- With approval, and by testing a new procedure that appeared theoretically promising.

Some et least of the current and generally approved practices of health depart=

methods which will give at least as good results with less expense to the

a” EY ee
} igh Cop “YI

REVIEW OF WORK OF COMMITTEE ON EVALUATION

The Committee on Evaluation of Public Health Practices wes appointed
as @ Sub-committee of the Committee on Administrative Practice on December 5,
1929.

The seeuhion of this committee followed the recognition by the Com~- ,

_mittee on Administrative Practice that, with the completion of the studies

of administrative health functions end their performance by official and non-
official health orgenizations, which led to the numerical expression of the
quantity and to some extent the quality of usual public health activities in

cities snd rural areas in the United States by the use of the Appraisal Forms,

ments were ant based on adequate evidence of necessity or effective results.

Our knowledge of the prevalent practice of techniques and methods
by public health departments is now reasonably complete.

To ensure progress in public health practice it is necessary to test
results of accepted or current methods objectively, to seek other effective
tampayor., te apply new resources of prevention and protection within existing S ‘
aveilable funds, and to demonstrate the possibilities of attaining higher
levels of health protection by changes in method or by introduction of new

procedures even if these involve an increase in public expenditures.

Inasmuch as there was no established technique or methodology to
which the committee could turn for procedure in evaluating the merits of many

of the existing public health practices it seemed best to initiate our studies

 

of quality and results, as distinct from quantity of health services, by sample |

inquiries where tradition and public acceptance had stamped present day activities

 

 

 

 
a 2s

We chose to measure the validity of existing isolation practice for
scarlet fever by the proved effect upon secondary cases among susceptible persons
exposed to the initiel case on its return home. We determined to test the rela»
tive edvantages to the pregnant women in terms of her survival of childbeering,
and of morbidity during the puerperal state following prenatal care of different
degrees of frequency and initiated early or later in pregnancy. We undertook :
to obtain exact proof of the relative value in the prevention of diphtheria
of artificial active immunization of children of the snensinies and school age
together with the effective percentage of immune child population in a community
necessary for effective control of the disease, and of the superiority, if any,
in the use of toxoid instead of toxin anti-toxin as immunizing agent. |

We have learned from the studies, carried out at our request, and to
some degree under the supervision of the committee and the field secretary of
the A.P.H.A. by highly Qualified persons and groups with the aid of funds put
at our Scashenl for this purpose, that exact answers to our ansuthais can be
obtained in some respects by the method of controlled leboratory experiments
supplemented by tests on human beings under practical and ueual field conditions,
as shown by the studies of Dr. Park on diphtheria toxoid.

We have learned that the clinico-statistical method presents many
difficulties, involves some fallacies, and gives to some dagres equivocal
snswers to questions of public health method which involve elso clinical practice
of i indnceed specialties. This is illustrated in the only partially
significant conclusions of the study of prenatal care.

We have learned thet economies in communicable disease control can
be safely made by modifying existing isolation procedures according to age of
patient, season of year, snd the clinical characteristics of the case in

scarlet fever.

 

 
a

~ 3 =

We have not yet been able to assure ourselves of the optimum percent-
ege of children under five to be inmuniged in order to prevent the spread of
diphtheria with the leest expense to the public and the individual.

We heave not yet learned whether an isolation practice in large
northern industrial cities which appears to be safe and effective for the
control of scarlet fever will be similarly successful under other climatic
end urban conditions in this country.

We heve discovered the inadequacy of the routine records of many
health departments upon which our objective opinion as to the results of
present isolation and immunization practices and with regard to the causes

of the results claimed or acknowledged depends.

While much has been learned as to limitation of available facts, as
to methods suitable for testing efficiency of health department practices, end
in the matter of relative merits of more and less intensive services, it is
apparent that we have only scratched the surface of inquiry in fields of public
health in which lerge sums oan annually spent for the public in a manner and
by means not wholly convincing as to direct and indirect health profits from
the expenditure.

fo review briefly the possibilities and pressing necessities for

.profitable evaluation of health practices we may agree that for vital statietics

there is little that offers hope of economy except in the matter of duplicating

records end transcripts for local, state and federal needs, and little that

can be done to improve accuracy of certification except by freedom from politics,

w better qualification of personnel and by extending the principle of con~

fidential certification of death as used successfully in some other countries,
in communicable disease control we may consider ourselves at the

threshold of sccomplishment, and realize that only by persistent testing of

theory against fact, of record against record, of laboratory experience against —

I
ee x ci 3

 
we Yo
field practice can we close the gap between what we know and what we can use,
and learn to discard the unprofitable in favor of the effective, regardless of
traditional usage or the spperent hindrance of existing laws. ‘The very uneven-
ness of performance and variation in regulation and practices among our states
and in cities within the same state convict us of an inconsistency in the
application of medical science to public service.

The existing recommended procedure for control of each commmnicable
disease should be periodically reviewed to secure better results at less unit
cost, or superior performance if need be at higher cost. Specifically we should
test performance in measles, whooping cough, scarlet fever and diphtheria snd
undertake s complete review of our procedures for the control of tuberculosis,

syphilis and gonorrhea.

in maternity end child hygiene and especially in thet field of largest
health expenditure end perhaps the least obvious progress, school health super~
vision, end in the realm of maternal mortality, the opportunities for test and
messurement, for experiment and observation in results fairly crowd upon one,
whether it be in the amount and character of prenatal care, the technique of
baby and preschool supervision, or in the wholesale and largely mechanics] un- |
profitable school health work. A recent partial analysis of the end results of
the discovery of remediable defects among the school children of New York City
suggests thet nearly 80 per cent of such handicaps fail of correction because of
conditions inherent in the methods of detection and subsequent action by public |
agents. Such performance would seem but a futile gesture which serves as a
sort of anesthetic to the official and parental conscience. Evaluation of school
health work would seem to offer perhaps the largest immediate opportunity for
improving the results and credit in public heelth work.

_sS es ww wh eS el el

 

 
= 5 =
In the field of sanitation two matters appear to demand particuler
review although great progress is properly credited to existing efforts. In
dividuel home sewage disposal and the control of milk by licensing and pasteur-
ization ordinances are still open to analysis on the basis of results and the
necessity of existing practices.
The people of this country still suffer massively from ik gieaad tabtnty
of infections and infestations directly related to the failure to separate their
foods from their feces. What we can efford to do, and what we can not afford
to do without, in the matter of individual home and farm disposal of humen
exereta are problems for which evaluation procedures are practicsble.
While the cost of five cents per capita per annum to urban populations
for sanitary control of milk supply seems sufficiently low, it is not yet proved
to entire satisfaction that the price of milk to the consumer is not unfavorably
affected by sanitary requirements which have but doubtful bearing upon the
~ pumity: and wholesomeness of the product. And - the other hand it is not entirely
cleer that some increase in precaution might not reduce the present residual
hezerd from milk, or thet abandonment of certain trede practices with the con-
sent of health departments might not permit consumption of more milk with a
reduction in retail cost.
Public health education as the youngest of the accepted functions of
the health departments hes not crystallized out of ite amorphous possibilities
and practices any set or formula or performance. In no field is evaluation more
difficult, or the hezard of misuse greater. We mist admit eo present lack of any
method of analysis of results, or objective teste of s2tantavinese at all compar-
able in validity to those available for judging the other functions of a health
department.
The Committee on Evaluation of Public Health Practices, has no |

independent sources of income with which to undertake or subsidize administrative

 
Sierras

-~6=-
research. Our activities must for the present, therefore, be limited to two
other possible directions, namely, the enlistment of capable permanent officers

in health departments in individual, local or combined inquiries into the merits

and locel health agencies to do with private funds what health departments may
have no resources to carry out. ‘The committee considers itself obligated to
plan and so far es its membership permits, to supervise evaluation studies in

public health at the request of health officers and private agencies.

wt ep et ecm

The studies completed or partially so, with grants received during
the pat three years from the Commonweelth Fund have been the following:
A. Studies on diphtheria toxin-entitoxin and toxoid.

fhe practicel result of these studies has been to influence physicians
ead health officers to use toxoid in preference to toxin-antitoxin in children
under school age, and to bring a desirable uniformity in higher antigenic
potency of commercial toxoid preparations and the suitable labelling of such
products on the basis of flocculation units. We have good reason to believe
thet the single toxoid inocculation et six months of age as advised by Dr. Park
will generelly prevail, with the result of a gradual increase in the percent
of all children immunized in a commmity, especially among those under five
years of age.

B. Epidemiological studies to determine (a) what effect active immmization
hes hed on the incidence of diphtheria when applied to children of specific age
groups end (b) what percentage of children of specific age groups need to be
immunized in order to bring about satisfactory control of diphtheria.

The results of these studies, which are still being reviewed for con~
tinuing end corroborating evidence from additional cities and subsequent years,

‘heve been es diversion of emphasis from routine immunization of school children

to specisl efforts in reaching and immunizing at least 30 per cent of the
children under five years and especially those in the letter half of their first
year of life. Efficiency in results, and economy in time end money have followed
the introduction of this improved procedure in various cities.

Certain inconsistencies in results in one city are being subjected to
further inquiry. An unexplored degree of inaccuracy in the claims of extent
of immnization in commnities by health officers required review of much
previously esccepted information. Large and small cities in verious parts of
the country heave benefited prectically from the principles of public action
resulting from these studies by Dr. Godfrey.

Both Dr. Perk end Dr. Godfrey are continuing to push inquiry further
in diphtheria contro], but limitation of funds is delaying progress et present.
= 7 =

: The committee has been convinced by the work carried on under its
auspices of the advisability of new end continued diphtheria studies in the
following directions:

(1)

(2)

(3)

(4)

The careful study and analysis of the diphtheria situation

as they existed end have been effected by special programs
in Detroit, Chicago, and Wilkes-Barre.

The study and analysis of dats which we hope will be sub-
mitted as a result of our past and future commmnications
with health officers. (It is proposed to send another
communication to health officers asking for date on diph-
theria immunization).

The specific study of the relationship between diphtheria
incidence and immunization status in Peoria and Decatur,

Ill. and in other communities having significant increases
in diphtheria (notification of such increases will come by
wire from the United States Public Health Service), together
with the observation and stimalation of such measures as will
tend te control the disease and furnish information which
will help to substantiate or refute tentative conclusions
reached.

The institution of careful epidemiological studies in
those communities visited in connection with (3). Such
studies would involve the investigation of such factors ast

(a) ‘the frequency with which diphtheria bacilli ere found
in children having discharging noses (but no other
clinical symptoms of diphtheria) and the role played
by those children in the tranemission of the disease.

(b) The frequency with which individual sources of in-
fection can be located by intensive work and the preve-
lence among them of

1. Missed cases, by age groups, :

2. Carriers by age groups, with the determination of |
virulence or avirulence.

(c) The determination of the immmization status, by Schick
test, of children by age groups (both preschool end school
ages to be included):

1. Among those who have had the proper dosage of an
spproved immunizing agent.

2. Among those to whom no immunizing agent has been
given.

(All the sbove studies, in cities having relatively
high incidences of diphtheria to be carried out
within the individual city by (a) ereas reporting
unusually high incidence of diphtherie and (b) areas.
reporting little or no diphtheria).

 
 

 

at:
(5) In selected cities having had no, or very little diphtheria
reported for at least five years, the institution of studies
to determine
(a) Carriers of diphtheria bacilli morphologically identified
by age grouns, with the determination of virulence or
non-virnlence of such carriers.

(b) The immunization status, by Schick test, of children by
age groups (both preschool and school ages to be included):

1. Among those who heve hed ths proper dosage of an
approved immunizing agent.

2, smong those to whom no active immunizing agent has
been given.

C. _ Studies in Scarlet Fever control by Dr. John BE. Gordon while still
undergoing test for corroboratiom of consistency in results or procedure recom
mended, have produced sufficient proof of benefit to be expected from modifying
our present isolation practice to more than justify the time and money spent
in the study. It may not be until 1936 when the third decennial revision of
stendard communicable disease control practice will be published, that there
will be wide spread acceptance of the innovations proposed, but benefit to
padtunt, quarantined households, and health departments is certain to result
from the less arbitrary period of isolation which seem to have been well justified
by Drs Gordon's observations.
The results of the studies and the logical extension of them for the
purpose of ereater accuracy and corroboration are as follows:
The tentative cgatiusiens reached, which must be tested before they
can be made ae part of accepted scarlet fever control methods, are:
(1) Theat the communicebility of scarlet fever is not fixed, and
thet no single specified isolation period will serve to
control sdeguately and economically the incidence of secondary
cases.
(2) That the following factors influence the communicsbility of
the disease end must therefore be taken into consideration

in establishing isolation periods which will effectively
and economically prevent the spread of scarlet fevers

(e) Age. Children under fifteen years of age having scarlet

fever have a longer period of communicability than do
adults. :
-9-=

(b) Season. Scarlet fever, in the individual patient = _
child or adult - is communicable or transmissible for
a longer period of time in winter than in summer.

(c) Climatic conditions. It seems quite probable that
communicability eas well as susceptibility, in fect
perhaps the entire epidemiology of scarlet fever, may
differ in various parts of the country because of a
difference in climatic conditions. The evidence here
is not conclusive but it is to be hope that the studies
in Richmond, Va., and Tecoma, Wash., will furnish
definite evidence regarding this problem.

(d) Condition of patient. ‘The incidence of scarlet fever
emong persons exposed varies in accordance with the
type of complications to which they are exposed.

(3) hat carriers and missed cases play an important role in spreading
ecerlet fever and that carriers and missed cases can be detected |
by careful clinical observation, and by periodic culturing.

Additional studies, es yet incompleted, include:

(a) A study to determine how the organism responsible for scarlet
fever is carried over from one season to another, thet is, what
hag of individual serves as & reservoir for the organism during

ot

A survey made in one school hes brought to light several individu-
als who hed scarlet fever @ year ago and still herbored the or-
genism. Their role in the spread of the disease is as yet un~
certein, but probably very real.

(b) The use of convalescent serum as a means of giving temporary pro~

tection to susceptible contacts.

Indications are that one dose if given early enough will protect
a large proportion of those to whom it is given. A study has
been made of 500 scarlet fever contacts who received convales-
cent serum and ¢ similar number of contacts who did not receive
the serum. Information gathered as a result of this study is

at present being analyzed.

(c) Immuno-transfusion es a means of treating aariene cases of
scarlet fever (Clinical problem)

(4) A study to determine the factors which govern the problem of
ear infection in scarlet fever.

{he variables. being considered include the clinical form of
scarlet fever, method of management, seasonal variation, age, —
sex and color of patient. (Clinical problem)

(e) A study of the incidence and management of nicsialhiagions
meningitis during the course of scarlet fever. (Clinical problem)

(f) A study of surgical scarlet fever and its management. (Clinical
problem)

ica

PRE Sa

 
* 10 =

The next important step, eside from the perfectly obvious one of con~
tinuing to gather information which will tend to support or refute tentative
conclusions already resched, is to test their validity by instituting control
measures based on then. :

One important step hes elready been taken in the inauguration of
modified scarlet fever regulations in Detroit. A reguletion of the Board of
Health of Detroit provides that uncomplicated cases of scarlet fever shall be
released from isolation:

In winter and spring (January to Suly)

At the end of twenty one days for patients over 15 years of age.
At the end of 28 days for patients under 15 years of age.
In the summer and fall months (July to January)
At the end of 14 days for patients over 15 years of age.
At the end of 21 days for patients under 15 years of age.

Obviously these regulations are based on the tentative conclusions
that the disease is communicable for a longer period of time in winter than in
summer, and longer in children than in edits.

These regulations have now been in effect for more than a year.

Thus far in no instance hes a patient released under these modified
regulations given rise to a return or secondary case. (this means that no
secondary cases occurred, because of the chenged regulations which would not
have occurred under the former regulations, which provided that all uncompli-
cated cases of scarlet fever be isolated for 23 days regard@less of age or time
of year.) |

It is particularly significant that in no instance has a secondary
case developed following a 14 day release. If this continues for another year
the recommendation that a 14 day period of isolation for adults be used in

other communities will seem justified.

 
- -~]l -
Further studies should include:

(1) The extension of the application of regulations designed to re duce
periode of isolation for scarlet fever.

(a) The institution of a year round period of isolation of 14 doys
for uncomplicated cases of adults.

(b) The institution of a 21 day period of isolation, both summer and
winter, for children under 15 years of age.

(ec) Studies designed to test the feasibility of still further re duc-
ing the isolation periods of sume r cases (14 days for adults
and 21 days fer children).

(2) The continuation of cereful epidemiological studies of all scarlet
fever cases and contacts, in a section of Detroit comprising approxi-
mately 100,000 persons, and in Richmond, Va.., and Tacoma, Wash. ,
and if possible im one or more rural arees, to determine the role
of missed cases and carriers in the transmission of scarlet fever,
and to institute measures designed for their proper management.

(a) after the role of the missed case and carrier has been reasonably
determined, to institute administrative practices designed to
prevent the spread of the disease from these sources.

(3) The continuation of the studies in other areas particularly in
Richmond, Va. and Tacoma, Wash., and if possible the institution |
of studies in one or more additional rurel areas, primarily to
determine the effect of climatic and rural conditions on the
epidemiology of scarlet fever, but also as a means of supporting
or refuting tentative conclusions reached principally as a result
of the Detroit. studies.

(4) The continuation of such studies as give promise of bringing about

a more scientific and effective management of scarlet fever, such as:

(a) The determination of and control of persons acting as reservoirs
for the disease during periods of low prevalence.

(ob) The use of convalescent serum and immano-transfusion in the
prevention and treatment of disease. (Clincial problem)

(c) The factors involved in the development of various compl ica-
tions of scarlet fever and the wore effective yrevention end
treatment of such complications. (Clincigl problem)

D. The study of maternal mortality and morbidity related to varisble
amounts and quality of prenatal care by Dr. Margaret Tyler and J. H. Watkins, Ph.D.
and HE. H. Welker, Ph.D. resulted in s few positive findings and recommendations

affecting public health practice, and in some negative oberservations which will

save subsequent students of this problem much loss of time.

ale ‘ ope antes

 
 

— =
Ps

“

< To have discovered that meh of the profit of prenatal come can be
obtained by using the nurse instead of the physician, and that the outcome of
childbirth to the mother ig probably affected to a greater degree by the quality
of obstetrical attendance than by any other fector, and this to a greater degree
in women presenting some eeetentiey of structure or function, fully justified
the meticulous care with which all factors in this most commlicated of heelth
techniques were analyzed, and the grant of funds for the purpose of this study.
We have learned that there is a limit beyond which frequency of medical
and of nurse attention during pregnancy produces a corresponding increase in
safety to the mother, end that even . onrtede. shag of geeketei care, if it
includes a competent medical examination of the patient, is a substential safe-
gaard to the expeetant mother. Ye have learned in this es in many another clinical
situation that routine practices are of less value than selective shevishe. which
only education of prospective patients will cause to be sought and obtained.
Moech superfluous service will certainly be avoided in the future and
many misdirected efforts and expenditures will be soared if the lessons of this
study are taken to heart by both public and private egencies interested in the
health havards df maternity. ,
Further study of this particular tonic, by the method used, does not
at present offer probability of practical benefit for health administrators.
While there has been prompt and effective publicatiion of the essential
conclusions and recommendations of the first three studies ebove described
A-, B., and C., the full effect and benefit from the last study D. will ime not
accrue until those interested in and critical of their own prenatel practices
have eccess to this statistical report of Tyler, Watkins and Welker in its entirety.
Haven Emerson, M.D., Chairman
Charles V. Chapin, M.D.
Louis I. Dublin, Ph.p.
Allen W. Freeman, M.D.
Joseph ¥. Mountin, M.D.
John L. Rice, M.D.

Henry F. Vaughan, Dr.P.#.
W. Fe Walker, Dr.P.4.