publichealth-5 C

Transcriber:	Kaene Dino, OOPS-SJTU
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Date finished:	May 23, 2006
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Welcome back. In this section I'd like to look at the preventive role of schools in relation to outbreak of infectious disease.

Now we've already looked at the development of the formal school medical services on the types of preventive treatments that were given in school clinics. In children's prevention is been noted a lot of the screening that went on for infecting infectious disease was fairly cruelled and quite often, only the worst cases of infectious disease would have been picked up by inspection on entry and re-inspection during the school life the child.

But schools did emerge important for the control a management about the infectious disease outbreaks. And as this common from this historical sociologist David Armstrong shows. The school might have established the mechanism for learning but also functioned as a laboratory and in a laboratory children could be subject to analysis, experimentation and transformation, and it's crucial in relation to development of infectious disease notification and infectious disease surveillance, which was I want you to come on and look at now.

It has to be remembered, the school located in the mixed community, children came from their homes, they mixed together in the classroom and they carried home any contagious diseases they were exposed to. So not respect, schools can't be recognized as crucial potential places for the introduction and transmission of infectious disease, and it became important component of the network of knowledge, the emerged at the end of the 19^th century to control and monitor amonidge infectious academic diseases.

And what you have here, it's representation of the systems of infectious disease surveillance that developed and this is a particular case from my own research in Britain towards the end of the 19^th century, but many similar source systems developed across the western Europe and north America around about the same time, and it's probably recognizable to you today as the source systems that are still in place, still in operation for reporting and monitoring disease.

And what you have the fact here is system by which infectious diseases were made public. You see the centre in this diagram, the local authority medical officer of health, and that was the person to whom medical practitioners and health hold heads had to report, the existence of infectious disease. So you see, on the top right of the side of diagram, a listed disease they came to be compulsorily notifiable to the local authority medical officer of health, small pox corollary, scholar fever and going down the list to papule fever has to be notified either by a general practitioner or in absence of general practitioner being cold in, the health hold head to the local authority. Now what was crucial in the context of the schools was the fact that measles, whooping cough, chicken pox, diseases that had very high instance among the children of school age were not notifiable in many places.

Now there is various reasons why that was the case, partly because the early symptoms of these diseases were very difficult to differentiate, from, for example, a common cold or a light fever, so for a desirer to not create confusion and to reduce cost on the local authority, these diseases, measles, whooping cough, chicken pox tended to be excluded from most diseases they had to be notified.

And in the bottom half of the diagram what you have is a representation of the source of things could happen once the local authority medical officer of health, possessed the knowledge, the infectious disease was located a particular place or in a particular group the population, so the left on the side, individuals might be subject to remove to hospital or isolation in the domestic setting is also crucial from the aspect of the schools, that children could be excluded from schools if they were known to have a certain infectious disease, such as scholar fever, small pox, deeper serer. It's also important to realize the schools themselves could become the subjective to the closure or disinfection in response to epidemic outbreak, and they also impacts in relation to diaries which could be closed and also in disinfection of homes, books and beddings and other words properties serving the individuals or distractions such as schools, these also became subjects to intervention but the local authority medical officer of health.

So schools have an important rote play and in this developing network of infectious disease surveillance admonitory because they become the places whereby local authority medical officer of health came to know about cases of infectious disease that otherwise wouldn't be notified.

What you have here is a post taken from the city Birmingham in 1903. That you actually placing chicken pox on the list of notifiable diseases, this would be a temperate measure during an outbreak and it made responsible and it also had the family or the medical practitioner to report a case of chicken pox to the local authority medical officer of health.

Under normal circumstances chicken pox was not a notifiable disease. A local medical officer is relied on the information provided to them by head teachers of schools. And so school is important for gathering information on non-notifiable but highly dangerous infectious diseases and they offered alternative route into the domestic arena because a local medical officer of health could get information from the school about the sick child and then visited the home.

And another important aspect is the fact that the schools, classrooms and facts became epidemiological laboratories, so intensive investigation took place into the transmission of infectious diseases within schools, within classrooms between contacts and the relationship of the transmission of diseases within classes and schools and the home environment.

We can see here the potential value that schools had in reducing mortality and morbidity from a disease that was not normally notifiable. What you have here is a graph of early child of mortality rates from measles in London between 1861 and 1910.

And what you can see in this graph is the mortality rates for measles of particular high for one-year-olds ranging from between 5 and 15 per thousand population. But what you also have, a fairly high mortality rates, and in this period for children aged 2, 3 and 4. And these are the ages which they were beginning to enter compulsory education. So that these rates might not seem particular high in relation to the rates for the one-year-olds that they were very important for a condition was considered to be a normal right of passage for a child in this period. Most parents considered that measles was a disease that children just went through. They got the disease, it was common and was very little luck could be done to avoid it. However rates, mortality rates are approaching 5 per thousand during heavily epidemic periods where were actually quite high and were worrisome for public health authorities and any route by which they could get information about the measles' outbreak was crucial to transcontrol measles and provide some form of prevention and treatment.

This is an example of this sort of response that was developed. What you have here is a copy of a certificate that they will be used in London and in the early 20^th century to notify parents that their child being discovered to be suffering from measles in the school.

You can see from the text that the notice from head-teacher is telling the parents that there is a case of measles in the school and it's possible their child might have contracted with the disease. And asking parents and this is crucial, is asking parents to monitor the condition of their child's health over the next 3 weeks, because it was known that it requires about 12 days for measles to develop after the initial infection.

And I am asking parents to keep that child out of school if any sign of disease emerged over that period. And you can also see from the bottom section of this certificate is the type of the information that the health authority were providing to parents about measles. They are suggesting that the early symptom is just like a cold, maybe slight cold. There is a running eyes or nose, sneezing and possibly a cough.There is also a crucial reminder that measles is actually a very serious illness for young children. And children actually die from it. And it's asking parents not to ignore the disease even though the symptom might not seem particular life-threatening.

Public health policy was developing in this period and was beginning to increasingly emphasize health behaviors, parenting skills and particularly for mothers the role of motherhood in protecting the health of children.

You have noticed from the previous line that the detailed incubation period of measles. How important epidemiological information was becoming. Parents were being informed of the incubation periods of measles and other diseases. And schools are the crucial component of collecting and analyzing this sort of information in relation to the natural history of disease. As school is developed, it's important condul its epidemiological information and become possible to tracing in detail both cases of the disease and their contacts. And information with guarded on immunity, susceptibility and carrier of disease. And you can see from the table on dip Syria cases that were examined in London at the beginning of 20^th century. There, a large amount of information was collected and tabulated over this period.

The table shows the number of dip Syria coachers that were subjected to laboratory analysis. You can see there was almost 6000 coachers which were taken over a 66 months' period. And the for almost 450 of these coaches were shown to be dip Syria carriers. And it is important to underline here that this sort of analytical work was being undertaken by school boards and this sort of analytical work was not just taking place in London and was taking place across Europe and North America as well.

The schools here are acting as the routes by which a laboratory diagnosis of dip Syria could confirm or engate a clinical diagnose of a disease. So you have increasing levels of certainty over whether the child had the disease, whether the child might pass on the disease to his or her classmates. So you have relatively sophisticated amounts of the information being collected and analyzed in the relation to particular diseases. And what I am intended to do was to promote an economic efficiency by individualization.

So what I mean by this is that individuals through the analyses of the coachers they provided, through the information whether they carry a particular disease. This knowledge about individuals enables more supposedly scientific decisions to be made in relation to public health policy. So rather than closing a school or closing a classroom when at these disease outbreak, it become possible simply to exclude those children who were known to have the disease and that was more economically efficient in terms of expenditures of schools, in terms of lost days of schooling and this was seem been more efficient from an economic aspect.

You've allready seen these next two images that relate to the plotting of scholar fever epidemic outbreaks in classrooms in London in the 1900s and I think it was also an interesting aspect that is worthy of our attention here. Taking the outbreaks in the broomly important schools in 1908 and 1907 first, what you have here is a representation of the progression of scholar fever epidemics  within both the classrooms and also the interaction between classrooms and domestic environment.

And first of all it's crucial to understand that this particular diagram couldn't have really been drawn 30 or even 20 years previous. It's only within the knowledge of the june theory of diseases and transmission of diseases via airborne and drop infection that this sort of imagery could be employed that intimates that people transmits diseases by close intact and via airborne and drop infection.

So what you have here is representation of individuals who are known or suspected of having scholar fever and each circle represents a case and there are different ways of representing whether case was supposedly contracted. So in the broomly street schools like an example, cases that were supposedly contracted outside of school are shown as half-shaded circles, cases that were contracted within the classroom are shown as clear circles. And also shown in the diagram are the intervals in days betweem cases as they were notified.

In the second diagram, for important girl school, you have a representation that shows the supposed progression of diseases as transmitted by two sisters who were in the same school but different classrooms.

The classrooms themselves are depicted as being within a dashed circular line which to me suggested this idea of semi permeability, the idea that the disease could pass from within the classroom to the outside and from the outside to within the classroom. You have the depiction of the link between the domestic environment and classroom environment via dense diagonal line that suggests some sort of unknown link between the school and domestic environment but also between the classes themselves server the link between the two classes also shown in this way. They also demonstrate that the school is important for gathering information and respect to children who attend the school but also the fact that concerning the important school case where the first case was a baby at home, the importance of school and the role in this systematic network of the collection of information of infectious diseases within the community at large. So you have this constant exchange of information between the schools and between the homes and local authority medical officers controlling these sources of information. And it was only by controlling these sources of information that the contact tracing can take place. And this sort of diagram's active representation can actually be produced.

And in the second case, which represents the outbreak of scholar fever in October 1907, we have the ultra supposed roots of transmission of the disease within the classroom environment itself. And I want to bring your attention first of all to the terminology that is used in the case. One of the terms that particularly stroke me was these normal boys on the tucked category. 19 boys within the class who were considered free from the disease, they were in need of a tucked during this epidemic outbreak nor did they have this disease previously. And because of this disease-free status, they are classified as being normal. All the children are classified somewhat differently. You have non-scholarty in a case, 5 boys are classified as having a confirmed case of scholatina. You have 5 other cases that were diagnosed as having a slight source throat but the actual presence of scholar fever was actually confirmed.

And retrospectively you have a classification of four cases that were missed. There is also a classification of previously protective boys now in this stage of immunization available for scholar fever, and the previously protective boys represent the category of a section of the class who were actually known to have these diseases during this previous outbreak. And this conferred the community on them. And that itself provided the indication of this type of records the schools were beginning to keep and accumulate on the disease and medical history of their children.

You can also see that some fairly paroic assumption being made in this diagram about this ultra transmission of diseases around the classroom. I'd like to bring your attention to the case No.11 contracted on the 7^th October which is in the third row of the desks down and the second column in from the left. And what you can see from this case is this previously protected boy who was reported of having a light soar throat now dissert the question over whether this light sort of throat here actually meant the boy's developed mild case of scholar fever or not but also this confused question about whether perhaps the report that the boy previously had diseases was accurate or not. What is also interesting is that this boy was supposedly infected by case No.8 which is directly moving in this diagram on the second row down. And what also had just this soar throat for who in addition was thought to infect case No.10 who was later classified as a missed case. What is interesting about this is the direction of these arrows and the ways in which the local authorities suspected that the disease moved around the classroom.

Now the arrow indicates the probable direction of the spread not probable by the dashed lines rather than the solid lines. Now what is intended not to recognize is the fact that these children may have had contact with the children outside the classroom in the playground. They may also have the contact with the children who didn't attend the school in the streets around their homes and also interacted with the people in the domestic environment, brothers and sisters, friends and relatives. So the classroom here is being treated as a closed environment and is being treated as if the disease is moving purely within the classroom and this relatively little interaction going on within the classroom and outside the world. And what was equally important is that all this information is available and has been gathered and can be used by local authorities to estimate the probable impact of the outbreak and could also be used in future years to determine how susceptible this particular class might be to an epidemic outbreak further down the line because of the information on the children who previously had diseases and was supposedly immune.

So overall what the section is attempted to do is illustrating the importance of schools for the control and management of outbreaks of infectious disease. And so is developing in this row alongside the rather more formal services that took place in terms of prevention treatment in the school medical clinics. So school is important in the public health efforts in a variety of ways. And what I've also done in the section is to consider in a limited way the relationship between school and domestic environment. And that's something the topic I want to go on to in the next section of this lecture.