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C H A P T E R
II
ONSET OF EPIDEMIC
The official records of
the State Department of Public Health show that no cases
of typhoid fever had been reported from the time the institution
was opened in 1931, through 1935. However, during the
Fall of 1936, four inmates of the institution became ill
with this disease. There was one additional case reported
in February, 1937. No cases of typhoid fever were reported
in 1938. Of the four cases occurring in 1936, the onsets
were approximately one month apart, and there was nothing
to indicate that the water supply was involved. The spacing
of the cases apparently pointed to infection by direct
contact with another case or a carrier. No carriers were
reported found in the institution following the occurrence
of these cases.
On July 9,
1939, the first person to become ill with typhoid fever
at Manteno State Hospital was a male inmate, "J.O.,"
who was 30 years of age. This patient was admitted to
Manteno State Hospital from Elgin State Hospital on August
15, 1935. At that time he was placed in one of the wards,
named Quine Cottage, where he remained until the onset
of his illness. According to staff physicians, this man
had not registered any complaints, but on the 8th of July
he became delirious and was transferred to the hospital
proper. The outstanding signs were the abnormal temperature
(which varied between 101 and 104 degrees), a relatively
slow pulse rate, and rapid loss of weight. The differential
diagnosis included tuberculosis of the abdomen, and pneumonia.
These diseases were ruled out on the 10th of July when
an X-ray examination was made.
A macula-popular
eruption was noted and blood specimens were submitted
for typhoid culture and Widal test. A report from the
Division of Laboratories dated July 17 indicated that
the agglutination test was positive in a dilution of 1:640
with H antigen but negative with O antigen. The blood-culture
specimen was received July 17, and a report dated July
24 indicated there had been no growth of any bacteria.
The patient died on July 15.
This man was
first placed in a mental institution in 1928, when he
was classified as a mentally deteriorated male patient.
After being placed in Quine Cottage he was not allowed
away from this ward; and, consequently, lived, ate and
slept in this one building with exception of those times
when the patients were taken out for short walks under
the supervision of an attendant. With the exception of
food that was brought in from outside by the patient's
family, all foods which he consumed were prepared in the
central kitchen of the institution and were served in
the ward with the assistance of some of the inmates.
The first
case was reported to the Illinois Department of Public
Health in July 19, and was investigated by one of the
district health superintendents on July 21.
During the investigation it was recommended to the managing
officer of the institution that all persons who had been
in contact with the case should receive typhoid vaccination
and also should submit 2 specimens of feces and urine,
at least 24 hours apart, to be examined for typhoid bacilli,
as the quarantine regulations of the Illinois Department
of Public Health required at that time.
Typhoid-release
containers for feces and urine were sent to the institution
by the Department of Public Health on July 24. In a letter
dated August 2, the managing officer of the institution
gave a list of the contacts of this typhoid case and stated
that they were receiving typhoid vaccine. At that time
he also acknowledged that the typhoid-release containers
had been received; however, the Department of Public Health
laboratory did not receive feces and urine specimens from
the contacts until August 10. The reports on these specimens
from the laboratory were all negative and were dated August
14.
Later examination
of the staff-meeting notes at Manteno State Hospital disclosed
that on July 15 "E.S.," a female patient in
Adams Cottage, had been sent to the hospital with chills.
fever. vomiting. and diarrhea. On July 16, a male inmate
from Billings Cottage had been sent to the hospital with
similar complaints. On July 21, diarrhea was reported
among the inmates in Billings Cottage. Other patients
were also reported who had symptoms suspiciously like
those of typhoid, but on whom no definite diagnosis had
been made. It should be noted in this connection that
widespread outbreaks of diarrhea were not uncommon in
this institution; and, consequently, not much importance
was attached by the staff physicians to the cases of diarrhea
occurring in the latter part of July.
Reference
to the graph showing the carious dates of the onset for
patients reported as having typhoid fever indicates that
apparently the epidemic reached a peak on August 18 in
the case of employees and other persons working on the
institution grounds, whereas the peak for inmates on this
chart apparently is August 23. (See Figs. 5 and 6, Chapter
VII, (Currently unavailable.)) It should be pointed out
that sane persons are more apt to complain and apply for
aid sooner than persons who are mentally ill. In a disease
such as typhoid fever, in which the onset is insidious,
this fact may prove to be a complication in compiling
epidemiological data. This is also borne out by examination
of the staff-meeting records for Manteno State Hospital.
From this
record it was noted that one of the staff physicians reported
on August 20 that he received calls, as officer of the
day, from many wards about patients' being ill and having
temperatures of 104 and 105 degrees.
These patients
were reported to the physician at the time as all new
cases, but he found later that they had all been ill for
several days previous to the time their condition had
been reported to him. Further examination of this record
shows that the dates of onset for inmates, as reported
to the Department of Public Health by the institution
authorities or gathered from patients' hospital records,
were inaccurate. For instance, one female patient, "H.
M.," had been reported to the Department of Public
Health having first become ill on August 26, while the
staff-meeting record for august 22 showed that a physician
had seen this patient on that date and at that time she
had a temperature of 103 and had been sick for 5 days
previously. Likewise, a male patient, "G. McC,"
had been reported on the patients' hospital record as
becoming ill on August 19. However, the staff-meeting
record for August 10 showed that the ward physician examined
this patient on that date and found him to have a temperature
of 101, with cough, chills, and rales in the chest, which
were common typhoid prodromal symptoms in this epidemic.
Early during
the month of August, cases of diarrhea with temperature
were reported from various male and female wards on the
hospital grounds. Other cases having abnormal temperature
only and such generalized symptoms as headache and backache
were reported, but apparently no definite diagnosis had
been made of any of these and they were treated, for the
most part, while remaining on their respective wards and
cottages. It is possible that many of these individuals
were suffering from typhoid fever in a mild form, and,
therefore, as possibly missed cases may have constituted
a source of infection and hazard to other persons on those
wards, since no precaution was taken in the disposal of
feces and urine from these ill inmate and their contaminated
dishes and linens received no special care.
The possibility
of existence of a typhoid epidemic was apparently not
recognized by the staff physicians until about August
15, at which time a telegraphic request was made to the
Department of Public Health for containers in which to
submit blood specimens for agglutination tests and typhoid
cultures. Specimens from 4 patients were received in the
Division of Laboratories on August 17. Agglutination tests
on these were negative but E. typhosa was isolated from
3 of the specimens. A telephone report was made on August
19 to the assistant managing officer at Manteno State
Hospital indicating that the results of these blood cultures
would probably be positive. During this telephone conversation
the assistant managing officer informed the chief of the
Division of Laboratories that there were more than 100
cases of suspected typhoid on the institution grounds.
It was agreed during this telephone conversation that
a Department of Public Health laboratory-staff member
should go to the institution. The remainder of August
19 and Sunday, August 20, were spent in preparing media
and supplies for an extensive laboratory study of the
outbreak.
Then it became
apparent that an epidemic was occurring, the director
of the Department of Public Health on his own initiative
ordered public-health personnel to proceed to the institution.
Illinois law charges the Department of Public Health with
the duty to "...investigate the causes of dangerously
contagious or infectious diseases, especially when existing
in epidemic form, and take means to restrict and suppress
the same..." and when "...local authorities
neglect or refuse to enforce efficient measures for its
restriction or suppression or to act with sufficient promptness
or efficiency the Department of Public Health may enforce
such measures as it deems necessary to protect the public
health..." Further, the State Civil Administrative
Code provides, "The Department of Public Health shall
have power:....To make sanitary sewage, health and other
inspections and examinations for the charitable, penal
and reformatory institutions..." In other words,
the Department of Public Health can make inspections of
State institutions and submit recommendations for needed
improvements, but has no authority to act as a control
agency until an epidemic actually occurs., As will be
disclosed in Chapter IV, in which the institution water
supply is discussed in detail, the Department of Public
Health had made inspections of the institution sanitary
facilities and had repeatedly made recommendations to
the institution authorities for correction of defects
in the water-supply system.
Accordingly,
on August 19, the director of the Department of Public
Health called the director of the Department of Public
Welfare by telephone and advised that Department of Public
Health personnel were being sent to the institution to
assist in controlling the epidemic. The director of the
Department of Public Welfare then, on that date, authorized
the installation of an emergency chlorinator on the institution
water supply. A chlorinator company in Chicago was called
by the institution officials, and by the late afternoon
of August 19 an emergency chlorinator was installed.
A department
of Public Health sanitary engineer arrived at the institution
on August 21 and proceeded with preliminary surveys on
sanitary conditions at the institution. A Department of
Public Health physician and a bacteriologist also arrives
at the institution on August 21, and from that date through
the remainder of the epidemic representatives of the Department
of Public Health were present at the institution at all
times.
It soon became
evident that a thorough and complete investigation of
the cause of the epidemic, and the development and execution
of measures to control it, would require the services
of many persons experiences in public-health work. Additional
epidemiologists were sent to the institution to collect
epidemiological data and to render consultation services
in clinical diagnosis of typhoid fever cases. An emergency
laboratory was established at the institution, operated
by experienced bacteriologists. Several more sanitary
engineers were detailed to the institution to conduct
surveys on pollution and plumbing, and to examine food-handling
methods. Milk sanitarians were required to check the milk
supply.
There was
an insufficient number of registered nurses at the institution
to carry out isolation technique properly, and considerable
difficulty was experienced in getting the lay attendants
to execute the strict isolation measures necessary. Therefore,
on September 20 nine Public Health Department nurses were
sent into the institution to serve on the various wards
and supervise isolation technique in those places.
Some administrative
difficulty was encountered in obtaining immediate execution
of control measures by regular institution personnel.
Consequently, by agreement between the director of the
Department of Public Health and the director of the Department
of Public Welfare, on September 19 an experienced Department
of Public Health sanitary engineer was loaned to the Department
of Public Welfare in order that he might serve direct
charge of the control of the epidemic. This transfer greatly
facilitated the prompt execution of necessary control
measures, because it established a direct liaison between
the personnel of the two State departments and resulted
in a marked improvement in the cooperation of the institution
employees.
Many of the
Department of Public Health personnel were retained at
the institution for several months. The estimated cost
of the epidemic to the State of Illinois for both the
Department of Public Health and the Department of Public
Welfare for extra personnel, travel and maintenance expense,
and supplies, occasioned by the outbreak, was $120,000.
This does not include any cost for time and loss of life
by those who contracted the disease.
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TABLE OF CONTENTS
Cover
Introduction
Chapter 1
Description of Manteno State Hospital
Chapter 2
Onset of Epidemic
Chapter 3
Preliminary Observations
Chapter 4
Water-Supply Study
Chapter 5
Control Methods Adopted
Chapter 6
Amoebiasis-Control Methods
Chapter 7
Epidemiology
Chapter 8
Discussion
Chapter 9
Legal Action Resulting From The Epidemic |
