The Birmingham age-herald., 1916-07-21

the outbreak.
 THE RECENT OUTBREAK
 June, July and August are usual ly, according to the records, the months of highest prevalence of typhoid fever in Birmingham. The mum Der of cases
 reported from June 1 to July IS for
 previous years averages about 11S. The
 number reported in this period of 1916 was 451. Thus there has been in the
 recent outbreak or epidemic an ex-
 cess over the usual of about 2S8 cases. According to the dates of develop
 ment of cases the outbreak began about June 9, progressively increased to reach it's maximum about June 2S, continued high until about July 6, and since July has been rapidly dimin- ishing. The period of causation of the outbreak proper extended apparently from about May 9 to about June 25. Tn the period of the outbreak the dis ease was generally distributed through out the city, and affected all classes of persons The case incidence was partic- ularly high, however among children be- tween and 15 years of age in families | living under prosperous circumstances 1 This fact taken with the geogra phical distribution of the disease. and the other | epidemiological features of the outbreak 1 suggested that some food or beverage ex- tensively distributed in the city, and eaten especially by children of families able to provide more than the necessities of life, was the chief medium of conveyance of the infection.
 Among the possible media of convey ance of uphold infection to be suspected in an outbreak, such as the recent one in Birmingham, are (a) water supply, and (b) food supply, including especially milk
 and milk products.
 THE WATER SITPPLY
 Water Supply.-It is estimated that over 90 per cent of the inhabitants of
 Birmingham use for drinking water which Is obtained solely, principally or occa- sionaly from the public supply. There fore, if the public supply should be in fected a large proportion of the popula. tion would be exposed According to the results of the field and meteorological ex-
 amnations of the public water supply, this water during the period of causation of the outbreak was free from evidence of
 dangerous contamination, and according to the geogra phicai distributor of the dis ease and the other findings from the in- vestigaton, there is no indication that the public water supply was & factor in the causation of the excessive number of cases constituting the recent outbreak of typhoid fever in Birmingham. Though the public water supply Is obtained from rivers which are exposed to considerable pollution, the equipment for purif1cation of the water appears adequate, if proper ly operated at all times. to insure the safety of this water as it is delivered to the consumers. There are in Birmingham number of wells and springs used as sources of water for drinking. Most of these are exposed obviously to pollution with human excreta, and other refuse matter. Water from them Is dangerous, and unless previc-4sly subjected to ade- quae purifcation process should not be used for drinking or culinary purposes The water from these wells and springs probably operates to some extent every year in the conveyance of typhoid infec- l ton.
 "Milk.-In the recent outbreak the cases of typhoid fever were distributed among the customers of large proportion of 1 the dairymen distributing milk in Bir- mingham, but there was no dispropor- I tionately large plumber of cases among | the customers of any of the dairymen | and there is no indication that milk as 1 such was an important factor in the con- veyance of the infection responsible for l the outbreak.
 INADEQUATE INSPECTION l ''In view of the inadequate inspection service, the progress of sanitation, and
 the adoption of cleanly methods at the
 dairy farms is surprisingly good. Further progress in this direction is obviously in- dicated. Under existing conditions the | milk supply is likely at any time to serve l as factor in the conveyance of typhoid, tubercular and other infections, and therefore. public and private (home) pas l teurization of milk should be encour- aged.
 Tee Cream.-Of the 300 cases specially | investigated. 26s gave a definite history of having eaten ice cream within the three weeks prior to onset of illness; 23 | gave a definite history of not having done so, and for eight the ice cream
 history could not be definitely obtained 1 Of the 269 users of ice cream, 16S gave a definite history of having eaten within | the three weeks prior to illness ice cream which had been made at one of the larger l ice cream factories in Birmingham. It I is estimated that this manufacturer (Man- | ufacturer 'X) supplies about 20 per cent l of the ice cream consumed in Birming- | ham The consumers of his ice cream | furnished about 55 per cent of the cases occurring in the outbreak. Less than $ l per cent of the cases can be fairly defi- nitely excluded from the users of this l ice cream. Among the users of ice cream from sources other than this, the num- Der Of cases were roughly proportionate to the amount of ice cream produced. l Of the 163 cases giving history of hav- g.
 turer x 146 gave history of not hav- | ing used ice cream from any source other l than this. No other ice cream manufac- ! turer in the city had among his customers l more than Il cases, which gave a his | tory of having eaten within the three | weeks prior to onset of illness ice cream
 obtained exclusively from his supply. The l excess of cases among the consumers Of ice cream made by Manufacturer K cor responds fairly closely to the excess of cases over the usual for the period. and constituting the outbreak.
 MANUFACTURER "X"
 If the case incidence among the users had been the same as that among the users of ice cream from all other sources. there would have been in the period. June 1 to July IS, 1916, only about 70 cases in excess of the average number reported for the corresponding period In each of the six years, 191O-1915.
 Besides the excess of cases occurring l in Birmingham among the users Of ice cream made by Manufacturer K out breaks synchronous with that in Birming- ham have been reported from several other communities in Alabama among persons who within the three weeks prior to onset of illness had eaten ice cream from this same source. Typhoid infection in an ice cream supply may have its origin in human excreta introduced into
 the cream by fingers, flies. water or other agents at (a) the dairy farm, (b) on the places at which containers for the ice cream and ingredients other than ice cream are prepared or handled, or (d) at the factory For an outbreak attribut-