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Chapter 22 - Typhoid and Paratyphoid Fevers
Typhoid and Paratyphoid Fevers
Dwight M. Kuhns, M. D., and Capt. Donald L. Learnard, MSC
HISTORICAL NOTE 1
The problem of typhoid and paratyphoid fevers is well recorded in the annals of military history. Until 1818, however, there were no records of disease and epidemiology in the United States Army. With the appointment of Dr. Joseph Lovell as the first Surgeon General of the United States Army and recognition of the Medical Department as a staff department of the Regular Army by Act of Congress, 2 the first system of reports was initiated.
Between 1818 and 1865, little of importance in regard to typhoid fever was recorded. Some data on the subject are contained in the Medical and Surgical History of the War of the Rebellion.3 Following the work of Petten-koffer in the middle of the 19th century, in which he demonstrated the importance of water supply in the epidemiology of typhoid fever, water sanitation was adopted by many cities and communities throughout the world. Following 1857, the mortality rate of continental Europe dropped markedly.4 In the Army, field sanitation became a matter of immediate concern, and problems of water and food supply were investigated. As a result, strict sanitary discipline was invoked, and efforts were made to educate personnel involved in food and water procurement.
With the onset of the Spanish-American War in 1898 and the campaigns in Cuba, the Philippine Islands, and Puerto Rico, typhoid fever became widespread throughout the Army. As a result of the alarming pace at which the death rate increased month by month, the Army set up a Typhoid Fever Board to study the epidemiology of typhoid fever in United States military camps, and Maj. Walter Reed, MC, Maj. Victor C. Vaughan, MC, and Maj. Edward O. Shakespeare, MC, were appointed as members. The board brought to light much of the present knowledge of the disease and its epidemiology.5
1 Acknowledgment is hereby made to Martin Roth, M. A., for his faithful assistance in the research for historical material for this section and in the final preparation of the manuscript.
2 Military Medical Manual. 5th ed. Harrisburg: The Military Service Publishing Co., 1942.
3 Medical and Surgical History of the War of the Rebellion.Medical History.Washington: Government Printing Office, 1888, vol. I, pt. III.
4 Bulloch, W.: History of Bacteriology.In A System of Bacteriology.[Great Britain] Medical Research Council. London: His Majesty's Stationery Office, 1930, vol. I, pp. 15-103.
5 Reed, Walter; Vaughan, Victor C.; and Shakespeare, Edward O.: Report on the Origin and Spread of Typhoid Fever in United States Military Camps During the Spanish War of 1898. Washington: Government Printing Office, 1904, vol. I.
In the year 1898, with a mean strength of 147,795 men, the Army reported 20,926 cases of typhoid fever resulting in 2,192 deaths. These figures are perhaps not too accurate since at that time typhoid fever was a term used to describe a wide variety of enteric conditions and since the, disease was often diagnosed as malaria. Records of the Office of the Surgeon General indicate an admission rate of 14,158.80 per 100,000 in 1898 with a death rate of 1,483.14 per 100,000.
The one important concept not appreciated by the Typhoid Fever Board was that of the carrier. It remained for Robert Koch (1902) to describe the various carrier states and the role of the carrier in typhoid epidemiology.6
In 1908, the Army sent Maj. (later Brig. Gen.) F. F. Russell, MC, to study the epidemiology of typhoid in foreign armies. His report was the basis for the appointment of a board which reviewed the history of vaccination against typhoid. The recommendations of the board led to the adoption of antityphoid inoculation in the United States Army, which was the first organization to establish the use of typhoid vaccination on a large scale and to determine definitely its value in preventive medicine. In March 1909, the first vaccine used as a protective measure against typhoid fever was introduced in the United States Army on a voluntary basis. In March 1911, the first large-scale immunization program was carried out in Texas on 15,000 troops used in quelling hostilities along the Mexican border, and by the end of that year 85 percent of the Army had been vaccinated. Siler, Dunham, and Longfellow 7 reported that, as a result of this vaccination program, the admission rate per 100,000 dropped from 30.52 in 1912 to 4.41 in 1913. In 1910, one of the most important steps ever taken in the control of typhoid fever was made by Maj. (later Brig. Gen.) C. R. Darnall, MC, who introduced the liquid chlorine, method of water purification, a method that has since been adopted the world over.8
The next significant date in the historical review of typhoid and paratyphoid fevers is 10 September 1916, the date the Army Medical School supplied the Army with its first paratyphoid A vaccine. The standard routine then became the administration of 6 doses of vaccine-3 of antityphoid and 3 of antiparatyphoid A.
By July 1917, the Army Medical School had perfected a new vaccine which included antityphoid, antiparatyphoid A, and antiparatyphoid B fractions. This new product was known as TAB vaccine (triple typhoid saline vaccine) and was administered to all newly inducted personnel as well as to individuals already in the Army. For the first time in history, typhoid fever became a disease of secondary importance in military operations, no longer ranking among the 30 diseases of most frequent occurrence.
Siler and his associates reported that the annual typhoid fever admission
6 Gay, Frederick P.: Agents of Disease and Host Resistance. Springfield: Charles C Thomas, 1935, p. 1557.
7 Siler, J. F., Dunham, G. C., and Longfellow, D.: Typhoid Fever. Baltimore: The Johns Hopkins Press, 1941.
8 See footnote 2, p. 463.
rate for the World War I period was 37 per 100,000 strength. Typhoid fever contributed only 0.04 percent of the total admissions to hospitals for all diseases and, of all deaths from disease during World War I, only 0.39 percent were attributed to typhoid fever. There were 1,529 admissions to hospital for typhoid fever among approximately 4,000,000 troops to give an annual rate of 0.37 per 1,000 strength throughout the Army. As had been anticipated, a higher incidence rate was experienced in Europe than in the United States. The greater prevalence overseas was, in all probability, due to breakdown of induced immunity in certain individuals by numerous and repeated exposures to massive doses of the causative organism in specific sections where food, milk, and water were contaminated, sewage. disposal inadequate, and a general low civilian health standard prevailed. Paratyphoid fevers were likewise not a major problem during the World War I period. Admission rates for the entire United States Army for this period were 0.05 per 1,000 strength annually, considerably lower than the admission rate for typhoid fever. Six deaths from paratyphoid fever were reported in 1918 and five in 1919.
The contrast between the typhoid-paratyphoid problem in World War I as compared with that of the Spanish-American War can be attributed to the continuous application of control measures. In those days, it was thought that: "The control of typhoid fever is based first, on preventing the transmission of massive or continuous infection by water, food and contact, that is, by water purification, food control and waste disposal, and second, on immunization by prophylactic vaccination." 9
For the 10-year period 1920-29, the, average number of admissions for typhoid and paratyphoid was 7.5 and 0.8, respectively, per annum, and during this time nine deaths were reported for typhoid with none from paratyphoid. The average annual admission rates per 1,000 troops during this period were 0.05 for typhoid and 0.01 for paratyphoid.
Since July 1917, all Army personnel had been inoculated with the triple typhoid vaccine containing Salmonella typhosa, Salmonella paratyphi, and Salmonella schottmülleri suspensions. In May 1928, the paratyphoid B con stituent was eliminated from the vaccine in view of the very low incidence of the disease, no cases leaving been encountered since 1922, and because of the, belief that it increased the toxicity of the product.
At the beginning of the 1930's, it was noticed that typhoid fever was more in evidence in the Army than it had been for a long time. Some attributed this to a loss of immunogenicity due to genetic aberrations in the organism. In 1933, Seckinger 10 published a report discussing the growing ineffectiveness of the vaccines produced from the old Rawlings strain which Russell lead brought
9 Dunham, George C.: Military Preventive Medicine. 3d ed. Harrisburg: Military Service Publishing Co., 1940, p. 163.
10 Seckinger, D. L.: Epidemiological Studies Upon Typhoid Fever in Georgia. Problems Associated With Its Control. South. M. J. 26: 933-941. november 1933.
back from England in 1908.11 On 4 October 1936, the Panama strain of Sal. typhosa, known as "Boxill" and "Chronic Carrier" and designated as "Strain 58" by the Army Medical School, was adopted for vaccine production, and it has been the one used throughout the Army from that time.12
Throughout this decade, the typhoid rate remained below the level of 0.10 per 1,000 average strength with the exception of 1931, when 18 cases occurred at Fort Des Moines, Iowa, in a command in which proper hygiene was not enforced. In this instance, all personnel had received the required vaccination some months previously, but heavily polluted well water was drunk with no attempt made at purification. Paratyphoid fevers were rarely encountered during this decade. According to Siler, 15 cases in all were reported; 3 of paratyphoid A, 11 of paratyphoid B, and 1 unclassified. On 1 August 1934, it was decided to remove the paratyphoid A fraction from vaccines for much the same reasons the paratyphoid B portion had been eliminated in 1928.
During the period 1933-39, some of the most important advances in the development of the understanding of typhoid epidemiology were made as a result of experience with the Civilian Conservation Corps. The organization had enrolled during its existence approximately two and one-half million youths who served for periods of 6 months or more in various camps throughout continental United States. Immunization to typhoid fever was routinely carried out by the United States Army Medical Department immediately subsequent to enrollment. Sanitary measures were applied to food, water, and the removal of waste.
Outbreak of typhoid fever in a partially immunized and nonimmunized group.-Despite the precautionary measures usually taken, outbreaks did occasionally occur. One such outbreak occurred at Ely, Minn., in 1934. One hundred and forty men were vaccinated at Fort Leavenworth, Kans., with the standard Army initial dose, followed a week later by the second inoculation. The unit was shipped to Ely, and, 10 days following arrival at camp, a high percentage came down with typhoid fever. In the cases that were clinically observed, the diagnosis of typhoid fever was confirmed by the laboratory of the Minnesota State Health Department. At this camp, there were a number of workmen of approximately the same age group as the Civilian Conservation Corps members, and many of them also contracted the disease. Eleven deaths occurred among the workmen, the course of the disease running for a longer time and with a greater severity than in the case of the immunized Civilian Conservation Corps personnel, all of whom recovered. Investigation
11 (1) Grinnell, F. B.: A Study of the Comparative Value of Rough and Smooth Strains of B. typhosus in the Preparation of Typhoid Vaccines. J. Immunol. 19: 457-464, November 1930. (2) Perry, H. M., Findlay, H. T., and Bensted, H. J.: Antityphoid Inoculation. The Role of Bacterium typhosum, Strain Rawlings. J. Roy. Army M. Corps 60: 241-254, April 1933. (3) Perry, H. M., Findlay. H. T., and Bensted, H. J.: Antityphoid Inoculation; Observations on the Immunizing Properties and on the Manufacture of Typhoid Vaccine.J. Roy. Army M. Corps 62: 161-177, March 1934. (4) Perry, H. M., Findlay, H. T., and Bensted, H. J.: Antityphoid Inoculation; Observations Relative to the Immunological Value of Different Cultures of "Bacterium typhosum." J. Roy. Army M. Corps 63: 1-12, July 1934.
12 See footnote 7, p. 464.
revealed that the camp's water supply was contaminated with coliform bacteria, indicating a, fecal contamination. It was discovered that blasting operations conducted in preparation of the camp had opened fissures in the rock strata, allowing seepage directly from the latrines to the water source.
This outbreak serves to add to the evidence that immunization is not entirely protective when large numbers of the causative organisms of typhoid fever are ingested, but such immunization does lower the mortality of the disease and check the seriousness and duration of the illness.
Generally speaking, between World War I and 1939, the Army had learned through its own experience, civilian health authorities, and the Civilian Conservation Corps, that sanitary precautions were as necessary in times of peace as in war. It had found that only through observance of strict water purification, inspection of foodstuff, examination of foodhandlers, control of human carriers, and continued immunization of individuals could typhoid and paratyphoid fevers become a disease of minor importance.
Table 78 furnishes an over-all view of typhoid and paratyphoid fevers in the Army from 1900 to 1941. It shows the number of admissions or cases per annum per 1,000 average strength for each year during that period. It
can be seen that the annual rate for typhoid and paratyphoid combined was reduced to a remarkably low level by 1920 and maintained there until 1931 when there was a slight increase.
WORLD WAR II EXPERIENCE WITH TYPHOID AND PARATYPHOID FEVERS
By 1940, standard regulations had become well established from actual experience gained in previous military operations in war and peace. These rules were described in Army regulations.13 Generally, they provided for the responsibility of commanders in regard to housing; water supplies; waste and garbage disposal; food and drink preparation; cleansing of dishes, messkits, and utensils; and examination of permanent foodhandlers. The Medical Department was charged with investigation of sanitary conditions, checking of water supplies, recommending types of water purification, and making periodic surveys of the potability of water.
Methods of water purification were the standard settling, filtration, and chemical (chlorine) processes, all water being considered impure until declared potable by the proper medical officer. In the field, the water sterilizing bag was to be used with calcium hypochlorite treatment, and, in the absence of sterilizing bags, the use of galvanized iron cans was authorized. In addition, units for individual use such as halazone tablets were to be available with proper instruction in their use.The men were advised to boil the water for 1 minute whenever chemical agents were not available.
All individuals known to be or suspected of being ill with any of the intestinal diseases were to be hospitalized unless recommended otherwise by the surgeon.Once in the hospital, the men were isolated and treated with due respects to body wastes, bedding, and linen.All cases of these diseases were investigated to ascertain, if possible, the source and route of infection.
Carriers.-No discussion of typhoid or paratyphoid fever would be complete without a discussion of the problem of carriers.According to Nichols, 14 carriers may be classified in three categories, the names of which are selfexplanatory: Incubationary, convalescent, and contact. During the World War I period, it was the general policy in the United States to send all Army typhoid carriers to Walter Reed General Hospital, Washington, D. C.There it was felt that surgery was indicated in certain cases. Occasionally such procedure effected a cure, though in general it was not considered to be indicated and many chronic carriers were never cured.
During World War II, known carriers of the causative organisms of these diseases were excluded from food handling, and regulations were established for keeping close contact with their assignments and movements. Com-
13Army Regulations No. 40-205, 31 Dec. 1942, and No. 40-210, 15 Sept. 1942.
14 Nichols, Henry J.: Carriers in Infectious Diseases.Baltimore: Williams and Wilkins Co., 1922.
manders were notified whenever carriers were to be transferred to their commands.Reports were made to The Surgeon General of any individual who retained his carrier state for more than 6 months. Through close cooperation with certain State boards of health, known typhoid and paratyphoid carriers were detected and reported to The Surgeon General by State health authorities. No provisions were made, however, to exclude or discharge carriers from the Army, although this problem had been discussed at length by members of the Army and the National Research Council.15 Known carriers were placed on duty not involving handling of food or other materials that might be contaminated.
World War 11 did not bring medical science closer to a solution of the typhoid carrier problem than did World War 1. During the second world conflict, the possibilities of antibiotic therapy in such cases had not been envisioned. Following the war, antibiotics such as Chloromycetin (chloramphenicol) were used but with little or no effect.
Preliminary data on admissions for typhoid and paratyphoid carriers, based on sample tabulations of individual medical records, are available for the years 1942-45 as shown in table 79.
Immunization.-The immunization policy of the Army directed that all military personnel on active duty receive routine immunizations. After
15 Memorandum for file, Capt. P. E.Sartwell, 21 Aug. 1944, subject: Conference with Professional Service on Typhoid Carriers.
1 September 1940, the paratyphoid fractions were reinstated, and the prescribed course included three 1 cc. subcutaneous injections of triple typhoid vaccine given approximately 3 years after the initial immunization. Only two complete series were required for any individual except, where deemed advisable by the medical officer concerned, in such cases as (1) outbreaks of the disease; (2) when personnel were assigned to a theater of operations; and (3) upon boarding an Army transport or airplane for travel beyond the limits of the United States, unless vaccination had been completed within 12 months prior to departure. Individuals over 45 years of age were not required to complete revaccination unless they were leaving the United States.
Special measures.-Special measures were executed during epidemics of any intestinal disease. Extra efforts were made to detect and hospitalize early cases and to detect and restrict carriers. Suspected common sources of infection (such as milk, water, and food) as indicated by epidemiologic study were excluded from use by the command until the proved cause or causes of the epidemic had been discovered or until adequate corrective measures had been applied to the suspected source or sources. Special attention was given to the examination of foodhandlers, sanitation of kitchens, mess, garbage-disposal methods, latrines, and the control of flies. Close cooperation with civilian health authorities in determining sources of infection was established wherever indicated.
Other required sanitation measures included compliance with local regulations regarding sewage disposal, collecting and processing of liquid wastes from kitchens and bathrooms, avoidance of water and stream pollution, analysis of sewage, and control of flies.
In the summer of 1942, The Surgeon General, recognizing the need for preventive measures in the control of typhoid and paratyphoid as well as other diarrheal diseases, consulted with the National Research Council. The recommendations of the National Research Council were later incorporated in Circular Letter No. 33, Office of the Surgeon General, dated 2 February 1943, Treatment and Control of Certain Tropical Diseases, a copy of which was furnished to each officer of the Medical Department. The circular advocated various preventive measures including the supervision of milk and water supplies and the protection of foods from flies and carriers. Fly breeding was to be combated at all times. All foods in which bacteria could multiply were to be refrigerated at 40° F. or less. Oysters were not to be served raw unless known to be from a safe source. Also prescribed were sanitary disposal of excreta, the. isolation of known cases of the disease with epidemiologic investigation of sources of infection, and continuation of the standard policy of vaccinating all personnel with triple typhoid vaccine.
The preventive medicine officer in each of the major theaters of operations established policies and procedures for prevention of intestinal infections, and port authorities-both sea and air-made every effort to apprehend and place under medical supervision each individual suspected of harboring a contagious disease. This was perhaps more effective in the European theater than in
other areas because medical facilities were fairly well established before large numbers of troops had arrived. Special epidemiologic reports were devised for typhoid which were forwarded to The Surgeon General when completed. In many cases these were not conveniently accomplished, the patient and the medical officer both being far removed from the source of infection.
Special methods for control of typhoid, paratyphoid, and other intestinal diseases included culturing of stools for the causative organism in all cases of diarrhea. This was feasible, even in theaters of operations, because laboratory service was available in most instances at hospitals, Army laboratories, and when necessary in regular public health laboratories. A period of 4 days between the time of specimen collection and the time of culturing was permitted for transit. Dish culturing was instituted throughout the various service commands of the Army for the purpose of periodically evaluating the thoroughness achieved in mess sanitation. Laboratories and laboratory technicians were evaluated by proficiency studies whereby known specimens were forwarded by the various service command laboratories thereby promoting skill in the laboratory detection of pathogenic organisms.
Incidence in the Army
In the initial phase of mobilization, the incidence of typhoid fever was no higher in the Army in the United States than in the 2 previous years of 1938 and 1939. There were 3 reported cases of typhoid fever in home troops in 1940 and 12 cases in 1941.The annual rates per 1,000 average strength for typhoid fever in the United States (among enlisted men only) were 0.02 for 1938, 0.02 for 1939, and 0.01 for 1940. In 1941, the rate was 0.01 indicating that control measures were effective during a period of inducting large numbers of troops from every section of the country.16
No significant difference in typhoid incidence among seasoned troops as opposed to fresh recruits was noted nor did any epidemics or sporadic occurrences take place among new inductees at induction and basic training centers. Paratyphoid fever was similarly of no great importance, though one minor epidemic was reported to have occurred at Camp Claiborne, La., in October 1941, when seven cases were reported to have been discovered. There are no records to indicate that this ever received official diagnostic confirmation. As the etiologic agent responsible had not been previously encountered, it was named Salmonella claibornei.
The history of typhoid and paratyphoid is different in the various theaters depending upon the level of sanitation of the areas concerned. Thus, in 1944, there were 25 cases of typhoid in the European theater (12 of which were brought in from North Africa) with a case rate of less t11ali 0.1 per 1,000 troops against 38 cases reported in the China-Burma-India theater where a case rate of 0.23 per 1,000 troops per annum existed.The cases can be traced to breaches
16 Holt, R. L.: Current Status of Immunization Procedures. Typhoid Fever. Am. J. Pub. Health 38: 481-484, April 1948.
of water discipline, food from unauthorized sources, or human carriers. In the China-Burma-India theater, local conditions were unhealthy, there was little or no enforcement of sanitary laws, and deplorable facilities existed for the disposal of garbage and human excreta.
Strange as it may seem, it was frequently found that, regardless of the theater, troops actually engaging in combat were less disposed to acquire typhoid and paratyphoid infections than supporting, reserve, or resting troops. While military control was not wanting at such places as rest camps, the opportunity for contact with native food and water facilities existed, and it was the belief of some of the United States troops that consumption of such commodities could lead to no ill effects. Thus, overconfidence in the protection conferred by vaccination may have led some Americans to believe they were completely immune to typhoid and paratyphoid fevers. One may note at this point that in many cases, especially in those that were of a sporadic nature, the source of infection was never determined.
The incidence (total cases) of typhoid fever in the United States and in overseas theaters and areas during World War II is shown in table 80. Table 81 shows the incidence of paratyphoid fever.A comparison of the two tables shows that the Army was somewhat less successful in controlling paratyphoid
fever than in controlling typhoid fever, although its program was, on the whole, efficient and admirable.
Experience during 1942.-By 1942, a large number of troops had been shipped to various theaters of operations, all immunized in accordance with existing regulations and instructed in sanitation procedures for field service. During the year, 36 cases of typhoid fever were reported for the total Army, 16 from overseas areas. In Latin America (Panama and the Antilles) and the China-Burma-India theater, admissions totaled 4 and 5, respectively, or 0.04 and 0.57 per annum per 1,000 troops. Although these commands reported the highest number of admissions, the case- rate in the Middle, East theater was relatively high, 0.33 per annum per 1,000.Only one case was recorded in the European theater, from Northern Ireland, but data concerning the source and mode of transmission in this case are obscure. 17
The incidence of paratyphoid fever in 1942 was about the same as that of typhoid fever, totaling 37 admissions, 18 of which were from overseas. The case rate for the total Army was 0.01 per 1,000 troops. Two cases were reported from the Middle East Command, one in September and one in October. The
17 Gordon, J. E.: A History of Preventive Medicine in the European Theater of Operations, U. S. Army, 1941-45. [Official record.]
only other locality to report more than 5 cases was Latin America with 7. It is readily discernible from this account that soldiers stationed in areas of good local sanitation, such as the United Kingdom, were no more likely to contract the disease than troops in the United States, the case rate per 1,000 men being approximately the same. In the Middle East and the Antilles Department, clinical and subclinical paratyphoid and other enteric fevers were rampant in the native population. Necessarily, Americans were exposed to local conditions and, unknowingly or carelessly, consumed highly contaminated foods and water. Considering at the same time the excellent preventive measures practiced in the Latin American theater, where the case rate for paratyphoid fever was 0.07 per 1,000 troops per annum, it is apparent that adequate military control can be exercised to prevent enteric fevers even in communities where natives are suffering from the disease.
Experience during 1943.-In the year 1943, United States troops were widely distributed all over the world. Large numbers of soldiers were engaged in active combat operations in North Africa, Sicily, Italy, and throughout the. Pacific Ocean area on isolated islands. They were stationed in northern regions such as Alaska, the Aleutian Islands, Iceland, Greenland, and Newfoundland, as well as in built-up areas in the United Kingdom, the Persian Gulf, Burma, China, Australia, New Zealand, India, and Hawaii. Air installations were in remote and farflung places such as the Azores, the Caribbean Islands, South America, and the Pacific. There were reported 175 cases of typhoid fever throughout the Army, 150 of which were from overseas, for a total Army case rate of 0.03 per 1,000 troops. In the Mediterranean theater, there were 83 cases, partly associated with an outbreak in a prisoner-of-war camp in North Africa during October, November, and December, the case rate being 0.18 per 1,000 troops. The Middle East theater reported 12 cases and a rate of 0.23 per 1,000 troops.
Eighteen cases were known in the Southwest Pacific, records not being available to state the exact locations. Twenty-five cases were reported from the China-Burma-India theater for a case rate of 0.63 per 1,000 average strength, the highest incidence throughout the Army during the year.
Paratyphoid fever was more prevalent than typhoid, with 271 cases reported of which 236 occurred in overseas commands. Of the various overseas areas, the Mediterranean area had 141 cases, though the area where the annual rate was highest was Latin America. Only 13 cases were reported from the Middle East, but the case rate of 0.25 per 1,000 troops was third highest throughout the Army. The China-Burma-India theater annual rate was significantly high at 0.20 per 1,000 troops, although there were only 8 admissions. The Southwest Pacific Command reported 18 cases, with a rate of 0.09 per 1,000, again omitting names of countries or islands involved. For the total Army, including the United States, paratyphoid fever was evidenced in only 0.04 per 1,000 average strength.
Experience during 1944.-In 1944, typhoid fever cases ranked second in the World War 11 years with a total of 149 and an annual rate per 1,000 average
strength of 0.02. The majority of these cases were overseas where the case rate reached 0.03 per 1,000 strength. The highest number of cases was in the Mediterranean theater where 46 were reported, but the rate was exceeded in the China-Burma-India theater with 0.23 for 38 cases. In the Southwest Pacific, there were only four cases with a rate of 0.01.
An interesting outbreak of typhoid fever occurred during the year (1944) in Company G, 349th Infantry in Northern Italy. In November and December, 19 members were admitted to hospital and diagnosed as having typhoid fever. One man, who had become aware of symptoms 30 days prior to reporting sick, died in a toxic state 10 days after being admitted. Although an extensive investigation was carried out to determine the source of the infection, no definite conclusions could be reached. Possible reasons for the outbreak were given as (1) indiscriminate drinking of water from wells, shellholes, and other places without using halazone or other purification methods (some patients explaining that they had been issued halazone tablets only once and after they were used, no reissue was made); (2) consumption by some soldiers of civilian food, including potatoes and salami, though there were no samples of the food available for examination; and (3) presence in the unit of individuals with subclinical typhoid fever. The outbreak followed a carrier pattern, 2 individuals from other units acquiring the disease after eating one or two meals with Company G, but the possibility of a carrier was not confirmed.18
A decrease in paratyphoid fever was noticed in 1944, with 191 cases for the total Army of which 150 were from overseas commands. No command suffered a serious outbreak, and the rate of 0.02 per 1,000 troops per annum was half the 1943 rate.The Mediterranean theater had the highest number of admissions, while China-Burma-India experienced the highest rate of the various theaters (0.22 per annum per 1,000 average strength).
Experience during 1945.- By 1945, although a great number of troops were in the field, the total admissions were slightly lower than the previous year with 30 cases in the continental United States and 115 overseas. The case rate, however, remained constant at 0.02 per 1,000 per annum for the total Army, with a slight increase to 0.01 in the United States. The overseas rate dropped to 0.02 per 1,000 troops as compared with 0.03 in 1944. The largest number of admissions was reported from the Southwest Pacific, a total of 50 being recorded.There were no cases of typhoid in the Middle East, and the European theater showed 35 cases with a rate of 0.01 per 1,000. The China-Burma-India theater continued to show a comparatively high rate incidence.All other theaters had few admissions and no specific outbreak is recorded.It is to be noted, however, that the Central and South Pacific areas had a rate of 0.04 per 1,000 average strength.
Paratyphoid fever was twofold higher in incidence than the previous year with 340 cases, case incidence throughout the Army rising to 0.04 per 1,000 average strength. Overseas commands contributed 310 cases with a
18 Bruner, D. W.: Salmonella Infections of World War II. [Official record.]
rate of 0.07. The Southwest Pacific reported 140 cases with a rate of 0.14. The Pacific Ocean area, including the Central and South Pacific, reported 20 cases, but in view of the large number of troops involved the rate amounted to 0.05.
Comparative incidence of typhoid and paratyphoid fevers and diarrheal diseases.-Since the epidemiology of the diarrheal diseases is similar to that of typhoid and paratyphoid fevers, it is of interest to show comparative incidence of the diseases (table 82). It is generally considered that neither typhoid fever nor paratyphoid fever was a particularly serious problem to the Armed Forces in either World War I or World War II. For the two world conflicts, these diseases were even less of a problem in the second than they were in the first war. While this may not be altogether apparent upon cursory inspection of these statistics, it is readily acknowledged when it is considered that many more men were under arms in the Second World War than in the First. It becomes clear on examination of the rates, especially when dealing with preliminary figures, that they are a more reliable index of incidence than are the absolute numbers of cases reported. The diarrhea-dysentery problem in World War II was at least as serious as in World War I. This lends support to the belief that typhoid-paratyphoid vaccine played a tremendously important role in the control of typhoid and paratyphoid fevers. In the occurrence of diarrheal diseases and dysentery, no such reduction took place since no effective vaccine for these diseases has ever been perfected.
Incidence in Civilian Populations
The fact that United States troops were relatively free from typhoid fever should not be interpreted to indicate that there was litilt opporturjity for exposure. The disease, when it, did occur in military personnel, often did so against a background of it in civilian populations, the latter having been far less immune to typhoid fever than were the Armed Forces of the various nations engaged in combat. The disease was prevalent throughout war-ridden Europe, especially in France, Belgium, Holland, and Germany. Figures for typhoid in Russia are not available but were probably substantial. By way of illustration, the city of Saint-Etienne, France, lead 570 cases with 27 deaths in the autumn of 1944. At Greater Liege, in Belgium, there were 104 cases from 1 August to 18 November 1944. Thus, civilian populations were always a potential source of infection.
Incidence Among Prisoners of War
During the early years of the war, prisoners of war
had an excellent record with respect to typhoid
and paratyphoid fevers. A minimum of sanitation seemed to suffice in
maintaining the low rates.It
was soon learned that the German Army had been perhaps as effectively
immunized as the United
States Army. However, under certain conditions such as extreme
deficiencies in sanitation,
immunity proved inadequate. It is for this reason that most
epidemiologists believe, that the control
of typhoid fever is basically more a matter of sanitationn than of
vaccination. Another set of
conditions that brought about an increased typhoid rate in prisoners of
war was the large-scale
breakup and disruption of the German Army. In May and Julie 1945, there
were 482 cases of
typhoid fever in German prisoners of war. Chart 48 shows the incidence
of typhoid fever among a
sample of 415 prisoners of war having typhoid fever during May and June
1945 in the European
A marked difference call be seen in chart 48 between May and June and even between consecutive days. Not all of the infections were in newly captured prisoners. Many of them occurred in prisoners who had been field for all appreciable period of time. In the Advance Section, Communications Zone, among 403,142 prisoners of war, there were 30 deaths from typhoid in the 6-week period from 1 May to 15 June 1945.It is to be noted that it was not possible to give the prisoners of war the best medical care, and it is not unreasonable to hypothesize that typhoid cases among prisoners of war may not always have been correctly diagnosed.
In certain instances, it was quite possible to trace the cases in prisoners of war. Prisoners as a rule were, field for a few days together with other pris oners not too far from the frontlines. They were then moved to the rear to a collecting point and again moved further back to larger camps. Some of the collecting points were strongly suspected of being the point of origin of the
19 See footnote 17, p. 473.
infection. The following report from a prisoner-of-war camp illustrates some of the symptoms of the disease as it occurred among prisoners of war:
Epidemiologic case report.-Prisoner-of-War Enclosure No. 11 was a collecting point in Normandy Base Section for prisoners of war captured in Germany. Three prisoners received on 6 June 1945 were ill on arrival with a disease characterized by severe headache, prostration, and high fever.The next day, 9 more men reported ill, and thereafter daily additions were made to the roster of patients with a similar disease, so that by 25 June 1945 the number was 101.About a third of the patients had a rash of the abdomen, not affecting the extremities, face, or back, and the fever was typhoidal in type. The infectious process was confirmed by laboratory examinations as typhoid fever in a significant proportion of patients and by pathologic examination after death in a number of instances. Most of the prisoners had been captured in Germany about the first of May.They had been held in various enclosures in Germany and then forwarded to the Normandy concentration point. Those with typhoid fever were in large part from PWTE, A7, near Welgesheim, but a number of different enclosures were represented.In general, the prisoners had left Germany in the early days of June and had arrived in Normandy between 4 and 8 June 1945.There had been no previous typhoid fever it the Normandy camp, and the period of incubation would indicate that in most instances infection had been acquired after capture and in prisoner-of-war enclosures near the frontlines.
As for the Pacific Ocean Area and the China-Burma-India theater, there were no reports of typhoid or paratyphoid among American prisoners of war.
Undoubtedly, there must have been some cases, but they were either undiagnosed or unreported. It is known that there was a high rate of diarrhea in the Philippines following the fall of Bataan and in the American prisoner-of-war camp in the Asiatic area. When the Japanese conquered the Philippine Islands, the Japanese Army Medical Department took over a Philippine vaccine-production laboratory and produced a. vaccine that contained typhoid, cholera, and dysentery bacteria antigens. The typhoid and cholera com ponents may have been effective. It is doubtful whether the dysentery component was effective, although the death rate in infants with dysentery was reported to be lowered.
On Bataan, in the reports of the patients hospitalized, there is no record or mention made of true cases of typhoid fever. In 1945, the senior author of this chapter observed 3,000 sick Japanese prisoners of war at the new Bilibid Prison in Manila.Although there were many cases of bacillary dysentery and also amebic dysentery, there were few if any cases of typhoid fever among the prisoners.
ADVANCES IN CONTROL DURING WORLD WAR II
During and following World War I, the safeguarding of water and food supplies had approached and attained so high a standard that there developed a tendency to relegate its importance to secondary consideration. In World War II, in order to correct this tendency, Army engineers were given greater responsibility in such aspects as the location and appraisal of water supplies and the proper treatment of water, including chlorination, while the role of the Medical Department became more advisory in nature.
Constant supervision of laboratory technicians was achieved by evaluation studies that had been initiated at the beginning of the war in the Fourth Service Command and adopted as standard procedure. Through studies of results obtained by the laboratories under evaluation, supervisory laboratories were able to determine and direct necessary training. Thus, the early diagnosis of diseases dependent on laboratory results was greatly aided by increasing the proficiency of technicians.
Dish culturing. -A constant evaluation of mess sanitation was maintained by the periodic culturing of dishes, utensils, and other culinary apparatus, as well as by directing better sanitary practice wherever and whenever indicated.
Detection of typhoid and paratyphoid fevers.-World War II brought with it several improvements and refinements in the techniques of the detection and confirmation of typhoid and paratyphoid fevers through laboratory methods. The main advance in this connection has been the introduction of new media for culturing typhoid and paratyphoid organisms, a field in which Hardy and
Watt 20 were among the first important workers.It has been said that the reason for the supposedly low incidence of paratyphoid in the continental United States during the decade 1930-40 was because effective techniques for the isolation of the organisms had not as yet been developed. The use of S.-S. (Shigella-Salmonella thiosulfate-citrate-bile) agar, modified brilliant-green agar, sodium selenite, and tetrathionate broths are examples of the progress made in the development of differential media for the growth of the various Salmonella species.
There was no marked change in the routine serologic diagnostic methods, although a great step forward was made when the Kauffmann-White Schema was introduced with the resulting simplification. The ultimate diagnosis of the infections from Salmonella organisms (including Salmonella typhosa) during World War II depended on the classical standby method of culturing the blood, urine, and stools of the patient.
Controlled examination of water.-In addition to local examination of water supplies, it was found that more constant results could be obtained by submission of water samples to central Army laboratories where highly trained technicians could perform the necessary examinations with a higher degree of accuracy than could be done by smaller laboratories not completely equipped for such procedures. Acting from a central location where complete results of examinations were known, personnel charged with water sanitation could more readily direct such measures of purification as were necessary. The basic reason for this centralization was the need for greater administrative rather than technical improvement.
Routine culturing of stools.-The practice of culturing stool specimens in all cases exhibiting diarrhea proved to be a valuable one, and many cases of salmonellal infections were detected in this manner which might otherwise have remained unnoticed. A point which may be mentioned at this time is the erroneous impression of some bacteriologists and even physicians that only formed stools are of value in culturing organisms of enteric and gastrointestinal diseases. One of the methods of improving the routine culturing of stools was found to be that of inoculating known specimens at regular intervals and letting the bacteriologists and technicians study the number of organisms present to produce any positive culture and diagnosis.
Carrier control and detection.-As has been mentioned earlier, little was accomplished in the therapy of typhoid and paratyphoid carriers.However,
20 Hardy, A. V., Watt, J., and DeCapito, T. M.: Studies of the Acute Diarrheal Diseases.Pub. Health Rep. 57: 521-524, 10 April 1942.
vigilance was not relaxed, and great zeal was displayed in the finding and apprehension of carriers. The sulfonamide drugs were found to be ineffective, and more recently the antibiotics have proved ineffective in completely eliminating the organisms from carriers.
Mobile laboratories.-Mobile laboratories were tested and found to be of considerable value in field operations where fixed laboratory service was nonexistent or simply not feasible. Immediate laboratory diagnosis of typhoid and paratyphoid fevers may prevent large outbreaks when sporadic infections occur.
Prophylaxis.-For the purpose of record, it is to be noted that there are two schools of thought on the merits of the Army's prophylactic vaccination. Some consider it most effective, while others attribute less value to it. The authors of this chapter accept the moderate viewpoint that while vaccination is effective on the whole, under extremely heavy infections the conferred immunity may break down. However, even in such cases, experience showed that the disease generally pursued a milder course in "immunized" persons. Thus, as is the case in a number of other diseases, vaccination does not provide absolute immunity to typhoid and paratyphoid fevers for the artificially induced immunity is overcome when organisms in sufficiently high numbers are introduced into an individual. Indeed, most of the recorded cases of typhoid and paratyphoid fevers occurred in immunized personnel. Rarely was it contracted prior to induction. Nevertheless, the mortality rates do indicate that the virulence. of the disease was indeed modified.
The occurrence of typhoid fever in "immunized" individuals in the Army is shown in table 83 formulated from data obtained by Lt. Col. (later Col.) Arthur P. Long, MC, who collected data during the war on immunized personnel who had developed the disease.21
Effective immunization against typhoid fever has been a problem to all armies and for that reason many nations have developed vaccines, often with considerable success, as for example, TAB endotoxoid which was used so successfully in South America. Considering the low rate of 0.02 per 1,000 troops during World War II, it is perhaps not unreasonable to suggest that despite the many modifications and variations in typhoid vaccines thus far devised, the United States Army vaccine probably is as effective as has been developed anywhere. 22
21 The Medical Department of the United States Army. Preventive Medicine in World War II, Personal Health Measures and Immunization. Washington: U. S. Government Printing Office, 1955, vol. III, ch. VIII.
22 Batson, H. C.: Typhoid Fever Prophylaxis by Active Immunization. Pub. Health Rep. Supp. 212, August 1949.