Communicable diseases

PUBLIC HEALTH IN EUROPE 3

No . 3 COMMUNICABLE DISEASES Not for S a l e Distributed b y the REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN 1974 Note Data and excerpts from "Public Health in Europe" may be reproduced provided that the source of the re- printed text is acknowledged . For rights articles in toto, gional Office for applications . of reproduction or translation of the application should be made to the Re - Europe. The Office welcomes such Authors alone are responsible for views expressed in signed articles . ii Reissued under ISBN: 9789289023610 (print) in 2025. Originally published under ISBN-10: 9290201223. ISBN 92 9020 122 3 ISSN 0300-4880 © World Health Organization 1974 CONTENTS Introduction - H. M¢'ller ........... . Page 1 Proposed measles vaccination policies - A. T. Roden 3 Congenital rubella and its diagnosis - J. A. Dudgeon 8 Congenital rubella surveillance - J. A . Dudgeon 17 International venereal disease contact-tracing procedures 1n Europe - R.R. Willcox . . . . . . . . . . . . . 24 Problems and implications of public health methods as applied to trachoma control programmes - B. Nizetic . . . . . . 36 The role of modern laboratory services in the surveillance and control of communicable diseases - A . Wahba 38 Malaria in Europe - M. Postiglione . . 43 The use of computers in vaccination and immunization schemes - T. McL . Galloway . . . . . . . 65 Tuberculosis in Europe - M. Arhirii 7 2 National communicable diseases surveillance programmes in Europe - M. R. Radovanovic . . . . . . . . . . . . 82 Selected demographic features and statistics relating to the European Region . . . . . . . . . . . . . . . . . . 87 iii INTRODUCTION by Dr H. Mpller Chief, Communicable Diseases Prevention and Control WHO Regional Office for Europe Copenhagen, Denmark The epidemiological situations in the southern and northern parts of the European Region of the World Health Organization are quite different. Every y e ar millions of people move from north to south for holidays, while millions more move in the opposite direction to work. Here lies an ob- vious task for WHO, and the programme of the Regional Office for Europe contains several activities aimed at reducing the health risks involved in these movements of population and improving epidemiological surveillance and preventive measures. As described in more detail in the articles which follow, the pattern of communicable diseases has changed greatly in most of Europe during the last ten years . Disease control programmes have therefore been adapted accordingly. In the industrialized countries some bacterial dis- eases have become rare, either as a result - at least in part - of improved socio - economic conditions (tuberculosis and typhoid fever are good ex- amples} or as a direct result of immunization by means of highly effective vaccines (e . g . , diphtheria and poliomyelitis). This reduction in incidence and prevalence has in itself given rise to discussion as to which of the clas- sical control measures should be continued and which should be discontinued. For instance, should we maintain compulsory smallpox vaccination and, if so, how often should it be given, or should we replace it by surve illance and vaccination only of certain groups likely to be exposed to infection? The past decade has seen the almost complete disappearance of ma- laria from continental Europe . Except for the persistence of transmission in a reduced area in Greece and the occasional reintroduction of the disease in a few parts of southern Europe, the continent is now free of indigenous malaria. Increased population movements, particularly of tourists and migrant workers, have, however, resulted in a rise in the number of im- ported cases; in 1972 these totalled 1240, including 15 deaths. This has resulted in a greater awareness by the medical profession and the general public that malaria is still a real danger. While some diseases are disappearing, others are still rampant even though good control measures are available, and this represents a challenge, both nationally and internationally. For example, venereal diseases, par- ticularly gonorrhoea, are becoming increasingly prevalent in the younger age-groups, while influenza continues to be a major cause of absence from work. The following articles reflect to some extent the work of the WHO Regional Office for Europe, whose objectives include assistance to Member States in the prevention and control of communicable diseases. This as- sistance is either direct (provision of staff, fellowships and equipment) or indirect, in the form of international courses and meetings organized by WHO. The reports of such meetings are not normally distributed through commercial channels. However, a limited number of copies of individual reports are available, upon request, to persons officially or professionally concerned with the particular subjects treated therein. The articles included in this issue fall into two general groups, name- ly, working papers or background documents for specific meetings con- vened by the Regional Office for Europe, and articles by staff members of the Office describing the situation in the European Region of WHO with re- gard to various communicable diseases and the measures being taken to control them. 2 PROPOSED MEASLES VACCIN~'I. TION POLICIES by Dr A. T. Roden Principal Medical Officer Departme nt of H ealth and Social Security, England The fundamental epidemiological consideration influencing the adop- tion of a policy of vaccination against measles is the extent to which it is desirable to attempt to interrupt the natural transmission of m e asles virus within defined communities. The effectiveness of live attenuated measles virus v a ccines is such as to permit the complete interruption of transmis- sion, with consequent elimination of the natural disease, provided that a sufficiently high proportion of susceptible persons are immunized by vac- cination. Experie nc e in Great Britain (Sutherland & F a yers, 1971; Warin & Rodgers , 1971), the USSR (Cumakov et al., 1970) and the United States of America (Scott, 1971) has shown that elimination of measles from the general community is dependent on achieving a high rate of vaccination of susceptible persons, probably of the order of 90 o/o . Even in communiti es that have achieved an a verage rate of this order, unvaccinated susceptible groups may exist which act as foci for the reintroduction of measles. When the disease flares up in these unvaccinated groups, infection occurs also, though to a less e r e xtent, among thos e previously v a cc ina ted , pr e - sumably due to waning of the immunity of some of the vaccinated individual s. This has been the experience in Oxford, England (Warin, 1971) and Rhode Island, USA (Scott, 1971). Complete interruption of transmission of measles in the general community The beneficial effects of complete interruption of transmission of measles, if it is found practicable to achieve this, are clear, but there may be consequential disadvantages. In the absence of measles from a com- munity, resistance to the disease would no long e r be acquired by natural infection and would depend solely on vaccination. Sinc e the vaccination procedure itself is associated in some cases with febril e reactions and, occasionally, with serious complications, it may prove difficult, in the ab- sence of any likelihood of acquiring the natural disease, to maintain a suf- ficiently high rate of vaccination to guard against its reintroduction. Those who failed to be vaccinated in childhood would grow to adult life sus- ceptible to measles. Infection of adults often gives rise to a more serious illness than among children and the presence in a community of a substan- tial proportion of susceptible adults would necessitate careful surveillance and reporting of cases of measles, with energetic measures for the control of outbreaks, similar to the measures adopted in Europe for the control of outbreaks of smallpox. 3 Partial interruption of transmission of measles in the general community The use of measles vaccine on a large r;cale has been shown in sever a l countries to r esult in p a rtial inte rruption of transmission of the n a tural in- fection . The benefits derived from this have b een a reduction in the inci- dence of measles and hence of the associated complications and mortality, with a corresponding diminution in the demand for curative medical serv- ices, a reduction in morbidity and the saving of lives. The s e b enefits may well b e only of a temporary nature since, in a partia lly protected com- munity, endemic foci of me a sles will inevita bly persist a nd will tend to af- fect increasingly older age -groups, a situation r e minisc e nt of the b ehaviour of smallpox in Europe during the eighteenth and nineteenth centuri e s. The end result of interference with the natur a l pattern of spr ead of measles in childhood, short of e limination of the disease from the general community, could we ll be worse than the initial state of affairs . Complete interruption of transmission of measles in selected communities Experience has shown tha t it is possible to eliminate m easles from residential institutions by vaccinating all susceptible entrants. It would seem to be theoretically possible to concentrate va ccination on vulnerable groups, such as young children in residential car e liable to high attack rates from measles, without greatly influencing the natural transmission of the disease in the general community. This would imply no attempt to influence the tr ansmission of mea sles among children in their own homes or among those attending schools. Vulnerable groups liable to high attack rates from measles include children from the age of, say, nine months up- wards in residential car e and pre-school children att ending nursery schools, day nurseries or other e stablishments accepting young children for day care. Protection of individua ls without inte rrupti on of tr a nsmission Susceptible individuals with pre-existing s erious physical incapacity or mental handicap are likely to d e velop severe illness as a result of nat- ur a l m ea sles virus infection. Such individuals are unfortunately also liable to rea ct adversely to vaccination which , i n some important diseases, such as leukaemia, may be a bsol utely con t r a -indicate d. In the United Kingdom it has been thought desirable to make special ar range ments for children suffering from chronic dis eases of the heart a nd lungs in order to attenuate possible reactions to vaccination by the simultaneous administra- tion of a calculated dos e of human norma l immunoglobulin of known measles antibody content. A difficult problem has been the us e of measles vaccine in children with a history or family history of convulsions. While the spe- cial preparation of human normal immunoglobulin give n with the vaccine may reduce the likelihood of a febrile reaction, and hence of a febrile con- vulsion, there is no certainty tha t it will prevent convulsions in a child with pr e -existing bra in d a mage. As long a s me a sles remains endemic in a ny community, susceptible individua ls with physical or mental handicaps will be specially vulne r a ble to the i ll- e ffec ts of the disease and the ir 4 protection by means of vac cination will continue to present problems. For those in whom vaccina tion is contra-indicated, protection or attenuation of the disease after exposure to infection, by means of human normal immuno- globulin, may need to be considered. Alternative policies of vaccination against measles The choice of a measles vaccination policy is governed by the desira- bility and feasibility of (a) interrupting transmission within defined communities, (b) protecting individuals or groups of individuals specially vulner- abl e to the ill-effects of the disease. A policy that is too selective, e.g., directed solely to susc eptible per sons with known physical or mental handicap, is unlikely to succeed in its objective of protecting such persons so long as measles rema ins en- demic in the community in which they are living. Such a policy would prove exp ensive of m edical manpower for the ascertainment of persons considered to b e in need of vaccination and would afford no protection to healthy per - sons, some of whom, particularly in the younger age-groups, may also suffer ill-effects from the natur al disease. Selective vaccination would need, therefore, to combine the protec- tion of vulnerable individuals with complete interruption of transmission of measles in selected communities liable to high attack rates of the disease. Mor e d e tailed consideration of the implications of such a policy will b e given later . The alternative to selective vaccination appears to li e in complete interruption of transmission of measles throughout an entire community. The disadvantages in the long term of partial interruption of transmission a r e likely to b e such as to outweigh the immediate benefits derived from a temporary reduction in morbidity and mortality. Community vaccination, therefore, should aim at the elimination of the disease. Selective vaccination The rationale of a policy of selective vaccination is to interfere as little as possible with the circulation of natural measles vi rus among healthy children, while offering protection to individuals and groups at spe- cial risk of serious illness as a result of natural infection. Such a policy presupposes that, in the general c ommunity under consideration , natural measles is usually a mild dis ease causing little permanent harm to most children in a normal state of health. In countries where measles is usual- ly a severe disease, or where facilities for medical care are inadequate, selective vaccination would seem inappropriate. Its merits even in coun- tries with adequate medical resources are open to doubt. 5 In all communities where measles is endemic most infants up to the age of about nine months are protected by maternally transmitted antibody. When this passive protection has waned the infant, if exposed to measles infection during the first two or three years of life, is liable to suffer a more severe illness than if infection is first encountered at a later stage of childhood. The protection of children from nine months to two or three years of age living in an environment which exposes them to a high risk of infection would therefore form part of a policy of selective vaccination. Such environments include: (a) residential institutions to which infants and young children are admitted; (b) nursery schools; (c) day nurseries; (d) other establishments accepting young children for day care. Institutions and establishments of this kind could be kept free from measles by the vaccination of all susceptible children before admission . In the general community selective vaccination would be offered, in the ab- sence of specific contra-indications, to all susceptible children with serious incapacity who are likely to develop severe illness as a result of natural measles virus infection. Selective vaccination as a permanent policy may be appropriate in areas where the incidence of measles falls largely on children more than three years of age, where the severity of thP. disease at this age is usually mild and where aggregations of children before entry to school are uncom- mon. As a temporary policy it could constitute a prelude to vaccination of the general child community. Community vaccination It has been argued above that vaccination against measles should not be introduced on a large scale unless the ultimate objective is to interrupt the transmission of th e disease comple tely a nd to maintain a community free from measles. This objective may be achieved by introducing vac- cination against measles into the regular schedule of immunization in childhood or by mass campaigns aimed at the elimination of the disease in particular localities. In areas where there is a low natural incidence of measles among children under three years of age or where a low incidence under this age has been achieved by previous vaccination campaigns it should be possible to concentrate vaccination on children aged three years or more. This carries the advantage of reducing the risk of the occasion- a l severe reactions to the vaccine which occur mainly in the fir st three years of life. Vaccination should be offered to all susceptible children, i.e., those not protected either by previous vaccination or by an attack of the disease, up to the age of 15 y e ars. 6 Elimination of measles by stages The evolution of measles vaccination policy in any particular country will depend on its epidemiological , geographic and economic circumstances and, in a country where these circumstances vary from region to region, may well differ according to the requirements of the local situation and the means availab l e to implement the de sired policy. In countries where there are many scattered rural communities with inadequate medical care it might be thought desirable by means of mass vaccination campaigns to establish measles-free areas and to proceed at a later stage to the e limination of the main foci of infection in urban and other densely populated communities. Alternatively, a national health authority may wish to start with selective vaccination in the main centres of population and to extend the programme, as resources permit, to community vaccination in the urban and then the rural areas . In compact and highly developed countries a start may best be made by introducing vaccination against measles into the regular sched- ule of immunization in childhood and, when sufficient progress has been achieved, initiating a vigorous effort to eliminate the disease from the en- tire country. Whatever the order of events, continued surveillance of the disease, of the effectiveness of vaccination, including the duration of the resulting immunity, and of adverse re actions to the vaccine is essenti al in order to assess the progress of the campaign and to make any necessary changes in policy or in the measures adopted for its implementation. REFERENCES ¥ Cumakov, M . P. et al. (1970) Epidemiological Review, 24 , 118 Scott, D. (1971) Amer. J. Epidem., 94, 37 Sutherland, I., & Fayers, P. M. (1971) Brit. med. J., 1, 698 War in, J.F., &Rodgers, J.S. (1 97 1)Med . Offr, 125,277 War in, J. F. (1 971 ) unpublished document 7 Introduction CONGENITAL RUBELLA AND ITS DIAGNOSIS by Professor J. A. Dudgeon The Hospital for Sick Children, London The viral etiology of rubella, although suspected for many years, was not finally established until 1938 when Hiro and Tasaka transmitted the disease to children with bacteria-free filtrates of nasopharyngeal washings taken during the acute phase of the diseas e . The report attracted little attention at the time because of the mildness of rubella as a human disease. Th e first indications of serious pathogenic properties of this virus were made by the late Sir Norman Gregg only three years later. Gregg's atten- tion had been drawn to an unusual epidemiological event - the appearance of a cluster of congenital cataracts in Sydney and in the surrounding area in New South Wales. Gregg also noted that the children were often small , ill-nourished, were difficult to feed and many had congenital heart disease. The link between these defects and rubella was established when Gregg ob- tained a history of rubella in early pregnancy from most of the mothers of these children (Gregg, 1941). Later Gre gg (1944) and Swan and his col- l eagues (Swan et al., 1943 ) discovered similar cases in which the outstand- ing anomalies were cataracts (usually bilateral), cardiac disease, deaf- ness, dental defects, mental deficiency and microphthalmos. Within the space of a few years confirmatory reports of the teratogenic role of ru- bella virus came from all over the world. These early studies from Australia e stablished a close association between rubella in early pregnan- cy and congenital malformations, but because of the retrospective nature of the surveys this risk (initially reported to be 80% following rubella in the first trimester of pregnancy) was almost certainly exaggerated. An opportunity to study this problem in more detail a rose in the nineteen-fifties when rubella appeared in epidemic form in several Euro- pean countries . Two important prospective surveys were carried out: one in Sweden and the other in the United Kingdom. Lundstr~m (1952) from Sweden reported the incidence of defects of the eyes, ears and heart together with stillbirths to be 11 %, 11 % and 8% for each of the first three months of pregnancy and 10 % for the first trimester. Manson and her colleagues in England reported the incidence to be 15. 6 "/o , 19. 7"/o and 13. O"/o for each of the first three months and 15. 6 "/o for the first trimester (Manson et al., 1960). These figures were based on a clinical diagnosis of rubella with a rash in the mother. As we now know that foetal damage can be caused by sub-clinical infection in the mother, these figures prob- ably underestimated the risk, just a s the earlier figures had ove restimated it. It is difficult to obtain precise figures relating to risk for a number of reasons, but one can conclude that, although the risk of foetal infection is very high following rubella in early pregnancy, this is not matched by a 8 corresponding high incidence of congenital defects (Dudgeon, 1969). Most authorities are agreed that the "at risk" period extends up to the 16th week, with a few cases occurring between the 16th and the 20th week. The over- all risk of foetal death, stillbirths and congenital defec ts during the first 16 weeks is between 20% and 30% (Dudgeon, 1967). A second important factor in the role of foetal infection is the immune status of the mother at the time of exposure to infection. The foetus is only at risk following primary maternal infection; it is not at risk after reinfection. These surveys by Lundstrom and Manson and her colleagues also established that the principal defects encountered were those involving the eye, hearing organs a nd the heart, occurring singly or in combination and sometimes associated with microcephaly and mental retardation. Those defects were known collectively as the "rubella syndrome" . It was also demonstrated that if children exposed to intra-uterine rubella were re- examined at intervals, the incidence of hearing defects observed later in childhood was much higher than when assessed at two years of age (Sheridan, 1964). T en years later rubella again appeared in epidemic form, first in Europe in 1962-1963 and then in more severe pandemic form in the United States of America from 1964-1965. Inevitably many young women were among those infected and, equally inevitably, many children were born with rubella defects. On this occasion, however, s eve ral new and unusual features were noted about these malformed children. Also by this time laboratory tests had been developed to detect rubella virus and to measure antibody, and the application of these procedures led to a better unde rstand- ing of the pathogenesis of foetal damage by rubella viruses. First, the number of cases observed was very great; to some extent it was a reflec- tion of the extent of the epidemics but was also due to more detailed assess- ment of the cases. Secondly, it was soon apparent that in addition to the classical type of rubella syndrome many "new" manifestations were ob- served which had either not been seen or had not previously been associated with intra-uterine rubella. Many infants were observed with purpura, hepatosplenomegaly, hepatitis and bone lesions to which various names such as the "expanded rubella syndrome" or "acute n e onatal rubella" were applied. Detailed clinical and virological examination of these cases re- vealed that intra-uterine rubella is frequently a multisystem disease in which many organs of the body may be affected. It is now generally ac- cepted that the term congenital rubella is the most satisfactory term for this condition. The effects of intra-uterine rubella are of a widespread nature (see fig. 1 ). It can be seen that virtually every organ in the body may be affected and one of the most important observations from the experience gained in 1962-1965 was the realization that multiple defects are extremely common in congenital rubella. One aspect is that several features may be limited to certain ages, and various combinations of defects may be observed in infancy and childhood (see table 1 ). 9 These types and combinations of d efects enabl e the clinician to sus- pect the presence of congenital rubella, which can be confirmed by means of laboratory tests. During the past few ye &.rs w e have made a detailed study at the Hospital for Sick Children in London of groups of children ex- posed to intra-uterine rubella. Many of these cases h ave been referred from different parts of the country or mate rial has b een submitted for laboratory investigation. The number of cases and the ir clinical classi- fication are shown in table 2. Main congenital rub e lla group: it can b e seen that the m a jority of thes e cases had multiple defe cts (255 out of 302) . This does not provide conclusive evidence on the rela tiv e incid enc e of multipl e and single defects becaus e the more severe cas e s are more like ly to be r e ferred to a spe- cialist hospital. Nevertheless, the more one sees of c ongenital rubella the more frequently on e finds multiple defe cts. The various combinations of defects in this group are shown in table 3. Congenital perceptive deafness: a special study was made on 160 cases of children with cong enital perceptive or sensorineural deafness. There was found to b e a higher incidenc e of rubella a ntibody in the deaf children under four years of age (54%) compared with 7. 1 % in randomly select e d children of the same age . Ther e was a very close correlation between the presence of antibody and a history of maternal rash or contact, but in 71 deaf children in whom there was no maternal history of rash or contact, 18 (25 % ) were judg e d to be due to intra-ut e rine rubella. If this a ssumption is corr ec t , then rubella is a more important cause of percep- tive d eafness than was previously thought to be the ca s e (Gumpel e t al. , 1971). The perc e ntage usua lly quoted is 5%. Children exposed to intra-ut e rine rubella but clinically normal at birth: this group of 228 children represents a highly s e lected group who have been studied by my colleag ue Dr Catherine Peckham. This was part of a more detailed study on the protective effect of immunoglobulin carried out by the Public He a lth Labora tory Service in England. The mothers of these children h ad b een exposed to rub e lla in pr e gnancy during an epidemic p e riod in 1961-1 962 ; the y h a d all rec e ived immunoglobulin, but despite this all had developed rubella which was diagnosed clinically. The child- ren had no obvious rubella defects at birth or within the fir st few months of life , but towards the end of the first year of life a numb e r of c a ses of deafness were r eported . Whe n examined at 1 to 3 years of age 22 % were found to b e d eaf and 48 % of the a ppa r e ntly normal children had rubella antibody in contrast to an expected figur e of 5 . 6 % in the control population (Butler et al ,, 1965 ). Some of these children hav e r ecently b een r e- examine d at 7 to 8 y ears of age a nd an additional number were found to have some degree of he a ring loss. However, this occurred only in those who w e re initially found to b e seropositive at 1 to 3 years of age . Those who were seronegative have remained normal . 10 Laboratory diagnosis Following the 1962-1965 epidemics three important observations were made which have since been used for the diagnosis of intra-uterine rubella. First, Plotkin et al., ( 1963) showed that rubella antibody was present in congenital rubella patients beyond the age of six months at a time when passively transmitted antibody from the mother should have dis- appeared. This finding was confirmed by Weller et al., (1964) and by other observers (Dudgeon et al., 1964, Cooper et al., 1965). Secondly, virus excretion in the urine and nasopharynx was found to occur in con- genital rubella patients in the first few months of life (Alford et al., 1964, Cooper & Krugman, 196 7) and thirdly, rubella antibody was detected in IgM immunoglobulin (Alford, 1965) indicating an immune response on the part of the foetus. Levels of total IgM which provide an additional marker of intra-uterine infection were found to be raised in many of these patients (Soothill et al., 1966). Depending on the age of the patient, the following tests can be utilized to make a laboratory diagnosis: (1) in the newborn: virus isolation from urine and nasopharynx; elevation of total IgM; detection of rubella antibody (haemagglutinin- inhibiting ( HI)) or virus neutralizing (VN); IgM antibody; (2) in infancy: presence of rubella HI or VN antibody after six months of age; (3) in children less than four years of age: presence of HI antibody. There are a number of patients who lack any detectable antibody, but this number is so small as not to invalidate the use of serology in retro spec - tive diagnosis. Recently, Cooper et al. (1971) have reported that in their experience 18. 5% of congenital rubella patients have lost HI antibody by their fifth birthday. Hardy and her colleagues had previously suggested that this may occur at an earlier age. We have been unable to confirm these find- ings. Marshall (1971) has found that although there is some decline in antibody after 12 months of age, decline in antibody to undetectable levels is an infrequent event in patients with multiple defects and in patients with deafness. The levels of rubella HI antibody in a group of 91 patients from birth to 17 years is shown in fig. 2. In our opinion, therefore, identifica- tion of intra-uterine rubella in children is possible by means of serological tests. 11 Fig . Fig . 2 ~D:18 1024 512 ~ 256 ~ 128 >- >, ~ 64 c <( :i: 32 ~ "' 16 .0 :::, °' 8 4 <4 MANIFESTATIONS OF CONGENITAL RUBELLA Low birth weight at term Failure to thrive Retarded growth MICROCEPHALY CATARACT CEREBRAL PALSY DEAFNESS RET INOPATHY Bulging and/or large --------~ Microphthalmos anterior fontanelle . :; . Glaucoma ·•_•:; Speech disorder -H • ·) Cloudy cornea ... Adenopathy Pneumonitis 0 - 2 months NGENITAL HEART DISEASE Myocardial damage Purpura HEPATOSPLENOMEGALY Jaundice - Hepatiti Osteopathy Shedding of virus 0 Infectiousness RUBELLA HI ANTIBODY LEVELS IN CONGENITAL RUBELLA PATIENTS WITH MULTIPLE DEFECTS FROM BIRTH TO 17 YEARS. 3 - 5 months 6 - II months 12 I - 4 years 5 - 9 years 10 - 17 years Table 1 SOME COMMON ASSOCIATION Of DEFECTS ACCORD ING In the Newborn In Infancy In Childhood I. LBW CAT CHD TO AGE 2. LBW CHD TCP HS Jaundice 3. LBW CAT CHD TCP HS Jaundice 4. LBW FTT CAT retinopathy CHD MR ?Deaf 5. FTT retinopathy CHD ?MR ? Deaf 6. FTT CAT CHD CP Deaf 7. Deaf MR Microcephaly 10. Deafness 8. Delayed Development and deafness 9. Deaf and/or retinopathy Deafness Single defects with the exception of deafness are uncommon in congenital rube!I~ LBW Low birth weight HS • Hepatosplenomegaly CAT Cataract FTT • Failure to thrive CHD Congenital Heart Disease MR Mental Retardation TCP Thrombocytopaenia CP Cerebral Palsy APPROPRIATE LABORATORY TEST FOR AGE In the Newborn Raised total lgM; Rubella lgM antibody; Rubella HI antibody In Infancy : - Rubella HI antibody In Childhood: - Rubella HI antibody 13 ..,. Table 2 Groue I Groue II PAT IENTS WITH CONGENITAL RUBELLA Inves tigat ed at the Hospital for Sick Children, Great Ormond Stre e t, London W. C . 1 Main congenita l rubella No. investigated No. excluded group Cases seen at or ~;:: referr e d to Hospital 302 l 5 for Sick Children Congenital e e rceetive or sensorineural deafness Cases of mod e rat e or severe perc eptive deaf · nes s seen at the 160 20 Nuffield Hearing and Speech Centre, Gra ys Inn Road Groue III Infants exeosed to intra-uterine infection 228 - but "normal" at birth * Insufficient dat a a v a il able Number accepted or comple t ed for analys is 287 (32 single defects 2 55 multipl e defects) 140 228 ...... U1 Table 3 DETAILS OF PATIENTS WITH MULTIPLE RUBELLA DEFECTS ACCORDING TO AGE AND SEROLOGICAL STATUS Rubella antibody status Type of defect 6 months - 4 years Total Seronegative Seropositive Two defects CAT+ CDH CHD + CPD 4 CHD + Retinopathy CHD + CNS Three defects CAT: CHD: CPD 2 CAT : CHD : CNS Multiple above + TCP: HA 2 FTT Total 8 Key to abbreviations: CAT CHD CPD CNS TCP HA FTT 68 72 88 90 91 93 247 255 Cataract Congenital heart disease Congenital perceptive deafness CNS disease Thrombocytopaenic purpura Haemolytic anaemia Failure to thrive Number showing presence of antibody 68/72 88/90 91/93 247/255 REFERENCES Alford, C .A., Neva, F.A. & Weller, T . H . (1964) New Engl. J. Med., 271, 1275 Alford, C . A . (1965) Amer . J. Dis. Child., ll0, 455 Butler, N.R . e t al. (1965) Brit. med. J., I, 1027 Cooper , L.Z . e t al. (1965) Amer. J. Dis. Child., ll0, 416 Cooper, L.Z . & Krugman, S. (1967) Arch. Ophtha l., J.J...., 434 Cooper, L.Z . e t al . (1971) Amer. J. Dis . Child,, 122, 397 Dudgeon, J.A ., B utl e r, N.R . & Plotkin, S.A. (1964) Brit. m e d . J ., I, 165 Dudge on , J.A . (1967) Arch. Dis. Child., 42, 11 0 Dudge on, J.A . (1969) Amer. J. Dis. C hild., 118, 35 Gregg, N . McA. (1941) Trans. Ophtha l. Soc. Aust., i, 35 Gregg, N . McA . (1944) ibid., 4, 119 Gumpel, Shirley M., Hayes, Kathleen & Dudgeon, J .A . (1971) Brit. med .J:.., ~' 300 Lundstr~m, R. (1952) Acta. Paediat. (Uppsala), .!.!_, 583 Manson, M. M ., Logan, W. P. D. & Loy, R. M. (1 960 ) Rep. on Puhl. Hlth Med. Sub., 101 Marshall, W.C. (1971) Personal communication a nd thes is presented to the University of London Plotkin, S.A . , Dudg eon, J .A. & R,msay, A .M. (196 3) Brit . med J ., ~' 1296 Sheridan, M. D. (1964) Brit. med. J., I, 536 Soothill, J .F ., Hayes, Kathleen & Dudgeon, J. A . (1966) Lanc et, _.!., 1385 Swan, C. et al. (1943) Med. J . Aust., I, 20 1 Weller, T.H . , Alford, C.A. & Neva, F.A. (1964) New E ngl. J. Med., 270, 1039 16 CONGENITAL RUBELLA SURVEILLANCE by Professor J. A. Dudgeon The Hospital for Sick Children, London Any programme of immunization against an infectious disease should include a surveillance programme to determine whether the immunization scheme adopted is having the desired protective effect. This has been well illustrated in the case of diphtheria, whooping cough, poliomyelitis and measles. It is equally important in the case of rubella because the vaccination programmes at pre sent recommended, for example in the United Kingdom and the United States, differ in their approach. The ob- ject of immunization is to prevent or control congenital rubella defects. There is good reason to believe that foetal damage from intra-uteri n e ru- bella is associated with primary maternal rubella in early pregnancy, therefore there is a prima facie case for active immunization. There is no evidence as yet that reinfection has ever led to congenital defects. As there are wide differences in the approach to immunization in different countries it is important to know, for example, whether mass vaccination of children early in life will continue to protect when these children have reached adult life. It is equally important to know whether the procedure of selective immunization recommended in the United King- dom, largely on account of uncertainties about the long-term protective- ness of vaccines administered in childhood, will also control the incidence of defects. Whichever method is adopted it should be possible to tell by means of a surveillance programme whether vaccination is effective. 1 The National Congenital Rubella Surveillance Programme now in operation in the United Kingdom is based on the following assumptions : (1) Congenital rubella can in most cases be diagnosed with a fair degree of accuracy on clinical grounds. (2) Laboratory diagnosis tests can provide confirmatory evide nce in the majority of cases. (3) The organization of a surveillance programme is facilitated in countries with a national health service and school medical service. The Surveillance Programme in the United Kingdom was set up in 1971 with two central registries, one in the north of England at Leeds and 1 Dudgeon, J. A. (1971) Pan Amer. Hlth Org., Scientific Pub. No. 226, p. 251 17 the other at the Hospital for Sick Children in London serving the southern part of the country. The scheme is organized for the Department of Health and Social Security and its succe ss depends on the voluntary co- operation of individual doctors, paediatricians and medical officers of health. It is ac tively supported by the ir professional associations, the British Paediatric Association and the Council of the Society of Medical Officers of Health. Patients suspected of having c ongenital rubella are referred to the registries from three sources : (a) from paediatricians: the se are in the main hospital referrals from paediatric departments where there is a strong presumptive diagnosis of rubella, or are patients "at risk" because of a history of rubella in pregnancy; (b) from phys icians in hearing a ssessment centres: all cases of c ongenital perceptive or sensorineural deafness up to the age of four years are referred for labora tory diagnosis ; (c) from medical officers of health : there are four main categories of referral s from this source. Category 1. Children aged 6-18 months referred by health visitors because of a "failed screening test for hearing" a nd subsequently seen in welfare clinics where a more d e tail e d test for hearing is carried out. Category 2 . Patients aged 5 years who at their first school medical examination are seen by an otologist because of deafness and the type of deafness is found to be of the sensorineural type. C a tegory 3. Patients aged 2-4 years who are seen in welfare or toddler clinics and in whom deafness is suspec ted. Such patients are probably present because of problem s with speech. Category 4. Patients born to mothers with a rubella rash in preg- nancy who have been placed on an "at risk" register by the local authority, even though no clinic al abnormalitie s have been f ound on clinical examination. Case report forms A special form for computer analysis has been devised (see Annex I ). The data to be recorded are as follows: detail s regarding the patient and instructions for completing the form (cover page); details of child's clinical condition; details of the history of the pregnancy, and details of laboratory diagnostic te sts. 18 Laboratory diagnosis Details of the tests used have already been referred to in the pre- ceding paper "Congenital Rubella and its Diagnosis". An important feature of the serological tests for rubella HI antibody has been the adaption of the microtechnique on capillary blood samples collected on absorbent paper ( see Annex II). A sample of blood from the mother is also collected on this type of paper. This method of collection of blood has been found to be very prac- tical for children attending clinics. Venous blood is collected from in- fants and children who are referred from hospital. The results of a typical case of congenital rubella referred to the registry are shown in fig. 1. Fig . 1. 6A FURTHER RESULTS Of LABORATORY INVESTIGATIONS C. R. IS) ( . Child .. 71/1 . . C.JUW. f No. Tiahy N, 11et 4/3n5 Mother . .7l/~ ... Rubella at R/r-. 2 Previous No : ~ LHW, PDA, CAT, HS, TCP 0 0. ., ~ 0 ,c C 0 ~ ., > 0 a.. SOURCE SPECIMEN DATE OF COLLECTION Child Serum 25.1.71 " 1.2. 71 Urine 25. 1. 71 Mother Senun 25. 1. 71 COMMENTS : Congenit-al Rubella confirmed -'en~enilal R ubo!l.l-StiSfl~ ..CoPgepjl;,I llubiU..AOl..coAI.U-lll8d DATE OF TYPE OF TEST RESULT TEST aet 4 d HI 64 aet 11 d IGM 36:(. (N) aet 4 d Culture Rubella virus+ HI 128 Other Co'llments : Typical case of congenital rubella, confirmed virologically and at autopsy . Signed .... '1-M .. Date .... _JllJle __ l _!ff~ . .. . The response to this scheme so far has been extremely satisfactory due to the excellent co-operation which has been obtained. Its continued success will depend on the close contact between the doctors who refer cases and the staffs working in the central registries, and more especially upon the exchange of information between the two. The scheme outlined can provide a guide regarding the incidence of congenital rubella and can also provide clinicians with valuable information on the cause of defects, thus helping to identify a child who may be at risk before any defect be- comes obvious clinically. 19 ANNEX I Name ... Referr ing Hospital /Centre Referring Doctor Address UNITED KINGDOM CONFIDENTIAL CASE REPORT CONGENITAL RUBELLA SURVEILLANCE PROGRAMME Central Registry ISouthl Reference No. INorthl Child .. Mother l. The Surveillance Programme for England and Wales will be run by two Central Registries set up for this purpose. They are located as folla,vs: • Hl North !serving Reg ion al Hospital Boards I, 2, J, II, 12, 13, 141: • Professor R. W. Smlthells, Department 01 Paediatrics and Child Health, 27 Blundell Stroet, Leeds LSI 3£T Itel : 22419 and 234551 121 South !serving Regional Hospital Boards 4, 5, 6, 7, 8, 9, 10. 151 : • Dr. J. A. Dudgeon, Department 01 Mlcroolology, Hospital for Sick Chi ldren, Great Ormond Street, London WCIN JJH Itel : Ol · 405 9200, Ext. 3051. 2. Doctors seeing patients with suspected congenital rubella are asked to notify the case by sending clin fcal details on the case report specially oesfgned for th is purpose and appropriate liboratory specimens to the Central Registry serving the Reg ional Board In which the referring hOS!)ltal Is located. J. Reports will be sent direct from lhe Registries to the referring doctor. A Xerox copy 01 this case report will be retained in the Registry INSTRUCTIONS The record form Is divide<! into six sections. You are asked to complete parts I - 5 as full y as possible. The folla,v ing notes are for guidance Section I : IDENTIFICATION Where born . enter the address 01 place 01 birth, including name and address of hOS!)ltal If kna,vn . Section 2: CLINICAL MANIFESTATIONS Section J : DEFECTS Section 4 . DISEASE IN INFANCY Sect ion 5 : MATERNAL HISTORY It Is Important to !!..llli, the findings NO/YES/? as this Is clearer Jnd less liable to error than a line deletion. No. 01 Pregnancy : Include spontaneous abortion or terminated pregnancy Section 6 : LABORATORY INVESTIGATIONS PLIASE LIAVE BLANK Specimens required for laboratory diagnosis . The laboratory diagnosis 01 congenital rubella fs made by antibody and immunoglooulln tests on serum. The type 01 test perfor med depends on the age 01 the child !see back page of this report . l For this purpose It is preferable to collect J-5mls. 01 whole blood from child and mother. The blood should be collected into a dry sterile container, without anticoagulants or preservatives, labelled with date a collection, the patient' s name and date 01 birth and posted to the Central Registry on day 01 collect Ion by first class mall. Alternatively, where facilities !or collecting blood by venl11uncture are not available, a screening test may be carried out by collecting capillary blood by finger11rlck on to sheets 01 fllttr paper specially prepared for the purpose and libelled Congenital Rubella Surveillance Programme. 20 I. IDENTIFICATION Patient's Surname . . ....... . .. . Forename .. .. . .. ............ . ...... .. . • Date of Birth .................. .. ............ .. Where born Age Mother 's Name ....... .. Home Address .. ..... .. National Health No. Sex Nationality Race Patient ...... .. . ..... Mother . .. . Referring Hospltal Registration No. Caucasian/Negro/Mongoloid Patient .... ..... .. ... Mother .. Please RING findings Negative. Positive or Suspect -1. e. No/Yes/? Do NOTtlck or cross out Insert data. e.g. weight etc. 2. CLINICAL MANIFESTATIONS Date ...... / .... /. .... B lrth weight ...... .. gm. Present weight .. . .... kg. One of Twins : No/Yes Dates of: - Gestational age . . ... wks. Dysmaturlty : No/Yes Present height . .. .. . cm. Monozygotlc/Dlzygotlc/N. K. First Symptoms .. I ... I .... : Admission ... / .... /.. : Discharge ... / .... /.. : Death* ... I. .. I .. 3. CONGENITAL HEART DEFECT NO/YES/? 4. Specify .. ••• ••••••••••• ••• ...... .. ........... I.ERVOUS SYSTEM DEFECT NoiYES/7 Fits No/Yes/? Mlcrocephaly No/Yes/? Cerebral Palsy No/Yes/? Mental Retardation No/Yes/? Encephalltls/Menlngltls No/Yes/? Full Fontanelle No/Yes/? other No/Yes/? Specify .... ................... EYE DEFECT NO/YES/? Cataract Rt No/Yes/? u No/Yes/7 Mlcr~hthalmos Rt No/Yes/? Lt No/Yes/? Retln~athy Rt No/Yes/? Lt No/Yes/7 Glaucoma Rt No/Yes/? Lt No/Yes/? other Visual Rt No/Yes/? Defects Lt No/Yes/? Specify ........... .. . . .. Rt No/Yes/7 DEAFI.ESS !Congenital Perceptive I Lt No/Yes/7 Moderate/Severe OTHER DEFECTS Inc luding gastro- Intestinal genitourinary. musculoskeletal NO/YES/? Specify. 21 DISEASE IN INFANCY Rash No/Yes Specify Failure to Thr ive No/Yes Heart Failure No/Yes Hep at omega ly No/Yes Splenomegaly No/Yes Prolonged Jaundice No/Yes Hepatitis No/Yes Thrombocyt~aenla No/Yes Purpura No/Yes Anaemia No/Yes Respiratory I nfectlon No/Yes Diarrhoea No/Yes Adenq,athy No/Yes OTHER INFa!MATION e.g. Virus Culture In referring hospltal No/Yes Results: *P. M. Report Annex I Annex I No. of Pregnancy: 5. MAT~RNAL HIST~Y Mother 's date of birth Normal Pregnancy: No/Yes Specify Abnormality ..... . • Contact In Pregnancy : NOIYl:S Rubella Rubella Vaccinated lndlvklual Other Speclly . No/Yes No/Yes No/Yes Type of Contact : Household No/Yes Other No/Yes 1 llness In Pregnancy : NO/YES/? Rubella with rash Rubella wltnout rash Sore throat 'Influenza' Febrile Disease Undiagnosed Rash Undiagnosed llespiratory Disease Undiagnosed Immunizations !include rubella vaccine and datel Specify .......... . Immune Globulin !Include date and dost No/Yes No/Yes No/Yes No/Yes No/Yes No/Yes No/Yes NolYes No/Yes . . . . . . . . . . . . ) OTHER INF~MATION Specify family history In close relatives e. g. deafness 6. RESULTS OF LAB~AT~Y INVEST)GATIONS C. R.IS)lNo·Chlld ... C.R. INI • Mother .. SOURCE SPECf1,1£N DATE OF COillCT lON Child Mother COMMENTS : Congenital Rubella confirmed Congenital Rubella suspecte<l Congenital Rubella not confirme<l Previous No: DATE OF TYPE OF TEST TEST Other Comments : RESULT Signed ......... . .. . . . . .. . . Date 22 ANNEX II CONGENITAL RUBELLA SURVEILLANCE PROGRAMMf MOTHER'S BLOOD ·-- NAM£ (Please RING findings! NATIONAL HEALTH No. Hf kna,vn) Rash in Pregnancy : NO YES - Birth Date Date Blood Taken HC>flE ADDRESS Contact with Rubella : NO YES - -in Pregnancy : DOCTOR: (For office usel CLINIC : CR (SJ No : HI Titre : LOCAL AlrrHOR ITY : Date tested : FINGER PRICK CARD SHOULD BE HELD CLIAR OF TABLE- Please 1111 each circle with blood, approx. 4 drops in each, r lace card Immediate! In ol hene envel<ljle 0000 Prepared by The Hospital For Sick Children. Great Ormond Street, London WCl ~JH CONGENITAL RUBELLA SURVEILLANCE PROGRAMME nurnnn m CHILD 'S BLOOD l!JWUl1W NAME NAT IONAL HEALTH No. (if known) Birth Date Date Bloo:l Taken HOME ADDRESS DOCTOR : CLI NIC: LOCAL AUTHORITY: FINGER/HEEL PRICK: Hold card clear of table . Please ti II each circle with blood. Replacecard in polythene envelope when dry. 0 0 0 (Please RI NG findings) MOTHER Rasn in Pregnancy: NO ? YES - - - Contact with Rubella in Pregnancy: NO ? YES --- CHILD -- Perceptive Deafness: NO ? YES - - -Rt. /Lt. /Bi lateral ot l1er Defects: NO ? YES - -- Type: For Laboratory Use CR No: Date tested: HI titre: Produc«I l)y Hit HoS9lt1I For Sick (hildrtn, CtUI Orl'IOnO SlrN1. Lonoon WC IN )JH 23 - INTERNATIONAL VENEREAL DISEASE CONTACT-TRACING PROCEDURES IN EUROPE by Dr R.R. Willcox Consultant V e nereologist, St. Mary's Hospital, London 1. Introduction A review is made of the scope of existing international venereal dis- e ase contact-tracing activities in Europe on the basis of the replies to a simple questionnaire sent in 1971 by the World Health Organization, Re- gional Office for Europe, to the 31 Member States in the Region. This questionnaire (Appendix 1) requested information on the exis- tence or otherwise of international venereal disease contact-tracing facili- ties and of an office dealing with such contact-tracing; it was also aimed at ascertaining whether efforts were being made to trace contacts of gonor- rhoea cases as well as those of primary and secondary syphilis, and at establishing the numbers of incoming and outgoing notifications relating to both diseases during 1970. Copies of any standard forms used in t:qese procedures were also requested. All but seven countries had replied by the time this paper was pre pared. Some limited data on the results of international contact-tracing, ob- tained from one European country, are also presented. 2. Countries not undertaking international contact-tracing Ten countries, i.e. Algeria, the Federal Republic of Germany, Greece, Iceland, Ireland, Malta, Monaco, Morocco, Romania and Spain, stated that they did not normally undertake such work. Two of these, however, the Federal Republic of Germany and Romania, reported the existence of an offic e whe re incoming data w e re handled, and one, Romania, had indeed sent some outgoing notifications. 3. 3. 1 Countries undertaking international contact-tracing Organization All 14 countries stating that they undertook such work did so for both primary and secondary syphilis a nd for gonorrhoea, and some (e.g., Sweden), where necessary, also for other venereal diseases (e.g., lympho- granuloma venereum). These countries (Belgium, Bulgaria, Denmark, Finland, France, Hungary, Luxembourg, the Netherlands, Norway, Poland, Portugal, Sweden, the United Kingdom and Yugoslavia) all stated that there was a central office which handled such matters. 24 3. 2 Incoming notifications The numbers of notifications received by the various countries of contacts of patients with primary and secondary syphilis and with gonor- rhoea during 197 0 are summarized in table 1. Table 1 CONTACT-TRACING IN EUROPE: INCOMING NOTIFICATIONS IN 197 0 Country Primary and Gonorrhoea secondary syphilis Belgium 18 1 Bulgaria 2 4 Denmark 15 64 Fed . Rep. of Germany 9 41 Finland 6 115 France 27 35 Hungary 3 40 Luxembourg 0 4 Netherlands 2 8 Poland 6 10 Romania 14 5 United Kingdom 24 36 Yugoslavia 10 35 136 398 Sweden reported a combined total of 35 cases of both diseases; Norway and Portugal did not provide figures. 3. 3 Outgoing notifications The numbers of notifications sent to other countries concerning con- tacts of patients with primary and secondary syphilis and with gonorrhoea in 197 0 for those countries providing figures are shown in table 2. Sweden reported a combined total of 434 cases for both diseases; Portugal had not yet separated external from internal notifications. 25 Table 2 CONTACT-TRACING IN EUROPE: OUTGOING NOTIFICATIONS IN 197 0 Country Primary and Gonorrhoea secondary syphilis Belgium 2 0 Bulgaria 3 2 Denmark 3 39 Finland 0 18 France 109 54 Hungary 5 21 Luxembourg 0 2 Netherlands 33 78 Poland 18 19 Romania 8 4 United Kingdom 7 41 Yugoslavia 9 0 197 278 3 . 4 Forms used 3. 4. 1 For international transmission Some standardization has been achieved within Europe, in that five countries (Denmark, the Federal Republic of Germany, the Nethe r- lands, the United Kingdom and Yugoslavia} already report on the same simple form written in English (Append ix 2). Sweden also uses a simple form written in Swedish. This is em- ployed for many communicable diseases and syphilis (early and late), gonorrhoea, soft sore and lymphogr a nuloma venereum are only five of the 52 conditions involved (Appendix 3). The remainder of the countries undertaking international contact- tracing (Belgium, Finland, France, Hungary, Luxembourg, Norway, Poland, Portugal} stated that no set form was employed but that reliance was placed on individual letters between the respective ministries of health or their equivalent. 26 3. 4. 2 For internal transmission Countries responding to the questionnaire (apart from Bulgaria) did not send the forms in use for internal contact-tracing, although such forms are necessary in the clinic for recording the information which is passed to the central office. The form used in this manner in the United Kingdom, which is also employed routinely for internal contact-tracing between clin- ics, is shown in Appendix 4. This form may, on occasion, if the data are more than usually involved, be additionally transmitted internationally. Neither were internal operational forms submitted. Appendix 5 is a copy of the card onto which the relevant information on incoming forms is trans- cribed by the Local Health Authority (City of Westminster) of London, and which is then used at clinic level as a working document. This is ul- timately permanently filed by the Local Health Authority. 4. Results of international contact-tracing The results obtained in one European country (England and Wales), where incoming and outgoing forms are handled at the Department of Health and Social Security, 1 are shown in table 3. Table 3 INTERNATIONAL CONTACT-TRACING IN ENGLAND AND WALES (July-December 197 0) Incoming Outgoing Information received 46a 54 Sufficient to pass on 41 28b Later reply received 23 10 Unable to locate 12 3 ? Mistaken identity 1 - Traced , found negative 3 3 Traced, status unknown 2 - Already under treatment 2 2 Found infected and treated 3 2 Total 100 69 33 15 1 6 2 4 5 a USA 13, Sweden 12, the Netherlands 10, Canada 5, Denmark 3, others 3 b USA 8, Malaya, the Federal Republic of Germany, Poland and Spain 2 each, 12 others 1 each 1 Figures by courtesy of Dr J. H . Berrie 27 In London, a total of 20 forms were passed during 197 0 by the Department of Health and Social Security to the Health Department of the City of Westminster. It was stated by Mr G. Peters, who under- takes this wo-rk, that 4 of these could not be traced because of lack of in- formation on the notifications, 4 had moved from the addresses given, 11 were traced and treated and 1 was traced but refused treatment. The majority of overseas notifications were from Canada, Denmark, the Netherlands, Sweden and the USA and frequently concerned either sea- men or members of the entourage of pop groups touring Europe, both types being difficult to trace owing to mobility. The shipping companies were reported as being helpful in giving information concerning ports of call of their vessels, as were pop magazine editors in providing information on where pop groups were appearing in the United Kingdom. If the numbers of foreign contacts seem to be small it should be re- membered that the maj ority a re not notified by the clinics to the centre as it is frequently assumed to be a hopeless task even to try to trace them from the scanty information provided. In other cases friends are involved and reliance is placed on voluntary persuasion of the patient by letter or by telephone. The total number of infections believed to have been im- ported into England in 1969 is shown in table 4. Table 4 IMPORTATION OF VENEREAL DISEASE INTO ENGLAND - 1969 Primary and Gonorrhoea Infection secondary syphilis Number Percent Number Percent Total cases reported 1 265 - 50 037 - Cases on which data 1 199 100.0 49 910 100.0 available Contracted in England 939 78. 3 47 013 94. 2 Contracted abroad 205 17. 1 1 858 3.7 Not known 55 4.6 1 039 2. 1 {From Report of Chief Medical Officer, Department of Health and Social Security for the year 1969) 28 APPENDIX 1 QUESTIONNAIRE ON NOTIFICATION OF THE INTER-COUNTRY SPREAD OF VENEREAL DISEASES One of the items on the agenda of the Working Group on the Inter- Country Spread of Venereal Diseases to be held in Copenhagen, in December 1971, is a consideration of methods at present in use for the inter-country tracing of contacts of patients with syphilis and gonorrhoea. In order that the meeting may have all available data for its consider- ation it would be greatly appreciated if y ou could kindly answer the follow- ing simple questions. (Please tick as indicated.) 1. A re there any arrangements in y our country to notify other countries of patients with: (a) Infectious syphilis (b) Gonorrhoea ( c} Both diseases? 2. Are there arrangements made through one governmental office? Yes No 3. If the answer to 2. is "yes 11 , a pproximately how many forms were received from, and sent out to, other countries in 197 0? Number received Number sent out 4. Have you a standard form which is used for the purpose of inter- country contact tracing? Yes No (Please send a copy or copies of th e forms used) 29 APPENDIX 2 UK FORM ADOPTED FOR USE IN FIVE EUROPEAN COUNTRIES Department of Health and Social Security Alexander Fleming House, Elephant and Castle London, S. E. 1 In strict medical confidence Dear Sir, Venereal Disease Contacts I send herewith information received about a venereal disease contact, and would be grateful for the return of the completed copy of this form. Venereal disease contact Surname: Age: Marital status: Address: Place of encounter: Other impo rtant data: C o ntact reported b y patient with 0 s yphilis, stage: D o ther V. D. , specify If infected, give disease: O not infected J. R.H. BERRIE Senior Medical Officer Christian name: Sex: 0 gonorrhoea stag e: D infected , brought to treatment (previously untreated for this infection) D infected, returned to treatment for this infection 0 previously treated for this infection 0 infected; not treated D unable to locate D located, examination refused 0 insufficient information to start investigation 30 I. ,.) . . . . . . ~ 0 0 :,,: :::, .. . V I ~ c( VI I:: i VI > c( ... ... c( ... ~ 0 z s jct ~ z c( M ot to go re ns o n te ck ni ng ar ln sju lm od d en 11 I an I kom m un (a n ge s o ve n fo r sm itt ba ro re ) ln fe kt io ns or t A rb e ts pl ot s, sk ol o, bo rn he m e l dy l fa r de n a n m o ld e V O rd os i I Sju kh us e h n a m n 01 Op pe n 02 sl ut en v br d v br d R em itt er on de I O ko re (a ng es a v o n m O lo nd e sju kh us l6k or e) C ra ig o u pp g ift er a v e pi de m io lo gi sk b et yd el se : Sm itt kd llo , sm itt v6 go r, o n dr o a n m O rk ni n gs vO rd o o m s td nd ig he te r (t e x liv sm ed el sh on te rin g) v id to gn o sm itt - sk yd ds 6t g0 rd er m m :~" T~6 ~l dog I nr N om n {Ej v id v e n e ris ka s juk do mo r) Yr ke [ti 'te l A dr es s Te l N at i~ no li t8 1 · tom e l" "Sv en sk ) A llm iin fa rli ga s juk do ma r 1 2 0 SL uk do m sf al l _ 0 Sm itt bo ra re G ru pp I (s e ba ks id on ) 1 ~ M 2 □ Kv O vr ig a B ak te rie sju kd om ar D 4 1. B ot ul is m Be tr O ff on de v e n e ris k sju kd om v pp ge s de ls sm itt k6 llo , de ls ev ko nt ok te r, i JD bO da fa lle n m ed n o m n , o dr as s, te le fo n o ch u n ge f6 rli g l:i ld er . G ru pp I I D 7. Ty fo id G ru pp V D 1 8. D ift er i D 4 2. G os tr oe nt er it , e lo ko rt od , ho s bo rn i 6 ld em u n de r tv 6 6r • D - 43 . Li st er io s O rt , da tu m l6" k~ -~~ ~ ~ - . ~ ~ d~ ;~-k ~W t;. -,~ j~f On . - So c st yr I 2 80 Fo st dc ill d de n 3 ~ - = 19 68 D 8. Pa ra ty fo id • D 9. Sa lm on el lo di a rn , • D 1 0. Ba ci llO r dy se nt er i• 0 11 . A m O ba dy se nt er i G ru pp I ll 0 12 . M en in go ko ck sju kd om D 1 :t. Po lio • D U . Pr im 6r , ic ke v a ri g hjd rn - o ch h j6r n- h1 nn ei nf lo m m ot io n• G n, pp I V (s e ba ks id on ) D 1 5. W ei l, sju kd om o ch a n dr o le pt os pi ro se r• D 1 6. Ep id em is k gu ls ot 0 17 . ln ok ul at io ns gu ls ot Ev ty p M ot ta go re ns a n te ck ni n g D 1 9. M jol tb ro nd D 2 0. Pa pe go jsj uk o o ch a n dr o o rn ith os er • G ru pp V I (se ba ks id on ) D 2 1. T ub er ku lo s D 2 2. Le pr o D « . Sc ho rlo ka ns fe be r D 4 5. Tu lo re m i D 4 6. U nd ul on tfe be r D 4 7. St el kr om p M a1 ks juk do 11 1a r 0 48 . Fi lo rio s• Ve ne ris ka s juk do ma r D 4 9. Sc hi _ st os om io si s• D 3 1. Sy fil is o ) m e df od d D 5 0 • Tn k, no s D 3 2. b) f6 rv or vo d D 3 3. G on or re D l 4. M juk s ch an ke r D 3 5. V en er is kt l ym fo - gr on ul om Pr ot oz os iu lc do ,,n ar D 5 1. M al ar ia • D 5 2. Ta xo pl os m os D U C 0 -4 12 9 >T j 0 :::0 ~ C: C/l tr1 tJ ,_, z C/l ~ tr1 tJ tr1 z ► t-c, t-c, M z tJ ,_, ~ L,) APPENDIX 4 FORM USET) IN THE UNITED KINGDOM f.'I CONFIDENCE Special Clinic Contact Report (Rev. 9/70} ref. No. To: The Medical Officer of Health/ Director of Special Clinic. (delete as applicable) A patient al this clinic uadcr lrl!atinent for of app roximately days/weeks/months duration has disclosed IN STRICT CONFIDENCE the information overleaf about an alleged contact. Signed ..... Designation for Director . Address .. . . . Special Clinic date Note : To fill in this form put ticks in the boxes aiain.\t the releva nt features , and comments in the spaces. For example, in the item for hai r ""blonde" might be wrillen in the space to the right of ··colour" a tick put against "d yed" and "ponytail" written in th e space to 1he right of " st}le". 32 19 IN CONFIDENCE PART I A ppendix 4 THIS FORM SHOULD BE DESTROY ED AS SOON AS Name and Nickname M ale/ Female Aae: Year~: Occup.11ion : MARITAL STATE 1 ----- - ·· ·- ----1··-- -- ·--1 Single j M,u·ricd ~cparntcd Widowed DESCRIPTION I j _ __ ◊t:r--de~~ European Afric..:n or Indian or APPEARANCE \\ <.st l i.dian Pak istani HAIR Colour I Wig I DycJ ~ Style HEIGHT Tall Short Medium I Approx. ht. ft. ins. BUILD Thin I Slim Medium ] Plump J Stout DRESS Well dressed 7 I Ordinary Dressed I I Unkempt Accent a nd Spcc.:ch Type of Contac t ·-··· PART IIA To be completed when address of contact is known A ddress . Hou~c _______ ,_ F_la_t _________ _ ~_R_o_o_n_, _______ ] ~ -F_lo_o_, __________ ,I_B_a_ck _____ ~_F_ro_n_t =:J,_M_ id_J_lc _________ ~ Time or arrival home ____ _ ··---------------~ I with fricllJ ~--------------'------- -- Living alone Y.ith fam il y l'ART 118 To be completed only "'hen address of contac t is not known ADDITIONAL DESCRIPTION Colour of Eyc.s (.ilas~cs .. Naib MARKS Teeth ____ .... ~F_r_cc_k_l_e, ________ ,I _ T_•t_"_'o_, ______ ~_P_im_p_lc_, _____ ~[_sc_a_r_, ________ ··- _J Physical Defec ts ~~- .. ~--- Habit, Head Gea r .. Coa l i-ootwcar Accessories 33 Appendix 4 PART III HAS BEEN DETACHED AND DESPATCHED Other Details Places frequented by contact. . Most likely place to find contact Most likely times Possible district of residence Other information_ r------------------------------------------------------------ 1 I STRICTLY CONFIDEJ\TIAL To the Physician-in-Charge. Address of Specia l Clinic Patient's Ref. No From Date The person (con Lael) dcscrih·d 111 !'art I "as: (a) Located Not located (b) Examined at Not examined (c) Already under treatment Brought und er treatmen t (d) In fected with Not infected •delete as applicable. Signed dl!~ignation . 34 CONTACT TRACING REPORT PART IJI t•C.I. Form No. • Medical Officer of Health/ Director of Special CLinic. date 19 .. A PPENDIX 5 C AR D USED BY LOCA L H EA LTH A UTHORITY, LONDO N CITY OF WESTMINSTER HEALTH Department Name No . Address Description Nationality Age Height Build Eyes Hair Coloured Yes / No Other features Disease D of E Place Frequents Received from Date Returned Report 35 PROBLEMS AND IMPLICATIONS OF PUBLIC HEALTH METHODS AS APPLIED TO TRACHOMA CONTROL PROGRAMMES by Dr B. Nizetic Regional Officer for Public Health Ophthalmology WHO Regional Offic e for Europe, Copenhagen, Denmark In providing eye health care for the population, two different ap- proaches a re possible . The first is the "horizontal" appr oach, whereby the overall eye health problems are tackled on a wide front and on a long- term basis through the creation of a system of permanent institutions (ophthalmological infrastructure). On the other hand, the trachoma control problem, in its manifold aspects, is tackled in endemic areas by the so-called ''ver tical" approach, whereby the solution of a given eye health problem is sought through the 1 application of specific measures by means of a single-purpose machinery. These two approaches are not mutually exclusive as they represent the same effort for eye health and the same final objective. Several trachoma control programmes have shown the need to ob- tain the b est possible knowledge of the local epidemiological b ehaviour of this disease before launching large-scale ope rations for its control. In the later stages ("consolidation" and "mainte nance" phases) incorpora- tion into general health services becomes increasingly important in strengthening epidemiological surveillance. This process of integration and the continuation of activities (especially the long-term coverage) are dependent on the existence and efficiency of general health services. Along with other factors, the latter is also challenged, in some hitherto trachoma-endemic countries, by induced alterations of ocular pathology resulting from intensive preventive and curative mass-control and other appropriate measures. These induced alterations, taken together, mean a considerable change in needs and demands for a more specialized medi- cal eye care and service. The constant confrontation with limited resources is a general and addi tional factor calling for better management of all (preventive, cura- tive and rehabilitative) eye health services and for making a comprehensive systems approach mandatory in the field of public health ophthalmology m general and in long-term ey e health planning in p a rticular. 1 The term "mass campaign" has become widely accepted for this type of programme. 36 The process of better management involves a wide variety of activities, including diagnosing existing and anticipated problems; assess- ing the significance of problems and defining aims and objectives in re- lation to them; finding alternative means for meeting objectives and mak- ing rational choices between them; obtaining the necessary resources; defining tasks of organizations, groups or individuals in order to make the best use of available skills; development of necessary manpower; com- munications; concern with morale, motivation, etc.; monitoring, control and evaluation so as to adapt and learn in the light of experience. In the early planning stages of trachoma control programmes, more stress is given to problems arising from the shortage of resources, where- as in the later stages, in many instances, emphasis is shifted, as in more developed countries, to the problems of co-ordination within the increas- ingly complex health systems, The appropriate use of clinical knowledge, epidemiological methodol- ogy and modern management procedures is a prerequisite for a lasting solution of the problem of trachoma-induced visual impairment and blind- ness in the community. 37 THE ROLE OF MODERN LABORATORY SERVICES IN THE SURVEILLANCE AND CONTROL OF COMMUNICABLE DISEASES by Dr A.H. W. Wahba Regional Officer for Health Laboratory Services WHO Regional Office for Europe, Copenhagen, Denmark Introduction The apparent conquest of many communicable diseases in the European Region may have led to prematurely optimistic attitudes which, in turn, may have caused some setbacks in the control of these diseases. On the national level, improved hygienic measures, immunization prog- rammes and the increasing use of antibiotic and chemotherapeutic sub- stances have greatly helped to stabilize the epidemiological situation wherever these measures have been carefully applied . On the other hand, partial implementation of immunization programmes and the improper use of chemotherapy may have adverse effects . Among several other import- ant aspects which may seriously affect epidemiological stability are the ever increasing mobility of large numbers of people (tourists and migrant workers), which gives rise to international health problems; changes in the patterns of import and export of meat and other food products, and the implementation of new industrial a nd agricultural projects in various countries of the region. The concept of epidemiological surveillance Epidemiological surveillance of communicable diseases consists in the follow-up of specific infections in terms of morbidity and mortality in time and place, involving the study of the ecology of the infectious agent with regard to host, reservoir, vector and environment, as well as the c omplex mechanism concerned in the spread of the infection and the ex- tent to whic h this spread occurs. The basic importa nce of the laboratory services is therefore quite clea r, as r a ti onal surveillance would require various tests for the isolation of t he infectious agent, its identification and typing, the determination of drug resistance, and also serological studies of single cases or populations through immunological surveys. This knowledge of the state of immunity of a given population provides a national basis for planning, executing and evaluating control measures and revealing the changing patterns of individual infections. A prerequisite for the successful development of a surveillance programme is the regular, prompt and mutual communication of information to all participating serv- ices . 38 Surveillance programmes The following diseases have been successfully included in national and international surveillance programmes: anthrax, brucellosis, cholera, diphtheria, gastroenteritis of infants, hospital infections, influenza, measles, rabies, respiratory virus infection, pertussis and parapertussis, poliomyelitis, salmonella, shigella, smallpox, streptococcal infections, tetanus, typhoid and paratyphoid fevers, venereal diseases and viral hepatitis. However, other diseases not mentioned in this list have also been dealt with in various national surveillance programmes. It is sometimes very rational to include certain non-communicable diseases in a communicable diseases surveillance programme. Public health laboratories Laboratory services in the European Region are characterized by a wide variety of organizational and structural set-ups, varying not only from country to country but also within the same country, with a consequent variety in services provided and population covered. On the other hand, there is an ever-increasing workload of activities, both quantitatively and qualitatively. Apart from the great demand arising from the development of community health services to which surveillance activities are linked, the number of new tests is increasing and existing tests are becoming more sophisticated. It may also be noted that there are at present two some- what opposed trends, but that, from a practical point of view with regard to surveillance activities, one does not exclude the other. The first trend is towards the maximal extension of laboratory services to the periphery, while the other is to regroup these services in defined geographic or demo- graphic centres. The work of public health laboratories should mainly be community- oriented, though for technical and economic reasons it may often be rational to make their services available to both the public health sector and the hospitals. When a separation between sanitary-epidemiological and clinical laboratories still exists at all levels, a co-ordination of both types of laboratories and the remaining components of the national health service is considered essential. A central laboratory should serve as a national reference laboratory, collaborating with a well-planned network of regional and peripheral laboratories. In certain instances, inter- national collaboration may be introduced as a temporary measure while national services are being developed. The participation of a public health laboratory service in surveil- lance activities at national or international levels can be successful only when adequate methods are used and the results are comparable and re- producible. 39 The role of laboratories in national surveillance programmes (a) On the national level The central public health laboratory or any other institution with corresponding functions, in collaboration with the epidemiological services, develops the plan and methodology of work. In certain instances, the conception of the surveillance programme may be fully elaborated and may comprise most of the infectious diseases. In other instances this prog- ramme may depend on national priorities or the available technical facili- ties, and would therefore take the form of pilot studies. The ideal situa- tion would be to conduct surveillance programmes for most infections on a long-term basis and adapt them to the various changes in the epidemio- logical situation. It is obvious that with certain infections, such as smallpox and cholera, surveillance programmes are only launched when a confirmed or suspected case appears in or near the country concerned, and tha t such a programme would last only as long as a danger of im- plantation or spread continued to exist. The task of the central laboratory in these programmes is to define the methodology (procedures, equipment , materials), to provide reference material, to train the participating personnel and to receive and correlate the results. (b) On the regional (provincial) level A regional public health laboratory, apart from taking part in the national surveillance programme , may also develop a regional programme of its own according to the existing problems of local importance, such as the presence of certain foci of natural infection. Regional programmes often include surveillance of alimentary, venereal and pulmonary diseases, which may simultaneously be part of nationwide activities. The regional laboratory will provide advice to the periphe ral laboratories and collect their data for retrieval to the central level. (c) On the peripheral (district) l e v e l Peripheral public health labor a tories, being in direct contact with the community, are often in the best position to detect in time anything un- usual in the incidence of communicable diseases in a given place, season or age-group. It is therefore of prime importance that well-trained staff should be on hand at these peripheral laboratories, particularly at geographic and demographic key points. If this is not possible, it would then be ad- visable to refer all major surveillance activities to the nearest regional laboratory where such expertise is available, and the peripheral laboratory should in consequence ensure the proper despatch of specimens. Another rational approach would be to d e fine the locations of the various expert laboratories in the country and to refer particular tasks to them since, with the modern facilties now available, the transport of biological m a terial pre- sents no problem. 40 The role of laboratories in international surveillance programmes Apart from their great importance in the surveillance of notifiable diseases, public health laboratories may participate in various inter- national activities such as the WHO poliomyelitis and salmonella prog- rammes; these programmes are generally co-ordinated by the national reference laboratory in every country, which is established by the govern- ment in order to provide consultant services in the specialized field and is responsible to that government. On the international level, laboratory activities may be co-ordinated by an international reference centre, which is an institution designated by WHO to assist in the development and maintenance of high standards of work in specialized fields. International reference centres have defined func- tions which include the identification and classification of micro-organisms, the maintenance of strains and their distribution to competent laboratories, the provision of sera and other reagents, the performance of studies initi- ated by WHO and the training of research workers. WHO also contributes to surveillance programmes by providing specific assistance in the form of consultantships and fellowships and also by making use of the services of the Serum Reference Bank in Prague. Laboratory technique s in surveillance There has been a great advance and improvement in the laboratory techniques used in surveillance activities, and these should all be applied whenever possible. These techniques include immunofluorescence, immune adherence haemagglutination, radioimmunoassay, special selective bacteriological media, cell and tissue culture, and electron microscopy. On the other hand, surveillance activities need not necessarily be depend- ent on very elaborate procedures, as long as the methods have been standardized so as to ensure comparability. Even with limited resources it may be possible to run certain surveillance programmes, such as microscopy for malaria or enteric parasites. Summary and conclusions 1. Communicable diseases are apparently regressing but, to achieve their ultimate effective control, networks of efficient public health labora- tories are necessary for the support of national and international surveil- lance programmes . These programmes will help the national health authorities to make rational policy decisions. 2. A surveillance programme is the expression of a real unity between public health activities and research. It promotes the standardization of methodology and thus improves the work of the public health laboratories, which should already have achieved a high degree of performance. 41 3 . More efficient utilization and introduction of recent technological achievements should be enforced in the public health laboratories of the Region. This is essential for the isolation, identification and typing of the etiological agents and for following up their spread in man, animals, vectors and the environment. 4. The continued provision of WHO servic e s such a s technical advice, refe rence centres and training facilities will be of great value and will h e lp to standardize th e methodology and provide r efe r ence material for the information and implementation of surveillance programmes. BIBLIOGRAPHY L a ngmuir, A. D. (1963) The surve illance of communicable diseases of national importance, New Engl. J. Med., 26 8 , 182 Raska, K . (1964) The epidemiological surveilla nc e programme, J . Hyg. Epidem. (Praha), VIII, 137 World Health Organization, Regional Office for Europe (1969) Communic- able diseases: methods of surve ill a nce, R e port on a S e minar, The Hague , 2]-30 M a y 1969, Copenhagen World Health Organization, Regional Office for the We ste rn Pacific (1971) First Regional Seminar on Methods of Epidemiological Surveillance and Geographic Pathology, Manila , 1-10 Decembe r 1971, Manila 42 MALARIA IN EUROPE by Dr M. Postiglione Regional Officer for Basic Health Services WHO Regional Office for Europe, Copenhagen, Denmark 1. Malaria in Europe: the present situation1 1. 1 General The European Region of the World Health Organization comprises 40 countries or territories with a total population in 197 2 of approximately 7 89 million. Annex II gives a detailed status of the malaria eradication and other anti-malarial activities in the European Region as at 31 December 197 2, specifying the total population of each country as well as: 1. 2 populations: in areas where malaria was never indigenous or dis- appeared without specific anti-malarial measures; of originally malarious areas; where malaria eradication is claimed ( maintenance phase) ; where eradication programmes are in progress ( in the consolidation, attack and preparatory phase) ; and where other anti-malarial measures are carried out, specifying each type of anti-malarial measure . Malaria in Algeria, Morocco and Turkey In three countries, Algeria, Morocco and Turkey, organized anti- malarial programmes are in operation (total population 67 . 5 million) . In Turkey, the malaria eradication programme ( MEP) has been going on for approximately 10 years with excellent results, so that prac- tically the whole country is now in the consolidation phase . Only a few foci are to be found and there is a limited frontier area in the east where attack operations are still in progress . 1 Definitions of the most important terms used in this paper are given in Annex I. 43 In Morocco, anti-malarial activities are carried out and further de - velopment is connected with progress in the establishment of the health infrastructure. In Algeria, the MEP is carried out by stages and through the basic health services with a minimum of malaria personnel. Sixty-three per cent of the original malarious territory has already been covered by DDT indoor residual spray ing operations and the rest will be covered in 19 7 4. The WHO malaria team is participating in the organization and expansion of the basic health services which proceed in parallel with the development of the MEP. 1. 3 Malaria in continental Europe Malaria transmission has ceased in continental Europe, with the possible exception of Greece, where a few indigenous cases were reported up to 19 7 2 in a small area of Macedonia. In the Soviet Union the areas under consolidation are found in the Republics of Azerbaijan, Georgia, Tajikistan, Kaz akhstan and Uzbekistan. No information on the malaria situation in the USSR has been received by WHO since the first semester of 197 0. The combined population of Greece and the USSR ( excluding the Ukrainian SSR and the Belorussian SSR) is approximate! y 2 00 million. The remaining 35 countries (total population approximately 521 million) have virtually no malaria transmission; they are divided into three groups: (1) countries where malaria has been eradicated, but where this has not yet been certified by WHO (countries in maintenance phase); (2) countries where malaria has been eradicated and certified by WHO (the WHO list of "certified" countries); (3) countries where malaria has never existed or disappeared be- fore 1957 (the WHO "supplementary list"). Although in these 35 countries there is no tr a nsmission, malaria cases may still be found and in c e rta i n a r e as a vector or vectors may be present. For practical purposes, therefore , malaria eradication has been achieved in the original malarious areas of continental Europe where the disease is no longer a leading cause of morbidity, mortality and disability and has practically no social and economic implications. This public he a lth success is basically due to improved health conditions since the eighteenth century, to the application of specific anti-malarial measures since the end of the last century and to the introduction of residual insecti- cides at the end of the Second World War. Nevertheless, malaria is still responsible for unnecessary suffering and avoidable deaths, and there has been an increase in imported cases during recent years. This is due to 44 an increase in travel, including travel by migrant labour, to an improve- ment in diagnostic facilities and probably also to a resurgence of malaria in tropical areas. l. 3. l Imported malaria in continental Europe An analysis is made here of cases reported to the WHO European Office (WHO /E URO) from countries in continental Europe for the years 1967 to 1972. However, in some cases figures are missing for certain years. In general, the number of cases reported is an underestimate because: (1 ) some (2) some (3) some examined; mild cases spontaneously recover without being diagnosed; serious cases reach a fatal issue without being diagnosed; case s are parasitologically negative when blood slides are (4) some cases escape investigation; (5) in some countries diagnostic facilities are inadequate; (6) some countries do not send reports regularly. Table l gives the numb e r of malaria cases r eporte d to WHO / EURO from countries in continental Europe from 1969 to 1972, classified by origin of infection. In 197 2 , 5685 cases were reported, of which 5640 were imported, 4 were relapses, 1 9 were induced and 22 were indigenous. From 1 969 to 1 97 2 there was a steady increa·se in the number of imported cases. The figures include also data from Portugal, an explanation for which is given later. Table 2 gives the number of import e d malaria cases reported by c ountri e s in continental Europe from 1967 to 1972 by species. The table shows tha t the species represented are mostly Plasmodium vivax, followed by P . fa lcipa rum and to a small extent by P . ma lar i ae and P. ovale . A significant number are unclassified. In 197 2, out of 5640 cases, 38 38 were P. vivax, 1610 P. falciparum, 42 P. malariae, 53 P. ovale, 20 mixed and 77 unclassified. These data suggest that the majority of cases are of the benign type (P. vivax) but there is still a large number (one-third) of all the cases in 197 2 capable of giving fatal issues (P. falciparum). P. malariae cases pose a special problem in view of their role in the production of induced cases; P. ovale cases present dif- ficulty in specific diagnosis; some cases are given as "unclassified" be- cause they have escaped further investigation. In 197 2 there were 15 deaths. The available reports are also incomplete for the following reasons: 45 Table 1 NUMBER OF MALARIA CASES1 REPORTED BY COUNTRIES OF CONTINENTAL EUROPE TO WHO/EURO FROM 1969 TO 197 2 CLASSIFIED BY ORIGIN OF INFECTION Total2 Imported 2 Relapses Introduced Induced Indigenous 1969 2 980 2 950 0 0 30 0 197 0 3 451 3 420 4 0 27 0 1971 5 073 4 993 3 1 76 0 197 2 5 685 5 640 4 0 19 22 17 189 17 003 11 1 152 22 1 confirmed microscopically 2 including cases for Portugese overseas territories which were negative in Portugal as follows: 1969 2063 1970 2561 1971 3934 1972 4400 1295 8 46 Table 2 1967 1968 1969 197 0 1971 197 2 Total NUMBER OF IMPOR TED1 MALARIA CASES REPORTED TO WHO / EURO FROM 1967 TO 1972 BY SPECIES P.v. P.f. P.m. P. o. Mixed Unclassified Total Deaths 446 238 31 37 2 85 839 no inf. 455 251 25 18 4 67 820 no inf. 680 532 31 30 9 1 668 2 950 25 2 427 648 39 31 31 244 3 420 11 3 684 1 008 49 45 34 17 3 4 993 11 3 838 1 610 42 53 20 77 5 640 15 11 530 4 287 217 214 100 2 314 18 662 62 1 including a large number of cases imported from Portuguese overseas territories as shown in table 1. 47 (1) there are no details concerning parasite species, age, pro- fessional groups, adequacy of treatment and other characteristics of cases terminating in death; (2) no information is available on strains of plas m odial species imported into Europe, nor on the immunological condition of the cases which can give some indication of the results of treatment and the possibility of transmission ; (3) inadequate knowledge is available with regard to the age, sex, and group of population (tourists, migrant labour and so on ) of im- ported cases. Table 3 shows the number of imported malaria cases reported by countries of continental Europe to WHO / EURO from 1967 to 1971 accord- ing to continent of origin. In 1971, out of 4993 imported cases, 47 39 came from Africa. Table 4 gives the number of imported malaria cases reported by countries of continental Europe to WHO / EURO from 1967 to 197 2 accord- ing to reporting country. During the last six years the level of imported cases has been approximately the same everywhere except in the United Kingdom and Portugal, where an increase has been noted. As regards Portugal, a very high increase has been noted since 1969; however, it should be mentioned that so far reports d ealing with imported m a l a ria in Europe have given as imported cases in Portugal both those shown as true imported cases and those "communicated" from overseas territories but found negative in Portugal. These latte r c a ses, which do not strictly follow the WHO definition of imported, have neve rthele ss been reported as such to our Office. This is shown in table 1. All the indigenous cases reported in 197 2 were notified from Greece (20 cases) and Corsica (2 cases). (See t a ble 1). In southern Europe the risk of the reintroduction of the disease as a result of movements of popula tion is a rea l one. The small outbreak of mala ria in Corsica in 1972, a t t ributed to infected Afri c a n workers, clearly shows tha t i n the M e dite r ranean l ands the reintroduction of malaria is more than a possibility. The re c e p tivi ty of southe rn Europe to malaria at the present time is nevertheless not well understood. It must neces- sarily depend on factors such as vector density, contact between vector and man as well as longevity of the vector under present conditions. In- vestigations supported by WHO are now being carried out in various coun- tries of southern Europe. 1. 3. 2 Epidemiological significa nce of imported cases The importance of importe d cas e s must b e vi ewed within the frame- work of the epidemiological conditi ons in which t h ey occur. 48 T a ble 3 NUMBER OF IMPORTED MALARIA CASES REPORTED BY COUNTRIES OF CONTINENT AL EUROPE TO WHO / EURO FROM 1967 TO 1971 ACCORDING TO CONTINENT OF ORIGIN Continent Year Africa 1 Asia Europe Americas Unknown Total 1967 525 168 2 Greece 9 135 839 1968 562 139 1 II 6 112 820 1969 2 770 78 0 8 94 2 950 197 0 3 269 50 1 Corsica 7 93 3 420 (France) 1971 4 7 39 84 1 II 9 160 4 993 Note: Information from USSR incomplete 1 Includes cases reported in Portugal (see table 1 ). 49 Table 4 NUM BER OF IMPORTED MALARIA CASES REPORTED BY COUNTRIES OF CONTINENT A L EUROPE TO WHO / EURO FROM 1967 TO 1972 ACCORDING TO REPORTING COUNTRY Country Albania Austria Belgium Bulgaria Czechoslovakia Denmark Germa ny, Feder a l Republic of Finla nd France Greece Hungary Ireland Ita ly Luxe mbourg Netherlands Norway Poland Portugalc Romania Spain Sweden Switzer land United Kingdom USSR Yugoslavia TOT A L a No information b Fir s t half-year only c See tab l e 1 1 967 1968 2 2 12 10 3 7 4 6 16 14 47 54 0 2 a a - - 4 17 5 2 2 4 32 12b 0 0 26 24 18 3 7 4 236 311 3 2 20 21 17 24 3 1 196 1 51 17 2 141 14 8 839 820 50 Year 1969 1970 1971 1972 2 1 7 6 6 12 1 0 10 12 3 6 7 9 8 3 4 10 7 13 16 13 28 55 52 85 101 2 3 8 4 a a 10 3 - - 17 10 25 37 3 8 4 4 2 0 0 1 32 33 37 31 b 0 1 0 0 29 16 26 12b 4 0 2 a - 4 3 2 3 2426 3 041 4407 4984 0 3 1 8 25 23 23 1 9 31 33 25 27 7 12 4 5 152 105 269 32 8 110 21b a a - - 12 1 3 13 14 2950 3420 4993 5640 In the receiving countries, the following situations may exist: Situa tion Vector and Transmission Result par a site 1 ve ctor and para- not possible possible danger to patient's site absent life; no danger to the com- munity (except for induced cases) 2 vector present ; possible danger to patient's life ; parasite reservoir danger to the community absent; malaria (possible epidemics) into eradicated which patients bring the parasites 3 vector present; present danger to patient's life ; parasite reservoir danger of adding to the local present fiarasite reservoir possible epidemics) The effects of imported case(s) on the above situations are in- fluenced by: (1) immunological conditions: immunity level of receiving com- munity (situations 2 and 3 ), as well as of the imported cases in relation to the stage of development of the disease (infectivity to mosquitoes); (2) strains of parasite: cases may import strains with special epidemiological, clinical, therapeutic and immunological features not present in the receiving countries. This may have a bearing on transmission, present a special clinical course and require spe- cial treatment; (3) parasite load: the effect on the receiving community depends on the receptivity and vulnerability of the latter, in relation to the number of imported cases, A sufficiently large number may so increase the parasite reservoir that, in the presence of other suit- able epidemiological conditions, transmission may resume and epidemics may develop. 51 Therefore special attention needs to be directed to movements of population, including studies on nomadism, transhumance, special engineering activities, seasonal workers, armed personnel, tourists, crews of sea and air vessels, etc. Epidemiological aspects may differ according to the group concerned. The special features of malaria among seafarers were reviewed by Postiglione (1971) (1). Every effort must be m ade to ensure that imported cases are detected and notified in good time. Should sickness occur, such cases should be subjected, as and when appropriate, to medical examination, parasitological diagnosis, treatment and follow-up. The life of the patient and of the community may be endangered if all these measures are not taken promptly where necessary. The most serious situation arises when a large group of P. falciparum cases move s into a susceptible community where vectors and other suitable epidemiological factors are present; epidemics and deaths may then ensue. The least serious situation arises when a single imported P. vivax case enters a community where no vector is present. At worst, the patient may suffer, but he will probably recover completely within approx- imately two years from the start of the infection. 1. 3. 3 Drug resistance The importation of strains of P. falcipa rum resistant to 4- aminoquinolines could constitute a threat to countries in the maintenance phase of malaria eradication. In non-receptive areas, failure to identify and adequately deal with such cases may lead to the death of patients. A WHO publication (2) gives definitions and degrees of drug re- sistance and suggests tr eatment of resistant cases. WHO publishes in the Weekly Epidemiological Record a list of countries in which cases of P. falciparum malaria resistant to 4-aminoquinolines have been reported. WHO/EURO distributes to all European countr ies a questionnaire to col- lect details about resistant cases , a nd attaches a note giving principles and standards relating to drug resi stance. So far, no resistant case has yet been reported to WHO/EURO, but clinicians and public health ad- ministrators must be made aware of the danger of this form of malaria being brought into Europe. 1.3.4 Induced cases Data on induced cases in the European Region are only available for 1969, 1970 and 1 971. Their importance in relation to the total num- ber of malaria cases reported to WHO can be seen from the figures given in table 5 . 52 Table 5 NUMBER OF INDUCED CASES REPORTED BY COUNTRIES OF CONTINENT AL EUROPE TO WHO/EURO FROM 1969 TO 1971 BY SPECIES Year Total number P. vivax P. falciEarum P. malariae 1969 30 11 3 16 1970 27 7 3 17 1971 76 58 0 18 53 The number of induced cases seems to be very small compared with the total number of cases reported. Although it may be true that the latter are mainly due to imported cases, there is reason to believe that induced cases are grossly under-reported. Induced cases may originate from malaria cases (in Europe mostly imported) through blood transfusions; indiscriminate us e of syringes by drug addicts; malariotherapy; accidents in laboratory experiments. Blood transfusions are by far the most frequent cause of induced malaria. Infection may be due to any species, but most frequently it is caused by P. malariae, which m a y p e rsist for many years without donors being aware that they are carriers. The data on parasite species quoted above show the prevalence of P.malariae; in fact, the 58 P.vivax cases reported in 1971 included 55 cases from one laboratory in one country, all infected by the same donor. As already indicated, in Europe the number of P.malariae cases declared is very small compared with the total number of cases reported. However, whil e P. vivax and P. falciparum have a short life (approximately two years), P. malariae may remain in the host throughout his life and therefore it remains the main source of blood transfusion-induced cases. This problem and the action required to prevent induced cases are re- viewed in detail in WHO Technical Report Series No. 272 (3). 2. Action required at national and international level At the national level, th e type of a ction requir e d d e p e nds on the existence of receptive and vulner a ble ar ea s in the r e ceiv ing country. Fundamental ac tions in respect of imported cases are detection, diagnosis, notification and treatment, without, however, submitting travellers to un- due inconvenience. These activities pre suppose adequate knowledge, through training and supervision of medical and health staff, of the proper diagnostic and treatment procedur e s. Important aspects of di a gnosis ar e : th e compila tion of the present and past history of the suspected c a se with r ega r d to time spent in malarious areas; the n ee d to r epe at p a ra sitological examination that may be negative in the first instanc e ; th e importance of know ing the para site species involved. Important features of tr ea tme nt a re: the prope r us e of modern drugs according to parasite species, in order to obtain a radical cur e (con- firmed by subsequent pa rasitological examinations) and to asc e rtain the state of non-infectivity to mosquitoe s (for receptive a r e as); knowledge of adequate and prompt treatment of v e ry serious complications of P. f a lciparum cases, which, if untreated, may cause de a th in a very short time, especially in children. It is a lso important to h a ve at hand quick- acting anti-malarial drugs, in addition to anti-shock and intensive care facilities . 54 In receptive countries special attention should be paid to the surveillance of 11 risk groups" and to epidemiological studies, with par- ticular reference to entomological features (vector density, resistance tests, etc.) . A nucleus of people trained and equipped for this work is necessary. In countries with adequate facilities, research on aspects of national and( or international importance concerning malaria is carried out, usually with WHO assistance . Health education and information of the public, particularly of those planning to travel abroad , should be properly co-ordinated by airlines and shipping companies, ministries of labour and other ministries, in order that knowledge on malarious areas of the world, preventive measures (chemoprophylaxis), diagnosis and treatment should be disseminated, and that the need to report quickly to a doctor in case of illness, suggesting the possibility of malaria, should be stressed (4). Co-ordination of all the agencies involved at national and inter- national level is essential. This task is usually performed by the gen- eral health services of the country at all levels, with the assistance, if necessary, of a specialized group for specific investigations. Utilizing the channels and resources availabl e to the health services, it should also be possible to carry out an evaluation at periodical inter- vals, in order to reassess the receptivity and vulnerability of areas, the effects of the application of methods and techniques, the need for continued specialized training and other aspects. At the international level, the main tasks are: collection of informa- tion, promotion and co-ordination of research; development of interna- tionally acceptable terminology, standards and methodology; co- ordination of efforts to prevent re-establishment of transmission; organi- zation of meetings for exchange of experience; and assistance in training courses. 3. Information on malaria and WHO publications WHO receives information on malaria from countries thr ee times a year and is sues it in a consolidated form in the Weekly Epidemiological Record (WER) semi-annually; in addition it reviews the situation every year in the Director-General's Report to the World Health Assembly. In the January 197 3 (No. 3) is sue of the WER (5 ), information is provided on the risk of contracting malaria in various areas of the world; on the way to protect oneself against that risk and on what to do if one develops fever after returning home. The information is also of value to travel agencies, carriers and tourist information offices, and includes informa- tion on the malaria risk in all countries as well as guidelines to assis t physicians advising on preventive measures (see Annex III). WHO promotes and supports research on malaria, including aspe cts related to imported malaria. Through its technical meetings, expert 55 committees, t echnical reports and other publications, WHO collects, reviews and makes known the opinions of experts and gives guidelines on standards, methods, techniques, nomenclature and other aspects relevant to the issue. M ee tings are organized at appropria te intervals for the purpose of exchanging experience a nd co-ordinating efforts on an inter- national basis. Assistance to training courses is given whenever re- quired in the form of lectures, teaching material (see "Ca se Studies on the Epidemiology of Malaria" (6)), material for demonstration, films and pamphlets. 4. The anti-malaria activities of the WHO Regional Office for Europe (WHO/EURO) One of the main objectives of WHO / EURO is to help eradicate malaria in countries of the Region where transmission persists and to prevent its reintroduction in those where it has been eradicated. The approach in the former is to carry out eradication activities through the basic health services under the guidance of a central office for malaria eradication. In the latter , activities are directed towards the prevention of reintroduction of the disease through epidemiological vigilance based on cas e reporting and the exchange of information on an international basis. Co-ordination of the activities of different countries is being promoted and epidemiological services are being provided. Receptivity to malaria and the potential risk of reintroduction of the disease in countries of southern Europe are being investigated. 56 REFERENCES 1. Postiglione, M. (1971) The importance of malaria for seafarers today, Ann. Med. nav., Vol. 1 2. World Health Organization (1967) Chemothera of malaria, Re ort of a WHO Scientific Group, Geneva Wld Hlth Org. techn. Rep. Ser., No. 37 5, pp. 25 and 55) 3. World Health Organization (1964) WHO Expert Committee on Malaria, Tenth Report, Geneva (Wld Hlth Org. techn. Rep. Ser., No. 27 2) 4. World Health Organization (1967) Prevention of the re-introduction of malaria, Report of a WHO Meeting, Geneva ( Wld Hlth Org. techn. Rep. Ser., No . 37 4) 5. World Health Organization (197 3) Status of malaria eradication, Geneva (Wkly epidem. Rec. , _l) 6. World Health Organization (1971) Case studies on the epidemiology of malaria, G eneva 7. World Health Organization (1966) WHO Ex ert Committee on Malaria, Twelfth Report, Geneva (Wld Hlth Org. techn. Rep. Ser., No. 324 5 7 ANNEX I DEFINITIONS; TERMS AND CONCEPTS 1. Eradication programme phases Preparatory phase - the time devoted to preparation for the attack operations. It ends when the epidemiological and geographical recon- naissance in the operational area is completed, the central and peripheral stations and essential services are established, the staff recruited and trained and the logistic and reporting systems organized. Attack phase - the phase during which anti-malarial measures ap- plicable on a large scale and aiming at the interruption of transmission are applied on a total-cover age basis in an operational area . This phase is sometimes c alled the period of total-coverage spraying. Consolidation phase - the phase that follows the attack phase; it is characterized by active, intense and complete surveillance with the ob- j e ct of eliminating any remaining infections and proving the eradication of malaria. It ends when the criteria for eradication have been met. Maintenance phase - the period which begins when the criteria of malaria erad1cat1on have been met in an operational area and which will continue until worldwide eradication has been achieved . During this period, vigilance is exercised by the public health services to prevent the spread of malaria impo rte d from across the borders of th e areas concerned. 2. Classification of malaria cas e s according to origin Autochthonous (1} indigenous - malaria acquired by mosquito transmission in an area where malaria is a regular occurrence; (2) introduced - n1alaria acquired by mosquito transmission from an imported case in an area where malaria is not a regular occurrence. Imported - malaria acquired outside a specific area . Induced - malaria acquired through artificial means, i.e., blood transfusion, common syringes, malariotherapy. Relapsing - renewal of clinical activity occurring after an interval from the primary attack greater than that due merely to periodicity. Cryptic - isolated and not associated with secondary cases, as de- termined through appropriate epidemiological investigation, including mass blood survey after the expiry of the incubation intervals. 58 Annex I 3. Vulnerability and receptivity Vulnerability to infection means either proximity to malarious areas or exposure to frequent influxes of infected individuals or groups and/or of infective anophe lines . Receptivity means the abundant presence of vector anophelines and the existence of other ecological and climatic factors favouring malaria transmission (7 ). 59 0-- 0 Country o r terri tory (l ) Albania Algcria 3 Andorr;:i Aus tri a Belgium B ul garia Belorussian SSR Czechoslovaki a Denmark Faroe Islands Finland Fr a nc e G e rm an Dem. Rep . Germany, F ed.Rep. Gibraltar Gr eece Gr een land Hunga ry Icela nd Ir e land Italy Liech t en ste in Luxembourg Malta M on aco Moro c c o (inc. Ifni )b Netherla nds Norwa y T o ta l (2) 2 334 14 h0l I 7 7 516 9 82 1 8 639 9 268 1-l 648 5 007 39 4 7 5 4 5 1 925 17 302 63 167 27 9 0 4 8 52 10 408 220 2 981 54 7 47 21 345 325 25 1 5 7 59 13 4 13 3 949 DET AILED STAT US OF M A LARI A ERA DI CATION AND OTH ER ANTI-MALARI AL ACTIVIT IES I :'< TH E EUROPEAN REGION AS AT 3 1 DE CE MBER 1972 P opulation in tho us a nds Wherl! eradication programmes Of areas (not in- Whe r e malaria Where in p r ogress Of a r ea s eluded in I 0) never indigenous o, malaria protected whe r e prophy- o r disappeared o ric,i na lly e r adica ti on In the In th e In the by ex - l ac tic drug con s o h- tensive administ r a ti on wi tho ut spec ific m alar ious claimed dation a ttack prepara- T o ta l mosqui t o is extensively anti -malaria l area s (maintcn- phase phase to r y phas e control used a s a con-measures a ne e phase) m easures trol measure (3) (4) (5) (6) (7) (a) (9) (I O) (11 ) 27 3 l 061 l 061 5 355 9 2-16 628 3 366 l 688 5 682 11 2 l 5 l 7 7 5 1 c., 9 Rl I o 7 3~ I 901 l 901 16 9 252 9 252 14 -17 5 I~ 3 17 3 5 0 117 39 4 7 54 51 76-l 16 1 I 61 l 7 302 63 167 27 4 091 -l 957 4 858 99 99 52 8 8 -19 I 559 l 559 220 2 981 50 333 4 414 4 414 21 345 325 25 4 369 11 390 966 l 387 2 353 11 258 2 155 2 155 3 949 Of a re a s whe r e ther e is only wid e avai lability of anti- mala rial d rugs (12) I 32 9 0 37 ► z z M :x: ...... ...... Of a r ea s wi th n o spec ifi c anti- mal a ri al me a sur e s (13) 3 305 Poland 33 632 3 3 5 I 3 Portu ~a l 9 848 7 3j0 Rom ?.. nia 20 8 14 12 7 45 San Ma rino 20 zn I Spai=ic 34 361 ') 876 Sw e den 8 208 8 208 Switz e rl a nd 6 470 6 470 Tur kcy d 37 22 4 Ukranian SSR 48 392 8 USSR 191 7 38 I 3 3 I') United Kingdome 56 7 55 56 7 55 Yugosla vi a 21 145 14 7 l b TOT AL 7 88 965 4 36 O'i'J 0-. .'.l Accurding to 2nd addendum tu plan o f op1.: ra ti on~ ,_. b Figures based on la st avai la bl e data (l lJ7 I) c Sa hara and Spanish No rth Africa includ t..· d d Fi gur e s given by tea m leade r TUR 20lll c Isl e of Man and Channe l Isl ands include d 119 l!IJ 2 468 2 468 ti 06 9 8 069 24 485 24 485 37 224 3b 309 915 37 22 4 48 384 48 384 I 7 8 4 I '! I 7 8 003 41 6 416 6 429 6 4 29 352 866 l 94 49 I 38 4 I 8 5 668 I 688 45 774 Sourc e : Repo rt on mal a ria a t Tw e nty-si x th Wo rld He a lth Assembly by the Direc to r-General o f WHO, May 197 3 . 11 2 I 5 9 I 69 3 305 ► ::i ::i (b )< ...... ...... ANNEX III Fig. 1 Information on malar ia risk b country - detail fr om the com rehensive table publi shed in the Weekly Epidemiological Record, No . 1973 WAiy tpid1•m. Hu. : N u. J. 19 J .m. 1973 Re/e,, jpldJrn. ltebd.: N° 3 - 19 jaov . l97J Tahh• I ( comir111ed) Tahleau l _,(suiu) ·--- ------------~---~-----------------------------, Couotr)' - Poy1 Kenya Lesotho • Liberia - Li beria Lybian Arab Rep. - Rep. arabe libycnne Madapsear Malawi • Mali Mauritania - Mauritanic Mauritius' - Maurice c . Morocco - Maroc M o1.ambique . Namibia 7 • - Namib1i..: 7 • Niger Nigeria - NigCria Portuguese Guinea - GuinC'C portugaisc RCunion - la RCun1on Rwanda• St Helena• - Sainte-HCICne 11 Sao Tome & Principe Senegal - ~n~gal Seychelles Sierra Leone Somalia - Somalie South Africa n - Afdque du Sud 13 . Southern Rhodes ia - RhodCSic du Sud South West Africa 1t • - Sud• Ouest africain u • Spanish North Africa 1• - Afriquc du Nord cspagnole 1• Spanish Sahara " - Sahara cspa• gnol 1• . • r . Notes. M ul 11 na nsk R,squc de p.i lu• d11m c • Yes Ou, 0 -o No Noo 0 0 X 0 0 0 0 1 North Eutern , Nyanz1, Wcttern, Cout. Prov.: 1-11. 1 Ri ft Valley Prov.: 2 !100 ; No rth Eattern Prov. : I !100. For countries where n111I.Jn1 n sk uosu - t'o ur lc.s pays o u 11 y 11, ri1quc Jc palull1smc ArcH w11h0Mt risk - Zo nes su,u nsquc: None - NCant None - NCant Whole country, except 2 small foci in the south· west of the country - Tout le pays, a I 'exception de 2 petits foyers dans le Sud•Ouest. Andramasina, Antanifotsy, Arivonimamo, lmcri• rina•fovoany, Ma.ojakandnana, Pl"Cf.; Nossi• Be. I. None - Ntaot None - NC:an1 None - Ntant N one - Ntant None - NCam N one - NCant None - Ntant 1 A11db Oep 8-10. 1 Incl. Ascen11on. TrlSlan da Cu nha . t o r 11II other a reas not 1ho,.n 1n column 3 Pour toulu Jes au1ru zones non mcnuonnt:a d11n1 la colonnc ] Mo otha with ruk M o11 oU 11 ya rilque • 4-6 & 11-12' 1-12 9-J 1-12 1-12' 7- 11 1 1-12 l-12 io 1-12 1-12 Alutudc below whichr11k ClUSII (metres) AJutude au--Ocuous de laquelle 11 ya ritquc (mitres) : ' 2000' I I 100 I 700 + ... . .. -,. + + + + Riak in urban 11 re:u; Raaque en LOnc urba1nc X 0 - Ve, Ou, - No N on • > ' ~ X • ' X ' X X H X X U 1 Risk vu y lo w - risque minime : Nairobi Area, Ceniral Prov., R1n Valley Prov. 1 • Cap-Vert : tcu nsk durin1 1-6 - Mo uu de risquc pendant 1-6. 11 O1k ar, town - ville : no risk duuna: 1-6 - pu de nsq ue pcn da n1 1-6. 11 Mo1aduhu : very lo w risk - n1<1,ue rnin1me . Low nsl. - peu de rt~uc : l:;utcrn, Nyanza, Wes1crn, Cout, Prov. Moder.Uc m,k - nsquc moyen Nonh Eastern Prov. • Exel. Ambosnra, An u1rabl, Tananar, \-c 1 Less risk - Moins de risque : 4-6. • Incl. Ro dr1.:ucs, Aaalega, St Brandon, Is . ' Incl. Walvl! Day, which l li an 1nte1n1I pa n o f So uth Africa bu1 1dmm1llered .is 1f it were pat1 of Nam1b1a - Incl. Walvis Bay qui fail partJe mttarante de l°Afnque du Sud ma11 qui est 11dm1n1.strec comme s1 elle relcv111 de la N1m1b1c. 62 11 Walv11 Bay, v. note 7. ,. v. Nam1b1a - Nam1b1c. 11 v Spam - Espaanc. 11 Compn 51n1 the Northern Rca,on (former Seauia cl Hamn) and the Southern Rcafon (fo rmer Rio de Oro) - Comprend la rt11o n scptcntno nale (anc1en Sc1u1ct cl Hamra) et la rti!O0 mh1d1onale (ancicn Rfo de Oro). N r- e;--~ 0 . .... .... ell ;::l . . . . . . . . . (/) ell . . . . . ,._ , ell . . . . . . ell ~ ·~ , . , . ' 63 / ~ □ ~ .. . " ., • 0 .. . . • C C 0 ~ N A nnex III i i -• Annex III MAL.ARIA PROPHYLAXIS - DRUGS AND DOSAGES Drug Pr oguann,:, Brand names: Paludrine, Chloriguane, Bigurnal, etc. Available in tablets of: 100 mg (0. 1 g) 25 mg (0. 025 g) (for children) Chloroquine,:, Brand names: Avloclor, Aralen, Nivaquine, Resochin, etc. Available in tablets of 100 mg (0.1g) of the base (active compound) and in tablets of 150 mg (O. 15 g) of the base. For children, available also in tablets of: 37. 5 mg, 50 mg, and 7 5 mg of the base and in the form of syrup, one teaspoon - ful of syrup containing 25 mg or 50 mg of the base. Amodiaquine':' Brand names: Camoquin, Flavoquine, etc. Available in tablets of 150 mg (0. 15 g ) and of 200 mg (0. 20g) of the base (active compound). For children, also available in the form of 2 flavoured powder (to be mixed with milk, etc . ), 1 teaspoonful containing 50 mg of the base. Pyrimethamine t, Brand names: Daraprim, Erbaprelina, Malocide, etc. Available in tablets of 25 mg and 50 mg. For children, available also in tablets of 12. 5 mg and in the form of elixir or syrup, 1 measureful containing either 6. 5 mg or 8 mg of pyrimethamine. Dosage Adults: 1 00 mg daily Children: - less than 1 year: 25 to 50 mg daily - 1 to 4 years: 50 mg daily - 5 to 8 years: 7 5 mg daily - 9 to 12 years: 100 mg daily N. B. In highly malarious areas, especially in tropical Africa, adults should take a daily dose of 200 mg. Adults: 300 mg base once a week Children: - less than 1 year: 37. 5 to 50 mg base 11 - 1 to 4 years: 50 to 100 mg base 11 - 5 to 8 years: 150 to 200 mg base 11 - 9 to 12 years: 200 to 300 mg base 11 N. B. In highly malarious areas, adults should take 300 mg of the base twice a week or, preferably, 1 00 mg of the ba s e every day. Adults: 300 to 400 mg base once a week Children: - less than 1 year: 50 mg base 11 - 1 to 4 years: 50 to 100 mg 11 - 5 to 8 years: 150 to 200 mg 11 - 9 to 12 years: 200 to 300 mg 11 N. B. In highly malarious areas, adults should take 300 mg of base, twice a week or 200 mg of the base, three times a week Adults: Children: - l ess than 1 year: - 1 to 4 years: - 5 to 8 years: - 9 to 12 years: 25 to 50 mg once a week 6. 25 II 6 .25 to 12.5 mg 11 12, 5 mg II 12. 5 to 25 mg 11 ~' International Non-proprietary Name (INN). 64 THE USE OF COMPUTERS IN VACCINATION AND IMMUNIZATION SCHEMES by Dr T. McL. Galloway County Medical Offic er of Health West Sussex County Council Chichester, United Kingdom The elaboration of antigens against more communicable diseases has made possible a great improveme nt in public health. This improvement is measurable and gratifying, but the possibilities for making this new health protection available are, as yet, not fully exploited. Any comprehensive scheme of vaccination and immunization entails a number of procedures, beginning in early infancy and continuing through school life, at least. Parents are anxious to have their children protected against preventable illness: in a series of 12 000 consecutive births in West Sussex, parental consent was refused for only seven babies, and doc- tors are equally pleased to provide this service. Nevertheless, the indices of protection, i.e., the percentages of children by age-groups who have completed the protection routines, are disappointing . In England, for whooping cough, diphtheria , and polio- myelitis they were 78°/o, 78°/o and 80°/o respectively in 1971, but these na- tional figures do not reveal the fact that a g rowing number of local health authorities succeed in protecting all or nearly all children at risk, whereas others protect only one-half (or fewer) of their children. 1 Doctors and parents are enthusiastic; there is no financial barrier whatsoever . From personal experience, the writer is convinced that fail- ure to secure better indices is an expression of a management communica- tions problem. Securing consent to vaccination and immunization, recording perfor- mance, memorizing a quite complicated (and changing) schedule of inocula- tions and its conscientious application to the records of thousands of bene- ficiaries, involving identification, appointment-making, etc., are tasks that, even if efficiently performed in health departments, are generally not well done by family doctors unless their offic e systems are unusually well organized. 1 United Kingdom, Department of Health and Social Security (1971) On the state of the public health, Appendix A 65 Since late 1962, the West Sussex County H ealth Department has used an electronic data-processing system in the management of its vaccination and immunization service. The records of all participating children are maintained on magnetic tape, new names b eing added as consent is received for those wi th no history of vaccination and immunization (usually newborn infants) or as children with a history of partial immunization take up resi- dence in the county. The computer is made aware of the schedule of procedures recom- mended by the health authority and agreed locally with the medical profes- sion and, at monthly intervals, the file is scanned, in an automated simu- lation of the traditional clerical process, to produce two sets of documents which are printed on continuous stationery at high speed. The first is an appointment postcard (fig. 1) for each of the benefi- ciaries due for a service in the current month. It bears the name and address of the child, the nature of the service due, the identity of the serv- ice source (family doctor or county clinic selected by the parent at the time of consent) and the day and time of the appointment. Since th e working hours of the county clinics are known, and the times when the family doctors do their vaccination and immunization work are nearly all agreed in advance of the monthly run, the appointment postcards are dispatched direct to the beneficiaries from County Hall. In respect of those few family doctors who cannot agree in advance a day and time for their work, the postcards are completed except for the appointment day and time, and sent in a bundle to the family doctor, who inserts the appointment day and time before posting them himself. The second documentary product of the computer run is an appoint- ment list (fig. 2 ). A list is prepared for each family doctor or clinic serv- ice source and gives particulars of the children due to attend, their appoint- ment times, the exact nature of the procedure due to be given, and the pay- ment due to the doctor for the service given. The children's names are grouped so that children for similar pro- cedures come at the same time . There are spaces fo r ticking off attenders, for writing down the identification of the batch of antigen (usually once only), for identifying defaulters and for comments (if any) . The clerical effort involved in c ompleting this record at the time of the clinic is trifling, and appointments proceed at the rate of 28 every 15 minutes. The appointment list, ticked off during the session, is signed by the clinician and returned to the County Health Department where it is checked, coded, punched and used to produce a current statistical appre- ciation, a list of payments due to the doctors, an updated magnetic tape which will form the starting point for the next month's computer run, and lists of children who fail to respond to three consecutive invitations. 66 Fig. 1 POSTCARD You are invite d to bring PHILIP born on 21 / 6 / 64 to (name and address of doctor) at 2. 00 on 22 / 4 / 70 for protection against: POLIO Dose 1. PARENT OR GUARDIAN OF (name and address of child) WEST SUSSEX COUNTY COUNCIL: HEALTH DEPARTMENT T e l ephone: Chicheste r (0243) 85100 Ext. 386 M etropolitan House, Northgate, Chichester POl 9 lBG Date as Postmark PROTECTION AGAINST DISEASE 1. Anyone who has been unwe ll or received tr eatm e nt from a doctor during the past four we eks should NOT keep this appointment, but should notify this office. Another appointment will be made in one month. 2 . If this appointment is for vaccination against measles and your child has already had th e disease please indicate on this card and return it to this office . This does not apply to appointments for vaccination against German measles . 3 . Please keep th e appointment promptly and take this card with you when you attend . 4 . Further appointments will be offered as they become due . T . McL. GALLO WAY County Medical Officer of Health 67 D a-- 00 r<lOM THE COUNTY HEALTH DEPARTMENT M ETROPOLITAN HOUSE NORTHGAfE CHICHESTER SUSSf.X h!eptionc CHICJ.HSHR l!i-100 Elli JU1 UU 10 D? ( name and address or doctor are enter ed here ) VACCINATION & IMMUNISATION GENERAL PRACTITIONER / CLINIC LIST 6 ~~-i I' is;;; ':i:E· j ,;;:;-l TR IPLF A~TIGEN • Pot I OMYrllfl S . , 02 QJ~! I ' I I I 1 123 i'J 1~ ' I n 12 12 ! 2 l ~ _t l ---i-- 1 s OS 7Z I 31 I i ; , -- -r· Ji: ! 27 ~ l 11 2i ~l 1· t •-- _ _ _ ,L_ I I OJ II 7 J 2 1 11 2 3; ·-· ~ 13 !~~~~~' - ' r-r-r --1- "' , 2°0 llb 7 Z 3 1 1 ;:,_ j • .,. ---t -- --;7- - · I " ·+ I I M -~Q~~. ~ ?. ' ._~ _ _!_! -- j--- "" i 02 02 7 3 l 1 1 2 3 ---- --~ - --- +- . - I I I I --------- F ~ ~~-~~ ~ ' ! IL r-- nz . 15 1 (:,urname of child} 02 .1 "> iW ~ 0 2 .1 s 02 .1s --- 02 . IS 02 . I 5 0 2 .1 ~ ( first name) 02 . 1 5 i: 11 Cl 7 J l t1 ? , 7• -r--- -- ----- ----- • -i, -21Cl1·!~J~ -- - ~-- -- ' __ __,__ 1, 10 o• 12 : 2: 1 , 2- J ~ I; 1---: §2 1 ' s ~~ 02 .1 5 02 .1~ 1~O70!1 l l # J . ' • - - l - ' ' I I I ! 02 .1 5 -- • II 1 2 721 21 11 ;- , 3 : I I I _ __J __ _ OI PH TH ED U-T ET ANUS + Pf1 L J n "'1YELJTI S ' -- 02.1 5 I ' I 0 1 12 o•l l l I i 2 3 ~I -l-+-1--~ 02 .1 5 L__ ililbS) 11 11 2 3: I I I PAGf No , PL [AS( Rfll.JR l'I, SY ; ,. tJ .:: 7.1 -i-- ~ I 1 11 UB 7 j 9 - i- 10 ~ " ..'l._ ,. "'I• '" ,, '""" ----k- - ·-- ____ _ x · Q(' - ~10_:'~b - ~ [ 1 . 00 7 <)O l Ql A ~7 l. , 1) 7 2 1 ! t, 7-. ~. )b --r- - l. C'IJ 711 ,., 71 '1- W h I - _, t . .. H 7 2 l '.>0' )k 4 l 1 . 00 72 1" 71 '-, l ,1 I 1,. '.>ll 77 127 1 l f 4 2 -~-- - I l e 5') 12123q5u 43 ------ l. 0 J 73 1.1 1qq53 4'- --- ----'-- l ,. QrJ 7 ? l4 'B l-.. 4S - - - - - - 1 .. 00 1,07c Jt, Q 40 ---- - --- 1 .. 00 7 30 1304 3 ~7 1 . 00 7 ' 141 ,Dl .. 8 -G"":oc,- .,-j-QQ94t37 .. 1. 01J~73002 11 ~ 1¼ -~- - - - I 1 . 00 olil l l l '.> .. 5 I ----ll-:-oo-6502q l >R 52 ~u NOTES GE NERAL PRACTITIO NE.AS ONLY ~ PL EAS[ RING HH ~PP'ROPRIAH lfTT(II IN COl 7 FOR RESUL T OF S MA LLP'() X VACCI NA TIO N AND NOH AN Y COMPLICATIONS 011 UNUSUAL IUACTION IF "(SULT IS • 0 111 C A SECOND AP N>I NT"4(NT Will If OfHll[O Az MA..1011 IIU,CTIO H ~' i ~ DOCTOl'IS AIIRANGIN G THClR 0 ~ SESSIO NS AR( ASUD TO (Nlfll (AT COL I) TH( DATI TH( Hl(ATMEN T IS Gi.'EN ~! 6 IT IS fSSOITIAt THAT HOS FORM H COMPLETlD AN D R£1" UII N(0 TOG(TH(A WITH ANT COMP't(T(O U NSCH(0Utf0 ""P'OINTM(NTS GIV(H· FORMS .! C • NO LOCA L AlACltON TO HI( COU NTY HIAlTH OEf'AIITM ( NT NOT l.AlfR THA N TH( DAT( S"°OWH AT THi TOP' Of THIS FORM I ClRflfl 11-lAI 11-1£ it,IQVI PAOCfOUAt S Mit, VI IH~ CAAAl(O Ql,f ANO I >l (AtB 'f Cl.AI HI lH( HlS 10 Wl'IIC" 1 Alril, lN IHUD CLINICS ONLY l ClllllfV TH AI 11-1£ A80VI PAOCl OUll!S l'IA V( 8H .. CAIIA,'cl au , ~ Li u·t The doctors' free dom to d eal with new patients is re spectecl and an " unschedul ed appointments II form is us e d to return information about un - planned procedures, These forms are us e d to coll ec t information about ne w entrants to the scheme and this information too is transferre d to the tape file . This automated m e thod of working has produced th e following r e sults : 1, For s eve ral years this h ealth authority had unique ly high protection indices; other authorities which have subsequently introduced comparable methods have achieved comparable indic e s in recent years. Table 1 Children born in 196 4 Children under 2 ye ars and protec t e d by vaccinated in 1965 3 1 December 1965 as percentag e of Area 1964 births Diph- Whooping Polio-theria Smallpox (per cough mye litis (per cent) cent} (per cent) (per cent) West Sussex 88 88 8 7 76 England & Wales 71 70 65 33 In subs e quent years the West Sussex fig ures have been in th e r eg ion of 100 per cent, indic ating a ppropriate protection of the entir e child popula- tion. (Routine smallpox vacc ination of infants was dis continue d in 1971.} 2 . Continuing health education to promote vaccination and immunization can b e discontinue d (ve ry few par e nts fail to consent, defaulting children are quickly recognized, and vigorous follow-up measures are take n by th e general practitioner or his attac h e d fi e ld staff to ensure that virtually all entrants complete the full series of proc e dures} . 3. The computerization of r ec ords and appointments has r elieved family doctors of a complicated and time - consuming managerial / clerical chore; consequently, relationships betwee n the County Health Department and gen - e ral practitioners have been vastly improve d (this is perhaps the most im- portant product of th e m e thod}. 4. Storag e spac e is save d since no manual records need be kept either in the health d epartment or by family doc tors. 69 5. The records are accurate, up-to-date and ab solutely secure (three generations of tape records are kept in different locations) and a ny individual record can be quickly retrieved if required. 6. The cost of translating the previously existing manual records to tape was high, but machine costs have fallen r elative to clerical costs; recent service cost analysis shows that this h ealth autho rity 's servic e is not onl y more successful, but also much less expensive than the national average cost. 1 7. The difficulty of recruiting and retammg intelligent, conscientious people for r epe titive humdrum work had b een increasing a nd the relief from clerical/ managerial drudgery has b een felt both in the Health D e partment and in general practitioners' offices . 8 . The system is entirely flexible and changes in the rec omme nde d sched - ule of procedures have been introduced without risk of confusion. Unsched - uled appointments, as well as migrations of patients between doctors and in and out of the county, have presented no special difficulties. This e ncouraging expe rience has shown c onvincingly tha t elec tronic data-processing systems make possible a new era in m edical record-keeping and health s ervic es administration. Other applications have been and are being developed. A g rowing number of health administrations have recently adopted systems of this kind and it seems likely that the forthcoming reorganization of the National Health Service will ensure that modern methods of administration and com- munication are us e d throughout the country. BIBLIOGRAPHY Ayyar, R. D., Ramakrishnan, S. P. & Singh, B. (1963) An analysis of the cases of typhoid, diphtheria and tetanus admitte d to the Safdarjung Hospital, New D elhi, in 1961 , Antiseptic (Madras), 60, 371 Brown, G . C . et al . (1964) Responses of infants to DTP-P vaccine used m nine injection schedules, Puhl. Hlth R e p. (Wash.), J.J.., 585 Davenport, F. M . et al. (1965) Further observations on the relevance of serologic recapitulations of human infection with influenza virus e s, J. exp. Med. , 120, l 087 1 Saunders J. (1970) Brit. J . prev. soc . Med., 24, 187 70 Evans, D.G. & Smith, J. W.G. (1963) Response of young infants to active immunization, Brit. med. Bull., .!1, 225 Fox, W. (1962) Lancet, I, 413, 473 Galloway, T. McL. ( 1963) Management of vaccination and immunization procedures by electronic computer, Med. Offr, 109, 232 Hanlon, J. J. (1950) Principles of public health administration, St. Louis Herbert, W. J. (1965) Multiple emulsions: A new form of mineral oil antig en adjuvant, Lancet, I, 771 Hilleman, M. R., Hampil, B. & Sweet, B. H. ( 1963) Poliovirus vaccines in mineral oil adjuvant: I. Animal toxicity and serologic response data, J. Allergy, 34, 413 McQueen, J. L. (1966) Personal communication Medical Research Council (1959a) Vaccination against whooping - cough, Brit. med. J., J, 994 Medical R e search Council (1959b) BCG and vole bacillus vaccines in the prevention of tuberculosis in adolescents, Brit. med. J., I, 379 Medical Research Council ( 1962) Inefficiency of purified diphtheria formol- toxoid in primary immunization against diphtheria, Brit. med. J., I, 267 Miller, D. L. (1964) Frequency of complications of measles, 1963, Brit. med. J., I, 75 Offic e of Health Economics (1963) The pric e of poliomyelitis, London, pp. 16-25 Smith, R. T. & Eitzman, D. V. (1964) Development of immune response: Characterization of response of human infant and adult to immunization with Salmonella vaccines, Pediatrics, 11_, 163 Sutherland, I. ( 1966) Personal communication Winslow, C. -E. A. (1951) The cost of sickness and the rice of health, Geneva (World Health Organization: Monograph Series, No. 7 World Health Organization ( 1960) European Technical Conference on the Control of Infectious Diseases throu h Vaccination Pro rammes: Re art, Geneva Wld. Hlth Org. techn. Rep. Ser., 198 World Health Organization (1961) The role of immunization in communicable disease control, Geneva (Public Health Papers, No. 8) 71 1. TUBERCULOSIS IN EUROPE by Dr M. Arhirii R egional Officer for Chronic L ung Diseases WHO R egional Office for Europe Copenhagen, D enmark Background In the years following the Second World War, the people of Europe, already sorely tried by the hostilities, had to face another peril : tubercu- losis. This disease, which had never been e ntirely conquered, although it had been contained within certain limits, had just broken out again, claiming many victims both among children, badly nourished because of the restrictions impos e d by the war, and among adults. On the initiative of the Scandinavian c ountrie s and assisted by UNICEF, funds were collected and doctors and nurses were sent to several central Eur opean countries to organize BCG vaccinatio n campaigns. In other countries, the governments or national voluntary organiza- tions shouldered their responsibilities and set up tuberculosis dispensaries , increased the number of sanatoria, organized vaccination campaigns and trained the necessary personnel. In addition, the discovery of powerful drugs (streptomycin which, discovered in 1944 was by then accessibl e to all countries; p-aminosalicyl ic acid (PAS}, thioacetazone and above all isoniazid, whose anti-tuberculosis action was discovered in 1951) had given new hope t o both patients and doc- tors . This was the period when tuberculosis c ont rol w o rk was stepped up in most European countries and when the foundations were laid for tubercu- losis control programmes. 2. What is the situation today, some twenty y ears later? Tuberculosis no longer ranks first among the cause s of death in Europe. In fact, this place has been taken over by cardiovascular diseases, road accidents, etc., and tuberculosis has undergone a spectacular decline and be en relegated to eighth or tenth pos ition; this, according to official statistics, represents a decline of about ten per cent every year in almost all countries . 72 Nevertheless, it must be admitted that the disease has not declined at the same rate everywhere, since in several European countries the tuberculosis mortality rate is still between 10 and 15 times higher than in the Netherlands, Denmark or Iceland. The number of new cases, too, is in constant decline although this reduction is less striking. It is nevertheless true that in certain countries, even those whose economic situation is flourishing, thanks to rapid indus- trial development, tuberculosis is still the leading cause of morbidity among the communicable diseases. Still more serious, it is not certain that the statistics collected in some countries are really complete, and it is feared that some patients are missed by the official records, even though they may be known to and treated by their doctors. It cannot be denied that very few countries have a national register, like the Danish Tuberculosis Index in Copenhagen, where the files of all known patients in the country are kept and are carefully brought up to date. Tuberculosis control methods are the same almost everywhere in Europe : 3. (a) BCG vaccination (newborn infants or schoolchildren) followed in many countries by revaccination if postvaccination tuberculin tests give a negative result; (b) active case-finding, normally in the form of mass radiography repeated every two or three years among large groups of the popula- tion or, more usually, among groups specially selected because they have a higher than average risk of contracting active tuberculosis; (c) treatment (fir st in hospital, then on an ambulatory basis) of all patients detected, regardless of the way in which diagnosis was es- tablished; (d) rehabilitation, if necessary, of certain patients, sometimes 1n specially designed centres. Effectiveness of control programmes These, briefly, are the control programmes which are sometimes rather unkindly referred to as "traditional". The question to be asked is whether these programmes, rooted in tradition as they often are, have proved their effectiveness, Are they appropriate in the present epidemi- ological situation? Many specialists and public health administrators have been asking these questions for a number of years. As noted above, all the "epidemiological indices" of tuberculosis (mortality rate, incidence of new cases, tuberculin index) are clearly on the decline, which fact in itself proves the effectiveness of the measures taken. However, some recent studies have shown that these trends first 73 appeared around the beginning of the twentieth century at a time when no one would have claimed that there were effective antituberculosis measures available. Even if it is agreed to attribute the acceleration of this trend, which has been observed since the fifties, to the measures taken, should they be continued in the same way? After much argument between the adherents of different schools of thought, it has been recognized everywhere that am- bulatory treatment of tuberculosis is more acceptable to the patient, more economical for society and no less effective than hospital treatment, ex- cept in certain special cases. Another question which is asked is whether treatment can be entrusted to general practitioners. The fact must be recognized that in many cases general practitioners go ahead with treatment on their own responsibility, without waiting for patients to be assigned to them by specialists. This is undoubtedly a g ood tendency, provided that the general practitioner is ac- quainted with modern treatment methods and retains close links with the health services, both to ensure notification of cases and for the examina- tion of possible contacts . The dissemination of recent discoveries in the field of the chemotherapy of tuberculosis should be expanded in order to ensure that general practitioners are kept fully informed. There is also another side to the question, that of whether the general practitioner always has the necessary equipment for carrying out a thorough examination of the patient. If not, as usually seems to be the case, he should be encouraged to call on the health services which have the neces- sary equipment, so that the person whose illness he has diagnosed and treated does not become a "second-class" patient who, as a result of in- appropriate treatment, could even run the risk of becoming a chronic case. 4. The value of case-finding The point has already been made that in most European countries case-finding is based on mass radiography examinations; but health admin- istrators have now started asking if they should continue to depend on this kind of examination and, if so , for how much longer and at what intervals. No satisfactory a nswer h a s ye t been fo und to these questions. It is known that in countries whe re examinations are carried out every two or three years they have been responsible for the detection of only 14% to 20% of patients found to be carriers of Koch bacilli after direct sputum examination, and only about 50% of those found to be positive as a result of sputum culture; the remaining cases were detected in other ways (med- ical examinations carried out because of the presence of symptoms, ex- amination of high-risk groups, etc. ). In certain countries, between 10 000 and 12 000 persons have to be examined in order to find one case of tuberculosis with tubercule bacilli present in the sputum. However, in view of th e fact that these examinations may assist the detection of diseases other than tub e rculosis, as well as persons with very 74 small fibrotic lesions who form a high-risk group, many specialists are in favour of continuing to carry them out on a mass scale. One solution to the problem which is gradually gaining acceptance would be to restrict examinations to certain population groups that are at greater risk than others of contracting tuberculosis (persons under 25 or over 40 years of age, employees in the public services, hospitals, the food industry, etc. ), a measure which would increase the yield and reduce the number of examinations. This solution assumes, however, that the health services and general practitioners take all the necessary steps to ensure that patients who consult them on their own initiative because of their symptoms undergo complete examinations (including bacteriological examination of sputum). It also assumes that the same facilities will be made available to the entire population, including the inhabitants of rural areas, where the density of medical services is much lower than in the towns. 5. The value of vaccination In certain European countries, the tuberculosis picture has changed so much, in particular with the dramatic decline in the number of cases among children and the reduction in the risk of infection, that it has be- come necessary to review the present BCG vaccination policy. There is certainly no doubt about the effectiveness of this method; what is being ques - tioned is the usefulness of continuing to vaccinate newborn infants, and the need for postvaccination tuberculin tests and revaccinations (carried out in certain countries, at fairly short intervals until the age of 18 or even 30 years). In order to answer these questions it is essential to be fami- liar with the true epidemiological situation of each country and to estimate the risks which a change of policy in this field might involve. But here and now it may be said that there is no longer a place for BCG vaccination campaigns and specialized teams in European countries. If vaccination is considered necessary, it can very well be carried out by the health per- sonnel of the basic health services (maternal and child care, health service centres, school health services) as part of the normal vaccination prog- ramme. The use of controlled vaccines with great antigenic potential provides sufficiently strong and long-lasting (from 10 to 15 years) allergy and pro- tection to make postvaccination tuberculin testing and possible revaccination unnecessary. 6. Transformation of the specialized services Since modern tuberculosis control methods no longer pose major technical problems, specialized personnel are not required to apply them. Control work may therefore be carried out by general health services per- sonnel and included in the routine work of the services. This, of course, requires that future doctors, nurses, midwives and other health personnel receive the necessary training and it may in some cases be found neces- sary to modify present training programmes. 75 But, it will be asked, if these techniques have been simplified so much that specialized personnel are no longer required, and ii the epidem- iological situation has improved so much that the scope of activities can be reduced, what is to become of the specialized services and the special- ists? Their main job will be to maintain surveillance of the epidemiological situation and to make decisions in the light of this situation. A service staffed not only by phthisiologists but also by statisticians and epidemiolo- gists is essential in order to collect data on the number of cases, their bacteriological situation and the forms of tuberculosis involved, on the ways in which they have been diagnosed, on tuberculin conversions, on BCG vaccinations, on treatment undertaken and its results, etc., and to interpret this data with reference to various parameters (age, sex, local- ity, etc . ). The specialists' task will not end there since, although tuberculosis is tending to decline, it has by no means disappeared. If this process is to be speeded up it is essential to know just where the efforts made will bear most fruit, and it is up to the specialized service to provide the in- formation required. In addition, certain patients pose special problems (chronic patients, patients excre ting bacilli and resistant to tuberculosis drugs, patients un- able to tolerate the usual drugs or those with special socio-economic or psychological problems) and the general practitioner and the basic services do not always have the time or the means to deal with them; the specialist services must therefore take care of these special case s. Since these services are more likely than others to have the appro- priate radiological and laboratory equipment for investigating the respira- tory system, as well as the necessary qualiiied personnel, they should, as is already the case in certain countries, assume responsibility for other chronic respiratory diseases which also need long-term treatment and sur- veillance. In this way it would be possible to take full advantage of the experience gained by these services in their tuberculosis control work. 7. Conclusion Although tuberculosis is no longer one of the leading causes of death in Europe it is nevertheless still an important public health problem be- cause there are still many patients requiring long-term treatment that sometimes involves considerable hardship because of the number of work- ing days lost and because of the cost of the disease. It seems that the efforts made by the community have not been in vain; nevertheless, the results could be better and the available means could be used more effectively and more economically. 76 Finally, it should be mentioned that the problems described here in order to stimulate their consideration by public health administrators have been discussed by s eve ral groups of specialists at meetings organized by the R egional Office for Europe of the World Health Organization. These meetings include the Technical Meeting on Tuberculosis Control in Rural Areas, Zagreb, 29 September-1 October 1970, the Technical Meeting on the Integration of Tuberculosis Control with the Work of the General Health Se rvices, Paris , 20-22 April 1971, the Study on the Effectiveness of Tu- berculosis Control Programmes , Warsaw 1968, Izmir and Istanbul, 1969, Copenhagen, 1970, and the Seminar on the Evaluation of Tuberculosis Control Programmes, Copenhagen, 19-23 June 1972. 77 Table 1 RATES OF MORTALITY FROM TUBERCULOSIS IN EUROPE, PER 100 000 POPULATION, 1947-49; 1957-59; 1967-69 and 1970 Country 1947-49 1957-59 1967-69 Austria 84.0 25. 5 15. 4 Belgium 55. 6 18. 9 8.4 Bulgaria - - 12. 4 Czechoslovakia - 33.4 10.0 Denmark 24.4 4.3 2. 0 Finland 152. 2 33. 1 9.3 France 73.5 25.0 11. 2 German Dem. Rep. 146. 3 22.2 12. 8 Germany, Fed. Rep. of 61. 2 17.3 1 o. 3 Greece - 19. 3 1 o. 8 Hungary 107. 6 32. 7 21. 7 Iceland - - 2.2 Ireland 106. 2 21. 0 9. 2 Italy 62. 7 19. 1 8. 9 Netherlands 29. 9 4. 2 1.4 Norway 48.4 7. 6 3. 6 Poland - 46.9 29. 1 Portugal 151. 9 53. 5 23.7 Romania - 38.6b 21. 5 Spain 118. 5 28.5 13. 5 Sweden 40.3 7 . 9 4.4 Switzerland 53.7 16. 2 7 . 6 United Kingdom England & Wales 49.4 9. 7 4. 1 Northern Ireland 66. 2 11. 2 4. 3 Scotland 73.6 12. 8 5. 0 Yugoslavia - 53.4c 20.0 a = 1969 b = Archives of the Balkan Medical Union, 1964, 2, No . 3-4 c = Tuberculosis in Yugos lavia 1956 - 66, Belgrade"-: 1967 Sources: World Health Statistics Report, 23, No. 8, 1970 World Health Statistics Annual, I-;- 1970 78 1970 13.0 7.7a 1 o. 5 9. 6 2. 8 8.3 8. 2 11. 1 8. 2 9. 5 19. 3 1.0 7. 5 7. 0 1. 2 2.7 25. 5 15. 1 18. 5 12. 8a 4. 8 6.3 3.3 4.3 5.4 18. 5 RA TES OF MORTALITY FROM TU BER CU LOS IS IN COUNTRIES OF EUROPE , PER 100 000 POPULATION, 195 7- 1959 AND 196 7- 1969 Ne ther l ands Denmark Iceland Norway England & Wales N . Ireland Sweden ~cotland Switzerland Belgium Ital y Ireland Finland Czechoslovakia Germany, Fed . Rep . of Greece France Bulgaria German Dem. Reo. Spain Austria Yugoslavia Romania Hungary Portugal Poland I I I .,.. :x :x X 0 >< ~x OX O X~O<X vOcX 0 DX <">"><I<"!'> >00< I I I I I I I ◊X~X~~ ,,., oooooa 1 1 1957-59 ----- 1967- 69 I I I I J I I 0 1 0 20 79 30 40 50 / 100 000 Fig. 2 70 60 50 ~ 0 -~ -:;; ..... :l 40 0.. 0 0.. 0 0 0 0 0 ~ (1) 0.. 30 2 "' ~ 20 10 0 DEATH RATES PER 100 000 POPULATION FROM TUBERCULOSIS ( ALL FORMS), 20 COUNTRIES IN EUROPE 195 7 / 1959 AND 1967 BY BROAD AGE-GROUPS 0 1- 4 excess rate in 1957 / 1959 rate in 1967 5 -14 1 5-24 25-44 Age-groups 80 45-64 6 5- 74 7 5+ Fig. 3 100 90 8 0 § 70 ..... ..., m ..... [ 60 0 p, 0 DECLINE IN TUBERCULOSIS MORTALITY IN THE EUROPEAN REGION 1967 RATES AS A PROPORTION OF 1957 / 1959 RATES 1957 / 1959 1967 :§; 5 0 ••• • • • • • ••••••••• • • • • • • • • • • • • • • • • • • 0 0 ..... I-< 40 (1) p, (1) -:;; 30 p::; 20 10 0 0 1-4 5-14 15-24 25-44 45-64 65- 7 4 7 5+ Age-groups 81 NATIONAL COMMUNICABLE DISEASES SURVEILLANCE PROGRAMMES IN EUROPE by Dr M. R. Radovanovic Regional Officer for Communicable Diseases WHO Regional Office for Europe Copenhagen, Denmark "Because of the great successes which have been achieved, it is perhaps tempting to assume that the problem of communicable diseases is virtually solved and that victory is just around the corner. There is, however, ample evidence that such complacency and a premature relaxa- tion of effort in the attack against communicable diseases could lead to disappointing setbacks or even disastrous consequences". 1 1. Introduction (Professor A. 0. Lucas, General Chairman of the Technical Discussions at the Twenty-first World Health Assembly) In most countries of the European Region, great progress has been made during the last few decades in communicable diseases control. It is difficult, however, to assess exactly the present extent of the individual communicable diseases problems, owing to incompleteness and short- comings in notification and lack of uniformity in methods of investigation, criteria of diagnosis and reporting practic e . Even if morbidity reporting were quite accurate and complete, the varied biological characteristics of many diseases and their multiple causes would prevent an exact mea- surement of their true extent. In addition, the ever increasing movement of people (migrant workers, tourists), urbanization and the international trade in foodstuffs are among the major factors which constantly change the ecological and epidemiological situation in the European Region and make an accurate assessment of communicable diseases and prediction of future trends on a regional basis very difficult. Nevertheless, the avail- able information2 indicates that there are still a number of communicable diseases of public health importance prevalent in the Region, despite the fact that many of them are fully amenable to effective control measures. 1 Document A21 /Technical Discussions/4 2 Wld Hlth Stat. Rep. 1961, 1964, 1966, 1967 • 1968, .!.1, .!2., 1..2, 20 and 21 32 The above facts call for a re-examination of present practices, a reassessment of the importance of individual communicable diseases, and consequently a possible revision of existing policies and priorities with respect to these diseases in individual countries and an improvement in inter-country co-operation for their prevention and control. Conditions differ in different parts of the Region and it is therefore a matter for each country to decide the order of priority in which individual communicable dise ases deserve to be included in overall public health planning and pro- gramming, taking into account health hazards and their socio-economic consequences as well as the resources available. The present situation could be improved through national communi- cable diseases surveillance programmes and international co-operation in this field. The national health administrations need to adapt their serv- ices to present concepts of communicable disease surveillance and WHO could assist them, inter alia, in developing a system for national surveil- lance programmes suitable for local conditions, in collecting, consolidat- ing and disseminating the epidemiological information available and by improving international co-operation in this field. 2. Purpose of a surveillance programme The purpose of a national surveillance programme is the continuous collection, consolidation and interpretation of epidemiological information concerning communicable diseases and their related factors (including agent, host and environment) within a country, in order to assist and guide an effective and rational approach to preventive and control measures. This requires a multidisciplinary approach, the exact nature of which will largely depend on the medical and public health resources avail- able. In the countries of the Region with adequate health services, a comprehensive surveillance programme is possible. Recent develop- ments in communica tion science allow the fast, accurate and efficient ana- lysis of data necessary for such programmes. But in countries where the health services in general, and statistical and laboratory diagnostic services in particular , are as yet insufficient, an ad hoc surveillance programme could b e carried out, e.g., by means of multi-exploitation repeated cross-sectional immunological surveys, simultaneously with action to improve the services. The purpose of such surveys is to :pro- vide rapid and objective information on the prevalence, distribution (age, sex, geographical) and trends of major infections. This information is essential for guiding vaccination policies, for planning and executing ra- tional preventive programmes and for assessing the effectiveness of such programmes. 3. Organization of a national surveillance programme A national surveillance programme should use the existing resources but should introduce more rational procedures and promote improved co- operation between the various services involved. The same structure 83 can be used for the surveillance of several communicable diseases, though the emphasis in the programme may vary in accordance with the diseases included in it. The structure chosen will also depend on such factors as the size of the country, the ease of communication and transport and the administra- tive set-up of the health services, but is likely to comprise the following three levels. 3. 1 National (central or federal) provision should include: (a) development of suitable methods and standardization of record- ing and r eporting procedures; (b) reception, consolidation, analysis and interpretation, storage, publication and distribution of epidemiological information, both within the country and internationally ; (c) co-ordination of the work of the services, especially the statis- tical and laboratory services, at the national level; (d) drafting of proposed legislation and regulations. 3. 2 Provincial services should be able to: 3.3 (a) a ssess the epidemiological situation, take the initiative in con- ducting surveys and other epidemiological investigations within the province and give these the necessary support; (b) co-ordinate the work of the provincial services; (c) promote, assist and co-ordinate the work of the local services. Local provision should include: (a) clinical and laboratory diagnosis ; (b) morbidity reporting and mortality registration; (c) epidemiological enquiries and surveys; (d) assessment of the effectiveness of vaccination programmes. 4. Functions of the representatives of the disciplines involved An effective surveillance programme requires co-operation between epidemiologists, clinicians, laboratory experts, health statisticians, public health administrators and others, depending on the disease . 8 4 4. 1 The epidemiologist (a) defines the purpose and scope of the surveillance programme and proposes technical guides; (b) assesses the extent of the problem and predicts future trends of the disease through analysis and evaluation of all available epidemi- ological information; investigates outbreaks; (c) assesses the effectiveness of control measures; (d) ensures dissemination of information; (e) prepares recommendations to the decision-making authority. 4. 2 The clinician 4.3 (a) in consultation with epidemiologists, defines the methods of clinical investigation, and standardizes diagnostic criteria, termin- ology and clinical classification of diseases; (b) assists in drafting procedures and forms for the recording and notification of cases and in establishing criteria for the collection of specimens for laboratory investigations. The laboratory expert (a} prescribes the methods for laboratory investigations; (b) assists in establishing criteria and procedures for the collection of specimens; (c) drafts forms for the recording and reporting of laboratory in- vestigations. 4. 4 The health statistician (a) in conjunction with epidemiologists and clinicians, makes ar- rangements for: (i) the collection of data; analysis of morbidity and mortality reports containing clinical, laboratory and epidemiological data; (ii) the planning and carrying out of surveys and other types of epidemiological investigation; (iii) an efficient system of data storage, linkage and retrieval. 85 4.5 The public health administrator (a) assesses the public health importance of a specific disease; (b) assigns to it the priority it deserves; (c) allocates resources accordingly; (d) co-ordinates the work of the services involved, ensures co- operation between various levels - central, provincial and local; (e) takes decisions regarding preventive and control measures. 5. Conclusions Improvements in the collective approach to public health action against communicable diseases in many countries of the European Region are possible and necessary. The ample resources available in many countries, the existence of a large number of WHO reference laboratories in the Region and the ease of communication and transport in most parts of the Region, are among the factors which should help the national health administrations to adapt their services to present concepts of communicable diseases surveillance. This can be done through better use of the existing resources. Each country must decide its own priorities for the gradual develop- ment of a national surveillance system; should public health priorities justify this, such a system may be applied not only to communicable dis- eases but also to other public health problems (e.g., cardiovascular dis- eases, traffic accidents and congenital disorders). Many public health problems do not begin or end at national bounda- ries; solutions may be required on an international level because the problems are international, or because only international resources could effectively cope with them. These are only a few of the reasons why countries should, in their own interest, participate in international activi- ties in communicable diseases surveillance. A promising start has already been made in Europe, e.g., salmo- nella surveillance and surveillance of rabies in wild-life, each involving a number of countries whose efforts are assisted and co-ordinated by WHO. 86 SELECTED DEMOGRAPHIC FEATURES AND STATISTICS RELATING TO THE EUROPEAN REGION This chapter presents selected demographic features and health statistics relating to the European Region, based mainly on information already published by the United Nations or by WHO Headquarters. Table 1 shows, for each country, the population in thousands, the population density per square kilometre, the annual rate of increase during the period 1963-1971, and the birth rate and the death rate per 1000 popu- lation in 1971 (or in the last year for which information was available). Maps 1 and 2 illustrate the number of notified cases of infectious hepatitis per 100 000 population in the European Region in 1962 and 197 2 respectively, as reported to WHO. Maps 3 and 4 illustrate the number of notified cases of poliomyelitis per 100 000 population in the European Region in 1953-1957 and 1972 res- pectively, as reported to WHO. Maps 5 and 6 illustrate the number of notified cases of typhoid and paratyphoid fever per 100 000 population in the European Region in 1962 and 197 2 respectively, as reported to WHO. 87 T able l SOME DEMOGRAPHIC C HARACT ER ISTICS OF THE EUR OPEAN REGION IN 1 971 OR I N THE LAST YEAR FOR WHI CH FIGURES ARE AVAILABLE Countr y A lbania Algeria Austria 81..•lgium Bul ga ria Czecho slo vakia Den mark Finland France Gc-rman Dem. Rep . Germany, Fed. Rep. Greece Hungary Iceland Ir e land Ita ly Luxembourg Malta Monaco M orocc o Nethe rlands Norwa y Poland Portugal Romania S pai n Sweden Switze rland Turkey United Kingd om Engla nd and Wa les No rthe rn Ireland Scotland USSR Yug o slavi a Data not applicab l e Data no t avai lab le a J CJ{:,lj b 11)70 C 1967 Popu lation (t housands) 2 226 14 769 7 456 9 726 8 540 14 500 4 966 4 684 51 260 15 954 of 59 17 5 8 957 10 364 214 2 971 54 078 341 325 24 15 234 13 194 3 905 32 7 49 8 950 20 470 34 134 8 105 6 34 5 36 162 48 8 15 1 534 5 217 245 066 20 550 Density Annual rate of increa s e Birth rate Death rate pof~fcr 1 963 -1971 per 1000 per 1000 in per cent ii 3 . 0 35 . 3a 7 .5a 6 3. 5 4 3. 4a I 0. 2a 89 0. 5 14 . 6 I 3. I 319 0. 6 14 . 5 12. 4 77 0 7 15. 9 9. 7 113 0 . 5 I 6 5 11 5 115 0. 7 15. 2 9. 8 14 0. -I I 3. 3 9 . 9 94 0. 9 17 . I 10 7 148 -0. 1 13 . 8 I 3. 8 239 0. 8 12. 7 II 9 68 ... 1 5. 9 8.3 Ill 0. 4 14 .6 11. 9 2 1. 8 19. 7 b 7. 1 b 42 0.5 22.8 10 . 6 180 0.8 16.8 9. 6 I 32 0.6 I 3. 0 12. 8 I 030 -0 . I 17 . I 9. 5 16 I 07 I. I 9. 2b 11. 4b 34 .. . .. . ... 323 I. 2 17. 2 K. 4 12 0. 8 16.8 l 0. 0 I 05 0. 8 17 . 2 8. 7 97 .. 21. 3 11. 1 86 I .1 19. 5 9 . 5 68 I .I 20. 0 9. I 0.8 14. l 10. 2 1 54 1 .2 I 5 . 2 9. 1 46 2. 5 39.6c 14 . 6C 323 0.5 16.0 11 .6 1 08 0 . 7 20 . 7 10. 6 66 0. 0 16. 6 11 . 8 11 I .I 17 . 8 8 . 2 80 I . 0 I 8 . 1 8. 7 Sources : Uni te d Na tions {I 97 2) Demogra ph ic Year Book 1971 88 Wo rld Hea lth Orga nization (197 3) World Heal th Sta tis tics R e po rt, ~. 6 , 9-- NOTIFIED CASES OF INFECTIOUS HEPA TIT ls PER l 00 000 POPULATION IN THE EUROPEAN REGION IN 1962, REPORTED TO WHO e"ZZ.a 100-10 c:=::J Figures not available to WHO Figures for Turkey, l 963 Sources: ~ < l 0 t:.:.:.:.:.:.:. United Nations { 1972) Demo,ra!hic Yearbook 1971 World Health Organization ( 97 ) Geneva ( unpublished material) 90 Map 2 NOTIFIED CASES OF INFECTIOUS HEPATITIS PER 100 000 POPULATION IN THE EUROPEAN REGION IN 1972, 1, 2 REPORTED TO WHO 1' ' q E:ZZ.,.a 100-10 CJ Figures not available to WHO 1 Figures for Portugal, 1969 2 Figures for Bulgaria and Romania, 1971 • ~<10 Sources: United Nations {1972) Demo,ra!hic Yearbook 1971 World Health Organization ( 97 ) Geneva ( unpublished material) 91 NOTIFIED CASES OF POLIOMYELITIS PER 100 000 POPULATION IN THE EUROPEAN REGION IN 1953-1957, l REPORTED TO WHO l 0 - l ~ l -0.l - >10 c:::zl<O. l ~ c:J Figures not available to WHO Figures for Finland and Spain are for the paralytic form only Sources: United Nations (1972) Demo,ra!hic Yearbook 1971 World Health Organization (97 ) Geneva ( unpublished material) 92 NOTIFIED CASES OF POLIOMYELITIS PER 100 000 POPULATION IN THE EUROPEAN REGION IN 1972, 1, 2, 3 REPORTED TO WHO ~ 10 - l ~ l - 0.1 - >10 c:z:J<o.1 c:J Figures not available to WHO 1 Figures for Finland and Spain are for the paralytic form only 2 Figures for Morocco and Portugal, 1970 3 Figures for Bulgaria, German Democratic Republic and Romania, 1971 Sou rces: United Nations ( 1972) Demo,ra!hic Yearbook 1971 World Health Organization (97 ) Geneva ( unpublished material) 93 Map 5 NOTIFIED CASES OF TYPHOID AND PARATYPHOID FEVER PER 100 000 POPULATION IN THE EUROPEAN REGION IN 1962, 1, 2 REPORTED TO WHO - >lO ~ 10-1 c:::J Figures not available to WHO I Figures for Algeria, 1961 2 Figures for Sweden include other Salmonella infections ~ < I Sources: United Nations {1972) Demo,ra!hic Yearbook 1971 World Health Organization ( 97 ) Geneva ( unpublished material) 94 NOTIFIED CASES OF TYPHOID AND PARATYPHOID FEVER PER 100 000 POPULATION IN THE EUROPEAN REGION IN 1972, 1, 2, 3 REPORTED TO WHO - >10 ~ 10-1 c:J Figures not available to WHO 1 Figures for Portugal, 1969 2 Figures for Morocco, 1970 3 Figures for Bulgaria and Romania, 1971 ~<1 Sources: United Nations ( 1972) Demographic Yearbook 1971 World Health Organization (1973) Geneva (unpublished material) 95