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tificate, that the document was dated within 24 hours of the time of departure, and that the child was apparently in good physical condition. If all of these requirements were satisfied the service identification card was issued to the traveler, and simultaneously with the issuance of this card the duplicate thereof was immediately mailed to the health officer of the city or town to which the passenger was destined.

It was to be expected that in the limited time at the disposal of travelers, the haste to board trains, and the difficulties encountered from those unable to make themselves comprehended, that errors in obtaining addresses would occur, but these were exceptionally rare, and it can be safely asserted that during the time the system was in operation in practically every instance health officers were promptly notified of arrivals from the infected city.

The Public Health Service did not at any time purport to guarantee safe entry into the place of destination, and it was made clear to all travelers that the local authorities had complete power to raise whatever barriers seemed necessary for the protection of their communities. It was also made plain that the service exercised no jurisdiction over intrastate traffic. The notification cards as received by the health officer at the point of destination merely guaranteed that the traveler came from uninfected premises and was apparently well at the time of departure from the city.

During the early days of the epidemic the notification cards were forwarded directly to the local health authorities. Subsequently, at the special conference of State and Territorial health officers with the Public Health Service for the consideration of the prevention of the spread of poliomyelitis, it was suggested that in dealing with communities of less than 10,000 population, many of which were without boards of health or other organizations capable of handling the situation, that the original cards be forwarded to the State board of health for official record and whatever further action appeared desirable, and that the duplicates thereof be sent to the local authorities. This recommendation met with the official indorsement of the conference. Thereafter the modified procedure was followed. Inasmuch as a number of States required that all newcomers make their presence known to the health authorities immediately after arrival the system served as a double check upon persons of this class originating in New York City.

The notification card used corresponded to the following form: Passengers leaving New York city for other States and accompanied by children under 15 years of age will please fill out this card.

NEW YORK,

1916.

To the Health Officer at point of destination:

The person named below left New York to-day.

Name

Point of destination

Local address at point of destination_

Number of children under 15 years of age accompanying_

This information is furnished you on account of the present outbreak of poliomyelitis (infantile paralysis) in New York City.

Respectfully,

RUPERT BLUE,

Surgeon General, U. S. Public Health Service.

Treasury Department,

Bureau of the Fublic Health Service, Washington.

Return after five days.

(Side of card for the address.)

To the HEALTH OFFICER,

Official business. Penalty for private use to avoid payment of postage, $300.

In those instances where travelers were unwilling or unable to give their local address at the point of destination, they were informed that notification cards would be withheld pending final decision in the matter. As a result of this action local health officers encountered but little difficulty in locating those arriving from New York City.

An embarrassing complication in the supervision of travel which it was necessary to overcome related to commuters having employment in the stores, shops, and factories of the city but living in Connecticut or New Jersey. Many persons of this class were under 16 years of age and daily traveled to their homes outside the city. Travelers of this class were cared for by the issuance of commuters' identification cards, secured in the ordinary manner and based upon information of the same character as that furnished by other persons, with the provision that the cards should be recognized as valid for a period of one week from the date of issue.

The handling of week-end excursionists destined to the beaches and other resorts also proved to be somewhat of a problem. This class of travel was both intrastate and interstate and was largely composed of children from infected as well as uninfected districts, so that it offered an excellent opportunity for the dissemination of the infection. After careful consideration the conclusion was reached that every attempt should be made to discourage this element of travel, and accordingly the certification of outgoing traffic of this character, so far as it could be determined, was refused. Baby parades at near-by New Jersey resorts and similar unnecessary gatherings of children at fairs and festivals were effectively controlled through notification of the respective managers of these affairs that restrictive measures would be applied in so far as the participation of children was concerned. It is believed that this attitude met with the hearty approval and support of the public in general.

It was expected that some difficulty would be encountered in handling travel in transit through New York City, but not originating therein, although fortunately but little trouble arose in this regard. The fear of the disease naturally led large numbers of those with children to select other routes of travel, so that the amount of traffic was considerably reduced, while the publicity given the epidemic and the almost universal requirement regarding certificates compelled others to obtain documentary proof of their place of origin. Under the conditions following the subsidence of the epidemic there was some relaxation on the part of local authorities at other places than New York City in issuing these certificates; this inevitably led to some confusion and made it necessary to secure other means of determining the place of departure. Officers were accordingly instructed to act upon such evidence as the possession of

through tickets, baggage checks and other confirmatory data, and to accord due credence for statements made in connection therewith. From the date of the inauguration of the notification system, July 18, 1917, until October 2, 1917, when it was terminated, registration cards for 85,242 children were forwarded to health officers of the United States and foreign countries and slightly more than that number were medically inspected. On an average 1,122 children were daily certified for travel out of New York City. The largest number certified on any one day was 2,088 on August 5, at the height of the epidemic, and the next largest number was 2,061 on September 2. From the beginning it was found that many adults were requesting and even demanding certification, having come from uninfected localities, and in order to accommodate these persons certificates for adults were also issued, so that a total of 22,647 persons certified should be added to the amount of work necessitated by this inspection. The following table indicates by weeks the number of children and adults certified and the localities to which they were destined:

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In view of the enormous amount of travel from the many stations and ferries of New York City the cordial cooperation of the traffic managers of railroad and steamboat lines was essential to the perfection of any arrangement of the character described. It was the first time there had ever been regulation of travel placed upon the large number of transient visitors to that city and the many thousands who daily passed to and fro between New York and near-by communities. After consultation with the managers of the respective roads this cooperation and assurance of accord with the purposes of the measures taken were readily obtained, and throughout the epidemic the aid and assistance rendered by transportation lines were of the utmost value.

Aside from the inconvenience to travelers brought about by the necessity of securing certificates, which the public bore with equanimity and generally without complaint, the effect of the adoption of the notification system upon the volume of travel is naturally a matter of interest. Obviously it is difficult to present definite figures regarding the movement of children to and from a city the size of New York, but the following conclusions seem warranted:

The travel of children into the infected area was unquestionably diminished. The factors in producing this result were the fear of the disease, which was at all times operating, and in part also the establishment of the notification system, particularly as it related to unnecessary travel. In so far as the movement of susceptible individuals into the city was reduced, the result was beneficial and certainly of some importance in limiting the extent of the infection and protecting other communities.

The travel of children from the infected area constitutes a different question. During the early days of the epidemic, previous to the establishment of the notification system, the normal exodus of the summer season was greatly accentuated and thousands of children departed from the city, not to return until the outbreak had subsided. However, nearby communities soon began to realize the dangers from this unrestricted flow and instituted more or less rigid quarantine regulations, so that ultimately this migration was considerably decreased. Many persons also, on account of these stringent regulations, elected to remain in the city throughout the epidemic. These facts must be taken into consideration in any estimation of the volume of travel. Bearing these facts in mind it is a safe conclusion that from the middle of July until the end of the season outgoing travel was perceptibly diminished, so far as children were concerned. This conclusion is corroborated by the testimony of passenger agents who reported a decided diminution in the amount of outgoing travel as judged by the sale of tickets. While this effect was not wholly due to the operation of the notification system, it is probable that such was a factor and should, therefore, be in part credited with whatever benefits were derived therefrom.

During the course of the epidemic information, as well as direct notice, was received from many towns, especially in Connecticut and New Jersey, that an absolute quarantine against children under 16 years of age arriving from New York City had been established. In such instances the health officer of the community was immediately informed that inasmuch as further notification of arrivals would be useless instructions had been given that the issuance of notification

cards for the community concerned had been ordered discontinued until such time as the embargo was lifted. In numerous instances this had the effect of raising the restrictions and the notifying of the public of such modifications. The standardization of the methods adopted by local quarantine officers of other States, through cooperation with the plan of notification above described, was therefore an important outcome of the registration system.

Visits of health officers from adjoining States to New York City for the purpose of inspecting the work in progress and the holding of conferences relative thereto tended toward the adoption of uniform methods. In all such instances the service representative recommended daily inspection and detention of incoming children, based upon the existing notification system, and this plan was quite generally followed. Medical officers were also detailed to nearby towns to confer with local health authorities on various aspects of the situation and this also served to acquaint outside officials with what was being accomplished.

Not the least of the benefits derived was the affording of local health officers a satisfactory means of immediately locating recent arrivals in their jurisdiction and thus enabling them to institute such measures of isolation or limitation of movements as appeared necessary. So strongly did this appeal to the health officers themselves that numerous commendatory letters were received regarding the effectiveness of the system. At the meeting of the special conference of State and Territorial health officers with the service for the consideration of the prevention of the spread of poliomyelitis the measures adopted received official approval and were recommended for enforcement in all infected territory.

In regard to the direct effect the establishment of the notification system had upon the dissemination of the disease it is believed that no claims are justified. With our almost entire lack of knowledge regarding the means of transmission of poliomyelitis, whether by adults or children, and other facts of importance concerning its etiology, it would be misleading to attribute more than certain indirect benefits from the procedures instituted. In so far as travel was restricted and the commingling of those from infected and uninfected districts was prevented it is believed that benefit necessarily accrued and tended toward the reduction of the incidence of the disease. It is also safe to assert, in view of the regulation of travel from infected premises and the consequent inability to obtain the necessary certificates, that certified travel was to a degree safer than that which was uncertified.

Toward the close of the outbreak, in the latter part of September, it became problematical what effect the opening of the schools and the return to the city of many thousands of susceptible children would have upon the course of the epidemic. It was decided, therefore, to continue the work of notification, with slight modifications, until such time as this effect had opportunity to manifest itself, that is, for a sufficient number of days after the opening of schools to cover what was believed to be the ordinary period of incubation of the disease. As no increased incidence resulted from this accession of susceptible material and as the epidemic gave every indication of being upon the wane, the work of notification was discontinued on October 2, health officers throughout the country being notified to this effect.

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