Immunization against attacks of small-pox and diphtheria has been pointed out as a safe procedure. It has been shown that individuals should by all means avail themselves of such protection at the proper time, not only to safeguard their own health, but also to avoid exposing others to the serious consequences which may result from these diseases.
II. The "May-Be-Done" Group
The second group of immunizations as cited previously in the classification of immunization procedures is the "may be done" group. Immunization against typhoid fever and whooping cough is placed in this classification.
Typhoid Fever.—The incidence of typhoid fever has been markedly reduced the last three decades through public-health measures which have provided for safe drinking water ; pasteurization of milk; pr6per handling of food supplies; disposal of human fecal waste without polluting water supplies, food, or the surface of the soil; government control of shellfish growing and shipment; and the eradi: cation of breeding places for flies. The education of the public regarding hand washing after use of the toilet, and instruction and supervision of convalescent and chronic typhoid carriers in personal hygiene, has also been a factor in reducing the incidence of the diseases.
Such public-health activities have been carried on more diligently in urban areas than in the rural communities. Consequently the disease continues to be more prevalent in the open country. All should use their influence to promote this phase of public health instruction.
Immunization against the disease is not necessary for the population as a whole, since thorough public sanitary measures consistently applied markedly reduce the occurrence of the disease. However, persons should avail themselves of protection from typhoid fever through immunization if they are exposed to special hazards, as floods, earthquakes, and other disasters, in which sanitary arrangements have become disorganized ; if they must travel or live in countries in which the sanitation is poor ; if they have to live for a time under unsettled conditions, as in the army; or if they are physicians or nurses, and are likely to come in contact with the disease in the routine of their work. Such persons need to be reimmunized every two years.
Whooping Cough.—Immunization against whooping cough has also been placed in the "may-be-done" group, because scientific opinion is still divided concerning the usefulness of vaccines for this disease. One authoritative opinion is that the "use of prophylactic vaccination is recommended by some observers, but for public health practice it is still in the experimental stage. There is some evidence that attacks are milder in the vaccinated."
On the other hand, there are many well-qualified physicians who feel that young children should be inoculated with the vaccine available, since this is the only means for protection, and in their opinion it will produce immunity in approximately fifty per cent of cases, and will lessen the severity of the disease in approximately another twenty-five per cent. They consider this procedure justifiable because of the severity of whooping cough in the preschool child, particularly in the child younger than three years of age.
It should be noted that whooping cough begins very much like an ordinary cold, and that it is particularly communicable in the early catarrhal stage before the typical cough confirms the diagnosis. These facts show why it is difficult to prevent the spread of the disease.
Children between six months and five years of age are most suscePtible, and after this there is some decrease in susceptibility. In cities, about half the reported cases of whooping cough are in children under five years of age, and ninety per cent in children under ten. The children in this age group should be kept away from children with cough and fever of any origin, particularly if whooping cough is known to be prevalent.
Children who develop whooping cough may communicate the disease to others for three weeks after the typical cough develops, and should not be allowed to re-enter school until the expiration of this period, and until released by the health-department physician. A public-health measure for the control of whooping cough in which all may participate is to report suspected and unreported cases to the health department, and to assist in protecting other children from exposure.
The "No" Group—Scarlet Fever
The third area of the immunization classification is the "no" group, and in it scarlet fever is listed. Since there is considerable controversy about the immunization procedure for this disease, such a classification may not be entirely justified, and it might have been more , logical to discuss the immunization for this disease in the "may-be-done" group.
Susceptibility to scarlet fever may be determined by the administration of a skin test, known as the Dick test, which is performed in a manner similar to that used for the Schick test for diphtheria. The immunizing treatment for the disease consists of administering to individuals showing a positive-reaction to the Dick test, three or more doses of sterile toxin at weekly intervals. Evidence is available that a child who becomes negative to the Dick test following the immunizing treatment is as well protected against scarlet fever as the child who gives a negative Dick test as the result of an acquired natural immunity.'
According to Dr. William A. Howard, of Georgetown University, the objection to the immunization procedure is based on the fact that scarlet fever is not caused by one single organism, but by a group of organisms. He feels that the immunization technique, as now used, does not include all the group, and therefore is impractical. He points out that since the reaction from the immunization procedure is so severe from each of the several injections, the individual might just as well risk an attack of the disease. "Active immunization of Dick-positive persons may be desired on a private basis, but is generally impracticable as a public-health measure.'
In summary, let it be noted that all persons, old and young, should be vaccinated for smallpox. All preschool children and those in the lower elementary grades should -be immunized against diphtheria. Persons who must live in an unsafe environment should keep themselves immunized against typhoid fever. Every precaution should be exercised to avoid exposure, particularly of children, to any disease, and particularly to those diseases for which no known immunization exists, or for which protection may not be absolutely established. The advice of the family physician should be sought regarding protection from disease, and whenever symptoms of illness appear.
D. L. B.
1 Report of a Committee of the American Public Health Association, "The Control of Communicable Diseases," Reprint No. 1697, P. St. United States Government Printing, Office, Washington, D. C., 1940.
2 Veldee, M. V.—Scarlet Fever, Its Prevention and Control," Reprint No. 5202, p. so. United States Government Printing Office, Washington, D. C.
3 Report of a Committee of the American Public Health Association, "The Control of Communicable Diseases," Reprint No. 1697, p. 36. United States Government Printing Office, Washington, D. C., 1940.
