A

CTIVITIES of the State Department of Health for the prevention and control of influenza in Ohio began shortly after the middle of September, before any outbreaks of the disease had been noted in the State. When influenza made its appearance during the last week in September, preparations for the expected battle were well under way, and in co-operation with local health authorities, the United States Public Health Service and the American Red Cross the preventive campaign was quickly extended.

Measures for the prevention of influenza in the State may be summarized under the following heads:

1. Provisions for reporting of

cases.

2. Educational activities.

3. Regulations restricting public gatherings.

4. Extension of medical and nursing aid to stricken communities.

5. Advice to local health of ficials on methods of fighting the disease.

6. Official action in regard to removal of restrictions on public gatherings.

Influenza was not a reportable disease in Ohio when the epidemic made its appearance. The first official pronouncement of the Department of Health in regard to the situation, however, included a request that physicians keep local health officials informed of the appearance and progress of the disease, and that these local

au

thorities communicate such reports promptly to the State Department of Health, which would in its turn report to the United States Public Health Service. This request was made in accordance with a telegram from Surgeon General Rupert Blue of the Public Health Service, pointing out the importance of restricting influenza in order to avoid interference with war production, and requesting full information of possible outbreaks.

A short time later (on October 10), when the Public Health Council, the advisory body of the State Department of Health, met to consider means of dealing with the situation, it included in the regulations which it adopted a provision adding influenza to the list of reportable diseases. Since the spread of influenza was so rapid, a system of telegraphic reports from the cities was installed at the suggestion of the Federal health authorities. City health officers reported daily by night letter the number of influenza cases and deaths for the current day. These reports were tabulated in the State Department of Health and a summary telegraphed to Washington each morning. The statistics thus collected from the cities and those received by telegraph, telephone, mail and newspaper reports from other health districts served as a constant index to the spread of the disease in the State.

In its first circular letter to local health officials, to the reporting feature of which reference has been

to

made, the State Department of Health began its educational work by giving information as to the means of spread of the disease and advice as to means of avoiding and treating it. These recommendations were also given publicity through the newspapers. To supply the many calls for influenza iiterature which soon began come in to the Department a mimeographed circular, giving in concise form the principal facts about the disease, was quickly issued and mailed out to applicants. The educational folder issued by the United States Public Health Service and reproduced in last month's OHIO PUBLIC HEALT!! JOURNAL was also distributed in considerable quantity. Provision of educational material to the newspapers was continued, an influenza article being included in each issue of the Department's weekly News Letter, which is sent to each newspaper in the State.

The main dependence of the Department, after the immediate opening of the outbreak, from the standpoint of education, was placed in a pair of circulars entitled "Influenza: How to Avoid It - How to Care for Those Who Have It", in content these circulars were identical, but one was of a size convenient for use as a poster and the other was a pocket-size folder. One hundred and twenty-five thousand copies of the poster and 200,000 copies of the folders were issued. A supply of these circulars was sent to each health officer and public health nurse in the State, as well as to many industrial concerns and private individuals who requested them. Each newspaper received a copy, with a request that the material be given. such use as possible, and a most

commendable response was made to this request, several papers going so far as ing so far as to reproduce the poster in large display type and in practically its original size.

The Public Health Service, the Red Cross and other agencies distributed educational matter in the State, both through the newspapers and direct to the public.

Upon the advice of the State Department of Health that the best means of preventing the spread of influenza was to restrict public gatherings so far as possible, many local health departments in whose communities the earliest outbreaks occurred, adopted regulations closing schools, churches, theaters and other places of public assemblage. That there was, however, considerable uncertainty and difference of opinion in regard to the circumstances under which such orders shou'd be adopted and the form which the orders should take, was evident in the many inquiries which came to the Department, and especially in the views which were voiced by health officers of the cities and the larger villages of the State at the conference of such officials held at the Columbus public library October 10, under the auspices of the Department. The demand was general that the State assume responsbility for stopping gatherings and prescribe a uniform course to be followed in all communities.

The Public Health Council considered a general closing order, applying immediately to all parts of the State, to be inadvisable, believing that each local situation could best be met by action suited to the locality's peculiar needs. Accordingly its action upon the question took the form of a set of "Instructions to Local Health Officers for

the Prevention and Control of Influenza." As restrictions upon crowds, these instructions directed that when an outbreak of influenza occurred in a community the local health authority should immediately close moving picture shows, theaters, schools, churches, lodges and other places of public assemblage, and should prohibit congregating or loitering in saloons, stores, pool or billiard rooms and other places. Public funerals, it was directed, should be prohibited during the presence of influenza, and street cars, factories, offices and other places which must be occupied should be as well ventilated as possible. All local health authorities were directed to enact regulations carrying out these instructions immediately, to be put into effect as soon as influenza should appear. In pursuance of these instructions, local regulations differing in details but tending in general to stop all unnecessary indoor public gatherings and to lessen the danger in all cases of necessary assemblage were quickly adopted throughout the State. The most important points of variation in these closing orders were in the restrictions placed upon saloons, confectioneries and similar places, some communities closing them entirely, others limiting the hours at which they were permitted to remain open and still others permitting them to remain open but taking steps to prevent overcrowding and loitering.

It quickly became evident in the development of the influenza epidemic that the medical facilities of many small communities would be overtaxed by the situation. Offers of assistance were received from the Public Health Service and the Red Cross, which expressed their

willingness to supply physicians, nurses and medical supplies, so far as possible with the resources at their command, upon request of the State Department of Health. At first requests for physicians were transmitted to the Public Health Service at Washington and physicians detailed from that office. This proved to be too cumbersome a procedure, however, so a change was made whereby the State Department of Health was empowered to employ physicians as needed, to be placed upon the Government payroll. Soon after this temporary arrangement was made, the Public Health Service assigned an officer to the Department for permanent duty as director of the Service's field work during the period of the emergency. The lists of the Volunteer Medical Service Corps were used in assigning physicians to duty, the ease with which men were obtained being a striking proof of the value of that organization.

The Lake Division of the American Red Cross established an emergency bureau in the Department office, to handle calls for nurses and emergency equipment. The prevailing shortage of nurses made it much more difficult to supply women for this service than it was to suply physicians, but no effort was spared to find nurses in response to the urgent calls which came in.

That many lives were saved by these arrangements for provision of doctors and nurses can not be doubted. In many communities physicians were among the first to fall ill and in several were among the first to die. This circumstance, together with the previously existing shortage of doctors due to the entry of so many of the profession

into the military service, created many most serious situations which were relieved only by the importation of medical aid from outside. In many small communities, especially in mining districts where living conditions facilitated the spread of the disease, whole families and neighborhoods fell victims and patients would have been without proper care or food had not nurses hastily been sent in. Several of the physicians and nurses assigned to duty contracted influenza themselves, exhaustion from the rush. of work which they were forced to perform making them easy victims.

Aside from the question of direct action by the State Department of Health to check the spread of influenza, much attention was given to advising local health officials as to courses of procedure. A tremendous amount of business was conducted, by long distance telephone, by telegraph, by letter and by personal interview with health officials who came to Columbus to consult the Department. Representatives of the Department visited communities where the attacks appeared most serious and aided local officials in organizing their forces for fighting the epidemic. At East Palestine, which perhaps suffered as seriously as any other community in the State, a leading business man of the town was put in charge of the health department at the instance of the State Department of Health, local physicians were assigned to districts and in general more efficient methods of control were instituted. Mining villages in Guernsey County were also among the storm centers to which members of the Department staff were sent. Attempts of com

munities to quarantine without State authority against neighboring places with serious outbreaks proved troublesome but such difficulties were ironed out as rapidly as possible. An interstate quarantine which Bridgeport and Martins Ferry attempted to enforce against Wheeling, W. Va., was abandoned after extended discussion between the Department, the Public Health Service and the officials of the interested cities. The village of Antwerp reported "a peculiar form of influenza, with an eruption in the palms of the hands and on the soles of the feet"; as local officials and physicians refused to accept a long-distance diagnosis of smallpox, it was necessary for the Department's epidemiologist to visit the village and confirm. confirm this diagnosis.

As

By the first of November requests for authority to remove restrictions on gatherings were pouring into the Department. The original instructions to the local health officials had provided that local regulations adopted in accordance with the instructions should continue in force as long as the emergency should continue. the outbreaks began to wane in many localities, a demand for reopening of schools, churches, theaters, etc., soon developed. State Department of Health followed the policy of discouraging such requests, all of which appeared premature. As the general situation in the State began to improve, however, it was felt that local restrictions could in some instances safely be lifted, but it was also evident that no relaxing of vigilance in any community should be authorized except after careful study of the local situation made it clear that such action would be

The