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Prevention and treatment of tuberculosis
223
PUBLIC HEALTH, August, 1947
THE MATERNITY AND CHILD WELFARE CONFERENCE The annual Conference on Maternity and Child Welfare was held at Friends' House, London, from June 24th to 27th, and was attended by more than a thousand delegates. For the first time the Conference was called an international one, and there was a hearty welcome for the representatives of 24 other countries. One day of the Conference was devoted entirely to papers by the foreign delegates, who described the effects on the health of mothers and children of German occupation and the other circumstances of war. It was encouraging to hear of the progress that had already been made in restoring the services, and of such new experiments as that reported by Dr. Bernard from France of universal premarital X-ray examination and Wasserman tests. There was a general report of rising birthrates and of difficulties in meeting the nutritional requirements. At the opening session of the Conference on June 25th, the Minister of Health spoke of his hopes for the future of the movement under the National Health Service, and of his desire to retain voluntary effort in the general scheme. Dr. Greenwood Wilson (Cardiff) urged that the duties of the health visitor should include work of the school nurse, child life protection, tuberculosis visiting, mental defect and mental illness, infectious disease, and the following up of persons suffering from illness. Dr. Fraser Brockington (West Riding) thought that the three lines of future progress would be special investigations, special care of mothers and babies in institutional training schools, and the fusion of preventive and curative work in the hands of specialist personnel. Sir Allen Daley, speaking of the future hospital services, gave a useful outline of the resources which should back up maternity and child welfare services of the local health authority. At the afternoon session, Sir Andrew Davidson gave his views on the social and preventive training of doctors, health visitors, and midwives. Another session of the Conference dealt with nutrition. Dr. Magee (Ministry of Health) estimated that an expectant mother on the present rations and allowances was receiving about 2,440 calories per day, leaving about 500 calories to be accounted for by canteens or other meals taken outside her home. Discussing the statistics, he considered it justifiable to conclude that the health of mothers and children had improved, both during and since the war, and that this was due to better national planning of diet. Mr. Sutherland (Oxford Institute of Social Medicine) urged a further attack on the still-birth rate, and Dr. Heaf (L.C.C.) spoke of the prospects of immunisation against tuberculosis by B.C.G. vaccination or by the vole-bacillus vaccine. At the final session there was discussion of the future of the family unit, the speakers being Dr. David Mace and Dr. Ethel Dukes, of the Marriage Guidance Council. Congratulations are due to the National Association of M. and C.W. Centres and for the Prevention of Infant Mortality, and to the Conference Committee, of which Dr. E. H. R. Smithard was chairman and Miss M. R. Lovelock the secretary, for the arrangements of this successful conference. We hope that in future years it will be possible to retain the support of delegates of all types of local authority, even if some are not directly responsible for child welfare under the National Health Service.
PREVENTION AND TREATMENT
OF T U B E R C U L O S I S
The fourth session of the Commonwealth and Empire Health and Tuberculosis Conference, held on July 8th to 10th, at the Central Hall, Westminster, had as subject specific methods in the prevention and treatment of tuberculosis, with a distinguished list of speakers who had been concerned with work on B.C.G., streptomycin, and the vole-bacillus vaccine. Prof. W. H. Tytler (Welsh National School of Medicine), in a lucid general picture of the situation, pointed out that the specific measures for immunisation were limited at present to B.C.G. and its prospective competitor, vole-vaccine. The dangerous age periods for tuberculosis infection were in infancy and the years 15 to 25. B.C.G. had been used for hundreds of thousands of infant vaccinations in France. There was now as much interest in its use for the later age group. It was now unquestionably safe, but the assessment of its efficacy was much more difficult. The more recent work in Scandinavia and Canada illustrated the advantages of B.C.G. vaccination and the apathy in the United Kingdom had been based on the lack of an urgent need of such an immunising agent to compensate for its disadvantages--for instance, the Lancashire rate of tuberculosis mortality without B.C.G. had been lower than the rates for the vaccinated in France. It was the extension of B.C.G. vaccination to adolescents unaffected by tuberculosis which had caused the present worldwide interest, so that the treatment was being given to non-reactors amongst young nurses and doctors working in sanatoria. In Scandinavia it was proposed to extend this method of immunisation to the civil population as well. In the
British Empire, Canada was in the lead, other Dominions were instituting the use of B.C.G. and in Great Britain there was now official backing for obtaining a regular supply of reliable vaccine. The case for vole-vaccine had not yet been proven, but he hoped that the controversy over this agent would not shake public confidence in immunisation. There was so far little evidence that streptomycin could cure advanced tuberculosis. Dr. E. R. Long (Pennsylvania University) spoke of the United States experiment with a group of North American Indians highly sensitive to tuberculosis, which had now been proceeding for some ten years with the most encouraging results in favour of B.C.G., in respect of both mortalityand the attack rate. A communication from Dr. A. Q. Wells (Oxford University), the discoverer of vole-vaccine, stated that it was too early to make definite claims, but so far it was believed that the vaccine was safe for use in human beings, and that it produced less reactions than B.C.G. An advantage of vole-vaccine was that its virulence could the maintained at a steady level by animal infection. Dr. H. C. Hinshaw (Mayo Clinic, U.S.A.), speaking on streptomycin, said that latterly information had been accumulating at a great rate, and that~a committee of the National Tuberculosis Association and the Trudeau Society had recently issued an evaluation of the present potentialities of the drug and its limitations. It was definitely advised for treatment of tuberculous meningitis, miliary tuberculosis, etc., but was not proven for pulmonary disease. Its use made great demands upon the physician's skill. Dr. H. S. Willis (Maybury Sanatorium, U.S.A.) also spoke on the lines and scope of research in the United States. He said that streptomycin in no way replaced established methods of treatment ; it was a "miracle drug " for a small section of tuberculous disease, but its use must be kept under strict scrutiny because of its toxic potentialities. Other sessions of the conference dealt with tuberculosis, including dust diseases, in the Commonwealth, and the effect of the National Health Service Act on tuberculosis work. At the latter, Dr. Norman Tattersall (P.M.O., Welsh Nationsl Memorial Association), in moving a vote of thanks to the Minister of Health for his opening address, voiced the anxiety of tuberculosis authorities over some possible effects of the Act, for example, the divorce of treatment from prevention and after care. He thought that after care should be obligatory for local health authorities. (The Minister has since so directed in Circular 118/47.) He also criticised the proposal that chest physicians should not be responsible for non-pulmonary tuberculosis. Thus the unity of treatment might be lost. The conference was attended by a very large number of delegates from this and other countries, and the National Association for the Prevention of Tuberculosis and its Secretary-General, Dr. Harley Williams, were warmly congratulated on the excellent organisation of all the meetings.
CORRESPONDENCE CONTROL OF SMALLPOX : A. CORRECTION
To the Editor of PUBLIC HEALTH S m , - - I n your June issue you have reported a discussion on the control of smallpox held at the Sessional Meeting of the Royal Sanitary Institute in May. Unfortunately, as the result of condensing two separate statements made by me into one sentence, you have misquoted me in such a way as t'o be somewhat misleading, and I fear I cannot accept responsibility for the statement that " Quarantine for all contacts must be insisted on and ensured by surveillance." The statement I made was: " I believe that in present circumstances . . . contacts must be under some degree of ' quarantine ' whether vaccinated or not, and irrespective of the type of disease." I had already made it clear that I was using the word " quarantine " in a limited sense in an attempt to conform to a systematised scheme for the control of any communicable disease. (American Public Health Association, Handbook on the Control of Communicable Disease.) I went on to qualify this statement by saying that " Quarantine implies some limitation of freedom of movement of susceptible persons exposed to communicable dis, ease for a period of time equal to the longest usual incubation period of the disease. In the case of smallpox, the degree of limitation of freedom varies somewhat according to the circumstances and whether the contact has been adequately vaccinated, but ordinarily he continues to live his normal life under surveillance until the expiration of the incubation period, calculated from the last day of contact." I shall be grateful if you will consider publishing this correction. I am, yours, etc., W. H. BRADLEY. Ministry of Health, Whitehall, S.W.1. j%uly lOth, 1947.
PUBLIC HEALTH, August, 1947
THE MATERNITY AND CHILD WELFARE CONFERENCE The annual Conference on Maternity and Child Welfare was held at Friends' House, London, from June 24th to 27th, and was attended by more than a thousand delegates. For the first time the Conference was called an international one, and there was a hearty welcome for the representatives of 24 other countries. One day of the Conference was devoted entirely to papers by the foreign delegates, who described the effects on the health of mothers and children of German occupation and the other circumstances of war. It was encouraging to hear of the progress that had already been made in restoring the services, and of such new experiments as that reported by Dr. Bernard from France of universal premarital X-ray examination and Wasserman tests. There was a general report of rising birthrates and of difficulties in meeting the nutritional requirements. At the opening session of the Conference on June 25th, the Minister of Health spoke of his hopes for the future of the movement under the National Health Service, and of his desire to retain voluntary effort in the general scheme. Dr. Greenwood Wilson (Cardiff) urged that the duties of the health visitor should include work of the school nurse, child life protection, tuberculosis visiting, mental defect and mental illness, infectious disease, and the following up of persons suffering from illness. Dr. Fraser Brockington (West Riding) thought that the three lines of future progress would be special investigations, special care of mothers and babies in institutional training schools, and the fusion of preventive and curative work in the hands of specialist personnel. Sir Allen Daley, speaking of the future hospital services, gave a useful outline of the resources which should back up maternity and child welfare services of the local health authority. At the afternoon session, Sir Andrew Davidson gave his views on the social and preventive training of doctors, health visitors, and midwives. Another session of the Conference dealt with nutrition. Dr. Magee (Ministry of Health) estimated that an expectant mother on the present rations and allowances was receiving about 2,440 calories per day, leaving about 500 calories to be accounted for by canteens or other meals taken outside her home. Discussing the statistics, he considered it justifiable to conclude that the health of mothers and children had improved, both during and since the war, and that this was due to better national planning of diet. Mr. Sutherland (Oxford Institute of Social Medicine) urged a further attack on the still-birth rate, and Dr. Heaf (L.C.C.) spoke of the prospects of immunisation against tuberculosis by B.C.G. vaccination or by the vole-bacillus vaccine. At the final session there was discussion of the future of the family unit, the speakers being Dr. David Mace and Dr. Ethel Dukes, of the Marriage Guidance Council. Congratulations are due to the National Association of M. and C.W. Centres and for the Prevention of Infant Mortality, and to the Conference Committee, of which Dr. E. H. R. Smithard was chairman and Miss M. R. Lovelock the secretary, for the arrangements of this successful conference. We hope that in future years it will be possible to retain the support of delegates of all types of local authority, even if some are not directly responsible for child welfare under the National Health Service.
PREVENTION AND TREATMENT
OF T U B E R C U L O S I S
The fourth session of the Commonwealth and Empire Health and Tuberculosis Conference, held on July 8th to 10th, at the Central Hall, Westminster, had as subject specific methods in the prevention and treatment of tuberculosis, with a distinguished list of speakers who had been concerned with work on B.C.G., streptomycin, and the vole-bacillus vaccine. Prof. W. H. Tytler (Welsh National School of Medicine), in a lucid general picture of the situation, pointed out that the specific measures for immunisation were limited at present to B.C.G. and its prospective competitor, vole-vaccine. The dangerous age periods for tuberculosis infection were in infancy and the years 15 to 25. B.C.G. had been used for hundreds of thousands of infant vaccinations in France. There was now as much interest in its use for the later age group. It was now unquestionably safe, but the assessment of its efficacy was much more difficult. The more recent work in Scandinavia and Canada illustrated the advantages of B.C.G. vaccination and the apathy in the United Kingdom had been based on the lack of an urgent need of such an immunising agent to compensate for its disadvantages--for instance, the Lancashire rate of tuberculosis mortality without B.C.G. had been lower than the rates for the vaccinated in France. It was the extension of B.C.G. vaccination to adolescents unaffected by tuberculosis which had caused the present worldwide interest, so that the treatment was being given to non-reactors amongst young nurses and doctors working in sanatoria. In Scandinavia it was proposed to extend this method of immunisation to the civil population as well. In the
British Empire, Canada was in the lead, other Dominions were instituting the use of B.C.G. and in Great Britain there was now official backing for obtaining a regular supply of reliable vaccine. The case for vole-vaccine had not yet been proven, but he hoped that the controversy over this agent would not shake public confidence in immunisation. There was so far little evidence that streptomycin could cure advanced tuberculosis. Dr. E. R. Long (Pennsylvania University) spoke of the United States experiment with a group of North American Indians highly sensitive to tuberculosis, which had now been proceeding for some ten years with the most encouraging results in favour of B.C.G., in respect of both mortalityand the attack rate. A communication from Dr. A. Q. Wells (Oxford University), the discoverer of vole-vaccine, stated that it was too early to make definite claims, but so far it was believed that the vaccine was safe for use in human beings, and that it produced less reactions than B.C.G. An advantage of vole-vaccine was that its virulence could the maintained at a steady level by animal infection. Dr. H. C. Hinshaw (Mayo Clinic, U.S.A.), speaking on streptomycin, said that latterly information had been accumulating at a great rate, and that~a committee of the National Tuberculosis Association and the Trudeau Society had recently issued an evaluation of the present potentialities of the drug and its limitations. It was definitely advised for treatment of tuberculous meningitis, miliary tuberculosis, etc., but was not proven for pulmonary disease. Its use made great demands upon the physician's skill. Dr. H. S. Willis (Maybury Sanatorium, U.S.A.) also spoke on the lines and scope of research in the United States. He said that streptomycin in no way replaced established methods of treatment ; it was a "miracle drug " for a small section of tuberculous disease, but its use must be kept under strict scrutiny because of its toxic potentialities. Other sessions of the conference dealt with tuberculosis, including dust diseases, in the Commonwealth, and the effect of the National Health Service Act on tuberculosis work. At the latter, Dr. Norman Tattersall (P.M.O., Welsh Nationsl Memorial Association), in moving a vote of thanks to the Minister of Health for his opening address, voiced the anxiety of tuberculosis authorities over some possible effects of the Act, for example, the divorce of treatment from prevention and after care. He thought that after care should be obligatory for local health authorities. (The Minister has since so directed in Circular 118/47.) He also criticised the proposal that chest physicians should not be responsible for non-pulmonary tuberculosis. Thus the unity of treatment might be lost. The conference was attended by a very large number of delegates from this and other countries, and the National Association for the Prevention of Tuberculosis and its Secretary-General, Dr. Harley Williams, were warmly congratulated on the excellent organisation of all the meetings.
CORRESPONDENCE CONTROL OF SMALLPOX : A. CORRECTION
To the Editor of PUBLIC HEALTH S m , - - I n your June issue you have reported a discussion on the control of smallpox held at the Sessional Meeting of the Royal Sanitary Institute in May. Unfortunately, as the result of condensing two separate statements made by me into one sentence, you have misquoted me in such a way as t'o be somewhat misleading, and I fear I cannot accept responsibility for the statement that " Quarantine for all contacts must be insisted on and ensured by surveillance." The statement I made was: " I believe that in present circumstances . . . contacts must be under some degree of ' quarantine ' whether vaccinated or not, and irrespective of the type of disease." I had already made it clear that I was using the word " quarantine " in a limited sense in an attempt to conform to a systematised scheme for the control of any communicable disease. (American Public Health Association, Handbook on the Control of Communicable Disease.) I went on to qualify this statement by saying that " Quarantine implies some limitation of freedom of movement of susceptible persons exposed to communicable dis, ease for a period of time equal to the longest usual incubation period of the disease. In the case of smallpox, the degree of limitation of freedom varies somewhat according to the circumstances and whether the contact has been adequately vaccinated, but ordinarily he continues to live his normal life under surveillance until the expiration of the incubation period, calculated from the last day of contact." I shall be grateful if you will consider publishing this correction. I am, yours, etc., W. H. BRADLEY. Ministry of Health, Whitehall, S.W.1. j%uly lOth, 1947.