Infectious Disease in a Total Institution: A Study of the Influenza Epidemic of 1978 on a College Campus
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Infectious Disease in a Total Institution:
A Study of the Influenza Epidemic of 1978
on a College Campus
JEFF SOBAL, PhD
FRANK C. LOVELAND, PhD
INFLUENZA, ONE OF THE MOST COM- that gave rise to this epidemic dividuals, cut off from the wider
MON infectious diseases in the emerged in Russia and China in society for an appreciable period
United States, has been called 1977 (5,6). In the United States, of time, together lead an enclosed,
"the last great plague of man" (1). the strain was first isolated in Jan- fully administered round of life"
Although it is no longer one of uary 1978 in Wyoming (6) and (18). The attributes of total in-
the most important causes of mor- was in the unique situation of co- stitutions that are relevant to
tality (2,3), influenza still consti- existing with two other major health include standardized mass
tutes a major disease problem (4). strains (A/Texas/77 H3N2 and activities under a central author-
It has recently exhibited antigen A/Victoria/75 H3N2) (9,10), a ity, the separation of residents
shifts that have produced strains circumstance foreboding a winter from administrators in a castelike
leading to major epidemics and of severe influenza in 1978. stratification, and a separate resi-
to increased influenza-related mor- A significant characteristic of dent subculture with its own ac-
tality (4-8). the influenza epidemic of that tivities and organization.
The 1977-78 epidemic of the winter was the rapid spread and Total institutions afford a clas-
"Russian flu" (A/USSR/1977 high incidence of the disease in sic example of the effects that so-
H-IlNl) is one of the most dra- schools with students in residence cial organization may have upon
matic examples of this phenom- (7,9,11-16), a pattern evidenced infectious disease. The first clearly
enon. Absent from the United in earlier influenza epidemics, in defined cluster of influenza in hu-
States since 1957 (9), the strain which isolated groups exhibited man beings occurred in a total in-
an epidemic although the inci- stitution, in 1918 at Fort Riley
Dr. Sobal is assistant professor, Depart- dence of the disease in the sur- military base in Kansas (1,19).
ment of Family Medicine, University of rounding community was low (17). The recent epidemics of the HIN1
Maryland, 10 South Pine St., Baltimore,
Md. 21201. Dr. Loveland is an associ- A residential school is an example strain of influenza in the United
ate professor, Department of Sociology of a "total institution," a "place States in 1946 and 1947 (8) have
and Anthropology, Gettysburg College, of residence and work where a been concentrated in military per-
Gettysburg, Pa. Tearsheet requests to
Dr. Sobal. large number of like-situated in- sonnel. The total institutions that
66 Public Health Reportshave been mentioned in the liter- Infectious disease researchers must and the disease's short duration, its
ature as the sites of influenza epi- examine the openings that may mild effects, and the specific target
demics include nursing and geri- exist in these boundaries, looking group involved-adults under age
atric homes (20,21), ships (19,22, for groups or persons who have 25 (8,11)-this epidemic provided
23), residential secondary schools contacts outside the institution an excellent opportunity to study
(15,16,24-31), colleges (9,11,15,19, and who thus may serve to intro- epidemiology in a total institu-
32), hospitals (33), prisons (16), duce the disease into the institu- tion. Other studies of colleges
and mental institutions (34). Fur- tion or to release a disease previ- provide indications of the influ-
ther research on influenza in total ously confined within the total in- ence of social factors upon insti-
institutions can lead to an under- stitution to a wider society. Par- tutional epidemics. Pons and asso-
standing of how their social struc- ticipation in group activities with- ciates (11), studying the 1978 in-
ture provides unique opportuni- in the institution may facilitate or fluenza outbreak on a university
ties for the spread of infectious inhibit an epidemic once the dis- campus, found the disease signifi-
disease. ease is introduced. The subcul- cantly more prevalent among stu-
Two aspects of total institu- ture of institutions must be de- dents residing on campus than
tions are pertinent to the spread lineated in terms of disease-rele- those residing off campus, al-
of influenza: the permeability of vant attributes. If some residents though both groups still had a
their boundaries and the groups have more contact with the rest high attack rate. These authors
and activities within the institu- of the institutionalized popula- interpreted the high incidence in
tion that affect social contact be- tion than others, then the attri- both groups as indicating that
tween the residents. The varia- butes of the institutional structure transmission had occurred pri-
tion in the openness of the boun- that promote or inhibit social par- marily through daytime activities,
daries of total institutions results ticipation become relevant to the such as classes, and attributed the
in differences in the amount of spread of communicable disease. higher rate for dormitory resi-
contact that residents have witlh Because of the rapid diffusion dents to their greater collective
the outside social environment. of the 1978 influenza epidemic exposure to the disease in the
January-February 1982, Vol. 97, No. 1 67evenings. Students under the age epidemic occurred during the spondents comprised 21 percent
of 23 were significantly more likely snowstorm, when the students of the total college population of
to contract the disease than older were confined within their insti- 1,844 students and 137 full-time
students. tutional boundaries. Glazen and and 35 part-time faculty members.
Layde and associates (32) in- associates (35), reporting an out- Less than 5 percent of the stu-
vestigated the 1978 influenza out- break of influenza in students im- dents were more than 22 years of
break on a large urban campus, mediately following a boarding age.
where the disease had spread pri- school recess, attributed the epi- Under our sampling procedure,
marily on one weekend in Febru- demic to the reconvening of the each residential area of the col-
ary 1978. The high attack rate of educational institution. lege community was assigned to 1
62.3 percent among undergradu- In contrast, Briscoe (30) report- of the 17 interviewers, who then
ates was in sharp contrast to the ed that an influenza epidemic in interviewed a quota sample of 25
low 9.4 percent incidence among a boarding school subsided slight- residents at each site. Respondents
faculty members. Some 50 to 75 ly after the half-term holiday were asked if they had or had not
percent of the influenza victims (which took place just as the had the flu, as measured by a self-
reported some absenteeism. Al- epidemic was peaking), but that it report question. All those who re-
though the average number of reappeared because the break was ported having the flu were then
days missed was less than 2, this shorter than the incubation pe- asked, in an open-ended question,
absenteeism resulted in a suspen- riod of the disease (usually 2 to 4 to list their symptoms (up to
sion of classes 1 week after the days); a nucleus of influenza car- seven). The date that the person
original weekend of onset. Den- riers who returned to the school first contracted the disease was re-
tal students had an attack rate of had rekindled the epidemic. corded, along with the number of
22 percent among 23-24 year olds, These three studies show that days of illness. In addition, rele-
14.3 percent among those 25 and vacations or recesses, by breaking vant student demographics were
26, and 8.3 percent among those the normal boundaries of total in- collected, including sex, year in
27 or older. stitutions, can lead to an epi- school, residence area, floor of res-
Glass and associates (9) investi- demic. Residents who are exposed idence, membership in a frater-
gated influenza in a county in to outside sources of disease dur- nity or sorority, and participa-
New Jersey, monitoring weekly ing school intermissions are con- tion in fraternity or sorority re-
absenteeism in 95 public schools, centrated in one place when they cruitment activities.
infirmary admissions in three resi- return to the institution. On the A large number of clinical
dential schools, and febrile illness other hand, intermissions, by sep- symptoms have been associated
in four nursing homes. The inci- arating residents from one an- with influenza: sudden onset,
dence of illness in nursing homes other, may reduce or prevent the chills, fever, headache, sore throat,
(which are also total institutions) spread of disease. hoarseness, cough, sputum, photo-
parelleled that of the general All of the studies we have cited phobia, nausea, vomiting, diar-
working population. Public school show that social organization can rhea, and abdominal pain (36)-
students had lower rates of ab- strongly influence influenza epi- the last four being less commonly
senteeism following Christmas va- demics in total institutions. We associated with the disease and
cation and after a week in which decided to pursue this subject fur- generally considered to be less in-
school was closed because of snow ther by analyzing an influenza dicative of it than the others. Be-
outbreak on a college campus in cause the symptoms for influenza
than at other periods. Glass and the period 1977-78.
associates concluded that the are nonspecific and the disease is
often over-reported (37), and be-
snow recess of the public schools Methodology cause serologic confirmation was
imposed a relative quarantine on To investigate the influenza epi- not possible in our study, we used
the students, preventing pupil-to- demic at a small private liberal a case definition to delineate the
pupil contact and an outbreak of arts college in Pennsylvania, we illness. A person was considered
disease. In contrast, residential had 17 students in a medical an- to have a case of influenza if he
school students-members of edu- thropology course conduct per- or she reported having the disease,
cational total institutions-exhib- sonal interviews based on a nine- reported at least 1 day of sickness,
ited the greatest risk of influenza question standardized interview and had two or more of the symp-
of any group. The peak of the schedule. The sample of 418 re- toms of fever, headache, and res-
68 Public Health ReportsNumber and percentage of persons Results 49.3 percent, second floor 44.6
with cases of influenza reporting percent, third floor 53.8 percent,
various symptoms The symptoms listed by students
who fit the case definition for and fourth floor 35.3 percent), al-
Number Percent having influenza are presented in though these differences were not
Symptoms reporting reporting the table, with the number and statistically significant.
percentage claiming that symp- There were no overall signifi-
Fever ............ 151 83.0 tom. There is considerable diver- cant differences between members
Headache ........ 113 62.1 sity in the 27 symptoms listed, al- of individual fraternities and so-
Cough ........... 104 57.1
rorities, although some of these
Aches and pains 90 49.5 though the ones included most
Sore throat ....... 87 47.8 frequently are central to influ- organizations had more than a 75
Qongested nose .. . 55 30.2 enza. percent attack rate, and members
Tired ............ 44 22.2
Hot and cold spells. 36 19.8 Of the total sample of 418 peo- of others were virtually unaffected
Runny nose ...... 26 14.3 ple surveyed, 40 were faculty by the disease. The patterns of in-
Vomiting ......... 14 7.7 members, and 378 students. fluenza among individual organi-
Dizziness ......... 14 7.7
Stomach ache ..... 13 7.1 Among the 378 students, 182 were zations suggest that larger social
Weakness ........ 10 5.5 considered to have had influenza, organizations of this type had a
Chest pain ....... 10 5.5 based on our definition, and 196 higher incidence of sickness than
Burning eyes ..... 9 4.9
Cold-type as not having contracted the dis- smaller ones, although a larger
symptoms ...... 8 4.4 ease. There was a highly signifi- sample is needed to confirm
Swollen throat cant difference (chi square, P < this relationship. A major student
glands ......... 7 3.8
Fainting .......... 6 3.3 0.01) between the students and social activity occurring during
Earache .......... 6 3.3 faculty in the attack rate for the the epidemic was "rushing," the
Dry throat ........ 4 2.2 recruitment of new members by
Loss of appetite ... 3 1.6 disease (5 percent of the faculty
Stiff joints ........ 3 1.6 and 48 percent of the students). fraternities and sororities. Despite
Diarrhea .......... 2 1.1 We examined subpopulations of our hypothesis that the additional
Laryngitis ........ 2 1.1 the students to analyze their sus- institutional activity of partici-
Cramps .......... 2 1.1
Sweating ......... 2 1.1 ceptibility to influenza, compar- pants in this social activity would
Stiff neck ........ 1 .5 ing students in the samples whose lead to their having greater sus-
cases fit our definition of influ- ceptibility to influenza than non-
' The percentages do not sum to 100.0 be-
cause respondents reported multiple symptoms.
enza with those whose cases did participants, the difference was
not. The sex difference between not statistically significant (49.6
those with the disease and those percent of those involved in the
piratory problems. (We realize without was not statistically sig- rushing and 46.2 percent of those
that the procedure we used was nificant (48.7 percent of those who not involved had the disease).
no substitute for laboratory con- contracted the disease were male In addition to examining the
firmation of the disease. Never- and 47.5 percent female). Al- prevalence of the disease, we
theless, it was the most applicable though first-year students had the studied its transmission by asking
indirect technique for a sociologi- highest rate (freshmen 56.7 per- respondents when they had first
cal study in which serologic con- cent, sophomores 46.2 percent, contracted influenza. December
firmation was not possible because juniors 44.0 percent, and seniors 14, 1977, was the date that the
of its complexity and cost in dol- 46.6 percent), the difference was first case of influenza was reported
lars and time (38).) When Layde not statistically significant. The at the campus infirmary. The ear-
and associates (32) used this tech- ecological variable of residence liest date that a case was reported
nique of symptomatic case defini- was not significantly associated
in our sample was January 1,
tion in their influenza survey at a 1978, and the latest date was
with incidence of the disease; 49.6
university, they found close agree- March 4, 1978. There were rela-
percent of the dormitory dwellers, tively few cases during January
ment between subjective report-
ing of the flu, the symptom-based 44.4 percent of the fraternity resi- 1978. The progress of the virus in
case definition, and laboratory dents, and 44.7 percent of the our sample is shown in the chart.
assay based on serologic tests (al- people who lived in apartments The number of cases was rela-
though there were minor discrep- off campus had influenza. The tively low until the end of the first
ancies between their survey and floor of residence showed differ- week in February, when a peak
laboratory followup). ences in the attack rate (first floor occurred; then came a 3-day lag
January-February 1982, Vol. 97, No. 1 69Progress of influenza on a college campus in 1978 Discussion
In the total institution that we
studied, the institution's ecology,
student demographics, and or-
ganizational activities (such as
fraternity and sorority rushing)
were examined in relation to an
influenza epidemic. The original
introduction of the disease in the
population occurred immediately
after the intersemester vacation, a
period when the boundaries of
the total institution were tempo-
rarily dissolved and many students
were undoubtedly exposed to in-
fluenza during contacts with the
larger social environment. It is
likely that the few cases that ap-
peared during January were due
to one of the H3N2 strains that
had been present in the State be-
fore the HlN1 virus appeared (6,
39). These cases may have been
caused by strains to which only a
few people were susceptible, espe-
cially since it was too early for in-
(which corresponds to the incuba- medical attention for their symp- fection from the A/USSR/77
tion period for influenza), fol- toms. The initial peak of cases oc- (HlNl) antigen, to which not
lowed by 9 days of rapid spread curred over a weekend, as did the many people under age 25 were
in the campus population, and main body of the epidemic, a re- immune. In view of the proxim-
finally, a decline in the number of sult suggesting that students "al- ity of the residential students to
cases. Twenty-four cases were re- lowed" themselves to attend to one another, the relative absence
corded on February 5 and 6, the their illness only after the week- of influenza during January prob-
first 2 days after the students re- day press of academic work was ably was not due to the "pre-
turned from their between-semes- completed. These observations in- seeding" phenomenon (17), in
ter break. The peak period was dicate that the survey data were which a virus enters a population
February 10-18, the modal day more representative of the true without producing an epidemic
being February 12. This pattern epidemiology of influenza on the for some time.
is in line with that in the college campus than the medical records. Social aspects of the total insti-
infirmary records, which show a The final variable that we as- tution we studied may have played
peak on February 13; 236 of the sessed was the duration of the dis- a role in the low level of influenza
total 800 cases brought to the at- ease. Duration ranged from 2 to during January. January is an un-
tention of the infirmary were re- 31 days among the students: in- usually inactive social period on
ported to it on that day. An esti- firmary cases averaged 4 days, and this campus, a period when stu-
mated 300 cases were not reported the modal value for our sample dents take a single month-long
to the infirmary. was also 4 days. There were no course and many attend off-cam-
Our survey was designed to re- statistically significant differences pus sessions and participate in
cord a proportional number of in the duration of the disease by internship programs. Normal or-
officially reported and unreported sex, class year, the students' par- ganized social activities are sus-
cases of influenza and also to re- ticipation in rushing, the floor on pended; those that continue are
cord the actual date of the onset which they lived, fraternity or so- fragmentary; classes are smaller;
of each case rather than the time rority membership, or area of resi- thus, organized contact is greatly
that the students decided to seek dence. diminished. All of these factors
70 Public Health Reportsmay have inhibited the spread of where either virgin populations history and implications for this
influenza. or groups with high resistance to year's influenza season. JAMA 240:
disease may be voluntarily or in- 2260-2263 (1978).
Although detailed descriptive
epidemiologic reports are not voluntarily concentrated. Institu- 9. Glass, R. I., et al.: Community-wide
tional residence can also create surveillance of influenza after out-
available, by the third week of breaks due to H3N2 (A/Victoria/75
February, H1N1 outbreaks such barriers that shield age-homo- and A/Texas/77) and HlNl (A/
as the one described here occurred geneous subpopulations from epi- USSR/77) influenza viruses, Mercer
in total institutions in 19 areas of demics occurring in the surround- County, New Jersey, 1978. J Infect
the United States, including Penn- ing population (24). Dis 138: 703-706 (1978).
sylvania (40), where the college Although the student social 10. Kendal, A. P., et al.: Laboratory-
we studied is located. In these to- based surveillance of influenza virus
groups and activities within the in the United States during the
tal institutions, explosive out- total institution that we studied winter of 1977-1978. II. Isolation of
breaks of influenza occurred last- did not make a significant differ- a mixture of A/Victoria- and A/
ing 1 to 2 weeks, the attack rates ence in the incidence or dura- USSR-like viruses from a single per-
were 40 to 70 percent, and the tion of influenza, such variables son during an epidemic in Wyom-
symptoms reported were similar ing, USA, January 1978. Am J
may play significant roles in dis- Epidemiol 110: 462468 (1979).
to those we found in our case ease transmission in other total
study (40). Thus, our study is 11. Pons, V. G., Canter, J., and Dohn,
institutions. More research on the R.: Influenza A/USSR/77 (HlNl)
probably representative of an epi- topic is needed, and we hope that on a university campus. Am J Epi-
demic in this type of total insti- future investigators will pay spe- demiol 111: 23-30 (1980).
tution.
cial attention to the role of to- 12. Foy, H. M., et al.: Influenza sur-
Our study also supports the ob-
servation by other researchers that tal institutions in epidemiologic veillance by age and target group.
processes. Am J Epidemiol 109: 582-587 (1979).
people over age 23 were largely
13. Penny, P. T.: Epidemic influenza
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IYH 0
SOBAL, JEFF (University of Mary- in one organization with clearly de- the student population, which was
land School of Medicine), and lineated social boundaries and a concentrated within the boundaries
LOVELAND, FRANK: Infectious dis- unique social structure. A survey of of the educational institution. The
ease in a total institution: a study of a sample of 418 persons (378 stu- faculty exhibited relative immunity
the influenza epidemic of 1978 on a dents, 40 faculty members) revealed to the disease compared with the
college campus, Public Health Re- that more than 48 percent of the stu- students, having only a 5 percent at-
ports, Vol. 97, January-February, dents contracted influenza and that tack rate. There were no significant
1982, pp. 67-72. the intersemester vacation was a so- differences in the incidence or dura-
cial factor that may have aided in tion of illness among the students by
The Influenza epidemic of 1978 the disease's penetration of the in- sex, year in school, residence area,
was studied on a college campus, stitution's boundaries. The vacation floor of residence, fraternity or so-
since a college is a type of "total exposed the students to the distase, rority membership, or participation
institution" in which work, residence, and the resumption of classes al- in fraternity or sorority recruitment
and recreation are all concentrated lowed influenza to spread rapidly in activities.
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