Diphtheria immunisation in a county area

PUBLIC H E A L T H DIPHTHERIA IMMUNISATION COUNTY AREA

AUGUST IN A

By W. B. STOTT, L.R.C.P. & S., D.P.H.,

Medical Officer o] Health, Cuckfield Rural, Cuckfield Urban and Burgess Hill Urban Districts; and H. LYNDHURST DUKE, O.B.E., M.D., SC.D., D.T.M.&H.,

(Colonial Medical Service, retired), Deputy Medical Officer o[ Health, Cuckfield R. ~, U.Ds, and Burgess Hill U.D. An account is given below of a campaign inaugurated in 1935 for the immunisation against diphtheria of the child population of a county area in East Sussex. The area c o m p r i s e s : (1) The Cuckfield Rural District, population 24,440 with 22 elementary schools; (2) The Cuckfield Urban District, population 13,600, with five elementary schools; and (3) The Burgess Hill Urban District, population 6,850, with three elementary schools. At the time of writing, the position with regard to immunisation in this area is that 91 per cent. of the children from one year to fourteen years of age, who attend or will attend the elementary schools, have received a course of three injections of T.A.F. Although exact figures for the country as a whole are not available, the percentage of children immunised is low, London for instance having only about 5 per cent. immunised. It is generally stated that the reason why parents will not take advantage of the facilities available for immunisation is because they are apathetic, but our experience is that if the parents are fully informed of the advantages of the procedure, the great majority will accept and accept willingly. A certain body of opinion holds that the voluntary system should be replaced by a compulsory system, but we do not share this view. Infant vaccination, for example, is compulsory but with a conscientious objector clause, and at the present time only about 30 per cent. of infants are being vaccinated. We have used T.A.F. throughout, and although it has frequently been stated that it is not practicable to give more than one injection in a rural area, we have not found that the necessity of giving three injections is of any serious disadvantage. • The children were Schick-tested three months after the final injection and 98 per cent. were found to be negative, showing that T.A.F. is not by any means a feeble antigen, as has been stated in some quarters; moreover, the immunity appears to last, as Schick tests carried out recently on a considerable number of children inoculated three years ago showed that 93 per cent. were still negative.

Inception and Development In 1935 a report was submitted to each of the three Councils, recommending that facilities should be made available for parents to obtain protection for their children against diphetheria. Previous to this the general practitioners had been asked whether they would be prepared to make a charge of 5s. for the course of three injections (at the time the British Medical Association had not fixed the fee now obtaining, of 2s. 6d. per injection) to parents whose children 234

attended or would attend elementary schools, the Councils to provide the prophylactic free of charge. All the general practitioners agreed to the suggestion and the Councils also resolved to act on the recommendation. Although all the parents were informed through the schools, infant welfare centres and district nurses, only 80 children were immunised under this scheme. In consequence of this poor response, early in 1936 all three Councils were recommended to pay to the general practitioners the 5s. fee for each child immunised. The C.R.D.C. agreed to the recommendation, but the other two Councils resolved to defer the matter, as no sum had been allowed in the estimates for that year. In 1937 the C.U.D.C. offered free facilities on similar lines, and the B.H.U.D.C. made a similar offer for children from one to six years of age only. In 1938 the latter Council extended their offer to children up to 14 years of age. All parents with children attending elementary schools in the C.R.D. received a circular letter with an acceptance form attached, setting forth the advantage of the Council's offer, and three months later it was found that 37 per cent. of the school children had attended the doctors' surgeries and completed the course. As it seemed probable that many more parents would consent to their children being immunised if the treatment was carried out at the schools, the co-operation of the head teachers and general practitioners was obtained and the parents were informed accordingly and asked to complete an acceptance form. Following this, acceptances were received in respect ot a further 40 per cent. of children, and these were immunised by the general practioners at the schools. There remained, therefore, 23 per cent. of children not immunised and it was resolved that the parents of these children should be visited by the district nurses. As a result, six months from the commencement of the enterprise 90 per cent. of the school children in the C.R.D. had been inoculated. A campaign on similar lines was carried out in the C.U.D. in 1937, and at the end of that year 84 per cent. of elementary school children had been immunised. Efforts to reach the under-school-age group of children were at first confined to the C.R.D. Parents of these children were circularised through the infant welfare centres and women's institutes but it was not found possible at that time to arrange for a personal visit to each parent by the district nurse. The percentage of children in this age group immunised at the end of 1937 was about 25. With the outbreak of war a considerable number of London children was evacuated to this area. It was therefore resolved to intensify the campaign, particularly among the one-to-five age group, comparatively few of whom had been immunised. The County Medical Officer of Health, whose co-operation throughout has been of the greatest assistance, kindly instructed the district nurses to visit all parents who had not accepted. Voluntary helpers were also recruited to help the nurses in this work. The parents had a choice of taking their children to the doctors' surgeries or to a special clinic arranged for them at the welfare centre or a nearby hall. Many parents,

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PUBLIC H E A L T H

however, prefer to have their children immunised at Cuckfield Urban D~strict. home and these were visited by one of us accompanied Number of children one to five years of age by a uniformed nurse. This was found to be a most Group . . . . . . . . . . . . . . . 509 effective method of dealing with active and passive Number immunised . . . . . . . . . . . . 456 opposition, as it is often possible to win over the Percentage . . . . . . . . . . . . . . . 89 parent and inoculate the child at one and the same Number attending elementary schools ... 1,250 visit. Wet or washing days and the dinner hour are Number immunised . . . . . . . . . . . . 1,160 the most propitious occasions for these visits, and Percentage . . . . . . . . . . . . . . . 93 previous notification by post-card often helps a busy Total percentage immunised 92 mother to make her plans. Burgess Hill Urban District. In dealing with the school children, success depends Number of children one to five years of age greatly on the efforts of the teachers. At one school Group . . . . . . . . . . . . . . . 284 in 1936 the percentage of acceptances rose from 35 to Number immunised . . . . . . . . . 246 90 in one week, following an appeal to the head Percentage . . . . . . . . . . . . . . . 87 teacher to take a personal interest in the success of the Number attending elementary schools ... 862 scheme. The district nurse has a definite place in the Number immunised . . . . . . . . . . . . 789 scheme by visiting those parents who have not Percentage . . . . . . . . . . . . . . . 91 accepted. We have found that the best plan is for the Total percentage immunised 90 doctor to carry out the injections at the school. A great deal of the success of the campaign in this It will thus be seen that throughout the three area has been due to the wholehearted co-operation districts only 9 per cent. of refusals was obtained. and enthusiasm of the general practitioners who, until The Council's scheme does not apply to children October, 1939, had carried out all the inoculations. attending private schools, parents of whom have to bear Up to this time a large percentage of the school the cost themselves~ A letter, however, was sent to children had been immunised but only a small pro- each principal advocating the procedure and at the portion of the " under five" group. T h e practical end of last term 75 per cent. of the children had been difficulty in dealing with this group is that the majority immunised. of mothers will not take their children to the doctors' surgeries and the general practitioners have no time to C h o i e e of Material go round giving the injections in the homes. There We have used exclusively T.A.F.: three 1 c.c. doses, is, therefore, no doubt that it simplifies a scheme of the second in 14 days and the third three weeks later. this kind if a doctor is available to travel the area and The Schick test is carried out not less than three act as immunising officer and Schick-tester. With months after the last injection. As a result of certain some parents, consent is conditional on their own limited control experiments on children in this area doctor giving the injections and in any event his advice and a consideration of the literature on the subject is sure to be asked. To obtain 80 per cent. acceptances it was decided to dispense with a pre-Schick test. All or more in this group the immunising officer is, how- children who were Schick-positive after a full course ever almost indispensable, to round up defaulters and of injections received at first one or two supplementary co-ordinate the progress of the campaign as a whole. inoculations, according to the intensity of the Schick Many parents will promise acquiescence and then do reaction. At the present time, all such children are nothing, and the busy practitioner cannot possibly deal given a full secondary course, irrespective of quality with such people. Now that the campaign has been of their reaction to the test. There have been no launched, a leaflet is sent from the Public Health De- serious reactions, indeed it is very rare for the child partment to each parent on the child's first birthday. to experience even the slightest discomfort. There is, This leaflet is one issued by the Central Council for of course, a tendency for parents to attribute to the Health Education, explaining the advantages of protect- injection any symptom, including even the rash of an ing the children against diphtheria and on the back exanthem, that the child may exhibit within the page is a communication from the Medical Officer of ensuing week or so. But repeated inquiries have Health informing the parent how the protection can be revealed only three cases where some tenderness and obtained. redness indicated a local reaction, and these signs disappeared in 48 hours. Results of the Campaign We believe that in a campaign of this kind it is Particulars relating to the number of children impossible to lay too much stress on the avoidance of immunised together with the percentage are given inconvenience to the child. Although perhaps it does below: - not matter so much in a large town, in a rural or small urban district it is most important to have no reactions Cuckfield Rural District. Number of children one to five years of age or sore arms. News travels rapidly in a small comGroup ............ 793 munity and one bad reaction in a village, such for Number immunised ......... 680 example as those described by. Lewis* with A.P.T. Percentage . . . . . . . . . . . . . . . 86 would deter many mothers from having their children Number attending elementary schools ... 1,950 inoculated. Number immunised ......... 1,824 93 Percentage . . . .... . . * Lewis, J. Tudor (Dee. 16th, 1939), Med. Offr., 68, 235. Total percentage immuniseci 91 235

PUBLIC HEALTH We have recently had some experience of A.P.T., one of us having used it to immunise the evacuated children in this area. With the younger children all went well; but among those of eight years and upwards local reactions were not uncommon, and there were several examples of severe local and general reactions with temperatures of 102 for several days. Neither the dosage (0"1--0"2 c.e.) nor the method of introduction (intra-muscular or subcutaneous) had any diseernible influence on the initial reaction. Moreover, in several eases where a severe reaction had followed an initial intramuscular injection of 0"2 c . c . A . P . T . , a subsequent injection of 1 c . c . T . A . F , a month later into the other arm produced an almost equally severe reaction. Nothing similar has occurred in our experience with T.A.F. when used alone. These incidents have led us to revert to T.A.E for all children over eight years of age. They are recorded not in any spirit of criticism but in support of our adherence to T.A.F. As far as possible any manifestation of alarm or distress by the child under treatment should be antieipated and forestalled. Some parents are upset by such demonstrations and the child may be prevented from completing its course. The method of introducing the needle is important, for a glimpse of the syringe sticking out of its shoulder will often turn smiles into tears. A sharp look-out must be kept for children who are labouring under strain or excitement. Pallor is a warning signal and so are a bracing of the muscles of limbs and face. Occasionally a child faints or is sick shortly after or even before an injection and the inevitability of this kind of thing sooner or later in a long series of inoculations emphasises the importanee of avoiding, as far as possible, any reactions ascribable to the drug itself. A bottle of smelling saIts is a very useful addition to the doctor's bag.

Apparatus and Method The apparatus employed comprises a n all-glass syringe of 3 c.c. capacity to which an Agla 214 needle is attached; a test tube to protect it; a metal spirit lamp; a small portable steriliscr; and an iodine bottle with a brush in the stopper. The needle is passed through the flame after each injection and the stopper of the container is also flamed before each withdrawal of material. The syringe is boiled before each session, and after each injection is returned to the sterilised tube. The injection is, of course, given intramuscularly, in the deltoid region, into each arm in turn. After each injection the site is gently massaged with the finger and thumb. Sometimes the inoculum fails to disperse immediately and the massage is then continued until the accumulation is no longer palpable. The point of the needle should be freely movable in the muscle before the fluid is slowly introduced. For the Schick test all-glass 1 c.c. syringes with 214 needles are used, the syringe being replaced after each test in a sterilised testtube. Spirit is used to sterilise the skin and the needle is flamed after each test.

Record Cards. Each child has a card allotted to it on which are noted name, address, birthday, school, the dates of 236

AUGUST Schick tests, and of the primary and supplementary injections. On the back of the card are spaces for home visits and account of the parent's attitude and any other relevant details. For the under school age children the cards are kept by the district nurse until the child goes to school, when they are taken over by the teacher and duly filed and docketed.

Opposition (a) From Members o[ the Local Authority. (1) " That the cost is too great." When considered in relation to the benefits accruing to the community objection on this score carries no weight. An epidemic might well cost a Council several thousand pounds in a single year, not to mention the attendant suffering and distress. There is in addition the incentive of the possible elimination of diphtheria altogether from the district. (2) " That it is not necessary in a rural area." It is now well recognised that children in rural areas are not exposed to the natural immunising processes which in a town environment lead to a considerable proportion of the children acquiring resistance against diphtheria. It is, therefore, all the more important to forestall the appearance of "carriers" by protecting the highly susceptible child population. In a reception area such a measure possesses a very special importance.

(b) From the Parents. Here opposition may take many forms, ranging from crude superstition to quotations from scientific digests. One mother, the solitary supporter of a specially convened diphtheria clinic, observed as she surveyed the empty room " T h e y won't come to-day; you see it's the thirteenth." Hostility is often traceable to some accident, real or imaginary, which local opinion has attributed to the injections. The two parents often disagree. Generally the father is the dissentient, often because he had " too much of that sort of thing " in the last war. A curiously obtuse but not uncommon argument is that in spite of all his injections he never had any illness! But there is often a genuine dread of exposing the child to the discomfort associated in the man's mind with inoculations against typhoid, plague, smallpox or some other disease, and this objection generally yields readily to explanation. Then there are the fatalists, who must be told that the Deity dispenses remedies as well as scourges, and helps those who help themselves. Lastly, there is, sad to relate, almost always a group of those who " j u s t don't hold with it " and who are completely impervious to all arguments, ahhough a ease of diphtheria in their midst will sometimes shake even their confidence. In setting forth the advantages of immunisation, experience has taught the futility, of false claims. There is no absolute guarantee against infection and it is foolish to pretend that there is. Evidence to the contrary will soon expose the deception and much damage will be done to the campaign. Parents appreciate straight talking, and there is no need to spoil a splendid case by exaggeration. It is safe to claim that immunisation will protect the majority of children from contracting the disease and that if an immunised

1940 child does get diphtheria the dreaded grave symptoms and after-effects will not develop. A word or two on the possible after-effects of diphtheria, heart impairment and paralysis, are often very useful. The absence of any disfigurement, temporary or permanent, after the injection, makes a strong appeal, and it is worth while deliberately to contrast this with the widely known local effects of smallpox vaccination. The extreme rarity of any reaction at all can also be stressed, in contrast to the discomfort that often follows anti-typhoid inoculation. A few simple facts about the mortality of diphtheria in young unprotected children--50 per cent. under two and. 25 "per cent. under four years of age--will impress parents who wish to postpone action until the child goes to school. It must be explained, also, that immunity takes some two months to develop fully and this fact is useful in combating the delusion, held also by certain members of Local Authorities, that immunisation is unnecessary until cases of diphtheria appear in the neighbourhood. The duration of protection is another point that requires careful handling. It should be made dear that both the degree and the permanence of the response differ in different children. It is unwise to administer injections when a child is not in good health, for both general principles and experience indicate that success depends considerably on the co-operation of healthy tissues. On more than one occasion in our experience attempts at immunisation have failed in children with glandular tuberculosis.

PUBLIC HEALTH THE GARCHEY SYSTEM OF DOMESTIC REFUSE DISPOSAL* By J. JOI~STONE JERVIS, M.D., D.P.H.,

Medical O~icer o[ Health, City o/ Leeds

The introduction of drains and sewers brought about the complete differentiation between excrement and domestic waste. The former, thanks to the engineers and chemists, has ceased to be a problem; not so the latter, which still defies solution in spite of such improvements in methods as the incinerator, the controlled tip and the salvage system. In wartime the dustbin has been elevated to an important place in the national economy; hidden among its unsavoury polymorphous contents lies one of the keys to victory. In peace the majority of things ordinarily found in the dustbin belong to the category of articles without replacement value; but in war paper, rags, bones and metals have a considerable monetary value. At any time waste is reprehensible and, if the people were educated to believe that, it would be possible to divide domestic refuse into two categories--saleable scrap and unsaleable residue. Of the existing systems of refuse disposal only the salvage system claims to prevent waste, hut even by this only a fraction is salved of what might be. So it comes to this, that there should be a sorting out of refuse in the house itself, scrap being separated from residue. The latter can then be disposed of through an adaptation of the water-carriage system, which is just what the " G a r c h e y " system is. The Garchey system is not a competitor of existing Summary (1) An account has been given of the initiation, systems, but an elaboration of them designed to meet development and results of a campaign against diph- the needs of flat-dwellers and those in large hoUsing estates with a uniform lay-out. All sorts of expedients theria in a County area. (2) Certain difficulties both in organising and in have been tried to overcome the difficulty of multifloored buildings, e.g., special bins with hoists, chutes, carrying out the scheme are discussed. (3) Reasons are given for the choice of the prophy- etc. However, bins are noisy and messy, and chutes lactic (T.A.F.) used, such as absence of reaction and are offensive and insanitary. In fact, the outstanding proved efficacy (only 2 per cent. Schick-positive three weakness of the flat system of housing is the difficulty months after a course of three injections and 7 per of dealing with domestic refuse. To overcome this Monsieur L. Garchey, a French engineer, invented his cent. after three years). (4) At the time of writing out of 5,648 children, system of removal by water and eventually had it one to fourteen years of age, 5,155 have accepted installed in several large blocks of flats built by the immunisation and have been inoculated, a percentage Paris Housing Corporation. I inspected the installaof 91 (87 per cent. one to five years and 93 per cent. tion in 1935 and was greatly impressed. The system seemed to work perfectly without offence and the school age children). (5) Since 1935, when the campaign was first in- tenants everywhere spoke of its efficiency. The disaugurated approximately 6,000 children have been posal stations were unobstrusively placed and were neat and orderly. In one instance the heating generimmunised under the Councils' scheme. ated by the burning of the residue was used t o h e a t the water for a large swimming bath. Any doubts I As we go to press, we have learnt with regret of may have had about the installation of a similar system the death of Dr. S. G. H. Moore, formerly Medical at the Quarry Hill Estate in Leeds were set at rest. Officer of Health for the City of Huddersfield, at The system is simplicity itself and no more complithe ag.e of 74. An obituary notice will appear in our cated than the one-pipe system of sewage disposal with which you are all familiar. The initial stage in next Issue. the process is the kitchen sink, a white glazed recepThe C.B. (military) has been conferred on Surgeon- tacle, 24 in. by 18 in. by 10 in., differing from the Rear-Admiral Sheldon Francis Dudley, O.B.E., M.D., ordinary sink in that (1) it has in addition to the small F.R.c.P., R.N., Hon. Physician to the King, and a Fellow of the Society of Medical Officers of Health, ¢ Abstract of a paper read to a joint meeting of the Royal in recognition of distinguished services during the Sanitary Institute and the Yorkshire Branch of the Society of Medical Officers of Health. wa.r,

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