NOTIFICATION AND ISOLATION.
We are confident from the actual discovery of the micro-organisms
causing certain infective diseases, that the other diseases of an
analogous nature are similarly caused by living contagia. On this
supposition, action is taken for the prevention of these diseases. This
action comes under a number of different heads, which may be classified
as follows:—
1. =Means for the early recognition of the infectious character of a
disease.= The bacteriological aids to recognition in diphtheria (page
299), enteric fever (page 301), and phthisis (page 310) have been
already mentioned. It is important to call in medical aid when any
suspicious symptoms arise, even when these symptoms do not appear to
be urgent. If an infectious disease is not recognised in its early
stage, it may be easily overlooked, and the patient cause a serious
epidemic. The following hints for teachers are in Brighton sent with
each circular letter as to excluding infected children from school. The
list is not exhaustive, but may aid in drawing attention to suspicious
symptoms. The only safe rule when in doubt is to _act as though a case
is infectious until a skilled opinion can be obtained_.
HINTS AS TO INFECTIOUS DISEASES.
As infection is sometimes spread by means of children attending school
while suffering from undetected infectious diseases, the following
hints may be useful to the teacher:—
1. Any scholar having a sore throat should be sent home and regarded
as infectious until the throat has been examined by a doctor.
If a scholar has enlarged glands in the neck, and especially if he or
she is very pallid, the suspicion of possible diphtheria should be
entertained. Many slight cases of diphtheria escape detection.
2. Any scholar suffering from a severe cold, with sneezing, redness
of the eyes and running at the nose, should be sent home. It may
mean an influenza cold or the commencement of measles, and both are
infectious. This recommendation is particularly important when measles
is known to be prevalent.
3. A child with a violent cough, especially if it is severe
enough to cause vomiting or nose-bleeding, should be suspected of
whooping-cough, and sent home, even if the characteristic “whoop” is
not heard.
4. Slight cases of scarlet fever sometimes escape notice, and the
patients are sent to school with the skin on the hands, etc., freely
“peeling.”
5. In any of the above instances, or any other case of suspicion, the
Medical Officer of Health, on receiving a confidential intimation,
will be glad to make an investigation.
SYMPTOMS OF ONSET OF SCARLET FEVER.
Sudden onset.
Usually vomiting.
Always headache.
Feverish, with dry, hot skin.
Sore throat.
Red rash on chest in a few hours.
MEASLES.
Severe “cold in the head” for 72 hours before the blotchy rash
appears. _Measles is extremely infectious in this preliminary stage._
Consider every severe influenza cold as possibly measles.
DIPHTHERIA
may be very indistinct.
Languor and sore throat.
Glands under and behind jaw are enlarged.
Patient very pallid.
White or yellow patches seen on examining inside throat.
Whenever doubtful, send the scholar home.
WHOOPING COUGH.
In a child under seven, a severe cough should always be regarded as
possibly whooping-cough, although no “whoop” has yet been heard.
2. The =notification= of all cases of infectious diseases to the
medical officer of health, is clearly a means to an end, that of
securing that the preventive measures to be next named are effectively
carried out.
3. =Means for the production of an artificial immunity.= This is only
practicable at present for two diseases of this country, small-pox
by means of vaccination (page 293), and a temporary immunity against
diphtheria by a dose of antitoxic serum (page 299). Apart from these
means, any measures for improving the health of a child tend in the
same direction. Enlarged tonsils, “adenoids” at the back of the nose
(causing the child to snore at night and to breathe through his mouth),
discharges from nostrils or ear, and similar conditions should receive
early medical attention.
4. =Isolation=: preventing the conveyance of the contagium from the
sick to the healthy.
5. =Disinfection=, _i.e._ destruction of the contagium of the disease.
The Infectious Disease (Notification) Act, 1889, and the corresponding
London Act of 1891, impose a dual duty of notification (_a_) on every
medical practitioner attending on or called in to visit an infectious
patient, as soon as he becomes aware of its nature; and (_b_) on
the head of the family to which the patient belongs or the nearest
relative. The intimation must be sent by each of these to the local
medical officer of health, the practitioner being paid a small fee
for his trouble. Usually notification by the householder is only
enforced when no doctor is in attendance. The diseases to which this
Act applies are small-pox, cholera, diphtheria, membranous croup[11],
scarlet fever, erysipelas, and the fevers known by any of the following
names: typhus, typhoid, enteric, relapsing, continued or puerperal. The
list of notifiable diseases may be extended by resolution of the Local
Authority.
The enforcement of notification is most important for the public
health. (_a_) It enables the medical officer of health to take
immediate steps to prevent the spread of infection, by enforcing proper
isolation of the patient, efficient disinfection, and by preventing
the attendance of children from infected houses, at school, etc. (_b_)
It enables the links of evidence connecting a series of cases to be
identified, _e.g._ cases due to a common milk supply, or attendance at
a particular school. (_c_) It has a valuable educational effect on all
concerned in the cases.
ISOLATION.
Both the patient and his attendant need to be isolated in diseases like
scarlet fever, diphtheria and small-pox. The rule is less absolute
in enteric fever. In the following description the standard of
requirements taken is that of the most dangerous infectious disease,
small-pox. The first point to decide is whether the patient may be
safely isolated at home. For small-pox this ought never to be allowed
in a town. For other diseases, this may be permitted, if the following
conditions can be fulfilled.
For =Isolation at Home= a couple of rooms are required, preferably
on a higher floor or in a detached wing of the house. The w.c. used
for the dejecta of the patient must not be used by any other members
of the household. All linen, towels, handkerchiefs, etc., should be
immersed in actually boiling water containing some washing soda, before
leaving the sick-room. Other articles to be washed, if they will be
deteriorated by soaking in boiling water or a chemical disinfectant,
must be tightly wrapped in bundles, and covered with a clean wet sheet
saturated with a strong disinfectant solution (page 331). Solid and
liquid excreta, expectoration and other discharges must be treated
as described on page 331. The nurse should not eat her meals in the
patient’s room. She should wear a cotton dress to be changed before
going out for a walk. Her hands must be thoroughly washed and brushed
after handling or helping the patient, particularly in enteric fever.
It is advantageous if the nurse has previously had the patient’s
complaint. Attention on the part of the nurse to minute detail is
essential, especially in view of the possibility of receiving infection
from infected articles as well as directly from the patient. The
measures required for the subsequent disinfection of the sick-rooms and
of clothing, bedding, books, etc., are given on page 332.
The use of =hospital isolation= has rapidly increased in recent years,
thus releasing private families from a serious burden. The number
of beds which a Local Authority should supply for their district is
usually stated as one for every 1,000 inhabitants, but in poorer
districts this does not suffice. The site of the hospital should be
well removed from houses. There must be a minimum zone of 40 feet
between all infected buildings and the boundary walls, and the same
distance between neighbouring buildings. A wall at least 6 ft. 6 in.
high should enclose the hospital site. The hospital is divided into
separate detached pavilions for the treatment of different infectious
diseases. A floor space of 156 square feet should be allowed for each
bed. The height of the ward should be about 13 feet, its width from 24
to 26 feet, and the total cubic space for each patient should be 2,000
cubic feet for scarlet fever, 2,500 for diphtheria. The lavatories and
water-closets are separated from the main ward by a cross-ventilated
lobby. In an isolation hospital every surface should be washable; all
corners should be rounded off, and all projections on which dust can
lodge avoided. The proportion of window space should be about 1 square
foot to every 70 cubic feet. Special isolation pavilions are required
for cases of doubtful diagnosis. The ventilation and warming of wards
must be carefully regulated. Cross-ventilation by windows open on
opposite sides of the ward can be maintained in nearly all weathers.
The temperature of the ward should be maintained at 55°-60° F.
=Ambulances= are usually provided by the Local Authority for the
removal of infectious patients. The ambulance should be cleansed and
disinfected after each journey. The use of private conveyances for
infectious patients is forbidden, except under special limitations.
The =hospital isolation of small-pox= is beset with special
difficulties. There is a considerable body of evidence indicating
that small-pox may be aerially carried from patients in hospitals
to people living within a zone of half a mile, or possibly further.
Without accepting the view that aerial dissemination of small-pox
to considerable distances from the patient frequently occurs, it
still remains true that, either by this means or by errors in the
administration of small-pox hospitals, they do frequently constitute
a source of danger to persons living in the vicinity. The Local
Government Board recommended that a Local Authority should not
contemplate the erection of a small-pox hospital. (_a_) On any site
where it would have within a quarter of a mile of it as a centre either
a hospital, whether for infectious diseases or not, or a workhouse, or
any similar establishment, or a population of 150-200 persons; (_b_)
on any site where it would have within half a mile of it as a centre a
population of 500-600 persons, whether in one or more institutions or
in dwelling-houses.
QUARANTINE.
This term has been chiefly employed to denote the limitation of the
movements of vessels coming from infected ports, for a term which, as
the name indicates, was formerly forty days, but is now shorter. It may
be conveniently employed, however, to signify the restriction of the
movements of all persons who have been apparently exposed to infection,
or who continue to live in infected dwellings. In this sense we may
speak of:
1. Domestic Quarantine.
2. Scholastic Quarantine.
3. National and International Quarantine.
=Domestic Quarantine=, to a varying extent, is desirable for the
members of a family of which one member has been attacked by an
infectious disease. For small-pox every member of a household should be
kept under strict watch until sixteen days have elapsed since the last
contact with the case of small-pox, or until successful vaccination has
been secured. For enteric fever this strict watch would be unnecessary,
but the remaining members of the household should be warned to call in
a doctor on the first symptom of malaise.
Quarantine is specially indicated for certain occupations. Thus if
the child of an out-door labourer had been removed to a hospital with
scarlet fever, it would be unnecessary to keep the latter away from
work during the following week. If, however, he were a milk-carrier,
or a tailor, or an assistant in a sweet-stuff shop this would be a
desirable measure.
The =Quarantine of School Children= is more necessary than that of
adults, because the former are more susceptible to infection. Children
are kept from school:
(_a_) Because the infectious patient still remains in the house.
In this case the healthy children must be kept from school until
the patient has ceased to be infectious and disinfection has been
thoroughly carried out; and for a further period longer than the
longest known period of incubation of the disease in question (page
287), a margin being left for contingencies. It would probably be 8
_plus_ 2 weeks for scarlet fever.
(_b_) Children are kept from school for a period exceeding the longest
period of incubation when the patient has been removed to hospital.
The table on page 322, modified from the Author’s _School Hygiene_, is
introduced as furnishing a convenient summary of the subject.
Objection is sometimes taken to the exclusion of children under the
above circumstances from school, on the ground that they continue to
mix with others in the street or in neighbouring houses. Clearly,
however, in a school-room, a suspected child may communicate infection
to children coming from widely scattered streets, while out-of-doors
the danger is comparatively slight, and among neighbours the danger is
very limited in area.
It is assumed in the following table that all infected articles have
been disinfected before the termination of the period of quarantine.
┌─────────────┬─────────────────────┬─────────────────────┬────────────┐
│ │ │ │ DURATION OF│
│ │ │ DATE AT WHICH │ QUARANTINE │
│ │ │ SCHOOL │ OF CHILDREN│
│ │ DURATION OF │ ATTENDANCE MAY │ EXPOSED TO│
│ DISEASE. INFECTION. │ BE RESUMED. │ INFECTION. │
├─────────────┼─────────────────────┼─────────────────────┼────────────┤
│_Scarlet │From 5 to 8 weeks; │Not less than 8 weeks│14 days. │
│ fever_ │ ceases when all │ from the beginning │ │
│ │ peeling of the skin │ of the rash, and │ │
│ │ has been completed, │ then only if no sore│ │
│ │ and when the child │ throat or sore │ │
│ │ is free from │ places. │ │
│ │ discharge from the │ │ │
│ │ nose or ear or sore │ │ │
│ │ places. │ │ │
│ │ │ │ │
│_Diphtheria_ │ At least 21 days; │Not less than 2 │12 days. │
│ │ often much longer. │ months, and not │ │
│ │ Absence of infection│ then if strength not│ │
│ │ should be confirmed │ recovered, or if any│ │
│ │ by bacteriological │ sore throat or any │ │
│ │ tests. │ discharge from nose,│ │
│ │ │ eyes, ears, etc. │ │
│ │ │ │ │
│_Small-pox │About 4 to 5 weeks │When every scab has │18 days. │
│ and Chicken │ │ fallen off. │ │
│ pox_ │ │ │ │
│ │ │ │ │
│_Measles_ │From 3 to 4 weeks; │Not less than 4 weeks│21 days. │
│ │ when all cough and │ from beginning of │ │
│ │ branny shedding of │ rash. │ │
│ │ skin has ceased. │ │ │
│ │ │ │ │
│_Rötheln │2 to 3 weeks │From 3 to 4 weeks │21 days. │
│(German │ │ from beginning of │ │
│ measles)_ │ │ rash. │ │
│ │ │ │ │
│_Mumps_ │About 21 days from │4 weeks from the │24 days. │
│ │ the beginning. │ beginning. │ │
│ │ │ │ │
│_Whooping │6 weeks from the │In about 8 weeks │21 days. │
│cough_ │ beginning of │ │ │
│ │ whooping, or when │ │ │
│ │ the cough has quite │ │ │
│ │ ceased. │ │ │
│ │ │ │ │
│_Typhus and │4 to 5 weeks │When strength │28 days. │
│ enteric │ │ sufficient. │ │
│ fevers_ │ │ │ │
│ │ │ │ │
│_Influenza_ │2 to 3 weeks │1 month │10 days. │
└─────────────┴─────────────────────┴─────────────────────┴────────────┘
=School Closure= is occasionally required to prevent the further
spread of an infectious disease. This can be enforced on the order of
any two members of the Local Sanitary Authority acting on the advice
of the medical officer of health. This ought to be only occasionally
necessary if notification of infectious diseases is strictly enforced,
and if suspicious individual children are excluded from attendance
at school. In diphtheria school closure may occasionally be rendered
unnecessary by systematic bacteriological examination of the throats
of children who had been exposed to infection (see page 299). School
closure is more useful for country than for town schools, as in the
former the homes of children are more remote from each other, but it
is occasionally necessary for both. For measles school closure is
specially indicated in Infants’ Schools. We have already seen that
this disease is chiefly fatal when caught at a tender age (page 297).
The early closure of Infants’ Schools, and particularly of the Babies’
Class is therefore indicated. It is unfortunate that the attendance at
school of children under six years of age is encouraged. Such children
have more severe and more frequently fatal attacks of diphtheria,
scarlet fever, measles, and whooping-cough; and these are frequently
acquired at school.
=International Quarantine= was originally enforced against plague; but
in many countries has been extended to other diseases, as cholera,
yellow fever, typhus fever, small-pox and leprosy. In England cholera
is the only disease in connection with which it has been in the past
enforced. It has now been entirely abandoned. It consists in the
compulsory isolation at the port of entry of all persons who have come
from an infected district, or have been in contact with a case of the
infectious disease against which quarantine is enforced, for a length
of time which will enable it to be determined whether the persons
detained are or are not incubating the disease. If this measure could
be strictly enforced, and if infectious diseases were conveyed only
by infectious persons, quarantine would undoubtedly be effective.
But in practice quarantine cannot be enforced in Europe; and as it
cannot be efficiently enforced it forms an ineffective and irrational
derangement of commerce. Thus if plague prevailed in France it would be
impracticable to detain for ten or twelve days every person entering
England. Furthermore, in this instance, infection is brought by rats as
well as persons; and measures effective for the latter do not prevent
the former from importing infection. Because of its impracticability
and of the disorganization of commerce which would be associated with
any attempt to enforce it, England has abandoned quarantine and other
countries are gradually following its example. England bases its
action on the ground that (_a_) _sanitation is the true chief means of
defence_, especially against cholera. It does not trust to this alone
but to this along with (_b_) _medical inspection_ at the ports, (_c_)
and _subsequent medical supervision_ of persons landed from suspected
vessels. By these means a watch can be kept over persons who have been
in contact with infection.
Regulations are issued at intervals by the Local Government Board
requiring the disinfection by steam of all rags and similar materials
imported from towns in which small-pox, cholera, etc., are prevalent.