Diphtheria Vaccinations as a Public Health Effort

By Philo Waters IV

Nowadays, diphtheria is a very rare disease that, for the most part, infects children. This last year (2018) in the UK, only 11 cases were documented amongst its entire population. Across the world, most children are vaccinated before they can even remember. It is a requirement of many public school systems for students to be vaccinated for diseases like hepatitis A, hepatitis B, polio, measles, smallpox, and more. One of these required vaccinations is for diphtheria, the deadly and highly contagious nose and throat disease. Somewhere along the timeline of the development of the diphtheria vaccination, we went from using it as a treatment, to a public health requirement.

The diphtheria vaccination was developed by German physiologist Emil Adolf von Behring in the year 1913. Prior to that, an antitoxin was available for treatment, with not so promising success rates. Von Behring was actually the first ever recipient of the Nobel Prize in Medicine for this discovery. It soon became a common vaccination for all children with access.

The Medical Officers of Health (MOH) in London and its surrounding districts took detailed notes of which children were vaccinated, how many of them were vaccinated, at which age they were vaccinated, which town they were vaccinated in, how many times they were vaccinated, and more.

Peter Fitzgerald. Inner v. Outer boroughs of London.

In Lewisham in 1873 (40 years prior to the vaccination development), there were 7 deaths caused by diphtheria [Lewisham 1873]. Over a 10 year span, that town averaged 9.1 deaths per year. That’s around 1.6 people per 10,000 individuals who died from diphtheria. At the time, because there was no vaccination to be used against diphtheria, they would keep record of deaths rather than occurrences. The MOH felt as if it were more important to track mortality rather than the incidents.

Leading up to the 1900s, there was a sense of urgency growing for doctors and scientists to develop a better treatment against diphtheria. The rates of occurrence for diphtheria increased. In one MOH report from Hackney in the year of 1897, they saw an increase of 191 diphtheria cases when compared to the previous year [Hackney 1897]. This MOH report notes that the officers really didn’t have a strong grasp of how, why and where diphtheria was being spread. They felt like their best guess was that personal contact with a sick individual was the major form of spreading of the disease. In addition, there was word that a promising antitoxin, believed to decrease mortality rates, was being developed and on clinical trials. However, this was all just word on the street.

By the time that the vaccination was rolling around, outbreaks of diphtheria were occurring more commonly. Lambeth in 1908, (5 years before the vaccination release) had an outbreak in their private school causing it to shut down for 3 weeks [Lambeth 1908]. At this point, the MOH was able to actually trace these germs back to two places where the same germ line was present.

Pretty soon after the development of the diphtheria vaccination, the MOH seemed to breathe a giant sigh of relief. One MOH report from East Barnet Valley in 1920 said that “[diphtheria] has lost its terrors since the anti-diphtheria vaccine has been used” [East Barnet Valley 1920]. While this seems dramatic to the modern world, one can only imagine the joy those health officers were experiencing. The report notes that if the vaccine was administered towards the beginning parts of the infection, there was almost a guarantee of survival. This was huge from a public health standpoint. To them, implementing the vaccine sooner rather than later was a major advantage giving children a leg up on the disease. This meant that the younger they could administer the vaccine, the better.

By the 1940s, immunization clinics starting springing up, particularly clinics designed for infants and early childhood ages kids. The borough of Sutton set up a diphtheria clinic every Friday starting at 2 pm [Sutton and Cheam 1949]. Infant Wellness Centers like this one were set up at different locations, like churches and the school, during different days of the week. These child centers specifically gave diphtheria vaccinations for all of the kids who came, as well as smallpox vaccinations if the parents requested. The public schools in Hornchurch provided immunizations for kids, along with a requirement of parental consent forms to be signed [Hornchurch 1938]. Children under the school age were also allowed to receive vaccinations upon special request by the parent. The administration of the diphtheria vaccination was now a fully fledged public health project.

Once more and more kids were getting immunized, the MOH reports started keeping track of how many kids were getting the vaccination. The Brentford and Chiswick 1953 MOH reports tells of 671 kids under the age of 20 who got the vaccine, and 398 of those got a second reinforcement vaccination for diphtheria. Also in 1953, the Barnes MOH reported 92.3% of all school aged children had been vaccinated at least once [Barnes 1953]. Quite a significant number given the day and age that they were in. The Crayford 1964 MOH report noted 640 kids who got vaccinated with 597 getting the reinforcement. In another borough in 1972, the diphtheria immunization was the most common vaccine for children by tenfold when compared to other big name diseases such as smallpox, tetanus, whooping cough and measles [Croydon 1972]. The commonality of having your child immunized against diphtheria was widespread and prominent all across the UK.

Outside of London, we can see many other countries that have adopted this public health effort of requiring diphtheria vaccinations. In her article in Health and History, Claire Hooker talks a lot about her studies of diphtheria and its public health implications in Australia. One thing that she says is very profound: “the lack of historical attention… that [diphtheria] has received derived partly from the success of a public health policy of widespread immunisation.” The fact that diphtheria does not and has not struck fear into parents for a long time says a lot about the health officers’ efforts in making the fight such a large public health project.

According to Alison Day, New Zealand’s Health Department actually struggled against the public in convincing them of the importance of the diphtheria vaccination. In the 1920s, just after the vaccine was developed, and the Health Department promoted it, the public was entirely skeptical of having their children vaccinated. It took decades of convincing by the government for the public to believe in the works of the vaccine. Eventually parents came around and in 1960, there was only one case of diphtheria, all thanks to the public health efforts of the Health Department.

Today, kids all over the world are getting vaccinated for diphtheria fairly quickly after being born. Thanks to Emil Adolf von Behring and the public health efforts of local and national governments, diphtheria outbreaks are incredibly rare and our fear of it is entirely minimal.

Bibliography

MOH Reports

  1. Barnes 1953
  2. Brentford and Chiswick 1953
  3. Crayford 1964
  4. Croydon 1972
  5. East Barnet Valley 1920
  6. Hackney 1897
  7. Hornchurch 1938
  8. Lambeth 1908
  9. Lewisham 1873
  10. Sutton and Cheam 1949

Secondary Sources

Day, Alison. “The Magical Formula: Reactions and Responses to Diphtheria Immunisation in New Zealand 1920–1960.” Health and History. 15.2 (2013): pp. 53-71.

Diphtheria in England: 2018.” Public Health England 13, no. 10 (March 22, 2019).

Hooker, Claire. “Diphtheria, Immunisation and the Bundaberg Tragedy: A Study of Public Health in Australia.” Health and History 2, no. 1 (2000): 52-78. doi:10.2307/40111374.