J R Soc Med 2004;97:244-247
doi:10.1258/jrsm.97.5.244
© 2004 Royal Society of Medicine
The Bradford smallpox outbreak in 1962: a personal account
Derrick Tovey FRCOG FRCPath
Old Charm Cottage, Old Scriven, Knaresborough HG5 9DY, UK
E-mail:
kaytovey{at}tiscali.co.uk
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INTRODUCTION
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Today it is fervently hoped that outbreaks of smallpox such
as that which
occurred in Bradford in 1962 will never arise
again. However, it is unwise to
be sure of ‘never’.
In 1962, just after I was appointed consultant
pathologist in
Bradford, isolated cases had been reported in England, but
these
were amongst people from South East Asia who had recently arrived
in the
UK. The Bradford outbreak had several unusual features,
particularly the
events leading up to its
discovery.
1 Since
I
am one of the declining number of persons still alive who
were heavily
involved in the outbreak I am persuaded that my
experiences at the time are
worth recording.
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BACKGROUND
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The first intimation of a possible outbreak was on 25 December
1961 when a
24-year-old man who had arrived at Heathrow Airport,
London, was suspected of
having smallpox. This was confirmed
on 10 January 1962. Another suspected case
was reported of a
man who had arrived from Pakistan on 19 December. A contact
of
the first case arrived in Bradford on 1 January and was immediately
isolated,
but remained symptom-free. A further man from Pakistan who developed
suspicious
symptoms was isolated, and was later discovered to have chickenpox.
In
view of these cases it was decided locally to put a hospital
which had been
designated for possible cases of smallpox in
a state of readiness should an
outbreak occur.
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THE OUTBREAK
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On 11 January 1962 a patient was admitted to the local fever
hospital with
pyrexia of unknown origin (PUO). Although the
patient was a
Bradfordian—in fact a cook at the Children's
Hospital—the
possibility of smallpox crossed the minds
of the clinicians. They sent a
sample of blood to the Haematology
Department at St Luke's Hospital (their
local laboratory) simply
stating PUO. It showed a mild anaemia, leucopenia,
thrombocytopenia
and a striking blood film with nucleated red cells,
myelocytes,
fragmenting granulocytes and vacuolation of the protoplasm,
condensed
nuclear bodies and atypical plasma cells and some Türck
cells.
Obviously this was a severe virus infection and the patient
was terminally
ill.
The same day a blood specimen was received from a male patient in our own
hospital (St Luke's). This was from a 40-year-old Bradfordian who had been
admitted with a history of severe fever, headaches and unexplained
thrombocytopenia; meningitis had been suspected. He died shortly after the
blood was taken and before a clinical diagnosis had been obtained. In fact a
post mortem was being performed while the blood film was being examined. To my
astonishment the blood count and film was almost identical to that of the
fever hospital patient (case 1).
I showed the films to my haematology colleague at Bradford Royal Infirmary
and he shared my concern that there were two cases of severe virus infection
in two separate hospitals. We consulted textbooks old and new, and an old
haematology book stated that these changes could occur in smallpox. We later
ascertained that these blood changes had been reported in
1925.2
I telephoned the consultant at the fever hospital and told him that his
patient, the cook at the Children's Hospital, had blood changes indicating an
overwhelming virus infection, and almost apologetically stated that these
changes had been described in smallpox. There was a pregnant pause at the
other end of the phone:‘You may well be right’. I then told him,
‘It looks as if there is another case here at St Luke's—a
40-year-old Bradfordian who as far as I know has never been abroad.’ He
stated that he would come over immediately to view our patient in the
mortuary. On arrival he immediately examined the flexures of the man's arm and
saw the petechiae often present in fulminating smallpox. We realized that we
were faced with a potentially catastrophic smallpox epidemic.
Our immediate difficulty was that we would not be able to obtain laboratory
confirmation of smallpox for at least 48 hours. At that time electron
microscopy had not been established to obtain a speedy laboratory diagnosis.
Specimens from the two deceased were dispatched by taxi to the local Public
Health Laboratory where Dr B P Marmion, the virologist (now resident in
Adelaide, Australia), tested the samples by, I believe, complement fixation
and egg culture. A quickly convened ‘council of war’ was held by
the regional medical officer, the chief medical officer of Bradford and his
deputy, the regional infectious diseases consultant and myself. Other
clinicians, hospital administrators, senior nurses and public health officers
were added later when required. Our first decision was to assume that the
clinical diagnosis of smallpox was correct and this group was given total
power to act.
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SOURCE OF THE OUTBREAK
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What was the source of the outbreak? The cook was employed at
the
Children's Hospital and it was quickly discovered that the
St Luke's patient
(case 2) had a child who had been a patient
in the Children's Hospital. An
immediate investigation of patients
in the Children's Hospital revealed that
six small children
were displaying spots, the classic early signs of smallpox.
One
child who had been transferred to a convalescent hospital (Wharfedale)
showed
similar early signs of the disease.
On the following day it became apparent that the source of the outbreak was
a child from Pakistan who had been admitted to the Children's Hospital with a
fever after arriving by air from Karachi on 16 December. She was thought to
have malaria, and Plasmodium vivax parasites were said to have been
found in her blood film. At first she responded to treatment but the fever
returned and she died on 30 December. Death was attributed to staphylococcal
septicaemia and a post mortem was performed at Bradford Royal Infirmary. The
pathologist found no reason to doubt the clinical diagnosis. When I told him
of our discoveries and that the Pakistani child had almost certainly had
smallpox, he admitted that he had never been vaccinated. He became ill that
evening and although receiving primary vaccination he died a few days later of
confluent smallpox.
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IMMEDIATE ACTION
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Every hospital in the city—St Luke's, Bradford Royal,
the Children's
Hospital and the fever hospital—and a convalescent
hospital outside
Bradford was ‘infected’. The delay
in diagnosis of the condition
meant that it could easily have
spread outside the hospitals. The isolation
hospital at Oakwell
was immediately staffed and the number of beds was
increased.
All cases were transferred to that hospital, plus a nurse at
the
Children's Hospital who had been diagnosed as chickenpox
but later shown to
have smallpox. Mercifully she recovered.
At first all hospitals were closed
until the situation could
be assessed, and the outlying hospitals were
requested to receive
urgent admissions which would normally have been referred
to
Bradford hospitals.
The first major task was to isolate, examine and vaccinate all immediate
contacts of infected persons. The size of this operation is illustrated by the
fact that the patient in St Luke's (case 2), although dying within 48 hours of
admission, had over 200 close contacts. Incidentally, his immediate family,
who had nursed him at home before hospital admission, never showed any
evidence of being infected. Unfortunately I have no information on their
vaccination history at that time.
This major task of tracing, vaccinating and placing under surveillance of
all possible contacts was immediately introduced: 285 000 persons were
vaccinated and well over a thousand contacts were traced in the first five
days after the discovery of the outbreak. One person, usually a hospital
pathologist, was designated control-of-infection officer in each hospital. I
was given the task of looking after St Luke's.
The Pakistani child had apparently been vaccinated in infancy and
revaccinated along with her father and mother in December 1961, but there was
no satisfactory evidence that the vaccine had ‘taken’. The cook
(case 1) and the St Luke's patient (case 2) had no history of a previous
vaccination.
My tasks were clearly defined and were: (1) to act as medical liaison
between the hospital and medical officers of health both locally and
nationally; (2) to undertake and organize surveillance of immediate contacts
including examination of their vaccination reaction and arranging
revaccinations where necessary; (3) to arrange for the examination of contacts
who became ill and to obtain specialist advice where necessary; (4) to
institute and supervise the measures necessary to isolate the ward block into
which patient 2 had been admitted and to prevent the spread of infection from
there.
I moved into the hospital and was forced to refuse requests from resident
doctors to leave the premises. This was a shock to my wife who was expecting
our second child and had never been vaccinated. She was vaccinated locally as
was our elder son. Such was the alarm at the time that when she telephoned our
local paediatrician in Pontefract to ask if she could come to the hospital to
have her vaccination site inspected, his immediate reply was ‘Don't come
to the hospital. I will see you at home’.
All immediate contacts of the patient were examined unclothed, in a
separate ward emptied for this purpose, and their temperatures were taken
twice daily. This could have been an embarrassment for the female staff
involved but no objections were ever made. I had an isolated incident where a
junior doctor left the hospital without permission and travelled to Manchester
to see a consultant in his private rooms. When he announced that he had come
from St Luke's Bradford the waiting room quickly cleared, much to the
consultant's annoyance. A nurse went by train to visit a friend, a fellow
nurse in a London hospital, and was ‘locked’ in her room for 2
weeks. One hospital attempted to revoke the appointment of a nurse or doctor
because he or she was employed at St Luke's. A tramp arrived in a Scottish
town proudly stating that he had been a patient at St Luke's: this caused
great consternation throughout the town.
Part of my task, and in many ways the most difficult, was dealing with the
press. The national press was often irresponsible, printing such headlines as
‘City in Fear!’ ‘Keep Out Pakistanis’, but the local
press, particularly the Telegraph & Argus, was helpful and
reported accurately the local position which was of ‘refusal to
panic’. The attitude of the national press has been described by
Butterworth.3
Luckily our tough measures were successful and although 6 of the 12 persons
who developed smallpox died only 3 were tertiary cases. There were two
contacts of case 2 in the hospital and although they contracted smallpox one
survived and the other died mainly because of the serious condition
necessitating his admission to hospital
(Table 1). Luckily no further
cases were reported and by mid-February the all-clear was given.
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COMPLICATIONS OF VACCINATION
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Unfortunately smallpox vaccination does have unpleasant side-effects,
ranging
from transient fever and local discomfort to fatal encephalitis.
In
1960 in England and Wales 408 699 persons received primary
vaccination, 8
developed encephalitis and 3 died. In the Bradford
outbreak where 280 000 were
vaccinated (either primary or secondary)
many experienced minor symptoms and
at least 6 (4 adults and
2 children aged three months) had symptoms severe
enough to
require hospital admission. Only one of these died, a man aged
49,
and his death was probably due to associated medical conditions.
Unfortunately
3 children died after clinical diagnosis of post-vaccinal
encephalitis,
although the post mortems in each case showed
only cerebral oedema and
congestion and the pathologist could
only go as far as to conclude
‘cerebral congestion following
vaccination’. One of the three was
of considerable interest.
The child, aged 1
years, had not been
vaccinated because of
an infected nappy rash, but had been bathed with her
sister
who had been vaccinated. She developed multiple skin lesions
from which
vaccinia virus was subsequently recovered at post
mortem. The brain showed
congestion.
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CONCLUSION
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This was a dramatic and in many ways unique outbreak of smallpox,
a
condition that I had never expected to encounter. I had been
trained as a
general pathologist with basic experience in all
branches of the subject
including bacteriology. Today the normal
practice is to be trained in one
discipline only—e.g.
as a clinical haematologist. My overwhelming
memories of this
outbreak were the diligence, enthusiasm and above all the
sheer
professionalism of the public health doctors, clinicians, nurses
and
administrators who successfully prevented a potentially
calamitous smallpox
outbreak. This ‘success’ was
due primarily to the fact that a
small group of regional and
local doctors, nurses and administrators had the
authority and
drive to introduce immediate measures to tackle the outbreak,
to
set in motion exhaustive tracing of contacts, and to initiate
ring local mass
vaccination. Thus in a month the outbreak could
be declared over.
A lesson to be learned from this outbreak is that, if ever a smallpox
epidemic arose again, it might well present itself to the clinicians not as a
textbook case but as PUO as in the Bradford outbreak or as a haematological
disorder or some masking disease.
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Acknowledgments
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I thank Professor R A Shooter for his help and support, and
Dr E Tansey of
the Wellcome Trust Centre for the History of
Medicine for encouraging me to
publish; also Dr R L Woodhead,
consultant physician in Bradford, who referred
me to the paper
by Butterworth.
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REFERENCES
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- Douglas J, Edgar W. Smallpox in Bradford.
BMJ 1962;i:612
-14
- Ikeda K. The blood in purpuric smallpox.
JAMA1925; 84:1807[Abstract/Free Full Text]
- Butterworth E. The 1962 smallpox outbreak and the British press.
Race1966; VII:347
-64
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INTRODUCTION
BACKGROUND
