GENERAL- HEADQUARTERS UNITED STATES ARMY FORCES, PACIFIC OFFICE OF THE CHIEF SURGEON COMMISSION ON SCHISTOSOMIASIS APO 500 Advaneg Echelon 12 December 1945 SUBJECT: Report of Survey of endemic areas of schistosomiasis in Japan TO ; Chief Surgeon, GHQ, AFPAC, AFO 500. Surgeon, Sixth Army, APO 442 Surgeon, Eighth Army, APO 343- 1. Pursuant to Order 973 AG PD-A 29 Oct 45, GHQ USAPPAC, Advance Echelon, personnel of the Commission on Schistosomiasis carried out surveys of the endemic areas of schistosomiasis in the Eighth and Sixth Army Commands between 29 October and 3 December, 1945, with the view of obtaining information concern- ing the present extent of these areas and the securing of other data which might be pertinent to the prevention of the disease in military personnel. 2. Personnel of Commission. The following- personnel was concerned in the conduct of the surveys in the Eighth Army Com- mand : Col Willard H. Wright, PHS 5090, USPHS, Field Director. Dr. Donald B. McMullen, Consultant to the Surgeon General. , Maj Harry J. Bennett, 0232730, SnC. Maj Fred B. Bang, 0403295, MC. Tec 3 Preston M Bauman, 13019292, -MC Tec 4 James W. Ingalls, 31253392, MC. Tec 4 George A. Paris, 19137029, MC. Tec 5 William M. Feigin, 12127102, MC. Major Bang and Tec 4 Paris departed Stateside on 25 November, and did not take part in the surveys in the Sixth Army Command. Tec 5 Feigin departed Stateside on 1 December. 3,. Contact with Japanese Government officials. Contacts were made with Japanese health officials through the office of Colonel C. F. Sams, Chief, Public Health and Welfare Section, SCAP. Available information concerning the present status of the endemic areas of schistosomiasis in Japan was obtained at several conferences with Prof. K. Nobechi, Chief, Division of Preventive Medicine, Institute of xVblic Health, Dr. II. Tate- bayashi, Chief, Section of Communicable Diseases, Ministry of •Welfare arid Social Affairs, Dr. Nobutaro Ishii, Chief, Research Laboratory of Parasitology, Government Institute for Infectious Diseases and Prof, K. Nagano, Chief, Parasitology Department, Kltasato Institute for Infectious Diseases. In general it may be said that little information of a specific nature was ob- tained from these officials in the way of morbidity rates, ) incidence surveys, etc. Nearly all specific data furnished the Commission 'published in 1*952, and there appeared to be little of more recent date available. Some of the Prefectural and local health authorities were able to furnish valuable data and where information of this sort was secured, it has been incorporated in this report. 4. Distribution of Sc his t os oma ,ja pon icum in Ja pan. There are five established endemic areas of schistosomiasis in Japan, viz; The Tone River area In Chiba and Ibaraki Prefectures, northeast of Tokyo, the meiu area, centered around the city of that name in Yamanashi Prefecture, approximately 80 airline miles due west of Tokyo; the Numazu area in Shizuoka Prefecture approximately SO miles southwest of Tokyo on Suruga Bay; the Fukuyama area, immediately to the north of the city of Fukuyama, and covering parts of Hiroshima and Okayama Prefectures; and the Kurume area, surrounding the City of Kurume, and covering parts of Saga and Fukuoka Prefectures. The first two of these areas are in the Eighth Army Command, and the last three in the Sixth Army Command. In addition to the established endemic areas, schistoso- miasis has been reported in other parts of Japan. In TB Med 160 (May 1945) egg carriers are listed in Tochigi, Aomori, and Fukui Prefectures, in addition to those in prefectures known to harbor the disease. The Commission has endeavored,to secure definite information concerning the occurrence of cases of the disease in the three above-mentioned prefectures. Japanese health authorities in Tokyo are of the opinion that the finding of egg carriers in Tochigi and Aomori Prefectures is probably indicative of imported cases and that the disease is not endemic in these prefectures. The same opinion was given in connection with Fukui Prefecture. However, attention was called to the data in TB Med 160 which lists 168 Schistosoma egg carriers in villages in Fukui Prefecture among 2,000 indi- viduals examined in 1937-1933, A further search of records in the Ministry of Welfare and Social Affairs disclosed reports for 1940 of 4 carriers in 110 examinations in Fukui City and 3 carriers in 70 examinations in villages. In view of the con- flicting opinion regarding this area, at the request of the Commission the Ministry telegraphed the Health Officer of Fu- kui Prefecture for specific information concerning the status of the disease in that Prefecture. At the time this report was compiled this information had not been received. The disease also existed formerly in certain parts of Tokyo Prefecture, but Japanese health officials stated emphat- ically that these endemic foci had been eradicated. 5. Method of conducting surveys. 'On entering an endemic area, as much information as possible concerning the status of the disease was obtained from prefectural and local health authorities and from practicing physicians. Based on this information, certain schools in various parts of the area were selected and a representative number of stool samples obtained from children in the higher age groups for microscopic exam- ination for schistosome ova. Surveys were then conducted in various parts of the area for Katayama noaoohora, the snail intermediate host of Schistosoma japonicum; when the snails were found, sufficient numbers were collected for transport to the laboratory for examination for incidence of infection. In addition, in certain areas, the stool examinations were sup- plemented by physical examination of the selected school child- ren for hepatomegaly and splenomegaly, physical conditions which are frequently associated with moderate to severe schis- t os ome infect ions. 6, Training of Malaria Survey Detachment personnel in conduct of schistosomiasis surveys. The period of six weeks allotted by the Office of the Surgeon General for surveys by the Commission did not provide sufficient time for the conduct of exhaustive surveys 5.n the endemic areas in question, although it was sufficient to provide certain basic information concern- ing the present status of the disease in these areas and to evaluate possible hazards to military personnel. It was be- lieved that some provision should be made for further and more exhaustive surveys in these areas and with that in view a mem- orandum was submitted to the Office of the Chief Surgeon, AFPAC, Advance Echelon, on 29 October, 1945, suggesting that certain personnel from Malaria Survey Detachments be assigned on tem- porary duty with the Commission for the purpose of receiving train .ng in survey work. Pursuant to that memorandum, the Surgeon, Eighth Army, assigned for this training the follow- ing named officers and enlisted men from the units designated? 442d Malaria Survey Detachment Capt Louis Olivier, SnC S/Sgt Kenneth PL Miller Tec 5 Stephen A, Dutton 54th Malaria Survey Detachment Capt- £dwin R. Helwig, SnC Tec 5 Donald Ayres Tec 5 Bartholomew 4-45d Malaria Survey Detachment 1st Et W. Yarrow Tec 4 Milton G. Grivas Toe 5 Owen P, Killeen 444th Ma 1 ar 1 a Survey Dotachrnent 1st HE John E. Chattin S/3gt James A. Pearson Pf c John A. P.ox 219th Malaria Survey Detachment Capt l«eonard K. Davis Tec 4 William J. Gannon Tec 4 R, W, Alruty Tec 5 A. A. Manning Between 6 and 10 November, one officer and two enlisted men from the above-mentioned detachments spent one day in the laboratory of the Commission at the 251st Station hospital receiving instruction in the technique of stool examination and in the identification of schistosome and other parasite ova. On 11 November, the entire party departed for Kofu, Yam- ana shi Prefecture, for instruction in field work under the tut- elate of Major Fred B. Bang,' Captain Louis Olivier, and Prof. K. Nagano, Chief, Parasitology Department, Kitasato Institute for Infectious Diseases, who had worked in the area and who kindly volunteered to accompany the group. Previous arrange- ments had been made with the Commanding Officer, 303d infantry, 97th Infantry Division, for quarters and mess for the group. The training included the interviewing of local health offic- ials, the collection and examination of stool samples from children in schools in the endemic area, demonstration of phys- ical examinations for hepatomegaly and splenomegaly, and the collection of snails for schistosome infection. The members of the party returned to their various stations on 17 November, it is believed that the training which these individuals re- ceived will enable them to carry on efficiently survey work in connection with this disease. For the reason that Malaria Survey Detachments under Sixth Army Command were to be deactivated at an early date, no training program was undertaken with such personnel. 7. Surveys in the Tone River area, Miiba and Ibaraki Prefectures. This area was surveyed en 29 and 30 October, 7, 8, and S Hovembe r, and 3 December, in company with Dr. N. Ishii and Miss Yasuko Mitoma of the Government Institute for Infec- tious Diseases. a4 General description and extent of infection. The infection in the Tone Diver area occurs in three foci, appar- 4 ently quite far removed from one another, without, insofar as we wore able to learn, any connecting links (Map I). One area is centered around the City of Sawara and includes parts of Toyoura, Tsunoraiya, Toyoshima, and Higashiota Townships, Katori County, and the Kita-Sawara area in Ibaraki Prefecture across the Tone River from Sawara. This area measures approximately 16 miles from oast to west and is about 5 miles in extent from north to south. Another area surrounds the City of Sakura and measures approximately 2X4 miles. A third area, concerning which there is some doubt at present, lies in Ibaraki Prefec- ture, extending east and west along the Tone River from Fukawa and northward as far as Maeshindon. Because of lack of time, opportunity was not had to survey this area. Since small scale maps (1:50,000) of these areas were not obtainable at the time of these investigations and are still not obtainable, considerable difficulty has been met in secur- ing information from heal'ch authorities concerning definite boundaries of these areas. Rov/evor, it is quite possible that these endemic zones are more extensive than known at present and that other endemic foci occur elsewhere in the Tone River Valley At present, the whole va ev of that river in Chiba and Ibaraki Prefectures must be regarded as a suspected endemic area, although the infection rate in known endemic centers la very low. Certain data were obtained from Dr. S. Murata, Chief of the Public Health Section Chiba Prefecture Office, concerning schistosomiasis surveys in the Tone River and other areas. The following table gives information concerning surveys made of the entire population in the places named, the stofcl exam- inations being conducted with the ant iformin-ether technique, which is much more efficient than is the technique using a single focal smear. Table 1. Results of schistosomiasis surveys carried out by Health Department Chiba Prefecture. Entire pop- ulation of areas surveyed* total number of persons unknown. County Town or village Year No*persons Inf e j.ted % Persons Infected Imba < flago, Chiyoda, lada, Sakura, Asahl, Uchisato —Hlgashikat-sushlka, Fuss, Tanaka. Ab iko 1925 167 0.91 Imba 3 h i s u i, Uc h 13 a t o, Rokugo 1923 31 0.36 County Town or Village Year No Persons Infected % Persons Infected Imba Usui t Aso, Shinu, Kosu, Baku, Aziki 1929 1 0.01 Katori Ni i jima, Sawa ra, Tsumiya 1934 31 0.35 Katori Uiga s h i od o, Sawa ra, Tsumiya, Okura, Toyoura 1935 21 0.26 'In addition to these surveys, a total of 2,673 persons was examined in Toyosato village and 1,536 persons examined in Tak- aoka village, Katori County, in November and December, 1940, without any being positive for schistosomiasis. In Higashikatsashlka County, 2,751 persons were examined in the village of Oka shiv a : a January, 1941, without any pos- itives being found. Apparently no surveys have been made since that time. b. Lxa m In a t i on of sc ho o 1 children for schlstosomia- s is« Three schools were surveyed in Chiba Prefecture, two of them being_in the Sawara area and one in the Sakura area. One school in ibaraki Prefecture was surveyed. All stool e xaminat ions conducted by the Commis s ion were carried out with the use of the plain sedimentation technique. This technique had previously been found to be the most effi- cient one for practical use in the field through research car- ried out by members of the Commission on Leyte and Borneo, The technique consists in taking five grams of feces, stirring the sample in water, straining the material through four layers of surgical gauze into a cc conical urinalysis flask, allow- ing the material to sediment and pouring off the supernatant fluid at least three times. One drop of the final sediment is placed on a slide and examined under the microscope. In the examination of school children in Japan, the Commission has followed the practice of examining two 22 x 22 mm cover glass preparations or one 22 x 40 mm cover glass preparation from each sample. Data are recorded for ail helminth parasites but no examination was rnado for protozoan parasites. ft should be noted that the findings of helminth ova other than those of S. japonicurn were made incidently; when the latter ova were found on a slide, the slide was discarded and no further search made. It is probable under these circumstances that some cases involving infection with other helminths were missed and that the incidence figures for these helminths are actually lower than the true incidence. The following data represent the results of stool examina tions conducted by the Commission on school children in Chiba and iboraki Prefectures. Table 2. incidence of S. laponicun other helminth parasites in fTcnTool children [ages H to 14 years) examined by Commission on Schistosomiasis in Chiba and Ibaraki Prefectures, Males Females No. pens .Number % No. % No. Percent Parasite Sxam'd. Infec!d.Inf.Total Inf *d. Inf’d .Total Inf’d. Infected Sakura School - Sakura Town S. ja nonturn 63 1 1.47 31 1 3.2 37 0 0 A. lumbri- 68 24 35.3 coides Hookworm 68 17 25.0 Triehurls 68 5 7.4 Tricltp.ra Snterobius 63 1 1.5 v e rm 1 c u 1 a r 1 s Hymen6lopis ’ LO • rH i—1 CO |o 1 nana IT e gaTrve 63 33 43.5 Sakura School - lads village S. japcrdcum 46 0 0 A. lumbri- 46 13 23.3 coides KH 1 1 o o q 6 3 46 3 17.4 Triehurls 46 3 6.5 Trichura Snterobius 48 2 4.3 vermicularis Nyrnenolepsis 46 1 2.2 nana Negative 46 24 52.2 7 paras ite No pers Exa m * d Table 2 (Contd) Males Number Percent Total No Infec’d Infec’d No Infec’d Percen Inf ec f d Females Total No Percent No Infec’d Infec’d Salcura School - No go Village S jaconicurn 51 0 0 A lumbricoides 51 13 37.3 Hookv;orm 51 7 13.7 Trichuris trichi ura 51 0 0 Negative ~5T 25 49.0 Toyoshirna School S .1aeon icum 76 1 1.3 J36" 1 4,0 50 0 0 A lumbr i c oides 76 49 54.5 Hookworm 76 7 9.2 Trichuris trichiura 76 5 6.6 Snterobin a vsr- mienlaris 76 2 2.6 C1 on orchis s in ens i s 76 3 3.9 Negative 76 20 26.3 Kit a - Sana ra School S ja non?, cum 31 1 ~T7S oT U~ 0 44 1 2.3 A lumbricoides 31 72 83.9 Hookworm 31 4 4.9 Trichuris trichiura 81 16 19.8 Clonorchls sinen r» 1 a ,uiC 31 5 6.2 Negative -1ST 3 9.8 Ho r iya ma Sc ho o 1 S japonic urn 63 0 9 A lumbricoides 68 47 6S.1 Hookworm 68 10 14.7 Trichuris trichiura CO CQ 4 5.9 Enterobius ver- micularis S3 2 2.9 Clonorchls sinensis 68 5 7.4 Me tag on irm is s p. "TS 2 2.9 Negative 63 12 17.6 It will be noted that the stool samples from the Sakura School arc divided into three sections, those from children from the Town of Sakura end those from children in the vil- lages of hada and Nogo. These villages ere a few miles from Sakura in an area in which schistosomiasis is supposed to be endemic. However, no infections were found in the children from these villages and it is possible that the infection lias died out or is at a very low ebb in these villages. . The information obtainec from these stool surveys sup- plements that obtained from the health authorities of Chiba Prefecture. It indicates that the disease is still present in the Sakura community and in the Sawara area as described above even though the incidence is at a very lov. level com- pared to oilier endemic areas in Japan. ( (c) Snail collections in the endemic areas in Chiba and lb a r a ka Pr e fe e I •Jr e s . “SeaFch was' made for the* snail In - ' termediate host of 3, japonicum in rice fields, drainage ditches, and in the Imba-Iluma swamp northwest of Sakura for a distance of approximately one mile beyond the town. Several species of snails were found but no specimens of Katayama nosophora were recovered. Snail surveys were conducted also in 1‘oyoshima Township and in the Kit a-Sawara area., as well as on an island in the Tone River north of the City of Sawara. Snails of tho genera By thin ia and Melania were found but no specimens of K. noso Tlcra could be located. Failure to find the snail intermediate host in areas adjacent to towns and villages in which the disease was demonstrated to occur indi- cates that it is only sparsely distributed throughout the endemic zones. This is in contradistinction to most of the other areas surveyed by tho Commission in Japan in which lit- tle difficulty was encountered in collecting the snail in regions in which the disease occurs. The low incidence rate of schistosomiasis in the Tone River area is no doubt associ- ated with the sparse distribution of the snail intermediate host. This scarcity cannot be assciated with control measures since little work of this nature has been carried out in this region. A limited effort was made in this direction between 1923 and 1931 when lime was applied to the irrigation ditches and a flame thrower used on the sides of the ditches and canals in Hi gas lika t sushi ka County around the villages of Tanaka, Tonise, and Abiko, and near the village of Nego, Imba County, However, the work was not continued and probably had little influence on the distribution of the snail. (d ) Morbidity and mortalitv in the Tone Rivor area. Little specific information was available on these points. Local physicians informed us that a flood inundated a large part of the Tone Hivor Valley in July 1927, and a large number of K. nosoohora were washed into the Sav/ara area. Within two months, 120 cases of schistosomiasis developed, all of which were acute and characterized by typical schistosome dermatitis 9 and fever. Three years later (1930), a similar flood occurred and six cases developed at Kessa, a small town in Ibaraki Pre- fecture, about 5 miles up the Tone River from Sawara. In 1939, a similar circumstance occurred and this flfeod was followed by the development of 21 acute cases in and near Sawara. In 1943, two acute cases developed in Moriyama, a small village about 12 miles down the Tone River from Sawara. As noted above, no positive findings were obtained from school children in this village. (e) Chemotherapy employee in the Tone River area. Because of the apparent low morbidity rate of schistosomiasis in this area., physicians are seldom called upon to treat cases of the disease and little information was obtained on this noint• 8. Surveys in the Kofu area, Yamanashi -prefecture. Ac- companied by Dr. Ncbutaro Ishii, Chief, Research Laboratory of Parasitology, Government Institute for Infectious Diseases, and his assistant, Miss Y.suhc Mitoma, the entire personnel of the Commission worked in the Kofu area between 1 and 4 Novem- ber. Major Bang returned to that area and continued work be- tween 7 end 15 November. The only information which the Commission could obtain from national health authorities concerning the incidence of infec- tion in the Kofu area prior to its investigation is as follows: Number of persons examined Percent positive 1925 1926 1927 1926 Total 698 49 4 630 203 2024 6.79 At Kofu, conferences we held with Dr. M. lenaga. Chief, Public Health Section, Yamanashi Prefecture, and Dr. Sakuro Sugiura, who operates a private hospital at Showa-Mura, within the endemic area. Mr. Y. Miyoshi, Head, Schistosomiasis Con- trol Office, Yamanashi Prefecture, furnished much valuable information and accompanied the party curing its investigations. (a) General description and extent ?f infection. The endemic area of schistosomiasis in the Kofu basin comprises approximately 93 square miles. (Map II) The average altitude of the area is about 400 meters but cases of the disease and the snail intermediate host have been found at Mutsusawa, 600 meters above sea level. This area has long been known as+ane endemic center of the disease, in fact even before the SadgisS6of the disease was determined and its etiology established. It was here in 1904 that Ketsurada discovered the pare s ite Schis- tosoma. japonlcum. In cooperation with the nations,1 government, a control pro- gram on schistosomiasis was inaugurated in 1943 with an appropri- ation by the Prefectural government of 1,000,000 Yen over a three year period. In addition, the national government plaged 130.,COO Yen per year for the work; this sum is said to have been received by the Prefectural government but never devoted to the purpose for which intended. At the present time, the endemic area comprises three sec- tions, viz: (l) a so-called control area in which banks of streams and rice paddies were treated 3 years ago with calcium cyanamide at the rate of about 500 pounds per acre; (2) an area under con- trol in which a.plication of the chemical was made last year; (3) an area in which no chemical has been applied. Calcium cyanamide, known to the Japanese as "lime nitrogen", was one of the chemicals tested by the Commission against Oncomelania quadrasi, the intermediate host of Schistosoma, .'japonicurn in the Philippine Islands. It was found to be very effective against this species of snail when applied at the rate now being employed in the Kofu area. In this area, application is made about 2 months before the nine is glanced in May. Sincecalcium cyanamide has a high fertilizing value, there are two distinct advantages to its use. The Commission was told that a material reduction had been made in the incidence of schistosome infection in the control area and that some reduction been effectoo in the area under con* trol, although it had not been possible to make more than one application of the chemical because of a shortage of supply and insufficient funds for its purchase. The original plan for cortrol called for the application of the chemical to the endemic area each year and undoubtedly it would be much more effective if repeated at intervals. As part of the control program, stool examinations are car ied out in four control stations which employ a total of 15 girl technicians, these technicians are given training for one month and then work*'under the close supervision of competent microscopists for a period of 5 additional months before being permitted to continue on their own responsibility. Most of the infection in the Kofu ere a. is contracted through working in the rice paddies. Bathing in streams in the endemic zone is prohibited by health department regulation but novertho- less some such bathing is done. Drinking water is invaribly obtained from artesian wells. Many farmers wear two pairs of trousers when working in the rice fields and this is said to provide protection against infection. The local health author- ities s.lso recommend the wearing of rubber boots. The population of the endemic area is 284, 987. Between 1 May 1944 and 30 April 1945, a total of 160,906 stool examin- ations were conducted by the control stations, of which 10,597 or 6*55 percent, were positive for S. .laoonicum* All of these examinations were mad© by moans of a single fecal smear with what the Commission would regard as inadequate nicroscope equip- ment. A breakdown of the examination figures is given in the following table; Results of stool examinations for Schistosomiasis in Kofu area Area Number persons examined Number persons Positive percent positive Control (Red on map) 81,031 5,026 6.20 Under control (Yellov: on map) 57.013 2,983 5.23 Uncontrolled (Blue on map) 22,,662 2,588 n.32 Totals 150.906 10,587 6.57 Table 3 In addition to stool examinations on the population in the endemic area, the Prefectural Health authorities Iv ve conducted stool and postmortem examinations of certain domestic and wild animals in the zone. The evidence obtained would seem to in- dicate that such animals are res ionsiblo to a considerable extent for the transmission of infection to the snail intermed- iate host. The results of those examinations arc as follows: Results of examinations for schi animals in the Kofu area 'between stosome infection in lower 1 May 1944 and 30 April 1945 Species No examined No positive percent positive Cattle 7059 2184 30.8 Goats 1118 158 14.1 Dogs 353 176 50.0 Horses 967 0 0 Rats (probably ing md mice, sop. includ- Microtus 170? 656 36.7 Moles 68 13 19.0 Skunks 10 9 90.0 Tabic 4 (b) t1k a n in a t i on of school children for schistoso - missis. On the basis of information furnished by the Chief of the health Section, Prefectural Government, the Commission selected four schools, two in the so-called control area and two in the uncontrolled area for obtaining stool samples for microscopic examination- Information was obtained from the Prefectural government concerning the incidence of infection in children in these schools as revealed by stool examinations between the period 1 hay 1944 and 39 April 1945. This in- formation is summarized in the following table. Table 5. Inc id once of schistosome infection in certain school? selected by the Commission for study, based on examinations by Yamanashi Prefectural Government, 1944-1945 Name of School No. pupils examined No. positive % Positive So-call' ~d co. jtrol area Shiozaki f'uo 3305 2833 Uncontrolled 550 627 area 24,3 22.13 Okamada Sancho 1177 376 267 234 22.7 32.95 TOTALS 7191 1738 24.2 The following data represent the results of stool examine tions conducted by the Commission on school children in the Kofu area. 13 Parasite No. 15k a r; pars. lined No. in- fected % in- Total No fe c t e d Nuuber fo . in- cited Jo In- fected Total Number No. in- fected Jo In- fected Shiozakl School S. ,1a pon icum 100 57 57.0 67 33 57.9 43 24 5 5.3 A. lunbrlcoides 100 32 32.0 Hookworm 100 19 19.0 Trichuris trickuro100 43 48.0 He ga t :1 ve ‘100 5 5.0 Ryuo school 3. japonic urn 153 51 38.3 36 23 42.4 67 23 34.3 A. 1umbraeoldes 133 102 76.7 Hookworm 133 36 27.1 Trichuris trichiuraI33 46 34.7 Negative 133 9 6.3 Okamada School S. 1 apon!cum 106 64 60.4 54 44 31.5 52 20 35.7 A. iumbricoides 106 33 33.0 Hookworm 106 34 32.1 Trichuris trichiura 106 21 13 i 9 Negative 106 3 7.5 Sancho School S. japonicum 119 73 6173 53 35 63«6 64 39 60,9 A. Iumbricoides 119 93 82.4 Hookworm 119 35 29.4 Tridiuxis trichiura 119 33 27.7 - Negative 119 4 3.4 Totals for all schools S. la nonicum. 453 245 rz r? O 55.5 233 r> n P 140 60.1 226 105 46.5 "A. lumDncoid.es 453 O I u o U • C5 Hookworm 453 124 27.1 Trichuris trichiura 453 148 o2.4 Negative 453 26 5.7 Table 6. Incidence of S. japor. icum and other helminth parasites in school children (ages 3 to 15 years) examined by Commission on Schistosomiasis ir ICofu ‘area, ' TALES FEMALES It will be seen that the incidence of schistosome infection in children in the four schools in question was nearly twice that obtained in examinations in the same schools by the Pre- fectural Health Depar tment. The great difference in the num- ber of examinations by the respective agencies renders impossi- ble a comparison of results. However, for the reason that the plain sedimentation technique is much more efficient than is the fecal smear technique, it would seem that the actual incidence of infection in the children is raugii higher than that found in the Health Department surveys and in all probability more nearly approaches the figure recorded in the surveys of the Commission, (c) Snail collections in the Kofu aroa> Snail collect ions were maoe in the vicinity of Kami jo and Kokuyo,vil- lages south of Kofu City. Numerous specimens of Katayama noso- phora, the snail intermediate host, were found without difficul- ty along the margins of the irrigation ditches and in one place along the edges of the rice paddies. On the return to the Tokyo laboratory of the Com ■’ scion, 200 snails were crushed and exam- ined for schistosome 5 snails were found infected. (d) Morbidity and mortality in the Kofu area It was not possible to obtain records of morbidity or mortality from the Prefectural Health Department. Dr. Sugiura stated that he treated approximately 2,000 patients a year and many more pa- tients are probably treated in the Yamanashi Hospital, other pri- vate hospitals, and in the public health dispensaries. Likewise, little information could be obtained concerning age distribution of clinical schistosomiasis in the area. The following data were furnished Major Bang by Dr. Sugiura in connection with patients treated by him in September 1944, Table 7 - Age distribution of clinical schistosomiasis in 505 oatients. A?e Grouo Total number Number of males Number of females 1-5 23 21 2 6-10 95 35 10 11-15 48 41 7 16-20 24 11 13 21-25 34 13 21 26-30 46 IB 28 31-35 29 9 20 36-40 28 15 13 41-45 43 21 22 46-50 50 23 27 50 and over 35 37 43 TOTALS 505 294 211 15 The number of cases involved is not sufficient to make the figures statistically signifleant However, the data bear out the impression gained from the stool examinations that males are more frequently infected than females, possibly because they are employed to a greater extent in the rice fields and because they are more prone to fish and swim in infested water. The rela- tively large number of cases in males in the age group 6-10 probably represents acute infections contracted for the first time while "the similar number of cases in the age group over 50 is no doubt indicative of chronic infections resulting from repeated exposure over a long period of time. [o) Chemotherapy employed in the Eofu area. Cer- tain information was obtained concerning chemotherapeutic meth- ods employed in the treatment of schistosomiasis in this area Dr. 3&buro Sugiura employs^"Stibnal", a Japanese manufactured preparation, said to contain 0,3 percent antimony in the form of sodium antimony tartrate in solution. The first dose is 10 cc, the second 15 cc, followed by 20 cc each for a total of 20 doses. Acute cases usually respond well to this treatment while chronic cases usually fail to show much improvement. Che of the public health dispensaries visited by the Com- mission used "Fuadin" in the treatment of the disease, the pro- duct having been produced by the I. 3. FarbenIndustrie Aktien- jesellschaft, Leverkusen-ani-Hhine, Germany. A considerable sup- p ly of the drug was on hand i'he initial dose was 1.5 cc, the second dose 3.5 cc, and the following doses 5.0 cc each. The drug is given every other day for 30 days for a total dose of 75.0 cc. This course of treatment has been employed for the past 5 years. It is an interesting commentary that for several weeks cases of schistosomiasis in American military personnel on Leyte were given a total doss of 40 cc of "Fuadin", until it was found through experience that such dose was insufficient. The total dose was then raised to 75 cc. 9, Surveys in the Numazu area, Shizuoka Prefecture. This area was surveyed by one member (V/HW) of the Comnission on 8 and 9 November, in company with Dr. N. Ishli of the Government In- stitute for Infectious Diseases. (a) General description and extent of infection. The endemic area in the vicinity of Nunazu (Ivlap llIT~covers about 10 square miles and extends from a mile to the east of the town of Numazu westward as far as Yoshiwara, It is bounded on the north by tho back road between these two towns and on the South by the main road (Tokaldo Highway) and the railroad (Tokaido Main Line) which follows the shore line of Suruga Bay. On the north the area extends to the foothills of Mt. Ashitaka and. in general borders the Numa River which rises in this moun- tain and flows into Suruga Bay at Suzukawa 16 The entire area is only about 10 miles Ion3 and approximately 1 mile wide. Much, of the area was a swamp, known as Fukushima, which was drained three years ago, and is now devoted to rice culture. There is a general impression among local physicians and among the .inhabitants of the nearby villages that the schis tosoniasis morbidity rate has been materially reduced since the drainage of the swamp. Previous data concerning the incidence of infection in the area was published in 1933 and included the results of 1113 stool exaninations made between 1920 and 1925, and 200 examinations made in 1926; of the total of 1313 examinations, 3.98 percent of t he in d 1 v 5 d ua 1 s w ere o o s i t i v o for Schistosoma japonic urn. (b ) Sbcanina tior of school childr on for s chi s toson;, as is . After conferences with local officials, the SucTo Primary School was selected and arrangements v/ere made to secure stool samples from the children. This school is in the heart of the endemic zone and examination of nivalis would probably provide more sig- nificant incidence figures than obtainable elsewhere in the area. There v/ere 1150 pupils in this school from the village of Sudo and the surrounding country. The following table presents the results of the stool examinations. Table 3. incidence of S. Japan!cun and other helminth par- asites in school children (ans 11 to 13 yrs ) at Sudo in the Pumazu area. No. pars. Parasito exam’d. N o. in - footed % in- N foc’d. Total hales o. in- foc1d . Female s % in- No in- fect. Total fec’d % in- foe fd, S. japonic urn # 155 14 9.0 65 12+ 13.5 83 1 1.2 A. lunbricoides 155 143 92.3 Hookworm 155 7 4.5 Trichurls trichiura 155 35 22.6 Fntorobius von. icul aris 155 2 1.3 Pa ra non imus we s t e rn an 1 155 1 0.6 Negative 155 9 5.3 +The sex of one nos it ivo individua1 is unknown. (c) Snail collections in the Numazu area. Snail col- lections wore made near the village of Sudo immediately to the east. No snails wore found in the rice paddies or in the irri- gation ditches. However, numerous K. nosophora were located on the borders of a small swampy area, which had apparently not 17 been drained thoroughly and was not under cultivation, although it was surrounded by cultivated land. A total of 315 snails was examined for schistosome cercariae, 100 by crushing and 215 by placing them in Individual containers and observing them for the emergence of cercariae on two days with an interval of two w j m days between observations. Of the 315 snails, 2, or 0.63 percent, were found infected. Dr. Ishii supplied the information that Mr, Y. Miyoshi, Head of the Schistosomiasis Control Office of Yam- ana shi Prefecture had collected snails in the Fumazu area in 1944 and found 13 oercent infected. This is said to be a much higher rate of infection than found at Mofu. (d) Merbid3ty and mortality in the Numazu area, No informat ion concerning these points could be secured from the local health officer and time was not available to proceed to Shizuoka, the Prefectural capital, in an effort to obtain such information from the Prefectural health authorities. Dr. M. On a of tbe Fuji Hospital, a private institution at Yoshiwara, stated that he had boon located there for 16 years and that dur- ing the past three years he has treated on an average of 5 to 6 cases each year, whereas formerly the number of patients was double these figures. Re attributes the reduction of cases to the draining of the Pukishima Swamp with the resulting decrease in exeosure. (e) Chemotherapy employed in the Fumazu area. Dr Qna uses :,StibnalM in the treatment of schistosomiasis, giving 10 cc of a solution containing 0.3 gram of antimony in the form of sodium antimony tartrate, every day for seven days and then every other day for a total of 16 to 20 doses, claims good results in acute cases, although chronic cases fail to respond well. 10. Surveys in the Murumo area, 3aga and Fukuoka Prefec- tures, Island of Kyushu. The Commission departed Tokyo 1910 hours, 15 November, and arrived at Kurumc 1350 hours, 17 Novem- ber. headquarters were with the 27th Marine Regiment, 5th Mar- ine Division. The Commission is indebted to Colonel Thomas ■Vorr.ham, CO, for the courtesies and facilities extended in the way of quarters, rations, and transportation during its stay in the Kurumc area. Lt Colonel Bonn J, Robertson, Executive Offi- cer, 1st Lieutenant Leslie F. Fultz, S-l, Captain Francis J. Lutz, S-4, Lt Commander Thomas 23. Me Go achy MC, Regimental Sur- geon, Lieutenant (jg) George Levy MC, and Lieutenant (jg) A, Littman MC, rendered valuable assistance to the work of the Commission, while 1st Lt Richard Woodard and Pfc Dewitt Trow- bridge acted as interpreters. Miss Sumlko Kakane also served as interpreter. Work in the area was carried on between 17 and 22 November. At Kurume conferences wore held with Mr Monzo TJno, officer in charge. Health Department, Kurume City, and with Dr. T. Inoue who conducts the Inoue Hospital, a private institution. A visit was made also to the Kyushu Medical School at Kurume and various members of the faculty interviewed. At Saga, Mr. H. Yokota, Chief of Foreign Affairs, and Dr. S. Sumita. Chief of the San- itary Section, Saga Prefecture, supplied valuable information. (a) General description and extent of infection. The endemic area of schistosoi.iiasis centered around IJurume in gen- eral follows the course of the Chi leu go River (Map IV). The area extends approximately 12 miles from east to west and approximately 9 mijoa from north to south at its greatest length and breadth; it covers aporoxir.ir.toly 100 square miles and lies within tho Counties (Gun) of Mil and Miyaki. Mo sustained program of control has been carried out in the area, although we were informed that lime was tried at one time without avail. The Chief of the Sanitary Section, Saga Prefec- ture, stated that before The ear ho had Inaugurated a program of sanitary privy cor s true time aimed at the control of schisto- somiasis but that this vert had boon interrupted. He had de- vised a typo of privy in.vclving the use of three separate septic tanks in successive compartments so that the fecal material would bo carried over from one compartment to another before being used as night soil. had found by experimental work that the time required for the passage of the fecal material through tho throe compartments permitted the natural destruction of schistosome and other helminth ova. This official recommends that human feces be permitted to stand in open containers for six months before being placed on the fields. However, he stated that few farmers follow his recommendations and that little has been accomplished from such a measure in tho way of control. Dr. InouG has conducted a considerable amount of research work on schistosomiasis and was able to give the Commission val- uable information, he also accompanied the Commission into the field for the collection of the snail intermediate host. In one of his papers, MThe results of researches in schistosomia- sis japonicun in connection with the skin reaction in school childrenn (free English translation) published in the Journal of the Kyushu Medical School, January 1942, ho cited figures for certain surveys carried out in the endemic area. The results cited are as follows* 19 Table 9. Results of skin tests and stool esaminations by Dr. T. Inouo in the endemic area of schistoso- miasis a r oun d Kurume. (1940) Skin reactions Stool s S. .laponlcum Ascaris xaminatlor Hookworm ■ sf Trichuris Number Town Tested No. Pos . % positive ? 0 3 . 1’ 0 « /o dos it ive Ho. % positive N o. % to • o o P<& it ive jL.„ „ Nametoishi 125 74 59.2 50 67.6 14 13.9 4 5.4 13 17.6 Asahi 975 350 33.8 29 8.8 190 53.8 75 22.7 76 23.0 Minamishi^eva 471 su 128 27.2 5 3.9 55 43.0 11 3.6 25 19.5 Kvomaclii379 46 12.1 1 2.2 3 15.2 0 0.0 2 4.3 Torihai School 322 151 18.4 15 9.9 37 24.5 9 6.0 11 7,3 + Sir.fcl e fecal smea ° Further information was obtained concerning infection in the endemic area from another paper published by Dr. Inoue in the Journal Kyushu medical School, 1940. This paper, entitled ?,Examinat ion of elementary school children for schistosomiasis in. an endemic area in Japan together w. th results of intradermal tests”, (free English translation) contained results of stool surveys conducted at various tines within the area. The data are translated as follows ; Table 10. Town Date survey No, examined ho. positive Percent positive Klyana 1921 276 2 0.7 Fumoto 1921 180 4 2.2 Kizato 1921 135 47 25.4 Tosu 1921 333 116 34.3 Asahi 1921 * 147 31 55.1 Kitaslii^oyazu 1921 %£0i, 55 11.6 ivl ina m i s h i % o y a s u 1921 120 9 7.5 Nagatoishl 1919 776 455 53.6 f» 1924 80 46 57.5 n 1924 56 22 44.0 n 1927 693 332 47.5 ii 1933 115 38 33.1 it 1934 115 49 42.6 n 1934 1062 140 17.7 2397 TS55 37.3 (+Table 10 - Results of stool examinations for schistosomiasis in the endemic area in 3aand Pu^voka Prefectures. (data.from pape r by Dr. T. In ouc ) . _ 20 Town Date survey No. examined No. positive Percent positive Miyanozin 1919 158 53 ‘ 34*4 ti 1924 142 24 16.9 n 1931 523 152 24.4 Yama kawa 1930 179 1 0.6 ti 1931 1305 1 0.1 Ogoyi School 1925 74 10 13.5 Yuge School 1930 177 14 7.9 Ogi School 1930 238 1 0.4 Kushiwara 1930 123 20 15.5 Mod o 1935 620 125 20.2 Azisaka 1321 513 296 53.7 Pukuda 1934 1375 24 1.7 ti 1935 2152 36 1.7 The following data were furnished by the Chief of the San- itary Section, Saga Prefecture, and represent results of surveys conducted by Prefectural health authorities during 1943 and 1944. Table 11. Results of stool surveys for schistosomiasis conducted by Health Department of Saga Prefecture 1945*1944* Town Date survey No. examined No. positive Percent positive Kizato 1943 360 62 17.2 ' ft 1944- 370 62 16*8 Tosu+ 1943 474 39 13.8 n 1944 474 89 13.8 Asaki 1943 619 117 13.9 ii 1944 1431 235 15.9 Kltashigoyazu+ 1943 420 19 4.5 n 1944 420 19 4.5 +There appears to be some repetition of figures in these data in that leu,two towns the same number of individuals v;ith the same numberedf positives is recorded for both 1943 and 1944. However, the interpreter insisted that the data are correct. The foilowing inf ormation was taken from the Annual Seport, Prefectural Health Officer, Fukuoka Prefecture, for 1942. Table 12. Stool examinations for schistosomiasis conducted by Fukuoka Prefecture, 1942. Town Date survey No. examined No. positive Percent positive Cururae City 1942 244 32 13.1 iamanato 1942 1926 2 0.1 The information furnished by the results of stool examina- tions in this endemic area over the past 20 years would seen to 5-ndicate that the distribution of the disease is spotty In nature in that some areas have a high incidence rate and other areas a low incidence rate. The data indicate further that there has been little apparent reduction in the incidence of infection in the area over the period in question. (b) Examinetion of school children for schistosomiasis. After c on s u11 atlon v;itli Sr. Inoue and a considera11 on of the available dita, three schools were selected from which to obtain stool samples from the pupils. Those schools wore as follows : Nagatoishi and Ajisaka, Fukuoka Prefecture, and Tosu, Saga Pre- fecture. information concerning the incidence of past infection was available fro., previous surveys and the schools wore distrib- uted throughout the heart of the endemic area. The following are the results of the oxaninat lor. s . Table 13. Incidence or: 3. jr.por.icun and other helminth parasites in school oh lid r on 3 to 13 yrs) examined by Commission on Schistosomiasis in the ICurume area. In o . Pars. No.in- ParasiteExam’d.fact’ d ifKL'US FEIALES % in - No, in - % N o. in - . fecTd.Total fec1d . inf.Total fec’d. % in- fected 3. .iaoonicun (Nagatoislii School, Fukuoka Prefecture) 114 49 43.0 (30 32 53.3 54 17 31.5 A. lumbricoides 43 42.1 Hookworm M 3 2.6 Trie hurls trichiura 4 3.5 Hu t s roh iu s v o rn icula r i s rr ' - 2 1.3 Negative 11 30 26.3 (A jisaka School, Fukuoka Prefecture) S. jaoonicun 119 23 19.3 59 17 28.3 60 6 10.0 A. lumbrico id e s nr- 31 63.1 Hookworm " 10 8.4 Trichuris trichiura T 13 10.9 Enterobius vermicularis -n o 0.0 Negative if 24 20.2 (continued ) H o. Pors. Parasite Ptcan’d. N o. in feet fd - % in- . fec’d .Total Hales psmalks N o. in - % in - 11 o. in - foe * d, focfd,Total foc'd. % in- foc1d. (Tosu School, Sa ga Prof Qctu.ro) S. .laponicun 95 13 13.7 49 9 13.4 46 4 3.7 A. 1unbr i c o id g a rr~ 66 69.5 Hookworm n 6 6.3 Prichuris trichiu ra j. - - 5 5.3 Tegativo ” 21 22.1 Insofar as could be learned, all previous surveys in the Xurumo area were based on a single fecal smear. The difference in techniques and differences in numbers examined make it diffi- cult to draw any comparison be cwoon the results obtained by the Commission and chcse ebtai, cc in previous surveys. However, it is evident that there has been Uncle, if any, decrease in the schistosomiasis infection rate in the areas in question over the period represented by the several surveys. (c ) Snail collections in the Kurums area . Collections were made in the area Ibmodlately to the cast of Ichibaru, in rice paddies and irrigation canals near the Chikugo River. Hero numerous specimens were found in the irrigation ditches and in one area the snails wore located in abundance around the stems of rice plants previously harvested. It was apparent that the irrigation canals had flooded and washed the snails into the paddies since the stems of the plants were bent over by the rush of the water. Snails were located in areas five to s5_x foot outward from the canals. Collections made near Ajisaka school revealed only a few specimens. In an area about l/2 by l/4 mile n car H1 s h id a , 311 a i 1 s were nunerous in t ho small i r r i ga t i on can - a is even though the area was well drained and most of the dit- ches dry: about 1000 snails were collected in this area. Hone was found in the rice paddies as at Ichibaru. Very few X. noso- phora were located in an area south of Tosu, although search was made at numerous places beginning 2 kilometers south of the town and working al lost to the town limits. However, immediate- ly to the cast of the village of Sonozak about 300 snails wore collected in an irrigation ditch which was entirely dry. These collecting stations are r.rkcd on Map IV. The following are the results of the examination of samplings of snails for schis- tosome cercariao; 23 Table 14 Results of examination of K. nosophora for schistosome cercariae (Kururne area). Collections ma_cTe~bv Commission on Schistosomiasis. No snails No with Area examined mature S% japonicum No with immature forms Percent inf ec 1 d No with car- cariae of other species of trematodes Tosu-Sonezak 210 IS 4 9.52 9 Kurume-Nishida 200 4 4 4.0 1 Kurume -Ichibaru 100 7 0 7,0 0 The foilov.ring informa.* 1 on concerning infection rate in snails was obtained from a 'apor entitled "Result of investiga- tions on the ecology cf the Katayama nosoohora , along the Chikugo River in Kururs City" ‘free Hhglish translation) by Konosuke, G. Pu jizawa _ Y. iaibo, Kin An Ran, v. Miyazaki, S, Nakano, /S. Nagazato, T. Ozav/a Rin To Sho, Lo Mai Ben, and Sai Shu Go,) published in the Journal of the Kyushu Medical School, April, /1942. Table 15 Results of examinations of snails in the Kurume area for cercariae of S» japonic uni No collecting Area stations in area Percent S. infection japonic urn in snails Ku rume-Nishida 2 0 to 7.3 Kurume-Nagatoishi 6 0 to 30.0 M iya k i - Gun (C oun t y ) 3 0 to 2,17 Fukuoka Prefecture S 0 to 6.45 In the experience of the Commission, infection rates in snails such as those cited a%ove indicate very marked foci of schistosomiasis in the population. it is believed also that such rates indicate that there has been little reduction with- in recent years of the schistosomiasis incidence rate in the commun it;/. (d) Morbidity and mortality in the Kurume area. The Chief of t he San It ary Sec i ion, Saga Prefecture, advised tha t there had been reported in that prefecture an average of 395 cases of clincial schistosomiasis per year during the past 5 years. The schistosomiasis morbidity rate in Saga Prefecture is 134 per 10,000 population. Similar data were not available for Fukuoka Prefecture, but would probably not vary widely from the Saga Prefecture figures, since part of Fukuoka Prefecture contains some highly endemic foci of the disease. No information was available concerning the mortality from rhe disease. Dr. Indue stated that he treated about 80 cases of the disease per year in his hospital• the age of the patients usually ran between 8 and IB years. He had no definite informa- tion concerning the number of deaths traceable to schistosomiasis but believes that there are very few. (e) Chemotherapy employed in the Kurume area. Dr. Inoue advised tHal lie''TmipToye d ~?-Nasbosanlf he the treatment of schistosomiasis. This is a p-s•minophenylstibinate derivative containing in each ampoule CO gram of antimony and manufactured by Banyu Pharmaoeutical Co-, ltd.. Honcho, Nihonbashi, Tokyo. He uses 1 ampoule every 3 days for a total dose of 0.1 to 0.15 gram. Good results are said to bo obtained in acute cases. 11. Surve--r of Fukuyama area, Hiroshlma and Okayama Pre- fectures * The Commission departed Kurume 0715 hours, 22 November and arrived Fukuyama 2315 hours, same date. Headquarters were established with the 3d Battalion, 162d Infantry, 41st Infantry Division, and appreciation is accorded Captain John E. Norton CO, for courtesies extended in the way of quarters, rations, and transportation. Miss Emiko T’ujii acted as interpreter for the Commission during its stay at Fukuyama. The survey in this area was carried out between 22and 27 November. (a ) General Rescript ion and estent of infection. The endemic area is situated immediately to the north of the 0ity of Fukuyama and lies partly in Hiroshima and partly in Okayama Prefectures (Map V). it is approximately 13 miles in extent from northeast to southwest and approximately 5 miles wide at its greatest breadth. in Hiroshima Prefecture, the area includes all or part of Hkiya, Mubeyama, Miyuki, Michinque, Kannabe, Senda, Mino, Yuda, and Takehiro Townships, although! the center of the area lies in Miyuki, Kannaba, and Mino Townships. In Okayama Prefecture, the infection occurs mainly in Takaya Town- ship* The outline of the a rea on Map V as the endemic zone is based on information received fro: many sources. The disease is probably absent from many parts of the area but the boundaries mark the limits within which due precautions should be taken by military personnel to excape infection. 25 During the investigations of the Commission, numerous parsons were interviewed n an effort to gain information concerning the extent of infection and otdr phases of the problem. Much of the early research work on schistosomiasis took place in this area around the village of Katayama, from which village the disease takes it name In 1904 in an autopsy in Yoshida Hospital at nearby Haga, Fujinami recovered the first females, japonicum from man. Organized control work was undertaken In 1918 oy the “Association Eradication of Endemic Disease’*, an associa- tion which comprises 3 villages. The association had three objectives, viz; Education of the population with the view of preventing acquisition of the disease; the use of lime on ir- rigation ditches and rice fields for the destruction of the snail intermediate host; and the substitution of horses for oxen as draft animals in the endemic a rea for the reasons that the former are more resistant to infection and seldom pass ova of the par- site in the feces. Until 1958, this association supervised all control work in the area; in that year, supervision reverted to the Health Department Hiroshima Prefecture* 3h the calender year 1944, a total of 50,COD y* n was spent in control work in Hiroshima Prefecture. one-hhli of this being appropriated by the Prefecture! H0verr ment and one-hall by the association of 8 villages. Dr. Takomaro Kitaj inn. He lath office of Hiroshima Prefecture, advised that in 1943 the program was augmented so that in addition to the lime treatment of irrigation ditches and rice fields some of the ditches were concreted, since it was found that the snails will not live in cemented ditches. How- ever, this program was not in operation in 1944 and 1945 because of the shortage of cement. Lime is still being used for snail destruction in parts of the area where r equired. The lino is applied in flay at the rate of approximately 10 pounds per 5 to 10 meters of ditch, d epending on the size of the ditch. This amount represents about t wice that employed in the treatment of experimental plots of the Commission on Leyte where it was found that other chemicals were more effective for the destruction of Oncomelanla quadrasi, the snail intermediate host of S japonicum in the pliilippines. Thpre is no question but that attempt's to control schistosomiasis in this area have mot with considerable success. The distribution of the snail intermediate host has been considerable restricted through the practice of liming and the Commission was unable to find snails in many areas in which they were said to have existed formerly. The educational program carried out by the “Association for the Eradication of Endemic Disease" has no doubt also con- tributed materially to the control of the disease. Everyone in the area is apparently quite familiar with the disease, its method of transmission, and the scedes of snail involved in that transmission. Even without an interpreter, it was possible to obtain from almost any man, woman, or child working in the rice 26 fields in the area accurate information on the distribution of the snail and whether cases of the disease existed in the conti- guous village. Charts showing the life cycle of the parasite and containing information in regard to the prevention of the disease were observed in some of the township schools visited by the Commission. In j)ast years, numerous stool examinations have been made in the endemic area, and other types of surveys conducted in an effort to obtain accurate information on the distribution of in- fection. If fort was .made to obtain Information on the results of these surveys from Dr. Takemaro Kitajima, Health Officer, Hiroshi- ma Prefecture, Hiroshima, Dr. T. Miyata, officer in charge Schistosomiases Control office, Hiroshima Prefecture, Fukuyama, and Lir. Shaichi Kawai, Assistant to the Health Officer of Okayama Prefecture, Okayama, However, all records were burned during the bombing of these three cities. ( b) Fxaminacion of school children for schistosomiasis • After consultc.tion~wi ta various authorities, it was decided to obtain stool- sam.ples f:’om cull* clreu in the township schools of Mino, Kannabe, and liiyuki, since these schools draw pupils from the center and from the fringes of the area in which the major portion of the disease is now confined. The following represent the results of these examinations. Table 16, Results of stool examinations of school children (ages 12 to 14 yrs.) in the Fukuyama area by Commission on Schistosomiasis. Parasite No. Exam’ d No, Inf ec’ c/o Total d Inf.No. Males Females No. c/o Total No. Inf. Inf. No. Inf’d No. Inf’d Mino-Mura School S. japonicurn 117 0 0 56 0 0 61 0 0 A. lumbricoides n 76 65.0 Hookworm n 21 17.9 Trichuris trichiura 7f 21 17.9 Negative ?f 27 29.1 Kannabo School S. japonicum 121 19 15.7 57 12 21.1 64 7 10.9 A. luinbricoid.es rr 49 40.5 Hookworm rt 10 8.3 Trichuris trichiura 8 6.6 Enterobius ver- micularis tt 1 0.8 Negative 58 43.8 27 Table 16, (Contd) Males Females Parasite No. No. c/o Total No. Jd Total No. No. ExamT d Infec’d . Inf. No. Inf. Inf. No, Inf'd Inf' d Mi yi&dr- -Mura School S, .laponicum 119 15 12.6 60 10 16.7 59 5 8.5 A. lumbricoides ,T 65 52.9 Hookworm u 13 10.9 Trichurls trichiura 19 16.0 Enterobius ver- miculsris ?t 1 0.8 Negative T? 39 32.8 The failure to find cases of infection in children at the I.iino-mura School would seem to confirm the impression of health authorities that the disease is at a very low ebb in that town- ship; this conclusion is in keeping also with the failure of the Commission to find the snai] intermediate host in this locality. It is apparent that the ujse an at the present time is centered around Kctayana village, an opinion which, is fostered by many of the individuals who were interviewed. (c) Snail collections in the Fukuyama area. A thor- ough search for the snail intermediate host of S. .japonioua was made throughout most of the endemic area. Collecting stations are marked alphabetically on the map. At Station A near the village of Haga very few K. nosouhora were found although speci- mens of Suec.inia, Planorbula and Melania were collected. This area had been heavily limed, and a considerable amount of lime still remained in the water and along the banks of the irrigation canals. The snail was very common in collecting station B, where there was no evidence that lime had been used. Here some K. nosophora were found in the water of the canals and others were located in rice paddies. The snails were not located in irriga- tion ditches or rice paddies at collecting station C but were found in a small swampy area measuring approximately 5 x 100 yards; here they were located under a heavy growth of weeds and grass and appeared to be only beneath the surface of the ground.. Snails were also found in collecting areas D and E. Beginning above the town of Saoka at collecting area F, surveys were made south to Nanukaichi in Okayama Prefecture and west as far as collecting station I near mino-Mura School. The area from F to 0, the bridge at Ina, was covered by walking through the rice fields and examin- ing the irrigation ditches. Here the ditches were well made, many of them of concrete,, while others had concrete or rock sides with natural bottom. The water in these ditches ran swiftly and was quite clear. Very few snails of any kind were seen and no K. nosophora were recovered. Hero the soil was more sandy and contained some gravel, in sharp contrast to the heavy black allu- vial soil found near the village of Katayama.. About the same conditions were encountered at collecting station H near lanu- kaichi; no snails were found here or at collecting station I, south of Takaya, although Melania spp. of snails were numerous. At collecting station J near Mino-Mura, no K. nosophora were located although the snail had formerly been endemic here. At area II, north of the town of Kannabo, conditions seemed to simu- late more closely those at Katayana. However, the ditches had been heavily limed end no K. nosophora could be found. The first snails in the valley were located at collecting station L to the northwest of the town of Kannab^e. The ditches in this area had been limed also but the snails were found in small rectangular swampy areas adjacent to the irrigation canals. These swampy areas may have been abandoned fish ponds. The snails were not num erous in this area. In collecting area M east of Sunahara, a single specimen of the snail was found after a lb minute search; the ditches in this area had been limed. In collecting areas N, 0, and F, between Chikata Station and Era, the irrigation ditches ere Jeep with steep banks and even in the lateral terminal canals tie water flows swiftly, a condition not favorable for K. nonopho?.; no soocimens were found in these areas. Similar conditions vwre found to prevail in the remainder of this section at coj.lccting stations Q,, R, 3, T, U, and V, and none of the snails was found in this entire region. The information obtained from the surveys of the Commission and from Japanese sources would seem to warrant the conclusion that in the Fukuyama area, K. nosophora is quite closely restrict- ed at the present time to s section comprising approximately 4 square miles centering at the Junction of the Kamo-gawa and Takaya gawa. The failure of the Commission to locate the snails else- where in the Fukuyama area does not necessarily indicate their absence; it does indicate, however, that the center of infection is in the above-mentioned area. The Commission was advised by Asst, Prof. Sakae Murakami, Okayama Medical School, that in 1936 or 1937 he crushed 300 to 400 snails collected in the area between Katayema and Kannabe and had found about 3 percent infected with 3. Japonicum. He stated that at the present time the snail was found in Okayama Prefecture only in the vicinity of Takaya. The following table gives the results of snail examinations by the Commission for cerearise of 3. Japonicum in specimens col- lected in the Fukuyama area. Table 17. Occurrence of cercariae of S. .Icponicum in Katayama nosophora collected in the Fukuyama area. No. snails No. positive rca examined for S. a japonicum Percent No.positive for positive cerceriae of other trernetodes Kanncbo (Station L) 101 16 15.84 0 Kat ayana (Stations A, B, and C) 200 2 1.0 0 liiyuki (Stations D and N) 200 1 0.5 0 (d) IJorbid j ty ai. \jo'rtcl: ty in the Fukuyama area. No information could be obtain A on these points for Okayama Pre- fecture. Mr. Kawai, repre serein tive of the Health Department of that Prefecture, state! that all records of his office had been burned in the bombing of the City of Okayama and he did not know whether there were any clinical cases of the disease at the present time. All records of morbidity and mortality of the disease in Hiroshima Prefecture had also been destroyed in the burning of the City of Fukuyama. However, Dr. Lliyata, in charge of the control office at Fukuyama, furnished fragmentary data, as fol loves: Table 18. Morbidity and mortality from schistosomiasis in Hiroshima Prefecture, 1941-1945. Year No. clinical cases No. deaths 1941 226 9 1942 About 200 2 1943 1472 No information i 1944 401 rr tr 1945 No information w tf It WciS learned that the above-mentioned figures are not based on cases occurring in the private practice of physicians in the area but represent cases diagnosed on physical examination by teams of physicians going from village to village within the en- demic area. Mr. Ryoichi Sato, a veterinarian and president of Miyuki- Mura, stated that it is the general impression that individuals acquire a certain resistance to schistosomiasis through early exposure to the disease. During the war when lime was difficult to obtain, control work in his township had to be neglected. As a result, the number of snails increased and there were a good many clinical cases of the disease in individuals in the teen ages because they were said to have escaped infection at an early age. Mr. Sato told the Commission that during the war many men of military age from, his township were rejected for military ser- vice because they were suffering from schistosomiasis. 12. The_presence of he aatemogaiy as an indication of schistosome inf op t len, Mr j c " i\.n g ' a wor k v;i t h the Cornell s s i on consisted in evaluating the pi’esene-.- of hepatomegaly or the so- called "liver index" as an imnicatLon of schistosomiasis. He chose to submit to th~ Murgeon General a separate report but has kindly furnished the Commission with a copy of that report. As indicated in the following extracted from Major Bang's re- port, he found a close relationship between the occurrence of hepatomegaly and schistosome infection as determined by stool examination. Tabic 19. Relation between palpable livers and r» cc of schistosomiasis in children 5 to 15 years of age. (Major Bang's exam- inations ) . , Place No. of area examined Percent with positive stools Percent with palpable livers Liver index Okemada Heavily endemic 106 60 50 0.7 Sancho n tr 89 55 59 0.8 Sakura Lightly endemic 68 1.47 9 i—i • o Asakwa Negative 36 0 3 0,03 The first two mentioned places are in the Yamanashi Prefecture, where schistosomiasis is heavily endemic end where clinical cases probably occur more frequently than in 31 ■raxy other in Japan. In order to compare results obtained in this area with those iron an area where the infection is not so severe, liver palpations were carried out on school children in the hururne area. The examinations were made by Lieut. Mg) George Levy, I.IC, USN, and Lt. (jg) A, Littman, MG, USIT, 27th' marine .Regiment, fifth marine Division, The results are given in the following table. Table 20. Results of liver palpations to determine schistosome infection in school children 7 to 13 years of age. School No, individuals enar,lined No. with stools positive No. infected with palpable liver No. not infected with palpable liver Nagatoishi 114 49 10 13 Ajisaka 119 Z'5 E 5 No 2 o Sa-grQ 95 ±5 0 3 the above-mentioned results, it will be seen that more children not infected with S. :japonicum showed some degree of hepatomegaly than did children harboring the parasite. In these three schools then, the liver index would have been of little value in disclosing cases of infection with S, .japonicurn. The difference in these results as compared with those in 19 may be due in part to the fact that the examinations were made by different individuals. However, it is probably more related to the fact that the children in the Kurumc area do not have as heavy infections as do those in the Kofu area where Major Bang’s investigations were carried out. It would seen therefore that the liver index tends to lose its value as a diagnostic measure when the level of infection in individuals in a community is lov; and not sufficient to produce a high morbidity rate for the disease in that community. 1 3. Summary. Til The five known endemic areas of schistosomiasis in Japan have been surveyed by the Commission on Schistosomiasis with the view of ascertaining the extent of these areas and gathering information which would be pertinent to the prevention of this disease in military personnel. The methods employed in the surveys included the compiling of all available information from national, prefecture!, and local health authorities, the collection end examination for schistosome ova of stool samples from children in certain representative schools in each area, the investigation of the liver index as an indication of schisto- some infection, and the collection and examination of Katayama nosophora. the snail intermediate- host of Schistosoma TapbniciLni, in an effort to determine its distribution within the area and the rate of infection with cerceriae of the parasite. (b) The endemic areas surveyed were, as follows.: (1) The Tone River area in Chiba and Ibarcgi Prefectures. (2) The ICofu area in Yamanashi Prefecture. (5) The Numazu area in Shizuoka Prefecture. (4) The Kurume area in Saga and Fukuoka Prefec- tures, Island of Kyushu. (5) The Fukuyama area in Hiroshima and Okayama Prefectures. The first two areas arc in the Eighth Army Command. The last three are in the Sixth Army Command. ic; individuals ml acted with o. .laponicua on stool examination have boon reportod from othor ~cre as including Tochigi, Aomori, me Fukui Prefectures, National health authorities arc of the opinion that such cases do not represent infection ac- quired in these prefectures hvt rather imported infections. A relatively large numl-.r of suae, cases hrs been reported from Fukui Prefecture (T3 Wed IcO) V',;: it is the view of Japanese health officials and parasitologists that these reports are either in error or represent cases of infection acquired else- where. A reply to a specific inquiry into the status of such reports had not been received from the health Department of Fukui Prefecture at the time this report was compiled. Schisto- somiasis was formerly endemic in certain perts of Tokyo Prefec- ture but it is said that all these foci of infection have now been eradicated. (d) In view of the limited amount of time allotted the Commission for the work in question, it has not been possible to conduct exhaustive surveys of any of these areas. With the view that more detailed studies should be made, the Commission undertook to train in laboratory and field work one officer and two enlisted men from each of five Llalarla Survey Detachments under Eighth Army Command. It is believed that such personnel is capable of carrying on such additional work as is indicated. (e) The Tone River area, which lies partly in Chiba Prefecture and partly in Ibarrgi Prefecture, apparently has the lowest infection rate of any area in Japan. T7hilc the disease is still endemic in certain parts of this river valley, it is at a very low ebb and at the present time there is probably very little transmission taking place. The Commission was unable to find specimens of K. nosophora' in any place in which a. search was made, although the snail undoubtedly still occurs in certain sections. However, the entire river valley from Torite east should bo regarded as a suspected endemic area until additional investigations prove otherwise. (f) From the standpoint of incidence of infection and morbidity rate, the Kofu area, Yamanashi Prefecturo, is the most important one in Japan. In spite of the fact that a control campaign has been aggressively carried on in this area for the past three years, it is apparent that little has actually been accomplished in the reduction of the incidence of infection or the number of clinical cases. This area appears to be particular- ly dangerous from the standpoint of the transmission of infec- tion, since exposure in any part of it would probably lead to clinic'1 cases of the disease. One battalion of infantry is now stationed in the area, together with an AMG detachment. (g; The Nu.ma.zu area in Shizuoka. Prefecture covers only about 10 square miles and is the smallest focus of the disease in .lapen, Only' 9 percent of 155 children from a school in the center of the e'er were found infected. Authorities stated that there has been a marked reduction in the number of clinical cases of schistosoniasis in this area since the drainage of a large swamp in oho hea :t cf the area three years ago. While all precautions against the acquisition of infection should be taken by military personnel on oaring the area, the opportunities for the transmission cf tho disease here are more limited than in most other endemic .togs. (h) The Kurume area in Saga and Fukuoka Prefectures. Island of Kyushu, is the most extensive endemic focus of schisto- somiasis in Japan. However. the infection is more spotty than in the Kofu area, some sections showing a high incidence of the infection while in other sections the disease is at much lower ebb. The distribution of the snail intermediate host within the area varies considerably, the snails being found in abundance in the high incidence zones and few in number or absent in certain other sections where the incidence was found to be lower. This situation is apparently due to the operation of natural factors since practically no control work has been carried out in this area. The Chikugo River runs through the heart of the Kurumc area: because of its clear wr. ter .and sandy bottom.it would no doubt present an attractive invitation for swimming or washing vehicles to troops not suitably indoctrinated in the prevention of the disease. Furthermore, Kurume is on the main convoy route between principal cities and ports in the southern and south- western parts of Kyushu to cities in the northern part of the Island occupied by United States Army Forces, At the present time, various units of the Fifth Karine Division are stationed in the endemic area. In summary, the probabilities for the acquisition of schistosomiasis by military personnel in this area are considerable. (i) The Fukuyama c.rtr, in Hiroshima and Ok ay ana Prefectures in our opinion ranks third in importance from the standpoint of possible transmission of the disease to military personnel. Through the organized control work which has been carried on in this area over thu past 30 yerrs, the disease has been gradually reduced end the distribution of the snail inter- mediate host considerably restricted. At the preseiit time, the infection seems to. be confined principally to the townships of ICarmabe and with the center of the focus at the village of Katayama where the disease was first discovered. One battalion of infantry is at present stationed near Fukuyama. The larger streams in the area are very inviting for swimming and bathing and, unless suitable educational measures are carried out, some of the troops stationed near the area and some wander- ing into the area in all likelihood will sooner or later expose themselves to infection. (j) The appended maps carry of the present boundaries cf cme various endemic areas. Such boundaries ere predicated on the ini■ mation furnished the Commission by Japanese health authorities and others and by results of the Commission’s own investigations. Effort has been made to place these boundaries at. safe limits; undoubtedly some of the informa- tion is in error ana could cnly be rectified through detailed surveys by trained pcrsonn■ 1 Even though the infection may not occur in all territory ine.Vad si w.rtnin boundary lines, from a standpoint of preventive medio.' e all stem ams and other bodies of fresh water within These lines should be regarded with sus- picion and due precautions taken to prevent military personnel coming in contact with such water. 14. R0 c prune nd a t i ons e While there is little probability that any appreciable mount of exposure to schistosonicsis will take place during the winter months in Japan, opportunities for such exposure will be considerably enhanced with the advent of warmer weather. In its contacts with the commanding officers and medical officers of units stationed in endemic areas of schistosomiasis, the Commission has endeavored to stress the importance of carrying out a suitable educational program for the prevention of the • disease. The following specific recommendations are offered for such consideration as may be deemed advisable. (a) It would appear desirable that all roads leading into known endemic areas of schistosomiasis be posted warning military personnel that they arc entering such an area and to beware of any contact with fresh water wdthin the area. Suita- ble warning/ signs should be placed along streams and other bodies of fresh water which arc apt to be used for fishing, swimming, bathing, or the washing of clothes or vehicles. (b) It is recommended that there be carried out, such as was done on Leyte, a suitable educational program of lectures and demonstrations on schistosomiasis, including specific infor- mation on the location of endemic areas of the disease. This program should be undertaken without delay for those troops now stationed in or near endemic areas and extended during the re- maining winter months to all military personnel in the occupa- tion forces. Such an educational program should be continuous in nature or at least be carried out at suitable intervals in that it nay reach replacements entering the country for the first time. Medical officers themselves should be especially familiar with all aspects of the disease in order that they may supervise such a program within the units to which assigned. (c) It is the opinion of the Commission that the stationing of large bodies of troops within endemic areas is inadvisable unless dictated by military necessity. (1) lb is believed that further survey work is warranted for the purpose of delimiting more closely the known endemic foci of the clsea.se, and investigating other areas in which the disease may be suspected to occur. It would seen that personnel most qualified to carry on this work is that already given some training by the Commission. (e) hiiilc vhe ult.. mate control of the snail inter- mediate host of s ohistosc ml as:' h is not of immediate military concern, excellent - or portunity is afforded for carrying out in- vestigations in a limited area with one or more of the chemical compounds tested by the. Commission on Leyte; research work of this character might contribute information of considerable value from the standpoint of public health and preventive medi- cine. Gucli investigations could be undertaken by suitably trained personnel of one of the Malaria Survey Detachments. In- formation concerning the above-mentioned chemicals can be found in the monthly reports of the Commission, copies of which are in the files of the Chief Surgeon’s Office, (f) It is recommended that any survey or other in- vestigational work which nay be undertaken by military personnel bo coordinated by a commissioned officer familiar with all phases of the problem in order that duplication of effort nay be avoided and the work of various units properly integrated. 15. Acknowledge;clients. Tlio Commission wishes to record its appreciation to Brigadier General Guy B. Denit, Chief Surgeon, United States Array Forces, Pacific for the opportunity of carrying out the surveys in question. The Commission is also greatly indebted to Brigadier General George V/. Rice, Surgeon, Eighth Army, and Brigadier General Mi. M, Hagins, Surgeon, Sixth Array, for the facilities which they have placed at its disposal and for the encouragement lent to the work. Colonel A. H, Schwichtenberg and other numbers of the staff of the Advance Echelon, Chief Surgeon’s Office, have been particularly helpful in arranging many of the details connected with the work of the Commission and their cooperation is greatly appreciated. Many other 36 individual mnbers of the occupation forces have given freely of their tine end advice. Finally, the Field Director wishes to connend end to thank all individuals connected with the Coj.iuission for their untiring services and their devotion to duty over tin period of tine represented by the work in question. WILLARD H. WIGHT, Colonel, U3PHS, Field Director, C or.ii.ii s s i on on S eh i s t os oni as i s. Erratua Perrgraph 7 tb). Two -c'.nols I Toyosblmn end iatc-Scwr.ro) sre in Ibr,ra((i Irt-iacturo. 3t ::ura end Uorlyanr, Schools art- In Chiba Prefecture* o j. j. ; ,v lIi . i Paragraph ID (c). The Health Department of Fukui Prefecture advised the Ministry of Welfare and Social Affairs by telegraph that there are no cases of schistosomiasis in that prefecture at the present tine. 37