Diphtheria is an Institution
an ACCOUNT OF THE APPLICATION OF THE SCHICK TEST AT THE ROYAL EASTERN COUNTIES INSTITUTION.
- Author:
Douglas Turner, M.B.
No doubt many Institutions for defectives get outbreaks of diphtheiia, and I thought, therefore, it might be of interest, and perhaps a help to those lespon- sible for other Institutions, to have an account of our experience heie and our method of dealing with it.
For several years we have had frequent small outbreaks of diphtheria. In *924, there were fifteen apparently separate outbreaks with a total of twenty eases, and in the early part of 1925, there were at different times six patients <ind eleven members of the staff down with mild attacks of the same thing. Of the whole thirty-seven cases, only two were serious, but it was obvious that at any time a severe epidemic might start. VV e seemed to resti ict each outbreak as^ it occurred by prompt isolation of contacts, and by the taking of many swabs till, m fact, the medical officer of health’s staff began to revolt at the amount of extra work they had to do. At each outbreak, one or two carriers were found but it was not clear these could have been the cause of the outbieak. Ihey Were sent with the actual cases of diphtheria to the Local Infectious Hospital and several of them spent many pleasant and idle months there till, at length, we tired of paying for them. Then the virulence of the bacillus in their throats was tested; they proved to be non-virulent. Ihey returned to the Institution, and they did not appear to be connected with any of the further outbi eaks.
It was obvious, however, that something must be done to try and check the trouble. Apart from the illness to the individual patient or patients, the con- stant alarms and quarantinings were upsetting all regular work and classes. After a good deal of consideiation, it was decided to try the Schick .Test, and operations began in the summer of 1925. Before making any test, the Assist- ant Medical Superintendent, Dr Munro, had the advantage of 1 eceiving instruc- tion and advice from the Director of the Burroughs Wellcome Physiological Laboratory, Dr O’Brien, to whom we are much indebted. The whole of the testing and injections have been carried out by Dr Munro peisonally,^ and the complete absence of bad results is, I believe, due to the extreme care with which he carried out all the details of treatment.
The friends of every patient had a full explanation of the method sent them, and only those patients whose friends gave their consent were tested.
By means of the Schick Test, it is possible to decide whether individuals are liable to catch diphtheria, or are immune. Those who prove susceptible can, in most cases, be made immune by the injection of a diphtheria toxin-antitoxin mixture. The test consists in injecting, into the left arm, a minute dose of standardised diluted toxin, and into the right arm, as a contiol, the same amount of diluted toxin which has been heated. The local leaction to the injections is watched day by day, and from the character of this it is decided whether the patient is likely to catch diphtheria or not.
We have now tested 1,037 patients and 47 staff. The following- are the results :?’
Number Positive ^Positive ?? Tested Reaction Reactions Under 5 years … … ?? 7 3 42.8 per cent. Five to under 10 years … ??? 48 16 33 per cent. Ten to under 15 years … … 157 42 26.7 per cent. Over 15 years … ??? ??? 825 187 22.6 per cent. 1,037 248 23.9 per cent. Staff.?Number tested: 47; Positive Reaction: 18; Percentage of Positive Reactions : 38 per cent.
It will be seen that the younger the patient the higher the percentage of positive reactions though the number of those tested under 5 years is too few to be of any value. The curious thing, however, is the high percentage of positive reactions among the staff. Possibly this may have been because only those members of the staff were persuaded to submit to the test who knew they generally caught everything that came along, or who had had attacks of tonsillitis.
The whole of the 266 cases who proved to be positive were then given injections of diphtheria toxin-antitoxin. The first injection was 0.5 c.c., followed by two other injections of 1 c.c. each at intervals of seven days. Most of the patients were given Calcium Lactate before and after the injections. All were kept in bed for the rest of the day, and were not allowed up while there was a raised temperature. We were fortunate in not having a single bad arm from the test itself, and only three reactions of moderate severity occurred with the pre- ventive injections. Two of these were in the staff. Many of the patients were low grade, both mentally and physically, and these results are, therefore, satisfactory.
No further cases of diphtheria have occurred since. This may be only coinci- dence, or it may be because we have now ceased to swab all cases of tonsillitis. Obviously, if the population of your Institution has been proved to be immune to diphtheria infection, or has been made so, theoretically at any rate, by injections of toxin-antitoxin, you may have, safely so far as the Institution is concerned, any number of diphtheria carriers, both virulent and non-virulent, amongst your patients and staff. If you swab for every bilious attack or mild tonsillitis, you will be constantly finding themv but if, having taken your stand on the Schick Test, you refuse to swab except in cases of real doubt, you may hope to be free of diphtheria.;
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