Reprinted from THE AMERICAN JOURNAL OF HYGIENE, Vol. 45, No. 3,
            305-334, May, 1947
                  Printed in U. S. A.

TYPHUS FEVER IN ITALY, 1943-1945, AND ITS CONTROL
           WITH LOUSE POWDER

BY

F. L. SOPER, W. A. DAVIS, F. 5. MARKHAM AND L. A. RIEHL 1

(Received for publication January 3rd, 1947)

A suggestion from the Office of The
Surgeon General of the United States
Army to the National Research Council
led, in 1942, to the development of an
effective pyrethrum-containing louse
powder, MYL, by a United States De-
partment of Agriculture group working
in Orlando, Fla.  Field tests of this
powder in artificial louse infestations
during the summer of 1942 gave such
promising results (Davis and Wheeler,
1944) that similar studies on natural in-
festations were planned for Mexico
(Davis et al., 1944) and the Middle East.
Early in 1943 it was demonstrated in
Egypt by the United States of America
Typhus Commission that two applica-
tions of MYL powder with a 14-day in-
terval between treatments would re-
duce the louse infestation of an indi-
vidual to a low level, and that with an
adequate staff large numbers of persons
could be deloused at central powder sta-
tions in spite of the time consumed in
removing the clothing of each individual
for dusting. Furthermore, in a village
where typhus was epidemic the spread
of the disease ceased following the de-
lousing treatment.

Later in 1943, in Algeria, a technique
was evolved for blowing louse powder
on the inner surfaces of garments,
especially those next the skin, without
undressing the person treated (Soper
et al., 1945).  Tests of MYL and the

1 Members of the typhus team of The Rocke-
feller Foundation Health Commission.

then new DDT powders, carried out in
the absence of typhus infection but con-
trolled by louse counts before and for
a considerable period after hand or me-
chanical application of the powders,
indicated that either should be efficacious
in arresting transmission of epidemic
typhus.

Since a resume of the Naples epidemic
with an account of the measures insti-
tuted for its arrest has appeared
(Wheeler, 1946), the present report will
not attempt to relate the particular ac-
tivity of each of the organizations which
collaborated in the fight against typhus
in Naples. Rather, it will describe the
evolution of the epidemic and the per-
sons affected thereby ; it will discuss the
measures instituted for the control of
the outbreak and evaluate their merits ;
and it will describe in some detail the
techniques and procedures recommended
for applying louse powder in the event
of subsequent typhus outbreaks.

The typhus team of The Rockefeller
Foundation Health Commission organ-
ized and administered the delousing
service in Naples under Col. W. H.
Crichton (British), Public Health Offi-,
cer, Allied Military Government (AMG) ,
Region III, 15th Army Group, from
December 9th, 1943, to January 2nd,
1944; continued in charge of the mass
delousing section of the typhus control
service under Brig. Gen. Leon A. Fox
and Col. Harry A. Bishop, United States
of America Typhus Commission, Janu-
ary 3rd to February 19th, 1944; and
resumed full responsibility for all de-

305         A.J.H.. 1947, VOL. 45: PP. 305-334


306     F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

lousing under Brig. G. S. Parkinson and
Lt. Cols. W. C. Williams and Gordon
Frizelle, director and deputy directors
of the Public Health Sub-Commission
for Italy, from February 20th, 1944, to
July 31st, 1945.

Administrative personnel were. drawn
from both military and civilian sources
including : Allied Military Government
agencies ; the Municipal Health Service,
Naples ; the Public Health Sub-Commis-
sion of the Allied Control Commission
for Italy; the Peninsular Base Section,
United States Army; the North African
Theater of Operations of the United
States Army (NATOUSA) ; malaria
control units from North Africa, Iran
and Iraq ; the Royal Army Medical
Corps (British) ; the United States of
America Typhus Commission, the
United States Navy, and the Italian
Red Cross and civilian medical profes-
sion.

Evo~lution of the epidemic

The earliest incursion of typhus in
the mainland of Italy during World
War II apparently occurred in late
February of 1943 when a hospital train
bringing soldiers from the Russian front
arrived at Foggia, where 281 soldiers
and officers were hospitalized. The train
then proceeded to Bari, where 226 others
were discharged to hospitals.  On the
12th and 13th of March, 80 cases of
typhus appeared among these repatri-
ated soldiers. Two additional eases were
reported from the crew of the hospital
train, a third in the staff of the Red
Cross Hospital in Foggia and another
in a soldier who had gone to Messina
on leave from one of the military hos-
pitals.

The first cases of typhus in Naples
were reported in March among patients
in the military hospital, one in a soldier
returned by train from the Russian

front and 3 ot,hers in men brought by
hospital ship from North Africa. The
initial case of typhus in civilians was re-
ported at Aversa, some 12 miles from
Naples, where the first of 8 cases, all in
the same family, had its onset on April
24th. The diagnosis was confirmed sero-
logically at the Cotugno San Giorgio
municipal contagious disease hospital in
Naples.  This patient had traveled to
Foggia province twice during the week
preceding onset, making portions of the
trip in military vehicles operating to
and from the military hospital,  The
commandant of this hospital at Aversa
claimed that there was no typhus among
his patients ; however, his records of
wounded and sick included several ty-
phus convalescents who were brought
from North Africa directly to Aversa.

In July two cases were reported
among patrons of a bathing establish-
ment in Naples and a third case (Giu-
seppe Grassi) with onset on the 16th
of the month, occurred at the Poggio-
reale prison, a large provincial institu-
tion located in the industrial area of
Naples.  Grassi was released on July
21st. On the 28th he was taken to the
Cotugno Hospital where a diagnosis of
typhus was confirmed serologically.

Poggioreale prison, the most impor-
tant in the area, was surrounded by
military barracks, airplane and locomo-
tive works and soap and textile plants.
Several direct hits during the Allied
air raids of 1943 rendered some of its
pavilions uninhabitable.  The bathing
plant was demolished, and hygiene in
the prison sank accordingly.   There
were no shelters, and while raids were
in progress the prisoners were herded
together in the basement. The inmates
were almost all louse infested, so that
conditions for the transmission of typhus
were ideal once the causal agent had
been introduced.


TYPHUS FEVER CONTROL IN ITALY

307

There were many opportunities for
the introduction of typhus into Pog-
gioreale during the winter and spring
of 19421943. The disease was unusu-
ally prevalent in North Africa at this
time, and there are records of large
numbers of prisoners, both French and
Italian, who were evacuated from Tu-
nisian prisons, some by way of Sicily
and others directly to Naples. Dr. Sa-
porito, Medical Inspector General for
Italian prisons,. admitted that there was
typhus among .the prisoners in Sicily 2
and that louse control there consisted
of burning and replacing clothing be-
cause there were neither chemicals nor
equipment for delousing. Large num:
bers of Yugoslav prisoners also passed
through Poggioreale as late as April,
1943, and the names of some of these
appear in the infirmary reports.

The records at Poggioreale are re-
stricted largely to the infirmary registers
which escaped destruction when the riot-
ing prisoners burned the personnel rec-
ords in the late summer of 1943, but a
number of the inmates were traced
through transfer records at branch pris-
ons. Following the case of Grassi, men-
tioned above, Vincenzo Petriccione, who
apparently contracted the disease in the
prison infirmary, became ill on? July
19th. On the 23rd he went to Cbtugno
Hospital, where the diagnosis of typhus
was made.  De Luca, a clerk in the
prison, became ill with the disease on
August 13th and Guerrino, one of the
carabinieri, contracted it on August

2 The first outbreak wae at Milazzo, Sicily,
where 37 oases with 9 deaths occurred among
Libyan prisoners between January and April,
1943.  Twenty c&BeB occurred among 130
Libyans at Nicosia in July, 1943, jUBt before
the Allied invasion. No civilian pasea had been
registered up to the prison break which came
in August during the invasion, but escaping
prisoners may have been responsible for scat-
tering the infection in Sicily.

15th. How many other cases occurred
among the prisoners and staff between
this time and December, when the first
cases were actually reported from the
prison, is not known, but inspection of
the infirmary records reveals a long list
of suspicious diagnoses, and one is im-
pressed by the frequency with which
acutely ill prisoners were liberated or
transferred to branch prisons.

Typhus appeared in men transferred
from Poggioreale in at least 4 branch
institutions.  One prisoner with a fully
developed infection was transferred to
Casoria on July 17th. In July and
August the Poggioreale infirmary was
filled to capacity so that patients -from
the prisons at Gragnano, Casoria and
Aversa, in whom typhus was diagnosed
serologically, were refused admission.
Some of these patients returned to
branch prisons while others were liber-
ated.

The Pozzuoli prison, a reformatory for
boys and mental delinquents which was
evacuated in July to receive the over-
flow from Poggioreale, is the most in-
teresting of the 4 branch prisons where
typhus occurred during the summer of
1943. Large numbers of prisoners were
transferred to Pozzuoli on July 12th,
26th, and ?7th, and shortly after their
arrival some 25 cases of typhus de-
veloped. One patient died only 6 days
after admission, and `onsets among the
others began on August 5th. When the
disease was finally diagnosed the prison
was quarantined, and the patients were
sent to Cotugno Hospital. Of no little
significance is the fact that during Au-
gust, when at least 25 typhus patients
were present, no less than 100 prisoners
were liberated, 40 or more were trans-
ferred to other institutions and some 25
escaped. In the mounting confusion of
August and September in Naples these
potential carriers of the disease were


308     F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

lost to sight.  Many probably sought
refuge in the air-raid shelters, locally
called tioveros, which were as ad-
mirably designed to protect runaway
prisoners from the law as honest citizens
from bombs. The ricovero in "Tunnel
9th of May," a main traffic artery be-
tween Naples and Pozzuoli, began to
yield cases of typhus in August and
September.

Although Naples is a city of nearly
a million inhabitants it is relatively
small and compact. The tenement dis-
tricts about the port and industrial areas
suffered extensive damage during the
Allied raids in the spring and summer
of 1943, so that large numbers of fami-
lies were forced to reside in air-raid
shelters. These were large underground
chambers, most of them old quarries for
tufa, the chief building material of the
region.  Many of the ricoveros were
equipped with lights, some had water
and toilet facilities and a few afforded
some measure of privacy in cubicles
built of wood or stone, but in general
the shelters were draughty, damp and
almost always dirty.   Most of their
permanent dwellers came from the poor-
est sections of Naples.

There are no official or reliable esti-
mates of the usual population of the
air-raid shelters in the summer of 1943,
but their estimated capacity of 220,000
must have been severely taxed during
the heavy raids of July, August and
September.

On September 23rd the Germans
ordered the evacuation of a zone 300
meters deep about the port and coastal
area, and some 300,000 persons were
obliged to leave their dwellings on that
day, which resulted in further cro.wding
of the air-raid shelters.  Among the
evacuees were thousands who lived in
the "Tunnel 9th of May." Typhus had
been incubating in this shelter for weeks,

and its occupants were now dispersed
to the shelters beyond the 300-meter
zone. With characteristic thoroughness
the Germans, before leaving Naples on
September 30th, opened the doors of
Poggioreale and Pozzuoli prisons and
emptied their infested occupants into the
already overcrowded shelters of the city.
Owing to the disorganization caused by
the German evacuation and the Allied
occupation of Naples this serious situa-
tion went unchallenged. Transportation
and communication facilities were in-
adequate for the needs of the civilian
health authorities, with the result that
the investigation of reported cases, iso-
lation of known cases and even the
preparation of reports were all delayed.

Persons affected by the epidemic

The final record of cases of typhus in
Naples and the vicinity from July 1st
1943, to June lst, 1944, may be classified
as follows :

                      CMWJ   Deaths
Civilian cases in Naples    1,403   318
Civilian cases outside Kaples   511 82
Italian military personnel      23     3
Italian civilian prisoners      37 11
Unverified civilian cases       46 15
                      --
                 2,020 429

The unverified cases were those not
hospitalized nor seen by the control
service staff, and the diagnoses were
not confirmed by laboratory tests.

These data and the data presented in
table 1 differ from those reported during
the epidemic, when l&s of cases were be-
ing  received from various sources.
Duplications have been eliminated by
careful checking of the names and
identifying information regarding cases
reported in municipal and provincial
health department lists, death certifi-
cates, hospital admission records and
laboratory reports, and the daily re-
ports of the case-finding section.


TYPHUS FEVER CONTROL IN ITALY              309

Only the 1,914 civilian cases in and
outside Naples are included in the analy-
sis in table 1, since soldiers and prison-
ers constitute specially selected groups.
Of the 1,914 patients, 91 per cent were
hospitalized ; and serological con&ma-
tion of diagnosis, based on Weil-Felix,
Castenada or complement-fixation test,
was recorded for 61 per cent. Eighteen
of the patients were nurses or hospital
attendants and two were physicians.

TABLE

Distribution of typhus cases among civilians
  in Naples and vicinity, by weeks,
  July, 1943, through May, 1944

Week
ending

=
I

=

July 4
   11
   18
   25

-

On-
set
-
0
  1
2
  1

-

Re-
port
__
0
0
0
3

-

on-
set
-
C
C
C
1

Aug. 1
    8
   15
   22
   29

Sept. 5    5    3   a
   12    6    8   1
   19    8    4   1
   26    11    7   0

act. 3    8   11   1
   10    3    8   0
   17    8    3   2
   24   6    6   1
   31     1    6   0

Nov. 7    9    5   2
   14    12    5   3
   21    32   12   5
   28   46   26   6

Dec. 5
   12
   19
   26

40
64
129
224
-

42
42
48
115

11
7
8
21
-

Naplea

-

-



--

l
I
I




I
,



I
I


,




,

-

-

Rb
port
-

0
0
0
0


1
0
1
2
0


0
0
0
2


0
1
0
2
1


0
2
3
3


7
9
11
4

-
-

--

--

-

Week
ending

Jan. 2
    9
   16
   23
   30

Feb. 6    43   75  37   32
   13   33   38  35   34
   20    16   38  28   37
   27    9   20  26   24

Mar. 5

            12

Total         19
           26

on- Re-
set   port   Apr. 2
--        9
0 0        16
1 0       23

-
I

--

TABLE I-Continued

-

On-
set
-
189
137
143
117
64

10
5
1
3


4
2
0
1
0


0
0
0
0
-
,403





-
403

-

RFJ-
port

199
237
153
116
130

12
9
3
2


3
4
1
0
2


0
0
0
0
-
,403





-
,403

-



--

-

On-
set
-

18
23
35
57
31

-

Re-
port
-
11
24
18
25
63

38   22
17   42
17   32
13   18

16   21
9    2
10   21
10   3
4    5

2
0
1
0
-
500


8
3
-

ill
-

11
3
0
3

500

_-








_-



-

8
3
-
511
-

-
I

T&d

2 Re
    poti
--
207 210
160 261
178 171

80 107
68 72
44 75

48 34
22 51
18 35

20 24
11 6
10 22

,903 1,903

8 8

3 3
--
,914 1,914

Table 1. contains the distribution of
these 1,914 cases, by week of onset and
of report, for Naples and outlying com-
munities from July 1st) 1943, through
May 28th) 1944. Between July 1st) and
September 26th (13 weeks), 32 cases
       in Naples and only 6
    During the next 5 weeks the
corresponding figures were 34 and 4.
In the following 5 weeks (to December
5th)) 90 cases were reported in Naples
and 15 outside, bringing the totals of


310


  24oT




  400 .





  10 .

:
t
c
0 120 -
i


   80 -





  40 .

F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

0  4  18  1  15  29  12 26  10  24     21  5 19 2  16  30  3   27  12  26   9  23  7   21
  July     bug.     Sept. o-at.    nav. Dao.    Jan.      Feb.    NW.
               1943                                      *pr.    May
                                                  1944
                             "cl& ending

FIGURE 1.  Typhus casea, by date of onset, in Naples and vicinity, July, 1943,
               through May, 1944.

reported cases to that date up to 156
for Naples and 25 outside. During this
interval, however, 209 cases had their
onset in Naples and 37 outside.

The date of onset was that given by
the patient or his family, and there was
a tendency for these dates to cluster
about days readily recalled; e.g., 45
cases with onset on New Year's Day.
Likewise the date of report is not always
epidemiologically significant, since it did
not necessarily coincide with the date of
hospitalization or of dusting with in-
secticide.

Although one or more cases occurred
in Naples each week after the middle
of August, the epidemic rise did not
actually begin until the week ending
November 7th, when there were 9 cases.
It reached its peak with 224 cases in
the week ending December 26th. The

recession was not quite so rapid, but by
March 5th, 1944, the number of cases
in Naples by date of onset had dropped
to 10.

Figure 1 shows the gradual rise of the
epidemic in November, a sharp sky-
rocketing in December, followed by a
reversal in the form of the curve in
late December and a rapid decline in
the following months. When incidence
in Naples is compared with that outside
the city it is apparent that both ac-
celeration and deceleration of the epi-
demic were more rapid in the city than
outside. The median date of onset for
the 1,403 cases in Naples was December
29th and that of reporting January 6th,
giving an average lag of about 8 days.

The distribution of families or house-
holds with two or more cases is shown
below :


TYPHUS FEVER CONTROL IN ITALY              311

   Cases in families

  No. of case.2        No. of families

2               130
3               49
4                 42
5                28
6                16
7                 9
8                 8
9                 6
10                 2
11, 12, 16, 18,20        1 each

Although louse-borne typhus is essenti-
ally a contact disease, only 1,089 of the
1,914 patients came from households
having more than one case. The break-
ing up of families due to conditions
prevailing in the city may have been
partly responsible for this, but it is
also probable that many cases were
never reported. The application of louse
powder to persons in the incubation pe-
riod may also have prevented the spread
of the disease within the family.

The distribution of typhus cases and
deaths by age and sex are contained in
table 2, and in figure 2 the histograms
showing the age distributions of cases
among males and females are compared.
The large number of persons between
the ages of 10 and 24 years in each sex
group is a conspicuous feature of figure
2 and may be a reflection of the break-
down of the normal discipline and order
of family life in this war-torn area.
Young people, when homeless, probably
frequented the shelters, where the risk
of exposure was greatest.  Thus 9 of
14 cases recorded for one of the shelters
were in boys from 13 to 20 years of age.

No less interesting is the greater num-
ber of cases in females between the ages
of 35 and 44 years. Greater exposure
may have been a factor here, and since
women at these ages are usually mothers
with numerous children, their illness
disrupts the life of the family and they

TABLE 2

Age and sex distribution of typhus cases and
deaths, Naples and vicinity, I%&%1944

=
I

-
I

Fend  T&d

9 1
--

-

e1
--

O-4
5-9
10-14
15-19
20-24

-

hfsb
-
40
70
124
175
94

33    73
64   134
112   236
134   309
121   215

-

Md
-

5
2
2
16
6

   -

kid 0'
   --

5
3
3
13
11

rota1
-
10
5
5
29
17

25-29   57   75   132   9    6   15
30-34    55   77   132  16   13   29
35-39    50   109   159  22   19   41
4044    51   97   148  24   27   51
45-49    59   70   129  31   21   52
m-54    35   64   99  20   27   47
55-59    24   35   59   14   18   32

60-64
65-69
70-74

15
12
4


2
3
0
1
-
171
-

24   39   9   15   24
11    23  11    9   20
9   13   4    9   13

75-79
80-84
85
Unknown

2
3
0
0
-

196

2    4
2    5
1    1
0    0
   _- -

204  < Loo
   - -

Totals

-

Deaths

-

--


-

are more likely to receive medical aid
and to be reported.

It is probable that cases of typhus
were less well reported among young
children in whom the disease may be
mistaken for a childhood exanthema.
The low frequency of cases among men
of middle age may have been due partly
to their employment on night shifts,
which reduced their risk of exposure in
the shelters, and to a large number of
missed cases.

Owing to the uncertainty regarding
the completeness of these data, attack or
fatality rates derived from them would
have little significance.

For practical purposes an assumption
of universal susceptibility is beiieved


312     F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

FEMALES

MALES

AGE

FIQURE 2.  Typhus eases by age and Bex, Naples and vicinity, 1943-1944.


TYPHUS FEVER CONTROL IN ITALY              313

justified.  The only recent account of  city. Districts T, U, and W to the east
typhus in Naples was that of a group  were industrial areas with few habita-
of 42 cases described in a bulletin of the  tions, and few cases were reported from
Commune of Naples in 1927, originat-  them.  The evolution of the epidemic
ing in the winter of `1925-1926 from  also varied within the districts. In area
two small ships from North Africa,  A, for example, half the cases occurred
which entered the port without the  by mid-December, while in area V this
formality of quarantine inspection. Vig-  stage was not reached until January
orous measures appear to have sup-  8th. Areas A, C, G, M, N, P, and Q ac-
pressed the spread of the disease at this  counted for more than 50 per cent of
time.  Prior to the epidemic, murine the cases.
typhus was not reported from Italy.   Outside the city 511 civilian cases
It is now known to be present in the  were reported from 60 different com-
area, but it seems unlikely that the  munities of which 495 occurred within
disease is sufficiently widespread to af- 25 miles of Naples (figure 4).  This
feet appreciably the susceptibility of  limited dispersion was probably due
the population as a whole.          to difficulties in civilian travel as well
Although exposure to infection was  as to less complete reporting of cases.
by no means universal, the distribution  The most remote point reached was
of cases shown in figure 3 indicates that  Lecce and the greatest number in any
typhus permeated most of the 24 alpha-  one locality was 46 cases in Torre de1
betically designated districts of the  Greco, a small, but busy, port at the

FIGURE 3.  Distribution of typhus case8 in Naples by administrative
    district, November lst, 1943, to April 30th, 1944.


314      F. I,. SOPER, W. A. DAVIS, F. S. MARKHAM AND IJ. A. RIEHL

foot of Vesuvius. This town like many  in the attack when fewer rickettsiae
others is really an extension of the city  are present in the blood stream, the lice
of Naples.                develop their infections more slowly
                        and the risk of transmission will lessen.
    Epidemic potential        In view of the intermediate character
The question of when a typhus patient  of the period of potential transmission,
becomes a menace to the community is  it was necessary to make an arbitrary
not easy to answer. .A person harbor-  assumption regarding its length, and
ing a, single infected louse is not a  it was decided to define this period as
likely focus of disease spread during  one of 18 days following onset unless in
the period of survival of that particu-  the meantime the patient had died, or
lar louse. The individual and his own  had been dusted or isolated.
lice may remain well for 10 or 12 days   For each case reported in Naples,
or until the febrile period begins.  The  therefore, with onset between November
febrile period may last from 16 to 18  lst, 1943, and April 30th, 1944, the
days, during which time the patient's  number of days (up to 18) elapsing
lice may become infected and remain  between onset and isolation, dusting or
so until their death some 10 to 15 days  death was counted. These periods of
after their first infective meal. During  infectiousness, when accumulated on a
this period the risk of transmission of  chronological basis, may be said to con-
typhus organisms from the' patient to  stitute the epidemic potential of typhus
his associates will be greaiest. Later  with respect to the uninfected popula-

FIQURE 4.  Distribution of typhus eases in and around Naples,
      July lst, 1943, to May 31st, 1944.


TYPHUS FEVER CONTROL IN ITA'?Y            315

Epidemic Potential -
@isolated cases)
Contact Dusting    . . . . . . . . . . . -.
              ----

lI,""".""`.""`*",L.JU
1   14   26   12   26   9   23   6   20   5   19    2   16   30
    Bw.        Dec.      JtXlh       Feb.     Mar.      Apr.
         1943                       1944
FIGURE 5. Typhus epidemie potential compared with the dusting activities,
      Naples, November lst, 1943, to April 30th, 1944.

100

tion of Naples.  Figure 5 shows the
trend of these data when plotted on a
semilogarithmic scale, compared with
the trends of persons treated daily by
the contact and station dusting serv-
ices. The dramatic evolution, progress
and decline of the epidemic and the
relation of the control measures to its
various phases are clearly depicted
here.

The organization and accomplishments
   of delousing activities

Headquarters for typhus control ac-
tivities were established at the Pro-
vincial Laboratory on December 14th,
and delousing with insecticidal powder
began on December 15th with the com-

pulsory dusting of 700 passengers leav-
ing Naples on the first passenger train
to depart after Allied occupation. The
first dusting crews were composed of
nurses and inspectors from the Munic-
ipal Health Department. These proved
to be intelligent, faithful workers and
formed the nucleus around which the
greatly expanded service developed
later.  Subsequently, recourse was had
to personnel hired through the AMG
Labor Office.

The delousing activities fell naturally
into the following categories for ad-
ministrative purposes and were initiated
on the dates indicated:

1. Contact delousing (December 16th,
  1943)


316    F. L. So@R, de A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

2. Air-raid shelter delousing (Decem-
  ber 27th, 1943)

3. Mass delousing : (a) Station (De-
  cember 28th, 1943) ; (b) Block
  (February 6th, 1944)
4. Flying squadron for work outside
  Naples (January 8th, 1944)
5. Institutional delousing (January 9th,
  1944)

6. Military and military labor delousing
  (December, 1943)

7. Refugee delousing (December, 1943)

is the least satisfactory of the three
pumps eventually used because it re-
quires refilling after each two or 3
dustings, and its delivery of powder
tends to be in masses rather than in
clouds of dust (Soper et al., 1945).
There were a few Dobbins "Super-
built" no. 133 guns on hand, and later
the Hudson "Admiral" no. 765 gun be-
came available, both of which were
found to be equally satisfactory and
far superior to the "Cadet" duster (see
figures 10-16).

There will be no discussion of institu- .-act or spot delousing. The names
tional, military or refugee delousing,  and addresses of all typhus patients re-
and no account of the isolation and  ported after November 1st were as-
treatment of the sick.  Casual refer-  sembled on December 12th so that the
ence only will be made to vaccination  homes could be visited and the contacts
as a method of combating the disease.  of the patients discovered and ,deloused.
Insecticide and dusting equipment.  An immediate result of this work was
The Surgeon's Office of the Peninsular  the finding of additional cases hitherto
Base Section made 20,000 two-ounce tins  unreported, and, subsequently, this dis-
of MYL available immediately.   The  covery of new cases became an impor-
Surgeon's Office, NATOUSA, sent 400  tant function ,of the contact-delousing
pounds of DDT concentrate by air and ' squads.
authorized the use of such amounts of   The careful records of names and ad-
MYL powder, up to 500,000 two-ounce , dresses of families dusted and new pa-
tins, as were required until the Allied ' tients found, which were kept by the
Control Commission stocks began to ar-  squads, provided the data for group-
rive in January. The relative amounts of  ing the cases by families.  They also
MYL and DDT used in Naples cannot  facilitated the preparation of block his-
be accurately determined, but since most  tories for certain areas, so that what
of the early work was done with MYL,  families had been dusted and when, in
to this insecticide must go the credit  relation to primary and subsequent ty-
for the early resulm of the delousing  phus cases, could be determined. Such
campaign.                information has aided materially in
Hand dust-guns were used in the ap-  evaluating the spot-dusting measures,
plication of the powder and the work-  which were those first employed.
ers were trained to follow a definite   In practice, all members of a patient's
procedure in dusting each person, for  family were dusted at the time of the
which written instructions (reproduced  squad's visit but absent members were
below) were issued, so that the chance  not sought out. The family was urged
of omitting certain points might be  to see that such persons attended the
lessened when dusters were working nearest mass-delousing station. The
under pressure. Most, of the work in  squad also powdered those other per-
Naples had to be done with the small  sons wishing to be dusted who lived in
"Cadet" type of Hudson duster, which  the same or contiguous buildings. Thus


TYPHUS FEVEd3 CONTROL IN ITALY              317

the term "spot dusting" more adequately
describes its work. The crew usually
worked in the courtyard or street in
front of the building in which the pa-
tient lived.

On January 12th this spot delousing
by persons accompanying the case-find-
ing units was reduced to the immediate
family and household contacm.  Later
in the month, however, the units re-
verted to a more extensive coverage and
shortly afterward collaborated with the
mass-delousing service in dusting resi-
dents of certain blocks in areas where
typhus persisted or where surveys re-
vealed an appreciable amount of louse
infestation,

Air-raid shelter delousing. The im-
pmelter as a
focus of typhus transmission was recog-
nized at once, but the organization and
conduct of delousing activities there
presented certain problems since the
work had to be done between 6 P.M. and
midnight, when the shelter held its
maximum population. The service was
organized to care for the dusting of ap-
proximately 10,060 persons weekly. Six
teams, each consisting of a physician and
12 dusters, made the rounds of some
80 to 90 shelters, at first every 7 days
and later once in 2 weeks, as the num-
ber of cases reported from the shelters
declined.

factorily and adequate transportation
and stocks of insecticide became avail-
able, plans were ready for opening 50
public delousing stations with an esti-
mated capacity of 100,000 persons daily.
Sites in hospitals, schools, churches,
railway and streetcar waiting rooms,
etc., were chosen with consideration for
population density and the known dis-
tribution of typhus. Each station was
under the direction of a foreman and an

assistant, who were responsible for the
conduct of the work and the keeping
of the daily records.

The first two stations opened on De-
cember 28th. The one at the Ascalesi
Hospital began by bringing children in
from the street to be dusted. Its record
jumped from 107 persons dusted the
first day to 577 on the third and 1,625
persons on the seventh day. The other
station at the Anguilli School had the
advantage of a large pediatric dispen-
sary in the same building and its clientele
was sent to be dusted. This station de-
loused 837 persons on the first day,
2,200 on the third and 3,585 on the
seventh day. The delousing stations be-
came popular overnight, so that soon
the sight of persons on the street with
powdered hair and clothing was too
common to cause comment.

The supervision of, the stations was
carried out by Italian civilian inspec-
tors, most of them physicians, who had
a varying number of stations to visit
twice daily.  They issued powder and
pumps, checked the work of the stations
and collected the daily reports of oper-
ating personnel, supplies received and
used, and the number of persons pow-
dered. When received at headquarters
these reports were summarized each day
to provide the supervisors and adminis-
trators with current data on the opera-
tion of every station. In a summary
of the work of 33 stations operating in
Naples on January 15th, 1944, there
were, on the average, 13 persons working
in each station, and an average of 1,611
persons were dusted per station. Some
2,500 pounds of powder were used in
the 33 stations, with an average of 21
persons dusted per pound. It was only
by daily checking of the activity of the
stations that a proper level of efficiency
could be maintained.

A problem involved in the operation


318

F. L. SOPEd, W. A. DAVIS, F.  S. MARKHAM AND L. A. RIEHL

of the stations was the hourly variation
in the volume of work to be done. Visit-
ing hours at hospitals, arrival and de-
parture of trains and the opening and
closing of business affected attendance
at the stations. The staff provided had
to be sufficient to deal with persons
coming to be dusted at rush hours,
which meant an overstaffing in slack

Mass delousing: (2) Block. As the
of the stations progressed it be-

  came evident that a certain portion of
- the population was not being reached,
   since typhus continued to occur in cer-
   tain blocks within walking distance of
   busy dusting stations. It was decided,
   therefore, to survey different sections
   of the city with a view to answering
   the following questions : (a) were per-
   sons living near the stations being dusted
   repeatedly while those at a distance
   were missed ; (b ) was the dusting of
   men, women and children of equal pro-
   portion ; (c) what proportion of those
    dusted still had lice?

For this survey, groups of blocks rep-
resenting different sections of a given
district were chosen and detailed maps
and census forms prepared.  By the
middle of February the canvass had
covered over 100,000 persons, of whom
77 per cent claimed to have been dusted
one or more times.  The percentage
varied from 65 around the Poggioreale
prison to 93 in Fuorigrotta. Approxi-
mately 20 per cent had been dusted once,
28 per cent twice and 29 per cent more
frequently.  Of some 13,000 children
who had been powdered, 11.6 per cent
were found to be louse infested, as
compared with 20 per cent of 2,500
undusted children.

As a result of these surveys, squads
were organized on February 6th to work
blocks having more than 5 per cent of
louse infestation, less than 70 per cent

of persons with a record of previous
dusting, or both.  Where typhus was
being reported dusting was carried out
if less than 90 per cent had been pre-
viously dusted. Block dusting was be-
gun when the epidemic in Naples was
definitely on the decline, so that, the
crews were augmented by persons re-
leased from the contact-delousing sec-
tion. After February 14th the residents
of each block where a case was reported
were dusted, as well as residents of
blocks contiguous to t.he one containing
the infected house.

Block-dusting crews always started at
the same point in each block, say the
northeast corner, and proceeded to the
right, calling at every door, entrance
or courtyard, moving from floor to
floor in the same manner, until they
returned to their starting point ready to
begin the next block. The squad kept
a record of the dusted and undusted
persons living in each household and
those who were away from home were
reached at school or at their place of
employment.

Plying squadron delousing outside
Naples.  The flying squadron began
work on January 8th, 1944, investigat-
ing typhus suspects outside Naples and
operating in much the same manner as
did the contact delousing squads in the
city. Household and neighborhood con-
tacts of infected persons were dusted,
and a search was made for new cases.
The squadron also vaccinated contacts
as well as others in infected areas. Al-
though 9'7 per cent of the cases of typhus
outside Naples occurred within a 25-
mile radius (figure 4), investigations
had to be carried out at greater dis-
tances, at times even in the zone of
military operations.

Some of the infected suburbs of
Naples were heavily populated areas,
and for these a special mobile unit was


TYPHUS FEVER CONTROL IN ITALY              319

organized to carry on more extensive
house-to-house delousing than could be
done by the squadron. A report of de-
lousing and vaccination activities per-
formed by the flying squadron is given,
by weeks, in table 3 with reference to
the probable cases of typhus seen from
January 1st through May 2&h, 1944.
Approximately 630 persons were dusted
per case seen.

TABLE 3

Weekly block dusting and vaccination of contacts
performed by the jlying squadron outside
   Naples, JanuamJ to May, i9&

Week
ending

Jan. 9
   16
   23
   30

Feb. 6
   13
   20
   27

Mar. 5
   12
   19
   26

Apr. 2
    9
   16
   23
   30

May 7
   14
   21
   28

Totals

=



--









--



-

Probable
lxse* seen

1
6
17
48

F%T
u


  13
  402
8,484
13,430

24     12,150
21    11,075
32    20,457
27    13,758

17    11,720
37    20,336
26     12,023
17     10,066

20     9,636
4     9,967
22     7,675
5     11,284
8     11,143

8     6,640
5     7,697
0     6,888
3     6,360

348    211,204

1



--









-

13
44
16
226

193
77
130
26

38
63
139
47

65
28
9
21
5

17
7
8
18

-~
1,190

It is difficult to appraise the work of
the flying squadron because of the like-
lihood of reinfection from Naples, and
because many persons residing in these
-areas may have been dusted in the
city.  In 7 of the 60 places outside

Naples where cases occurred no delous-
ing was undertaken and in 26 places
where measures were taken no subse-
quent cases occurred during a 12- to 14-
day post-treatment period, so the typhus
potential in these communities must be
regarded as minimal.

Xummary  of delousi?g activities.
From the middle of December, when
dusting operations began, until the epi-
demic subsided, over 3,000,OOO applica-
tions of powder were made in Naples
and the surrounding towns.  Table 4
contains a day-by-day report of dustings
by the services in Naples between De-
cember 15th, 1943, and January 15th,
1944, while the work was being organ-
ized and developed. Table 5 contains
the weekly report of all dustings through
May 31st, 1944. From the standpoint
of economy of effort and material, it is
now important to decide whether con-
tact or spot dusting alone is sufficient
for typhus control or whether this
method plus station delousing should be
employed in future programs.

An appraisal of typhus control by
     louse powder

For evaluating the effect of dusting
with louse powder upon the spread of
typhus, the outbreak in Fuorigrotta,
which was epidemiologically a part of
Naples, has been chosen for considera-
tion. This community, with its 11,000
inhabitants, is the area designated "M"
in figure 3. Various tunnels through a
narrow, high land barrier connect it
with western Naples, but for the most
part epidemiological factors appear to
have operated locally. The eastern half
of Fuorigrotta, lying west of the Naples
tunnels, is characterized by narrow
streets, bad sanitation and housing con-
ditions like those of Naples. The west-
ern half contains two municipal housing
projects, one of which consists of a


320    F. L. SOP+ W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL


           TABLE 4         damage during the Allied air raids of
    Daily dusting totals, Naples,      1943 so that its two shelters did not
December f&h, 1943, to January 15th, 1944   have a large resident population, but

Date

-



c

ontact
usting

!iCOVt?TC
usting

Dec. 15        700
   16        435
   17        576
   18      1,060
   19      1,387

20      1,311
21      1,569
22      1,391
23         713
24      1,345

25
26
27
28
29

944
1,765

1,131
1,404
1,767
2,042
3,078

600
600
180

30  3,683  3,386   ma
31   4,041  1,675   447

Jan. 1
    2
    3
    4
    5

6
7
E
9
10

1


,


,
I
I




1

,


,
--

5
-

2,56E  1,808   446
5,15r  3,311   492
11,495  4,231   485
19,581  2,463  1,055
22,93E  3,838  1,761

28,65E  3,344  1,041
37,96C  3,360  1,275
38,971  3,405  1,224
37,75c  1,911  1,226
66,12C  2,994  2,092

11
12
13
14
15

63,2X  3,533  2,321
66,47f   147  1,58E
60,86S    112   954
59,99E    149  1,414
53,15:    71  1,648

Totals

185,331

`9,647  !I,354

ZZZ

    the German air attacks in the late fall
   and winter caused many people to re-
   sort to shelters at night. Since the com-
rotah  bined capacity of the two shelters did
   not exceed 5,000 they were extremely

700  crowded during the raids.
435   The first typhus case in east Fuori-
576 grotta had its onset on December lst,
~~~~~  1943, but was not reported until Janu-
,
                 TABLE 5

2oc
1,41c

-
1,215
665
1,304
1,96f

6,762

-


I
:.

1,131   Dec. 19

1,404      26

2,367
3,586  Jan'

5,023   "9
         16

7,569      23

6,163      30



4 822  Feb'  '
8:961      13

16,214      20

23,099      27

28,534   Mar.  5

33,043      12

42,595      19

43,600      26

41,089
72,622  Apr* ;

69,064      16

69,426      23

62,595      30

62,862
56,838  May  7
         14

i73,094      21
         28
         29-3:

1,311
1,569      Weekly dusting totals, Naples,
       Decembw         to
1,391         1514 1943,  May 3lst, 1944
                     -
713
1,345   Week ending   Station*     Other
              -       _-

TOtd

1

29,732   15,606    45,338
24,281   11,215    35,496 ,
6,403   3,206    9,609
4,550   3,367    7,917
2,307    1,762    4,069

collection of 4-family cottages, each with
a garden plot, and the other of a group    Totals   2,628,208  380,249  3,008,457

of large 5-story apartment buildings.     * Includes mass delousing in out-of-town
The town suffered relatively slight shtions,

-

-

4,158    4,158
8,864    8,864

18,159   20,332    38,491
197,350   30,824   228,174
408,163   27,558   435,721
334,785   19,085   353,870
188,346   29,052   217,398

174,000   24,829   198,829
165,493   18,815   184,308
147,701   16,742   164,443
144,200   20,534   164,734

139,355   20,664   160,019
130,829   18,046   148,875
102,421   20,986   123,407
83,564   11,931    95,495

80,902   13,197    94,099
66,887    8,914    75,801
61,883   16,954    78,837
64,442   7,675    72,117
52,455    5,933    58,388


TYPHUS FEVER CONTROL IN ITALY              321

ary 6th. The second case in this section
occurred December 10th and was re-
ported on the 18th. This patient had
slept in the shelter and was the probable
source of many of the subsequent cases
there' and in the Via Grotta Vecchia.
At the other end of the town two, cases
of typhus had their onset in the munic-
ipal housing developments. on Decem-
ber 2nd.  The people in this section
used the shelter in Rione Duca d'Aosta.

A criterion for determining the effec-
tiveness of dusting operations must now
be considered. Obviously delousing an
individual during the incubation stage
of typhus will not prevent infection
from developing, so that cases may be
expected to appear over a period of from
10 to 12 days after dusting begins, but
when such persons are thoroughly
dusted before onset the chances will be
materially lessened that they will infect

?ecstatlon was welcomed by the people.'
In the western end of the community
more persons per case were dusted owing
to the greater density of population,
with the result that here only one case
had its onset more than 15 days after
spot dusting began. In the eastern sec-
tion of the community where the popu-
lation was more scattered and nearer
to Naples the final case had its onset on
January 29th, which was 6 weeks after
contact dusting was started in Fuori-
grotta.

Because of the alarm created by the
discovery of 59 cases during the first
week of January, a mass-delousing sta-
tion was opened on January 7th and
nearly 20,000 dustings were done in
the first 5 days. Beginning with Janu-
ary 24th, applicants were refused dust-
ing if they had been powdered during
the previous 2 weeks.  In the subse-

.*46 per cent more than tw&e.- When the
station was closed at the end of April
over 58,000 dustings had been done,
representing an expenditure of 1.5
tons of louse powder in addition to the
cost of labor and supervision.  Could
the job in Fuorigrotta have been accom-
plished with less money and material?

-I

lice and so be likely to transmit the
disease to others.  Hence if cases de-
               t.0 apear

after an interval of from 12 to 15 days,
the presumption is that the treatment

has reduced transmission of the disease.
It is also obvious that with an average.
lag of from 8 to 10 days between onset
and report, the effectiveness of control
measures will be reduced. For maxi-
mum eficiency, therefore, the dusting
service must be accompanied by an ade-
quate and skilled case-finding service.

Figure 6 shows the individual cases'
in Fuorigrotta plotted in order of onset
above the horizontal line and the same
cases plotted below the line when re-
ported. On the 20th of December when
spot dusting began in Fuorigrotta, only
18 of the 106 onsets had occurred and
of these only 5 had been reported.
Twelve days later, on January lst, 87
cases had had their onset with the proba-
bility that none could have been pre-
vented by the dusting. During the next
3 days 6 more cases occurred, but by
January 5th the epidemic was virtually
over although 13 cases had their onset
between that date and January 29th.

Figure 7 shows the rise and fall of
the epldemi?@tentlal curve in Fuori-
                               -
grotta plotted to a semilogarithmic
me. Between December 10th &Oth.
i.e., 10 days prior and subsequent to
the beginning of contact dusting, the
number of undeclared cases in the area


          FUORIGROTTA               DATE OF ONSET                     7944

1     5       10  Dec;smber fgg      2.5      Jo 1     5       10 Jonyyry N)   25      Febru'qry
              I I I1 I I II, ,a I ! I I I1 I I I I,, , , , I I I I, I I, I IL II ! I II I, I I L I I- I ,I I f,

DATE OF REPORT

Fabvuory

FIGURE 6. Fuorigrotta: individual typhus cases bs date of onset and report, with reference to dusting aetivitiea.


TYPHUS FEVER CONTROL IN ITALY              323

rose steadily. The straight line fitted  was not accelerated by the mass dusting
to the logarithms of the numbers of  activities begun on January 7th.
cases indicates a rate of increase of   A study of individual block histories
17.2 per cent daily. If the curve had  in the city of Naples further strengthens
continued to rise at this rate during
c   s on January 9th there  the impression that prompt coverage
another                by the contact-dusting and case-finding
would have been some 368 undeclared `<services resulted i mm
eases in the cornmu&. Actually there     of-`\
         ---              transmission.  A single block in area a
were only 17. While one cannot prove  P, for example, had 43 of the 195 cases
that dusting was wholly responsible for  occurring in this district. Twenty of
the subsidence of the outbreak, one can  these had onset after spot dusting be-
confidently assert that it was an im-  gan, but 13 of them occurred within 12
portant contributing factor, particu-  days of the first dusting. Of the remain-
larly in view of the fact that no vacci-  ing 7, four had been dusted before on-
nations were done. Figure 7 also reveals  set. How many patients in the Naples
that the fall of the epidemic potential  epidemic were actually dusted before on-


    SOO-

               r 368

                      /
                      /
                  /


   loo -                /

B                   /
3
3                                      b

f                                       .
ifi                                        .

I
%                                         .     .
                               o ??
                                            ?
                                             ?
   ?? ?                                                ? ?

                                              o ?
                    ?
              ?                    ? ???????  ? ?




                                                         ? ?

           ? ? ? ?  ? ?  ?      ?        ?                 ?? ?

                 ?            ?

                 ?         ?           ?                  ? ??
             ?
          ??      ??
  ??                                ?
          ? ?    ?    ?    ?    ?    ?     ?         ?    ?    ?    ?
         1 s 10 15 20 2s so 6 10 15  20. 25 20

            Dweribr lM.2             Jammy 1944
FIQURE 7. Fuorigrotta: rise and fall of the typhus epidemic potential with reference to
      dusting activities, December lst, 1943, to January 31st, 1944.


324      F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEBL

set is unknown, for the case histories
are commonly incomplete on this point.
From information available, however,
it was ascertained that at least 10 per
cent of the patients or their families
were dusted prior to the onset of ill-
ness.

For Naples as a whole (figure 5) the
peak of the epidemic potential curve
was attained approximately 15 days
after contact and spot delousing began.
On December 10th there were fewer
than 60 undeclared cases in the city, and
by the end of the month there were
over 300. With the exception of the
work at the railway station, dusting in
Naples between December 15th and 28th
was done around typhus cases in homes,
hospitals and shelters, yet within  15
days after dusting was initiated the
upward trend of the potential curve
was arrested and reversed.

Thus spot dusting by itself was ap-
parently an effective method of control-
ling transmission of the disease.  The
dusting stations probably also rendered
certain infected persons innocuous by  :

destroying the potential vectors, and
the reduction in the lousiness of the
population unquestionably decreased
the likelihood of transniission by per-
sons unfortunate enough to contract the
disease.

  Xtation versus block delousing
The mass delousing station probably
ffers the most practicable method of
caching great numbers of people in
a large metropolitan area quickly, but
for smaller populations block dusting
is preferable because it affords more
uniform and extensive coverage.
The relative efliciency of the two
methods was tested in two small com-
munities in the metropolitan area:
Arzano, with a population of about
8,500, and Casoria with one of about

10,000.  Relatively little dusting had
been done in either community before
the beginning of the experiment. A
mass delousing station was established
in Arzano after the town had been sur-
veyed and each family given a ticket
admitting its members to the station for
dusting.  Of more than 800 children
examined before the station was opened,
33 per cent were found to be louse in-
fested. A similar degree of infestation
was revealed in Casoria. Squads with
carefully prepared maps and family rec-
ords then dusted all blocks in Casoria
between April 3rd and 12th, with an
expenditure of 107 man-days of labor.
The station in Arzano operated from
April 2nd to 29th, requiring 229 man-
days of labor. Both communities were
immediately resurveyed. Block dusting
ilz Casoria had reached 86.6 per cent `of
the inhabitants and the residual louse
infestation in approximately 3,000 chil-
dren was 5.4 per cent, while in Arzano
only 53.9 per cent of the population had
been dusted and 9 per cent of 2,537
children were found infested.

Block dusting was, therefore, more
extensive and effective and became the
method of choice for most of the work
outside Naples. Its effectiveness, how-
ever, depends on the availability of
trained personnel and adequate trans-
port, while the stations are more easily
supervised and better suited to the
training of new personnel for an ex-
panding project. Finally, had an epi-
demic been present in Arzano, a greater
proportion of its population would
doubtless have applied for-dusting.

Residual lousiness

A survey in late April at 4 delousing
stations in Naples revealed the distri-
bution of residual louse infestation by
age and sex of the applicants.  Of ap-
proximately 9,000 persons, 9.7 per cent


TYPHUS FEVER CONTROL IN ITALY              325

were lousy and 66 per cent of those
infested were males.  There was less
lousiness among both males and fern&s
between the ages of 10 and 44 `years
than among persons over 45. In the
latter group, infestation increased with
age, especially among females.

In July, 1944, new surveys were made
in those districts of Naples where the
greatest number of typhus cases had oc-
curred and the most intensive powder-
ing had been done. The results indicated
that the epidemic and dusting had not in-
spired any "louse-consciousness." Some
35,000 persons, including more than 9,000
children, were examined. Of the latter,
641 (7 per cent) had never been pow-
dered and had an infestation rate of 28
per cent, while 34 per cent of those who
had been powdered were found to be
infested at the time of the survey. In
the Pallonetto Santa Lucia district, one
of those most affected by typhus, 53
per cent of the children were louse in-
fested at a time when practically every-
one lived within a lo- or 15-minute walk
from a free delousing station open 8
hours a day.

In late April and early May, 1944,
14,584 persons were examined in 81
shelters, where among 5,300 children,
8.5 per cent were infested. Routine
dusting in the shelters stopped in June
and another survey in late August re-
vealed about 5,000 still living there,
with almost 50 per cent of the children
infested.

It should not be inferred from the
results of these surveys that DDT is not
all that its champions claim it to be, an
almost perfect i&e&i&de.  Mass dust-
ing in Naples was not a louse eradication
project, it was a typhus control measure
for reducing the louse population to a
point where typhus transmission would
cease. Unless all the clothing possessed
by all the people is dusted at about the

same time, no more than a temporary
tied& `in lousiness can be achieved
in crowded metropolitan districts.

-Vaccination.

Vaccination was not a part of the
initial program in Naples and was used
on a small scale for only a few weeks
following the peak of the epidemic.
From January through March, 1944,
some 26,000 persons were vaccinated by
a 3-dose technique and another 10,000
by a one-dose method, but nothing can
be deduced regarding the effect of this
measure upon the course of the epi-
demic. The 1,190 vaccinations adminis-
tered b,y the flying squadron outside
Naples are reported in table 3.

Postepidemic organization of typhus
       control teams

The civilian doctors who were re-
leased when the dusting stations in
Naples were discontinued were em-
ployed to keep the public health officials
and practicing physicians in the area
alert to the possibility that typhus might
remain undetected during the summer
and reappear in epidemic form with
the return of cold weather. The towns
within a radius of 20 miles were re-
peatedly visited, with special attention
paid to those communities where cases
had occurred.  The contagious disease
hospital, as well as the infirmary of the
Poggioreale prison, which had been one
of the primary points of dissemination
during the previous winter, was kept
under observation.

During the fall of 1944 arrangements
were made through the Ministry of the
Interior for a series of meetings with
the provincial health officers and their
representatives throughout. liberated
Italy. At these gatherings the epidemio-
logical and clinical features of both
louse-borne and murine typhus were dis-


326      F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

cussed, the importance of early diag-
nosis and reporting was emphasized and
the technique of dusting demonstrated.
Each provincial representative was re-
quired to dust at least 15 or 20 individu-
als under expert supervision. An emer-
gency supply of powder and of dust
guns was left in each province so that
the local officers could do immediate
spot dusting should typhus or suspected
typhus patients appear within their
jurisdiction.

These meetings began in October,
1944, and extended to all but two of
the southern provinces, both in Sicily.
In December a similar instruction tour
was undertaken in the liberated prov-
inces to the north. Delegates from the 3
Sardinian provinces met in Cagliari.
Also in December, the typhus control
service, in cooperation with the Office
of Hygiene of the Commune of Rome,
supplied and supervised a dusting squad
at the Prenestina railway station, where
large numbers of refugees from the
north were being discharged. This work
was discontinued in June, 1945, after
dusting operations in the northern
camps had been adequately organized.

Postepidemic typhus

Between June lst, 1944, and March
31st, 1945, when the Naples headquarters
were closed, 24 cases of typhus with two
deaths were investigated; only one of
these cases occurred in Naples. The pa-
tient, a baker, had arrived from Sicily
only 10 days before onset, and his serum
gave a positive complement-fixation reac-
tion for murine typhus. The epidemio-
logical and serological evidence is strong-
ly suggestive that 17 of the 24 cases were
of the murine type. All were either food
handlers or closely associated with ra-
tion dumps where rats were numerous.
In addition to the one case in Naples,
10 of the 24 cases were in the vicinity

of that city, 6 were in Brindisi, 3 in
Sardinia, two in Calabria and one each
in Sicily and Leghorn.  During the
months of April through July, 1945,
scattered cases were observed in north-
ern Italy in connection with the move-
ment of displaced persons from Ger-
many, Austria and Yugoslavia. Spot
dusting about these imported cases was
done by the local authorities who had
previously been provided with powder
and guns.

At Cappizi, Sicily, a series of 39 cases
with 9 deaths occurred between March
12th and May llth, but typhus was not
suspected until 26 cases had occurred,
when the local authorities initiated con-
tact delousing. As usual, much powder
was used after the epidemic was over.
At Palermo typhus was recognized in
May after 10 or 12 cases had occurred
and, in spite of the local activities, some
25 cases and 3 deaths had occurred be-
fore the outbreak ended. Figure 8 shows
the distribution of cases during this .
period.

RECOMMENDATIONS

Materials required for dustilzg. A
motor compressed-air unit with multiple
guns is a valuable apparatus for dusting
large groups of people quickly, such as
those in institutions, travel centers, de-
mobilization points, ports, and hospitals,
as well as in labor, refugee and prison
camps, where such an apparatus may
be installed. With this implement the
worker can dust more people with
greater efficiency, since he is not fa-
tigued by the operation of the gun.
The simple hand-operated gun, however,
is inexpensive, portable and enables
many workers to operate in a limited
space. Dusting units with hand guns can
be of any size, and additional dusters
can be trained in a few moments from


FIWJRE 8. Postepidemic distribution of typhus cases in southern Italy,dk+, 1944, to &TWA, 1945.
                            Lt! WC.    ,A% 1 L
                                                             ! .i


328      F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RJJZEGL

among the persons to be deloused. One
person can easily carry a hand gun and
enough powder to dust from 200 to 300
persons, and a pack mule can transport
guns and powder sufficient for several
thousand dustings. The most satisfac-
tory hand pump used is one with ex-
centric entry and discharge air tubes
to and from the dust chamber, exempli-
fied by the Dobbins "Superbuilt" no.
133 and the Hudson "Admiral" no.
765 (Soper et al., 1945).

The 10 per cent DDT louse powder
can be readily blown from the dust
guns. It does not kill nits but remains
active and kills lice as they hatch for a
considerable period, varying with the
amount of insecticide used and the
thoroughness of its application. In the
Naples campaign a pound of powder was
sufficient for dusting 20 persons, but
in colder countries where more clothing
is worn, a conservative estimate would
be one pound for 15 persons. No evi-
dence of sensitization or intoxication due
to the DDT louse powder was observed
during the Naples control activities.

Instructions for dusting.  Members
of dusting squads should be trained to
follow a definite routine in dusting so
as to reduce the likelihood of missing
one or more important points. The op-
erator should bear in mind that the
powder should be distributed on the
inner surfaces of the inner garments
and on the skin itself. Clothing should
be removed from the first persons dusted
so that the distribution may be observed.
If properly done, the inner surface of
garments should be covered and powder
should be visible on the hairs of the
chest, back, thighs, armpits and of the
pubic and perineal regions. Since body
lice are most often found in the seams
of the clothes, those about the neck
(figure 9), armpits, waist, shirt tail, and

crotch of the pants should receive par-
ticular attention. A definite routine for
dusting is as follows :

1. Dust inside the hat (figure 10).
2. Dust the head, pumping the powder

against the scalp especially above the
back part of the ears (figure 11).

3. With the arms of the treated person
extended at shoulder height at the side
(not in front) of the body, insert de-
livery tube first up the right and then
up the left sleeve and pump powder
in between the skin and the innermost
garment (figure 12). Powder should
reach the armpit and the gun should be
shifted to eject the powder about the
shoulder.

4. The delivery tube is next inserted
at the back of the neck and a liberal
charge of powder shot down the back,
care being taken to dust the neckband
(figure 13).

5. The tube is next inserted inside
the clothing from in front and powder
sprayed first on the right side, then on
the chest and finally on the left side,
special care being taken to reach the
armpits again (figure 14).

6. (a) For men : The trousers are
loosened and the tube inserted in front
next the skin and a good dose of powder
delivered to the crotch and pubic area
(figure 15). With the tube still in con-
tact with the skin, the underclothing
is powdered, with special attention to
the waist and side seams.
(a) For women : The skirt is lifted
in front and the body and the inside of
the underclothing are powdered as with
men.

7. (a) For men: With the trousers still
loose, the tube is inserted at the rear
of the garment next the skin and the
powder distributed over the buttocks
and rear of the crotch (figure 16).
(b ) For women : The skirt is lifted


TYPHUS FEVER CONTROL IK ITALY             333

behind and the body and underwear
are powdered.3

Administrative procedures. Contact
or spot delousing is of primary import-
ance in the event of a typhus outbreak.
By the time a ease is discovered, which
may be several days after onset, infec-
tion may have been transmitted to the
contacts, and these, when dusted during
the incubation period, may be rendered
innocuous at onset. Dusting only the
immediate family contacts may not be
sufficient to arrest the spread of the
disease; hence all persons in the build-
ing where the patient's onset occurred
as well as others in the neighborhood
should be dusted by the spot-delousing
squads.

Btation delousing can be organized on
a large scale with a minimum of trained
personnel. Persons missed by the mobile
units can be referred to a station for
treatment. Also, the large-scale dust,ing
reduces the louse burden of the com-
munity and for the time being protects
those treated both from infestation by
infected lice and from uninfected lice.
Long continued work at a given station,
however, is not economical because it is
difficult to avoid redusting applicants,
while an appreciable proportion of per-
sons never applies for treatment. When
trained workers are available more
efficient work can be done by block-
dusting squads, which follow a syste-
matic plan that insures more uniform
distribution and coverage.

Institutional delousing. A minimum
of trained personnel is required for this
work since persons in the institution
can be instructed and pressed into serv-
ice as dusters.

Quarantine. It is virtually impossible
to enforce quarantine in circumstances

3 If more than one layer of clothing is worn;
steps 3 to 7 must be repeated for the second
layer from the skin.

under which typhus flourishes, since in-
fected persons can always find ways of
avoiding barriers on fixed travel routes.
On the other hand, infested and panicky
citizens welcome dusting and when
treated are relatively innocuous as trav-
elers. All wearing apparel carried out
of the epidemic area should, however,
be dusted.

Isolation. Adequate care and hospital-
ization of the sick is practically impos-.
sible during a large typhus epidemic,
and the public aversion to isolation hos-
pitals is the chief cause of the conceal-
ment of cases. A thorough application
of 10 per cent DDT louse powder to
the patient, his clothing and bedding,
and to the members of his household
will greatly reduce the spread of typhus
in the community. The patient should
be hospitalized only if he requires and
can obtain better care there than he
would receive at home.

Vaccination. In the presence of an
epidemic, mass vaccination should be
undertaken only if personnel and trans-
portation required cannot be used more
profitably for case-finding, and contact-
or mass-delousing operations.  Vaccina-
tion should be available to doctors,
nurses, assistants, dusters and others
who may be exposed by reason of their
occupation to serious risk of infection.

SUMMARY

A well-seeded epidemic of typhus
fever was revealed in Naples in No-
vember, 1943, following the German
evacuation and the Allied occupation
of that city. The peak of the outbreak
was reached in December and the trend
reversed in January, 1944. In Naples
1,403 civilian cases were reported with
an additional 511 cases from 60 points
outside the city. Final cases in Naples
occurred in April, 1944, while those in


334      F. L. SOPER, W. A. DAVIS, F. S. MARKHAM AND L. A. RIEHL

outlying towns ceased in May, 1944.
None of the sporadic eases or small out-
breaks observed in other parts of Italy
in the following year could be traced to
the Naples epidemic.

Delousing services were established in
December, 1943, so that an opportunity
was afforded to test the efficacy of large-
scale dusting with louse powders (MYL
and DDT) , applied with hand dust-guns
without the removal of clothing.  De-
lousing was welcomed by the people and
more than 3000,000 applications of
powder were made during the outbreak.

Examination of results revealed that
the epidemic potential, i.e., the number
of undeclared cases in the population
each day, reached its peak 15 days after
contact or spot delousing began and be-
fore the effect of mass dusting at sta-
tions could have become operative. This
was true of Naples as a whole and of the

community of Fuorigrotta where a more
exact appraisal of the efficacy of dust-
ing was possible.

Spot dust,ing of the patient's family
and of persons otherwise associated with
him is believed to have been an im-
portant factor in arresting and revers-
ing the trend of the epidemic. Delousing
in fixed stations and air-raid shelters and
the systematic dusting in areas block by
block, through reducing the louse bur-
den of the community, supplemented
the work of the spot-dusting squads.

During the winter of 1944 provincial
health officers and their representatives
were equipped with powder and dust
guns to be used should cases of typhus
appear in their jurisdictions.

Instructions for dusting with hand
guns are given with recommendations
as to dusting procedures in the event of
an epidemic of louse-borne typhus.

REFERENCES

Davis, W. A., and Wheeler, C. M. The use of insecticides on men artificially infested with
   body lice. Amer. Jour. Hyg., 1944, 39: 163-176.
Davis, W. A., Juvera, F., and Lira, P. H.  Studies cm louse control in a civilian population.
   Amer. Jour. Hyg., 1944, 39: 177-188.

Soper, F. L., Davis, W. A., Markham, F. S., Riehl, L. A., and Buck, P.  Louse powder studies
   in North Africa (1943).  Arch. de I'Institut Pasteur d'Algerie, 1945, $3: 183-223.
Wheeler, C. M. Control of typhus in Italy, 1943-1944, by u8e of DDT. Amer. Jour. Pub.
   Health, 1946, 36: 119-129.