An experience of diphtheha in westminster

A five-year-old girl from Bangladesh living in Westminster developed diphtheria. She was the second case reported in 1982:

2 weeks previously, a three-year-old English girl, died of the disease in Winchester on 19 August, 1982. Contacts of the dead girl were traced in the Westminster area and three carriers of a toxigenic strain of 'Corynebacterium diphtheriae' were isolated. Circumstantial evidence alone suggested a probable link between the two cases. The organisms identified, in both the cases and the carriers of toxigenic organisms were identical and of a strain not recently encountered in the U.K. It is likely that the source of infection was a chance importation by a healthy carrier probably from the Indian sub-continent.

Introduction

Diphtheria is now regarded as a disease of the past, and undoubtedly immunization has played a significant role in its control in this country. In 1914, there were 59.324 notifications and 5863 deaths in England and Wales. The number of deaths declined, but notifications changed little, until after 1940 when routirfe immunization of the child population was introduced. Over the next 10 years notifications fell 50-fold and by the 1970s had reached single figures. Prior to 1982, the last reported death from diphtheria was in 1975.

The case history

On 5 September a five-year-old Bangladeshi girl presented in the casualty department of Westminster Children's Hospital with stridor and follicular tonsillitis. She had been well until 2 September, when she developed a cough and complained of a sore throat.

She was admitted to hospital and treated as a case of croup. The folowing day her condition deteriorated and on re-examination of her throat, a grey exudate was seen extending backwards covering the uvula and tonsils. A clinical diagnosis of diphtheria was made and she was transferred to Coppett's Wood Isolation Hospital. On 7 September, a sucrosefermenting strain of 'Coryne­bacterium diphtheria' var mitis was isolated from her throat swab. She was treated with benzyl penicillin and diphtheria antitoxin. She required a tracheostomy and was maintained on intravenous fluids and strict bed rest. After 5 days she improved and was extubated, and subsequently made a full recovery.

Toxigenic 'Corynebacterium diphtheria' with the same biochemical characteristics as the patient, were isolated from the nose and throat of her sister aged 7 years and throat of her brother aged 3 years.

Background to the case in Westminster

On 19 August, 1982, a three-year-old English girl died of diphtheria in hospital in Winchester. She was an Army child and lived in barracks in Westminster. However, she had left there with

her mother, brother and sister, a few hours before the men of the barracks returned from the Falklands War.

Investigation of close contacts living in the barracks revealed three child carriers of toxigenic strains of diphtheria in two families.

A probable connection' between the child who died in Winchester, the Bangladeshi case in Westminster and one of the carriers living in the barracks was established on the following circumstantial evidence: one of the barrack carriers had attended a day nursery which was also attended by a close friend of the Westminster case. The children lived in the same block of flats, and this child was assumed to ,be the link between the two cases. However, repeated nose and threat swabs of this presumed link child, failed to grow 'Corynebacterium diphtheriae'.

No other direct link between the two cases could be established. The organisms isolated from the dead girl, her carrier siblings and carriers contacts at the barracks were indistinguishable from that of the case and her family carriers in Westminster, on the basis of sugar-fermentation reactions and phage type.

MEASLES AND MODELS

Although measles is a mild disease for most people, it can result in severe complications and death. The Expanded Program on^lmmunization (EPI) of the World Health Organization (WHO) estimates that each year approximately 1.5 million children die of measles around the world. Pneumonia and diarrhoea cause most of the deaths, but other important complications include bronchitis, croup laryngitis, otitis, stomatitis, proteinlosing enteropathy, deafness and blindness. In developing countries up to 10% of infected children often die acutely with the highest death-to-case ratio occurring in infants. In those who survive recovery is slow. Affected children have marked weight loss from diarrhoea and the inability to eat or drink because of severe stomatitis and general malaise. Catch-up weight gain can take longer than three months, and the ilness can precipitate marasmus or kwashiorkor in those whose nutritional status is marginal at the onset of infection. Severely malnourished children suffer more complications and are more likely to die. Even in the developed world, the health impact of measles can be substantial. Between 1970 and 1975 there was an average of 6000 hospitalizations in the United States for measles annually. In Denmark, approximately 9% of cases developed otitis, 7% respiratory complications and 0.3% encephalitis.

Because the essential epidemiological characteristics of measles are well known and clearly defined, measles has been of continuing interest to epidemic theorists. Live attenuated measles virus vaccine

was introduced in 1963 and its ability to provide protection in a high proportion of those vaccinated was rapidly demonstrated. The first successful measles elimination programme started in 1966 as part of a programme of smallpox eradication and measles control in 21 countries of West and Central Africa and provided a useful opportunity to merge theoretical and implementation considerations. From surveillance data generated in Africa the late professor George McDonald developed mathematical models simulating the transmission of measles. His models suggested two approaches that might interrupt measles transmission in West Africa: Annual mass vacci­nation reaching at least 90% of susceptible children: or, an ongoing programme in which 75% of all susceptible children were vaccinated as they became susceptible at approximately six months of age. Absence of the necessary infrastructure necessitated the choice of mass campaigns. Using this approach, measles transmission was interrupted for varying periods: in the Gambia, a zero incidence of indigenous measles was achieved and maintained for more than two years.

Mathematical models also played a role in the measles elimination programme which began in the US in 1966. No precise estimate was made of the immunization levels needed to interrupt transmission, the effort in the US focused on achieving high immunity levels through the routine immunization of infants at one year of age and of immunizing at school entry children not previously immunized. However, in 1966 funding was directed to the development of programmes to prevent .rubella and as a result the effort was incomplete.

COMMON COLD

Common cold is an acute inflammation of the upper respiratory tract involving the nose and throat. It is one of the most familiar ailments which afflict mankind. Susceptibility to colds is almost universal, particularly among children. The cold is highly contagious, especially indoors, and places where groups of people congregate are excellent trtransmission spots for the infection.

In large urban communities where the climate is temperate the general population averages about three colds a year. This median is higher among susceptible adults and children. The incidence is lowest in the summer, rises in the autumn, reaching its peak in midwinter and declines in the spring.

Colds are definitely communicable and are transmitted either by direct contact or by spread of the infected droplets of discharge. The common cold is due to one or more viruses. When the cold virus attacks the mucous membranes of the nose and throat, these tissues are weakened and become susceptible to infection by bacteria which are also generally found in the body. The bacteria are secondary invaders and the virus paves the way for their entry into the mucous membranes. Although they are not responsible for the common cold, the bacteria may initiate a secondary infection which either intensifies the local inflammation present, prolonging the cold, or causes new complications such as purulent sinusitis or otitis, an inflammation of the ear. Infants and young children appear to be more susceptible to these secondary infections than adults.

A cold usually begins abruptly , with a sense of soreness and dryness in the nose or back of the throat. Within a few hours the nasal passages feel congested, sneezing develops and a clourless watery discharge comes from the nose. After fourty eight hours the cold is usually at its peak, and is accompanied by excessive watering of the eyes, huskiness of the voice, and difficulty in breathing as the congestion spreads. Frequently a headache, a sense of lethargy and malaise, and vague pains in the back and limbs accompany a cold. A fever is rarely present, although in children a temperature of 38.9 C or even higher often develops.

The uncomplicated cold generally lasts from one to two weeks and terminates without special treatment. The latter is confined to relief of symptoms and control of complications. Bed rest should be enforced whenever possible and as much isolation as is practical. Plenty of fluids, a light diet, and keeping warm promote greater comfort. Aspirin in small repeated doses generally gives relief as does gargling in cases of sore throat.

Measures must be taken to ward off the infection and decrease its incidence. A well-balanced diet, sufficient rest, proper dress both indoors and out, all help to keep the body resistance high. Undue exposure to sharp changes in temperature should be avoided. Proper ventilation of rooms, with sufficient humidity in the air, helps to keep the mucous membranes in healthy condition. Particular care should be taken to avoid contact with persons who have colds. Simple hygienic measures like washing the hands before eating or covering a sneeze all help to decrease the occurrance

EGYPTIAN TRAVELLERS

My wife and I intend to go to Egypt at the end of August and I would like to know what your experts consider are the measures we can take prior to this.

We have been advised with regard to smallpox and typhoid but I am concerned about ye/low fever and especially about dysentery. Are there any required safe prophylactic measures for dysentery? Failing that, can you advise me about the most suitable drug to take should either of us develop dysentery whilst sailing up the Nile from Cairo to Aswan?

Vaccination can be divided into two distinct categories. First, those which are required by International Health Regulations and second, those which are medically recommended. In the first group,

travellers proceeding direct from the UK to Egypt do not require vaccination against smallpox, cholera or yellow fever from June 1, 1979. Yellow fever is only required if the travellers have come up from the south through the Sudan. For the medically recommended vaccinations, all travellers to Egypt should be adequately protected against typhoid tetanus and poliomyelitis. Infective hepatitis is prevalent in Egypt and so an injection of gamma globulin should be considered: 2 ml gives a family adequate cover for two months and 5 ml for 4 to 6 months.

Regarding protection against dysentery and other causes of diarrhoea, sensible food hygiene precautions are most important but the use of Streptotriad, one tablet twice daily whilst away and for the first 2 days after return has been found to be the most effective prophylactic. The 10 commandments for the prevention of diarrhoea are as follows.

(1) Boil all drinking water or milk.

(2) Be very careful of shellfish — preferably see them alive
first.

(3) All cooked food to be well and recently cooked.

(4) All fruit, including tomatoes, to be peeled.

(5) Lettuce and unpeeled fruit sterilized by chlorination — no
watercress.

(6) No leftovers or food on display.

(7) Be wary of local ice cream — only from large firms.,

(8) No food from street hawkers.

(9) Avoid fly-infested restaurants. (10) Take one tablet of
Streptotriad twice daily. Lomotil (Searle) or Imodium (Janssen)
are certainly the most effective therapeutic agents for acute
diarrhoea. Lomotil must not be given to anyone with an atropine
sensitivity.

There are two other points which must be remembered.

(1) Outside Cairo malaria is prevalent up the Nile Valley so
an antimalarial should be taken. One tablet of Paludrine daily whilst
away and for 28 days after leaving the malarious area is recom­
mended.

(2) 'Schistosomiasis haematobium' is rampant in the Nile Valley
and there should be no fresh-water bathing.

VACCINE SENSITIVITY

, / have a patient whom I understand is allergic to tetanus vaccine. Her young daughter was given a 1/10 dosage of tetanus vaccine as a test. She was violently sick within about 10 days and it was some 2 or 3 days before she returned to

normal. In view of the family history the mother

has asked whether it would be wise to immunise

her second child.

Although tetanus is now relatively rare in Britain it remains a serious disease with an appreciable mortality. Most cases follow trivial wounds and children because of the frequency of minor injuries, must be considered at special risk. Every effort should be made to protect them.by immunization. The enquirer is understandably concerned about the risks of immunization because of the family history of sensitivity to tetanus vaccine. It does not necessarily follow, however, that the second child will react in the same way as the first. Nevertheless, it would be sensible to take • precautions against anaphylaxis and the following regimen is suggested.

Provided the child is not sensitive to aspirin an antihistamine together with aspirin should be given orally, in dosage appropriate for age; one hour before the injection of a test dose of vaccine. If there is no disturbance within 20 minutes the full dose of vaccine should be given.'If given before exposure to the allergen, antihistamines are of prophylactic value in type I hypersensitivity reactions and aspirin, by prostaglandin inhibition, is also hejpful in suppressing the effects of histamine, it would be wise to repeat the same regimen when subsequent dosages of vaccine are given.

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С. Лексические тесты.

The Common Cold.

All children catch 1... It's not unusual to them to have as many as eight a year and there is little you can do 2... them. But the good news is that by the time adulthood is reached, 3... people will have a certain 4... against them — which is why parents often 5... children through 6... colds with scarcely a sniffle themselves.

The 7... cold is 8... by a virus which enters the body through the nose. It is very 9... and can be passed by coughirtg or 10... . Symptoms start up to four days after catching the 11... and include a runny or blocked nose; sneezing and 12... throat. A cold is best 13... at home and there is some truth in the saying that if

you treat 14... it will 15... seven days and if you don't it will last a week (but feel like a fortnight!).

1. common 2. last 3, numerous 4. colds 5. sore 6. virus

'7. to prevent 8. immunity 9. infectious 10. most 11. a cold 12. sneezing