The American Journal of Tropical Medicine and Hygiene - Volume s1-29, Issue 4, 1949

As part of the U. S. P. H. S. project in Liberia, a clinical laboratory survey of the major infectious diseases of 5 sections of Liberia was done during the year of 1947 and the first half of 1948. A total of 8,846 persons was selected as a fair sample of clinic admissions and were given routine stool, urine and blood examinations and some special tests.

In all of the areas studied intestinal helminthiasis ranked highest in relative prevalence, followed in most instances by the diarrheas-dysenteries, treponemiasis and malaria.

In the Sanoquelle District T. gambiense were found in gland puncture or blood smear or both in 19 per cent of a series of routine clinic patients. This is evidently the area of highest trypanosomiasis incidence in the Republic. The Sanoquelle District is also the area of greatest schistosomiasis concentrations. A routine urine survey of the leprosy colony in this district revealed 16 per cent with S. hematobium while 2 per cent of their stools showed S. mansoni.

A detailed and repeated study of the stools of leprosy patients over a 3-year period revealed that 36 per cent of them harbored E. histolytica during the period, most of them having intermittent bouts of diarrhea or dysentery.

The high incidence of individual mycotic infections and of some of their etiological combinations are presented as well as a comparative study of the microbic flora of tropical ulcers during the dry and wet seasons in Liberia.

• 1.  A total of something over 500 veterans have been examined in the Tropical Disease Clinic of the Regional Office of the Veterans Administration, Winston-Salem, N. C., in the past eighteen months.
• 2.  Of four hundred and eighty-four examined for intestinal protozoal and helminthic infections three hundred and nine or 63.8 per cent have yielded positive findings.
• 3.  One hundred and ninety-one or 39.4 per cent have had infections by E. histolytica. With very few exceptions these infections have been accompanied by significant symptoms and disability.
• 4.  Other tropical infections have been of much less importance. The incidence of relapsing malaria is rapidly decreasing; no serious sequelae of filariasis or schistosomiasis have been seen.
• 5.  The most striking fact has been the almost invariable failure of the veteran to obtain an accurate diagnosis in advance of the investigation in the Clinic.
• 6.  Of perhaps equal importance is the frequency with which the diagnosis of record has been psychoneurosis.
• 7.  The findings of this study made of a selected group of veterans emphatically indicates the necessity for a competent survey to determine the actual importance of chronic tropical and parasitic infections among the total veteran population of the country.
• 8.  The lack of adequately trained clinicians and laboratory technicians in tropical medicine and medical parasitology is reflected in the problems of many veterans and in the ultimate costs to the taxpayers.

In Texas 286 of 859 (33.3 per cent) specimens of the genus Triatoma were found naturally infected with Trypanosoma cruzi. The species of Triatoma which were examined included: T. gerstaeckeri, T. lecticularius, T. protracta, T. Sanguisuga, T. neotomae and T. rubida. One or more individuals of each of these 6 species were found to be carriers of the trypanosome.

Bird malaria parasites have never been described from the Malay Peninsula, as far as the author is aware, although some were reported from the East Indies by Uegaki (1930) and others. The observations on avian plasmodia which are reported here, were made by the author while working in the Institute for Medical Research, Kuala Lumpur, Federated Malay States, in 1945.

Avian plasmodia were obtained from seven kinds of wild birds which were captured in the vicinity of the city of Kuala Lumpur. The species of plasmodia and their hosts are listed below.

Three species of parasites, Plasmodium relictum, P. circumflexum and P. lophurae, were found in 198 hosts belonging to seven species. The infection rate averaged 19.2 per cent. The highest rate was estimated as 69.6 per cent, and was found in the case of P. circumflexum and Munia striata. Most of the hosts were very heavily infected.

• 1.  Weekly administration of suppressive doses (0.5 gm.) of chloroquine diphosphate, without recourse to antimosquito measures, not only effectively controlled malaria in the village of Saideh, Lebanon, but reduced the splenic index from 59 to 6, and the average size of enlarged spleens (AES) from 1.9 to 0.12, within an average treatment period of 26 weeks.
• 2.  The splenic index decreased only from 70 to 50 during the corresponding period of eight months when effective malaria control was established for the neighboring village of Amik by means of D.D.T. residual spray.
• 3.  Chloroquine diphosphate can be administered in weekly suppressive doses for at least seven months without undesirable side-effects, even in pregnancy, and is recommended for the treatment of splenomegaly due to chronic malaria.
• 4.  It is concluded that malaria eradication within a single season will be facilitated by the combined operation of mass suppressive medication with chloroquine diphosphate and appropriate application of D.D.T., thereby simultaneously reducing both the human and insect reservoirs of the disease.

This paper is the second in a series of cytologic studies on Toxoplasma. The first dealt with the cytologic structure of the parasite as found in the ascitic fluid of the infected mouse and as revealed by the Feulgen reaction (1). An investigation of the inflammatory reaction to Toxoplasma, simultaneously, in the omentum and in the peritoneal fluid follows logically because: 1. The close juxtaposition of this tissue and the fluid obligates their concomitant consideration; 2. Certain artifacts of common occurrence with other tissues may be avoided with the omentum; (a) Sectioning for microscopic examination is unnecessary; (b) The blood vessels and nerves may be observed in situ in relatively lengthy unmutilated portions; (c) The inoculation is without trauma to the omentum so that infection results from an unmodified selective migration of the parasite; and 3. The varied cellular structure of the omentum permits the assumption of a similar pattern of invasion for other tissues in the mouse.

Six thousand eight hundred and two Salmonella strains from 500 outbreaks and isolated cases were studied. The strains originated from the United States, the Caribbean Islands, Venezuela and Colombia. The distribution of the Salmonella types was discussed. The source of infection could be traced in 79 outbreaks to cases of disease, human carriers, fowl, pork, eggs, water and rodents contaminating food in storage. Examination of food samples collected in Illinois and in Puerto Rico showed a higher number of samples infected in the Caribbean. Food inspection lessens the danger of salmonellosis.

• 1.  Plague which was first demonstrated in New Mexico in 1938 has apparently been present in Rio Arriba County for 6 years.
• 2.  During a 14-week study in 1948, 3,298 animals were collected from which 4,650 fleas, 337 ticks and 38 lice as well as 3 tissue samples were obtained.
• 3.  Plague was isolated 18 times from tissue and ectoparasites of prairie dogs and twice from ectoparasites from marmots. Indirect evidence of plague in smaller rodents was obtained from a study of population numbers.

Throughout this paper “typhus” is to be taken as meaning epidemic, louse-borne or “classical” typhus.

This disease is known to prefer temperate climates, and Arabia is notoriously hot. Typhus most frequently occurs where people are crowded together, and Arabia is sparsely populated.

Together these statements might lead us, to assume that typhus does not occur in Arabia, and a glance at existing maps of typhus distribution in the world will show the whole of Arabia as a blank.

So far as I know, the outbreak here described from Yemen is the first to be recorded from Arabia proper. The countries bordering upon Northern Arabia, especially Egypt and Iraq, are old typhus foci, but the nearest focus to El Yemen, the Arabic Kingdom now discussed, is Ethiopia, and it may well be that it is from Ethiopia that typhus came to Yemen (Fig. 1)

• 1.  Human cases of Q fever in Northern California appear to be at least as frequently associated with contact with sheep and goats as with cattle.
• 2.  Serologic studies, however, indicate that infection with C. burneti is much more prevalent in sheep (37.9 per cent) and goats (43.6 per cent) epidemiologically linked with human cases, than in cattle similarly associated with human infections.
• 3.  Serologic surveys of the general sheep and cattle population, as sampled through animals received at slaughterhouses, indicate that the extent of infection in this group is small; 3.1 per cent of the cows and calves and 3.5 per cent of the sheep examined were found to possess antibodies. Too few data on goats were available for analysis.
• 4.  The serologic data indicate that infections in man, sheep and quite probably goats, are epidemiologically related.
• 5.  That the role of sheep and goats in the epidemiology of the human disease is important finds additional support in the demonstration that the rickettsia is excreted in the milk of these species.
• 6.  The possibility of air-borne transmission of Q fever is considered and discussed.

Until quite recently the opinion has been widely held that poliomyelitis was essentially a disease of temperate climates, that it was relatively uncommon in the tropics, and in particular, that epidemics in tropical regions were rare. This impression has been borne out by reports from many tropical areas, such as those listed by McKinley in 1935 (1); by reports from the Health Section of the League of Nations during the 1930s (2); and many others. Simmons el al (3) stated that: In British Malaya, poliomyelitis is rare; in Burma, poliomyelitis is so rare that it was never listed in their records. Comments from a number of other tropical or subtropical countries have referred to the local endemicity of the disease and to the fact that, the patients have been largely confined to infantile age groups.

But within recent years there has been reason to question the rarity of the disease in the tropics, as well as the absence of epidemics there.

During an epidemic wave of yellow fever, which entered the western part of the State of Minas Gerais in 1935, virus spread throughout the numerous small discontinuous forest patches which characterize this area. These forest patches are uninhabited by humans but have a permanent population of cebus monkeys. Evidence is presented which indicates that the virus probably persisted in these isolated forests only for a short time after the cessation of human infections. There is no evidence that virus is active in this area at the present time.

Aedes leucocelaenus Dyar and Shannon is shown to be an efficient vector of yellow fever virus, producing fatal infection, by bite, in laboratory animals.

On the basis of an assumed transmission rate of 1.00 for Aëdes aegypti, the following transmission ratios were obtained: Aëdes leucocelaenus, 1.29; a mixed group of Haemagogus capricornii and H. spegazzinii, 0.73; H. equinus, 0.45; Aëdes scapularis, 0.31; and H. splendens, 0.16.

• 1.  Three types of anal swabs for the diagnosis of Enterobius vermicularis infection were studied: (i) The NIH cellophane swab as described by Hall (ii) the wet pestle swab as described by Schüffner and Swellengrebel and (iii) the transparent adhesive cellulose tape as suggested by Graham, but used in the manner first described by Jacobs, and prepared for microscopic examination in a manner described as new in this paper, the essential feature of the new modification being the use of toluene to clear the preparation.
• 2.  On a small series of transparent adhesive tape specimens it was found that using a drop of toluene between the slide and the tape to clear the preparation increased the positive findings by an average of 24 per cent and decreased the time necessary for examination by an average of 40 per cent.
• 3.  Of 236 positive specimens obtained by simultaneous use of the NIH and wet pestle swabs, 91.5 per cent were diagnosed by wet pestle as compared with 75 per cent by NIH swab. Respectively, the pestle and NIH preparations averaged 88 and 52 eggs per preparation.
• 4.  Of 160 positive specimens obtained by simultaneous use of the wet pestle and transparent tape, 76.3 per cent were diagnosed by wet pestle and 95.6 per cent by transparent tape. Respectively, the pestle and tape preparations averaged approximately 50 and 1,000 eggs.
• 5.  The greater efficiency of the tape technic was found to be due in part to the ease with which the novice can be taught to use it properly. Some of the physicians, nurses, medical students, parents, and matrons made frequent serious technical errors in the use of the others but all were about equally efficient in taking specimens with the transparent adhesive tape.

The successful results reported in the treatment of Wuchereria bancrofti infections with 1-diethylcarbamyl-4-methyl-piperazine (“hetrazan”) 2 (1) prompted us to try this new drug in case of Loa loa infection. To date, we have treated five cases. As is frequently the case in Loa loa infections, microfilariae could not be found in the venous blood. However, the clinical picture is distinctive and a diagnosis can be established without the finding of microfilariae. Good results have been obtained in all five cases. All were completely relieved of symptoms and the only recurrence was in one case in which the chief manifestation was an unusual one, diffuse pruritis.

THE CASES We have tabulated the important clinical findings in the five cases (Table 1). All were adults; there were four men and one woman. Three were missionaries in the French Cameroons, one a merchant from the same area, and the fifth a physician who had worked for several years in Angola.

• 1.  In an attempt to develop a therapeutic regimen suited for rapid mass administration to unhospitalized ambulatory patients, Fuadin (“Repodral-Wintrop”) was employed in the treatment of 55 Syrian villagers known to be infected with S. haematobium.
• 2.  Treatment was preceded by a complete physical examination including blood studies, examination of thorax and abdomen, blood pressure, temperature, and radial pulse measurements, and individuals showing organic or other complicating conditions other than urinary schistosomiasis were ruled out. The general physical condition of the villagers is discussed briefly.
• 3.  The drug was administered intramuscularly over a three-day period to adults in a course of 34 cc. of a 6.3 per cent solution, comprising a total of nine injections. The first day, three injections of 2 cc., 4 cc., and 4 cc. were given at four-hour intervals. On the subsequent two days, three injections of 4 cc. each were given daily at three hour intervals. In school children, a total dose of 17 cc. was administered in nine injections given over a three day period. The first dose of 1 cc. was followed by two doses of 2 cc. each at three hour intervals, and the remaining six doses were given as three 2 cc. doses daily taken at three hour intervals.
• 4.  Reaction to the drug was generally mild, although considerable muscular soreness developed in the buttocks, the site of injection. Transitory constitutional reactions developed in some of the cases, particularly among the adult group. In no case, was it felt that the toxic manifestations were severe enough to warrant discontinuance of the treatment.
• 5.  Follow-up studies were made for a five-day period immediately after treatment, and repeated two weeks later. Effectiveness of treatment was judged by egg-hatching experiments, with particular attention to the percentage of cases showing: (1) free-swimming miracidia in diluted urine sediments, (2) unhatched, normal-sized eggs, (3) small, degenerate eggs and (4) no eggs. Later follow-up studies, while admittedly desirable, would have been complicated by constant opportunity for re-infection.
• 6.  Because of the unavoidable brevity of the second follow-up study, it is not felt that any sweeping claims can be made concerning the intensive therapeutic regimen described herein. It is felt, however, that cessation of egg production in roughly 50 per cent of the cases during the last three days of the second observation period, and the complete cessation of production of free-swimming miracidia in from 60 to 70 per cent of the cases during the last four days of the second observation period, constitutes evidence of definite improvement.
• 7.  Attention is called to the possible value of such an intensive short-course treatment as a prophylactic approach applicable to public health programs, where mass reduction in viability of eggs voided by man, the only suitable definitive host for this parasite, would prevent suitable snail hosts becoming infected, thus contributing heavily toward a reduction of the disease in endemic areas.
• 8.  In view of the apparent lack of toxicity of Fuadin when given under the intensive regimen, its further trial and study under similar conditions seems indicated.

E. batatas (Linnaeus) is reported attacking man in the San Joaquin Valley of California. This is a tropical mite whose reported distribution in the United States has previously been limited to the extreme southeastern portion of the country. Although human chigger infestations had not been verified prior to this investigation, the mites are now known to occur in two counties in the southern half of the San Joaquin Valley. Based on evidence at hand, it is believed that the distribution of chiggers infesting man in California is much more general than is now known

The vector relationship, if any, of E. batatas to disease has not been ascertain to date. It is, however, a very annoying pest and for the reason alone has a definite public health significance.

Control is somewhat complicated by the fact that it is reported to have a very wide host range.

The relation of fly habits to cultural sanitation and DDT fly control have been presented with some of the specific problems encountered in various food handling and food processing establishments. The success of fly control with DDT sprays is shown to be governed by the extent to which it is coordinated with the biology of the insects concerned and with the sanitary measures practiced.

At the April 16 meeting of the Biological Stain Commission the Board of Trustees voted that hereafter Giemsa stain will be certified in two varieties, namely “Giemsa stain, Azure B type, for malaria and blood work” and “Giemsa stain, Azure A type, for hematology and bacteriology”.

The Azure B type closely resembles tinctorially and spectroscopically the Grübler and Hollborn Giemsa stains of the 1930's and is the variety especially recommended to give the faintly greenish blue tint to parasite cytoplasm which contrasts well with the grayish or greenish blue background of the thick film stained at pH 7.0. This is recommended by many malariologists for thick film work.

The Azure A type gives darker red chromatin stains, grayer or more violet blue lymphocyte cytoplasm, and perhaps somewhat heavier staining of microorganisms. Its useful life is probably shorter under average tropical storage conditions. It is preferred by many American hematologists.

The annual business meeting of the Officers and Council was held at noon on December 6, 1948 at the Roosevelt Hotel. Those present were: Doctors J. S. D'Antoni, N. H. Topping, M. F. Boyd, F. J. Brady, P. E. Russell, H. Most, M. E. Barnes, H. R. Cox, W. A. Sodeman, E. I. Salisbury, H. E. Meleney, E. C. Faust, and T. T. Mackie. Those absent were Doctors E. G. Hakansson, J. Andrews, K. R. Lundeberg, and J. C. Snyder. The President, Dr. J. S. D'Antoni, presided.

The minutes of the previous meeting held on December 1, 1947 were approved as published in the JOURNAL of March 1948 subject to the correction of the name of a new member, Luis Najera A., which was erroneously recorded as Angulo, L. N.

The President appointed Dr. M. E. Barnes and Dr. H. Most as the Resolutions Committee.

The Secretary's report was then presented as follows.