Typhoid
Fever
Public Health Aspects MILTON S. SASLAW, MD, DrPH JOEL L. NITZKIN, MD, MPH RONALD FELDMAN, MD WILLIAM BAINE, MD KENNETH PFEIFFER, PE MARGARET PEARSON, RN, MA
In February and March, 1973, a typhoid fever outbreak occurred in South Dade Labor Camp, Homestead, Florida. There were 210 recorded cases and no deaths. Public health aspects of the outbreak are discussed.
Introduction
History
The last major recorded epidemic of typhoid fever in the United States occurred in Manteno State Hospital, Illinois, in 1939. There were 453 cases, with 60 deaths. Sanitation procedures generally have been improved markedly since that time, but despite such improvement the South Dade Labor Camp near Homestead, Florida, developed a sizable outbreak early in 1973 (172 hospitalized, 38 not hospitalized, no deaths) (Table 1).
A 7-year-old girl was hospitalized January 14, 1973, with a diagnosis of possible appendicitis. Two weeks later she was shown to have typhoid fever. Epidemiological study indicated that her next-door neighbor, a 40-year-old female, had a Vi antigen titer of 1:320. This woman was quite friendly with the patient, and the judgment of the physicians was that she was the likely source of contagion. On February 23, two cases living at the same camp were reported to the Dade County Department of Public Health as "suspect typhoid fever." On that day, an epidemiologist and a sanitarian from the health department visited the homes of the patients and determined that: (1) there was no elicitable social or geographic relationship between the two, nor between either one and the proven case of the previous month; (2) there was an adequate chlorine residual in the water in each of the two housing units. On February 27, laboratory confirmation that Salmonella typhi was recovered from the stools of the two suspects was presented. Within 15 min a meeting was called involving the Director of the Dade County Department of Public Health and key personnel of the epidemiology, sanitation, and sanitary engineering staffs (including the assigned Epidemic Intelligence Service Officer). A representative team, including nurses, was dispatched immediately to review the situation at the camp. Background data on the camp's water supply were
Dr. Saslaw is Director, Dade County Department of Public Health, 1350 N.W. 14th Street, Miami, Florida 33125. Dr. Nitzkin is Chief of the Office of Consumer Protection, Dade County Department of Public Health. At the time of the outbreak, Dr. Feldman was Epidemic Intelligence Service Officer, Field Service Branch, Center for Disease Control, Atlanta, Georgia 30333. Dr. Baine was Epidemic Intelligence Service Officer, Bacterial Diseases Branch, Center for Disease Control, Atlanta, Georgia 30333. Mr. Pfeiffer was Assistant Head (Engineering), Office of Consumer Protection, Dade County Department of Public Health. Miss Pearson was Associate Chief (Nursing), Office of Consumer Care, Dade County Department of Public Health. Dr. Feldman's present address is: Departments of Gastroenterology and Medicine, University Hospital of San Diego County, San Diego, California. Dr. Baine's present address is: Department of Internal Medicine, Parkland Memorial Hospital, Dallas, Texas. Mr. Pfeiffer's is: Vice President of Operations, Florida Water and Utilities, 10700 Caribbean Blvd., Miami, Florida. Miss Pearson is retired, home address: 538 N.E. 38th Street, Miami, Florida. This article was presented in part at the 101st Annual Meeting of the American Public Health Association, November 6, 1973, in San Francisco, California. 1184 AJPH NOVEMBER, 1975, Vol. 65, No. 1 1
TABLE 1-Typhoid Fever Cases in South Dade Labor Camp, Homestead, Florida, February to May, 1973 Finding
Hospitalized
Not Hospitalized*
Total
Blood culture positive Stool culture positive Culture unspecified, positive 7 4-fold rise in "0" titer
108 22 35
3 1 32 2
111 23 67 9
Total
172
38
210
*
Cultures and titers positive on routine surveys. No illness reported.
reviewed. Through the past 2 years water testing had occasionally yielded unsatisfactory samples, usually evanescent and with low bacteriological counts. However, in December, 1972, an apparent increase in gastroenteric diseases was reported. Water samples taken December 29 showed high coliform counts. The engineer of the Dade County Department of Public Health, sent to the camp to determine the problem with the water supply, made recommendations on January 2, 1973, which were relayed to the camp management January 9, 1973. The conclusion was that the system could provide an adequate and safe water supply if properly serviced and maintained. Follow-up bacteriological samples collected January 3 and 12, and February 1 and 8, were all negative. Additionally, the presence of chlorine residuals was recorded on January 8. On February 22, on a routine inspection, no chlorine residual was observed. The water plant operator stated that the equipment had been in satisfactory operation that morning, but that later a failure had occurred. This was corrected the same day, and on the next day adequate chlorine residuals were again observed. From February 27 on, the problems faced by the Dade County Department of Public Health included (1) search for the cause of the outbreak; (2) tangential involvement in medical care and management of patients; (3) surveillance of residents; (4) follow-up of cases and suspects; (5) communications; (6) consideration of immunization; (7) initiation of quarantine; and (8) recommendations for future avoidance of similar outbreaks.
Search for Cause Intensive investigation of the water supply and of the sewage system was begun immediately. A number of suspicious findings were observed. These systems had originally been installed about 1940, and were replaced in 1969. The water was supplied from two wells. The first suspicious finding was that these wells were reported at first to be 50 feet deep with 38 feet of casing. The well driller's job log confirmed these depths. By sounding, however, an approximate depth of 20 feet was discovered. Later in our studies, we noted that the certificate provided by the state's Sanitary Engineering office had approved the 20 foot depth.
Second, in the center of the well house was a floor drain connected to an outside dry well surrounded by a vitreous clay pipe. When fluorescent dye was introduced into this well, it appeared in the water supply in 3 ".2 min. Third, dye was also painted on the ground about 10 feet from the water wells. In less than 15 min, the dye appeared in the water. Fourth, several holes were dug in the area of the well house. The old sewer system, abandoned in 1969, but close to the origin of the water supply, was found to contain human feces, as evidenced by the recovery of Salmonella
saint-paul. Fifth, inspection of the character of the ground revealed many solution channels in the area surrounding the wells. Sixth, about 100 yards from the wells was a common toilet facility. Immediately outside this facility was a grease trap, connected only to the sinks. Upon emptying the trap, human feces were found in it. Seventh, about 1000 feet away from the wells was a 50,000-gallon storage tank. This tank was cleaned and found to contain beer cans, bottles, other rubbish, and feces.
Medical Care Migrant laborers receive medical care through a nonprofit, voluntary health organization, Community Health of South Dade, Inc. (CHI). Funds are provided under a federal grant, supplemented by Dade County. This organization works in close relationship with the Department of Family Medicine of the University of Miami School of Medicine. All cases suspected of possible typhoid fever were screened by physicians in one of two clinics operated by CHI. Some of the suspects were hospitalized starting on Tuesday, February 27. The Dade County Department of Public Health Director communicated with an Assistant Director of James M. Jackson Memorial Hospital (county hospital) on the evening of Wednesday, February 28, and learned that 43 beds were available either at Jackson Memorial or Variety Childrens Hospital. At that time, the 43 beds were considered adequate for any immediate need. On February 28 also, a sample of residents at the camp were surveyed to determine the potential magnitude of the problem. This survey was carried out by Community Health Inc. personnel under the direction of the Dade County Department of Public Health. The preliminary study revealed that 20 to 25 per cent of the residents were involved. On March 2, 1973 (Friday), 35 public health nurses did a door-to-door check for all sick individuals, every contact, and every person who had been ill any time during the previous three weeks. These individuals were referred to physicians working in a temporary clinic set up by CHI in the auditorium of the camp. On Friday, it was apparent that additional bed space was needed. That evening, contact was made with the Director, Department of Hospitals, who agreed that every case and suspect would be hospitalized at Jackson Memorial Hospital. On Saturday, March 3, a high level Hospital Administrator was at the camp, and from then on, no patient was denied admission. TYPHOID FEVER
1185
Surveillance of Residents From March 2 on, repeated home visits were made by public health nurses, and any ill people were sent to the emergency clinic for physician evaluation. All suspects were hospitalized, and treatment with chloramphenicol or ampicillin for 14 days was utilized. After the sick were appropriately cared for, a rectal swab program was initiated
for all residents. Three successive daily samples were collected by public health nurses. As three negative swabs were collected, a notice of clearance was provided to each individual (Figures 1 to 3). Because of the unreliability of the water supply's chlorination system, the chlorine level was raised to 10 ppm, by which technique enforced boiling was assured. In a matter of a few days, a line was brought in from a
DADE COUNTY
DEPARTMENT OF PUBLIC HEAIT 1350 N. W. FOURTEEN STREET MIAMI, FLORIDA 381S3 DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES DIVISION OF HEALTH To: From:
Re:
0e
MILTON S. SASLAW. MD. MPH. DIRECTOR March 13, 1973
TELEPHONE 377-0341 Whom it May Concern Joel L. Nitzkin, M.D., Chief Office of Consumer Protection Policies and Procedures Concerning Quarantine at South Dade Labor Camp
During February and March of this year we have experienced a common source outbreak of typhoid fever caused by a contaminated water supply at South Dade Labor Camp near Homestead, Florida. To date, 196 persons have been hospitalized with 102 confirmed as typhoid Fever. On March 4, 1973, Milton S. Saslaw, M.D., Director of the Dade County Department of Public Health issued a quarantine notice to each resident of South Dade Labor Camp. The notice allowed residents to leave the Camp premises to work and to buy food, but prohibited visiting outside the Camp, attending school or changing
residence without prior approval.
During the past 10 days the health department has proceeded to obtain 3 rectal swab cultures on every man, woman and child in the Camp in an attempt to detect possible typhoid carriers and/or suspect cases during the incubation period. Two forms have been designed (copies attached) to assure adequate followup of cases and orderly release from quarantine for all typhoid cases and all other Camp residents.
The "STATEMENT OF UNDERSTANDING AND AGREEMENT" requires the patient to report for rectal swab cultures one month after onset of illness and prohibits change of residence without health department permission. The statement also prohibits
certain occupational pursuits. The "RELEASE FROM QUARANTINE1" is based on 3 consecutive negative rectal swab cultures and releases the individual from all restrictions imposed by the quarantine notice of March 4, and the "Statement of Understanding and Agreement." The release form will allow children to immediately re-enter school and provide the adults with written evidence of freedom from typhoid fever. Culture positive asymptomatic individuals and those still positive for typhoid will not be released from quarantine until appropriate treatment has been given and post-treatment cultures have been evaluated. Those few individuals who remain positive after re-treatment will be managed in accordance with the guidelines specified in the 1970 Edition of Control of Communicable Diseases in Man.
Approved and Forwarded: FIGURE 1
1186 AJPH NOVEMBER, 1975, Vol. 65. No. 1 1
MilFtUn Release from quarantine.
i'I'2i-/,-/ikL'. SR Saslaw,
M.D. ,Director
DADE COUNTY DEPARTMENT OF PUBLIC HEALTH 1350 N. W. FOURTEEN StREET IAMIY, FLORIDA MISS DEPARTMENT OF HEALTH & REHAINLITATIVE SERVICES DIVISION OF HEALTH HLTOW I. S^SLAW. Me. "M. WRecToS
TELEPHNE 3774341
Q U A RA N T I N E
FRO M
R E L E A S E
This is to certify that
Birthdate:
, South Dade Labor Camp, has shown no evidence of typhoid on
of House Nvwber
three (3) consecutive rectal swab cultures taken at least a day apart.
Signed:
Date:
L I BER A C IO N
PHN
C U A R E N T E N A
D E
Por la presente certifico que
vecino de
(n&ero de
la casa)
, ,
-
nacido en
del Campo de Trabajadores del Sur
de Dade (South Dade Labor Camp),, ha tenido tres cultivos negativos a tifoidea toma-
dos por isopo rectal en tres
dtas
consecutivos. EPHN
Fecha FIGURE 2
neighboring public water utility to provide a temporary potable supply. Later, a permanent connection replaced the wells.
Follow-up of Cases and Suspects Each hospitalized individual was contacted by a public health nurse while still in hospital. Explanation of time for reswabbing was provided. Those patients who failed to present themselves at CHI for recheck were visited in their homes by the public health nurses, and samples were collected. Release notices were issued to all those from whom three negative samples were obtained. Blood samples also were collected appropriately for confirmation of typhoid fever, basically among suspects with negative stool samples. Public health nurses were stationed at the camp, daily seven days a week through March and five days a week through mid-May, and they made occasional visits through July. In all, over 6700 rectal swabs were collected and examined.
Release form.
Communications A large scale outbreak of this nature naturally leads to reaction varying from concern to alarm. News medianewspapers, magazines, TV, radio, local, state, and national-all clamored for updated information, and pressed for answers before investigations were complete. Official hearings also were held-two congressional, several state-as well as a large number of unofficial ones. In order to assure that all media received the same data, several policy decisions were invoked. First, the truth, the whole truth, and nothing but the truth was the basis of all responses. Naturally, these items changed from hour to hour, as data were reported in. Second, one man, the Director, provided all news items for about 10 days. Third, because of the impossibility of one man's responding to all calls, a tape recording was prepared daily, and this was played back to all callers. Fourth, while providing up-todate information, every effort was exerted to avoid creating widespread alarm. Fifth, meetings of key health department TYPHOID FEVER
1187
DADE COUNTY DEPARTMENT OF PUBLIC HEALTH 1350 N. W. FOURTEEN STREET MIAMI, FLORIDA 33195
im
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES DIVISION OF HEALTH MILTON S. SASLAW. MD. MPH. DIRECTOR TELEPHONE 377-0341
STATEMENT OF UNDERSTANDING AND AGREEMENT
I,
,
of
Birthdate:_
_
(current Dade County address)
understand that the germ of typhoid fever may persist in my body even after a full course of hospital treatment.
This may cause me to get sick with typhoid fever
again, or may cause me to become a carrier of typhoid who might give this disease to other persons.
In order to protect my own health and the health of other persons, I agree to the
1.
2.
following:
I will not change my place of residence without the permission of the Dade County Department of Public Health until I receive a properly signed "RELEASE FROM QUARANTINE." I shall report to the special clinic at the South Dade Labor Camp at 9:00 a.m. (date) to begin the series of 3 rectal-swab cultures as
on
directed by the health department. 3.
I understand that additional medical treatment may be needed to completely cure me from typhoid.
4.
I shall not work as a restaurant worker, babysitter, maid or hospital worker until I have received a properly signed "RELEASE FROM QUARANTINE."
5.
I understand that failure to obtain a properly signed "RELEASE FROM QUARANTINE" may result in my name being placed on a national listing of possible typhoid carriers.
Date:
Signed: (Patient, Parent
or
Guardian)
Witness: Witness: FIGURE 3
A and B, statements of understanding.
personnel were held at least daily to review and update all known facts, and to assure complete handling of every situation. The Florida State Division of Health, Bureau of Preventable Diseases, Section on Epidemiology, assisted the local program by sending out appropriate notification bulletins to every State Health Officer and to the administrative officer in every migrant program throughout the country. Three national releases were published in the Morbidity and Mortality Weekly Report by the Center for Disease Control. 1188 AMPH NOVEMBER, 1975, Vol. 65, No. 11
Immunization This was considered very seriously. After much deliberation and discussion with the Center for Disease Control, mobilization of a massive typhoid vaccination campaign in all or part of Dade County, or even in the camp alone, was ruled out because: * The vehicle of transmission in the outbreak had been identified and was amenable to direct control; * Further propagation of the outbreak on a wide scale, requiring person-to-person transmission of
DADE COUNTY DEPARTMENT OF PUBLIC HEAL[TH 1350 N. W. FOURTEEN STREET MIAMI, FLORIDA 33125
I -
.$7-r:, WA
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES DIVISION OF HEALTH
J. 9
MILTON S. SASLAW. MD. MPH. DIRECTOR TELEPHONE 377-0341
DECIAPACION REFERENTE A ENTENDER Y ESTAR DE ACUERDO: Yo,
, nacido en _
_
_
_
_
, vecino de Fecha (domicilio en Dade County al presente),
_ _ _
he sido informado y comprendo que el germen de la fiebre tifoidea puede permanecer en mi cuerpo aun
despugs
de completar un tratamiento de hospital.
Esto
puede ser causa de que me enferme de nuevo con la tifoidea, o puede ser que me convierta en un portador de tifoidea y pueda contaminar a otras personas. En orden de proteger mi propia salud y la de otras personas, yo estoy de
acuerdo y consiento en lo siguiento:
1.
Yo no cambiare de domicilio sin el permiso del Departamento de Salud del Dade County hasta que yo reciba una notificacion privada liberandome de la cuarentena; esa notificacion se titulara "LIBERACION DE CUARENTENA".
2.
Yo concurrirg a la Clinica de los Trabajadores Migratorios del Campo Sur de Dade (South Dade Labor Camp Clinic) a las 9 AM del dia Fecha para ser sometido a la prueba de tres isopos rectales consecutivos siguiendo las instrucciones del Departamento de Salud.
3.
Yo he sido informado y entiendo que para completar mi curacion es posible que yo necesite ser tratado de nuevo.
4.
Mientras no reciba la "LIBERACION DE CUARENTENA", yo no trabajare en restaurantes ni en ningun otro establecimiento que expenda comidas, ni cuidare' ninos de otras familias, ni trabajare en un hospital.
5.
He sido informado y entiendo que de no recibir la "LIBERACION DE CUARENTENA" mi nombre sera incluido en la lista nacional de portadores de ti-
foidea.
Fecha:
Firma:
(Paciente o persona autorizada)
Testigo-.
Testigo: FIGURE
infection, was not anticipated on the basis of established knowledge of the epidemiology of typhoid; * Typhoid vaccine, even when administered according to the recommended schedule, with two injections spaced 4 weeks apart, does not afford complete immunity against infection; * Vaccination is accompanied by considerable mor-
bidity; * Diversion of available health workers to undertake
a predictably unprofitable mass vaccination campaign could not be justified.
Quarantine Considerable pressure was exerted by different individuals and groups to declare the situation an emergency and/or to quarantine the camp. The argument advanced for calling the situation an emergency was that the hospital bed TYPHOID FEVER
1189
shortage could be compensated for by sending patients to other of the 35 hospitals in Dade County. However, three considerations militated against such action. First, at the beginning of the outbreak, no estimate of bed needs was available, and 43 beds were known to be available. Second. the wisdom of distributing typhoid patients throughout the county was open to question. And third, an alternative lay in the fact that there were two large rooms available at the camp, which could have been used as ward rooms for boys and girls, if necessary. In this way, better control over treatment was considered probable. Because Jackson Memorial Hospital handled all admissions, no further action was required. The problem of quarantine was considered and discussed with appropriate representatives of the camp. These representatives warned that any attempt at quarantine would result in mass exodus. Such exodus could only be contained by support from the National Guard, in which case rioting might be anticipated. A compromise plan was developed. A letter was written (in English and in Spanish) and was delivered to each house stating that all residents were expected to remain in residence. They were authorized to leave camp to purchase food and to work in the fields. Children normally bused to school off the camp grounds were restricted to the camp, until they were cleared by presenting three successive daily negative stool samples (Figure .4). Intensive investigation revealed that only two families had left the camp prior to February 27. One family returned when the news media announced the typhoid outbreak. The second family was traced to a neighboring county. The health officer was notified, and the members of that family were cared for appropriately. The voluntary restrictions worked exceedingly well. A door-to-door study was made in each of the other labor camps. Three individuals were found
As a result of the typhoid outbreak, the following recommendations were made, both to a Congressional committee and to a state legislative committee: * All migrant housing during construction should be subject to the same laws as all other local housing; the same inspection, licensing, building codes, etc.; * All water and sewage plants should be approved by health department engineers. These should be inspected and approved during construction. Other agencies may also be involved; * All water supplied should be via approved public water utilities; * Each camp should have a representative group who inspect quarters and all other buildings, perhaps on a bi-weekly basis, at regular periods, to seek out (1) violations, (2) broken fixtures, (3) unsanitary conditions, etc; * A formal mechanism for reporting of needs should be established and this should include a follow-up to ensure correction; * An intensive program in health education in the language of the migrant farm worker should be
A
B
to have typhoid fever. Each of these three gave a definite history of having drunk the water at South Dade Labor Camp.
Recommendations
initiated; * A serious review of water standards should be carried out both nationally and statewide; * Water supply and sewage disposal authority should
be combined; All multiple toilet facilities should be eliminated; ATENCION!!!
NOTICE!!! A Cada Uno de los Residentes del Campamento de South Dade
To Each Resident of South Dade Labor Camp March 4, 1973
Because of the large outbreak of typhoid fever no one is permitted to change his residence from this camp. Should it be necessary for you to move you must first notify the camp manager of your new address. The reason for this is so that the health department can make sure that you receive proper treatment should you become ill. You may go to work or go out to buy food but visiting outside the camp is not allowed.No one will be permitted to attend schools outside the camp. Any person having stomach symptoms or fever should report to the auditorium. The water in the camp is highly chlorinated, and therefore safe to use for any purpose. In order to get rid of the bad taste we advise that you boil the water before using it.
March 4, 1973 Debido a la gran cantidad de personas afectidos por la fiebre
tifoidea no se permitira a nadie cambiar su residencia de este
campamento. Si le fuere necesario mudarse es necesario que usted notifique al gerente del campamento de su nueva direccion. La razon de esto es a fin de que el departamento de salud puda asegurarle tratamiento adecuado dado caso usted se enferme. Usted puede ir a trabajar o salir para comprar alimentos pero al visitar fuera del campamento es prohibido. No se permitira a nadie asistir a escuelas fuera del campamento. Cualquiera persona que tenga sintomas estomacales o fiebre debe reportarse al auditorio. El agua del campamento esta altamente clorificada y por lo tanto segura para cualquier uso. A fin de eliminar el mal gusto aconsejamos que se hierva antes de usarse. Remember it is for your benefit to remain within the camp Recuerde que es para beneficio suyo el quedar dentro del available. is where proper treatment readily campamento donde habra tratamiento apropiado para todos. Por orden de: Ordered By: Milton S. Saslaw, M.D. Milton S. Saslaw, M.D., Director Director del Departamento de Salud Condado de Dade Dade County Department of Public Health FIGURE 4 A and B, notices of modified quarantine.
1190 AJPH NOVEMBER, 1975, Vol. 65, No. 1 1
* Water supply under pressure and toilets should be provided in each living unit; * Adequate mechanisms of enforcement must be developed to allow for speedy effective action without threat of opposition; * Adequate funding is essential for proper implementation; * Adequate funding is necessary for adequate housing; * Adequate water supply and toilet facilities should be provided, in the fields (responsibility of property owners); * Water plant operators certified under the grand-
father clause should be required to take formalized
training. ACKNOWLEDGMENTS Cooperation from many agencies must be mentioned. In the present outbreak, besides many sections of the Dade County Department of Public Health, great assistance was freely made available by Organized Migrants in Community Action, Redlands Christian Migrant Association, Community Health of South Dade, Jackson Memorial Hospital, Variety Childrens Hospital, Homestead Air Force Base, Red Cross, Dade County Manager and staff, Florida State Division of Family Services, Florida State Division of Health, National Center for Disease Control, and a host of others.
HOW I STOPPED SMOKING
...
(Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
NO MORE BLOWING IN THE WIND I noticed in the last few issues of AJPH that you are publishing letters from former smokers. I found the articles most interesting because I was, at that time, a pack-a-day smoker. In reading the articles and in having my close friend's support, I began to believe in myself. Now, when I board a plane, I can finally say, "I prefer sitting in the nonsmokers section, please." It was difficult, as self-discipline always is, but my friend helped relieve the temptation of my reaching for a menthol cigarette by buying me four cigars. I found them most distasteful. I also from the very beginning had to convince my will power to control my bodily habit (mind over body). When I finally and I thought for me quitting was imachieved self-discipline, also did I my new-found integrity possible. I wish to thank you for publishing articles written by former smokers whose text was not medical terminology warning of the health hazards, risks, and consequences; but rather on the human sidethe slice of life. Also, I wish to thank my supportive friend whose uniqueness is a rarity to be admired. Together, you have helped me reacquire the moments of life I would have literally blown to the wind. I write this letter for your perusal in hope you may publish it, so that at least one smoker now will feel the elation shortly in saying "I kicked the habit." Joyce A. Smith 10901 Amherst Ave. Silver Spring, MD 20902 ...
TYPHOID FEVFR 1191
Fever
Public Health Aspects MILTON S. SASLAW, MD, DrPH JOEL L. NITZKIN, MD, MPH RONALD FELDMAN, MD WILLIAM BAINE, MD KENNETH PFEIFFER, PE MARGARET PEARSON, RN, MA
In February and March, 1973, a typhoid fever outbreak occurred in South Dade Labor Camp, Homestead, Florida. There were 210 recorded cases and no deaths. Public health aspects of the outbreak are discussed.
Introduction
History
The last major recorded epidemic of typhoid fever in the United States occurred in Manteno State Hospital, Illinois, in 1939. There were 453 cases, with 60 deaths. Sanitation procedures generally have been improved markedly since that time, but despite such improvement the South Dade Labor Camp near Homestead, Florida, developed a sizable outbreak early in 1973 (172 hospitalized, 38 not hospitalized, no deaths) (Table 1).
A 7-year-old girl was hospitalized January 14, 1973, with a diagnosis of possible appendicitis. Two weeks later she was shown to have typhoid fever. Epidemiological study indicated that her next-door neighbor, a 40-year-old female, had a Vi antigen titer of 1:320. This woman was quite friendly with the patient, and the judgment of the physicians was that she was the likely source of contagion. On February 23, two cases living at the same camp were reported to the Dade County Department of Public Health as "suspect typhoid fever." On that day, an epidemiologist and a sanitarian from the health department visited the homes of the patients and determined that: (1) there was no elicitable social or geographic relationship between the two, nor between either one and the proven case of the previous month; (2) there was an adequate chlorine residual in the water in each of the two housing units. On February 27, laboratory confirmation that Salmonella typhi was recovered from the stools of the two suspects was presented. Within 15 min a meeting was called involving the Director of the Dade County Department of Public Health and key personnel of the epidemiology, sanitation, and sanitary engineering staffs (including the assigned Epidemic Intelligence Service Officer). A representative team, including nurses, was dispatched immediately to review the situation at the camp. Background data on the camp's water supply were
Dr. Saslaw is Director, Dade County Department of Public Health, 1350 N.W. 14th Street, Miami, Florida 33125. Dr. Nitzkin is Chief of the Office of Consumer Protection, Dade County Department of Public Health. At the time of the outbreak, Dr. Feldman was Epidemic Intelligence Service Officer, Field Service Branch, Center for Disease Control, Atlanta, Georgia 30333. Dr. Baine was Epidemic Intelligence Service Officer, Bacterial Diseases Branch, Center for Disease Control, Atlanta, Georgia 30333. Mr. Pfeiffer was Assistant Head (Engineering), Office of Consumer Protection, Dade County Department of Public Health. Miss Pearson was Associate Chief (Nursing), Office of Consumer Care, Dade County Department of Public Health. Dr. Feldman's present address is: Departments of Gastroenterology and Medicine, University Hospital of San Diego County, San Diego, California. Dr. Baine's present address is: Department of Internal Medicine, Parkland Memorial Hospital, Dallas, Texas. Mr. Pfeiffer's is: Vice President of Operations, Florida Water and Utilities, 10700 Caribbean Blvd., Miami, Florida. Miss Pearson is retired, home address: 538 N.E. 38th Street, Miami, Florida. This article was presented in part at the 101st Annual Meeting of the American Public Health Association, November 6, 1973, in San Francisco, California. 1184 AJPH NOVEMBER, 1975, Vol. 65, No. 1 1
TABLE 1-Typhoid Fever Cases in South Dade Labor Camp, Homestead, Florida, February to May, 1973 Finding
Hospitalized
Not Hospitalized*
Total
Blood culture positive Stool culture positive Culture unspecified, positive 7 4-fold rise in "0" titer
108 22 35
3 1 32 2
111 23 67 9
Total
172
38
210
*
Cultures and titers positive on routine surveys. No illness reported.
reviewed. Through the past 2 years water testing had occasionally yielded unsatisfactory samples, usually evanescent and with low bacteriological counts. However, in December, 1972, an apparent increase in gastroenteric diseases was reported. Water samples taken December 29 showed high coliform counts. The engineer of the Dade County Department of Public Health, sent to the camp to determine the problem with the water supply, made recommendations on January 2, 1973, which were relayed to the camp management January 9, 1973. The conclusion was that the system could provide an adequate and safe water supply if properly serviced and maintained. Follow-up bacteriological samples collected January 3 and 12, and February 1 and 8, were all negative. Additionally, the presence of chlorine residuals was recorded on January 8. On February 22, on a routine inspection, no chlorine residual was observed. The water plant operator stated that the equipment had been in satisfactory operation that morning, but that later a failure had occurred. This was corrected the same day, and on the next day adequate chlorine residuals were again observed. From February 27 on, the problems faced by the Dade County Department of Public Health included (1) search for the cause of the outbreak; (2) tangential involvement in medical care and management of patients; (3) surveillance of residents; (4) follow-up of cases and suspects; (5) communications; (6) consideration of immunization; (7) initiation of quarantine; and (8) recommendations for future avoidance of similar outbreaks.
Search for Cause Intensive investigation of the water supply and of the sewage system was begun immediately. A number of suspicious findings were observed. These systems had originally been installed about 1940, and were replaced in 1969. The water was supplied from two wells. The first suspicious finding was that these wells were reported at first to be 50 feet deep with 38 feet of casing. The well driller's job log confirmed these depths. By sounding, however, an approximate depth of 20 feet was discovered. Later in our studies, we noted that the certificate provided by the state's Sanitary Engineering office had approved the 20 foot depth.
Second, in the center of the well house was a floor drain connected to an outside dry well surrounded by a vitreous clay pipe. When fluorescent dye was introduced into this well, it appeared in the water supply in 3 ".2 min. Third, dye was also painted on the ground about 10 feet from the water wells. In less than 15 min, the dye appeared in the water. Fourth, several holes were dug in the area of the well house. The old sewer system, abandoned in 1969, but close to the origin of the water supply, was found to contain human feces, as evidenced by the recovery of Salmonella
saint-paul. Fifth, inspection of the character of the ground revealed many solution channels in the area surrounding the wells. Sixth, about 100 yards from the wells was a common toilet facility. Immediately outside this facility was a grease trap, connected only to the sinks. Upon emptying the trap, human feces were found in it. Seventh, about 1000 feet away from the wells was a 50,000-gallon storage tank. This tank was cleaned and found to contain beer cans, bottles, other rubbish, and feces.
Medical Care Migrant laborers receive medical care through a nonprofit, voluntary health organization, Community Health of South Dade, Inc. (CHI). Funds are provided under a federal grant, supplemented by Dade County. This organization works in close relationship with the Department of Family Medicine of the University of Miami School of Medicine. All cases suspected of possible typhoid fever were screened by physicians in one of two clinics operated by CHI. Some of the suspects were hospitalized starting on Tuesday, February 27. The Dade County Department of Public Health Director communicated with an Assistant Director of James M. Jackson Memorial Hospital (county hospital) on the evening of Wednesday, February 28, and learned that 43 beds were available either at Jackson Memorial or Variety Childrens Hospital. At that time, the 43 beds were considered adequate for any immediate need. On February 28 also, a sample of residents at the camp were surveyed to determine the potential magnitude of the problem. This survey was carried out by Community Health Inc. personnel under the direction of the Dade County Department of Public Health. The preliminary study revealed that 20 to 25 per cent of the residents were involved. On March 2, 1973 (Friday), 35 public health nurses did a door-to-door check for all sick individuals, every contact, and every person who had been ill any time during the previous three weeks. These individuals were referred to physicians working in a temporary clinic set up by CHI in the auditorium of the camp. On Friday, it was apparent that additional bed space was needed. That evening, contact was made with the Director, Department of Hospitals, who agreed that every case and suspect would be hospitalized at Jackson Memorial Hospital. On Saturday, March 3, a high level Hospital Administrator was at the camp, and from then on, no patient was denied admission. TYPHOID FEVER
1185
Surveillance of Residents From March 2 on, repeated home visits were made by public health nurses, and any ill people were sent to the emergency clinic for physician evaluation. All suspects were hospitalized, and treatment with chloramphenicol or ampicillin for 14 days was utilized. After the sick were appropriately cared for, a rectal swab program was initiated
for all residents. Three successive daily samples were collected by public health nurses. As three negative swabs were collected, a notice of clearance was provided to each individual (Figures 1 to 3). Because of the unreliability of the water supply's chlorination system, the chlorine level was raised to 10 ppm, by which technique enforced boiling was assured. In a matter of a few days, a line was brought in from a
DADE COUNTY
DEPARTMENT OF PUBLIC HEAIT 1350 N. W. FOURTEEN STREET MIAMI, FLORIDA 381S3 DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES DIVISION OF HEALTH To: From:
Re:
0e
MILTON S. SASLAW. MD. MPH. DIRECTOR March 13, 1973
TELEPHONE 377-0341 Whom it May Concern Joel L. Nitzkin, M.D., Chief Office of Consumer Protection Policies and Procedures Concerning Quarantine at South Dade Labor Camp
During February and March of this year we have experienced a common source outbreak of typhoid fever caused by a contaminated water supply at South Dade Labor Camp near Homestead, Florida. To date, 196 persons have been hospitalized with 102 confirmed as typhoid Fever. On March 4, 1973, Milton S. Saslaw, M.D., Director of the Dade County Department of Public Health issued a quarantine notice to each resident of South Dade Labor Camp. The notice allowed residents to leave the Camp premises to work and to buy food, but prohibited visiting outside the Camp, attending school or changing
residence without prior approval.
During the past 10 days the health department has proceeded to obtain 3 rectal swab cultures on every man, woman and child in the Camp in an attempt to detect possible typhoid carriers and/or suspect cases during the incubation period. Two forms have been designed (copies attached) to assure adequate followup of cases and orderly release from quarantine for all typhoid cases and all other Camp residents.
The "STATEMENT OF UNDERSTANDING AND AGREEMENT" requires the patient to report for rectal swab cultures one month after onset of illness and prohibits change of residence without health department permission. The statement also prohibits
certain occupational pursuits. The "RELEASE FROM QUARANTINE1" is based on 3 consecutive negative rectal swab cultures and releases the individual from all restrictions imposed by the quarantine notice of March 4, and the "Statement of Understanding and Agreement." The release form will allow children to immediately re-enter school and provide the adults with written evidence of freedom from typhoid fever. Culture positive asymptomatic individuals and those still positive for typhoid will not be released from quarantine until appropriate treatment has been given and post-treatment cultures have been evaluated. Those few individuals who remain positive after re-treatment will be managed in accordance with the guidelines specified in the 1970 Edition of Control of Communicable Diseases in Man.
Approved and Forwarded: FIGURE 1
1186 AJPH NOVEMBER, 1975, Vol. 65. No. 1 1
MilFtUn Release from quarantine.
i'I'2i-/,-/ikL'. SR Saslaw,
M.D. ,Director
DADE COUNTY DEPARTMENT OF PUBLIC HEALTH 1350 N. W. FOURTEEN StREET IAMIY, FLORIDA MISS DEPARTMENT OF HEALTH & REHAINLITATIVE SERVICES DIVISION OF HEALTH HLTOW I. S^SLAW. Me. "M. WRecToS
TELEPHNE 3774341
Q U A RA N T I N E
FRO M
R E L E A S E
This is to certify that
Birthdate:
, South Dade Labor Camp, has shown no evidence of typhoid on
of House Nvwber
three (3) consecutive rectal swab cultures taken at least a day apart.
Signed:
Date:
L I BER A C IO N
PHN
C U A R E N T E N A
D E
Por la presente certifico que
vecino de
(n&ero de
la casa)
, ,
-
nacido en
del Campo de Trabajadores del Sur
de Dade (South Dade Labor Camp),, ha tenido tres cultivos negativos a tifoidea toma-
dos por isopo rectal en tres
dtas
consecutivos. EPHN
Fecha FIGURE 2
neighboring public water utility to provide a temporary potable supply. Later, a permanent connection replaced the wells.
Follow-up of Cases and Suspects Each hospitalized individual was contacted by a public health nurse while still in hospital. Explanation of time for reswabbing was provided. Those patients who failed to present themselves at CHI for recheck were visited in their homes by the public health nurses, and samples were collected. Release notices were issued to all those from whom three negative samples were obtained. Blood samples also were collected appropriately for confirmation of typhoid fever, basically among suspects with negative stool samples. Public health nurses were stationed at the camp, daily seven days a week through March and five days a week through mid-May, and they made occasional visits through July. In all, over 6700 rectal swabs were collected and examined.
Release form.
Communications A large scale outbreak of this nature naturally leads to reaction varying from concern to alarm. News medianewspapers, magazines, TV, radio, local, state, and national-all clamored for updated information, and pressed for answers before investigations were complete. Official hearings also were held-two congressional, several state-as well as a large number of unofficial ones. In order to assure that all media received the same data, several policy decisions were invoked. First, the truth, the whole truth, and nothing but the truth was the basis of all responses. Naturally, these items changed from hour to hour, as data were reported in. Second, one man, the Director, provided all news items for about 10 days. Third, because of the impossibility of one man's responding to all calls, a tape recording was prepared daily, and this was played back to all callers. Fourth, while providing up-todate information, every effort was exerted to avoid creating widespread alarm. Fifth, meetings of key health department TYPHOID FEVER
1187
DADE COUNTY DEPARTMENT OF PUBLIC HEALTH 1350 N. W. FOURTEEN STREET MIAMI, FLORIDA 33195
im
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES DIVISION OF HEALTH MILTON S. SASLAW. MD. MPH. DIRECTOR TELEPHONE 377-0341
STATEMENT OF UNDERSTANDING AND AGREEMENT
I,
,
of
Birthdate:_
_
(current Dade County address)
understand that the germ of typhoid fever may persist in my body even after a full course of hospital treatment.
This may cause me to get sick with typhoid fever
again, or may cause me to become a carrier of typhoid who might give this disease to other persons.
In order to protect my own health and the health of other persons, I agree to the
1.
2.
following:
I will not change my place of residence without the permission of the Dade County Department of Public Health until I receive a properly signed "RELEASE FROM QUARANTINE." I shall report to the special clinic at the South Dade Labor Camp at 9:00 a.m. (date) to begin the series of 3 rectal-swab cultures as
on
directed by the health department. 3.
I understand that additional medical treatment may be needed to completely cure me from typhoid.
4.
I shall not work as a restaurant worker, babysitter, maid or hospital worker until I have received a properly signed "RELEASE FROM QUARANTINE."
5.
I understand that failure to obtain a properly signed "RELEASE FROM QUARANTINE" may result in my name being placed on a national listing of possible typhoid carriers.
Date:
Signed: (Patient, Parent
or
Guardian)
Witness: Witness: FIGURE 3
A and B, statements of understanding.
personnel were held at least daily to review and update all known facts, and to assure complete handling of every situation. The Florida State Division of Health, Bureau of Preventable Diseases, Section on Epidemiology, assisted the local program by sending out appropriate notification bulletins to every State Health Officer and to the administrative officer in every migrant program throughout the country. Three national releases were published in the Morbidity and Mortality Weekly Report by the Center for Disease Control. 1188 AMPH NOVEMBER, 1975, Vol. 65, No. 11
Immunization This was considered very seriously. After much deliberation and discussion with the Center for Disease Control, mobilization of a massive typhoid vaccination campaign in all or part of Dade County, or even in the camp alone, was ruled out because: * The vehicle of transmission in the outbreak had been identified and was amenable to direct control; * Further propagation of the outbreak on a wide scale, requiring person-to-person transmission of
DADE COUNTY DEPARTMENT OF PUBLIC HEAL[TH 1350 N. W. FOURTEEN STREET MIAMI, FLORIDA 33125
I -
.$7-r:, WA
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES DIVISION OF HEALTH
J. 9
MILTON S. SASLAW. MD. MPH. DIRECTOR TELEPHONE 377-0341
DECIAPACION REFERENTE A ENTENDER Y ESTAR DE ACUERDO: Yo,
, nacido en _
_
_
_
_
, vecino de Fecha (domicilio en Dade County al presente),
_ _ _
he sido informado y comprendo que el germen de la fiebre tifoidea puede permanecer en mi cuerpo aun
despugs
de completar un tratamiento de hospital.
Esto
puede ser causa de que me enferme de nuevo con la tifoidea, o puede ser que me convierta en un portador de tifoidea y pueda contaminar a otras personas. En orden de proteger mi propia salud y la de otras personas, yo estoy de
acuerdo y consiento en lo siguiento:
1.
Yo no cambiare de domicilio sin el permiso del Departamento de Salud del Dade County hasta que yo reciba una notificacion privada liberandome de la cuarentena; esa notificacion se titulara "LIBERACION DE CUARENTENA".
2.
Yo concurrirg a la Clinica de los Trabajadores Migratorios del Campo Sur de Dade (South Dade Labor Camp Clinic) a las 9 AM del dia Fecha para ser sometido a la prueba de tres isopos rectales consecutivos siguiendo las instrucciones del Departamento de Salud.
3.
Yo he sido informado y entiendo que para completar mi curacion es posible que yo necesite ser tratado de nuevo.
4.
Mientras no reciba la "LIBERACION DE CUARENTENA", yo no trabajare en restaurantes ni en ningun otro establecimiento que expenda comidas, ni cuidare' ninos de otras familias, ni trabajare en un hospital.
5.
He sido informado y entiendo que de no recibir la "LIBERACION DE CUARENTENA" mi nombre sera incluido en la lista nacional de portadores de ti-
foidea.
Fecha:
Firma:
(Paciente o persona autorizada)
Testigo-.
Testigo: FIGURE
infection, was not anticipated on the basis of established knowledge of the epidemiology of typhoid; * Typhoid vaccine, even when administered according to the recommended schedule, with two injections spaced 4 weeks apart, does not afford complete immunity against infection; * Vaccination is accompanied by considerable mor-
bidity; * Diversion of available health workers to undertake
a predictably unprofitable mass vaccination campaign could not be justified.
Quarantine Considerable pressure was exerted by different individuals and groups to declare the situation an emergency and/or to quarantine the camp. The argument advanced for calling the situation an emergency was that the hospital bed TYPHOID FEVER
1189
shortage could be compensated for by sending patients to other of the 35 hospitals in Dade County. However, three considerations militated against such action. First, at the beginning of the outbreak, no estimate of bed needs was available, and 43 beds were known to be available. Second. the wisdom of distributing typhoid patients throughout the county was open to question. And third, an alternative lay in the fact that there were two large rooms available at the camp, which could have been used as ward rooms for boys and girls, if necessary. In this way, better control over treatment was considered probable. Because Jackson Memorial Hospital handled all admissions, no further action was required. The problem of quarantine was considered and discussed with appropriate representatives of the camp. These representatives warned that any attempt at quarantine would result in mass exodus. Such exodus could only be contained by support from the National Guard, in which case rioting might be anticipated. A compromise plan was developed. A letter was written (in English and in Spanish) and was delivered to each house stating that all residents were expected to remain in residence. They were authorized to leave camp to purchase food and to work in the fields. Children normally bused to school off the camp grounds were restricted to the camp, until they were cleared by presenting three successive daily negative stool samples (Figure .4). Intensive investigation revealed that only two families had left the camp prior to February 27. One family returned when the news media announced the typhoid outbreak. The second family was traced to a neighboring county. The health officer was notified, and the members of that family were cared for appropriately. The voluntary restrictions worked exceedingly well. A door-to-door study was made in each of the other labor camps. Three individuals were found
As a result of the typhoid outbreak, the following recommendations were made, both to a Congressional committee and to a state legislative committee: * All migrant housing during construction should be subject to the same laws as all other local housing; the same inspection, licensing, building codes, etc.; * All water and sewage plants should be approved by health department engineers. These should be inspected and approved during construction. Other agencies may also be involved; * All water supplied should be via approved public water utilities; * Each camp should have a representative group who inspect quarters and all other buildings, perhaps on a bi-weekly basis, at regular periods, to seek out (1) violations, (2) broken fixtures, (3) unsanitary conditions, etc; * A formal mechanism for reporting of needs should be established and this should include a follow-up to ensure correction; * An intensive program in health education in the language of the migrant farm worker should be
A
B
to have typhoid fever. Each of these three gave a definite history of having drunk the water at South Dade Labor Camp.
Recommendations
initiated; * A serious review of water standards should be carried out both nationally and statewide; * Water supply and sewage disposal authority should
be combined; All multiple toilet facilities should be eliminated; ATENCION!!!
NOTICE!!! A Cada Uno de los Residentes del Campamento de South Dade
To Each Resident of South Dade Labor Camp March 4, 1973
Because of the large outbreak of typhoid fever no one is permitted to change his residence from this camp. Should it be necessary for you to move you must first notify the camp manager of your new address. The reason for this is so that the health department can make sure that you receive proper treatment should you become ill. You may go to work or go out to buy food but visiting outside the camp is not allowed.No one will be permitted to attend schools outside the camp. Any person having stomach symptoms or fever should report to the auditorium. The water in the camp is highly chlorinated, and therefore safe to use for any purpose. In order to get rid of the bad taste we advise that you boil the water before using it.
March 4, 1973 Debido a la gran cantidad de personas afectidos por la fiebre
tifoidea no se permitira a nadie cambiar su residencia de este
campamento. Si le fuere necesario mudarse es necesario que usted notifique al gerente del campamento de su nueva direccion. La razon de esto es a fin de que el departamento de salud puda asegurarle tratamiento adecuado dado caso usted se enferme. Usted puede ir a trabajar o salir para comprar alimentos pero al visitar fuera del campamento es prohibido. No se permitira a nadie asistir a escuelas fuera del campamento. Cualquiera persona que tenga sintomas estomacales o fiebre debe reportarse al auditorio. El agua del campamento esta altamente clorificada y por lo tanto segura para cualquier uso. A fin de eliminar el mal gusto aconsejamos que se hierva antes de usarse. Remember it is for your benefit to remain within the camp Recuerde que es para beneficio suyo el quedar dentro del available. is where proper treatment readily campamento donde habra tratamiento apropiado para todos. Por orden de: Ordered By: Milton S. Saslaw, M.D. Milton S. Saslaw, M.D., Director Director del Departamento de Salud Condado de Dade Dade County Department of Public Health FIGURE 4 A and B, notices of modified quarantine.
1190 AJPH NOVEMBER, 1975, Vol. 65, No. 1 1
* Water supply under pressure and toilets should be provided in each living unit; * Adequate mechanisms of enforcement must be developed to allow for speedy effective action without threat of opposition; * Adequate funding is essential for proper implementation; * Adequate funding is necessary for adequate housing; * Adequate water supply and toilet facilities should be provided, in the fields (responsibility of property owners); * Water plant operators certified under the grand-
father clause should be required to take formalized
training. ACKNOWLEDGMENTS Cooperation from many agencies must be mentioned. In the present outbreak, besides many sections of the Dade County Department of Public Health, great assistance was freely made available by Organized Migrants in Community Action, Redlands Christian Migrant Association, Community Health of South Dade, Jackson Memorial Hospital, Variety Childrens Hospital, Homestead Air Force Base, Red Cross, Dade County Manager and staff, Florida State Division of Family Services, Florida State Division of Health, National Center for Disease Control, and a host of others.
HOW I STOPPED SMOKING
...
(Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
NO MORE BLOWING IN THE WIND I noticed in the last few issues of AJPH that you are publishing letters from former smokers. I found the articles most interesting because I was, at that time, a pack-a-day smoker. In reading the articles and in having my close friend's support, I began to believe in myself. Now, when I board a plane, I can finally say, "I prefer sitting in the nonsmokers section, please." It was difficult, as self-discipline always is, but my friend helped relieve the temptation of my reaching for a menthol cigarette by buying me four cigars. I found them most distasteful. I also from the very beginning had to convince my will power to control my bodily habit (mind over body). When I finally and I thought for me quitting was imachieved self-discipline, also did I my new-found integrity possible. I wish to thank you for publishing articles written by former smokers whose text was not medical terminology warning of the health hazards, risks, and consequences; but rather on the human sidethe slice of life. Also, I wish to thank my supportive friend whose uniqueness is a rarity to be admired. Together, you have helped me reacquire the moments of life I would have literally blown to the wind. I write this letter for your perusal in hope you may publish it, so that at least one smoker now will feel the elation shortly in saying "I kicked the habit." Joyce A. Smith 10901 Amherst Ave. Silver Spring, MD 20902 ...
TYPHOID FEVFR 1191
