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Health Education—Cancer
PUBI.IC tIEALTH, June, I954 for it are m a d e on such grounds. I n 1950, deaths f r o m tuberculosis in Britain fell by 20% ; in 1951, by a further 14%. M i g h t this have been instanced in the vaccine's favour if it had been widely i n t r o d u c e d previously ? It is w o r t h noting, too, that in D e n m a r k b e t w e e n 1940 and 1950 the n u m b e r of fresh cases notified decreased by only "O/ while the death rate fell by almost 50~ ~ One w o u l d have 6/o e x p e c t e d the value of B.C.G. to be m o r e clearly reflected in the m o r b i d i t y rates than in the d e a t h rates which, as we have seen, are so greatly influenced by o t h e r factors. (3) Claims are m a d e that B.C.G. prevents tuberculous meningitis. T h i s may well be true a n d if so is a great p o i n t in favour of the vaccine, but for such an i m p o r t a n t claim there does n o t appear as yet to be impressive statistical evidence. (4) T h e m o s t serious claims m a d e for the use of the vaccine are based on the results of trials carried out in various countries, and they m e r i t very serious consideration. L e t us divide these trials into three groups. (i) Trials carried out in contacts specially exposed to the disease. All such trials have b e e n criticised on statistical grounds, but the s u m m a t i o n of evidence is that the vaccine i s of value in this particular group. (ii) Trials a m o n g peoples w i t h a h i g h incidence of tuberculosis and a low s t a n d a r d of living. 8 H e r e again, the vaccine has been s h o w n to be of value. (iii) Trials a m o n g c o m m u n i t i e s v, ith a high s t a n d a r d of living and a fairly lo~ incidence of tuberculosis. A survey of Swedish conscripts, p u b l i s h e d in 1950, 4 p r o v i d e d suggestive evidence in the vaccine's favour, but the p r e l i m i n a r y resul[s o f a trial carried out in America were p u b l i s h e d in S e p t e m b e r . 5 A l t h o u g h it s e e m s f r o m the m e t h o d of follow-up e m p l o y e d to be too early to judge, there was no evidence of a beneficial result f r o m B.C.G. in the m o r b i d i t y comparisons, and no evidence that tuberculosis in the U . S . A . w o u l d be m o r e effectively controlled b y a d d i n g a B.C.G. campaign.
T h e M.R.C. T r i a l I n S e p t e m b e r , 1950, the Medical Research Council, in co-operation w i t h the education and p u b l i c health authorities in N o r t h L o n d o n , B i r m i n g h a m a n d M a n c h e s t e r areas, began a trial of the vaccine in E n g l a n d in an effort to determ i n e its value in school-leavers. T h o s e taking part are volunteers f r o m Secondary M o d e r n Schools b o r n in 1936, 1937 a n d 1938, and they entered the trial d u r i n g their final two t e r m s at school. Each volunteer was x-rayed a n d skintested a n d a p r o p o r t i o n of the negative reactors were vaccinated with B.C.G. or Vole vaccine. W h e n the intake finally e n d e d in D e c e m b e r 1952, approximately 50,000 y o u n g people h a d j o i n e d the scheme. T h e follow-up is being c o n d u c t e d b y postal forms and annual health visitor visits, and by annual x-rays. D u r i n g the intake it was f o u n d t h a t large n u m b e r s of children could be quickly skin-tested and vaccinated using a syringe w i t h a p l a t i n u m needle flamed b e t w e e n each test. P r o v i d e d a n u r s e is available to swab the arms, and a clerk is provided, it should be quite simple to skin test 1O0 children an h o u r in any future scheme. C o n v e r s i o n to M a n t o u x positive occurred in almost every case following B.C.G., and complications mainly consisted of shallow ulceration, w h i c h was n o t infrequent, and abscess f o r m a t i o n in the regional glands, w h i c h was rare. It is h o p e d to follow-up the volunteers long e n o u g h to obtain evidence of the degree and d u r a t i o n of the p r o t e c t i o n a f f o r d e d , and to d e t e r m i n e the value o f the vaccines w h e n applied to the general population in industrial communities. In deciding u p o n its application, however, we should be guided by the following considerations : - (1) T h a t those w h o are likely to benefit m o s t will be contacts. T h i s m e a n s that it can be m o s t effectively used if a vigorous search can be m a d e for all c o n t a c t s . (2) W i d e s p r e a d use of B.C.G. will p r o b a b l y n o t be a "substitute for efficient case-finding and t r e a t m e n t of cases of established tuberculosis.
r45 (3) It is difficult to be completely certain how long the i m m u n i t y lasts, possibly about five y e a r s ; thus it will be best, if it is to be used on a ~ i d e scale, to give the vaccine to ~ group w h e r e danger f r o m the disease is going to be great in the succeeding years. T h i s g r o u p is the school-lcavers as the m o r b i d i t y rate rises s t e e p l y in adolescents. (4) In countries where the infection rate is not high a n d w h e r e B.C.G. is not used, the M a n t o u x test can be of great value as a diagnostic and a case-finding procedure. I f we vaccinate large n u m b e r s of the p o p u l a t i o n this m e t h o d of case-finding will be lost. REFERENCES I HASLINGS, H . W . (1953.) Tuberculosis in Hawaii. American Revirw of Tuberculosis, 68, 839. 2 Drolet, J. G., & TOWELL, A . M . (1952.) Diseases of the Chest, 21, 527. :~ARONSON, J. D. (1948.) B.C.G. Vaccination among American Indians. American Review of Tuberculosis. 57~ 96. t DAHLSTROM, G., & DIES, H. (1951.) The efficacy of B.C.G. Vaccination. ,4cta tuberculosea Scandinaviea Supplement, 27. 5 PALMER, C. E., & SHAW, W. L. (1953.) American Review of Tuberculosis, Sept., 68, 462.
CORRESPONDLNLE HEALTH EDUCATION~ANCER
To the. Editor of PUBLIC HEALTH SER,--Propaganda in favour of the early treatment of cancer depends upon the theory t h a t those who come early for t~eatment stand a better chance of survival than those who delay. There is no evidence that this is true. Undoubtedly those who are in Stage I of the disease when they come for treatment stand a better chance of survival t h a n those who are in Stage IV, but Dr. Malcolm Donaldson says " it is doubtful if anybody believes t h a t ' a short history of the disease' and ' e a r l y stage growJ.hs' are synonymous," and refers to the important influence of the type of tumour. Figures which show clearly the better prognosis of Stage i tumours show no beneficial relationship be~veen short history of symptoms and the chance of survival. They are commonly used to prove the first point by those who r e c o m mend cancer propaganda, but are dismissed as providing instlfhcient statistical evidence to prove the second. Until thete is evidence to show t h a t short history of symptoms, provides a better chance' of survival, propaganda to the public in favour of early treatment is not juslified. It is for those who believe this to be true, to produce their evidence. Dr. Malcohn Donaldson refers to the need for Local Authorities to make tests on a large scale. Such tests on an immense scale have already been made in Canada and America, in Some areas for 28 years, and have failed to produce the evidence which the propagandists require. .I believe, as The Lancet says, that the time ba~ come for a realistic and unbiased appraisal. Yours faithfully, R. N. CORNOW. PROTECTION OF CHILDREN AGAINST TUBERCULOSIS Dr. R. L. Midgley, Hon. Secretary, Joint Tuberculosis Council, has enquired what information is now available concerning the extent to which the J.T.C.'s. recommendations in regard to the protection of organised groups of children against infection by tuberculous adults are being implemented by local health authorities. These recommendations received the approval of the Ministries of Health and Education and the Home Office but it is not known how far thay have been implemented locally. Dr. Midgley would much appreciate information from M.O's. of local health and education authorities as to progress which has been made on these lines. His address is Hawkmoor Chest Hospital, Bovey Tracey, Devon.
Obituary tributes to the late Professors W. L. BURGESSand Sir JAMES SPENCE, and to Drs. MABEL BRODIE and A. A. MUSSEN, whose deaths have occurred recently, will appear in our next issue.
T h e M.R.C. T r i a l I n S e p t e m b e r , 1950, the Medical Research Council, in co-operation w i t h the education and p u b l i c health authorities in N o r t h L o n d o n , B i r m i n g h a m a n d M a n c h e s t e r areas, began a trial of the vaccine in E n g l a n d in an effort to determ i n e its value in school-leavers. T h o s e taking part are volunteers f r o m Secondary M o d e r n Schools b o r n in 1936, 1937 a n d 1938, and they entered the trial d u r i n g their final two t e r m s at school. Each volunteer was x-rayed a n d skintested a n d a p r o p o r t i o n of the negative reactors were vaccinated with B.C.G. or Vole vaccine. W h e n the intake finally e n d e d in D e c e m b e r 1952, approximately 50,000 y o u n g people h a d j o i n e d the scheme. T h e follow-up is being c o n d u c t e d b y postal forms and annual health visitor visits, and by annual x-rays. D u r i n g the intake it was f o u n d t h a t large n u m b e r s of children could be quickly skin-tested and vaccinated using a syringe w i t h a p l a t i n u m needle flamed b e t w e e n each test. P r o v i d e d a n u r s e is available to swab the arms, and a clerk is provided, it should be quite simple to skin test 1O0 children an h o u r in any future scheme. C o n v e r s i o n to M a n t o u x positive occurred in almost every case following B.C.G., and complications mainly consisted of shallow ulceration, w h i c h was n o t infrequent, and abscess f o r m a t i o n in the regional glands, w h i c h was rare. It is h o p e d to follow-up the volunteers long e n o u g h to obtain evidence of the degree and d u r a t i o n of the p r o t e c t i o n a f f o r d e d , and to d e t e r m i n e the value o f the vaccines w h e n applied to the general population in industrial communities. In deciding u p o n its application, however, we should be guided by the following considerations : - (1) T h a t those w h o are likely to benefit m o s t will be contacts. T h i s m e a n s that it can be m o s t effectively used if a vigorous search can be m a d e for all c o n t a c t s . (2) W i d e s p r e a d use of B.C.G. will p r o b a b l y n o t be a "substitute for efficient case-finding and t r e a t m e n t of cases of established tuberculosis.
r45 (3) It is difficult to be completely certain how long the i m m u n i t y lasts, possibly about five y e a r s ; thus it will be best, if it is to be used on a ~ i d e scale, to give the vaccine to ~ group w h e r e danger f r o m the disease is going to be great in the succeeding years. T h i s g r o u p is the school-lcavers as the m o r b i d i t y rate rises s t e e p l y in adolescents. (4) In countries where the infection rate is not high a n d w h e r e B.C.G. is not used, the M a n t o u x test can be of great value as a diagnostic and a case-finding procedure. I f we vaccinate large n u m b e r s of the p o p u l a t i o n this m e t h o d of case-finding will be lost. REFERENCES I HASLINGS, H . W . (1953.) Tuberculosis in Hawaii. American Revirw of Tuberculosis, 68, 839. 2 Drolet, J. G., & TOWELL, A . M . (1952.) Diseases of the Chest, 21, 527. :~ARONSON, J. D. (1948.) B.C.G. Vaccination among American Indians. American Review of Tuberculosis. 57~ 96. t DAHLSTROM, G., & DIES, H. (1951.) The efficacy of B.C.G. Vaccination. ,4cta tuberculosea Scandinaviea Supplement, 27. 5 PALMER, C. E., & SHAW, W. L. (1953.) American Review of Tuberculosis, Sept., 68, 462.
CORRESPONDLNLE HEALTH EDUCATION~ANCER
To the. Editor of PUBLIC HEALTH SER,--Propaganda in favour of the early treatment of cancer depends upon the theory t h a t those who come early for t~eatment stand a better chance of survival than those who delay. There is no evidence that this is true. Undoubtedly those who are in Stage I of the disease when they come for treatment stand a better chance of survival t h a n those who are in Stage IV, but Dr. Malcolm Donaldson says " it is doubtful if anybody believes t h a t ' a short history of the disease' and ' e a r l y stage growJ.hs' are synonymous," and refers to the important influence of the type of tumour. Figures which show clearly the better prognosis of Stage i tumours show no beneficial relationship be~veen short history of symptoms and the chance of survival. They are commonly used to prove the first point by those who r e c o m mend cancer propaganda, but are dismissed as providing instlfhcient statistical evidence to prove the second. Until thete is evidence to show t h a t short history of symptoms, provides a better chance' of survival, propaganda to the public in favour of early treatment is not juslified. It is for those who believe this to be true, to produce their evidence. Dr. Malcohn Donaldson refers to the need for Local Authorities to make tests on a large scale. Such tests on an immense scale have already been made in Canada and America, in Some areas for 28 years, and have failed to produce the evidence which the propagandists require. .I believe, as The Lancet says, that the time ba~ come for a realistic and unbiased appraisal. Yours faithfully, R. N. CORNOW. PROTECTION OF CHILDREN AGAINST TUBERCULOSIS Dr. R. L. Midgley, Hon. Secretary, Joint Tuberculosis Council, has enquired what information is now available concerning the extent to which the J.T.C.'s. recommendations in regard to the protection of organised groups of children against infection by tuberculous adults are being implemented by local health authorities. These recommendations received the approval of the Ministries of Health and Education and the Home Office but it is not known how far thay have been implemented locally. Dr. Midgley would much appreciate information from M.O's. of local health and education authorities as to progress which has been made on these lines. His address is Hawkmoor Chest Hospital, Bovey Tracey, Devon.
Obituary tributes to the late Professors W. L. BURGESSand Sir JAMES SPENCE, and to Drs. MABEL BRODIE and A. A. MUSSEN, whose deaths have occurred recently, will appear in our next issue.