PNEUMONIA CONTROL

By ROBERT K. MADDOCK, Passed Assistant Surgeon, United States Public Health Service

Recommendations.-It is recommended

1. That the advisory committee be expanded to include representatives from the medical schools, laboratory groups, and nursing associations because of the wider interest that may be fostered.

2. That the laboratory diagnostic service be placed on a 24-hour basis.

3. That antipneumococcus serum be furnished free to all persons in the District of Columbia regardless of their ability to pay.

4. That specific antipneumococcus serum be provided for the other types of pneumonia for which it has been shown effective.

5. That definite arrangements be made with the Visiting Nurses Association to provide nursing care to pneumonia cases treated in the home.

6. That records be kept of the typing work done in other laboratories than that of the health department, and that some system be developed so that uniformity in this work may be expected in all reporting laboratories.

7. That records be kept on as many pneumonia cases as possible, and that these records be comparable to those obtained from the serum treated cases, in order that the effect of the serum treatment can be accurately appraised. 8. That a definite program be developed for the education of the practicing physician so that the need for consultants will be eliminated as soon as possible. 9. That a definite program be arranged for the education of the nurses in the District of Columbia as to the need for early diagnosis in pneumonia, nursing phases of the serum treatment, and a review of the essentials of general nursing of these patients.

10. That a program of education be presented to the general public of the District of Columbia, stressing more the need for immeditae medical advice in the presence of the early symptoms of pneumonia, and the prevention of the disease by treating other respiratory infections, rather than stressing the serum treatment of the disease.

Pneumonia has long been recognized as one of the major causes of death in the United States. However, until recently no method that promised any degree of success in the reduction of the number of these deaths was available. It was known that anti-pneumococcic serum would reduce the fatality rate in treated cases by about one-half, but this method of treatment was being used only in the large medical centers. The State of Massachusetts, in a study extending over a 5-year period, showed that if serum and typing facilities were made available, pneumonia could be treated effectively in the homes and small hospitals.

The report of this study has been followed by the establishment of pneumonia control programs in many States and cities. All of these programs make available antipneumococcic sera of one or more types and free typing service, usually without cost to the patient. It is as yet much too early to determine what effect these programs will have on the mortality rates from pneumonia in these respective areas.

Deaths from all forms of pneumonia in the District of Columbia have averaged 691 during the past 5 years. The death rate for the white race during the years 1929-32 was 88.4 per 100,000 and for the colored race 235.7. Of all cities of 100,000 population or over in the United States, the District of Columbia has the tenth highest pneumonia death rate.

TABLE 1.—Deaths and death rates per 10,000 for lobar and broncho-pneumonia in the District of Columbia, by color, 1920-36

TABLE 2.-Death rates per 100,000 population from lobar and broncho-pneumonia in the District of Columbia from 1929 to 1933, by age groups and color

Realizing that an attempt should be made to reduce the mortality from pneumonia, the Congress appropriated for the fiscal year 1938 the sum of $8,000. The expenditure of this money was limited only in that it be used specifically for pneumonia control.

Administration. The pneumonia control program is to be administered by the bureau of preventable diseases of the District Health Department.

The appropriation of $8,000 has been budgeted as follows:

Purchase of serum-.

Salary of typing technician_.

Incidental expenditures_.

Total_

$5, 600 1,800

600

8,000

An advisory committee composed of members of the District Medical Society has been formed to assist and advise in this work.

DIAGNOSIS OF PNEUMONIA

Clinical. Two physicians, who have had special training and experience in the diagnosis and serum treatment of pneumonia, have been employed on a part-time basis for the purpose of assisting any physician who requests aid in establishing a diagnosis.

Laboratory.-A laboratory for typing pneumococci has been established under the direction of the chief of the laboratory division of the health department. A specially trained technician has been appointed to help with this work.

Bottles for the collection of sputum specimens have been prepared and are available to any physician in the District of Columbia. Bottles are also available for blood cultures. Wrapped with these specimen bottles are instructions and suggestions. The specimen bottles are available in the permit room in the District Building and they may be obtained between 9 a. m. and 11 p. m.

Typing is to be done by the Neufeld method, and frequent checks by mouse inoculation tests are contemplated. Blood cultures are to be made on all cases.

This typing service is to be made available between 9 a. m. and 11 p. m., and any physician may obtain it without cost.

TREATMENT

Serum. Enough serum is available for the treatment of 150 cases of type I pneumonia at an average dosage of 100,000 units. This serum is to be administered under the supervision of the consultants. Only patients afflicted with type I pneumonia will be treated, and these cases only if the disease has existed for less than 96 hours. In order to obtain serum, the attending physician must certify that the patient is unable to pay the usual charge for serum without substantial hardship. This serum is to be free. Form 2 is to be presented as justification for the issuance of serum by the health department.

In all cases in which serum is used, form 3 will be made out.

86980-39-20

Nursing. As yet no definite plan for home nursing has been made, although an arrangement with the Visiting Nurses Association is contemplated.

Hospitalization.-Whenever hospitalization is deemed necessary, the patients may be transferred to Gallinger Hospital or, if they are able to pay for their own hospitalization, to the hospital of their choice. Home treatment is to be encouraged in all cases in which it is feasible. Other services.-No arrangements for oxygen or other services are being considered at the present time for cases treated at home.

Research. Records are to be kept of all typing performed by the health department laboratory and of all cases treated by specific serum issued by the health department.

Epidemiological studies are contemplated in the future; however, no plans for the pursuit of these studies have been made.

EDUCATIONAL ACTIVITIES

Medical profession.-Scientific papers dealing with the various phases of pneumonia are to be presented to the medical societies in the District. One seminar of this kind has already been held by the District of Columbia Medical Society. No educational program has as yet been formulated.

As each case of pneumonia is treated by the consultants, individual instruction will be given to the attending physician.

Nurses. No program for the education of nurses has been arranged. Laity. A few press releases, which for the most part have been announcements of the existence of a pneumonia control program, have been made. More publicity for the program in the press is planned.

SUMMARY

1. A program designed to reduce the mortality from pneumonia in the District of Columbia has been organized by the department of health.

2. This program is similar to those in other States and cities.

3. Typing facilities are available without cost for all physicians in the District of Columbia.

4. Type I antipneumococcus serum is available without cost for 150 persons who would be unable to purchase it.

5. Two physicians have been appointed by the department of health to demonstrate the serum treatment of pneumonia to the physicians of the District of Columbia.

COMMENT

The success of a program of this type depends upon three main factors: (1) The willingness and ability of the practicing physician and

the health department to cooperate with each other; (2) The ability of the physicians in a community to diagnose pneumonia within the first hours of the disease, and treat it with serum; (3) The proportion of the pneumonia patients to seek aid from such physicians during the early hours of their illnesses.

If all cases of Type I pneumonia in a community are treated with serum within the first 96 hours of their illnesses the death rate for all pneumonia may be reduced by about one-eighth; however, tremendous effort over a long period of time will be required for even an approximation of such a figure.

SANITATION (SANITARY CONTROL)

By C. T. WRIGHT, Passed Assistant Sanitary Engineer, and L. M. FISHER, Sanitary Engineer, United States Public Health Service

Recommendations.-It is recommended

1. That additional office space be provided for use of inspectors.

2. That a private office be provided for the director in which conferences can be held.

3. That the clerk be assigned to the work of filing and improving the records of the bureau, the compilation of reports, to act as secretary to the director, and other similar work as may be required.

4. That a full-time inspector be assigned as "desk inspector" to receive all complaints, reports of inspectors from the field, keep records of court cases, contact persons by phone for abatement of nuisances, and follow all complaints through to completion.

5. That the assistant director spend the greater portion of his time in the field supervising the work of the field forces.

6. That inspectors assigned to outlying areas be given travel allowances for use of their own automobiles.

7. That one light truck and driver for use in collecting samples be provided so that the passenger automobile now used for collecting samples can be made available to the administrative staff to inspect field work.

8. That eight additional inspectors, four with engineering training, be furnished this bureau.

9. That before employment, new personnel be required to qualify as to both education and experience.

10. That a course of instruction be prepared and classes be held for the entire personnel and a strong effort be made to give the field forces a better under-standing of the objectives sought.

11. That consideration be given to the advisability of including the bureau of sanitary inspection and the bureau of food inspection in a division of sanitation headed by a qualified public health engineer.

12. That an engineer trained in public health engineering practices be placed in charge of the activities of this bureau.

13. That the inspection of plumbing and the advance approval of plumbing installation plans be made a function of the bureau of sanitation.

14. That full police authority be conferred upon three or more selected sanitary inspectors to assist in the enforcement of health laws.