NHMRC Poliomyelitis Committee report Feb 1952

NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL

POLIOMYELYTIS COMMITTEE

The Committee met in Adelaide at 2pm, Monday February 4^th 1952, the Sessions closing at 5pm Friday 8^th February

NOTE: This abbreviated report of the NHMRC Poliomyelitis Committee’s first meeting, is to present its Scope of Study and Responsibility. As Chairman, Dr Cook took a strong stand of principle in determining the Committee’s preferred Scope of Study. 

 It appears from a perusal of Council reports that Council did not decide to provide this direction and that Dr Cook’s preference to ‘overcome objections rather than to retire from them’ prevailed. 

There were present:

Dr C.E. Cook (Commonwealth) – Chairman

Dr H.G. Wallace (New South Wales)

Dr H.G. McClosky (Victoria)

Dr D.W. Johnson (Queensland)

Dr D.N. Robinson (South Australia)

Dr D.J.R. Snow (Western Australia)

Dr H.M.L. Murray (Tasmania)

Dr. H. McLorinan and Dr J.A.R. Miles (Co-opted)

Dr I.O. Thorburn (W.A.) attended the clinical and therapeutic sessions

STATE REPORTS

State representatives from New South Wales, Victoria, Queensland, South Australia and Western Australia presented concise historical reports upon the incidence and epidemiological features of poliomyelitis in recent years, and measures taken to meet the situation and the problems encountered.

Similar detail was not available from Tasmania where recent administrative changes had prevented full compilation and interpretation.

It was found that different methods had been used by the various States for the presentation of the epidemiological information and critical comparison was in consequence difficult. It was agreed that the data supplied should be analysed and collated by the Commonwealth Department of Health for presentation in a more readily comparable form.  Dr Murray (Tasmania) undertook to supply the report for Tasmania at an early date so that the final presentation might summarise the experience of the Commonwealth.

ADMINISTRATION

All the States in which poliomyelitis has recently been epidemic have constituted Consultative Councils or Advisory Committees. The functions of these bodies vary. In Western Australia and South Australia, for example, their purpose is to assist and advise the Government on general problems relating to the administration and organisation of treatment and after-care. In New South Wales and Victoria on the other hand, the Consultative Council is also invested with some executive powers.

All States have in some form provided a free Consulting Service to assist practitioners in diagnosis. In all States it is usual to isolate the patient in the metropolitan infectious diseases hospital or in the infectious diseases ward of a country hospital during the acute stage. The period of detention here varies from 14 days in Queensland to 21 days in Victoria and South Australia. Except in Victoria, the patient is then transferred to a Children’s hospital or a general hospital with orthopaedic facilities for the muscle check, upon which his future disposal is decided. This may be:

• Discharge with periodical out-patient review;
• Admission to the out-patient department for treatment;
• Admission as an in-patient to an orthopaedic ward

Out-patient treatment throws the burden of transport between the home and the hospital upon the patient. This objection has been met in New South Wales by payment of transport costs subject to a form of means test. Owing to pressure upon bed accommodation and the difficulties confronting out-patients in arranging to attend hospital, in New South Wales and South Australia attention has recently been given to the development of domiciliary physiotherapy as practised in Victoria.

In Victoria, domiciliary after-care methods, based upon the itinerant physiotherapy service developed by Dame Jean McNamara have been organised several years. In the metropolitan area the patient is usually admitted to Fairfield Infectious Diseases Hospital and continues his after-care treatment there, if not discharged to his home for domiciliary treatment.  The domiciliary service for children is conducted by the Children’s Hospital and that for adults by the Health Department. Outside the metropolitan area the patient is admitted to a poliomyelitis ward in a major country hospital and domiciliary service being limited by shortage of trained staff, generally undergoes his after-care treatment there. The Health Department provides orthopaedic supervision in 16 centres, conducting clinics for all ages at regular intervals in all large country towns. Where transport is necessary for the patient it is provided by the Red Cross Society. This organisation also makes available a limited number of beds in its Melbourne hostels for the accommodation of country cases brought to the city for special purposes.

New South Wales, Victorian and South Australia have appointed special officers to conduct epidemiological enquiry into individual cases and to co-ordinate all administrative and therapeutic organisation involved including epidemiological and clinical research, control, hospital accommodation, the provision of special equipment, after-care and rehabilitation. In Victoria there are there such officers, in New South Wales and South Australia, one each. In the other States, these duties are undertaken, in whole or in part, by Medical Officers of Health who are not exclusively concerned with Poliomyelitis.

During 1951 in Victoria a detailed study of the epidemiological and clinical features of each individual case has been made. The mass of information accumulated has been recorded to a standard form and will be transferred to punch cards for statistical analysis.

PROBLEMS

Staff: All States have been hampered in their efforts to provide adequate treatment in and out of hospital by a shortage of physiotherapists. It is hoped that this situation will in the near future be improved by:

• The increased number of girls undergoing training;
• The recent opening of a training school in Western Australia; and
• Organised immigration of physiotherapists from England

Considerable assistance has been rendered by the use of physiotherapists aides.

Transport: Representatives of all States emphasised the risks associated with the transport of patients over long distances to hospital during the acute stage, even when movement id effected by ambulance.

Unqualified Practitioners” In South Australia there is concern in the popular appeal of untrained persons, variously labelled as chiropractors, spinal adjustors, osteopaths, etc. who with complete disregard for limp, scoliosis, torticollis or hyperextended knee, publicise their ability to have walking in two weeks the patient ordered by the orthopaedist to remain four months in bed.

Accommodation: In Victoria it is felt that a special after-care institution is required to replace and augment the present accommodation at Fairfield which might not be available should another disease become epidemic. This special institution, it is held, should be:

a) Permanent, admitting in non-epidemic times cases other than poliomyelitis requiring comparable conservative orthopaedic care; and

b) Separate the other hospitals for the following reasons:

• Where surgery is undertaken, surgical cases tend to fill most of the available beds;
• More efficient treatment with a staff specially trained in the care of poliomyelitis

Melbourne also needs a special after-care hostel to accommodate country cases called to the city for special attention, the number of beds available in Red Cross hostels being insufficient.

Problems still confronting other States are well detailed by Dr Wallace (New South Wales). Dr Wallace emphasized that two administrative problems will eventually require the most earnest consideration:

1. After-care: 

The recent epidemics have left in their wake a considerable number of severely disabled persons, a large proportion of whom are in the 15-30 years age-group. At present there is no institution set aside for the reception of such persons, and owing to their disability they will unavoidably, unless means are devised for their rehabilitation, gravitate to homes for the incurables. Their needs are mainly:

• Nursing care;
• Vocational training which will lead to some form of lucrative employment, even if for a short time each day;
• Social contacts and companionship

Other special needs are:

• Domestic assistance for disabled housewives;
• Special educational facilities for children of school age

At present, the relatives and friends of these disabled persons are bearing almost the full burden, and there is strong evidence that such responsibilities impose a heavy and undue strain upon their resources. Breakdown is often inevitable, and organization, whether by Government or by voluntary agencies, is required to provide for the needs of this class. It is abundantly clear that such organization must not be long delayed. 

2. Training and Placement: 

Two classes of persons require particular attention:

• Those not eligible for assistance under the Commonwealth Rehabilitation Scheme, but who are ambulant or like to become sufficiently so to accept some kind of regular employment;
• Those who are unlikely to become ambulant and those who have partly lost the use of the upper limbs.

The placement of partly-disabled people is a matter which, it seems, can be carried out only if fully organized in conjunction with employing agencies and employers. In New South Wales at present employers on the whole are reluctant to accept handicapped persons as employees. Very serious consideration of the possible solution of this problem is an urgent matter.

EPIDEMIOLOGICAL AND CLINICAL RECORDS:

Collect detailed information, The Commonwealth should establish a Poliomyelitis Bureau, Case incidence statistics, a standard, national muscle chart

CONTROL:

Interstate quarantine, Isolation of Contacts, Food Handlers, Schools, Reduction for the opportunity of exposure, Operative procedures, Immunisation, Immigration

SUBJECTS excluded from this abbreviated report cover: Diagnosis, Acute Stage: Respirators, After-Care Institutions, Rehabilitation – Resolutions, Psychological Problems, Commonwealth Poliomyelitis Institute

PAPERS presented by committee members:

During the sessions of the Committee the following papers were read and discussed:

1. Epidemiology:

• ‘Lessons in epidemiology and control of poliomyelitis to be derived from modern knowledge of the virus’ by Dr J,A.R. Miles S.A.
• ‘Suggestions for attention of field studies of epidemiology in all States’ by Dr B.F. McClosky, Vic.
• ‘Lessons in epidemiology and control in the 1947-48 epidemic in South Australia’ by Dr N.D. Crosby
• Poliomyelitis and Atmospheric Conditions’ by Dr D.J.R. Snow W.A.

2. Diagnosis and Clinical Aspects

• Dr R.A.A. Pellew, S.A. and Dr H. McLorinan, Vic

3. Management

• ‘Management of the Acute Phase’ by Dr H. McLorinan, Vic
• ‘Management of the Convalescent Phase’ by Dr W.J. Betts, S.A.

4. Research

• ‘Current and Pending Research’ by Dr J,A.R. Miles S.A
• ‘Investigation on the occurrence of Coxsackie virus in S.A.’ by Miss Nancy Atkinson

DEMONSTRATIONS at Northfield Infectious Diseases Hospital

In addition, the Committee visited Northfield Infectious Diseases Hospital, the Adelaide Children’s Hospital and the Somerton Home for Crippled Children, where clinical aspects and treatment in the earlier and late stages were demonstrated and discussed.

SCOPE OF STUDY AND RESPONSIBILITY:

Some uncertainty was evinced by members regarding the propriety of extending the scope of the Committee’s scope and discussions to include the orthopaedic techniques of after-care. Two States were represented by medical officers, whose duties comprehend the conduct, guidance and supervision of all aspects of poliomyelitis management from epidemiological research and to rehabilitation, and they were very interested in the details of late therapy as practised in South Australia. Representatives of the other States were medical officers engaged in the wider field of general health administration, whose concern with poliomyelitis is predominantly in epidemiology and control. For some of these, the interest in treatment, after-care and rehabilitation tended to be limited to the administrative implication of these activities. Western Australia met this situation by arranging for the attendance of Dr A.R. Thorburn at the clinical and therapeutic sessions.

It is submitted that there is value in the Committee covering the wider field. Admittedly the study of orthopaedic and re-educational methods, both new and old, assessment of their value and decision regarding their adoption or rejection, must undisputedly remain the prerogative of the individual therapist. The meeting of this committee however, at present offers the Medical Officer of Health his only opportunity personally to inform himself of opinion and practice in poliomyelitis in other States. Thereby he may be assisted perhaps to readier appreciation of the needs or shortcomings of the establishment in his own State and to a better appreciation of the merit of requests and recommendations made to his Department by institutions or by the practicing profession.

The direction of Council on this point would be appreciated.

A divergence of opinion was evident amongst members regarding the limitations to be imposed upon the Committee’s recommendations by consideration of administrative practicability.

In one view the Committee is regarded as an advisory body which will identify the epidemiological, control, therapeutic and social problems arising in and residual to a poliomyelitis epidemic, sift all the accessible information and, after careful consideration, recommend a remedial course of action irrespective of political, administrative or departmental objections which appear to make the recommendation unacceptable.

The protagonists of this view hold that a committee member cannot presume to anticipate the reaction of a State Government to a recommendation. He should not impair the expression of a technical opinion of the Committee generally, by withholding support from a recommendation for purely administrative reasons. His objections, real or supposed, may not in any case extend to all or even to more than one State. It is argued further that it should be the responsibility of the committee not to retire from opposition, but to overcome it. 

In the contrary view, administrative experience is not to be discarded as of no value. A member primarily represents his State Department and knowing or suspecting that a recommendation will be difficult or impossible of execution, owing to administrative factors beyond his department’s control, he should not embarrass his superiors by voting for it, nor help to vitiate the resolutions of the Committee by assisting in the multiplication of ineffectual resolutions impossible of practical resolution.

The direction of Council on this point of policy would be appreciated.

Cecil Cook
Convener