336 be measured in the routine assessment of human immunocompetence, and further experiments are under way. Ontario Cancer Foundation,
Kingston Clinic, Kingston, Ontario, Canada K7L 2V7.
HUGH F. PROSS.
of Tumour Biology, Karolinska Institute, Stockholm, Sweden.
MIKAEL JONDAL.
Department
NATIONAL DRIED MILK SiR,—The sale of National Dried Milk has declined in this area, as in Oxford. Some authorities had contributed to this by discouraging the sale of all foodstuffs in infantwelfare clinics. Dr Baum and Dr Harker (Jan. 18, p. 159) are surely asking the wrong question. It is valid to point out the relative cheapness of National Dried Milk, but is this really the milk to promote in 1975 ? The recent D.H.S.S. report1 recommends the promotion of breastfeeding. If this is not possible and artificial milks are used then " such milk feeds should contain a concentration of than that of phosphate sodium and protein which is lower cow’s milk and nearer to that of breast milk " (para. 6.3.1, p.
25). There
several " humanised " modern milks comwhich though more expensive than National Dried Milk fulfil these criteria. The report also recommends that " National Dried Milk should be modified " (para. 6.3.5, p. 25). Present Government policy subsidises cow’s milk, which keeps the price of doorstep milk falsely low and thereby encourages its use for infant feeding on grounds of economy alone. Would it not be wiser to suggest to Government that it should either subsidise the commercial modern milk preparations or modify the already subsidised N.D.M. as soon as possible ? The money for this could be raised by taking the subsidy off doorstep milk, which is an undesirable food for infants. are
mercially available
Ipswich Hospital, Heath Road Wing, Ipswich IP4 5PD.
CHRISTOPHER NOURSE.
MENINGOCOCCAL INFECTIONS SIR,—Your interesting annotation (Dec. 14, p. 1431) on the chemoprophylaxis of meningococcal infections began with the statement that meningococcal infections are on the increase throughout the world. The published figures I have seen indicate that the increase in these infections is by no means universal. In Europe, between 1967 and 1971 the number of reported cases of meningococcal infections increased appreciably in Belgium, France, Portugal, Spain, Switzerland, and Yugoslavia, but not in Austria, West Germany, Greece. Italy, Netherlands, or Sweden.1-3 Since 1971, however, only in France of these countries has the reported annual incidence continued to rise 1; in Portugal and Belgium it has fallen slightly while in Spain, Switzerland, and Yugoslavia it has fallen appreciably. In Finland, an outbreak of group-A meningococcal meningitis began in 1971, and in the first six months of 1974, 367 cases were reported compared with 111 cases in the whole of 1971. In France, a period of high incidence was previously recorded in 1963-64 3; indeed, infections reported since 1967 to the World Health Organisation from most other countries in Europesuggest that the incidence of meningococcal infection may rise and fall sporadically. The time scales, however, do not usually coincide in the different countries-thus, peak incidences were recorded in Belgium in 1971 and 1972, in Italy in 1970, in the Netherlands in 1967 and again in 1972, in Spain in 1971 and in Yugoslavia in 1970. In Asia, of the countries that report to the W.H.O. only the figures from Turkey suggest that the incidence of meningococcal infection is increasing; the number of reported cases remained relatively static between 1967 and 1971, but then increased more than tenfold in 2 years, from 263 in 1971 to 3178 in 1973. No further details are available
1. Wld Hlth Statist. Rep. 1969-74, vols. 22-27, nos. 8. 2. Lambert, P. M. Comm. Med. 1973, 129, 279. 3. Serre-Boisseau, F. Bull. Wld Hlth Org. 1973, 48, 675. 4. Wkly epidem. Rec. 1974, 49, 362.
SIR,—Dr Baum and Dr Harker (Jan. 18,
p. 159) ask why have chosen to feed their babies on National Dried Milk. From my experience in buying N.D.M. from 1960 to 1966 I am not surprised at this trend. In most of the country N.D.M. is available only at child-health clinics. The hours during which the clinics are open are more limited and less convenient than those of grocery shops and many people find the clinics hard to reach. The sale of N.D.M. has also been surrounded by a remarkable amount of red tape. At one time one had to pay with postage stamps, and when this procedure was suddenly changed about 1960 the postage stamps were angrily refused. Some clinics refused to give change if they were not paid with the exact amount. Once the caretaker of a clinic refused to sell me N.D.M. during normal hours because he said he was on holiday (which was denied by the M.O.H.). With relief we changed over to buying the well-subsidised dairy milk for children. The lack of publicity for N.D.M. which your correspondents describe is only one aspect of the poor salesmanship which has reduced the sale of N.D.M. from 40% in 1956 to 3% in 1973.
progressively fewer mothers
. ;1’7
501 Chancery Hall, 3 Sir Winston Churchill Square,
Edmonton, Alberta, Canada T5J 2C3. 1.
-1 J7
40
47
all
97
OV
07
Iv
f4
m
Meningococcal infection,* England and Wales, 1929-74: Registrar General’s notifications.
M. S. BEARE.
Present-day Practice in Infant Feeding. H.M. Stationery Office, 1974. See Lancet, 1974, ii, 1029.
*
Cases
were notified as follows: 1912-49 cerebrospinal fever; 1950-68, meningococcal infection; 1970 to the present, meningococcal meningitis. Figures for 1968, 1969, and 1974 are
estimates.
337 of this apparent rise in the incidence of the disease in
Turkey. In North America, the number of reported cases in Canada increased about fourfold between 1967 and 1973, but the most recent published figures for the first five months of 1974 suggest that the incidence has now fallen 1; in the U.S.A. there has been no recent increase in meningococcal infections-indeed the number has been falling since 1969.õ The incidence of meningococcal meningitis has undoubtedly risen considerably in Brazil however,6.7 but from nowhere else in South America or in Oceania have I found any reported evidence that the disease is increasing in incidence at present. That the incidence of meningococcal meningitis has been rising in England and Wales since about 1967 there can be little doubt. This is shown both by the Registrar General’s notifications and by the laboratory-proven cases reported to the Public Health Laboratory Service; the estimated figures from the Hospital In-patient Inquiry, although at present only available up to 1972, lend support to this. Moreover, since the same sources show that the total number of cases of meningitis due to other bacteria has not been rising in parallel, it is likely that the reported increase in meningococcal meningitis in this country is real. Information from the Communicable Disease (Scotland) Unit in Glasgowsuggests not only that a similar increase in the incidence of the disease is occurring in Scotland but that the number of cases of meningococcal septicaemia has also risen. It is interesting to relate the present period of increased incidence with earlier periods. The figure shows the annual number of Registrar General’s notifications since 1929. Apart from the rise during the 1939-45 war, peaks of incidence have occurred in the early 1930s, perhaps in the early 1950s, and now in the 1970s. The numbers being notified at present have not yet proceeded much beyond the levels seen in the 1930s or 1940s. The ratio of deaths to notified cases, which has remained relatively static at between 20% and 30% for about 30 years, exaggerates the true death-rate because deaths are compulsorily certificated whereas notifications are incomplete. However, if it is assumed that the completeness of notifications has been about the same throughout this period, it is of some interest that the ratio has not altered very much since the introduction of chemotherapy in the late 1930s. I am grateful to Dr P. M. Lambert, senior medical statistician, Office of Population Censuses and Surveys, London, for his help and advice in the interpretation of some of the statistics. Central Public Health Laboratory, Colindale Avenue, London NW9 5HT.
N. D. NOAH.
DISINFECTANTS AND SMALLPOX SiR,-The Memorandum on the Control of Smallpox 8 recommends the use of a " white fluid " for terminal disinfection. Such fluids are not now commonly used in hospitals, having largely been replaced by clear soluble
phenolic fluids.
asked about be used instead of the white fluid
Questions
are
now
being
whether such fluids can recommended. The answer must be a regretful " no ". It would not be difficult to test the newer disinfectants against a suspension of a poxvirus, such as vaccinia, and it is probable that many would be found to be effective. However, an 5. U.S. Centre for Disease Control, Morbidity and Mortality. Annual Supplement 1973, 22, no. 53. 6. Wkly epidem. Rec. 1974, 49, 168, 381. 7. Communicable Diseases (Scotland) 1974, 74/44; and personal communication. 8. Ministry of Health and Scottish Home and Health Department. H.M. Stationery Office, 1964.
environment contaminated by a case of smallpox may contain crusts which are hard, dry, fragments of inspissated secretions containing the virus, and to be effective a With the steady disinfectant must penetrate these. reduction of smallpox throughout the world, crusts are exceedingly difficult to obtain, and no acceptable experimental model exists. The only well-defined disinfectant known to have been tested against such crusts is a white fluid to B.S. 2462: 1961 recommendation (Group WF or WG) at a concentration of 2-5%. Efforts are being made to obtain crusts from Asia and if these are successful it is hoped that tests will be made on them, in a laboratory competent to do so. Meanwhile, the recommendations for white fluids must stand. If difficulty’is experienced in obtaining them, the British Disinfectant Manufacturers’ Association, Alembic House, 93 Albert Embankment, London SE1, will advise. Public Health Laboratory Service Board, Colindale Hospital, Colindale Avenue, London NW9 5EQ.
J. C. KELSEY.
TREATMENT OF ALLERGY TO COW’S MILK SiR)—We were very interested in the paper (Jan. 18, p. 136) on cow’s milk allergy by Dr Shiner and her colleagues. Since we have been looking at the duodenal juice as a diagnostic test and have treated two babies with disodium cromoglycate, our experience may be of further interest. The second of twins, born on Feb. 5, 1974, weighed 3170 g. at birth. Symptoms started within a few days of birth: diarrhoea, vomiting, and poor weight gain. Investigation at the age of seven weeks excluded cystic fibrosis and various metabolic diseases. Jejunal biopsy showed broad villi and non-specific abnormalities. Enzyme studies were normal. Gel-precipitin test for milk antibodies were positive at 1/2 dilution. Duodenal juice was examined for precipitating antibodies to cow’s milk. A double diffusion (Ouchterlony) technique on commercial plain agar plates was used. The method comprised two separate diffusions on the same plate. (a) Neat cow’s milk was placed in the centre well of one set and doubling dilutions of duodenal juice (neat 1 : 16) placed in the outer wells. (b) Neat duodenal juice placed in the centre well of another set and doubling dilutions of cow’s milk (neat 1 : 16) placed in the outer wells. The plates were then incubated overnight at 4C and any precipitation arcs noted. Positive reactions were obtained to cow’s milk. Further tests were done on 8 duodenal juices and the following:Nutramigen’, ’ S.M.A.’, ’Ostermilk ’,Cow & Gate’, ’Velactin ’, and saline. The eight duodenal juices were negative to all, but the patient’s juice was negative only to saline and velactin. Further tests are in progress against &bgr;-Iactoglobulin and IgE antibodies against cow’s milk in the juice. The baby was started on cow’s-milk-free formula with complete cessation of symptoms within 48 hours and satisfactory progress. Reintroduction of cow’s milk at the age of six months resulted in diarrhoea and vomiting. At this stage disodium cromoglycate 50 mg. 4 times a day (in chloroform water) was given. Cow’s milk was reintroduced five days later. Since then the baby has been able to tolerate normal cow’s milk in adequate amounts.
A boy born on March 20 weighed 3120 g. He was discharged home after 48 hours. Diarrhoea and vomiting started from about that time. Various cow’s milk changes were made with poor general progress. At the age of six months he was wasted and not thriving satisfactorily. Jejunal biopsy showed minor, nonspecific abnormalities, and enzyme studies were normal in maltase, lactase, and sucrase activity. Duodenal-juice studies were positive to cow’s milk (see above). Withdrawal of cow’s milk resulted in cessation of symptoms. On challenge with cow’s milk, abdominal distension, vomiting, and diarrhoea occurred. For the first 3 months he was treated with cow’smilk-free formula and then was started on disodium cromoglycate 50 mg. 4 times daily. Cow’s milk was reintroduced five days later and since then he has been able to tolerate a perfectly normal diet. Tv’o months later disodium cromoglycate was reduced to
Kingston Clinic, Kingston, Ontario, Canada K7L 2V7.
HUGH F. PROSS.
of Tumour Biology, Karolinska Institute, Stockholm, Sweden.
MIKAEL JONDAL.
Department
NATIONAL DRIED MILK SiR,—The sale of National Dried Milk has declined in this area, as in Oxford. Some authorities had contributed to this by discouraging the sale of all foodstuffs in infantwelfare clinics. Dr Baum and Dr Harker (Jan. 18, p. 159) are surely asking the wrong question. It is valid to point out the relative cheapness of National Dried Milk, but is this really the milk to promote in 1975 ? The recent D.H.S.S. report1 recommends the promotion of breastfeeding. If this is not possible and artificial milks are used then " such milk feeds should contain a concentration of than that of phosphate sodium and protein which is lower cow’s milk and nearer to that of breast milk " (para. 6.3.1, p.
25). There
several " humanised " modern milks comwhich though more expensive than National Dried Milk fulfil these criteria. The report also recommends that " National Dried Milk should be modified " (para. 6.3.5, p. 25). Present Government policy subsidises cow’s milk, which keeps the price of doorstep milk falsely low and thereby encourages its use for infant feeding on grounds of economy alone. Would it not be wiser to suggest to Government that it should either subsidise the commercial modern milk preparations or modify the already subsidised N.D.M. as soon as possible ? The money for this could be raised by taking the subsidy off doorstep milk, which is an undesirable food for infants. are
mercially available
Ipswich Hospital, Heath Road Wing, Ipswich IP4 5PD.
CHRISTOPHER NOURSE.
MENINGOCOCCAL INFECTIONS SIR,—Your interesting annotation (Dec. 14, p. 1431) on the chemoprophylaxis of meningococcal infections began with the statement that meningococcal infections are on the increase throughout the world. The published figures I have seen indicate that the increase in these infections is by no means universal. In Europe, between 1967 and 1971 the number of reported cases of meningococcal infections increased appreciably in Belgium, France, Portugal, Spain, Switzerland, and Yugoslavia, but not in Austria, West Germany, Greece. Italy, Netherlands, or Sweden.1-3 Since 1971, however, only in France of these countries has the reported annual incidence continued to rise 1; in Portugal and Belgium it has fallen slightly while in Spain, Switzerland, and Yugoslavia it has fallen appreciably. In Finland, an outbreak of group-A meningococcal meningitis began in 1971, and in the first six months of 1974, 367 cases were reported compared with 111 cases in the whole of 1971. In France, a period of high incidence was previously recorded in 1963-64 3; indeed, infections reported since 1967 to the World Health Organisation from most other countries in Europesuggest that the incidence of meningococcal infection may rise and fall sporadically. The time scales, however, do not usually coincide in the different countries-thus, peak incidences were recorded in Belgium in 1971 and 1972, in Italy in 1970, in the Netherlands in 1967 and again in 1972, in Spain in 1971 and in Yugoslavia in 1970. In Asia, of the countries that report to the W.H.O. only the figures from Turkey suggest that the incidence of meningococcal infection is increasing; the number of reported cases remained relatively static between 1967 and 1971, but then increased more than tenfold in 2 years, from 263 in 1971 to 3178 in 1973. No further details are available
1. Wld Hlth Statist. Rep. 1969-74, vols. 22-27, nos. 8. 2. Lambert, P. M. Comm. Med. 1973, 129, 279. 3. Serre-Boisseau, F. Bull. Wld Hlth Org. 1973, 48, 675. 4. Wkly epidem. Rec. 1974, 49, 362.
SIR,—Dr Baum and Dr Harker (Jan. 18,
p. 159) ask why have chosen to feed their babies on National Dried Milk. From my experience in buying N.D.M. from 1960 to 1966 I am not surprised at this trend. In most of the country N.D.M. is available only at child-health clinics. The hours during which the clinics are open are more limited and less convenient than those of grocery shops and many people find the clinics hard to reach. The sale of N.D.M. has also been surrounded by a remarkable amount of red tape. At one time one had to pay with postage stamps, and when this procedure was suddenly changed about 1960 the postage stamps were angrily refused. Some clinics refused to give change if they were not paid with the exact amount. Once the caretaker of a clinic refused to sell me N.D.M. during normal hours because he said he was on holiday (which was denied by the M.O.H.). With relief we changed over to buying the well-subsidised dairy milk for children. The lack of publicity for N.D.M. which your correspondents describe is only one aspect of the poor salesmanship which has reduced the sale of N.D.M. from 40% in 1956 to 3% in 1973.
progressively fewer mothers
. ;1’7
501 Chancery Hall, 3 Sir Winston Churchill Square,
Edmonton, Alberta, Canada T5J 2C3. 1.
-1 J7
40
47
all
97
OV
07
Iv
f4
m
Meningococcal infection,* England and Wales, 1929-74: Registrar General’s notifications.
M. S. BEARE.
Present-day Practice in Infant Feeding. H.M. Stationery Office, 1974. See Lancet, 1974, ii, 1029.
*
Cases
were notified as follows: 1912-49 cerebrospinal fever; 1950-68, meningococcal infection; 1970 to the present, meningococcal meningitis. Figures for 1968, 1969, and 1974 are
estimates.
337 of this apparent rise in the incidence of the disease in
Turkey. In North America, the number of reported cases in Canada increased about fourfold between 1967 and 1973, but the most recent published figures for the first five months of 1974 suggest that the incidence has now fallen 1; in the U.S.A. there has been no recent increase in meningococcal infections-indeed the number has been falling since 1969.õ The incidence of meningococcal meningitis has undoubtedly risen considerably in Brazil however,6.7 but from nowhere else in South America or in Oceania have I found any reported evidence that the disease is increasing in incidence at present. That the incidence of meningococcal meningitis has been rising in England and Wales since about 1967 there can be little doubt. This is shown both by the Registrar General’s notifications and by the laboratory-proven cases reported to the Public Health Laboratory Service; the estimated figures from the Hospital In-patient Inquiry, although at present only available up to 1972, lend support to this. Moreover, since the same sources show that the total number of cases of meningitis due to other bacteria has not been rising in parallel, it is likely that the reported increase in meningococcal meningitis in this country is real. Information from the Communicable Disease (Scotland) Unit in Glasgowsuggests not only that a similar increase in the incidence of the disease is occurring in Scotland but that the number of cases of meningococcal septicaemia has also risen. It is interesting to relate the present period of increased incidence with earlier periods. The figure shows the annual number of Registrar General’s notifications since 1929. Apart from the rise during the 1939-45 war, peaks of incidence have occurred in the early 1930s, perhaps in the early 1950s, and now in the 1970s. The numbers being notified at present have not yet proceeded much beyond the levels seen in the 1930s or 1940s. The ratio of deaths to notified cases, which has remained relatively static at between 20% and 30% for about 30 years, exaggerates the true death-rate because deaths are compulsorily certificated whereas notifications are incomplete. However, if it is assumed that the completeness of notifications has been about the same throughout this period, it is of some interest that the ratio has not altered very much since the introduction of chemotherapy in the late 1930s. I am grateful to Dr P. M. Lambert, senior medical statistician, Office of Population Censuses and Surveys, London, for his help and advice in the interpretation of some of the statistics. Central Public Health Laboratory, Colindale Avenue, London NW9 5HT.
N. D. NOAH.
DISINFECTANTS AND SMALLPOX SiR,-The Memorandum on the Control of Smallpox 8 recommends the use of a " white fluid " for terminal disinfection. Such fluids are not now commonly used in hospitals, having largely been replaced by clear soluble
phenolic fluids.
asked about be used instead of the white fluid
Questions
are
now
being
whether such fluids can recommended. The answer must be a regretful " no ". It would not be difficult to test the newer disinfectants against a suspension of a poxvirus, such as vaccinia, and it is probable that many would be found to be effective. However, an 5. U.S. Centre for Disease Control, Morbidity and Mortality. Annual Supplement 1973, 22, no. 53. 6. Wkly epidem. Rec. 1974, 49, 168, 381. 7. Communicable Diseases (Scotland) 1974, 74/44; and personal communication. 8. Ministry of Health and Scottish Home and Health Department. H.M. Stationery Office, 1964.
environment contaminated by a case of smallpox may contain crusts which are hard, dry, fragments of inspissated secretions containing the virus, and to be effective a With the steady disinfectant must penetrate these. reduction of smallpox throughout the world, crusts are exceedingly difficult to obtain, and no acceptable experimental model exists. The only well-defined disinfectant known to have been tested against such crusts is a white fluid to B.S. 2462: 1961 recommendation (Group WF or WG) at a concentration of 2-5%. Efforts are being made to obtain crusts from Asia and if these are successful it is hoped that tests will be made on them, in a laboratory competent to do so. Meanwhile, the recommendations for white fluids must stand. If difficulty’is experienced in obtaining them, the British Disinfectant Manufacturers’ Association, Alembic House, 93 Albert Embankment, London SE1, will advise. Public Health Laboratory Service Board, Colindale Hospital, Colindale Avenue, London NW9 5EQ.
J. C. KELSEY.
TREATMENT OF ALLERGY TO COW’S MILK SiR)—We were very interested in the paper (Jan. 18, p. 136) on cow’s milk allergy by Dr Shiner and her colleagues. Since we have been looking at the duodenal juice as a diagnostic test and have treated two babies with disodium cromoglycate, our experience may be of further interest. The second of twins, born on Feb. 5, 1974, weighed 3170 g. at birth. Symptoms started within a few days of birth: diarrhoea, vomiting, and poor weight gain. Investigation at the age of seven weeks excluded cystic fibrosis and various metabolic diseases. Jejunal biopsy showed broad villi and non-specific abnormalities. Enzyme studies were normal. Gel-precipitin test for milk antibodies were positive at 1/2 dilution. Duodenal juice was examined for precipitating antibodies to cow’s milk. A double diffusion (Ouchterlony) technique on commercial plain agar plates was used. The method comprised two separate diffusions on the same plate. (a) Neat cow’s milk was placed in the centre well of one set and doubling dilutions of duodenal juice (neat 1 : 16) placed in the outer wells. (b) Neat duodenal juice placed in the centre well of another set and doubling dilutions of cow’s milk (neat 1 : 16) placed in the outer wells. The plates were then incubated overnight at 4C and any precipitation arcs noted. Positive reactions were obtained to cow’s milk. Further tests were done on 8 duodenal juices and the following:Nutramigen’, ’ S.M.A.’, ’Ostermilk ’,Cow & Gate’, ’Velactin ’, and saline. The eight duodenal juices were negative to all, but the patient’s juice was negative only to saline and velactin. Further tests are in progress against &bgr;-Iactoglobulin and IgE antibodies against cow’s milk in the juice. The baby was started on cow’s-milk-free formula with complete cessation of symptoms within 48 hours and satisfactory progress. Reintroduction of cow’s milk at the age of six months resulted in diarrhoea and vomiting. At this stage disodium cromoglycate 50 mg. 4 times a day (in chloroform water) was given. Cow’s milk was reintroduced five days later. Since then the baby has been able to tolerate normal cow’s milk in adequate amounts.
A boy born on March 20 weighed 3120 g. He was discharged home after 48 hours. Diarrhoea and vomiting started from about that time. Various cow’s milk changes were made with poor general progress. At the age of six months he was wasted and not thriving satisfactorily. Jejunal biopsy showed minor, nonspecific abnormalities, and enzyme studies were normal in maltase, lactase, and sucrase activity. Duodenal-juice studies were positive to cow’s milk (see above). Withdrawal of cow’s milk resulted in cessation of symptoms. On challenge with cow’s milk, abdominal distension, vomiting, and diarrhoea occurred. For the first 3 months he was treated with cow’smilk-free formula and then was started on disodium cromoglycate 50 mg. 4 times daily. Cow’s milk was reintroduced five days later and since then he has been able to tolerate a perfectly normal diet. Tv’o months later disodium cromoglycate was reduced to
