Antony Hollingworth - 'The introduction of a diphtheria immunisation programme during a time of war'
Diphtheria is a preventable life-threatening infection. In 1963 it was estimated that a General Practitioner (GP) would see one case of diphtheria every 400 years of practice and in 2020 there were no toxigenic cases reported in the United Kingdom (UK). However, the situation was very different before the start of the Second World War when the annual incidence of the disease was approximately 60,000 cases, 3000 of which would prove fatal. Most of these deaths occurred in children; until the Second World War, diphtheria was the commonest cause of childhood death in the UK. A vaccine, developed in the UK, had been available from 1921, the impact of which, in several other countries, had reduced infection rates considerably while remaining unchanged in the UK. The aims of the dissertation are to improve the understanding of why, in the twenty years prior to the Second World War, take-up in the UK of diphtheria vaccine was relatively poor, challenging the conventional explanations for why, during the Second World War take-up improved and arguing that immunisation coverage during that period never reached a sufficient level to provide ‘herd immunity’.
Policy prioritisation within the Ministry of Health (established 1919) in the inter-war period was problematic due to a rapid turnover of Ministers of Health (there were six within its first five years and a total of fifteen Ministers of whom only five were in post for two years or more). The interwar period saw many other chronic health problems competing for the attentions and limited finances of British public health officials. Some in the public health profession were distrustful of immunisation, with many MOHs preferring to concentrate on identifying carriers and confining patients to isolation hospitals. Public health doctors favoured the continuance of expensive institutional solutions to the infection and paid less attention to preventive medicine. The previously cautious attitudes to smallpox vaccination and the associated Anti-vaccination League activity were undoubtedly further factors explaining official reluctance to both immunising and making immunisation compulsory. Diphtheria was a mainly urban disease and an overall gradual fall in the deaths from all childhood infections may have influenced diphtheria’s lack of prioritisation.
The problems created by war, especially the threat of aerial bombing, evacuation of urban children (potential vectors) and associated fears of a widespread epidemics ultimately resulted in a change of policy with free prophylactics being provided to Local Authorities. The Ministry’s scheme was not applied on a large scale until 1941-42. The Ministry together with the CCHE and the MOI ran spirited publicity campaigns, however, surveys conducted during the war suggested they were not as successful at influencing uptake as anticipated. It became compulsory for those joining the services but the Ministry stopped short of making immunisation compulsory. In all, 262,000 notified cases of diphtheria were recorded in Britain during the Second World War of which 12,000 were fatal perhaps if the Ministry had heeded calls for compulsory immunisation and released the resources required earlier, that outcome could have been very different.
Using official material from the National Archives, supplemented by archives held at the Wellcome Library, contemporary local Medical Officer of Health reports and newspaper reports, this thesis aimed to provide a sounder understanding of the slow progress of diphtheria immunisation in Britain between 1920 and the end of the Second World War.
 JM Last, ‘The Iceberg ‘Completing the clinical picture’ in General Practice’, Lancet, (1963), p.30.
 Public Health England, Diphtheria in England 2020 Health Protection Report 7/15 (London, 2021), PHE Gateway number GOV-7997, p. 5.
 Ibid, p.3.
 Ministry of Health (hereafter MoH), Annual Report 1938-39 (London HMSO, 1939), Command Document (hereafter Cmd) 6089, pp. 24,232.
 Jane Lewis, ‘The Prevention of Diphtheria in Canada and Britain 1914-1945’, Journal of Social History, 1/20 (1986), p.163.
 Herd Immunity is a form of indirect protection that applies to contagious diseases. It occurs when a sufficient percentage of the population has become immune to said infection whether through previous infection or immunisation.