with mem- branes were not diphtheritic, Similar membranes often failed to give cultures of the diphtheria bacillus, a commond finding being C. xerosis, often in almost pure culture0 The significance of this observation was uncertain as the organism is a nonpathogenic member of the* corynebacterium group. Delayed healing was an indi- cation for culturing a wound for the diphtheria bacillus. One patient had a clean granulating wound that did not heal. Two others had positive cultures from draining sinuses associated with osteomyelitis. Four patients with diphtheritic would infection show' ed failure of skin grafts to take, either partially or completely. Wounds other than those associated with battle casualties were also infected with diphtheria bacilli, one infection complica- ting circumcision and another engrafted on a nnn-specific penile ulcer. The Clinical Disease in Germany.—An increase in diph- theria had taken place in Germany over the past two decades. From 1924 to 1927 a particularly severe clinical form had been noted. Again in or thereabouts, diphtheria began to be more frequent. The peak year in Munich was 1943* with a moderate decline of cases and deaths for 1944 and 1945, although from $00 to 700 cases of diphtheria were being admitted to hospitals of that city each year and the laryngeal form was common. A higher incidence of diphtheria appeared to exist in Germany than in the United States. The disease was of a mild type except in those coming late to treatment0 The observed frequency of sever myocarditis among patients of the U. S. forces was less than expected. Peripheral nerve paral- ysis developing late in the clinical course was above expectancy. In a series of cases coming to autopsy only one had received anti- toxin as early as the fifth day. No evidence existed of a corre- lation between the severity of infection and the type of diphtheria bacillus. The principal difficulty appeared to rest in late diag- nosis and failure to observe the cardinal principle of administer- ing diphtheria antitoxin on the basis of clinical observation rather than awaiting bacteriologic confirmation <, A special survey of diphtheria in late spring and early summer of 1945 was directed toward determining the conditions which had produced diphtheria and to formulating recommendations for the subsequent winter, when the Army of Occupation would in all proba- bility encounter a problem in relation to diphtheria because of 8 more intimate contact with civilian populations. While little diphtheria existed in the military population at that time, the disease was prevalent in the civilian populations of Central and Northern Germany, in Berlin and Bremen particularly. The relation of late complications and deaths to delayed administration of antitoxin was confirmed. The occurrence of at least half of cases among civilians in the adult age group suggest- ed a likely increasing rate for military personnel. There was every reason to believe that the prevalence of the disease among troops in the Spring of 1945 would be exceeded the following winter under conditions confronting an occupation array. >, Diphtheria Among Prisoners of UDar.V-Durlng the period of active operations more than twice as many cases of diphtheria occurred among German prisoners of war than among the much greater numbers of American troops. From September 1944 to June 1945, inclusive, diphtheria cases among United States troops numbered 1202; and for prisoners of war the figure was 2859. The rates were of course far greater, in the order of about ten times; for prisoners of war 6.2 per thousand per year, with a maximum incidence in March 1945 of 10.8 per annum, (Table 12) This disproportionate incidence among prisoners of war compared with soldiers of the United States Army was in about the same ratio as held for diarrhea and dysentery, and for typhus fever. Only incomplete data are available for deaths. The advance Section of Communications Zone cared for 695,400 prisoners during the six-week period from 1 May to 15 June. During that time, 1080 cases of diphtheria occurred among the prisoners, of whom 40 died. The mortality rate per thousand per year was thus 0.499 and the case fatality 3.7 percent. Prisoners of war included numbers of relative- ly young persons, some aged no more than 14 to 16 years, and the greater case fatality was therefore not altogether unexpected. The exaggerated frequency of diphtheria among prisoners of war during the spring of 1945 was indicated by such unusual cir- cumstances as existed in a particular week in April, when more patients with diphtheria came from the relatively small group of prisoners of war in two single enclosures, than from the approximate- ly three million American soldiers. The disease occurred in great- est numbers among prisoners who had been confined since the winter and early spring of 1944-45. Summer brought fewer cases but carrier rates remained high among groups where the disease had been preva- lent. In some sampled groups ten percent of prisoners were carriers of virulent C, diphtheriae. 9 Diphtheria in the Several Theaters of Operation.—The Euro pean Theater ranked fourth among the nine theaters of the United States Army in respect to rates for diphtheria. The highest rate for any theater was that of 0.84 for the Mediterranean area. The best record was in the North American theater with a rate of 0.02, The rates for continental United States were particularly good, 0,06. (Table 13) For all theaters diphtheria occurred more fre- quently in 1945 than in other years of the war. Vincents Angina.—In contrast with the experience of the first World War, Vincent angina was a matter of far less con- cern during present military activities. The attack rate for troops for the total experience was two per thousand per year. The condition was most common in 1943 and the rates for 194$ were easily the most favorable, (Tablex14) Meningococcus Meningitis. -\Menlngococcus meningitis was present in epidemic proportions in Great Britain during 1940 and 194-1. It was not surprising, therefore, that the disease appeared rather promptly among the first contingents of American troops that arrived in the British Isles. The disease among troops of the theater was more frequent that year than in any other of the war period and the annual incidence of 1.32 per thousand strength per year was relatively great, (Table 15) The experience of the United States Army coincided with that of the British civilian population, and of British troops stationed in the United Kingdom at that time. To an extent the situation carried over through 1943 but the rates never reached the same height that had characterized 1942 during any month, and the annual rate was somewhat lower. Meningitis was far less frequent in the general popula- tion of Great Britain in 1944, and likewise among American troops. Much the same situation held when the main forces of the United States Array moved into Europe, for again the rates in 1945 for meningococcus meningitis among United States troops were satisfactory. The disease showed no variations in prevalence in Great Britain that year as compared with the continent and for both localities was favorable. (Table 16) Epidemic meningitis was little more than half as frequent} among American troops in Europe in this war as it was in World War I, the average rates for the two periods being 1.11 in 191B and 0.67 for the present experience. This favorable behavior of a disease which so characteristically invades military populations was in agreement with the relatively low prevalence of meningococcus men- ingitis in continental United States, where the severe outbreaks of the first World War were never noted. 10 The epidemiologic pattern of the disease in Europe in World War II was much the same as has been described in the pre- vious war, in that the condition tended to occur sporadically. No extensive epidemics appeared and such groupings of cases as were noted were of minor nature. That a goodly proportion of the infections among American troops were imported from the Zone of the Interior became manifest by the frequency with which the dis- ease was recognized on board transports, and the decidedly greater frequency among newly arrived troops, compared with those resident in the theater for appreciable periods. Mortality from Meningococcus Infection.—Two deaths -among troops of the theater were ascribed to meningococcus septi- cemia and 99 to meningococcus meningitis, a total of 101 from men- ingococcus infections. The mortality rate per thousand strength for the period of operations was 0.03 and the case fatality 4»6/6. The remarkable improvement in mortality and case fatali- ty in civilian practice which became evident with the advent of the sulfonamides was clearly duplicated in this military experience. Those whose experience extended to the days of serum treatment and especially to the serious outbreaks of the previous war still found difficulty in appreciating that a case fatality of 4,6 percent could exist for a general military experience involving so many different field conditions, and the results of treatment by so many different medical officers. The case fatality during World War I was 43.3 Tor American troops stationed in Europe and the annual mortality was 0.43. Meningococcus Meningitis in the Various Theaters of Operations.—Meningococcus meningitis was a more common disease in the European Theater than in any other of the nine theaters of operation..s The number of cases was 2138 and the attack rate was 0,67 per thousand per year. This was almost double that of the next reporting theater, the Mediterranean area, whose rate was 0,36 per thousand strength per annum. In comparison with troops stationed in the Zone of the Interior the experience of the European Theater was very favorable, since the rate for domestic troops during the war period was 0.80. Epidemic meningitis for all foreign Theaters of Operation had an average incidence of 0,41 which was appreciably less than that holding for the European Theater. (Table 17) 11 Program of Control.—The usual isolation measures were rigidly practiced. The routine search for carriers of meningococ- ci, so commonly practiced in former years, was almost completely discarded, Bacteriologic examinations were usually made of im- mediate contacts and sometimes for small groups of closely associ- ated persons under special epidemiologic situations, but no mass survey was ever attempted. Principal reliance was placed on prompt separation of individuals suspected of having the disease, on fre- quent clinical inspections and examinations of exposed persons, and on institution of the general measures designed to control infections spread by secretions of the upper respiratory tract. Working quarantine was discouraged. Because this method had been employed for many years, it was instituted in many instances with- out reason or measurable accomplishment. Chemoprophylaxis found its best indication in the con- trol of meningococcus infections. Proof was definitely brought forth that meningococcal infections could be controlled by the prophylactic administration of sulfonamides, particularly, sulfa- diazine. Following the administration of sulfadiazine the inci- dence of carriers dropped to low levels and remained low for a prolonged period. Simultaneously with this reduction in carrier incidence, a striking reduction in the number of cases of menin- gitis could be expected. The conditions under which healthy personnel should receive sulfadiazine during an epidemic could not be exactly de- fined, The decision was based on the judgment of the Surgeon but certain general rules for guidance were suggested, A single case of meningitis was considered rarely to justify general prophylactic treatment of the unit. An exception might be a single case in a unit living under crowded conditions which were apt to persist for a number of days, as on a troop transport. In general an incidence of more than 0,2 per thousand per week among large concentrations of troops and the occurrence of more than two cases in a week at a camp or station with a strength of ten thousand or less warranted consideration of this measure. Particular consideration was given to an existing concentration of cases in a particular unit. In- stead of treating an entire command it was many times better to treat a particular unit, such as a regiment or a battalion in which the incidence was especially high. Two grams of sulfadiazine was administered by month in one day in a single or divided dose, This dosage was effective in reducing the carrier rate and caused practically no toxic reactions. 12 Tuberculosis.—Tuberculosis control in the European Theater was combined with the clinical management of patients under the direction of the Senior Consultant in Tuberculosis, Lt, Col. Theodore Badger, M.C., a member of the Staff of the Chief Consultant in Medicine of the Division of Professional Services. This concentration of effort and activities was most logical, in that the senior consultant in tuberculosis was not only skilled in the management of the clinical disease but experienced in field methods and control measures. The Division of Preventive Medicine acted in a consulta- tive capacity, with interest in integrating the work in tuberculo- sis into the general preventive medicine program of the theater. Its facilities and staff were at the disposal of the Consultant and the relationship maintained was in the best traditions of the coor- dinated effort which marked the practice" of medicine and preventive medicine in the Theater, Field survey work in tuberculosis was practiced most ex- tensively in the air Forces, Many hospitals of the Communications Zone gave particular concern to the members of their organizations, and numerous surveys of Ground Force and Communications Zone units were conducted by the consultant in tuberculosis. All of these sources are drawn upon in the preparation of this summary of events in tuberculosis control, with the technical details of particular studies and the results obtained left for more formal presentation by those jprincipally concerned. \ Incidence of Tuberculosis among United States Troops.4- The tuberculosis rates for troops of the European Theater were maintained at a satisfactorily low level during the three and a half years during which operations were conducted in the United Kingdom and on the continent of Europe. The rates were highest dur- ing the first two years of the theater, with the high point of 1,31 per thousand strength per annum in 1943. The mean annual rate there after showed a satisfactory downward trend. That for 1945 was some- what higher than 1944, but not appreciably so. The special epidem- iological factors existing in the first half of 1945 might reason- ably have been expected to produce a higher rate of incidence than that recorded. The overall rate for tuberculosis during the entire period of activities of the theater was 0,77 per thousand strength per annum. The data for the several years are presented by months in Table 18 13 Several factors would appear to have influenced the down- ward trend of the tuberculosis rate among troops of the European Theatero First of all was the thorough sifting out of active cas- es of tuberculosis at induction points by mass chest x-ray survey, thereby reducing sources of infection and contacts. The relative- ly high rate of 1943 may be accounted for on the basis of early lack of experience at induction stations and the fact that universal pre- induction chest x-ray examination did not become effective until April 1942. A sampling by the Office of The Surgeon General in 1943 of some 50,000 x-rays of the chest made of men inducted in 1942 to determine how much tuberculosis had been overlooked, indi- cated that ten to fifteen cases per 10,000 men had visible lesions that had failed of detection at the time of induction. % The low rates of 1944 and 194$ bear witness to the thor>4 oughness of the preinduction chest x-ray examination that emerged * from greater experience in the interpretation of films. Sources of infection were thus reduced to a minimum within troops of the theater. Sources of infection from outside the Army were also decreased by the command prohibition of the consumption of whole fresh milk in the theater, a matter of no small importance since contamination of milk with tubercle bacilli was known to be sefi4* ous. Furthermore, both the soldier and the medical officers of the theater were conscious of tuberculosis, and roentgen examination of the chest was widely used for troops of all echelons when tu- berculous infection was suggested. These factors contributed to the falling rate. Data for the period from September 1944 to June 1945 are available for the period of operations on the continent. The frequency of tuberculosis among troops stationed in the United Kingdom was significantly greater than that for troops serving on the continent, with rates of 1,03 compared with 0,60 for the two parts of the theater. To an extent this was a reflection of 4 the active case finding in tuberculosis in the United Kingdom dur* ing most of this period, primarily among forces of the 8th Air Force The relatively great accretions in rates for April and May of 194$ and particularly the two peaks in the curve of inci- dence noted for the weeks ending april 20 and May 11, coincide with the return of American Prisoners of War who had appreciably great involvement with tuberculosis. (Figure 1) Special attention is given this group in a later section. The distribution of tuberculosis for all troops of the European Theater by weeks during the period of active operations on the continent is presented in Table 19, 14 Figure 1. Tuberculosis, all forms, in troops in Continental, Europe, European Theater of Operations, U.S, Array, rates per 1000 strength per annum, by weeks, September 1944 to June 1945, inclusive. Field Surveys. first field survey of troops of the European Theater for tuberculosis was in 1943. The primary object- ive was to determine the frequency of the disease among military units who had been stationed for a year or more in the theater. Survey of 1943.—The selection of units included all branches of the service, and the numbers subjected to roentgen examinations varied from 200 to 1,000 men of a unit. Units in- cluded some who had been in the European Theater for a year or more, others who had spent a year and two years in Iceland. Some units had never been examined by roentgen ray before or after en- listment. The units included ground forces, engineers, the mem- bers of station and general hospitals, colored troops, and fighter and bomber groups of the air Force. Three separate surveys were accomplished during the year, the first in February, another in July, and a third in October, The results are presented in Table 20. No significant amount of unrecognized tuberculosis was apparent among American troops of the theater. The majority of men studied had not been examined previously by roentgen ray dur- ing service in the and very few had been on foreign service for less than one year. The results led to comprehensive recom- mendations for the disposition of patients with pulmonary and other forms of tuberculosis received at United States hospitals in the European Theater, a second recommendation provided for routine roentgen examination of the associated platoon, mess mates and bunk mates of soldiers found with open tuberculosis, to be repeated in six months. No need was believed to exist for a mass x-ray survey of troops of the European Theater. Survey of British Civilians employed by the United States Army-—When the headquarters of the European Theater of Oper ations moved to the continent in the summer of 1944 British civil- ians, principally clerks and office workers, were given physical and roentgen examinations as a basis for acceptance for overseas duty. The results are shown on Table 21. The incidence of reinfection type tuberculosis among British civilian employees was nearly four times as great as that demonstrated by similar roentgen studies of United States $.10 cases per hundred, compared with 1.39 for United States troops. Employees with demonstrable tuberculosis lesions, whether active or inactive, were not accepted for overseas duty. Survey of 78th Fighter Group.—Roentgen survey of approx- imately 1200 men of the 78th Fighter Group, 8th Air Force, was made in the autumn of 1944. The survey arose from the original finding 15 of a case of active tuberculosis in the 83rd Fighter Squadron, 78th Fighter Group, 8th Air Force. Approximately 2$0 men of the 83rd Fighter Squadron had been examined and seven cases of active tuber- culosis were found. The indications were that no single focus of contacts was responsible since the patients did not come from any one barrack or duty department. Because of the demonstrated high incidence a more extensive survey was undertaken. In the course of the general survey, 20 men with positive roentgen findings were interviewed and examined individually. Twelve were admitted to hospital, including one with active pulmo- nary lesions with cavitation, two with pleural effusion of which one was probably non-tuberculous and nine patients with apical in- filtrations of questionable activity. Five cases of pulmonary tu- berculosis were found, of whom four gave a definite family history of tuberculosis but none showed evidence of activity. The 20 men interviewed came from eight different barrack buildings. In only one instance were any two from the same sleep- ing room and they slept at the far corners of the building. Two of the men with apical infiltration had worked together. One stated that a man from his office had been evacuated from the 83rd Fighter Squadron with tuberculosis. No significant contacts were determin- ed with British civilians. The active cases were believed due to reactivation of old lesions, with additional effect from contacts among the men themselves. Tuberculosis Among Nurses.—A definite increase in tuber- culosis occurred among nurses in the later years of the theater. No nurse was known to have developed tuberculosis in 194-2. Four were observed the following year, and for 1944->30 patients were recognized. For the first five months of 194-5 the number was 38. The high rates for tuberculosis and especially that of 5<.24 per thousand per annum for the first five months of 1945 were not satisfactorily explained by simple presumption of a greater susceptibility of young women to tuberculosis„ The lower thres- hold of resistance was conceivably influenced adversely by the con- ditions of war, fatigue, climatic changes, frequency of acute respiratory infections, changes in diet with relative deficiencies and the chronic mild anemias that were commonly found, but these factors are difficult to measure and evaluate. Carelessness in isolation technique in the nursing of tuberculosis patients was too widespread0 Medical officers responsible for the care of tu- berculous patients did not always impart the rules for prevention of spread of infection and for the protection of personnel,, Nurses individually grew careless. No one cause can justly be credited* with the progressively increased rates. (Figure 2 Table 22). 16 Figure 2 Tuberculosis, all forms, in Nurses, European Theater of Operations, U, S* Army, Rates per 1000 strength per, annum February 1942 to May 1945, inclusive. Survey of Officer Candidate School.—Chest x-ray ex- aminations were made of candidates at the Ground Force Officers Training Center from March to May 1945. (Table 23) Since the men came from units all over the European Theater, the results present a cross section of the incidence of tuberculosis in the theater area, except that the general physical examination before entrance to the school and in some instances preceding roetgen examinations, may well have eliminated unlikely candidates. General Survey of the Eighth Air Force.—a general survey of Eighth Air Force troops in the United Kingdom was taken in April of 1945* The original plan was to survey the personnel longest in the United Kingdom, but the redeployment program fre- quently interferred. During a three-month period mobile units examined approx- imately 30,000 men. Follow-up investigation sufficient to estab- lish a positive diagnosis was completed by 16 July 194-5 for approx- imately 80 percent of the questionable cases. Records of 23,250 apparently healthy military personnel showed 33 or 0.14$ to have active pulmonary tuberculosis requiring hospitalization. Persons with probable activity numbered 19; and 1,037 gave evidence of inactive pulmonary tuberculosis requiring follow-up study, or 4-.4- percent of those surveyed. Certain individuals with abnormal x-ray findings had already returned to the Zone of the Interior by the time units were notified of the results of the examinations. The necessary follow-up was accomplished in the Zone of the Interior, but the results were lost to the survey. American RaMP (Recovered Allied Military Personnel).— American soldiers recovered from German prisons as United States troops entered Germany, were returned through the normal evacuation system for casualties. They were admitted to hospitals when pri- mary or complicated malnutrition was serious. As patients they were examined roentgenologically for evidence of tuberculosis with the results shown in Table 24. The sample was not representative of RaMP in general, since the men examined were all patients in hospital. The incidence of tuberculosis was approximately eight 't£me»c’that of United States troops in 194-3* and 20 times that of the officer candidates of 194-5; although the members of the last two groups were normal, healthy United States troops on full duty and the comparison is scarcely j ust. 17 The influence of starvation on tuberculosis during the period of imprisonment of RAMP could not be immediately evaluated. Many unknown factors could conceivably play a significant'role in the apparently high incidence. It is reasonable to believe that factors peculiar to the situation were reflected in the higher rates Surveys of United States troops in all theaters showed the incidence of tuberculosis to have been at a rate of about 1,0 cases per thous- and per annum ever since the war started. In the European Theater three briefly maintained peaks of incidence of a few weeks duration, but never exceeding a yearly rate of 4 per thousand, constituted an exception to anticipated behavior of the disease. Four factors are important in evaluating the causes of these incidents associated with the liberation of American RAMP. The first was the liability to infection, American troops were well screened by individual roetgen examination before induct- ion, and the low rates for active tuberculosis minimized contact spread of tuberculosis within the army. The RaMP before capture by the Germans were presumably like all other soldiers of the United States AmQr, Segregation of United Statds prisoners from those of allied armies was usual, and contacts from other active sources of tuberculosis were apparently not important. In the migration of prisoners from camp to camp across Germany, gross contamination of living quarters by previous occupants ill with tuberculosis was known to have occurred. These contacts may have been a source of infection. The individual constitutional factor and 'familial back- ground of these soldiers was not known0 The influence of environ- mental factors was apparent in the extreme degree of malnutrition which' commonly existed and in the extremely favorable opportunities for contract wherever an open case of tuberculosis was present* Finally, the reported 101 cases of tuberculosis for the week ending 11 May 1945 are believed to include an unknown number of Allied rather than American RAMP. None of these four factors can be identified as the single cause responsible for the high tuberculosis rate among American RaMP, It is reasonable to believe that if the men had continued as prisoners for a matter of years, the tuberculosis rate would have increased inevitably, first through the opportunity for contact, and secondly because of the long continued effects of malnutrition. Tuberculosis Among Displaced Persons and Allied RAMP.— As was the experience with acute communicable diseases, the real tuberculosis problem of the theater was among Displaced Persons, On December 18, 1944> 304. tuberculous patients of varying 18 nationalities but mostly Russian, were admitted to an American Gen- eral Hospital, Four were dead on arrival; 90 percent had moderate to advanced disease; 28 died of tuberculosis within the first week in hospital and up to 21 May, five months after admission, a total of 73 or one-third had died0 Signs and symptons of serious nutri- tional and vitamin deficiencies were the principal associated com- plications, to such an extent that symptons related to tuberculosis were with difficulty from those due to malnutrition. Seme 1600 military and civilian nationals were sent to another Ger- man Hospital in Besancon near Dijon about the middle of March, 194-5. Seventy-five percent were Russian, but Yugoslavs, French, Italians, Poles, Turks, Belgians, Dutch, Czechs, Greeks, Hungarians, and Serbs were included0 Almost half had tuberculosis, principally advanced disease complicated by sever malnutrition, Other displac- ed persons, largely under the care of the hospitals of the 3rd Army- in Germany, included many with tuberculosis among the thousands liberated at Mauthausen, Nurnburg, Cham and other camps, a sample of 2,4-39 inmates studied by roentgen examination showed 972 to have active tuberculosis, a rate of 4-00 per thousand0 The principal factor which produced this fulminating disease was the opportunity for intense and frequent recurrent con- tact with patients seriously ill with open tuberculosis. The star- vation diet produced a serious malnutrition, and doubtless contrib- uted to the rapid progress of the disease. Tuberculosis in Various Theaters of Operations.—The Euro- pean Theater fared very well in comparison with other theaters of operations in respect to rates for tuberculosis. The mean annual rate of 0,77 ranked eighth among theaters and compared very favor- ably with the rate for continental United States, rtiich was 1,19, Of the nine theaters of operation, the highest rates for tuberculosis occurred in the China-Burraa-India theater, followed closely by the Africa-Middle East Theater. The best rate was at- tained in the Mediterranean area, (Table 25) Measles.—Admissions for measles among troops serving in the European Theater was at the favorable rate of 1,00 per thous- and strength per annum. For troops of the American Expeditionary Force serving in France in 1918 the rate was 5.50, The number of primary admissions for measles for the whole period of operations was 31880 The occurrence by months and by years is shown in Table 26, where the usual seasonal predomi- nence in the months of March and April is consistently demonstrated. 19 The distribution throughout the various years was characterized by its regularity; the greatest rate was in 194-3 which coincides with the year of greatest prevalence in the Zone of the Interior. The rate then was only 1,17, compared with 0.86 for 194-3, which was the most favorable year. All of the common communicable diseases including measles, German measles, chickenpox, and whooping cough had much the same his tory of being especially prevalent among newly arrived troops, and in those units concentrated in staging areas after recent arrival. Such difficulty as the United States army experienced with measles would appear largely related to imported infection, with contact commonly occurring on board transports. Infection acquired from civilian populations of Great Britain and France was a lesser con- sideration. Little or no difference existed between the rates for measles on the continent and in the United Kingdom during the year of operations in the two localities. The rate for the continent was 0.65 and for the United Kingdom 0,$3, Table 27. The usual relative position of the European Theater among other theaters of the United States Army in respect to the fre- quency of communicable diseases was maintained for measles. The rate of 1.00 gave the theater fourth position. Mumps and measles were most prevalent In the parts of the world where numbers of troops were small and wh$re conditions ordinarily would not suggest an undue frequency of the disease, , namely in the Latin American Theater and in Alaska, The best record among theaters was that attained by the Pacific Ocean Area and the African-Middle East Theater. (Table 28) No deaths from measles were recorded in summaries of med- ical experience for the European Theater during the four years over which operations extended. German Measles.V-The attack rate for rubella was almost identical with that of measles. The number of oases was 2904 and the average rate for the period of operations was 0.91* The dis- ease was most common in the first year of the theater when the rate was 1.50, but the annual variations were never great. (Table 29) The rate for German measles on the continent and in the United Kingdom during the time the troops were stationed in both areas in 1944 and 1945 were statistically the same in a year of generally low incidence• (Table 30) 20 No theater had a problem of any moment with German measles As with measles the rates were relatively high in the Alaskan, the North American and the Latin American Theaters; and in general, theaters of the American area had more German measles than the areas embraced in the general European region. (Table 31) One death from German measles is recorded in summaries of medical experience in the theater. The attendant circumstances are unknown and the authenticity of the cause of death was not determin- ed. It was an unusual circumstance to have a recorded death from German measles but none for measles. MumpsXr-The importance of mumps in military practice often remains unappreciated. In World War I epidemic parotitis was the - most frequently Ooserved communicable disease, other than influenze. The period of disability is- relatively long and once introduced into a command the infection tends to spread intermittent ly until the greater part of susceptibles are exhausted. Mumps is primarily a disease of recruits and as such was much less a problem in a theater of operations. Nevertheless the number of reported cases during the period American troops were in Europe was 10,263. The history of mumps in the European Theater w as charact- erized by the frequency with which note was made of the arrival of troop transports with patients with mumps aboard. Repeatedly such instances served to introduce the disease into units to which re- cruits came as replacements. EPIDEMIOLOGIC CASE REPORT NO 1 - The 54Bth Quart- master Battalion arrived from the Zone of the Interior 17 March 1944. Mumps occurred aboard the transport on which they travelled and in the headquarters detachment of the battalion four days after the unit landed in England. Another case in the 953rd Quartermaster Ser- vice Company of the same organization developed some days later. After the usual incubation period of two to three weeks more cases appeared in these two units and the disease spread to two other companies, the 961st and the 966th Quartermaster Service Companies. The outbreak eventually lead to a noneffective rate of approximately ten percent of the battalion as a whole and extended over about two months time. Incidence.—The most characteristic feature of mumps in this military population was the regularity with which the disease occurred during the four years. The average rate for the 21 theater was 3.23 per thousand strength per annum, and no great variation was observed from year to year . ( Table 32) It is rath- er simple to pick out the time when measurable accretions to troop strength took place by the mounting incidence of mumps. The rate for the first months in 194-2 were greater than at any subsequent period. Conditions were relatively stable in 194-3 because such major additions to troop strength as occurred came from the return of seasoned troops from Africa, Mumps was a minor problem. Great numbers of new troops fresh from the Zone of the Interior arrived in 1944- and also during the months of greatest seasonable prevalence of this communicable disease. The rates were again enhanced in a degree comparable with 194-2. Mumps in 194-5 was no problem as a veteran army plunged through Germany. The seasonable distribution of mumps requires no comment. It followed established behavior patterns in being most commonly observed in the spring. Although the period of operations on the continent was characterized by a generally low-incidence of mumps, the difference between the prevailing rates in the United Kingdom and those of the continent marked the difference between freshly arrived troops and veteran combat organizations, (Table 33) The rates in the United Kingdom were 3.29 and for troops serving on the continent 1.5A Mumps in Other Theaters.—While more cases occurred in the European Theater than in any other, the troop strength was much greater, A comparison based on rates shows the theater to have been third. (Table 34) The Alaskan Theater strangely enough had the greatest rate for the war period and’ the best record was obtained by the Mediterranean Theater where the relative standing for most other communicable diseases w$s usually close to the top. The rates for all overseas theaters was 2.27, compared with domestic rates,in * continental United States of 6,33> which was about three times as great. Control Measures.—No outspoken epidemic occurred. The control measures were those directed against diseases spread by secretions of the upper respiratory tract. The principal difficulty encountered was the tendency of many commanders to impose working quarantine as a control measure, a procedure which has been repeat- edly demonstrated of little value and yet affects adversely both training activities and the morale of troops. Such epidemiologic studies as were undertaken were in connection with freshly arrived troops and in search of causes of the prolongation of minor outbreaks 22 Two deaths from mumps were recorded in-the theater during the four-year period. S allpox.V-Smallpox did not occur among American soldiers the European Theater of• Operations, The one case of rged aglinat the European Theater of Operations in the statistical data derived from the Medical Statistics Division of the Office of The Surgeon General is known to be in error, as the re- sult of a field investigation made in the theater. Smallpox occurred from time to time among civilians in the United Kingdom, and in several instances American soldiers travelled on transports bearing British troops infected with small- pox. The first contact of American troops with smallpox in the United Kingdom was in July 1942 when a ship arrived at Glasgow carrying some 12,000 service and civilian personnel, including patients determined to have variola major. Subsequently, the dis- ease spread to a moderate extent among the people of that city, a matter of concern to American authorities because of the heavy traffic from the Zone of the Interior, Control measures institut- ed by Scottish health authorities were rapidly effective. Not long thereafter a ship arrived in Liverpool with 4,000 United States troops aboard, and a member of the Royal Air Force who had developed smallpox enroute. Such instances were not of particular concern because United States troops had been revac- cinated immediately before departure for overseas duty. Observa- tion during the period of incubation was directed, and a survey of the vaccination status introduced as a preventive measure. Oc- casional instances of similar nature were noted over subsequent years, but regularly without untoward incident. In early 1944 smallpox became mildly epidemic in Gibraltar, a center of ship- ping and travel to the United Kingdom, This circumstance led to intensification of scrutiny and inspection by both British and American authorities. Smallpox was even less of a concern in the course of continental operations than it had been in Britain, The French population was in general well vaccinated, and the few infections that occurred among civilians were isolated and sporadic. The number of cases of smallpox recorded for the Entire United States Army during the period of the war was 89. Ten of them occurred in continental United States. The greatest number was observed in the China-Burma-India Theater, where 36 soldiers contracted this communicable disease. The Africa-Middle East Theater was next with 23, and 13 cases were noted in the exper- ience of the Mediterranean Theater, In all other areas the num- bers were small and three theaters had no smallpox, (Table 3$) 23 Month Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Casesl Rate Cases Rate J anuary 154 .57 1 .09 85 1.38 68 .35 February 230 .81 0 — 5 .59 65 .92 160 .78 March 454 1.20 3 3.80 5 .60 194 1.88 252 .95 April 337 1.04 2 2.28 2 .19 151 1.62 V(XS2 .83 May 313 .94 3 1.41 3 .32 155 1.54 152 .69 June 182 .45 4 1.13 4 .33 83 .65 91 .35 July 54 .40 2 .31 8 .42 44 .40 August 26 . .17 4 .46 6 .31 16 .13 September 33 .17 3 .24 6 .26 24 .15 October 44 .23 5 .30 12 .33 27 .19 November 66 .32 4 .36 22 ,54 40 .26 December 94 .31 5 ,54 38 .58 51 .23 Total 1987 | .62 35 CO o 112 .42 935 .64 905 .66 Source; Division of Medical Statistics, Office of The Surgeon General, War Department, YTashington, D#C# Scarlet Fever European Theater of Operations, U#S. Army Cases and Rates per 1000 strength per annum February 1942 to June 1945, Inclusive. Table 1 Table 2 Scarlet Fever United Kingdom and Continent European Theater of Operations, U.S. Army Cases and Rates per 1000 strength per annum September 1944- to June 1945, Inclusive Month Total United Kingdom Cont. Lnent Cases Bate Cases Rat© Cases Rate 1944 September 24 .15 18 .27 6 .06 October 27 .19 21 .50 6 .06 November 40 .26 22 .54 18 .16 December 51 .23 31 .52 20 .12 1945 January 68 '.35 23 .47 45 .31 February 160 • 78 27 .57 133 .84 March 252 .95 46 .91 206 .92 April 182 .S3 34 ,38 14S .82 May 152 .69 16 .54 136 .71 June 91 .35 9 ,20 82 .38 Total 1047 .51 247 .52 800 .51 Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D.C • Theater Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army 29564 lo 40 3110 1,02 13327 1.98 9381 1.25 3746 ,97 United States 26824 2o04 2892 1.14 12991 2,53 8256 2,06 2685 1.86 Total Overseas 2740 ,34 218 ,42 336 .21 1125 ,32 1061 ‘ ,44 Europe 1987 ,62 35 ,48 112 • 42 935 ,64 905 ,66 Alaska 87 44 .88 28 .24 7 ,08 8 .34 North America 52 o 31 10 ,25 * 28 .39 7 ,17 7 .45 Africa-Middle- East 39 ,30 1 .17 19 ,36 14 .30 5 ,21 Mediterranean 250 9 18 0 — 52 .12 101 ,15 97 .40 Southwest Pacific 183 , 15 102 1,52 47 ,24 19 ,03 15 o o China-Burma- % India 45 ,14 11 1.95 16 ,35 12 , o 00 6 ,06 Pacific Ocean Area 91 ,09 14 ,10 32 .11 27 ,07 18 .09 Latin America 6 ,02 1 ,01 2 ,02 3 ,03 0 ,00 Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D, C, Scarlet Fever Total Army, Continental United States and Theater of Operations, u*S« Array Cases and Rates per 1000 strength per annum January 1942 to June 1945, Inclusive Table 3 Month Total 1942 1943 1944 1945 Cases Rate Cases 'Rate Cases Rate Cases Rate Gases Rate January 99 ,37 0 _ _ 15 ,24 84 ,54 February 157 ,55 0 — “ 4 .47 48 ,68 105 .51 March 244 ,65 0 — 2 ,24 120 1,16 122 • 46 April 252 ,78 0 — 2 .19 144 1.55 106 ,49 May 208 • ,62 0 -- 4 ,42 102 1.01 102 .46 June July 198 105 .49 ,78 .31 6 10 .49 .52 92 93 ,72 ,85 100 .38 August 48 .31 2 ,23 2 ,10 44 ,35 September 61 .31 4 ,32 0 — 57 .35 October 51 ,26 6 ,36 5 ,14 40 ,29 November 70 .34 10 .90 2 ,05 58 ,38 December 104 ,35 1 11 20 .31 83 ,37 Total 1697 ,50 25 ,34 57 ,2_2 896 ,61 619 .45 Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, Do CV ■' Rheumatic Fever European Theater of Operations, U*S, Army Cases and Rates per 1000 strength per annum February 1942 to June 1945, Inclusive Table 4 Table 5 Rheumatic Fever United Kingdom and Continent European Theater of Operations, U. S. Army Cases and Rates per 1000 strength per annum September 1944 to June 1945, Inclusive Month Total United Kingdom Continent Cases Rate Cases Rate Cases Rate im September 57 .35 50 .76 7 .07 October 40 .29 19 •46- 21 .22 November 58 .38 40 .98 IB .16 December 83 .37 39 .65 44 .26 1945 January 84 .54 32 .65 52 .35 February 105 .51 34 .72 71 .45 March 122 .46 36 .71 86 .40 April 106 .49 39 .75 67 .37 May 102 .46 23 .77 79 .41 June 100 . .38 16 .35 . _ 34 .39 . Total 857 .42 22ij «I£L_ 529 *22 Source; Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D.C. Theater Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases m Rate Cases Rate Cases Rate Total Army 16552 .78 820 .27 6330 .94 7055 .94 2347 .61 United States 14011 1.07 745 .29 6146 1.20 5681 1.42 1439 1.00 Total Overseas 2541 .32 75 .15 184 .12 1347 .39 908 .37 Europe 1597 .50 25 .34 57 .22 896 .61 619 .45 Africa-Middle- • East 48 .37 1 .17 2 .04 30 .63 15 .63 China-Burma- India 103 .31 0 0 0 0 SI .52 52 .43 Mediterranean 382 .28 0 0 89 .21 210 .32 83. c 34 Alaska 58 .21 15 .30 17 .15 18 .22 8 .34 North America 32 .19 7 .17 3 .04 13 .31 9 .58 Southwest Pacific 165 .14 17 .25 4 ca o . 59 .11 85 .22 Pacific Ocean Area 122 .12 2 .01 12 .04 75 .57 33 .16 Latin America 34 .10 8 .08 0 0 22 .26 4 .10 Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D. C. vV-, Rheumatic Fever Total Army Continental United States and Iheaters of Operations, U. S. Army Cases and Rates per 1000 strength per annum January 1942 to June 1945, Inclusive Table 6 Table,? Streptococcus Sore Throat European Theater of Operations, U. S. Army- Cases and Rates per 1000 strength per annum February 194-4 to June 1945, Inclusive Month 1944 1945 Cases Rate Cases Rate January 167 to . February 142 2.02 201 .98 March 320 3.10 203 .77 April 272 2.93 113 .52 May 197 1.96 334 1.51 June 144 1.13 387 1.47 July 65 .60 August 100 .79 September 143 .87 October 136 .98 November 82 .54 - 228 . 1.01 _J)eceq||er 1829 1:24 1405 1.03 Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D.C. Table 8 Diphtheria in England and Wales Rates per 100,000 population per annum 1939 to 1945, Inclusive Year Cases Rate 1939 47698 115.0 1940 46281 110.6 1941 50797 121.7 1942 41404 98.8 1943 36077 85.6 1944 29446 69.4 1945 25000 53.9* *Based on i L944 population. Sources Division of Medical Intelligence League of Nations reports. Table 9 Diphtheria in Occupied Countries Continental Europe Rates per 100,000 population* per annum 1939 to 1943 Inclusive Country 1939 1940 1941 1942 1943 Germany (1939) 79,375,281 i 180.9 164.3 208.1 288.1 287.2 Greater Germany 95,162,000 ■ 18J.S ( 179.7 \ 215.3 295.0 295.3 Balguln (1941) 8,386,553 28.8 i *■ 50.9 i 65.11 191.6 France (1942) 38,000,000 i, 4 35.9 ] 134.7 1 * 52.6 81.8 118.7 Denmark (1939) 3,805,000 { I 29.1 ! 122.6 23.1 42.6 66.4 Netherlands (1939) 8,728,569 14.6 « i 19.8 63.6 222.7 638.9 Norway (1940) 2,937,000 . | f I 4.7 88.9 1 284.3 752.8 ♦Population figures given in the 1944 world almanac • Source: Medical Intelligence Summary No. 8, Office Of The Chief Surgeon, European Theater of Operations, U. 3. Army, 27 April 1944 Month Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases late Cases late Cases Rate J anuary 128 • 48 7 .64 10 .16 111 .57 February 130 .46 0 0 3 .35 7 .10 120 .58 March 200 .53 3 3.80 0 . 0 20 .19 177 .67 April 245 r o 0 4 ,38 11 .12 230 1.05 May 231 .69 i .47 4 .42 4 .04 222 1,00 June 190 .47 2 .56 3 .25 8 .06 177 .67 July 15 .11 0 0 4 .21 11 .10 August 17 .11 5 ,57 2 ,10 10 .08 September 17 .09 5 ,39 3 ,13 9 .05 October 30 ,16 4 ,24 4 .11 22 .16 November 78 ,38 11 .99 12 .29 55 .36 December 96 ,32 3 ,32 14 ,22 79 .35 Total 1377 ,43 34 ,47 60 .23 246 .17 1037 .76 V Sources Division of Medical Statist War Department, Washington] tics, 0 D, C, ffice of The Su rgeon General, Diphtheria European Theater of Operations* U. S* Army Cases and rates per 1000 strength per annum* by months February 1942 to June 1946 Inclusive Table 10 Table 11 Diphtheria European Theater of Operations, U.S, Army Cases and rates per 1000 strength per annum, by months September 1944 to June 1945* Inclusive Total United Kingdom Continental Eurooe *Cases Rates Cases Rates Cases Rates 1944 September 9 .05 5 .08 5 .04 October ! 22 .16 7 .17 15 .15 November 55- .36 8 .20 47 .42 . December 79 .35 4 .07 75 .45 1945 January 111 .57 16 ' .32 95 ; .65 February 120 .58 10 .21 110 .69 March 177 .67 10 .20 167 .78 April 230 1.05 11 .28 219 1.22 May 222 1.00 33 1.10 139 .99 June 177 .67 4 .09 173 .80 Total 1202 .59 108 .23 1094 .69 Source: Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D.C e Table 12 Diphtheria Prisoners of War European Theater of Operations, Continent Only Cases and rates per 1000 strength per annum, by months September 1944 to June 1945 Month Cases Rates 1944 September 4 1.6 October 27 4.7 November 82 5.3 December 86 6.7 1945 January 101 6.3 V February 56 3.1 March 326 10.8 April 461 7.3 May 610 5.5 June 1106 5.9 Total 2859 6.2 Source: Division of Medical Records, Office of the Chief Surgeon, U.S. Army Theater Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army 4470 .21 188 .06 651 .10 1610 .21 2021 .52 Continental U. S. 830 to o « 115 .05 182 .04 274 .07 259 .18 Total Overseas 3640 .45 73 .14 469 .29 1336 .38 1762 .72 Mediterranean 1143 .84 7 .33 211 .49 622 .94 303 1.26 Africa-Middle East 69 .53 2 .35 45 .84 14 .30 8 .33 Pacific Ocean Area 459 .44 10 .07 120 .41 312 .80 17 .08 European 1377 .43 34 .47 60 .23 246 .17 1037 .76 South West Pacific 456 .38 4 .06 10 .05 79 .14 363 .93 China-Burma-India 104 .31 3 .53 17 .37 53 .33 31 .26 Alaska 14 .05 3 .06 2 .02 6 .07 3 .13 Latin America 14 .04 9 .09 2 .02 3 .03 0 -"O North America 4 .02 1 .02 2 .03 1 .03 0 0 Source; Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D, C. Diphtheria Theaters of Operations of the U. S. Army Cases and rates per 1000 strength per annum# by months January 1942 to June 1945 Table 13 Month Total 1942 1943 19 44 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 499 1.9 80 7.3 200 3,3 219 1.1 February 484 1.7 0 0 59 7.0 211 3.0 214 1.0 March 659 1.7 0 0 77 9.3 328 3.2 254 1.0 April 568 1.8 0 0 84 8.0 265 2,9 219 1.0 May 608 1.8 6 2.8 82 8.7 274 2.7 246 1.1 June 8441 2.1 15 4.2 60 5.0 294 2.3 475 1.8 July 346 2,6 21 3.3 137 7.2 188 1.7 August 357 2.3 25 112 5.8 220 1.7 September 426 2.1 22 1.7 147 6.3 257 1.5 October 462* 2.4 39 2.3 191 5.2 232 1.7 November 461 f 2.3 41 3.7 177 4.3 243 1.6 December 605 2,0 32 3.4 258 4.0 315 1.4 Total 6319 2.0 201 2.8 1464 5,5 3027 2.1 1627 1.2 Source: Division of Medical Stat War Department, Washingti istics, on, D. Office c C. >f The Surgeon Genera 1. Vincent* s Angina European Theater of Operations# U. S. Army Cases and rates per 1000 strength per annum# by months February 1942 to June 1945 Inclusive Table 14 Month Total 1942 IS 43 19 44 1945 Cases Rate Cases Rate Cases Rate Cases KRate Cases Rate January 194 ©72 19 1,74 98 1,60 77 ,39 February 245 , 86 0 0 30 3,55 108 1,54 107 ,52 March 361 ,96 0 0 29 3,50 165 1,60 167 ,63 April 286 ,88 4 4,56- 23 2,18 124 1,33 135 ,62 May 251 ,75 7 3,29 8 ,85 151 1,50 85 ,38 June 181 ,45 6 1,69 9 ,74 91 ,72 75 ,28 July 89 ,66 6 ,94 20 1,05 63 ,58 August 67 ,43 9 1,03 11 ,57 47 ,37 September 82 ,41 8 ,63 19 ,81 55 ,34 October 99 ,51 16 ,96 27 ,74 56 ,40 November 94 ,46 12 1,08 39 ,95 43 , ,28 December 189 ,63 28 3,00 85 1,31 76 ,34 Total 2138 ,67 96 1,32 319 1,21 1077 ,73 646 ,47 Source: Medical Statistics Division, OfJ War Department, Washington, D, ?ice of 3, The Surgeon General, Meningococcus Meningitis European Theater of Operations, U, S* Army- Cases and rates per 1000 strength per annum, by months February 1942 to June 1945 Inclusive Table 15 Table 16 Meningococcus Meningitis Continental Europe and United Kingdom European Theater of Operations, U, S, Army Cases and rates per 1000 strength per annum, by months September 1944- to June 1945 Inclusive Month 1 Tc >tal United Kingdom Continental Eurooe L_Caasi Hates Cases Rates Cases Rates 1944 September 55 .34 29 .44 26 .27 October 56 .40 31 .74 25 .26 November 43 .28 15 .37 28 .25 December 76 .34 38 .63 38 .23 1945 January 77 .39 28 .57 49 .33 February 107 .52 12 .25 95 .60 March 167 " i .63 23 .46 144 .67 April 135 .62 11 .28 124 .69 May 85 .38 12 .40 73 .38 June 75 .28 2 .04 73 .34 Total 876 .43 201- .43 675 .43 Source: Medical Statistics Division. Office of The Surgeon General , War Department, Washington, D.C. Theater To tal 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army 13836 .65 1065 • 35 6903 1.03 4216 • 56 1652 .43 Continental U. 10502 .80 860 .34 6184 1.20 2689 .67 769 .53 Total Overseas 3334 .41 205 .40 719 .45 1527 .44 883 .36 European 2138 .67 96 1.32 319 1.21 1077 .73 646 .47 South West Pacific 248 .21 44 .66 57 .29 76 .14 71 #18 China-Burma-India 92 .28 7 1.24 11 .24 42 ,26 32 .26 North America 56 ,33 6 .15 36 .50 12 .29 2 .13 Alaska 65 .24 17 .34 37 .32 9 .11 2 .09 Latin America 38 .11 17 .17 13 ,11 6 .07 2 .05 Mediterranean 493 .36 2 .09 153 .35 241 .37 97 .40 African-Middle East 29 .22 1 .17 19 .36 5 .11 4 ,17 Pacific Ocean Area 175 .17 15 .10 74 .25 59 .16 27 .13 Source: Medical Sta' bistics Divisic >n« Office of The Surgeon General, War Department, Washington, D, C. Meningococcus Meningitis Total Army, Continental United States and Theaters of Operations Cases and rates per 1000 'strength per annum January 1942 to June 1945 Inclusive. Table 17 Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 258 • 96 14 1.28 117 1.90 127 .65 February 231 .81 0 o f 22 2.60 66 .94 143 .69 March 265 .70 4 5.06 37 4.47 80 .77 144 .54 April 258 .80 0 0 27 2.55 63 .68 168 .27 May 363 1.09 1 .45 14 1.48 55 .55 293 1.32 June 271 .67 2 .56 28 2.31 82 .64 159 .60 July 69 .51 3 .47 13 .68 53 .49 August 144 .93 8 .91 45 2.33 91 .72 September 145 .73 14 1.11 30 1.29 101 .62 October 108 .56 11 .66 30 .82 67 .48 November 154 .75 17 1.53 42 1.03 95 .62 December 178 . 59 5 .54 45 .69 128 ,56 Total 2444 .77 65 .89 347 1.31 998 .68 1034 .75 Source: Medical Stat War Departmei istics it. Was! Division ilngton. 4 , Office of The D« C. Surgeon General, Tuberculosis European Theater of Operations, U, S. Army Cases and Rates per 1000 strength per annum, by months February 1942 to June 1945, Inclusive Table 16 Table 19 Tuberculosis Continental Europe and United Kingdom European Theater of Operations, U, S. Army Cases and Rates per 1000 strength per annum, by months September 1944 to June 1945, Inclusive Month To tal United Kingdom m Continental Europe Cases Rates Cases Rates Cases Rates 1944- September 101 .62 70 1.06 31 .32 October 67 •4$ 43 1.02 24 .25 November 95 .62 36 .88 59 .53 December 128 .56 67 1.11 61 .37 1945 January 127 .65 53 1.08 74 .50 February U3 .69 44 .93 99 .62 March 144 .54 55 1.09 89 .42 April 168 .77 38 .98 130 .72 May 293 1.32 42 1.40 251 1.31 June 159 .60 35 .76 124 .57 Total 1425 .69 483 1.03 942 — .60 Sources Medical Statistics D1 War Department, Wash! vision, Of ngton, D.C Tice of The Surgeon General, . X-Rays || Primary Tuberculosis Reinfection Tuberculosis Non-Tu- Extra Taken Calcified Healed Uns table Apparently Healed Active berculcms Pulmonary - Pulmonary Anoma- lies No. % No. % No. % No. % No. % No. % No. % Survey I Groups A thru F (Feb. 1943) 3031 480 15.8 4 °'ir 35 1.1 3 - 0.09 142 4.69 112 3.6 91 3.0 Survey II Groups G thru L (Oct, 1943) 3634 628 17.1 11 0.3 51 lo40 4 0.11 93 2,5 97 2.6 123 3ol Survey III W0 A® CoS (July 1943) 578 99 17,0 0 - 5 0«87 0 - 16 2„ 76 40 6.9 15 2.6 Total 7243 1207 16 o 0 15 0.21 91 1© 3 7 0o09 251 3,4 249 3.4 229 3,1 Note: Percentage s are ba ised o n tota^ L X-r ays take n in e ach sur1 rey Source: Annual Report* Division of Theater of Operations, U, Professional So Army, 1943 Services, Office of the Chief Surgeon, European Tuberculosis Survey European Theater of Operations, U. S. Army, 1943 Table 20 Table 21 Tuberculosis Survey of British Civilians Saployed by the European Theater of Operations, U. 3. Amy, Cases and Percent X-ray, 19X2 Cases Percent Total Chest X-rayed — 586 Healed primary tuberculosis 71 12.50 Unstable primary tuberculosis 0 0.0 Reinfection type tuberculosis (total) 29 5.10 Minimal 23 A.10 Moderately advanced 5 0.90 far advanced 1 0.17 Old Pleuritia 19 3.30 Sourcel Annual Report, Division of Professional Services9 Office of the Chief Surgeon, European T Water of Operations, U. S. Army, 19AA Types Total Cases Cases Percent 1942 1943 1944 1945 Pulmonary 50 69.4 • 0 3 17 30 Pleurisy with effusion 19 26.4 0 1 11 7 Other 3 4,2 0 0 2 1 Total 72 100.0 0 4 30 38 Source: Semi-annual Report on Tuberculosis Service, Office of the Chief Surgeon, European Theater of Operations, U. So Army, June 1945 Types of Tuberculosis in Nurses European Theater of Operations, U# S* Army February 1942 to 31 May 1945, Inclusive Table 22 Table 23 Tuberculosis Survey of Officer Candidate School European Theater of Operations, U. S. Army, Cases and Rate per 1000, 194-5 Cases Rat© per A1000 Total candidates X-rayed — $24-0 Active tuberculosis 2 0.38 Diffuse miliary calcification 4- 0.76 Fibro-calcific scars 2 0.38 Doubtful parenchymal lesion 1 0.19 Sources Semi-annual report on Tuberculosis Service, Office of the Chief Surgeon, European Theater of Operations, U. S. Army, June 194-5 Table 2X Tuberculosis in American Recovered Allied Military Personnel 77th Field Hospital, European Theater of Operations, U, S. Army, Cases and Percent X-rayed, 194-5 Cases Percent Total X-ray — 2750 • Pathology present 149 5.41 Atypical pneumonia 64 2.32 Lobar pneumonia 13 0.47 Pulmonary edema 4 0.14 Miscellaneous 43 1.59 Tuberculosis 16 0.58 Minimal 6 Moderately advanced 6 Apparently healed 4 Pleural effusion (Tbc) 9 0.35 Total tuberculosis 25 0.91 Sources Semi-annual report on Tuberculosis Service, Office of The Chief Surgeon, European Theater of Operations, , U. S. Army, June 194-5 Theater Total 1942 ■ 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army 22,035 1.04 4,696 1.54 7,394 1.10 6,239 (O CO . 3,706 .96 Continental U* S, 15,617 1.19 4,144 1.63 6,006 1.17 3,868 .96 1,599 1.11 Total Overseas 6,418 o CO . 552 1.08 1,388 CO « 2,371 ,68 2,107 .87 China-JBurma-India 397 1.19 4 .71 68 1.48 231 1.45 94 .78 Africa-Middle East 141 1.08“ 8 1.39 78 1.46 40 .84 15 ,63 Alaska 284 1.05 81 1.61 99 .86 70 .84 34 1.45 Latin America 311 o 89 118 1.15 105 .87 60 ,70 28 .72 Pacific Ocean Area 893 o 85 126 .86 284 .96 282 .71 201 ,97 Southwest Pacific 1,004 . 83 108 1.61 96 ,49 301 .54 499 1.28 North America 138 .81 37 ,91 73 1,02 25 ,59 3 ,91 Europe li 2,444 .77 65 ,89 347 1.31 998 .68 1,034 .75 Source; Medical Statistics — Divisio n. Office of The Surgeon-Genera il. War Department, Washington , D. 6. , I, § 3 © w a u *h © C © a ■P <{ P* d OS H +> • JS o CO to -p d hO M TJ • d © p © * W -P d LO •H O £> O «H rH -HO rH -P ° © O d fid O d u -P U iH 3 ® d © p A do a cm o © 4 o to 43 o> >> © « |« * £ M s § d w co +> © P e2 S u 10 CM © H * Month To tal 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 161 ,60 25 2.28 67 1.09 69 .35 February 382 1,34 40 4.73 182 2.59 160 ,78 March 893 2,37 11 13.92 49 5.91 415 4.02 418 1,58 April 772 2,39 11 12,54 31 2.93 482 5,19 248 1.13 May 491 1,47 17 7,98 32 3,39 251 2,50 191 ,86 June 253 ,62 12 3,38 53 4*37 95 *75 93 ,35 July 60 ,45 3 ,47 29 1,52 28 ,26 August 22 ,14 4 ,46 2 ,10 16 ,13 September 20 ,10 1 ,08 3 ,13 16 ,10 October 18 ,09 0 0 4 ,11 14 ,10 November 27 ,13 1 ,09 6 ,15 20 ,13 December 89 ,30 7 ,75 36 ,55 46 ,20 Total 3188 1,00 67 ,92 310 1.17 1632 1.11 1179 to 00 c Source; Medic< War D al Stat; spartmei istics Divisic its Washington m* Off; ip D, C, Lee of i :heSurgec m Gener al. Meats les European Theater of Operations, U. S. Army Cases and Rates per 1000 strength per annum, by months February 1942 to June 1945 Inclusive Table 26 Table 27 Measles United Kingdom and Continent European Theater of Operations, U. S. Array- Cases and Rates per 1000 strength per annum, by months September 1944 to June 194-5, Inclusive Month Total United Kingdom Continent* al Europe Cases Rates Cases Rates Cases Rates 1944 September 16 .10 11 .17 5 .05 October 14 .10 8 .19 6 ,06 November 20 .13 14 .34 6 .05 December 46 .20 25 .42 21 .13 1945 January 69 .35 34 .69 35 .24 February 160 .78 26 o55 134 to o March 418 1.58 61 1.21 357 1.67 April 248 1.13 38 .98 210 1.17 May 191 .86 24 .80 167 .87 June 93 .35 9 .20 84 .39 Total 1275 .62 250 .53 1025 .65 Source; Medical Statistics Division, General, Washington, D.C. Office of The Surgeon Theater Tota 1 194 2 1943 1944 1945 Gases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Array 75010 3o 54 13830 4» 53 40898 6.08 15170 2,02 5112 1,32 United States 68363 5o21 12718 5o01 39606 7e 71 12823 3,20 3216. 2,23 Total Overseas 6647 o83 1112 2,17 1292 • 81 3347 • 67 1896 ' • 78 Latin America 752 2o 16 245 2,38 85 ,70 138 1.60 284 7» 28 Alaska 443 1.63 223 4,44 151 I. 31 62 • 75 7 • 30 North America 188 1.11 42 1,04 103 1.44 34 • 81 9 • 58 European 3188 loOO 67 o 92 310 1.17 1632 1.11 1179 • 86 Southwest Pacific 753 ©62 430 6,41 154 • 79 90 • 16 79 • 20 Mediterranean 689 o 51 4 ,19 356 ,83 179 • 27 150 • 62 China-Burma-India 159 o 48 6 1,07 27 • 59 71 • 45 55 • 45 Africa-Middle East 53 o 41 0 0 38 • 71 3 • 06 12 • 50 Pacific Ocean Area 422 o 40 95 064 68 • 23 138 • 35 121 • 58 Source: Medical Sta Washington, tistics Do Co Divisio n, Offic e of Th e Surgeon Gener< a.1, War Department, Measles Total Army, Continental United States and Theaters of Operations, Ui S, Army Cases and rates per 1000 strength per annum, by months January 1942 to June 1945 Table 28 Month Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 87 .32 3 .27 34 .55 50 .26 February 234 .82 0 0 9 1.06 61 .87 164 .80 March 751 1.99 6 7.59 42 5.07 230 2.23 473 1.79 April 848 2.62 18 20.52 40 3.78 474 5.10 316 1.44 May 496 1.49 28 13.15 38 4.05 282 2.81 148 .67 June 277 .68 27 7,60 34 2.80 156 1.23 60 .23 July 66 .49 13 2.03 20 1.05 33 .30 August 28 .18 8 ,91 1 .05 19 .15 September 25 .13 „ 5 ,39 5 .21 15 .09 October 28 .15 1 .06 4 .11 23 .17 November 25 .12 2 .18 10 .24 13 .09 December 39 .13 1 .11 15 .23 23 .10 Total 2904 .91 109 1.50 221 00 o 1363 .93 1211 00 00 o Source; Medical Statistics Division, Office of The Surgeon General, War Departmeht, Washington, D. C, German Measles European Theater of Operations# U* S. Array Cases and Rates per 1000 strength per annum, by months February 1942 to June 1945, Inclusive Table 29 Table 30 German Measles Continental Europe and United Kingdom European Theater of Operations, U. S, Army Cases and Rates per 1000 strength per annum, by month September 1944- to June 1945, Inclusive Month Total United Kingdom Continental Europe PftS®? Rates Cases Hates Cases Rates 1944 September 15 .09 7 .11 8 .08 October 23 .17 13 .31 10 .10 November 13 .09 4 .10 9 .08 December 23 .10 12 l .20 11 .07 1945 January 50 .26 11 .22 39 .27 February 164 .80 24 .51 140 .88 March 473 1.79 68 1.35 405 1.89 April 316 1.44 41 1,06 275 1.53 May U8 .67 27 .90 121 .63 June 60 .23 5 .11 55 .25 Total 1285 .63 212 .45 1073 .68 , Source: Medical Statistics Division, General, War Department, Wash Office lington, of The Surgeon D.C • Theater Total 1942 194 $ 1944 194 L5 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army ♦ ♦ ♦ ♦ 79634 11.84 13422 1.79 10257 2.65 United States ♦ ♦ ♦ ♦ 77736 15.14 11058 2.76 8098 5.60 Total Overseas 7484 .93 1063 2.07 1898 1.19 2364 .68 2159 ,89 Latin America 1561 4.48 308 2.99 162 1.34 541 6.29 550 14.10 Mediterranean 420 .31 6 0 192 .45 106 .16 122 .51 Alaska 655 2.41 162 3.22 476 4,14 14 .17 3 .13 North America 272 1.60 36 ,89 217 " 3,03 13 ,31 6 .39 Europe 2904 <>91 109 1.50 221 ,84 1363 ,93 1211 ,88 Southwest Pacific 831 .69 248 3,70 400 2,05 132 ,24 51 ,13 Pacific Ocean Area 600 ,57 176 1,19 162 ,55 115 ,29 147 ,71 China-Burma- Indi a 181 ,54 23 4,09 49 1,06 58 ,36 51 ,42 Africa-Middle East 60 ,46 1 ,17 19 ,36 22 ,46 18 ,75 ♦Data not available Source; Medical Statistics Division, Office of The Surgeon General War Department , Washington, D, C. German Measles Total Army, Continental United States and Theaters of Operation, U. S. Army Cases and Rates per 1000 strength per annum January 1942 to June 1945, Inclusive Table 31 Mon+.Vi Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 792 2.95 51 4.66 301 4.90 440 2.25 February 1059 3.72 5 16.21 52 6.15 413 5.87 589 2,86 March 2026 5.38 1 1.27 47, 5,67 1041 10.08 937 3.54 April 1948 6.03 13 14,82 67 6.34 1204 12,95 664 3.03 May 1605 4.81 10 4.70 55 5.83 985 9.80 555 2.50 June 1067 2.63 19 5.35 55 4.54 761 5,98 232 .88 July 326 2.42 16 2.50 75 3.92 235 2.16 August 235 1.52 26 2.96 57 2.95 152 1.20 September 160 .80 17 1.34 46 1,97 m .59 October 220 1.14 24 1.43 104 2.84 .66 November 300 1.47 26 2.33 153 3.73 IZ1 .79 December 525 1.74 34 3.64 236 3.63 255 1.13 Total 10263 3.23 191 2.63 998 3.78 5657 3.84 3417 2,49 Source: Medical Statistics Divisions Office of The Surgeon General War Department, Washington, D. C. Mumps European Theater of Operations# U, S. Army Cases and Rates per 1000 strength per annum# by months February 1942 to June 1945# Inclusive Table 52 Table 33 Mumps Continental Europe and United Kingdom European Theater of Operations, U, S. Army Cases and Rates for Troops Serving in the United Kingdom and on the Continent September 1944 to June 1945 > Inclusive Month Total United ingdom Continents 1 Europe Cases Rates Cases Rates Cases Rates 1944- September 97 • 59 &s 81 lo23 16 .16 October 92 55 1,32 37 .38 November 121 co 79 82 2.00 39 .35 December 255 11.13 187 3oll 68 .41 194-5 January uo 2.25 281 5.70 159 1.08 February 589 2,86 268 5.67 321 2.02 March 937 3.54 261 5ol7 676 3.16 April 664. 3.03 144 3.72 520 2,89 May 555 2.$0 130 4c 35 425 2.22 June 232 088 60 1.30 172 .79 Total 3982 1.94 154-9 3.29 2433 1.54 Source: Medical Statistics Di-' General, War Departmei vision, Office of The Surgeon at, Washington, D.C. Theater Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army 101359 4o79 17893 5o 86 40855 6o07 27098 3o 61 15513 4o00 United States 83076 6o33 15351 6o05 37270 7o26 19665 4o90 10790 7o47 Total Overseas 18283 2027 2542 4o95 3586 2025 7433 2o 12 4723 lo94 Alaska 1114 4ol0 541 10o 77 530 4o61 26 o31 17 o 73 North America 605 3056 171 4o22 362 5o05 39 o 93 33 2013 Europe 10263 3o23 191 2063 998 3o78 5657 3084 3417 2049 Africa-Middle East 335 2©57 10 lo 74 197 3o69 86 lo82 42 lo 76 Latin America 832 2039 615 5o98 89 <>74 105 lo22 23 o59 China°Burma-India 528 lo 59 16 2084 45 o98 224 1<>40 243 2o01 Southwest Pacific 1733 io 44 621 9,26 371 lo 90 366 ©66 375 o 96 Pacific Ocean Area 1276 lo22 218 lo 48 421 lo43 345 ©87 292 lo41 Mediterranean 1597 lo 18 159 7o 46 572 lo33 585 a 89 281 lo 17 Sources Division of Medical Statistics, Office of The Surgeon General, War Washingtons Do C 0 Mumps Total Army, Continental United States and Theaters of Operations, U* So Army Cases and Rates per 1000 strength per annum January 1942 to June 1945, Inclusive Table 34 Table 35 Smallpox Total Army, Continental United States and Theaters of Operations, U, S, Army Cases and Rates per 1000 strength per annum January 1942 to June 1945, Inclusive Theater Cases Rates Total Army 89 •004. United States 10 .001 Overseas 79 .010 China-Burma-India 36 .108 Africa-Middle East 23 .176 Mediterranean 13 .010 Latin America A * Alaska 2 * Europe 1 * Southwest Pacific 0 Pacific Ocean Area 0 * North America n 0 • * Rate not calculated Source; Division of Medical Records, Office of the Chief Surgeon European Theater of Operations. Tables 1. Scarlet Fever* European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, February 194-2 to June 1945, inclusive0 2. Scarlet Fever, United Kingdom and Continent, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, September 1944 to June 1945, inclusive. 3. Scarlet Fever, Total Army, Continental United States and Theaters of Operations, U.S, Army, cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusive. 4. Rheumatic Fever, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, February 1942 to June 1945, inclusive« $, Rheumatic Fever, United Kingdom and Continent, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, September 1944 to June 1945, inclusive, 6. Rheumatic Fever, Total array, Continental United States and Theaters of Operations, U.S. Army, cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusive. 7. Streptococcus Sore Throat, European Theater of Operations, U.S Army, cases and rates per 1000 strength per annum, February 1944 to June 1945, inclusive0 8. Diphtheria in England and YJales, rates per 100,000 population per annum, 1939 to 1945, inclusive. 9. Diphtheria in occupied countries, Continental Europe, rates per 100,000 population per annum, 1939 to 1943, inclusive. 10, Diphtheria, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive. 11, Diphtheria, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, by months, September 1944 to June 1945. 12, Diphtheria, Prisoners of War, European Theater of Operations, Continent only, cases and rates per 1000 strength per annum, by months, September 1944 to June 1945. 13. Diphtheria, Theaters of Operations of the U.S. Army, cases and rates per 1000 strength per annum, by months, January 194-2 to June 194-5. 14-. Vincent’s Angina, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, February 194-2 to June 194-5, inclusive. 1$, Meningococcus Meningitis, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, by months, February 194-2 to January 194-5, Inclusive. 16. Meningococcus Meningitis, Continent and United Kingdom, Euro- pean Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum by months, September 1944- to June 194-5, Inclusive, 17. Meningococcus Meningitis, Total Army, Continental United States and Theaters of Operations, cases and rates per 1000 strength per annum, January 194-2 to June 194-5, inclusive, 18. Tuberculosis, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, by months, February 194-2 to January 194-5, inclusive. 19. Tuberculosis, Continent and United Kingdom, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, by months, September 1944- to June 1945, inclusive. 20. Tuberculosis Survey, European Theater of Operations, U.S. Army, 1943. 21. Tuberculosis Survey of British Civilians employed by the Euro- pean Theater of Operations, U.S. Army, cases and percent X-rayed, 1942. 22. Types of Tuberculosis in Nurses, European Theater of Operatibfls, U.S. Army, February 1942 to 31 May 1945, inclusive. 23. Tuberculosis Survey of Officers Candidate School, European Theat- er of Operations, U.S, Army, cases and rates per 1000, 1945. 24. Tuberculosis in American RAMPS (Recovered Allied Military Per- sonnel) 77th Field Hospital, European Theater of Operations, U.S, Army, cases and percent X-rayed, 1945. 25. Tuberculosis, Total Army, Continental United States and Theat- ers of Operations, U.S. Army, cases and rates per 1000 strength per annum, January 194-2 to June 1945, inclusive* 26. Measles, European Theater of Operations, U.S. Army, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive, 27. Measles, United Kingdom and Continent, European Theater of Opera tions, U.S. Array, cases and rates per 1000 strength per annumm, by months, September 1944 to June 1945, inclusive0 28. Measles, Total Army, Continental United States and Theaters of Operations, U.S, Army, Cases and rates per 1000 strength per annum, by months, January 1942 to June 1945, inclusive. 29* German Measles, European Theater of Operations, U.S. Army, Cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive, 30. German Measles, Continent and United Kingdom, European Theater of Operations, U.S. Army, Cases and rates per 1000 strength per annum, by months, September 1944 to June 1945, inclusive, 31. German Measles, Total Army, Continental United States and Theat- ers of Operations, U.S. Army, Cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusive, 32. Mumps, European Theater of Operations, U.S, Army, Cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive, 33« Mumps, European Theater of Operations, U.S. Army, Cases and rates for troops per day in the United Kingdom and on the Continent, September 1944 to June 1945, inclusive, 34o Mumps, Total Army, Continental United States and Theaters of Operations, U.S. army, Cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusive, 35. Smallpox, Total Army, Continental United States and Theater of Operations, Cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusive. Figures 1. Tuberculosis, All F.qrms, In Troops on Continental Europe, European Theater of Operations, U.S. Army, Rates per 1000 strength per annum, by weeks, September 1944 to June 194$ Inclusive. 2. Tuberculosis, All Forms, In Nurses, European Theater of Opera tions, U.S. Army, Rates per 1000 strength per annum, February 1942 to May 194$ Inclusive. Epidemiologic Case Reports 1. Mumps aboard transport and introduced into units to which recruits came as replacements0 A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY - 19^5 PART III - Epidemiology Section 5 “ Arthropod Borne Disease Number 1 - Typhus Fever by Colonel John E0 Gordon, M0C„ Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART III Epidemiology Section 5 - Arthropod Borne Diseases Number 1 Typhus Fever Page Typhus i? ever oooo.oooooooooo.aeoeo.aoo X Typhus in the German Reich, 1939 to The Allied Invasion « • • 1 Distribution and Spread in Germany, .. ... ... .... . 1 Incidence by Population Groups. ... .... ....... . 3 Mo r tali ty . . ® . . -> . icoo............... 3 Typhus in the Rhineland .......c..... 4 German Program for Typhus Control .......o...... 4 Louse Control Measures oooooo«...ooco...«.o 4 Vaccination ...coo......... 4 Medicaj. Care coo.©.................... 5 Development of Measures and Methods for Typhus Control. ... 5 Training in Methods of Typhus Control ..o......... 6 Training in the United Kingdom . . ............ . 6 Training in Typhus Control on the Continent ......... 7 Immunization Against Typhus Fever ...o.. ........ 8 # Procurement of Supplies DD X Powdere...?.................. 9 Hand Dusters, Powder Dusters, 2-ounce Sifter Cans. ... 10 Typhus Vaccine coo©................. 10 Cordon Sanitaire000000.00000000000.00.0 11 Page Case Finding Teams 11 The Technical Details of Typhus Control 11 Preventive Measures to be Instituted in Advance of Known Typhus Immunization . . . . . . . ' . . . 12 Prevention of Lousiness among Troops ......... 12 Information on Epidemics 12 Supply 13 Training of Control Teams 13 Refugees « • • . 13 Control Measures - Sporadic of Endemic lyphus Diagnosis. . 13 Isolation. ......... « 13 Foreign Quarantine 13 Immunization . ... ......... . 13 Delousing. ' 14 Specific Epidemiologic Procedures. ......... . 14 Civilian Communities ...o............. 14 •typhus in Military Installations . 14 Typhus in Camps for Prisoners of War, Refugees and Displaced Persons. ............... 14 % Operation of Case Finding Tsams .............. 15 Operation of Insect Control Group ............. 15 Control Measures - with Typhus Declared Epidemic. ..... 15 Administrative Management of Typhus Control in the European Th o a te 16 Page Areas of Responsibility 17 Changes in Administrative Authority 17 Conduct of Field Operations 19 % The Medical Department* * . . . 19 Civil Affairs Division G-5. 19 United States of America Typhus Commission 20 Field Operations in Typhus Control, ETOUSA . 20 Typhus Control in the United Kingdom 21 Typhus Control in France, Belgium and the Netherlands ... 21 Typhus in the Rhineland 22 The Rhineland or Westraark . 23 Aachen Outbreak . . • 23 Munchen Gladbach Outbreak 24 Cologne Outbreak. 27 Hermulheim Epidemic 28 Moselle and Nahe River Area 29 Palatinate Area 29 Alsace and Lorraine 29 General Course of the Rhineland Epidemic. 29 Typhus Fever by Population Groups 32 Case Fatality 33 Summary ................. . • 33 Typhus in the Inner Reich 35 Geographical Limits of the Inner Reich. 36 Page General Course of the Epidemic in the Inner Reich 37 Special Epidemiological Problems . . • • 39 Dachau Concentration Camp.. . . . . . 39 Typhus in the Nordhausen Area . 42 Typhus in Siegberg Prison. ..... 42 Typhus at Buchenwald Concentration Camp 43 Typhus at Flossenberg Concentration Camp 43 Typhus in the Mauthausen Camp 45 Typhus in the Liberated Countries 45 Typhus Among German Prisoners of War 46 Typhus Among Recovered Allied Military Personnel (RAMP). . • 46 Typhus in the Russian Occupied Areas of Germany « 47 Typhus in British Occupied Germany ... 47 Typhus in U« S. Military Forces 48 Control Measures ............ 49 Case Finding Teams 49 Insect Control Teams .... .......... 49 Immunization ... ........... 49 Care of Patients 50 Cordon Sanitaire 50 Summary 51 Recommendation of Future Control Measures 53 List of Figures List of Tables List of Epidemiologic Case Reports PART III Epidemiology Seotion 5 - Arthropod some Diseasd Number 1 -ITyphus Fever Typhus Fever*-Epidemic louse-borne typhus fever has al- ways developed its greatest potentialities under conditions of war and famine0 Medical intelligence summaries of the Office of the Chief Surgeon, ETOUSA, medical notes of the health division of UNRRA, and the weekly epidemiological records of the Health Section of the Secretariat of the League of Nations all served to reveal that typhus fever became established in Germany in 1939* These reports continued thereafter to give pertinent facts about its incidence and its distribution* No question existed that ty- phus would be encountered in Germany vdien the U*S* Army entered that country in the early spring of 1945* The important consideration v»hioh faced Army medical authorities Tvas how much typhus would bo uncovered and ■where it would be found* Typhus in the German Reich, 1939 to The Allied Invasion®— The primary European focusoflouse-borne typhus for many years— and very likely for centuries—has been in the states of Eastern Europe| in Russia, Poland, and the Balkans® Other recognised European endemic foci are in the Iberian peninsula and in Eire, neither of which had an influence on areas occupied by the Ihitod States Army® fyphus first appeared in Germany in 1939, at which time eight oases were reportedo The source of infection was Russia, but the exact geographical origin within that country was not determined* Epidemic typhus had long been prevalent in many parts of Russia, particularly in "White Russia and the Ukraine, but no detailed nor reliable information 7ms available during the Tvar years as to its distribution and incidenceG Distribution and Spread in Germany®—Six isolated oases of typhus occurred in 1940 among civilians of the original 1919 territory of Germany® The geographical location 7ms not given in available reports but all cases were reported to be the result of importation of the disease from Russia® in the years that followed, the number of oases increased sharply and the disease 7ms scattered throughout Germany® This 7»as the direct result of the importation of infection from Poland and Russia by the German armed forces, by prisoners of war and by con- script labor from endemic typhus fever areas® In spite of delousing measures, the primitive conditions under Tdiich conscript laborers were compelled to live mad© it impossible to keep them free of lice® Under-nutrition may have activated latent typhus Infection® At any rate, there were many outbreaks of typhus fever in prison camps; and sometimes the disease extended to the native German population0 The essential freedom from lice of most Germans prevented extension of the infection to epidemic proportionso Cases were nevertheless sufficiently numerous that German health authorities began system- atically to delay publication of information concerning typhus fever* and stopped announcements altogether after January 19440 By 1941* typhus was rampant® A total of 2*351 cases were reported for that year in Greater Germany, which included Germany proper and the annexed territories, principally Polando The German Reich had 395 cases and 1946 were in the annexed territorieso The distribution was not uniform; but it was known that 44 of the 74 administrative districts in Germany were affected® The incidence was greatest in the eastern part of Germany, less in the central part and least in the western and southern districts® As might be ex- pected, the most heavily infected administrative divisions were those into which Polish territory had been incorporated® The number of known cases by population districts is presented in Table 1® The data are incomplete and represent only a part of the cases reported in 1941, the geographic distribution of the remainder being unavailable® Hie reported typhus for 1942 was 2742 cases© A greater increase over the previous year would have been anticipated, since conditions inside Germany were steadily deteriorating© The ex- planation apparently lies in the action of the German Government in suppressing reports of the disease because of the morale factor© Of the 2742 oases, 2400 were reported from Germany proper, while only 342 were from the annexed territories© ftie distribution differed significantly from that of 1941, when most cases were from the an- nexed territories© Typhus in 1942 predominated in the large industrial areas of Germany, where many foreign conscript laborers were employed® In the course of the year, 53 of the 74 administrative districts were affected® The distribution was more uniform and more widespread than in the previous year, with typhus occurring even in northwest Germany® Ihe districts reporting typhus and the numbers of oases in 1942 are presented in Table 2® The United States Public Health Reports set the total number of typhus fever cases in Germany in 1943 at 5,068© Ihis probably represents the most accurate annual report on typhus in Germany up to that timeo The disease continued to appear in the heavily popu- lated industrial areas, and the general geographic distribution re- mained widespread© Table 3 gives the number of cases reported by German health authorities by districts for 1943© 2 The annual distribution of typhus fever for the period 1939 to 1945 for Germany and annexed territory is presented in Figure 1, Table 40 The data for Germany proper as compiled by the League of Nations are illustrated in Figure 2© The above facts show that typhus in Germany was at first fairly well localized in the eastern part of the country, where in- fected Polish and Russian prisoners of war were internedo It sub- sequently spread in a centrifugal manner to the adjacent German populationo When industrial activities were more or less consoli- dated within the inner areas of the country and as more foreign laborers moved into these crowded areas, the major foci of typhus infection shifted to these localitieso The typhus problem thereafter was seriouso Typhus spread to all principal regions of Germany and became epidemic in some areas0 Considering the frequency with which new infections were introduced, control measures would appear to have been good*, in that typhus was held to reasonably low levels© The final debacle of the war led to conditions marked by disorgani- zation and great shifts of population of such extent that the epidemic potential was extremely dangerous when American troops entered the country0 Incidence by Population Groups0— The first typhus in Germany was among Polish and Russian prisoners of war and con- script laborers (displaced persons)© As typhus increased, the displaced persons still accounted for the majority of infections, with the remainder occurring among prisoners of war and German civilianso This can be explained by the unsanitary and crowded living conditions of the displaced persons group, which presumably led to heavy louse infestation© Their resistance to disease was also undoubtedly lowered as a result of long hours of labor and insufficient food© As a rule, louse infestation was not common among German civilians © Official records showing the incidence of typhus among German soldiers are not available; but typhus did occur in the German army and in some instances in epidemic propor- tions© In 1941 a fairly serious outbreak appeared among troops stationed on the Russian front© Naturally the German high command found it convenient to suppress reporting of the disease in the armies© Figure 3, Table 5 presents data on the distribution of typhus by population groups for the years 1942 and 1943© Mortality©—The case fatality from typhus was much higher in German than in non“German groups despite the lowered resistance of the latter and presumably the inferior medical care they received© The explanation is not wholly apparent© The non-German group consisted of a great many Poles and Russians, who might be expected to possess some degree of acquired immunity as a result of the excess incidence of typhus in those countries for so many years© (Figure 3)© 3 Tophus in the Bhineland© — In the latter part of 1944 and the early months of 1945, typhusapparently appeared for the first time in significant numbers in the Rhineland section of Germany© This was of importance to military authorities of the United States because plans called for our troops to enter Germany through this area in the early spring of 1945» German Program for typhus Control©—Although the German government made every effort control lihe spread of typhus in Germany, their control program as a whole served only to keep the disease within reasonable limits© That of itself was no mean accomplishment, because many factors in Germany favored transmission*, The shifting of displaced foreign workers from place to place, the crowded living condition in air raid shelters and industrial areas, the insanitary conditions in cities as a result of frequent bombings and the resultant louse infestation gave rise to situations about which the Germans could do little*, Furthermore the infectious agent was repeatedly reintroduced from foreign sources© Louse Control Measures*,—Louse infestation was prevalent among the displaced foreign workers, and according to report little was done toward delousing them until typhus actually was present© Even then delousing facilities were inadequate and to a great extent ineffective© Information also indicated an increase in louse in- festation of German troops, particularly toward the end of the war© Delousing had always been a problem in the German army. The German soldier found proper delousing facilities only after his unit had been withdrawn from the front, with the result that he was fortunate to obtain delousing treatment once in six months. The lousi- cid© powder available to German troops was considered ineffective and had an offensive odor. Furthermore it was not of general issue. Lous© infestation in the camps holding allied prisoners of war was also heavy, and adequate delousing facilities non-existent. The German civilian was probably the most louse-free group in Germany, since his bathig facilities and living conditions as a rule continued good. Vaccination©—Vaccination against typhus was the exception rather than the rulein Germany, even in the German army itself© In 1942 the United States Office of War Information stated the reason most of the German forces were unvaocinated was that the German laboratories for typhus research had failed to develop mass production of vaccine© The two vaccines developed by Hermann Eir, the Gorman typhus research expert, were too complicated for mass production, although laboratories for the production of typhus vaccine were established in Berlin, Riga and Cracow© Reports indicate that two kinds of vaccine were made, one from chick embryo and the other from lungs of mice experimentally 4 Fierore 1 Typhus Verer ir* and annexed territory* bv years, January 1*52 to June XJ4b. Figure 2 Trend of typhus fever in Germany, number of cases by quarters, 1938 to 1943. NON-GERMAN UNCLASSIFIED GERMANS Figure 5 Typhus fever in Germany, elements of population affected and mortality rates, by years, 1942 to 1943. infected with Rickettsia© Vaccine was available only for those individuals who were most apt to come in contact with the disease, such as doctors, nurses, medical department personnel and workers in delousing centers0 It was available to soldiers over 38 years of age, to high ranking army officers, and rather generally for the Luftwaffeo The Weigl vaccine had limited application because of the technical difficulties in its production© Medical car©omcnMedioal care of patients with typhus fever in German hospita1s~was for the most part goodc Special wards were set aside in hospitals where necessary? and in epidemic areas typhus fever hospitals were constituted© 'Ihe exception to this was in the concentration camps where medical care was decidedly inadequate and in many instances disgraceful© Development of Measures and Methods for Typhus Control©«— Ih© program of the United States army for control of typhus fever in Europe was based on the cardinal principle of education© As many individuals as possible were acquainted with the causes of the disease and the methods for its prevention© A comprehensive program gave attention to six major considerations? a© An adequate system of reporting cases of typhus fever in all population groups involved© Satisfactory procedures already existed in respect to military personnel of the U© S© Army and to prisoners of war© Reporting of the disease among displaced persons and German civilians required special consideration and methods© b© A system of case finding, employing the epidemiological method for prompt discovery of new cases and the existence of newly developing foci of infection© 0© Provision for isolation and hospital care of patients with typhus fever© d© The establishment of a policy in respect to quarantine of highly infected areas or camps? and the institution of a cordon sanitalre to protect larger districts relatively free of typhus from infection transmitted from areas of high endemicity or actual epidemic© e© Delousing of patients, contacts and at times of large segments of the normal population, particularly of camps and of highly infected villages? the us© of DDT powder to be the standard procedure© fo Specific protection by immunization of all military personnels of those civilians intimately concerned with typhus con- trol, of intimate contacts, and as determined by circumstances, of large population groups such as inmates of concentration campso 5 Training in Methods of Typhus Control©—Since the preventa- tion of the disease among military personnel exerts such an important influence on the success of military operations, the first objective was the thorough indoctrination of officers and men of the armies on the hazards of the disease and the methods of protecting troops against infection© Special stress was placed on the louse and the methods for control of infestation by lice; particularly on the technics for personnel protection and for mass delousing© The effort to this end was instituted long in advance of any possible exposure of an American soldier© Training in the United Kingdom©--Training in the United Kingdom in tide early unorganized days of 1942, and later in the year when preparations for the North African invasion got under way, included little more than informal discussion with individual units© Most of those destined for Africa were reached, and because the number of troops was not great, indoctrination was believed to have been satisfactorily accomplished© The first organized instruction was initiated in the spring of 1943, with the opening of the Field Service School at Shrivenham, England* Here medical officers and nurses were taught technical methods by means of lectures, motion pictures, and the demonstration of materials and equipment* The school continued for several months after the Normandy invasion and medical officers of all branches of the service were trained in the subject* In addition to the instruction of medical officers and nurses at the Field Service School, a special course on typhus con- trol was given to the representatives of units then in the United King- dom, including officers of the line, of the Quartermaster Corps and of the Medical Corps, with the intent that those specially trained officers would constitute the instructors for the military personnel in general© That all personnel might be informed of the methods of typhus pre- vention and control, detailed instructions were issued by directive© As the time for the Normandy invasion approached, troops were specifically briefed on the subject of typhus at the marshalling areas just prior to embarkation for the Continent, and each soldier was issued a can of louse powder© Other educational work consisted of the circulation of motion picture films, the publication of popular articles in army- periodicals, and informative circular letters and directives by the Office of the Chief Surgeon and by command headquarters© Quartermaster Sterilization Companies and Fumigation and Bath Chits were given first hand and personal instruction in the use of their materials and equipment in the control of lice© 6 A group of officers from ETOUSA was sent to North Africa, Italy and Egypt during the winter of 1943-44 to study the methods of typhus control practiced in those countries* As a result of their observations, the members of the mission were of the opinion that the conditions which caused the Naples epidemic would in- evitably be duplicated in other parts of Europe as military oper- ations were extended to the Continent* The mission recommended that a special type of organization, to be called Typhus Control Units, be established in the European riheater to initiate control operations and to coordinate the activities of civil and military organizations immediately on the development of an epidemic* Scarcity of medical officers and enlisted personnel to staff such units prevented their immediate organization© The control of typhus among civilians of liberated countries and among displaced nationals was an accepted and direct responsibility of G-5 Civil Affairs and Military Government* The ‘ organization of this branch was so incomplete prior to D-Day that it was impossible to introduce into their program a thorough course of instruction in methods of typhus control© Nevertheless, through the cooperation of the United States of American Typhus Commission and the Division of Preventive Medicine of the Office of The Chief Surgeon it was possible to bring a certain measure of instruction on modern methods for attacking the disease to American, British, French, Dutch and other personnel in Great Britain who were to be concerned with civil affairs in continental Europe© Training in Typhus Control on the Continent,,“-The character of military operations in Trance from D-i)ay to November 1944 pre- cluded further organized and general instruction of troops in forward areas on the prevention of typhuso Information was acquired shortly after the landing in Normandy that typhus had occurred near Cherbourg among German Todt workers as late as May 1944, and German prisoners captured in the Normandy campaign were in many instances infested with lice© Temporary arrangements were made to manage a possible epidemic© During July 1944, two delousing teams were organized in each Quartermaster Sterilization Company then on the Continent© The teams consisted of five enlisted men with a non-commissioned officer in charge, and were equipped with one 6x6 truck, an initial issue of 400 pounds of DDT powder and twelve hand dusters© The staff was trained in delousing and the relation of that procedure to the control of typhus© They remained at their assigned duties but were on call by the Office of the Chief Surgeon should typhus fever appear among civilian or military populations© The organization of these teams was possible through the close cooperation of the Office of The Chief Surgeon and the Quarter- master, Advance Section, Communications Zone. Later in the year. 7 Advance Section trained the entire personnel of its Sterilization Companies in delousing and typhus control work, a circumstance which contributed greatly to the satisfactory performance of control measures when typhus became epidemic the following springe With ever growing evidence that typhus would be encountered among civilians and displaced persons in Germany, and since control of the disease in such groups had been delegated to G~5, Public Health Section, the Surgeon of the TVrelfth Army Group requested the assistance of the theater Preventive Medicine Service in organizing and training G-5 personnel of the Armies in typhus control® Initiated in September 1944, the training consisted in acquainting G-5 public health officers of the Armies with all aspects of the problem, and in instructing ECAD units in actual control measures© A standard plan was developed for use by Armies in stamping out the disease wherever it might be found and for prevent- ing its spread from endemic areas in Germany to other countries of Western Europe© The United States of America Typhus Commission under- took a similar program with 21st Army Group, and later with the Pre- ventive Medicine Service in the Sixth Army Group© In addition, other staff members of the Typhus Commission were engaged during the summer and early fall of 1944 in training French Civilian and military personnel in typhus control methods© \ Immunization against Typhus Fevertroops stationed in the tfoiteVTingdom in the early days of were routinely given three 1 cc injections of typhus vaccine as an initial immuni- zation, followed by a 1 cc stimulating dose at yearly intervals© In preparation for D-Day, all individuals who had no record of immunization against typhus since 1 July 1943 were reimmunized© On 15 March 1944, typhus immunization had been brought to the following statuss Ground Forces 99$ immunized. Air Forces 96$ and Communications Zone 98$© Further provision was made that an additional 1 cc® of typhus vaccine was to be administered every four to six months in the presence of serious danger of infection® Following instructions from the Wiar Department, two injections of 1 cc each was adopted as standard practice for initial immunization in January 1945® In preparation for the Spring campaign of 1945, all troops who had had. no typhus vaccine since 15 September 1944 were reimmunized between 1 December and 20 December 1944© he immunization on 1 November 1944 had been considered, but because of the favorable typhus situation in France, delay until shortly prior to entry into Germany was deemed advisable© No case of typhus had occurred in France since the occupation of that country, and indeed none was subsequently reported until two cases developed among Russian displaced persons at La Courtine during the latter part of February 1945© 8 Intelligence reports indicated an entirely different situation in Germany, Repeated reference was made to outbreaks of typhus in all sections of the Reich, It was thus highly de- sirable that troops should have maximum immunity during the peak of the typhus season, January through March, and at the time of the invasion of Germany, Plans were made to reiramunize all troops again on 1 April 1945, if the situation warranted. No such immunization ever became necessary, although reimmunization in March and suc- ceeding months was widely practiced and directed for all personnel connected with typhus fever control. Procurement of Supplies. DDT Powder*—The use of DDT powder was early decided upon as the most practical method for controlling the louse vector of typhus fever* The timely provision of adequate stocks of this insecticide and the necessary equipment for applying it was a major supply problem* This was particularly true in 1944, when intensive military operations required the use of all avail- able transport for essential war material* It was not possible to stock typhus control materials on the continent in preparation for the inevitable need, but as a substitute all agencies acted energetically to accumulate large stock piles in Great Britain. Fortunately, the areas on the continent first occupied by Allied troops and later at the critical point of the tactical situation in December were free from typhus even during the usual peak of the typhus season. Not until the advance across the Roer River in February 1945 was the full impact of the disease made manifest. Its control then became an essential factor in military operations* The unprecendented magnitude of the problem that was suddenly forced upon the armies led to much higher shipping priority for typhus control supplies than had previously been enjoyed. By the time supplies were needed, ample quantities were available on the continent* From an insignificant monthly demand for about 3*5 tons of DDT powder in January 1945 by G-5 of the armies, the requirements jumped to approximately 150 tons by the following April 1945* Through the cooperation of G-5, SHAEF, the Chief Quartermaster Theater and the Medical Supply Division of the Office of the Chief Surgeon, 756,000 pounds of DDT powder were provided for continental use from 1 January to 31 May 1945, Of this amount 525,000 pounds of powder were issued to units concerned with typhus control* The problems or supply just presented related only to intra-theater effort and concern® Particular commendation is due the Service of Preventive Medicine in the Office of the Surgeon 9 General and the Director o±* the UoSoAo Typhus Commission in Washington for the diligence and effort exercised at the sources of supply, which made possible long in advance of need the huge stock piles accumulated in the "United Kingdom0 One of the most satisfactory features of typhus control as it developed in Germany was that never in the course of operations did a shortage of dusting powder exist* Hand Dusters, Powder Dusters, 2-ounce Sifter cans*—The common method of applying DDT powder was” "Hand dusterso They were issued to all units concerned with the delousing of civilians* Due to a shortage in the United States of the better quality of Dobbins and Hudson dusters, only the small Hudson Cadet type was available in the theater* A small number of these guns were provided by the Chief Quartermaster from military stocks for the early control work among civilians* The deficiency was eliminated in December 1944 by the shipment of 1800 better type dusters by air from the Zone of the interior at the urgent request of G-5, SHAEF* From 1 January to 31 May 1945, G-5 supplied an additional 3,700 dusters and the Quartermaster provided 6,800 during the period from March to June 1945* The uncovering of large forced labor camps in Germany and the placing into operation of the cordon sanitaire required the rapid delousing of large numbers of persons* Through the cooper- ation of the UoSoAo Typhus Commission, G-5 SHAEF was able to secure 34 powder dusters which were shipped by air to the theater to supple- ment the nine on hand* Although Quartermaster stocks of 2-ounce sifter cans were in ample supply and were available for emergency civilian needs, actually only two to three thousand cans were used for this pur- pose* They were the principal reliance for preventive delousing of troops* Typhus Vaccine*—The original supply plan for typhus vaccine in epidemic control placed the responsibility for mili- tary needs on the Supply Division of the Office of The Chief Surgeon* The Bhited States of America Typhus Commission established a separate stockpile to be drawn upon by Civil Affairs groups, SHAEF Missions, public health representatives of European governments in exile, UNRRA and similar organizations* It soon became evident that distribution of typhus vaccine from a single source to all using agencies including the United States Army, would avoid waste and accumulation of surplus stocks* Decision was therefore taken that henceforth the Typhus Commission would be responsible for the overall supply of typhus vaccine to the theater* In accordance with this arrangement vaccine was shipped to United states Army medical supply depots in Great Britain and the 10 Continent from the warehouses of the Commission in London and Paris, for distribution to all using agencies® As in the case of DDT powder, supplies always exceeded demand and permitted wider practice of control through specific immunization than was originally planned® f\ y f Cordon Sanitaire Q-«jpie policy of local quarantine of in- fected was adopted as aji integral part of the projected plan for control of typhus® as to area, extent and procedure necessarily rested on immediate epidemiologic circumstances and could not Ite determined in advance® A detailed plan for a cordon sanitaire was prepared in late 1943* It was apparent even then that the Shine River would constitute an important factor in military operations and that pro- gress in all liklihood would be held up there temporarily® The most reliable medical intelligence indicated that relatively little typhus existed west of the river but that the east bank and from there north and east was heavily infected® The general plan for typhus control, determined almost two years in advance of operations provided for prompt establishment of a cordon sanitaire, extending from Switzerland to 'the sea along the Rhine and Waal rivers to be put into effect as the West Rhineland was occupiedo A strong effort was to be made to clear the Rhineland of such typhus as might exist there; and by the cordon sanitaire to protect France, the other liberated countries, and the United Kingdom from invasion by the disease*. Case Rinding Teams The following morning the entire population of tjie village was deloused by dusting, and vaccinatede In the course of the follow- ing week the number of demonstrated cases increased to 58, No single secondary case occurred after the accepted incubation period. This outbreak and the control measures employed demonstrated clearly the potentialities associated with the introduction of typhus into a susceptible civilian community, and the results to be expected from prompt inauguration of modern control methods. Moselle and Nahe River Area*—This part of the Rhineland was occupied by the third U* S* Army* It was much less affected by typhus fever than other parts of the province* A small group of outbreaks involved twelve towns and included 69 patients* The first localized epidemic was not discovered until 23 March 1945, long after the larger outbreaks to the north had come to light*. Ten new localities with typhus present were discovered in April and none in May* Eight scattered cases in May occurred in three towns originally recognized in April as being infected* Palatinate Area*--The first typhus fever in this Seventh U* S* Army area was determined during the early part of April* During the remainder of the month six communities were invaded and the number of cases was eighteen* May saw only one newly invaded town and a total of five cases in the area* Alsace and Lorraine,--Although not included in the iihine- land, it is worthy of note that typhus did not occur in Alsace and Lorraine, this being territory occupied by the First French Army0 Few imported Eastern European foreign workers had been brought into the area by the Germanso General Course of the Rhineland Epidemic*—In inter- preting data on. the progress of the epidemic, -the number of patients involved and the communities that were invaded, it is es- sential to understand the sources of reports* The chaotic conditions 29 in Germany had led to a complete breakdown in the official system for reporting communicable disease* A method extemporized by United States Military Government detachments in cities was the principal source of information for German civilian populations. This procedure gradually became formalized, but reporting from towns was always much better than from rural districts. Reports of typhus fever in displaced person camps were forwarded through the Displaced Persons branch of Military Government. Many cases were reported through Army sources. The best available data in relation to recognized outbreaks in what- ever population they occurred came from the special Typhus Case Finding teams attached to Armies • It was necessary to have been on the ground to appreciate the difficult conditions under which these data were gathered. Attempt was regularly made to check their reliability through a second source and as far as reported cases go, the numbers are believed to be reasonably accurate. Undoubtedly a goodly number of infections with typhus fever were never recognized as such, and others never came to report. The first patient with typhus fever was recognized on 3 March 1945, although the illness antedated that time. During the first month of active operations in the Rhineland, March 1945, no less than 23 towns, cities or villages were found invaded by typhus. (Figure 5). It most instances frank typhus fever was present when the community was occupied by American soldiers . The patients commonly represented an accumulation of typhus fever infections over the previous six weeks. Many were convalescent. Others were of recent origin and some developed the disease within an accepted incubation period after the American forces took over. Some few true secondary infections occurred. A lesser number (8) of invaded communities represented fresh outbreaks of typhus fever that developed after American occupation. These situations arose principally during the latter days of March and represented centers of the disease established by the migration of persons, ill or incubating the infection, from localities where typhus had been epidemic. In two instances, the outbreaks were fairly sizeable, those at Hermulheim and at Neuss. During March records were obtained of 560 patients with typhus fever- In some few instances these referred to old cases, with the patient no longer infectious and discharged from medical care. The great bulk were still in hospital, had developed the disease prior to the arrival of American troops, and were in various stages of convalescence. The available information was insuf- ficient to determine precisely how many patients had developed the disease before arrival of United States troops and how many first presented symptoms thereafter. It is furthermore impossible to know what proportion of new infections developed within an accepted 30 Figure 5, Typhus fever in the Rhineland, cases and localities, March to June 194$. incubation period and what proportion represented true secondary- infections. Nevertheless, an estimate of about 150 new■infections within the Rhineland in March after occupation by American forces would be fairly close to fact. During April the number of localities from which typhus fever was reported was greater by three than for March, the number being 26. It is significant, however, that no further cases developed in April in 19 of the communities from which typhus was reported in March. That only four had further cases in April indicates a most satisfactory performance in control. It is by no means certain that the patients in the four communities continuing to report typhus fever in April were definitely related to the original outbreak. Particularly in the larger cities, persons were continually entering from across the Rhine as well as from other parts of the Rhineland. The apparent continued presence of typhus fever in these instances may very well have resulted from reintroduction of the disease, rather than from secondary infection arising from previously existing cases. In the Rhineland as a whole, 22 fresh outbreaks were dis- covered during the month of April, They appear to have developed most often through migration of persons from previously infected communities of the Rhineland, particularly Cologne. Some few out- breaks were known to have arisen from persons in the incubation period of typhus fever who crossed the Rhine and later developed the disease in the Rhineland. The total number of cases discovered in the Rhineland in April was 91; of which 24 were related to existing centers of infection of the previous month and 67 were associated with newly developing outbreaks . The month of May in turn showed a distinct improvement over April. The number of communities with typhus fever was only thirteen. Of the 26 localities were typhus had occurred in April, 18 had no cases during May, and eight communities had a limited number of secondary infections, five of them large cities. Only three new centers of infection were recognized. Two of the communities reporting typhus in May had previously had cases in March but none in April. The course of events remained undetermined. It was not possible to ascertain whether the circumstances corresponded to a reintroduction of the disease or a continued chain of infection with an intervening missed case. Total typhus infections in the Rhineland in May numbered 37. Twenty-six came, from foci established in previous months, eleven from newly developing outbreaks , The five cases that occurred in June were all single cases in separate localities, four previously invaded and one new. Information is presented in Table 6 31 for infected communities, together with the distribution of cases during the four months of the epidemic • The number of recognized cases of typhus fever was 693. About 400 were present when American troops entered the region, and represented the accumulation from February. The number of new cases in March was about 150 which decreased to 91 in April, 37 in May and 5 in June. The end of March found the possibility of further extension virtually eliminated. No more than a reasonable endemic level characterized the month of April, and the first of June found the region practically free from the disease. (Figure 6). Typhus Fever by Population Groups.--No camps of Allied prisoners of war were found in the Rhineland. Prisoners previously held there by the Germans had been evacuated across the Rhine, This group consequently does not enter into a consideration of typhus in the Rhineland. Among the many German prisoners of war captured in the Rhineland only three contracted typhus fever during the period March to May. Recently captured prisoners were usually found free of lice; they were maintained so by repeated dusting with DDT powder. Relatively few had been vaccinated in the course of their military service, and they were not vaccinated when taken. Their freedom from typhus suggests the greater relative importance in typhus control of assuring freedom from lice as compared with specific immunization. In general prisoners lived under no better conditions than the displaced persons. Figure 7, The native German civilian population suffered far less from typhus infection than did the group of displaced persons . The population of the Rhineland, including the Saarland and Palatinate, was about fifteen times the estimated population of displaced persons in the region, a number placed at about 500,000. Nevertheless only about one-third of total infections were estimated to have occurred among the native population. About two-thirds of the cases, some 400, were among displaced persons . Louse infestation was far more frequent than in the native population. Living quarters were more crowded and less provision existed for adequate sanitation and cleanliness . During the Rhineland experience only two American soldiers developed typhus fever. Both were physicians engaged in typhus control. In one instance the prescribed reimmunization had not been practiced. Fourteen months had elapsed between the last immunization and the appearance of the disease. The infection was mild. The second patient was so mildly ill that recognition of the disease as typhus fever almost escaped attention. He had been vaccinated within three weeks of becoming ill, was never sufficiently 32 Progression of typhus fever in the Rhineland, cases and localities, March to June 1945. •<= ONE CASE JURE IMS S CASES MAY ISAS 37 CASES Figure 6 APRIL IMS tl CASES MARCH IMS SCO CASES Figure 7 Delousing in a prisoner of war enclosure is performed by Nazi prisoners, Stenay, France, March 1945. indisposed to enter hospital and spent only three days in quarters. Lack of prompt recovery led to the suspicion of typhus and the Weil Felix test was found strongly positive. Case Fatality.—Accurate records on the number of deaths among 693 patients were not obtainable. Information was available for 388 patients, of whom 61 were known to have died, a case fatality rate of 16 percent. Striking differences were observed between the case fatality of native Germans and that of displaced persons, largely of eastern European origin. Twenty one of a group of 60 German patients died, to give a case fatality of 35 percent. Only 5 deaths occurred among 143 patients from the displaced persons group, a case fatality of 3 percent. Summary. —-Within the Rhine Province proper and the contiguous German territory west of the Rhine, the Saarland and the Palatinate, about 400 cases of epidemic louse borne typhus fever occurred in the months immediately preceding the entrance of U, S. Forces, or within the first few days of occupation. The region from North to South was heavily seeded with infection. The potentialities for spread were great. The whole area seethed with foreign people, conscripted laborers moving this way and that and in all directions, hoping to reach their homes, in search of food, seeking shelter. Most of the typhus was within this group and they carried the disease with them. They moved along highways and in country lanes--now a dozen Roumanians pulling a cart loaded with their remaining belongings! here a little band of Frenchmen working their way toward France, then some Netherlanders, or perhaps Belgians; and everywhere, the varied nationalities of the East, Ukrainians, Poles, Czechs, Russians. They moved mostly on foot, halted, then gathered in great camps of sometimes 15,000 or more, extemporized, of primitive sanitation, crowded, and with all too little sense of order or cleanliness. These were the people with typhus, the carriers of the virus, the fuel for epidemics; more than a half million of them in the Rhineland, wearied with the war, undernourished, poorly clothed and long inured to sanitary underprivilege and low level hygiene. Add to this shifting population the hundreds of released political prisoners, often heavily infested with typhus but happily far fewer in numbers; the German refugees, first moving ahead of our troops and then sifting back‘to their homes through the American lines . Rarely if ever has a situation existed do conducive to the spread of typhus. Figure 8. Typhus fever in s stable population is bad enough. It has demonstrated its potentialities in both war and peace. The Rhineland in those days of March 1945 could scarcely be believed by those who saw it—it is beyond the appreciation of those who did 33 not. Here were the Four Horseman riding abreast, on the move, with the third well in the lead. It was Wild West, the hordes of Genghis Khan, Klondike gold rush and Napoleon’s retreat from Moscow all rolled up into one. Such was the typhus problem in the Rhineland. Recovering from the Battle of the Bulge at Bastogne, the American troops moved forward and towards the Rhineland on 23 February 1945. The first typhus was discovered in Aachen on 3 March 1945. In quick succession two major centers of infection came to light, one of them spread over a considerable area. At no time thereafter did typhus fever increase in numbers, despite rapidly deteriorating sanitary conditions and factors conducive to its* spread. The end of March saw the situation safely under control. April had almost no cases in comparison with March— one sixteenth the number--while May ended with 29 cases reported for the month and the disease essentially absent. Only two localized epidemics of any size occurred after American occupation, one in Hermulheim and the other in Neuss. both were toward the end of March, about two weeks after the country was overrun, and they resulted from the widespread and rapid dispersal of typhus infested persons . As sharply developing and extensive as these outbreaks were, one was curbed without a single secondary case. The other was limited to the first wave of cases, a few scattered secondary infections, and the third wave consisted of no more than one case. A number of factors contributed to this favorable result. The newly developed methods of typhus control proved their worth, wherein reliance was placed on delousing by dusting with DDT powder and on specific immunization with typhus vaccine. .The conclusions arising from the previous single test to which these procedures have been put in the Naples outbreak of 1944, were here justified, extended and confirmed. The time of the year when the Rhineland situation pre- sented was of itself a favoring oircumstance. Had the timing of military operations in the Rhineland been a feature of December rather than of March, the typhus problem would have been far greater and perhaps much more serious. It might well have occurred at that time, except for von Rundstedt and his Ardennes counter offensive. Finally, the careful planning which had carried through all echelons, led to an informed medical department more than adequately supplied with all the things it needed, and ready for prompt action. From both a military and an epidemiological standpoint, the prompt limitation of typhus in the Rhineland was of far reaching significance. Militarily it permitted unhampered preparation for the assault on the Rhine and the final campaign within German proper. There was no loss of manpower, since only two American 34 Figure 8 A Polish woman is dusted with DDT powder at a displaced person's camp at Heidelberg, Germany, June 1945, soldiers contracted the disease, both physicians closely engaged in typhus control. The armies were free of the need to provide medical care for large numbers of civilians ill with the disease. Epidemiologically, a large territory was provided essentially free of typhus and fronted by a strong natural barrier upon which to base a cordon sanitaire. This also was significantly important. The inner ,Reich was known to be more heavily seeded with typhus than the Rhineland. The conditions favoring the spread of the disease would be even more pronounced in the final debacle of Germany. The two great advantages arising from such a cordon sanitaire were first, that it would aid greatly in limiting the extension of typhus into neighboring states and into Great Britain, where supply bases were located. Secondly, it made possible a safe and close base for military and typhus fever control operations within the Reich itself. The practical working of a cordon sanitaire depends upon the presence of a strong natural boundary separating a clean from a contaminated area. These conditions were now provided. The clean area existed, the boundary was stronger than ever by reason of the blown bridges. The necessary orders were issued establishing a cordon sanitaire along the oast bank of the Rhine, to go into effect progressively as territory was acquired. Travel other than military had from the beginning been prohibited at our single Remagen bridgehead, as much for military and security reasons as from epidemiologic considerations. The number of ports of entry was limited. Provision was made for universal delousing of all persons other than military before the cordon was passed, whether by foot, by vehicle or by air. The more serious problem of typhus in the Inner Reich was now faced with greater assurance. Typhus in the Inner Reich,-~The Remagen bridgehead came into American hands on 7 March 1945, As it gradually expanded through addition of territory the existing opinion that typhus would be a serious problem became more and more justified. Typhus was found in a great many of the cities, towns and villages along the east bank of the Rhine, in Dusseldorf, Mulheim, Remagen and Duisberg; sometimes a few cases only, sometimes as many as ' sixty. Rumors, informal reports and sometimes just plain conjecture brought word of 300 patients with typhus in Seigburg, just ahead of the First Army; and of the conditions in the great concentration camps at Buchenwald, Dachau and Belsen. The great assault of the Rhine got under way on 24 March, the British 21st Army Group and the U, S, Ninth Army to the north. 35 the First and Third Armies in the center, and somewhat later the II* So Seventh Army and the First French Army to the All found typhus fever; the British scarcely any, the Ninth some, the First and Third a great deal, while in the south the Ho So Seventh and the First French Armies again encountered relatively littlec The first really serious situation arrived when Buchenwald concentration camp was occupied by the Third Army on April 12th» The British soon uncovered Belsen camp, with still more typhus and misery® Then followed in order Dachau, Flossenberg and finally Mauthausen, all with hundreds of cases of typhus fever and sometimes thousands 0 These concentration camps with their political prisoners and their typhus fever would have been problem enough® Added to the situation were millions of conscripted laborers suddenly released from employment and from camps that were many times typhus infested. They scattered throughout the country. They were gathered in large improvised camps. They spread typhus widely. German prisoners of war increased by thousands ® Changing policy held them in Germany and the huge aggregations in temporary camps and enclosures gave fertile opportunity for the breeding of typhuso Thousands of native German civilians had evacuated their homes in the early stages of operation and preceded to Inner Germany ahead of their retreating troops . The end of the war was complicated by their return. Finally came the release of many thousands of German prisoners of war to return to their homes, — agricultural workers, certain trade specialists and the older men of the Wehrmachto Germany in the spring months of April and May was an astounding sight, a mixture of humanity travelling this way and that, homeless, often hungry and carrying typhus with them. Succeeding parts of this discussion will deal in turn with the progression of the epidemic through the weeks of the Spring of 1945; the outbreaks in the more important centers, particularly the concentration camps; the extent to which typhus was imported into neighboring countries; and finally the incidence of typhus in the United States Army itself. Geographical Limits of the Inner Reich.—For the purpose of this analysis the Inner keich will be understood to include that part of Germany east of the Rhine and north of Switzerland which fell under the influence of the United States Army. It included not only a major part of Germany but the westernmost part of Czechoslovakia, the Sudentenland, and the greater part of Austria. Figures 9, 10 and 11 illustrate the area concerned. 36 Figure 9. Typhus fever in the Inner Reich, cases and localities, during week ending 20 April 194-5* Figure 10* lyphus fever in the Inner Reich, cases and localities, during week ending 1 June 1945. Figure 11. lyphus fever in the Inner Reich, cases and localities, during week ending 29 June 1945. Limited information will be presented on typhus in- the British zone of influence, based on reports from the Twenty-First Army Group, but the data presented on numbers of cases and the description of control measures refer only to activities in the American zone. Typhus in Russian held areas is likewise excluded from considerationo General Course of the Epidemic in the Inner Reich.y-The typhus KjDidemic in the Inner keich in the Spring of 1945 was no orderly developing process, with a sharp increase to epidemic proportions and a progressive but more slowly ordered decline. The cases reported in a given week represented not so much the progression of the disease as the progression of the armies . The more territory that was uncovered, the greater was the number of reported cases, for Western Germany in the area of the American advance was rather uniformly seeded with typhus. To be sure, there were heavily involved communities and others lightly affected. There were great accumulations of cases in the concen- tration and prison camps, and in nearby small communities. New cases occurred during the time covered by this analysis, which is 24 March to 29 June 1945. Sometimes they reached considerable numbers, but the great fluctuations from week to week corresponded much more to the discovery of the disease than to its actual occurrence. Reporting of typhus fever during the advance through inner Germany proper was even more disorganized and irregular than it had been in the Rhineland. In the beginning no attempt was made to separate cases that developed during the period of report from those convalescent or actually closed. A new com- munity would be uncovered, with typhus promptly discovered. The patients ordinarily included those acutely ill, those convalescing, and some who had recently recovered. Actual records of onset were commonly lacking and about all that could be done was to count noses • Eventually a certain separation became possible for patients in newly uncovered localities, as to whether they repre- sented active infections—to include both acute and convalescent oases—or whether they were cases of record which had been closed at the time the area was occupied. The number of new oases reported from so-called old localities,—those recognized as foci of infection in previous weeks—was likewise inexact. Many were not newly developing infections at all, much less secondary infections, but newly discovered infections existing prior to occupation and not coming to light until days and sometimes weeks later, as an orderly sorting of the sick from the well became possible in concentration camps. The experience at Dachau is illustrative and is described in a later section. 37 Not until late May and early June, not until the last great concentration camp came under American control, did weekly reports of typhus give indication of the true course of the epidemic—and that course was one of satisfactory and progressive improvement. The first week in June showed far fewer cases than the last two weeks of May, 427 compared with weekly numbers of 1961 and 1502* The end of June saw the number of newly reported oases from all localities, old and new, reach a level of 75. Table 7 gives four kinds of information by weeks from 24 March 1946 to 29 June 1945 inclusive. The number of cases of typhus reported from localities not previously known to harbor the disease is divided according to active cases found at the time of investigation; and cases of record, the patients having recovered or died. The number of newly reported cases—not necessarily newly developing oases—that occurred in old recognized typhus infected communities is presented in Column 4 of the table. Total cases represents oases by week of report, irre- spective of date of onset. Finally the number of communities known to be typhus infected during a given week was subdivided according to whether typhus was recognized for the first time that week or had existed in the community previously. For the week ending 24 March 1945, typhus was reported from only one locality, the town of Koenigswinter in the Remagen bridge- head. The eleven patients were all foreign forced laborers. (Table 7.) No typhus was recognized during the week ending 31 March. In the week of 7 April, 42 cases were reported from eight newly captured localities. The succeeding week 71 came from nine other places, 52 of them from the Buchenwald concentration camp, which was the first large infected camp to be uncovered by American forces . During the week of 21 April twelve new cases were reported from two localities which had previously had typhus. In addition, the number of newly recognized cases was markedly increased by dis- covery of 873 cases in 25 new localities. The majority (777) were from the large prison camp at Siegburg. For the week ending 28 April 337 cases were found in 29 new places, while 7 old localities reported 25 new cases. ' Two large epidemics were included, the prisoner of war camp at Nurnburg accounting for 134 patients (all Russians) while Guderselben in the Nordhausen area had 45. The numbers continued to be great in the week ending 4 May; 848 typhus patients were discovered in 52 newly conquered communities. Two hundred were in the hospital of the labor camp at Flossenburg, and 357 in the camp hospital at Dachau. Typhus was re- ported from more now places (52) during this week than in any other week of the epidemic period; and an additional 178 new cases occurred in 13 old localities. 38 For the next week, that of 11 May, 451 oases were discovered in 41 new localities, of which 246 were in the Mauthausen concentration camp. The number of new oases reported from 20 old fooi of infection was 1175, of which 822 were from Dachau alone, and represented not so much newly developing as newly recognized oases* During the three weeks ending respectively 18 May, 25 May and 1 June, many more active oases were discovered in new localities. This was largely the result of the work of case finding teams, which with the cessation of hostilities and a return of the area to more settled conditions were able to survey the region with care, going into new areas and discovering new fooi which had been missed during the rapid advance of the armies. The majority of the new oases found in old localities during this time were from the Dachau camp, where many patients with illness of unde- termined nature were ultimately recognized as infected with typhus fever. The month of June showed a progressive and well marked improvement, to such an extent that only 75 oases were reported for the last week of that month. The number of secondary oases was almost negligible, considering the size of the epidemic in the preceding month. The disease was quickly snuffed out in the newly infected communities where it was found. The epidemic was at an end • Scattered cases were recognized in July, 64 in all; and a few in August, 32. Subsequent events showed that typhus in Germany had been brought under complete control, for during the winter of 1945-1946 no more than a reasonable endemic incidence prevailed. The epidemic of typhus fever within American occupied territory included 16506 patients. The outbreak within the Inner Reich accounted for 15810 of that number. Typhus was recognized in 518 localities of the Inner Reich and about 11,000 active oases in an acute or convalescent stage of the disease were observed during the three months of the epidemic. Special Epidemiological Problems .—The more important of the outbreaks in camps andprisons are now presented in some detail. Collectively, they constituted the great bulk of typhus infection in Germany. Daohau concentration camp »\-The Daohau camp, located in Bavaria \bout 5 kilometers north was one of the largest and certainly one of the most notorious of the Nazi installations housing political prisoners. It was liberated by units of the U, S. Seventh Army on 1 May 1945. (Figure 12). 39 An estimated 35,000 to 40,000 prisoners were found in the camp, living under conditions unusually bad even for a German camp of this kind and probably worse than any other that came into American hands. Extreme filthiness, louse infsstation and over- crowding prevailed throughout the camp buildings. Several carloads of human bodies were found packed in box oars in the railroad yards adjacent to the camp, the vestiges of a shipment of prisoners from camps farther north who were transferred to Dachau in the late days of the war to escape the advancing United States troops , (Figure 13). The number of patients in the camps with typhus fever at the time it was first occupied will never be known. Days passed before a census of patients could be accomplished. Several hundreds were found in the prison hospital, but their number was small compared with the patients who continued to live with their comrades in the camp barracks, bedridden and unattended, lying in bunks four tiers high with two and sometimes three men to a narrow shelf-like bed; the sick and the well; crowded beyond all description; reeking with filth and neglect - and everywhere the smell of death. During the first few days little more could be done with the limited staff that was available than make the rounds of the barracks, pulling out the dead and the dying. Although some hundreds of patients were in the camp hospital with typhus fever on 1 May when the camp was first taken, large numbers died and many were added before the first census of patients was made on 3 May. At that time the hospital population was 297 . In the course of the next week this number was increased by 822. For the week ending 18 May, 1,253 additional cases were recognized, and the greatest number (1,343) came during the week ending 25 May. For the week of 1 June 1945, 277 new infections came to record and as of 1 June 1945, 1,580 patients were under treat- ment in the several hospitals associated with the camp. The daily distribution of oases is presented in Figure 14. The record is not by day of onset but sets forth the number of patients recognized on a given day as having clinical symptoms of typhus or being in the convalescent stage of that disease. In many instances the onset was days before, and not uncommonly weeks. This was particularly true of cases recorded in the second and third week of the experience • The records of the first week include two principal groups, patients found in barracks so severely ill with acute and apparent typhus as to be transferred to hospital, and a lesser number reporting ill for the first time and sent to the camp dispensary with early typhus. Thereafter, a thorough search was 40 Figure 12 Bodies found in a crematory room when Dachau Concentration Camp was liberated by the Seventh Army. Many had di«d of typhus. May 1945. Figure 13 Box cars filled with bodies of prisoners who died en route to Dachau were found at Seeshaupt, Germany by the Seventh Army, May 1945. JUNE 1445 Figure 14 Typhus fever admissions, Dachau Concentration Camp, Germany, 4 May to 9 June 1945. made barrack by barrack for all patients with typhus , As a result, reported cases increased strikingly,, The experience of 23 May is illustrative. After a number of days when the number of newly recognized cases ranged from 100 to 150, there was a sudden rise to 700o On this particular day a group of some 600 patients previously under observation in the inner camp hospital and carried as typhus suspects were officially notified as typhus fever. Available records failed to demonstrate how many of the 4,032 patients of the Dachau epidemic were actually ill with typhus at the time the camp came under American jurisdiction, how many developed the disease within the succeeding 14 day incubation period, and how many represented true secondary infections after American responsibility came into play. The relatively small numbers reported in the last days of May, and the essential dis- appearance of the disease in June would suggest that secondary infections were held to a very satisfactory level. Certainly the majority were either ill at the time the camp was taken over or were within the inoubationary stage of the disease. Even the appreciable figures cited fail to include all who contracted typhus fever in Dachau concentration camp. Freed from the sort of existence they had been living, it was no wonder that those strong enough should attempt to escape. Many of the prisoners did so, and scattered widely through the nearby country, especially to the region south of Munich, Some were actually in the clinical stages of typhus fever and many were incubating the disease. They were later found with typhus fever in other areas . The epidemiologic significance of such movements of prisoners and displaced persons will be discussed subsequently. An energetic program of control was instituted at Dachau by the Surgeon of the Seventh U, S, Army, The camp was promptly quarantined. Hospitals were moved in to augment the small prison hospital in the care of patients , A consultant of the United States of America Typhus Fever Commission spent ten days at the camp. Case finding teams from the Office of the Chief Surgeon aided in the early control work through survey of the surrounding area for former inmates developing typhus after leaving. The dusting of prisoners with DDT powder was started 3 May 1945 and completed 8 May, Three officers and six enlisted men equipped with two power dusters, twenty hand dusters and three hundred pounds of powder were made available for the work. One power duster was set up in a central position within the prison compounds, and all ambulatory prisoners were passed through this dusting station. The other power duster, supplemented by hand dusters, was used in the prison hospital and in blocks of barracks t© assure that all patients with typhus were freed of lice. Prisoners, supervised by Amy personnel, quickly mastered the technic 41 and were used liberally in dusting operations . In the course of the five day period, 36,045 persons were dusted and 2,500 pounds of DDT powder was used. A dusting station, operated by prison labor and supervised by an enlisted man, was set up at the gate of the compound and no one - visitor, physician or attendant - was allowed to leave the enclosure without first being dusted. Immunization of prisoners against typhus fever was put into force as soon as conditions permitted. The primary emphasis was on delousing. In respect to case fatality, data are available for 2,336 cases reported up to 1 June. The number of patients who died was 311, and the case fatality rate was 8.3. Of all the centers of infection encountered in this generalized outbreak in Germany, Dachau was easily the most extensive; and because of the deplorable conditions under which control measures were instituted, it was easily the most difficult to control and the most serious in its epidemiologic portent. Typhus in the Nordhausen Area. This part of Central Germany near Leipzig was captured by the First U. S. Army in mid April 1945. The region contained several forced labor camps, two of which had typhus patients at the time they were captured by American troops . Fifty one (51) patients were in the Gudersleben camp which housed 560 workers. They had received excellent attention from two Russian doctors and a staff of Russian nurses who were among the prisoners. No deaths occurred and by 2 May, 18 had been discharged from the hospital. The entire camp personnel was dusted with DDT powder on 17 April. Nine new cases were reported 2 May. It is probable that some were incubating the disease at the time they were disin- fested , Five other confirmed cases of typhus in the Nordhausen area were discovered in the hospital at Camp Dora where they were being treated for typhoid fever by a German civilian doctor. Four (4) ' were conscript laborers and the fifth was a nurse at the hospital. Inmates of the camp and the staff of the hospital were deloused and as of the end of May, no further cases had been reported. Typhus in Siegberg Prison.—The Siegberg Prison was on the east bank of the Rhine near Bonn, Germany. It was liberated by elements of the First. IT. S. Army on 20 April 1945. Living quarters in the camp were bad and most of the prisoners were infested with lice. A hot bed of typhus was present, with no less than 777 patients with the disease. More than 1,000 cases were said to have occurred since January 1945, with about 290 deaths. Control measures were immediately put into force by Army personnel augmented by prison help. Isolation of patients, dusting of the entire prison personnel and vaccination of the hospital workers 42 were the measures usedo UVrenty-five (25) new cases appeared as of 4 May 1945 and eleven between that time and 18 May0 Precise in- formation as to the numbers that occurred from 18 May to 1 June is lacking* except for the statement that the disease rapidly disappearedo \ at Buchenwald Concentration C amp Buchenwald camp was itScated in Central " Germany near Weimar-«md was liberated by troops of the Third Uo So Army on 10 April 19450 It had long had the reputation of one of the most notorious of the German concentration campso About 25<,000 men from almost every country in Europe were housed at the camp® Fifty two patients with typhus were isolated in a separate ward of the camp hospital at the time the camp was occupied*, They were of -various ages and their nationalities were as follows s 21 Polish 13 Russians 6 Germans 3 French 1 Czechoslovakian 1 Belgian * 1 Hungarian 1 Lithuanian According to the German medical officer at the concen- tration campp typhus had occurred in epidemic proportions twice during the past winter with some several hundred cases in allc The present hospital population was the residue from those epidemics Typhus in Buchenwald was said to have originated from patients brought into the camp from other prisons in Germany0 The insanitary and crowded living quarters naturally contributed to the spread of the disease among the permanent residents0 The case fatality rate at Buchenwald was 25 percent and measurably higher among western Europeans than for Russians and Poles0 The first members of the medical department of the Third Uo So Army who entered the camp started an intensive typhus con- trol program which was continued by the First Uo So Army when it took overo Figure 150 Twenty dusting teams were organized and the entire personnel of the camp was deloused with DDT powder0 Living quarters were thoroughly cleaneds and clothing and bedding were disinfested by steam or gas0 The hospital staff of about 150 doctors and attendants were immunized against typhuso Typhus at Flos sen berg Concentration near Weiden* Germany on the Czechoslovakian 'border, the camp formerly housed conscript laborers employed at the assembly center of a Messersohmidt aircraft factory0 It was liberated by the 43 Third Army late in April 1945. The camp population included Poles, Roumanians, Czechs, Yugoslavs, French and Bulgarians, in about that order of numerical importance. Just prior to the allied occupation the Germans had evacuated all except 1,600 workers, leaving behind only the sick, the injured and the non-transportables. The prisoners were started on a march to Dachau. The original cblumn of about 14,000 reached Cham, some 80 kilometers away, with a strength of only, 6,000. Some became ill and died along the way, a number presumably of typhus fever. The majority scattered along the route of the march, with the result that typhus subsequently broke out in a large number of small communities. The area gave rise to one of the most serious epidemiologic problems anywhere in Germany. Figure 16. Typhus had not occurred in Flossenberg until September 1944, when a number of workers sent from the Cologne area became ill shortly after arrival. By 15 October, 82 cases of typhus were determined on clinical evidence, with 26 having a Weil Felix agglutinin titer at serum dilutions of 1/1200 or more. A diagnosis of typhus was not permitted by the Sohutz Staffel doctor in command, and isolation of the patients was not practiced. The accepted diagnosis was of grippe but physicians continued to submit requests for Weil Felix examinations. With a change of SS supervisors in February 1945, the diagnosis of typhus was permitted and patients with the disease were transferred to a single ward block staffed with immune personnel. The height of the epidemic came in February. Beginning about the first of that month, a general movement of workers from camp to camp within Germany came into common practice with frequent exchanges of prisoners between Dachau, Buohenwald and other camps including Flossenberg. This undoubtedly served to enhance trans- mission of typhus generally. The incidence and mortality in the various population groups of the Flossenberg camp during the period 14 February to 1 May 1945 is shown in Figure 17. At the time of the American occupation, 200 patients were in the prison hospital with typhus, most of them convalescent and properly isolated in separate wards. Typhus control measures had been undertaken by the Germans before the arrival of American troops, and new oases were at a minimum. The measures that had been employed were disinfestation of clothing, block isolation of patients, camp quarantine and tjie use of immune medical personnel to care for patients. Additional measures initiated by the united States Army included the selective administration of typhus vaccine and the delousing of all inmates and attendants. Since the greater part of the camp population had been removed and many of those remaining had already had typhus, the control of the disease was comparatively simple. Only 69 typhus 44 Figure 15 Two dying prisoners lie among hundreds of dead on a barracks floor. Concentration camp at Wiemar, Germany, May 1945. Figure 16 Flossenberg Concentration Camp was liberated by the 97th Infantry Division, Germany, May 1945. Figure 17. lyphus fever, Flossenberg Concentration Camp, cases and deaths, by nationality, 14 February to 1 May 1945. fever patients were under treatment at the hospital on 14 May, of whom 36 were convalescent % the 1st of June only a handful remainedo Typhus in the Mauthausen Camp©“>-Ihe Mauthausen concentra- tion camp was liberated by units of1' tEe Third Uo Sc Army on 5 May 1945o Because of early reports of great numbers of patients with typhus, the Third Army Typhus Case Finding team followed close on the forward elements who took the installation, and indeed arrived shortly after it was overrun© Mauthausen, with two smaller adjacent camps, was located on the north bank of the Danube River near Linz, Austria* The total population of the three camps was approximately 28,000, of whom 3,000 were Jewish women from many countries of Europe© Living quarters were crowded and unsanitary, and louse infestation was unusually prevalent throughout the camp areas© Figure 180 A case finding study revealed 246 definite cases of typhus and 30 others with fever and suspected of typhusj 134 were males and 112 were females© Xhe exceedingly high rate for females was the result of unusually crowded living quarters, and failure to isolate women with typhus although the men had been segregated in a fashion in a corner of the camp hospital© The majority of the patients were Russians, Poles and Czechs© Epidemiological enquiry showed that during the previous winter as many as 600 cases of typhus had been present in the camp at one time, the disease having originally been introduced by a Russian prisoner of war in 1942© Since that time typhus had been present in epidemic proportions every winter© Typhus continued to be a problem in this camp for the next month© The control program was effective in reducing the incidence of the disease, but new infection was repeatedly intro- duced by displaced persons and it was evident that a number had escaped the initial delousing, because frankly secondary cases occurred© Nevertheless, on 1 June 1945 only 70 patients remained in the hospital© Typhus in the Li berated Countries fever began to be reported with increasing frequency in"the liberated countries of Western Europe during April© Nearly all of the infections were related to repatriated persons who had returned to their homes from labor and prison camps in Germany© Despite the number of potential sources of infection that were set up in France, Belgium and the Netherlands, only a few confirmed secondary cases were reported© The season of the year was a favoring circumstance and the louse population in the countries to which they returned was low© From 45 political and patriotic motives, prisoners were often returned in violation of the required quarantine period, and in too many instances before they were properly deloused* (Figure 19) Typhus fever was reported in France to the number of 276 cases as of 30 June 1945o Table 8. Denmark had 15 cases, Belgium 136 and 49 occurred in Holland, all in countries previously free from the disease* The number in June was nearly half that for May because of the general subsidence of the epidemic* When by accident or by force of politics, some relatively few unprocessed individuals were introduced into the country of origin, typhus promptly followed; a circumstance which demonstrates the material protection afforded the other countries of Europe by the cordon sanitaire, the mass delousing and the other control measures which were put into effect in Germany* Typhus Among German Prisoners of War* —The first confirmed typhus fever to appear among German prisoners of war was in March 1945* A large proportion of recently taken prisoners were found infested with lice, and very few had been vaccinated against typhus fever* Theoretically the conditions favored sizeable outbreaks, but because of the strict control under which prisoners were held, preventive measures were more than usually effective* The following brief account of typhus fever in a prisoner of war enclosure is in illustrations* EPIDEMIOLOGIC CASE REPORT NO. 1* Two confirmed cases of typhus *rere reported in two different prisoner of war en closures >n the Remagen area early in April* The enclosures housed thousands of prisoners* One alone had 183,000 and the crowded conditions were decidely conducive to the spread of typhus. By application of strict quarantine, isolation of patients and mass delousing a major outbreak was averted* In fact no confirmed secondary case occurred in either camp* A total of 90 recognized infections of typhus fever was reported among German prisoners of war during the three months under consideration; three in March, 21 in April, and 66 in May* The increasing numbers of prisoners that were taken as the war drew to a close, and did not represent an increase in rates* No frank outbreak of typhus fever occurred in any of the prisoner or war camps* Typhus Among Recovered Allied Military Personnel (RAMP)—Only two confirmed cases of typhus occurred among recovered American prisoners of war* Brief case histories follow* ♦ EPIDEMIOLOGIC CASE REPORT NO* 2* A major of the Medical Corps was captured 20 December 1944 and imprisoned in Stalag 12A Limburg, Germany on 2 January 1945* He served as physician to the prison illustrations j 46 Figure 18 An infirmary at a Nazi concentration camp, Linz, Austria, May 1945. Figure 19 Liberated French and Belgiums wait for transportation to a displaced persons camp. Delousing is required before crossing the Rhine River (the Cordon Sanitaire)• Cologne, Germany, April 1945. infirmary until 1 April 1945 when he was liberated* He was well until 13 April when he was admitted to the 61st General Hospital with fever, an eruption of the skin and malaise* The clinical reaction was typical of mild typhus, and on 21 April that diagnosis was confirmed by a positive Weil Felix test in serum dilution of 1/1280* In all pro- bability this officer contracted the disease while a pri- soner in Stalag 12A where typhus was presento The last typhus vaccination was in August, 19440 EPIDEMIOLOGIC CASE REPORT N0o 3„ An American enlisted man, held prisoner of war for some weeks, had been moved from one prison to another as the Germans tried to evade the advancing allied Armies* He stated that he was infested with lice most of the time* The patient became ill on 12 April with a low grade fever and a feeling of general malaise, but a rash of the body was not seen* The diagnosis of mild typhus fever was confirmed by a positive Weil Felix test in serum dilutiop of 1/320* Typhus occurred most commonly among Russian recovered prisoners of war and only in this group to an extent approaching truly epidemic proportions* When the large allied Prisoner of War camp at Numberg was uncovered in April, nearly all of the more than 300 patients with typhus were Russians* Russian prisoners of war recovered by American troops during the three month period April to June, included 382 with typhus* Typhus was not very common among the British and French prisoners of war who came into American hands; 15 British and 3 French as of the first of June* Typhus in the Russian Occupied Areas of Germany*—Knowledge of the extent to which typhus occurred in the Russian occupied area of Germany remained meager* No information was obtained from Russian liaison officers concerning those parts of Eastern Germany, Austria, and Czechoslovakia which came under Russian influence* Rumor had it that there were many thousands of cases* Certainly the refugees entering the American area from Eastern Germany frequently brought typhus with them* The disease had apparently been introduced into Germany originally in the early years of the war from Poland and Russia* Medical intelligence which generally proved very reliable had indicated that eastern Germany was more heavily infected than the western and southern parts of the country* It is thus logical to assume that there was even more typhus in the Russian area of occupied Germany than in the American Zone, al- though factual proof is lacking* Typhus in British Occupied Germany*—British responsibility was related to that part of Germany to the North and West* ‘ Formal reports of the typhus situation in that area are lacking but the 47 conditions were always fairly well known through personal visit of American Typhus control officers to 21st Army Group Headquarters and through exchange of information with the representative of the Ue So Ao typhus Commission who was attached to that organization® The total number of cases and the number of infected localities were much less than in the American Zone® The major out- break centered about the large concentration camp at Belsen an epidemie which ranked in size and importance with that at Dachau© The numjper of patients with typhus fever approached three thousande Other ‘tjfian Belsen, the cities and towns with typhus fever were said to numqer about ten and oases were few0 Typhus in U0 S0 Military Forces,"-Only three confirmed cases of typhus occurred among U« So troops serving in the European theatero Two infections were contracted in the Rhineland and one within the Inner Reich, All three patients had mild attacks of the disease, as indicated by the case histories* EPIDEMIOLOGIC CASE REPORT NO* 4* A captain of the Medical Corps investigated a typhus outbreak at Fischbach Germany on 23 March 1945, He was intimately exposed to the disease while examining and disinfesting patients but does not recall ever having found lice on his person. On 9 April he developed a macular rash. He was never delirious, stuporous or disoriented. His convalescence was rapid and uneventful, A Weil Felix test on 17 April was positive in a serum dilution of 1/640, The patient had not received a stimulating dose of typhus vaccine since the original course in April 1944, EPIDEMIOLOGIC CASE REPORT NO, 5, A lieutenant colonel. Medical Corps, accompanied the officer noted in Case Report No, 4 and both became ill on the same day. The illness in this instance was even less severe. The patient observed no rash at any time. He remained on quarters status during his illness and returned to duty 15 April, A stimulating dose of typhus vaccine had been administered on 23 March 1945, the day pre- vious to his exposure to the disease. The stimulation ante- dating that was in September 1944, EPIDEMIOLOGIC CASE REPORT NO, 6, A sergeant of the 15th Infantry became ill 4 April 1945 complaining of pains in the legs, headache and fever of 102°, He eas admitted to hospital and observed for several days. On 22 April he was transferred to a general hospital with the diagnosis still undetermined. The patient had daily chills with fever up to 104° for 11 days and at one time developed a slight rash on the wrists, ankles, and abdomen, A Weil Felix test performed 5 May was positive in dilution of 1/320, No likely source of infection could be determined and there was clinical difference of opinion as to the identity of the disease. 48 It is to be noted that 21 cases of typhus are contained in the Statistical Health Reports® A number are known to concern prisoners of war and not American soldiers® The cases cited in- clude all verified instances of typhus infection among American soldiers in Europe0 Control Measures ® —The general overall plan for the con- trol of typhus in Germany has been discussedo It is pertinent however to review briefly just how the plan unfolded and how it was put into effect in the control of typhus in the Inner Reich® The first consideration was to find promptly the many victims of typhus® Notwithstanding the rapid advance of the armies, a reasonably accurate account of typhus in each of the army areas was maintained, and reports were received without great delay® The forward divisional medical units of armies were on the alert to report typhus wherever it was encountered - in hospitals, prisoner of war camps, labor camps and prisons® Case Finding Teams® —The reports of existing disease were investigated by the special typhus Case Finding teams attached to armies® Eight such teams were furnished by the Office of the Chief Surgeon and the service was augmented by special teams organized by the Annies themselves® Each corps had at least one team® The Case Finding teams not only kept the Array Surgeon, and in turn the Chief Surgeon, informed about the incidence of typhus and the general regions where it was occurring, but they initiated typhus control measures of an immediate and urgent nature, subsequently turning over to the regularly constituted medical authorities of the unit occupying the area the responsibility of further and routine measures® Their primary function was that of medical scout® Insect Control Teams®—The most important single measure for the control of typhus was the delousing of typhus patients and contacts with DDT powder as soon as practicable® This was done by numerous specially constituted delousing teams equipped with both hand and power dusting equipment® The teams were made up of medi- cal department personnel of detachments, battalions and regiments® ftiey frequently made use of civilians who worked under their supervision® In large scale operations the delousing teams of Quartermaster Corps troops from Fumigation and Bath Units were of distinct aid® Several thousand persons were often deloused in a single day® Immunization® important control measure was the immunization of the immediate contacts of patients with Cox type typhus vaccine, a measure also employed routinely for medical personnel and hospital attendants of patients® In some instances entire populations of infected camps and other centers of infection were immunized® 49 Care of Patientso—Medical care for typhus patients origi- nating from the civilian and displaced persons groups was provided in German civilian hospitals© The prison hospitals of concentration camps were in large part staffed by doctors of the camps themselves© Uo So medical installations were sometimes used in emergencies© As the epidemic developed in Germany and Austria, the cardi- nal principles of the control program remained unchanged, but speci- fic applications became better defined and standardized© Modifications to fit specific circumstances were added, all of which are incorporated in the general scheme already discussed© Cordon sanitaire©—The surprise establishment of the first bridgehead across the Rhine at Remagen on 7 March 1945 required im- mediate action to prevent the spread of typhus westward from the in- ner Heicho Initially, a verbal agreement was effected with the First Army that civilians would be prohibited from crossing, pending estab- lishment of formal control by publication of the order for a cordon sanitaire© Similar agreements were made on 20 March with the Third and Ninth Armies© For all practical purposes a cordon sanitaire was now functioning, although it lacked official sanction by higher headquarters© A conference in Paris on 26 March attended by the field director of the Uo S© A© Typhus Commission and representatives of the Chief Surgeon, ETO, of the Surgeon 12th Army Group and from G-5, SHAEP approved the principle of establishing a cordon sanitaire and all agreed to support the informal arrangment pending an official order© The original plan for a cordon sanitaire prepared in 1943, served as the basis for a SHAEF directive of 31 March 1945 establish- ing a Sanitary Border extending from a point at the French-Swiss- German border, along the east side of the Rhine River to the Waal River, and thence along the north side of the Waal to the North Sea© All civilians and all liberated prisoners of war leaving Germany were to be deloused with DDT powder before crossing the boundary© The SHAEF order was followed 12 April 1945, by an order of the European Theater of Operations providing for specific ports of entry for passage from east to west to apply to all civilians and liberated prisoners of war© Guard stations were established at intermediate points to prevent illicit crossing© Transportation of passengers by river or canal boats was suspended© The French government agreed on 11 April to establish a cordon along the Swiss and Italian borders and to institute measures for the control of dis- placed persons arriving at seaports and by air© Delousing stations at ports of entry were located near bridges, usually in a displaced persons center© Military Police per- mitted civilians to cross only if their identification papers had the 50 necessary endorsement shewing recent disinfestation., Delousing stations were maintained at entraining points for civilians moving across the Rhine, by rail, and similar provision existed for air travel,, Figure 20o Ihe 820th Quartermaster Fumigation and Bath Company was assigned the task of operating stations of the cordon sanitaire0 Power dusters proved of great value but mechanical difficulties and breakdowns were frequent unless operated by trained personnel,, As of early April, the First Army was operating a port of entry at Oberkassel, the Third Army at Wiesbaden, the Seventh Army at Mann- heim, and the Ninth at Wesel„ Summaryo —The validity of intelligence reports on the frequency of typhus fever within the Inner Reich, east of the Rhine, was promptly demonstrated as American troops pushed into Germany,, About twenty large centers of infection were uncovered within the American zone of influence, usually related to the prin- cipal concentration camps for political prisoners0 Several hundred smaller areas with typhus were scattered throughout the country, commonly aggregated about the concentration camps„ A goodly number of localized outbreaks was discovered in March,, A flood of cases came to light in April and in early May, as operations extended well into German territory,, The full impact of modern control measures became evident in May© June saw the situation established within definitely safe limits, and by July Western Europe returned to a state of low grade typhus eudemicity* Conditions in Western Europe in many respects favored a much greater spread of typhus fever than actually occurred„ Germany was in chaos„ The destruction of whole cities and the path left by advancing armies produced a disruption of living conditions contri- buting to the spread of the disease,. Sanitation was low grade, public utilities were seriously disrupted, food supply and food distribution were poor, housing was inadequate and lack of order and discipline was rampant,, Still more important, a shifting of popu- lations was occurring such as few countries and few times have ex- perienced,, Native Germans, disloged from their homes and often moving long distances to escape the enemy, were finding their way back home,, Millions of foreign peoples imported as conscript labor were milling about the country, often aimlessly, sometimes seeking their way back to their native landso The roads, the countryside, were full of released German prisoners of war who lacked transportation and were finding their way to their homes on foot„ There was the minor group of released allied prisoners of war, not a very important factor in the spread of typhus within Germany, because they were promptly evacuated in an orderly manner, but potentially capaole of trans- mitting typhus to their native countries„ 51 Two deoidely important factors served to limit the extent of the outbreak. The most significant was the time of the year that allied troops entered Germany, Had this been in December instead of March, as would have happened except for disrupted military plans, the problem would have been infinitely more serious. Von Rundstedt»s Battle of the Bulge, although of serious import militarily, had the favorable aspect of postponing contact with typhus until the Spring months « Spring brought a lower potential of louse infestation, it permitted life outdoors instead of crowding within existing habitations, and the movement of displaced persons and refugees was facilitated with consequent greater dispersal. Dispersal of course, has advantages and disadvantages. It tends to disseminate infection broadly — it limits concentrated outbreaks. Early repatriation of all Russian nationals, both prisoners of war and conscripted labor, was undertaken in May and completed in June, A large part of available American transport was turned to this end, with the result that thousands of Russians were repatriated each day. They were the population groups with the heaviest incidence of typhus, Ikider any interpretation of governing circumstances, much credit must be given to the efficiency of recently developed methods of typhus control, and to the cooperative effort of army agencies which assured they were executed satisfactorily. The value of delousing through dusting with DDT, and the usefulness of typhus vaccine were tried and tested on a scale greater than ever before and under con- ditions epidemiologicjailly more conducive to extensive and continued spread of the disease. The results attained in the Naples epidemic were confirmed and extended. The pre-epidemic planning was the result of integrated action by at least four agencies, the Office of the Chief Surgeon, ETO, the G-5 Public Health Section of SHAEF and its lower echelons, the Office of the Surgeon of 12th Army Group and the United States of America typhus Commission, Cooperation continued as the problem developed in the field, A general division of responsibility gave the Medical Department, through the Chief Surgeon and the principal operating agency for the armies, the 12th Army Group, the obligation for typhus control among troops, prisoners of war, and returned allied military personnel. Military Government assumed the control of typhus among German civilians and foreign displaced persons. The latter was the major effort. When typhus control for civilians and displaced persons surpassed the facilities of Military Government, all echelons of the Army Medical Department and all of the agencies named joined in a common attack on the problem with the full resources of each. 52 Figure 20 Displaced persons enroute from Borna, Germany to their homes in France, May 1945. No single factor contributed more to the satisfactory end of the outbreak than that never in the course of the epidemic were the fundamental supplies of EOT powder and vaccine lacking. The foresight which led to the development of manufacturing facilities in the Uhited States, the accumulation of stock piles in the mited Kingdom and the adequate distribution to major commands on the con- tinent was largely the contribution of the staff of the Office of the Surgeon General, Preventive Medicine Service, and of the United States of America Typhus Commission. Naturally, occasional difficul- ties arose in local distribution, but the supply system was such and the stock piles so great that they were promptly remedied. The middle of July saw a satisfactory situation in respect to typhus in Western Europe. A slight reservoir of infection con- tinued to exist within Germany j one of decidely more serious portent in European Russia and Eastern Europe generally. There was need for active concern during the winter of 1945 - 1946. Recommendation of Future Control Measures.—A number of recommendations were made by the Chief Surgeon of the European Theater as of 15 July 1945. Personnel of the United States Army remaining with the Army of Occupation or associated with it were to be revaccinated as of 1 October 1945. This date, somewhat - earlier tham might otherwise be followed, was believed desirable because of the relatively long interval since troops of the ETO were last vaccinated, December 1944, and because of the potentialities for recrudescence of the epidemic. It was recommended that all German or other prisoners of war held by the United States Army as of 16 September 1945 should be immunized or given a stimulating dose if primary immunization had been practiced since capture. They are largely unimmunized either by the U. Sc Army or by the Wehrmacht. All displaced persons still remaining in the American Zone should be simularly treated as of 1 September 1945. This staggering of dates obviated overloading existing medical facilities. The cordon sanitaire appeared to have served its purpose and recommendation was made that it be discontinued as of August. Particular attention should necessarily be devoted in the winter of 1945 - 1946 toward assuring a low level of louse infestation, especially in the displaced person and prisoner of war groups, and also in the German civilian population. Troops of the U. S. Army could be expected to remain essentially free of lice as they did during the course of operations. Freedom from lice was to be assured through periodic surveys of the groups mentionedj with energetic application of delousing by dusting where indicated. It was finally recommended that a typhus control expert be continued on the staff of both Eastern and Western Districts of the 53 American Zone, for case finding, to provide diagnostic service and to advise on control measures0 The Eastern District, because it was in continuity with a long existing endemic focus of typhus was to be considered the point of greatest concern© 54 Table 1 Geographical Distribution of Typhus Fever in Germany 1941 Districts Cases Eastern Prussia 193 Frankfort-on-Oder 87 Koslin 50 Schneidemuhl 35 Berlin 32 Stettin 29 Austria 19 Danzig 14 Leipzig 12 Breslau 13 Potsdam 10 Dresden 7 Sudetenland 2 Source: The united Natic )ns Relief and Rehabilitation Administration of Communicable Diseases and Medical Notes, Volume II, Number 3, 7 February 1945« Table 2 Geographical Distribution of Typhus Fever in Germany 1942 Districts Cases Prussia Bavaria Saxony Wurtembury Baden Hamburg Ihuringiz Hesse Mecklenburg Brunswioh 1017 170 64 75 21 111 27 22 22 16 Bremen i * ! 6 Anhalt i 13 Lippe 1 Saarland 5 Oldenburg 2 Austria 120 Sudetenland 25 Sources The Bhited Nations Relief and Rehabili tation Administration Bulletin of Com- municable Diseases and Medical Notes, Volume I, Number 4, 26 July 1944® Table 3 Geographical Distribution of Typhus Fever in Germany 1943 Districts Cases Prussia 1238 Bavaria 126 Saxony 72 Wurtembury 26 Baden 5 Hamburg 20 Thuringiz 6 ' Hesse 20 Hecklenburg 133 Brunswioh 83 Anhalt 36 Lippe 2 Saarland 16 Oldenburg 2 Westmark 22 Austria 49 Sudetenland 16 Sources Medical Intelligence Summary #3, Office of the Chief Surgeon, European Theater of Operations, U®S» Army, 9 February 1944* Table 4 Typhus Fever in Germany and Annexed Territory hy years January 1939 to June 1945 inclusive0 Year Cases 1939 1940 1941 1942 1943 1944 1945* 8 516 2351 2742 5058 No official record 16506 * U«S* Occupied Zone Sources: 1939 - Health Section of the Secretariat of the League of Nations, Weekly Epidemiological Record, 26 April 1945 o 1940 - 1943 The Halted Nations Relief and Rehabilitation Administration Bulletin of Communicable Diseases and Medical Notes, Volume I, No* 4, 26 July 1944* 1945 - Division of Preventive Medicine, European Theater of Operations, Uo So Army* Thble 5 Typhus Fever in Germany Elements of Population Affected and Mortality Hates 1942 - 1943 Population Elements No, of Cases Percentage of Total No. of Deaths Mortality Rate Non Germans 2,069 88.9 95 4.6 Uholassified 172 7.4 22 12.8 Germans 86 3.7 17 19.7 Totals 2,327 100. 134 •6.71 Sourcei The Uiited Nations Relief and Rehabilitation Administration Bulletin of Communicable Diseases and Medical Notes, Volume II, Number 3, 7 February 1945. Table 6 typhus Fever in the Rhineland Cases by months and localities March to June 1945, inclusive March April May June Total Aachen 9 3 2 14 Arloff 13 13 Baohenau 4 4 Bad Godesburg 4 4 Bad Kreuznaoh 5 5 Baumholder 12 2 14 Bergzabern 1 ■ ■ - ■ ■ ■ ■ 1 Beuren 1 . 1 Bonn 10 2 .. . ‘ v 12 Brand 1 1 Brauweiler 2 2 Breyel 13 13 Cologne 188 2 9 199 Fisohbaok 6 6 Gusenburg 1 1 Hermulheim 58 58 Homburg 1 1 2 Johannesthal 3 3 Koblenz 1 1 Kaiserslautern 2 4 6 Kronenburg 7 7 Krefeld 6 6 Kusel 2 2 Lebach 8 1 9 Mainz 1 1 Mamagen 1 1 Meisenheim 19 4 23 Merten 1 1 Mo Gladbach 30 1 31 Neuhaus 9 9 Neuss 48 15 2 65 Otzenhausen 6 v 6 Raumbach 2 2 Remagen 1 1 Rheydt 17 17 Rheindahlen 20 20 Rockenhausen 2 2 Rondorf 12 12 Saarbrucken 1 1 1 3 Schwanenburg 30 30 Table 6 (Gont‘d) Typhus Fever in the Rhineland Cases by months and localities March to June 1945, inclusive March April May June Total St. Wendel 1 1 Suchteln 6 6 Sulzbaoh 3 3 Trier • 2 2 4 Vi ers en 2 2 Voehem 1 1 Wegburg 10 10 Wesseling 1 1 2 Wassenburg 55 1 56 Tohal 560 9l 37 r* 693 Source: Division o f Preventive Medioine^ Office of the Chief Surgeon, European Theater of Operations, U» S« Army® Week ending Active cases Hew Localities Cases of • Record Old Localities New cases Total cases Hew Old Total 2* March 11 .. 11 1 - 1 7 April *2 - - *2 8 - 8 lU April 71 2*00 - *71 9 - 9 21 April 873 296 12 1181 25 2 27 28 April 337 - 25 368 29 7 36 U May 8*8 775 178 1801 52 13 65 11 Nay Ujl 1326 1175 2952 *1 20 61 18 May 71* 3 1775 2*92 50 *0 90 25 May 312 - 16*9 1961 32 3* 66 1 June 320 21 ll6l 1502 26 38 6* 8 June 17 - *10 *27 7 25 32 15 June * - **7 U51 3 27 30 25 June 7 - 75 82 2 11 13 29 June 2* - 51 75 7 9 16 Total *031 *821 6958 15810 292 226 518 Source: Division of Preventive Medicine, Office of the Chief Surgeon* European Theater of Operations, U, S, Any. Typhus Fever in the Inner fieich Cases by week of report and origin, 2U March to 29 June 19^5» inclusive 1 Table 8 Typhus Fever in Allied Countries Number of cases reported March to June 1945, inclusive* Country March April May June Total England 10 11 21 France 8 141 127 J 276 Belgium 3 64 69 136 Denmark 1 10 4 15 Netherlands 1 11 37 49 Scotland 1 • 1 Total 8 5 237, 248 498 Source: Health Section c >f the Se >cretari at of the League of Nations, 13 December 1945, FIGURES 1. Typhus fever in Germany and annexed territory, by years, January 1939 to June 1945o 2. Trend of typhus fever in Germany, number of cases by quarters, 1938 to 1943* 3. Typhus fever in Germany, elements of population affected and mortality rates, by years, 1942 to 19430 4o A power duster is used to delouse liberated slave laborers and political prisoners, Munster, Germany, May 19450 5* typhus fever in the Rhineland, cases and localities, March to June 1945. 6. Progression of typhus fever in the Rhineland, cases and localities, March to June 1945. 7. Delousing in a prisoner of war enclosure is performed by Nazi prisoners, Stenay, France, March 1945. 8. A Polish woman is dusked with DDT powder at a displaced person's camp at Heidelberg, Germany, June 1945. 1 9. typhus fever in the Inner Reich, cases and localities, during week ending 20 April 1945. 10. Typhus fever in the Inner Reich, cases and localities, during week ending 1 June 1945. 11. Typhus fever in the Inner Reich, cases and localities, during week ending 29 June 1945. 12. Bodies found in a crematory room when Dachau Concentration Camp was liberated by the Seventh Army. Many had died of typhus. 13. Box cars filled with bodies of prisoners who died en route to Dachau were found at Seeshaupt, Germany by the Seventh Army, May 1945. 14. Typhus fever admissions, Dachau Concentration Camp, Germany, 4 May to 9 June 1945. 15. Two dying prisoners lie among hundreds of dead on a barracks floor. Concentration camp at Wiemar, Germany, May 1945. 16. Flossenberg Concentration camp was liberated by the 97th Infantry Division, Germany, May 1945. 17* Typhus fever, Flossenberg Concentration Camp, cases and deaths, by nationality, 14 February to 1 May 1945o 18* An infirmary at a Nazi concentration camp, Linz, Austria, May 1945* 19. Liberated Ffench and Belgiums wait for transportation to a displaced persons camp. Delousing is required before cross- ing the Rhine River (the Cordon Sanitaire), Cologne, Germany, April 1945. 20. Displaced persons en route from Borna, Germany, to their homes in France, May 1945. TABLES 1, Geographical distribution of typhus fever in Germany, 1941„ 2, Geographical distribution of typhus fever in Germany, 1942 c 3o Geographical distribution of typhus fever in Germany, 1943« 4» Typhus fever in Germany and annexed territory, by years, January 1939 to June 1945, inclusive0 5® Typhus fever in Germany, elements of population affected and mortality rates, 1942 to 19430 6, Typhus fever in the Rhineland, cases by months and localities, March to June 1945, inclusiveo 7a Typhus fever in the Inner Reich, cases by week of report and origin, 24 March to 29 June, 19450 8o Typhus fever in Allied Countries, number of cases reported, March to June 1945, inclusive*, EPIDEMIOLOGIC CASE REPORTS 1* Outbreak of Typhus in a Prisoner of War Enclosure* 2* Medical Officer Contracts Typhus in the Rhineland* 3, Mild Case of Typhus in a Medical Officer* 4* Questionable Infection of an Infantry Sergeant* 5* Typhus in a RAMP. 6. lyphus in a RAMP* A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19a - 1945 PART III » Epidemiology Section 5 - Arthropod Borne Diseases Number 2 - Malaria and Others by Colonel John E» Gordon, M0C. Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OP CONTENTS PART III - Epidemiology Section 5 “ Arthropod Borne Diseases Number 2 * Malaria and Others Page Malaria. «o..o»oooeeoo..oo».seooo..« X Incidence of MaXaria in Great Britain. . , o o . . 0 . « o o 2 Malaria in the United States Array in Britain 0 o « • 0 « . 0 3 Recurrent Malaria after Primary Infection in America 0 0 0 s i+ Importation of Acute Malaria by Crews of Aircraft. . . 8 . 0 I4. Recurrent Malaria Among Troops Returning from Africa .... and Italy 000. ......o. ....... 9. .coo B Later Experience in Great Britain. ..©co. ..00.00 5 The Clinical Disease ooooo«eoe»«..oe.osoo 6 Program of Control in Great Britain. • 8 Malaria in Continental Western Europe. oee8oo.a.oo 11 Frequency of Malaria in the United States Army during Operations in Western Europe ooooo.o.oc8.ooo 12 Causes of Recurrence and Relapse oooooocoo.oooo 13 Epidemiologic Aspects of Recurrent Malaria in the Europena Theater of Operations© 000000.000000000.0 llj. The First Infantry Division0 .000.00000000000 15 Malaria in the Second Armored Division .000000... * .16 Malaria in the Seventh Army. 0000000009000000 18 Page Comparison v/ith other Theaters of Operation. .••••••• 19 Control Measures on the Continent 19 Protection of Patients with Malaria from Mosquitoes. .... 19 Mosquito Control •••••••• ......... 20 Plague ••••• 22 Epidemiologic Investigations o .............. . 25 Control Program ......•* • • 2I4. Trench Fever .••••• 2 5 Pappatio Fever • 26 Relapsing Fever. . • • • 26 Dengue Fever ........ 27 Leishmaniasis. 27 Other Theaters of Operation • 28 List of Figures List of Tables Epidemiologic Case Reports PART III EPIDEMIOLOGY Section 5 - Arthroped Borne Diseases Number 2 A Malaria and Others Malaria.—-The United Kingdom is not a malarious area, Indi- genous malarial infections were known to have occurred in some parts of England before 1900, more especially in the south and east*, but by the early part of the present century indigenous malaria was apparently either absent entirely or a very rare disease© Localized epidemics occurred during and after ’florid War I© They were initiated by the return of infected soldiers from abroad into areas where the conditions -were suitable for transmission of the disease© During the years 191? and 1918 a number of cases of malaria occurred in various parts of England among children and adults who had never left the country© In the latter year they became so numerous in some locali- ties that malaria was made a notifiable disease© There are only four species of anopheline mosquitoes indigenous to Great Britain and only one could be considered a dangerous vector of malaria*, Anopheles labranchiae variety atroparvus *, a member of the maculipennis complex© It is especially dangerous because the adults habitually live in close association with men*, either in dwellings or in animal houses© The species breeds in the United Kingdom almost ex- clusively in brackish water which occurs primarily in the coastal areas© It spends the winter in a semi-active condition in the adult stage*, resting in dark poorly ventilated farm buildings and houses* It may take an occasional blood meal during the winter© Breeding is resumed in spring and the first generation of adults usually appears in late May© In localities where more than five cases of indigenous malaria occurred in any one year since 1917 atroparvus was always present in the houses in large numbers© In districts further inland where only one or two indigenous oases of malaria occurred*, it was never possible to determine whether they were infected by atroparvus or by the related messeaej but it was believed that the variety atroparvus was responsible and the reason why the disease did not spread was because this sub-species was not sufficiently numerous in the locality© because this species was present in small or large numbers throughout the country there was always a danger that fresh oases of malaria might occur if an infected person came into such an area and was exposed to their bites© Fortunately it was only,during the summer months that temperature conditions were such as to allow the completion of the parasitic cycle in the mosquitos and this takes about 15 to 20 days in England® The conditions of favorable temperature and humidity occurred most commonly along the southern and southeastern parts of England, usually on the coast and this was where locally contracted cases of malaria had been most commonly recordedo In many other parts of England, although the mosquito was present and human carriers had been introduced, the disease rarely spread until warm weather had continued for some time, combined with a high relative humidity of over 60 per cent*, In such areas if malaria occurred, it was usually only as isolated cases.. The distribution of indigenous malaria after the 19114--19I8 war was about the same as it was for the recorded prevalence of malaria during the 18th century0 It is illustrated in Figure 1® The problem of transmission of malaria by mosquitoes is seldom serious in Great Britain and most measures against mosquitoes are usually undertaken to reduce their numbers to a level at which they no longer cause a nuisance by their biteso The three factors involved in the spread of malaria all ex- isted in the United Kingdom in Two of these, a susceptible population and a suitable mosquito vector, were not new. The third, the malarial parasite in the blood stream of patients, was provided in increasing abundance with the hospitalization of malarial patients of the American forces returning from Africa, and from the various armed services of Great Britain as they returned from overseas0 Pre- cautionary steps were necessary to prevent the spread of this disease® The matter was of particular importance to American military authori- ties because most of the United States troops were stationed in the areas most involved, in eastern and southern England® The Ministry of Health of Great Britain was careful in guarding against the reintroduction of malaria by their home coming troops during the recent war® There was a small flurry of excitement when it was realized that a fair amount of mosquito breeding was taking place in the bomb craters of London and in several of the other southern districts® Only the harmless culex pipiens was found in the craters and the mosquito found breeding in the Underground was culex molestus® Incidence of Malaria in Great Britain®-—During the nineteenth century malaria was prevalent to a limited extent in England and Wales particularly in the southern region, along the eastern seacoast from Hull to Hastings, along the Thames and the Ouse, and in areas above Portsmouth, Liverpool and Bristol® 2 DURING THE 18TH CENTURY AFTER THE 1914-18 WAR Figure 1 Distribution of indigenous malaria in Great Britain, during the 18th century and after the 1914-18 war. Deaths from malaria from the year 1910 through 1916 ranged from 50 to 60 each year© In 191? the number increased to 126,s for 1918* it was 197 and in 1919 the number reached 268a While most deaths before the war represented individuals who had contracted the disease in the colonies and had returned to England for reasons of health* a goodly percentage were cases of indigenous malaria which was smouldering in certain coastal districts0 The most noteworthy of these was the area comprising Cheerness* Queensborough and the Isle of Shepps y0 Indigenous oases also occurred on the Isle of Grain* and in the Hoo rural districto The rise in the number of deaths for the years 1917“1919 was largely due to the return of infected troops from the Middle East© A rise in the incidence of indigenous malaria was likewise associated with these returning troops* of sufficient proportions to warrant the term outbreak applied by the Ministry of Healths This situation was soon brought under control by the efforts of special malaria officers in the areas most involved*, but a few oases of indigenous malaria continued to be reported yearly© For the eleven years from 1933 19^3* "the number was 27* with the largest number in any one year being six in In recent years only two to four infections were contracted in England or Wales in any one year0 Malaria in the United States Army in Britaino—Available records give no evidence of indigenous malarial infection ever having occurred among United States troops stationed in Great Britain during the course of the war just passedo The oases that were recorded were in all instances due to an original infection acquired outside the territorial limits of the United Kingdom© The majority were recurrent attacks with well established history of previous malaria* though a number were representative of primary clinical manifestations after previous use of suppressive atabrine management© It is to be noted particularly that the data presented in Table 1 represent numbers of admissions to hospital and not numbers of patients with malaria among members of the commando Numerous individuals were admitted to hospital as many as three or four times* and instances were known of eight admissions of the same patient with recurrent malaria© On the other hand many active cases of malaria were certainly included under undiagnosed fevers0 It is a fair assumption that the number of hospital admissions gives indi~ cation of a number of patients with malaria that is less than fact* rather than greater© 3 Recurrent Malaria After Primary infection in America, —Malaria among United States troops in the United Kingdom was reported With more or less regularity frcm the early days of the Theater0 The first case was included in the records of 1942« Because of the great proportion of cases of undiagnosed fever were of malarial nature, the data for that condition are likewise included0 The reported frequency of the condition tended to parallel that of malaria, although it is by no means to be assumed that all instances of undiagnosed fever were actually recurrent malaria0 The first case of undiagnosed fever was reported in May 1942 „ (Table 2) During the course of 1942, 20 cases of malaria were re- ported among United States troops and 51 of undiagnosed fever0 Clinical histories of the patients involved showed them to have acquired their original infection in continental United States, with recurrence taking place in Great Britain,, Despite the influence that might have been expected from the return of casuals from Africa after the onset of that campaign in November 194-2, the rates for malaria and undiagnosed fever evi- denced |no appreciable increase during the early part of 194-3. Importation of Acute Malaria by Crews of Aircraft., —The first \|yent of any considerable importance developed in October 1943„ Ten B~a| Liberator crews arrived in England, the first group of the season destined for the Eighth Air Force to fly their planes over the South Atlantic route, since the North Atlantic was the preferred route for bombers during the summer, Of the one hundred officers and men of the crews, 17 subsequently developed malignant tertian malaria, Only the men of one crew escaped infection, and they were the single crew who had been adequately indoctrinated in malarial prevention and had fully practiced preventive measures„ Of some crews, as many as three or four of the ten men were infected. The situation was of more than ordinary importance because the crews had been trained to work as a unit and if one member dropped out, the remainder were greatly affected. The crews of the ten aircraft had recently completed training in America. They flew to Florida* then to Puerto Rico* British Guiana, and to Natal, Brazil,, A few planes proceeded from there to Ascension Island and to Roberts Field, Liberia0 Most of the Liberators flew directly from Natal to Dakar, but all of the planes whether flying directly or indirectly landed at Dakar and Marrakesh, subsequently arriving in England by way of St„ Mawgans in Cornwall,, No medical officer checked the physical condition of the crews during the course of their flight* They were sent into regions where malignant tertian malaria was prevalent without satisfactory indoctrination in malaria 4 MONTHS AFTER FIRST ATTACK KEY INITIAL ATTACK SUPPRESSED ATTACK SUPPRESSED OR ABORTIVE RECRUDESENCE RECRUDESENCE ABORTIVE ESCAPE RELAPSE ESCAPE ATTACK TIME SPENT IN ENDEMIC AREA AFTER INITIAL ATTACK Figure 2* Special study of recrudescence and relapse after primely malarial attack. First General Medical Laboratory, England, 1944, discipline, and in a number of instances without personal protective equipment such as gloves, head nets, mosquito bars and mosquito repel- lent o The living quarters at Dakar and Marrakesh offered little protection against mosquitoes, and nightly guard duty was required of a part of the men0 Few realized that they were taking any particular risk and no chemoprophylaxis had been gLven0 The source of infection was believed to be in either Dakar or Marrakesh® As a result of this experience, a comprehensive survey of the South Atlantic route was instituted by the Air Transport Command, faci- lities at the various ports of call were improved, and attention given to malaria discipline0 Subsequent importation of malaria from this source was not observed,, Recurrent Malaria Among Troops Returning From Africa and ItalYo —Malaria became a problem of distinct medical importance with the arrival of four divisions of infantry and a special brigade of engineers from North Africa« The 1st Infantry Division arrived on 5 November 194-3 and was followed shortly by the Ninth Infantry, the Second Armored Division, the 82nd Air Borne Division and the 1st Engineer Special Brigade® Malarial recurrences occurred among these troops in appreciable numbers shortly after their arrival, to such extent that for December reported cases of malaria had increased to 392, and of undiagnosed fever to 83® The rate for the year 1943 reached 2®54 per thousand for all troops of the theater, in comparison with 0®28 for the previous year® The rate for undiagnosed fever remained essentially the same® Throughout the winter and spring of 1944, a steadily in- creased progression was noted in numbers of reported malaria, and to a lesser extent for undiagnosed fever® During the month of May 1944, the 1632 cases of malaria gave a monthly rate of 16®2 per thousand per year® The number of patients with undiagnosed fever was 142 and that rate was l„4lo The decided increase in reported cases in late spring was in agreement with the usual clinical pattern of recurrent malaria, although influenced to an extent by the active preparations then under way for the invasion of the continent® Troops were housed in marshal- ling areas under difficult living conditions and were participating with increasing frequency in rigorous training maneuvers® Later-Experience in Great Britain®—With the departure to the continent of the four divisions and the special brigade from which malaria had principally originated, the frequency of the disease in Great Britain decreased decidedly® By December of 1944, the number of cases among troops stationed in the United Kingdom was 140 and 5 the rate 2,3 per thousand per year, Undiagnosed fever evidenced the same behavior, with I46 cases in December and a rate of 0„77, During 1945 the incidence of malaria in Great Britain receded to the original conditions which held during the first years of the theater0 Malaria became a relatively uncommon disease, with rates less than 2 per thousand per year0 The Clinical Disease,—The malaria encountered among combat troops returned from the Mediterranean theater was almost entirely vivax infection,, All units had been in service in malarial regions and had been on suppressive atabrine therapy until arrival in the United Kingdom, The malaria that occurred was from recurrent infection. In a majority of instances clear cut histories of previously existing clinical malaria were obtained, but the absence in a considerable number led to the obvious conclusion of parasitism without clinical malaria. Sampling of various groups of patients indicated that the proportion without previous history of attack was about 30 percent. The experience of the 2nd Armored Division was illustrative of conditions, A survey by personal interview and by examination of the records of the division was made during the last two weeks of April, 1944« Of a strength at that time of about 3454 officers and men gave a history of one or more attacks of malaria, roughly about one-sixth. Men of the division suffering a single attack of the disease, either in the Mediterranean theater or in England numbered 1£7B2, and those who had a second attack included 672, Recurrences among all persons contracting malaria were thus in the proportion of 27,4 per 100, which is a decidedly creditable record, A single recurrence was noted for 437j 146 had two. If a history of three or more recurrences is accepted as the criterion of chronicity, only 90 such instances were found among the 672 who had more than one attack and the rate for chronic infections in the complete series was 3o7 percent. The ninety chronic infections included 45 patients with three recurrences, 20 with four and 15 had five attacks. Six patients experienced six separate bouts while one other person had seven and two had eight. When the dates of inital attack were aligned and properly integrated it became evident that relapses occurred between seven and ten months after the initial infection, most of which had been acquired in August and September of 1943, The incidence of late relapse in March through June was to be expected because late relapses of this order are known to be characteristic of benign tertian infections. 6 A group of 57 patients was subjected to special study at the hospital of the First Medical General Laboratory in the spring of 194-4« Thirty-two were admitted in relapse, or 56$* The present episode was the first malarial experience for 17, while the remainder had had one or more bouts in the endemic zone* All had been stationed in malarious countries about six months previously,, Twelve were admitted in the first recrudescence after a relapse occurring in the European theater0 Thirteen infections could be considered chronic in that they had had more than one recrudescence following the late relapse,, Six of the patients considered to have chronic infections had been inadequately treated as judged by liberal standards0 The data on recrudescence and relapse after primary attack are presented in Figure 2 for 39 patients of the series who were sufficiently long under observation to give adequate information,. An individual may or may not have had a malarial experience in the endemic region* Included as relapse are those cases with long delayed incuba- tion periods* Primary attack when it occurred is shown in relation to subsequent length of residence in the malarious region* Recrudescence is understood to represent a clinical reaction of sufficient moment to require a course of treatment, as of about the same parasite gener- ation as that of the preceding attack, and recurring within eight weeks* A recrudescence suppressed by prophylactic treatment is one that re- quires little or no increase in antimalarial drugs to bring about clinical cure* An abortive recrudescence is an episode lasting a day or two which has followed an attack out of the endemic area and requires institution of treatment* Likewise shown are attacks characterized by symptoms of malaria, appearing within eight weeks after stopping suppressive therapy when out of the endemic area and requiring treat- ment* An abortive escape is an episode requiring no therapy* A re- lapse is considered as an event occurring more than eight weeks after a previous malarial episode when not an escape attack* The value of the several observations on recurrence in malaria were particularly favored in this instance through transfer within a relatively short period of time of a large body of men from a malarious area to one where for all practical purposes no opportunity for natural reinfection existed* For benign tertian malaria the rate of recurrence was not high, and compares favorably with the behavior of civilians living under much less rigorous conditions* 7 Program of Control in Qreat Britain. —The decision to re- turn troops to the United Kingdom from endemic malaria areas in Africa and Italy in preparation for the assault on the continent brought full appreciation that a goodly percentage of malaria recurrence was to be expected,, Instructions were therefore issued in August of 1943 setting forth principles for the management of patients with malaria* It was first emphasized that men who had taken suppressive treatment during the period of exposure would not suffer their initial attack in all likelihood until some weeks or even months after the medication was discontinued. For the protection of other patients and in order to prevent spread of malaria to civilian communities with- in the theater, effective screening of patients with diseases trans- mitted by mosquitoes was accomplished by keeping the patient under a mosquito bed-net or in a screened room, especially between dusk and day- light* Patients were treated until clinical symptoms of malaria had disappeared and until the blood was free from malarial parasites, as evidenced by two negative thick smear examinations at two day intervals* Thick blood smear examinations for malaria parasites were directed for all patients who had had recent duty in overseas endemic areas, irrespective of whether or not they gave a history or presented symptoms of malaria* Carriers detected by these examinations were treated until the blood was free from parasites* Before discharge or the granting of furlough or side leave, patients with a history of malaria were warned that they were liable to a recurrence at some future time and should have a blood examination for malarial parasites in the event of any febrile illness* Intensification of mosquito control operations was directed in and about station re- ceiving troops from overseas areas where malaria was endemic* Shortly thereafter, in September 1943$ comprehensive directions were issued by the Division of Professional Services concerning the drug treatment of malaria both as a suppressive and in the management of clinically definite infections* Detailed information was provided medical officers on various features such as the relative efficacy of atabrire, quinine, and plas- mochin, on the adverse effects occasionally noted in the use of these agents, and on the need for conservation of quinine* Drug suppressive treatment was defined as an emergency procedure to be employed only when troops must accomplish a particular mission in an area where the risk of malaria was substantial and where protection by mosquito control measures was not possible* It was stressed that at present no drug was known which in safe doses would prevent mosquito trans- mission of malarial infections, but that atabrin taken regularly and in proper doses could be expected to suppress clinical symptoms 8 for varying periods of time, thus enabling men to remain active in spite of infections which otherwise would incapacitate them0 When troops returned to areas with proper protection against mosquito- borne disease, suppressive treatment should be discontinued as soon as feasible a Further attention was given to the management of the clinical attack in respect to both complicated and uncomplicated malariao The treatment of replaces and recrudes cense was given particular attention,, The increasing moment of this problem in late 1943 brought about intensification of the general measures which had already been defined* The immediate consideration was in respect to the general military population of the United States Army, which even then was being pointed toward the campaign on the European continent* The second consideration related to the British civilian population, in that the United States Army had a definite obligation to assist in preventing a recurrence of even such a mild outbreak of malaria as occurred following the previous war* The program that was put into practice was based on four general principles* Emphasis was first placed on the prompt treat- ment of patients with malaria to render them noninfective to mos- quitoes as quickly as possible* The second measure involved the use of atabrineas a suppressive of malaria* Thirdly, action was taken to protect other patients in hospitals and troops of nearby regions from contact with malaria-transmitting mosquitoes when patients with malaria were under treatment* Finally, control of mosquitoes in the general military area was intensified as a general protective measure for the health of the command* The first two objectives fell within the obligations of the Division of Professional Services, the last two were functions of the Preventive Medicine Service, The increasing frequency of chronic relapsing malaria within the theater led to the publication of directions for the management of patients convalescent from that condition, with particular attention to diet, rest, and to rehabilitation* The control of mosquitoes, particularly in hospital areas and in regions occupied by the troops affected, was brought about by field studies by the entomologists of the central division of preventive medicine, by coordinated effort with the Corps of Engineers and through comprehensive directions for the information of the command * 9 Consideration was given to a choice of hospitals through a policy of admitting patients with malaria only to instal- lations located in areas essentially free of anopheles mosquitoes. Because of the time of the year when the problem presented, namely the autumn of 1943* it was not deemed essential to seriously con- sider such a procedure until the following summer. The difficulties which any selective program of hospitalization introduces into a scheme of evacuation requires that the need be definitely defined and outweigh the military disadvantage. By the time the next mosquito season arrived, most of the troops with malaria had de- parted for the continent, malaria in Great Britain was declining rapidly and the matter was dismissed frcm consideration. The increasing numbers of recurrent malaria that came in the spring of 1944* and the assignment of the seasoned troops most affected to lead the invasion of France, required energetic measures to reduce the number of non-effectives from malaria among these highly important tactical troops, if they were to be in a state of greatest usefulness. Individuals debilitated by reason of relapsing malaria were removed from combat units during the final training period in Great Britain. About two weeks before departure for Normandy all personnel with a history of malaria within the past twelve months were required to resume atabrin suppressive therapy. The dosage was increased frcm 0.4 gn. weekly, to 0.1 gm with the evening meal each day except Sunday, and was to be continued indefinitely. Supplies of atabrin sufficient for 14 days were issued to all soldiers with a history of malaria at the time of embarkation for combat duties. Other significant changes made in the management of malaria just prior to the Nomandy D-day included the recommenda- tion that specific antimalarial therapy was to be delayed until confirmation of the diagnosis by demonstration of the plasmodium whenever feasible and without danger of injury to the patient. Two prescribed routines for the treatment of malaria with quinine and with atabrin were outlined, and information was given on the treatment of cerebral malaria and on the management of convalescents. Reassignment for limited service was recommended for patients with a history of three or more relapses, who showed a persistently palable spleen, failure to regain accustomed weight, persistent mild anemia, or general lowering of resistance and depreciated physical status. Evacuation to the Zone of the 10 Interior was recommended for patients with a history of three or more relapses where debility, malnutrition, anemia, and spleno- megaly were so pronounced as to render them obviously unfit for useful service in the theatere Suppressive therapy in relapsing malaria was increased to OolO gram daily, beginning in the fourth week of hospitalization and continuing thereafter for three months under supervision of the unit medical officer. Malaria in Continental Western Europe.—In modern times malaria had not been a problem in the areas of France lying within the proposed zone of operations for the invasion of Europe. Al- though anopheline mosquitoes were to be found in northern France serious danger of malaria was not to be anticipated north of Quimper on the Brittany peninsula* Thorough review of all available sources of information in the course of medical planning gave assurance that the malarial problem in further extension of operations in northern Europe was likely to be minimal* Belgium was essentially free from the disease, and Germany had had little malaria for many years* Only the Nether- lands continued to have malaria to an appreciable extent* Con- ceivably the flooding of that country in the face of successful advance by allied troops would further aggravate conditions* This was the one country of possible operations where malaria had not largely disappeared* France was the country of principal concern because operations were to begin there* During the last five decades, malaria had been steadily disappearing, leaving only a few scattered areas with a mild degree of endemicity* Benign tertian malaria occurred almost exclusively, although occasionally quartan and even falciparum infection had been recorded* The principal areas were stated to be in Brittany, the coast of Vendee, Gasogne, and the Mediterranean littoral* Some few isolated foci were still maintained in the interior* The malaria situation in the cpuntries of northwest Europe as it existed at the time operations started, according to available medical intelligence, is set forth in Figure 3o The in- vasion of continental Europe was initiated with rather certain assurance that malaria would be of little more importance than it had been in Great Britain* 11 Frequency of Malaria in the United States Army During Operations in Western Europe,—The question of how much of the malaria among United States troops on the continent of Europe represented primary infection of indigenous origin and how much was referable to recurrence of to primary clinical manifestation after infection in other regions, was not as easy to answer as it had been in relation to experience in Gfreat Britain0 The available medical records do not distinguish indigenous and recurrent in- fections j and evaluation necessarily dependent on the general opinion of medical officers serving with troops, and on individual case reports 0 No cases of indigenous malaria were known to have occurred in Great Britain0 Some few did occur in Rrance, but the number was not susceptible to even rough approximation,, The surgeon of the First United States Amy was of the opinion that no indigenous infections were represented in reported malaria in the First Array, in Normandy or subsequently, All of the units coming from malarious areas served with the First Army and most of the malaria occurred in that organi- zation,, . In southern France, in Delta Base Section, occasional instances were rather definitely marked as of local origin, although the number was certainly small0 No question can arise that the great proportion of the malaria reported among United States troops in France was representative of recurrent infection, almost to exclusion of all else, The proportion of indigenous infections would almost surely be less than one percent of reported cases0 No separation of malaria reported on the continent from that occurring in Great Britain was available for the month of June 1944, the first in Europe, For the theater as a whole, 1517 cases of malaria and 292 of undiagnosed fever were determined, which to- gether essentially duplicated the frequency during the preceding month of May0 July had 1915 cases, of which 1381 were among continen- tal troopso The rates were inordinately high, 266,4 per thousand per year, since the strength was relatively small and largely com- posed of veteran divisions heavily seeded with malaria. The subsequent behavior of malaria is set forth in Table 3, showing the incidence of malaria on the continent and in Great Britain for the period of September 1944 to June 1945, inclusive. Rates on the continent decreased sharply to reach 5„1 per thousand strength in November 1944* The number of cases was materially less, but the principal effect on the rates came from the huge additions to continental troop strength* 12 AREA OF HIGHEST INCIDENCE • AREA OF LOW INCI DENCE Figure 3 Distribution of indigenous malaria in countries of Western Europe, showing areas of high and low indemioity. Malaria cases essentially doubled during December 1944, because of the inclusion at that time of the forces of the Mediter- ranean Theater -which had entered France frqca the south during the preceding August,, These troops included three divisions of infantry with high malaria rates dating from their experience in Italy,,. The theater rate was not greatly affected, rising from 5ol to 6,8, be- cause of continuing additions to troop strength0 Conditions were somewhat improved during the winter months of January and February, but March 1945 saw a strong up- surge in both numbers of cases and rates© The number of cases was 2142, the j*ate 10© 0© For the theater as a whole 2211 cases of malaria and 1550 of undiagnosed fever were reported, with rates for the two conditions of 8©3b and 5»9o The greatest number of cases for any single month of the theater experience was 2526 in May, with an additional 1934 cases of undiagnosed fever© A most significant feature of the experience of the spring of 1945 was the disproportionate increase in reported cases and rates for undiagnosed fever, (Table 3) as compared with the previously existing ratio between that condition and malaria© This was influenced in large part by the customs of reporting in the Seventh Army© The redeployment of troops to other theaters and to the Zone of the Interior began in May, and early involved the veteran divisions of the First and Seventh Armies which had furnished most of the malaria© The incidence for the theater decreased sharply with the change in population that took place, so that for the following October only 66 cases of malaria were represented in the theater experience; and for December 1945, only 2 patients with malaria were admitted to hospital© Malaria had ceased to be a problem© Causes of Recurrence and Relapse©—Because of the known presence of anophelines in the area occupied by the First U© S© Army in July (Normandy) the question of new cases arising from our own reservoirs was given full consideration© Although the best available opinion indicated no danger of spread of malaria in the part of France concerned, all patients discharged from hospital after malaria were put on atabrin when returned to their units© Case studies showed that all patients who developed malaria had previously been in malarious regions© In Normandy, 13 under the rigorous conditions of the St0 Lo campaign, and not at the time on suppressive treatment, they developed clinical disease. Theoretically, recurrences should not have occurred since all were supposedly on atabrin management. With few exceptions patients admitted that they had not been taking the drug. Various explana- tions were given by officers and men. Many said atabrin was not available under combat conditions when separated from their units. Others objected to the drug because it disagreed with them, or caused various unpleasant symptoms; therefore they did not take it. It is believed that there would have been few recurrent cases had all personnel with a history of malaria been provided with atabrin and adequately indoctrinated with the necessity for taking it. The decline in malaria in the First Army after July and August was believed due principally to the depletion of the reser- voir of parasitized individuals as the Result of death or evacuation from the army area. The policy of two full weeks of vigorous quinine therapy which was inaugurated on 30 July 1944 by the First Army un- doubtedly had an effect, as did increased emphasis on atabrin sup- pressive therapy. Improved climatic conditions likewise contributed. Corroboration of the expressed opinion of medical officers of the First Army, that laxity in malaria discipline with failure to take atabrin prophylactically was the chief reason for recurrences, was obtained by survey of a group of 94 patients evacuated to a general hospital in Britain in July 1944o The number of patients with a previous history of malaria was 78, of -whom 21 clamed to have been on atabrin and 57 had not. Sixteen of the group had previously experienced no clinical manifestations of the disease; and the number who had taken atabrin was 3$ and 13 had not. It appeared that most of the attacks had occurred after soldiers ceased taking the malaria suppressive treatment, although an appreciable proportion represented breakthroughs, in that attacks developed during the course of treatment. Epidemiologic Aspects of Recurrent Malaria in the European Theater of Operations,—The malaria of the European Theater was al- most entirely recurrent malaria. The cases were contributed in al- most their entirety by seven divisions together with attached troops, which came from the Mediterranean Theater, Three Infantry Divisions, an Armored Division and the 1st Engineer Special Brigade arrived in the United Kingdom in November of 1943* The malaria rate for the theater had been negligible before their arrival. It promptly in- creased to the extent of a major medical problem. 14 The troops of these divisions spearheaded the invasion of Normandy, Despite previous elimination of the men most affected by malaria, and the requirement of atabrin suppressive treatment i&r those with a history of the disease, the attack rate increased greatly in the early months of the campaign. The theater rate was again affected adversely when three divisions of infantry from Italy with attached troops became a part of the theater forces in November 1944o The effect which these heavily seeded divisions had on the incidence of malaria in the theater is best illustrated by examining the individual histories of the units in respect to the disease. The experience of the 1st Infantry Division and of the 2nd Armored division will be used because of the satisfactory and complete records available from the time of their entrance into action in another theater until operations in the European Theater ceased. Particular interest attaches to these observations be- cause rarely are circumstances such that a large body of men are suddenly transported from a highly malarious region to what for all practical purposes was a region free from malaria. The 1st Infantry Division.—The 1st Infantry Division arrived in the United Kingdom from the Zone of the Interior in August 1942. The unit remained in England until November when it sailed for Tunisia. Malaria had been no problem up to that time nor was it during the campaign in Tunisia, since no more than 25 to 30 cases of malaria occurred during the several months in that country. Some few cases were noted in Algiers in May 1943 when the division moved into Oran in preparation for the assault on Italy. (Figure 4) Scarcely had the 1st division landed in Sicily 10 July 1943 when the rate for fevers of undetermined origin rose pre- cipitately. How much of this observed frequency was due to malaria and how much to sand fly fever remains unknown, but the rate for malaria paralleled that of undetermined fever although never approaching it in amplitude of curve. Malaria was prevalent during the voyage to England in late October after the conclusion of the Sicilian campaign. Many recurrent infections were reported after arrival in that country. The spring of 1944 was accompanied by a decided increase in the frequency of malaria just before D-Day, a most distressing cir- cumstance because the troops occupied an important place in plans for the initial assault. 15 The early days of the campaign in France were characterized by rates which exceeded, beyond all comparison, those of the original experience in Sicily and despite the dilution brought about by heavy replacements from battle losses0 Malaria continued to be a signi- ficant medical problem of the division throughout the year, and even in the spring of 1945 the rates were still high* Malaria in the 2nd Armored Division.—The 2nd Armored Divi- sion landed in French Morocco, Nofth Africa from the United States in December 1942* The division was faced with a serious malaria problem from the beginning* During January 1943 the malaria rate reached 235 per thousand per annum0 For the first four months the division was bivouaced about twelve miles east of Rabat* Scattered throughout the area were numer- ous ponds, breeding anopheles mosquitoes in great numbers* Although no actual epidemic of malaria existed in that part of Morocco, local sources of information revealed many chronic malaria carriers in the area, that the adult mosquito population was infected, and obviously the newly arrived troops were highly susceptible* In spite of all protective measures 90 cases of malaria were reported in the division during the week ending February 5o (Figure 5.) Subsequently the number decreased rapidly, to reach a low point in April* With the onset of warm weather the expectancy had been for an increased incidence* Several factors were responsible for the dramatic arrest of the disease* The ponds became smaller and some dried up completely, which reduced mosquito breeding* Soldiers of the division also became more concerned about the dangers of the disease and learned how to protect themselves from mosquitoes* Per- haps the most important single factor was the energetic control of mosquito breeding by the newly organized malarial control unit of the division* Units bivouaced near the worst breeding places had always had the highest rates and these units showed the most dramatic im- provement after control measures were put into effect* In late April atabrin suppressive treatment was started according to existing regulations for the Ncrth African Theater* Because the division was not in combat and because of the excellent results already obtained through mosquito control, the atabrin program was not warmly received* An entirely new environment was encountered in May when the division moved to the region of Porte-aux-Poules, Algeria* Al- though the terrain was primarily rocky and dry, mosquitoes were present in tremendous numbers* The bivouac was unfortunately close to a large swamp area, approximately 30 miles in extent* Mosquito 16 Figure 4 Malaria in the 1st U. S, Infantry Division, North African and European Theaters of Operations, rates per 1000 strength per annum, by weeks, May 1943 to May 1945. Figure 5 Malaria in the 2nd Armored Division, North African and European Theaters of Operations, rates per 1000 strength per annum, by weeks, January 1944 to June 1945. breeding was unbelievably great and although culicines were most common, surveys showed anophelines. Control was difficult by reason of the division being engaged in intensive amphibious training maneuvers0 With considerable moving about and frequent night problems in preparation for the invasion, malaria again became more frequent in June* Most of the 2nd Armored Division took part in the suc- cessful invasion of Sicily in July while the remainder moved to the region of Bizerte0 The Sicilian campaign proceeded rapidly and by the first of August most of the units of the division were well established in bivouacs along the northern coast of the island and west of Palermo, while other units were dispersed over a wide area around Corleone and Prizzi engaged in active patrol duties* The week ending 7 August reached an all time high in newly reported malaria, with 129 cases confirmed by blood examinations for the Sicilian portion of the division and 21 case® for the third of the division in Africa* For the entire division, the rate for August was 309 o Many patients in July were reported as having fever of undetermined origin or as possible malaria because proper diagnostic facilities were not available to units in combat* The later precise determination of the nature of these illnesses accounts in large measure for the apparent abrupt increase in malaria in August, and likewise indicates that the rate for July was much more than the recorded rate of 106 per thousand per year* The malaria rate was greatly improved by the middle of October when the onset of the rainy season virtually put an end to the mosquito breeding control program* The division embarked for England in early November. The history of the division in the United Kingdom was much like that of the 1st Infantry Division* Malaria was comnon immediately after arrival, the winter was marked by a favorable improvement but a marked increase took place in the spring Just before D-Day and again in France during the early months of the campaign* The better record which followed was related in large part to the extensive replacement of individuals infected with malaria as the result of casualties, and of course to the natural evolution of the disease* 17 Malaria In the Seventh Amy.-r-The second principal In- fluence on the malaria rates of the European Theater came from the addition to the theater forces in November of 1944- of the task force from the Mediterranean Theater which had landed in southern France, These troops were heavily infected with malaria, if anything more so than those which had earlier transferred to England, They had been subjected to longer continued exposure. Lacking available individual records of the three divisions which made up that force, the frequency of malaria and the impact on the rates for the theater can best be determined by assessing the behavior in respect to malaria for the force as a whole. The number of troops entering France from the Mediter- ranean during the period 15 August to 1 November when the contin- gent became a part of the European Theater, was 122,088, The cases and rates for malaria according to currently existing strength are shown in Table 4, for the days in Naples immediately preceding operations in France, for the period in France when the force re- mained under the control of the Mediterranean Theater and for the remainder of the war as a part of the Seventh Army of the European Theater, The frequency of malaria in the Seventh Army was repre- sentative of malaria in the troops exposed to the disease in Italy until 10 November 1944, when fresh troops from America first aug- mented the Seventh Army, Since malaria in the Seventh army as a whole was almost completely a factor of the original troops, the rates were consequently greatly diluted. To give a clearer idea of the progress of the disease, rates are presented in column 4 of Table 4 computed from reported cases and the average strength of the original force. This procedure also gives a figure measurably below actual fact, because no allowances is made for losses of the original force from battle casualties, non-battle injuries, and diseases other than malaria. However, the rates on this basis are still great and represent more nearly the course of what took place. The number of troops entering the theater in the first force which came to England was 51*787 and through France by way of the Seventh Amy about 123Q88, a total of 173,875. Service troops and separate units served to bring the total to about 306,459, a figure which is likely low because of casuals and small units that were missed. If the rates for malaria are based on this strength some 24,660 cases of malaria occurred among 306,459 troops exposed to that disease in Africa and Italy and the rate for malaria was about 115 per thousand per year. 18 Comparison with other Theaters of Operation. —--Despite the practically complete lack of acquired malaria the frequency of re- current malaria led to the European Theater having a position of seventh among Theaters of Operation in rates for malaria, The highest rate during the war was that of the African Middle East Theater which was closely followed by the Far Eastern organizations„ The Mediter- ranean rate was high but that in the China Burma India area was de- cidedly good. Little malaria was noted in the American theaters. Table 5, Control Measures on the Continent.—The same general principles that had been defined for the management of recurrent malaria in Great Britain continued to guide activities in the more extensive problem presented in the early months of operations in France, Atabrin suppressive therapy was directed for all personnel with a previous history of malaria. The principles of medical management continued as described in instructions issued Just prior to D-Day, Administrative practice was altered early in the course of operations in regard to the evacuation of patients. On 22 June 1944-, the evacuation policy of the First Army was changed to a 10 day basis, which meant that if patients when first seen were judged to require more than ten days hospitalization they were evacuated to the rear. In order to conserve manpower and to keep in the army area as many men as possible, malaria was divided into two groups, complicated and uncomplicated. Complicated malaria involved patients with cerebral malaria, those with a history of three or more relapses who showed symptoms of persistently palpable spleen, failure to gain accustomed weight, persistent anemia and general lowering of resistance of physical status. Patients with complicated malaria were treated until transportable and then evac- uated. Simple, uncomplicated cases were initially treated in the evacuation hospitals of the army, until subsequently a parti- cular field hospital was designated as a malaria treatment center. Patients were given a full two week course of treatment with quinine and a period in the convalescent hospital before returning to duty on suppressive atabrin therapy. Protection of Patients with Malaria from Mosquitoes,— Many of the newly established hospitals in Normandy were under canvas and almost without exception they were in improvised quarters. Several inspections w$re undertaken to assure that all were familiar with the need to protect patients with malaria from contact with raosquitqes. Action was also instituted to 19 remedy the occasional deficiencies in supplies to accomplish that end, such/as bed nets and mosquito bars. Mosquito Control.-—A sanitary survey of the proposed in- vasion aPrea made shortly in advance of operations and based on in- telligence reports, revealed that large areas along the coast and the low lying sections of the Normandy peninsula were flooded. Under these conditions troops entering the area would likely be under considerable annoyance from mosquitos. Since anopheline species were indigenous to the region, consideration was invited to the possibility of promoting an epidemic of malaria since many of the troops destined for action there were malaria carriers, A period of cool weather during the latter part of June and early July 1944- eased the situation, A field survey of the region in mid-July gave evidence of Anopheline larvae in the vicinity of Carentan, Further identifica- tion was not made but it was presumed for the time that these were atroparvuso The distribution was believed to be spotty and related to the flooded areas near Carentan which were then receding, a cir- cumstance which could be expected to have a favorable effect on mosquito incidence. Information obtained from local French physi- cians indicated little, malaria among civilians of the region. At the request of the Surgeon, Ninth Air Force, a repre- sentative of the Preventive Medicine division made a survey of the area during the latter part of July to determine feasible measures of control. Breeding of mosquitoes was extensive throughout the area but the institution of general large scale control measures such as airplane dusting was deemed neither necessary nor practi- cable, Repellent sprays and bed nets were recommended for hospitals and for seme of the static combat units, such as anti-aircraft gun crews and ground crews of the air corps. The species of mosquitoes most commonly found were culex pipiens, Aedes caspius, Theobaldia annulata, anopheles of the maculopinnis group, both the fresh water breeder, messeae, and the brackish water breeder, Labranchiae atropavus. The last named species was found breeding in enormous numbers in pools left by the receding flood waters, a sufficiently high mosquito population to support a malaria epidemic was believed unlikely despite the numbers of recurrent malaria cases among American troops. No cases of in- digenous malaria were reported among American troops that summer. The British to the north around Caen had some 40 cases, with about 500 cases among civilians. 20 The addition of large areas of southern France to the territory of the theater in November 19-44 brought a malaria district of more serious proportions, actually the only part of France where malaria was of any particular consideration Figure 6* An aerial survey of the coast during the latter part of February indicated favorable mosquito breeding places in the vicinity of areas where American troops were stationed, particularly those around Miramas, and the Marignane and Istres Airports, Consider- able difficulty from salt water breeding Aedes was also antici- pated in the localities farther east where recreation centers were being established. A concerted mosquito control program was therefore initiated by the Delta Base Section, beginning about 15 April 1945, to prevent mosquito breeding within a five mile radius of the three areas mentioned. When staging areas for the re- deployment of troops were established in the Marseilles dis- trict, still nearer the heaviest anopheles breeding places, control operations were necessarily greatly expanded. About 900 German prisoners of war and Yugoslav laborers were employed in ditching and clearing the affected areas. Airplane dusting with DDT was used extensively. Mosquito bars, repellents, aerosol bombs and DDT residual effect sprays were employed in barracks, tents, and buildings. Since a number of the recommended procedures were of recent development and not always familiar to medical and other officers, specific directions for their use were issued as a theater directive. As a further aid in the application of pre- ventive measures against malaria, the comprehensive Technical Medical Bulletin of the War Department on that subject was re- published as a circular letter of the Office of the Chief Surgeon. 21 plague.—No American soldier stationed in the European Theater ever contracted plague* As a matter of fact, plague was absent from the United States forces throughout the world during the whole course of the war* Furthermore no plague infected rat was ever identified on board a United States ship during the course of active operations* The first threat of plague came when troops of the theater were stationed in Great Britain* This infectious disease appeared in the Azores Islands during the autumn of 1942, when 54 cases occurred among natives* It reappeared in lesser numbers in 1943 when American troops were stationed there and again in 1944* The sources of infection were well removed from islands where United States troops were located and the danger was actually minimal because of the energetic action taken ad, American installations to eliminate rats and fleas* The possibility nevertheless existed that plague might be inported into Great Britain because of the extensive air travel which came through the Azores* Ports of entry for international air traffic were advised of the situation and emphasis was placed on sanitary inspection of airplanes and the control of passengers arriving in the theater by way of those islands. The territory lying along the Suez Canal was a recognized plague area of long standing* The disease had last been reported in 1932, the Suez remaining free from plague until 1939*. Some few scattered cases were reported at that time and there is every reason to believe that an epidemic began to build up from then on, because each year a few scattered infections occurred* A serious epidemic developed in November of 1943o The disease spread northward, in- volving a number of towns and villages, and eventually became epidemic in Port Said in April 1944q In all, the number of cases in the area during the winter of 1943 - 1944 was 1581* The heavy shipping passing through the Suez Canal made the existence of this relatively remote outbreak of more than usual concern to the European Theater* Dakar and West Africa generally had a long history of plague* The region was a characteristic and recognized endemic focus of the disease* The war brought a generally decreased emphasis on rat control from 1939 to 1944* and there was general agreement 22 Figure 6 Search for malaria vectors, Marseilles district, April 1945, among local observers that the rat population of Dakar had in- creased measurably,, It was therefore not surprising that plague appeared in the city on 20 April 1944 and that rather typically the first infection involved a native occupying a guard hut near the docks of the arsenal district,, The outbreak reached its height in mid-summer, with a gradual decrease in number of cases during the autumn months so that the last case of plague in Dakar was noted on 24 November 1944» The number of persons infected, all civilians, was 5660 A small outbreak of plague in Oran in early 1945 was of still more intimate concern to health authorities of the European Theater, because of the extensive maritime and air traffic between the North African coast and the French port of Marseilles« The outbreak in Oran was a part of a general increase in plague along the North African coast which started in Ferryville in the autumn of 1944o The first recognized infection in Oran was on 29 December 1944, with death of the patient in the early days of January„ Sub- sequently, eight other natives contracted plague, all of the pneu- monic form„ Plague of both bubonic and septicemic forms appeared in Casablanca on 20 July 1945» The outbreak was limited to three cases, two natives and one European, with no cases among American soldiers stationed in the city0 The reported cases occurred within a single week, which speaks for the efficiency of the control measures em- ployed o Epidemiologic Investigations^—The presence of plague in a number of African ports led to several instances of suspected plague on ships calling at French ports„ The SS Batory left Algiers, then a plague port, proceeded to Great Britain and subsequently called at Morlaix on 21 October 1944« A French soldier had' died enroute, and the ship carried United States Army personnel0 In- vestigation of the circumstances at the port of call in Great Britain revealed a death from septicemia believed not to be plague, but remaining unconfirmed because proper specimens were not taken for bacteriologic examination,, No case of plague developed among French or American personnel,, Contacts had been isolated immediately and the entire personnel inspected daily« Inspection at the port of Plymouth by British Health authorities revealed no suspicious cases„ At Morlaix all passengers and crew were examined, with no reason to believe that plague had existed or was present on board the ship,, No dead rats were found and the sanitary condition of the ship was satisfactoryo On the 7th of November 1944 the SS Alfred Moore arrived at Marseilles with report of the death of a French soldier at sea ployed. 23 from an illness suspected of being bubonic plague. The ship was placed in quarantine pending inquiry. Pathological and bacterio- logical examinations of tissues obtained at autopsy of the patient failed to reveal evidence of plague. Despite the laboratory report the ship was treated with DDT residual spray and personnel were dusted with DDT powder. No secondary infections occurred among contacts during the time the vessel was quarantined in the outer harbor. Several ships engaged in traffic from North Africa during the Spring of 194-4 called at the port of Agaccio in Corsica where plague had been identified. On arrival at Marseilles quarantine was practiced before passengers were disembarked. No reported case of plague went uninvestigated. Perhaps the greatest number of suspected cases arose from errors in compiling the Weekly Statistical Report. The item pneumonia directly followed that of plague on the prepared fora, with the result that from time to time a clerical error caused a case of pneumonia to be reported as plague. The location of the unit ordinarily served to identify the probably nature of the circumstance, but individual investigation was nevertheless made. In all instances of reported plague in the course of mari- time traffic arriving at ports of the European Theater, confirmation of the diagnosis remained indefinite. It is doubtful that the European Theater was ever directly exposed to the danger of plague infection. Control Program—Because of the particular circumstances which made Marseilles particularly susceptible to the introduction of plague. Delta Base Section maintained a continuing program of rat control measures, utilizing a four man team in and around the city. No plague infected rat was ever identified. A comprehensive program for the control of plague was pre- pared in anticipation of possible difficulty. The experience at Dakar had demonstrated the usefulness of DDT as a means of direct attack on the flea through disinfestation of persons and premises, rather than the indirect approach through rat control. The later experience at Oran confirmed the usefulness of sulfadiazine' as a chemoprophylactic agent in management of contacts. These important additions to the program of plague control were combined with recognized measures of immunization, quarantine, and rat control. 24 french Fever.—Medical intelligence reports of early Decem- ber 1944 indicated that the German Army.in the Netherlands was ex- periencing a five day fever sometimes termed Wohlhynian fever* It appeared to have occurred over the past three years and to have been observed also in Greece and in Russia* At times as many as 15 per- cent to 20 percent of troops of a command were affected* It was rarely fatal* The chief clinical features were described as pain and tenderness of the legs and over the lumbar region; with some headache and prostration during the fever* The temperature was commonly elevated for a week, and tended to reappear suddenly after five or six days* The total duration of the illness was sometimes as long as two or three months* The disease was con- sidered to be transmitted by body lice* The clinical features of the condition described were similar to those known as Trench Fever in World War I, a febrile illness of rapid onset with temperatures reaching 103° F* and 104° accompanied by dizziness, severe headache, eye pain, conjunctivitis, and occasionally leucocytosis* The feces from lice fed on patients had been shown to be infective* The intelligence reports were passed to Surgeons of armies for their information, since the Germans had experienced this infection in the areas where some of our armies were then engaged* Routine inquiry was made of captured, German medical officers and of prisoners of war from the enemy medical depart- ment* No evidence was ever obtained that the infection existed among American soldiers, nor that the disease was prevalent among the German military command engaging American forces* Only twice in the history of the theater was a case of Trench Fever reported, one being from the 15th United States Amy on 1 June 1945 and the second in July 1945o Confirmation of the diagnosis was never obtained in either instance* As a matter of fact, these were the only two cases of trench fever reported in the U* S* Army in the course of the war from all theaters* 25 Pappataoi FeverSandfly fever was not a disease indi- genous to any part of the area included within the European Theater. The disease was reported among troops who arrived in southern France from the Mediterranean Theater in the course of Operation Anvil* Thirty-three patients were admitted to the 2yth Evacuation Hospital between 1 September and 20 September 19W+» mostly from a single unit. With the movement of troops northward, the advent of colder weather and the absence of the sandfly vector, no more oases occurred. The diagnosis was made by medical officers long familiar with the condi- tion through experience in Italy and Sicily, and the outbreak occurred shortly after the men arrived in the theater. There is no reason to doubt the nature of the condition. During 19J-15» two oases were reported in May and five in June. In the African-Middle East Theater this disease constituted a principal medical problem, with an average annual rate of 25»75* Sandfly fever was relatively frequent in the China-Burma-India and Mediterranean Theaters, but largely absent from other areas of in- fluence * (Table 6) Relapsing Fever.—Relapsing fever has never been reported with any considerable frequency in Great Britain or in the territory included within countries of northwest Europe. During the course of operations, only two cases of relapsing fever were incorporated with- in medical records of the Theater. One case occurred in Great Britain and the other on the continent. EPIDEMIOLOGIC CASE REPORT NO. 1. An enlisted man serving with the 280th Station Hospital since February I9I4J4. was admitted to hospital on 7 August 19144- with the complaint of lossof appetite of four or five days dura- tion, drowsiness, and fever for one day. His temperature was IO30 Fo, the throat moderately injected, and a sparse maculopapular eruption was generally distributed over the body. An intermittent fever reaching heights of 102° F. and IO30 F. occurred each evening until 12+ August, aocora- pained by transitory inflammatory joint involvement. The generalized skin eruption continued, with new lesions appearing each day and progressing through a series of changes from macules to maculopapules and gradually fading with a residual pigmentation. The blood was negative for malarial parasites. After a week of freedom from fever, he 26 was readmitted on 27 August with a temperature of 103#2°F., complaining of headache, and tenderness and aching of the legso The skin eruption was again evident and the course was characterized by daily fluctuations of temperature from 98° F. to 103° Fo Dark field examination of the blood re- vealed motile organisms similar to Borrelia reourrentis# Similar though imperfectly stained spirochete's were found in stained blood smears# Mouse innooulation resulted in illness of the animal and spirochetes were found in the blood# The diagnosis of relapsing fever was made*. The history gave no evidence of louse or tick bites prior to the onset of illness, nor had there been known contact with insects or animals# The patient had slept in a haystack about a week prior to the onset of his illness and the rash appeared a few days later. For all theaters, the disease was uncommon# The number in Continental United States was 25# and for overseas theaters 159® The majority were in the China-Burma-India theater, 91 in all, while 37 occurred in the Mediterranean Area and 22 in the African-Middle East Theater# (Table 7) Dengue Fever#—Dengue fever was not indigenous to the area included within the European Theater and no cases were known to have been imported through arrival of troops from the Mediterranean or other areas# Leishmaniasis,,—Four patients with Leishmaniasis were admitted to hospital during thecourse of operations in Europee Three oases determined in Great Britain were representative of the visceral form of the diseaseo An instance of cutaneous leishmaniasis was observed in a soldier serving on the continent0 All four patients gave a history of previous service in Africa,, EPIDEMIOLOGICAL CASE REPORT N0„ 2. An enlisted man took part in the African and Sicilian campaigns,, He re- turned to England in October 19143° With the exception of mild diarrhea in Sicily and enroute to "England his health had been reasonably good until 2 December 1914-3° He then had shaking chills and fever with a slight cough, but no other complainto The symptoms continuing, he was admitted to hospital on 6 December 19h3 "with a temperature of 105° F„ Blood studies showed Ij.o2 million red blood corpuscles and a white blood co.unt of 6,200 with 35 P9** cent polymorphonuclear leucocyteso The patient continued a remittent fever, varying 27 ■between 102° F. and 101|° F, with almost daily chills* The number of leucocytes decreased to the ij.,000 level, with slight lowering of polymorphonuclear cells to about per cent* A moderate anemia developed and on the 12th day of the disease a therapeutic trial of atabrine had no effect* On 19 December the spleen was noted to be about two centimeters below the oaustal margin on deep inspiration* There was a slight generalized lymphadenopathy. Sternal bone marrow smears re- vealed leishmania both inside and outside cells* A splenic puncture on 15 March 19i4i+# served to reveal leishmania on direct smear and culture* EPIDEMIOLOGICAL CASE REPORT NO. 3* An enlisted man was admitted to hospital 8 January 19h5p complaining of an ulcer on the left wrist of nine months duration* He had service in the North African "campaign, including a short term in Corsica* In mid April 19kh» he noticed a pea sized painless lump just above the styloid process of the left wrist. This gradually increased in size and broke down to form an open running s ore about three centi- meters in diameter and surrounded by an area of erythema which was painless. Numerous subcutaneous nedules and palpable cord-like thickenings of the lymphatic vessels surrounded the ulcer* Laboratory examinations of exudate from the lesion revealed numerous Leishman- donovan bodies* Other Theaters of Operation*—The Africa Middle East theater was the center of leishmanasis for the United States Army* No loss than 515 of the cases for troops of the array as a whole occurred in that locality* The four that were noted in the European theater came from that endemic focus of the disease* Other than the China-Burma-India theater only scattered oases were observed else- where* (Table 8) 28 Month Total iq U2 19*2 !c )U1+ 19U9 Cases Hate Cases Rate Cases Hate Cases Hate Cases Hate January 123U Uo60 0 3 .27 325 5-29 906 Uo62 February 1302 u.57 0 - 3 .35 327 u.65 972 U.72 March 2971 7-88 0 - 0 - 760 7.36 2211 8*36 April 3399 I0o5l 0 - 0 - 1072 11-53 2327 10.63 May . U160 12. Uj 0 - 2 0 21 1632 l6„2U 2526 HoUO June 3773 9-29 2 -56 8 066 1517 H-93 22U6 80 52 July 1921 lU.29 1 .16 5 .26 1915 17 -58 August 1533 9-89 6 .68 3 0I6 152U 12o01 September 1022 5ol2 U -32 k .17 101U 60 20 October 825 U. 29 5 *30 **3 . lol? 777 5-58 November 951 U065 1 0O8 207 5 = 05 7*»5 U.87 December 1660 5-52 1 oil 392 6.03 1267 5-59 Total 2U75I 7-78 20 0 28 670 2.51* 12873 8.71* 11188 8„l6 Source s Medical Stal iistics I )ivision i, Offic e of th b Surge© n Genera il6 War Departnw snt 9 WashingtonB D0 Co Malaria Suropean Theater of Operations, U0S0 Army Cases and Hates per 1000 strength per annum, by months February to -June I9U5, Inclusive Table 1 Month Tc >tal 19*2 19*3 19 UU 19 Cases Rate Cases Hate Cases Bate Cases Bate Cases Bate January 812 3o0 7 .6 31 o5 77** 3-9 February 9^2 3o3 0 - 3 oU 27 ok 912 u.u March 1716 ba 6 0 - ll 1.3 155 1-5 1550 5-9 April 191b 5-9 0 - 7 o7 122 1.3 1785 8,2 May 2079 6,2 1 -5 2 .2 1U2 lob 193* 8.7 June 1923 baJ 0 - 2 0 2 292 2-3 1629 6.2 July 232 1.7* 6 .9 8 oU 218 2o0 August 6U6 U.2 5 06 9 -5 632 5-0 September 232 1. 2 7 • 6 b ,2 221 IcU October 192 loO 13 08 11 -3 168 1.2 November 230 lol 16 loU 21 <.5 193 1-3 December 955 3»2 3 o3 83 1.3 869 3o8 Total 11873 3.7 51 -7 168 06 3070 2.1 858U 6-3 Sources Division of Medical Statistics, Office of the Surgeon General, War Department, Washington, Do C0 Undiagnosed Fever European Theater of Operations, U.S. Army Cases and Bates per 1000 strength per* annum, by months February to June 19^5» Inclusive Table 2 Month Malaria JO Fndiagnosed Fever Total United Kingdom Conti rn©nt Total United Kingdom Contiz lent Cases Hate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate ismr September 101U 6c 20 536 gel Uyg H-9 221 loU 6U -97 157 1.6 October 777 5-58 232 5-6 5U5 5-6 168 lo 2 33 -79 135 loU November 7^3 U.87 178 565 5-1 193 1-3 20 -**9 173 1.6 December 1267 5-59 1U0 2»3 1127 60g 869 3-8 U6 -77 823 Uc9 19U5 January 906 U062 93 1»9 813 5-5 7JU 3-9 31 -63 7U3 5-1 February 972 60 l. 3 912 5-7 912 UcU 21 oUU 891 5-6 March 22X1 8.36 69 loh 21U2 10c 0 1550 5-9 39 -77 1511 7-1 April 2327 10.63 TU io9 2253 120U 1785 802 36 -93 17U9 9-7 May 2526 11,1*0 68 203 2U$g 12o 8 193U 8o7 18 060 1916 10c0 June 22U6 go 52 61 lo3 2185 10c 1 1629 6o2 * ♦ total IU989 7-30 1511 3-2 13U78 8*5 10035 308 -73 8098 * Data not available Sources Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, Do C0 Malaria and Undiagnosed ?ever United Kingdom and Continent European Theater of Operstti-ons, U.S„ Army Cases and Rates per 1000 strength per annum by months September to June I9U5, Inclusive Table 3 Table 4 Malaria in the Seventh U„S0 Army (a) European Theater of Operations, U0S„ Army Cases and Rates per 1000 strength per annum, by weeks Week ending 18 August 1944 to Week ending 29 June 1945, Inclusive Week Ending Cases Rates based on Army strength Rates based on strength of ori- ginal MTO contin- gent 1944 - August 18 97 44o3 25 616 273o0 September 1 433 174 o 7 8 410 163.4 15 333 141*0 22 326 143.4 29 301 116.2 October 6 260 111. 2 13 223 95*7 20 247 104.1 27 265 117 o 4 November 3 172 77.7 10 145 57.6 61.76 (b) 17 , 165 58.3 70.28 24 47 13.6 20.02 December 1 40 10.3 17.04 8 53 13*5 22.57 15 43 10.9 18.31 22 33 8o0 14c 06 29 47 11.2 20.02 1945 - January 5 42 9*6 17.89 12 43 9*5 18.31 19 41 8.7 17.46 26 46 8.9 19o59 February 2 58 10.1 24 c 70 9 68 11c 3 28.96 16 73 13o8 31c 09 23 85 16.4 36.20 Table 4 (Cont'd) Malaria in the Seventh U.S0 Army European Theater of Operations, U0So Army- Cases and Rates per 1000 strength per annum, by weeks Week ending 18 August 1944 to Week ending 29 Jfctne 1945* Inclusive Week Ending Cases Rates based on Army strength Rates based on strength of ori- ginal MTO contin- gent 1945 - March 2 96 18o0 40o89 9 136 26,3 59o93 16 203 33o9 86o46 23 120 20o0 51 oil 30 207 34o5 88ol7 April 6 175 31.1 74o54 13 191 34»5 81,35 20 242 43o6 103o07 27 199 34o6 84,76 May 4 369 65,0 157ol7 11 313 48,9 133o31 18 400 6601 170o37 25 372 60o 6 158,44 31 308 51o2 131.18 June 8 255 32o8 108,61 15 71 (o) 6o0 30o24 22 36 3,8 15.33 29 . 42 _ 4o6 17o89 Total 8447 38.8 78o21 (a) Troops of Seventh Army landed in Southern France 15 August 1944o ($) First additions to troop strength from non~MT0 sources (c) 3rd and 45th Infantry no longer shown in Army reports0 The 2d Armored Division was added0 Sources Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, t) 0 Co Theater Total U2 19 **3 19^ 191 [5 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army U23869 20o0 19067 60 2 160715 23*9 I6U165 21,9 79922 20,6 Continental U,S, 76829 5*9 1598 06 8U7U 1.7 32292 8,1 3W+65 23*9 Total Overseas 3U70UO 1*3.2 17U69 3^o 1522U1 96* 131873 38,0 1*51*57 18,7 China-Burma- India 125*0 9U1 16.5 8316 181,0 27777 17**. U511 37*3 South West Pacific 103395 85*7 3533 52,7 U783U 2U5ol 29590 53oU 22U36 57.6 Africa-Middle last 10365 79*5 780 136. 6537 123*0 2781 59*0 267 11,2 Pacific Ocean Area 81263 77*8 1780 1201 61U39 208ol 16955 1*3.0 1089 5*3 Mediterranean 69580 51.u 221 10. u 23076 53*5 U0682 61.7 5601 23*3 Latin America 16073 U60I 10156 99* >*355 36.0 1206 ih,o 356 9-1 European 2U751 7o8 20 *3 670 2*5 12873 8*7 11188 8,2 Horth America **7 *3 25 0 6 7 ol 9 0 2 6 *U Alaska 23 .1 13 *3 7 *1 0 .0 3 ol Sources Division of Medical Statistics8 Washington8 D„ 0o Office of The Surgeon Generals War Departments Malaria Total Army, Continental United States and Theaters of Operations, U.S. Army Cases and Hates per 1000 strength per annum January to June Inclusive Table 5 Theater Total ■ 1 1 ■ ... 19U2 19U3 19 UU 19U5 Cases Kate wases Kate Cases Hate I “Oases Hate cases Hate Total Army Continental 10726 -51 310 olO 3332 0 lTk O 6189 .82 895 .23 United States 0 0 0 0 0 0 0 0 Total Overseas African-Middle 10726 1=33 310 c6o 3332 2o09 6189 1.77 895 -37 East 3357 25° 75 287 50«,02 2081 39-00 920 19.^2 69 20 89 Mediterranean China=Burma- H95T 3-66 0 — 581 1-35 3753 5.69 623 2.59 India 2361 7.u 12 2ol3 666 lU„H6 1U92 9-35 191 lo58 Latin American Southwest 10 c03 k oOU 3 0O2 3 .03 0 0 Pacific Pacific Ocean 30 0 02 7 olO 1 o01 21 oOL 1 0 8 Area k oOOU 0 — 0 0 0 k o02 European 7 o002 0 ~ 0 0 0 7 o01 North American 0 0 . 0 - 0 0 0 - 0 0 Alaskan 0 0 0 — 0 0 0 — 0 0 Sources M W edical Statist! ashingtonB D, C cs Divls 0 ionB Off —--— 3 ice of The Sur| ;eon 0-cn eral, Wg ir Departments Sand Fly Fever Total Army, Continental United States and Theaters of the U„ S„ Army, Cases and Rates per 1000 Strength per Annum January I9U2 to June Inclusive Table 6 Table 7 Relapsing Fever Total Army* Continental United States and Theaters of Operations, Number of Cases January 1942 to June 1945, Inclusive Theater Cases Total Amy 184 Continental United States 25 Overseas 159 China-B urma-Indi a 91 Mediterranean 37 Africa-Middle East 22 European 2 Latin American 5 Southwest Pacific 2 Alaskan 0 North American 0 Pacific Ocean Area 0 Sources Medical Statistics Divisions Office of The Surgeon General, War Department, Washington, Do C* Table 8 Leishmaniasis Total Amy, Continental United States and Theaters of Operations, Number of Cases January 1942 to June 1945, Inclusive Theater " Cases Total Amy 344 Continental United States 4 Overseas 340 Africa-Middle East 315 China-Burma-India 17 European 4 Mediterranean 3 Latin American 1 Alaskan 0 North American 0 Pacific Ocean Area 0 Southwest Pacific 0 Sources Medical Statistics Division, Office of The Surgeon General Washington, Do C. s War Department FIGURES 1. Distribution of indigenous malaria in Great Britain, during the 18th century and after the 1914-18 war • 2* Special study of recrudescence and relapse after primary malarial attack. First General Medical Laboratory, England, 1944. 3. Distribution of indigenous malaria in countries of Western Europe, showing areas of high and low indemioity. 4. Malaria in the 1st U. S. Infantry Division, North African and European Theaters of Operations, rates per 1000 strength per annum, by weeks. May 1943 to May 1945. 5. Malaria in the 2nd Armored Division, North African and European Theaters of Operations, rates per 1000 strength per annum, by weeks, January 1944 to June 1945. 6. Search for malaria vectors, Marseilles district, April 1945. TABLES 1. Malaria, European Theater of Operations, U. S. Army, Cases and Rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive. 2. Undiagnosed Fever, European Theater of Operations, U. S. Army# Cases and Rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive. 3© Malaria and Undiagnosed Fever, European Theater of Opera- tions, U. S« Army, United Kingdom and Continental Europe, Cases and Rates per 1000 strength per annum, by months, September 1944 to June 1945, inclusive. 4# Malaria in the Seventh U, S. Army, European Theater of Operations, U, S« Army, Cases and Rates per 1000 strength per annum, by weeks. Week ending 18 August 1944 to week ending 29 June 1945, inclusive. 5* Malaria, Total Army, Continental United States and Theaters of Operations, U. S. Army, Cases and Rates per 1000 strength per annum, January 1942 to June 1945, inclusive. 6. Sand Fly Fever, Total Army, Continental United States and Theaters of Operations, Cases and Rates per 1000 strength per annum, January 1942 to June 1945, inclusive. 7. Relapsing Fever, Total Army, Continental United States and Theaters of Operations, Number of Cases, January 1942 to June 1945, inclusive. 8. Leishmaniasis, Total Army, Continental United States and Theaters of Operations, Number of Cases, January 1942 to June 1945, inclusive© EPIDEMIOLOGIC CASE REPORTS 1* Relapsing fever, occurring in Great Britain. 2* Leishmaniasis, visceral form. 3. Leishmaniasis, cutaneous form*