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families. One of the women lived at a boarding house a week while sick, previous to going to bed, and with two others apparently was infected by a carrier at the boarding house, one case had an onset the same as the first mentioned person and the other followed seventeen days later. It is probable that, with an interval of only seventeen days between onsets, there was a common source for both cases. Wheeling Typhoid Fever. An investigation was commenced to determine the economic effect of the endemic typhoid fever upon Wheeling, but was interrupted before being completed. Only one day could be given to the investigation, but during that time the homes of 42 cases of typhoid fever were visited and data were obtained from 22 families. The average cost to the person was $58 per case of typhoid fever. This included the cost of medical attendance, medicine, nursing, hospitalization, and loss of wages; only five of these patients were wage earners, nearly all being children. The only other expense which should be considered is the difference in cost of food, which would be an actual saving, but very difficult to determine.

Expense of medical services to 22 patients..

Expense of medicine, estimated by patients..
Wages lost by the 5 wage-earners..

Hospital expense of 3 patients.....

Private nurses at home for 2 patients.

Total expenses for these patients..
Average expense per case of typhoid.

Wheeling's 199 cases during 1917 may have cost.

$

587.50

77.80

360.42

180.75

85.00

1,291.47

58.70

11,692.30

This cost should be balanced with the capitalized cost of a safe water supply. Elm Grove-Typhoid Fever. Because the bacteriological analysis of the city water supply showed unsatisfactory conditions, and investigtion was made November 14th, although no cases of typhoid fever had been reported from that district. The county health officer, who lives at Elm Grove, stated much typhoid had existed there during the summer, but he made no investigation and did not report the cases he attended personally. The investiagtion uncovered the following number of cases of typhoid in families using the municipal water; July 2 cases, August 12, September 12, October 7 and November 8 cases. The greatest incidence was in the weeks ending September 8th and 15th, five cases being reported for each week. Elm Grove receives its water from Wheeling creek at Patterson, a near-by suburb. The waterworks were found to be equipped with a mechanical filter. The log records at the plant showed that no coagulants were used between July 22 and August 6, 18 and 22, 27 and 30, September 1 to 6, 18 to 22, 27 to 30, October 1 to 18 and November 4 to December 1 (verification by later visit). The operative at the plant said coagulants were for overcoming muddiness and when the water was clear no coagulants were used; when used the amounts varied between .28 and 11.9 grains per gallon or .04 and 1.5 pounds per 1,000 gallons. One of the physicians interviewed stated that he attended a typhoid patient, with onset August 19, living on Barnett creek, three miles above the intake of the water supply, that the family privy overhung the stream and received the typhoid dejecta, although part of the time the family had a trained nurse. This physician is the town's health officer and he neither reported this case to anyone nor made any effort to see if it might endanger the drinking water. The necessary action needed for the city was an improvement of the water supply; the epidemiologist wrote to the West Virginia Traction and Electric Company

advising the minimum dosage for clear water to be .5 grains per gallon or .07 pounds per 1,000 gallons. An inspection made December 9th showed this minimum to be followed and no cases of typhoid were reported to have occurred during the three weeks following its adoption. The three weeks previous gave five known

cases.

Kanawha Valley-Smallpox. The first investigation of the outbreak was made November 2, the next day after the attention of the director was first called to the situation by a man, with smallpox, who was seen in a doctor's office. Then at Marmet it was found that one case of smallpox was in quarantine, that seven members of two families had had smallpox in October, and that another family living up Lens Branch had had five cases, beginning in July. None of these had been reported to the department. A local physician had seen these mild cases but had made no vaccinations nor instituted quarantine. One family was advised by the county smallpox physician to remain at home. Many exposures resulted locally. After a trip to Wheeling the work against the outbreak was taken up on November 9 and continued nearly daily until the 28th. On the ninth at Marmet five houses were visited and two cases found and quarantined. November 10th a general quarantine was placed by the State Health Commissioner over Marmet November 11th permits to travel were issued to 62 persons at Marmet, they having been vaccinated. Not one of them developed smallpox. November 15, in Malden 143 children were examined in school; at Marmet 14 were vaccinated; at Chelyan several houses were searched, finding but six cases of varicella, November 16, visiting with the county health officer, inspected a case and vaccinated five; in Oakland saw two cases and vaccinated five, and in Longacre vaccinated 42. November 17, at Berlin eight cases were found, at Quarrier three, and ten persons vaccinated. The store at Quarrier was closed after business hours and the coal manager was consulted. Leewood and Eskdale were visited. November 18, the wholsesale business houses of Charleston agreed to require vaccination of their traveling salesmen. November 20, vaccinated 76 at Chelyan and searched Handley. November 21, tracked down rumors of cases at Witchers and found chickenpox; also vaccinated 26 at Marmet. November 22, visited seven cases. November 21, tracked exposures at Clendenin, quarantined two families and vaccinated 30 persons who were exposed. November 26, visited St. Albans and South Charleston, vaccinating five exposures. November 27, at Ward, saw three cases under quarantine and vaccinated 55. The local physician, Dr. Flannagan, with two nurses were vaccinating everybody at the camp. During these trips a petition was circulated and was anxiously signed to demand compulsory vaccination. Upon presentation to the County Court it was at once adopted making vaccination compulsory for school children and others in Kanawha county, in accordance with Section 21, Chapter 150 of the Code. The work of Dr. H. C. Scaggs, county health officer of Fayette, is especially commendable in his efforts to control the outbreak. Several thousand persons in the two counties were vaccinated thereby checking the outbreak. Through the cooperation of Mr. Geo. S. Laidley, Superintendent of Charleston schools and with the assistance of local physicians, all the school children of the city were vaccinated, the school board furnishing the vaccine.

Pierce-Typhoid Fever. A trip was made to Pierce, Tucker county, at the request of Dr. H. R. Werner, city health officer of Thomas. Pierce is a coal town located on Sand River one mile above its mouth which is on the Blackwater river, two miles above Thomas. It contains 108 residences. There were 14 cases of

typhoid fever with one death in eleven houses, and mostly occupied by foreigners. At one house the Italian housekeeper nursed two men with typhoid fever and milked three cows, furnishing milk to eleven families. The dairy was at once closed. Six men were immunized against typhoid. A carrier is supposed to have been the distributing agent. To combat the outbreak, the Buxton and Landstreet Coal Company was advised to established a local hospital and to move all patients into it. Immediate action was taken and the advice followed. Sanitary privies had been used. They were plentifully sprinkled with lime. They were located along the banks of Sand river, which was then frozen over, all were full and overflowing. A cleaning of them was commenced at once. The water for Thomas was pumped from the Blackwater river and supplied to consumers untreated. Owing to the danger of a future waterb-orne outbreak of typhoid, a telegram was sent to the engineering division of the state health department asking that an emergency chlorinating apparatus be installed. Within three days it was in service.

Berkeley Springs-Diphtheria and Scarlet Fever. Owing to some local disturbance and the indefinite reporting of diphtheria in a family, the trip to Thomas was continued to include Berkeley Springs. The family reported as being diphtheritic was found to have six cases of typical scarlet fever. This had not been reported. Three other unreported cases of scarlet fever were located. Physicians were consulted and the County Court addressed upon important local health questions. The silica and sand works were visited to note any influence they could have upon inducing tuberculosis. The influence exerted at the pulverizing mill was considered to be very great, since the men work in and constantly inhale the dust of the powdered sand.

Logan County-Smallpox. An extensive outbreak of smallpox in the valley of the Guyandotte river was reported and an investigation made upon request from a local coal company. The investigation was made January 11 to 13, 1918. Numerous unreported cases were found. At Amherstdale three cases with onsets in December were seen, in Logan five cases, Shamrock five cases, Cora one, Gay one and at Loma one case. None of the persons who had smallpox had ever been vaccinated. Thirty-four persons were vaccinated by the epidemiologist and many by local physicians. Posters on smallpox were posted in the railroad stations.

Gibbstown-Smallpox. By direction of Governor Cornwell, to whom a complaint had come, an investigation was condusted in northern Mason county. At Gibbstown a local physician previously had seen some cases which he diagnosed as chickenpox and did not vaccinate anybody nor isolate or quarantine any of the persons involved. Nine cases of mild but distinct smallpox were found and seventeen persons were vaccinated. There were no later cases reported.

Edgington-Smallpox. The Home of the Good Shepherd, a convent in Edgington, maintains a large modern laundry doing public work. The girls of the convent do the laundry work. There are about a hundred and fifty children and many sisters. An explosive appearance of smallpox among the laundry workers excited the neighborhood, resulting in a request for assistance. The first persons to develop smallpox began showing symptoms January 14, 1918. Within eight days, up to and including the day of the investigation, 48 cases of smallpox developed. There were nine sisters who developed the disease. Not one person who had smallpox had ever been vaccinated. The investigation revealed the fact that about Christmas time a little girl was admitted to the convent, having pustules on her hands but her condition was not suspected nor recognized, although

she told a sister her little brother at home had had the same kind of spots on him. The entire outbreak came from this one exposure. The ages of the persons infected ranged from eight to twenty-seven, Three days before the investigation was made the disease was recognized, and all others in the convent were vaccinated up to the previous night, excepting seventeen who were omitted because of shortage of vaccine. These were vaccinated by the epidemiologist. Owing to the supposed isolation of the persons of the convent it had not previously been deemed necessary to require vaccination, but the authorities agreed to vaccinate all future applicants on admission. The soiled clothing brought into the laundry had nothing to do with the introduction of the infection, else the girls who handled the clothing would have been the first to become infected. This was not the case. Not half the girls who handled soiled clothing and none of the drivers had smallpox. The laundered clothing did not carry the disease from the laundry to the homes of the patrons. The operation of the plant was suspended two weeks. None of those vaccinated contracted smallpox, and no outside cases occurred. Respectfully submitted,

H. B. WOOD, Director Division of Preventable Diseases.

ANNUAL REPORT OF DIVISION OF SANITARY ENGINEERING

DR. S. L. JEPSON,

State Health Commissioner,

DEAR SIR:

Charleston, West Virginia.

I have the honor to submit herewith the third annual report of the Division of Sanitary Engineering of the West Virginia State Department of Health. This report covers the fiscal year from July 1st, 1917, to July 1st, 1918.

The creation of the Division of Sanitary Engineering, its duties, powers and organization were all discussed in some detail in the first annual report, and I do not feel that it is necessary to comment upon them again at this time other than to note that owing to the pressure of work, the Division has found it impossible to assume, as yet, some of the duties imposed upon it by the act of legislature creating it. For example, we have not yet been able to take up the problems of the disposal of trade wastes, the sanitation of mines, or dairying methods. For the first two years our work was largely devoted to the improvement of municipal water supplies; more recently we have been turning our attention to general sanitation, and now rural sanitation occupies the field.

It should be recognized that the greater portion of morbidity in the city originates in the country. We commonly think of the cities as unhealful places in which to live, and speak of getting back to the fresh country air, pure water, fresh milk, and fine vegetables, yet experience the nation over has shown that because perhaps of the poorer heating facilities in the country homes the windows are kept closed and tuberculosis is rampant; the “pure” water is polluted by the insanitary privy; the milk is handled by the same antiquated methods used by our grandfathers, and commonly is contaminated with stable manure and other filth, and the lack of ice means that its bacterial count mounts to such figures that diarrheal diseases in infants are by no means uncommon on the very farms where good milk should be had.

Considerable work has already been done in rural sanitation. A complete and careful survey was made of the entire county of Braxton. This survey is commented upon at greater length elsewhere in this report. Selected communities

have been surveyed and given a rating based on the general sanitary tone of the community. During the coming year it is our plan to devote much of our time to the sanitation of mining camps. Here, too commonly, are the same factors retarding sanitation that are found in the rural districts but with the congestion encountered in the city. It is the belief of this office that careful sanitary surveys of mining camps should be productive of a great saving in life and health, provided the recommendations offered are acted upon.

The big industries the country over have found that money spent in improving the living conditions of their labor, in securing better sanitary conditions in the districts in which they operate, has been money well invested, and that its cost has been paid back several fold in the fewer hours of lost labor due to illness. One large paper company in West Virginia found that typhoid fever probably cost them well in excess of $10,000 a year, presenting a return on an investment of more than $200,000. In other words, that company could have spent $150,000 to eliminate typhoid fever among its workers and have realized a handsome profit from the investment. It is going to be our effort to impress these facts upon the coal operators, for the coal mining camp commonly represents the most insanitary conditions to be encountered in West Virginia.

PROTECTION OF WATER SUPPLIES

-CHLORINATING PLANTS

During the past year a number of new installations of chlorinating plants have been effected. The ten installations which have been made under the supervision of the Division are briefly commented upon below. It is notable that the emergency equipment owned by the Division was called into service three times to protect communities threatened with or already experincing typhoid fever. Two of the installations mentioned below were in connection with mining camp supplies. At last we feel that the employees of labor in some of the mines at least are waking up to the importance of mine sanitation.

GASSAWAY

In the month of July 1917, Gassaway, a town of 1500 inhabiatants on the Coal & Coke Railroad ninety miles from Charleston, suffered from a severe epidemic of typhoid fever. An emergency chlorinating plant was installed at the pump station in spite of the antagonism of the manager of the water company. Treatment of the water with chlorine rendered the city water safe, and had it not been for a prolongation of the outbreak by secondary contact cases, typhoid would have immediately subsided. The effect of the installation of this emergency chlorinating plant belonging to the Division of Sanitary Engineering was, that a permanent machine was purchased by the water company and it is now giving good satisfaction and is the only protection of the community against water-borne typhoid.

LEWISBURG

After an investigation of the water supply at Lewisburg, the hypochlorite treatment there was declared by this Division unsatisfactory. This led to the purchase by that city of a liquid chlorine apparatus and the installation of this machine was made during the late fall of 1917. Weekly reports regarding its operation, which are received at this office, show that it is working satisfactorly.

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