CHAPTER XLVI.

NOTIFICATION AND ISOLATION.

We are confident from the actual discovery of the micro-organisms causing certain infective diseases, that the other diseases of an analogous nature are similarly caused by living contagia. On this supposition, action is taken for the prevention of these diseases. This action comes under a number of different heads, which may be classified as follows:—

1. =Means for the early recognition of the infectious character of a disease.= The bacteriological aids to recognition in diphtheria (page 299), enteric fever (page 301), and phthisis (page 310) have been already mentioned. It is important to call in medical aid when any suspicious symptoms arise, even when these symptoms do not appear to be urgent. If an infectious disease is not recognised in its early stage, it may be easily overlooked, and the patient cause a serious epidemic. The following hints for teachers are in Brighton sent with each circular letter as to excluding infected children from school. The list is not exhaustive, but may aid in drawing attention to suspicious symptoms. The only safe rule when in doubt is to _act as though a case is infectious until a skilled opinion can be obtained_.

HINTS AS TO INFECTIOUS DISEASES.

As infection is sometimes spread by means of children attending school while suffering from undetected infectious diseases, the following hints may be useful to the teacher:—

1. Any scholar having a sore throat should be sent home and regarded as infectious until the throat has been examined by a doctor.

If a scholar has enlarged glands in the neck, and especially if he or she is very pallid, the suspicion of possible diphtheria should be entertained. Many slight cases of diphtheria escape detection.

2. Any scholar suffering from a severe cold, with sneezing, redness of the eyes and running at the nose, should be sent home. It may mean an influenza cold or the commencement of measles, and both are infectious. This recommendation is particularly important when measles is known to be prevalent.

3. A child with a violent cough, especially if it is severe enough to cause vomiting or nose-bleeding, should be suspected of whooping-cough, and sent home, even if the characteristic “whoop” is not heard.

4. Slight cases of scarlet fever sometimes escape notice, and the patients are sent to school with the skin on the hands, etc., freely “peeling.”

5. In any of the above instances, or any other case of suspicion, the Medical Officer of Health, on receiving a confidential intimation, will be glad to make an investigation.

SYMPTOMS OF ONSET OF SCARLET FEVER.

Sudden onset. Usually vomiting. Always headache. Feverish, with dry, hot skin. Sore throat. Red rash on chest in a few hours.

MEASLES.

Severe “cold in the head” for 72 hours before the blotchy rash appears. _Measles is extremely infectious in this preliminary stage._ Consider every severe influenza cold as possibly measles.

DIPHTHERIA

may be very indistinct. Languor and sore throat. Glands under and behind jaw are enlarged. Patient very pallid. White or yellow patches seen on examining inside throat. Whenever doubtful, send the scholar home.

WHOOPING COUGH.

In a child under seven, a severe cough should always be regarded as possibly whooping-cough, although no “whoop” has yet been heard.

2. The =notification= of all cases of infectious diseases to the medical officer of health, is clearly a means to an end, that of securing that the preventive measures to be next named are effectively carried out.

3. =Means for the production of an artificial immunity.= This is only practicable at present for two diseases of this country, small-pox by means of vaccination (page 293), and a temporary immunity against diphtheria by a dose of antitoxic serum (page 299). Apart from these means, any measures for improving the health of a child tend in the same direction. Enlarged tonsils, “adenoids” at the back of the nose (causing the child to snore at night and to breathe through his mouth), discharges from nostrils or ear, and similar conditions should receive early medical attention.

4. =Isolation=: preventing the conveyance of the contagium from the sick to the healthy.

5. =Disinfection=, _i.e._ destruction of the contagium of the disease.

The Infectious Disease (Notification) Act, 1889, and the corresponding London Act of 1891, impose a dual duty of notification (_a_) on every medical practitioner attending on or called in to visit an infectious patient, as soon as he becomes aware of its nature; and (_b_) on the head of the family to which the patient belongs or the nearest relative. The intimation must be sent by each of these to the local medical officer of health, the practitioner being paid a small fee for his trouble. Usually notification by the householder is only enforced when no doctor is in attendance. The diseases to which this Act applies are small-pox, cholera, diphtheria, membranous croup[11], scarlet fever, erysipelas, and the fevers known by any of the following names: typhus, typhoid, enteric, relapsing, continued or puerperal. The list of notifiable diseases may be extended by resolution of the Local Authority.

The enforcement of notification is most important for the public health. (_a_) It enables the medical officer of health to take immediate steps to prevent the spread of infection, by enforcing proper isolation of the patient, efficient disinfection, and by preventing the attendance of children from infected houses, at school, etc. (_b_) It enables the links of evidence connecting a series of cases to be identified, _e.g._ cases due to a common milk supply, or attendance at a particular school. (_c_) It has a valuable educational effect on all concerned in the cases.

ISOLATION.

Both the patient and his attendant need to be isolated in diseases like scarlet fever, diphtheria and small-pox. The rule is less absolute in enteric fever. In the following description the standard of requirements taken is that of the most dangerous infectious disease, small-pox. The first point to decide is whether the patient may be safely isolated at home. For small-pox this ought never to be allowed in a town. For other diseases, this may be permitted, if the following conditions can be fulfilled.

For =Isolation at Home= a couple of rooms are required, preferably on a higher floor or in a detached wing of the house. The w.c. used for the dejecta of the patient must not be used by any other members of the household. All linen, towels, handkerchiefs, etc., should be immersed in actually boiling water containing some washing soda, before leaving the sick-room. Other articles to be washed, if they will be deteriorated by soaking in boiling water or a chemical disinfectant, must be tightly wrapped in bundles, and covered with a clean wet sheet saturated with a strong disinfectant solution (page 331). Solid and liquid excreta, expectoration and other discharges must be treated as described on page 331. The nurse should not eat her meals in the patient’s room. She should wear a cotton dress to be changed before going out for a walk. Her hands must be thoroughly washed and brushed after handling or helping the patient, particularly in enteric fever. It is advantageous if the nurse has previously had the patient’s complaint. Attention on the part of the nurse to minute detail is essential, especially in view of the possibility of receiving infection from infected articles as well as directly from the patient. The measures required for the subsequent disinfection of the sick-rooms and of clothing, bedding, books, etc., are given on page 332.

The use of =hospital isolation= has rapidly increased in recent years, thus releasing private families from a serious burden. The number of beds which a Local Authority should supply for their district is usually stated as one for every 1,000 inhabitants, but in poorer districts this does not suffice. The site of the hospital should be well removed from houses. There must be a minimum zone of 40 feet between all infected buildings and the boundary walls, and the same distance between neighbouring buildings. A wall at least 6 ft. 6 in. high should enclose the hospital site. The hospital is divided into separate detached pavilions for the treatment of different infectious diseases. A floor space of 156 square feet should be allowed for each bed. The height of the ward should be about 13 feet, its width from 24 to 26 feet, and the total cubic space for each patient should be 2,000 cubic feet for scarlet fever, 2,500 for diphtheria. The lavatories and water-closets are separated from the main ward by a cross-ventilated lobby. In an isolation hospital every surface should be washable; all corners should be rounded off, and all projections on which dust can lodge avoided. The proportion of window space should be about 1 square foot to every 70 cubic feet. Special isolation pavilions are required for cases of doubtful diagnosis. The ventilation and warming of wards must be carefully regulated. Cross-ventilation by windows open on opposite sides of the ward can be maintained in nearly all weathers. The temperature of the ward should be maintained at 55°-60° F.

=Ambulances= are usually provided by the Local Authority for the removal of infectious patients. The ambulance should be cleansed and disinfected after each journey. The use of private conveyances for infectious patients is forbidden, except under special limitations.

The =hospital isolation of small-pox= is beset with special difficulties. There is a considerable body of evidence indicating that small-pox may be aerially carried from patients in hospitals to people living within a zone of half a mile, or possibly further. Without accepting the view that aerial dissemination of small-pox to considerable distances from the patient frequently occurs, it still remains true that, either by this means or by errors in the administration of small-pox hospitals, they do frequently constitute a source of danger to persons living in the vicinity. The Local Government Board recommended that a Local Authority should not contemplate the erection of a small-pox hospital. (_a_) On any site where it would have within a quarter of a mile of it as a centre either a hospital, whether for infectious diseases or not, or a workhouse, or any similar establishment, or a population of 150-200 persons; (_b_) on any site where it would have within half a mile of it as a centre a population of 500-600 persons, whether in one or more institutions or in dwelling-houses.

QUARANTINE.

This term has been chiefly employed to denote the limitation of the movements of vessels coming from infected ports, for a term which, as the name indicates, was formerly forty days, but is now shorter. It may be conveniently employed, however, to signify the restriction of the movements of all persons who have been apparently exposed to infection, or who continue to live in infected dwellings. In this sense we may speak of:

1. Domestic Quarantine. 2. Scholastic Quarantine. 3. National and International Quarantine.

=Domestic Quarantine=, to a varying extent, is desirable for the members of a family of which one member has been attacked by an infectious disease. For small-pox every member of a household should be kept under strict watch until sixteen days have elapsed since the last contact with the case of small-pox, or until successful vaccination has been secured. For enteric fever this strict watch would be unnecessary, but the remaining members of the household should be warned to call in a doctor on the first symptom of malaise.

Quarantine is specially indicated for certain occupations. Thus if the child of an out-door labourer had been removed to a hospital with scarlet fever, it would be unnecessary to keep the latter away from work during the following week. If, however, he were a milk-carrier, or a tailor, or an assistant in a sweet-stuff shop this would be a desirable measure.

The =Quarantine of School Children= is more necessary than that of adults, because the former are more susceptible to infection. Children are kept from school:

(_a_) Because the infectious patient still remains in the house. In this case the healthy children must be kept from school until the patient has ceased to be infectious and disinfection has been thoroughly carried out; and for a further period longer than the longest known period of incubation of the disease in question (page 287), a margin being left for contingencies. It would probably be 8 _plus_ 2 weeks for scarlet fever.

(_b_) Children are kept from school for a period exceeding the longest period of incubation when the patient has been removed to hospital.

The table on page 322, modified from the Author’s _School Hygiene_, is introduced as furnishing a convenient summary of the subject.

Objection is sometimes taken to the exclusion of children under the above circumstances from school, on the ground that they continue to mix with others in the street or in neighbouring houses. Clearly, however, in a school-room, a suspected child may communicate infection to children coming from widely scattered streets, while out-of-doors the danger is comparatively slight, and among neighbours the danger is very limited in area.

It is assumed in the following table that all infected articles have been disinfected before the termination of the period of quarantine.

┌─────────────┬─────────────────────┬─────────────────────┬────────────┐ │ │ │ │ DURATION OF│ │ │ │ DATE AT WHICH │ QUARANTINE │ │ │ │ SCHOOL │ OF CHILDREN│ │ │ DURATION OF │ ATTENDANCE MAY │ EXPOSED TO│ │ DISEASE. INFECTION. │ BE RESUMED. │ INFECTION. │ ├─────────────┼─────────────────────┼─────────────────────┼────────────┤ │_Scarlet │From 5 to 8 weeks; │Not less than 8 weeks│14 days. │ │ fever_ │ ceases when all │ from the beginning │ │ │ │ peeling of the skin │ of the rash, and │ │ │ │ has been completed, │ then only if no sore│ │ │ │ and when the child │ throat or sore │ │ │ │ is free from │ places. │ │ │ │ discharge from the │ │ │ │ │ nose or ear or sore │ │ │ │ │ places. │ │ │ │ │ │ │ │ │_Diphtheria_ │ At least 21 days; │Not less than 2 │12 days. │ │ │ often much longer. │ months, and not │ │ │ │ Absence of infection│ then if strength not│ │ │ │ should be confirmed │ recovered, or if any│ │ │ │ by bacteriological │ sore throat or any │ │ │ │ tests. │ discharge from nose,│ │ │ │ │ eyes, ears, etc. │ │ │ │ │ │ │ │_Small-pox │About 4 to 5 weeks │When every scab has │18 days. │ │ and Chicken │ │ fallen off. │ │ │ pox_ │ │ │ │ │ │ │ │ │ │_Measles_ │From 3 to 4 weeks; │Not less than 4 weeks│21 days. │ │ │ when all cough and │ from beginning of │ │ │ │ branny shedding of │ rash. │ │ │ │ skin has ceased. │ │ │ │ │ │ │ │ │_Rötheln │2 to 3 weeks │From 3 to 4 weeks │21 days. │ │(German │ │ from beginning of │ │ │ measles)_ │ │ rash. │ │ │ │ │ │ │ │_Mumps_ │About 21 days from │4 weeks from the │24 days. │ │ │ the beginning. │ beginning. │ │ │ │ │ │ │ │_Whooping │6 weeks from the │In about 8 weeks │21 days. │ │cough_ │ beginning of │ │ │ │ │ whooping, or when │ │ │ │ │ the cough has quite │ │ │ │ │ ceased. │ │ │ │ │ │ │ │ │_Typhus and │4 to 5 weeks │When strength │28 days. │ │ enteric │ │ sufficient. │ │ │ fevers_ │ │ │ │ │ │ │ │ │ │_Influenza_ │2 to 3 weeks │1 month │10 days. │ └─────────────┴─────────────────────┴─────────────────────┴────────────┘

=School Closure= is occasionally required to prevent the further spread of an infectious disease. This can be enforced on the order of any two members of the Local Sanitary Authority acting on the advice of the medical officer of health. This ought to be only occasionally necessary if notification of infectious diseases is strictly enforced, and if suspicious individual children are excluded from attendance at school. In diphtheria school closure may occasionally be rendered unnecessary by systematic bacteriological examination of the throats of children who had been exposed to infection (see page 299). School closure is more useful for country than for town schools, as in the former the homes of children are more remote from each other, but it is occasionally necessary for both. For measles school closure is specially indicated in Infants’ Schools. We have already seen that this disease is chiefly fatal when caught at a tender age (page 297). The early closure of Infants’ Schools, and particularly of the Babies’ Class is therefore indicated. It is unfortunate that the attendance at school of children under six years of age is encouraged. Such children have more severe and more frequently fatal attacks of diphtheria, scarlet fever, measles, and whooping-cough; and these are frequently acquired at school.

=International Quarantine= was originally enforced against plague; but in many countries has been extended to other diseases, as cholera, yellow fever, typhus fever, small-pox and leprosy. In England cholera is the only disease in connection with which it has been in the past enforced. It has now been entirely abandoned. It consists in the compulsory isolation at the port of entry of all persons who have come from an infected district, or have been in contact with a case of the infectious disease against which quarantine is enforced, for a length of time which will enable it to be determined whether the persons detained are or are not incubating the disease. If this measure could be strictly enforced, and if infectious diseases were conveyed only by infectious persons, quarantine would undoubtedly be effective. But in practice quarantine cannot be enforced in Europe; and as it cannot be efficiently enforced it forms an ineffective and irrational derangement of commerce. Thus if plague prevailed in France it would be impracticable to detain for ten or twelve days every person entering England. Furthermore, in this instance, infection is brought by rats as well as persons; and measures effective for the latter do not prevent the former from importing infection. Because of its impracticability and of the disorganization of commerce which would be associated with any attempt to enforce it, England has abandoned quarantine and other countries are gradually following its example. England bases its action on the ground that (_a_) _sanitation is the true chief means of defence_, especially against cholera. It does not trust to this alone but to this along with (_b_) _medical inspection_ at the ports, (_c_) and _subsequent medical supervision_ of persons landed from suspected vessels. By these means a watch can be kept over persons who have been in contact with infection.

Regulations are issued at intervals by the Local Government Board requiring the disinfection by steam of all rags and similar materials imported from towns in which small-pox, cholera, etc., are prevalent.