Generally speaking, any unnecessary public gatherings are inadvisable during any epidemic. While our exact knowledge of the mode of transmission of influenza is incomplete, it is unquestionably a contact disease. People who have been exposed and who have not yet contracted the disease are known to have transmitted it to a third person. A certain number of people from infected homes will attend public gatherings as long as they are able, for it is impossible to get together any large group of persons all of whom are going to play fair. It is true that these meeting places may be used in a measure to allay panic and to instruct the public in health measures, but there are many efficient and far less dangerous methods of accomplishing the same results. Vaughan in discussing assemblies in large halls mentioned that in a hall at Camp Forest, which held 9,000 people, the individuals had a space of about 16 inches laterally between their noses. He pointed out that if many of them were talking, coughing or sneezing, the air contamination would soon become so great that it could make little difference whether there was a roof over the building or not. He emphasized the fact that it is just as possible to crowd men in the open as it is indoors. Ventilation is undoubtedly an important factor, but it cannot correct overcrowding. As far as the educational value of the public gatherings was concerned, it may be observed that regular attendants of theatres and moving-picture houses during the year of 1918 had become quite accustomed to appeals regarding all sorts of public movements from speakers who appeared between the acts, or pictures, but that the closing of these places threw a wholesome scare into them which made them pay far closer attention to prophylactic measures than almost anything that could have happened. “Object-lessons are always superior to didactic teaching.” In Chicago a new argument for the closing of theatres was advanced. It was said that with no place to go many people retired earlier and obtained more than their accustomed amount of rest. It was believed that this aided in increasing their natural resistance. The argument that the closing of these places served only to delay the epidemic is an argument in favor of the measure, because the virulence of the disease decreased rapidly as the epidemic progressed.
The Closing of Schools
Boards of Health generally were opposed to the closing of the public schools. This position gave rise to innumerable clashes with anxious parents. The health authorities took the position that children were relatively insusceptible to influenza; that while they were quiet in a well-ventilated schoolroom they were little exposed; that those who coughed or sneezed could be examined at once, and that daily school inspection would lead to early discoveries of all cases, so that doctors and nurses could take immediate steps to treat the patients and to protect the families from which they came. Copeland advocated the continuance of the schools in New York, and based his position on the fact that out of 1,000,000 children in New York City 700,000 came from tenement homes. He believed these children were far better off in school, where they received daily medical attention, than upon the streets or in unhygienic homes.
In Pittsburgh the school children were quizzed as to the number of sick at home, and this gave valuable information on the stage of the epidemic. They were sent home with printed warnings against sneezing, coughing and spitting, and were thus used as a means of instructing their parents. The Pittsburgh schools were kept open until the sickness of a number of teachers and the withdrawal of many scholars made it advisable to close.
Three very potent arguments have been brought forward in favor of closing the schools: (1) As long as the schools are open children from infected homes are forced into contact with children from uninfected homes, and we are at present unaware of the extent to which the disease may be carried by a third person. (2) Children in as yet uninfected homes which are comfortable and hygienic are far better off than they are in school, and can hardly be considered in the same class with children from unclean tenements. (3) If the period of greatest contagion is before symptoms develop, inspection, while valuable for the institution of treatment, cannot hope to aid in curbing the epidemic. It is evident that different measures must be employed in applying closing orders to crowded cities, moderately large towns and rural districts. The difficulty lies in determining the best means for serving each community.
The Closing of Public Dance Halls
Public dances should undoubtedly be prohibited during epidemics. They not only present all the bad features of other public gatherings, but during the dancing people are brought in very close contact and often breathe directly into each other’s faces. In addition, air currents are stirred up and a certain amount of dust is raised. During the exercise the dancers breathe more rapidly and deeply, thus inhaling unusually large amounts of dust, droplets and contaminated air. Another feature is found in the “resistance-breaking” element of alternate overheating and rapid cooling of the body.
Regulation of Public Eating and Drinking Places
Public eating places are a necessity and cannot be closed. People should be cautioned against using them as places of amusement and of congregation during epidemics. Boards of Health should feel it just as much their duty to see to the sterilization of dishes and eating utensils as they do to the enforcing of any other public health functions, and they should also insist on the daily inspection of the employees of such establishments. The beer saloon question may be passed over for the present, but the soda-water fountain as conducted during the 1918 epidemic was undoubtedly a great menace. Ice cream, syrupy mixtures, etc., of various kinds are readily contaminated by pathogenic organisms which may serve as secondary infectors, if in no other capacity. The syrups, moreover, adhere to the spoons and glasses, which are rarely thoroughly washed and are practically never sterilized between customers. The use of paper dishes and glasses is probably a step in the right direction, but the spoons should be thoroughly washed and sterilized. The fact that soda-water employees are not always selected for high-grade intelligence, and are generally left largely to their own hygienic procedures, makes the chances of transferring infections at these places enormous. If soda fountains are allowed to continue business at all during the epidemics, it should be only under the very strictest supervision by Boards of Health. The scalding of all utensils should be enforced by law.
People generally should be cautioned to use exceptional cleanliness in the preparation of all foods in the home. In discussing the recent epidemic Lynch and Cummings (50) stated that “the mess-kit wash water proved the major route of transmission from sick to well in the army.” Vaughan said: “I am pretty certain, not convinced, that hand-to-mouth infection is of more importance than droplet infection.”