Diphtheria immunisation: Its possibilities and difficulties

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PUBLIC HEALTH.

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D i p h t h e r i a I m m u n i s a t i o n : Its P o s s i b i l i t i e s and D i f f i c u l t i e s . By ELWIN I t . T. N:~SH, ~.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health, Borough of Heston and Isleworth; and j. GR..\H.Xal FORBES, 51.,~., ar.D., I:.a.C.P., D.P.H., Principal Assistant Medical Officer, London County Council.

No ordinary meeting of the Society has attracted so large a gathering as that held in London, on March 24th, 1983, at which the papers on l)iphtheria lmmunisation, by Dr. Nash and Dr. Forbes, were submitted. Readers are fortunate in having so very full a description as that given by Dr. Nash of the methods that have proved so s~ccessful in inducing parents with, their children to attend in large numbers at his clinics. The un]ort~nate part is that the excellent slides and the interesting film he sho.wed i n / u r t h e r explanation cannot be reproduced. Dm E. H. T. N A S H . I N cons!der.ing the possibilities of diphtheria lmmumsatmn, it is well to bear in mind tile difficulties that arise with regard to the interpretation o.f statistical figures and results, which often seem to be somewhat obscure. W e must not let enthusiasm for the obvious decrease in tile incidence of the disease blind us to, these factors, particularly in regard to the periodic rise and fall o.f the disease, which may in itself be responsible for much that we want to claim in the first outburst of enthusiasm as a result of a decrease which has followed an immunisation campaign. In order to see what the possibilities are, it is probably better to start with the facts and figures from America, where they have been years ahead of us on this side o.f the Atlantic in that direction. In going through the health reports of the wtrious states, one is struck by the different manner in which the Americans approach ttle problem with regard to publicity, by methods that are altogether more intensive and more spectacular than our sober-minded ideas. For instance, I have, through the courtesy of the United States Public Health Service, been supplied with some of their broadcasts. Take for instance, one, via., " The Prevention of Diphtheria." This is a concise but forceful broadcast, urging the claims of immunisation, amongst which is a very striking paragraph u r g i n g parents to let the baby's first birthday present be a complete protection against diphtheria. This is headed " The 395th Public Health 13roadcast from the United States Public Health Service." In another instance I was supplied with the forty-fourth broadcast on diphtheria alone.

It will, I think, b~ a long time before this country uses the wireless in the same manner as it is used on the other side of the Atlantic, vet there is surely nothing at the present time which will enable information of the kind we want disseminated, to reach the remotest homes in the same way as the wireless broadcast. In going thro.ugh the records of the various states in America, North and South, one is impressed by the zeal with which they have taken up this matter of immunisation. Their propaganda has been urged, to an extent quite unknown in this country, by slogans, by placards and by broadcasts. In New York State, for instance, an intensive campaign was waged by tile broadcasting of a five years' campaign round the slogan " No more diphtheria in 1930." Lee Frankel, the second Vice-President of the Metropolitan Life Insurance C o m p a n y (whose activities in the campaign were immense), in a report on " the five year diphtheria campaign," records that in New York State during that period, 749,922 children received three doses of toxin antitoxin, 189,604 of whom were under five years of age, and 376,491 between five and nine }rears of age. The deatl)-rate fell from 6'4 to 2"5 per 100,000. T h e cases fell from 4,370 in 1925, to 1,613 in 1930. t t e further records that in contrasting the cities where combined active (ampaigns were conducted with those where " no effort of any sort was being made,, where there was no intelligent public opinion, no active work on the part of the health departm e n t s , " he found that in the 53 cities in the United States where active campaigns were

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conducted, there had been a reduction in the diphtheria death-rate of 32"9 per cent., whereas in 31 cities which were quite inactive, instead of a reduction in the death-rate, there had been an actual increase of 9"3 per cent. Professor C. :E. A. Winslow, in a paper read last year before the Royal Sanitary Institute Coflgress at Brighton, made the following statement with regard to immunisation : " T h e result has been a proportionate decrease in the diphtheria death-rate as striking as that which followed the introduction of antitoxin 40 years a g o . " He further recorded that in New Haven, with a population of 160,000 " we had for the years 1920-22 an annual a~erage of 377 cases of diphtheria with 16 deaths. In 1923, immunisation was begun. For the seven year period 1925-31 the average number of cases was 29 per year, and the average number of deaths two. In 1931, there were four cases with one d e a t h . " How this was accomplished is set forth in the " Connecticut Health Bulletin," for May, 1931, and will be referred to later when dealing with publicity. There is a general and marked fall in the incidence of diphtheria in those areas where active campaigns had been conducted. The actual amount of i,nmunisation necessary to produce these striking results has now been more or less standardised. Dr. E. J. Godfrey, Director of the New York State Health Service, has pointed out that no. immunity scheme could satisfactorily produce any diminution of diphtheria even when t h e school population was immunised to the extent of 60 to 70 per cent., until, in addition to. this, the pre-school population was adequately protected to the extent of 35 per cent. I should like to refer to a most interesting report entitled: " A National Survey by the Members of the Preventive Medical and Dental Services, presented to President Hoover, at the \Vhite House Conference in 1931, on Health Prevention for the PreSchool Child." The thoroughness with which this information was ferreted out from the 156 cities and the rural areas of 42 States is an instance of the efforts of the United States of America in this direction. They, too, have their difficulties (of population) in the same way that we have, and the difference in the response is very well illus-

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trated in chart 33 of that report, which shows the range of numbers of pre-school children immunised in the 156 cities; the numbers falling from 50 per cent. in Niagara Falls, to i per cent. in Columbus, Ohio, and Butte (Montana). Tlaeir figures show a general response such as we cannot produce in this country. A further record showed that the ten cities in the country with the highest percentage'of children immunised were: Niagara Falls, 50; Syracuse, 48; New Haven, 48; Yonkers, 45 ; Rochester, 44 ; Elmira, 48 ; Schenectady, 41; Utica, 41; Detroit, 40; H i g h l a n d Park, 39. Again, if we take the ten largest cities in the States, the difference in the response is shown by the percentage of pre-school children immunised, viz., in Detroit, 40; New York, 35; Philadelphia, 27; Chicago, 23; Baltimore, 19; Los Angeles, 15; Boston, 15; Pittsburgh, 15; Cleveland, 10, and St. Louis, 10. In addition, this survey shows a wide range of authorities with the different average percentages of pre-schocl children immunised, indicated in five groups according to their economic status, demonstrating that in the highest economic group, 21 per cent. of the pre-school children were immumsed; in the second, 16 per cent.; in the third, 11 per cent. ; and in the fourth and fifth, 10 per cent. each. A further contrast is made between the different public health services as compared with immunisation. It is interesting to= note how the percentage immunised in the five social grades varies in the different districts. For instance, in Des Moines, the highest percentage immunised amongst the pre-sehool children is 31 per cent. in the highest social grade; 1 per cent. in the fourth grade; and 3 per cent. in the lowest; whereas Boston's figures in the highest social grade are 14 per cent. ; the lowest percentage being 8 per cent. in the third social grade, and the highest percentage, namely, 29 per cent., in the lowest social grade. Detroit, in the highest social grade, has 43 per cent. immunised; 35 per cent. in the second grade; 42 per cent. in the third grade; 37 per cent. in the fourth grade, and 42 per cent. in the lowest grade, and despite these high percentages of immunisation more or less evenly distributed through the five social groups, Detroit has one (~f the highest incidences of diphtheria, and one still rising.

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H o w far such figures are due to m i x e d nationalities, h o w f a r to c o l o u r e d p o p u l a t i o n s , a n d h o w far to r e l i g i o u s differences, t h e r e does not a p p e a r to be a n y t h i n g to indicate, except in the case of H o n o l u l u , which will be referred to later. I t is i n t e r e s t i n g to note that there is o n l y a v e r y s l i g h t difference between the p e r c e n t a g e of children i m m u n i s e d in the u r b a n d~stricts as c o m p a r e d with rural, w h i c h is v e r y different f r o m the results o b t a i n e d so far in this c o u n t r y . T a b l e I s h o w s the p e r c e n t a g e a n d the different ages. TABLE I.

Urban Rural Under Under Under Under Under

1 2 3 4 5

......... ......... ......... ......... .........

3% 22% 24% 27% 32%

3% 18% 22% 26% 29%

In contrast, T a b l e I I g i v e s tile figures for vaccination against smallpox. TABt.E I I .

Urban Rural Under Under Under Under Under

1 2 3 4 5

......... ......... ......... ......... .........

3% 17% 21% 28% 44%

1% 5% 8% 11% 18%

I n the s a m e v o l u m e is g i v e n a c o m p l e t e list of the 156 cities s h o w i n g the p e r c e n t a g e of p r e school c h i l d r e n i m m u n i s e d a c c o r d i n g to their o r d e r of r a n k i n g . It would a p p e a r t h a t a m o n g

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the A m e r i c a n p e o p l e in the m a t t e r of safeg u a r d i n g their children a g a i n s t d i p h t h e r i a , the rural p o p u l a t i o n is f a r a h e a d of the rural p o p u l a t i o n of this c o u n t r y . T h e r e p o r t of the C i t y o f N e w a r k , N e w J e r s e y , e m p h a s i s e s the fact t h a t with o n l y 15 p e r cent. of the pre-school children i m m u nised, d i p h t h e r i a increased 50 per cent., a n d d e a t h s 200 per cent. T h e y also e m p h a s i s e the fact of " cases of d i p h t h e r i a o c c u r r i n g in p a r t l y imm:unised children, a n d in t h o s e w h e r e a t e r m i n a l Schick test h a s not been c a r r i e d out to d e t e r m i n e susceptibility or i m m u n i s a t i o n . " D r . D . Griswold, the H e a l t h C o m m i s s i o n e r for O h i o , in the Illinois Health Quarterly (Vol. I I I , 1, 1931) tried out t w o counties. " I n one, the p a r e n t s were b y v a r i o u s m e t h o d s of publicity, told to t a k e their children to their f a m i l y p h y s i c i a n s a n d h a v e t h e m immunised. T h a t is, it w a s a s i n g l e a n d i n d i v i d u a l service of t h e doctor to the patient, a n d the o n l y result w a s rather less t h a n 2 p e r cent. i m m u n i s e d . " I n the a d j a c e n t c o u n t y , where, in a d d i t i o n to the a b o v e m e t h o d s , m a s s m o v e m e n t s were p u t into o p e r a t i o n , f r o m 95 to 98 p e r cent. of the a v e r a g e a t t e n d a n c e at the schools were f o u n d to h a v e b e e n i m m u n i s e d . " O f the m a n y r e p o r t s on d i p h t h e r i a c a m p a i g n s , o n e of the m o s t i n t e r e s t i n g is t h a t recorded by Drs.~Villiam Wild, and Kathryn Tirrell, on d i p h t h e r i a control in B r i d g e p o r t , Connecticut. I n this, t h e y p o i n t out h o w B r i d g e p o r t has been afflicted with d i p h t h e r i a s i n c e 1880. No real d i m i n u t i o n in t h e disease h a d t a k e n place until 1929-1930.

TABLE I I I . DIPHTHERIA CONTROL IN BRIDGEPORT.

By WILLIAM F. WILD AND KATHRYN R. TIRRELL. Deaths.

Cases.

1926 January February March April

.. .. ..

.. .. .. .. ..

May June . . . . July . . . .

August September October November December

Total

..

15

.. ..

15 23

28 28 27 27 20 26 17 20 16 25 27 34

..

168

295

,.

.. .. .. .. ..

7

• °

.. ..

• °

..

9

..

7

,.

• ° • °

....

21 21 16

1927 1928

15

10

9

1929 1930

35 35 34 19 20 16 8 5 13 18 21 25

20 6 14 11 11 10 6 1

0 1

5

0

4 5

1 1

6

249

99

8

5 5 3 6

1926 1927 1928 1 9 2 9 1930 3 3 3

1 4 3

4 4 1

0 2 0

1 (} 0

1

1

0

0

0

0 0 0 0 0 0

1 1 3 1 1 1

0 2 1 0 2 1

0 1 0 0 1 0

0 1 0 0 0 0

3

1 1

3 6

5 1

1 0

0 0

33

12

26

21

5

2

0

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In 1926, they commenced an immunisation campaign, Schick testing and immunising with three doses of toxin antitoxin, both school children and pre-school children, without a n y very satisfactory result until they put into operation the administrative methods which lhey claim were the deciding factors in the eradication of diphtheria. T h e i r additional efforts were a second swab from nose and throat before liberation of a patient or carrier, compared to one previously, on successive days. T h e swabbing o.f contacts was extended to all women and children under the same roof, and the father of the patient or carrier; the father was only examined if a food handler. If the patient was a school child all the members of his class at school, and often all the other children teachers and persons connected with the school, such as janitors, were also examined. Table III shows the decrease in the cases and deaths since the administrative machinery was employed, in additio.n to the immunisation campaign, while Table IV shows secondary cases of diphtheria in the same family.

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must admit the cogent claim that immunisation is in the main responsible. A very important paper was published in America in 1931, by W a i t e r W . Lee. He emphasised the fact that unless all the factors bearing on the figures are taken into account, and the natural trends, as I emphasised at lhe commencement, are allowed for, the true relationship of the immunisation to the decline in diphtheria incidence max, be masked either for good or bad. H e shows how the mortality in New York from 1870-1930 has diminished with comparatively small oscillations along the line of " fitted t r e n d , " for the last three years remaining within twice the standard deviation. T h e final drop, however, was equal to seven times the standard deviation, or equal to the expected rate in 1945. (See Chart A). This he empfiasised, can only be due to immunisation. DEATH RATI[, LOGARi "n.4MIC $1

D,~TH RATE, LOGAR|TH M IC

t

I

I

Nr'W YOR~,CITY

TABLE I V . DIPHTHERIA CONTROL IN BRIDGEPORT. WILLIAM F. WILD AND KATHRYN R. TIRRELL. Secondary cases of diphtheria in same family. 1926

1927

1929

1930

0 6 5

3 0 2

0 0 0

January February March April

1 l 2

0

4

3

0

0

May

1

3

2

0

0

2 2 2

5 2 4

2 1 0

0 0 0

0 0 0

0 0 1 3

0 2 1 4

1 2 3 3

1 0 0 1

0 0 0 0

15

32

28

7

0

..

June . . July ... August ... September October November Deeember Total

..

2 4 1

1928

T h e writers emphasise the cyclic variations in the character of diphtheria, and urge, as I have done at the commencement of this paper, that we must not be led away by this fact to claim for immunisation or administrative methods, results which may have been in large measure due to the character and habits of the disease. Notwithstanding the possibilities that the type of the disease may be urged against the claim that immunisation has b r o u g h t about the diminution in the incidence of diphtheria, we

tl

,,

%.

OrATH RATE PER t00~O0 POPULATION F I T T £ D TR[ND STANDARD O~.'VIATION

"

"~.

I1"

. . . . . . . . . TWICE STANDARD D[VIATIOP¢

|1~]10

1880

I~0

I~0

L~IO

19~ I

1930

CHART A. DXPttTHERTA MORTALITY--NEw YORK CITY, 1868-1930. C h a r t reproduced from G r a h a m Forbes' " Prevention of D i p h t h e r i a . " T a k e n from a paper by W. W. Lee (Journal of Preventive Medicine, May, 1931).

In discussing the deaths in age-groups he gives the following figures :--0-4. P e r c e n t a g e of t o t a l A r a t i o of t o t a l

... ...

70 17-5

5-9.

10-14. 15 a n d over '23 4 3 5"75 t 0.75

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PUBLIC HEALTH.

" W h a t , " he asks, " is the relative value in the prevention of diphtheria in New York City of the immunisation of a child six months of age and a child 14 years of age? After 15 years of age the individual is quite unlikely to die of diphtheria. The 14-year-old child after immunisation has a relative value of one for one year when he passes into the 15 and over group, where he is unlikely to die of diphtheria. The six-months-old infant is, however, for five years in a group in which he is 1.7"5 times as likely to die of diphtheria as the 14-year-old child, and his protection has, therefore, the relative value of the im,nunisation of 87"5 children 14 years of age. This child graduates to the five to nine group, where he is the equivalent of 28"7 children 14 years of age, and then into the 10 to 14 group, where he is the equivalent of five children 14 years of a g e . " He also makes similar analyses for other towns, but repeatedly points out how much of the decrease may have nothing to do with immunisation. Shirley W y n n e in " Guarding the Health of Seven Million People " (i.e., New York City) indicates the difference of the actual cases of diphtheria compared with the expected number during the peri(nt of diphtheria immunisation. (See Chart B.)

OF"IMMUNIZATION ONDIPHTHERIA PREVALENCE ] *',.,~I"

I [

1

~,~trdg

iiil

~f'l" Cn,urr B. INI~LUKNCt~ OF IM.~IUNISATION ON DIPItTHt~RIA PREVALI~NCE. F r o m " Safeguarding Seven Million Lives." (New York City Health Report by Dr. Shirley Wynne).

There is at the present time an undoubted trend towards the use of toxoid antitoxin and R a m o n ' s anatoxin instead of toxin antitoxin,

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and the advantages claimed of earlier and more certain immunisation appear to outweigh the definite tendency to reactions in older children. Toxoid alone is now being strongly urged, the advantages being set forth below by Dr. C. H. K i n n a m a n in the sixteenth biennial report of the K a n s a s State Board of Health, 1980-1982. 1. Toxoid does not contain animal serum, ~lnd for that reason does not sensitise to animal protein. 2. Immunity develops more rapidly after toxoid than after toxin antitoxin. 8. A higher percentage of children become Schick negative after two doses of toxoid a month apart, than after three doses of toxin antitoxin a week apart. 4. The use of two doses instead of three simplifies the procedure. 5. The simplified procedure will make it easier for the family physician to immunise y o u n g children. 6. Toxoid is a more stable product than toxin antitoxin, and is much less likely to deteriorate on standing. Toxoid is now being extensively used in America and Canada, and the excellent results obtained have been recorded in a paper b y Drs. Mary Ross and Nell McKinnon, in the Canadian Public Health Journal. T h e y summarise their results in the following manner : - " The reported cases of diphtheria that occurred subsequent to toxoid immunisation of school children in Toronto are compared with the cases which it is estimated w o u l d have occurred in the absence of immunisation. In 16,829 children given three doses of toxoid and observed from one to three years, the number of cases estimated to occur is 222. The actual cases were 23. This is a reduction of approximately 90 per cent. No deaths occurred in these 23 cases. This 90 per cent. reduction in cases, with elimination of deaths in this group of children, was accomplished without producing one reaction of any significant degree, possible reactions, forming 10 per cent. of the school children, being excluded by the judicious use of the reaction test." O'Brien and Parrish in the Lancet, of July 23rd, 1932, published a very valuable account of immunisation by potent unconcentrated toxoid, utilising the Moloney test as the guide to the elimination of cases that would react badly. T h e y found (Table V) that out of 906 subjects aged one to 28, 5 per cent. showed definite reaction, and 12"7 mild reactions.

PUBLIC HEALTH.

250 TABLE V. Group.

Numbers.

Ages

A. B. C. D. E. F.

18 under 3 244 3-15 204 6-15 141 1-18 197 11-18 102 19-28

Total

906

Nil or faint, 18 211 170 127 148 72 746 (82.3%)

Reaction. Mild.

0 23 27 12 37 16 115 (12.7%)

Deftnite. 0 10 7 2 12 14 45 (5%)

These M positive cases were immunised with three doses of 1'0 c.c. of T . A . F . at fortnightly intervals; a few received toxoid, all of whom suffered with local or general reactions. None of the cases with nil or faint reactions was affected locally or generally by the toxoid injections subsequently. The results of this potent toxoid inoculation gave an immunity of 95 per cent. within five weeks of the final inoculation. The toxoid used by R a m o n has an L F up to 15, whereas O'Brien and Parrish have been using some with an L F of 36, and have recently produced in their laboratory, toxoid with an L F of 150 per c.c. T h e outstanding merit appears to be the certainty with which sensitives are weeded out by the Moloney test, and the rapidity and high percentage of immunity produced. In my opinion, it is absolutely imperative to ensure that there shall be no uncomfortable reactions following immunising injections, if we are to succeed in a widespread immunisation of y o u n g children. In this country the amount of immunisation is insignificant. Thanks to the pioneering efforts of Parlane Kinloch in Aberdeen, and Harries in Birmingham, the leaven has begun to work, but only slowly, despite the very valuable contributions to the scientific side by O'Brien, Parrish, and Okell. H u t t tried hard to get Holborn to safeguard itself, but despite the support of his council to the extent of producing a film for propaganda purposes, and well advertised health weeks, his results are but meagre. More recently the work has spread, and more particularly Edinburgh, Birmingham and Cardiff have managed to get considerable numbers immunised. Cork also achieved success on a wide scale, following a severe epidemic of diphtheria.

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U p to the end of 1930, the number of children immunised in London was, according to Graham Forbes, merely 1 per cent. of the school population. The latest figures to hand--March, 1 9 3 3 are those published by Professor Johnstone Jervis, Medical Officer of Health of Leeds, where he records the comparative failure of the immunising efforts in Leeds. He states that from May, 1928, to July, 1932 their total immunisation out of a school population of 69,063, of which 23,325 ai'e under seven years years of age, was 2,336. He also records that 30 per cent. withdrew their consent or defaulted after having given it. Letters were addressed to the general practitioners in 1928, and again in 1931. The total result of this appeal, together with the free supply of immunising materials, was that 69,5 children in all were immunised by the general practititioners. Publicity in any sense, let alone the American sense, or an organised campaign, does not appear to have been used. W h a t a contrast to Honolulu I T o come now to our own work. I have kept strictly to toxoid antitoxin from the beginning, partly, I suppose, because I felt that I was dealing with a preparation which, whilst effective, was certain not to produce the untoward results that I experienced with toxoid in 1924-5. It is useful to look back and see what was accomplished at that time amongst the children, and the results that accrued. The institution in which the toxoid was used was a poor law school of about 500 boys which were drawn from all parts of the country, and mostly of a debilitated type on entry. Diphtheria had been occurring in single cases for the last few years, until in 1923 there were 13 cases, add in 1924, 23 cases. Despite vigorous dealing with contacts there was no improvement. I then informed the authorities that in my opinion it was imperative to test and immunise the whole institution. T o this they demurred. My reply was that I must inform the Ministry of Health of their refusal as I considered it the only solution of the difficulty. :Eventually a conference with them was arranged by the Ministry of Health at Whitehall. The Ministry supported my action, and it was eventually arranged that my suggestions should be carried out. W e swabbed the nose and throat of every

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inmate; I and my chief assistant examined the 1,200 swabs. The time taken over this was more than we scheduled for, as after the end of two days our eyes gave out and we had to slow down. P u t t i n g it shortly, we isolated nine virulent carriers, one of whom was the nurse in charge of the school infirmary. Il was found that there were 63 Schick positives a m o n g the boys, who were immunised with toxoid provided by O'Brien. The result, apart from the troublesome reaction in adults, which need not have occurred if the directions laid down by O'Brien had not miscarried, were triumphant. Beyond a doubtful laryngeal case admitted three weeks previously, notified in July, 1925, of which there was no bacterial confirmation, there has not been a case of diphtheria notified from that school since 1925, a period of eight years. Had the Moloney test been in existence there would have been no unpleasant happenings to mar the splendour of the toxoid triumph. W e commenced our recent campaign in 1929. U p to the end of 1932 we have tested 3,824 children, the results of which are shown in Table VI. TABLE VI. PRIMARY SCHICK TEST RESULTS. Age.

Neg.

Positive.

Neg.

Total.

% 1 2 3 4 5 6 7 8 9 10 tl 12

13 & over

2 6 9 20 46 47 64 83 113 101 61 49

190 169 178 207 436 392 347 328 311 268 140 92

1.04 3.42 4.81 8.81 9.54 10.7 15.5 20.1 26.6 27-3 30.3 34-7

192 175 187 227 482 439 411 411 424 369 201 141

58

107

35.1

167

659

3,165

Av.% Total

Neg. 17.2

3,824

Summarised the results are as follows : - l're-school children, i.e., under Five. Total cases, 781; positive, 744; negative, 37 ; percentage immune, 5. Up to and including six years of age. Total cases, 1,263; positive, 1,180; negative 83; percentage immune, 7.

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From six years to ten inclusive. Total cases, 2,054 ; positive, 1,646 ; negative, 408; percentage immune, 19"8. From eleven years to adult life. Total cases, 507; positive, 339; negative 168; percentage immune, 33"1. It is, of course, realised that some cases are still in progress at the end of the year. The number of certificates of immunity, therefore, does not correspond with the total Schick tested. T h e results to the end of 1932 are : Total cases actively immunised 2,598 Total cases naturally immune ... 659 Total certificates issued . . . . . .

3,257

Our only variant in procedure has been that the final dose was recently increased from 1 c.c. to 1"5 c.c. of T . A . M . The first two injections have been given at weekly intervals, and the final one two weeks later. The re-Schicking of the cases at a later date revealed the weakness of the position, which hitherto has been one great stumbling block in the progress of immunisation, viz., the comparatively high percentage of cases that are not com. pletely immunised by three doses of T . A . M . This is even more apparent with T . A . T . as revealed in the American figures of cases of diphtheria following what has been supposed to be immunisation. The re-Schicking or, as the Americans call it, the posterior Schick, is to my mind vital if we are to keep faith with the parents, despite the pronouncement of the League of Nations Committee that it is unnecessary. In circular 170 of the Ministry of Health (November, 1932), one is glad to see that the Ministry has come down definitely on the side of ascertainment of susceptibility of the case by the preliminary Schick and by subsequent re-Schicking, in order definitely to establish that the patient is completely immunised. As set out in the circular, they are standardising the use of "2 c.c. diluted diphtheria toxin controlled by the inactivated toxin injection in the other arm. Their recommendation that a third injection of 0"2 c.c. of 1 in 100 to a 1 in 200 dilution of formol toxoid (Moloney test) shall be given in addition to the the other two, is rendered necessary by the recommendation that the immunisation shall be carried out by formol toxoid which produces reactions of considerable severity in

252

PUBLIC HEALTH.

a b o u t 5 per cent. of the children, a n d still more so in adults. T h e i r r e c o m m e n d a t i o n that the L F shall be from 25 to 3 5 necessitates this test, as this L F is a p p r o x i m a t e l y d o u b l e w h a t is b e i n g used in America, a n d on the C o n t i n e n t at the present time. T h e r e is one a d v a n t a g e in the use of toxoid over the other preparations, in that, as is p o i n t e d out in the circular, i m m u n i t y can be p r o d u c e d in t w o m o n t h s , w h e r e a s in the earlier p r e p a r a t i o n s the time taken to p r o d u c e a satisf a c t o r y i m m u n i t y is c o n s i d e r a b l y longer. It s h o u l d be noted also that the a g e at which toxoid s h o u l d be used in i n f a n c y is raised to a year, as c o m p a r e d with nine m o n t h s which is r e c o m m e n d e d b y the A m e r i c a n authorities for T . A . T . I a m not sure whether, at the present time, this c o u n t r y is r e a d y for a M o l o n e y test in every case, in addition to the two others. If the use of formol toxoid is s t a n d a r d i s e d there is no d o u b t it m u s t be carried out, as the occurrences of reactio.ns of a n y m a g n i t u d e will tend not o n l y to hinder the progress, b u t definitely put back the clock. It is g l a d news to see that the M i n i s t r y have also come d o w n definitely on the s i d e of the posterior S c h i c k in o r d e r to ensure that the individual is i m m u n i s e d . A t the same time, so l o n g as I am g e t t i n g such satisfactory results in one clinic with T . A . M . , which, h a v i n g been used to the extent of 4,000 cases, has established a confidence in the public mind, I a m loath indeed to venture out into new fields, a l t h o u g h I have been pressed to use both floccules a n d alum toxoid, but I feel m u c h in the s a m e position as a s u r g e o n who, in a s k i n g a practitioner to give an anaesthetic--finds that the m a n is o n l y used to g i v i n g c h l o r o f o r m , and has g o t to face the fact that it is wiser in the p a t i e n t ' s interests for the anaesthetist to use a m e t h o d to which he is a c c u s t o m e d than to insist on his u s i n g what is r e c o m m e n d e d as a safer f o r m of anaesthetic to w h i c h he is a s t r a n g e r . T a b l e V I I gives the a n a l y s i s of 2,292 Schick positive cases that were g i v e n three doses of 1 c.c. of T . A . M . as the original i m m u n i s i n g course, a n d re-tested from four to seven m o n t h s later. T h i s shows that 11"9 per cent. of our cases are not i m m u n i s e d with the usual three doses. It is this n o n - i m m u n i s e d g r o u p , if left uni m m u n i s e d , a m o n g s t which cases of d i p h t h e r i a arise that b r i n g the work into discredit. T h i s

MAY, TABLE VII.

Age.

Positive Percentage Neg. only after not Neg. after after 3 T.A.M. immunised 3 T.A.M. additional and not yet by 3 injections, completed, injections.

1

108

3

2

4 -4

2 3 4 5 6 7 8 9 l0 11 12 13 & over

107 115 131 232 241 223 234 222 188 91 62

4 6 10 40 38 31 36 27 2¢) 9 12

1 1 3 2 4 2 4 4 2 2 2

4.4 5.7 9.0 15-3 14.8 12.9 14.6 ]2.2 10.4 10.7 18.4

65

5

3

10.9

2,019

241

32

11-9

Total

N.B.--Injections 1 and 2 of 1 c.c. of 'F.A.M. were given at weekly intervals. The third injection of 1 c.c. was given 14 days after the second. failure to immunise, and so also the final full i m m u n i s a t i o n , can o n l y be ascertained b y the use of the posterior S c h i c k and R e - S c h i c k i n g . T h e further a n a l y s i s of 355 cases (Table V I I I ) refers to those w h o were o r i g i n a l l y S c h i c k positive a n d received an i m m u n i s i n g course of two 1 c.c. injections of T . A . M . at weekly intervals and a third injection of 1'5 c.cs. of T . A . M . 14 d a y s after the second injection. T h e y were re-tested at various times TABLE V I I I .

Positive Percentage Neg. only after not Age. Neg. after after 3 T.A.M. immunised 3 injections, additional and not yet by 3 injections, completed, injections. 1

23

0

1

2 3 4 5 6 7 8 9 10 11 12 13 & over

24 20 27 56 46 33 14 23 20 15 2

5 4 1 7 7 5 2 0 3 1 0

1 3 1 4 2 1 0 0 1 2 1

0

0

0

303

35

17

Total

4.1 20.0 25.8 6.9 16.4 16-3 15.3 12.5 0.0 16.6 16"6 33.3

14-6

1933.

PUBLIC HEALTH.

over f o u r m o n t h s f r o m the last i m m u n i s i n g i nj ection. T h e p r e s e n t s h o r t series of 365 c a s e s does not a p p e a r to s h o w a n y a d v a n t a g e at all in u s i n g a third injection of 1'5 c.c. instead of 1 c.c., but this c a n p r o b a b l y o n l y be determ i n e d after a m u c h l o n g e r experience. T h e m o r e recent figures, however, in the first t w o m o n t h s of this year, are g i v i n g r a t h e r m o r e s a t i s f a c t o r y results. It m u s t be b o r n e in m i n d t h a t the total 356 in 1,.3 s u b - d i v i s i o n s is of little use f r o m a s o u n d statistical point of view. T h e i m p o r t a n t p o i n t e m e r g i n g f r o m this ret e s t i n g is that we h a v e h a d tO g i v e m a n y f u r t h e r injections of T . A . M . , a n d then re-test so as to e n s u r e that we are, as far as is h u m a n l y possible, c a r r y i n g out the u n d e r t a k i n g to protect the child. W e are now r e - S c h i c k i n g all o u r o r i g i n a l cases after t w o y e a r s . T h e p a r e n t a l r e s p o n s e is splendid, a n d so are the children. L a t e r I shall be able to g i v e the results a n d the perc e n t a g e s of r e v e r s i o n s to S c h i c k positive. T h e s e , as has been p o i n t e d out b y P a r r i s h a n d Okell, are certain to o c c u r in certain cases that h o v e r r o u n d the line of c o m p l e t e i m m u n i s a tion, not entirely safe b u t t a k i n g b u t little to s t i m u l a t e t h e m to s a f e t y a g a i n . A n d w h a t of the s a f e g u a r d i n g ? We have not so f a r h a d a s i n g l e case of d i p h t h e r i a in a period of three y e a r s a m o n g s t those children we h a v e certified as i m m u n e , either n a t u r a l l y or as a result of o u r efforts. F o u r cases were notified as d i p h t h e r i a , but two were V i n c e n t ' s a n g i n a , a n d the third a tonsilitis. T h e fourth, which o c c u r r e d recently, h a d a sore t h r o a t w i t h o u t e x u d a t i o n , a n d two successive cultures f r o m nose a n d t h r o a t failed to reveal K . L . B . T h e patient was S c h i c k n e g a t i v e . W e have, as e v e r y o n e else h a s had, cases of d i p h t h e r i a o c c u r r i n g d u r i n g the actual course of i m m u n i s a t i o n a n d directly after the inoculations, but b e f o r e i m m u n i t y is established. F o r e x a m p l e , in the first year, seven children w h o were f o u n d to be Schick positive c o n tracted d i p h t h e r i a p r i o r to the c o m p l e t i o n of the i m m u n i s i n g course. O n e child of five had one injection of T . A . M . w h e n it contracted a fatal infection. N o n e of the o t h e r children w h o c o n t r a c t e d the disease h a d had m o r e t h a n two doses of T . A . M . I ~ry a n d i m p r e s s the facts on the p a r e n t s b y the f o l l o w i n g notice : - -

253

Please Read Carefully. HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Department, 92, Bath Road, Hounslow. W h a t the Certificate Means.

Most children who have had this treatment .are protected for a number of years. An occasional child, however, loses the protection quickly, due to a peculiarity of the child's blood or body. If you wish to get the best out of the treatment, have your child tested again in a year or two. If he or she is still safe, no further injections are necessary. If the protection has been lost, it can be restored. Although your child, if protected, is extremely unlikely to contract diphtheria, do not assume that it is quite impossible. A very few cases of diphtheria have occurred among immunised children. Such attacks are rarely serious but you should always get your doctor to see a sore throat. ELWIN H. T. NAsm Medical Officer of Health. W e h a v e o n l y had three cases t h a t h a d to be left u n f i n i s h e d ; one, an adult o w i n g to reactions, a n d the o t h e r two, a b r o t h e r a n d sister w h o s e reactions were so e n o r m o u s t h a t after c o n s u l t a t i o n it was c o n s i d e r e d a d v i s a b l e to m a k e n o f u r t h e r a t t e m p t at i m m u n i s a t i o n . A p a r t f r o m these, reactions even of the slightest character, are p r a c t i c a l l y nonexistent. I w a n t to e m p h a s i s e the figure of 659 n a t u r a l l y i m m u n e s , i.e., 20 per cent. of the total cases tested. A c c o r d i n g to the practice a d v o c a t e d b y the L e a g u e of N a t i o n s C o m mittee, a n d also in recent A r m y orders, these s h o u l d h a v e had their three inoculations. I c a n n o t subscribe to the a b a n d o n m e n t of the p r i m a r y Schick t e s t i n g on the g r o u n d s of time, trouble or expense, quite a p a r t f r o m a n y t h i n g else. It is u n s o u n d , unscientific, a n d s u r e l y an e m p i r i c i s m little r e m o v e d f r o m the m e t h o d s of the p a t e n t m e d i c i n e v e n d o r . W h a t r i g h t have we to inject a p a t i e n t w h o d o e s not need it with a n y d r u g or bacterial p r o d u c t ? O u r e x p e r i e n c e is t h a t the large m a j o r i t y of the p a r e n t s a p p r e c i a t e v e r y h i g h l y indeed the scientific s o r t i n g of the children, a n d if their child is n a t u r a l l y i m m u n e t h e y are d e l i g h t e d to be a s s u r e d that no i n o c u l a t i o n s are n e c e s s a r y . I a m c o n v i n c e d that, so far as m y a r e a is concerned, this t h o r o u g h n e s s is o n e of the p r i n c i p a l c o n t r i b u t o r y causes to such success as h a s been attained. W e h a v e h a d the usual experience, an early rush of the m o r e intellig e n t a n d e n l i g h t e n e d parents, the f a l l i n g off

254

PUBLIC HEALTH.

as they are dealt with, and then the waverers coming in after a period of hesitation and doubt; later comes the period when it is hard to convince those that remain. Then it ig that a new push is required, a new offensive, simply in order to bring the facts before the public, to make them talk and think. One is apt to be despondent at the inevitable falling off, and to despair at the lessened effect of one's advice and efforts to propagate the gospel of safety from diphtheria. It is well on these occasions to bear in mind the words of Dr. D. M. Griswold, of the State Department of Health, Michigan, when one of the doctors at a meeting asked advice with regard to the opposition to and want of progress in his campaign. He said to his enquirer, " You feel quite agitated about this? " The reply was, " I am, because I feel that people's lives are at stake." Dr. Griswold retorted : " D o n ' t you know most any of us could do these things in a v a c u u m . " It is when opposition and apathy are becoming evident and the intelligent people are finished with, that it behoves us to put on our thinking caps and evolve some fighting scheme. T o those who want to start out on a campaign, I would commend the Massachusetts Department of H e a l t h ' s pamphlet on diphtheria, published in Vol. 17, No. 3, of the " Common H e a l t h , " and " P a u Diphtheria," published by the Hawaii Board of Health. One great difficulty in this country is to find the funds for extensive publicity. W e do not appear to get the very substantial sympathetic financial support of lay bodies such as the Metropolitan Life Insurance Co., and the Milbank Memorial F u n d of New York. The only efforts I know of in this direction are the films by the Mutual Property Insurance Co., and the leaflets issued by them and the Wesleyan and General Insurance Co., and the leaflets issued by the National Baby W e e k Council, paid for by. Messrs. John K n i g h t , Ltd., the soap makers. Our attempts in this country are, compared with those even in Honolulu, like playing doll's house. Publicity adapted to the psychology of the people of this country, I am sure, has got to be undertaken in a much more intensive manner than fieretofore. I have just been inspecting the latest American film on diphtheria and its prevention. So far as propaganda for immunisation is concerned, it is like the others I know--mixed in its effect.

MAy,

I have not seen one that shows the actual testing or inoculation being done. There is no evidence of the actual insertion of the needle, and in this last one referred to, directly a n y t h i n g of that kind is due the film switches to a caption and takes you no further than the cleaning of the arm. To an anxious parent it is worse than useless, because the immediate thought is : " T h e y dare not show that because it h u r t s . " For this reason I have had a fihn taken in my own centre during the progress of an ordinary Monday afternoon immunisation clinic, and when the film, as I have written it, is complete, it will contain a certificate that the children were actually inoculated. One of my chief difficulties has been with the R o m a n Catholic portion of my population who, unlike the Bishops of that Church in New York, seem to be apathetic, and the clergy unhelpful even when appealed to. I have been into the boys' school and talked to the elder boys. On the last occasion I went in just before closing time. The boys were interested, so I let the head master go, and talked to the boys and answered questions for an hour. The only result was a letter from a parent saying that they prefered God's method of protecting their children to mine, and straafing me soundly for keeping the boy late ! To repeat my warning at the beginning of my paper, I must illustrate this well by the figures of diphtheria in mv district, which are given in Table IX. TABLE IX. Year. 1924 1925 1926 1927 1928 1929 1930 1931 1932

Rate per 1,000 No. of Cases. of Population. Population. 105 86 68 56 99 370 165 62 57

2.23 1.77 1-30 1-03 1-67 5.94 2.2 .8 .71

47,700 48,620 52,110 55,870 59,730 63,070 75,000 76,230 80,618

If this warning were not borne in mind, and the record of the number of cases occurring in the district presented, it might be made to appear that the diminution in the incidence of diphtheria was due to the efforts in the direction of immunisation, but when the number of cases in the outbreak of 1929 and 1930 are shown, one realises what a very large amount of additional immunisation must have resulted

1933.

PUBMC HEALTH.

from the presence of that large increase of cases in the area. Much as I would like to claim this diminution for one's efforts, veracity forbids. W h e n we see the extent of the system of propaganda u ~ d by our American confreres, we stand amazed, but are bound to admit that the results of the advertising campaigns are such that we can only regard with awe. New York City, for instance, covers its hoardings with posters 23-ft. by 9-ft. with the appeal for the children to be safeguarded. The largest moving sign in the world, over the buildings in New York, proclaims the need to " protect your children from diphtheria," that " diphtheria is preventable," and that it is imperative to " see your doctor." Healthmobiles, i.e., clinics on wheels, " tour the congested sections of the city, the parks and the beaches where children gather in large numbers." Further, 120,000 letters were sent to mothers on the birth of their children, urging immunisation when the child is nine months old. 120,000 letters were sent to mothers when the child reached nine months, advisin G that it is time to be seeing a b o u t immunisation. T w o hundred 24-sheet posters displayed for two months through the courtesy of the General Outdoor Advertising Co. Three hundred three-sheet posters displayed for two months through the courtesy of the Criterion Advertising Co. 400,000 homes received the pastoral letter by Cardinal Hayes. This letter was read at the masses in 211 Catholic churches on a certain Sunday, and 400,000 copies of the Cardinal's letter distributed a m o n g the parishioners. T w o weeks later, Bishop Molloy requested the pastors of 193 Catholic churches in another part of the diocese to announce the diphtheria campaign at the masses on Sunday, urging parents to get their children immunised. Bishop Molloy also sent a personal, letter to each of the 140 parochial schools in the same area asking the authorities to lend their assistance. Three thousand specially prepared posters were displayed for a month in seven of the great chain stores. Eleven of New York's largest departmental stores gave generously of their advertising spaces. 25,000 handbooks of information specially prepared by the diphtheria prevention committee were distributed to doctors, principals, school teachers, social workers, nurses, and other community health workers. 11,846 letters were sent to practising

255

physicians from the health commissioner and the courity medical societies. 300,000 families were canvassed by the practising physicians. T w o million leaflets were distributed with the bills of the five electricity companies. 7,225 physicians, of whom 41 per cent. agreed, were asked to set aside a special day for immunisation at a fee of $6.00 for tile three toxin antitoxin treatments. 161 newspapers, including the huge metropolitan dailies, local borough papers, foreign language press, newspapers for the coloured community, weekly papers, trade papers, press associations, and medical journals, published regular releases on the progress of the campaign, as well as stories on the danger and prevention of the disease. A huge painted sign, 200-ft. by 20-ft., carried the diphtheria message on the roof of a Broadway and 23rd Street building. It was illuminated a t night. The sign was painted and displayed by the General Advertising Company as one of its contributions to the diphtheria campaign. One million leaflets were distributed to New York's children on Child Health Day. Three hundred lectures and radio talks were given on the dangers and prevention of diphtheria. 300,000 copies of five " Health Tabloids " were i ~ u e d in cooperation with the boy scouts and other agencies, including tuberculosis, health and medical societies, and a special 4-page feature was put in the Italian paper Corriere d'America for four consecutive Sundays. 120,000 placards were displayed for seven weeks in subways, elevated trains, street cars, omnibuses, ferries, etc., and it was estimated that 8,495,205 persons at some time or other saw these diphtheria n o t i c e s . In co-operation with the county medical societies, 11,345 waiting-room cards were distributed to physicians for posting in their waiting-rooms. The diphtheria campaign was conducted by funds donated by the Milbank Memorial Fund, and the Metropolitan Life Insurance Company. Such is the publicity New York used. For this informatiQn I am ifidebted to Dr. S h i r l e y W y n n e , the Health Commissioner for the City of New Y o r k . T o give another instance of intensive publicity, I am going to quote the record of Itonolulu, the particulars of which I have obtained from the Board of Health of Hawaii. One c a m p a i g n started in 1929, and at the end of 1930, the death-rate had dropped 52 per cent. In September, 1930, the cam-

256

PUBLIC HEALTH.

paign was intensified and commenced on November 3rd. " The wheels of the campaign " were set in motion by letters to the Consuls of China, Japan, Portugal, and Great Britain; to the [)residents of the Chinese and Japanese Chambers of Commerce, and of the Korean National Association and the Filipino Labour Commission; to the principals of private and parochial schools; and to all the clergymen asking them to make pulpit appeals. Bishop Imamura, of the Hongwani Mission, volunteered to distribute several thousand circulars printed in Japanese through the Buddhist churches, and the Fathers of the Catholic Mission offered to circulate 5,000 leaflets printed in English, through the Catholic churches of the city. For this purpose, the committee printed and distributed 36,000 :English leaflets, 6,000 Japanese leaflets, and 1,000 Chinese leaflets; 2,000 leaflets with additional information were distributed among the teachers. Twenty-five thousand posters were purchased from the Metropolitan Life Insurance Company, and .500 posters in Japanese were printed a n d distributed in the Japanese stores and neighbourhood. Slides were shown in twelve of the cinemas the week before the immunisation began, and on the m o r n i n g of November 3rd, three of the larger dairies in the city used milk bottle tags, furnished by the committee, urging their customers to protect their children against diphtheria. The local broadcasting station gave from four to ten minutes each evening of the week before the commencement of the work. Small signs were distributed to the physicians to place in their waiting-rooms, and 11,000 notices were printed to be enclosed in the physician's monthly " statement " to his private patients. All publicity material was distributed by the boy scouts on October 24th, ten days before the actual commencement, on which date the first release was freed for newspaper publicity. Campaign stories were published by five language papers, two Japanese, two Chinese, two Filipino, one Korean, and one Hawaiian, and the two dailies and one weekly published in English, from October 24th, through November and into the early part of December, almost daily. T h e editors were also generous with convincing editorials. " Approximately 2,600 square inches of space was given by the Press to publicity for the c a m p a i g n . "

MAY,

" In all, 23,444 children were inoculated with toxin antitoxin at the public clinics at the 18 centres established over the two years, without accident or reaction." " One hundred and fifty interpreters, recorders and helpers, most of whom were women volunteers, were necessary to keep the individual records ; girl scouts and junior high school girls, assisted in wiping arms, r u n n i n g errands and piloting bewildered mothers." The accompanying Table (X) illustrates difficulties of nationalities such as we have not to face, and show the number that failed to complete their course. T~mLs X. Race. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Spanish . . . . Negro .... Others --_ __ Caucasian Hawaiian Japanese . . . . Chinese . . . . Asiatic Hawaiian .. Hawaiian . . . . Korean .... Other Caucasian .. Portuguese . . . . Filipino . . . . Porto Rican ..

No. Incompleted, 0 0 5 34 275 81 29 24 17 15 49 35 29

Percentage Incompleted. 0-0 0.0 2-2 5.2 6.0 7.0 7-1 7.5 8-2 9.2 9.4 14-9 19.0

In all, 23,444 have been immunised, of whom 51 per cent. were under six years of age. W e can show nothing like this so far as I am aware. Apparently medical men in Honolulu differ little from our own brethren in their antipathy to keeping records, as illustrated by the following statement: " A record of inoculations administered privately during the 1930 campaign is unavailable for the reason that the majority of doctors failed to make a record on the immunisation cards provided by the Board of Health, which is to be regretted." Possibly one of the best accounts of t h e campaign necessary to produce the results which have made New Haven so conspicuous a success, in that it was at the top of the list of the towns within the r a n g e of 100,000. population, from a point of view of the efficiency of its campaign and results, is that set forth in a paper by Dr. John L. Rice, the Health Officer at New Haven. He states : " In looking back over eight years' personal experience with diphtheria prevention, it is impossible to pick out any one particular thing that

rosa.

PUBLIC

has been the most important ill interesting the public, nor is there any way of really evaluating the effectiveness of a n y one particular procedure. Apparently a large number of approaches are needed to bring success, some more important in one community than in another." lie records that 25 of the doctors in the town, immunised in the neighbourhood of 1,000 children, apart from the public health department: ;Everything apparently is pressed into the campaign. The daily newspapers gave one or more news items every week containing, amongst other things, the four w o r d s " child," " diphtheria, . . . . prevention," " toxin antitoxin," which sooner or later left an impression of value. School teachers and church officials are pressed tO play their part. Theatres carry lantern slide notices of the dates of the school clinics. T h r o u g h o u t the eight years, anti-diphtheria films have been shown over and over again in the local theatres, as well as at the schools. For a considerable time Saturday morning shows were p u t on at a central theatre for groups of about 1,000 school children each; the children paid a cent or two each to see the show, which consisted of movies and talks on diphtheria, and other pictures. Posters were broadcast through the city, and put in all the doctors' waiting-rooms. The birthday card reached every child in New Haven on its first birthday, with a message on diphtheria prevention. Two large exhibitions were promulgated, seen by hundreds of thousands of people. Local pamphlets, state health department pamphlets, insurance company booklets, and many others were used as literature. Articles are published over and over again in local bulletins, trade organs and school papers. In conclusion, Dr. Rice states : " Probably diphtheria has been the main theme in more talks and addresses in New Haven in the past eight years than all other medical topics put together. The speakers have included many different people, from the nurses to the mayor. There have been talks to school children, to teachers, to parent-teachers' associations, to nurses' g r o u p s , physicians, service clubs, to the general public, and to the special groups, in addition to broadcasting." W i t h regard to difficulties, they may be classified under the heads of : - -

HEALTH.

e:,;

1. 1.ack of propaganda and educational Imsll I0~ public health authorities. 2. Ignorance of the public with regard to the advantages of immunisation. 3. Opposition by particular organisations. 4. In some cases religious opposition. 5. Lack of an epidemic or some outbreal~ ~o stimulate the demand for safeguarding. 6. A low mortality in a n y outbreak. Conditions 1 and 2 must be taken together, as the ignorance of the public must be largely, if not entirely, put down to the lack of education by public health authorities. W e in this country are apt to look askance at the flamboyant methods of propaganda used by our brethren on ihe American continent, especially the United States. Our respectability rebels and our insular pride stands aloof from importing into our professional problems the methods of the marketplace and the habit of mind of the huckster. The time has come, however, when in the light of results achieved we ,nust doff the cloak of ultra respectability and tackle the job on the lines of the American merchant who, having goods to sell, finds that publicity pays. \Ve also have to educate our public to buy health or safety from a particular disease at ~he trifling cost to themselves of a little trouble and possibly a tram fare or two. A statistical survey in our annual report reaches a favoured few. True, we have in this country a certain number of districts circulating Better Health as a medium for sober-minded statistically-worded articles. Speaking generally, we put no punch into our propaganda. I have attained some slight success which has been due to propaganda, coupled with the entire freedom from uncomfortable reactions resulting from the immunisation. My most helpful item of propaganda was a severe outbreak of diphtheria, coupled with a high mortality. Year 1928 1929 1930

............ ............ ............

No. of l)eaths. 7 23 19

In January, 1930, when tire work was commenced, a public meeting was held at tire largest school, which was addressed by l)r. l.ethem, of tile Ministry of Heahh, and tire film " Risk of Diphtheria Banished," lent by the Mutual Property Insurance Co., was shown. This film was subsequently dis-

258

PUBLIC HEALTH.

p l a y e d in three local c i n e m a s for a week. T h e c o m p a n y also offered to s u p p l y leaflets. L e t t e r s of invitation were issued to the p a r e n t s t h r o u g h the schools, e n c l o s i n g a n e x p l a n a t o r y leaflet a n d a c o n s e n t f o r m . M e m b e r s of the council were also invited to a t t e n d . T h e school hall w a s p a c k e d . M y n u r s i n g staff acted as stewards, a n d distributed appropriate literature. T h i s first m e e t i n g w a s excellent. P r e p a r a t i o n s had been m a d e for c o m m e n c i n g the actual S c h i c k t e s t i n g a n d i m m u n i s a t i o n w o r k the f o l l o w i n g week. S u b s e q u e n t l y a m e e t i n g w a s held at Isleworth, which w a s a d d r e s s e d b y D r . Bousfield, but the r e s p o n s e was p o o r c o m p a r e d w i t h Hounslow. A later a n d m o r e successful m e e t i n g w a s held in the third section of the district in the H e s t o n p a r i s h hall. T h e h e a d teachers of all the schools were were written to a n d f u r n i s h e d with leaflets a n d c o n s e n t cards. In J u l y , 1930, the f o l l o w i n g a d v e r t i s e m e n t was inserted in the 10cal press, a n d small p o s t e r s were d i s p l a y e d on the c o r p o r a t i o n ' s vehicles a n d notice b o a r d s : - HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL. Diphtheria Prevention.

The Council has '~rranged that any ratepayer's children can be protected against diphtheria free of charge. Two thousand children have already been protected since January, 1930. The protection is not complete until three months after the course of inoculations, but the protection lasts for many years, if not for life. If, after this offer, your child develops diphtheria, a very grave responsibility rests on you. All enquiries can be made of the head teachers of any of the Heston and Isleworth Schools, or at the Public Health OffiCe, 92, Bath Road, Hounslow. ELWIN H. T. NASH, Medical Officer of Health. A m o n g s t the school children m u c h of the success d e p e n d s on the h e a d teachers. T r u e , the class of p o p u l a t i o n a n d the religious d e n o m i n a t i o n s are i m p o r t a n t factors, but the p r i n c i p a l factor is the h e a d teacher. T a b l e X I s h o w s the consent f o r m s c o m i n g in f r o m o u r v a r i o u s schools. I n the case of the s e c o n d on the list the h e a d teacher interviewed e v e r y p a r e n t c o m i n g with a new child, a n d a s k e d w h y t h e y h a d not b e e n i m m u n i s e d , a n d g a v o t h e m the leaflet a n d consent form. T h e first school a c h i e v e d its result l a r g e l y t h r o u g h s i m i l a r m e t h o d s , but p r o m p t e d m o r e b y n e r v o u s n e s s of d i p h t h e r i a , on the part of the head teacher.

MAY, TABLE XI.

Percentage Number on Consenting Registers to I m m u of Schools. nisation.

School. A° Junior, mixed B.

Boys..

C. D. E. F. G. H. I.

Girls Infants Infants Girls Infants Girls Mixed

J.

Boys

K. L. M. N. O. P.

Junior, mixed Boys Girls a n d

.. Infants

Mixed .. Junior, mixed Infants Q. Senior, mixed R. Junior, mixed S. Central, mixed T. Girls and Infants U. Girls and Infants V. Boys .... W. Boys .. .. X. Boys .... Y. Infants ....

331 448 409 297 64 297 280 331

85

70 63 51

46 43 42 41

681 311 565

36 29 28

325 199 248 279

24 23 22 22 22 20 "19

255

544 452 335 619

204 137 414 153 84

19 17

17 14 14 10 2

*Newly opened school•

My health visitors, when visiting new births, d i s t r i b u t e the literature. T h e s a n i t a r y i n s p e c t o r s leave it in e v e r y h o u s e w h e r e infectious disease is b e i n g i n v e s t i g a t e d . E v e r y dental notice c o n t a i n s a leaflet, a n d so o n ; but there is n o e p i d e m i c , a n d a new p u s h on different lines m u s t be u n d e r t a k e n . W h e n a r r a n g i n g the w o r k in the i m m u n i s a tion clinic I a l l o w e d no white coats for the medical officers, n o r the usual u n i f o r m s a n d c a p s for the n u r s e s in a t t e n d a n c e . :Everyt h i n g w a s d o n e to dissociate the p e r s o n n e l from memories of painful procedures associated with the usual white-coated doctor, a n d u n i f o r m e d nurse. T h e nurses I p u t into a p a l e blue overall with a white collar. I a m certain t h a t at the c o m m e n c e m e n t these satorial restrictions were wise, but now I d o not t h i n k it w o u l d m a k e m u c h , if a n y , differe n c e ; b u t I feel it w i s e r to c a r r y on as I haire begun. T h e a d d i t i o n a l bait p r o v i d e d was a large t r a y of boiled sweets, f r o m which the child chose one, g e n e r a l l y the g a u d i e s t coloured, after the inoculation was c o m p l e t e d . A n o t h e r i m p o r t a n t point: is not to a t t e m p t to take the children s i n g l y . H a l f - a - d o z e n at

1933.

PUBLIC

a time in the room, s o t h a t they can see w h a t is g o i n g on, m a k e s all the difference in the world. T h e m a s s p s y c h o l o g y is such t h a t in the vast m a j o r i t y of cases it is i m p o s s i b l e to see a n eyelid quiver d u r i n g the inoculation or Schick test. O f course, with the infants, a n occasional howler occurs, which will u p s e t a few more, b u t for the m o s t part, tears are rare. W h e n a f t e r four to six m o n t h s the child is re-Schicked and found immune, a formal certificate is g i v e n to t h a t effect, t o g e t h e r with a card w o r d e d a s follows : - HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Office, 92, Bath Road, Hounslow. Diphtheria Immunisation

HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Office, 92, Bath Road, Hounslow. Diphtheria

Immunisatlon

a n d I learnt m o r e a b o u t the cost a n d efficiency of a d v e r t i s i n g in the s p e n d i n g of that £ 2 0 t h a n [ h a d ever k n o w n before. I learnt how to get l a r g e p o s t e r s p r i n t e d at special rates b y special firms c a t e r i n g for t h a t class of w o r k . I learnt also the cost of s p a c e on h o a r d i n g s in v a r i o u s g r a d e s of p r o m i n e n c e a n d s t r a t e g i c i m p o r t ance. I learnt also to a certain extent how m u c h pull m y effort p r o d u c e d , s o m e of it quite unexpected. The accompanying Chart C s h o w s the n u m b e r of c o n s e n t f o r m s received w e e k b y week just before a n d after the a d v e r t -

ising campaign.

Clinic.

Tiffs is to certify that (Name) ............................................................... (Address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w a s immunised and tested, and is believed to be immune to diphtheria. To the Parent or Guardian. In the event of this child being ill in the future and the doctor suspects diphtheria, please show him this certificate, when he will tear off and use the card printed below. ELW1N H . T. NASa, Medical Officer of Health. 'This card should be retained by the parent or guardian.

Clinic,

This is to certify that ~Name) ............................................................... (Address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w a s i m m u n i s e d and tested, and is believed to be immune to diphtheria. Date ....................................... Signed ....................................... Medical Officer of Immunisation Clinic. To the Doctor in attendance.--lf you consider this a case of definite diphtheria, I shall be glad if you will post this card with your notification to the medical officer of health of the district where the case is notified. To the Medical Officer of Health concerned.--If this child is definitely suffering from diphtheria, I should b e glad if you would inform me, particularly indicating the character of the attack, " Mild/ severe," and enclose this certificate with your letter. ELWIN H. T. NASH, Medical Officer of Health. T h i s is to e n s u r e as far as possible (a) t h a t the doctor called to a sore t h r o a t k n o w s e x a c t l y w h a t the position is, a n d ( b ) t h a t if there is a n y d o u b t a b o u t a case, we can get into touch with the doctor so as to m a k e a full investigation. After 20 m o n t h s I o b t a i n e d a g r a n t of £20 f r o m m y council for p r o p a g a n d a p u r p o s e s ,

259

HEALTH.

iil

I

|Iil I!t' liII

I 1 I I t

I

rtil til x

/X \J

[ \

iJ",

7,'

\/ 11

Ill

I

ill

11

I

iltl

i

i

~-~ I t

It

t

,I CHART C. D1PItTI|ERIA IMMUNISATION. N u m b e r of Consent F o r m s

Received. Borough of Heston and Isleworth. Showing the number of consent forms received as the result of a week's advertising campaign at a cost of £17 10s. R o u g h l y s p e a k i n g , it cost o n e s h i l l i n g each to g e t the children to the clinic. T h e r e is n o d o u b t t h a t with a m o r e intensive a n d prol o n g e d c a m p a i g n the cost per h e a d would h a v e been less, as the a d v e r t i s i n g effect is undoubtedly cumulative. O n l y as recently as the first week in F e b r u a r y of this year, I was r u n g u p b y a councillor of one of the L o n d o n b o r o u g h s , who, a p p a r e n t l y , are r e h o u s i n g o v e r 300 families in blocks of flats. H e h a p p e n s to o w n p r o p e r t y in m y a d m i n i s t r a t i v e a r e a . He h a d been struck b y one of m y p o s t e r s p r e v i o u s l y , a n d h a d conceived the idea of m a k i n g it a condition of t e n a n c y of the c o r p o r a t i o n p r o p e r t y that all the children s h o u l d be immunised beforehand. In view of the a g g r e g a t i o n of children, this is an excellenl suggestion. I a m a n x i o u s l y a w a i t i n g the results of his efforts. T h i s , 16 m o n t h s after the week d u r i n g which the p o s t e r s a p p e a r e d ! V e r i l y an instance of b r e a d cast u p o n the waters.

260

PUBLIC HEALTH.

I intend shortly to ask for a further grant for propaganda, as our attendances are falling off, only j u m p i n g up in spurts when any serious case of diphtheria occurs. Our best publicity agent at the present time is the intelligent mother who has had her children immunised. Another means of spreading the news is to take prominent people one knows or meets, to see the immunisation clinic a: work. The amazement with which they see the children inoculated one after another without an eyelid flickering, starts them talking, and they keep talking of the wonder that they have seen. Publicity in an area like mine, which has merely an artificial line between itself and adjacent populous areas, is difficult compared with the possibilities in a self-contained area like a town with no contiguous urban areas. I n these cases, propaganda can be carried out all over the town's area, but it is difficult when on one side of a street the local authority slrenuously shouts the importance of immunization, while on the other side of the street the local authority is silent. And further, if the authority shouting stands alone, folk are apt to think that as the surrounding authorities do not bother about it that it really does not matter if they themselves do not bother. The only criticism I have h a d in my area was by some members of the building fraternity, who stated that I was frightening people away from the district with my posters, by reason of the fact that people coming into, the district to look a t houses, who had seen nothing of the propaganda elsewhere, were greeted in my area by large posters headed " Diphtheria." However, I care not. I shall do the same again whenever I can get the money to do it with, happy in the thought that there are close on 4,000 children in nay area ~afeguarded, of whom roughly, 38 per cent. are under school age. You may ask why I have confined myself to T . A . M . , in view of the general pronouncement abroad, and more recently by the League of Nations Committee in favour of toxoid or R a m o n ' s anatoxin. As has recently been pointed out by O'Brien, concentrated toxoid was used in my area in 1924-25, some three months after R a m o n commenced with anatoxin. U'nfortunately, on this occasion, O'Brien's

MAY,

warning, that the preparation was only to be used for children, miscarried, and one of my medical staff and one of my nursing staff who were Schick + were made very ill, my medical officer seriously so, the effect lasting for several months. In neither case was the immunisation continued to completion. My medical officer has since been successfully immunised without the slightest mishap by T.A.M. The introduction of the Moloney test would, at the present time, obviate any repetition of the unfortunate happenings of those early days, which were in no way due to the preparation, but to the unfortunate manner of its use in adults against advice which miscarried. I felt in launching my scheme under the peculiar circumstances in the locality instanced above, that it was imperative not to have any set-back, and that the factor of safety had to be high. One mother whose child is made ill by a marked reaction is a greater hindrance than 100 satisfied mothers are a help. Thus T . A . M . was the preparation of choice, and with the exception of variations in the final dose and interval, it has been used in the same manner from the commencement, so that the results obtained are strictly accurate and comparable. In order to keep the factor of safety high I arranged for Dr. Guy Bousfield, who has probably done more immunising than any one else in this cotlnty, and his team of co-workers to take over the actual immunisation work, although both I and my deputy had had experience in the work. As the clinics had to be cut down, the team diminished, and now Dr. Bousfield alone carries on the work. I should like here to pay a special tribute to,his efficiency, and the humanelv tactful way he deals with the mothers and children, and to die loyal way in which he carries out the suggestions I make for carrying" on the work. The recent re-Schicking was showing at first, results which frankly were unexpected, but the numbers are so far so small that I must wait and see what is going to happen. I only mention it as showing the importance of the point emphasised by Parrish and Okell of the fluctuations round about the immunising line, and more recently e m p h a s i ~ d by Young and C u m m i n g s of the Health Department of Michigan. In order to ascertain the possibility of turning the system of immunisation over to the

1933.

PUBLIC HEALTH.

general practitioners in the area, as is done so much in America, particularly in Detroit and New York, I sent out the following questionnaire : No. of children immunised--1929-30-31-32? W h a t preparation was used? At what intervals were the inoculations given ? Did you use a preliminary Schick test? If so, please give numbers positive and negative. Did you subsequently test the patients after immunisation? If so, what percentage (if any) of the patients immunised subsequently became Schick positive, a n d at what interval ? In your opinion would it facilitate anti-diphtheria immunisation if : - (a) The toxoid antitoxin was supplied to the practitioners free ? (b) A fee was paid for the immunisation ?

The returns that came in indicated that roughly a total of 79 children had been immunised in the four years; about 48 by one practitioner; about 25 by another; four by another ; and one by each of two other practitioners. This shows that only 15 per cent. of the practitioners replying had done any immunisation. T . A . T . was used in four cases, and T . A . M . in the rest. These were given at weekly intervals. About 50 cases were recorded as having a preliminary Schick test, 48 by one practitioner, and one was done at our clinic. " About " 48 cases were recorded as having a posterior Schick test, all by one practitioner. Twenty-two per cent. of the replies were to the effect that immunisation would be facilitated if T . A . M . was supplied free to the practitioners, and if they were paid a fee for the inoculations. In no case were any records kept. If the immunisation is carried out by the general practitioners it must, I am absolutely convinced, be done on a uniform plan as regards methods and material. An interesting investigation of the reasons for not providing diphtheria protection in 50 families where diphtheria occurred was undertaken in the City of Detroit, and the report is as follows : Did not believe in it, 8. Neglect, 24. Did not know about it, 8. Fear, 3. Too old, 7. " In other words, 48 per cent. of 50 families in which diphtheria occurred failed to secure diphtheria protection because of neglect, and 32 per cent. because they did not believe in it, or did not know about it." Finally, in dealing with the difficulties of

261

diphtheria immunisation, I feel that I must call attention to the serious statements by Dr. C. H. Kinnaman, :Epidemiologist to the Kansas State Board of Health, which, so far as I can ascertain, have not been confirmed by other observers. The first is to the effect that " we have observed in Kansas that diphtheria is apparently of a more virulent type as the number of immunised children is increased." The second is that " when 50 per cent. or more of the children are immunised in a rural community, the non-immunised child is in greater danger of a fatal termination if it contracts diphtheria than in counties where no immunisations have been d o n e . " These statements were published in September, 1931, and, as I say, I know of no confirmation by any competent observer. True, K a n s a s has practically half a million children immunised, but at the same time, as I stated at the beginning, we must beware that we do not ascribe to our own actions, results which are solely due to natural changes in the type and incidence of the disease. These changes, as has been pointed out in the leading article of the Medical Officer of March l l t h , 1933, may vary very materially in different localities. For instance, in my outbreak in 1928-29, the mortality was just on 11 per cent. Reports from districts wide apart testify to the increased severity in type of the disease in recent years, and this severity appears to be common to countries where immunisation is non-existent, and to those where it is widely practised. A final dictum of Dr. Griswold's, though cruel in its criticism, is worth remembering; it is that " parents who allow their children to remain unprotected in communities of this kind (where immunisation is offered) are unfit to be parents, and each death which occurs from diphtheria under these circumstances should be referred to the coroner for investigation." BIBLIOGRAPHY.

Activities of the Massachusetts Department of Public Health. Order No. 2976. American Public Health News. Bridgeport, Connecticut. Report from Dr. Rich. Shea, Health Officer. Brookline, Massachusetts. Report of Board of Health, 1930. Bulletin of Hyglene, 1931, 1932. Detroit Department of Health. City Health Bulletin, Jan., 1930, Vol. xlv, No. 1 ; Mar. and Apr., 1930, Vol. xiv, No. 3.

262

PUBLIC HEALTH.

City of Montreal. Health Bulletin, Vol. xviii, No. 6, 1932. City of Montreal. Reports of Department of Health, 1930, 1931, 1932. City of Newark, New Jersey. 45th Annual Report of the Department of Health. Connecticut Health Bulletin, May, 1931. Diphtheria. State Department of Public Health, Tennessee. Diphtheria. The Common Health. Massachusetts Department of Public Health, Vol. xvii, No. 3. Diphtheria; Diphtheria Carriers. New York State Department of Health, Albany, N.Y., Dr. Thomas Parran, Jr. Diphtheria and its Eradication. Dr. William H. Park, Director, Bureau of Laboratories, New York City Department of Health. Diphtheria : Carrier Infection among Family Associates. Yoshio Kusama and James A. Doull, American Journal of Preventive Medicine, Sept., 1931. Diphtheria Control in Bridgeport. William F. Wild and Kathryn R. Tirrell, American Journal of Preventive Medicine, Sept., 1931. Diphtheria Immunisation by Three and Four Injections of Toxin Antitoxin. Dr. V. K. Volk, American Journal of Public Health, Aug., 1931. Diphtheria Immunisation in Philadelphia and New York City. Walter W. Lee, American Journal of Preventive Medicine, May, 1931. Diphtheria Mortality in Large Cities of U.S.A., 19301931. Journal of American Medical Association, May, 1931-May, 1932. Diphtheria on the Increase--Why ? City of Detroit Department of Health, Weekly Health Review, Oct., 1931. Diphtheria Prevention in Detroit. Drs. H. F. Vaughan and Buck, Weekly Poster and Medical Digest, Dec., 1932. Diphtheria the Outlaw. Dr. Harold White, School Board, Vancouver, B.C. Effect of Diphtheria Immunisation upon Case Incidence and Mortality. Dr. C. H. Kinnaman, American Journal of Public Health, Sept., 1931. Guarding the Health of Seven Million People. Department of Health Annual Report, New York City, 1929. Hawaii Board of Health. Pau Diphtheria, 1930. Health Protection for the Pre-School Child. White House Conference on Child Health and Protection, New York, 1931. Illinois Quarterly, Vol. iii, No. 1, 1931, State Department of Public Health. Institutional Diphtheria. Drs. Young and Cummings, Michigan Department of Health, American ffournal of Public Health, Nov., 1932. Iowa State Department of Health. Biennial Report, 1930. Journal of Clinical Research, Jan., 1933. Kansas State Board of Health. 16th Biennial Report. Lancet, July 23rd, 1932 ; Feb. 1 lth, 1933. Medical Participation in Public Health Work. Dr. H. F. Vaughan, Commissioner of Health, Detroit, American Journal of Public Health, Sept., 1932. Mother and Child, Feb., 1933. New York State Department of Health. Health News, Feb. 23rd, 1931.

MAY,

Pennsylvania. Year Book of Department of Health, 1929, 1930, 1931. Province of British Columbia. 33rd Report of Provincial Board of Health. Prevention of Diphtheria. Dr. James Graham Forbes. Royal Sanitary Institute Congress Report, 1932. Rural Health. The Common Health, Massachusetts Department of Public Health, Vol. xix, No. 3, 1932. Saving Children's Lives. Diphtheria Prevention Commissioner, Department of Health, City of New York, 1932. State of New Mexico. 7th Biennial Report of the Bureau of Public Health. The Efficiency of Toxoid in Controlling Diphtheria. Mary A. Ross and Neil E. McKinnon, Department of Epidemiology and Biometrics, University of Toronto, Canadian Public Health Journal. The Five Year Diphtheria Campaign, 1926-1930. Lee K. Frankel, PH.D., State Committee on Tuberculosis and Public Health, New York City. The Physician as Health Worker. Drs. L. O. Geib and H. F. Vaughan, Journal of American Medical Association, Aug., 1931. Toxid as a Prophylaxis Against Diphtheria. City of Detroit Department of Health, Weekly Health Review, Oct., 1931. Toxoid. Public Health Monthly Bulletin for Feb., 1933. Newark Department of Health. Dr. C. V. Craster. DR. G R A H A M

FORBES.

I n the desire to confine attention as m u c h as possible to the p o i n t s chosen for discussion, a n d in order to a v o i d repetition of the l a r g e a m o u n t a l r e a d y p u b l i s h e d on the m a i n topic, I p r o p o s e to devote m y c o n t r i b u t i o n in p a r t to a n a t t e m p t e d outline of the p r o g r e s s which h a s b e e n m a d e in G r e a t Britain a n d I r e l a n d i n t h i s i m p o r t a n t b r a n c h of p r e v e n t i v e w o r k d u r i n g the past two y e a r s up to the end of 1932, t o g e t h e r with certain features b e a r i n g u p o n its possibilities a n d difficulties. C o m m e n c i n g with L o n d o n , as r e g a r d s the i m m u n i s a t i o n w o r k in the twelve m e t r o p o l i t a n b o r o u g h s w h e r e special clinics h a v e been p r o vided at the child welfare centres, the records c o n t i n u e to s h o w steady, if slow, p r o g r e s s ; m o r e m a r k e d in s o m e t h a n others, a n d now r e a c h i n g an a g g r e g a t e of nearly 18,000 k n o w n or p r e s u m e d i m m u n e since the w o r k first s t a r t e d ( i n c l u d i n g o v e r 31,500 dealt with in 1932) as c o m p a r e d with the total of 12,000 u p to t w o y e a r s a g o . T h e f o l l o w i n g are the inclusive totals dealt with in each b o r o u g h since tbe clinics o p e n e d u p to the e n d of 1932, of p r i m a r y S c h i c k n e g a t i v e s or n a t u r a l l y i m m u n e , a n d t h o s e i m m u n i s e d with three doses, the figures for the latter b e i n g also s h o w n s e p a r a t e l y in brackets.

1933.

PUBLIC

Vv'andsworth heads the list with close on 4,250 (3,266 immunised); L a m b e t h coming next with 2,664 (1,788); Hackney, 2,082 (1,538); Holborn, 1,723 (1,271); St. Marylebone, 1,400 0,202); Camberwell, 1,233 (922); Westminster, 1,229 (1,026); Deptford, 1,031 (743); then Battersea, 843 (707); Southwark, 734 (559); Stoke Newington, 386 (342); and Bermondsey, unfortunately, far behind with 130 (50 immunised). In Poplar with 170 (128) and Finsbury 30 (18), the clinics have been closed for want of support since 1930. In the 14 boroughs, with twelve at present carrying on immunisation work, the combined figures amounted to nearly 17,900, including 13,555 immunised, at the end of 1932. There has been recent evidence of a welcome increase of interest on the part of the general practitioner to make use of immunisation among his private patients, as shown by the scheme which has been put forward by the Kensington, Hammersmith and Paddington Branch of the British Medical Association, and by the adoption in Lambeth of facilities by which it has been arranged that both primary and secondary Schick tests are performed by those in charge of the immunisation clinics, whilst the immunising injections are to be given by the practitioner. Furthermore, although the problem--of no small m a g n i t u d e - - o f the introduction of immunisation into the London elementary schools has yet to be solved, a very marked advance may be claimed in the work on a smaller scale, which has been conducted during the past year in the residential schools, the majority outside the metropolitan area, whose control has been taken over by the London County Council from the poor law authorities. By the end of 1932, among a total of over 6,100 children in 21 schools, with parental consent, 2,750, or nearly 45 per cent. had been Schick tested, yielding close on 1,000 Schick positive, or 32 per cent. of those tested, and about 900 had received the full immunising course. Later Schick testing of 300 inoculated children showed that 95 per cent. had become immune. This work is proceeding steadily as well as that in many other residential institutions, such as the Royal Hospital School, Greenwich, Dr. Barnardo's Homes, and Spurgeon's Orphanage, where, for a number of )'ears now, immunisation of susceptible newcomers has been the routine procedure, and diphtheria

HEALTH.

26a

outbreaks, formerly of common occurrence, have become a thing of the past. In Greater London, among the many districts and boroughs encircling the metropolis, there has been established in the past three years almost a ring of immunisation clinics, including those at East and West Ham, Dagenham, Ilford, \Valthamstow, Tottenham, Wood Green, Willesden, Acton, Heston and IsIeworth, Croydon (in institutions), Godstone, Beckenham, and Bromley, borough and rural--comprising a population of 1,485,000, where the numbers immunised, or known Schick negative, now reach over 23,000, or more than double those of two years ago. To that total the chief contributing centres have been Heston and Isleworth, 3,250 ; Acton (in the short space of four months) over 2,700 ; Beckenham, Dagenham and West H a m (Plaistow Hospital), each over 2,300, Ilford nearly 2,200. In addition, Croydon over 1,500; W o o d Green, over 1,400; Bromley (Kent), and Godstone, nearly 1,200 each ; East Ham, over 1,000; and Willesden, only 200; also Walthamstow, opening in 1932, about 200. So that, irrespective of hospitals and residential institutions, in the whole of Greater London (metropolitan and outer ring), there is an aggregate of over 40,000 presumed immune, as compared with under 20,000 at tile end of 1930. In tile provinces there is now a long list of towns and districts, where immunisation has been adopted or maintained before or since 1930, numbering 120 in 35 different counties, in addition to the 25 boroughs and districts of Greater London, and not inclusive of the many places where the preventive work is confined to individual hospitals and residential institutions. T o attempt the enumeration of those tested and immunised in the many centres of diphtheria preventive work has at this stage become impossible with any hope of even approximate accuracy. But, from the progress shown in the more active centres it may be concluded with some certainty that the number ascertained, so far as was possible at lhe end of 1930--under 125,000 in E n g l a n d - has in two years been more than doubled. In Wales, the only two known centres of this work, Cardiff, and the urban district of Ogmore and Garw, have now respective totals of 12,400 and 2,800 as compared with just over 12,000 and 1,800 two years ago. In Scotland, I have been unable to collect full records from all places, but Edinburgh's

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total at the end of 1932 had reached nearly ]7,200, as against 15,800 at the end of 1930. In Aberdeen city over 16,000, and Aberdeen county 12,400, and in Dundee about 4,000, had been dealt with at the end of 1932. In Ireland, the most important contributions to the growth of a protected population have been made in the city and county of Cork, where Dr. Saunders and Dr. Condy, respectively, have continued their active campaigns with considerable success, without any slackening in the response, and apparently uncffecked by the opposition of the anti-vaccinist. In Cork--with a population of 78,500, at the end of 1932, since June, 1929, the total of known or presumed immunes had reached nearly 7,500, or 30 per cent. of the child population under 15, as against 4,800, two years ago ; and, post hoc or propter hoc, Cork's long record of high diphtheria incidence and mortality extending back to 1919 (with an annual average of nearly 400 cases and over 30 deaths, and with over 600 cases and 74 deaths in 19q0) had fallen to 85 cases and 16 deaths in 1932. CORK CrrY. Cases Deaths 1930 ...... 624 ... 74 1931 . . . . . . 288 ... 24 1932 ...... 85 ... 16 In Cork county (population 287,260), Dr. Condy reports that a total of over 8,500 have been immunised or known to be immune since July, 1929, to the end of 1932, and that in that par t of the 'county where the campaign has been actively carried on, there has been a very material fall in incidence and mortality during the past twelve months, whereas in the rest of the county where immunisation work is to be extended at the first opportunity, the previous heavy toll still continued without any decline. CORK COUNTY. Year Cases Deaths 1930 ...... 337 ... 50 1931 ...... 241 ... 31 1932 ...... 210 ... 31 IMMUNISED AREAS. Cases in Cork ~'- Passag~ Year R.D. \Vest 1930 ...... 172 ... 22 1931 ...... 95 ... 2 1932 ...... 44 ... 1 Elsewhere in the Irish Free State, in county

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Louth, Dr. Musgrave reports the start of a further campaign, undertaken in 1932, in parts previously unprotected in the Dundalk area, where over 500 further children have recently been immunised, in addition to the total of 1,500 immunised in successive campaigns during 1928 and 1929 in Dundalk town. Up to the end of 1932, in Dublin city about 3,800 children had been immunised, and in Wexford and Galway counties a total of about 2,000. In 1932, Dr. J. A. Harbison reports that in a Dublin county rural district over 100 children were immunised, and the work is still proceeding. T h u s in the Irish Free State an aggregate of over 23,000 have been immunised or known to be immune, as compared with 13,000, two years ago. R e t u r n i n g to England, time allows of only brief reference to the more important individual centres, where preventive inoculation has been conducted continuously for 'two, three or more years as part of a now established public health measure in dealing with endemic diphtheria, irrespective of the activities prompted by the urgency of epidemic prevalence. In the order of the numbers dealt with in each place (in the majority, up to the end of 1932) mention may be made of the following : Birmingham.--50,000 since 1925, approximately 20 per cent. of the child population under 15, including 11,800 dealt with in 1932, and more than double the 23,000 at the end of 1930. 1930.--2,363 cases, 87 deaths. 1931.--1,802 cases, 63 deaths. 1932"--1,184 cases, 36 deaths. Manchester.---Over 21,000 since 1927, including about 12 per cent. of those under 15, and 6,800 during 1932, as against the total of 9,500 up to the end of 1930. 1930.--1,059 cases, 57 deaths. 1931.--735 cases, 60 deaths. 1932.---1,086 cases, 86 deaths. Bristol.--Since October, 1929, to end of ]932, 12,500 dealt with, including about 13"5 per cent. of the population under 15, and 5,800 i m m u n i ~ apd subsequently Schick negative, as compared with the total of 7,400 dealt with at the end of 1930. 1930.--1,484 cases, 39 deaths. 1931 .--828 cases and 31 deaths. 1932.--576 cases, 22 deaths. * 1932 figures of notified cases and deaths, throughout must be read as provisional.

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Liverpool.--9,400 since 1926 (including nearly 4 per cent. of the child population under ten, and over 6,600 in 1932) as compared with a total of trader 500 only, up to two years ago. 1930.--4,063 cases, 234 deaths. 1931.--3,240 cases, 190 deaths. 1932.--3,317 cases, 184 deaths. Watsatl.--8,300 since 1927 (including about 29 per cent. of the population under 15), as compared with 5,600 in 1930. 1924-28 (average) 320 cases and 32 deaths. 1 9 2 9 . I 6 7 cases, 15 deaths. 1930.--151 cases, 12 deaths. 1931.--122 cases, 11 deaths. 1932.--60 cases, 3 deaths. Plymouth.--4,500 since 1927, including 9 per cent. of the population under 15, an increase of 3,000 since the end of 1930. 19.q0.--629 cases, 23 deaths. 1931.--367 cases, 17 deaths. 1932.--450 cases, 17 deaths. Salford.IOver 4,000 since September, 1929, about 7 per cent. of the population under 15, including 2,300 in 1932. 1930.--741 cases, 30 deaths. 1931.--580 cases, 31 deaths. 1.932.--727 cases, 22 deaths. Leeds.--2,600 since 1928 (2 per cent. of those under 15) as compared with about 500 at the end of 1931. 1930.---1,014 cases, 54 deaths. 1931.-989 cases, 87 deaths. 1.932.---895 cases, 48 deaths. Coventry.--2,500 since April, 1929, or over 6 per cent. of the children under 15. 1930.---493 cases, 41 deaths. 1931.I192 cases, 11 deaths. 1932.--114 cases, 4 deaths. Smethwick.--Nearly 2,200, November, 1930 up to tile end of 1932, (representing 10 per cent. of the total population under 15, and over 15 per cent. of the children in the most affected area); but only 23 attended in the last 15 months up to March, 1933. 1930.---281 cases, 21 deaths. 1931.--211 cases, 16 deaths. 1932.--76 cases, 5 deaths. In these ten c o u n t v ' b o r o u g h s (with a total population of 4,340,(i00), at the end of 19,'52, an aggregate of 117,000 had heen fully inoculated orwere known to be imnmne, representing 2"7 per cent. of the total population, as compared with 51,300 at the end of 1930, while in London (metropolitan) with about, the same population, the number was under 18,000 only. Records from other immunisation centres have been obtained, including Dewsbury, 2,000 (all in 1932) ; Chatham, over 1,700 ; Birkenhead, 1,550; Dover, 1,400 (in 1932); Poole, 1,360 (in 1931) ; Lowestoft, 1,300 ; Blackburn,

265

Chester and Oxford, about 1,000; Wakefield, since February, 1932, about 850. In Halifax and Hastings, clinics were opened in 1932. In Hull, with a population of 315.200, in spite of a diphtheria incidence and mortality steadily increasing year by year to reach the record total of nearly 1,700 cases and 126 deaths, more than double that of 1980, the response to the facilities afforded had yielded a total of under 600 children only, over a period of four years up to the end of 1931. But, happily, better attendances at the four clinics were recorded in 1932, with a total of 437 children immunised, and 108 known immune, as primary Schick negatives--or only 29"3 per cent. out of 368 tested--showing also, the low degree of immunity still existing among Hull children, in spite of the increased diphtheria prevalence ever since 1929. HIJLL DIPHTHERIA RECORDS. Case mortality per cent. 1930 8Sl cases (2"8 per 1,000), 47 deaths 5-3 1931 1,138 cases (3"6 per 1,000), 93 deaths 8"2 1932 1,692 cases (5"3 per 1,000), 126 deaths 7"4 It should be staled, however, that with the possible exception of Birmingham and W a l sail, the" numbers immunised represent a proportion of the child populations in the various towns quite insufficient yet to affect the diphtheria incidence and mortality rates during the past three years. Such decline as has occurred is (as in a number of other places, e.g., Sheffield, Bradford, Nottingham, Portsmouth, D e r b y and Northampton, where no preventive inoculation measures have been applied), in all probability due to the natural course of diphtheria prevalence on the downward grade, following the high incidence of the peak year experienced [n many places in 1930. In this connection, I venlure to refer again Io tile work of E. S. Godfrey, of New York State,* quoted on a previous occasion six months ago, showing that reduction in the attack and death-rate of any district could not be expected until at least a third of the 0-5 population had been protected, even if as high a proportion as 50 per cent. of the school population had already been immunised. Conditions of sudden epidemic prevalence are more likely to attract attention and prompt *" American Journal of Public Health," March, 1932, xxii, 3, 237-57.

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urgent preventive measures in small urban districtsandscattered rural areas, than in populous centres where the disease is normally endemic. In the former, as a rule, there occur long periods of quiescence, producing a sense of false security but also a low degree of immunity a m o n g the entire child population. U n d e r such circumstances of unpreparedness, an epidemic outbreak cannot fail to exact a heavy toll and assume alarming proportions, capable perhaps of maintaining a hold over several years, as has, indeed, been the case quite recently in the last seven years in a number of widely scattered districts of which I have records ; thus in the remote hill districts of Cumberland about Brampton, and at Padiham in Lancashire, at K i n g ' s Lynn in Norfolk, Whittlesey in the Isle of Ely, and now this year at March ; also at Leominster in Herefordshire, Lye and Wollescote in W o r cestershire, and Trowbridge in Wiltshire. Here, in London, one has little conception of the state of actual panic resulting from the rapid spread of these sudden waves of epidemic among a hitherto unexposed population--so graphically described in the medical officers' reports ; one relating to the migration of whole families, fleeing panic-stricken from the danger zone, as if to escape the plague ; another stating that so certain was the risk of attack in the face of the existing " scourge of diphtheria " that people had come to dread having any children, and how intense was the relief to be able to record in 1931, that not a single case had been reported, after the previous five or six years of alarm! A third reports that in 35 years' experience, the sudden increase in prevalence in 1929 and 1930 had surpassed all previous records. In two of the districts, immunisation was resorted to in response to the urgent call for action, and quite a considerable proportion of the child population were inoculated--post hoc or p~'opter hoc the epidemics subsided. In two other districts no active measures were taken until a second or third year's high prevalence stirred local apathy to respond to the means of protection offered, but it was then too late to avert the course of the outbreak, which in four years had taken a toll of 470 stricken and 40 dead in a population of 4,500 under 14. In yet other instances of sudden epidemic, the local opposition to the idea of inoculation, the " not holding " with such measures, and the activities of the anti-vaccinist, effectively checked the needful response; the disease was thus

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allowed free play, in one place of 12,500 levying 180 cases and 15 deaths in tile course of 15 months, and in another, a town of 90,000, 350 cases and 24 deaths in the year. As to the possibilities and difficulties attending the adoption of preventive inoculation ; search through the recent annual reports of medical officers of health of England and W a l e s affords opportunity for observation and reflection on the variety of factors concerned which may make or mar the success of the attempt to bring about the control of diphtheria by immuhisation, and I would put before you what appear to me to be of importance. It is obvious in the first place, that as the medical officer himself is of necessity the prime mover in introducing the scheme and gaining the sanction of his local authority, his own personal conviction as to the value and safety of the measures he considers necessary must admit of no doubt, cavil or half-heartedness. Fie must, in fact, carry conviction and be a really determining influence sufficient to convince the lay committee of the soundness of his proposals, and of the indispensable extra assistance required, and thus to gain their wholehearted consent, with evidence both as to the prospect of safeguarding life and health, and as to the economic saving to be expected-for example, that for the cost to the ratepayers of one case of diphtheria some 200 children can be protected with comparative certainty from attack. Secondly, of ahnost equal importance, is the unqualified support and co-operation of practising colleagues, even if it may suggest to some of them trespass on their rights and means of livelihood, however narrow-minded such a view would appear when viewed in the interests of the better health of the community. But it is surely clear that by the removal of any professional antagonism or disapproval of preventive measures, and the gaining" of full co-operation of the medical practitioners through the opportunity of obtaining the consent of private patients, the greater is the likelihood of a successful anti-diphtheria campaign. The gaining of professional confidence, at tile present stage now reached of general acceptance as to the value of immunisation, would seem to be assured by the development already referred to of the tendency towards preventive inoculation as a part of private practice. I submit this point for discussion as to one of the possibilities to be considered--

1938.

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whether or not immunisation at this time may be regarded as a justifiable and safe procedure to be made use of in private practice. I have noted a number of places in which the general practitioner is already taking an active part in conjunction with the medical officer of health, as, for instance, in Manchester, Liverpool, Leeds and elsewhere, and, as previously mentioned, in Lambeth the necessary Schick testing is to be undertaken by the medical officer in charge of the borough clinic before and after immunisation by the practitioner. In regard to the necessary response of the general public and the securing of parental consent to immunisation, there can be little doubt that the personalily and determination of the medical officer concerned is bound to play a large part, dependent on his influence, powers of persuasion, and handling of parents, and appreciation of their doubts, so that, their confidence once gained, a hold is maintained to ensure the full course of attendance and subsequent following-up of each child, until the desired protection is made certain. At the risk of repetition, I cannot refrain from mentioning a striking instance of the value of personal influence, which I have quoted elsewhere, in connection with the commencement of immunisation work under conditions which could scarcely have been more discouraging to medical officer and parents alike. In a certain district in Wales, it so happened that on the very day that the clinic was due to open for the first time, in January, 1928, there appeared in all the daily papers the alarming account of the disaster attending the inoculation of children at Bundaberg, in Queensland, yet despite the gravity of the news, and the inevitable check to public confidence in similar preventive measures, so sure a hold had been established among the parents, who had previously given consent, that only a dozen that d a y withdrew their permission. The clinic--thus opened under so threatening a cloud--has continued at work ever since, with a total approaching 3,000 immunised, equivalent to one-tenth of the total population, and about a half of all the children under 1,5. There is, however, no getting away from the fact that even the best fitted in the public health service is too often faced with what may prove an almost insuperable obstacle to the conducting of an immunisation campaign, in the attitude and mentality of the local community towards acceptance of the means of protection. The difficulties presented, indeed,

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call to mind only too plainly the parable of the sower, the obvious application of which I need not further dilate on. T h e y would seem to be much more apparent in some parts of the country than others--displaying a local intolerance due perhaps, in part, to racial make-up and heredity, responsible for an apathy incredible, and ignorance defying education, a type of opposition in the past which Jenner and others have had t o contend with. W h y , for instance, should the people of a midland county district yield so poor a response in the face of an outbreak unequalled in 40 years, so that, when appeal by active propaganda was made to 2,,500 parents, only four attended at a special meeting called by the medical officer--and the combined efforts of the county authorities eventually resulted in securing the immunisation of less than 80 children only, in a population of 12,400--a very disheartening result ? Much the same indifference has been evident in eastern counties among people of the Fen country, and in Norfolk and Suffolk. Yet, on the other hand, elsewhere a very different type of response has been forthcoming; in Oxford, for example, an attendance of 75 and 85 per cent. of the school population was secured; while in many other centres, consents have been given for 30-50 per cent. or more of the children to be immunised. In Heston, as we have heard from Dr. Nash, the demand for protection surpassed all expectation, and was more than could be dealt with until extra staff and sessions were arranged. From the quoted examples of the progress made in various places, there are sufficient contrasts presented from which various conclusions might be drawn. B i r m i n g h a m ' s response, for instance, as compared with that in Hull. Is the explanation the type of inhabitant to be persuaded, or rather the long-standing preparation among parents of children of school and pre-school age, and the now thorough working organisation--despite separate control--between school and health services in Birmingham, whereby it has been possible to secure the appointment of the necessary special staff, both for carrying out the testing and immunisation, a n d the equally important following-up and home visiting? A p p l y i n g again the parable--as in husbandry, so in preventive medicine, preparation of the soil calls for special personal attention and choice of suitable fertilising

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measures ur educational propaganda of ahnost unlimited scope, to awaken interest and bring warning to parents of the danger of indifference to the risk Qf diphtheria. Added to which, there is the necessity of counteracting the very harmful effect of the activities of the antivaccinist--more on the alert than: ever to create opposition against this as against every other form of preventive inoculation, whatever tlm disease concerned--presenting moreover one of the difficulties which every medical officer of health has to confront in starting an immunisation campaign; and therefore, a matter well suited for present discussion. The peculiar and almost fanatical creed adhered to is only too well known as an absolute negation of the value of any form of therapeutic or prophylactic vaccine or serum, despite the overwhelming mass of evidence in their favour; whilst in place of the control of diphtheria by immunisation, there is advocated as infallible, the vague influence of improved sanitation and better housing. After having heard Dr. Nash's opening paper, one must congratulate him heartily, as well as his colleagues, on the thoroughness o f the preventive measures carried out in Heston and Isleworth under conditions little short of ideal in every respect. There is, I think, no ouesdon tlmt the work of immunisation cannot be regarded as com. plete without the performance of the Schick test after an interval of three or more months following the inoculation course, in all, if possible, or as m a n y as can be made to attend. Herein lies the importance of a system of following-up by advisory card to each parent concerned, the success of which will again depend on the hold maintained and the confidence inspired by those responsible for the work. It is possible, however, that administrative difficulties and lack of the required help may prevent so desirable a check on the results of immunisation, and that preventive efforts have to be confined to the recognised course of inoculation, and to be concentrated on securing the inoculation of as many children as possible, without certainty as to the proportions still requiring further treatment. It is encouraging to find that at most of the cemres referred to, a good proportion of those receiving the full immunising course, subsequently attended for Schick testing; for the precaution cannot be too closely observed of advising a parent that without the later test

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the desired protection cannot be regarded as certain in every inoculated child. There is, however, a very considerable amount of disparity to be found in the results of the later Schick testing which appears difficult to account for, and therefore calls for discussion in the attempt to arrive at an explanation, and to obtain a reliable standai-d as to the effect of the particular prophylactic employed, the size and spacing of doses and the interval of time allowed to elapse before lhe final Schick test. The discrepancies mentioned vary as much as from a9.6 per cent. to over 9.5 per cent. Schick negative after inoculation. But the unusually high proportion of postimmunisation Schick positives obtained in Bristol, of 42 per cent. in 1931, and 60 per cent. in 1932, a m o n g a total of over 4,000 tested, and in Leeds in two much smaller totals, of 29 per cent. a m o n g 76, and 4ti per cent. a m o n g 105 tested, are certainly quite exceptional. In attempting explanation, it has been suggested, on the one hand, that the Schick test toxin was employed in too great strength (this, however, has not been verified): on the other hand, that reactions which had been read as Schick positive were, in reality, pseudo-reactions causing abnormal staining of too slight a character to be regarded as positive reactions. There is some support of sucla an explanation in the fact that investigation of certain unexpected results showed that tlie blood of the supposed positive reactors contained from half to five units of antitoxin per c.c.--much in excess of the small amount needed to prevent a positive reaction. In the records collected from over 30 sources of Schick retesting, the Schick positives were below 10 per cent. in 13 (five groups being under ,5 per cent.), between 10 and 20 per cent. in twelve, between 20 and 30 per cent. in six, between 30 and 40 per cent. in three, between 40 and 50 per cent. in three, and in one, 60 per cent. were still Schick positive. In those places where immunisation only has been found practicable, as in Manchester, Liverpool, Cardiff, and elsewhere, it is claimed to be more advantageous to devote the time to inoculating as m a n y children as possible, rather than to undertake a smaller number and to retest those whose further attendance can be relied on. Tile difficulties a n d possibilities attaching to the question of the respective advantages--of whether to Schick test or not after immunisation, and the arguments for and

19:33.

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HEALTH.

269

S O M E RECORDS OF S C H I C K T E S T I N G AFTER [ M M U N I S A T I O N .

Showing the proportions per cent of (1) Schick tested among the corresponding group of numbers immunised ; (2) Schiek negative among those tested ; (3) Non-immune Schick positives who received further immunising doses.

Centre.

Number of Immunised.

Percentage Schick Tested.

Percentage of tested found Schick Negative.

West Ham (Plaistow Hospital) Southwark .. .. .. L.C.C. Residential Schools .. Holborn . . . . . . Cork City .. ....

733 363 900 1,117 2,219

58 90 33 76 93

98.8 97 95 95 94

(1) Edinburgh Westminster Bromley Peele . . .

. . . .

. . . .

. . . . . . . . . . . . . . .

24 49 96 63

637 875 251 1,239

(Of 913 tested) 85 (2)~ (Of 1,166 tested) 92 91 90.5 (i)f 90.4 / . ( O f 208 over 10 years) . ,. f

2,613 2,385 1,427 1,502 720 3,850 162 1,254 732 1,954 4,900

Wandsworth . . . . Heston and Isleworth Wood Green . . . . Ilford St. Marylebone Plymouth •• Oxford . . . . Lambeth •• Deptford .• Beckenham •• Walsall . . . .

.. •. •. •.

Dagenham •• Wakefield •• Ogmore and Garw Cannock, R.D. Stoke Newington Leeds . . . . Bristol, 1930

..

Bristol, 1931

..

Bristol, 1932

..

•.

1,760 632 782 440 •. 318 .. 202 600 •. 5,485 (school) 1,892 (pre-sehool) •. 3,098 (school) 388 (pre-school) •. 1,617

85"6

re) ~ ( O f 502 under 10 years) 72 90 96 88 85.7 86-7 78 86 85.5 85 63 85 73 83.5 67 83 81.2 43 83.5 77 (1) 79% (Of 292) 40 (2) 85% (Of 374) (3) 87% (Of 573) (4) 75% (Of 757) 48 75 73 18•6 67 -8 73 63 83 62 68 71 (1) 38 38 (2) 17-5 54 (1) 80 77 (2) 68 50 (1) 83 69 (2) 70 39.4 78

a g a i n s t , will n o d o u b t p r o m p t lively d i s c u s sion. I n this c o n n e c t i o n , it h a s b e e n p u t f o r w a r d t h a t i n o c u l a t i o n w i t h t o x o i d a n t i t o x i n floccules, with the better p r o s p e c t of i m m u n i s i n g 95 p e r c e n t . of t h o s e i n o c u l a t e d , s h o u l d be u s e d in preference to t o x o i d , w h o s e p o w e r w a s m o r e limited, p r o d u c i n g , it h a s b e e n stated, not a b o v e 80 or 85 p e r c e n t . S c h i c k n e g a t i v e . E v e n b e t t e r r e s u l t s t h a n 95 p e r cent. i m m u n e

Percentage of Schick positives receiving further Inoculation. Not undertaken• Not stated. Not completed• 85.

t

Majority.

Not stated• Majority. Not stated.

l Majority.

J

Majority. 90. 57.5 Majority. Majority. Majority. N o t completed. Majority. Majority. 82. All. 96. Majority. 94. 85. All. 98. Not stated. The majority. Not stated.

l

N,,Tt stated.

h a v e b e e n r e p o r t e d in the use of T . A . floccules, b y H a r r i e s a n d D u d l e y , w h o h a v e , I believe, o b t a i n e d 100 p e r cent. S c h i c k n e g a t i v e b y m e a n s o f o n l y t w o i n o c u l a t i o n s a n d w i t h i n the space of one month. It w o u l d , o n the w h o l e , a p p e a r t h a t the e v i d e n c e in f a v o u r o f this prophylactic affords ground for hope that from tile p o i n t of v i e w of i m m u n i s i n g p o w e r , a n d a b s e n c e of reaction, T . A . F . a p p r o a c h e s t h e m u c h - d e s i r e d ideal i m m u n i s i n g a g e n t , if its

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p r o d u c t i o n m a y b e c o m e p o s s i b l e at a l o w e r cost t h a n a t p r e s e n t . A m o n g the possibilities of achievement, a n d a s a n o b j e c t of e m u l a t i o n i n i m m u n i s a t i o n work, there should not be omitted reference to w h a t tins b e e n a c c o m p l i s h e d i n N e w Y o r k C i t y d u r i n g t h e p a s t f o u r y e a r s , w i t h a total of o v e r 680,000 i m m u n i s e d - - r o u g h l y 45 per c e n t . of t h e c h i l d r e n u n d e r 15 y e a r s - - i n a total p o p u l a t i o n o f o v e r s e v e n m i l l i o n s , s i n c e the c o m m e n c e m e n t of 1929, a s s o c i a t e d w i t h , a n d p e r h a p s i n p a r t r e s p o n s i b l e for a r e d u c t i o n in diphtheria incidence and mortality from 10,776 c a s e s a n d 642 d e a t h s i n 1928, to 3,585 c a s e s a n d 212 d e a t h s i n 1932. It has been p o i n t e d out that the difficulty c o n f r o n t i n g t h e a t t e m p t at s u c h a c h i e v e m e n t i n L o n d o n is t h e l a c k of a c e n t r a l l y o r g a n i s e d c a m p a i g n o n a l a r g e e n o u g h scale. D o e s the f u t u r e h o l d t h e p o s s i b i l i t y of the r e m o v a l of t h a t d i f f i c u l t y ? DISCUSSION. Dr. {lay Bousfield (Medical Officer, Diphtheria Immunisation Clinics, Camberwell, Lambeth, Heston and Isleworth) referred to the lack of support received from the L o n d o n County Council in the diphtheria immunisation campaign. This was due either to extreme apathy or complete cowardice. If .a manifesto could be presented to the health authorities of the county by some responsible body, some good might be done. Dr. I. Greenwood Wilson (Medical Officer of Health, Dewsbury), gave details of the work carried out in his district since March, 1932. Of 1,900 immunisations, 199 had been done by private practitioners with material supplied by the health department. Most of the 55 adults were teachers who had expressed a desire to be immunised i n order to protect themselves, and give a moral lead to the children. It had been decided to abandon the preliminary Schick test and to concentrate rather on Schick testing afterwards. Postimmunisation and Schick testing had, however, been most disappointing, only 16 cases reporting. The total cost of the immunisations was ~::115, which worked out at 3s. 7d. per head for three injections, as against 0£7 for the treatment of one case of diphtheria for six weeks in the local fever hospital.

Dr. R. A. O'Brien, c.m~. (Director, Wellcomc Physiological Research Laboratories) said their hopes were based largely on the use of potent toxoid. The aim, of course, was to get rapid immunisation, but that could not be obtained without the risk of occasional reaction. If the public asked for imnmnisation without any reaction, then progress must be very slow. The use of the Moloney test had been the key to the campaign in Canada, and experience here, as far as they had gone, was favourable. In a paper to be published, Dr. Parrish reported the immunisation of two groups of tuberculous children, suffering with hone disease in sanatoria, in a very short

MAY,

time without a single troublesome febrile reaction, but using the intradermal toxoid test. With regard to the number of injections, with mass campaigns it might be found expedient to dispense with the initial and final Schick tests. Dr. H. A. Bulman (Assistant Medical Officer of Health, St. Marylebone) disagreed with Dr. Nash on the question of the anterior Schick test. In his view, the test could be abandoned safely and with advantage in children under 14 years of age. T.A.F. (toxoidantitoxin floccules) he held to be a safer immunising agent than T.A.M. (toxoid-antitoxin mixture), and if purchased in fairly large quantities would be found to cost little more than T.A.M. No reaction had been encountered with the use of T,A.F.--even with adults. With T.A.M. a number of rather bad reactions had resulted in nurses who had received the injections. Dr. Bulman urged the performance of the posterior Schick test in all cases. With regard to propaganda, in St. Marylebone special invitations were sent out to the parents, but a follow-up visit by the health visitors and the medical officer was essential in most cases to secure the attendance of the children; indeed the success of the campaign depended largely upon the amount of personal work put into it. Dr. A. B. McMaster (Medical Officer of Health, Dover), in describing the work carried out in his area, said that unfortunately many of the parents did not return with their children for re-Schicking, but it was hoped to have a public presentation of certificates to those completely immunised, and to use this as a means of propaganda" to secure a greater percentage of children coming up for the final test. Over a thousand children had been completely immunised at a cost of 2s. 3d. per child. The total cost to the town was ~171, representing the expenditure incurred in treating seven children in the isolation hospital. Dr. J. S. Logan (Deputy Medical Officer of Health, Swlndon) referring to the question of reactions, asked : (1) whether there was any advantage in waiting until the Schick positive reaction had subsided before the injections were begun; (2) if anything was to be gained by spacing the injections at fortnightly instead of weekly intervals; (3) if there had been any complaints of sore throat after the injections. Dr. Bousfieid, replying, said with regard to (1) that it made no difference, and (2) that good spacing of doses was desirable, but in clinic work it was found necessary to make the intervals as short as possible, otherwise there was a possibility that the course might not be completed. He had had no complaints of sore throat following injections. Dr. R. Veitch Clark (Medical Officer of Health, Manchester) referring to the abolition of the initial and final Schick tests, said there appeared to be only one reason why the practice had been established, namely, the desire to secure immunisation of the largest possible number of children with the least disturbance to the individuals, and, as a very much smaller contributory reason, with the least expenditure of time and money. The results in Manchester had justified the procedure. Mass protection was desired, and the more immunisations that could be done the better the results. Over 20,000 children had been immunised,

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and amongst them there had been no recorded case of diphtheria. Dr. E. W. Caryl Thomas (Medical Officer of Health, Dagenham) asked if there was any significance in the sore throat which occurred during the week following the first injection. He would not like to omit the first Schick test, nor the last as 25 per cent. were found to be still positive. Some 2,500 children had been treated, the average each session being 133. There appeared to be familial susceptibility in some cases, and several families with from three to six children were quoted. Drs. O'Brien, Bousfield and Forbes all stated in reply that the question of sore throat had not arisen in their experience. Dr. A. H. Macdonald (Chief Medical Officer, Dr. Barnardo's Homes) said he had dispensed with Schicking in children under six years of age. Above the age of six, 60 per cent. had been found positive. Dr. H. E. Marsden (Medical OffÉcer of Health, V~:est Lancashire Rural District) stated that in his area the clinic was held at the schools, with the advantage that the children were always available when the injections were due. He had found acceptances higher in the case of the Roman Catholic schools than in the others. Dr. D. J. Thomas (Medical Officer of Health, Acton) remarked on the absence of local reaction in some 400 children who had been immunised in connection with a mixed epidemic of diphtheria and scarlet fever.

Dr. W. G, Booth (County Medical Officer, Holland (Lincs.) County Council) enquired if there were any experience of the work having been carried out by general practitioners. In rural areas it was impossible for the part-time medical officers to do the work. He suggested that if some scheme could be evolved whereby children could go to their private doctor and be immunised at the expense of the local authority, the number of protected children could be greatly increased. Dr. Nash, in reply, said that in his district some 15 per cent. of the general practitioners had done a little immunising work. The question of making use of the general practitioner was one for e~tch medical officer of health to decide, and it depended largely on the psychology of the people in the particular area. He had under consideration the possibility of private medical practitioners co-operating in the work of immunisation, and also the question of fees to be paid for the services. In Detroit, and other American cities the private doctor assisted in the work to a considerable extent. The President (Dr. G. H. Pearce) described the activities of the immunisation clinic in Heckmondwike. He had been amazed at the success attained. Up to the present, 650 children had been immunised, and no reaction or trouble of any kind had been reported. No Schick testing, either before or after, was done. A vote of thanks to the speakers, proposed by Dr. Veitch Clark, was carried by acclamation and conveyed to the openers by the President on behalf of the Society.

THE D i r e c t o r y of M a t e r n i t y a n d C h i l d W e l fare Centres, recently published, takes the place o f List I I , 3,([. & C . W . 9, issued b y the Ministry of H e a l t h in March, 1926, but, unlike that list, which covered E n g l a n d only, includes all such centres as are k n o w n to be in existence t h r o u g h o u t the U n i t e d K i n g d o m , u p to F e b r u a r y 28th, 1938. T h e total n u m b e r of addresses at which m a t e r n i t y a n d child welfare centres, or certain activities c o n n e c t e d therewith, are at work, is n o less t h a n 8,408. It s h o u l d not, however, be inferred that there are o n l y 8,408 centres in the U n i t e d K i n g d o m , for at s o m e of these addresses as m a n y a s ten sessions per week are held, each a t t e n d e d b y different g r o u p s of m o t h e r s a n d children. It s h o u l d be p o i n t e d o u t also, that a l t h o u g h the D i r e c t o r y records 1,085 addresses at which post-natal c o n s u l t a t i o n s are held, these are b y n o m e a n s necessarily separate c o n s u l t a t i o n s from those for ante-natal cases. A p p a r e n t l y o n l y a c o m p a r a t i v e l y few centres hold special sessions at w h i c h m o t h e r s are seen d u r i n g the first six weeks after confinement, with a view to e n s u r i n g that n o obstetric complication persists. S i m i l a r l y , the list records t o d d l e r cons u l t a t i o n s as b e i n g held at 2,980 addresses, a l t h o u g h m a n y of the replies received o n l y

indicated the n u m b e r of toddlers with which the centres were in t o u c h . T h e n u m b e r of c o n s u l t a t i o n s for toddlers o n l y c a n n o t be a c c u r a t e l y g i v e n from the i n f o r m a t i o n available. T h e D i r e c t o r y s h o u l d be of real value in a n y public health d e p a r t m e n t , a n d is well w o r t h the m o d e s t price (2s. 6d.) c h a r g e d for it. C o p i e s m a y be obtained f r o m the A s s o c i a t i o n of M a t e r n i t y a n d C h i l d W e l f a r e Centres, C a r n e g i e H o u s e , 117, Piccadilly, L o n d o n , ~¥.1.

THE A m e r i c a n P u b l i c H e a l t h A s s o c i a t i o n a n n o u n c e s its sixty-second a n n u a l meeting, to be held in I n d i a n a p o l i s , I n d i a n a , U . S . A . , f r o m OctQber 9th to 12th, 1933. T h e scientific p r o g r a m m e will cover every aspect of m o d e r n public health practice, from the v i e w p o i n t of the health officer, the l a b o r a t o r y worker, the epidemiologist, the child h y g i e n i s t , the industrial hygienist, the nurse, the vital statistician, the health educator, the food and nutrition expert, a n d the s a n i t a r y engineer. T h e A m e r i c a n P u b l i c H e a l t h Association, 450 S e v e n t h Avenue, N e w Y o r k City, will be g l a d to send more complete i n f o r m a t i o n to a n y o n e interested.