VACCINATION OF SCHOOL-CHILDREN.

ALTHOUGH during the four months prior to November, 1881, there had been only twelve new introductions of small-pox into localities in the State outside of Chicago, and these had, in no instance, given rise to any serious or alarming spread of the disease; yet a careful study of the local conditions, and of the progress of the epidemic elsewhere, led to the conclusion that its wide-spread prevalence throughout the State was highly probable. A special meeting of the STATE BOARD OF HEALTH was, therefore, called early in November, and, as previously recited, the situation was thoroughly canvassed.* Among other matters, evidence was adduced of the existence of a very large percentage of unvaccinated or imperfectly vaccinated. school-children, and it was shown that, outside of Cook county, there were less than half a dozen localities where a certificate of vaccinal protection was required from scholars before admission to the schoolroom. Roughly estimated, from information already acquired, it was believed that fully one-half of the public school-children were unprotected against small-pox by vaccination at the date of this. meeting.

The importance of this factor, in a sanitary problem of the character now presented, may be seen by a glance at the figures of population. According to the school census of 1882, the population of the State in that year was 3,331,644, of which number 1,037,567, or over thirty-one per cent., were of the school age, 6-21 years, and of these 713,431 were enrolled scholars. Manifestly, if this large element of the population could be secured against danger of variolous infection, it was imperative that it be done forthwith.

*

The act constituting the STATE BOARD charges it with "the general supervision of the interests of the health and life of the citizens of the State;" and empowers it with "authority to make such rules and regulations as it may from time to time deem necessary for the preservation or improvement of the public health." In the exercise of this supervision, and believing that a sanitary necessity existed of sufficient gravity to justify the BOARD in fully exercising its authority, the following Order was issued:

*See ante, page 212.

ILLINOIS STATE BOARD OF HEALTH-NO. 50.

OFFICIAL ORDER

CONCERNING THE VACCINATION OF SCHOOL-CHILDREN.

OFFICE OF THE SECRETARY,

SPRINGFIELD, December 1, 1881.

AT a special meeting of the STATE BOARD OF HEALTH, held in the city of Chicago, on Tuesday, Nov. 22, 1881, the following resolution was unanimously adopted:

Resolved, That, by the authority vested in this Board, it is hereby Ordered, that on and after January 1, 1882, no pupil shall be admitted to any public school in this State without presenting satisfactory evidence of proper and successful vaccination. OFFICIAL:

JOHN H. RAUCH, M. D.. Secretary,

TE foregoing Order is issued, in the belief that it is entirely feasible to make smallpox of "as little effect as any extinct epidemic of the Middle Ages:" and that the first, and absolutely necessary, step to this end is to secure the general vaccination of children, so as to prevent the accumulation of unprotected persons as these grow up.

During the past fifteen years, 1867 to 1881, both inclusive, out of an aggregate of 227,113 individual scholars attending the public schools of Chicago, there have occurred only 17 cases of small-pox and varioloid. This immunity is the direct result of a requirement of the Health Department of that city, the enforcement of which was begun in 1867, and by which, evidence of successful vaccination is made a condition precedent to admission to any Chicago public school,

It is, probably, unnecessary to add anything to the testimony of these figures. They are in themselves an unanswerable argument for the value of vaccination. What has been done in Chicago may be done the more readily in smaller towns and villages, in proportion as these latter are less exposed to frequent importation of the disease or to large accessions of unprotected immigrants.

Small-pox is now wide-spread through all the Northern States from the Atlantic to the Pacific, and is daily making its appearance at many new points in our own State. To some extent this is due to the recent enormous immigration; but it is undoubtedly true that the neglect of vaccination among our own people has also much to do with the present alarming disposition to a spread of the disease. This emergency, therefore, seems to offer a favorable opportunity for inaugurating in the State at large a measure which has proved so signally successful in its chief city.

In making vaccination to this extent obligatory, however, the BOARD has duly considered not only the rights but the prejudices of the public on the subject, and the following suggestions and instructions are intended to secure its just rights and to remove existing grounds for honestly-entertained prejudices.

INSTRUCTIONS.

AS TO "SATISFACTORY EVIDENCE OF PROPER AND SUCCESSFUL VACCINATION."

The object of this measure is to make sure that children in attendance at the public schools are properly protected against small-pox, to the end that their health and lives may be preserved and interruption of schools by the disease may be avoided.

Evidence of this protection will be most readily and usefully afforded by means of the Certificate Form 51). prepared and furnished by the STATE BOARD. Such certificate, filled out in accordance with the following instructions, will be received as the "satisfactory evidence" required by the Order:

1. Every public scholar under the approximate ages of twelve years if a girl, or fourteen years if a boy-see next paragraph-must present to her or his teacher, on or before the date specified, a certificate signed by a legally-qualified physician, stating (1) Name: (2) Age: (3) Residence: (4) Date of Vaccination-as near as may be; (6) Date of Examination, accurately; and (7) Result, as shown on the child's person.

The date of examination and the result, as shown on the person of the child, are matters which the physician must testify to of "his own knowledge." All else may be qualifiled in accordance with the facts--as to information and belief,

2. Children over the approximate ages above given-that is, who have passed through the developmental changes occurring about those ages, and which changes are known to frequently impair the protective power of vaccination performed prior thereto-must pre

sent certificates showing that they have been vaccinated, or revaccinated, as the case may be, subsequent to those ages. In case, however, a given child has passed the years mentioned and such changes have not yet taken place, re-vaccination is not indispensable, provided the evidence of a successful primary vaccination is conclusive. The physician is the sole judge in each case, and his certificate must convey the necessary information to the teacher.*

3. A certificate from a legally-qualified physician that a given child is protected by a previous attack of small-pox or varioloid; or that it would be dangerous at the present time to vaccinate a given child; or that such insusceptibility has been demonstrated as, in itself, amounts to protection-shall be accepted by school authorities in lieu of the "satisfactory evidence" required by this Order.

4. All vaccinations should be performed by competent medical men; or, if by a nonprofessional person of sufficient skill and experience, the result must be examined and certified to by a legally-qualified physician. Such authority only is competent to pronounce upon the sufficiency of vaccinal protection, or upon the danger or inadvisability of performing the operation at a given time, or in certain conditions of the system.

5. In case of failure in a primary vaccination, the attempt should be repeated often enough (at intervals of a fortnight) to demonstrate the insusceptibility of the child. Five repetitions are not too many, and it not unfrequently happens that the seventh, e ghth or ninth attempt is successful. Where less than five repetitions are advised by the physician, he must assume the responsibility of asserting the proper protection of the child. His endorsement of the certificate to that effect shall be received by the school authorities as entitling the child to school attendance.

6. If more than one in five primary vaccinations are failures, the physician should suspect the quality of his virus, and obtain a supply from a new source. With most physicians it is undoubtedly unnecessary to urge the importance of examination at a proper interval after the operation. Such examination should be always made, because, among other reasons, without it the vaccinator deprives himself of the only proof of the value of the virus employed, and his vaccinees may thence be reposing in a false security, which may prove disastrous.

7. To facilitate the tabulation of returns, and their subsequent examination in the Secretary's office, the use of the following terms, to describe the result, is desired: Typical, if the resulting sear is well-marked, characteristic, of normal size, and perfect in outline, depression and pitting; or Modified, if, while well-marked and characteristic, the scar is less than normal size and of irregular contour; or Bad, if the scar be less than onefourth of an inch in diameter, or simply a smooth, flat, shiny mark.

The physician should always insist upon revaccination where the scar is "Bad," as thus defined.

8. Legally-qualified physicians may obtain the Scholar's Certificate blanks from teachers, school directors or other officers of public instruction; from county clerks; or, by mail, direct from the Secretary's office, at Springfield.

TO SCHOOL AUTHORITIES.

I. The execution of this Order is necessarily devolved upon the various officers of public instruction-county superintendents, school directors, trustees and teachers-each and all of whom are hereby authorized and directed to aid in its enforcement in their respective capacities. In all cases, however, the assistance and cooperation of the local health authorities should be invited.

Much of the success of this effort to protect the children from a loathsome pestilence will depend upon the wisdom, firmness and intelligent action of the school authorities. Timely notification and instruction will save much unnecessary friction; and exact information will soon dispel ignorant and bigoted opposition. It only needs that the public be rightly informed to secure ready cooperation. All inquiries will be promptly answered from this office, and every available facility afforded for meeting emergencies. It is not desired, except as a last resort, to arbitrarily enforce this measure; at the same time it should be clearly understood that it will be enforced.

II. County superintendents are respectfully requested to secure a prompt distribution of the copies of the orders, certificates, returns, etc., forwarded to them; to explain to directors and teachers the scope of the Order, and to advise as to the methods of its enforcement. It is especially desired that they communicate fully and promptly to the Secretary's office any difficulties encountered, and suggestions which their individual knowledge of local conditions and circumstances may warrant.

III. School directors are the immediate source of authority for the action of teachers under this Order. The Attorney-General says that the law which directs all officers and employes of the State to enforce the rules and regulations of the STATE BOARD OF HEALTH, unquestionably includes school directors. He adds: In enforcing the orders of the BOARD OF HEALTH, of course the law will protect them the school directors in using any necessary means to carry out the orders, even to the extent, should it become necessary, of excluding from the schools those who refuse to comply." Instructions to this effect should, therefore, be given to the teachers by their directors.

Provision should be made by School Boards for the gratuitous vaccination of the children of those unable to pay for the same. Local boards of health have the right to do this at the expense of the town, county or city funds. Where there are no regularly organized boards of health the county commissioners act in that capacity, or the super

*The minimum ages here given were chosen advisedly, for the purpose of securing as many revaccinations as possible.

visors, assessors and town clerks of townships. These officers have all the power. authority and responsibility of a board of health, and will generally be found quite willing to assist in this method of protecting the public health.

IV. Teachers-who should, in all cases, be vaccinated or revaccinated at the present time-should familiarize themselves with the Scholar's Certificate; see that it is properly filled out when presented; make a record of its data for their own use; fill up the blank return (Form 52, S. B. H.) and forward said return, in its accompanying envelope, to the Secretary's office, in Springfield, as herein directed.

In the examination of the Certificate

1.-Special attention must be paid to the entries in 4. Date of Vaccination;" "6. Date of Examination;" and "8. Previously Vaccinated."

Any certificate relating to a recent vaccination-that is, one performed within the past twelve months-must show the date of such vaccination and the date of examination; and an interval of not less than eight days must be shown between the two dates.

Any certificate relating to a previous vaccination only-that is, one performed prior to January 1, 1881-must state the year of such vaccination, and the date of examination, which examination must have been made since December 1, 1881.

Any such certificate not conforming to one or the other of these requirements is imperfect, and must be returned to the certifying physician for completion. This is essential in order to be assured that the child has been recently examined, and that the record concerning its vaccination is matter of knowledge, and not of presumption or opinion.

2.-A certificate of recent vaccination issued by a legally-qualified physician, and in which the result has been a failure, shall be received as a substantial compliance with the Order, entitling the child to admission pending the result of the repeated operation. Similarly, a certificate of a legally-qualified physician setting forth that the bearer is protected by reason of a previous attack of small-pox or varioloid; or that it would be dangerous to vaccinate the bearer at the present time, shall be valid as entitling such child to admission to school.

3.-Certificates of successful vaccination, or revaccination; or of protection by previous attack of small-pox or varioloid; or that it is dangerous to vaccinate, will, after the data have been entered on Form 52, be returned to the children, and shall be valid, as entitling to admission, until otherwise ordered.

Certificates in which the result is entered "failure," will be taken up on presentation and forwarded with the Returns.

(The final paragraph of this circular refers to the mode and time of making the Vaccination Returns (Form 52).1

This action of the BOARD met with a cordial and efficient support from the State Superintendent of Public Instruction, who furnished the following letter, which was appended to the circular given above:

To County Superintendents of Schools, School Boards and Teachers:

The STATE BOARD OF HEALTH, for the purpose of restricting the spread of the smallpox and of depriving the disease of its most serious effects, has, in the exercise of authority given by the act creating the BOARD, passed the Order recited above, relative to the vaccination of the pupils of the public schools; and county superintendents are asked by the BOARD to assist in distributing to the districts the circulars and blanks sent them: school boards are instructed to enforce the Order in the schools in their charge, and teachers to inspect certificates of vaccination presented by their pupils, to make a record of them for their use, and a return of the same to the Secretary of the BOARD in this city. in the way and at the times indicated.

I need not say that the BOARD has in view, in making this Order, an end, whose accomplishment is of great concern to the whole community. Neither need I say to you. who have so often known of schools discontinued for several weeks, or broken up for a term, by the presence of small-pox in the vicinity, that the purpose of the BOARD has an intimate connection with the welfare of our schools.

I bespeak, therefore, for the BOARD your cordial and faithful cooperation in carrying out its plans according to the instructions given.

JAMES P. SLADE,

State Superintendent of Public Instruction.

It was not to be expected that a measure so radical and so sweeping as the School-Vaccination Order could be enforced without some friction and opposition, and an immense amount of labor. This was the first exercise of authority in sanitary matters, on any large scale, which the BOARD had ever been called upon to attempt. It is true that during the yellow-fever epidemics of 878 and 1879 orders had been issued and quarantine restrictions imposed; but this only in a

comparatively small area, and affecting only a few individuals, relatively. Then, too, there was, in these instances, the important moral support begotten of the fears aroused by the immediate presence of the disease.

But, at the time when the School-Vaccination Order was issued, small-pox had invaded only a few localities, and those mainly in the vicinity of, or in close connection with, Chicago. In the State generally, and to the large majority of the population, the horrors of a small-pox epidemic were unknown as matters of actual experience. To very many persons the Order seemed an unnecessary interference, and the members of the BOARD were looked upon as alarmists. On the whole, however, the criticisms and opposition were less than had been anticipated; and the amount of protective work (vaccination and revaccination) accomplished during December and the early part of January was so reassuring; while the difficulties caused by unfavorable weather, bad roads and inadequate supplies of virus were so great, that it was deemed safe and advisable to extend the time for making the returns from the schools, and for the strict enforcement of the Order, from January 1st to January 25th.

Circular No. 22, from the Department of Public Instruction, under date January 21, indicates some of the difficulties encountered and questions which had arisen up to this time:

To School Boards and Teachers:

The recent Order of the STATE BOARD OF HEALTH, concerning the vaccination of children attending the public schools, has given rise to many questions regarding the duties imposed by it upon school boards and teachers; and, since it is impossible to answer these inquiries, fully, in any other way, I have prepared this circular, to which your attention is respectfully called.

POWERS OF THE BOARD OF HEALTH.

"SFC. 2. The STATE BOARD OF HEALTH shall have the general supervision of the interests of the health and life of the citizens of the State. They shall have charge of all matters pertaining to quarantine; and shall have authority to make such rules and regulations, and such sanitary investigations as they may, from time to time, deem necessary for the preservation or improvement of the public health; and it shall be the duty of all police officers, sheriffs, constables, and all other officers and employés of the State, to enforce such rules and regulations, so far as the efficiency and success of the BOARD may depend upon their official cooperation." Rev. Stat. Ill., Chap. 126 a.l

OPINION OF THE ATTORNEY GENERAL.

"Under this section, broad duties devolve upon the BOARD OF HEALTH, and ample power is given to enable them to discharge such duties. They not only have the right, but it is their duty to make any and all rules and regulations which they may deem necessary to preserve the public health. Such rules and regulations, when promulgated, have the force and authority of law, and are to be enforced, if necessary, by the entire power, including school officers, etc., of the State."

EXPENSES OF VACCINATION.

"Local boards of health may incur expenses for vaccination of those who are unable to pay for the same, when, in their judgment, it is necessary to prevent the spread of disease and for the general health of the public, and may incur such other expenditures as to them in the exercise of a sound discretion, may seem prudent and necessary, either to effect a cure or prevent the spread of any epidemic or contagious disease. The expenses so incurred should be paid out of the general fund of the municipal body represented by the board of health incurring the expense, as the town, county or city." ¡Extract from opinion of Attorney General, given STATE BOARD OF HEALTH, Dec. 31, 1882.1

ORDER OF THE BOARD OF HEALTH.

In the exercise of its power the STATE BOARD OF HEALTH issued the following Order, which was directed and distributed to school authorities, last month: