1025
population as a whole is also expected to increase by about 2-5%; we have disregarded both these G.N.P. has been projected during the ten factors. years at a modest year-to-year growth figure of 24 % . hence, it is estimated that 442,337 males of working age-the combined workforce of an area of total population of about 1’3 million (e.g., Birmingham and Coventry combined)-will have died from Ten years
cardiovascular disease E8135 million
at
1974
at a
cumulative
cost
of
some
prices.
Requests for reprints should be addressed
to
D. B. L.
Public Health NON-TOXIGENIC CORYNEBACTERIUM DIPHTHERIÆ IN A BOARDING SCHOOL A. E.
E. H. GILLESPIE JEPHCOTT General Hospital, Northern Laboratory, Sheffield S5 7AU
Public Health
C. DAVENPORT Central Health District, Derbyshire Area Health Authority, Main Centre Office, Main Centre, Derby DE1 2PH
J. W. EMERSON Surgery, Butts Road, Bakewell P. J. MORONEY Moor Lodge Hospital, Sheffield S10 4LH A non-toxigenic strain of CoryneSummary bacterium diphtheriæ var. gravis was isolated from 31 boys during an outbreak of sore throats at a boarding school of 15 staff and 134 pupils. Despite the non-toxigenicity of the strain involved, conventional isolation procedures were observed and all boys at the school were treated with antibiotics. Restrictions on the school were only The
relaxed when no further carriers were detected. The rationale of such management of an episode involving a non-toxigenic strain is discussed. INTRODUCTION
THE incidence of diphtheria declined dramatically after the introduction of widespread immunisation in the 1940s and a pattern of sporadic small epidemics (particularly amongst schoolchildren) has emerged.l,2
Few isolates of Corynebacterium diphtheria are now being made, and most of these prove to be nontoxigenic. Thus the laboratories contributing to the Communicable Disease Report isolated only 131 strains of C. diphtheria during the past two years, and of these strains at least 117 (89%) were non-toxigenic. When a toxigenic strain was isolated it was often found to have come from abroad. Non-toxigenic strains were not commonly recognised before 1935, since when they have increased in relative number and importance.3 While these strains are usually regarded as totally non-virulent, -there are reports of clinical diphtheria being caused" by such strains.4 We investigated an epidemic " of non-toxigenic C. diphtherice var. gravis strains in a closed community.
We feel
might
be
experience in managing this outbreak helpful in handling similar situations in the
our
future. PATIENTS AND METHODS
The outbreak involved the 15 staff and 134 scholars of a residential boys’ preparatory school. At the onset of the incident nose and throat swabs were taken from cases of sore throat and examined at the Public Health Laboratory for all common pathogens. Similar swabs examined during screening procedures were plated onto tellurite blood-agar at the school and the plates were taken to the laboratory for incubation and examination. Suspicious colonies were examined by gram-stain and nigrosin techniques. Fermentation tests were made on all strains in serum-water sugars.5 Toxigenicity tests were carried out on all early isolates by both subcutaneous injection into guineapigs and the Elek plate method.6 Later isolates were investigated for toxigenicity by the Elek plate method alone. THE
"EPIDEMIC"
On May 5, 1974, organisms resembling C. diphtheria (later established to be a non-toxigenic strain of C. diphtheriae var. gravis) were isolated from the throat swabs of 3 of 7 boys with sore throats. Over the next eight days sore throats developed in 12 more boys and the corynebacterium isolated from 4 of these. Management at first followed the conventional pattern. Cases were isolated as they arose, initially in the sick bay, and when cultures proved positive they were moved to the local infectious diseases unit. The immune status of all scholars was ascertained and arrangements for giving booster doses of vaccine were made. As far as was practicable, links between the school and the outside community and with other schools were temporarily cut. After it became clear that the strains involved were not toxigenic handling the situation became more difficult. No relaxation of the isolation procedure was considered until the extent of carriage within the school had been established by swabbing all the academic staff and pupils. 24 boys were symptomless carriers. No member of staff was positive. The hazard of leaving untreated boys with symptoms and the risk of allowing this high carrier-rate to persist were weighed against the hazards and likely success of treatment. Boys with symptoms in the hospital were treated with erythromycin and were not allowed back to school until they were bacteriologically clear. All boys at school were given a course of erythromycin (0-5 g. three times a day for five days) in an attempt to clear all symptom-free carriers in the school-i.e., both the 24 known and any others who might have escaped detection by the single screening procedure. Minor drug intolerance with complaints of nausea and gastrointestinal upset were common and in 14 cases penicillin therapy was substituted. No major toxic effect was recognised in any recipient of antibiotics. Screening of the entire school was repeated three days No further carriers were after treatment finished. detected. All restrictions on the school were relaxed, but it was agreed that any sore throat occurring would be scrupulously investigated. There was only one treatment failure. He was not treated further but was allowed home for the summer holiday during which he became clear of infection. A final re-examination of the entire school was made on return for the Michaelmas term and no carriers were detected.
was
DISCUSSION AND CONCLUSIONS
The C. diphtheriae strain involved in this investigation was not toxigenic. It could be argued that there
1026
danger at any time and that no control measures necessary. Similarly, the sore throats experienced could have been due to concurrent respiratory virus infections. These were indeed prevalent at the time and we feel that some of the symptoms may have been produced by these infections. However, distinctions between virulence and toxigenicity of C. diphtheria have been clearly demonstratedand non-toxigenic strains have been known to produce disease since 1922,8 so we felt it unwise to completely ignore the organism’s presence. There was also an unlikely but speculative risk of the strain regaining toxigenicity by relysogenisation. This hazard was pointed out by Taylor et al.9 in 1962. Its actual likelihood is not known and it has not yet been recorded in vivo, but it can be demonstrated in vitro with apparent ease." These considerations, taken with the high carrierrate of an organism which is not part of the normal flora of schoolchildren’s throats and which was very likely to be passed on to other schools, prompted us was no
Talking Politics
were
’
take action. The actual isolation procedure did disrupt school life to some extent, but this must be weighed against the unwillingness of other headmasters to expose their pupils to an organism, however non-virulent, with the connotations of " diphtheria ". Treatment caused no recognised significant toxic effect, but gastrointestinal side-effects were common. Published reports do list these 11; however, some boys were in a highly excitable state and symptoms were of the type associated with hysterical illness to which school communities are susceptible.l2 Whatever course of action is chosen it can only be effective if each person involved clearly understands his duties and responsibilities and is in frequent contact with all others concerned. The considerable distances involved clearly hampered liaison in this instance. Strenuous efforts were made to establish clear lines of communication, but as they had to be maintained principally by telephone they were not entirely satisfactory until a personal meeting of the Medical Officer of Environmental Health, general practitioners, infectious disease physician, and Public Health Laboratory staff was arranged. Only then could a full exchange of information and opinions take place and logical coherent action be planned. These arrangements allowed an active rational approach to be applied and be seen to be so done by the community involved. to
We thank Prof. M. G. McEntegart for helpful advice and Dr T. M. Pollock for access to C.D.R. Statistics.
Requests for reprints should be addressed
to
A. E.
J.
REFERENCES 1. Br. med. J. 1973, i, 63. 2. Lancet, 1970, i, 1215. 3. McEntegart, M. G., Zamiri, I. Br. med. J. 1973, i, 486. 4. Edward, D. G., Allison, V. D. J. Hyg., Camb. 1951, 49, 205. 5. Cowan, S. T., Steel, K. J. Manual for the Identification of Medical Bacteria. p. 109. Cambridge, 1965. 6. Jameson, J. E. Mon. Bull. Min. Hlth, 1965, 24, 55. 7. Frobisher, M., Jr., Parsons, E. I., Updyke, E. Am. J. publ. Hlth,
1947, 37, 543. Jordan, J. H., Smith, F., Kingsbury, A. N. Lancet, 1922, ii, 1052. Taylor, I., Tomlinson, A. J. H., Davies, J. R. R. Soc. Hlth J. 1962, 82, 158. 10. Freeman, V. J. J. Bact. 1951, 61, 675. 11. Kuder, H. V. Clin. Pharmac. Ther. 1960, 1, 604. 12. Br. med. J. 1966, ii, 1280. 8. 9.
CHANCELLOR’S TIGHTROPE Conservative Chancellor come down
THE
HAD a House with
to
the
Budget like that, observed a Tory M.p. wryly, soon after Mr Healey sat down on April 15, the a
Labour benches would have been in uproar. He was thinking mainly about the Chancellor’s prediction of a further rise in unemployment, but he could have said it with equal justice about the cuts in public spending too. Mr Healey has proposed to take S900 million out of the spending programme for 1976-77 (this figure is calculated on 1974 prices): not as savage a slice as the El 180 million which his predecessor Mr Barber removed-from a less extensive total programme-in December, 1973, to the violent condemnations of the Labour benches, but a substantial sum even so, at a time when the public services are clamouring for more. The cutback in the health and personal social services sector amounts to t75 million- £ 14 million off the current account and S61 million off the capital. This is roughly in line with the burden this sector was asked to bear by Mr Barber. Health and personal social services account for 8% of Mr Healey’s cuts against 9% of Mr Barber’s, with current expenditure hit less hard than it was in 1973 but capital spending hit rather harder. The cut in the capital programme amounts to 14%, against 12-8% in 1973. Not a palatable diet for the Labour benches, which is no doubt why they remained so sparsely inhabited during the four-day debate. The main charge against Mr Healey, in fact, was from the other side, which said that his cuts were too little and too late. He has timed them not for the year just beginning but for the financial year beyond them. The Government, he explained, had learned from past experience that cuts of this kind took time to carry out. The Conservative benches were sceptical: the real reason, they believed, was that the Government wanted to get the referendum out of the way before it struck. Indeed, the charges of deception went still further. These cuts, declared some Conservative M.P.s, were not really cuts at all: only moderations in the planned growth of spending. Mr Healey, in their view, deserved about as much credit as a man who increases his daily consumption of whisky from one bottle to twoand then claims it as a cut, on the grounds that he had originally intended to treat himself to three. Mr Enoch Powell, the sternest of the Chancellor’s critics, said that if Mr Healey was really intent on cutting public spending he should impose a complete moratorium on additional expenditure on many sectors. The critics went further: they asserted that even these cuts-which-were-not-really-cuts would not happen, because the Chancellor was no longer in control of public spending. They pointed out with full statistical documentation that the spenders had evaded such constraints before: and they quoted the report of an all-party select committee which monitors public expenditure to show how the really big public-spending reductions are always a year or two away. Each successive white-paper on public expenditure, they demon-
population as a whole is also expected to increase by about 2-5%; we have disregarded both these G.N.P. has been projected during the ten factors. years at a modest year-to-year growth figure of 24 % . hence, it is estimated that 442,337 males of working age-the combined workforce of an area of total population of about 1’3 million (e.g., Birmingham and Coventry combined)-will have died from Ten years
cardiovascular disease E8135 million
at
1974
at a
cumulative
cost
of
some
prices.
Requests for reprints should be addressed
to
D. B. L.
Public Health NON-TOXIGENIC CORYNEBACTERIUM DIPHTHERIÆ IN A BOARDING SCHOOL A. E.
E. H. GILLESPIE JEPHCOTT General Hospital, Northern Laboratory, Sheffield S5 7AU
Public Health
C. DAVENPORT Central Health District, Derbyshire Area Health Authority, Main Centre Office, Main Centre, Derby DE1 2PH
J. W. EMERSON Surgery, Butts Road, Bakewell P. J. MORONEY Moor Lodge Hospital, Sheffield S10 4LH A non-toxigenic strain of CoryneSummary bacterium diphtheriæ var. gravis was isolated from 31 boys during an outbreak of sore throats at a boarding school of 15 staff and 134 pupils. Despite the non-toxigenicity of the strain involved, conventional isolation procedures were observed and all boys at the school were treated with antibiotics. Restrictions on the school were only The
relaxed when no further carriers were detected. The rationale of such management of an episode involving a non-toxigenic strain is discussed. INTRODUCTION
THE incidence of diphtheria declined dramatically after the introduction of widespread immunisation in the 1940s and a pattern of sporadic small epidemics (particularly amongst schoolchildren) has emerged.l,2
Few isolates of Corynebacterium diphtheria are now being made, and most of these prove to be nontoxigenic. Thus the laboratories contributing to the Communicable Disease Report isolated only 131 strains of C. diphtheria during the past two years, and of these strains at least 117 (89%) were non-toxigenic. When a toxigenic strain was isolated it was often found to have come from abroad. Non-toxigenic strains were not commonly recognised before 1935, since when they have increased in relative number and importance.3 While these strains are usually regarded as totally non-virulent, -there are reports of clinical diphtheria being caused" by such strains.4 We investigated an epidemic " of non-toxigenic C. diphtherice var. gravis strains in a closed community.
We feel
might
be
experience in managing this outbreak helpful in handling similar situations in the
our
future. PATIENTS AND METHODS
The outbreak involved the 15 staff and 134 scholars of a residential boys’ preparatory school. At the onset of the incident nose and throat swabs were taken from cases of sore throat and examined at the Public Health Laboratory for all common pathogens. Similar swabs examined during screening procedures were plated onto tellurite blood-agar at the school and the plates were taken to the laboratory for incubation and examination. Suspicious colonies were examined by gram-stain and nigrosin techniques. Fermentation tests were made on all strains in serum-water sugars.5 Toxigenicity tests were carried out on all early isolates by both subcutaneous injection into guineapigs and the Elek plate method.6 Later isolates were investigated for toxigenicity by the Elek plate method alone. THE
"EPIDEMIC"
On May 5, 1974, organisms resembling C. diphtheria (later established to be a non-toxigenic strain of C. diphtheriae var. gravis) were isolated from the throat swabs of 3 of 7 boys with sore throats. Over the next eight days sore throats developed in 12 more boys and the corynebacterium isolated from 4 of these. Management at first followed the conventional pattern. Cases were isolated as they arose, initially in the sick bay, and when cultures proved positive they were moved to the local infectious diseases unit. The immune status of all scholars was ascertained and arrangements for giving booster doses of vaccine were made. As far as was practicable, links between the school and the outside community and with other schools were temporarily cut. After it became clear that the strains involved were not toxigenic handling the situation became more difficult. No relaxation of the isolation procedure was considered until the extent of carriage within the school had been established by swabbing all the academic staff and pupils. 24 boys were symptomless carriers. No member of staff was positive. The hazard of leaving untreated boys with symptoms and the risk of allowing this high carrier-rate to persist were weighed against the hazards and likely success of treatment. Boys with symptoms in the hospital were treated with erythromycin and were not allowed back to school until they were bacteriologically clear. All boys at school were given a course of erythromycin (0-5 g. three times a day for five days) in an attempt to clear all symptom-free carriers in the school-i.e., both the 24 known and any others who might have escaped detection by the single screening procedure. Minor drug intolerance with complaints of nausea and gastrointestinal upset were common and in 14 cases penicillin therapy was substituted. No major toxic effect was recognised in any recipient of antibiotics. Screening of the entire school was repeated three days No further carriers were after treatment finished. detected. All restrictions on the school were relaxed, but it was agreed that any sore throat occurring would be scrupulously investigated. There was only one treatment failure. He was not treated further but was allowed home for the summer holiday during which he became clear of infection. A final re-examination of the entire school was made on return for the Michaelmas term and no carriers were detected.
was
DISCUSSION AND CONCLUSIONS
The C. diphtheriae strain involved in this investigation was not toxigenic. It could be argued that there
1026
danger at any time and that no control measures necessary. Similarly, the sore throats experienced could have been due to concurrent respiratory virus infections. These were indeed prevalent at the time and we feel that some of the symptoms may have been produced by these infections. However, distinctions between virulence and toxigenicity of C. diphtheria have been clearly demonstratedand non-toxigenic strains have been known to produce disease since 1922,8 so we felt it unwise to completely ignore the organism’s presence. There was also an unlikely but speculative risk of the strain regaining toxigenicity by relysogenisation. This hazard was pointed out by Taylor et al.9 in 1962. Its actual likelihood is not known and it has not yet been recorded in vivo, but it can be demonstrated in vitro with apparent ease." These considerations, taken with the high carrierrate of an organism which is not part of the normal flora of schoolchildren’s throats and which was very likely to be passed on to other schools, prompted us was no
Talking Politics
were
’
take action. The actual isolation procedure did disrupt school life to some extent, but this must be weighed against the unwillingness of other headmasters to expose their pupils to an organism, however non-virulent, with the connotations of " diphtheria ". Treatment caused no recognised significant toxic effect, but gastrointestinal side-effects were common. Published reports do list these 11; however, some boys were in a highly excitable state and symptoms were of the type associated with hysterical illness to which school communities are susceptible.l2 Whatever course of action is chosen it can only be effective if each person involved clearly understands his duties and responsibilities and is in frequent contact with all others concerned. The considerable distances involved clearly hampered liaison in this instance. Strenuous efforts were made to establish clear lines of communication, but as they had to be maintained principally by telephone they were not entirely satisfactory until a personal meeting of the Medical Officer of Environmental Health, general practitioners, infectious disease physician, and Public Health Laboratory staff was arranged. Only then could a full exchange of information and opinions take place and logical coherent action be planned. These arrangements allowed an active rational approach to be applied and be seen to be so done by the community involved. to
We thank Prof. M. G. McEntegart for helpful advice and Dr T. M. Pollock for access to C.D.R. Statistics.
Requests for reprints should be addressed
to
A. E.
J.
REFERENCES 1. Br. med. J. 1973, i, 63. 2. Lancet, 1970, i, 1215. 3. McEntegart, M. G., Zamiri, I. Br. med. J. 1973, i, 486. 4. Edward, D. G., Allison, V. D. J. Hyg., Camb. 1951, 49, 205. 5. Cowan, S. T., Steel, K. J. Manual for the Identification of Medical Bacteria. p. 109. Cambridge, 1965. 6. Jameson, J. E. Mon. Bull. Min. Hlth, 1965, 24, 55. 7. Frobisher, M., Jr., Parsons, E. I., Updyke, E. Am. J. publ. Hlth,
1947, 37, 543. Jordan, J. H., Smith, F., Kingsbury, A. N. Lancet, 1922, ii, 1052. Taylor, I., Tomlinson, A. J. H., Davies, J. R. R. Soc. Hlth J. 1962, 82, 158. 10. Freeman, V. J. J. Bact. 1951, 61, 675. 11. Kuder, H. V. Clin. Pharmac. Ther. 1960, 1, 604. 12. Br. med. J. 1966, ii, 1280. 8. 9.
CHANCELLOR’S TIGHTROPE Conservative Chancellor come down
THE
HAD a House with
to
the
Budget like that, observed a Tory M.p. wryly, soon after Mr Healey sat down on April 15, the a
Labour benches would have been in uproar. He was thinking mainly about the Chancellor’s prediction of a further rise in unemployment, but he could have said it with equal justice about the cuts in public spending too. Mr Healey has proposed to take S900 million out of the spending programme for 1976-77 (this figure is calculated on 1974 prices): not as savage a slice as the El 180 million which his predecessor Mr Barber removed-from a less extensive total programme-in December, 1973, to the violent condemnations of the Labour benches, but a substantial sum even so, at a time when the public services are clamouring for more. The cutback in the health and personal social services sector amounts to t75 million- £ 14 million off the current account and S61 million off the capital. This is roughly in line with the burden this sector was asked to bear by Mr Barber. Health and personal social services account for 8% of Mr Healey’s cuts against 9% of Mr Barber’s, with current expenditure hit less hard than it was in 1973 but capital spending hit rather harder. The cut in the capital programme amounts to 14%, against 12-8% in 1973. Not a palatable diet for the Labour benches, which is no doubt why they remained so sparsely inhabited during the four-day debate. The main charge against Mr Healey, in fact, was from the other side, which said that his cuts were too little and too late. He has timed them not for the year just beginning but for the financial year beyond them. The Government, he explained, had learned from past experience that cuts of this kind took time to carry out. The Conservative benches were sceptical: the real reason, they believed, was that the Government wanted to get the referendum out of the way before it struck. Indeed, the charges of deception went still further. These cuts, declared some Conservative M.P.s, were not really cuts at all: only moderations in the planned growth of spending. Mr Healey, in their view, deserved about as much credit as a man who increases his daily consumption of whisky from one bottle to twoand then claims it as a cut, on the grounds that he had originally intended to treat himself to three. Mr Enoch Powell, the sternest of the Chancellor’s critics, said that if Mr Healey was really intent on cutting public spending he should impose a complete moratorium on additional expenditure on many sectors. The critics went further: they asserted that even these cuts-which-were-not-really-cuts would not happen, because the Chancellor was no longer in control of public spending. They pointed out with full statistical documentation that the spenders had evaded such constraints before: and they quoted the report of an all-party select committee which monitors public expenditure to show how the really big public-spending reductions are always a year or two away. Each successive white-paper on public expenditure, they demon-
