1. General Organization and Methods. The Bureau of Communicable Diseases of the Health Department under Dr. Dwight M. Lewis, includes two Divisions, dealing respectively with Epidemiology and with Venereal Diseases. The latter will be discussed in a succeeding chapter.

The Division of Epidemiology is under the direct control of Dr. Lewis, with F. U. Thatcher as an assistant, four nurses and a stenographer. This staff is well adapted to the purposes in hand, and is achieving excellent results.

The first task of the Division is to secure the prompt reporting of the ordinary communicable diseases to the health department, and the results attained in this respect are better than the average for American cities.

Systematic investigations of reported cases are made as the need is indicated by the epidemiologist or his assistants, and consulting diagnostic service is provided to physicians. In both respects an ample volume of service is rendered. Individual epidemiological case histories are made for typhoid, diphtheria, scarlet fever, poliomyelitis, and meningitis, and all essential facts concerning these diseases are recorded. Records of cases are filed, with disease incidence correlated with other epidemiological information, such as source of milk supplies, schools attended and the like. Spot maps of important diseases are maintained as are chronological charts of cases.

Control practices in general correspond with accepted standards of the American Public Health Association. All known diphtheria contacts are cultured and controlled, susceptible contacts are either passively or actively immunized, cases are released on culture. Antitoxin is distributed free to physicians for any case or contact, unable to pay for it, and the virulence test is used on all initial positive cultures, (being made in the State Laboratory). Typhoid cases are released from isolation only after negative cultures. All known susceptible contacts of smallpox, and 99.5 per cent of the first grade school children are vaccinated. Child contacts of scarlet fever are effectively controlled for 7 days.

Hospitalization of communicable disease cases is carried out on a contract basis at the New Haven Hospital and 40% of the cases of typhoid, and 22% of the cases of scarlet fever were thus cared for in 1926; but only one of the 29 cases of diphtheria occurring in 1926 was hospitalized. There were no cases of smallpox occurring during the year.*

*During the months December 1927 to March 1928 an epidemic of smallpox broke out in Middletown, Conn. which spread to other surrounding communities and ultimately caused nearly 150 cases. In the middle of January two cases were found in West Haven and one in Killingworth (derived from the Middletown outbreak) which had been in contact with many New Haven residents and one case in New Haven itself. The Board of Health at once inaugurated a vigorous campaign for general vaccination (although without compulsion except in the ease of known contacts). The efficiency of the Department and the response of the public were so remarkable that within a week's time 100,000 vaccinations had been performed. Not a single ease has occurred in New Haven since January, although if the disease had spread as it did in Middletown there would have been at least 800 cases. The cost of the whole campaign to the city was estimated at less than $7000. (See Monthly Bulletin, New Haven City Department of Health for February 1928). All in all, this is one of the most successful anti-smallpox campaigns in the entire history of public health and respects the greatest credit on the Department of Health.

2. Appraisal of Communicable Disease Control. The Appraisal Form allots 175 points for communicable disease control, and New Haven in 1926 obtained 159 of these points. A perfect score was recorded for reporting (except in the case of typhoid fever) in record keeping, in general methods of diphtheria control, typhoid control, smallpox control, scarlet fever control and control of ophthalmia, in home visitation of communicable disease and in diagnostic service. The losses are distributed as follows: 1 on reporting of typhoid and paratyphoid; 7 on low percentage of diphtheria cases hospitalized; 1 on somewhat low percentage of scarlet fever cases hospitalized; and 7 on immunization of pre-school children (16% immunized, whereas full credit is given for 25% or more).

These results on the Appraisal Form indicate the activities which may well receive greater emphasis as the facilities of the department become more readily available. Already, as we shall see, the department has begun to focus its diphtheria immunization campaign on pre-school children who are most susceptible to the disease. Although one reason for the low rate of hospitalization of diphtheria and scarlet fever cases may have been the mildness of cases, it is somewhat surprising to find that less than 4% of the diphtheria cases were hospitalized; but with the progressive decline in this disease the situation promises to take care of itself.

3. New Haven's Diphtheria Program. The ideal standard of performance in respect to diphtheria control set by the Appraisal Form is an exceedingly high one, purposely set high to encourage progress in this important field. In spite of the fact that New Haven does not as yet quite meet this standard, the results accomplished during the past few years have been so remarkable as to place the city in the forefront of American municipalities in this regard.

Between 1880 and 1890, the diphtheria death rate of New Haven ranged from 50 to 100 per 100,000. The introduction of antitoxin treatment cut the mortality to a figure between 10 and 20. At or about that level, it remained until 1921, and it seemed as if no further progress could be made since, if antitoxin alone be relied upon, some cases will always be treated too late to be cured. Then there began the use of a new method of control, the active immunization of children by the use of toxin-antitoxin so as to protect them against the disease in the future. Dr. Rice began an active campaign along this line almost as soon as he took office. A vigorous effort was made, and has been continued, for the protection first of school children because they were easiest to reach, and then of children of pre-school age, the most important group of all since it is during the first years of life that diphtheria mortality is greatest.

Physicians attached to the Bureau of Child Hygiene go from school to school holding sessions for the immunization of all children whose parents desire it, and the nurses go from home to home in the particular districts explaining the procedure and urging its adoption. During 1926, 1,677 children of pre-school age, 1,008 kindergarten children, and 2,509 grade children were immunized, while 64 pre-school and kindergarten children and 1,630 grade school children were found to be naturally immune by the use of the Schick test. Dr. Rice estimates that as a result of thc last four years work, 75% of the 29,000 old pupils in New Haven's schools are already protected against diphtheria; that of the 3,000 new pupils entering the schools last fall, 25% were protected before entrance and 70/ more will be protected during the year; and that of the 17,000 children of pre-school age, 25% are protected and 8% more will be reached during the winter. Every effort has been made to secure the active cooperation of physicians in this program by urging them to immunize their private patients.

As a result of this remarkable campaign, the incidence of diphtheria has been so reduced that there were but 3 deaths from diphtheria among residents of New Haven in 1925, 1 in 1926 and 3 in 1927. The following death rates (for residents) have been recorded.

RESIDENT DEATH RATE PER 100,000 FROM DIPHTHERIA, NEW HAVEN.

Among all the cities of over 100,000 population in the United States, New Haven ranked third in 1925 from the standpoint of diphtheria incidence, only Duluth and Norfolk having lower death rates. In 1926 it was tied with Youngstown, Ohio, for first place.

For the first nine months of 1927, (the last period for which the State Board of Health has issued figures), New Haven ranked as follows in comparison with the other large Connecticut cities with respect to case incidence of diphtheria indicating that the decrease of cases of this disease has been as striking as the decrease in the death rate.

CASE INCIDENCE OF DIPHTHERIA IN LARGE CONNECTICUT CITIES, FIRST NINE MONTHS OF 1927.

This record is one of which New Haven may certainly be proud. With the progress of the campaign for the immunization of pre-school children, we may confidently look forward to the practical elimination of diphtheria as a cause of death in the near future.

4. The Importance of Promoting the Use of Sera and Vaccines. The control of diphtheria is one outstanding example of what can be accomplished by the almost miraculous sera and vaccines which modern biologic science has placed at our disposal. In the prevention of typhoid fever and smallpox, in the treatment of scarlet fever and tetanus, we may have the aid of similarly potent products. It would seem obvious that every possible effort should be made to foster their widest possible application for the saving of human life.

The State Law of Connecticut has since 1915 authorized the State Department of Health "to procure diphtheria antitoxin, tetanus anti-toxin and vaccine lymph for the free use of people of the State upon whom the purchase thereof would impose a financial hardship, and to distribute the same to town, city and borough health officers who shall furnish the same to such persons upon recommendation of attending physicians." In 1919 this law was amended to include "other biologic products" in addition to the three mentioned.

In the past it was the policy of the State Department of Health to interpret this law somewhat broadly and to distribute biologic products freely to all physicians, merely requiring them to sign a slip stating that payment for the same would impose financial hardship.

During the sessions of the 1927 legislature the Committee on Appropriations became greatly concerned about the use of these state sera and vaccines for persons not really indigent and insisted on the setting up by the State Department of Health of elaborate machinery for distributing such materials only through local health departments with an exact accounting of every package to see that not one was used except by the poor. This is of course in accord with the law as it stands, and the State Department has no other course than to comply. The present procedure, however is most vexatious for both health officer and physician and cannot but tend to decrease the use of sera and vaccines and the consequent protection of the public against disease. It would be highly desirable to amend this law at the 1929 session of the legislature so as to remove the present limitations as to indigence and to permit the wider use of sera and vaccines recognizing that these products are not primarily medicines for the poor but means of checking the spread of communicable disease and thus promoting the public health.

5. The Hospitalization of Communicable Disease. Special note should be made of the extraordinary advantageous arrangements made by the City for the hospitalization of cases of communicable disease. Such cases are cared for in the Isolation Building of the New Haven Hospital at a fixed rate of $3.00 a day the particular types of disease to be covered in this way being specified by a joint agreement between the Hospital, the Department of Health and the Department of Charities. The city originally contributed $75,000 toward the construction of this pavilion.

The care of such cases of communicable disease in 1926 cost the city $5,370, while the estimate of the American Public Health Association for this item in a city of the size of New Haven is $36,400. There are two reasons why New Haven cares for its communicable disease at about one seventh the normal figure. One is that the terms of the contract are extraordinarily favorable to the city since it pays only $3.00 a day for service which costs the hospita1 $7.00 a day. The major element of economy lies, however, in the feet that the care of city communicable disease cases in a ward of a general hospital is inherently far more economical than the maintenance of a special isolation hospital by the city itself. It is on this latter plan which necessarily involves large overhead and the upkeep of empty beds for much of the year upon which the A. P. H. A. estimate is based.

In one respect only New Haven has in the past lacked the advantage of cooperation with a general hospital. According to the contract with the New Haven Hospital, smallpox cases could not be received in the Isolation Hospital on Davenport Avenue, a provision inserted in deference to prejudice of neighboring property-owners when the pavilion was built. The city has therefore been forced to maintain a special smallpox hospital on the grounds of the Poor Farm which of course lay empty most of the time, and when it was needed the expense of renovation and staffing was necessarily very great.

The prejudice against treatment of smallpox in the Isolation Ward of a general hospital is of course entirely unreasonable and it is gratifying to note that negotiations between the Health Department and the Hospital have led to the removal of this restriction.

6. Retrospect of Achievement in the Control of Acute Communicable Diseases in New Haven. In a later chapter we shall review the vital statistics of New Haven for a period of fifty years in some detail. It may be of interest here, however, to note what has been accomplished with respect to the particular group of diseases now under consideration, (excluding tuberculosis which will be considered in another chapter). In the table below we have computed the average death rate from each of these diseases for three three-year periods, fifty years ago, twenty-five years ago, and today. The picture is a striking one.

DEATH RATES FROM CERTAIN OUTSTANDING COMMUNICABLE DISEASES.

DEATHS PER 100,000 POPULATION

* This figure is abnormally high for the period on account of the water epidemic of 1901.

The results obtained in the reduction of diphtheria, scarlet fever and typhoid fever are nothing less than astounding. From their early place as major causes of death, these diseases have now become of almost negligible importance The reduction in the total death rate from this whole group of communicable diseases (from 453 per 100,00(J in 1875-77 to 159 in 1924-26) amounts to the saving of 529 lives every year in the city of New Haven.

7. The Problem of the Future Pneumonia. It will be noted that pneumonia is the only one of the major acute communicable diseases which has failed to show a satisfactory reduction. The table below which includes all acute communicable diseases (except tuberculosis) among residents of New Haven* indicates the relative extent of the present problem and makes it clear that pneumonia and its allied diseases, influenza and bronchitis, account for 12 times as many deaths as whooping cough, typhoid fever, measles, scarlet fever, encephalitis and diphtheria put together.

*Unless otherwise specified all figures and rates in this report include nonresidents.

DEATHS AMONG RESIDENTS OF NEW HAVEN FROM

ACUTE COMMUNICABLE DISEASES IN 1926.

Not only is pneumonia the most important acute communicable disease in New Haven, but the death rate from this cause is substantially higher in New Haven than in other American communities. We called attention to this fact in the 1916 Survey and the condition still obtains. The Census Mortality Statistics for 1924 (the last year for which such comparative data are available) gives New Haven a pneumonia rate of 123 against a rate of 116 for the Registration Cities as a group, and of 98 for the entire Registration Area. Climatic conditions, to which reference has been made in an earlier chapter, no doubt contribute materially to this circumstance.

It is clear that pneumonia is the major problem of the future, so far as the communicable diseases are concerned. The reason is that we have no sound basis of knowledge on which to base our campaign against it. We do not even know to what extent the element of contagion is really the determining factor in the spread of this disease or whether lowering of vital resistance plays a major part. The City of Pittsburgh is treating pneumonia on the basis of the former assumption and is isolating and placarding and disinfecting just as it does for scarlet fever. On the other hand, recent bacteriological studies seem to suggest that multiple cases of pneumonia in a particular group of persons are often due to quite different strains of pneumonia organisms. Pearl has brought forward suggestive evidence of the significance of hereditary factors in pneumonia. What we need at the moment is more light on the bacteriological and epidemiological and physiologica1 factors involved in a large number of cases of this disease so that we may really know what factors are most important. If the facts can be ascertained, there is reasonable ground for confidence that sanitary or serological or hygienic measures can be devised which will be really effective.

Many investigators all over the world are studying this problem; but there seems no reason why New Haven should not do its share. The high calibre of its health department, and the presence of the Yale Medical School, with some of the leading authorities on pneumonia in the United States on its faculty, would appear to promise contributions of great value. It seems to us highly appropriate that the Board of Health should create a New Haven Pneumonia Commission to make an intensive local study of this vitally important health problem. With the decrease which is taking place in the ordinary acute communicable diseases, the staff of the Health Department Division of Epidemiology should be able to devote a considerable part of its energies to such a study.

8. Summary and Recommendations. On the whole, New Haven's campaign against acute communicable diseases is well organized and successful. Typhoid fever, scarlet fever, and diphtheria have all been reduced to almost negligible importance; and the program for immunization against diphtheria, in particular, has brought notable triumphs, placing New Haven in the very forefront of American cities in this regard. This program should be continued with vigor so that the pre-school population may be more widely immunized so that the ground already work may not be lost, and so that diphtheria may wholly disappear as a cause of death in this city.

The major health problem of New Haven, in the field of the communicable diseases, is pneumonia and the city should feel a special responsibility for doing its part in accumulating the knowledge necessary to combat this enemy successfully.

We therefore make the following recommendations:

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