EPIDEMIOLOGY OF OPHTHALMIA NEONATORUM IN KENYA

1145 INTRODUCTION

Public Health EPIDEMIOLOGY OF OPHTHALMIA NEONATORUM IN KENYA MARIE LAGA HERBERT NZANZE ROBERT C. BRUNHAM GREGORY MAITHA LOURDES J. D. D’COSTA J. K. MATI MARY CHEANG

FRANCIS A. PLUMMER WARREN NAMAARA J. O. NDINYA-ACHOLA ALLAN R. RONALD V. B. BHULLAR LIEVE FRANSEN PETER PIOT

Departments of Medical Microbiology and Gynaecology and Obstetrics, University of Nairobi and Kenya Medical Research Institute, and City Council Clinic, Nairobi, Kenya; Departments of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Canada; and Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium

Summary

In

a

Nairobi

prophylaxis

hospital where against ophthalmia

ocular neo-

natorum has been discontinued, 1019 women were screened for Neisseria gonorrhoeae and Chlamydia trachomatis during labour and 7 and 28 days postpartum. The prevalence of gonococcal infection was 7% and that of chlamydial was 29%. 52.4% of gonococcal isolates produced penicillinase. The incidence of ophthalmia neonatorum was 23.2 per 100 live births, and incidences of gonococcal and chlamydial ophthalmia were 3·6 and 8&mid ot; 1 per 100 live births, respectively. Of 181 cases of neonatal conjunctivitis, 31% were caused by C trachomatis, 12% by N gonorrhoeae, and 3% by both. In 67 babies exposed to maternal gonococcal infection and 201 exposed to maternal chlamydial infection, rates of transmission to the eye were 42% and 31%, respectively, and to the throat were 7% and 2%. Gonococcal transmission rate was higher in mothers with concomitant chlamydial infection (68%; p=0·01). Postpartum endometritis was associated with ophthalmia neonatorum (p<0·001). Ocular prophylaxis at birth for gonococcal ophthalmia should be reintroduced.

THE impact of sexually transmitted diseases (STD) on maternal and child health is an area of much investigation. How much does STD contribute to prematurity, perinatal and puerperal infections, infertility, and infant morbidity? Ophthalmia neonatorum is one of the most often identified perinatal infections related to maternal STD. In Kenya more than 60% of cases in one clinic were attributable to Neisseria gonorrhoeae or Chlamydia trachomatis.1 Ophthalmia neonatorum was one of the first infectious diseases for which effective prophylaxis was developed. In 1880, Crede2 showed that ocular instillation of silver nitrate was highly effective in the prevention of gonococcal ophthalmia. Unfortunately, this inexpensive form of neonatal prophylaxis is poorly applied or has been abandoned in many developing countries, including Kenya. This is a tragic development, in view of the suspected high prevalence of maternal infection with N gonorrhoea. We report here a 6-month prospective cohort study of maternal gonococcal and chlamydial infection and ophthalmia neonatorum in babies born in a large maternity hospital in Nairobi, Kenya. Our goal was to develop precise epidemiological data to formulate a disease control strategy. METHODS

From June to December, 1984, 10 mothers were recruited daily Pumwani Maternity Hospital, Nairobi. Women were selected on the basis of residence near a follow-up clinic, being in established labour, and verbal consent. A medical history and cervical smears for intrapartum cultures for Ngonorrhoeae and C trachomatis were taken. At delivery, cord blood was sampled and details of labour and delivery were recorded. Mothers and babies were examined 24 h after delivery and were invited to attend one of the three postnatal clinics at days 7 and 28 postpartum. At day 7, a postnatal history was taken and a pelvic examination done. Smears for gram stain and cultures for N gonorrhoeae, C trachomatis, and other pathogens were repeated. The infants’ history was taken and their eyes were examined for evidence of conjunctival inflammation and discharge. If ocular discharge was present, the severity was scored with standard clinical criteria.3 On day 28 a history was taken and clinical examination was done. at

A, Dubois F, Barin F, Dubois MC, Coursaget P Hepatitis B vaccine: Clinical trial in high risk settings in France (September 1975—September 1982). Dvtl Biol Stand 1982; 54: 267-84. 20. Couroucé AM, Laplanche A, Benhamou E, Jungers P, Crosnier J, Degos F. Long term immunogenicity and clinical efficacy of hepatitis B vaccine. In: Tron F, ed. Hepatitis B vaccine symposium new findings and perspectives. Mames La Coquette. Pasteur Vaccins, 1984: 21-27. 21. Hadler SC, Francis DP, Maynard JE, et al. Long term immunogenicity and efficacy of hepatitis B vaccine in homosexual men. N Engl J Med 1986; 315: 209-14. 22. Jilg W, Schmidt M, Deinhardt F, Zachoval R. Hepatitis B vaccination: how long does 19. Goudeau

Maupas P, Goudeau A, Coursaget P, Drucker J, Bagros P. Immunisation against hepatitis B m man. Lancet 1976; i: 1367-70. 9. Barin F, André M, Goudeau A, Coursaget P, Maupas P. Large scale purification of hepatitis B surface antigen (HBsAg). Am Microbiol (Inst Pasteur) 1978; 129B: 8.

87-100. 10 Adamowicz P, Gerfaux G, Platel A, et al. Large scale production of an hepatitis B vaccine. In: Maupas P, Guesry P, eds. Hepatitis B vaccine. INSERM symposium no 18. Amsterdam: Elsevier/North-Holland Biomedical Press, 1981: 37-49 11 Hilleman MR, Bertland AV, Baynak EB, et al. Clinical and laboratory studies of HBsAg vaccine. In: Vyas GN, Cohen SN, Schmid R, eds. Viral hepatitis. Philadelphia: Franklin Institute Press, 1978: 525-38. 12 Szmuness W, Stevens CE, Harley EJ, Zang EA, Taylor PE, Alter HJ. Hepatitis B vaccine: Demonstration of efficacy in a controlled clinical trial in a high risk population in the United States. N Engl J Med 1980; 303: 833-41. 13. Crosnier J, Jungers P, Couroucé AM, et al. Randomised placebo-controlled trial of hepatitis B surface antigen vaccine in French haemodialysis units: I, medical staff. Lancet 1981; i: 455-59. 14. Crosnier J, Jungers P, Couroucé AM, et al. Randomised placebo-controlled trial of hepatitis B surface antigen vaccine in French haemodialysis units II, haemodialysis patients. Lancet 1981; i: 797-800. 15. Szmuness W, Stevens CE, Zang EA, Harley EJ, Kellner A A controlled clinical trial of the efficacy of the hepatitis B vaccine (Heptavax B); A final report. Hepatology (Baltimore) 1981; i: 377-85. 16. Francis DP, Hadler SC, Thompson SE, et al. The prevention of hepatitis B with vaccine. Ann Intern Med 1982; 97: 362-66. 17. Beasley RP, Hwang L-Y, Lee GC, et al. Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B vaccine. Lancet 1983; ii: 1099-102. 18. Lo KJ, Tsai YT, Lee SD, et al. Immunoprophylaxis of infection with hepatitis B virus in infants born to hepatitis B surface antigen positive mothers J Infect Dis 1985; 152: 817-22.

protection last? Lancet 1984; ii: 458. CE, Alter HJ, Taylor PE, Zang EA, Harley EJ, Szmuness W. Hepatitis B vaccine in patients receiving hemodialysis. Immunogenicity and efficacy N Engl J Med 1984; 311: 496-501. Maupas P, Chiron JP, Goudeau A, et al Active immunization against hepatitis B in an area of high endemicity II Prevention of early infection of the child. Prog Med

23. Stevens

24.

Virol 1981; 27: 185-201. 25.

Maupas P, Chiron J-P, Bann F, et al Efficacy of hepatitis B vaccine in prevention of an early HBsAg carrier state in children Controlled trial in an endemic area (Senegal).

26.

Coursaget P, Chiron JP, Barm F, et al. Hepatitis B vaccine: immunization of children and newborns in an endemic area (Senegal). Dvtl Biol Stand 1983; 54: 245-57 Coursaget P, Yvonnet B, Chiron JP, Diop-Mar I. Long term efficacy of hepatitis B

Lancet

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1981; i. 289-92.

vaccine in infants from 221-24.

28.

endemic

area.

Ann Virol

(

Inst Pasteur) 1986, 137E:

Coursaget P, Yvonnet B, Chotard J, carrier state in

infants from

an

et al. Age and sex related study of HBV chronic endemic area (Senegal). J Med Virol (in press).

AR, Kent SBH, Strick N, Taylor P, Stevens CE. Hepatitis B virus contains pre-S gene-encoded domains. Nature 1985; 315: 154-56. Neurath AR, Kent SBH, Parker K, et al. Antibodies to a synthetic peptide from the pre-S 120-145 region of the hepatitis B virus envelope are virus-neutralizing.

29. Neurath 30.

an

Vaccine 1986; 4: 35-37

1146 Cultures

were

neonatorum was

repeated if clinically indicated. Ophthalmia diagnosed where the baby was younger than 28

days and had an abnormal ocular discharge from one or both eyes and there was at least one polymorphonuclear leucocyte per oil immersion field (1000 x ) on a gram stained smear of the discharge. Maternal gonococcal infections were treated with 2 g intramuscular spectinomycin in a single dose. Women with chlamydial infections were given erythromycin 2 g orally for 7 days. Babies with gonococcal ophthalmia neonatorum were given 125 mg intramuscular ceftriaxone in a single dose. Babies presenting with non-gonococcal ophthalmia were treated with topical tetracycline ointment. Culture proven chlamydial ophthalmia was treated with oral erythromycin 50 mg/kg daily for 10 days. Cervical specimens during labour were obtained by locating the cervix with the index finger, inserting a swab along the finger, and by sweeping the swab around the inside of the dilated cervix. At day 7 cervical specimens were taken in the usual way after display of the cervix. Specimens for N gonorrhoeae were inoculated immediately on modified ThayerMartin media. Specimens for C trachomatis culture were inoculated into 2SP transport media and kept at 70°C until cultured on cycloheximide treated McCoy cells. Rapid plasma reagin (RPR, Wellcome) and Treponema pallidum haemagglutination (TPHA, Wellcome) tests for syphilis were done

TABLE II-PREVALENCE OF MATERNAL CHLAMYDIAL INFECTION DURING LABOUR AND

1

WEEK AFTER DELIVERY

I

I

presumed to have intrapartum chlamydial infections despite negative culture since chlamydial ophthalmia developed in their babies in the first 28 days of life. tI8I, no of babies in whom ophthalmia neonatorum developed. ND =not done. *These mothers

were

-

on

maternal and cord blood

Conjunctival swabs

sera.

cultured for N gonorrhoeae and C trachomatis as described above and for aerobic and facultative anaerobic bacteria on blood agar and an enriched chocolate agar medium. Additional specimens for N gonorrhoeae and C trachomatis cultures were taken from the oropharynx. The chi-square test with Yates’ correction, t tests, and logistic regression analysis were done with the SAS computer statistical package. All values are means and SEMs unless otherwise stated. were

RESULTS

1013 mothers and 1019 newborn babies were enrolled. There were 6 sets of twins. Most women were urban residents of lower socioeconomic group and 99% had attended antenatal clinics. The mean number of children per mother was 1-96 (SEM 2-08). 785 women (77%) were seen at day 7 postpartum and 538 (53%) at day 28.

Prevalence

of Maternal Infection and Sensitivity of Intrapartum Cultures We defmed intrapartum maternal gonococcal infection as a positive cervical culture for Ngonorrhoeae during labour or at day 7 (if the woman reported that she had not resumed sexual intercourse) or when gonococcal ophthalmia neonatorum arose in the baby within the first month of life. 67 such maternal infections were identified. Table I gives details of cultures. The observed sensitivity of an TABLE I-PREVALENCE OF MATERNAL GONOCOCCAL INFECTION

DURING LABOUR AND 1 WEEK AFTER DELIVERY

intrapartum culture for N gonorrhoeae was 70% (47 of 67) and that of the day 7 culture was 73% (38 of 52). The overall prevalence of gonococcal infection was 6-6%. In women for whom there were cultures from both day 0 and day 7 the prevalence was 7-5% (52 of 696). 52% of gonococci were penicillinase producing. Maternal intrapartum chlamydial infection was defined as described for gonococcal infection. In 82 of 845 (10%) women intrapartum cultures were positive for C trachomatis, and at day 7, 93 of 509 (18%) women had positive cultures (table 11). Chlamydial ophthalmia neonatorum developed in 38 babies whose mothers had negative cultures for C trachomatis; 19% of all maternal chlamydial infections were diagnosed in this way. Overall, at culture was done in 928 women. The estimated sensitivity of the intrapartum culture was 43% (82 of 192) and for day 7 was 61% (93 of 152). The prevalence of C trachomatis infection, overall, was 21% (201 of 938), and was 29% (120 of 416) in women for whom there were cultures at both day 0 and day 7. Concomitant maternal gonococcal and chlamydia infections were identified in 19 (2%) mothers. least

one

Incidence Rates and Aetiology

of Ophthalmia Neonatorum Table HI shows the incidence of ophthalmia neonatorum according to aetiology. Of 781 newborn babies seen at follow-up, 181 had signs of ophthalmia neonatorum, an incidence rate of 23%. 157 (87%) cases were detected within 7 days of birth and 24 (13%) between 8 and 28 days after birth. In 96 newborn babies with ophthalmia neonatorum not attributable to gonococcal or chlamydial infections, Haemophilus influenzae was isolated in 12, Streptococcus pneumoniae in 10, Streptococcus viridans in 2, Staphylococcus in 11, Escherichia coli in 2, and Moraxella spp in 2. Cultures were negative in 57 babies.

aureus

TABLE III-INCIDENCE OF OPHTHALMIA NEONATORUM ACCORDING TO AETIOLOGY IN

*These mothers

were presumed to have intrapartum gonococcal infections despite negative culture since gonococcal ophthalmia developed in their babies in the first 28 days of life. t181, no of babies in whom ophthalmia not done. neonatorum developed. ND =

781MOTHERS

1147

Overall, sexually transmitted agents were isolated from the eyes of 47% of babies with ophthalmia neonatorum; C trachomatis was the most frequent cause (35%), and N gonorrhoeae accounted for 15% of cases. In babies with non-gonococcal, non-chlamydial ophthalmia neonatorum, maternal infection with C trachomatis was present in 24 cases and maternal gonococcal infection in 3.

of Transmission from Mother to Baby Pathogen-specific ophthalmia neonatorum developed in 28 of 67 babies whose mothers had Ngonorrhoeae infections, a transmission rate of 42%. In 5 of the 67 exposed babies, N gonorrhoeae was isolated from the throat, a transmission rate of 7%. The transmission rate of penicillinase producing N gonorrhoeae (PPNG) was 39% (13 of 33) and non-PPNG was 37% (11 of 30). Non-gonococcal, non-chlamydial ophthalmia developed in 3 of the 39 remaining babies (8%). Of 201 babies exposed to a maternal chlamydia infection, 63 presented with culture-positive C trachomatis ophthalmia neonatorum, a transmission rate of 31%. 5 of the 201 exposed babies also had throat cultures positive for C trachomatis, a trarismission rate of 2%. N016.-gonococcal, non-chlamydial ophthalmia developed in 24 (17%) remaining babies (p > 0 -1). The transmission rates should be regarded as minimum estimates since, swabs were cultured only from those babies with signs of conjunctivitis. Of 19 babies exposed to mothers infected with both N gonorrhoeae and C trachomatis, ophthalmia neonatorum developed in 6 from whom both organisms were isolated; gonococcal ophthalmia developed in 7; and chlamydia ophthalmia developed in 2. From women with both infections, transmission rates were 68% for gonococcal and 47% for chlamydial infection. The gonococcal transmission rate was significantly higher in mothers with concomitant infection (p 0-01). Rate

=

Onset and

Severity of Ophthalmia Neonatorum by

Aetiology

17) and concomitant gonococcal and chlamydia SD 17), than for chlamydial ophthalmia (2-9, SD 1 15) and non-gonococcal, non-chlamydial ophthalmia (3-2, SD 53), (p <0 05, t test). SD

ophthalmia (53, Risk

Factors for Ophthalmia Neonatorum

Possible risk factors studied for the occurrence of maternal gonococcal and chlamydia infection included age, area of residence, marital status, and parity. Single women had a greater risk of gonococcal infection (odds ratio 26, p < 001), but no other significant risk factors were identified. Postpartum endometritis in the mother was a significant risk factor for ophthalmia neonatoram (table iv). As expected, maternal gonococcal or chlamydial infection were strongly associated with pathogen-specific ophthalmia

Non-gonococcal, non-chlamydial ophthalmia significantly more frequent among babies from mothers with chlamydial infection (p 0035); this was not the case for mothers with gonococcal infection. Maternal age, residence, parity, duration of labour, duration of rupture of membranes, and birthweight showed no relation to ophthalmia neonatorum. 38 (4%) mothers had a positive RPR and TPHA, and 72 (7%) had a positive TPHA and negative RPR. None of the mothers had clinical signs of active syphilis. 1 baby was born with clinical and serological evidence (FTA-IgM+ cord blood) of congenital syphilis and died within a few hours of birth. Of the 37 other babies, none had clinical or serological evidence of congenital syphilis. neonatorum.

neonatorum was

=

DISCUSSION

We have shown that ophthalmia neonatorum is a major public health problem in Nairobi and that at least half of the cases from a group of 1019 infants at risk are caused by sexually transmitted agents. Similar incidence rates of neonatal conjunctivitis have been reported in smaller surveys in other African countries.4,5

incidence of gonococcal ophthalmia is alarming because of the threat of permanent damage to the eye as a result of corneal involvement.6,7 Although the actual risk of blindness is difficult to estimate, in a clinic based study in Nairobi 16% of infants with gonococcal ophthalmia neonatorum proved to have corneal The

The mean onset of gonococcal ophthalmia neonatorum was 46 (SD 69) days, that of chlamydial ophthalmia was 49 (SD 6-7), and that of non-gonococcal, non-chlamydial ophthalmia was 4-5 (SD 5-3). The severity score of ophthalmia3 was higher with gonococcal ophthalmia (6-9,

2-8%

neonatorum

TABLE IV-RISK FACTORS IN THE DEVELOPMENT OF OPHTHALMIA NEONATORUM IN THE NEWBORN*

*Nos

are

odds ratios and

p-values by chi-square. NS, not significant.

1148 lesions.’

Furthermore, corneal gonococcal infection developed

ulcer and disseminated in 1 of 70 such patients. Because of antimicrobial resistance in N gonorrhoeae in many parts of the world where ophthalmia neonatorum is a problem treatment can be difficult. Since over half of the gonococcal isolates in this series were penicillinase producing, gonococcal ophthalmia neonatorum should not be treated with penicillin in Kenya. We have shown that ceftriaxone alone and parenteral kanamycin plus topical tetracycline are effective treatment regimens for gonococcal neonatal conjunctivitis.8,9 The main risk factor for gonococcal ophthalmia neonatorum was maternal postpartum endometritis. This relation will be explored more fully elsewhere (F. Plummer and others, unpublished). Several hypotheses might explain it: (1) both conditions might arise as a result of maternal chorioamnionitis; (2) factors protecting mothers against postpartum upper genital tract infection might also protect the newborn against ocular infection; and (3) there may be differences in the pathogenicity of strains. C trachomatis ophthalmia neonatorum was the most frequent identifiable type of ophthalmia (incidence 7%). This is in contrast to our earlier study in which N gonorrhoeae was the predominant cause of neonatal conjunctivitis.’ This difference may be due to the fact that parents may seek medical advice in gonococcal conjunctivitis, because of the severity of the symptoms, whereas many babies with less severe forms of ophthalmia may never come to medical attention. Maternal postpartum endometritis seemed also to be a risk factor for chlamydial ophthalmia neonatorum. Conjunctivitis in the newborn resulting from exposure to a maternal gonococcal infection was clinically more often apparent than that arising from exposure to a maternal chlamydial infection. The rate of transmission of chlamydial infection was in accord with that of other reports,"," the rate of transmission of gonococcal disease is not so well known, but was reported to be 30% in Cameroon.12 The higher rates of transmission for both agents when present concomitantly in the mother suggests that these microorganisms may act synergistically to enhance the efficiency of transmission and/or their virulence. Our finding that in almost half of babies with nongonococcal, non-chlamydial ophthalmia there was a variety of other microbial agents is m accord with that of other workers who compared cases of neonatal conjunctivitis with controls.3,13 The mode of acquisition of these organisms is not clear. Maternal chlamydial infection was associated with non-gonococcal, non-chlamydial opthalmia, which suggests that some cases were caused by C trachomatis. The striking relation between non-gonococcal, non-chlamydial ophthalmia in the newborn and postpartum endometritis in the mother may indicate an identical aetiology or multiple aetiologies with a common risk factor such as chorioamnionitis. We have confirmed here that infants with gonococcal conjunctivitis may also have a gonococcal infection of the pharynx.’ This could be a source of reinfection after local treatment of gonococcal ophthalmia, and may also be the portal of entry for disseminated gonococcal infection or for lower respiratory tract infection, as is the case in neonatal infection with C trachomatis.14,15 We saw no cases of disseminated gonococcal infection or of respiratory disease presumed to be due to N gonorrhoeae although earlier we found a strong correlation between pharyngeal infection with N gonorrhoeae and a history of coughing.I pneumonia

in 3 newborn babies, none of whom had been exposed C trachomatis. We attribute this low incidence to the short follow-up in our study, since most cases of chlamydial pneumonia arise between 6 and 12 weeks of age." We have also shown a very high prevalence of STD in pregnancy in Nairobi, where over one-third of pregnant women had at least one sexually transmitted infection that was potentially hazardous to their offspring, despite the fact that 99% of the women had had some formal antenatal care. Because of the impact of STD on neonatal health, pregnancy outcome, and maternal puerperal morbidity, mother and child health programmes in areas with a high prevalence of STD should incorporate STD-control activities in their antenatal and postnatal care. Since control of STD in pregnancy may not be immediately implementable, ocular prophylaxis at birth is a logical first step in the reduction of morbidity due to STD in pregnancy. Given the high incidence of gonococcal ophthalmia neonatorum, its potential for causing blindness, and the difficulty of treatment, prevention of this disease must be a

arose

to

priority. The need for prevention of chlamydial ophthalmia may less clear-cut. However, chlamydial pneumonitis develops in 20% of infected infants, and some workers suggest that untreated C trachomatis ophthalmia neonatorum may progress to corneal vascularisation, scarring, and pannus formation.16.17 In addition, the infection requires systemic treatment with erythromycin for at least 10 days, which is impractical and expensive, particularly in developing countries.18,19 Non-gonococcal, non-chlamydial ophthalmia neonatorum is a less important health hazard since it is generally mild, without complications, and easily treatable with topical tetracycline. Silver nitrate is effective in the prevention of gonococcal ophthalmia and is inexpensive. Its drawbacks are toxicity and presumed lack of activity against chlamydia. However, the efficacy of alternative agents, such as tetracycline ointment and erythromycin ointment, against resistant gonococci is unknown. We are currently conducting a trial of silver nitrate and tetracycline ointment in the prevention of gonococcal and chlamydia ophthalmia neonatorum. Until that study is completed we would recommend silver nitrate as the agent of choice for ocular prophylaxis in Africa.

be

We thank Dr Mugo for support; Ms Jane Kanene, Ms Ann Maingi, Ms Daniel Nganga, Sister Wanjala, Sister Bosire and Sister Ruminjo for helpful assistance and patient tracing; and Ms Ruth Auma and Ms Yvette Baeten for

typing. This study was supported by grants from the Subprogramme Science and Technology for Development, Commission of European Communities, Brussels, and the International Development Research Centre, Ottawa,

Canada.

Correspondence should be addressed to M. L., Department of Microbiology, Institute of Tropical Medicine, Nationalestraat 155 B-2000 Antwerp, Belgium.

REFERENCES 1 Fransen L, Nsanze H, Klauss V, et al. Ophthalmia neonatorum in Nairobi, Kenya. the

roles of Neisseria gonorrhoeae and Chlamydia trachomatis.J Infect Dis 1986, 153: 862-69. 2 Forbes GB, Forbes GM. Silver nitrate and the eyes of the newborn: Crédé’s contribution to preventive medicine. Am J Dis Child 1971; 121: 1-3. 3. Sandstrom K, Bell TA, Chandler JW, et al Microbial causes of neonatal conjunctivitis. Pediatrics 1984; 105: 706-11. 4 Meheus A, Delgadillo R, Widy-Wirski R, Plot P Chlamydial ophthalmia neonatorum in Central Africa. Lancet 1982; ii: 882. 5. Maybe DCW, Whittle HC. Genital and neonatal chlamydial infection in a trachoma endemic area, Gambia. Lancet 1982; ii: 301-02.

1149

The story of

Occasional Book IF I HAD A SHIP ... A REMARKABLE book is published this week. It is full of facts that deserve to be recorded and looked at as a part of the history of post-war Europe and which have to a large extent been ignored by historians of the Spanish Civil War. The facts that Jim Fyrth describes in The Signal was Spain1 indicate that the English people as a whole in 1936 had realised that the time had come to say "No" to the increasingly fascist governments of central Europe and that this realisation lay behind their widespread determination to send help to the Spanish people who supported their republican government. The poet Julian Bell came home from China, where he was comfortably established as a professor of English, determined to go and fight on behalf of the Spanish republic, as he said, "to fight fascism in the only place where at that time it could be fought". He was followed by other poets and intellectuals but Fyrth illustrates particularly the extraordinary outpouring of help that came from ordinary English men and women. More than a thousand committees working for some form of "Help for Spain" have been recorded, though perhaps that for Spanish Medical Aid is best remembered. Twentynine foodships sailed filled by voluntary efforts, a stream of lorries took food and clothing, and more than 2000 British volunteers joined - and fought with the International

Brigades. The Spanish conflict began in July, 1936. A few days later Isabel Brown, working at her Relief Committee for the Victims of Fascism, received a telegram from friends on a Spanish committee supported by socialists, communists, and liberal intellectuals, including the poet Lorca, asking for medical help. Isabel wasted no time and a Spanish Medical Aid Committee was established, representative of all shades of political opinion. The real work was done by Isabel herself in the office and by Leah Manning, president of the National Union of Teachers, and Audrey Russell, a young paediatrician at University College Hospital. Leah made repeated journeys to Spain sorting out problems on the spot. Audrey, together with another paediatrician, was particularly concerned with the foodships and food supplies for the thousands of refugee children. Both she and Leah sailed with the 4000 Basque children who came to England the end of the history books. at

war.

Their

names

do

not

appear in the

6. Smith CA, Holse L. Ophthalmia neonatorum. Public Health Rep 1955; 70: 462-70. 7. Rodger FC. Blindness in Africa. Royal Commonwealth Society for the Blind London: Lewis, 1959. 8 Fransen L, Nsanze H, D’Costa L, Brunham RC, Ronald AR, Plot P. Single-dose kanamycin therapy of gonococcal ophthalmia neonatorum. Lancet 1984; ii: 1234-37. 9. Laga M, Naamara W, Brunham RC, et al. Single dose therapy of gonococcal ophthalmia neonatorum with ceftriaxone. N Engl J Med (in press). 10. Grossman H, Schachter J, Sweet R, Bishop E, Jordan C. Prospective studies in chlamydia in newborns. In: Mardh P-A, Holmes KK, Oriel JD, Piot P, Schachter J, eds. Chlamydial infections. Amsterdam: Elsevier Biomedical, 1982: 213-16. 11. Beem Mo, Saxon EM. Chlamydia trachomatis infections of infants. In: Mardh P-A, Holmes KK, Oriel JD, Piot P, Schachter J, eds. Chlamydial infections. Amsterdam: Elsevier Biomedical, 1982: 217-20. 12. Galega FP, Heymann DL, Nasah BT. Gonococcal ophthalmia neonatorum. the case for prophylaxis in tropical Africa. Bull WHO 1984; 61: 85-88. 13. Prentice MJ, Hutchinson MR, Taylor-Robinson D. A microbiological study of neonatal conjunctivae and conjunctivitis. Br J Ophthalmol 1977; 61: 607-10. 14. Wiesner PJ, Tronca E, Bonin P, Pedeiser AHB, Holmes KK. Pharyngeal gonococcal infection. NEngl JMed 1973; 288: 181-85. 15. Handsfield HH, Hodson WA, Holmes KK. Neonatal gonococcal infection. Orogastric contamination with Neisseria gonorrhoeae. JAMA 1973; 225: 697-701. 16. Forster RK, Dawson CR, Schachter J. Late follow-up of patients with neonatal inclusion conjunctivitis. Am J Ophthalmol 1970; 69: 467-72. 17. Mordhorst CH, Dawson C. Sequellae of neonatal inclusion conjunctivitis and associated disease in parents. Am J Ophthalmol 1971; 71: 861-67. 18. Schachter J. Chlamydial infections. N Engl J Med 1978; 298: 540-48. 19. Rees E, Tait A, Hobson D, Karayrannis P, Lee N. Persistance of chlamydial infection after treatment for neonatal conjunctivitis. Arch Dis Child 1981; 56: 193-98.

Spanish

medical aid has been told in part

before, perhaps because poets served on that particular front, but Fyrth tells it rather differently. He spares no horrors; he acknowledges what English medicine learnt, about blood transfusion and wound surgery; but he tells it in more personal detail. He mentions many different individuals by name and tells of their homes and their background and their individual ways of work. He makes one understand how they had come from the far corners of the English-speaking world to endure unbelievable discomfort and disaster for a cause they thought important. At the same time he does not disguise the difficulties involved in trying to build a unified service with men and women often holding such different political beliefs. The problems of amalgamating the Partido Obrero de Unificación Marxista and some less doctrinaire units were often great. In the London office I remember them only too well. Fyrth tells in detail of the work of the Quaker units. "There were several miles of people desperate with hunger and exhaustion and still the stream shows no sign of diminishing." Because of their hatred of war the Quaker units were largely involved with refugees, which in the later months of the war became a major problem, but as someone has written "the business-like Quaker organisation was an oasis of society. Its atmosphere was not particularly inspiring but it was almost the only foreign organisation in which you knew for certain that everyone had a different job to do and was doing it and in which there were no nondescript hangers on with nominal jobs or none." He also gives a detailed account of individual committees in Britain under the heading Response in Britain. This, though it might be described as pedestrian, is important because it provides documentary evidence for the historian of the widespread character of the people and places involved in raising Aid for Spain. "Spain needs your help" was the slogan. Street-theatre groups were active. A dozen women of the Brighton Unity Theatre stood in Brighton fish market and on street corners in Lewes reciting "We are the women of Spain standing here with our children ... if Spain falls, France falls; if France falls we are left alone". There was nowhere for refugees to go except the sea. The Basque government applied to foreign nations to accept them. 4000 children came on one ship to Britain on one day. An emergency camp was set up. One hairdresser cut more than 2000 heads of hair. Local schools collected 6000 eggs. The monument to the International Brigades stands proudly on the South Bank in London but few today remember Potato Jones in his old tramp steamer running to beleaguered Spanish ports, except those of us who are very old, and who listened to the wireless to hear if he had got

particularly

through. I had a ship the sailor said A ship that sailed for Spain And if I had that ship right now I’d sail there once again.

Jim Fyrth concludes, "Beyond Britain, also, the threads forward connecting the Spanish struggle with the vision

run

of

our own

world ... In 1986 American International

Brigadiers were organising a mobile surgical unit to go to the aid of the Nicaraguan people ... these experiences have contributed to the development of liberation theology ... the history of that war and movements of solidarity -with those who fought to defend their Republic are not an exercise in nostalgia but have significance for our own time." JANET VAUGHAN 1 The

Signal was Spain: the Aid Spain Movement in Britain 1936-39. By Jim Fyrth. London: Lawrence and Wishart. 1986 Pp 344 £17 50 hardback; £6.95 paperback.