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Recommendations to the War Department for the Control of the Influenza Epidemic

Excerpts on the Influenza and Pneumonia Pandemic of 1918

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RECOMMENDATIONS TO THE WAR DEPARTMENT FOR THE CONTROL OF THE

INFLUENZA EPIDEMIC

About the middle of September when it was recognized that a most serious situation existed at Camp Devens, and that the disease was certain to spread to other camps in the United States, it was recommended by this office that during the continuance of the epidemic new men should not be sent to Camp Devens, nor should men be sent away from that camp. Camp Devens was then overcrowded, having nearly 10,000 men in camp at the time over and above the normal housing capacity. It was pointed out that new men brought into the camp at this time would almost surely contract the disease and add to the already heavy burden of the camp in caring for them. Further, that in transferring men from the camp, a virulent form of disease would almost surely he conveyed to other stations. The War Department in returning this communication stated that it was impossible to cancel the movement of registrants who were due at Camp Devens on September 25, but that orders had been issued to cancel the movement of 3,000 registrants who were due to report at Camp Devens on October 7. The disease had at this time made its appearance at Camp Dix, and similar action was recommended with respect to sending new men to Camp Dix, or sending men away from that camp as had been recommended for Camp Devens. The War Department ordered all future movements of registrants to Camp Dix canceled during the continuance of the epidemic.

The following telegram was sent to the commanding officers of all camps (Sept. 27):

Reference all movements of men to and from your camp at this time. All possible precautions will be taken against transfer of any influenza contacts, but movements of officers and men not contacts will be effected promptly as ordered.

The effect of this order was to restrict movements of troops very slightly, if at all. Under orders previously issued, camp commanders were not authorized to transfer "contacts" of any communicable disease. Further, practically all men in the infected camp had been exposed to the disease and their transfer to other stations resulted in the introduction of disease to stations previously uninfected.

On September 26 the situation was reviewed in a letter addressed to the Chief of Staff, and as at this time there were 18 camps heavily infected, emphasis was laid on the fact that the disease was now no longer local, and the restrictive measures recommended for Camp Devens and Camp Dix in the earlier communication should be applied to all military camps. It was then predicted that if the experience at Camp Devens should be repeated in all our military camps that our losses by death would amount to 8,000 to 10,000 men in the 16 cantonments alone. This prediction was justified as shown by the experience of subsequent weeks. In the summary of recommendations it was urged that-

1. All draft calls of registrants destined for severely infected camps in the immediate future be canceled. The list of severely infected camps is herewith appended. The duration of the need for such cancellation can not now be estimated.


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2. Transfer of military personnel from one camp or station to another be reduced to the minimum required by urgent military necessities, especially restricting military movement of troops from an infected to an uninfected camp or station, or vice versa.

Influenza-pneumonia developed also on troopships bound for Europe during this period. Many cables were received from the other side indicating explosive outbreaks of the disease, with high fatalities among troops. It was reported that troops were arriving "improperly clothed, having only one blanket, no overcoats, and light cotton underwear." Overcrowding of troopships was considered by this office as the most menacing insanitary condition then existing with reference to the spread of disease. Under date of October 1, the attention of the War Department was invited to this condition, and request made that-

The overcrowding of troopships be immediately relieved covering such shipments as may be imperative during the present epidemic. It is believed that the present authorized capacity of troopships should be reduced at least one-half for the present, and it was so recommended.

The action taken on this recommendation was as follows:

In view of the instructions which had already been Issued from the War Department on the subject of physical examinations and inspections, prior to departure to camps, and prior to embarkation, your recommendation for a reduction in the transport capacity to 50 per cent, and that troops be held in quarantine for one week prior to embarkation, is disapproved.

It may be said in passing that the severe outbreak of influenza and pneumonia and the heavy mortality therefrom on troopships was not due except in part to unsatisfactory sanitary conditions. In general, the sanitation of ships was very good. Overcrowding and lack of sufficient hospital space, medical personnel, and supplies undoubtedly increased the percentage of pneumonia complications, and also the case mortality from that disease. But it should be emphasized that the epidemic outbreak would have occurred in the same troops had they remained in camps in the United States, and the fatality therefrom would have been practically the same as occurred aboard troopships. In later shipments of troops, after the peak of the epidemic had been passed in the majority of Army camps, recommendation was made that only commands who had passed through the epidemic be selected for shipment overseas; that those who had actually had the disease could now be transported overseas with safety, and those who had not had the disease might be assumed to be immune from an attack if they had lived in the camp which had passed through a severe epidemic without contracting the influenza. Therefore, shipments of troops made later than October 15 were accomplished with very little influenza and pneumonia among troops en route.

Early in the epidemic (Sept. 28, 1918), before the disease had actually appeared in the majority of Army camps, the following review was submitted to the Chief of Staff by the Surgeon General, together with appropriate recommendations:

1. The present influenza epidemic among troops in the United States has assumed serious proportions, and as the disease extends to other camps, the noneffectiveness and mortality may be expected to materially increase. Every possible measure must be taken in all camps and stations, infected as well as noninfected, to prepare for handling epidemics of this disease, to restrict Its ravages, and reduce the mortality therefrom. With this end in view, it


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is recommended that instructions be sent to commanding officers substantially as follows:

2. Influenza is a "crowd" disease. Epidemics of the disease will be more extensive and the complications more frequent and serious In direct proportion to the degree of overcrowding In camps. Where housing facilities or tentage are inadequate to allow for each man in camp a minimum of 50 square feet of floor space in barracks or tents, immediate steps will he taken to remove a part of the command and place them in camp under canvas if no other means are available for relieving overcrowding. If the camp is not infected, the number of men in camp in excess of the number for which accommodations are available, based on the minimum of 50 square feet per man, may be reported to The Adjutant General with a view to their transfer to another camp or station which is noninfected, and where accommodations may he available.

3. The prevention of overcrowding of influenza patients in hospitals or barracks extemporized as hospitals, is of the greatest importance. For each influenza patient under treatment the minimum of 100 square feet of floor space is required; furthermore, each patient must be kept and treated in a cubicle during the continuance of the disease. Hospital facilities will be entirely inadequate as soon as the disease assumes epidemic proportions. Early provision must be made to completely vacate barrack buildings, preferably near the base hospital, which In the presence of an epidemic will be required as extemporized hospitals. Early provision in bed capacity must be made in advance as admissions will frequently number well over 1,000 daily during a well-developed epidemic. The treatment in regimental infirmaries or in parts of barracks occupied by well men, of a disease as contagious as influenza, should not be permitted. Barrack buildings used as temporary hospitals ordinarily will be administered by the hospital staff as an adjunct to the main hospital.

4. Temporary details of commissioned and enlisted personnel, including cooks and kitchen helpers, from the line may be necessary to assist the medical officers in handling the situation, Additional medical officers and nurses will be supplied from the Surgeon General's Office so far as they are available upon proper request, Unskilled workers must come from an extemporized personnel detailed from the line or other camp source to supplement the trained personnel on duty at the hospital. Sufficient trained Medical Department enlisted men are not available for transfer.

5. It is recommended that a synopsis of these instructions, if approved, be transmitted by wire to all camps and cantonment commanders, department and independent station commanders. The element of time is of vital importance. Delay in sending out these instructions by mall, in the view of this office, would not be justified in the present emergency.

The War Department action on the foregoing recommendations was prompt and efficacious. A night letter was sent to commanding generals of all camps, embodying in full the substance of the above letter. The effect of these instructions in camp was to secure the fullest possible cooperation and support on the part of commanding officers for camp surgeons, commanding officers of base hospitals, and others responsible for the management of the epidemic in camps. Special inspectors from this office visited the majority of these camps during the height of the epidemic, and no single report was received indicating that the line of the Army had not given the Medical Department all assistance and support that it was possible for them to give. The telegraphic instructions sent to commanding officers at this time, it is believed, were responsible more than any other measure for the efficient management and handling of the emergency. The Medical Department alone would have been unable to meet the emergency without criticism if the support and cooperation of commanding officers had not been directed by the War Department.


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For troops in the United States, as a whole, the epidemic may be said to have run its course within a period of about eight weeks. For each individual camp the duration of the epidemic was about four weeks. Thus the period from September 15 to November 15 represents the period of abnormal high mortality due to influenza pneumonia. Subsequent to November 15 influenza continued in nearly all camps, but with relatively few cases in comparison with those reported during the height of the epidemic. The influenza appearing subsequent to November 15 was, as a rule, less virulent and less frequently complicated by pneumonia. The mortality rates subsequent to November 15 approximated those obtaining during the corresponding period of 1917.

In France the epidemic followed much the same course and extended over much the same period of time as in the United States. The high-water mark for deaths from influenza and pneumonia among troops in the United States was 6,160 for the week ending October 11 and in the American Expeditionary Forces, France, 1,451 for the week ending October 17, 1918. There were approximately 1,600,000 officers and men in the United States and the same number in the American Expeditionary Forces, France, during the months of September, October, November, and December, 1918. It is of interest to note that the disease was much less prevalent and fatal among our troops of the Expeditionary Forces than among troops in the United States. During the last four months of 1918 deaths from influenza and pneumonia number 22,186 in the United States and 8,842 in the American Expeditionary Forces, France, the respective commands being of approximately equal strength. The question arises, Why should the disease have been much more fatal in camps in the United States than among our troops abroad? These explanations suggest themselves:

(a) Camps in the United States were filled to overflowing with new draftees who were unaccustomed to Army conditions, who were unseasoned, and who were huddled together in large groups under conditions most favorable for contact and droplet infection from man to man, Troops in the United States were therefore more susceptible to all camp diseases, including influenza, than were the more seasoned troops composing the American Expeditionary Forces in France. Furthermore, unseasoned troops when attacked by diseases are less resistant to the effects of the disease than seasoned troops.

(b) The practice of housing men in large numbers in a single room in cantonments in the United States was conducive to high incidence of any prevailing acute respiratory disease, and especially influenza and its most serious complication, pneumonia. In France, conditions were entirely different. Practically all combat divisions were in the advance zone at the time and well spread out over wide areas. Where troops were billeted, the men were separated in small groups in their billets and shelters and were able to remain more or less isolated from other groups. Further, they were living more or less in the open during active operations, and while it might assumed that individual resistance would be greatly reduced by the fatigue and stress of battle and that such troops would be more susceptible to influenza, it appears that the wide separation of these men and their life in the open, during this period, more than offset the disadvantageous conditions of fatigue and stress under which


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they were living. It is commented upon by medical officers who served in France that in commands of the Service of Supply, where troops were housed in barracks with a large number of men to a single room, the epidemic ran much the same course with high mortality as it did in cantonments in the United States. It was observed that the percentage of infection and the fatalities from influenza and pneumonia in France were much greater among troops of the Service of Supply than among troops at the front. There is but one explanation that satisfactorily covers this divergence, and that is the different method of housing and the degree of dispersion of men over wide areas at the front as against the crowded barracks on restricted areas in the Service of Supply.

(c) Soldiers in France were of longer service and a large proportion of them had passed the preceding winter in camps in the United States. Many of them had had influenza in a mild form earlier in their service and thus acquired a relative immunity.

[The next four paragraphs in the report duplicate the preceding four paragraphs exactly and have been deleted from this version-ed.]


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In comparing sick rates for the month of December, 1917 and 1918, it will be noted that in December, 1918, fewer cases of measles, scarlet fever, and meningitis are appearing, while influenza has taken the place of the three diseases mentioned in maintaining sick rates at about the same level as last year. The pneumonia of December, 1917, was, as a rule, a complication of measles and scarlet fever. The pneumonia of 1918 is almost entirely a complication of influenza. The comparative freedom from measles, scarlet fever, and meningitis in the last quarter of the calendar year 1918, and the first half of the year 1919, was probably due to the fact that new, unseasoned men were no longer coming into Army camps, and that the men already in camps had passed through epidemics of camp diseases and were relatively immune. For the greater part of the period up to the outbreak of the influenza epidemic new men were pouring into the camps at the rate of about 200,000 per month. From the date of the signing of the armistice, November 11, all draft calls were canceled. The statistics of sickness and death among troops in camps in the United States for the winters of 1917- 18 and 1918-19 will not be properly comparable as no new men have been inducted during the latter period. Further, the conditions in Army camps were more favorable in other respects for the winter of 1918-19 than for the previous winter; construction work had all been completed, ample hospital facilities were ready, camp machinery was moving smoothly, supplies and personnel were adequate and satisfactory, and the criticisms of unpreparedness which were directed against the Medical Department in 1917 (for which the Medical Department was not responsible), could no longer in fairness or truth be made in the winter of 1918-19.