1890-1964

Immunizable Disease Occurrenceand Prevention in Seattle

REIMERT T. RAVENHOIT, M.D., M.P.H., MARY JO LEVINSKI, P.H.N.f MARY JOHNSON, P.H.N.,and ASTRID M. RAVENHOLT, P.H.N.

WITH the excellent antigenic materialsnow available a person and entire com¬

munities can be provided with virtually com¬

plete protection against historically importantdiseases such as smallpox, diphtheria, pertussis,tetanus, and poliomyelitis. Why, then, is im¬munization with these antigens incomplete?Why isn't everyone immunized?The answer is complex and varies by time,

place, person, and antigen. Obviously, becauseof great cultural differences and varied ex¬

periences with disease the extent of applicationof immunization differs greatly by country.Less obviously within the United States, theextent differs by State, county, city, and neigh¬borhood according to community origins, ex¬

perience with disease, intelligence, education,wealth, and availability of immunization frompublic and private sources. But even under thebest of circumstances in many of this country'smost progressive communities, many people re¬

main unimmunized. Why?During recent years the authors and their co-

workers have devoted considerable efforttoward answering this question and toward im-

Dr. Ravenholt is associate professor in the depart¬ment of preventive medicine, University of Wash¬ington School of Medicine. From 1954 to 1961 hewas director of the division of epidemiology andcommunicable disease control, Seattle-King CountyHealth Department. Mrs. Levinski is a researchassistant, University of Washington, and Mrs. John¬son, a public health nurse with the health department.Miss Ravenholt is now with the Department of State,U.S. Consulate, Recife, Brazil.

provement of the immunization status and pro¬grams of the Seattle-King County community.Therefore, this report of related findings andactivities may be of value to others who are sim¬ilarly engaged.

MethodsA first vital step toward improvement of any¬

thing is an accurate assessment of its currentstatus, and though one should be able to achievefairly accurate knowledge of a community's im¬munization status by examining its records onoccurrence of disease and immunization ac¬

tivities, in most communities, as was true inSeattle, one would search in vain for thoroughand readily useful records of these events.To rectify gross defects in a community's pub¬

lic health records is at first an onerous but ulti-mately a satisfying task. Pertinent records us¬

ually are incomplete and scattered, and it is a

laborious task to assemble fragmentary datafrom diverse sources. But by combining datafrom death records, routine and special reportsof local and State health departments, and thedaily newspapers, one can construct a useful rec¬

ord of disease occurrence and immunization ac¬

tivities, especially for recent decades (1).

Background of Immunizations

Initially, after this community was foundedin 1851, problems pertaining to the occurrence

of communicable disease were handled by one

or more private medical praetitioners. But be¬cause of a rapid increase in the population of

Vol. 80, No. 11, November 1965 981

the community and therewith in its healthneeds, the first of many health ordinances was

passed in 1872. The Seattle Board of Healthwas empowered to "contract with some com¬

petent physician to vaccinate all persons who inhis opinion require it." In August 1872 thefirst health officer of Seattle, Dr. G. A. Wood,was paid $111 for vaccinations that he had per¬formed.the first recorded immunizations andprobably the first expenditure for organizedpublic health work in this community (2).During the 1870's and 1880's, public immuniza¬tion activities by Seattle health officials consistedof an unknown number of smallpox vaccina¬tions given school children, travelers, andothers, especially whenever smallpox occurredin Seattle or in nearby communities.Smallpox. The most severe smallpox epi¬

demic in Seattle (37 deaths per 100,000 resi¬dents) occurred in 1888. However, a prolongedepidemic from June 1892 to February 1893, with84 cases and 19 deaths (fig. 1) caused a

greater official reaction. About 10,000 personswere vaccinated at the city's expense. A totalof 490 persons in 19 dwellings werequarantined,and a hospital for the care of smallpox andother contagious diseases was established.Many of the smallpox victims during 1892 were

railroad employees, and during January andFebruary 1893 the health officer or his assistantsmet all "boats, ferries, and trains, and inspectedall passengers for smallpox as an emergencymeasure. All persons unable to show evidenceof recent vaccination were vaccinated and, like¬wise, all persons living in lodging houses were

either vaccinated or the house closed" (3).In 1899 the Seattle School Board adopted a

regulation requiring all children to show satis¬factory evidence of vaccination before enteringschool. Such compulsory vaccination was prac¬ticed to a variable extent until 1919, when anti-vaccinationists succeeded in enacting a Statelaw making compulsory immunization illegal.

Abolition of compulsory immunization was

followed by a decrease in the proportion of vac¬

cinated children. In 1935 only about 40 per¬cent of elementary school children had ever beenvaccinated, and the persistence of variola minorduring most of the first half of this century andthe occurrence of epidemics of variola major in1926 and 1946, approximately 150 years after

Figure 1. Smallpox cases and deaths per100,000 population, Seattle-King County,Wash., 1890-1960

1890 1900 1910 1920 1930 1940 1950 *9*0

Jenner's discovery of an excellent immunizingagent, are indicative of persistent defects in pub¬lic health leadership and practice. But withtime, education, and persuasion, the acceptanceof vaccination has greatly improved.Although complete success in preventing

smallpox in the Seattle-King County commu¬

nity since 1946 is no doubt especially the resultof thorough vaccination of international trav¬elers, additional protection has been attainedby the routine vaccination of a large proportionof the children, and special vaccination pro¬grams for certain occupational groups such as

military trainees and workers in hospitals andairports, who would be likely receptors andpropagators of imported smallpox if they re¬

mained susceptible.Although annual school immunization pro¬

grams ordinarily produce a moderate numberof undesirable events, such as contact vaccina¬tion of siblings and playmates with eczema andoccasionally some spread of the vaccination toother parts of the body, no definite instances ofencephalitis or death from such vaccinationhas been observed in this community among theseveral hundred thousand persons vaccinatedduring the last decade. Smallpox vaccination

982 Public Health Reports

remains an imperfect procedure, but as long as

endemic foci of the disease exist anywhere on

this earth it probably would be premature todiscontinue the routine vaccination of children.The public body possesses enormous inertia, andit was only after many decades of professionaland public education that the vaccination ofvirtually all children in this community was

achieved. Now it remains essential to main¬tain this hard-won vaccination momentum bycontinuation of sound vaccination programs, atleast until worldwide eradication of smallpoxhas been achieved.Diphtheria. Coincidental with the Alaska

Gold Eush in 1898, diphtheria attained a peakmortality rate of 62 deaths per 100,000 residents(fig. 2). At that time diphtheria was a majorscourge of childhood, as can be seen in the fol¬lowing item from the Seattle Post Intelligencer,October 11, 1898:

Diphtheria Pursues a Family. Bessie M. Coates,the 2-year-old daughter of Mr. and Mrs. Frank Coates,died at South Park Sunday of diphtheria. This dreaddisease has nearly destroyed the family. Virde Coatesdied September 30 and Jessie Coates, September 24.A nephew of Mrs. Coates is now iU with the samedisease. Two of the Coates children have just recov¬

ered. Mr. Coates is in Alaska.

A rapid increase in Seattle's population, from110,053 residents in 1900 to 284,638 in 1910,accompanied and followed the rush to theAlaska goldfields. This great immigration andimproved reporting of disease resulted in a

recorded peak diphtheria morbidity of 268 cases

per 100,000 residents in 1908. Subsequent majorwaves of diphtheria coincided with the unusu¬

ally great immigration and travel associatedwith World Wars I and II.Diphtheria antitoxin, introduced during the

1890's, caused little change in morbidity andmortality from diphtheria, and toxin-antitoxin,introduced about 1922, was not used much inthis community. However, the advent of diph¬theria toxoid in 1927 made possible the generalsubstitution of artificial active immunizationfor the naturally occurring diphtheria infectionand disease.In 1931, in response to an outbreak of diph¬

theria especially among Japanese children(fig. 2), a continuing annual program of im¬munization was started in the schools, and each

year since has been an important component ofthe health department's total immunizationactivities. Yet three decades elapsed from theintroduction of diphtheria toxoid until it was

applied sufficiently to entirely prevent diph¬theria in this community.As elsewhere in the United States, diphtheria

continued to be a cause of illness and deathamong adults in Seattle after it had largelyceased to be a problem among the children (fig.3). Some epidemiologists have attributed theextended occurrence among adults and the shiftin median age distribution of cases and deathsas indicating an increasing problem of diptheriaamong adults.supposedly because of waningimmunity due to decreased repetitive naturalexperience and little artificial experience withdiphtheria antigen. For this reason a smallamount of diphtheria toxoid has been combinedwith tetanus toxoid, and the combination (adultDT) is often recommended for reimmunizationof adults. However, it now seems evident thatthe shift in the median age distribution of diph¬theria during the 1950's was but a manifestationof the decreased occurrence of diphtheria amongchildren, the main recipients of the vaccine, andthe straggling occurrence of diphtheria amongskidroad and other pockets of susceptible,never-immunized adults.

Figure 2. Diphtheria cases and deaths per100,000 population, Seattle-King County,Wash., 1890-1960

CasesDeaths

1890 1900 1910 1920 1930 1940 1950 1960

VoL 80, No. 11, November 1965 983

During the last decade especially, the immu¬nity status of adults in the community has im¬proved because of the durable effects of toxoidimmunization in childhood. Furthermore,thorough immunization of children with diph¬theria toxoid has achieved virtual eradicationof the causative organism from this community,as indicated by the prolonged absence of diph¬theria from the small proportion of residentswho have never been immunized and by theabsence of Corynebacterium diphtheriae fromthe many thousands of throat cultures examinedby the Seattle-King County Health Depart¬ment yearly. Both local and national diph¬theria patterns during the last two decades in¬dicate that if a person is thoroughly immunizedwith diphtheria toxoid during childhood he isordinarily adequately protected for life, espe¬cially if he resides in a well-immunized com¬

munity.Pertussis. Pertussis continued to be a prev¬

alent cause of childhood illness and a not in-frequent cause of infant death until after WorldWar II (table 1). Since then the combined

effects of preventive use of pertussis vaccine(killed organisms) and, to a much lesser extent,the therapeutic use of antibiotics has virtuallyeliminated both morbidity and mortality frompertussis in Seattle. During the last 15 years,only one death has been ascribed to pertussis inthis community, although hundreds of caseshave been recorded. Many of these cases of se¬vere and prolonged bronchitis, reported as

whooping cough during recent years, probablywere not caused by Bordetella pertussis.

It is known that the thorough application ofpertussis vaccine was delayed, especially be¬cause pediatricians and others were apprehen-sive concerning the possibility that the vaccinemight cause encephalopathy (4). For this rea¬

son pertussis antigen was omitted from the an¬

nual school immunization program during themid-1950's, until additional knowledge of itssafety accumulated and opposition to its use

waned, and until the investigation (by H. F.Newman, M.D.) of an outbreak of pertussis in1958 among poorly immunized children in a

lower socioeconomic neighborhood and school

Figure 3. Diphtheria mortalogram, Seattle-King County, Wash., 1890.1960

1 Registration of deaths in King County, outside of Seattle, incomplete before 1908.Source : From review of all death records for indicated years.

984 Public Health Reports

in King County re-emphasized the need for useof the pertussis antigen in the school program.

Since then, although pertussis immunizationhas been more thoroughly applied, a substantialnumber of cases have been recorded each year

Table 1. Pertussis in Seattle-King County,Wash., 1916-64

Year

1916.1917.1918.1919.1920.1921.1922.1923.

1924.1925.1926.1927.1928.1929.19301931.

1932.1933.1934.1935.1936.1937.1938.1939.

1940.1941.1942.1943.1944.1945.1946.1947.

1948.1949.1950.1951.1952.1953.1954.1955.

1956.1957.1958.1959.1960.1961.1962.1963.1964.

Mor¬talityrate *

4.94.53.05.54.92.33.03.6

.77.02.32.71.63.1.42.4

.6

.41.7.6.41.61.0.2

1.01. 1.2.7.2.2.5

.4

. 1

until 1964. But during 1964, when a particularattempt was made to verify the clinical and epi¬demiologic validity of each reported diagnosis,only 16 cases qualified for acceptance of thediagnosis, according to Dr. Donald Peterson,now director of the epidemiology and communi¬cable disease division, Seattle-King CountyHealth Department. If specific identificationof B. pertussis also were required for eachdiagnosis, one might now experience difficultyin demonstrating the presence of this diseasein the community.

Tetanus. Tetanus never has been an im¬portant cause of illness or death in the Seattle-King County community. Only six cases andone death from tetanus are known to have oc¬

curred in the community during the last dec¬ade. Throughout this century, the occurrenceof tetanus has been remarkably sparse andscattered (fig. 4), and there is no record ofepidemic occurrence of neonatal or woundtetanus in Seattle such as has occurred elsewhere(5, 6). As with diphtheria, thorough immuni¬zation of all children during infancy and at thetime of entry to school will expectedly providethe community with virtually complete pro-

Figure 4* Tetanus mortalogram, Seattle-King County, Wash., 1890-1960

1 Per 100,000 population.Source: From review of all death records for in¬

dicated years.

VoL 80, No. 11, November 1965 985

tection from tetanus. However, unlike the dis¬appearance of C. diphtheriae, the causativeorganism of tetanus will probably persist in thecommunity indefinitely despite optimumimmunization (6).

Poliomyelitis. This disease was first recog¬nized in Seattle in 1901, and the first epidemic(88 cases with 15 deaths) occurred in 1910, soon

after major improvements were made in thecommunity water supply (_/, 7). During thenext four decades, poliomyelitis attack ratesmanifested a natural epidemic periodicity,usually 3 or 4 years (fig. 5). Reported mor¬

bidity, which included some nonparalytic dis¬ease, was then sustained at the high rate ofabout 20 cases per 100,000 residents for 7 yearsuntil the introduction of Salk vaccine in 1955and its rapid application. Poliovirus appar¬ently was eradicated from King County within6 years after the Salk vaccine was introducedand before the live, attenuated Sabin oralvaccine was introduced.The effects of application of the killed polio¬

virus (Salk) vaccine on the epidemiologic pat¬terns of poliomyelitis occurrence in this com¬

munity indicated clearly that such immuniza¬tion not only provided individual protectionbut also had a substantial inhibitory effect on

the propagation of poliovirus (7). Detailedaccounts of the difficulties experienced inachieving thorough immunization of the com¬

munity against poliomyelitis and of an exhaus-tive investigation of a "rebound" epidemic ofpoliomyelitis in 1959 have been published(7-9). Since 1961 poliomyelitic disease has notbeen identified in Seattle-King County.The live attenuated poliovirus vaccine is now

being used for immunization of infants and pre¬school children in Seattle, but because of itsresidual slight pathogenicity in adults (espe¬cially type III) little of this vaccine has beenused for adults in the community.

Influenza. This disease remains a sporadiccause of extraordinary morbidity and mor¬

tality. During epidemic years such as 1918-20and 1957-60, it was the foremost micro-parasitic cause of illness and death in Seattle.The recent Asian influenza, although much

less virulent than the agent causing the 1918epidemic, produced an excess of 265 deaths inSeattle-King County during the last 4 months

Figure 5. Poliomyelitis cases and deaths per100,000 population, Seattle-King County,Wash., 1890-1964

40

309aoa

8oo

fc 20

o.8e

sou

1900 1910 1920 1930 1940 1950 1960

of 1957 compared with the number of deathsduring the same months of 1956 (table 2).

All age groups experienced increased mor¬

tality from respiratory disease, though most ofthe excess deaths were of elderly persons andascribed to diseases of the cardiovascular sys¬tem. Four school children died of respiratorydisease (probably influenza) during the timethat roughly half of the 190,000 school chil¬dren in the community were ill with influenza.a case fatality rate of roughly 1 per 25,000.Interestingly, despite these four deaths frominfluenza, an appreciable decrease (.24 per¬cent) occurred in the total number of deaths ofschool children during the fall of 1957, com¬

pared with the same months of 1956. This un¬

expected finding prompted a review of all deathcertificates of children for the 2 years, whichshowed that the lower mortality for schoolchildren during 1957 was mainly a result ofcomparison with the unusually large numberof deaths of children from leukemia during theautumn of 1956 (10). This finding illustratesthe current relative importance of leukemia as

a cause of death of children and also indicatesthat children with leukemia are not especiallysusceptible to death from Asian influenza.

986 Public Health Reports

Theoretically, it should now be possible tosubstitute artificial immunization for the nat¬ural occurrence of influenza. But in Seattle,as elsewhere, the influenza vaccine has beenused mainly in persons with known healthhandicaps or in members of certain occupation¬al groups. No attempt has yet been made toprevent the introduction and propagation of in¬fluenza in the community by thorough immu¬nization of children and young adults. Despitemore than two decades of use and development,immunization for influenza remains so unsatis¬factory that few experts recommend its generalapplication (11, 12). However, it is perhapsonly by general application of still imperfectvaccines that the evolutionary emergence of newantigenic strains of influenza could be sup¬pressed.by inhibiting the great reproductionof stem organisms which is ordinarily a requi¬site for large evolutionary divergence of anti¬genic characteristics by means of serial selection.

Measles. In Seattle, as in most large urbancommunities, measles epidemics have occurredwith a natural periodicity of not more thanseveral years. But despite its continued im¬portance as a cause of severe short-term illnessof nearly all children and as an occasional cause

of encephalitis, mortality from measles hasgreatly decreased. During the peak year of

1924 a total of 44 deaths in Seattle were as¬

cribed to measles, whereas during the lastdecade only 4 deaths have been ascribed to mea¬sles among the roughly 200,000 children in thiscommunity who have had the disease. Al¬though considerable immune globulin has beenadministered in the Seattle population duringrecent decades for the purpose of modifying thedisease, little of the favorable mortality trendcan be ascribed to this practice. More impor¬tant has been the decreased prevalence of viru¬lent streptococci and certain other micro-or¬ganisms, and the effective treatment of com-

plicating infections with antibiotics.This community has recently participated in

cooperative field studies of the measles vaccine(13), and local praetitioners are now admin¬istering the vaccines to many children. How¬ever, the duration of artificially acquired im¬munity and its long-term effects on the ecologyof measles is not yet known. It is not unlikelythat the partial application of the measles vac¬

cines may for some time upset the naturallyfavorable ecologic trend of the disease.as thenumber of susceptible adults increases becauseof decreased prevalence of measles virus due toimmunization of many, but not all, childrenand perhaps because of a waning of artificiallyinduced immunity. Unless public health agen-

Table 2. Mortality impact of Asian influenza, Seattle-King County, Wash., Septembei>-December 1957

1 Decrease.

VoL 80, No. 11, November 1965 987

cies now assume the burden of immunizingchildren of low socioeconomic status againstmeasles, the number of adults susceptible tothe disease will increase greatly.Typhoid. Many Seattle residents have been

immunized against typhoid during the last halfcentury. For many years such immunizationwas mandatory for loggers and others workingon the Cedar Eiver (municipal) watershed.During recent decades many residents prepar¬ing for foreign travel and all military recruitshave been immunized, despite poor evidence ofthe vaccine's effectiveness (12). In this com¬

munity as elsewhere, the conquest of typhoid hasbeen achieved mainly by sanitary improvementsin water and food supplies and not by immu¬nization (lli).

Rabies. Despite the sporadic prevalence ofrabies among dogs during the first three decadesof the 20th century, especially during WorldWar I and during the depression years (1932-38), only six deaths of local residents have beenascribed to this disease. During 1934, when 82dogs were reported to have died of rabies inKing County, 68 persons received the "completePasteur treatment," and 75 were treated incom-pletely. Nevertheless, two Seattle children diedof rabies, one after being severely bitten aboutthe head by a rabid dog and despite a full courseof Pasteur treatment, and a nonimmunized 8-year-old girl, not known to have been bitten, 20days after her pet dog died of rabies.In recent decades a moderate proportion of

dogs have been immunized for rabies, and alldogs in Seattle are now required to be leashedwhen not restrained to private property. Since1938 the rabies virus has been identified in KingCounty only in bats, one in 1962, three in 1963,and three in 1964; with the prolonged absenceof rabies among dogs during recent decades,few persons have been immunized against thedisease.

Other diseases. Immunizations for plague,typhus, cholera, yellow fever, and Eocky Moun¬tain spotted fever have been used selectivelyamong small numbers of local residents prepar¬ing for travel to endemic areas. Of these dis¬eases only plague, with three deaths in 1907 andtwo in 1913, and Eocky Mountain spotted fever,with single cases in 1935, 1937, 1938, and 1940,have been identified in Seattle.

Although BCG is known to be an effectiveimmunizing agent (12), few Seattle residentshave been immunized with the vaccine becauseof the great eflicacy of other control methodsand the current low risk of tuberculous infec¬tion.An inactivated mumps virus vaccine has been

used experimentally in a few men after ex¬

posure to mumps, with little evidence of itsvalue. Similarly, autogenous and other vac¬cines have been used experimentally or hope¬fully by various investigators and medical prae¬titioners in the community, without evidence ofsubstantial benefit (10).Patterns of ImmunizationPassive imnmnization. Antibodies have been

administered to many residents of this commu¬nity for the prevention and treatment of vari¬ous diseases.Diphtheria antitoxin, introduced during the

1890's, has usually been administered to personswith recognized cases of diphtheria and theirknown nonimmunized contacts, but withoutmuch improvement in the case fatality rate.Tetanus antitoxin has, since the beginning of

this century, been administered to persons withrecognized cases of tetanus, without accuratemeasurement of its value, and during the lastseveral decades tetanus antitoxin has been ad¬ministered prophylactically to many personswith lacerations.a practice which has probablycaused more disease than it has prevented.Likewise botulinus antitoxin has been admin¬

istered in the few recognized cases of botulism,without clear evidence of benefit.During the first several decades of the 20th

century many physicians administered anti¬serums experimentally to patients with menin¬gitis, pneumonia, and so forth, but this practicewas discontinued with the advent of antibiotics.Immune globulin, the usual material of

choice for passive immunization during the lasttwo decades, has been used rather extensivelyfor temporary prevention or modification ofrubeola, infectious hepatitis, and poliomyeli¬tis.but with comparatively trivial overall ef¬fect upon mortality and morbidity from thesediseases. This material has also often been ad¬ministered to pregnant women exposed to ru¬

bella, despite lack of dependable evidence of its

988 Public Health Reports

effectiveness. During 1953 and 1954 when thehealth department distributed virtually all im¬mune globulin available in the community, alimited amount was allocated to pregnantwomen; when the material once again becameavailable commercially this practice was dis¬continued.

Passive immunizing agents have usually pro¬vided only an illusory solution to problems ofmicroparasitism, and despite the known efficacyof immune globulin for modification of rubeolaand prevention of icteric hepatitis, the difficul¬ties of administering this short-term protectionto the right person at the right time remain gen¬erally insurmountable.

Previous immunization activities. The rec¬ord of immunizations provided by the Seattle-King County Health Department during recentdecades (table 3) reveals a pattern of increasingkinds and numbers of immunizations. A demo-gram of the population to which these immu¬nizations were given has been published (1) andalso an account of the programs by which thepopulation has been immunized against polio¬myelitis (7). Thorough knowledge of past im¬munization activities is a necessary basis for ac¬curate and authoritative decisions concerningneeded improvement in community immuniza¬tion programs. And descriptions of previousepidemics and related immunization activities

Table 3. Number of immunizations performed by the Seattle-King County Health Depart¬ment (s), Wash., 1930-59

Immunizations

Total number J_Smallpox_Diphtheria_

Total number]Smallpox_Diphtheria_Pertussis_Tetanus_Typhoid_Typhus_Cholera_Plague_Rocky Mountain

spotted fever_

Total number *__Smallpox_Diphtheria_Pertussis_Tetanus_Typhoid_Typhus_Cholera_Rocky Mountain

spotted fever_Immune globulin_Poliomyelitis_Influenza_

1930

3,427150

3,277

1940

16, 0165,740

10, 223

53

1950

55, 91413, 43917, 6695,483

17, 6121,132288206

4738

1931

22, 750250

22, 500

1941

15, 2935,169

10, 096

28

1951

22, 1973,5515,3085,1105,9681,606218205

50181

1932

11, 446171

11, 275

1942

16, 94111, 2625,679

1952

118, 64730, 57534, 80815, 48435, 3032,033

151162

4784

1933

12, 893418

12, 475

1943

26, 46513, 00713, 439

19

1953

97, 28924, 65530, 7937,054

31, 0842,683

284437

104195

1934

10, 847400

10, 447

1944

26, 87313, 16410, 238

971

2,500

1954

87, 16322, 92525, 8817,330

26, 2113,519

258383

143513

1935

16, 89111,6635,228

1945

29, 13611,35116, 2681,490

27

1955

194, 82633, 93436, 86433, 33336, 8683,540

466426

43207

49, 145

1936

13, 5423,512

10, 030

1946

428, 559415, 535

8,8453,923

3114535134

1956

265, 40230, 18867, 6758,788

67, 9573,495

435497

42198

86, 127

1937

18, 97211, 0517,921

1947

23, 5604,124

13, 5762,6272,664

378927320

6

1957

257, 9006,085

41, 2807,650

41, 5814,255

417493

41182

152, 0013,915

1938

6,5853,0803,505

1948

34, 8355,344

18, 0595,4935,484

27697711

10

1958

324, 59851, 36752, 10411,99752, 3014,139

388600

200149, 0902,412

1939

7,5184,3653,153

1949

45, 19510, 47620, 2096,9246,961

352148100

25

1959

299, 68151, 99649, 78327, 89850, 4704,756

740822

286112, 418

512

1 Conferred by a lesser number of procedures, usingcombinations of antigens. For example, some diphthe¬ria immunizations were by DTP, some by DT, andsome by diphtheria toxoid alone.Source: Records of the Seattle-King County Health

Department (1947-59), King County Health Depart¬ment (1945-46), Seattle Health Department (1930-46), and estimates of former health officers of the num¬ber of immunizations performed by the King CountyHealth Department for 1930-44.

VoL 8Q, No. 11, November 1965 989

can be useful for educating the public to partic¬ipation in current immunization programs.

* Ascertaining immunization status. In addi¬tion to knowledge of previous immunizationactivities, the director of public immunizationprograms needs accurate knowledge of the cur¬

rent immunization status of children and se¬

lected other groups within the community. Be¬cause an unrecorded number of immunizationsare performed by private physicians, accurateknowledge of the immunization status of thecommunity can be obtained only by special sur¬

veys. Eepresentative or quota sampling sur¬

veys have been made in many communities withthe leadership and assistance of the Communi¬cable Disease Center of the Public Health Serv¬ice (15). These surveys were useful for a timein measuring and emphasizing immunizationdeficiencies among lower socioeconomic groupsand as a stimulus to community immunizationactivities, but they have limited value forroutinely ascertaining and improving the im¬munization status of most communities.In Seattle, crude estimates of community im¬

munization status were used until 1959, whenthe poliomyelitis immunization status of allchildren in selected schools was ascertained.Deficiencies in school records of each student'simmunization status were remedied by theschool nurses, who obtained information fromparents by interviews via telephone or in thehome, and plans were formulated for a more

comprehensive survey the following year. Inpreparation for that survey, the school nurses,with the assistance of Dr. Vivian Harlin, direc¬

tor, medical department, Seattle Public Schools,were encouraged specifically to obtain and re¬

cord, as accurately as possible, each student's im¬munization history.After completion of the 1960 school immuni¬

zation program (in April), a roster-type surveyform was prepared and used for studying a rep¬resentative one-third sample of all second-gradechildren attending public and private schools inSeattle and King County. School nurses were

directed to list every second-grade student ineach school and to indicate their immunizationexperience, especially the most recent date ofvaccination against smallpox, diphtheria, per¬tussis, tetanus, and poliomyelitis. For each stu¬dent with inadequate immunization, the nurses

were asked to ascertain the reason (s). When¬ever school nurses failed to obtain all the re¬

quested information, the authors (M.J.L. or

A.M.E.) remedied the deficiencies by interviewsvia telephone or in the home.

Status of immunization. The 1959 survey ofa few schools had revealed that roughly 93 per¬cent of the elementary school children in Seattlehad received at least three doses of Salk vac¬

cine (7). In the poorest districts, however, onlyabout 46 percent of the kindergarten childrenwere protected on entry to school, despite thegeneral availability of free immunization atneighborhood clinics.The 1960 survey of 34 percent, or 6,595 of the

19,334 second-grade children in 87 of the 273elementary schools of the city and county, pro¬vided more accurate knowledge of the immuni¬zation status of elementary school children

Table 4. Immunization status of second-grade children, by antigen, Seattle-King County,Wash., May 1960 1

1 All schools combined; 6,595 children in survey.2 Students had smallpox vaccination within 5 years, DTP within 3 years, and at least 3 poliomyelitis inoculations.3 Students had received antigen sometime but less completely or recently than those considered adequately

immunized.

990 Public Health Reports

(table 4). The vaccination status of children inthe city and county public schools and in pri¬vate schools was similar. A total of 84 percentof the children were fully immunized with allantigens, 14 percent were incompletely immu¬nized, and 1.1 percent had never been immunizedwith any antigen.Reasons for nonimmumdzation. The leading

reason for nonimmunization was religious ob-jection, as indicated in table 5. In addition tothe parents who forthrightly stated that theyobjected to immunization because of religiousbeliefs, there were others who said that they did

Table 5. Reasons why second-grade childrennever immunized.Seattle-King County,Wash., May 1960 1

Reasons

Child factors_Allergy:Eczema_Eczema of sibling_Asthma_Allergy 2_

Illness or absence at timeof clinics_

Muscular dystrophy_Sickly child2_Has had pertussis 2_Child objects to immuni¬

zation 2_Parental factors 3_

Religious objection_Did not believe in im¬

munizations_Opposed but reason not

stated_Neglect or procrastina-

tion_Fear of immunization_Ignorance_Chiropractor_Naturopath_Food fadists_Frequent moving_Foster home_Reason refused_Unknown_

TotaL

Number of childrennever immunized for.

Small¬pox

67

2623

22

14855

20

16

26191311

215

DTP

10

1

9550

11

105

Polio¬mye¬litis

11

113149

26

1416331

142

AUanti¬gens

7247

11

74

1 From survey of 6,595 second-grade children enrolledin public and private schools.

2 Quote.3 Opposition to immunization, like causation of death,

is usually complex, but the stated simple reasons ap¬peared to be the dominant or most informative reasons.

"not believe in immunization" or were "opposedto immunization" but did not state the reasons.

It is likely that some of these also were opposedbecause of religious training. Chiropractors,naturopaths, and food fadists.people who are

generally unimpressed by scientific evidence.not infrequently refused immunization for theirchildren.Parental factors were much more important

causes of nonimmunization than child factors.Seventy-two (1.1 percent) of the 6,595 childrenhad never been immunized because of parentalfactors, whereas only 2 children had never beenimmunized because of child factors. An ap¬preciable proportion (0.8 percent) of the chil¬dren had never been vaccinated for smallpoxbecause of various allergic conditions. In thelowest socioeconomic school districts, neglect,procrastination, and fear of immunization,rather than religious objection, were the mainreasons for nonimmunization.These findings indicate the high level of im¬

munization that can be attained, without legalcompulsion, by a combination of private andpublic means. Immunizations have been pro¬vided by various programs in the Seattle-KingCounty area for: (a) persons of all ages, at a

continuing central clinic, where almost all theantigens have been offered free of charge on a

walk-in basis, 8 hours per day, 5 days per week;(b) children at central and neighborhoodweekly well-child clinics and in the annualschool program; and (c) the general publicor selected high-risk groups by special pro¬grams.

Improving Community Immunization Status

Because roll-call surveys of immunizationstatus are simple to perform and facilitate im¬plementation of corrective measures, three are

recommended for routine or periodic use to im¬prove the immunization status of communities.Birthday roll call. A survey based on birth

certificates of all or a representative sample ofall infants when they are 1 year old could be ac¬

complished by interviews via telephone and inthe home by public health nurses.

School-enrollment roll call. The immuni¬zation status of every child entering elementaryschool and the reasons for nonimmunization

Vol. 80, No. 11, November 1965 991

could routinely be ascertained by school nursesand their assistants and recorded on rosters list-ing all students by age and school. Copies ofthese rosters could then be sent to the communi-cable disease control officer to provide him withmaximally accurate knowledge of the immuni-zation status of children entering each schooland to facilitate the planning of appropriateremedial programs.Public housing move-in roll call. It is well

known that the least provident families gen-erally are also the least well immunized. Manyoutbreaks of poliomyelitis and other diseaseshave shown the great epidemiogenic potentialof a moderate number of nonimmunized chil-dren congregated in public housing projects(7,9). Therefore, it is recommended that pub-lic health nurses routinely visit all families mov-ing into public housing to inform them of avail-able services, to ascertain their immunizationstatus, and to encourage and arrange for neededimprovement.The parents' objection to immunization is usu-

ally less than absolute and changes with time,disease occurrence, and many other factors.Hence if immunization were made readily andpersuasively available repeatedly, many chil-dren whose parents initially refused immuniza-tion could be immunized. Not only is it im-portant to attain maximum reduction in thenumber of nonimmunized children for their in-dividual protection and because of their epi-demiogenic potential but it is important be-cause resistance to immunization is communi-cated from one nonimmunized generation toanother.The hard core of resistance to immunization,

which exists in most communities, presents afascinating and worthy challenge to the inge-nuity of public health workers, and it is only byadequate immunization of these social groupsthat eradication of disease or complete preven-tion by immunization can be achieved.

SummaryThe secular experience of the Seattle-King

County community with the occurrence of im-munizable diseases such as smallpox, dipntheria,pertuLssis, tetanus, poliomyelitis, influenza, andmeasles, with related preventive activities, isreviewed. The findings of the study indicate

that eradication of these and other diseases bymeans of immunization is especially dependenton thorough immunization of children of allsocioeconomic, cultural, and neighborhoodgroups within the community rather than onthe general level of immunization.For this reason three routine or periodic roll-

call surveys of immunizations and reasons fornonimmunization (at first birthday, on entryto elementary school, and when moving intopublic housing) are recommended for ascer-taining and improving the status of immuniza-tion in every community.Such a roll-call, or roster, survey of all (6,595)

second-grade school children in a representativeone-third sample (87) of the elementary schoolsin Seattle and King County during 1960 re-vealed that 84 percent of all the children werefully immunized with all recommended vac-cines, 14 percent were incompletely immunized,and 1.1 percent had never been immunized witha vaccine.In the upper socioeconomic neighborhoods,

immunization was deficient mainly because ofreligious beliefs. In the lower socioeconomicneighborhoods, neglect, procrastination, andfear of immunization, rather than religiousbeliefs, were the main reasons for non-immunization.

REFERENCES(1) Ravenholt, R. T.: Historical epidemiology and

grid analysis of epidemiologic data. Amer JPublic Health 52: 776-790, May 1962.

(2) Horton, R. J. M.: Notes on early public health inSeattle. Seattle-King County Department ofHealth, 1951. Mimeographed.

(3) Westman, R. T.: Fifty-four years of health andsanitation; excerpts from annual reports.Seattle Health Department, 1943. Mimeo-graphed.

(4) Byers, R. K., and Moll, F. C.: Encephalopathiesfollowing prophylactic pertussis vaccine. Pedi-atrics 1: 437-457, April 1948.

(5) Axnick, N. W., and Alexander, E. R.: Tetanus inthe United States: A review of the problem.Amer J Public Health 47: 1493-1501, Decem-ber 1957.

(6) Maxey, K. F.: Preventive medicine and publichealth. Appleton-Century-Crofts, Inc., NewYork, 1956.

(7) Ravenholt, R. T.: Poliomyelitis in an immunizedcommunity. Public Health Rep 76: 166-178,February 1961.

(8) Ravenholt, R. T.: Poliomyelitic paralysis and ton-

992 Public Health Reports

sillectomy reconsidered. Amer J Dis Child 103:64-74, May 1962.

(9) Ravenholt, R. T., Mulhern, M., Johnson, M., andBoyle, R.: Poiovirus excretion by preschoolchildren during an epidemic. Amer J Dis Child103: 75-83, May 1962.

(10) Ravenholt, R. T.: History, epidemiology and con-trol of staphylococcal disease in Seattle. AmerJ Public Health 52: 1796-1809, November 1962.

(11) Langmuir, A. D., Henderson, D. A., and Serfling,R. E.: The epidemiological basis for the controlof influenza. Amer J Public Health 54: 563-571, April 1964.

(12) Edsall, G.: Efficacy of immunization proceduresused in public health practice. In The role of

immunisation in communicable disease control.Public Health Papers No. 8. World HealthOrganization, Geneva, 1961, pp. 51-84.

(13) Guinee, V. F., et al.: Collaborative study ofmeasles vaccines in five United States com-munities; preliminary report. Amer J PublicHealth 53: 645-651, April 1963.

(14) Ravenholt, R. T., and Lehman, S. P.: History,epidemiology and control of typhoid fever inSeattle. Med Times 92: 343-352, April 1964.

(15) Serfling, R. E., Cornell, R. G., and Sherman, I. L.:The CDC quota sampling technic with resultsof 1959 poliomyelitis vaccination surveysAmer J Public Health 50: 1847-1857, Decem-ber 1960.

Public Health Service Staff AppointmentsDr. Donald Harting has been appointed di-

rector of the National Institute of Child Healthand Human Development, Public HealthService.

Dr. Harting was assistant director of the In-stitute in 1963-64, and became acting directorOctober 1964, succeeding Dr. Robert A. Ald-rich. He joined the Institute after serving asdirector of the Center for Research in ChildHealth, which became the nucleus of the In-stitute of Child Health and Human Develop-ment when it was established in January 1963.

Commissioned in the Public Health Servicein 1947, Dr. Harting served as chief of thePublic Health Administration Branch, Bureauof State Services, 1960-62, and chief of theProgram Development Branch, Division ofGeneral Medical Services, 1954-60. During1951-54, he served in Chicago as regionalmedical director of the Children's Bureau inthe Midwestern States.

Dr. Harting received his medical degreefrom Harvard Medical School, Boston, in1946. He interned in pediatrics at Massa-chusetts General Hospital and was research

fellow in pediatrics there until September1949. He received the master of public healthdegree in maternal and child health fromJohns Hopkins School of Public Health in1950, and served a year's residency in clinicalpediatrics at the University of Colorado Medi-cal Center in Denver.

Dr. Alfonso H. Holguin has been appointedchief of the Tuberculosis Branch, Communi-cable Disease Center. He has been assistantchief of the branch since July 1964.A native of El Paso, Tex., Dr. Holguin re-

ceived his medical degree from the Universityof Texas and his master's degree in publichealth from Harvard University. He hasbeen with the Public Health Service's Com-municable Disease Center since 1958, in boththe Laboratory Branch and the TuberculosisBranch.

Dr. Holguin is a member of the AmericanMedical Association, the Association of Mili-tary Surgeons of the United States, the Ameri-can Public Health Association, and the AlphaOmega Alpha Honor Medical Society.

Vol. 80, No. 11, November 1965 993