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time by the Council's medical staff in connection with outbreaks of this disease.
At these inspections over 22,088 children were examined. Scarlet fever in recent
years has been of such a mild type that there has been much difficulty of control
because many cases were unrecognised, some of them pursuing their usual
occupations while still in an infectious condition.
In addition to investigations by medical officers, valuable work was done by
school nurses in following up the medical officers' visits for scarlet fever and diphtheria,
as well as in connection with minor infectious ailments. In 1928 the prevalence
of diphtheria shewed a slight increase, 5,178 cases having been reported as
occurring among school children as compared with 5,097 in the previous year.
During the year 196 schools were visited owing to outbreaks of diphtheria
in the localities concerned, involving 281 visits by assistant medical officers, whilst
in a number of these schools a nurse was also in attendance daily during the outbreak,
with a view to advising the head teachers and swabbing suspects. In the course
of these investigations and during ordinary medical inspections, etc., 6,406 swabs
were bacteriologically examined in the Council's pathological laboratory, of which
659 showed the presence of micro-organisms indistinguishable from B. Diphtheria,
and the remainder were negative. These 659 positive results related to 457 children,
of whom 151 were officially notified as cases of diphtheria. In 22 cases which yielded
several successive positive results tests were made for the virulence of the microorganisms
and 7 of them proved to be virulent, whilst 15 were avirulent. These
latter cases were readmitted to school without further treatment.
Diphtheria.
Diphtheria is a disease of children of school age and younger, and in London
it is an endemic disease, that is to say, cases continue to occur throughout the year.
There is a regular seasonal prevalence every autumn, and the deaths of children,
between the ages of 2 and 7 years, from the disease rise concurrently. In spite of
improved sanitary conditions, better housing, more efficient medical supervision
of children in the school and home, earlier diagnosis, earlier treatment and admission
of cases to hospital, diphtheria in London has shewn no diminution in incidence
and mortality during the past few years. It is true that since antitoxin treatment
came into more or less general use in 1895, the case mortality per cent. has decreased
from 17.8 in the period 1895-98, to 4.7 in the years 1923-26, and had fallen to as low
a figure as 3.3 per cent. in 1927, yet the incidence of diphtheria has remained higher
during the past nine years than for many years before the war, with a definite increase
in the number of deaths. For example, whilst the average number of cases of
diphtheria occurring among all persons annually between 1903 and 1919 was appromately
7,850 cases; in the period 1920-28, the average was 12,960. During the same
periods the average annual numbers of deaths were approximately 633 (1903-1919),
and 703 (1920-28). A noticeable feature of this general prevalence has been a
tendency for the disease to become established in certain localities for long periods
and to develop exacerbations of virulence from time to time in various districts.
It is now well known that diphtheria and certain other infectious diseases are
subject to cyclic prevalences. The period 1903-19 was associated with comparative
quiescence in the epidemic history of diphtheria. In the years 1920-21, especially
the latter, there occurred an intensive outbreak of both scarlet fever and diphtheria
in London and throughout the country, but whilst the incidence of scarlet fever has
since diminished to a more normal level, that of diphtheria has remained relatively
high in London, in spite of modern knowledge of the factors which favour the spread
of the disease. Since the inception of the school medical service preventive measures
in the schools have been progressively improved, and every possible effort has been
put forth, through medical supervision, swabbing of throats, etc., exclusion of
suspects, "carriers," etc., from school, to reduce the incidence in the schools to a
minimum Yet the disease continues to levy a heavy toll upon the health and lives
of London children. It will thus be appropriate to review the means available for
16479 I 2
Recent
increase in]
diphtheria
in London.