View report page

Report of the Medical Officer (Education).
133
shown to be very small. The result of holding up all infants would, as far as direct school effects
are concerned, not affect the measles mortality by 1 per cent., and after a few months, when stability
had been assumed, with secondary infections of the younger children in the family going on as before,
would probably scarcely have any measurable effect on the mortality of children under school age.
No hope is therefore here held out of materially affecting measles mortality in London by school
closure. The mortality of this disease must be attacked by other means, such as compulsory (parental)
notification, some hospital isolation for bad cases, education of parents as to means of treating the
disease, and probably also the adoption of more scientific (aseptic) treatment of actual cases and
especially improvement in regard to habits of life, housing and space to live.
On April 6th, 1911, shortly after the wave of measles had passed its height, a conference of representatives
of various public bodies met at the County Hall and passed a series of resolutions, viz.:—
(1) That a better organisation is desirable in London for the control of measles in schools.
(2) That during a serious outbreak of measles, children under five years should be excluded from
school attendance.
(3) That compulsory notification of measles is desirable.
(4) That the cleansing of the infants' departments and of the furniture, lower walls and floors
thereof shall take place once a week.
(5) That accommodation should be provided in the Metropolitan Asylums Board's hospitals for
urgent non-pauper cases of measles.
(6) That in the interests of public health the school regulations should provide that all children
from houses infected with measles should be prohibited from school attendance.
These resolutions were later reported upon by me as follows:—
(1) It is difficult to see what better organisation can be found, as every practical means has been
utilised to deal with the problem of controlling measles in elementary schools. It has been demonstrated
that closure of schools is useless, that by warning parents upon the appearance of measles in a school,
by excluding susceptible children in the class or classes affected, especially those under five years, and
by impressing upon the school teachers the importance of watching for the first symptoms of the disease
and for segregating the affected classes, it is possible to watch the course of an outbreak and to take
proper measures to prevent or to limit the spread of the disease. By the present system an outbreak
can be followed and dealt with in detail accordingly, whereas by resorting to the cruder method of school
closure the source of knowledge of the incidence of cases would be cut off, and consequently it would
be impossible for appropriate measures to be taken either by the school medical service or by the local
public health authority.
(2) Particular attention is paid to children under five, and unprotected children under five years
are wholly excluded when such action is considered necessary as a protective measure. It has been
pointed out that in view of the immunity conferred in almost every case by one attack of measles it
is unnecessary to include in a general order for the exclusion of children in an affected class as a
protective measure, those who are protected by a previous attack, whatever their age.
(3) Notification would not be likely to decrease the actual incidence of the disease, but by removing
cases to the hospital a milder type of illness might probably prevail in time, and thus be the means of
reducing the mortality. Notification without removal would be of little avail except to enable the local
medical officer of health to give advice in regard to sanitary precautions. Doubt might be expressed
as to whether any benefits accruing from a system of notification would be commensurate with the
considerable cost to the public which would be incurred. If notification is to be of any real value, it
should be accompanied by the provision of hospital accommodation, at least for serious cases, or where
inefficient or insanitary home conditions prevail; but this raises a larger question, and is referred to
under resolution (5).
There is, however, an increasing need for some measure being adopted whereby it shall be the
statutory duty of every parent or guardian to notify any illness of a suspicious nature in a school child
to the head teacher of the school where such child attends. In the case of children below school age the
local medical officer of health might be notified. This would be a most salutary innovation, not only
as regards the control of measles, but of other infectious illnesses, as it would enable health authorities
to bring pressure to bear upon parents with a view to obtaining prompt medical advice and ensuring
early diagnosis. Many years ago I elaborated a scheme of free diagnosis of illness in school children,
but it had objections in cost and liability to abuse.
(4.) Whilst it is quite desirable that the cleansing of the infants' departments and of the furniture,
lower walls, and floors thereof should take place once a week, it is not at all likely to affect the
epidemic distribution of such a disease as measles.
(5) It would of course be desirable that urgent non-pauper cases could be acommodated and
treated in the M.A.B. hospitals, but unless the disease were made notifiable there would be no compulsion
to notify the cases, and consequently as a large proportion of the class referred to as non-pauper
cases would probably not seek medical attendance and advice, the responsibility of deciding whether
such cases should go to hospital would devolve to a considerable extent upon the local medical officer of
health. Notification and removal to hospital could scarcely be dissociated, since notification without
removal to hospital would hardly produce any practical benefits, whereas the latter would necessarily
entail notification before the patient could be admitted.
Measles is in its most infectious and dangerous stage during the first few days of illness, if therefore,
isolation by removal to hospital is to be effective from a preventive point of view, it is imperative
that the patient should be removed immediately the onset appears. In the recent epidemic only pauper
cases of measles were admitted to the M.A.B. hospitals as a general rule, and these probably did not
amount to more than 2 to 3 per cent, of the number of cases which actually occurred.