Diphtheria Immunisation

Advertisement from The Propeller 21 October 1937

In the early 1930s, diphtheria was one of several infectious diseases whose occurrence had to be notified to the local Council, along with scarlet fever, whooping cough, infantile paralysis and others. New South Wales was at that time seeing between 3,000 and 4,000 cases of diphtheria a year, resulting in around 200 deaths.[1]  In the State in 1934, there were 193 deaths from the disease, although this was some way short of the 286 deaths reported from whooping cough.  The fatality rate in 1936 was between 3% and 4% of cases.  From time to time there were spikes in the numbers as local outbreaks flared up.

A large number of diphtheria cases were reported in the St George area in early 1936.  Kogarah Council’s relieving Health Inspector reported that twelve cases had occurred in the municipality in April, and there had been a further seventeen cases in the previous three months of the year.[2]  Hurstville Council was seeing around four cases a week, as was Rockdale Council[3].  The Sydney Morning Herald reported that the Prince Henry Hospital treated 150 patients in March alone.[4]

In May 1936, the Health Department contacted NSW Councils regarding a proposed mass immunisation campaign against diphtheria for those between the ages of one and fourteen, to commence on 1 June.  The campaign had been decided upon at a conference representing the State Cabinet, the British Medical Association and the Hospitals Commission.  To be effective at least fifty per cent of the children in the State would need to be immunised.  The Councils in the St George area – Hurstville, Kogarah, Bexley and Rockdale, took different views on the proposal.

Whilst it was very desirable that public immunisation should take place, local authorities had various considerations to take into account.  The St George example shows how slowly progress occurred.

At Hurstville, a small committee, consisting of Mr Doig the Health Inspector, Alderman Dr Shute, and the Mayor, Alderman Smith, was asked to present a report to Council for its consideration at its meeting of 30 June 1936.  The result of the meeting was that while Council did not wish to make difficulties regarding the scheme, it was not supportive of it.

The Mayor, Alderman Smith, said the proposal would turn the Council Chambers into a hospital if the scheme was proceeded with.[5]  The proposal involved a lot of responsibility and also expense to the Council.  The proposal of general public inoculation had many dangers and possibilities from both the medical and legal standpoints.  Extra staff would have to be obtained to assist the inspector in tabulating and arranging schedules of patients; provision would have to be made for doctors, nurses, resting rooms, instruments and other medical conveniences.  There was also the possibility of only a few presenting themselves for inoculation, which would only increase the danger of infection by the increased number of carriers.

The report considered the possibility of liability in case of accidents.  The onus for any errors would be on Council.  It was a fact that an overdose of anatoxin, or an injection in a child with a weak heart, could have fatal results.  Insurance risks would not cover these aspects.  There was also the difficulty in assessing the financial ability of parents to pay the four shilling cost per child.  Hurstville also had the problem of residence to consider, as the municipal boundary cut right through the township.

The committee recommended that if the scheme was to have any utility, it would have to be universal.  The Government would have to declare immunisation compulsory.  Council would have to be reimbursed for all expenses and protected against all risks.  The facilities available to local authorities were inadequate and generally unsuitable; hospitals were in a far better position to undertake such treatment.

Alderman Dr Shute said the whole scheme was too risky and was definitely a Government job.  As well as diphtheria, there were also typhoid, smallpox and other diseases to be protected against.

Rockdale Council considered the matter at around the same time, and came to similar conclusions.[6]  In answer to its enquiry, the Department of Health had informed them that no funds would be available to offset any expense incurred by Council, although at the same time it had informed them that Councils had a definite obligation to prevent infectious diseases.[7]

In contrast, Bexley Council decided to give the scheme its support.  One of the Bexley Aldermen was Dr J B Whittemore, whose professional advice may have been persuasive.  Bexley Council intended to ask for the co-operation of local doctors, teachers, hospital authorities and parents.[8]

Sutherland Shire was also supportive of the scheme, stating on 25 June that the present health staff employed by Council could handle it adequately.[9]

Throughout June, there were at least ten cases of diphtheria a week over the four St George municipalities.  Scarlet fever was also rife, and the Rockdale Health Inspector, Mr J V Tyrell, reported that at Rockdale School half of one class had been absent; the school had been disinfected and fumigated.[10]  It was likely that some of the school books that pupils had been using would be destroyed.

In the first six months of 1936, the St George District Ambulance transported 220 cases of diphtheria to either the Coast Hospital or the Children’s Hospital in Sydney.[11]

Ryde Council appears to have been the first Council in Sydney to get underway, in August 1936.  On 8 September 1936, Bexley Council decided to distribute forms in the schools recommending a scheme in the municipality for immunisation against diphtheria.  Its Health Inspector, Mr A G Baker, said that if the scheme had been adopted two months ago when it was first mooted, a child’s life could have been saved, as one died from the disease on Monday last.[12]  Alderman Dr Whittemore said that there would likely not be a big response at first, “there always being prejudice against new methods”, but as time went on, those who had been immunised would fully appreciate the benefit.

To its great credit, Bexley Council pushed forward with its scheme, and in March 1937 co-operated with another progressive Council, Ulladulla, in seeking protection for its health inspectors against possible legal action in case of misadventure.  At this time there was no authority either in the Local Government Act or the Public Health Act which authorised councils to adopt such a scheme, and it was considered that concerted action should be taken to protect council officers.[13]  The matter went to the Department of Public Health for consideration.  It is typical of how bureaucracy works that it had not considered the matter before proposing the immunisation scheme.  Alderman Dr Whittemore expressed his disgust that some parents, who could afford to immunise their children, which any doctor could do for them, were now holding off in anticipation that whatever Council-run scheme was put in place would be cheaper.[14]

The Director-General of Public Health, Mr E S Morris, announced in May 1937 that legislation would be put in place “in the next session” to validate any expenditure incurred by Councils in the immunisation campaign against diphtheria.[15]  Despite there being no Council-run immunisation scheme, the publicity had had the welcome result that some parents had gone ahead anyway and had their children immunised by their local doctor: the Senior Medical Officer of Health, Dr H G Wallace, said that since the benefits of immunisation had been advertised last year, between 40,000 and 50,000 children in the State had been immunised, meaning that notifications in the current year were already around half of the previous year’s.[16]  This was confirmed by Kogarah’s Health Inspector, Mr Bardsley, who reported only fourteen cases in the first five months of 1937, as against around forty for the same period in 1936.

The Metropolitan Medical Officer of Health, Dr Graham Drew, pointed to the results which had been achieved in Queensland following an immunisation scheme there – some municipal and shire councils had seen immunisation rates of between 90 and 100 per cent.[17]  Dr Drew addressed a joint meeting of Rockdale and Hurstville Councils in June 1937, and described diphtheria as “the child-slayer”.  Immunisation was like a fire brigade, putting out the fire of disease.  Alderman Dr Shute seconded Dr Drew’s remarks.  The Government would supply the anatoxin free of charge, and the Council could charge four shillings per child or eight shillings per family, which would be enough to cover Council’s expenses in paying for the attendance of a doctor and nurses, and also to subsidise those who were unable to pay.  He estimated there would be 12,000 children in the Hurstville municipality who would require immunisation, with only a few hundred having been privately immunised.

Hurstville Council decided to adopt the scheme when the Government legalised the expenditure involved, although it was still of the opinion that the treatment should be made compulsory.[18]  Its Health Inspector, H S Doig, was experienced in mass inoculation work.  So it could not afford to stand aloof, and risk losing its reputation as a healthy suburb.

At the same time, Kogarah Council was home to several dissentient voices. Alderman Bell of Kogarah Council was heard, saying that it was the council’s job solely to administer the Local Government Act, and ratepayers’ money should not be spent on immunisation, which was a Government job.[19]  Alderman Poulton stated that “there were a lot of diseases far worse than diphtheria.”[20]  Poulton knew of people whose health had been compromised by immunisation.  In the face of his own Health Inspector’s figures, Alderman Ferry stated that there was “very little diphtheria in St George and the present uproar was only a scare.”[21]  It seems surprising that no-one wrote to the local press to contest statements such as these. ‘Hygeia’ wrote to the Propeller praising Dr Shute for advocating the scheme.[22]  This overlooked the fact that Alderman Shute had been one of Hurstville Council’s committee of three which had recommended no action the previous year.

At the end of June 1937 a conference of Council Health Inspectors was held in Sydney to discuss the practicalities of setting up the scheme.  The local Health Inspectors and a number of local Aldermen attended.[23]  From this point onwards, Councils began making preparations, seeing that it would be more expedient to take part than be the one pointed at for refusing.

The Department of Public Health sent to Rockdale Council 5,000 pamphlets about immunisation.

Bexley Council had taken the lead from the start, and it carried out the first local immunisation session, at Kingsgrove Public School on 18 August 1937.  Each child had to make four appointments; the first for a skin test, followed by three inoculations, concluding on 4th, 5th or 6th October.  It was hoped to treat 1,000 children, at three venues: Kingsgrove Public School, Bexley School and Carlton School.  Children not attending school could also have the inoculations, the schools acting as depots.[24]  The Mayor of Bexley publicly congratulated his Health Inspector, Mr A G Baker, for his fine work.

Kogarah Council’s Health Inspector reported on 17 August that he had a list of 1,000 children for immunisation.  Not a minute too soon, as four more cases of diphtheria in the municipality were reported that week.  In answer to a question as to how many school age children lived in the municipality, Mayor Battye said that 6,400 medals had been distributed during Coronation Week, so that could be taken as a guide.[25]  This also showed what work remained to be done.

At Hurstville, Mr Doig had visited the home of a child, the third from the same family to fall ill with the disease, and had recommended that the parents take a swabbing to ascertain whether they were carriers.  He reported that there were 2,500 children awaiting inoculation, plus another 1,000 of pre-school age.[26]

Rockdale began its inoculations on 15 September, at Rockdale, Arncliffe and Brighton Schools.  Mr Tyrrell reported that 1,200 children were to receive inoculation.  “Mr Jackson had two clerks to assist him in co-operation with the nurses from St George Hospital, and the results had been very satisfactory.”[27]  It was certainly of great help that the four St George Councils had the services of St George Hospital to call on.  Some rural councils, such as Moree, were eager to undertake inoculation, but had no medical officer who could assist, and if not for the work of the Far West Children’s Health Scheme, rural children might have gone without.

“It doesn’t hurt a bit.”

Hurstville collected £140 in fees for the first lot of inoculations, and as only 82 applications had been made for free treatment, the scheme looked like being financially worthwhile[28].  Mr Doig proposed holding a clinic at Hurstville Oval on 8 and 9 November to accommodate pre-school age children.  Advertising for this clinic stated “1,500 children have been successfully immunised during the past two months in Hurstville.”  In its 1937 campaign, Hurstville held 32 clinics in all, and administered 5,200 separate inoculations.[29]

The Hurstville Propeller carried an editorial on 28 October 1937 fully supporting the campaign.  The article stated that the serum used was from the laboratories of the Department of Public Health, (which must have had to step up its supply quite markedly in response to the demand from Councils) and concluded “Your children’s health should be your first consideration.”

Kogarah’s programme was also now underway, at Kogarah Intermediate School.  On a motion of Alderman Moore, Council thanked Doctors Stafford and Richardson, also the nurses from St George District Hospital.  172 children had been inoculated.

At Bexley, Mr Baker reported that 1,157 applications had been made, with 980 completing the treatment, some being found to be self-immunised.  Very few had asked for free treatment, and the scheme was in the black to the amount of £61/18/-.  508 had been treated at Bexley School, 317 at Carlton, 155 at Kingsgrove, 20 at the Marist Brothers, and ten at the Hurstville Convent.[30]

Sutherland Shire treated 1,382 children, and saw a credit balance of £33.  Their Health Inspector, Mr Cooper, suggested paying half of this to St George District Hospital in recognition of nursing services, and this thoughtful gesture was accepted.[31]

Dr Shute was extremely happy with the results of Hurstville’s first campaign and congratulated Health Inspector Doig.  Mr Doig reported that 1,316 children were treated at Hurstville, and suggested letters of appreciation be sent to Miss Dunne (teacher in charge of Hurstville Infants) and Mr Hinder (headmaster at Peakhurst School) for their valuable co-operation.  No child’s application for treatment was rejected.  Doctors Hornbrook, Figtree, Prott, Ashby and Crakanthorp had been most assiduous.  Experience had shown that 350 children could be inoculated in one hour by a doctor (!).  He was confident the scheme would greatly raise the standard of public health in the municipality.[32]  He added that there had been only 28 cases of the disease in Hurstville in 1937, and he expected that to reduce further.

By April 1938, Hurstville had begun to feel that Kogarah was half-hearted in its efforts.  It was a ridiculous position to be in to have half the children immunised and half not, stated Alderman Mallard, simply because some attended school in Hurstville Municipality and some in Kogarah Municipality.[33]  It was moved to ask Kogarah Council if it had any serious intention of proceeding with the immunisation scheme.  Kogarah did not reply.

Cases of diphtheria continued to arise in Kogarah, eight in May 1938.  Mr Bardsley, Kogarah’s Health Inspector, reported in June 1938 that St George Girls’ High pupils had been treated, and that pupils at Carlton South were about to be.[34]  As its first campaign was coming to an end, Hurstville was pushing ahead with its second campaign.  From now on, regular immunisation campaigns were to be a feature of the duties of Council’s Health Inspector.

Bexley was even tempted to report that it had defeated the disease, no notifications having been received for several weeks.[35]  Although this was undoubtedly premature, it marked a turnaround in how municipalities saw infectious disease.  From being something which could only be contained, it had become something which could be completely defeated.

The disease had not been defeated, not yet.  It was sobering to know that two children in the same street in Hurstville died of the disease in 1938.  Mr Doig suspected that a carrier lived in the vicinity, and took pains to ensure that the all the remaining thirty children in the street were immunised.[36]

The following table from the NSW Department of Health is eloquent tribute to the effectiveness of inoculation.  It enumerates deaths from diphtheria in Australia for each decade.

1926-1935 4,073
1936-1945 2,791
1946-1955 624
1956-1965 44
1966-1975 2
1976-1985 2

[1] Propeller 23 July 1936, p7.

[2] St George Call 1 May 1936, p6.

[3] Propeller 7 May 1936, p7.

[4] Sydney Morning Herald 4 May 1936, p8.

[5] Propeller 2 July 1936, p1.

[6] Propeller 2 July 1936, p1.

[7] Propeller 30 July 1936, p1.

[8] Propeller 18 June 1936, p3.

[9] Propeller 25 June 1936, p1.

[10] Propeller 16 July 1936, p1.

[11] Propeller 30 July 1936, p3.

[12] Propeller 10 September 1936, p7. This was possibly Keith Lincoln, son of Mr and Mrs Lincoln of West Kogarah.

[13] Propeller 11 March 1937, p3.

[14] St George Call 21 May 1937, p2.

[15] Propeller 20 May 1937, p7.

[16] Propeller 20 May 1937, p7.

[17] Propeller 4 June 1937, p2.

[18] Propeller 24 June 1937, p2.

[19] St George Call 11 June 1937, p1.

[20] St George Call 25 June 1937, p1.

[21] Propeller 8 July 1937, p1.

[22] Propeller 24 June 1937, p2.

[23] Propeller 1 July 1937, p2.

[24] Propeller 12 August 1937, p3.

[25] St George Call 3 September 1937, p1.

[26] Propeller 10 September 1937, p1.

[27] Propeller 8 October 1937, p1.

[28] Propeller 21 October 1937, p2.

[29] Propeller 30 December 1937, p4.

[30] Propeller 18 November 1937, p4.

[31] Propeller 9 December 1937, p1.

[32] Propeller 27 January 1938, p8.

[33] Propeller 7 April 1938, p1.

[34] Propeller 23 June 1938, p1.

[35] Propeller 22 July 1938, p6.

[36] Sydney Morning Herald 15 November 1938, p15.

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