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for making prevalence of such diseases known to teachers and parents. The necessity of looking for
missed cases is insisted upon. In this connection advice is given that the services of teachers and
attendance officers should be utilised for giving information, both to the medical officer of health and
to the school medical officer, not only of the existence of known cases of such disease, but also of any
children who have recently been kept at home with illness of a suspicious character or concerning
whom circumstances suggest the possibility of infection; and it is pointed out that" the absence of several
children of one family from school at the same time, no matter what name is given to the complaint
that keeps them at home, should be reported. In practice it has been found that such information of
absentees has materially aided the medical officer of health in taking measures for the suppression
of infectious disease."
The ability of medical officers of health to utilise information concerning children who have
recently been kept at home with illness of a suspicious character or concerning whom circumstances
suggest the possibility of infection, should be distinctly greater in the future, inasmuch as the Council's
General Powers Act of 1908 empowers sanitary authorities to appoint health visitors whose services
might be utilised in making preliminary enquiries. No doubt so far as practicable early inquiry should
be made into all cases of absence from school in which the cause of the absence is unknown, and any
improvement which could be effected in this direction would tend to lessen the attendance at school
of infectious children.
On the subject of school closure the memorandum states that closure " should be advised by
the medical officer only in circumstances involving risk of an epidemic, and not then as a matter of
routine nor unless there be a clear prospect of preventing the spread of infection such as cannot be
expected from less comprehensive action," the reason being that it will deprive the medical officer
of health and school medical officer of information respecting attacks in their early stage or illness of
doubtful nature which would otherwise be obtainable, and in any circumstances will interfere seriously
with the education of the scholars. This sentence is no doubt intended to be read with a later sentence
that " Closure of a school or of a particular class is justified when the general evidence points to this
school or class as the source of infection and when cases of an infectious disease continue to occur in
this class or school after every effort to discover the infective cases has been made." This question
deserves comment for the reason that diphtheria has frequently persisted in a class or school during
long periods, although it could not be alleged that the number of cases of the disease occurring at any
one time could be deemed to constitute a circumstance " involving imminent risk of an epidemic."
In some cases the closing of the class or school or the intervention of holidays has eventually terminated
this incidence of the disease and has, indeed, appeared to be necessary for this purpose. Under
these circumstances it may be that the interests of education would be served by an earlier closure
than that which eventually has to be adopted.
In determining whether closure of a class or school is necessary on account of prevalence of
infectious disease the medical officer of health will no doubt make every effort to arrive at a correct
conclusion as to whether the disease is spreading in the school, or is due to infection outside the school. In
this matter he will doubtless be guided by his knowledge as to whether in the several invasions of
families under his observation the first person to be attacked is the school-attending child. If he
finds it possible to limit closure to a particular class or classes he will often be acting wisely if he excludes
from other classes in the school the brothers and sisters of children who are members of the class which
is closed. It is of course necessary that he should as far as practicable compensate for loss of information
as to attacks in the early stages, which he would have derived from the school, by information,
obtained by means of enquiring in the homes; but it may be pointed out that closure of a school must
prevent attacks due to infection at school and that fresh invasions of families from this cause must
cease.
With respect to diphtheria the memorandum recommends the use of bacteriological methods
for the discovery of infectious cases. These methods have been increasingly utilized in recent years,
but it must be recollected that much more needs to be known concerning the extent to which they
can be relied upon not only in indicating all infectious cases, but in distinguishing between such
children and others who are not infectious. Beyond this it must not be forgotten that much may
depend upon the completeness with which this method is applied, and that the mere sampling of
children in a class by this means cannot be expected to give sufficiently satisfactory results.
The memorandum suggests that in the light of further knowledge which will be gained, some
modification of the rules for exclusion and closure may be indicated, and this observation especially
needs to be borne in mind in connection with efforts made to deal with disease on bacteriological
findings. It is further necessary to remember that infectious diseases vary very greatly at different
times in respect of virulence, and probably also in respect of infectiousness. At the present time both
scarlet fever and diphtheria have a very low fatality, and it will not do to assume that measures which
may suffice for the moment will be found equally efficacious at other times.
Among the risks to which school children are now exposed must be included that of infection by
smallpox. Owing to the increased number of children who now remain unvaccinated, the amount of
risk from smallpox to which children may be exposed in school if the disease again becomes prevalent,
cannot be regarded as negligible. Under these circumstances it is well to remember that smallpox is a
highly infectious disease, that the period between infection and appearance of the eruption may not
infrequently be 16 or 17 days, and that the condition of the children as to vaccination needs to be taken
into account in determining the question of closure of the class or of the exclusion of particular children.
To the London County Council.
November, 1910. Shirley F. Murphy,
Medical Officer of Health.