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Nevertheless it is sometimes practicable and helpful to segregate uninfected contacts
so as to vaccinate them with B.C.G. or until the index case has been treated sufficiently
to render his or her infectivity much less menacing. These measures can be of particular
value in newborn contacts of cases under treatment. It is however necessary, particularly
in the case of young infants, to balance the possible benefits of boarding at a nursery
or temporary foster home against the physical dangers of intestinal infection and the
psychological damage of estrangement from parents and home.
Public ignorance of the mode of spread of tuberculosis is still too widespread and
calls for continued health education. There are unsuccessfully treated patients who are
still infectious and therefore of some danger to the community who are discharged
from hospital simply because treatment has not been successful. Provision of hospital
beds for active infectious lung cases solely for the purpose of segregation is not sufficiently
made by hospital authorities.
Although over a third of newly diagnosed cases are infectious, only 5 per cent. of
all the known cases on London chest clinic registers are infectious. This reduction is
attributable to successful modern drug and surgical treatment. Clearly therefore, early
and intensive treatment of diagnosed cases makes the most important contribution to
reducing infection.
Contact of susceptible members of the population with unknown infective cases
can only be prevented when these cases are diagnosed. To wait till such cases develop
symptoms which lead them to doctor or hospital is to court late discovery. It is a better
public health measure to make available—and for the adult public to accept—a periodic
X-ray examination especially for those age-sex groups and occupations with the higher
prevalence rates. At present less than one-tenth of the adult London population submits
itself for X-ray investigation in any year. This is far too little to have any appreciable
effect on the rate of discovery of unknown infectors, particularly those among middle
aged and older men.
School teachers and child minders of all kinds should because of their special contact
with groups of children submit to regular chest X-ray examination.
Vaccination of uninfected persons (that is negative tuberculin reactors) with B.C.G.
vaccine has been shown to give substantial protection against human infection. Since
most serious first infection occurs in infancy and in adolescence, these are the two groups
who will most benefit by its application, and of these adolescents and young adults
are the more urgent. Details are given later of the Council's activities in this field.
(ii) To reduce the development of disease after infection
The factors which decide whether or not an infected individual will develop tuberculous
disease are compounded of hereditary disposition, nutritional state, special
occupational or other exposure (e.g., in nurses and doctors), physical fatigue, emotional
stress, predisposing disease, e.g., diabetes or stomach excision and other factors as yet
unrecognised.
To prevent the tuberculin reactor from becoming a patient with tuberculosis requires
avoidance of the factors mentioned, together with periodic X-ray examination to
reveal disease in its early manifestation.
(iii) To reduce mortality from tuberculosis is a matter of early diagnosis and adequate
treatment. Improvements in treatment in recent years have been remarkably successful
and further improvements are likely. In some patients however treatment for a variety
of reasons is unsuccessful and this is particularly so in the older male patient. Here the
disease is not new but in almost all cases is the relapse of an old lesion, and in most of
these cases the relapse is slow and 'silent' so that by the time diagnosis of breakdown
has been made the disease process is well advanced. Here again repeated periodic X-ray
examination would be likely to reveal active disease at an earlier stage than is usually
seen.
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