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Communicable Disease Control in Schools
Communicable Disease Control in Schools PAUL F. WEHRLE, M.D.
The modern school health program has properly departed from the earlier single objective of control of contagious diseases by medical inspection of school children. The experience of school health programs over more than seven decades, together with recent careful appraisals of the value of certain phases of present programs,9.13 suggests that even more substantial changes are needed if we are to meet the modern needs of the child in school and to derive maximum benefit from professional services. Although these changes are long overdue in many areas, it should be recalled that school health services will, in most sections of this country, continue to make a substantial contribution in better control of infectious diseases and their sequelae. It is apparent that the classic contagious diseases of childhood no longer present significant problems in school health. Effective antigens are currently available, and effective immunization can be maintained against diphtheria, pertussis, poliomyelitis and, more recently, measles. Antibiotics, though not applicable to mass prophylaxis of streptococcal disease except under unusual circumstances,l1 provide effective therapy of scarlet fever and other streptococcal disease, a striking reduction in sequelae, and prompt clearance of the convalescent carrier state. 12 During a recent evaluation of school absences in two large elementary schools, total absences amounted to 8.0 per cent of potential attendance, as noted in Table 9. School absence due to the classic "contagious" diseases of childhood represented less than 0.4 per cent of total school attendance, as shown in Table 10, and represented less than half the days lost from illnesses in this category of disease recorded in similar studies only 15 years ago. 5 It should be noted, however, that all the acute communicable diseases, including the "common contagious diseases," still account for approximately two thirds of school absenteeism and thus still deserve attention. The role of the school health program in Supported by the Hastings Foundation.
985
986
PAUL
F.
WEHRLE
Table 9.
School Absences in 2 Large Los Angeles City Elementary Schools, 1962-63 (Kindergarten and Grades 1-6 Inclusive)
SCHOOL
STUDENT
STUDIED
ENROLLMENT
MEAN
DAILY EN-
ATTENDANCE
ROLLMENT
TOTAL
PERCENT
ABSENCES
ABSENT
SCHOOL YEAR
A ......... B .........
765 749
689 676
121,316 119,586
11,647 7,716
9.6 6.5
Total ........
1514
1365
240,902
19,363
8.0
Walborg S. Wayne and P. F. Wehrle: Unpublished data on school absenteeism in Los Angeles.
Table 10.
School Absences by MaJor Category-Schools A & B, 1962-63 SCHOOL DAYS ABSENT AND PERCENT OF ALL SCHOOL DAYS
School A
STATED REASON
School B
FOR ABSENCE
Respiratory illness, acute. "Contagious" diseases ... Gastrointestinal illness, acute .. Miscellaneous illness. . . Nonillness ............. . Total ........ .
Total, Both Schools Number %
Number
%
Number
%
5,686 509 738 2,406 2,308
4.7 0.4 0.6 2.0 1.9
4,979 294 478 812 1,153
4.2 0.3 0.4 0.7 1.0
10,655 803 1,216 3,218 3,461
4.4 0.3 0.5 1.3 1.4
11,647
9.6
7,716
6.5
19,363
8.0
the application of effective prophylaxis against respiratory illness when effective techniques become available will require further evaluation. GENERAL CONSIDERATIONS
Modern school health supervision should include four measures important in health education for future acceptance of preventive medicine techniques as well as for further gains in the control of communicable disease as a health problem for the school child himself. These general areas for attention may be described as follows: Health Education In addition to the information customarily supplied about the pm:. pose and function of the various organs of the body, some information should be supplied about the common communicable diseases, their mode of transmission, the need for proper advice concerning therapy, and the importance of personal hygiene and environmental sanitation in the control of at least some of these infections. If we are to have adults interested in accepting various preventive medicine services in
CoMMUNICABLE DISEASE CONTROL IN SCHOOLS
987
the future, this would seem a logical beginning. In addition to the evaluation of the child on entry into school and the informal conferences with teachers, parents and student, appropriate guides for classroom education may be developed by school health personnel. Appropriate materials are also available from various voluntary and official health agencies. Immunization An inventory of prior immunization experience should be included as a portion of the initial detailed health appraisal, whether done by the private physician or the school physician. This should be discussed with the parent, who must be present if the examination is to be of value. This provides an entry into the family for an important facet of health education in addition to providing protection against specific diseases, and may provide the only approach toward preventive services for some families. Deficiencies in health care and particularly in immunizations 7 are well known in some segments of our population. Environmental Sanitation The health service should include orientation in hygienic principles for cafeteria personnel, including part-time student employees. In accordance with local health codes, persons with potentially infectious skin lesions (e.g. furuncles) or acute gastrointestinal upsets should not be permitted to handle food. In addition, representatives of the health service should ensure that adequate handwashing facilities are available for the food service personnel as well as in school restrooms, and that soap and paper towels, often absent, are supplied. Reporting of Disease Although reporting of cases of specified communicable diseases to local health agencies is the responsibility of the private physician, some of these may be of special concern to parents. Close exposure within the schoolroom to at least rubella (for the benefit of mothers who may be pregnant) and meningococcal disease (due to public concern) should be madE' known to parents of classroom contacts. Instructions to seek advice from their physician should accompany notification of this exposure. SPECIFIC TYPES OF INFECTION
Diseases for Which Immunization Is Available A current immunization on entry into school. Any promptly. Table 11 lists, by adequate protection against
history should be available for each child deficiencies noted should be corrected specific disease, minimal requirements for each. Additional current information is
988
PAUL
Table 11.
F.
WEHRLE
Recommended Immunization Schedulesjor School Children*
DISEASE
IMMUNIZING
PRIMARY
CONSIDERED
AGENT
DOSES
IMMUNIZA-
BOOSTER
COMMENT AND
TION
ADVISEot
CONTRAINDICATION
INTERVAL
Pertussis ........ OPT (adjuvant)
3
4-8 weeks
School entry & q. 3 years
Diphtheria ...... OPT (adjuvant)
3
4-8 weeks
School entry & q. 3-5 years
Tetanus ........ OPT (adjuvant)
3
4-8 weeks
School entry & q. 3 to 5 years
Measles ........ Live attenuated vaccine plus measles immune globulin or live "further attenuated vaccine" alone Poliomyelitis .... Oral poliovirus vaccine
Smallpox ....... Vaccinia
None needed
2 or 3
See text
Single trivalent dose on school entry for those previously immunized School entry & q. 5 years
Omit pertussis antigen if seriou S reaction followed prior use and in children over 8 years of age Over 8 years of age use OT. Adult type OT antigen q. 4-5 years is preferred at 12 years and older Use of combined DT antigen as above provides adequate protection Gamma globulin is advised, unless "further attenuated" vaocine is lISed, to reduce frequency of reaction. (See text.) Contraindicated in leukemia and related disease, marked egg hypersensitivity and after recent gamma globulin administration None
Eczema, steroid therapy or known immunologic defect
* Adapted from those of the American Academy of Pediatrics and the United States Public Health Service as applicable to school programs. t Booster doses should be provided on recognized exposure to clinical disease with exception of measles.
available in handbooks published by both the American Academy of Pediatrics! and the American Public Health Association. 2 Copies of each should be available for reference in the health office. Actual immunization should be provided as a portion of the complete health services best provided by the private physician. If these services are not available, it then becomes the responsibility of the school health service, with parental consent, to provide this protection on school entry and as indicated during subsequent school years. Contraindications should be observed and the manufacturer's directions for the volume of dose should be followed. Although alternate antigens are available for some of the diseases listed, the routines included in the table represent current practice and have proved satisfactory. Since some represent relatively new antigens and recent changes in methods of administration have been suggested, it may be appropriate to review the background for at least some of these recommendations. Of the more than 20 antigens presently marketed, either individually or in various combinations, only those listed are of sufficient general utility to warrant inclusion in the school health program. Pertussis is a serious disease, particularly among young infants. Children entering school should be protected for their own benefit as well as to prevent the school child from transmitting the infection to
COMMUNICABLE DISEASE CONTROL IN SCHOOLS
989
infants and younger siblings at home who may not yet have been protected. Owing to the frequency of local and systemic reactions with this antigen among older children and adults, pertussis antigen should be omitted in children older than eight years. Modified disease may occasionally occur among older children despite immunization earlier in childhood, but it is seldom of clinical importance other than serving as a potential hazard to unimmunized infant contacts. With the availability of adult type D.T. antigen, adequate sustained protection against both diphtheria and tetanus may be provided with a single injection at four- or five-year intervals in children above the age of 12 years. A booster D.T. inoculation should be given, of course, on injury or exposure to diphtheria. Although some physicians use inactivated poliovirus vaccines, most prefer the oral poliovirus vaccines, owing to convenience in administration and the increased resistance to alimentary infection with excretion of virus by those subsequently exposed to natural infection. Anyone of the three accepted routines may be used. Two doses of trivalent vaccine may be given with an interval of eight weeks between doses, or three doses of monovalent vaccine may be used. In the latter case the sequence should be types 2, 1, and 3 with the interval between types 2 and 1 not less than eight weeks, and at least six weeks between the latter doses. s Another acceptable routine is types 1, 3, and 2 at six-week intervals. Regardless of the sequence used, it is suggested that an additional dose of trivalent vaccine be administered approximately one year after the completion of the primary series. In addition, a single dose of trivalent vaccine should be administered upon initial entry into school for those children who, as infants, received the full course of oral vaccine immunizations as described above. Prior use of inactivated vaccine does not preclude oral vaccine use, and children with prior inactivated vaccine histories should receive two doses of trivalent vaccine at eight-week or greater intervals upon entry into school. All children entering school who have not been immunized against measles or who do not have a dependable history consistent with the natural disease should receive measles vaccine. Of the five routines available,s the two listed in Table 11 are the most practical. Inactivated measles vaccine alone does not provide the durable protection desired, and its use preceeding the administration of attenuated vaccine necessitates additional visits and injections. Although the live attenuated vaccine may be administered safely with or without the simultaneous administration of gamma globulin, most physicians will prefer to use the two combined, or live "further attenuated" vaccine alone, because of the lessened frequency of clinical reactions. Diseases for Which Immunization Is Not Available or Is Impractical A number of diseases are listed in Table 12 which occasionally
990
PAUL
F.
WEHRLE
arouse considerable apprehension or have caused confusion in the management of schoolroom exposures. Local health department authorities should be consulted if questions about school exclusion arise, and adequate treatment should be provided by the private physician as indicated. Table 12 is intended to serve as a general guide, and the school physician is referred to the American Public Health Association Handbook and to the appropriate State Health Department regulations for more definitive statements or applicable regulations.
Table 12. DISEASE
Communicable Diseases of Potential Concern in School Health (Immunization Impractical or Not Available) SUGGESTED MANAGEMENT
SUSCEPTIBLE CONTACTS IN
OF CASE
CLASSROOM
Chickenpox * ................ Exclude for one week Conjunctivitis (bacterial or viral) * ................... Exclude until antibiotic treatment is instituted Enterobiasis ................. Referral for treatment. Exclusion not indicated Hepatitis, infectious * ......... Exclude until jaundice has cleared and clinically well
No treatment or notification needed
No treatment or notification needed No treatment or notification needed. Very common infection of minor consequence Observe for mild clinical infections; refer for evaluation. Household contacts of cases should receive gamma globulin. Intensify attention to handwashing Meningitis, aseptic * .......... Exclude until clinical re- No treatment or notification covery. Majority due needed to mumps, ECHO or Coxackie viruses Meningitis, meningococcal * .. Exclude until clinical re- Household contacts should receive antibacterial prophycovery laxis. Notification of occurrence of case to families of schoolroom contacts for individual advice from family physician Mononucleosis ............... Exclude until clinical No treatment or notification recovery Mumps * ................... Exclude until clinical No treatment or notification recovery Pediculosis .................. Exclude until applica- No treatment or notification tion of insecticide Respiratory disease (common cold, influenza and A.R.D.) .. Exclude only with sys- No treatment or notification temic symptoms; personal hygiene emphasized Rubella * ................... Exclude until clinical Notification of parents of close contacts recovery
COMMUNICABLE DISEASE CONTROL IN SCHOOLS
Table 12.
991
Communicable Diseases (Continued)
Salmonella and Shigella infection * .................. Exclude until clinical re- Emphasize importance of covery. Emphasize hyhandwashing gienic measures to prevent spread from convalescent carrier state Scabies ..................... Exclude until treatment Observation only started Staphylococcal disease * ....... Exclude until treatment No treatment or notification started. Exclude from food handling in cafeteria Streptococcal disease * ........ Exclude until treatment No treatment or notification started. Exclude from food handling in cafeteria Tinea capitis ................ May attend school if No treatment or notification under treatment. Skull cap for M. audouini or T. tonsurans Tuberculosis * ............... Exclude if "adult type" Source must be sought, and disease, renal, drainadditional conversions among associates must be ing sinuses, or symptodetermined matic. Otherwise may attend school
* Reporting
to local health department usually required.
It should be emphasized that closing of schools has not been shown to be an effective means of controlling an outbreak of any communicable disease. Indeed, better health supervision can be gained by continuing classes, and it is readily apparent that personal hygiene is likely to be better under school conditions than in neighborhood play. Occasionally, as in intense outbreaks of influenza, it becomes unprofitable to continue classes, owing to high absenteeism among teachers and pupils alike. Some of the diseases listed in Table 12 deserve special comment. Chickenpox is ordinarily a relatively mild infection, and there is no need for precautions or notification of schoolroom contacts. Although modification of the disease is possible,lO it is not adVised, since conditions in which it may be indicated are not likely to occur among school children. Increased attack rates of infectious hepatitis have been occasionally observed in schools and at times have been almost limited within these schools to particular classrooms. In at least one instance close interpersonal relations were shown to be of greater importance in spread of infection than simple classroom contact. 6 Examination of hygienic practices and correction of deficiencies are usually all that is required in the prevention of spread within the school. Although there is little reason to notify other parents of schoolroom
992
PAUL
F.
WEHRLE
contact with viral meningitis, the public apprehension aroused by a serious episode of meningococcal disease is sufficient to warrant notification of the families of class contacts and suggest that they consult their physicians for advice about prophylaxis. Our own experience with several hundred cases of this disease in children would indicate that prophylaxis is necessary only among household contacts, where increased risk is readily demonstrable. Schoolroom contacts of clinically diagnosed cases of rubella should probably be identified so that mothers in the early stages of pregnancy can seek individual guidance from their family physician. As yet no dependable prophylaxis is available for prevention of infection, although clinical symptoms may be suppressed by gamma globulin. 4 Since convalescent carriers are a common feature of enteric bacillary disease, the occurence of more than an occasional isolated case should prompt a review of hygienic practices. Guidance from the health department should be sought with cases of enteric disease among food handlers in the cafeteria or with greater prevalence than occasional cases among the students. The school is an important facet in community tuberculosis control. Determination of tuberculin reactivity is a part of the initial health inventory on entry into school. In rural or suburban schools with tuberculin-positive rates less than 1 per cent in higher grades there is little merit in repeated annual testing, and perhaps the test on entry and another on entry into high school may be sufficient. On the other hand, this sort of program may be an extremely important casefinding device in schools serving the central metropolitan areas with relatively high tuberculosis incidence, and frequent or even annual testing may be needed here. The frequency of testing should be determined on the basis of local conditions and in consultation with local health department personnel.
CONCLUSION
It is apparent that school health programs must adapt to changing needs and newer concepts in preventive medicine and health conservation in order to best utilize available professional services. The role of the school in effective control of communicable disease is apparent, and this portion of the program can provide an important entry for educational efforts in preventive medicine and family-centered care. Although the role of the classic contagious diseases is rapidly decreasing in importance as a health problem for school children, communicable diseases still account for the majority of absenteeism and require attention in the newer programs.
COMMUNICABLE DISEASE CONTROL IN SCHOOLS
993
REFERENCES 1. American Academy of Pediatrics: Report of the Committee on the Control of Infectious Diseases. Evanston, Ill., American Academy of Pediatrics, 1964. 2. American Public Health Association: Control of Communic~,ble Diseases in Man. New York, American Public Health Association, 1965. 3. Committee on Control of Infectious Diseases: Current Status of M~asles Vaccine and Measles Vaccine Schedules. Newsletter, May 1965, pp. 7-10. Evanston, Ill., American Academy of Pediatrics. 4. Krugman, S., and Ward, R.: Rubella, Demonstration of Neutralizing Antibody in Gamma Globulin and Re-evaluation of the Rubella Problem. New England J. Med., 259: 16-19, 1958. 5. Metropolitan Life Insurance Co.: School Absenteeism. Stat. Bull. Metrop. Life Ins. Co., 31:4-7, 1950. 6. Mosley, W. H., Speers, J. F., and Chin, T. D. Y.: Epidemiologic Studies of a Large Urban Outbreak of Infectious Hepatitis. Am. J. Pub. Health, 53: 1603-17, 1963. 7. Public Health Service: First Annual Immunization Conference Proceedings. Communicable Disease Center, Atlanta, Ga., 1964. 8. Report of a Special Advisory Committee on Oral Poliomyelitis Vaccine to the Surgeon General of the United States Public Health Service, J.A.M.A., 190: 49-51, 1964. 9. Rogers, K. D., and Reese, G.: Health Studies-Presumably Normal High School Students. I. Physical Appraisal, II. Absence from School. III. Health Room Visits. Am. J. Dis. Child., 108:572-600, 1964; 109:9-42, 1965. 10. Ross, A. V.: Modification of Chickenpox in Family Contacts by Administration of Gamma Globulin. New England J. Med., 267:369-76, 1962. 11. Wehrle, P. F., Feldman, H. A., and Kuroda, K.: Effect of Penicillin V and G on Carriers of Various Groups of Streptococci in a Children's Home. Pediatrics, 19:208-16, 1957. 12. Wehrle, P. F., Feldman, H. A., Mou, T. W., and Shields, F.: Penicillin V Therapy of Scarlet Fever and Acute Streptococcal Pharyngitis. Clinical and Serological Response. Antibiotics Annual, 1956-57. New York, Medical Encyclopedia Inc., 1957. 13. Yankauer, A., Lawrence, R. A., and Ballou, L.: A Study of Periodic School Medical Examinations. III. The Remediability of Certain Categories of "Defects." Am. J. Pub. Health, 47:1421-9, 1957. Los Angeles County General Hospital 1200 North State Street Los Angeles, Calif. 90033
The modern school health program has properly departed from the earlier single objective of control of contagious diseases by medical inspection of school children. The experience of school health programs over more than seven decades, together with recent careful appraisals of the value of certain phases of present programs,9.13 suggests that even more substantial changes are needed if we are to meet the modern needs of the child in school and to derive maximum benefit from professional services. Although these changes are long overdue in many areas, it should be recalled that school health services will, in most sections of this country, continue to make a substantial contribution in better control of infectious diseases and their sequelae. It is apparent that the classic contagious diseases of childhood no longer present significant problems in school health. Effective antigens are currently available, and effective immunization can be maintained against diphtheria, pertussis, poliomyelitis and, more recently, measles. Antibiotics, though not applicable to mass prophylaxis of streptococcal disease except under unusual circumstances,l1 provide effective therapy of scarlet fever and other streptococcal disease, a striking reduction in sequelae, and prompt clearance of the convalescent carrier state. 12 During a recent evaluation of school absences in two large elementary schools, total absences amounted to 8.0 per cent of potential attendance, as noted in Table 9. School absence due to the classic "contagious" diseases of childhood represented less than 0.4 per cent of total school attendance, as shown in Table 10, and represented less than half the days lost from illnesses in this category of disease recorded in similar studies only 15 years ago. 5 It should be noted, however, that all the acute communicable diseases, including the "common contagious diseases," still account for approximately two thirds of school absenteeism and thus still deserve attention. The role of the school health program in Supported by the Hastings Foundation.
985
986
PAUL
F.
WEHRLE
Table 9.
School Absences in 2 Large Los Angeles City Elementary Schools, 1962-63 (Kindergarten and Grades 1-6 Inclusive)
SCHOOL
STUDENT
STUDIED
ENROLLMENT
MEAN
DAILY EN-
ATTENDANCE
ROLLMENT
TOTAL
PERCENT
ABSENCES
ABSENT
SCHOOL YEAR
A ......... B .........
765 749
689 676
121,316 119,586
11,647 7,716
9.6 6.5
Total ........
1514
1365
240,902
19,363
8.0
Walborg S. Wayne and P. F. Wehrle: Unpublished data on school absenteeism in Los Angeles.
Table 10.
School Absences by MaJor Category-Schools A & B, 1962-63 SCHOOL DAYS ABSENT AND PERCENT OF ALL SCHOOL DAYS
School A
STATED REASON
School B
FOR ABSENCE
Respiratory illness, acute. "Contagious" diseases ... Gastrointestinal illness, acute .. Miscellaneous illness. . . Nonillness ............. . Total ........ .
Total, Both Schools Number %
Number
%
Number
%
5,686 509 738 2,406 2,308
4.7 0.4 0.6 2.0 1.9
4,979 294 478 812 1,153
4.2 0.3 0.4 0.7 1.0
10,655 803 1,216 3,218 3,461
4.4 0.3 0.5 1.3 1.4
11,647
9.6
7,716
6.5
19,363
8.0
the application of effective prophylaxis against respiratory illness when effective techniques become available will require further evaluation. GENERAL CONSIDERATIONS
Modern school health supervision should include four measures important in health education for future acceptance of preventive medicine techniques as well as for further gains in the control of communicable disease as a health problem for the school child himself. These general areas for attention may be described as follows: Health Education In addition to the information customarily supplied about the pm:. pose and function of the various organs of the body, some information should be supplied about the common communicable diseases, their mode of transmission, the need for proper advice concerning therapy, and the importance of personal hygiene and environmental sanitation in the control of at least some of these infections. If we are to have adults interested in accepting various preventive medicine services in
CoMMUNICABLE DISEASE CONTROL IN SCHOOLS
987
the future, this would seem a logical beginning. In addition to the evaluation of the child on entry into school and the informal conferences with teachers, parents and student, appropriate guides for classroom education may be developed by school health personnel. Appropriate materials are also available from various voluntary and official health agencies. Immunization An inventory of prior immunization experience should be included as a portion of the initial detailed health appraisal, whether done by the private physician or the school physician. This should be discussed with the parent, who must be present if the examination is to be of value. This provides an entry into the family for an important facet of health education in addition to providing protection against specific diseases, and may provide the only approach toward preventive services for some families. Deficiencies in health care and particularly in immunizations 7 are well known in some segments of our population. Environmental Sanitation The health service should include orientation in hygienic principles for cafeteria personnel, including part-time student employees. In accordance with local health codes, persons with potentially infectious skin lesions (e.g. furuncles) or acute gastrointestinal upsets should not be permitted to handle food. In addition, representatives of the health service should ensure that adequate handwashing facilities are available for the food service personnel as well as in school restrooms, and that soap and paper towels, often absent, are supplied. Reporting of Disease Although reporting of cases of specified communicable diseases to local health agencies is the responsibility of the private physician, some of these may be of special concern to parents. Close exposure within the schoolroom to at least rubella (for the benefit of mothers who may be pregnant) and meningococcal disease (due to public concern) should be madE' known to parents of classroom contacts. Instructions to seek advice from their physician should accompany notification of this exposure. SPECIFIC TYPES OF INFECTION
Diseases for Which Immunization Is Available A current immunization on entry into school. Any promptly. Table 11 lists, by adequate protection against
history should be available for each child deficiencies noted should be corrected specific disease, minimal requirements for each. Additional current information is
988
PAUL
Table 11.
F.
WEHRLE
Recommended Immunization Schedulesjor School Children*
DISEASE
IMMUNIZING
PRIMARY
CONSIDERED
AGENT
DOSES
IMMUNIZA-
BOOSTER
COMMENT AND
TION
ADVISEot
CONTRAINDICATION
INTERVAL
Pertussis ........ OPT (adjuvant)
3
4-8 weeks
School entry & q. 3 years
Diphtheria ...... OPT (adjuvant)
3
4-8 weeks
School entry & q. 3-5 years
Tetanus ........ OPT (adjuvant)
3
4-8 weeks
School entry & q. 3 to 5 years
Measles ........ Live attenuated vaccine plus measles immune globulin or live "further attenuated vaccine" alone Poliomyelitis .... Oral poliovirus vaccine
Smallpox ....... Vaccinia
None needed
2 or 3
See text
Single trivalent dose on school entry for those previously immunized School entry & q. 5 years
Omit pertussis antigen if seriou S reaction followed prior use and in children over 8 years of age Over 8 years of age use OT. Adult type OT antigen q. 4-5 years is preferred at 12 years and older Use of combined DT antigen as above provides adequate protection Gamma globulin is advised, unless "further attenuated" vaocine is lISed, to reduce frequency of reaction. (See text.) Contraindicated in leukemia and related disease, marked egg hypersensitivity and after recent gamma globulin administration None
Eczema, steroid therapy or known immunologic defect
* Adapted from those of the American Academy of Pediatrics and the United States Public Health Service as applicable to school programs. t Booster doses should be provided on recognized exposure to clinical disease with exception of measles.
available in handbooks published by both the American Academy of Pediatrics! and the American Public Health Association. 2 Copies of each should be available for reference in the health office. Actual immunization should be provided as a portion of the complete health services best provided by the private physician. If these services are not available, it then becomes the responsibility of the school health service, with parental consent, to provide this protection on school entry and as indicated during subsequent school years. Contraindications should be observed and the manufacturer's directions for the volume of dose should be followed. Although alternate antigens are available for some of the diseases listed, the routines included in the table represent current practice and have proved satisfactory. Since some represent relatively new antigens and recent changes in methods of administration have been suggested, it may be appropriate to review the background for at least some of these recommendations. Of the more than 20 antigens presently marketed, either individually or in various combinations, only those listed are of sufficient general utility to warrant inclusion in the school health program. Pertussis is a serious disease, particularly among young infants. Children entering school should be protected for their own benefit as well as to prevent the school child from transmitting the infection to
COMMUNICABLE DISEASE CONTROL IN SCHOOLS
989
infants and younger siblings at home who may not yet have been protected. Owing to the frequency of local and systemic reactions with this antigen among older children and adults, pertussis antigen should be omitted in children older than eight years. Modified disease may occasionally occur among older children despite immunization earlier in childhood, but it is seldom of clinical importance other than serving as a potential hazard to unimmunized infant contacts. With the availability of adult type D.T. antigen, adequate sustained protection against both diphtheria and tetanus may be provided with a single injection at four- or five-year intervals in children above the age of 12 years. A booster D.T. inoculation should be given, of course, on injury or exposure to diphtheria. Although some physicians use inactivated poliovirus vaccines, most prefer the oral poliovirus vaccines, owing to convenience in administration and the increased resistance to alimentary infection with excretion of virus by those subsequently exposed to natural infection. Anyone of the three accepted routines may be used. Two doses of trivalent vaccine may be given with an interval of eight weeks between doses, or three doses of monovalent vaccine may be used. In the latter case the sequence should be types 2, 1, and 3 with the interval between types 2 and 1 not less than eight weeks, and at least six weeks between the latter doses. s Another acceptable routine is types 1, 3, and 2 at six-week intervals. Regardless of the sequence used, it is suggested that an additional dose of trivalent vaccine be administered approximately one year after the completion of the primary series. In addition, a single dose of trivalent vaccine should be administered upon initial entry into school for those children who, as infants, received the full course of oral vaccine immunizations as described above. Prior use of inactivated vaccine does not preclude oral vaccine use, and children with prior inactivated vaccine histories should receive two doses of trivalent vaccine at eight-week or greater intervals upon entry into school. All children entering school who have not been immunized against measles or who do not have a dependable history consistent with the natural disease should receive measles vaccine. Of the five routines available,s the two listed in Table 11 are the most practical. Inactivated measles vaccine alone does not provide the durable protection desired, and its use preceeding the administration of attenuated vaccine necessitates additional visits and injections. Although the live attenuated vaccine may be administered safely with or without the simultaneous administration of gamma globulin, most physicians will prefer to use the two combined, or live "further attenuated" vaccine alone, because of the lessened frequency of clinical reactions. Diseases for Which Immunization Is Not Available or Is Impractical A number of diseases are listed in Table 12 which occasionally
990
PAUL
F.
WEHRLE
arouse considerable apprehension or have caused confusion in the management of schoolroom exposures. Local health department authorities should be consulted if questions about school exclusion arise, and adequate treatment should be provided by the private physician as indicated. Table 12 is intended to serve as a general guide, and the school physician is referred to the American Public Health Association Handbook and to the appropriate State Health Department regulations for more definitive statements or applicable regulations.
Table 12. DISEASE
Communicable Diseases of Potential Concern in School Health (Immunization Impractical or Not Available) SUGGESTED MANAGEMENT
SUSCEPTIBLE CONTACTS IN
OF CASE
CLASSROOM
Chickenpox * ................ Exclude for one week Conjunctivitis (bacterial or viral) * ................... Exclude until antibiotic treatment is instituted Enterobiasis ................. Referral for treatment. Exclusion not indicated Hepatitis, infectious * ......... Exclude until jaundice has cleared and clinically well
No treatment or notification needed
No treatment or notification needed No treatment or notification needed. Very common infection of minor consequence Observe for mild clinical infections; refer for evaluation. Household contacts of cases should receive gamma globulin. Intensify attention to handwashing Meningitis, aseptic * .......... Exclude until clinical re- No treatment or notification covery. Majority due needed to mumps, ECHO or Coxackie viruses Meningitis, meningococcal * .. Exclude until clinical re- Household contacts should receive antibacterial prophycovery laxis. Notification of occurrence of case to families of schoolroom contacts for individual advice from family physician Mononucleosis ............... Exclude until clinical No treatment or notification recovery Mumps * ................... Exclude until clinical No treatment or notification recovery Pediculosis .................. Exclude until applica- No treatment or notification tion of insecticide Respiratory disease (common cold, influenza and A.R.D.) .. Exclude only with sys- No treatment or notification temic symptoms; personal hygiene emphasized Rubella * ................... Exclude until clinical Notification of parents of close contacts recovery
COMMUNICABLE DISEASE CONTROL IN SCHOOLS
Table 12.
991
Communicable Diseases (Continued)
Salmonella and Shigella infection * .................. Exclude until clinical re- Emphasize importance of covery. Emphasize hyhandwashing gienic measures to prevent spread from convalescent carrier state Scabies ..................... Exclude until treatment Observation only started Staphylococcal disease * ....... Exclude until treatment No treatment or notification started. Exclude from food handling in cafeteria Streptococcal disease * ........ Exclude until treatment No treatment or notification started. Exclude from food handling in cafeteria Tinea capitis ................ May attend school if No treatment or notification under treatment. Skull cap for M. audouini or T. tonsurans Tuberculosis * ............... Exclude if "adult type" Source must be sought, and disease, renal, drainadditional conversions among associates must be ing sinuses, or symptodetermined matic. Otherwise may attend school
* Reporting
to local health department usually required.
It should be emphasized that closing of schools has not been shown to be an effective means of controlling an outbreak of any communicable disease. Indeed, better health supervision can be gained by continuing classes, and it is readily apparent that personal hygiene is likely to be better under school conditions than in neighborhood play. Occasionally, as in intense outbreaks of influenza, it becomes unprofitable to continue classes, owing to high absenteeism among teachers and pupils alike. Some of the diseases listed in Table 12 deserve special comment. Chickenpox is ordinarily a relatively mild infection, and there is no need for precautions or notification of schoolroom contacts. Although modification of the disease is possible,lO it is not adVised, since conditions in which it may be indicated are not likely to occur among school children. Increased attack rates of infectious hepatitis have been occasionally observed in schools and at times have been almost limited within these schools to particular classrooms. In at least one instance close interpersonal relations were shown to be of greater importance in spread of infection than simple classroom contact. 6 Examination of hygienic practices and correction of deficiencies are usually all that is required in the prevention of spread within the school. Although there is little reason to notify other parents of schoolroom
992
PAUL
F.
WEHRLE
contact with viral meningitis, the public apprehension aroused by a serious episode of meningococcal disease is sufficient to warrant notification of the families of class contacts and suggest that they consult their physicians for advice about prophylaxis. Our own experience with several hundred cases of this disease in children would indicate that prophylaxis is necessary only among household contacts, where increased risk is readily demonstrable. Schoolroom contacts of clinically diagnosed cases of rubella should probably be identified so that mothers in the early stages of pregnancy can seek individual guidance from their family physician. As yet no dependable prophylaxis is available for prevention of infection, although clinical symptoms may be suppressed by gamma globulin. 4 Since convalescent carriers are a common feature of enteric bacillary disease, the occurence of more than an occasional isolated case should prompt a review of hygienic practices. Guidance from the health department should be sought with cases of enteric disease among food handlers in the cafeteria or with greater prevalence than occasional cases among the students. The school is an important facet in community tuberculosis control. Determination of tuberculin reactivity is a part of the initial health inventory on entry into school. In rural or suburban schools with tuberculin-positive rates less than 1 per cent in higher grades there is little merit in repeated annual testing, and perhaps the test on entry and another on entry into high school may be sufficient. On the other hand, this sort of program may be an extremely important casefinding device in schools serving the central metropolitan areas with relatively high tuberculosis incidence, and frequent or even annual testing may be needed here. The frequency of testing should be determined on the basis of local conditions and in consultation with local health department personnel.
CONCLUSION
It is apparent that school health programs must adapt to changing needs and newer concepts in preventive medicine and health conservation in order to best utilize available professional services. The role of the school in effective control of communicable disease is apparent, and this portion of the program can provide an important entry for educational efforts in preventive medicine and family-centered care. Although the role of the classic contagious diseases is rapidly decreasing in importance as a health problem for school children, communicable diseases still account for the majority of absenteeism and require attention in the newer programs.
COMMUNICABLE DISEASE CONTROL IN SCHOOLS
993
REFERENCES 1. American Academy of Pediatrics: Report of the Committee on the Control of Infectious Diseases. Evanston, Ill., American Academy of Pediatrics, 1964. 2. American Public Health Association: Control of Communic~,ble Diseases in Man. New York, American Public Health Association, 1965. 3. Committee on Control of Infectious Diseases: Current Status of M~asles Vaccine and Measles Vaccine Schedules. Newsletter, May 1965, pp. 7-10. Evanston, Ill., American Academy of Pediatrics. 4. Krugman, S., and Ward, R.: Rubella, Demonstration of Neutralizing Antibody in Gamma Globulin and Re-evaluation of the Rubella Problem. New England J. Med., 259: 16-19, 1958. 5. Metropolitan Life Insurance Co.: School Absenteeism. Stat. Bull. Metrop. Life Ins. Co., 31:4-7, 1950. 6. Mosley, W. H., Speers, J. F., and Chin, T. D. Y.: Epidemiologic Studies of a Large Urban Outbreak of Infectious Hepatitis. Am. J. Pub. Health, 53: 1603-17, 1963. 7. Public Health Service: First Annual Immunization Conference Proceedings. Communicable Disease Center, Atlanta, Ga., 1964. 8. Report of a Special Advisory Committee on Oral Poliomyelitis Vaccine to the Surgeon General of the United States Public Health Service, J.A.M.A., 190: 49-51, 1964. 9. Rogers, K. D., and Reese, G.: Health Studies-Presumably Normal High School Students. I. Physical Appraisal, II. Absence from School. III. Health Room Visits. Am. J. Dis. Child., 108:572-600, 1964; 109:9-42, 1965. 10. Ross, A. V.: Modification of Chickenpox in Family Contacts by Administration of Gamma Globulin. New England J. Med., 267:369-76, 1962. 11. Wehrle, P. F., Feldman, H. A., and Kuroda, K.: Effect of Penicillin V and G on Carriers of Various Groups of Streptococci in a Children's Home. Pediatrics, 19:208-16, 1957. 12. Wehrle, P. F., Feldman, H. A., Mou, T. W., and Shields, F.: Penicillin V Therapy of Scarlet Fever and Acute Streptococcal Pharyngitis. Clinical and Serological Response. Antibiotics Annual, 1956-57. New York, Medical Encyclopedia Inc., 1957. 13. Yankauer, A., Lawrence, R. A., and Ballou, L.: A Study of Periodic School Medical Examinations. III. The Remediability of Certain Categories of "Defects." Am. J. Pub. Health, 47:1421-9, 1957. Los Angeles County General Hospital 1200 North State Street Los Angeles, Calif. 90033