TB - PH - PRBV MED 3, RICKETTSIAL DISEASES IN JAPAN AND KOREA PUBLIC HEALTH AND WELFARE TECHNICAL BULLETIN PH & W GHQ, SOAP APO 500 FEBRUARY 1947 Introduction The two rickettsial diseases that are well recognized and established are the typhus fever group and the Tsutsugamushi fever group. These diseases can be differentiated by specific seraiogical reactions, using highly puri- fied antigenb. GROUP I - TYPHUS NEVER 1, LOUSE-BOREL TYPliJ5: — ”eoidemic typhus'tLur ope an typhus,11 nshirami typhus” (shirami—"louse” in Japanese), "hashin chibusd,” (eruptive typhus-Japanese) arc synonyir.s in this area, ! Lousc-hornc typhus is an acute infectious disease caused "by Rickettsia T)rowa.zcki and usually characterized by sudden onset of* head" ache, continuous fever of 12-14 days duration which ends by rapid lysis, and the appearance of a macular exanthema tens rash on the; 4th to 6th day. All the prefectures in Jap°n all of the provinces of southern Korea reported cases during the 1945-46 season. The majority of cases in Japan were located in and about the T Oky o-Y ok oh ama area, tho Osaka.- Kobe area, and tho prefectures of Aomori and Hokkaido, a* Clinical Course—-Incubation period is 8 to 12 d-ys after the Rickettsia prowazeki has gained entrance into tho body by way of breaks in the skin or inhalation. Onset is usually sudden with a severe hcad- a,chc and fever. However, it may be proceeded by g( neral malaise, weakness, mild headache and olcva.tcd temperature. During the period of Invasion, there are chills or rigor followed by fever, loss of apuctitc, severe headache, ncuro-muscular pains, and back ache. The temperature rises rapidly es high as 1C2°P to 105°F (38,9° to 4C,6oC), At first there is a relative bradycardia which becomes ur on or t i onal to the fever as illness continues. The fa.ee is flushed. Tho natient is apathetic. There may be a slight dryness of the throat and tongue. The sale on is often palpable and tender. The skin eruption usually appears by the fifth day as round or oval, 1 pink erythema/t ous macules first in the axillary areas and the "base of the neck. The chest, hack, and abdomen become involved and the eruption may spread to the extremities. In severe cases, it may become hemorrhagic. At this time there is usually a cough which is loose. Rales that arc sibilant and sonorous arc often present over both lungs. The conductive arc injected. The tongue is dry, cea.tcd, and fissured. Deafness is a frequent complaint. During the second week the fever remains high but irregular. In the seriously ill the pulse rate rises in proportion. The pulse is poor in quality. The blood pressure may dr on sharply. Incoherence, dclcrium, or coma may develop, (in fatal cases such conditions may be- come worse with muscular twitching, dehydr-tion, and incontinence of urine and foccs). After 10-12 days there is a marked remission of the temperature. It returns ranidly to normal during the end of the second week and in the third week. The signs of mental confusion, deafness, etc., clear rapidly. The general weakness 'Aay pars 1st for weeks. In fatal eases death probably occurs from neurological involvement although azotemia and pneumonia may be the important factors, h, C omul i cat ions:—Secondary bacterial bronchopneumonia, parotitis, otitis media, gangrene of the extremities (toes), and pressure sores arc the chief complications, c. Diagnosis:— ' ’ • (1) Differentiation— A tentative diagnosis (suspect ease) i.<. based on the clinical picture. Louse-borne typhus must be dlfforentiated,.:from murine typhus, scrub tyihus, tynhoid fever, relapsing fever, malaria and small pox, (2) Serological Differentialion; 1 Wcil-Folix Comulonent Fixation j OX-19 ; OX-2 OX-K Lousg Mur ino i Lousc-borne tjmhus i ■ . XXX X - XXX - Murine Typhus XXX X - - xxx Scrub Tyuhus ~ * *~ . 1 xxx ; - i (a) ¥oil-Pcli.x reaction is used to show the presence of agglutinins in rising titer for protcus OX-19 in serum taken from the patient as soon as the disease is susnoctod and 2 to 5 day intervals until the diagnosis is established. 2 Complement fixing anti-bodies usually appear after - the second week, A highly purified specific anti- gen makes the test very specific. This tost is necessary to differentiate he tv; eon cases of epidemic typhus and murine typhus and in previously vac- cinated individuals, (3) Animal Inoculations 30 cc of whole "blood is withdrawn in early febrile period. Separate the scrum and grind the clot. Suspend the material in 10 cc of normal saline and inoculate 2 male guinea pigs with 5 cc each of the suspension intraperitoncally. The temperature of the animals should rise on 12th day. Pass 10$ brain suspension on 3rd febrile day to two male guinea pigs using 1 cc suspension intraperitoneally. The temperature should rise in 6-7 days. In rats typically there is no febrile reaction to louse-borne strains of typhus. In contract to murine typhus, louse-borne typhus seldom produces a scrotal reaction in guinea pigs or rats. Whether there is a febrile or scrotal reaction or not, the animals blood-should be checked for specific antibodies hy the complement fixation tost, d, prognosisi— The fatality ranges from 10$ to 60$, Some factors axe ago, sex, state of nutrition, and presence of partial immunity. The fatality rate is high above the ago of 40 and low in children. Neuro- logical symptoms of increasing severity, spreading eruption, elevated pulse rate, hypotosion, oliguria, and development of bacterial penumonia indicate poor prognosis. Death rarely occurs before 10th day; usually between 14th and 18th days. c. Treatment; — (l.) Symptomatic and supportive (a) Good nursing care and appropriate supportive therapy. (b) Maintenance of adequate fluid intake (2,000-3,000 daily' (c) High caloric diet with high or tcin intake, (d) Preferable to use penicillin instead of sulfa, drugs for treatment of bacterial complications, (2) Para-amino benzoic acid is given in initial doses of 4 to 8 gm. and maintenance doses every 2 hours (usually 2 gins.) arc given to keep the concentration in the blood between 10 and 20 mg. per 100 cc, The drug is given until the patient’s temperature returns to normal or below. s When-..given qarly' this medication tend? to shorten . , the course, ' amelipra.te the- symptoms, and decrease the f at al i ty r at o , ,.1 The drug is np-t standardized end is not available for general clinical use,,at present. f• Immunity:— Infection -confers substantial immunity against the disease, but instances of seepnd and even third attacks have been reported, g. Vaccination:—The chances of, infection arc greatly reduced by vaccination, llo proven deaths have occurred in individuals completely vaccinated prior to their infection. The clinical course is much-less severe and the duration shortened to such a degree that many cases arc >erroneously diagnosed as murine typhus, h* Pathology: — Gross pathological changes arc not distinctive. The rash is usually evident because of.its pcctcchial character. Skin necroses or gangrene arc occasionally found. There may bo symmetrical gangrene of the skin covering the extremities, i,e,, blood is usually dark in color. The spleen is slightly enlarged before the second week but tends toward' normal size later. Microscenic ally there are perivascular infiltrations about artcroiolcs, small arteries, venules, and small yelps. Focal infil- trations, when they arc sharnly demarcated- and arc proliferative, form Fracnkol’s 11 typhus nodules” in the skin and brain (cortex, pons, medulla., and basal ganglia). Thrombosis in small vessels and subsequent hommorhagic manifcstations cause the pctcchiac. Thrombi are.rare in largo blood vessels. Myocarditis in the acute phase of the disease is indicated by> infiltration of the myocardium. There is atrophy of tostieulAx' ttlmlcs and interstitial orchitis is usually present. i, Etiology and Transmission (1) Causal agent is Pickettsia. an intracellular parasite found in the circulating blood during the active stage .of the disease. At autopsy they may be found in the brain, spleen, bone marrow, etc. Staining with Giemsa gives the organism' purplish tint; Machiavcllo (basic fuchsin) stains reddish. The organisms may bo cultivated in the yolk sac of fertile hens eggs or the lungs of mice, Male guinea, pigs arc suitable laboratory animals. (2) Transmission is accomplished .through infective excrement from human lice (possibly fleas and bed bugs) rubbed into skin abrasions or inhaled particles of this material. The species af lice involved in the order of importance are: Pedicuius humanus van, c orpar 1s (body louse)} 4 Pedicuius hum-nus otitis (head louse): Pthlrius nub is (cr ab 1 ous c), (a) Life History of the body louse. Lice nor no Ujf in- habit the under surfaces of clothing next to the skin. In hcavy infestations they may be found in the outer layers. The fen-ole deposits 3 to 5 eggs daily for 2 to 24 days, Eggs hatch in 7 to 10 days, Mynahs uass through three stages reaching maturity in 14 to 16 days. Mating occurs in 2 to 4 days and egg deposition 2 to 4 days later. The average life of a normal louse is 30 days, Life of infected lice nay be shortened. The louse be- comes infected only by feeding on infectious blood and becomes infective in 8 to 10 days following an infectious blood meal. Lack of blood meals is fatal to adult lice in about nine days, Newly hatched lice die in 2 days without feedings, & similar history is true for head lice and crab lice. j. Hoidcmiolo.ao Occurrence is chiefly between the months of October and late June with the peak in May or June although occasional eases may occur the year round. In 1946 the peak was reached in late March in Japan. The reservoir is still unknown for the interepidemic uoriod; occasional eases, mild, unreported c»sqb or unrecognized eases may bo responsible. Predisposing factors are those which tend toward an increase in lousiness and an accelerated distribution of lice from person to person. Colder weather causes close crowding of the papulation and the wearing of more and heavier clothing. Often the individual wears all of his clothes all the time because they pro all ho noGsosscs, Lowered standards of sanitation and personal hygiene, the mass movement of troops, refugees, repatriates, and the general uonulaco during ■eost-w'ur periods, particularly play major roles in creating ideal conditions for the arnea,ranee of an epidemic, k. Prophylaxis and Control The ground work which is laid prior to the tyohus season is of the greatest importance and when carefully -planned and executed, will result in effective control and eventual eradication of the disease, (1) Procedures -npdor to the tyohus season (a) American t.vuhus control officers arc from the U, S, Military Government Teams and arc in overall super- vision of tyohus control operations. 5 (b) Civilian typhus., control of floors; Civilian public health officials with sound edu- cational .background, judgement and experience in public health administration should be selected and designated as typhus control officers in each prefecture (japan) or province (Korea) and city, teicy should be relieved of all other unrelated , duties. They should be- given full authority to .call on such municipal, prefecture! or provincial agencies as arc deemed necessary to carry out their elans effectively. These men should bo trained and restrained by Military Government personnel in methods of typhus control. Instruc- tion should bo given to all men appointed for cities'and for each prefecture or province. These men should bo responsible for training and re- training of all personnel employed for typhus control work; and for publicity and education directed towards the general public; specifically, such groups as: Medical Associations Purses Associations Physicians and Nurses Teachers in Public Schools Block Associations Nc ighborhood As s ociat ions Illiterate and poorer classes of people, (c) Tr ai n in • P r ogr am s: 1, pc or, ‘-nigation and Training of Typhus Cout r ol Teams., Case finding teams, sanit-ry (disinfesting) teams and vaccinating teams should bo re- organized for typhus control work not later than 1 November each year. Notraining of old members and training of now members should be accomplished as early as possible. Retrain- ing of all members at regular intervals of two to throe weeks should bo Planned, All workers of Sanitary Teams and ca.sc finding teams should bo selected from Profoctural In- sect and Rodent Control personnel, Por the • typhus season they are retrained with emphaAis on louse control. Personnel of all teams should be full, time, -salaried workers and should bo, trained in all "liases of tyohus control. If 6 an cpidcnic throa.tons, they can be used as instructors and cadres for othor teams. Suf- ficient transportation for oa.ch toan should bo available and a .surplus naintined if the need bee ones evident, 2, Training of civilian "physicians and nurses. A training program should be designed to ac- quaint physicians and nurses with typhus fever and its control. The no' d for ca' ly ease re- porting and isolation should bo stressed. The meetings should bo conducted by local nodical associations or nurses associations, 3, Training of Block and neighborhood Association Ghiofe (Jap an); Voluntary Service Gr quo Heads (Korea) Such persons should receive training in typhus control procedures and they in turn should in- form the inhabitants under their surveillance, (d) Publicity and Educational Programs Publicity and educational programs on lousc-borno typhus and its control should be instituted in October and continued through May of the following year as part of a well planned nublie health education program, Each prefecture (Japan) and province (Korea) should institute continuous programs designed to carry typhus information into every school and every home through tho agency of information meetings of teachers (parent- toachor associations), radio, newspapers, magazines, posters, leaflets, motion pictures, (i.c,, can animated cartoon or typhus control), slide films, contests in schools, and circulating exhibits. The danger of tyohus should be stressed and people should be told what they as individuals can. do to rid themselves of lice without relying on tho use of DPT alone. Block and Neighborhood Association Chief (Japan), Voluntary Service Group Hoads_(Korea) and Bed Cross Associations should be utilized to the fullest extent in the educational and publicity programs. (c) Distribution of Supplies Marly distribution and maintenance of adequate stocks of typhus control supplies to the eight key points in Japan and to the six points in Korea is essential. 7 Available sup olios a. Insecticide, powder, louse (10$ DDT in pyrophyllito or talcum) I 1. Larvicidc, DDT, powder, dusting (10$ DDT in talcum) .1 _c, Larvicido, DDT, powder, dissolving (100$ DDT) d, Insecticide, spray, residual effect DDT (5$ DDT in kerosene) c_. Pyre thrum emulsion (30X) or 10X) f. Cresolis compound (Liquor crcsolis) g. Duator, powder insecticide, plunger type, hand operated* h. Outfit delousing, gasoline engine driven i_. Sprayer, insect, knapsack type, plunger type, cyl inch"ical shape, Jd Sprayer, liquid, insect, continuous spray. (£) Mo s s Vacc inat i on Ideally all persons should receive an initial two doses of 1 cc each, typhus fascine 7-10 dpys apart, and a ‘booster cose once every six months* If there is insufficient vaccine for this plan, alternate plans arc suggested, dependent on supplies; 1_. Vaccination with 1 cc of all persons living in . the largo abaters of population where typhus was op id ora ic in 194-5 - 1946. 2. Vaccination with 1 cc of oil persons living in a. city "ku" where secondary eases axe occurring. 3. Vaccination with lee of all persons living in a proscribed area ("zone") where secondary eases arc occurring, 4. , Vaccination with 1 cc of all commuters holding season tickets. (in cities, .as Tokyo, Os°ka, etc.) (g) Vfvc c in-11i on of key pc r s onne 1 8 All now porn ons actively engaged in typhus control operations should receive the full course of the vaccine, Former workers to receive a "booster dose of 1 cc vaccine,. Special groups of people, i,c,, nurses, doctors, hosnital and institution personnel, control team members, railway trainmen, street car motornon and con- ductors, nolicemon, etc, should receive the full proscribed course of vaccine and a "booster dose once every six months, (h) Disinfesting of possible typhus foci Soutine disinfestation of all persons entering and leaving Jails, prisons, vagrant homes, orphanages, homes for poor and aged, infectious disease hospitals and similar institutions should be continued on a, year round In addition all persons in these institutions should bo clelouood once each month (more often if lice continue to bo found). Hand dusters, spray equipment, DDT insecticide nowder, residual DDT spray md pyrethrum emulsion should be distributed to each institution. Steam sterilizers or dry heat chambers should be. installed and used in infectious disease hospitals, Jails, public baths, etc, for the disinfection of clothing and bedding. Cells of Jails and prisons, rooms of hospitals, public baths (rooms, baskets, etc,,) should be sprayed with DDT residual effect spray to which is added 2]o (content) crcsolis solution. Use of a rickcttsicidal spray will kill rickcttsiae in louse or flea faces in addition to its insecti- cidal power. If fire hazard is grca.t, Pyrcthrum emulsion (30X or 10.x) plus 26/o crcsolis content, using water as the diluent, may be substituted, (See Picket tsicidal program. Addenda 6) (i) Disinfesting of zonos Although, it would bo hazardous in the year following an epidemic to establish zones for routine monthly dusting on the bmsis of concentration of cases during the previous typhus season, such a plan has advantages. Such zones wore established at Inchon and at Seoul, Korea in 1944 -1945, 9 '(J) Permanent disinfesting stations Disinfecting'stations should he established at health centers end operated on a year round basis, A few stations established near crowded railway stations should bo established to care for migratory •r •people-. Persons would bo free to come to such ■ stations-for delouslng. On entering a disinfesting station, each’person should be examined for presence ■ of lice (’head or body lice) and if found infested, receive a thorough dusting with DDT powder, (k) Distribution of Insecticide powder tc individuals In an effort to encourage personal cleanliness ('’freedom from lice", the "5th freedom") insecticide dusting powders (DDT or pyre thrum) could be dis- tributed through the health centers to each in- dividual or family living in a ku, particularly those kus where great numbers of. typhus causes have occurred, (l) Typhus Control Teams--(Organization and general duties) ,1. Case Pinning- Teams - ("Checking" and Roving" teams) Working from-s-Ku (ward) office, henku (school district) office, city health office, town health office, village health office, Health Centers, etc, a. Organization Doctor 1 In charge Nurses, 2 Assistant to doctor, vaccination work, take temperatures. Workers 2■ Disinfestation work b, Duties. Intensive and extensive case finding (hunting) by "r oving" tc ams. Investigate all reported suspect typhus cases by "checking" teams. Visit all persons in the neighborhood in an a,ttempt to locate now suspects jrho ma$r have ■ boon contacts of reported cases. Vaccinate all family or household contacts of cpsos with 1 cc typhus vaccine, Take tcnmoralur es of contacts. Disinfest all family or household contacts as well ps potlent or corpse. (Clothing, extra clothing, hods, bedding, floors in- cluded in due ting procedures,) Mark house or building to indicate that it is disinfested and quarantined. Direct that quarantine of house or building must be done within 6-8 hours following discovery of ease. hesnonsible for expeditious removal of all susTocct typhus eases to an isolation hospital within 6-8 hours after discovery of ease. Reporting of suspect cases, cases or corpses within 2 hours after discovery. Instruct members of household as to early symptoms and not to bathe or wash clothing for three days, 2. Sanitary (disinfecting) toxins a, Organicati on Leader 1 In charge, inspects work, in change of surmlies Clerk and Inspector 1 keeps records, inspects work, assists in work. Workers 4 Performs dusting and spraying, Tq. Duties Arrange itinerary of work based on reported eases. Responsible for performance of focal dusting, zonal dusting, focal spraying, and zonal spraying and marking of homes processed. Reporting of any new suspects or new causes found by team members and execution of dis- infesting -orocodures in such instances. 11 Give disinfesting instructions for family - absentees to-report for dusting one. vac- cinations at leu (ward) or Ronku office by noon of following dry. Instruct persons not to bathe or wash clothing for three days, 2d Vaccination terms a. Organization Doctor 1 In charge Purses 2-4 Perform vaccination techniques. Tq, Duties Ob train addresses of reported suspect typhus CpGGS. Responsible for focal and/or zonal vaccination. Responsible for vaccination of special groins; prisoners, policemen, nurses, doctors, in- mates of institutions (orphanages, vagrant homes, old people*s homes), railway employees, street (tram) car employees, bus drivers, etc. Responsible for prompt reporting of any new suspect eases of.typhus discovered by rep rted t- team members, ' r, / 4, Suggestod Aciditional Sanitrv (disinfesting) teams a. Central Health Office Sanit ary (disinfesting) To am. Organization D ct r or Nurse - 1 in charge of team Inspector - 1 inspects work, keeps records, etc, Workers - 4 perform disinfesting techniques, ' a Duties Assist in focal and zonal operations if necessary Perform disinfesting operations for special groups, i,c,, routine •' is infos ting of migrants in railway stations, (work to bo done at night) etc. 12 b. Disinfcsting Station Teams Organisation Dect r or Purse 1 in charge (examines clients far lice) Inspector 1 inspects work, keeps records, and helps, examine clients for lice, etc.) Workers 2 to 10 (dependent upon the size of the station) per- form dusting techniques. Duties Pofform disinfesting operations in special disinfesting stations. Doctor or nurse responsible for operation of station and work done. Also responsible for screening out of suspect typhus cases. Inspectors examine persons reporting for treatment for presence of lice. Disinfesting technicians responsible for application of dust to clothing and heads of persons sent to them by inspectors. Instruct persons, DDT’d not to bathe or wash clothes for throe days, c_. Special Disinfesting or small groups of trained personnel. Organization Nurse's or trained personnel from staff of: Ku-office, Ecnku, Village town, etc., health office. Jails and prisons . Hospitals Orphanages Poor Farms Vagrant Homes Dormitories Other institutions of various sorts. Duty \ To perform disinfcoting procedures within their particular offices or institutions. 13 ■ Disinfesting 'tlio absentees from tho focal or zonal dusting procedures. Routine disinfesting of the inmates (if any) Routine disinfosting of incoming and outgoing - •J ■ patients, prisonerst orphans, etc. (2) Procedures when outbreaks of typhus occur. (a) General When cases of typhus occur, the following control measures should he instituted. Such measures should he modified in accordance with the needs of the local situation* Control mo a,sure s should he directed towards two general methods - l) louse control and eradication of infected lice, 2) the development of active immunity "by the use of typhus vaccine. The use of either or both of these methods requires Judgement and adaptation of the measures outlined below to suit tho Problem at hand. In general disinfestation with insecticide powder.and spray is a simple pro- cedure but a relatively temporary measure. The chief asset of immunization is its ,fholding4’power. Inoculation with typhus vaccine should therefore be practiced to tho fullest extent possible under existing local conditions and availability of vac, c inc supply, (b) Definition of Terms 1* Suspect case of typhus fever: any Person with elevated temperature and headache of sudden or gradual onset. If tho case is known to be suffering from some other cause (boils, severe cold, pneumonia, broken log or arm, or oth r definitely recognizable disease) such a case need not be considered a suspect. 2. Confirmed case' of typhus fever: a case in whom tho Woil-Polix tests, complement-fixation tests, rickettsial agglutination tests, or autopsy findings support the clinical diagnosis. Con- firmation is done after the patient been isolated in the hospital (not in the home) 14 3, Focal Disinfesting; the application of 10‘jo DOT dust to Persons living in the homes of the suspect case and not over 50C persons in an area of ICO motors radius. Those 500 will ho those persons living next to and around the case. Whore 500 or loss persons live within 100 motors of the case, then all persons will he dusted in their homes. Do not dust out- side 100 motor radius of the ca.se for focal disinfesting, 4, Zonal Disinfesting; the application of 10;1 DDT dust to persons living in designated areas where several cases have occurred in close proximity to each other in location and time. The size of a zone may vary from one block to »n area, with a, population of 30,000 - 50,000 or more persons. (A 6 m?n sanitary disinfesting team should he able to thoroughly dust 2000 - 3000 persons in a 5 day period). Disinfesting work is done in the homes and should he carried out simultaneously in all zones. 5, Focgl Vaccination; the administration of 1 cc of cox-type typhus vaccine, to persons living in the homo of the suspect case and to the 500 Persons dusted in the 100 meter radius. Available amounts of vaccine will he a, limiting factor. 6_. Zonal Vaccination; the administration of 1 cc of cox-type typhus vaccine to all persons living in the designated ”zone”, 7. Spot m°ps; large maps on which reported suspect cases can he aecurately located. Maps of each ku (ward), city, and village should he utilized where typhus occurs. The maps help in judging the concentration of cases, and help to more correctly evaluate where more intensive and effective work must he done. (c) Operation of typhus control plan. 1. When case is reported personally; a. A person with elevated temperature and headache; 15 Reports to; (any one of the foil wing) Doctor Hearost Policeman Chief of his dormitory, shop, factory . Family head. Local-Health Office Ku (ward) Village, Town. Chief of block or neighborhood associa- tion Bed Cross Represen- tative, Health Center (nearest) 2, When case is disc avere.d. by,; (any one of the follov/ing) Family head Loctor Chief of block or Polio oman End Cross Representative Chief of his dormitory, shop or factory I (When discovered by any of the above, the infor- mation is transmitted directly to the proper henith office. or is sent through a doctor, policemen, messenger or phone at once.) 3, When the case is reported to the local health office by any person, neighborhood or block association chiefs, policeman, doctor, visiting . nurse or Bod Cross representative: a. Local Health Office; (Procedure) Immodiately uispatches the local office casc-f indin a* team (s) to the address or drosses of 11 suspect” c°scs. Case-finding team (s) institutes measures as listed in 4. Spots case on large scale map of area Eeports Gase(s) to city health office Decides if Zonal disinfesting is necessary Lispatehes Sanitary (disinfesting) teams(s) to the addresses of suspect tyohus cases. They perform the follov/ing duties: Complete any disinfesting op or ations in the homo of the patient not done by the case finding team. 16 Pcrf or ms Focal disinfesting procedures in the neighborhood of the ease. House to House work Head, body and clothing of all norsons living in each house to he thoroughly dusted with 10$ DDT powder (l-g- - 2 oz/ person) Extra clothing, and bedding dusted with 1C$ DDT powder. Focal disinfesting to ho done same day as the case is reported, Hepoat disinfesting in 7 and 14 days. Performs Zonal disinfesting procedures if concentration of cases (secondary cases) appear (for size of zone see definition of 2one in Zonal Disinfesting) House to House work Head, body and clothing of all persons living in each house to be thoroughly dusted with 10$ DDT powder. Extra clothing and bedding to bo dusted with 10$ DDT powder. Disinfestation of Zone to bo completed in 5 days. FiCpo.at disinfesting in 7 and 14 days, -Dispatches va.c c inn t i on to am ( s) to the address of the suspect typhus ca.sc, b. Vaccination toam(s) perform the following duties: Vaccinate any person not vaccinated in the homo of the patient by the case-finding team. Perform Focal Vaccination procedures on all persons living in the neighborhood of the with 1 cc typhus vaccine (500 persons depending on the concentration of population and the availability of the vaccine) Performs Zone! vaccination -procedures if p concentration of cases develops. Zonal vpccination with 1 cc typhus vaccine to ho done only on direction. Size of zone to he .as in definition of Zone for Zonal delousing. 4. When p. co.se is reported into any health office hy the roving case-team (team in the field), this team initiates the following option at the homo of the patient. a. Doctor Examines the patient, and classifies the patient a s a typhus suspect or not. He docs not diagnose the case as typhus. Orders isola11 on of the patient (if suspect). Orders quarantine of the family of the suspect for 14 days. Reports suspect case within 2 hours after discovery to the nearest local health office hy messenger or phono, h. purses Lists family names. Requires family to have any absentees report'to the local health office hy noon of the following day for processing. Questions patient, and household members, and neighbors as to possible source of infection. Secures names of possible con- tacts (relatives, visitors, etc.) Takes temperatures of the family members. Organizes and performs vaccination with 1 cc typhus vaccine of all members of the family and/or household. 18 c, Workers Arely dust (DDT 10$ powder) to; Patient: head, clothing, "bedding, and his extra clothing, (patient should ho transferred to clean clothing and "bedding whore possible). Family members; head, clothing, extra clothing (especially that clothing which is worn at odd times), extra bedding. Floors of house, particularly around the bed of the patient. Apply spray (pyrethrum emulsion in wafer plus 2 to 3fo crcsolis content) to: Floors, bedding of patient, clothes of patient. Apply the spray to inside of garments, along the seams of bedding, (DDT spray, residual effect may bo used if the fire hazard is not considered to be too great.) Note; In some localities there are disinfection teams for the disinfection ana isolation of contagious disease coses. These can bo utilized in the above program by changing the solution used in spraying from their present 3$ lysol or crcsolis content in water to a 3$ lysol or crcsolis content in either pyrethrum emulsion in water or DDT spray, residual effect. This will relievo the case finding team of additional equipment and avoid duplication of work, (d) Typhus Control in Bur al Areas, smaller towns, dab or camps, etc. 1_, General principles a. When one or more cages of typhus fever occur in a civilian community of less than 1000_ (and not more than 5000) population; 19 Isolate paticnt(s) Quarantine household 14 drays. Disinfect every individual. If possible, vaccinate everyone living in the community us in; one close technique of 1 cc. (Full Prescribed course of vaccine if possible). Disinfest all Patients and known contacts with 10DDT insecticide powder and treat the homes with either DDT residual effect spray ■nlus 2 to 3$ crcsolis content, or pyre thrum emulsion ulus 2 to 3-t crcsolis in the final dilution where the fire hazard is great, Repeat disinfesting operations in ? and 14 days. Vaccinpto all family or household contacts (two 1 cc doses one week apart) Apply ,,foc»ln disinfesting and vaccination procedures. Disinfesting work is to be done house to house, h,. When typhus appears in towns above 5000 population and in citios. a complete typhus control program should be established as outlined, but modified to fit the existing 1 ocal situa,tion. c_, If typhus fever eases appear in labor camos. camps of displaced persons and refugees, dormitories, barracks, etc., the following applies; Disinfest all inmates, staff personnel and attendants, their extra clothing, bedding. Vaccinate all inmates, staff personnel and attendants with full course of typhus vaccine. Use residual effect spray and crcsolis 2$ content and/or pyrethrum emulsion spray and 20 c res oils 2j content on the floors, halls, store-rooms, kitchens, etc., outlined in BICKDTTSICIDAL- SPEAY PROGRAM (see addend? 6) Quarantine of such camus and institutions should he imposed for 14 days after of the last case, necessary regulations should he issued preventing unnecessary civilian travel into or out of such areas until tyuhus has heon controlled. (o) Port Quarantine Procduros (See Memorandum Per; Imperial Japanese Government, AG- 014.33 (5 llov 46)GG, (SOAP HI 927/10) APO 500, dated 5 November 1946, Subject: Repatriation. (f) Pr oner ca.ro of Pisinfesting Equipment Responsible men with mechanical skill should he trained in the proper use of the gasoline driven outfit and charged with res onsihility of proper maintenance of the machine an:.-dusting heads. On Sanitary (disinfesting) teams, some one person should he responsible for conditioning of the hand ....ustors and spray equipment, 1_, Outfit, Dolousinp, gasoline orpine driven. a, Clean oqulomcnt after each day’s operation. h. Clean all air filters after each day’s operation, cy Onorato engine in omen a.way from dust if possible. d, When available, use accessory outfits alternately to relieve the load on any one outfit. o. Use proper pra.de lubricating oil (S.A.E, - 20) :f, Clean and oil centrol valve on dusting heads. 21 2_. Hand dust or s a, Clean the inside of the pump each day. b, Clean and oil the leather plunger after e ach day ’ s on c r ~ t i on. c_. Exercise care so as not to dent the cylinder pump walls, 3_. Spray equipment a. Clean spray nozzle. b. Tighten hose clamps, _c. Clean screen filters, d, General maintenance. 2. MURIKB (BLEA-DOHHE) TYPHUS; Manchurian Bcvcr. a. General Murine typhus is an acute infectious febrile disease caused by Rickettsia. pr pja zeki, var, nooserit usually characterized by sudden onset of severe headache, chills, and fever that is continuous for 12 to 14 days, A roseate, macular, exanthematous rash appears about the 5th day. The disease is relatively mild and has a. low mortality as compared to louse-borne typhus and scrub typhus. Unfortunately, in Japan, statistics prior to 1945-1946 do not ■istinguish between epidemic and murine typhus. The general belief is that most of the sporadic cases reported from 1923 to 1945 were cases of murine typhus. Those cases occurred in the prefectures of Akita, Aomori, Hyogo, Iwatc, Tokyo-To, Y°mayata, Osaka, and Yamaguchi, Un- doubtedly this disease could bo found in nearly all prefectures of Japan. The disease is also present in southern Korea. b. Clinical Course. The disease may start gradually after an incubation period of 4 to 14 days with irregular development of symptoms, the temperature rising stop by step. Usually the onset is abrupt. In general, the clinical course is similar to that of louse-borne typhus, but the disease pursues a comparatively mild course. Complications «ro rare nnd the mortality low,n During invasion the temperature rises to 38,5° 0 to 40,0 G (101,2 B to 104,0 7 B) in 3 to 6 days, and terminates in rapid lysis about the 14th day. The mental condition is much less altered than in louse-borne typhus. Delirium is almost wholly lacking. The 22 most characteristic finding is the rash which about tho 5th day. This rash characteristically consists of rose or dark red macules which fauo into the surrounding areas and do not disappear on pressure,. Tho eruption is less extensive and potechiae are loss common than in louse- borne typhus. Tho exanthem may last from 2 to 10 e.oys disappearing rapidly. Recovery is usually by tho 16th day when tho temperature has returned to normal. Convalescence to complete recovery varies from 2 to 4 weeks after normal temperature has been reache. , c. Complications are usually few. A bacterial pneumonia is most common, d. Prognosis is usually good. 0• Diagnosis; (1) Differential )n; requires differentiation from louse- borne typhus, scrub typhus, relapsing fever, typhoid fever, malaria, an'1 Weil’s disease. (2) Serological Differontiation; ! .’/o il-Folix Complement Fixation ■OX-19 i OX-2 OX-K Louse Murine L ou s c -b or no Typhus XXX X - 1 XXX _ .. Murine Typhus 1 ' 1 XXX I X - 1 i _ Scrub Typhus ! - i - 1 - - (a) The Wnil-ffolix a, glut inati on rotation us in;-; Proteus CX-19 is positive after the 6th day of tho disease. (b) Comp1ement-fixati ■n and specific rickettsial agglutination vising highly purified murine antigens are tho most reliable procedures,. •These antibodies begin to appear after tho second week of the disease, (3) Animal Inoculation; Inoculation of guinea pigs with infectious material from suspected murine typhus cases produces an obvious scrotal rea.ction. However, such a reaction has boon noted in guinea, pigs inocula.tcd with material from known louse-borne ca.ses. Murine typhus produces a febrile disease in laboratory rats 23 with presence of rickottsia. in the scrotal sac. f. Treatment is symptomatic and supportive such as that in louse-borne typhus. g. Immunity is usually produced by one attack. It is possible that second infections may occur. Some cross immunity is given to louse- borne typhus, h. Vaccination is possible but not usually done because of the clinical mildness of the disease and the low mortality rate- A vaccine has been developed and is undergoing a field trial in the U, S,. i. Pathology is similar to the pathology of louse-borne typhus but usually loss marked. j . Etiology anm transmission; (1) Causal '-'/cent is Rickettsia prowazeki vsr, moosorif ?n intracellular organism mPrphologic»lly snr:. possibly (at tines) i maun el o,; jically indistinguishable from Rickettsia pr ~wazaki of louse-1) or no typhus. Considcr- ahlo hut incomplete cr )ss immunity, may exist hetween the two infections. (2) Transmission is accomplished from rodent to rodent and from rodent t man chi ’fly hy rat fleas, Xenonsy11a choopis and Xcnopsylla. astia and to a, lesser extent by the rat louse, Polypi.ax spinulosfa and the tropical mite, Liponyssus bacrtl. These ecto-parasitos become infected by ingestion of blood from infected rodent hosts. Human lico are capable of acquiring the infection, but die in 10-11 days as a result of feeding on in- fectious blood. In the flea, the organisms multiply in the epithelial colls of the nidgvit. In 10-12 d'-ys they escape into the lumen of the gut and are discharged with the feces. They may remain viable for at least 36 days. Man becomes infected, net through the ’’bite" of the flea, but from infective, flea ex- crement rubbed into skin abrasions, or through the conjunctivas, or by inhalation of this material or by accidental ingestion of infected fleas. (a) Life History of Pl^- Vcc tor; In general the life history of the flea is similar with few exceptions. The eggs are comparatively large, (0,5 mm long) glistening white and rounded at bxth ends. The 24 female deposits fr in 3 to 18 eggs at one laying, on the host animal or in the nestis of their hosts* Under optimum conditions of 18,3 C to 26.7 0 (65 F to 80° F) and 70;'o humidity) the eggs hot eh in from 2 to 12 days, The »ro very a.ctivc, slender, 13 segmented, yellowish, white with sogmontally nr rented bristles with "biting mouth p»rts, They feed on fo.eeos of adult floes end dried "blood chiefly. The lory no ns n rule pnss • through 3 developmentel stages, and the entire larval period ranges fr on 9 to 15 days under natural conditions. The larvae then become quiescent, suins a cocoon, and pupate, The pupal stage varies from 18 days to m«ny months before the adult emerges, Longevity of the adult fleas is quite remarkable. Under natural conditions adults may live long Qs 375 days (X. choopis). The average length of life rang, s from 30-50 mays. The rat fleas show no evidence of disease mue to H. urowazekl infection, k. Up i domi ology: Cases hT murine typhus nre typically sporadic and arc known to occur during the louse-borne tynhus season and probably through the year. In many parts of the world the disease is more prevalent in the summer and fall months. This corresponds to the peak of density of the flea population, murine typhus is most commonly found among workers on docks, grain elevators, etc. The incidence is the highest among males. The rat is the common reservoir host, but other rodents may play a role, 1 • Frophy 1 a,xis and Control (1) Pr ophy1axis Control of murine typhus fever in a civilian population is based up ~>n the promise that the typhus infected fleas are the primary .agent in the transmission of the disease to man with rodents a.s reservoir animals of the infection. Hecent experiments indicate that the use of DDT dusts and sprays ar.. effective in the control of floats and when used as auxiliary measures with the fundamentals of rat control, an effective control of murine typhus should be a.ccomplishod, 25 (2) Control Mothoos (a) Tho procedures ns outlined for the control of louse-lor no typhus will apply to a great extent, since each suspect tynhus case must he considered as possible louse-borne typhus and must he dealt with accoreingly. 1,. Case Finding Teams. No change should ho nade in tho general duties and operation of cose finding teams. 2, Va.ee inati on tpaus . No change should he made in tho general duties and operation of tho vaccination trams. (Vac- cination against louse-borne tynhus. No murine tynhus vaccine is available in this theater.) 3. Sanitary (disinfosting) tcams p. on Leader 1 Inspector and clerk 1 Norders 4 h. Duties Flea_ control_ Sanitary teams should perform their regular duties as outlined for louse typhus control. Additional sanitary teams should he used to carry out a detailed r xlont control pro- gran (see Insect and Hodont Control), Consider all suspect of tynhus as possible cases of 1 ouso-h orne typhus. Npjea 1 disinfestation (see definition of " f oc a 1 i i s i rife s t at i an*1) 26- In addition to regular disinfnatation, duties: Applicati on of ICoo DDT dug t to; Rat “burrows Area in front of openings to rat "burrowa Eat harborages (W.rk to "bo done in and around all ‘buildings in focal area. "Dust nay be applied with' hand or lower dusters). Gats and dogs. (Dust fur lightly) Infested areas and grassy lawns may he successfully treated with DDT dust. Application„pf 5,o DDT spray, residual effect to; Floors of hulldings. Wall surfaces to a heighth of one meter above the floor. Use at rate of 1 liter per 25 sq’. meters of surfa.ee. Earthen floors and underneath buildings dosage should he increased to 2 liters nor 25 sq. meters of surface. Beds (if any), mattresses 11 futon", etc. Apply spray directly to surfaces and’ into cracks and crevices in beds and '•'■long seams of bedding and seams and tufts of mattresses. Use at the rate of 1 liter for each 5 beds and mattresses or equivalent-. Flea, breed! ng and fie a harboring areas , sleeping quarters of animals, (cats, dogs) infested barracks, warehouses, theaters, . recreation halls, restaurants, railway stations, basements, houses, dormitories, vagrant homes, dog kennels, ground under building’s, railway cars, street cars, buses, public bath houses, etc. Zonal disinfostatq.on (if necessary) (see definition of 11 z onal" dr lousing) 27 Disinfesta.tion procedures _at Japanese and Korean ports of entry and dob arka.tion. ( see Mom or and urn F or: Imp or i al J ap anc sc Government, AG 014,33 (5 Nov 46)GC, (SOAPIN 927/10) APO 500, dated 5 November 1946, subject, Repatriation, Rodent Control (See section on Insect and Rodent Control) GROUP II - TSUTSUGAMUSHI Fi-YTE. GROUP 1. General Scrub Typhus ■ (larval nito ’borne) Japanese Flood (Rivrr) Fever Enrol Typhus (S. F, As ip.) Islond Fever (South Pacific) Tsutsu.'pnushi fov* r (disease nito fever) Kodani Fever (Hairy Mite fever) Akunushi Fever (Rod mite fever) Shimamushi fever (striped nito fever) Yochubio (nito disease or fever) Shashitsu (sand nito ache or fever) Scrub typhus is an acute infectious eisoa.se caused by Eickcttsia, or lent alls, usually characterized by the appearance of a 11 pr in ary” eschar at the site of the nito1 s bite, sudden onset of headache, sudden fever which is continuous for 12 to 14 days and ends by rapid lysis, and the appearance' of a macular exanthematous rash on the 5th to 7th day, Akita and Niigata prefectures aro the only areas involved in Japan as far as' is known. Korea also hap affected areas in the southern half. 2• Clinical Course The bite of the nito may occur anywhere on the body but is most co non on the nock, in the axillae and -toins, and in other locations where the course of the mite is impeded by constrictions of clothinj, such as collar lino, belt line, tap of shoe's or .boots, etc. Following the bite, incubation takes Place in 4 to 16 days, Turin,-: the period of incubation a small papule develops which becomes encrusted. .By the time of onset of symptoms the ’’primary lesion” is usually a, black eschar 2 to 10 mm, in diameter. Onset is usually sudden and lacks prodromal symptoms. Occasional cases have -malaise, anorexia, headache, dizziness, nausea and phot opsia, (However, persons bitten by 28 an uninfected mite may complain of similar symptoms, "but these subside in 2 - 3 days). Sudden fever is the usual onset, 1 rises step-wise for the first four to six days, until it reaches 38.9 1 C - 40.6° 0 (102 F - 105' F) end then'may he remittent for 10 to 14 days. General malaise, headache of increasing severity and sudden chills are characteristic. Conjunctivac are injected. Often restlessness, cough and delerium de- velop rapidly. General lymphadonopathy with tenderness appears early, especially of the regional lymph nodes draining the ’’primary" lesion. Less commonly slight xanthopsia, tinnitis, slight deafness, dizziness, Joint pa.ins and op is taxis are present. The pulse rate is slow and regular as a rule. From the third to seventh day discrete a rasphorry-red macular exanthem appears. Often the rash is not marked and may escape notice altogether, Alien the r-ash is apparent, it may spread from the trunk to the upper parts of the extremities. Seldom docs it involve the hands, feet or face, Enanthem may appear on the soft palate and is not petechial. The rash may he of short duration. Signs of pneumonitis are almost always found. Congestion of the nasal, mucosa may ho present. Spleen is enlarged and tender during the first week. Toward the end of the second week and during the third week after the onset of headache and fever, the temperature begins to fall rcmittently and. intermittently to normal. Mild cases arc able to resume normal activi- ties in four to six weeks after their temperature returns to normal, 3. Complications Pneumonia (secondary), gangrenous atorna.titis, suppurative lymph- adenitis, and cystitis arc more frequent complications, 4, Pi agnosis a. Differentiation In the early stage scrub typhus must be differentiated from "''laguc, louse-borne and murine typhus, dengue, malaria and infectious hepatitis which nay be in the same areas. The limited geographical distribution should reduce the error in making a tentative diagnosis. Gf great help is th>e presence of the characteristic necrotic ulcer (eschar) with its regional lymphadenopathy. b. Serological Differentiation 29 Woil-Folix Complement-Fixation OX-19 OX-2 I OX-K Louse Murine Louse-borne typhus- _ ■ 1 '■ XXX Murine tyohus XXX ’ x j ‘ - I - j' XXX Scrub tyohus L ; i . ■ . XXX I i i , I . . (1) Weil Felix reaction is nsec!, to show agglutinins in rising titre for protons CX-K in scrum taken from scrub typhus patient as soon a,s the disease is sus- • ■peetod and at 2 to 5 day intervals until the diagnosis is demonstrated by a rising titre, Tho'peak titre is usually reached during the third week and is followed by a rapid decline to negative within several weeks, v,. A titre of l/l60 is significant if only one result is available, (2) No sa.tiafactory complement fixation test has been devised as yet. c. Animal inoculation; The blood clot from a specimen taken from a patient is ground with saline, centrifuged at lev; speed and 0.3 cc of the supernatant fluid injected via I,P. route into white mice. Infected nice die in 10-16 days. Smears of scrapings from the serous membrane of the peritoneal cavity and of the spleen will show the causalivc Rickettsia when fixed with methyl alcohol and stained wiih G-eimsa* 5. Prognosis Signs which in combination may indicate a poor prognosis arc; a. Increa.sc in pulse ra.te out of proportion to the temperature rise; b. Onset of muscular twitchings, convulsions and coma; c. Increasing leukocytosis with a relative and absolute decrease in lymphocytes, ' Case fatality rate in Japan varies from 15 to SOy. The higher rate occurs in persons beyond 30 years of ago. Ago, physical condition, stage of disease on institution of hospitoi care, and coexistence of other diseases arc foetus to bo considered. Other of the Pacific report a lower fatality rote. This may bo duo to a. milder strahn or confusion of murine and scrub typhus in areas where both diseases occur. 6• Treatnent a, Symptomatic and sun-portive t (1) Good nursing Care and appropriate supportive therapy, (2) Maintenance of adequate fluid intake (2000 to 3000 cc daily.) (3) High caloric diet with high -protein diet. (l) Preferable to use penicillin instead of sulfa drugs for treatment of bacterial complications. b. The results of experiments in the laboratory with susceptible animals indicates that -the sodium salt of para-amino-bonzoic acid may have beneficial therapeutic action in ocrub typhus. Results of field trials conducted in Burma with this compound in patients are promising. 7, Immunity Some immunity is conferred by one attack, but second attacks arc not uncommon and arc relatively mild. 8. Vaccination Ho suitable vaccine has boon available. Intensive research on the preparation of a scrub typhus vaccine is being carried out in the U. S. A, Laboratory results arc promising. 9• Pathology The gross anatomic changes arc not striking. The lymph nodes arc enlarged and, in the drainage area, of the ’’primary” lesion, may show great enlargement as well as irregular areas of necrosis'. The heart is often pale and flabby, Pocal hemorrhagic mottling duo to extravasation of blood is seen in the lungs, often with interstitial pneumonitis. The liver is always congested and the spleen enlarged. The brain may show multiple punctate hemorrhages. Microsc epic ly the section of the primary lesion consists of a necrotic cutaneous lesion with thrombosis of vessels limited to the narcotic zone. Basically the disease is characterized by a disseminated, focal vasculitis and perivasculitis of the smaller blood vessels of the skin, lungs, heart and brain. The predominating coll is a, largo basophilic macrophage. The most striking lesion is found in the heart. It is a diffuse, interstitial myocarditis characterized by many largo basophilic mononuclear colls. In the lungs a rickettsial pneumonia (interstitial) is found. Sections of lynch nodes from drainage areas show largo foci of necrosis. Kidney sections show changes of acute glomrrule-nephritis, Brain lesions vary from perivascular collections of histiocytes to a, typical "typhus nodule", A diffuse interstitial orchitis is occasionally seen. The arteritis is not os frequently soon in scrub typhus, in any' of the ergons as in louse-borne typhus. 10, Etiology and Transmission a, is Rickettsia oriontalis, an intracellular parasite found in lymphocytes and endothelial phagocytes of the tissues in the "primary" lesion, lymph nodes and spleen. It is also recovered in the blood in the incubation period. The organism shows a bluish tint with Griemsa, staining and a reddish tint with Machiavollo staining. It may bo cultivated in the yolk of fertile hen’s eggs, b. Transmission is accomplished through the bite of certain larval mites. The mite", Trqiqbiculq. akamushi. is an orange-red color with hairy body and lc$s. The infection is inherited from adult mites (the larval mite foods but once), T. delionsis is also incriminated, (l) Life History of the Mite Vector This group of mites of the acrine family, Trombidiidaot are commonly known as "harvest mites" and locally in Japan as "Kodani mites" (hairy mites). Adult female deposits the eggs on the ground during the summer and autumn. ITowly hatched larvae usually are found attached to the inside of the cars of field mice and receive their initial, infection from these reservoir animals. The engorged larvae drop to the ground, and pass through the nyirphal form following which they reach maturity. The following serin ‘ adults deposit their eggs and the infection is pa.sscd through the egg.to the resultant larval offspring. If nan accidentally is crcposcd to the attack of the mites, infection results. 11. Epidemiolo.y and Distribution In Japan, Formosa., and Korea, the disease occurs most frequently during July and August; loss so in Juno and September, Occasional cases are found in other months. The field mouse (vole) Microtus nantcbnlli is tile chief reservoir in Japan although other small rodents may day . a role. Persons handling hemp, vegetables, grains and hay during the harvest season in endemic regions are particularly in danger of infection. Conditions that produce a moist, damp soil favorable to the development of the mite vo found in fields along the course of rivers subject to fro quen t inund at i on, 32 12. Prophy 1 -1 xis and Control In mite infested localities certain precautions should "be followed: a. Avoid sleeping; on the ground. b. Bathe as soon as possible after exposure with strong soap, c. Anit-mite solutions. Repellent, insect spray, clothing (dimethyl phtalatc or dibutyl phthalatc). Impregnation of socks and clothing is a satisfactory method of individual .protection, Good results axe obtained by spraying with a nwct" or 1 ar gc droplet type sprayer. Two to three ounces axe required to impre riant a coverall or shirt and trousers, or uniform. Repelling or killing effect on mites will last one week or longer provided clothing is not washed out. The larval form of T_. Ak aims hi m ay bo destroyed by spraying infested round with petroleum emulsion. Clean cultivation of infested areas, burning of grass and debris, flood control in frequently flooded areas and reclamation of flood lands also tend to irradicatc the in- festation. 33 OUTLINE OF SUBJECTS TO BE COVERED IK LECTURES OK TYPHUS CONTROL TO PR3SE0TURAL AH) PROVINCIAL HEALTH OFFICERS I, Introduction: (to include) A, General History 3, History of typhus in Japan and Korea II. Entomology and Epidemiologyj A. Entomology of the louse and the course of the infection in the louse (intestinal tract infection which is fatal to the louse in 11 days) B. Mechanism of infection 0, Incidonco effects and mortality as influenced By: 1. Age 4, Occupation 2* 3ox 5. Resistance and acquired immunity. 3, Season (Largely a reflection of infected louse-to~raan opportunity of contact) D. Miscellaneous factors* 1, General hygiene 2, Travel and Crowds (contact chance) III. Etiological agent and its pertinent Bacteriology and immunology: A* Definition and classification with morpholo,y and viaBility. B, Animal reactions in guinea pig, rat, mouse, and monkey, \ C, Immunology in Humans: Common and specific antiBodies (murine and louse Borne) resulting from: 1. Infection 2. Vaccination D, Bacteriological relationship of murine and ,,louso~Borne,f typhus (close). IV. Pathology and Diagnosis: A. Pathology B. Diagnosis: 1. Symptoms 2. Signs 3. LaBoratory aide* (a) Bacteriological ( B) Inmun ol ogi c al (1) Wcil-Felix (2) Complement Fixation (3) Rickettsial Agglutination test. (c) Animal Inoculation and immunity tests. ADDENDA 1 V. Clinical Goufse A. Prognosis 1, Without vaccine 2, With vaccine (a) Full course (b) One dose B, Treatment — symptomatic VI, Control Measure (directed at elimination of infpcted lice and active immunization of potential patients) A. Non-specific measuress B. Delouslng procedures: C. Vaccination D. Isolation and quarantine VII, Control Techniques: A. Early, rapid reporting of any headache and fever B* Checking of reported illness and instituting of control'measures: VIII. Organization A, National B, Profectural 0, Local 1, City health officers 2, Ku or machi health officers 3, Ca.ac~f inding teame 4, Disinfecting teams 5, Immunizing 6, Special gr cups; (a) Hospitals (b) Jails and detention cells . ■(c) Vagrant camps, dose-houses,•etc, IX. Supplies - source and amounts X. Transportation: mobility for increased effectiveness of personnel XI. Publicity A. Schools B. Posters 0, newspapers and pamphlets D, Radio and Movies E, Organized groups such as railroad workers, teachers, volunteer firemen etc. XXI. Insect and Rodent Control (emphasis on relation to murine typhus) ; „ i XIII. Discussion period. I XIV. Demonstrations - actual field demonstrations of typhus control methods, supplies, and equipment. addenda i TYPHUS SURVEY CARD ( sample) CASE HISTORY 1. Number_ 2, Name of Patient 3. Age 4. Sex £, Residence Grim. Village Ku Cho 6, Place of onset of Illness _____ 7, Bate of onset 8. Date of first visit of doctor 9. Date of reporting 10, Date of hospitalization 11, Lice or Dot? 12, Dusted or not before onset with DDT Date Dusted 13, Vaccinated before onset? Date vaccinated 14, Name of Hospital _ Name of Doctor in charge __ CLINICAL HISTORY 15, Prodromal symptone; a. Back pain? „ t. b. Anorexia? __ c. Nosebleed? d. Tired? e. Headache? f. Vomiting? g. Impaired Hearing? h. Chills? i. Muscle pain? J, Diarrhea? k. Insomnia? l, Chilly sensation? a. High fever? n. Cough? o. Lightheaded? 16, Observation; a. Facial expression; (1) Flushed f . (2) Conjuctivitis b. Rash; Date of Appearance (1) Pace (2) Ghost _ (3) Arms end legs c. Impaired Hearing d. Stupor __ o. Delirium _ • f. Excitable g, Comp h. Pneumonia i. Heart: (l) Weak Pulse __ J, Enlarged: liver __ fc_ (2) Blood pressure spleen _ k, Gangrene 1. Pregnancy _ (l) month (2) abortion BLOOD EXAMINATION a, (Woil-Polix) Date of exeminations Titre b, (Complement Fixation) Results . Date of examinations ■ ADDENDA 2 DISINFESTATION TECHNIQUES 1, Disinfestation, o.s applied to the oxton.iino.tion of lico and fleas in clothing, or bedding, may he readily acccmnllshod by dusting with DDT insecticide powder. This procedure is sinplo and is par- ticularly adaptable to field use, 2, Lice begin to die within six (6) hours after exposure to DDT powder. All are dead within twenty (20) hours after exposure. Louse eggs aro not killed by DDT powder and will hatch in 7 - 10 dgys. Properly treated clothing and bedding remains lousicidal far 21-30 days and if not washed, will kill newly introduced lico and newly hatched nymphs during that period. It is necessary to redust the in- dividual if the dusted clothing is changed or washed before the expiration of the hatching oeriod of the eggs. Fleas begin to die in about four hours, 3, Procedure for Disinfestation a0 It is advantageous to sot up sanitary (disinfesting) teams of 6 persons including one well-trained supervisor to direct the operation when hand dusters are used, (12 persons when power dusters are used). Individuals learning the dusting technique should remove the clothing of the first few persons after dusting to note whether the uropor amount has been applied,. b. The chamber of each gun is filled to about 3/4’s of its total capacity. Tho procedure as outlined below will deliver approximately Lg- ounces of powder per nerson* Loss th*>n this amount is ineffective, c. Tho individual to be dusted is directed to remove hat, loosen collar and belt and to stand or sit with hat in hand, d. Dust the hair until whited, separating tho hair to insure even distribution. Dust inside of hat with band, if any, turned up, 6, Insert nozzle of powder gun in right sleeve at the wrist next to tho skin with the arm held straight out to tho side and at shoulder height* Direct two full plunger strokes of powder toward the arm-pit. Repeat for the left sleeve, f. Insert nozzle in front of shirt at collar next to tho skin and direct two full plunger strokes each toward the right armpit, toward the belly, and toward the left arm-pit, (3 positions), g. Insert nozzle in back of shirt at collar next to the skin and direct two full plunger strokes each on top of the right shoulder, toward the right axilla, the middle of tho back, the left axilla and on top of the left shoulder. (5 positions). Deoosit additional powder on the nock band and under the collar itself whore lice frequently abound. ADDENDA 3 h, Insert nozzle in front of trousers at the waist hand next to the skin, with the person standing, and direct two full plunger strokes each toward the right leg, the crotch and the left leg. (3 positions), I, Insert nozzle in hack of trousers, next•to the skin and direct two full plunger strokes each toward the right leg, the buttocks crease and the left leg, (3 positions). J, Insert nozzle at belt line of trousers and deposit powder around the waist, k. In dusting women an extra, quantity of dust can bo blown in at the collar, thus dispensing with dusting at the waist. It is much more satisfactory to use women teams for dusting women and infants, l, Whore multiple layers of clothing are worn, it is desirable to dust each layer of clothing, m, With hand dusters, two full even strokes in ea,ch position are required. With the newer duster, a momentary pressure on the trigger to release a like amount of powder is all that is necessary; the exact timing is locorned by experience* n. Instruct nersons not to shake powder from clothing nor to wash clothing for at least 3 days, 'o, Instruct nersons not to bathe for 3 days, 4, Pisinfcsting by Individuals a. This is readily achieved by disciplined workers who instruct each individual to shako half of the contents of a 2 ounce can of louse powder onto the head, axillary, and pubic hair; the inner surfaces and seams of underwear, shirt and crotch of trousers. Instructions should be given to take special care to rub the powder well about the inner surfaces of the collar and armpits of the underwear and shirt, par- ticularly the seams, since lice are ordinarily found in these locations, 5• Disinfestation of Clothing and Bedding. a. Clothing not on the person of the individual may bo dis- infected by dusting with louse powder, (Sodding may be treated similarly). ill sxxrfaces, including the seams and inner folds of clothing and bedding, should bo treated. It is desirable to fold and arrange extra bedding in piles. Dust is applied to surfaces by inserting the nozzle between layers. Two persons should work together—one to operate the dust gun and one to manipulate the bedding, A minimum of 20 hours after ex- posure- is required to insure death of all lice. Eggs are not destroyed by this method and louse powder must remain in the clothing and bedding ADDENDA 3 for about 10 days, or until all eggs have hatched in order to kill all newly-hatched nymphs, b, Exposure of infested clothing and bedding to a temperature of minus (-) 23,3°C (~10°P) or colder for at least 2 hours and storage at ordinary temperatures for 3-4 weeks thereafter will destroy lice and their eggs. Laundering of clothing with hot water and will serve to disinfest such garments, hut provision should he made to prevent infestation of the laundry and operators and the reinfestation of clothing subsequent to laundering or cleaning, c. Heat. Clothing and bedding exposed to high temperatures will kill lice, (1) Dry Heat — a temperature of 60° C. for 30 - 45 minutes in a dry heat chamber is effective. Temperatures effective against lice will also kill the eggs and rickottsia, (2) Steam Sterilization -—- 15 lbs, pressure 15 - 20 minutes. (3) Boiling water - 5 minutes, 6, Disinfection of Clothing and Bedding a, Delousing with DDT louse nowder docs not kill Rickettsia prowazeki, the causative a&ent of typhus fever. Therefore, hospitals admitting patients with typhus fever must take proper precautions to disinfect the clothing of such ■oatients. This is readily accomplished with steam sterilization or boiling in the case of articles of clothing or bedding not injured by heat. In case of woolens, leather and other such articles, disinfection should be achieved by application of crosol solution or use of dry heat, b. Use of rickettsicidal spray (residual DDT and cresol (2$ content); or pyrothrum emulsion with 2cjo crosol content) - (see Riokettsici- dal Spray Program). ’ 7* Disinfection and disinfestation of buildings, etc. (See Rickettsicidal Spray Program and under Murine tynhus, flea, control). \ ADDSOT4 3 "ASSEMBLY LINE” DUSTIDG -TDOHUIQUB The assembly line11 method of dust amplication is designed for use in mass disinfesting operations whore large groups of repatriates or other persons are to be treated. This method servos to: 1, Speed up the -processing operations 2, Insure a more complete application of dust 3, Distribute duties so each person em loyed as a worker is responsible for only one or two steps of the dusting procedure. 4« Simplify training of workers, 5, Simplify ease in supervision of work, PROCEDURE A# Application of insecticidal dusts to clothing of individuals should follow the recommended stops of procedure, using either power dusting equipment or hand oncrated dusters. B, The Sanitary (Disinfesting) team is composed of 14 to 16 persons (7-8 men; 7-8 women) as follows; 1 - General Supervisor 1 - Assistant Supervisor (man) 1 Assistant Supervisor (woman) W ork e r 1 (man) - fl f2 (nan) " #3 (nan) n $4 (man) M (nan) Worker #1 (woman) ,T #2 (woman) n $3 (woman) " #4 (woman') H #5 (woman) 1 - baggage duster (if needed) 1 — supply nan 1 - nochanic C* Duties of team members Worker *,-1 (man & woman) - dusts hat and hair \ Worker $2 (nan & woman) - dusts uo Doth sleeves and under cellar Worker #3 (man & woman) - dusts down front and around nock band Worker $4 (man & woman) - dusts down back and over shoulders. Worker; #3 (non & woman) - pants (front & roar), around waist, D, Duties of Supervisors: € “ Chief - In charge of dusting operations Assistant - (nan) - Supervises work of non dusters Assistant - (woman) - Supervises work of women dusters ADDENDA 4 B. Duties of addition??! porsonnol: . Baggage duster. ~ 'applies dust to bagg’age Supply -man - tends to powder supplykeeps extra {pens filled. Mechanic - responsible for care of dusting equipment. D, Operation ' * • V ■ . ’ * ' ■ i 1, Individuals .to be dusted are divided into 2 linos - one line for men and a second line for women and children, 2, Individuals leave baggage (if any) on nlatform where a person employed as a worker applies DDT to extra clothing, blankets, etc. Individuals file by workers in proper line, whore each executes the step' in the procedure for which ho or she is • • responsible, 4, Individuals, when dusted, claim their baggage and are guided to another area, or placed on board boat or train (in case of repatriates). 5, Supervisors walk between lino of dusters and can easily watch the progress of the work and moke corrections. ADDHLTDA '4 "ASSEMBLY LINE" DUSTI1IG PLAIT MSN DUSTERS Mon Supply Table Outfit DelousintT WOMEN DUSTERS Women WORKER #1 WORKER #1 Hat and Hoad Hat and Hoad •WORKER #2 WORKER Both sleeves & under collar Both sleeves & under collar WORKER #3 WORKER #3 Down front & around neck Band Sup o r v i s or1s Walk Down front & around nock hand WORKER #4 WORKER #4 Down hack & over shoulders Down hack & over shoulders WORKER 35 WORKER #5 Pants Front & Rear Around Waist At ound Waist Fr ont & Rear ADLEITLA 4 11ICICST T SI CI DAL SPmAY PH OGHAM 1, Circumstantial evidence has gradually been building-; up as regards the role that infective fecal material from lice and fleas may play in the spread. of typhus fever, Experiments have shown that a spray containing a 2p eresolis content is effective in killing the causative organism of typhus fever, Pickettsia prowazeki* Based on the above information, a spray schedule, coordinated with the regular control program- armors advisable* 2, Materials Available. Snrpys Insecticide spray, DDT residual effect. Emulsions Pyrethrum emulsion (30 a) Pyrethrum emulsion (10X) Qrosolis Oresolis compound - or local preparations containing crosol Apparatus Knapsack tyoe sprayer Hand, continuous operation, sprayer 3, Method of Preparation of Sprays a* Stock materials obtained should.be mixed in quantities desired, immediately preceding actual use, in areas whore work is to be undertaken or at a central point and sent out v/ith the proper typhus control to amis* b. The sprays should have 3p eresolis compound content in the finished product. Mixing may be done in any convenient barrel, drum or tub. c• Pormulao of Sprays Spray #1 Insecticide spray, PUT residual effect - - ~ 30 Liters Gres oils compound - -- -- -- -- -- -- 600 cc Add crosolis compound slowly to'spray material stirring continuously v/ith wooden paddle until thoroughly mixed. This spray to be used for residual effect DDT and for rickottsicidal effect. ADDjilFDA £ Pyrethrun emulsion (30x) -------- -1 Liter Water 30 Liters Crcsolis Compound - -- -- -- -- -- - 600 cc Add pyrethrum slowly to volume of water desired. Stir■continuously until mixed. Add cresolis in same manner to mixture of emulsion end water. This spray to he used for quick killing of fleas and for rickettsicidal effect. So rav #3 Pyre thrum emulsion (10X) -3 Liters Water go Liters Cresolis compound - -- -- -- -- -- - -600 cc. This spray is -prepared and used for the same purpose as spray #2 if the pyrethrum (10X) emulsion is furnished instead of the pyrethrum (30X) emulsion, 4, Spray #1 - residual effect DDT - cresolis spray Schedule of use Twice monthly Railway Stations and largo transfer moints. Corridors - floors and vTallop seats or honchos Staircases - stops, walls, hand rails ,!Rost!J rooms (if any) - floors walls, stools, etc. Offices and miscellaneous rooms. Railway cars and coaches used for passenger trans- portation. Floors, walls, ceiling, seats or honchos. Based on a III Class coach of approximately 16 x 2-J x 2g- motors, about 5-6 liters of spray would ho required for one car. Streetcars - Floors, walls, ceiling, scats or honchos. Buses - Floors, walls, seats or honchos. Jails and -orisons - Floors and walls of cells, corridors, latrines, offices. Infectious Disease Hospitals - Typhus wards Vagrant houses - Floors and walls of all rooms, corridors, hath houses. ADDENDA 5 Orphan a. ;os - Floors and walls of rooms, toilets, hath houses. Dormitories. noor farms, similar institutions, if lice ore detected or eases occur. Railway care, street oars and buses should ho marked in a prominent place with a date on v;hich work was done. Method of Airulica.ti on Dosage rate for interior application for DDT residual effect should he approximately 1 Liter per 35 sq, meters of space. Application A rather coarse, wot spray should he used. Hold nozzle of snraycr close to surface to he treated, (10 ~ 20 cm.). Surface should he moistened hut with no run-off. Liquid may also he applied with a large paint brush if no other equipment is available, Proca.uti ons Use competent trained personnel, Oocn fires, electric motors, light bulbs, heating equipment, etc., should ho kent out of direct con~ tact with the spray. Do not "fog" the spray with high arcssure atomizers. Leave doors and windows op.cn during processing and for several hours after, until drying and ventilation is complete. Workers should avoid prolonged contact of spray with the skin as the solvent, kerosene, will cause a mild dermatitis. 5, Spray if 2 or So ray #3 - Pyre thrum - crosolis spray Schedule of use. These sprays arc to he used in pla.cos where fire hazard is great in addition to general use. Twice Monthly - on alternate weeks with spray #1 Railway Stations and large transfer points Corridors, staircases, waiting rooms, ,,rcptu rooms, offices. Railway cars and coaches ADDSLDA 5 . Streetcars ' Buses Jails and Prisons Va/rant houses *■ Infoctious disease hospital wards Once o,ach week Theaters - floors, scats, rest rooms, lounging rooms, store rooms, kitchens, sloshing quarters. Immediately Typhus houses - floors, beds (if any), extra clothing, bedding, mattresses, Caro should be taken to treat the cracks and crevices in floors, between mats, etc. Also scams of clothing, bedding, mattresses. This work should bo done immediately following dusting operations in the home of a suspect typhus ease. This work should bo repeated at weekly intervals over a three week period, 6, The spray program should be coordinated with the general typhus control procedures, and should bo vigorously executed during the months of December, January and February. If the typhus situation during the spring warrants a change1 in tactics, this spray program may bo modified to meet the changing conditions. 7, The larger centers of population should receive strict attention* in particular: •Sapporo Hakodate Hokkaido Aomori Sendai * Toky o-Y ok oh ana ar o a, Nagoya Kyot o * 0 a ak a-IC oh e ar c a- * Important areas. ADDENDA 5 IllJ'QliMATION GQITCEHITIITG- DDT DDT ("chichioro-diphcnyl-trichlorocthonc”) was first prepared in 1874 "by Zcidler. The reaction of anhydrous chloral and chi or ohonzone in the presence of concentrated sulfuric acid produced: a material which in chemically pure form is a white crystalline solid, practically odorless, with low volatility, rather stable, and insoluble in water, hut soluble in many organic solvents. It has the following chemical name; l-trichloro~2,2-bis(p-chlorophGnyl)ethanc, , - Preparation; ”The compound is prepared fr.on. 1 molecule of chloral or chloral hydrate and 2 molecules, of monochlorahcnzenc in the presence of sulfurnic acid (oleum is used commercially) 11 The DDT crystalizos from the reaction mass, and the sulfurnic acid is then removed hj washing, The compound contains many isomers, in which the chlorine atoms on the benzene rings are attached in other positions, and other impurities. If pure p,p1-DDT is desired,, it may be obtained by rccrystallization of the technical material from ethyl alciohol, Several recrystallizations arc necessary to obtain a pure product,” Technical DDT is a fine white powder which varies from yellowish white to white in color. Storage at high temperatures or exposure to sunlight docs not cause deterioration. Under conditions of high humidity it tends to cake. Some producers offer a product so treated as to pre- vent hard clumping, DDT insecticide is covered by patents assigned to J. n, G-cigy, Basel, Switzerland, the first application for a patent being filed in Switzerland on 7 March 1940, Toxicity; DDT acts both as.a contact poison and a. stomach poison for insects. The toxic effect is exerted principally on the nervous system ana results in characteristic ”DDT tremors”, progressive paralysis and death. DDT when applied in the form of a spray or powder will continue to kill insects which cone in contact with treated areas for several weeks or months, DDT is a toxic substance to humans and care should be exercised in handling. All persons working with this material should bo well trained in methods of application. Poisoning nay occur from ingestion of DDT or by absorption of solutions of DDT through the skin. Therefore care should be taken to prevent contamination of foods (particularly butter, milk, etc,) by DDT. Contact with oil and organic solvent DDT spray solutions should be avoided. Inhalation of dusts containing DDT is not particularly dangerous, but when the dust cloud is dense, use of respirators is advisable. ADDE1IDA 6 Emulsions for impregnation of garments containing 1$ DDT arc safe for this use hut during processing tongs should he used to handle tno clothing in solution, DDT Insecticide Proparadions?, DDT nay he incorporated in the preparation of various insecticidal and niticidal formulae. 1, Dus t s a. Insecticide powder, louse DDT (concentrate) 10$ Pyrophyllito 90$ To form a 10$ DDT content dust h, Larvicide DDT, powder, dusting DDT (concentrate) 10$ 'Talcum 90$ To form a 10$ DDT content dust Manufacture of 10$ DDT Insecticido Dusts “Either pyrophyllitc or talc can ho mixed with DDT to produce louse powder. While 10$ is"used in the standard Army product, the concentration is not critical and from 5;j to 10$ will ho effective. The pyrophyllito or talc should ho neutral or very slightly acid. Alkaline dusts will cause the DDT to decompose, A hammer will should he used for this operation. Do not attempt to use a stone mill, hall mill, paint mill or odgerunnor, since the frictional heat developed will cause the DDT to soften and cako-up. A hammer mill of the hiado typo is to he preferred to the saddle typo. If cither the pyrophyllito or the DDT is lumpy, break up the larger lumps hy hand and mix 25 Ihs, of DDT with 25 Ihs. of pyrophyllito, This mixing con he done in any type of mechanical agitator or in a, tumbler drum. Put this mixture through the hammer mill once, then add 200 Ihs, of additional pyrophyllito. Mix and put through the hammer mill a second time. Do not try to put unnixed DDT through the hammer mill. Mixing and milling equipment should he avilahlc in Japan and Korea. Blade type hammer mills should ho available in plants which formerly ground pyrethrum flours for export.” In the specifications for DDT louse powder as used hy the Army, the following is stated: 90$ should Pass U.S, Standard mesh #525 99$ should pass U.S, Standard mesh #100 99$ of the finished material should go through the U, S. Standard mesh #80, ADDENDA ’6 The approximate particle size corresponding to these meshes arc as follows: Mesh #325: 44 miera • Mesh #100: 149 nicra • • • Mesh # 80: 177 nicra 2. Solutions: Several typos of solutions for use as sprays may he prepared. a. Insecticide spray, residual effect DDT (concentrate) 5# Methylated naphthalene 150 Kerosene 8 0# For use in the control of roaches, ’bedbugs, mosquitoes, houseflies, phiclotonus flies, fleas, outs, etc. A solution, giving residual effect, may he prepared by dissolving 7 pounds DDT concentrate in one gallon of kerosene. Use at rale of one quart per 250 sq, ft. b. Insecticidc. liquid, finished spray DOT (concentrate) 1.Op Than i tc .2,5-# Kerosene 96,5# For use as a general inseciticdc whore the soray is applied directly on the insect by means of an ordinary hand spray g*un. This spray should not be used to give a residual effect a.s the DDT content is too low0 c. Insecticide spray, dolousing (stock solution) DDT (concentrate) 6# Benzyl benzoate 68# Bcnzocainc 12# (ethyl p-amino benzoate) Tween 80 (wetting agent) .... 14# Prior to use dilute with 5 parts (by volume) of v/ator to form 1# DDT content. Designed for use on individuals against louse infestation of the hairy parts of the body. This spray is lousicidal and ovicidal, 2/3 oz, required per individual. Solution nay also be used in the treatment of Scabies, by application to affected parts. ADDEEDA '6 d• Insccticldo DDT emulsion concentrate DDT 2 54 Xylene 65^ Triton x-lOC (emulsifier) . . , 10$ To 1)0 used as a 2 $ wo tor dilution lor louso proofing of clothing. May also ho usod in omula1one for preparation of larvicides, residual suraying against mosquitoes, flies, hedhugs, etc, For impregnation of clothing, mosquito har, etc., dilute 1:11 hy weight to form 2$ aqueous emulsion, 30 gallons is sufficient for 125 suits of winter (50)6 wool) underwear (or garments of similar weight). One quart of solution nor suit of underwear is required, 2Jo of dry weight of garment should he DDT, Pickettsicidal Sprays (See Eickotteicidal Spray Program) List of component.ingredients of DDT insecticide -products: DDT. - Technical (concentrate) Dusts DDT - technical • ■ • Pyrophyllite Talcum Solutions and sprays DDT - technical Methyl,ated naphthalene Thamite Benzyl Benzoate Bcnzocaino (ethyl p-amino-henzoath)" Xylene Kerosene - Diesel oil - Puel oil Tween - 80 (wetting agent) * * Triton x-100 (emulsifier) Oresolis compound ADDENDA -.5 RICKETTSIAL DISEASES IN JAPAN ANN KOHEA Contents v . Page Introduction 1 GklOUP I - TYPHUS FjSVEH ...... ; 1 1. Louse-borne (epidemic) tophus 1 a. Clinical course 1 I. Complications 2 c. Diagnosis 3 (1) Differentiation 2 (2) Serological Differentiation . 2 (a) Weil-Felix reaction 2 . (1). Complement Fixation 3 (3) ( Animal Inoculation 3 d. Prognosis_ 3 c. Treatment, 3 (1) Symptomatic and Supportive . . . 3 (2) Para,- amino-benzoic-acid ' 3 f. Immunity 4 g, Vaccination , . , 4 h. Pathology 4 i, Ltiolo y and Transmission . 4 (1) Causal agent 4 (2) Transmission . . 4 (a) Life history of body louse . . . 5 J. Epidemiology . . . . 5 k. Prophylaxis and Control . 5 (l) Procedures prior to typhus season . . 5 (a) American tyehus control officers 5 (b) Civilian typhus control offic rs 6 (c) Training Program 6 1_. and training of tynhus control teams ..... 6 2. Trainin., of civilian physicians and nurses.. 7 3_. Trainin' of Block and ik i. hb or hood Associa- tion .Chief.(Japan), Voluntary Service Group Heads (Korea) ........ 7 (d) Publicity and ECuqa.tion nro rams 7 (e) Distribution of Supplies 7 1,. Available Supplies 8 (f) Mass vaccination 8 (p) Vaccination of ,koy personnel 8 (h) Disinfesting of possible typhus foci 9 (i) Disinf os ting of zones 9 (j) Permanent disinfesting stations 1C (k) Distribution Qf Jnsopticice powder to individuals 10 Payo (1) Typhus C ontr ol Toans (Or :a,niz ati on and General Duties) 10 1_. Case-finding Teams . , . 10 a. Organization 10 b. Duties . . , 10 2, Sanitary (Disinfesting) Tca.'.s 11 a. Organization • 11 b. Duties 11 3, Vaccination Teams . 12 a. Organization 12 b_. Duties 12 4, Su^jested additional Sanitary (Disinfestiny) Teams 12 a, Central Health Office Sanitary Taams .. 12 b, Disinfestiny Station Teams 13 cm Special Disinfostin, Teams 13 (2) procedures when outbreaks of typhus occur 14 (a.) General , 14 (h) Definition of Terms * 14 1_, Suspect case of typhus fovar 14 2. Confirmed cmn of typhus fever 14 «5. Focal Disinfestiny 15 4. 2on°l Disinfesting 15 15, .Focal Vaccination 15 ,6. Zonal Vaccination 15 7_. Spot Maps ’ 15 (c) Operation.of Typhus Control Plan 15 1_. When suspect case is reported personally ,, 15 2, When suspect case is discovered by; (Family He a.., etc.) 16 3, When suspect case is reported to local health office by: (any person,.etc) ... 16 a. Local Health Office (Procedure) ... 15 b_. Vaccination Team (procedure) 17 4, When suspect case is reported into any health office by a roviny case finding team: 18 a. Doctor (Duties) 18 b. Nurses (Duties) . • 18 cm Workers (Duties) 19 (cl) Typhus Control in Eural areas 19 !l. General principles 19 a. In Community of less than 1,000 popu- lation 19 b_. In Community of more than 5,000 popu- lation 20 c_. In Labor Campsh etc, . . .• 20 ( o) P or t an tine Pr oc o dur c s 21 (f) Proper C.aro of Disinfecting Equipment 21 1.. Outfit Dclousin : 21 2. Hand Dusters 22 3. Spray Equipment 22 Page 2, Flea-borne (Murine) Typhus 22 ■ a. General 22 b. • Clinical Course . . ; '. , 22 c. . Complications . . . • . . ,• ,• . . . . . . . . , 23 d. Prognosis . ■ ,v 23 c. Diagnosis . . -;.... 23 (1) .'Differentiation ...... 23 (2) Serological Differentiation 23 (a) The Wcil-Folix reaction 23 (b) Complement Fixation . 23 (3) Animal Inoculation 23' f. Treatment 24' g. Immunity 24' h. Vaccination . 24' i. Pathology 24' J. Etiology and Transmission S4" (1) Causal Agent 24 (2) Transmission 24 (a) Life History of Flea Vector 24 k. Epidemiology 25 l, Prophylaxis and Control 25 (1) Prophylaxis 25 (2) Control Methods 26 (a) General Methods 26 1_. Case-Finding Tennis 26 2, Vaco in? ,t ion Teams 26 3. Sanitary (Disinfesting) Teams 26 a. Organization .... 26 b. Duties 26 Flea Control 26 Rodent Control 20 GROUP II - TSUT;SUGAMUSHI FEVER GROUP 28 1. General 28 2. Clinical Course 28 3. Complications 29 4. Diagnosis 29 a. Differentiation 29 10 Serological Differentiation 29 (l) Well-Folix reaction 30 (6) Complement Fixation 30 c. Animal Inoculation 30 5. Prognosis and Fatality Rate 30 6. Treatment 31 a. Syntomatic and Supportive 31 b, Para,-ajnino-bonzoic~ac id 31 7. Immunity 31 8. Vaccination 31 9. Pathology 31 Pago 10* Etiology and Transmission 32 a. Causal Agent 32 b, Transmission 32 (l) Life History of the Mite Vector 32 11, Epidemiology and Distribution . 32 12, Prophylaxis and Control 33 ADDENDA 1, Outline of Subjects Covered in Lectures on Typhus Control 2, Typhus Survey Cord (Semple) 3, Disinfestation Techniques 4, wAssembly LlnoM Dusting Technique 5, P.lejcottsiciAal " Spray Progrom 6, Information concerning DDT