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199
Report of the County Medical Officer—Education.
The methods to be adopted for controlling measles require careful consideration. Compulsory
notification has been advocated as essential to the control in measles, but iu every area in which it
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has been tried this procedure has ultimately been abandoned. JSorne authorities are of opinion that
systematic closure of infant schools when measles is prevalent is necessary to prevent the spread of
the disease, whilst others would limit protective action to the exclusion of children under compulsory
schocl age, owing to the greater danger to life when children are attacked by measles at an early age.
In this connection it is interesting to note that out of the total number of deaths from measles during
1913, viz., 1,570, no less than 1,460 occurred in children under five years of age. The control of
measles in London schools has been the subject of serious consideration by the London Education
Authority for the past ten years, and from time to time special investigations have been carried out
with a view to elucidating various factors which aid in disseminating infection, and ascertaining the
best methods of control. The general practice in the past has been to limit exclusion for protective
purposes to children in infants' departments, and in this connection it is important to keep the
following general considerations in view :—
(1.) It is estimated that 90 per cent, of the children have had measles by the time they
leave the infant school.
(2.) The severity of an attack of measles varies during each epidemic, and virulence
increases with the number of children attacked by the disease.
(3.) The severity of an attack depends also on the age of the child ; the younger
children usually suffer more severely, and are liable to suffer from complications which may
be fatal or which may predispose to tuberculosis, ear discharge, or injury to eyesight.*
(4.) Climatic conditions also have a marked influence on the spread and severity
of the disease.
If, therefore, children cannot be protected from contracting measles ultimately, efforts should,
at any rate, be made to protect them from an attack in early years. In any scheme for preventing
the spread of measles it follows that strict supervision should be exercised over children in infants'
departments, particularly children under five years of age. The scheme adopted in London aims at
obtaining the co-operation of teachers and attendance officers, and through them, securing the
education of parents as to the necessity for care and attention when cases of measles occur in the
family.
For purposes of school control head teachers are required to furnish from time to time returns
showing the proportion of children who have already had measles, together with the range of age in
each class, thus providing a basis for taking preventive action upon the occurrence of outbreaks. For
various reasons these lists cannot be perfectly reliable, and some cases of measles are not infrequently
found to occur in classrooms from which all known susceptible children have been excluded.
Consequently it becomes necessary to extend the period during which the children known to be
unprotected are excluded, otherwise the object of the exclusion is frustrated. When measles occurs
in any class of r,n infants1 department, the attention of the head teacher is drawn to the iufectivity
and danger of the disease, and to the necessity for exercising close supervision, for excluding children
who show suspicious symptoms, and for avoiding all mixing and massing of the classes. If the class
affected contains children of the age of five or under, those of them who are susceptible are excluded
during the period when they may develop the disease and infect other children. It is recognised
that certain of the susceptible children, excluded from an infected class, will develop the disease,
whilst others will be found not to have been infected or to be immune. After a certain period,
therefore, the crop, infected by the first case, will be exhausted and those children who are
not infected may safely return to school. In older children the risk of spread is not so great
owing to the lower proportion of susceptibles. If the percentage is low little risk is incurred by
allowing the few unprotected children to continue attendance at school. On the other hand if the
percentage of susceptible children is high, and there are indications of wide spread of the disease, all
unprotected children in the department may be excluded for varying periods even though certain of
the classes may not already be infected. It is of fundamental importance in the successful control of
measles in the schools that the first case should be recognised and notified to the School Medical
Officer within eight days of the date of the patient's last attendance at school. It would be of
further assistance if the date on which the measles rash appeared could be furnished with the notification,
but under present conditions it is not possible to obtain this information. If the occurrence of
the first case is notified sufficiently early, it becomes possible for the School Medical Officer to require
the exclusion of susceptible children from school attendance before any child, who may have been
infected from the first case, becomes capable of infecting other children. Such an exclusion should
be calculated to cover the period from the 10th day to the 16th day from the date when the first
sufferer ceased attending school. Those children who were infected with measles by the initial case
would manifest symptoms of the disease during this period, and those susceptibles who were not
infected might afterwards safely return to school. The complete observance of this procedure would
ensure satisfactory control and the disease could be kept in check. The aim should be to control the
incidence curve, so that instead of its being very markedly accentuated during comparatively short
periods at certain seasons, it should take the form of low waves with the least possible difference in
height between the crests and the troughs.
The actual curve representing the notifications of measles received by the school medical officer
is shown in the middle of the annexed diagram (H.), where the notifications received from the
schools have been plotted out week by week during a period of seven years. The excess of cases at certain
periods followed by periods of depression is well marked. If reference be made to the lowermost
curve, which is a theoretical curve, deduced from the actual mortality figures, it will be seen that the
form is much more regular and approximates to the low waves just described. The most noteworthy
modification of the true wave of notifications is that produced during the period immediately after