Bull. Org. mond. Sante' 1956, 15, 43-121 Bull. Wld Hlth Org.

POLIOMYELrIIS IN 1954 A. M.-M. PAYNE, M.D., M.R.C.P. Division of Communicable Disease Services, World Health Organization M.-J. FREYCHE, M.D. Division ofEpidemiological and Health Statistical Services, World Health Organization

SYNOPSIS As in an earlier study, the authors have endeavoured to review the world incidence of poliomyelitis on the basis of the available statis- tical information (official notifications of cases and deaths) and to compare these data with data received from various sources regard- ing the prevailing viruses. It is certainly not yet possible to establish side by side the carto- graphy of actual poliomyelitis cases and that of the prevalence and distribution of the polioviruses. However, it may not be too early to make a start in this direction. In Africa there was a rise of about 40% in the number of polio- myelitis notifications. Part of this increase is probably due to improved reporting. Characteristic epidemics were observed in the west (Senegal, under French administration), as well as in the east (Sudan, Kenya, , Northern and Southern , ). In America the most outstanding outbreaks were observed in Alaska, in Wyoming, Nebraska, Iowa, Florida, and California, and all round the Caribbean Sea (Costa Rica, Guatemala, Haiti, Jamaica, Puerto Rico, Trinidad). In the Asiatic countries the number of notifications was generally of the same order as in 1953. The incidence also declined in Europe, in spite of the fact that Greece was afTected by the most serious epidemic recorded in its history. Other outbreaks were recorded in Finland, Switzerland, and Austria, where the incidence had also been high in the previous year. An increase was also noted in Scotland. Finally, in Oceania, poliomyelitis took on epidemic proportions in (in the territory of the Federal Capital and in the States of Victoria and Western Australia) and in the Hawaiian Islands.

The present article is another contribution to the series of similar studies which have appeared since 1935 in the epidemiological publications of the League of Nations Health Organisation and of the World Health Organization.4-7, 15-18, 40-42

503 - 43 44 A. M.-M. PAYNE & M.-J. FREYCHE

In 1955 we published I such data as were available to us on the incidence of poliomyelitis in 1953 together with information regarding the types of poliovirus isolated in that year and in previous years. We also indicated that we considered that certain other information was important in planning to apply control measures against the disease-particularly, the age incidence of clinical disease, the age incidence of infection and the state of immunity of the population, and the characteristics of prevalent viruses including those other than poliovirus which might cause clinical symptoms similar to poliomyelitis. The present article includes similar data on the incidence of polio- myelitis in 1954 a together with data regarding the age incidence in certain countries. We have also included such information as we have been able to collect regarding the prevalent types of poliovirus in 1953, 1954, and 1955. Further information regarding the age incidence of clinical disease and of infection and the status of immunity of populations and their significance in planning vaccination programmes will be the subject of a subsequent study. As we have previously stressed, the information regarding prevalent virus types is at present fragmentary and restricted to a relatively small part of the world. Furthermore, the statistical information itself is subject to the well-known errors arising from variable standards of reporting and the lack of specificity of the diagnosis of non-paralytic poliomyelitis, the figures for which in many countries cannot be separated from the figures for the more specific diagnosis of paralytic poliomyelitis. Caution should therefore be used in drawing conclusions from such data.

REPORTED INCIDENCE Africa (Table I)

In 1954, some 3900 cases of poliomyelitis were recorded for the greater part of the African continent, as against about 2800 In 1953. These figures do not include those for the Anglo-Egyptian Sudan, for which the informa- tion available regards only the number of hospitalized cases during the first six months of the year. Nine-tenths of the cases occurred in no more than eight countries or territories: the Belgian Congo, Egypt, Union of South Africa, Kenya, Senegal (French West Africa), Tanganyika, , Angola. In all these territories, except the last named, the number of notifications exceeded-sometimes considerably-the figures for the previous year. It also increased in the French Cameroons as well as in

a For some countries we have received revised or final figures for one or more of the years 1950-53 since our previous study was published.7 These are given in the present paper and explain certain differences in data that may be observed between the two publications. POLIOMYELITIS IN 1954 45

Northern Rhodesia and in Ruanda-Urundi, but the number of cases recorded remained small. On the other hand, a considerable fall in the apparent morbidity was noted in Morocco (French zone) and, more especially, in Angola. In half the countries or territories for which statistics are avail- able, the number of notified cases was insignificant (less than 10).

North Africa In Morocco (French zone), the number of notifications had more than doubled in 1953 (75) as compared with 1952; in 1954 it dropped back to 57. In the absence of detailed information for 1954, it should be noted that, in 1953, 39 of the cases were recorded during the first seven months of the year in Casablanca, including 28 among Europeans. Among Non- Europeans in Morocco, the majority of the patients were infants under one year of age, while among Europeans, on the contrary, the majority belonged to higher age-groups. Serological examinations carried out in March and August- on 360 persons living in Casablanca and district (233 under 20 years of age and 127 aged 20 and over) showed the presence of neutralizing antibodies for the three types of poliomyelitis virus in about 80% of the children under 5 years of age. These results differ sharply from those given by a similar investigation carried out in a district of the United States of America situated in the same latitude.26 The increase in the number of poliomyelitis cases recorded in Egypt in 1952 and 1953 was probably due to more complete notifications than in previous years.7 This increase continued in 1954 for the whole of the country (with the exception of the Governorship of Alexandria, to judge by the 1953 figures relating to the 46-week period for which information for the administrative subdivisions is available); 673 cases (provisional figure) were notified (512 in the Governorship of Cairo, 46 in that of Alexandria, and 115 in the rest of the country), as against 551 (44 deaths) in 1953.

West Africa An important epidemic broke out in Senegal (French West Africa) in May. One case only had been notified in 1953 and 80 (7 deaths) during the previous 14 years. Of the 335 cases (13 deaths) recorded during the year, 298 (11 deaths) occurred among the African population and 37 (2 deaths) among persons of European descent. 207 notifications were made in the Dakar " delegation ", with 8 deaths, 50 (1 death) in the Kaolack district, the others occurring mainly in the Saint-Louis subdivision, in the Ziguinchor district (situated between the Gambia and Portuguese Guinea), and in the Thies district. The eastern part of the territory seems to have remained free from the disease. 46 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE I. NOTIFIED CASES OF, AND DEATHS FROM, POLIOMYELITIS: VARIOUS COUNTRIES, 1950-54

1950 1951 1952 1953 1954 Country or territory cases deaths cases deaths cases deaths cases deaths cases deaths

AFRICA North Africa Algeria 86 28 35 20 36 Egypt 8 18 12 260 23 551 44 681 56 Morocco: French Zone 64 64 33 75 57 Tunisia 24 44 10 24 28 West Africa French West Africa Senegal 20 - 2 335 13 Upper Volta 6 3 35 22 2 Central West Africa Angola 9 764 60 37 2 378 19 123 7 Belgian Congo 337 19 461 27 603 24 736 59 750 43 Cameroons (French) 18 8 2 2 38 2 French Equatorial Africa: Middle Congo 5 1 135 5 46 * 39 21 50 - Central East Africa 156a 7b a b,c a Kenya 126a| 15bc 240 1 9 60d 6d 538 34 Ruanda Urundi 38 3 38 2 21 32 2 73 2 Tanganyika 14 24 5 90 10 153 24 170 12 Uganda 18 l 45 3 253 15 45 3 42 2 South Africa 10 - 22 - 328 4 28 11 * at 21 22 - 38 5 7 21 Mozambique i 7 l 221 2 23 2 7 1 30 6 24 4 4 R1u nion - 57 13 168 14 98 13 28 5 184 16 Southern Rhodesia 161 463 270 339 566e Union of South Africa

AMERICA North America 60 4 33 80 2 67 3 365 Alaska

See notes on page 50. POLIOMYELITIS IN 1954 47

TABLE I. NOTIFIED CASES OF, AND DEATHS FROM, POLIOMYELITIS: VARIOUS COUNTRIES 1950-54 (continued)

1950 1951 1952 1953 1954 Country or territory _ cases deaths cases deaths cases deaths cases deaths cases deaths

AMERICA (continued) Canada (excluding Yukon and North West Territories): all forms 911 41 c 2568 162 c 4755 31 1 8888 481 c 2381 157 c paralytic cases 284 1148 2181 3691 1157

Greenland 25 261 23 - Mexico 804 134 1834 371 771 236 1787 302 609 United States of America: all forms 33 300 1904 c 28 386 1551 c 57 879 3145 c 35 592 1450 c 38 476 paralytic cases 10 037 21 269 15 648 18 308 Central America Costa Rica 28 3 53 5 7 9 6 1081 159 El Salvador 2*g 2/ 371gl 9/ 1l0g 5 15' 4/ 40g Guatemala 13 3 39 1 66 7 37 5 132 15 Nicaragua 10 1 42 1 24 191 5 41 Panama Canal Zone (including cities of Panama and Col6n) 74 38 33 13 19 West Indies Cuba* 32 15 345 37 34 Jamaica 13 1 2 2 2 4 752 Puerto Rico 38 4 89 57 6 31 3 118 Trinidad and Tobago 1 10 3 6 1 189 1 Western South America Chile 653 135 251 43 575 97 554 86 593

Colombia g 133 67 29 154 112 Peru 31 f 53a 27/ 127a 34/ 79a 73a Eastern South America

Argentina 586 1015 695 46 2579 179 652* Brazil: Federal District and capitals of States and Territories 66* 17 123* 26 133 25 951 52 487 Uruguay 99 9 95 7 27 56 86 Venezuela 112 9 125 14 260 17 314 39 257* 12*

See notes on page 50. 48 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE I. NOTIFIED CASES OF, AND DEATHS FROM, POLIOMYELITIS: VARIOUS COUNTRIES, 1950-54 (continued)

1950 1951 1952 1953 1954 Country or territory cases deaths cases deaths cases deaths cases deaths cases deaths

ASIA Western Asia 5 - 4 1 2 - 7 - 13

Iraq 49 1 45 - 92 2 72 - 55 Israel 1604 202c,h 918 177c,h 874 163c,h 636 129c,h 785 68* Jordani 23 - 39 6 15 3 54 9 54 6 Lebanon 3 5 58 24 51 Syria 21 - 15 - 3 13 Turkey 12 1 27 1 71 9 32 2 41 3

South-Eastern Asia

Cambodia 1 - 7 - 105 13 16 - 5 1 Ceylon: Notified cases 190 66c 212 67c 241 81c 155 70 c 114 Cases treated in hospitals c 311 40 321 24 301 30 204 25 Cases treated in dispensariesc 56 79 51 337 Malaya, Federation of: all forms 44 3 199 21 126 14 133 13 128 8 paralytic cases 182 123 125 122 Philippines 435 59 89 25 192 39 125 31 233* 48*

Portuguese 16 3 3 2 4 3 3 2 6 -

Sarawak 28 _ 7 - 7 1 2 1 1 - Colony a,f 82 14 81c 9 55c 7c 43c 4c 71c 4c Thailand: Bangkok 283i 91 80 10 89 7 Viet Nam 458 27 77 4 77 3 76 _ 11

Far-Eastern Asia Hong Kong 16 3c 28 3c 19 4c 22 3c 49 gc Japan 3212 775 4230 570 2317 508 2286 441 1921 442

EUROPE Northern Europe Denmark: all forms 1571 36 383 1c 5676 263c 1591 86c 352 4c paralytic cases 308 20 2450 695 72 See notes on page 50. POLIOMYELITIS IN 1954 49

TABLE I. NOTIFIED CASES OF, AND DEATHS FROM, POLIOMYELITIS: VARIOUS COUNTRIES, 1950-54 (continued)

1950 1951 1952 1953 1954 Country or territory cases deaths cases deaths cases deaths cases deaths cases deaths

EUROPE (continued) Finland 322 36 150 22 c 82 19 c 316 23 c 790 30 c Iceland:

all forms 17 1 85 - 30 - 7 - 11 paralytic cases 26 11 6 6 Norway: all forms 905 99 2233 207c 724 69c 1095 109c 584 paralytic cases 706 1563 528 923 438 Sweden: all forms 1704 157 551 48c 492 56c 5090 216c 1009 paralytic cases 1164 339 363 3029 554

Central Europe Austria 160 29 414 66 200 39 566 56 829 89* Germany: Federal Republic 2830 284 1269 159 9517 729 c 2242 187 c 2713 230 c West Berlin 49 6 115 14 211 16C 86 8c 85 sc Saarland 35 1 217 12 23 2 89 4 27 2 Switzerland 380 37 889 87 579 51 764 58 1628

Western Europe Belgium 86 24 118 24 897 34 c 184 19 c 198 30 c France 1979 292 c 1493 201 c 1665 223 c 1834 240 c 1534 146 c Ireland, Republic ot (paralytic cases) 201 30 c 63 15c 96 12c 245 33 c 82 15c

Luxembourg 6 1 2 - 61 4 7 - - : all forms 77 8c 568 32 c 1712 72 c 159 8 c 74* paralytic cases 541 1338 66 151 : England and Wales k all forms 7760 734 c 2614 191 c 3910 275 c 4547 320 c 1960 112c paralytic cases 5565 1529 2747 2976 1319 Northern Ireland 273 25 c 80 10c 142 7 c 290 15c 54 4 c Scotland k 1112 64 c 316 24 c 217 12 c 368 13c 421 21 c

See notes on page 50. 50 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE I. NOTIFIED CASES OF, AND DEATHS FROM, POLIOMYELITIS: VARIOUS COUNTRIES, 195C-54 (concluded)

1950 1951 1952 1953 1954 Country or territory cases deaths cases deaths cases deaths cases deaths cases deaths

Southern Europe Greece 374 13 291 16 55 3 140 4 1222 20 Italy 2035 203 2867 233 c 2708 246c 5010 375 c 3379 Malta 154 8 43 - 37 2c 26 1 c 14 1 c Portugal (Mainland) 179 29 107 25 132 20c 100 28c 106 16 Spain (paralytic cases) 1705 543 1584 936 872 Trieste:

Former Zone A 2 - 25 4 c 3 -c 18 - c 11* _* Yugoslavia 104 16 299 18 128 10 715 41 330* 26*

OCEANIA Australia 2206 113c 4736 346 c 1743 109 c 1677 115C 1999 French Oceania _ 140 9 1 1 _ Gilbert and Ellice Islands - 147 14 7 Guam 13 - 9 2 _ _ 12 1 3 Hawaii Islands all forms 55 2 216 1 paralytic cases 30 - 16 - 156 14 41 2 144 1 Netherlands New Guinea 2 31 7 5 New Zealand: White population 70 2 26 1 861 54 397 26 401 Maoris 2 1 1 29 3 6 1 Papua and New Guinea (Australian administration) 107 36 2 3 15 Solomon Islands: British Protectorate 1 1280 156 2 -

* Provisional or approximate figure . No information available a Cases treated in hospitals and dispensaries b Deaths in hospitals c 1948 nomenclature (excluding sequelae) d Notified cases and deaths (corresponding figures for 1952 122 cases, 10 deaths) e 11 months / Deaths for the whole territory 9 Reporting area h Jewish population From 1950, including Western Jordan (old territory, 1950: 10 cases, 0 death) i6 months k Confirmed cases I Preliminary figure for the whole population 68 (in 1953: 501). POLIOMYELITIS IN 1954 51

East Africa In the Anglo-Egyptian Sudan, 377 cases were treated in hospitals and dispensaries during the course of the financial year ending on 30 , as against 24 in 1952/53, 111 in 1951/52, and 226 during the eighteen months ending on 30 June 1952.

Central West Africa An epidemic outbreak was reported in the Cameroons (under French administration), 26 cases (1 death) being noted in June in the Mbam area in the west centre of the territory. For the whole of the country, however, no more than 38 cases (2 deaths) were reported for the whole year as against 2 cases (1 death) notified in 1953. A previous report 7 referred to 116 poliomyelitis notifications in the Middle Congo (French Equatorial Africa) for 1953 as against 46 for 1952. According to fresh information, this figure, plus 4 additional cases, refers to the whole of French Equatorial Africa and is distributed as follows: Gabon, 29; Middle Congo, 39; Ubangi-Shari, 31; Chad, 21. In 154, 50 cases were said to have occurred in the Middle Congo and 8 in Gabon. In the Belgian Congo, the provisional number of cases notified in 1954 rose progressively from mid-July to a maximum of 84 (2 deaths) for the last four-week period of the year. The final number of notifications for the whole year (750, with 43 deaths) does not differ much from that for 1953 (736, with 59 deaths). These figures are made up as follows: Eastern Province, 195 (6 deaths); Leopoldville Province, 172 (11 deaths); Kivu, 169 (10 deaths); Katanga, 151 (13 deaths); Equator Province, 56 (3 deaths); Kasai, 7. In comparison with 1953, there is to be noted a certain fall in the number of notified cases in Leopoldville Province, in Katanga, and especially in Kasai, although a sharp increase took place in the rest of the territory, notifications in the Eastern Province being three times more numerous than in 1953. 95 % ofthe final notifications and 91 % ofthe deaths occurred among Africans (96% and 81 % in 1953). In Angola, the apparent poliomyelitis incidence seems to have fallen sharply after the 1953 epidemic, 123 cases (7 deaths) being recorded. The majority occurred in the Luanda " health delegation " (67 with 7 deaths as against 110 with 4 deaths in 1953), the health district of the Congo (27 cases as against 181 with 11 deaths), and that of Benguela (19).

Central East Africa There was, on the other hand, a serious epidemic in Kenya: 538 cases (34 deaths) being recorded as against 60 (6 deaths) for 1953 and 608 (47 deaths) for the whole of the previous 13 years. The first cases were notified in , the peak of the epidemic being reached in June 1954, 52 A. M.-M. PAYNE & M.-J. FREYCHE with 43 notifications for the week ending 5 June. 229 cases (19 deaths) were noted in Nairobi, 115 in the remainder of the Central Province, 106 (12 deaths) in the Rift Valley Province, 56 (1 death) in Nyanza Province, etc. The European population was, it seems, particularly stricken, the disease affecting young adults in particular. Among Africans, the incidence was highest among young children. A number of cases were complicated by respiratory and bulbar paralysis. According to Walker,39 this epidemic, which ran on into 1955, must be attributed to a type 1 virus. It could have been caused by the recent arrival of a large number of receptive Europeans (immigrants and military per- sonnel) who suddenly upset the conditions of feeble endemicity previously obtaining. The disease spread slowly from east to west; certain facts indicate that infection through the digestive tract may have played a part in its spread.39 In Tanganyika, annual notifications increased progressively from 14 in 1950 to 153 (24 deaths) in 1953 and 170 (12 deaths) in 1954, whereas the total number of cases recorded for the period 1945-49 did not exceed 143 (16 deaths). More than half occurred in Western Province, where an epidemic outbreak took place between September and November in the Nzega district in the north-east of the province (especially in the Busongo- Ulaya area); 85 paralytic cases (7 deaths) were recorded there. According to Kerr & Pease,12 this outbreak affected mainly children under the age of three. It was followed by a second mild outbreak, with 8 known cases, which lasted from March to . The number of deaths finally recorded was 11 among 79 hospitalized paralytic cases and 10 among 15 cases with respiratory paralysis. 33 cases (4 deaths) were registered in Northern Province, from the end of March, the others being mainly in Tanga, Central Province, and Eastern Province.

South Africa In Northern Rhodesia, the number of notifications (30 cases, 1 death) equalled the number for the year 1946. Between 10 April and 30 December, 8 cases were observed in Northern Province, the same number in Southern Province, 7 in Western Province, 6 (1 death) in Central Province, and 1 only in Eastern Province. 184 notifications (16 deaths) were recorded in Southern Rhodesia. These figures exceed those of 1951 (168 notifications, 14 deaths), a year when incidence was high. The number of patients increased from the month of September to reach a maximum in December, with 79 notifications (6 deaths). For the whole of the year, 110 cases, including 70 paralytic ones (8 deaths), occurred among the population ofEuropean descent, as against only 74 (8) in the African population. 76 cases (7 deaths) were observed in the Northern Region; 47 in the Western Region, 32 (6 deaths) in the POLIOMYELITIS IN 1954 53

Midlands Region, 24 (3 deaths) in the Eastern Region, and only 5 in the South-Eastern Region. It should be noted here that the first three of these areas are adjacent to the Southern and Central Provinces of Northern Rhodesia, where a certain number of cases were also noted in 1954 (see above). The age-distribution of the cases and deaths among Europeans is shown below: Age-groups (years) <1 1-4 5-9 10-19 20-29 30-39 40-49 50-59 60+ Total Cases 2 36 17 17 16 13 7 1 1 110 Deaths - 2 - 3 3 - - - 8 In the Union of South Africa, the incidence of the disease rose consider- ably from August 1954 to October (74) and November (207). The number of cases recorded during the first eleven months of the year (566) had been exceeded only once during the previous 34 years (2276 in 1948). From 1920 to 1944, the annual totals amounted only to a few score; after the sharp epidemic noted in the latter year (825 cases, with 62 deaths, recorded during the second half-year), annual totals were much higher: Year 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 Cases 634 183 75 2276 308 161 463 270 339 566* * January-November

America (Table I) 30 In comparison with 1953, a considerable rise in the morbidity rate was noted in Alaska, Costa Rica, Guatemala, Jamaica, Puerto Rico, Trinidad and Tobago. In the United States of America, it increased by 8 % in com- parison with the previous year. The number of notifications fell, however, in Argentina, Brazil, Canada, Mexico, Nicaragua, and Salvador. Greenland, where an epidemic occurred in 1953 (261 cases, 23 deaths), was unaffected by poliomyelitis in 1954. North America A serious epidemic occurred in 1954 in Alaska: 365 cases (178 per 100 000 inhabitants) were recorded (189 with paralysis, 136 without paraly- sis, 40 not specified), as against 67 in 1953. Only 257 notifications had been made during the previous 15 years, with a maximum (80) in 1952. From July onwards, the districts of Anchorage and Seward were parti- cularly affected; only a few isolated cases in inland districts were reported during the closing months of the year. The epidemic seems to have spared the south-east part of the territory. In Canada, the record epidemic of 1953 was followed by a definite regression in 1954. The final number of cases notified was only 2381 (16 per 100 000 inhabitants), as against 8888 (60 per 100 000 inhabitants) 54 A. M.-M. PAYNE & M.-J. FREYCHE in 1953 and 4755 (33 per 100 000 inhabitants) in 1952. In the Yukon (9000 inhabitants) and in the North-West Territories (16 000), the data for which are not included in these figures, the apparent morbidity rate was practically nil; 158 cases of poliomyelitis had been registered there in 1953, the majority in the Yukon. For the country as a whole, the subdivision of the cases into " paralytic ", " non-paralytic ", and " non-specified " was fairly similar to that of the preceding year:

Year Paralytic cases Non-paralytic cases Non-specified cases 1953 42% 35% 23% 1954 49% 29% 22% The geographical distribution of the 8734 notifications made between 28 December 1952 and 26 is known, and these data may no doubt be used for purposes of approximate comparison with the figures for the following year. It can thus be seen that, in Manitoba, there were 13.8 notifications per 100000 inhabitants in 1954 as against 287 from 28 December 1952 to 26 December 1953, the figures for being 5.5 as against 61; for Ontario, 5.0 as against 46; and for Saskatchewan, 22 as against 128. A smaller improvement took place in British Columbia (17.1 as against 65), in Alberta (50 as against 142), and in New Brunswick (11.2 as against 16.4). An increase in apparent morbidity took place, however, in three Provinces: Prince Edward Island (75 notifications per 100 000 inhabitants as against 10.4), Nova Scotia (20 as against 4.7), Province of Quebec (17.9 as against 11.4). According to the final statistics, 157 deaths (481 the previous year) were attributed to poliomyelitis, including 80 (33) in the Province of Quebec, 28 in Alberta (108 in 1953), 21 (124) in Ontario, and 7 (72) in Saskatchewan. The mortality-rate for the country as a whole was 1.0 per 100 000 inhabitants, as compared with 3.3 for 1953. Distribution by age-group is known for only six provinces (Alberta, British Columbia, Manitoba, New Brunswick, Saskatchewan, Newfound- land), as regards 1952, 1953, and 1954. The population of these territories in 1954 was 4 956 000, or about one-third of the total population of the country; 80 % of the poliomyelitis notifications were recorded there in 1952, 68 % in 1953, and 470% in 1954. Of these, 40% were of the paralytic type, the remainder being described as " non-paralytic " (39 %) or " non- specified " (21 %). A glance at Table II will give the reader an idea of the distribution of the notifications by age-group from 1952 to 1954. Distribution by sex is also known only for the same provinces. As usual, it shows a slight preponderance in the number of male patients (51 % in 1954, as against 54% in 1953 and 53% in 1952). In the United States ofAmerica, in 1954, there were 38 476 notified cases of poliomyelitis, i.e., 24 per 100 000 inhabitants. This rate is the fourth POLIOMYELITIS IN 1954 55 highest recorded, coming after those of 1916 (42 cases per 100 000 inhabi- tants, for 28 States and the District of Columbia), 1952 (37 per 100 000 inhabitants, for the whole ofthe USA) and 1949 (28 per 100 000 inhabitants). The maximum incidence was noted a month later than in 1953, a little later than in Canada.

TABLE II. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: CANADA (SIX PROVINCES *), 1952-54

1952 1953 1954 Age-group1 (years) number attack- number attack- number attack- of cases 0 rate ** of cases 0 rate ** of cases rate *

under 1 78 2. 1350 150 2.5 31 2.8 1-4 714 18.7 J 1197 20.1 ( 181 16.0 1 5-14 1532 40.2 177.0 2119 35.5 234.2 429 38.0 45.2 15-19 392 10.3 113.0 478 8.0 136.3 128 11.3 35.7 20 and over 954 25.0 32.8 1869 31.3 63.1 331 29.3 11.0

unspecfied 141 3.7 - 152 2.6 - 29 2.6

Total 3811 100.0 80.9 5965 100.0 123.7 1129 100.0 22.8

* Newfoundland, New Brunswick, Manitoba, Saskatchewan, Alberta, British Columbia ** Number of notifications per 100 000 inhabitants of each age-group In Wyoming and Florida, the morbidity-rate reached a record level. In comparison with 1953, the number of cases notified increased considerably in Wyoming (88 per 100 000 inhabitants as against 25), Nebraska (53 as against 17), Delaware (24 as against 9.1), Florida (51 as against 22), Iowa (55 as against 24), Kentucky (27.5 as against 12.5), and New Mexico (nearly 30 as against 14). Sharp falls were, however, noted in the following States: Minnesota (22 notifications per 100 000 inhabitants as against 74 in 1953), Maine (14 as against 36), Rhode Island (15 as against 36), Mary- land (9.5 as against 20), and Arizona (23 as against 45). It was in the eastern sector of the USA, where the population is thickest, that the disease was apparently the least widespread in 1954, as was the case during the preceding six years: 5 7 in 19 States, the attack-rate remained below 20 cases per 100 000 inhabitants; 16 of these States lie to the east of a line running from the eastern boundary of North Dakota to that of Texas and dividing the country into two more or less equal parts (Fig. 1). As in 1953, it was in California that the greatest number of notifications were recorded (A636 as against 5782 in 1948, the highest figure previously registered). A serious epidemic occurred in Los Angeles between mid- July and mid-August. In Florida, where the incidence of poliomyelitis 56 A. M.-M. PAYNE & M.-J. FREYCHE

FIG. 1. DISTRIBUTION OF POLIOMYELITIS: UNITED STATES OF AMERICA, 1952.54*

Vw 5950

Cases per 100 000 inhabitants 0.1-9.99 , 10-19.9 M 20-29.9 30-39.9 M 40-49.9 E 50-59.9 * 60 + 1 Final figures POLIOMYELITS IN 1954 57 reached the highest figure since 1920, three successive outbreaks occurred: at Key West, at the beginning of the season, in July at Fort Lauderdale, and in Leon County at the end of the season when an unusually large number of young women were affected.

FIG. 2. POLIOMYELITIS ADMISSIONS, BY AGE-GROUP: UNITED STATES OF AMERICA, 1954 (RATES PER 100000 INHABITANTS)*

* Based on a diagram published by the National Foundation for Infantile Paralysis, after tabula- tion of 24950 original acute admissions reported by hospitals to the Foundation.'s

In Fig. 2, the distribution by age-group of the 24 950 cases hospitalized in 1954 is shown; it can be seen that among these cases children of 2-8 years and especially those between 5 and 6 years seem to have been more par- ticularly affected. Although these children belong to an obviously selected group, it is perhaps permissible to believe that their distribution by age- group does not differ much from the actual state of affairs for the country as a whole.23 Table III shows that certain changes took place between 1944 and 1954 in the age-group distribution of the cases notified. The percentage of patients 20 or more years of age changed from 11.7 in 1944 to 24.5 in 1954; for the 5-19-years group, however, the percentage fell from 64.9 to 50.7 while that for children under 5 years remained practically stationary (24.8% in 1954 as against 23.4% in 1944). The proportion of paralytic cases was 48 % of the total notifications in 1954 as against 44% in 1953, 37% in 1952, and 35% in 1951, but this fact does not call for any special comment. It is more interesting to note 58 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE III. PERCENTAGE DISTRIBUTION OF POLIOMYELITIS, BY AGE-GROUP: UNITED STATES, 1944-48 and 1952-54 * t

Age-grouP 1944 1945 1946 1947 1948 1952 1953 1954

under 5 23.4 24.8 27.1 23.4 30.5 28.0 25.0 24.8 5-9 31.7 30.4 29.0 29.9 28.3 26.0 28.6 27.3 10-14 22.0 20.7 17.5 19.4 15.0 14.9 15.6 15.0 15-19 11.2 10.6 10.3 10.5 8.3 9.0 8.9 8.4 20 and over 11.7 13.5 16.1 16.8 17.9 22.1 21.9 24.5

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

* Based on a table published by the National Foundation for Infantile Paralysis.23 t Data for 1944-48 based on 81 250 cases reported by health departments of 39 States and the District of Columbia. Data for 1952 (July-December), 1953, and 1954 based on, respectively, 35 882 23698, and 24950 original acute admissions reported by hospitals to the National Foundation for Infantile Paralysis. that the cases recorded as "non-specified" constituted 18 % of the 1954 notifications as compared with 22 % in 1953, 41 % in 1952, and 45 % in 1951. In Mexico, 609 cases were recorded, as against 1787 (302 deaths) for the previous year. Three-quarters of the cases were noted in the Federal District (164) and in the States of Chihuahua (62), Durango (57), Jalisco (44), Nuevo Leon (42), Coahuila (32), Puebla (30), and Sonora (25). Compared with 1953, the figures recorded by the States have not increased to any appreciable extent except those for Chihuahua (22 notifications in 1953) and Durango (21). On the other hand, they fell steeply in the Federal District (164 notifications as against 902 for 1953), and in the States of Coahuila (32 as against 111), Guanajuato (19 as against 112), Jalisco (44 as against 114), Nuevo Leon (42 as against 99), Puebla (30 as against 96), and San Luis Potosi (6 as against 35).

Central America In Guatemala, 132 cases (15 deaths) were notified in 1954, more than half of which occurred between May and July, as compared with 37 (5 deaths) for 1953. This is the highest figure noted since 1939, the year from which statistics are available. In Nicaragua, 41 cases were noted, 25 of which occurred between October and December, as against 191 (5 deaths)-the previous maximum- in 1953. The poliomyelitis epidemic which occurred in 1954 in Costa Rica seems to have had no precedent, according to the figures since 1939 when POLIOMYELITIS IN 1954 59 statistics first became available: 1081 cases (159 deaths) were recorded as compared with 285 from 1939 to 1953 (excluding 1952, for which the number of notifications is unknown). In 1944, the figure was 84, the previous maximum. The first case was noted on 21 February at San Isidro del General, 100 kilometres south of the capital; at San Jose, the southern parts of the town were the first to be affected. Other cases were reported shortly after- wards in each of the seven provinces, with the sole exception of the cantons of Alfaro Ruiz and Flores in the provinces of Alajuela and Heredia. A total of 1014 cases (152 deaths) was recorded between 28 February and 28 August: 497 (79 deaths) in the Province of San Jose (including 293 in the capital and the surrounding district), which thus had the highest pro- vincial morbidity-rate (157 cases per 100 000 inhabitants); 122 (17 deaths) in the Province of Cartago; 118 (12 deaths) in the Province of Puntarenas; 115 (20 deaths) in the Province of Alajuela; 56 (10 deaths) in the Province of Heredia; 56 (8 deaths) in the Province of Guanacaste, where the apparent morbidity was lowest (53 cases per 100 000 inhabitants); 50 (6 deaths) in the Province of Limon. The epidemic reached its peak during the week ending 15 May, with 111 notifications (14 deaths). Fig. 3 shows the age-group distribution of the cases notified during the epidemic (March-August). The rates are calculated per 100 000 inhabitants of each age-group.

West Indies In 1954, poliomyelitis in epidemic form appeared in a number of territories of the West Indies including Jamaica, Haiti, Puerto Rico, and Trinidad. The information available on these exceptional outbreaks is summarized below. In Jamaica, only 119 cases of paralytic poliomyelitis-or 2-13 cases per annum-had been recorded between 1927 and 1953. In June 1954, 4 cases were reported among adults in the semirural parish of Clarendon in the south central part of the island. In July, the disease appeared in the urban zone of Kingston and subsequently spread simultaneously to the east, north, and west. By early September, the disease was prevalent throughout the island. In December, there were still a -number of cases in five of the outlying parishes. For the year as a whole 752 cases were notified, including 306 in the parishes of Kingston and St. Andrew, while in the remaining twelve parishes of the island the number of notifications varied from 10 (Trelang), to 64 (Clarendon). The average morbidity-rate was 50 cases per 100 000 in- habitants, while the parish figures varied from 12 to 98 cases per 100 000 inhabitants. It is possible that in certain localities notifications were not very complete. 60 A. M.-M. PAYNE & M.-J. FREYCHE

FIG. 3. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: COSTA RICA, MARCH-AUGUST 1954 (RATES PER 100000 INHABITANTS)

mn - Nano

500 uu

400 v - -~~~-IO-Uu

300 =00

200 to

100 .100

0 3 + * ^ag - i.Oups 4-0 561)

FIG. 4. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: JAMAICA, 1954 (RATES PER 100000 INHABITANTS) *

lvi.,115~~~~~~~~~~~~~~~~~~~~~~m

INs 1SO

100

50 50

0 _Jo

Asg eG,.ups so M" v Based on 723 cases reported up to the week ending 4 December. POLIOMYELITIS IN 1954 61

Fig. 4 gives the distribution by age-group of the 723 cases recorded up to 4 December; the rates are slightly lower than those which would be obtained for the year as a whole if the information were available. Young children were severely affected; curiously enough, adults of 20-29 years of age come next; the incidence was relatively lower among schoolchildren and adolescents. In certain parishes, nearly half the notifications concerned patients of this latter age-group, 42.3 % being females. It would appear that respiratory or bulbar forms of the disease were limited mainly to adults.25 In Puerto Rico, 118 cases, all paralytic, were noted in 1954 as against 31 for 1953, but between 1 -the month when the epidemic began-to 31 , the number of confirmed cases was 218, includ- ing 119 cases of paralysis (16 deaths), 89 non-paralytic cases, and 10 non- specified. This was one of the most serious epidemics of poliomyelitis recorded in Puerto Rico since 1928, others occurring in 1946 (307 notifica- tions) and in 1942 (117 notifications). The first cases were reported in the municipality of Toa Baja; by 31 Janu- ary 1955, 40 cases (287 per 100 000 inhabitants) (5 deaths) had been recorded there, all among the inhabitants of rural areas. The disease spread subse- quently to neighbouring municipalities, especially those of Cataino and Bayamon, where 31 and 30 cases respectively (156 and 63 per 100 000 inhabitants) were noted, and in the relatively remote municipality ofArecibo (22 notifications, i.e., 29 per 100 000 inhabitants). Of the 218 cases confirmed between 1 November 1954 and 31 January 1955, 18% occurred among infants of under 1 year, 69% among children of 1-4 years, 10% among those of 5-9 years, and 3°% only among subjects aged 10 or more years. This distribution is similar to that noted during the course of the 1942 and 1946 epidemics.29 In Trinidad and Tobago, 189 cases (1 death) were recorded in 1954, a figure never previously reached. Between 1939 and 1953, the number of notifications had as a rule never exceeded 10 per annum, with the exception of 1941 (59), and 1942 (150). The figures for 1943 are not known. The majority of cases occurred between July and September with a maximum (53) in August. Males were, as usual, more affected than females (109 cases as against 80). The distribution by age was as follows: Age-group (years) <1 1-4 5-9 10-19 20-39 40+ male female male female male female male female male female male female Cases 20 21 50 30 10 11 18 11 9 7 2 0 Western South America In Chile, the number of cases notified in 1954 (593) was about the same as that noted during three recent years: 653 in 1950, 575 in 1952, and 554 in 1953. During the greater part of the year, the monthly incidence 62 A. M.-M. PAYNE & M.-J. FREYCHE

FIG. 5. NOTIFIED CASES OF POLIOMYELITIS, BY FOUR-WEEK PERIOD: CHILE, 1946-54

was about the same as the maximum figures recorded between 1946 and 1953 (Fig. 5).

Eastern South America In Venezuela, poliomyelitis incidence rose towards the middle of the year in certain parts of the States of Zulia, Lara, and Trujillo. The provi- sional number of cases recorded in the " notification zones " remained, however, about the same as that for the previous year (257 with 12 deaths, as against 255 with 26 deaths) and for the years 1952 and 1941. Thefinal number for 1954 is not yet known; in 1953 it was 314 (39 deaths). In the Federal District and the State and Territorial capitals of Brazil, apparent morbidity decreased by about 50 % as compared with 1953, which was a record year; 487 cases (28 deaths for the January-August period) were recorded for 1954, as against 951 (52 deaths). During the period 1944-52, the number of notifications had varied from 66 to 170, and the POLIOMYELITIS IN 1954 63 number of deaths from 17 to 35 per annum. In Rio de Janeiro, the disease assumed epidemic proportions with a recorded total of 356 patients (245 residents and 111 non-residents). The resident attack-rate was 9.3 per 100 000 and the case-fatality rate, 4.2 %.21 In Uruguay, 28 cases of poliomyelitis were reported in December, includ- ing 14 in the Department of Canelones and 8 in that of Montevideo. Such a monthly figure had never been reached since 1939, except in 1950 (42 notifications). For the whole of the year, the number of notifications was 86 as against 56 in 1953, but this figure has been exceeded several times in the past, especially in 1943 and 1945 (167 and 181 notifications, respectively). In Argentina, the provisional number of cases notified was only 652, as against 2579 final notifications (179 deaths) in 1953. The greatest number of cases was observed between January and April (447). This was the end of the seasonal outbreak, which began in and reached its peak in December, with 224 notifications. The previous outbreak, which was much more serious, also began in October (1952) and the number of monthly notifications reached very high figures: 574 in and 616 in April.

Asia (Table I) No statistics or only inaccurate or fragmentary data are available for the majority of the Asian countries. In India, for example, only the number of patients hospitalized is known (1080 in 1954 as against 1045 in 1953); in Indonesia, 90 cases of paralytic poliomyelitis (9 deaths) were reported in 1953; the figures for 1954 are not known. In Ceylon, the number of notifications between 1951 and 1954 seems considerably lower than the number of patients treated in the hospitals and dispensaries. More than 80 % of the cases notified for the continent as a whole (a total of only 3600 in 1954, not including the above-mentioned countries) were recorded in Japan (1921) and in the Near-East countries (Iraq, Israel, Jordan, Lebanon, Syria, Turkey) (1032, including 785 in Israel alone). Next in order come the Philippines (233), the (128), Bangkok (Thailand) (89), and the colony of Singapore (71). Poliomyelitis incidence seems to have receded in Iraq (55 notifications in 1954 as against 72 in 1953), in Japan (1921, with 442 deaths, as against 2286, with 441 deaths) and, probably, in Viet Nam (11 as against 76). In Ceylon, the number of patients treated for poliomyelitis in hospitals was 204 (301 in 1953), the number of patients received in dispensaries being 337 (51). On the other hand, higher figures than those recorded in 1953 were noted in Hong Kong, Israel, Lebanon, the Philippines, and the colony of Singapore. The number of notifications underwent little change in Jordan, the Federation of Malaya, Bangkok (Thailand), Timor, and among the Arab refugees of Palestine. 64 A. M.-M. PAYNE & M.-J. FREYCHE

In Lebanon, an appreciable proportion of the 51 cases noted in 1954 (24 in 1953) occurred during the first six months of the year, whereas in 1952, when 58 cases were notified, the outbreak of poliomyelitis seems to have been limited to the second half-year. In Israel, despite a 34% increase in the population, the number of poliomyelitis cases (practically confined to the Jewish population) fell progressively from 1604 in 1950 to 636 in 1953, including 129 deaths. A certain recrudescence took place, however, in 1954 (785 notifications; 68 deaths). The maximum number of notified cases occurred a month earlier than in 1953. In India, available information refers only to hospitalized patients, most of whom were paralytic cases. The hospitals of Madras State treated 382 cases (338 in 1953), those of the Punjab 329 (as against 380) and those of Bombay 233 (as against 31). There were 61 (as against 76) hospitalized cases in Uttar Pradesh, 37 (as against 102) in West Bengal, 25 in Ajmer (as against 12), and 13 in the State of Delhi (as against 97). In the colony of Singapore, 71 cases (4 deaths) were noted (43 in 1953). Higher figures had been recorded in 1946 (125 notifications in the town of Singapore alone), 1948 (157 for the colony as a whole), 1950 (82), and 1951 (81). As happened during the last two years, the majority of the cases occurred in the first half-year. In the Philippines, by far the greater part of the notifications derive from the town of Manila, where 175 cases, practically all paralytic, were recorded in 51 weeks. For the country as a whole, the annual total (provisional figures) was 233 (48 deaths) as against 125 (31 deaths) (revised figures) in 1953. Far-Eastern Asia In Hong Kong, notification of poliomyelitis cases has been compulsory since July 1948. The number of notifications was higher than during previous years, being 49 (9 deaths) as against 22 cases in 1953. In Japan, during 1954, the apparent morbidity-rate remained lower for most of the year than the minimum figures recorded during the preceding three years. The peak was noted a month earlier than in 1953. The total number of notifications was 1921 (442 deaths) as against 2286 (441 deaths) in 1953. One-third of the cases were observed in the prefectures of Osaka (8.4 notified cases per 100 000 inhabitants, as compared with 5.9 in 1953) and Fukuoka (7.9 as compared with 2.4). Fairly high attack-rates were, however, reported in the prefectures of Oita (7.2 cases per 100 000 in- habitants, as against 3.2 in 1953), Saga (5.8 as against 3.8), and Tokushima (5.3 as against 3.0). There was a sharp decline, on the other hand, in the prefectures of Akita (0.6 notifications per 100 000 inhabitants, as against 7.8 in 1953), Tottori (1.5 as against 5.3), Hokkaido (2.5 as against 5.6), and Wakayama (4.3 as against 6.0). POLIOMYELITIS IN 1954 65 Europe (Table I)

Some 19 000 cases of poliomyelitis were reported in 1954 in 25 Euro- pean countries or territories (27 000 in 1953 and 32 000 in 1952). A certain number of epidemic outbreaks were, however, observed: in Greece, there were approximately nine times more notifications than in 1953;

TABLE IV. NOTIFIED CASES OF POLIOMYELITIS: EUROPE, 1947-53 AND 1954

Number of cases Rate per 100000 inhabitants Quotient Country or territory 1947-53 1947-53 1954 1954 1954 median maximum median ,maximum median

Greece 374 146 1222 4.9 2.0 15.5 7.8 Finland 322 228 790 8.0 5.0 18.9 3.2 Switzerland 889 658 1628 18.7 14.2 33.1 2.3 Yugoslavia 715 135 330 4.2 0.9 1.9 2.1 Trieste: former Zone A 25 a 6 a 11 8.5a 2.0 a 3.7 1.9 Spain b 1705 543 872 6.1 1.9 3.0 1.6 Austria 3508 566 829 50.7 8.1 11.9 1.5 Scotland c 1693 382 502 32.9 7.5 9.8 1.3 Italy 5010 2708 3379 10.6 5.7 7.1 1.2 Belgium 897 183 198 10.3 2.1 2.2 1.0 Germany: Federal Rep. 9517 2830 2713 19.6 5.9 5.5 0.9 Portugal: Mainland 200 107 106 2.6 1.4 1.3 0.9 France 1979 1665 1534 4.7 3.9 3.6 0.9 Ireland, Republic of b 291 96 82 9.8 3.3 2.8 0.8 Norway 2233 724 584 67.7 21.8 17.2 0.8 Saarland 217 33 27 22.8 3.8 2.7 0.7 Sweden 5090 1481 1009 71.0 21.8 14.0 0.6 England and Wales c 8709 4475 2397 19.8 10.1 5.4 0.5 Netherlands 1712 160 74 16.5 1.6 0.7 0.4 Berlin: Western sectors 1218 211 85 59.4 9.7 3.9 0.4 Northern Ireland 290 142 54 21.0 10.3 3.9 0.4 Malta 154 37 14 49.4 11.7 4.4 0.4 Denmark 5676 928 352 131.0 22.1 8.0 0.4 Iceland 622 85 1 1 444.3 58.6 7.1 0.1 Luxembourg 61 61 - 20.3 2.0 0.0 0.0 Il a 1949-53fb Paralytic cases c Total notifications 66 A. M.-M. PAYNE & M.-J. FREYCHE in Finland the figure was two and a half times greater; in Switzerland, it was twice as high; and in Austria, one and a half times. There was a smaller increase in the Federal Republic of Germany, Scotland, Portugal, Iceland and Belgium. A more or less considerable fall, on the other hand, took place in Northern Ireland, Sweden, Denmark, the Saar, the Republic of Ireland, England and Wales, the Netherlands, Malta, Norway, and Yugoslavia. There was a slight tall in the number of cases in the former Zone A of Trieste and in Italy, France, and Spain. In the western sectors of Berlin, the incidence of the disease remained more or less the same as in 1953. Table IV shows that for 9 countries or territories the 1954 notifica- tions were higher than the median for the seven preceding years; the maxi- mum observed during that period was, in fact, exceeded in Greece, Finland, and Switzerland.

Northern Europe The only increase in poliomyelitis incidence took place in Finland (Fig. 6). FIG. 6. DISTRIBUTION OF POLIOMYELITIS: SCANDINAVIA, 1953-54*

Cases per 100000 Inhabitants

L O 0.1-9.9 0 10-19.9 E 20-29.9 M 30-39.9 40-49.9 50-59.9 *0 +. * Preliminary rates, with some corrections of the situation shown for 1953 in Fig. 7 of our previous study.' POLIOMYELITIS IN 1954 67

In Norway, the number of notifications was only 584, or 17 per 100 000 inhabitants, in 1954 as against 1095 in 1953 (33 per 100 000 inhabitants). 1951 was characterized by a still higher incidence. The majority of the Norwegian prefectures reflected this improvement, with the exception of Nordland, with 235 notified cases (103 per 100 000 inhabitants) as against 197 in 1953 (86 per 100 000 inhabitants), and Troms, with 96 (79 per 100 000 inhabitants) as against 82 (68 per 100 000 inhabitants) in 1953. For the country as a whole, the proportion of non-paralytic cases (excluding Oslo, where only paralytic cases are recorded) was a little higher than in 1953 (26% instead of 17%).

TABLE V. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: NORWAY, 1953-54

1953 1954 Age-group (years) number of attack- number of attack- cases a % rate b cases a rate b

under 1 29 2.6 47.1 13 2.2 21.0 1-4 156 14.2 64.3 93 15.9 38.6 5-14 308 28.1 56.6 178 30.5 32.1 15.44 499 45.6 35.0 233 39.9 16.4 45-64 47 4.3 6.2 21 3.6 2.8 65 and over 4 0.4 1.2 5 0.9 1.5 unspecified 52 4.8 - 41 7.0 -

Total 1095 100.0 32.6 584 100.0 17.3

a Final figures b Number of notifications per 100000 inhabitants of each age-group

Table V shows the distribution of notifications by age-group in 1953 and 1954, years for which such information is available. In Sweden, only 1009 poliomyelitis cases (14 per 100 000 inhabitants) were notified in 1954 as against 5090 (71 per 100 000 inhabitants) (216 deaths) in the previous year. During 1953, the most severe epidemic ever known took place, and in the capital alone the number of cases was as high as for the whole country in 1954. In 1954, the rate of 30 cases per 100 000 inhabitants was reached in only three counties (" Lan ")- Kalmar (33), Gotland (33), and Kronoberg (30)-while, in 1953, onlythecoun- ties of Norbotten and G6teborg and Bohus had a morbidity-rate lower than this. The number of monthly notifications remained generally about the median figure for the years 1946-52, the maximum being noted in September, 68 A. M.-M. PAYNE & M.-J. FREYCHE or a month earlier than in 1953. Of the cases notified 55% were of the paralytic type (60 % in 1953). In Finland (Fig. 7), 790 cases (19 per 100 000 inhabitants) were recorded as against 316 in 1953. Only the total of 794 cases (21 cases per 100 000 inhabitants) reached in 1945 is higher than this figure. Of these cases,

FIG. 7. NOTIFIED CASES OF POLIOMYELITIS, BY MONTH: FINLAND, 1946-54

66% occurred in rural areas (80% in 1953). The proportion of paralytic cases remained high: 78 % of the notifications as against 85 % for the four last months of 1953. In spite of the generally high incidence, the counties (" Laani ") which had been severely stricken in 1953 were relatively free from the disease. These are the Aland Islands, where no case was notified, and the counties of Kuopio and Oulu. Three southern counties were seriously affected in 1954: Uusima (about 37 cases per 100 000 inhabitants), Kymi (32 per 100000 inhabitants) and Mikkeli (37 per 100 000 inhabitants) (Fig. 6). POLIOMYELITIS IN 1954 69

At Helsinki, in Uusima county, the morbidity-rate was 39 per 100 000 inhabitants (5 in 1953). In Denmark, the revised number of notifications (352, of which only 20 % were paralytic cases, with 4 deaths) remained much lower than during most of the preceding ten years. In 1953, 1591 notifications (86 deaths)

TABLE VI. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: DENMARK, 1950-54

Age-group (years)

<1 1-4 5-14 15-64 65+ total

number of cases 52 451 688 379 1 1571 1950 a percentage 3.3 28.7 43.8 24.1 0.1 100.0 attack-rate b 66.8 130.7 98.3 13.7 0.3 36.8

number of cases 10 58 195 119 1 383 1951 a percentage 2.6 15.1 50.9 31.1 0.3 100.0 attack-rate b 12.8 17.5 26.7 4.3 0.3 8.9

number of cases 146 1784 2213 1529 4 5676 1952 a percentage 2.6 31.4 39.0 26.9 0.1 100.0 attack-rate b 192.6 564.4 292.7 55.0 1.0 131.0

number of cases 44 397 659 490 1 1591 1953 a percentage 2.8 24.9 41.4 30.8 0.1 100.0 attack-rate b 56.6 129.8 84.8 17.5 0.2 36.4

number of cases 3 77 163 111 1 355 1954 c percentage 0.8 21.7 45.9 31.3 0.3 100.0 attack-rate b 3.9 25.5 20.6 3.9 0.2 8.1

a Final figures b Number of notifications per 100000 inhabitants of each age-group c Preliminary figures were recorded. In Jutland, stricken in 1953 by a serious epidemic (1161 cases), only 128 notifications (provisional figure) were recorded in 1954. The average attack-rate for the whole of the country did not exceed about 8 cases per 100000 inhabitants, as against 36 in 1953 and 131 in 1952. In 1954, only seven counties had an attack-rate of 10 to 20 cases per 100 000 inhabitants, whereas rates higher than 10 per 100 000 inhabitants were recorded in 1953 for each of the administrative divisions of the country (Fig. 6). Table VI shows the distribution by age-group of the total number of cases notified during the years 1950-54. 70 A. M.-M. PAYNE & M.-J. FREYCHE

Central Europe Poliomyelitis morbidity increased in 1954 by 21 % in the Federal Republic of Germany, by 46% in Austria, and by 113 % in Switzerland. In West Berlin, on the other hand, the situation remained stationary. Only in the Saar was any improvement recorded (27 notifications as against 89 in 1953). In the Federal Republic of Germany, 2713 notifications (5.5 per 100 000 inhabitants) were recorded in 1954 as against 2242 (4.6 per 100 000 in- habitants) in 1953 and 9517 (19.6 per 100 000 inhabitants) in 1952. Most of the " Lander" were affected by this increase, apart from Bremen and Hamburg, where the recorded incidence was lower than at any time during the preceding eight years, and in particular Schleswig-Holstein, where only 74 notifications were recorded as against 452 in the previous year. In Hessen (349 as against 99), the attack-rates were relatively high in the districts of Kassel (10.6 cases per 100 000 inhabitants) and Darmstadt (8.8 per 100 000 inhabitants). In North Rhine-Westphalia (655 notifications as against 230), the incidence was 8.6 cases per 100 000 inhabitants in the district of Munster. The highest rates were recorded in Bavaria and Lower Saxony: 18.9 cases per 100 000 inhabitants in Lower Bavaria, 14.5 in Upper Bavaria, and 14.2 in the district of Hanover (Lower Saxony) (Fig. 8). The distribution by age in the Federal Republic and in West Berlin is given in Fig. 9; it can be seen that children of 1-5 years, and especially those between 1 and 3 years old, seem to have been more particularly affected. For the Federal Republic as a whole, 230 deaths were attributed to poliomyelitis, i.e., 8.5 per 100 notified cases and 0.5 per 100 000 inhabitants, as compared with 8.3 per 100 notified cases (0.4 per 100 000 inhabitants) in 1953 and 7.7 per 100 notified cases (1.5 per 100 inhabitants) in 1952. It was only from the tenth four-week period on that the number of notifica- tions exceeded the figure for 1953, reaching its maximum during that period, a month later than in the two preceding years. According to Anders,' the average percentage of paralytic cases in the Federal Republic and West Berlin would seem to have been about 80% as against 82% in 1953 (these figures being calculated on the basis of 2142 cases in 1954 and 1379 cases in 1953). In Austria, the incidence had already risen in 1953. A further rise took place in 1954; 829 cases (89 deaths-provisional figure) were recorded (12 per 100 000 inhabitants as against 8 in 1953 and 3 in 1952). Distinctly higher figures had, however, been recorded in 1947 (3508 notifications, 315 deaths) and in 1948 (1064 notifications, 77 deaths). The recrudescence affected more especially Carinthia (28.6 cases per 100 000 inhabitants as against 7.4 in the previous year), Lower Austria (25.6 cases per 100 000 inhabitants as against 8.6), the district of Vienna (10.4 per 100.000 POLIOMYELITIS IN 1954 71

FIG. 8. DISTRIBUTION OF POLIOMYELITIS: FEDERAL REPUBLIC OF GERMANY AND WEST BERLIN, 1953-54

1954

bun,

Cases per 100 000 inhabitants

EaO.1-2.9 V3-5.9 E6-8.9 9-11.9 g 12-14.9 J 15-17.9 *18+

FIG. 9. POLIOMYELITIS, BY AGE: FEDERAL REPUBLIC OF GERMANY AND WESTi BERLIN, 1954 (RATES PER 100000 INHABITANTS) *

s0 gm

- -- -- .- ----. -- IA 3I ------|----.30

.--1

* Based on a diagram published by Anders I and used by kind permission of the author. 72 A. M.-M. PAYNE & M.-J. FREYCHE

FIG. 10. DISTRIBUTION OF POLIOMYELITIS: AUSTRIA, 1952-54

1 ' / '

1953

Cases per 100000 Inhabitants

Lij-0.1-3.9 4-7.9 811.9 12-15.9 16-19.9 20-28.9 24 + inhabitants as against 4.1) and the Tyrol (11.0 per 100 000 inhabitants as against 6.6). In Upper Austria; on the other hand, as well as in Styria, and especially in the Vorarlberg, the incidence dropped. The highest attack- rates were recorded in Carinthia and in Lower Austria (Fig. 10). For the country as a whole,-it-was-only- inB Octoberw-- that the peak of the seasonal outbreak was reached, this being very exceptional. POLIOMYELITIS IN 1954 73

FIG. 11. DISTRIBUTION OF POLIOMYELITIS: SWITZERLAND, 1952-54

Cases per 100000 inhabitants

El 0 El 0.1-9.9 m10-19.9 20-29.9 30-39.9 [ 40-49.9 E50-59.9 * 60+ 74 A. M.-M. PAYNE & M.-J. FREYCHE

In Switzerland, 1954 may be considered an epidemic year, 1628 notifica- tions, i.e., 33 per 100 000 inhabitants, being recorded as against 764 (16 per 100 000 habitants) in the previous year. One must go back to 1944 to find higher figures (1793 notifications, 41 per 100 000 inhabitants). The incidence was highest in the Cantons of Berne (70 cases per 100 000 inhabitants),

FIG. 12. NOTIFIED CASES OF POLIOMYELITIS, BY FOUR-WEEK PERIOD: SWITZERLAND, 1946-54

Zurich (51 per 100 000 inhabitants), St. Gallen (41 per 100 000 inhabitants), Zug (86 per 100 000 inhabitants), Obwald (76 per 100 000 inhabitants), and Schwyz (56 per 100000 inhabitants). In 1953, only the Canton of Glarus, with 140 cases per 100 000 inhabitants, recorded a higher rate than 40 (Fig. 11). For the whole of the territory of the Confederation, the maximum figures recorded during the period 1946-52 were exceeded throughout most of the year 1954 (Fig. 12). POLIOMYELITIS IN 1954 75 Western Europe

Poliomyelitis receded, on the other hand, in most of the countries of Western Europe, with the exception of Belgium and, above all, Scotland. In Luxembourg, no cases were recorded. In the Netherlands, only 74 cases were notified (0.7 per 100 000 inhabi- tants) as against 159 (1.5 per 100 000 inhabitants) in the previous year. These figures seem insignificant when compared with the totals notified during the two epidemic years 1952 (1712 notifications) and 1943 (1931 noti- fications). One must go back to 1937 to find such a low morbidity. In Belgium, the number of notifications was about the same as in 1953: 198 cases (2.2 per 100 000 inhabitants) as against 184 (2.1 per 100 000 inhabitants) (897 in 1952). A slight increase was noted in Hainaut, and in the provinces of Liege and Namur, but in the rest of the country the attack- rate was lower than in 1953. The majority of the cases notified in these three provinces occurred in the districts of Thuin and Charleroi (Hainaut), Li6ge and Verviers (Li6ge), and Philippeville (Namur). In France, the seasonal outbreak of 1953 continued, although in a milder form, until . The prevalence was subsequently low, being lower until August than that noted in 1953 but increasing suddenly in September. Altogether 1534 cases (3.5 per 100 000 inhabitants, 145 deaths) were noti- fied as against 1834 (4.2 per 100000 inhabitants, 240 deaths) for 1953. Most of the cases occurred in the Departments of the Seine, Nord, Seine- et-Oise, Morbihan, Bouches-du-Rhone, Loire-Inferieure, Aisne, Maine-et- Loire, Haute-Vienne, Charente, Dordogne, Pas-de-Calais, and Sarthe. The notification rates remained relatively low: in 72 Departments and the territory of Belfort (out of a total of 89), they were less than 5 per 100 000 inhabitants. The highest rates occurred in Morbihan (17), Haute-Vienne (11.1), Charente (11.1), Aisne (9.4), Basses-Alpes (9.4), Dordogne (9.2), Loire-Inf6rieure (8.7), Maine-et-Loire (8.4), Hautes-Alpes (8.2), Sarthe (7.3), and Deux-SRvres (7.3). Most of these Departments are grouped in the west centre of the country, with the exception of Aisne in the north and the two Departments of the Alpes in the south-east. In England and Wales, poliomyelitis incidence was lower than during the preceding five years. The number of confirmed cases was 1960 (4.4 per 100 000 inhabitants), as against 4547 (10.3 per 100 000 inhabitants) in 1953 and 3910 (8.9 per 100 000 inhabitants) in 1952. Representing 67% of the cases notified, the proportion of paralytic patients remained similar to that for previous years (650% in 1953, 70% in 1952). The notification rates decreased, more especially in the counties where the largest number of noti- fications had been recorded in 1953, namely Dorsetshire, Essex, Kent, Lancashire, London, Middlesex, Northamptonshire, Somersetshire, South- ampton, Surrey, Sussex (West), Warwickshire, Wiltshire, Yorkshire (West Riding), and Glamorganshire. Increases were, however, reported in County 76 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE VIl. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: ENGLAND AND WALES, 1950-54 *

- 1 - ______- ______Age-group (years)

<1 1-2 3-4 5-9 10-14 15-24 25+- unspe- total cified

number of cases 291 1249 1148 1728 908 1102 1295 31 7752 1950 percentage 3.8 16.1 14.8 22.3 11.7 14.2 16.7 0.4 100.0 attack-rate ** 41.7 79.2 56.3 32.0 19.2 4.5 17.7

number of cases 78 331 359 591 315 399 527 9 2609 percentage 3.0 12.7 13.8 22.6 12.1 15.3 20.2 0.3 100.0 attack-rate** 11.6 22.6 18.4 11.3 7.1 1.9 6.0

number of cases 135 584 570 976 379 510 742 6 3902 1952 percentage 3.5 15.0 14.6 25.0 9.7 13.1 19.0 0.1 100.0 attack-rate ** 20.6 40.5 27.9 13.5 9.2 2.6 8.9

number of cases 124 495 584 1219 516 645 935 20 4538 1953 percentage 2.7 10.9 12.9 26.9 11.4 14.2 20.6 0.4 100.0 attack-rate ** 18.6 39.7 33.6 18.0 11.6 3.3 10.3

number of cases 58 292 254 562 210 254 323 2 1955 1954 percentage 3.0 14.9 13.0 28.8 10.7 13.0 16.5 0.1 100.0 attack-rate** 8.7 20.6 15.3 7.1 4.6 1.1 4.4

* Confirmed cases, excluding cases recorded in Port Health Districts * Number of notifications per 100 000 inhabitants of each age-group

Durham (160 confirmed cases as against 70 in 1953), Northumberland (68 as against 29) and East Suffolk (27 as against 15). The highest attack- rates were noted in Yorkshire (East Riding) (16.2 cases per 100 000 inhabit- ants), County Durham (10.9 per 100 000 inhabitants), Westmorland (10.4 per 100 000 inhabitants), Isle of Wight (9.7 per 100 000 inhabitants), Gloucestershire (9.7 per 100 000 inhabitants) and Norfolk (9.3 per 100 000 inhabitants). Table VII probably gives a fairly correct picture of the actual distribution of the disease by age-group. In the country as a whole, poliomyelitis caused fewer deaths in 1954 than during preceding years: 112 deaths were attributed to it (5.7% of the notified cases, 0.3 per 100 000 inhabitants), as against 320 in 1953 (7 % and POLIOMYELITIS IN 1954 77

0.7 per 100 000 inhabitants), 275 in 1952 (7% and 0.6 per 100 000 inhabi- tants), and 191 in 1951 (7.3 % and 0.4 per 100 000 inhabitants). In Scotland, on the other hand, confirmed cases (421, i.e., 8.2 per 100 000 inhabitants), were more numerous than during each of the three preceding years. This figure may be compared with the annual totals known for the epidemic years 1947 (1434 confirmed cases) and 1950 (1112). A certain concentration of cases was noted only in September and October, particularly in the adjoining counties of Kincardine, Aberdeen and Banff in the north-east of the country. The final number of deaths was 21 (5 per 100 confirmed cases; 0.4 per 100000 inhabitants), as against 13 (3.5 per 100 confirmed cases; 0.3 per 100 000 inhabitants) for 1953 and 12 (5.5 per 100 confirmed cases; 0.2 per 100 000 inhabitants) for 1952. As in 1953, the maximum incidence occurred relatively late (during the eleventh four- week period of the year); during the epidemic years of 1947 and 1950, the peak was reached two months earlier. In Northern Ireland, 54 cases (3.9 per 100000 inhabitants), paralytic for the most part, were notified in 1954 as against 290 in 1953 (21 per 100000 inhabitants), this being the lowest figure since 1950. 17 cases occurred in County Antrim and 14 in Belfast. In the Republic of Ireland only paralytic cases are recorded. Of these there were 82 in 1954 (2.8 per 100 000 inhabitants) as against 245 (8.3 per 100 000 inhabitants) in 1953, which was one of three years with the highest incidence since 1940. Southern Europe The year 1954 was characterized by the most severe epidemic which has ever affected Greece; except in Portugal, the notification rates fell in comparison with the previous year. The slight recrudescence of poliomyelitis observed in Portugal did not affect the capital: only 15 cases (2 deaths) were notified in Lisbon as against 86 (14 deaths) for the remainder of the mainland, whereas in 1953 the provisional number of notified cases in the capital was 23 (6 deaths) and 66 (22 deaths) in the mainland provinces. The attack-rate remained low: about 1.3 final notifications per 100 000 inhabitants for 1954 as against 1.2 in 1953. Up to the present, the Portuguese mainland has suffered little from poliomyelitis. According to the final figures (available since 1936), the highest rates recorded so far were 2.9 and 2;6 cases per 100 000 inhabitants in 1939 and 1947 respectively. In the adjacent islands ( and Madeira), on the other hand, an epidemic is said to have occurred during the winter of 1954: 30 cases were observed in January, 33 in February, and 9 (2 deaths) in March, against none in 1953 and 22 during the six preceding years, for which data are available. The number of notifications in 1954 was 86 (5 deaths), i.e., about 14 per 100 000 inhabitants. 78 A. M.-M. PAYNE & M.-J. FREYCHE

FIG. 13. DISTRIBUTION OF PARALYTIC CASES OF POLIOMYELITIS: SPAIN, 1952-54

Paralytic cases per 100000 inhabitants r'

In Spain, 872 paralytic cases were notified, as against 936 in 1953 and 1584 in 1952. The provisional number ofdeaths was 81, as against 68 in 1953 and 115 in 1952. Half the total number ofcases occurred in seven provinces: Barcelona, Sevilla, Cordoba, Murcia, CQdiz, Guipuizcoa, and Mailaga. The average notification rate for the whole country was 3.0 paralytic cases per 100 000 inhabitants as against 3.3 in 1953 and 5.6 in 1952. The highest attack-rates were observed in the provinces of Guipuizcoa (8.7 paralytic cases per 100 000 inhabitants) Barcelona (8.5 per 100 000 inhabitants), Huesca (8.0 per 100 000 inhabitants), Soria (7.4 per 100 000 inhabitants), Almeria (6.5 per 100 000 inhabitants), and Cordoba (6.5 per 100 000 inhabitants). Alava, the Balearic Islands, and Logrofno Province remained untouched by the disease. The highest notification rate observed in 1953 had been in Cuenca Province (8.6 per 100 000 inhabitants). In 1952, the incidence had been particularly high in the five neighbouring southern pro- vinces, 39 paralytic cases per 100 000 inhabitants being noted in Almeria 38.9 in Cadiz, 29.0 in Granada, 19.0 in Cordoba, and 18.4 in Malaga (Fig. 13). POLIOMYELITIS IN 1954 79 Fig. 14 shows the distribution of poliomyelitis in Italy, by provinces, for 1953 and 1954. It will be seen that the notification rates receded in general, especially in the regions most stricken in 1953, i.e., Valle d'Aosta; the Provinces of Bergamo, Brescia, Mantua above all, and Varese, in Lombardy; the Provinces of Belluno, Padua, Rovigo, Verona in particular, and Vicenza, in Veneto; the Province of Savona in Liguria; in Emilia- Romagna; in the Provinces of Arezzo (in particular), Florence, Pisa, and Sienna in Tuscany; in the Province of Perugia in Umbria; in the Marches, Campania (Province of Caserta), Apulia (Province of Brindisi) and, finally, Sicily (Province of Enna). A notable recrudescence occurred in-the Pro- vinces of Sondrio (24 cases per 100 000 inhabitants as against 14 in 1953), Trento (19 as against 8), Campobasso (10 as against 2), Lecce (9 as against 5), Potenza (10 as against 4), Palermo (13 as against 6), and, more especially, in the three Sardinian Provinces (Cagliari, with 38 cases per 100 000 inhabitants as against 8 in 1953; Nuoro, 22 with 22 cases per 100 000 inhabitants as against 3; and Sassari, with 11 as against 2). The situation improved somewhat in the Provinces of Forli (Emilia-Romagna) and Brindisi (Apulia); but the attack-rate remained relatively high there (13 cases per 100 000 inhabitants). It remained more or less the same in the Province of Bari (Apulia). For the country as a whole, 3390 cases

FIG. 14. DISTRIBUTION OF POLIOMYELITIS: ITALY, 1953-54

Cases per 100000 inhabitants

01-2.9 E 3-5.9 6-8.9 9-11.9 12-14.9 15-17.9 18 + 80 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE Vil. NOTIFIED CASES OF POLIOMYELITIS, BY AGE-GROUP: ITALY 1950-53 *

Age-group (years)

un- <3 3-4 5-9 10-14 15-19 20-29 30-39 40-49 50+ speci- total fled

number of cases 1445 304 161 60 13 23 4 - 4 20 2034 1950 percentage 71.0 15.0 7.9 3.0 0.6 1.1 0.2 - 0.2 1.0 100.0 attack-rate * 40.8 4.3 1.4 0.3 0.3 0.1 - 0.0 4.4

number of cases 2063 456 183 70 29 21 2 1 - 42 2867 1951 percentage 72.0 15.9 6.4 2.4 1.0 0.7 0.1 - - 1.5 100.0 attack-rate ** 57.7 5.0 1.7 0.7 0.3 0.0 0.0 - 6.1

number of cases 1987 365 192 76 28 17 7 1 5 30 2708 1952 percentage 73.4 13.5 7.1 2.8 1.0 0.6 0.3 - 0.2 1.1 100.0 attack-rate * 53.9 5.2 1.8 0.7 0.2 0.1 0.0 0.0 5.7

number of cases 3166 883 598 170 77 44 12 6 - 54 5010 1953 percentage 63.2 17.6 11.9 3.4 1.5 0.9 0.3 0.1 - 1.1 100.0 attack-rate 92.8 16.2 4.1 1.9 0.6 0.2 0.1 - 10.41

* Excluding Trieste (former Zone A) ** Number of notifications per 100000 inhabitants of each age-group were notified in 1954 (7 per 100 000 inhabitants), as against 5028 in 1953 (10.4 per 100 000 inhabitants); the figures concerning the former zone "A " of Trieste (11 and 18 per 100 000 inhabitants in 1954 and 1953 respectively) are included in these totals. For the whole of the peninsula, despite the sharp drop in the notification rate recorded in 1954, monthly figures remained almost always higher than the median figures for the period 1946-52. Table VIII gives the avail- able information on the distribution of notifications by age-group. In Yugoslavia, where the incidence had been high in 1953 (715 final notifications as against 128 during the preceding year), the provisional number of notifications fell to 330, i.e., 1.9 per 100 000 inhabitants, the number of deaths remaining about the same (26 as against 25). This reduc- tion took place only in Croatia (56 %) and Slovenia (77 %), both of which were severely stricken in 1953; in the other republics there was, on the contrary, a slight increase. A serious epidemic occurred in Greece, however. The number of notifications rose to 1222 (20 deaths), or about nine times more than in 1953, and exceeded the total number of cases recorded during the five preceding years. This epidemic seems to have been preceded by an initial POLIOMYELITIS IN 1954 81

FIG. 15. NOTIFIED CASES OF POLIOMYELITIS, BY MONTH: GREECE, 1946-54

small-scale winter outbreak, which lasted from November 1953 to (49 notifications in November and 68 in December, as against 27 for the other ten months of 1953); the number of cases recorded subsequently increased rapidly, reaching a peak of 324 in (Fig. 15). The geographical distribution and the distribution by age-group are not known.

Oceania (Table I) Of approximately 2300 poliomyelitis cases notified in 1954 (2200 in 1953), 1999 occurred in Australia and 216 in the Hawaiian Islands. The others were recorded in New Zealand, Netherlands New Guinea, Guam, the Marshall Islands, and Nauru. In the Cook, , and Fiji Islands and in New Caledonia, where several cases had been recorded in 1953, the disease seems to have disappeared. Nor, as in 1953, is there any mention of it in the statistical tables published for the other islands of Oceania. 82 A. M.-M. PAYNE & M.-J. FREYCHE

FIG. 16. NOTIFIED CASES OF POLIOMYELITIS, BY FOUR-WEEK PERIOD: AUSTRALIA, 1946-54

In Australia, the disease took on epidemic proportions in the State of Victoria, in Western Australia, and in the territory of the Federal Capital. In the State of Victoria, where 27% of the population of the country lives (about 11 per kM2), the number of notifications was 582 (24 per 100 000 inhabitants). During the fifteen preceding years this figure was exceeded only in 1949, when 730 cases were notified. Western Australia contains only 7 % of the population and has a very low population density (0.3 per kM2); 456 cases were, however, registered there provisionally (72 per 100 000 inhabitants), this being the highest figure for this State since 1939. During the nine-year period, 1939-47, the total number of notifications never exceeded 59; in 1948, 312 cases were recorded; their number, however, had fallen to a few score per year over the period 1949-52. In the territory of the Federal Capital, where 1 case had been recorded in 1952 and I in 1953. 28 cases were notified, which represents a case-rate of 90 per 100000 inhabitants. The notification rates receded, however, in the other parts of POLIOMYELITIS IN 1954 83 the continent, especially in South Australia. For the whole of Australia, the number of notifications reached its peak (137) during the week ended 13 March. At the end of the year, the seasonal recrudescence was relatively moderate (105 notifications for the thirteenth four-week period of the year, as against 96 for the preceding period) (Fig. 16). It is interesting to note that the gathering of very large crowds in Western Australia in connexion with the visit of Queen Elizabeth IL and the Duke of Edinburgh in 1954 does not seem to have had any effect on the spread of the epidemic, and the fall which began just before the arrival of the royal couple continued without any interruption.34

FIG. 17. NOTIFIED PARALYTIC CASES OF POLIOMYELITIS, BY MONTH: HAWAII, 1948-54

In the Hawaiian Islands (Fig. 17), 216 cases were notified (144 paralytic; 1 death) as compared with 55 (45 paralytic; 2 deaths) in 1953. Only in 1952 was a similar number of paralytic cases observed (156), but then 14 deaths occurred. The notification rates recorded were as follows: 29 per 100 000 84 A. M.-M. PAYNE & M.-J. FREYCHE inhabitants in Honolulu; 127 in the rural part of Oahu Island; 39 in Maui Island (all paralytic), and a few cases in the islands of Lanai, Kauai, and Hawaii.

PREVALENT TYPES OF POLIOVIRUS Africa (Table IX) Angola 27 (C. Placido de Sousa-personal communication) 1953 was an epidemic year. Three viruses were isolated, one type 1, one type 2, and one unidentified. Egypt 38 (C. B. Galloway and D. Horstmann-personal communications) In 1955, 88 strains were isolated from cases diagnosed as paralytic poliomyelitis; 27 were type 1, 44 type 2, and 11 type 3. Types 1 and 2 were isolated during the period February-July, the greatest number being in June and July. Type 3 was relatively scarce apart from June and July, but further studies are needed to interpret both this and the predominance of type 2. Attention was also called to the importance of viruses other than poliovirus isolated from cases with clinical pictures indistinguishable from paralytic poliomyelitis. A comparison of the relative frequency of the three types of poliovirus isolated from paralytic cases with that shown in a survey of normal infants during the same period in the same area is of some interest. In paralytic cases yielded 11, 22, and 5 strains of types 1, 2, and 3 respectively; whereas normal children yielded 3, 2, and 11 respectively. Type 3 was thus relatively more frequently isolated in normal children.

South Africa (J. H. S. Gear-personal communication) In 1954, type 1 virus was responsible for the outbreak in Kenya. Type 3 was prevalent in Southern Rhodesia. In the Transvaal (Union of South Africa), all three types were present, type 1 predominating. In Johannesburg (Union of South Africa), three waves of infection were noted, the first early in the season due to type 3, the second in midsummer due to type 2, and the third in autumn due to type 1. The outbreak in Port Elizabeth (Union of South Africa) was predominantly due to type 2.

America (Table IX) Canada Fig. 18, prepared by Dr A. J. Rhodes (personal communication), shows the distribution of poliovirus types isolated in Canada between 1947 and POLIOMYELITIS IN 1954 85

FIG. 18. DISTRIBUTION OF POLIOVIRUS TYPES ISOLATED IN CANADA, 1947.55*

0 Reproduced by kind permission of Dr A. J. Rhodes.

1955. It will be noted that throughout this period type 1 predominated and only two type 2 strains were isolated. Additional information confirms that type 1 predominated in Montreal in 1954 and 1955 (V. Pavilanis-personal communication). However, in Nova Scotia in 1955, type 3 predominated (F. P. Nagler & S. F. Kitchen -personal communication). In Ontario in 1955, types 1 and 3 were about equally prevalent (11 and 15 isolations), and 6 strains of type 2 were also isolated (N. A. Labzaffsky-personal communication). In Manitoba also both types 1 and 3 were present (J. C. Wilt-personal communication).

Latin America (G. Contreras-personal communication) In 1953-54 90 strains of poliovirus were isolated in Santiago, Chile, 80 % of which proved to be type 1. In an outbreak in February-March 1954 in a city in the south of the country, 4 type 1 viruses were isolated from 15 specimens; two unidentified viruses were also isolated. Of 160 strains isolated during the severe epidemic in Chile in 1955-56, 80% were type 1. From the 1956 outbreak in Argentina, 14 type 1 and 2 type 2 strains have been isolated. 86 A. M.-M. PAYNE & M.-J. FREYCHE

In 1955, 10 strains from Sao Paulo, Brazil, were studied; 6 were type 1, one type 2, and 3 type 3. About 300 strains in all have been isolated from patients, mostly in Chile; 90% were poliovirus, of which 80% were type 1, 15 % type 2, and 5% type 3. The remainder have not yet been further identified.

United States of America

A considerable body of information is available from the USA for 1954 and 1955, partly as a result of the 1954 poliomyelitis vaccine field trial and partly through studies undertaken in connexion with the large-scale applica- tion of vaccination in 1955. In the Summary Report of the field trial 28 isolation of 423 strains is reported in the areas involved in the trial; 235 (55 %) were type 1, 53 (13 %) type 2, and 135 (32 %) type 3. The data given in the Summary Report do not, however, make it possible to identify the relative preponderance of the three types in the different areas. Other information tabulated for 1954 includes certain figures gathered in connexion with the field trial but contains additional data. The total number of strains recorded for 1954 by the sources cited is 574, of which 215 (38%) were type 1, 65 (11 %) type 2, and 294 (51 %) type 3. The apparent excess of type 3 over the figures for the field trial would doubtless be reduced if the figures for New England could be included, for which only combined figures for 1954-55 are at present available. This serves to illustrate the danger of sampling error in determining the prevalence of types. It does, however, appear that type 3 was unusually prevalent in 1954. How often this occurs is not known, but according to the fragmentary information reported last year a similar prevalence of type 3 may have occurred in 1950, at least in the north central States and in Massachusetts. For 1955 the total strains recorded (excluding New England) number 1152, of which 899 (78%) were type 1, 87 (8%) type 2, and 166 (14%) type 3. This approximates to the proportions more usually quoted. In our last report,7 for example, 84 % of 2200 strains were type 1, 7 % type 2, and 9 % type 3. The distribution of virus types in 1954 reveals that in the north-east of the country in general type 1 predominated, whereas type 3 predominated in Kentucky, Utah, and Washington. In most parts of the country both viruses were prevalent, and in some areas, notably Illinois, type 2 infections were quite frequent. In 1955, type 1 predominated in most parts of the country, particularly in the north-east and in Illinois and Kentucky. In the south and in most central states type 3 was also prevalent, though generally to a lesser extent. In Louisiana, Mississippi, and Minnesota type 2 was isolated about as frequently as type 3. POLIOMYELITIS IN 1954 87

Asia (Table IX)

India - Greater Bombay (P. V. Gharpure-personal communication) Virus isolations, most of them in the years 1953-55, totalled 77. Of these, 56 were type 1, 8 type 2, and 4 type 3. The study of 9 viruses is not yet complete.

Israel2 (H. Bernkopf-personal communication) In the years 1951-54 type 1 virus has predominated, types 2 and 3 each having been isolated once only. In 1955, type 1 was again predominant (60%) but type 2 was present in 16% and type 3 in 8 % of 50 isolations. 8 strains have not yet been further identified.

Europe (Table IX) Belgium 31 The relative frequency of the three virus types in 1954 has been estimated by studying 49 distinct foci comprising a sick person and his family. The figures given do not therefore represent the actual numbers of viruses isolated. The great majority (71 %) of foci resulted from infection with type 1 virus. Types 2 and 3 were responsible for the remainder, the latter being about twice as frequent as the former. The epidemic in the region of Charleroi was due to type 1.

Denmark (H. von Magnus-personal commumncation) The severe outbreaks in 1952 and 1953 were due to type 1 virus. A very low incidence followed in 1954 and 1955. In 1954 only type 1 was isolated, and in 1955 all three types were isolated from the 9 of 13 paralytic cases who had virus in their stools. In the other 4 cases facial palsy was the only paralysis.

England and Wales 8 (F. 0. MacCallum-personal communication) The final analysis of strains of poliovirus isolated in 1953 from appar- ently unrelated cases of paralytic poliomyelitis occurring in England and Wales, and investigated at the Virus Reference Laboratory, was: 38 (42.7 %) type 1; 43 (47.2%) type 2, and 9 (10.1 %) type 3. The type 3 cases were all from the north of England, whereas the other two types were fairly evenly distributed. The same method of study of apparently unrelated paralytic cases in 1954 showed a marked shift from 1953. Five strains isolated from paralytic 88 A. M.-M. PAYNE & M.-J. FREYCHE cases from January to June were type 1. Of 30 strains isolated from cases of paralytic poliomyelitis from 1 July to 31 December, 27 were type 1, 3 type 2, and none was type 3. Each of these was a single case or repre- sented a small localized outbreak from which other strains of the same type were isolated. All six strains from the north of England were type 1. Poliomyelitis virus type 1 was isolated from only four of 23 cases of typical non-paralytic poliomyelitis in 1954. In 1955 no organized investigations were carried out, but from the material sent for diagnosis from patients in the southern half of England and Wales, 11 strains of type 1, 2 of type 2, and 17 of type 3, of which 5 were from fatal cases, were isolated. A similar finding is reported from London and Cardiff (J. A. Dudgeon, A. J. H. Tomlinson, and A. D. Evans-personal communications), both types 1 and 3 being prevalent, whereas type 2 was isolated once only. Limited observations in Sheffield, on the other hand (C. H. Stuart-Harris- personal communication), did not reveal the presence of type 3 virus. In the Cambridge area all three types were isolated, type 2 being detected in one town early in the season, and types 1 and 3 in other areas, mainly from September onwards.

Finland (N. Oker-Blom-personal communication) 200 strains of poliovirus have been isolated in the years 1953-55. In all three years type 1 has been predominant, although in 1954 and 1955 a few type 2 strains were recovered in Helsinki and Turku. No type 3 strain had been isolated before 1956, when one strain has so far been isolated. 81 strains of viruses other than poliovirus have also been isolated in human fibroblast cultures from paralytic (17) and non-paralytic (25) cases, the remainder originating from healthy persons (35) or persons with other diagnoses (4). These viruses have not yet been further identified.

France. In the 3-year period 1953-55, 270 strains were isolated at the Institut Pasteur, Paris.20 In 1953 and 1954 types 1 and 2 were approximately equally prevalent, type 3 being found in 6%-9%. In 1955 there was a marked change, type 2 being found only in 7% as against 42%-50% in previous years and type 3 being present in 17 %. Type 1 was found in 72 % as against 40% in 1953 and 1954. A few untypable strains were isolated from non-paralytic cases and contacts. It is of interest to note that the distribution ofvirus types among paralytic and non-paralytic cases is practically identical, but that this differs very considerably from the distribution among contacts, type 2 being much more frequently found among them. POLIOMYELITIS IN 1954 89 The data reported in the reference cited do not make it possible to subdivide the type 2 isolations both by clinical status and by year. It may be that a larger number of symptomless contacts was examined during the years 1953-54, and that type 2 virus was frequently isolated from them. Thus the annual figures cited do not necessarily represent the relative proportion of types responsible for clinical disease. It will be noted that the over-all figure indicates that type 1 was responsible for two- thirds of clinical cases. The viruses reported by R. Debre, J. Celers & V. Drouhet-personal communication-were isolated from patients in the HOpital des Enfants malades, Paris. The majority of the patients came from Paris and its en- virons, but a few serious cases came from the provinces or the Union fran9aise. In 1954 type 1 virus predominated but types 2 and 3 were also isolated, mainly in Paris and Bagneux. In 1955 type 1 was again predominant but type 3 was considerably more prevalent than in the previous year, mainly outside Paris itself. In Paris type 2 was isolated sporadically, with type 1 predominating. Germany North Rhine- Westphalia 10 (W. Kikuth & W. Hennessen-personal communication) In 1954-55, 880 patients were classified according to the presumed type of infecting virus on the basis of complement-fixation test results; 63 % were considered to be due to type 1 virus, 25 % to type 2, and 12 % to type 3. Marburg-Giessen (R. Haas-personal communication) In 1954 type 3 predominated, whereas in 1955 type 1 was most frequently isolated, but all three types were isolated in each year. Hamburg-Bremen 14, 19 (H. Pette & H. Lennartz-personal communica- tion) In 1953 in Hamburg both types 1 and 3 were prevalent whereas in Bremen type 1 only was isolated. In Hamburg in 1954 all three types were isolated, type 2 being recovered most frequently from paralytic cases. The incidence was low in Hamburg in 1954. In the other areas tabulated type 1 was most frequently isolated in both 1953 and 1954. In 1955 all three types were isolated in the north-western part of the country whereas in the south type 1 predominated. Iceland (B. Sigurdsson-personal communication) There were few cases of poliomyelitis in 1953 and 1954 and no virus isolations were made. In 1955 there was a severe epidemic in Reykjavik 90 A. M.-M. PAYNE & M.-J. FREYCHE

apparently due to type 1. Towards the end of the year and early in 1956 there were two localized outbreaks of disease resembling but not typical of poliomyelitis, about one-quarter of the cases showing some degree of paralysis. No poliovirus could be isolated and it is believed that these outbreaks were not due to poliovirus.

Republic of Ireland (P. N. Meenan-personal communication) The limited information available refers mainly to the eastern half of the country. 1953 was a year ofhigh prevalence. Type 1 virus predominated. In 1954 and until the incidence was low. During this period 5 type 2 strains were isolated and one type 1. The increased incidence of disease in the last quarter of 1955 was associated with a preponderance of type 1.

Italj Tuscany 36, 37 (R. Davoli-personal communication) In 1953 infections due to type 1 were prevalent among paralytic cases. Since this was an epidemic year the probability of detecting the epidemic strain was high as compared with that of isolating viruses causing sporadic cases. Although there is the possibility of sampling error, the results suggest a type 1 epidemic, at least in Florence. In 1955 all three types of virus have been isolated from paralytic cases. This was not an epidemic year and the figures therefore reflect the endemic distribution of viruses. However, there appears to have been a localized type I outbreak in the town of Livorno.

Northern Italy 22 (A. Giovanardi-personal communication) In the years 1953, 1954 and 1955, type 1 virus has most commonly been isolated from paralytic cases. However, in Lombardy in 1953 and 1955 type 2 was also prevalent. Type 3 has been detected in only 3 of 195 cases. Rome and surrounding area (I. Archetti and T. De Sanctis Monaldi- personal communications) In 1955 a total of 17 strains af type 1, 3 type 2, and 1 type 3 viruses were isolated. Thus there was less type 2 than in Tuscany and Lombardy. Trieste (I. Archetti-personal communication) The outbreak in Trieste in 1955 was due to type 1 virus. Palermo 24 (G. Alessandro & F. G. Oddo-personal communication) The outbreak in 1954 was due to type 1 virus. POLIOMYELITIS IN 1954 91 Netherlands 11 (J. D. Verlinde-personal communication) The distribution of virus types in the Netherlands has been studied in some detail. 1954 was a year of very low incidence and during the disease year (April-April) only type 3 was isolated. In 1955 the morbidity rate was 4.4 per 100 000 population. Type 2 virus was predominant in the provinces of Overijssel, Gelderland, and Limburg. The data for the neigh- bouring area of Germany is limited, but all three types were excluded. hi the southern parts of the province ofNoord Brabant both types 1 and 2 werd prevalent. In the province of Zuid Holland types 1 and 2 were prevalent, but type 1 predominated in the cities of Rotterdam and Dordrecht. In the country as a whole type 2 was predominant in July, August, and Septemberg whereas type 1 was the predominant virus in November and December, This appears to have been due to the rather late type 1 outbreak in Rotter4 dam and Dordrecht, which occurred when the infection due principally tq type 2 virus was subsiding in the eastern part of the country.

Norway (O. Lahelle-personal communication) In 1952 type 1 virus only was isolated (25 strains). In 1953 type 3 predominated but type 1 was also present. In 1954 and 1955 both types 8 and 3 were prevalent. Type 2 has only been recovered 4 times in a total of 100 isolations in 4 years. The specimens were obtained from patients admitted to hospitals in the southern part of Norway. In 1955 almost all isolates, including 30 ECHq viruses, have been obtained from patients with aseptic meningitis.

Sweden 35 (G. Olin and A. Svedrmyr-personal communications) The severe epidemic of poliomyelitis in Stockholm in 1953-54 wa caused by type 1 virus. A total of 395 type 1 strains were recovered. Ir the period May- all three types, were recovered. There were few paralytic cases during this period. In 1955 type 1 again predo4 minated, but the incidence remained low. Numerous ECHO viruses have been isolated, mainly from cases of aseptic meningitis. About 70 % of these seem to be related to ECHO type 6.

Switzerland In 1955, type 1 virus was prevalent in Geneva (E. Grasset & V. Bonifas24 personal communication). In Berne and Zurich, type 1 was also prevalent in the second half of the year, although all three types were isolated (U. Krech and J. Lindemann-personal communications).

7 92 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

type Area Cases,specimens,Poliovirus Year a es tpc.mnetc. ~~1 23

AFRICA

Angola 1953 1 1

Egypt: Cairo 1955 27 44 17

Egypt: Cairo July 200 specimens 3 2 11 1955

Kenya 1954 |_11 l

Southern Rhodesia 1953 2 1954 4

Union of South Africa: Transvaal 1953 4 1 7 1954 34 9 17

Union of South Africa: Cape Province 1953 1 1954 5 15 1

Union of South Africa: Johannesburg 1953 Oct. 1 Nov. 1 Dec. 1 1 1954 Jan. 1 3 Feb. 2 2 1 March 1 6 2 April 4 1 May I June 1

Union of South Africa: Port Elizabeth 1954 Jan. 4 1 Feb. 1 1 March 1 5 April 3 May 1 June 2 2 (type not specified) Union of South Africa 200

Personal communication POLIOMYELITIS IN 1954 93

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS

Other viruses Other information Source

AFRICA

1 Epidemic year C. Placido de Sousa " |

11 88 polioviruses isolated. Most cases be- C. B. Galloway tween 1-2 years. Highest incidence in June- July.

96 Rectal swabs trom " normal" afebrile chil- D. Horstmann dren aged 5-24 months.

J. H. S. Gear*

J. H. S. Gear*

3 J. H. S. Gear,*

J. H. S. Gearv

J. H. S. Gear*

J. H. S. Gear-

20 Coxsackie B; Meningo-encephalitis diagnosed as abortive J. H. S. Gear* 8 Coxsackie A; poliomyelitis. 17 mumps; 3 herpes 94 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Area Year Cases, specimens, Poliovirus type etc. 1 23

AMERICA

Argentina 1955-56 39 specimens 14 2

Brazil (Sao Paulo) 1955 10 strains 6 1 3

Canada 1947-55 176 isolations 164 2 10

Canada: Montreal 1954 35 isolations 33 1 1 1955 20 isolations 15 1 1

Canada: Ontario 1955 15 paralytic 3 1 4 143 non-paralytic 8 5 11

158 cases 11 6 15

Canada: Manitoba 1955 12 paralytic 1 20 non-paralytic

32 cases

Canada: Specimens from: 1955 British Columbia 23 2 Ontario 34 2 1 Quebec 18 New Brunschwick 2 Nova Scotia 116 4 1 25 Prince Edward !sland 10 Other 3 1

206 specimens 9 2 25

Chile: Santiago 1953-54 90 strains 80 %

Chile: Southern Chile Feb.-March 15 4

Chile 1955-56 160 strains 80%

* Personal communication t In most instances, " not typed " indicates that attempts at typing were unsuccessful in a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 95

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses t Other information Source

AMERICA

3 G. Contreras *

G. Contreras & R. Mouva *

These flgures do not include those tabulated A. J. Rhodes below.

25 type 1 viruses came from the Chicoutimi V. Pavilanis area, Quebec Province, where there was an 3 ECHO outbreak. Most viruses were isolated from clinical poliomyelitis, save 1 of type 1 from an 18-months-old child with " gastro- enteritis ". 3 ECHO = 2 meningitis, 1 para- lytic poliomyelitis.

1 ECHO N. A. Labzaffsky * 2 Coxsackie; 20 ECHO 1955 epidemic was mild without unusual features.

J. C. Wilt Serological evidence of type 1 infection was obtained in 3 paralytic cases and of type 3 infection in one.

1 ECHO S. F. Kitchen & 5 Coxsackie; 1 ECHO F. P. Nagler*

1 Coxsackie; 22 ECHO 8 ECHO

G. Contreras

2 Sharp outbreak in a city 900 km south of G. Contreras* Santiago

Severe epidemic G. Contreras * 96 A. M.-M. PAYNE & M.-I. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

| Area | Year Cases, specimens, Poliovirus type etc. ~~1 23 AMERICA (continued)

USA: New England 1954 & 1955 291 197 5 14

USA: Massachusetts 1954 paralytic cases 6 1 6 non-paralytic cases 1 2 7 1 8

1955 68 paralytic cases 67 1 64 non-paralytic cases 59 3 2 43 unknown 42 1 175 168 5 2

USA: Massachusetts (Boston) 1955 32 patients 21

USA: Connecticut 1955 52 paralytic not vaccinated 41 2 1 6 paralytic vaccin- ated 4 93 non-paralytic not vaccinated 30 1

45 non-paralytic vaccinated 5 196 specimens 81 2 2

USA: Syracuse, N.Y. 1954 & 1955 90-95% 3 3-5%

USA: Pennsylvania and New Jersey 1954 171 4 29 1955 147 63 21 USA: District of Columbia and neighbouring areas of Maryland and Virginia 1955 63 cases 25 1 108 contacts l

* Personal communication t In most Instances, " not typed" Indicates that attempts at typing were unsuccessful; in a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 97

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses t Other information Source

AMERICA (continued)

41 ECHO (26 ECHO-6); The polioviruses were obtained from pa- J. L. Melnick, 4 Coxsackie A; tients with paralysis and from those with E. P. Davidson & 19 Coxsackie B; aseptic meningitis. Patients yielding ECHO D. C. Davis * 11 not typed + Coxsackie viruses were characterized by the aseptic meningitis syndrome.

54 (5 Coxsackie; Of 37 patients with ECHO-6 infections, 22 S. Kibrick' 2 ECHO-2; 1 ECHO14; were classed as paralytic but only 1 had a 4 adenovirus; muscle score over 20 according to the 40 ECHO-6; 2 not typed) criteria used in the 1954 field trial."

3 adenovirus; All " other " viruses were from patients diag- 6 Coxsackie; 2 not typed nosed as non-paralytic poliomyelitis.

Results of virus isolations from a group of K. Habel & fatal cases in the 1955 Boston outbreak. A. Shelokov

Of the 52: 1 ECHO-6; The 3 patients yielding "other" viruses J. L. Melnick & 1 Coxsackie A9; believed to be also poliomyelitis infections D. C. Davis* 1 Coxsackie B on serological grounds.

Of the 93: 10 ECHO-6; 1 Coxsackie A9; 9 Coxsackie B; 5 not typed Of the 45: 14 ECHO-6; 4 Coxsackie B; 2 not typed Only specimens collected within 3 weeks of onset are included. ECHO-6 includes ECHO-6'. Most patients were under 20 years old and S. S. Kalter most were non-paralytic. " Orphan " viruses were isolated from 40% of clinically diag- nosed poliomyelitis cases, some of which were paralytic. Coxsackie B and 12 untyped viruses isolated K. Hummeler from cases of clinical poliomyelitis.

Isolations carried out for poliomyelitis sur- K. Habel & veillance unit. A. Shelokov 6 not typed ll 98 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Poliovirus type AreasYC specimens, Year |: ~~~Area | a es tpc.mneetc. 1 ~~ ~~~23

AMERICA (continued)

USA: Washington, D.C. 1955 37 cases

USA: Tennessee 1954 24 4 1

USA: Kentucky 1954 27 7 87

USA: Kentucky and 1955 17 4 2 southern Indiana

USA: Illinois 1954 177 37 15 18 1955 94 paralytic 55 6 2 213 non-paralytic 38 4 6 141 suspected poliomyelitis 5 225 contacts 54 6 152 10 14

USA: Michigan 1953 10 paralytic 19 non-paralytic 29 141 1954 57 paralytic 25 2 20 80 non-paralytic 11 4 7

137 36 6 27

USA: Minnesota (State 1953 394 385 1 8 Board of Health and De- partment of Bacteriology 1954 10 6 2 2 and Immunology, Univer- sity of Minnesota) April-Dec. 191 paralytic 81 14 21 1955 266 non-paralytic 20 7 5 441 96 20 25

USA: Specimens from: 1955 15 paralytic 7 6 Iowa (3), Nebraska (12), 13 non-paralytic 5 1 4 Kansas (15), Oklahoma 72 unknown 35 6 19 (87), and Missouri (138) _ __ 100 isolations 47 7 29 255 specimens * Personal communication t In most instances, " not typed" indicates that attempts at typing were unsuccessful; in a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 99

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other virusest Other information Source

AMERICA (continued)

1 Coxsackie A; 1 poliovirus of unspecified type was isolated. K. Habel & 9 Coxsackie B (4 B2, 4 B3); All isolations from non-paralytic polio- A. Shelokov 1 adenovirus; 11 not typed myelitis and aseptic meningitis.

M. M. Lipton & A. J. Steigman*

M. M. Lipton & A. J. Steigman *

M. M. Lipton & A. J. Steigman*

7 not typed H. J. Shaughnessy* 3 not typed 23 not typed 4 not typed 5 not typed 35 not typed

G. C. Brown

G. C. Brown* 6 Coxsackie A 4 Coxsackie B 1 ECHO 11 Cases from 10 counties participating in vaccine field trial.

J. T. Syverton *

16 paralytic and non-paralytic patients were studied by both laboratories. Corrected totals.

2 not typed H. A. Wenner * 3 not typed 12 not typed 17 not typed 100 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Poliovirus type Area Year Cases, specimens, etc.etc. 1 2 3 AMERICA (continued)

USA: North Dakota 1954 5 2

1955 90 specimens 4 1

USA: Arkansas 1955 43 paralytic 10 1 6 37 non-paralytic 4 1

1 ~~~~~14 7 ______~~~~~ USA: Mississippi 1955 41 paralytic 5 5 55 non-paralytic 154 2 2 19 7 7

USA: Louisiana 1954 paralytic and 6 3 8 non-paralytic 1955 170 paralytic 65 20 33 168 non-paralytic 26 4 12 91 24 45

USA: Specimens from: 1954 43 paralytic 16 7 Montgomery, Ala.; Char- 105 non-paralytic 12 6 leston, S.C.; Broward, Fla.; - Palm Beach, Fla. 148 specimens 28 13

USA: Specimens from: 1955 45 paralytic 22 6 4 North Carolina, Tennes- 480 non-paralytic 64 19 see, Georgia, New Mexico, 558 suspected cases West Virginia, Alabama, or contacts 38 9 South Carolina, Florida, - -_ - Indiana 1083 specimens 124 6 32

USA: Utah 1954 118 14 | 12 91 Colorado 13 3 6 4 Wyoming 7 3 2 2 137 specimens 20 20 97 37 paralytic 8 8 21 19 non-paralytic 2 5 12 6 unknown 6 75 contacts 10 7 58

USA: Washington July-Dec. 36 paralytic 8 4 18 County Hospital, Seanle)(King, 1954 g 1 ~~~30non-paralytic 1 1 1 1 1 5 66 cases 9 5 23

v Personal communicatlon t In most Instances, " not typed " Indicates that attempts at typing were unsuccessful; In a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 101

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses t Other information Source

AMERICA (continued)

All except one were non-paralytic cases in R. G. Fischer * children of 1st 3 school grades in vaccine field trial. 90 patients suspected of poliomyelitis. 2 of 5 isolates from paralytic cases.

4 not typed J. P. Fox, L. Potash & 11 not typed H. M. Gelfand *

3 not typed J. P. Fox, L. Potash & 11 not typed H. M. Gelfand

1 not typed In neither year was there a notable polio- J. P. Fox, L. Potash & myelitis epidemic in this area. These results H. M. Gelfand reflect essentially endemic conditions. 16 not typed 47 not typed l

S. S. Kalter0 4 Coxsackie

26 = 58 % positive S. S. Kalter 16 Coxsackie 89 = 19 % positive 9 not typed 47 = 8 % positive

L. P. Gebhardt

1 Coxsackie Poliovirus type 2 was also recovered from Kirby & Evans " later stool specimens of the paralytic case 13 Coxsackie yielding Coxsackie. 14 (13 B2, 1 B4) Adults with a diagnosis of poliomyelitis 102 A. M.-M. PAYNE & M.-J. FREYCHIE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES Poliovirus type Area Year CaCae,seies es,spcimn.etc. 1 ~~ ~~~~23

AMERICA (continued)

USA: Specimens from: 1951-53 Charleston, W.Va. 16 2 Phoenix, Ariz. 10 4 18

USA: Poliomvelitis vaccine 1954 Observed areas: field trial areas vaccinated 14 2 4 control 114 34 63 others 7 2 13 Placebo areas: vaccinated 13 2 control 39 6 25 others 48 9 28 235 53 135

ASIA

India: Greater Bombay 1953-55 477 56 8 4

Israel 1951-54 70 isolations 54 1 1955 50 isolations 30 8 4

Viet-Nam: Saigon 1952-55 18 cases 11 1

EUROPE

Belgium 1954 49 foci 35 5 9

Denmark 1955 13 paralytic + +

England and Wales 1953 90 38 43 9

Jan.-June 1954 paralytic 5 July-Dec. 1954 30 paralytic 27 3 35 32 3 23 non-paralytic 4 2

Personal communication t In most Instances, " not typed " indicates that attempts at typing were unsuccessful; in a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 103

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses t Other information Source

AMERICA (continued)

Isolations in course of longitudinal study. J. L. Melnick, No clinical poliomyelitis. Endemic situation. E. P. Isaacson & M. Walton

Poliomyelitis Vaccine Evaluation Center""

Some of these are included in other reports |______|tabulated above. ASIA

9 not typed P. V. Gharpure *

14 not typed 18 specimens contained both poliovirus and H. Bernkopf' Coxsackie virus. 8 not typed H. Bernkopf*

4 not typed R. Netter* 2 Coxsackie

EUROPE

The epidemic in Charleroi was due to type 1. Quersin-Thiry & Dekegel 3

In 1954, type 1 only was isolated. In 1955, 9/13 H. von Magnus * had poliovirus in stools. All three types were represented. Incidence was very low in 1954 and 1955.

All type 3 strains came from northern Goffel and England. The other two types were fairly F. 0. MacCallum* evenly distributed. 6 strains from northern England in 1954 were all type 1.

2 not typed 2 non-paralytic cases were diagnosed as current type 1 poliovirus infection after neutralization test. 104 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Area 1 Year ~~Cases, specimens, Poliovirus l | etc. | 1 2 typel 3

EUROPE (continued)

England and Wales: 1955 30 11 2 17 Southern half

1953 3 specimens 3 England and Wales: London (St. George's Hospital) 1954 2 paralytic 1 1 non-paralytic 1 1 3 isolations 1955 79 specimens 25 paralytic 13 1 11 14 non-paralytic 10 4 39 isolations

England and Wales: London Sept.-Dec. 27 7 (tounty Hall) 1955

England and Wales: 1955 paralytic 4 2 4 Cambridge area non-paralytic 2 1

England and Wales: Oct.-Nov. paralytic 3 2 Cardiff area 1955 non-paralytic 5 1

England and Wales: 1955 7 encephalitic 6 1 Sheffield 2 bulbar 1 1 2 paralytic 1 1 11 8 3

Finland: Specimens from: 1953 Helsinki 15 paralytic 5 11 non-paralytic 5 1 10 other 36 10 1 Aland Islands 35 4 45 ~~~~~5

Finland: Specimens from: 1954 Helsinki 116 paralytic 64 1 11 60 non-paralytic 14 13 8 other 2 184 78 1 26 Aland Islands 3 7 Turku 19 3 12 Kuhmoinen 1 101 4 45

*Personal communication POLIOMYELITIS IN 1954 105

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses Other information Source

EUROPE (continued)

Goffe $ and F. 0. MacCallum

3 fatal cases J. A. Dudgeon & A. M. Peach

Sporadic, localized outbreak in South-West London.

Only one isolation recorded in any group of related cases. A. J. H. Tomlinson *

Type 2 isolated in July-August; type 1 in P. J. Wormald * September-November: type 3 in August- September-November.

| A. D. Evans

C. H. Stuart-Harris *

H. Oker-Blom

Severe poliomyelitis outbreak in Aland Islands.

H. Oker-Blom I 106 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES i~~~~~~~~~~~~ Poliovirus type Area Year AreaPCases,(contnetc.specimens,) |_ 2 _3 1 ~~1 1

EUROPE (continued)

Finland: Specimens from: 1955 Helsinki 46 paralytic 31 6 47 non-paralytic 14 2 11 12 other 2 115 45 3 19 Tornio 11 Aanekoski Varkaus 47 3 31

France 1953-55 744 specimens 1953 68 isolations 29 30 4 1954 87 isolations 35 43 8 1955 115 isolations 83 8 20 270 isolations 112 paralytic 73 19 20 67 non-paral'tic 44 10 9 91 contacts 30 52 3

France: Paris (H6pital des 1954 172 cases Enfants malades) 44 paralytic 34 8 2 3 non-paralytic 2 1 17 contacts 9 5 3 64 isolations i45 14 5 1955 221 cases 65 paralytic 39 7 19 2 non-paralytic 2 14 contacts 12

0~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 81 isolations 53 8 20

Germany: 1954 364 examinations 197 87 31 Nordrhein-Westfalen

Germany: 1954-55 880 554 221 104 Nordrhein-Westfalen

Germany: Marburg-Giessen 1954 28 stools 13 isolations 1 3 7 1955 56 stools 13 isolations 9 1 2

Germany: Hamburg and Bremen 1953 15 9 6

* Personal communication t In most instances, " not typed " indicates that attempts at typing were unsuccessful; in a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 107

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other virusses 1 Other information Source

EUROPE (continued)

H. Oker-Blom

5 All untyped strains isolated from non-para- Lepine, Barski & 1 lytic cases or contacts. Robbe-Fossat " 4

4 6

83 stool specimens: J. Celers, V. Drouhet 53 hospitalized patients & R. Debre 30 contacts

98 stool specimens- 76 hospitalized patients 22 contacts

Complement-fixation test results Hennessen, Jacob & Seichert 10

Total for 1954 and 1955. W. Kikuth & Complement-fixation test results. W. Hennessen *

R. Haas * 2 not typed

1 not typed

Kl6ne 14 '08 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Poliovirus type Area Year Cases, specimens, |_ 2_ 3_ etc. ~~~12 3

EUROPE (continued)

Germany: Specimehs from: 1953 Bremen 36 Westerland 2 Neunkirchen 6 Fussen 1 Munchen 1 46

Germany: Specimens from: 1954 Hannover 4 Offenbach 8 1 Landshut 10 Munchen 2 1 Arnsberg 1 Helmstedt 3 Hamburg 14 paralytic 2 9 3 7 non-paralytic 1 2 4 34 12 9

Germany: Specimens from: 1955 Hamburg and area paralytic 17 6 7 non-paralytic 5 4 4 Bremen and area paralytic 4 6 3 non-paralytic 5 2 2 Oldenburg paralytic 4 3 2 non-paralytic 1 1 M unster paralytic 1 2 1 non-paralytic 1 1 Helmstedt paralytic 3 1 5 non-paralytic 2 Gotti ngen 1 7 Mainz 5 1 Ulm paralytic 9 Munchen paralytic 5 63 26 32

Iceland: Reykjavik 1955 8 specimens 6

Iceland: Specimens from: Patreksfjordur 1955-56 8 specimens Dyrafiordur 1956 16 specimens

Ireland: Republic of: 1953 Specimens from: Dublin 2 1 Co. Kildare 3 Co. Carlow 1 Co. Wicklow 8 isolations 1

Personal communication POLIOMYELITIS IN 1954 10')

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses Other information Source

EUROPE (continued)

| Lennartz & Klbne"

Lennartz & K16ne '

2 Coxsackie Includes Kiel, Lobeck, Ulzen. H. Pette & H. Lennartz Includes Coxhaven, Drangstett.

1 Coxsackie

1 Coxsackie

Single examples of all three types have also been isolated in other towns.

There were few cases in 1953 and 1954. 1955 was an epidemic year (475 cases per 100 000 B. Sigurdsson * population).

These two outbreaks were considered not to be due to poliovirus. In Patreksfjordur there B. Sigurdsson * were 124 cases, 26 paralytic (cf. Sigurdsson et al.31).

P. N. Meenan * 110 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

AreaCYearGases, specimens, Poliovirus type Area | Year | a es,tc.ies etc. ~~1 2 3 EUROPE (continued)

Ireland: Republic of: 1954 Specimens f,om: Dublin Aug. 1 Co. Tipperary Aug. 1 Co. Louth Oct. 1 Co. Kilkenny Oct. 1 Co. Kildare Jan. 1955 1 5 isolations 1 4

Ireland Republic of: 1955 Specimens from: Co. Longford Aug. 1 Co. Kilkenny Sept.-Oct. 3 Dublin Oct. 1 1 Co. Wexford Oct.-Nov. 4 Co. Cavan Nov.-Dec. 2 12 isolations 10 2

Italy: Tuscany: Oct.-Dec. 427 cases Specimens from: 1953 21 specimens Florence 8 Pistoia 1 Arezzo 1 Lucca 12 12 13 isolations

Italy: Tuscanv: 1955 114 cases Specimens from: 39 specimens Florence ~~~~~36 3 Pistoia i Lucca ~~~~~1 1 Li-or no i i ~~~~~10 1 Massa and Carrara Pisa 1 1 29 isolations 15 6 8

lttly 1953 75 cases 29 10 1954 50 cases 29 1 1955 70 cases 26 20 2 Specimens from: 195 cases Lombardy 139 cases 59 27 3 Piedmont 36 cases 17 2 Trieste 3 cases 2 Tuscany 2 cases 2 Umbria 9 cases 2 Campania 6 cases 4 118 isolations 84 31 3 74 contacts 41 33

* Personal communication t In most instances, " not typed " indicates that attempts at typing were unsuccessful; in a few cases, however, typing was not attempted. POLIOMYELITIS IN 1954 111

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other virusest Other information Source

EUROPE (continued)

P. N. Meenan* All strains in the 1954 season were isolated from paralytic cases in Dublin Fever Hospi- tal, so the figures are biased in favour of eastern Ireland.

P. N. Meenan

After the 1953 epidemic had subsided, inci- dence was low until September 1955.

R. Davoli v and Terai, Terni-Pons & Lo Monaco"'""

Epidemic year with type 1 prevalent among paralytic cases.

R. Davoli * and Terai, Terni-Pons & Lo Monaco"","7

3 not typed 2 untyped viruses were from paralytic cases.

Monaci et al." 112 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Poliovirus type_ Area Year Caesa es spcmes 1 tec.mnletc.~ ~ ~ 11 2 3

EUROPE (continued)

Italy: Trieste 1955 35

Italy: Rome 1954 19 cases 1 1955 30 cases 3 2 1

Italy: Rome 1955 14 1

Italy: Palermo 1954 136 cases 14 specimens 9

Netherlands: 1954 Specimens from: Groningen 1 case Friesland 4 cases 2 Drenthe 1 case Overijssel 5 cases Gelderland 5 cases Utrecht 1 case Noord Holland 16 cases Zuid Holland 15 cases 6 Zeeland 3 cases Noord Brabant 8 cases 1 Limburg 15 cases 1 5 74 cases 1 14

Netherlands: 1955 Specimens from: Groningen 15 cases 3 Friesland 10 cases 5 Drenthe 3 cases Overiissel 65 cases 3 5 Gelderland 97 cases 1 14 Utrecht 12 cases 5 1 Noord Holland 41 cases 1 Zuid Holland 115 cases 31 16 2 Zeeland 7 cases 3 Noord Brabant 86 cases 6 12 3 Limburg 18 cases 1 12 2 469 cases 46 72 8

Norway: Southern part 1952 25 1953 7 1 24 1954 12 6 1955 12 3 10

Personal communication POLIOMYELITIS IN 1954 113

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (continued)

Other viruses Other information Source

EUROPE (continued)

19 from clinical poliomyelitis; 2 from aseptic I. Archetti * meningitis; 8 from contacts; 6 unknown.

1 Coxsackie A6 and Cases diagnosed as poliomyelitis T. De Sanctis Monaldi 1 Coxsackie A. 1 Coxsackie A7

I. Archetti I

Oddo 24

Hofman et al.1' and J. D. Verlinde'

A year of very low incidence.

Hofman et al.11 and J. D. Verlinde -

40 Coxsackie A; 16 patients with poliovirus and Coxsackie 38 Coxsackie B; virus: 4 ECHO. 1 = type 1 + Coxsackie A 1 = type 1 + Coxsackie B 8 = type 2 + Coxsackie A 4 = type 2 + Coxsackie B 2 = type 3 + Coxsackie A. The frequency of type 1 increased, and of type 2 decreased, rapidly from September to December. Specimens in all years were obtained from 0. Lahelle * patients with paralytic poliomyelitis or aseptic meningitis. 30 ECHO - 14 A. M.-M. PAYNE & M.-J. FREYCHE

TABLE IX. POLIOVIRUS TYPES AND ASSOCIATED VIRUSES

Area Year Cases, specimens, Poliovirus type etc. 1 2 3

EUROPE (continued)

Sweden: Stockholm May 1953- April 1954 369 paralytic 248 1 213 non-paralytic 121 191 other 16 1 773 375 1 1 May-Dec. 1954 33 paralytic 2 4 9 130 non-oaralytic 2 2 128 other 291 4 4 11

Sweden: Stockholm area April 1954- 3 - 22 1 2

Switzerland: Geneva 1955 18 isolations 18

Switzerland: Berne July-Dec. 67 isolations 57 2 8 1955

Switzerland: Zurich July-Dec. 22 cases 5 2 1 1955

OCEANIA

Australia: Western Australia 1954 436 cases 10 specimens 9

Personal communication POLIOMYELIllS IN 1954 115

ISOLATED IN VARIOUS COUNTRIES IN RECENT YEARS (concluded)

Other viruses Other information Source

EUROPE (continued)

1 adenovirus; 2 ECHO During the heavy 1953-54 epidemic, type 1 Svedmyr, Melen & 10 ECHO obviously dominated. Kjellen3*6 4 adenovirus; 3 ECHO

47 ECHO 1 adenovirus: 5 ECHO Few paralytic cases. Many cases of aseptic meningitis not caused by poliovirus. 70 % of ECHO viruses related to type 6.

G. Olin

15 paralytic cases in Geneva; 1 case in Lau- E. Grasset & sanne; 1 case in Neuchatel. V. Bonifas

U. Krech

J. Lindemann *

OCEANIA

Epidemic year, though clinically mild. 436 cases (4 deaths): 45 % paralytic; 20% of D. J. R. Snow* survivors had residual paralysis. 116 A. M.-M. PAYNE & M.-J. FREYCHE

Discussion The material collected so far, although considerably more complete than that collected last year, is insufficient to justify any general conclusions. Furthermore, the very nature of the data and the way in which they are collected make interpretation difficult. The majority of studies do not represent random samples and the figures are certainly liable to bias in a number of ways. In an epidemic year, for example, the most common finding is that all or nearly all viruses isolated are type 1, but it is seldom that a sufficient proportion of cases can be examined to enable one to determine whether or not the other two types are also causing cases. In these circum- stances the proportion of cases caused by types 2 and 3 may be low although the actual number may be about the same as in a non-epidemic year. In a non-epidemic year the chance of isolating all the types of virus which are causing cases is increased, since it is possible to examine a suf- ficient proportion of clinical cases to ensure this. Thus figures which suggest that types 2 and 3 were more prevalent as causes ofdisease in a given (non-epidemic) year than in a previous (epidemic) year may in fact mean only that type 1 was less prevalent. Another cause of bias is that, generally speaking, there is a greater demand for laboratory diagnosis when interest is aroused by the presence of an epidemic. Epidemics are often localized to a relatively small part of a country and if these areas only are investigated a false picture of the over-all prevalence of the virus types responsible for clinical disease may be obtained. In some reports an effort has been made to overcome this by reporting the prevalent types of virus in apparently unconnected foci rather than the total number of viruses isolated. It is therefore not considered profitable to discuss at the present time the relative prevalence of virus types in different areas and different years, but to await the accumulation of more and better data. The relationship of the incidence of poliomyelitis to the percentage distribution of virus types has been examined by Shelokov and co-workers.32 In the USA in 1952 they found that a high incidence was associated with a high percentage of type 1 isolations and that where the incidence was low all three types were isolated although type 1 predominated. The data presented here, as far as they go, support this finding, although the pos- sibility of bias must be borne in mind, but they are too incomplete to permit of definite conclusions. Shelokov and co-workers have also shown that the percentage distribu- tion of virus types was the same for paralytic and non-paralytic cases.32 Only the data collected from the USA are adequate for analysis in this way. POLIOMYELITIS IN 1954 117

The percentage distribution in the USA in 1954 and 1955 of virus types according to paralytic status, where this is known, is tabulated below: Virus type (/%) 1 2 3 1954 Paralytic 42 10 48 Non-paralytic 39 14 47

1955 Paralytic 74 10 16 Non-paralytic 76 8 16 Table X, prepared by rearranging the data, gives the percentage of paralytic cases for each virus type in the two years 1954-55.

TABLE X. PERCENTAGE OF PARALYTIC CASES BY POLIOVIRUS TYPE: USA, 1954-55

Poliovirus Poliovirus Poliovirus Poliovirus types Year type 1 type 2 type 3 1+2+3 NP I P %P NP P I%P NP P %P NP P %P

1954 27 63 70 10 15 60 32 72 69 69 150 68 62 1955 250 363 59 27 49 64 52 78 60 329 490 60

NP = Non-paralytic P = Paralytic

The text-table above and Table X show that not only is the percentage distribution of virus types the same among paralytic and non-paralytic cases within a given year even when studied in two years of widely different prevalence of types, but also that the percentage of paralytic cases for each of the three types remains approximately constant at 60 %-70 %. It should, however, be stressed that this refers to the percentage of paralytic cases among persons suffering from readily recognized clinical disease and not, of course, to the percentage of paralytic cases resulting from infection. The percentage of paralytic cases reported by Shelokov and co-authors was a little higher, 67 %-80 % (average 75 %).32 The precise ratio ofparalytic to non-paralytic cases will depend on the method of selection of cases for study as well as on other possible factors. For example, a special investiga- tion to detect minor illness among siblings or contacts would naturally reveal a higher proportion of cases classed as non-paralytic. In view of this the agreement seems remarkably good. Thus in three years in the USA approximately two-thirds of 1279 clinical cases of poliomyelitis confirmed by virus isolation showed paralysis. This is higher than the percentage of paralytic cases generally reported in the USA, but the significance of this discrepancy is difficult to interpret since the paralytic status is not specified 118 A. M.-M. PAYNE & M.-J. FREYCHE in all cases. However, it may be accounted for partly by selection, the more serious cases being hospitalized and subjected to laboratory confirmation, and partly by the inaccuracy of the clinical diagnosis of non-paralytic poliomyelitis. The figures reported from France for 1953-55 show the same phenome- non-a closely similar distribution of types among paralytic and non- paralytic cases with two-thirds caused by type 1. However, they also show that the distribution among contacts may be very different, type 2 being much more frequently isolated. This is not easy to interpret since selection may have greatly influenced the result. We have previously pointed out 7 that the results of serological surveys suggest that the three types are, as a generalization, equally prevalent over a period of years, the difference in prevalence among clinical cases probably largely reflecting differing poten- tialities of individual strains for invasion of the central nervous system, although the part played by other endogenous and exogenous factors cannot yet be assessed. It is tempting to postulate on the basis of the similar distribution of types among paralytic and non-paralytic cases that the characteristics of the infecting virus and type-specific immunity in the host determine whether or not the central nervous system is invaded; whereas non-specific factors and possibly group immunity acting equally in infections with all three types may be responsible for determining whether an infection that has reached the central nervous system becomes paralytic or remains non-paralytic. A variable proportion, which may be up to two-thirds or more, of cases diagnosed as non-paralytic poliomyelitis, presenting the clinical picture of aseptic meningitis, is due to other viruses (mumps, Coxsackie B, ECHO-6, Herpes simplex, LCM, various members of group A and group B ence- phalitis viruses, and others as yet undefined) as well as to bacteria (lepto- spirosis). A number of reports of the isolation of Coxsackie and ECHO viruses and others as yet unidentified from stools of suspected cases of poliomyelitis have been tabulated in Table IX in order to give some idea of the magnitude of this problem, although it should be borne in mind that isolation of virus does not prove etiological relationship. These reports are, however, far from complete. Clinical disease resembling paralytic poliomyelitis may be due to other viruses (see the reports from Iceland, Egypt, and Massachusetts). RSSE may also cause confusion.9 But there is little doubt that apart from rela- tively infrequent episodes the great majority of paralytic cases are due to poliovirus. For this reason and because paralysis is the result of poliovirus infection, which is of major public health importance, it has been repeatedly stressed by the World Health Organization that the incidence of paralytic and non-paralytic cases should be reported separately. There are many countries where this is still not yet done. This will become increasingly POLIOMYELITIS IN 1954 119 important as poliomyelitis vaccination comes into wider use, since the evidence available so far suggests that the main result of vaccination is to decrease the number of paralytic cases, the number of non-paralytic cases being relatively unaffected. Unless the two groups can be separated the beneficial effect of vaccination may be obscured.

ACKNOWLEDGEMENTS

Our thanks are due to all the members of the WHO Expert Advisory Panel on Virus Diseases and to the many other virologists who have so generously made available the results of their work for this study. Thanks are also due to those who helped greatly in the collection of these data by making inquiries among their colleagues working in this field. The assistance of Mr. C. Lederrey, Division of Epidemiological and Health Statistical Services, WHO, in the analysis of the data presented in this paper is also gratefully acknowledged.

REtSUMEt

Cette 6tude fait suite a celle qui a ete publiee en 1955 sur la r6partition de la polio- myelite dans le monde en 1953 et sur les types de virus isol6s. Les auteurs analysent les donn6es dont on dispose pour 1954, ainsi que les informations relatives aux divers types de virus isol6s en 1953, 1954 et 1955. Ces dernieres ne sont que fragmentaires et ne concement que des secteurs tres limites de la population du monde. En Afrique, plus exactement dans la plus grande partie du continent africain, 3900 cas de poliomyelite ont et6 declares en 1954 - contre 2800 en 1953. Neuf dixiemes des cas se sont produits dans huit pays ou territoires. Les poussees les plus caract6ristiques furent enregistrees au Senegal, au Kenya et en Rhodesie du Sud. En Amerique, le taux de morbidite a considerablement augmente par rapport a 1953 en Alaska, au Costa Rica, au Guatemala, a la Jamaique, ai Porto Rico, ai la Trinite et a Tobago. L'augmentation a et6 de 8 % aux Etats-Unis. Ce taux a baisse, en revanche, dans quelques pays: Argentine, Bresil, Canada, Mexique, Nicaragua et Salvador. En Asie, les donnees sont fragmentaires et souvent inexactes. Dans l'Inde, par exemple, seuls les cas hospitalises sont connus. II semble, d'une faqon generale, que l'incidence n'a pas varie sensiblement par rapport ai 1953. En Europe, 1900 cas ont 6te declares dans 25 pays ou territoires - contre 2700 en 1953 et 3200 en 1952. I1 y a eu cependant quelques epid6mies: en Grece, le nombre de cas d6clares etait environ neuf fois superieur a celui de 1953. En Finlande, ce chiffre etait 2,5; en Suisse, 2; en Autriche, 1,5. En revanche, l'incidence a baiss6 en Irlande du Nord, en Suede, au Danemark, dans la Sarre, la Republique d'Irlande, en Angleterre et Pays de Galles, aux Pays-Bas, 'a Malte, en Norvege et en Yougoslavie. En Oc6anie, on a signale quelque 2300 cas, dont environ 2000 en Australie et plus de 200 aux iles Hawaf. Le rapport entre l'incidence et la repartition des types de virus a et6 etudie par cer- tains auteurs. Ils ont constate, en 1952 aux Etats-Unis, qu'a une incidence elevee corres- pondait une forte proportion de virus de type 1, et que, lorsque l'incidence etait faible, les trois types etaient pr6sents - avec predominance toutefois du type 1. Les donnees figurant dans cette etude confirment cette observation, mais elles sont trop partielles pour que des conclusions nettes puissent etre proposees. 120 A. M.-M. PAYNE & M.-J. FREYCHE

Une etude analogue a ete faite par les memes chercheurs sur la relation entre le type de virus et la forme (paralytique ou non paralytique) de la maladie. Elle a montre que la r6partition des types ne differe pas selon la forme que prend la maladie, et que la proportion des formes paralytiques est de 60Y%-70%. I1 est probable qu'une partie des cas diagnostiques comme poliomyelite non paralytique soient dus a d'autres virus (oreillons, coxackie, encephalites A et B, etc.) ou meme a des leptospires. Il est possible que certains cas de paralysie ne soient pas causes par le virus poliomyelitique, contrai- rement au diagnostic pose. Mais ils sont rares et il est hors de doute que la plus grande partie des cas paralytiques est d'origine poliomyelitique. L'OMS a souvent souligne la necessite de declarer independamment les cas non paralytiques et les cas paralytiques, en raison de l'importance de cette derniere forme pour la sante publique. Cette necessite est plus evidente encore au moment oil va se g6neraliser la vaccination antipoliomyelitique. On sait que le resultat principal de la vaccination est de diminuer le nombre des cas paralytiques, celui des cas non paralytiques n'etant guere affect6. Les bienfaits de la vaccination ne peuvent etre estimrs de fa9on pr&ise que si l'on distingue l'une de l'autre, dans les d6clarations, les deux formes de la poliomyelite.

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