PUBLIC HEALTH AND TYPHOID FEVER
Abstract
The purpose of this report is to challenge the claims of the American Water
Works Association and the Chlorine Chemistry Council that the implementation of
chlorination and filtration virtually eliminated waterborne disease from the United States
during the early 20th century. The evidence presented in this report indicates that many
factors were responsible for the decline in typhoid fever and other waterborne diseases.
Increased efforts towards public health, including health education and the
founding of health organizations like the Children’s Bureau, coincided with the reduction
of waterborne disease. Improvements in the average lifestyle, especially the ubiquity of
running water and refrigerators, were also important. Milk production improved and
nutritional standards rose, strengthening both the immune system and the health
awareness of the average individual.
The effects of hygiene, refrigeration, and nutrition with respect to the eradication
of typhoid fever in the United States is assessed by examining a contemporary case study
of typhoid and paratyphoid fever in Jakarta, Indonesia. In this community-based casecontrol study of 1,397 participants, “typhoid fever continued to be associated with
hygienic practices (no use of soap for hand washing, sharing of food, and no toilet in the
household) and recent intrahousehold typhoid fever in the preceding 12 months” among
other factors such as flooding, crowded households, and the purchasing of food from
street vendors (Vollaard).
This report concludes that improvements to public health education, public health
services, and the average American’s lifestyle during the turn of the twentieth century
may have been just as significant as the introduction of chlorination and filtration of
drinking water, with respect to the concurrent, sharp decline in waterborne disease.
Introduction and Objectives
Although the American Water Works Association states that “by the 1920's, the
use of filtration and chlorination had virtually eliminated epidemics of major waterborne
diseases from the American landscape,” this report attempts to demonstrate that
additional factors, such as overall improvements in public health, quality of life, and food
safety actually contributed significantly to the decrease in typhoid fever and other
waterborne diseases. Information was gathered from works published by the Centers for
Disease Control and data presented in “Risk Factors for Typhoid and Paratyphoid Fever
in Jakarta, Indonesia” published June 2, 2004 by The Journal of the American Medical
Association.
In this report, the exposure routes for typhoid fever are discussed, followed by an
assessment of changes in public health, lifestyle, and food safety during the early 20th
century. Finally, the case study of Jakarta provides contemporary support for the
argument that the elimination of waterborne diseases was multifaceted.
Results and Discussion:
Typhoid fever and paratyphoid fever are similar diseases caused by the
microorganisms Salmonella typhi and S. paratyphi, respectively. Both diseases are
characterized by fever, headache, malaise, anorexia, enlargement of spleen, and
constipation. Complications leading to a fatal outcome are more likely to arise from
typhoid fever than from paratyphoid fever; however, approximately 100,000 organisms
must be ingested to cause typhoid fever, whereas only about 1,000 S. paratyphi are
capable of causing paratyphoid fever. Either bacterium can be transmitted by water or
food (especially milk and milk products) contaminated with the feces of another infected
person or a carrier. Flies are sometimes a vector for disease transmission as well.
Residents of the United States are fortunate that typhoid fever and paratyphoid
fever are no longer prevalent in their wealthy, industrialized nation. At the beginning of
the 20th century, however, these diseases were still a significant threat with a typhoid
death rate of 28.1 per 100,000 in 1905 (“Mortality Statistics, 1905”). By 1936, the death
rate had been reduced to 2.4 per 100,000 (“Mortality Statistics, 1936”). Although the
implementation of water filtration and chlorination coincides with the decline of this
waterborne disease, many other changes in public health practices were occurring
simultaneously (“Achievements in Public Health”).
Major shifts in public health and medicine were initiated in the late twentieth
century, the results of which can be seen in the early 1900’s. One example of these
initiatives was the professionalization of the medical field, as indicated by the formation
of societies for medical specialties and the proliferation of medical texts and periodicals.
Academic institutions expanded their array of course offerings to include sanitation,
bacteriology, and public health (Cassedy 112). By 1900, the government was
increasingly involved in public health and 40 of the 45 states had their own health
departments (“Achievements in Public Health”). During this period, many non-profit
organizations were founded with the aim of promoting health, including the Red Cross
and the National Association for the Study and Prevention of Tuberculosis (Cassedy 117118).
The augmentation of public health services was further demonstrated by an
emphasis on children’s health. This concern was specifically addressed with the creation
of the Children’s Bureau in 1912. Its early efforts focused on improving the birth and
death rate statistics, surveying contemporary child health activities, and initiating
significant research in child nutrition, maternal health, and mental health. The Children’s
Bureau was involved in the enforcement of the first federal child labor law, and in 1921
the Bureau became responsible for the Sheppard-Towner Act which distributed grants to
states for the purpose of reducing child and maternal mortality. By its termination in
1929, this program had established 3000 child health and prenatal centers (Cassedy 117).
These efforts contributed to the significant reduction in child and infant mortality rates in
the United States: in 1900, 30.4% of all deaths were those of children younger than five
years old, but in 1997 only 1.4% of deaths were children under five (“Achievements in
Public Health, 1900-1999”).
Preventative health programs, including education and vaccination, were
expanded in the late 1800’s and continued through the turn of the century. Health
departments offered free smallpox vaccinations to immigrants and schoolchildren
(Cassedy 109). Diphtheria could be diagnosed and treated in 1900, but by 1920, it was
also a preventable disease due to a publicly available vaccine (Rosen 312). Citizens had
other opportunities to improve their own health through lectures and newspaper articles
that provided information on the latest developments in the medical field, as well as free
clinics about personal hygiene and childcare. These programs not only indicate a trend
toward preventative medicine, but free vaccines, free clinics, and distributed newspapers
were able to reach Americans of virtually every social class (Cassedy 110-111).
The proliferation of health education was simultaneous to changes in standards of
living for most Americans. “The coming of running water, in particular, not only made
waste disposal safe and easy but made washing both easy and enjoyable for families with
well-equipped bathrooms. By World War I a majority of city dwellers had probably
achieved such a standard” (Cassedy 102). Clean water from a household tap made the
hygiene emphasized by the health education movement practical for those connected to a
water system.
Refrigeration in homes and businesses was another innovation that improved
health. Colder temperatures inhibit microbial growth in food, both of pathogenic
organisms like S. typhi, and those organisms that cause food spoilage. When food is kept
below 15C, refrigeration greatly reduces the growth rate of S. typhi. Food refrigerated
below 7C yields a growth rate of zero. Although S. typhi will multiply again when the
temperature is raised (refrigeration does not kill the organism), the reduced growth rate
decreases the number of organisms present and thus decreases the likelihood of infection
(“Salmonella typhi”).
The first home refrigerator went on sale in 1916, and by 1920, 10,000 had been
sold; by 1925, 75,000 had been sold. From 1928 to 1935, 8 million new refrigerators
were sold (“The History of American Technology”). The increased use of refrigeration
directly correlates with the decrease in typhoid mortality in the U.S. Refrigeration
reduced the level of exposure to food-borne organisms, like S. typhi, and bolstered
immune systems by enabling people to eat more fresh, nutritious foods.
In addition to the improvement in food technologies, a series of food and drug
laws were passed with the intention of improving public health. In 1898, the Association
of Official Agricultural Chemists established a committee on food standards. The
standards created by the committee were soon adopted by many states. In 1902, the
Biologics Control Act was passed, prohibiting interstate commerce of misbranded and
contaminated drink and drugs. The Meat Inspection Act was passed the same year after
“shocking disclosures of unsanitary conditions in meat-packing plants.” (“Milestones in
US Food and Drug Law History”) In 1930, the McNary-Mapes Amendment authorized
new FDA standards of quality and fill-of-container for canned food. These acts and laws
contributed to overall public health and their timing correlates to the decrease in typhoid
mortality in the US.
One of the more important acts relating directly to the spread of S. typhi was the
1922 Milk and Dairies Act, which provided the first legal definition of pasteurization.
This legislation led to an increase in the number of pasteurization and bottling plants in
the U.S. (“Milk Processing”).
Milk was recognized as a source of infectious disease as early as 1893. That year,
Nathan Strauss, a New York City philanthropist, with the help of Dr. Abraham Jacobi,
established milk-heating depots in New York to distribute safe milk to children. At this
time, the death rate of children under five years old was 135 per 1,000 due to raw milk
consumption. After Strauss introduced milk "sterilization," the death rate of children
under five years old who consumed raw milk dropped to half (“Irradiation can prevent
food borne illnesses”). Contaminated milk was a significant vehicle of S. typhi and
pasteurization later helped to eliminate this exposure route. Increasing numbers of
children began drinking pasteurized milk during the early 1900s, but it wasn’t until 1906
that slow, low-temperature pasteurization eliminated the unpopular “cooked milk” taste.
In 1908, Chicago became the first of many cities to mandate the pasteurization of milk.
The statistics on typhoid mortality in Chicago show a sharp decline in typhoid deaths
between 1902 and 1904, followed by a steady decrease until 1915 when mortality rates
reached near zero. Although pasteurization in Chicago took place after the initial decline
in typhoid fever incidents, it is likely that pasteurization contributed to the final
elimination of the disease—if pasteurization had not been adopted, it may have been
possible for S. typhi to survive autonomously within the dairy industry.
The dramatic increase in nutritional research in the early 1900’s played a
significant role in reducing nutritional deficiency diseases and elevating overall health.
In 1916 vitamins were discovered and researchers learned that lack of “vital amines”
could cause disease. The discovery of vitamins and other findings from nutritional studies
led to public health policies concerning diet such as food-fortification programs, the
1921-1929 Maternal and Infancy Act, and the first employment of nutritionists by state
health departments during the 1930’s. The federal government developed food relief and
commodity distribution programs including school lunch programs, nutrition education
programs, and national food consumption surveys (“Achievements in Public Health,
1900-1999”). Though better nutrition did not directly prevent or cure typhoid fever, it did
strengthen individuals’ immune systems, which may have contributed to the decline of
the disease in the early 1900’s.
To support previous claims that improved personal and food hygiene practices, in
addition to the increased health awareness spread by progressive public health initiatives
at the turn of the twentieth century, were essential to the effectiveness of filtered and
chlorinated water in “virtually eliminating” typhoid fever, it is best to look at the results
of a well-documented, contemporary case study on the risk factors of typhoid fever. The
study of Jakarta, Indonesia is considered because “all respondents reported that they
boiled drinking water before consumption and that they kept water boiling for several
minutes” (Vollaard).1
Assuming that each of the participants was in fact drinking water that was not
contaminated with live S. typhi or S. paratyphi, the incidents of typhoid and paratyphoid
fever in Jakarta can be attributed to behavioral risk factors. The study compared hygienic
practices, the occurrence of intrahousehold typhoid fever within the preceding twelve
months, crowding (>6 persons per household), reported flooding, the buying of food
and/or ice from street vendors, and the sources of drinking water (piped or non-piped)
between participants who contracted typhoid fever, paratyphoid fever, nonenteric fever,
and those who had no fever. Between June 11, 2001 and February 4, 2003, “1019
consecutive patients with fever lasting 3 or more days were included [in the study]. [The
study] identified 88 S. typhi and 26 paratyphi A infections…Every second patient with
nonenteric fever was selected as a fever control… Also during the surveillance,
1
There is no indication in the report that the water supply in the study area was treated with chlorine. The
drinking water source of approximately half of each group of participants (those with typhoid fever,
paratyphoid fever, nonenteric fever, and the community control group) was contaminated with fecal
coliforms. However, “fecal contamination of drinking water was not significantly associated with either
community controls were randomly selected within a random household in every third
rukun tetangga (ie. the smallest administrative unit of 40-60 area households)…All cases
were subject to a household visit within a month after the febrile episode that prompted
the blood culture.” (Vollaard).
Information gathered from interviews, water samples, and stool samples collected
during the household visits is summarized in TABLE 1. By comparison with the community
controls, significantly associated risk factors for typhoid fever include crowding, the
recent occurrence of typhoid fever within the household, no use of soap for handwashing,
no toilet in the household, flooding, the use of ice cubes2, and sharing food from the same
plate. Eating with hands was common in each group and low income3 ranged from 38%
of the paratyphoid cases to 60% of the nonenteric fever cases. Relatively few of the
participants used piped drinking water (10% of typhoid cases versus 20% of community
controls), which may suggest that quantity of water attributed to lack of hygiene as well.
The main finding of this study is that in Jatinegara, Jakarta, typhoid and
paratyphoid fever largely follow distinct routes of transmission. Typhoid
is spread predominantly within the household, whereas paratyphoid is
mainly transmitted outside the home. No fecal carriers among food
handlers in the households were detected and there was no association
between the level of contamination of drinking water and either typhoid or
paratyphoid fever. (Vollaard)
The report goes on to explain that “the entrenched habit of boiling water from the
water mains or groundwater pumps” may account for the lack of association
between contaminated water and enteric fever. This lack of an association
demonstrates the relevance of personal and food hygiene to the rate of typhoid
typhoid or paratyphoid fever in comparison with both control groups” (Vollaard). S. typhi is generally
killed by boiling water.
2
The ice cubes were often purchased from street vendors.
fever within a community, and portrays the disease’s various routes of
transmission, in addition to a contaminated water supply.
Table 1. Risk Factors for Typhoid and Paratyphoid Fever in Jakarta
In conclusion, it is impossible to disregard the number of changes to American
public health during the turn of the twentieth century. The introduction of health
education was supported by improvements to food technologies. Food safety
3
Defined as below the median income of the community controls (US $105).
standards were raised and enforced by government regulations. The case study of
Jakarta, Indonesia—where necessary education and regulations have not taken
hold—provides strong evidence that the spread of typhoid fever is not solely a
effect of contaminated drinking water. The study recommends the implementation
of hygiene education programs and regulation of street vending to decrease the
number of typhoid incidents. Overall, the United States was fortunate that a push
towards health education coincided with the availability of relevant technologies,
which included, but was not limited to, the chlorination and filtration of drinking
water.
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