1336 A TYPHOID CARRIER ON SHIPBOARD WILBUR A. SAWYER, M.D. Director of the Bureau of the Hygienic Laboratory of the California State Board of Health BERKELEY, CAL. An investigation just completed by the California State Board of Health has traced twenty-seven cases of typhoid among sailors. to a carrier in the crew of a lum- ber steamer. Four of the patients succumbed to the disease. This typhoid carrier is unique among those already reported inasmuch as he was a member of a ship’s crew and infected a large number of his com- panions without having anything to do with the handling of their food. The danger from typhoid on this ship was so well known among sailors that the vessel was ‘ealled the “fever ship” and it was difficult to secure desirable men for the crew. . For three and a half years it has been noticed at the United States Marine Hospital in San Francisco that a large part of all the typhoid cases has come from the steamship Acme, a vessel carrying lumber from Humboldt Bay, usually from Arcata, to San Francisco Bay and sometimes to San Pedro, the port of Los Ange- les. This observation was reported-to the State Board of Health and the Health Department of San Francisco. An investigation, carried on by the latter, brought: to light evidence pointing to a member of the crew as a carrier. This man, H. O., was investigated during two weeks in the City and County Hospital in San Francisco, but was discharged on Dec. 15, 1911, after the city bacteriologist had reported that the blood gave negative Widal tests and that typhoid bacilli could not at that time be demonstrated in the stools. ‘The investigation by the city showed that the solution of this problem involved work in other cities. The State Board of Health was notified of this -fact and immediately assigned the investigation to the Division of Epidemiology of the Bureau of the Hygienic Labora- tory. The director of the bureau began work on the problem on Dec. 28, 1911. The Acme takes fuel oil in San Francisco but dis- charges cargo in Oakland. No passengers are carried, and there are usually only twenty-one men employed on board. These are the captain, first mate, second nate, chief engineer, assistant engineer, two firemen, one cook, one waiter, and twelve seamen. ; Sanitary surveys showed that the ship was on the whole no less sanitary than most vessels of her kind. There was evidence of recent alterations made by the owners in their attempt to check the series of typhoid, cases by making the vessel more hygienic. The mess- room for the officers was clean and attractive. The crew took the food which was set out for them and ate it sitting on the cargo. The galley was not so clean as is desirable. Dishes were washed in hot water in a small tank heated by steam coils. The forecastle housed twelve men in very close quar- ters. There were three tiers of bunks and very little unoccupied space. The air conditions had recently been rendered less objectionable by the placing of a ventilator through the deck overhead. At the first inspection the sailors’ water-closet was in a filthy state and suggested opportunity for the spread of infection by flies. Before the investigation had terminated conditions had been greatly improved by the replacing of the bowl, the installation of a system of constant flushing with sea- water, and the cementing of the floor. The danger of conveyance of infection by flies was very slight while the TYPHOID: CARRIER—SAWYER JOUR. A. MLA, Alay 4, 1912 ship was at sea and practically free from them, but considerable when the vessel was tied at fly-infested wharves. - The introduction of typhoid bacilli to the ship in the food-supply could be almost entirely ruled out. No fresh milk was taken aboard, condensed milk being used. Fresh vegetables, such as lettuce, radishes, celery, and onions, were eaten raw by the crew, but all the food except meat was purchased exclusively in San Francisco, Other ships buying in the same market were free from typhoid. . The drinking-water supply for the galley was taken through a pipe and faucet from a large closed iron tank. Near the forecastle was a new covered barrel from which the crew obtained water through a faucet for drinking and washing. Near the deck-house was an old cask which had escaped destruction at the time the altera- tions were made, when the other water-containers were - replaced. It lay on its side, and water was obtained from it by dipping through a small square hole with a common drinking-cup. It is apparent that members of the crew reaching into the dark barrel would wet their hands and contaminate the water. This cask was called the officers’ cask. It supplied water for the officers’ table and for any members of the crew who found it convenient to drink from it. The officers’ cask has recently been thrown overboard and has been succeeded by a small barrel with a faucet. Samples were taken from each water-supply and were examined for colon bacilli. All the examinations were negative except one of two tests made of samples taken from the officers’ cask. A portion of this one sample. of water showing colon bacilli was incuhated in lactose bile and later plated on Endo medium, but typhoid bacilli could not be demonstrated. Possibly the results would have been different if the officers’ cask had not been freshly filled shortly before each examination. In order to eliminate as far as possible infection from unknown water-supplies the owners had specified for some time past that all the drinking-water should be taken aboard in San Francisco. This meant that the officers’ cask might receive contamination for nearly a week between fillings. Limiting the water-supply to a single safe source did not prevent further cases from developing. It was evident that there were several methods hy which typhoid bacilli might be readily distributed by one member of the crew to the others. The infection could be spread by contamination of the food during preparation, by pollution of the officers’ cask, by soiling of the hands of the crew in the crowded forecastle or the insanitary toilet, or by transference of infectious material by flies from the toilet to the food-supply. The contamination of the officers’ cask seemed to explain most satisfactorily the possible distribution of typhoid bacilli from a carrier to the majority of the cases. Inquiry showed that the men did not frequent any particular boarding-house or saloon in Arcata or San Francisco. They ate on board ship during their term of service and most of them had never gone ashore in Arcata. In San Francisco they scattered about town as did the sailors from the other ships and they had no special rendezvous. Other ships than the deme coming into San Francisco are comparatively free from typhoid. In order to find out whether any other ships sailing to and from Humboldt Bay and taking water there were troubled with typhoid, a number of ships accessible in San Francisco Bay were visited and the owners af other vessels were interviewed. In no instance had VouuMe LVIII NUMBER 18 there been recent cases of typhoid fever on board the ships. On six ships sailing to Humboldt Bay we asked whether the men knew of any vessels on which there had been typhoid, and on four of the six the reply was made that the Acme had had trouble with the disease. No other ships were mentioned as having typhoid. Dr. 8. B. Foster, the officer representing the United States Public Health and Marine-Hospita! Ser- vice at Eureka, reported that no cases of typhoid had come under his care since January, 1908. . The evidence already presented gave ground for a strong suspicion that the series of typhoid cases amo1g the crew of the Acme arose from a focus on board the ship. Every effort was then made to detect the source by examination of individuals who might be carriers. It was impossible to lay the blame on any one cook or waiter as these men had been changed at short intervals during the series of cases. A similar situation existed with regard to the seamen and firemen. With the excep- tion of the captain (G. O.), the first mate (J. H.), the chief engineer (L. P.), and the winch-driver (H. 0.). no members of the ship’s company at the time of begin- ning the investigation had been aboard for any con- siderable period. When the first visit to the Acme was made, she was in dry-dock and all the men TYPHOID CARRIER—SAWYER COURSE OF TYPHOID CARRIER.CH. oO 1537 Surgeons James M. Gassaway and 8. D. Brooks for placing hospital records at our disposal. We were fortunate in being able to find and interview four of tire early patients, V. B., I. O., L. P., and O. K. The results of the searching of records and interviewing of former patients enabled us to secure the information shown on the chart illustrating this article. All the evidence tended to indicate that the winch-driver (H. 0.) was responsible for the series of cases on the Acme and also for the single case received by the Marine Hospital since January, 1908, from the steamer Arcite. For the sake of brevity and clearness the chart has been made to show the history of H. O., the winch-driver, from the time of his taking service on the steamer Arctic to the time when our investigation was completed. The chart shows also the length of his stay aboard each ship on which he served, and indicates by initials all typhoid patients known to have come from these ships into hospitals and gives the dates of their stay under treat- ment. A study of the dates shows that all the cases received their infection while on board ship with H. 0. The diagram shows also that patients from the Acne were cared for in three cities, San Francisco, Oakland GASES OF TYPHOID WITH TIME IN HOSPITAL . VES. 1, 9O70)= HOVE, 1607 had been discharged except the four mentioned above. Of these Manne Horta | zeus only the captain (G, 0.) and the —owswone _ imoamusenevs winch-driver (H. 0.) had been SA OHRID BanceTion. Ware aboard during the entire series of cases. The captain had never had typhoid. The winch-driver had had the disease four years. before, but he had been examined in Decem- ber, 1911, by the city bacteriologist of San Francisco and his stools had 4 DAS, WAR.©, LSOB(T = MAR.26, 100867 S.S.Nove “aces, HHAR.22,1808 + APR.4, 1608 SS.Anctic — emontas, sows APR, 10S - JUNE 13,1808 S.S.ABERDEEN 1 MONTH. ES DAYS JUNE 19,6508 = JULY 31)308 SS.AcMe SYEARS, TMONTHS AUG.10,1E56~ MARIG, BIE been found free from_ typhoid | bacilli. The firet mate had not had php SS. Agence. steams. 13 oars Co 7 HO. NOVIS.I997 JAN. 908 . MAY S,I90B MAY 15,1908 DIED AUG T1968 OCT 231808 |. SEPTIOI9S OCT. 17,1908 OCT 3.1908 066.28)908 . NOV. 23900 JAN. 16,1909 APR.26J909 tune 4,909 |. NOV. 11,1909. DEC. 16,1909 DEG. 09 JAN. 21,1919 |. OLC.18,1909 YAN. 271910 LP. FEO.24,910 APR. 6,190 |. MAR.26/910 MAY 20,1610 . JULY SITIO AUG. 24,190 SEPT.I0,I90 OCT 27,190 MARINE HOSPITAL, SAN FRANCISCO , SEPT.BOPI0 0EC.14,190 DIED . NOV. 10.1910 JAN. 95,1911 NOV. 18,1910 JAN. 23,911 DULY 71511 JULY 1A I5t1 KL. SEPT.AAISIY NOY 22,!511 SEPT. 16,81 OCT. 26.1511 . NOV 23,181 DEC 24,102 DIED . DEC. 9, BIL JAN. 27012 WAN. 11,7999 JAN. 23,1909 DED AQ FRANCISCO T1908 OATES NOT KNOWN OUTSIDE OF FH 2 FEB.22,19)) APA. SI) OAKLAND typhoid. Heé had been aboard for a year, and two years previously he had been in service on the same ship. The chief engineer had been on the Acme since April 6, 1910, and had been infected with typhoid on the ship in February, 1911. The first laboratory investigation consisted of examin- ations of blood, feces and urine from the captain (G.0.), the first mate (J. H.), and the chief engineer (L. P.). Specimens were taken at the ship on December 30, and January 3, and additional samples from L. P. on Janu- ary 16. Examination of the blood showed a positive Widal reaction for the engineer (L. P.). The other blood examinations were négative. Examinations of the urine and feces of each of the three men failed to reveal typhoid bacilli. Shortly after the specimens from the captain, first mate, and chief engineer had been found to be free from typhoid bacilli, it was learned that two seamen of the Acme had just come down with typhoid and were under the care of the United States Marine Hospital in Los Angeles. It was decided to begin the investigation anew by making a thorough investigation of hospital records and of the names and dates on back pay-rolls of ship-owners, and also by interviewing as many of the early patients of the typhoid series from the Acme as could be reached. ‘The records of the United States Marine Hospitals in San Francisco and Los Angeles were of great value, and we are greatly indebted to C proportional to MAR. 20,1510 APR. 24,1311 JAN, 24,912 FEB. 24 Ke FES. 2:92 MAH. 14,182 + | maaine HOSPTTAL LOS ANGELES Chart showing periods of service of a typhoid carrier on six ships and resulting cases among the crews; prepared by Dr. W. A. Sawyer. director of the California State Hygienic Laboratory. Copyricht, 1912, by California State Board of Health. ength of stay of carrier on board ships. Lengths of ships are and Los Angeles. That there were other undiscovered cases can be little doubted. In fact, one victim, J. F., who was reported by one of the crew, was omitted from the statistics because the diagnosis could not be con- firmed by other evidence. The cases were not limited to the seamen. L. P. was chief engineer, and J. B., who died in the German Hospital in San Francisco, was first mate. It will be noticed that during the stay of H. O. on the Acme, covering a period of forty-three months, there were twenty-six cases. During his period of service next in length (two and one-fourth months on the Arctic) one case occurred. In all there were twenty-seven cases of typhoid fever, four of which were fatal. Of the patients twenty-one were in the United States Marine Hospital in San Francisco, and three of them died, making the mortality 14.3 per cent. During the period beginning with H, 02s return to work after his illness and ending Feh. 22, 1912, sixty-three typhoid patients were admitted into the Marine Hospital in San Francisco from all other ships entering San Francisco Bay, including the river boats, foreign ships and government boats. OF these sixty-three patients six died, showing a mortality 1538 of 9.5 per-cent. The cases traceable.to the carrier, H. O., were one-fourth of all the. typhoid cases admitted and were responsible for: one-third of. the resulting deaths. Under the care of the Marine Hospital in Los Angeles during the same period there were three cases from the Acme and fourteen cases from other ships. All of the seventeen patients recovered, All the cases which could be collected and confirmed showed that there had been twenty-seven cases traceable to H. O. and that four of the patients had died. This gives a mortality of 14.8 er cent., which suggests that the infection being dis- tributed by H. O. was more virulent. than the average strain of typhoid. The evidence collected strengthened all previous. sus- picions that the infections came froma carrier on board the Acme, and special suspicion fell on H. O. It was decided to make thorough laboratory examination of TABLE 1—AGGLUTINATION TESTS ON THREE SUSPECTS AND TWO CONTROLS TYPHOID. CARRIER—SAWYER Serum of Serum of Control Dilution of Serum L. P. vs. Tested L,. P. Vs. i. 0, H. 0. Hopkins | +t Gen. > B @ 9 2 | [Hitt ——_ w S PEP TELE beet | | | | A+ Pitti dd [a+++ | [Mette ttl PVE EET | b++4++ TABLE 2.—RESULTS OF CULTURE EXAMINATION , Nee Staal Rus- No. of Colonies Colonies a 1p after Name Spec. | Endo | Suspicious | pusseli’s Plates | in 48 Hours Med rs as Positive | Negative G. O. Urine G None 0 0 0 G. O. Feces 12 Few 14 0 14 G. 0. Feces 11 Few 25 0 25 H. O. { Urine 6 Few 5 0 . 5 H. QO. | Urine 6 Few 0 5 H. OQ. Feces 12 Very many 107 55 52 L. P. Urine 6 Very few 20 0. 20 L. P. Feces 18 Very few 10 0 10 L. Pe. Feces 6 Very few 5 0 5 L. P. Feces 6 Very few 5 0 5 material from all persons under slightest suspicion and to begin with the chief engineer. (L. P.), the captain (G. 0.), and the winch-driver (H. 0.). The plan included keeping each man under investigation in a hos- pital for at least twenty-four hours. This would insure that the specimens were bona fide and properly taken. The A. W. Beadle Co., owners of the Acme, generously met the expense of keeping the men in the Roosevelt Hospital in Berkeley. On March 2, the Acme came into port at Oakland and the captain (G. 0.) and winch- driver (H. 0.) came to the hospital. Specimens of blood, urine, and feces were obtained from the two men during their stay of thirty hours. On March 10 the chief engineer (L. P.) reported for observation. Similar specimens were obtained from hin during the following twenty-four hours. All three of the men were given fluidextract of cascara on admission to the hospital and