Curtailing the ‘Assassin of Children’

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CHAPTER 3: ‘Get Them Young’. The Health Department and the expansion of childhood immunisation 1941-1962

The 1940s and 1950s saw the introduction of several new vaccines for use on infants and schoolchildren in addition to diphtheria. Pertussis, tetanus and BCG were, by 1960, established within the Department’s immunisation framework, with polio immunisation undertaken as a mass campaign.1 The growing importance of immunisation as a preventative measure led to greater efforts at promotion and persuasion of parents by the Health Department, which itself had to fully appreciate the ramifications of this new area of public health.
This chapter will consider how the Health Department implemented a successive number of immunisation programmes aimed at infants, preschoolers and schoolchildren. The increasing number of vaccines on offer led to the development of new methods to assess safety with specialists from organisations such as the World Health Organization (WHO) asked to offer their expertise. These developments, together with the introduction of an immunisation schedule, will be considered in light of a power shift from general practitioners (GPs) towards the Department and experts in determining immunisation. Relationships between the Health Department and GPs will also be examined in the light of the Department’s continuing policy of promoting immunisation at the family doctors’ surgeries. The use of more controversial vaccines such as pertussis and BCG together with their implications for New Zealand will also be considered.

Diphtheria Immunisation 1941-1960

The onset of World War Two had serious consequences for the fledgling diphtheria immunisation programme which commenced in 1941. Staff shortages due to doctors being sent overseas meant some districts were without key personnel. In Southland immunisations of schoolchildren did not begin until 1943 when a Medical Officer of Health could finally be appointed.2 Hamilton did not have a School Medical Officer at all during wartime which seriously hampered immunisation efforts in that health district.3 In the Auckland Health District little was achieved before 1942 due to a shortage of vaccine; in that year about 3000 schoolchildren received immunisation.4 Nevertheless, some districts were able to commence immunisation from inception of the programme and in the Otago Health District around 2000 children per year were immunised from 1940 to 1943.5 In 1942, for New Zealand as a whole, the School Medical Service immunised 14,917 school children of whom 12,989 completed the course.6 Nevertheless, this was not a huge number when compared to the scheme in South Auckland in 1937-38, where the district’s 17,531 children were offered immunisation with 9,251 accepting.7
An epidemic of diphtheria in 1946 in the North Island clearly showed that these numbers were not high enough to prevent further outbreaks of the disease and that still more needed to be accomplished. In 1946 there were 1,638 notified cases of diphtheria although rates had been increasing since 1943.8 South Auckland Health District reported more cases of the disease (245) in the first six and a half months of 1946 than for the whole of the previous year.9 The Health Department noted in its Annual Report that this was part of a worldwide trend, particularly in under-immunised countries. Following the war there had been a resurgence of a virulent strain of diphtheria in Europe that had caused ‘great mortality’. Norway, a country where little immunisation had been carried out, had 71 cases in 1939 but 22,787 in In Britain, due to the National Immunisation Scheme, figures had decreased from 47,698 cases in 1939 to 35,994 in 1943, although clearly these numbers were still of great concern.11
The 1946 epidemic acted as a catalyst for the Department. With the end of the war and a return of medical personnel more immunisations could take place. The Department targeted those most at risk, and left virtually untouched by school campaigns, namely the preschoolers. They hoped to have 70 percent of children under five immunised.12 In 1946, 66,533 children received an immunisation and of this number, 40,409 were aged three months to five years, a huge increase on previous figures.13 Public Health nurses had also been granted permission to immunise and they administered about a third of this total.14 Some districts held Saturday morning clinics to enable parents unable to attend during the week to bring along preschoolers for immunisation. Nearly 11,500 children under five were immunised in Auckland with about half attending the clinics for that purpose, and the remainder going to their doctor’s. 15 Fear of the disease was a powerful motivator for parents, especially during an epidemic. By 1947 case numbers had halved to 546, with the Health Department modestly claiming that this ‘fall in the incidence of diphtheria is world-wide and cannot be claimed as the result of the Department’s campaign of inoculation, important though that is’. 16
The diphtheria epidemic of 1946 was the last to strike the shores of New Zealand. The efforts of the Department appeared to be paying off when by 1950 only 56 cases of diphtheria were notified, and in 1954 the figure was only 69 despite the postwar baby boom.17 The Department commented that ‘the majority of cases occurred in persons who had not previously been immunized and it is certain that if immunization were more general the disease would almost disappear’. 18 This time the Department had the resources and staff to be able to continue implementing a widespread diphtheria immunisation programme. Immunisations carried out by the Department numbered 29,181 for 1948, 26,918 in 1953 and in 1954, 26,701 booster doses were given out (16,651 of combined pertussis and diphtheria).19 This was almost double the number immunised in the early 1940s and very likely more as numbers immunised by doctors were not always included. Prioritising diphtheria immunisation was a successful move by the Department. By 1961 with only one case of diphtheria notified, the Department declared ‘a spectacular victory for immunisation’ in the light of the high incidence of the disease only a few years previously.20 In a way it was, as through utilising schools and establishing clinics the Department had, by the early 1950s, substantially reduced the incidence of the disease. This was, however, later than other countries. Historian Clare Hooker has pointed out that in Australia ‘Federal and State governments took advantage of their increased role in wartime to conduct broad, intensive advertising campaigns in most municipalities’ with the result that in the state of Victoria, 78,000 children were immunised during 1942-43.21 Nevertheless, Hooker qualified this statement, arguing that ‘diphtheria control remained slow’ and that it ‘was not until the 1970s that it truly became a rare disease’, well after New Zealand.22
In Britain, which operated a national immunisation programme from 1940, 50 percent of its child population was immunised by 1943. 23 Jane Lewis, a social policy historian, argued that the ‘huge increase in numbers immunised and the concomitant decrease in the death rate from diphtheria was due entirely to the national scheme’. 24 By 1950 there were 952 cases with 49 deaths and by 1965, 25 cases with no deaths.25 This reflected a similar pattern to the one demonstrated in Australia; immunisation proved to be a reasonably protracted experience to reduce the incidence rate to very low levels. New Zealand, however, was not able to make significant progress with the immunisation programme until after 1945 due to lack of resources and medical personnel. Moreover, it was most likely that diphtheria immunisation was not a
priority it for the Health Department and health districts during the war. The impetus of the 1946 epidemic focused attention on diphtheria in a way that had previously not been possible. As a result substantial gains were made with immunisation campaigns and levels of diphtheria were, by the 1950s, comparable to those in both Britain and Australia.

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Doctors, Plunket and Public Health Nurses

To facilitate diphtheria immunisation in New Zealand after 1946, School Medical Officers in each district were directed to spend at least half their time on immunisation when visiting schools. Children aged five to seven were to be routinely offered immunisation with older children being done on request. To try and gain access to the under-fives, extra clinics were held at district head offices in addition to the ones held at preschool centres (Plunket rooms and kindergartens). Nonetheless, the most important change was to allow Public Health nurses to undertake immunisation work which could then be done during a routine home visit. It was hoped that many more babies could be immunised in this way. A trial had been undertaken in North Auckland District in 1945 and was then extended throughout New Zealand. Public Health nurses were to focus on immunising all infants aged six months to one year and this goal was to ‘become the Department’s long-term attack on the diphtheria problem’. 26 The Medical Officer of Health for each district was to assume ‘full responsibility for the work and assure himself that all nurses are working to a standard technique and are competent to do immunisations’.27
Nurses very quickly played a vital role both in administering immunisations and providing information to mothers. They now had the advantage of being able to offer immunisation immediately to a ‘defaulter’ mother if she wished her baby to be immunised at home. Most importantly, it eased the staffing requirements of the immunisation programme that had been floundering in many areas due to a lack of qualified personnel. South Auckland Health District, by 1946, had gone from being one of the best-protected districts to one of the worst.28 In the Wellington and Nelson Health Districts, Public Health nurses were utilised in the rural areas and were able to offer immunisation to small groups in places where visits by the School Medical Officer could not be arranged.29

Chapter 1: Introduction
Chapter 2: Curtailing the ‘Assassin of Children’. Diphtheria immunisation in New Zealand 1920 1941
Chapter 3: ‘Get Them Young’. The Health Department and the expansion of childhood immunisation 1941-1962
Chapter 4: ‘Something Everybody Did?’ Attitudes and responses to immunisation policy 1941 1962
Chapter 5: From Salk to Sabin: international influences on polio vaccine policy in New Zealand 1955-1962
Chapter 6: Re-inventing Disease Perception: immunisation and public health policy 1962-1972
Chapter 7: ‘Slow to Change?’ The Health Department and immunisation policies 1972-1990
Chapter 8: ‘Crises of Confidence?’ Vaccine controversies and medical and public responses 1973-1990
Chapter 9: Empowerment and Expectation: the changing nature of parental attitudes towards immunisation 1973-1990
Chapter 10: Conclusion
Appendix
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Child Immunisation: Reactions and Responses to New Zealand Government Policy 1920-1990.

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