OF EXPERT COMMITTEES TO THE INTERIM COMMISSION

OFFICIAL RECORDSOF THE

WORLD HEALTH ORGANIZATION

No. 8

REPORTS

OF EXPERT COMMITTEES

TO THE INTERIM COMMISSION

These reports of expert committees are printed in the form in which they werepresented to the Interim Commission at its fourth and fifth sessions. Publicationdoes not imply acceptance by the Commission of any of the recommendations orimplications of such reports.

The decisions of the Interim Commission on the reports are recorded in theMinutes of its sessions as published in the Official Records.

United NationsWORLD HEALTH ORGANIZATION

Interim Commission

350, Fifth Avenue, New York Palais des Nations, GenevaAPRIL 1948

FOREWORD

This number of the Official Records contains all the reports presented by expertcommittees to the Interim Commission of the World Health Organization up to andincluding its fifth session.

One of the principal responsibilities of the Interim Commission has been to submitto the first World Health Assembly proposals on the programme of the World HealthOrganization in the first year after its establishment. Although the protracted life of theCommission has involved the assumption of some technical functions, it should be remem-bered that much of the work of the expert committees, as summarized in these reports,has been in the direction of surveying needs and requirements rather than of makingrecommendations on particular technical problems.

BROCK CHISHOLM, M.D.

Executive Secretary,Interim Commission.

TABLE OF CONTENTS

Page

I. EXPERT COMMITTEE ON BIOLOGICAL STANDARDIZATION : Report on the First Session . 5

II. EXPERT COMMITTEE ON MALARIA : Report on the First Session 8

III. EXPERT COMMITTEE FOR THE PREPARATION OF THE SIXTH DECENNIAL REVISION OF THEINTERNATIONAL LISTS OF DISEASES AND CAUSES OF DEATH :

(a) Report on the First Session 17

(b) Report on the Second Session 21

IV. EXPERT COMMITTEE ON QUARANTINE : Report on the First Session 27

V. EXPERT SUB-COMMITTEE FOR THE REVISION OF THE PILGRIMAGE CLAUSES OF THE INTER-NATIONAL SANITARY CONVENTIONS :

(a) Report on the First Session 32

(b) Draft Regulations for the Control of the Pilgrimage 42

VI. EXPERT COMMITTEE ON TUBERCULOSIS : Report on the First Session 49

VII. EXPERT COMMITTEE ON THE UNIFICATION OF PHARMACOPIAS : Report on the First Session 54

VIII. EXPERT COMMITTEE ON VENEREAL DISEASES : Report on the First Session 6o

[WHO . IC/83113 June 1947

I. EXPERT COMMITTEE ON BIOLOGICAL STANDARDIZATION

REPORT ON THE FIRST SESSIONHeld 9-13 June 1947, Palais des Nations, Geneva

(presented to the Interim Commission at its fourth session). 1

The Interim Commission of the World HealthOrganization inherited the functions of the Leagueof Nations Health Organization with regard tobiological standardization.

Desirous of giving this work an adequate inter-national technical direction, the Interim Com-mission adopted the following resolution duringits second session (November 1946) :

" The Interim Commission requests its Chair-man and its Executive Secretary to appointa small body of experts, whose number is notto exceed eight, to form the nucleus of the futureCommittee on Biological Standardization.

" These experts will define the subjects whichappear to be the most urgent for study, andwill draw up a plan of work covering the settingup of international standards and units in thefields selected, to be submitted to the InterimCommission for approval ".Acting upon this resolution, the Chairman and

Executive Secretary appointed the following sevenmembers, a seat being reserved for an expert fromthe Union of Soviet Socialist Republics :

Dr. J. Orskov, Director, State Serum Institute,Copenhagen, Denmark ;

Professeur Jacques Tréfouël, Directeur de l'Ins-titut Pasteur, Paris, France ;

Major-General Sir Sahib Singh Sokhey, Director,Haffkine Institute, Bombay, India ;

Dr. W. Aeg. Timmerman, Director, Rijks Institutvoor de Volksgezondheid, Utrecht, Nether-lands ;

Professeur E. Grasset, Directeur de l'Institutd'Hygiène, Geneva, Switzerland ;

Dr. A. A. Miles, Director, Department of Bio-logical Standards, National Institute forMedical Research, London, United Kingdom ;

Dr. M. V. Veldee, Chief, Biologics Control Labo-ratory, United States Public Health Service,Washington, D.C., United States of America.

In December 1946, a note by the Secretariatreviewing the position regarding existing inter-national standards and suggesting new substancesfor standardization was circulated to these experts.2On the basis of their comments, a provisionalagenda was drafted, which was submitted to theInterim Commission at its third session (April1947).3 At the opening meeting of its first session,held in Geneva 9-13 June 1947, the Expert Com-mittee on Biological Standardization adopted thisagenda, somewhat modified, and elected Dr. W.Aeg. Timmerman (Netherlands) to the Chair.

1 Off. Rec. WHO, No. 6, pages 12, 53, 190, 214.2 WHOJC/BS/i, an unpublished working document.3 WHO.IC/BS/2, an unpublished working document.

The report which follows is based on the decisionswhich were, without exception, unanimously takenby the Committee.

* *

1. National Control Centres.

The Committee approved the principle of therecommendation of the Inter-Governmental Con-ference on Biological Standardization of 1935 4,

" That each country should have a nationalcentre or centres, recognized by the competentauthority, to take charge of the internationalstandards and equivalent national standards ;

" And that every such centre should have aqualified staff to control the application of theinternational standards in its own country, andthus to serve as the recognized national scienti-fic authority in this field."The Committee, however, considered that for

simplicity and efficiency it was desirable to limitthe number of control centres in each countryto one, which would be solely responsible to theCommittee for the custody and distribution of allinternational standards within its country's boun-daries ; the Committee also considered that suchcontrol centres should be established whether ornot a particular country was able at the sametime to maintain laboratories equipped to fulfilall the requirements laid down in the aboveresolution.

The Committee recommended that the Secre-tariat should

(a)

(b)

(c)

ascertain whether national control-centresdesignated before the war are still active,approach the health authorities of interestedcountries in which there are no nationalcontrol-centres with a view to establishingsuch centres, anddraw the attention of national control-centres to the need for all reasonable eco-nomy in the use of international standardsand for establishing national standardsin terms of international units.

2. Emergency Replacement of Standards.The Committee approved the emergency action

taken by the Department of Biological Standardsof the National Institute for Medical Research,Hampstead, in replacing the following inter-national standard preparations :

4 See " Report of the Inter-Governmental Confer-ence on Biological Standardization, held at Geneva,1-4 August 1935 ", Quart. Bull. Hlth. Organ. 1935, 4,638-642 (Vol. 4, Extr. No. 11) (C.H.1178 (I)).

- 6 - BIOLOGICAL STANDARDIZATION

I. The oestrus-producing hormone,2 . Androsterone,3. Progesterone,4. Pituitary (posterior lobe),5. Neoarsphenamine,

and in altering the method of dispensing thesolution of /3-carotene as the standard for vitamin A.

It also approved the measures taken by theDepartment of Biological Standards of the StateSerum Institute, Copenhagen, in replacing thefollowing standard preparations :

1. Clostridium perfringens antitoxin,2 . Clostridium septicum antitoxin,3 . Diphtheria antitoxin for the flocculation

test.

3. Adoption of International Standards.The Committee approved the action of the

Department of Biological Standards, Hampstead,in setting up the following provisional inter-national standard preparations and defining theunits thereof :

I. Vitamin E (1941),2 . Heparin (1942),3. Penicillin (1944).

These three provisional standards were adoptedas definitive international standards.

The Committee took note of the existence ofa dry reference preparation of staphylococcus /3-antitoxin, set up at the Copenhagen Institute, butdecided to postpone the question of adopting itas an international standard.

The Committee wished to express its warmestthanks to the Directors of the Department ofBiological Standards in Hampstead and Copen-hagen for the initiative thus taken during the waremergency.

4. Replacement of Digitalis Standard.An an emergency measure, the Committee

authorized the Department of Biological Standards,Hampstead, to proceed immediately with thepreparation of the third international standard fordigitalis to replace the second international stan-dard, the stocks of which are almost exhausted. Italso recommended that the new standard shouldconsist of a mixture of a number of preparationsof the powdered leaves of Digitalis purpurea, eachpreparation selected to conform as nearly as pos-sible to the existing standard preparation, and thatthe final mixture of these preparations be subjectedto comparative assays in a number of laboratoriesin various countries. The results of these assaysshould be submitted to the Committee with aview to the adoption of the final mixture of pow-dered leaves as the third international standard.In the meantime, the Department of BiologicalStandards, Hampstead, was authorized to issuethe first international standard in place of thesecond international standard, when the stocks ofthe second were exhausted.

5. Replacement of SulpharsphenamineStandard.

The Committee authorized the Department ofBiological Standards, Hampstead, to proceed withthe selection of a suitable batch of sulpharsphena-

mine to serve as the second international standardfor that substance, and to arrange for its assay incomparison with the first international standardin laboratories of various countries. The resultsof these comparative assays would be submittedto the Committee, with a view to the adoption ofthis preparation as the second internationalstandard for sulpharsphenamine.

6. Standardization of Antigenic Substances.

(1) Toxoids.The Committee recommended that international

preparations of diphtheria and tetanus toxoidsshould be set up for reference in the biologicalassay of these antigens, and that the generousoffer of Dr. Veldee to provide specimens of thehighly purified toxoids recently prepared in theUnited States should be gratefully accepted. Aftera preliminary examination by the Department ofBiological Standards, Copenhagen, these toxoidsshould be distributed to laboratories in interestedcountries for examination with a view to theirsuitability as international reference preparations.At the same time, opinions should be invited frominterested workers on the desirability and possi-bility of adopting these preparations as inter-national standards for diphtheria toxoid andtetanus toxoid respectively and of defining theiractivity in terms of units.

(2) B C G.The Committee agreed that it was at present

impracticable to set up a standard for BCG vaccine.However, in order to meet the urgent need foruniformity of the BCG vaccines in current use, theCommittee recommended that :

(a) the original strain of BCG kept at thePasteur Institute, Paris, should be madeinternationally available,

(b) the State Serum Institute, Copenhagen,which already distributes on behalf of theCommittee a number of the internationalpreparations, should also distribute theBCG strain,

(c) the preparation and use of the vaccine ineach country should be centrally co-ordinated.

(3) Old Tuberculin and P.P.D.The Committee recognized that, in addition to

the existing international standard for Old Tuber-culin, there was a definite need for an independentinternational standard for the Purified ProteinDerivative (P.P.D.) derived from Mycobacterimntuberculosis. A preparation of P.P.D. originallyobtained by Dr. Madsen and stored for the dura-tion of the war at the National Institute of Health,Bethesda, is available and has already undergonepreliminary comparative tests. The Committeerecommended :

(a) that funds should be made available for thetransport of this preparation from Wash-ington to the State Serum Institute,Copenhagen, and

(b) that the State Serum Institute shouldorganize a comparative trial of this prepa-ration by various workers, with a view toits adoption as an international standard.

BIOLOGICAL STANDARDIZATION -7 -The Committee recommended that, when suffi-

cient experimental data on the P.P.D. preparationwere secured, interested workers should be invitedto express their opinion upon the desirability andpossibility of defining the biological activity bothof P.P.D. and of Old Tuberculin in terms of inter-national units.

(4) Other Antigenic Preparations.After detailed discussion, the Committee con-

sidered that it was at present impracticable to setup standards for :

(a) Haemophilus pertussis vaccine,(b) Vibrio cholerae vaccine,(c) Pasteurella testis vaccine,(d) Smallpox vaccine,(e) Yellow-fever vaccine.

The Committee was of the opinion, however,that progress in these fields would be greatlyfacilitated by exchange of the relevant strains ofbacteria and viruses, and comparison of theirantigenic potency and its methods of assay.

As regards yellow-fever vaccine, the Committeefelt strongly that this vaccine, among others, shouldbe standardized as soon as it is practicable to do so.In the meantime, close consultative liaison shouldbe established between the Expert Yellow-FeverPanel (to be set up by the Expert Committee onQuarantine) and the Expert Committee on Biolo-gical Standardization, particularly with regard tothe minimum requirements of yellow-fever vaccineintended for use in conformity with the inter-national sanitary regulations.

7. Human Blood Antigens.(r) The A B 0 System.

The Committee recommended that internationalstandards for Anti-A serum and Anti-B serumshould be established. To this end, a pooledsample of high potency human Anti-A serum andone of Anti-B serum should be submitted to com-parative tests by various workers and their potencyexpressed in appropriate units.

(2) The Rh System.The Committee recognized two urgent problems

concerning the Rh antigens, namely :(a) The provision of an agreed interna-

tional nomenclature ;(b) The establishment of standard antisera

for those Rh antigens which are important inmedical and obstetrical practice.The Committee decided to create an Expert

Sub-Committee on Rh Antigens to study these twosubjects and report on them. This Sub-Committeeis to consist of geneticists and hmnatologists, tobe proposed after consultation with interestedworkers in the various countries.

8. Antibiotics.

(a) The Penicillins.The Committee considered that recent progress

in the identification and definition of the differentpenicillins does not at present justify any change

in the International Standard for Penicillin (1944)or any redefinition of the unit of activity.

It was, however, considered desirable to set upas a reference preparation a substantially purespecimen of penicillin K (IV).

(b) Streptomycin.The Committee considered that it was at present

impracticable to establish an international standardfor streptomycin.

Nevertheless, to promote uniformity in theassay of streptomycin potency, it is necessary toestablish an international reference preparation.The activity of this preparation should be expressedboth as milligram-equivalents of pure streptomycinbase, according to current practice in the UnitedStates of America, and in provisional internationalunits, which should have substantially the samevalue as the S-unit originally proposed by Dr. S.Waksman.

9. Vitamins.The Committee considered that the following

problems in the domain of vitamins were the mosturgent :

(a) The replacement of the present inter-national standard for vitamin A, which is apreparation of a-carotene, by a standard con-sisting of a vitamin A ester.The existing international preparation of a-

carotene should then be established as an inter-national standard for a-carotene, for agriculturalpurposes.

(b) The replacement of the existing inter-national standards for vitamin D, which wererespectively preparations of calciferol (vitaminD2) and irradiated ergosterol, by an internationalstandard consisting of vitamin D3.

The Committee decided to create an ExpertSub-Committee on the Fat-soluble Vitamins tostudy these two subjects and report on them, themembers of the Sub-Committee to include expertsalready at work on these problems.

The Committee also discussed the vitamins notyet standardized and considered that they wereeither sufficiently well characterized by physicaland chemical means or at this stage so ill-definedin their biological action as to preclude any attemptat standardization.

10. International Salmonella Centre.The Committee discussed the proposal of Dr. J.

Orskov that the International Salmonella Centreestablished in 1938 at the State Serum Institute,Copenhagen, should be taken over by the WorldHealth Organization and its scope extended, underthe name of International Enteric Centre, toinclude the dysentery, coliform and Proteus groupsof bacilli.

The Committee recommended that the Inter-national Salmonella Centre should be taken overas such by the WHO but that consideration of theproposed extension of its activity to include thedysentery and other intestinal bacilli should bedeferred until the Committee had consulted otherexperts in these fields.

- 8 --[WHO . IC/79]30 June 1947

II. EXPERT COMMITTEE ON MALARIA

REPORT ON THE FIRST SESSION

Held 22-25 April 1947, Palais des Nations, Geneva


Outline.I. Introduction.

2. New Developments and Opportunities.3 . Recommendations for a Malaria Committee and Policy for the WHO.4. The Darling Foundation and Prize.5 . The Fourth International Malaria Congress (1948).6 . New Antimalarials and Chemotherapeutic Control.7 . DDT.

8 . Recommendations for a Second Meeting of the Expert Committee on Malaria in 1947.

9. Miscellaneous.

io. Recommended Resolutions for the Consideration of the Interim Commission, to be Placedbefore the World Health Assembly.

1. Introduction.The Committee on Epidemiology and Quaran-

tine of the Interim Commission, in its first reportagreed " that the problem of malaria was suffi-ciently urgent and important to warrant immediateaction ".2 It was decided to appoint a committeeof five experts " to study and advise on thisimportant problem ". It was anticiiated thatsubsequently it would be necessary for this com-mittee to continue certain investigations and tosubmit a report in due course.

The report of the Committee on Epidemiologyand Quarantine was adopted by the Interim Com-mission at its second session.3 It was felt that theMalaria Committee should meet just before thethird session of the Interim Commission and preparea note for consideration of the Commission ; butthis was not possible.

At the third session of the Interim Commission(II April 1947), the Committee was renamed" Expert Committee on Malaria ".4 The inter-pretation of the Secretariat of the terms of referencewas that this Expert Malaria Committee " wouldadvise the Interim Commission and also makerecommendations to the World Health Assemblyconcerning the creation of a Malaria Committee,with the help of the draft constitution submittedby Dr. Gabaldón 5, and also concerning theprogramme of work for such a committee ".

I Off. Rec. WHO., No.219, 221.

2 Off. Rec. WHO, No. 4,Ibid., pages 32-33.

4 0/1. Rec. WHO, No. 5,5 Oft Rec. WHO, No. 4,

6, pages 54-55.

pages 168-169.

pages 23, 128.pages 164-166.

181-182,

The necessity for giving expert direction to thefield work to be carried out by the field missionsof the World Health Organization was emphasized.

The first meetings of the Expert Committee onMalaria, appointed under its terms of reference,6were held in Geneva (22-25 April 1947), and thefollowing were present :

Members:Dr. Mihai Ciuca, Co-Director, Cantacuzène

Institute, Professor of Bacteriology, Uni-versity of Bucharest, Roumania ;

Dr. N. Hamilton Fairley, Wellcome Pro-fessor, London School of Hygiene, Lon-don, United Kingdom ;

Dr. Arnaldo Gabaldón, Chief, Malaria Divi-sion, Ministry of Health and SocialWelfare, Maracay, Venezuela ;

Dr. Paul F. Russell, International HealthDivision, Rockefeller Foundation, NewYork, United States of America.

Secretary:Dr. E. J. Pampana (Interim Commission

Secretariat).Also present :

Dr. Brock Chisholm, Executive Secretary ;Dr. N. Goodman, Director of Field Services ;

andDr. J. M. Vine, Chief of the Interim Com-

mission Mission in Greece.

At the time of the meeting, there had been nonomination of a member by the Union of SovietSocialist Republics.

Dr. Arnaldo Gabaldón was elected Chairman.

6 Off. Rec. WHO, No. 4, pages 164-166.

MALARIA - 9 --

2. New Developments and Opportunities.

The period from 1939 to 1947 has been markedby world events which have had a profound effecton malariology, not only creating new problemsbut especially bringing up new opportunities fora degree of practical malaria control and evenof practical malaria eradication impossible, infact, unthinkable, in pre-war days. As regardsmalaria, it is now possible for the WHO to goa considerable way towards its objective, " theattainment by all peoples of the highest possiblelevel of health ".

In many regions of the world, malaria is still,by all standards, the greatest obstacle in the wayof the objective of the WHO. The Second WorldWar intensified the incidence of and increased mor-tality from malaria in many regions, and therehave been in each of the war and post-war years-and there will doubtless be in 1947-severeepidemics of malaria. UNRRA helped to meetemergency post-war needs, but now the only inter-national agency which can furnish appropriateaid and technical assistance is the WHO or itsInterim Commission. It must be rememberedthat malaria is still-as it has been in the past-the most important preventable disease in thetropics and sub-tropics, East and West.

Malariology has come of age, and it is not anexaggeration to say that a new era has begun inmalaria treatment and control. War-needs sti-mulated notable advances, and we now have, inthe new antimalarials (see Section 6 below) andin DDT (see Section 7) weapons of great practicalvalue.

But the war, which brought about theseadvances, at the same time greatly restricteddissemination of knowledge about them, so thatthere is a real need for the WHO to spread inform-ation and to make it possible through fellowshipsand travel grants to send malaria officers to areaswhere the new measures are in active use.

In particular, DDT-spraying at last offers amethod of controlling malaria in many areas atcosts within the economic means of the people.But it will sometimes require the initiative, tech-nical advice and assistance of the WHO to startsuch a programme and to bring it to a point whereGovernments can carry it forward.

Although the new weapons are much moreeffective, they still have important limitations,so that there are research needs which the WHOcan profitably explore.

The Committee believes that never before hasan international body faced such great oppor-tunities over wide areas for the practical controlof one of the world's greatest afflictions.

3. Recommendations for a MalariaCommittee and Policy for the WHO.

In view of the great importance of malaria inthe world today and the fact that many aspectsof the disease require highly specialized and tech-nical handling, the Expert Committee on Malariaof the Interim Commission strongly advises theCommission to recommend to the Health Assem-bly at its first meeting that the Executive Boardbe directed to establish at once in the WHO

a committee of experts to be called the " MalariaCommittee of the World Health Organization. "1

The basic objective of this Committee shouldbe to assist the WHO and the United Nations incarrying out their international public-healthfunctions in the specialized fields of malariaresearch and the epidemiology, therapy, controland eradication of malaria in different parts of theworld.2

Functions.

The ways and means by which such a MalariaCommittee could most effectively aid the WHOhave been carefully considered, and the ExpertCommittee recommends that the general functionsof the proposed Malaria Committee of the WorldHealth Organization should be along the followinglines :

(1) The first and primary function of the pro-posed committee should be to act as an expertmalaria advisory group to the WHO and, asrequested by the Director-General, to otheragencies of the United Nations.

It would seem to be highly desirable, if anyother body of the United Nations contemplatesa project which involves some aspect of malaria-such as, for example, education, treatment orcontrol-that advantage be taken of the expertadvice of the proposed Malaria Committee andalso that there be only one malaria advisory boardwithin the United Nations specialized agencies.

(2) A second basic function of the MalariaCommittee should be that of an internationalco-ordinating and intelligence centre, collectingpertinent data, disseminating useful information,suggesting new methods, providing practical advicein respect of all phases of malariology. Further-more, it should concern itself with the developingof an informed public opinion in regard to theincidence, treatment, control, prevention anderadication of malaria.

(3) The Malaria Committee should give technicalassistance to Governments, upon request, in orderto strengthen national malaria treatment, control,research, or training services ; and, where appro-priate, it should be prepared to recommend tothe WHO that the latter provide such facilitiesto special groups.

With the new insecticides and antimalarials,malaria epidemics can be stopped effectively andquickly when a suitable organization and thesupplies are available. Therefore, the Committeeshould be specially alert regarding possibilities ofassisting in the control of epidemic malaria, whichin the recent past and even today is so disastrousin certain areas.

(4) Although great advances have been made,there is still need for fundamental research in thefield of malaria. It is advised that the proposedMalaria Committee plan and stimulate researchand, where appropriate, recommend the financingof specific projects by the WHO.

See " Constitution of the WHO ", Off. Rec. WHO,No. 2, Article 38, Section V B.

2 Ibid.

- lo - MALAkIA

(5) Another function which the Expert Com-mittee believes should be undertaken by theMalaria Committee is the recommending of WHOmalaria fellowships, upon request of Governments,either to enable senior malariologists to makeuseful tours to other countries, or to provideyounger men an opportunity to attend trainingcourses at a school of malariology. It may beadvisable for the proposed Committee to recom-mend, plan and supervise one or more WHOinternational malaria courses along the lines ofthose set up by the Health Organization of theLeague of Nations, with special emphasis onmalaria control.

(6) The Expert Committee strongly recommendsthat provision be made so that the proposedMalaria Committee or its individual members asindicated may make tours from time to time inorder to give help to a malaria programme, or toobtain a cleasr understanding of a problem orproject, or to obtain new and useful information.Such tours should be subject to agreement withthe Governments concerned and to approval bythe Director-General.

(7) Finally, the Expert Committee believes thata most important function of the proposed Com-mittee should be to promote co-operation andagreement between nations in regard to malarianomenclature, standards, indices, epidemiologicalprocedures, laws and regulations. It is speciallyimportant that the proposed Committee considermost carefully what further steps might be recom-mended to prevent the inadvertent transportationof malaria vectors across national boundaries andinto areas where they are not now present.

Or ganization.

The Expert Committee considered at somelength the question of the membership of theproposed Malaria Committee. It would seemessential that such a Committee be large enough toensure that there is, in the first place, propergeographical representation so that all parts of theworld where malaria is a problem will have the intelli-gent understanding of the Committee. Secondly,since malariology is a very wide subject rangingfrom engineering to entomology and from patho-logy to therapeutics, appropriate technical repre-sentation is also essential.

Budgetary needs must be considered, and theExpert Committee has therefore decided to recom-mend that the proposed Malaria Committee of theWorld Health Organization consist of not less thannine members. The Expert Committee stronglyadvises that this is a minimum number below whichthe proposed Committee could probably not func-tion with efficiency.'

The Expert Committee advises that the membersof the proposed committee be appointed for termsof three years and that they be eligible for reap-pointment without reference to previous terms of

" The former Malaria Commission of the League ofNations consisted of some 50 members, 21 of whomconstituted a study committee.

service. It is also recommended that the membersbe appointed by the Chairman of the ExecutiveBoard and the Director-General, from a list of namesof individuals actively engaged and well known insome phase of malariology, the list to be preparedin the first instance by the present Expert Corn-mittee and thereafter by the Malaria Committeeof the World Health Organization, each list tocontain at least twice as many names as there areappointments to be made.

The Expert Committee further recommends thatthe Malaria Committee of the World HealthOrganization should be provided with a secretarythoroughly familiar with and competent in thefield of malariology and appointed by the Director-General, who may delegate to him the Director'sfunctions as ex-ogcio Secretary of the Committee.

The Expert Committee believes that normally twosessions of the proposed Committee each year willbe necessary in order for it to carry out its functionsproperly. But conditions will vary from time totime, and it is therefore recommended simply thatthe proposed Committee meet at places and timesdecided by the Committee, with approval by theDirector-General, and that, if a sudden meeting isnecessary, it may be called by the Director-Generaland the Chairman of the Malaria Committee.

The Expert Committee recommends that theproposed Malaria Committee be empowered toelect its own Chairman and adopt its own rules ofprocedure.

The Expert Committee further recommends thatthe Malaria Committee, with the approval of theDirector-General, be empowered to invite to itsmeetings technical experts, when it seems essentialto a proper understanding of a problem at hand.

Finally, the Expert Committee calls attentionto the Pan American Malaria Commission, and itrecommends that, when the Health Assemblydefines geographic areas for regional organiza-tions, there be established at once, if malaria is aproblem, regional malaria commissions appointedby the regional directors. It is recommended thatthe Organization of the Pan American MalariaCommission be used as a guide for the formationof such regional Malaria Commissions. Particularattention is called to the system of sub-committeeswithin the Pan American Commission.

It is further recommended that there should beestablished very close relationships between theseregional commissions and the Malaria Committeeof the World Health Organization and that thelatter be empowered, with the approval of theDirector-General, to invite one or more chairmenof regional malaria commissions or sub-committeesto attend its meetings as observers.

4. The Darling Foundation and Prize.

The Expert Committee on Malaria supports therequest of the Interim Commission to the Secretary-General of the United Nations that the funds ofthe Darling Foundation be transferred to the WorldHealth Organization or to its Interim Commission,according to the resolution of the Interim Com-mission adopted during its third session 2.

2 Off. Rec. WHO, No. 5, page 125.

MALARIA

Should this transfer be effected, the Committeeconsiders that the statutes of the Darling Founda-tion should be modified, the draft of the revisedstatutes to be entrusted to the future MalariaCommittee, according to the recommended resolu-tion presented in section io of this report.

5. The Fourth International MalariaCongress.

The Fourth International Malaria Congress willbe held in Washington, D.C., United States ofAmerica, 10-15 May 1948. An invitation has beenreceived from the convener (Dr. M. F. Boyd) forthe Malaria Committee to take active part in itssessions. It is expected that, by the time theCongress is held, the Malaria Committee of theWHO may already have been appointed, butalso that, because of the shortness of time, itmay be unable to accept such an invitation.Because of this fact, the Committee advises theInterim Commission to appoint an observer torepresent the Committee in the said Congress.

6. Chemotherapeutic Control of Malaria.

The following report, bearing on the chemo-therapeutic control of malaria, is included forpurposes of supplying information to the InterimCommission regarding (1) recent anti-malaria drugswhich have become available since the war, and(2) lines of investigation which, in the opinionof this Committee, might be undertaken in thefuture. Owing to the absence of funds for the pur-pose, no definite recommendations are made tothe Commission at this juncture.

Malaria proved a grave menace to troops operat-ing in malarious areas during the Second WorldWar, and great national efforts were directed tothe discovery of more effective drugs to suppressand cure malaria. These chemotherapeutic dis-coveries made during the war have greatlyincreased our capacity to control and eradicatemalaria in times of peace.

Atebrin.

Though atebrin had been widely used before1939 and was known to be capable of replacingquinine in the treatment of malaria, its value andcorrect dosage as a suppressant had not beenworked out. Investigations in volunteers experi-mentally infected with both falciparum and vivaxsporozoites while taking one tablet of atebrin(o.i gramme) every day revealed that even theheaviest falciparum infections were suppressedand cured by this regimen, while vivax infectionswere completely suppressed though not radicallycured. Subinoculation revealed that erythrocyticparasites appeared in submicroscopic numbers inthe blood of such volunteers, but, provided atebrinwas present in sufficient concentration in theplasma, the parasites were destroyed, and, in thecase of falciparum infection, radical cure resulted.If correct, these experimental fmdings implied thatthere should be no deaths from falciparum malariaand no blackwater fever, provided an adequate

daily dosage of atebrin is taken. Field resultswith few exceptions confirmed these findings.Atebrin administration became a matter of strictmilitary discipline, and, following this, malariawas reduced to insignificant proportions, ceasingto be a disease of military importance.

The 4-Amino-Quinolines.

Much new work was also done on two newdrugs-sontochin (SN 6911) and resochin (SN7618)-which had been synthesized and patentedby German chemists in 1939. The action of thesedrugs was found to be essentially similar to atebrin,but resochin, which is now called chloroquine oraralen, possessed the advantage of not discolouringthe skin and being effective in one-half the thera-peutic dosage. Like atebrin, aralen produces itstherapeutic effects by schizonticidal action anddoes not affect the exo-erythrocytic parasites.It is, however, a drug of great potentialities, andis being selected for very wide field-trials, bothas a suppressive and for therapeutic purposes.

The 8-Amino-Quinolines.

The value of plasmoquine (1) as a gametocide,(2) as a causal prophylactic in falciparum malaria,and (3) in combination with quinine in radicallycuring vivax relapsing malaria has been recog-nized for many years. Recently, in the UnitedStates of America, new drugs of this series havebeen synthesized, the most promising of whichis pentaquine. Pentaquine has a similar thera-peutic action to plasmoquine ; it can be given inslightly larger dosage, but unfortunately, likeplasmoquine, may produce serious toxic complica-tions. Hmolytic anTmia and hmoglobinuriahave both been recorded in patients receivingpentaquine, and for this reason its therapeuticuse is likely to be restricted to hospital patients.

The Biguanides.

A remarkable series of antimalaria drugs syn-thesized during the war were the biguanides, themost important of which is paludrine. This drugis an effective schizonticide ; it possesses an actionsimilar to quinine and atebrin in benign tertianmalaria, producing clinical but not radical cure.It cures overt falciparum malaria with greatregularity in a dosage of 0.3 gramme daily forten days : in one series, io6 out of 107 falciparuminfections were radically cured by this treatment.It also has a sterilizing action on gametocytesand later sexual stages, the sexual cycle notproceeding further than the early oôcyst stage inmosquitoes fed on carriers while taking paludrine.

Its most remarkable action, however, is as asuppressant drug : when given in suppressivedoses either daily or two or three times a week, itacts as a true causal prophylactic in falciparuminfections, and as a partial causal prophylacticin vivax infections. As a result of this action,falciparum infections are terminated in the pre-erythrocytic stage, so that erythrocytic parasitesnever reach the blood stream.

A remarkable feature of paludrine is the latitudeallowed between the effective therapeutic doseand the toxic dose. A daily dosage of 1.0 gramme

- 12 - MALARIA

has been frequently taken for three to four weekswith impunity. Yet a single dose of 50-10o mg.given from 29 to 131 hours after severe sporozoitefalciparum infection eradicates the disease. Simi-larly, a single dose of 0.1 gramme will often ter-minate a clinical attack of either vivax or falci-parum malaria ; generally, recrudescence follows afew weeks later. General Covell has recentlyreported that a single dose of 0.3 gramme of palu-drine has been found to be very effective fortreatment of overt malaria in Indian villages ; hebelieves this to be the best treatment for village use.

Field-trials with Paludrine.

In the first field-trials with paludrine, onlyone tablet of 0.1 gramme weekly was given. Field-trials in India and Africa, arranged by the MalariaSub-Committee of the Colonial Medical ResearchCouncil in England, indicate that a single tabletweekly is sometimes insufficient as a suppressive ;for occasional overt attacks occur even in regionsof low endemicity, and in hyperendemic areasthis dosage is definitely insufficient. This failureis not surprising, as the results obtained in experi-mentally infected volunteers at Cairns indicatedthe minimal effective dosage to be oa gramme,given at least twice weekly. General Covell reportsthat when the dosage is increased to two tabletsof 0.1 gramme a week, given at three to fourdays' interval, paludrine appears to be entirelyeffective ; but the series is so far too small to reachfinal conclusions. Arrangements have also beenmade to test in hyperendemic areas one dose of0.3 gramme weekly, but no field results are yetto hand. Field-trials, arranged by the MalariaSub-Committee of the Colonial Medical ResearchCouncil, are being made in Malaya by Dr. Field,in India and Ceylon and in many parts of Africa.

Projected Chemotherapeutic Investigationsand Field-trials.

Two outstanding drugs are now available forfield-trials :

(1) Aralen (chloroquine), produced by Win-throp in the United States ;

(2) Paludrine, manufactured by Imperial Che-mical Industries in England.

It is understood that supplies of both thesedrugs will be made available gratis by the manu-facturers for field-trials undertaken under thedirection of the WHO.

Aralen.- This is a most effective schizonticideboth as a suppressant and for therapy. It gradu-ally " builds up " in the blood, and the concentra-tion is maintained for some time after medicationceases. This is an advantage in a suppressantdrug, since occasional doses can be missed withimpunity. On the other hand, it is more likelyto be associated with occasional toxic features,as is the case with atebrin. The standard tabletcontains 0.25 gramme of base.1

1 Editor's Note : Today each tablet of Aralendiphosphate - the Winthrop brand of chloroquinediphosphate - contains o 25 gms of the salt equiva-lent to o.155 of the chloroquine base. Consequently,all the dosages of this report should be modifiedaccordingly.

Paludrine.- This drug has a direct action bothas a schizonticide and as a causal prophylactic.It is also a primary gametocide and should directlyaffect the carrier-rate, quite apart from any secon-dary effects dependent on early termination of theprimary trophozoite wave in malaria infection.The standard tablet contains 0.1 gramme ofpaludrine.

The potentiality of these two drugs when givenin suppressive dosage should be fully explored(a) in volunteers or patients needing therapeuticmalaria, and (b) in highly malarious villages.These investigations should be undertaken notonly from the standpoint of suppressing malariafever, but also from the standpoint of preventionof infection and radical cure. Following chemo-therapeutic control, the ensuing loss of premunityin village populations might increase the tendencyto epidemics, but this is a risk which can now betaken, since the means at our disposal for con-trolling epidemics have so vastly improved.

(a) Chemotherapeutic investigation on volunteersor patients needing therapeutic malaria.

(i) Chemotherapeutic suppression: Volunteers orselected patients needing treatment with indirectmalaria are generally infected with falciparumor vivax sporozoites either by the bites of infectedmosquitoes or by intravenous injection of sporo-zoites derived from the salivary glands of infectedanophelines. For the purposes outlined here,repeated infection could be made with vivax andlalciparum sporozoites, while such selected patientswere receiving one of the various regimens ofpaludrine or aralen.

When such investigations are undertaken, itis suggested that they be planned as follows :

Series I Receives one tablet of aralen(0.25 gramme of ¡base) once week-ly, exposure to infection com-mencing 4 weeks after administra-tion of the drug has been ini-tiated.

Series II - Receives 0.3 gramme of palu-drine once weekly, administrationcommencing 2 days after the firstexposure to infection.

Series III - Receives 0.1 gramme of paludrinetwice weekly at 3-4 days' interval,drug administration commencing2 days after first exposure toinfection.

Series IV - Receives one-half tablet of aralen(0.125 gramme of base) twiceweekly at 3-4 days' interval, drugadministration commencing 4weeks before exposure to infec-tion.

Series V - Receives 0.1 gramme of palu-drine three times in each week -i.e., at 2 or 3 days' interval, drugadministration commencing 2days after first exposure to infec-tion.

MALARIA - 13 -

In all these experiments, the drugs should becontinued for two weeks after last exposure toinfection.

Patients developing clinical attacks of malariaduring the period of drug administration or there-after should be treated with standard therapeuticdoses of the same drug-i.e., paludrine or aralen-which was being used for suppressive purposes. Inthis way, the development of paludrine-resistantor aralen-resistant strains would be detected.

(2) Gametocyte carriers: Mackerras found atCairns that (r) the sexual cycle was inhibited anddid not proceed beyond the small oticyst stage inthe mosquito if paludrine was present in the bloodof the carrier ; (2) the action was reversible sincefalciparum gametocyte-carriers later regained theircapacity to infect mosquitos normally, the timedepending on the dosage of paludrine administeredto the carrier.

Additional experiments on gametocyte carriersshould, in our opinion, be carried out when theyare receiving paludrine as follows :

Series I - 0.3 gramme once weekly.Series II - 0.1 gramme twice weekly.Series III - 0.1 gramme thrice weekly.

It would be most important to determine whethersporozoite infection of the salivary glands canoccur under these regimens, and, if so, on whatdays of the week the carrier becomes infective.

(b) Chemotherapeutic Field-trials.

Two types of experiments are visualized :

(r) A comparison of the efficacy of aralen andpaludrine in adjacent villages or in the same village.

(2) The eradication of malaria entirely in a givenarea by chemotherapeutic means.

Throughout, it would be essential to selectvillages and areas where DDT or Gammexane willnot be used.

(1) Comparison of the efiEciency of aralen and palu-drine in adjacent villages with similar spleenand parasite rates.

In the ideal field-trial, the value of the twodrugs would be determined for a cross-section ofthe whole village community, including (r) infantsand young children without premunity and(2) older children and adults who had developedpremunity as a result of repeated infections.

Two adjacent highly malarious villages wouldneed to be selected. In village " A ", one-half ofthe population, comprising approximately 50% ofall age-groups, would receive paludrine in appro-priate dosage once weekly, while the other 50%would be given a placebo. Adults would receive0.3 gramme of paludrine once weekly, while thedosage in the age-groups under 15 years would bescaled down according to age.

In village " B ", a similar experiment would beconducted except that aralen would be substitutedfor paludrine in 50% of all age-groups. The doseof aralen would be 0.25 gramme for adults, and

this would again need to be scaled down in thelower age-groups. The control half of the popula-tion in each village who were taking the placebowould (r) afford an accurate index to malariatransmission, and (2) ensure a reservoir of game-tocyte carriers, provided individuals without pre-munity-i.e., infants and young children-wereadequately represented. As overt attacks wouldbe immediately treated, the health of the grouptaking the placebo would be adequately cared for.

Field-trials of this type are more readily plannedthan carried out. The difficulties associated withthe administration of a placebo may be not incon-siderable, and with new drugs it is at first difficultto determine the appropriate dosage in the lowerage-groups, and, having determined it, to ensurethat it is properly administered. For these reasons,the simpler field-trials outlined below may bepreferable-at least in the first instance.

(a) Children under 5 years of age would receiveno suppressant drug, but clinical attacks would beimmediately treated as they arose. Parasite ratesand spleen rates would be determined at statedintervals ; where possible, this would be monthly,otherwise every two months. The remainder ofthe population-i.e., those over 5 years-wouldonce weekly receive aralen in one village andpaludrine in the other village. The dosage ofaralen for adults would be one tablet (0.25 grammeof base) and for children 6-15 years of age one half-tablet (0.125 gramme of base) once weekly. Thedosage for paludrine 'would be three tablets (0.3gramme) for adults and two tablets (0.2 gramme)for children aged 6-15 years once weekly.

Drug administration should start one monthbefore the malaria season commences and becontinued for one month after transmission ceases.Drugs would need to be administered under strictsupervision and an accurate roster kept for thepurpose.

In all suspected febrile attacks, blood examina-tions would be made. When possible, spleen andparasite rates would be determined at monthlyor two-monthly intervals. Whenever feasible, thesporozoite rates of mosquitos trapped in thevillages should be made for purposes of comparison.It is possible that the sporozoite rate in the palu-drine-treated villages would be lower than in thearalen-treated villages.

Observation should be continued throughout theperiod of non-transmission to determine the generalhealth of the village population and the incidenceof vivax relapses.

(b) A comparison in two other similar malaria-infected villages should be made, the populationover 5 years of age receiving drugs as follows :

(r) One village should receive one half-tabletof aralen (0.125 gramme of base) twice aweek.

(2) Another village should receive paludrine(0.1 gramme) twice a week-i.e., Wednesdaysand Sundays.

Similar parasite and spleen surveys should bemade in the children under 5 years and in the other

- 14 - MALARIA

age-groups as have already been described. Asimilar follow-up during the period of non-trans-mission should be instituted.

Therapy. - Throughout, overt attacks in bothchildren and adults should be treated with thera-peutic doses of the same drug as was used forsuppressive purposes-i.e., aralen or paludrine.This would afford an index to the possible develop-ment of aralen-resistant and paludrine-resistantstrains.

(c) In two other villages of high endemicity'similar drug-regimens would be instituted, buthere paludrine or aralen would be compared in thesame village. Children under 5 years wouldreceive no drugs unless they developed overtattacks of malaria. The other age-groups would bedivided into two halves and receive suppressivedrugs as follows :

Village z - One-half of the adults wouldreceive 0.3 gramme of paludrine once weeldy,and the other half 0.25 of aralen once a week.Children would receive 0.2 gramme of palu-drine, or 0.125 gramme of aralen base.

Village 2 - One-half of the adults wouldreceive o.i gramme of paludrine twice a week,and the other half, 0.125 gramme of aralenbase twice a week- i.e., at 3-4 day intervals.Children 6-15 years old could receive the adultdose of paludrine-i.e., 0.1 gramme twice weekly.The adult dosage of aralen would probably beregarded as excessive for children ; one quarterof a tablet-i.e., 62.5 mg. twice weekly might besubstituted.

(2) Extirpation of malaria from village areas bychemotherapy.

Two areas with similar parasite and spleen ratesshould be selected. In one area, " A ", all thepopulation should receive paludrine except onecontrol village on the periphery of the area ; inthe other area, " B ", all should receive aralenexcept one village used as a control located on theperiphery of the area.

Details regarding this type of field-trial anddosage to be adopted could be considered later.

7. DDT.

The discovery of the insecticidal properties ofDDT has meant the introduction of a very power-ful arm in the control of malaria. It has beenused as a larvicide and as a mosquitocide andfound very effective. The final general use of thisinsecticide as larvicide or as mosquitocide willdepend on future research.

As a larvicide, DDT may probably be of res-tricted use in ordinary anti-anopheline work, ascompared to its employment as a mosquitocide.As a larvicide, it may result in being a more expen-sive measure; and therefore its effects, in compa-rison with those obtained when used as mosqui-tocide, in relation to their relative cost, should bestudied. In countries where the malaria seasoncoincides with the rainfall, it may have a limited

effect, which may reduce its economic use. Also,and especially when used from aeroplanes, it mayinterfere with the normal biological cycles of thetreated environment, which may upset the economyof the region, not only from the standpoint ofanimals but also of plants, both crops and trees.There is no doubt that, as an emergency measure,DDT, as larvicide, has a wide usefulness. A greatdeal of study should be given to these points, andspecial care should be taken not to carry on expe-riments with DDT as a larvicide in districts whereit is also used as a mosquitocide, because a decreaseof density of anophelines has been observed inplaces where it has been used only as a mosquito-cide.

It is probable that the widest use of DDT willbe based on its utilization as a mosquitocide tocontrol malaria by the destruction of the adultvector-insect. As this requires its use as a house-spray, it will also affect other domestic insects,particularly flies ; and in this way DDT mayindirectly influence the local morbidity and mor-tality from causes other than malaria. The futuresuccess of a world-wide malaria control by DDTwill depend on the solution of a large number ofproblems which need further study.

A country-wide programme by DDT house-spraying will depend on the budgetary facilitiesthat each country may have, and, as there are manynations of low economic level where the malariaproblem is extremely important, it is basic thatspecial attention should be given to reducing thecost of the work. It should be remembered thatin many field experiments to control malaria moreemphasis is laid upon the decrease in the diseasethan upon the actual amount of money involvedto obtain such reduction. At the present time,enough is known of the possibilities of DDT sothat it is time for giving serious consideration toproblems of cost. It is felt that at present, whenall the emergencies of the war are over, the InterimCommission should not back routine programmesto control malaria by DDT, which would be outof financial reach by the health authorities of theaided countries. On the other hand, it is consideredthat any effort on the part of the World HealthOrganization to help in the development of low-cost methods to control malaria by DDT house-spraying would be very important. The Com-mittee, in this respect, wants to emphasize that,with this powerful arm, the time has come whenmore effort should be devoted to developingmethods for more practical and economical controlof the disease under consideration.

The reduction of cost of a DDT programme willrest on the increase of knowledge on the followingpoints :

(a) bionomics of the anophelines,(b) methods of application, and(c) organization measures.

Attention should be given, therefore, to stimu-lating efforts in this direction in the different areasof the world.

In reference to cost, the Committee wants tocall attention to the recently observed trend inthe market to increase the price of DDT, which atpresent is hard to understand. It should berecalled that in industry it generally happens that

MALARIA - 15 -

the larger the amounts of a given material, thelower the prices of its production. Steps should betaken to advise those concerned to give consi-deration to this problem, as it is suspected that anartificial increase in price of DDT may be seen inthe near future, which may be a hindrance to itswider use.

It is suspected, as mentioned above, that adecrease in morbidity and mortality from diseasesother than malaria may be obtained by the wideuse of DDT, in a similar way as was observedafter the introduction of better water-supplies andchlorine when a reduction was noticed in diseasesother than typhoid, diarrhcea and dysentery. DDTprobably will have to be used as a recurring measure-as chlorine is used in water-supplies-andtherefore expenditures may be expected to bemaintained. Because of this fact, special attentionshould be paid to the collateral benefits on generalmorbidity and mortality just mentioned, to avoidthe possibility of budgetary reduction which over-optimistic health authorities may impose.

8. Recommendations for a Second Sessionof the Expert Committee on Malaria in 1947.

There will perforce be a considerable timeinterval between the present session of the ExpertCommittee and the first meeting of the definitiveMalaria Committee of the World Health Organi-zation, recommended in this report. Therefore, itis urged that the Interim Commission at its nextsession authorize and provide for a second sessionof this Committee, to be held in November 1947.Such a meeting is essential if the World HealthOrganization desires the advice and guidance ofits malaria ,experts in regard to its 1948 malariaprogramme, which involves the expenditure of aconsiderable sum of money. It is strongly feltthat all malaria projects of the WHO should bereviewed by its Malaria Committee, as a matterof sound policy. There has been no opportunityfor the Expert Committee to study the 1948malaria programme, and it would seem advisableto make provision for such a review before the endof this year. Moreover, there are other matterswhich should receive attention without delay.These include the preparation and disseminationof reports regarding new antimalarials and insec-ticides and the inauguration of a WHO malariafellowship programme.

9. Miscellaneous.

Draft Resolution presented by Dr. Ciuca.

The Committee draws attention to the seriousmalaria epidemic in Tulcea (Roumania), where thesupply of antimalarial drugs and insecticides isgrossly inadequate. This epidemic threatens toextend also to neighbouring regions in the countryand even to cross the border into adjacent countries.

The Committee recommends that the Secretariatcollect more complete information and that itapproach the League of Red Cross Societies witha view to supplying the necessary antimalarialdrugs and insecticides to combat this seriousemergency.

10. Recommended Resolutions.

The Expert Committee on Malaria submits thefollowing recommended resolutions for the consi-deration of the Interim Commission, to be placedbefore the World Health Assembly :

I.

Whereas the World Health Organization, forthe application of its statutory functions in thefield of malaria, would benefit from the advice ofa group of outstanding malariologists conversantwith the many aspects of the malaria problem inthe different parts of the world, as regards malariaresearch, epidemiology, therapy, control and era-dication,

The first Health Assembly resolves :

1. That the Executive Board be instructed toestablish, during its first session, a MalariaCommittee of the World Health Organizationwith the following terms of reference :

(a) to act as an expert malaria advisory bodyto the World Health Organization and,when requested by the Director-General, toother specialized agencies of the UnitedNations and to Governments requestingadvice or technical assistance in the field ofmalaria ;

(b) to act as an international co-ordinating andintelligence centre in the field of malaria ;

to study and stimulate and, where appro-priate, to recommend the ;financing ofmalaria research and field investigations, todevelop specialized malaria training throughfellowships or otherwise and to promoteco-operation and agreement among thenations in the fields of malaria research,epidemiology, legislation, therapy, preven-tion, control or eradication ;

2. That the Malaria Committee of the WorldHealth Organization shall consist of no fewerthan nine experts, appointed for three yearsand eligible for reappointment ;

3. That the Malaria Committee of the WorldHealth Organization be empowered to elect itsown Chairman, adopt its own rules of proce-dure, and, with the approval of the Director-General, to invite to its meetings technicalexperts when deemed necessary ;

4. That the Chairman of the Executive Board, inagreement with the Director-General, appointthe first nine members, selecting them from thelist presented by the Expert Committee onMalaria of the Interim Commission, and thathenceforward the selection for new appoint-ments be made from a list, including two can-didates for each nomination, presented by theMalaria Committee of the World HealthOrganization ;

- 16 - MALARIA

5. That, when the World Health Assembly definesgeographic areas for Regional Organizations,there be established at once, if malaria is aproblem, regional malaria commissions ap-pointed by the regional director.

Whereas the Darling Foundation was createdby private funds with a view to honouring thememory of Dr. S. T. Darling, killed by accidentduring a study mission of the Malaria Commissionof the League of Nations ;

Whereas the Darling Foundation had the pur-pose of granting periodically a medal and a prizeto a malariologist who particularly distinguishedhimself with his work ;

Whereas, with the liquidation of the League of

Nations, the Statutes of the Darling Foundationare no longer applicable ;

The first Health Assembly resolves :

I. That the Malaria Committee of the WorldHealth Organization, in consultation with theDirector-General, draft the new statutes of theFoundation and submit these for approval tothe Executive Board ;

2. That such Statutes should entrust the MalariaCommittee with the selection of the candidateto whom the medal and the prize should beattributed ;

3. That the medal should be solemnly awarded bythe World Health Organization and that theDirector-General should be the administratorof the Fund of the Darling Foundation.

- 17 -

[WHO .IC/8i]29 May 1947

III. EXPERT COMMITTEE FOR THE PREPARATION OF THE SIXTH DECENNIALREVISION OF THE INTERNATIONAL LISTS OF DISEASES AND CAUSES OF DEATH

(a) REPORT ON THE FIRST SESSION

Held 10-21 March 1947, Ottawa, Canada

(presented to the Interim Commission at its fourth session) 1.

1. Summary of Developments priorto the First Session.

1. The Interim Commission was entrusted byArticle 2 (k) of the Arrangement establishing it,with the task of " reviewing the existing machineryand of undertaking such preparatory work as maybe necessary in connexion with :

" (i) the next decennial revision of the Inter-national Lists of Causes of Death ; and

" (ii) the establishment of International Listsof Causes of Morbidity ". 2

2. To meet this responsibility, the InterimCommission decided at its second session, inNovember 1946, to set up a committee of experts.3

The Chairman and Executive Secretary of theInterim Commission, acting jointly upon thisresolution, appointed the International 4 Com-mittee for the Preparation of the Sixth DecennialRevision of the International Lists of Diseases andCauses of Death, composed of the followingmembers :

J. E. Backer, Sc. D., Chief, Demographic, Section,Central Bureau of Statistics, Oslo, Norway ;

Dr. S. T. Bok, Professor of Medicine, Universityof Leiden ; Chief, Section for Statistics,Institute for Preventive Medicine, Leiden,Netherlands ;

Dr. D. Curiel, Medical Chief, Division of Epide-miology and Vital Statistics, Caracas, Vene-zuela ;

W. Thurber Fales, Sc. D., Director, StatisticalSection, City Health Department, Baltimore,Maryland, United States of America ;

Dr. M. Kacprzak, President of the NationalHealth Council, Warsaw, Poland ;

Dr. P. Stocks, Chief Statistician (Medical),General Register Office, London, UnitedKingdom ;

Dr. J. Wyllie, Professor of Preventive Medicine,Queen's University, Kingston, Ontario,Canada.

1 Off. Rec. WHO, No. 6, pages 12, 45, 190, 214.2 Off. Rec. WHO, No. 2, Section VC.3 For the resolutions, see Off. Rec. WHO, No. 4,

page 161.4 This Expert Committee of the Interim Commis-

sion is referred to, in this and other documents of thesame series, as the " International Committee ", inorder to differentiate it from the expert United StatesCommittee.

The agreement of the French authorities on theFrench expert suggested was not obtained, and atthe time of the meeting there had been no nomina-tion of a member by the Union of Soviet SocialistRepublics.

The secretariat of the International Committeeincluded :

Dr. Marie Cakrtova, Medical Officer of theInterim Commission, and

J. T. Marshall, Assistant Dominion Statistician,Ottawa, Canada.

who was appointed co-secretary to the InternationalCommittee.

The terms of reference of the InternationalCommittee were defined as follows :

(a) To review the developments as regardsmorbidity and mortality classification whichhave taken place since the Fifth DecennialRevision in 1938 ;

(b) To formulate proposals to be submittedthrough the Interim Commission to Govern-ments ;

(c) To consider suggestions from Governmentsand agencies interested in the problem ofmorbidity and mortality classification ;

(d) To prepare recommendations regarding theInternational Conference for the SixthDecennial Revision of International Listsof Diseases and Causes of Death.

It had been realized that, in facing this task, theInternational Committee would have the advan-tage of the very large amount of preparatory workaccomplished by the United States Committee onJoint Causes of Death. This Committee had beenappointed in 1945 by the Secretary of State ofthe United States, in compliance with a resolutionof the Fifth International Revision Conference in1938, including among its members and consultantsrepresentatives of the Canadian and BritishGovernments and the Health Section of the Leagueof Nations.

The United States Committee decided that,before taking up the matter of joint causes, itwould be advantageous to consider classificationfrom the point of view of morbidity and mortality,since the joint-cause problem belongs to bothtypes of statistics.

In approaching the problem of morbidity clas-sification, the Committee acted upon another

- /8 - REVISION OF INTERNATIONAL LISTS

resolution of the Fifth Decennial Conference, whichrecommended that the " various National Lists inuse should, as far as possible, be brought into linewith the detailed International List of Causes ofDeath ". With this objective in mind, the UnitedStates Committee, utilizing the experience inmorbidity classification accumulated in the lastdecade in Canada, the United Kingdom and theUnited States, and keeping to the framework ofthe International List, prepared, in a series ofworking sessions, a single classification suitable forboth morbidity and mortality statistics.

The United States Committee presented theresults of its work in the " Proposed StatisticalClassification of Diseases, Injuries and Causes ofDeath ", consisting of two volumes :

Part I - Introduction and List of Categories ; andPart II - Tabular List of Inclusions (Tentative

Edition).

This document was then submitted for criticismand review to various agencies and individuals inCanada, England and the United States. TheMinister of Health in the United Kingdom ap-pointed for this purpose a special investigatingbody-namely, the Medical Advisory Committeeon the Sixth Decennial Revision of the Inter-national List of Causes of Death-composed ofexperts in medical statistics and in the variousfields of medicine.

After making further modifications based on theamendments suggested by the Medical AdvisoryCommittee and other agencies, the United StatesCommittee met in Ottawa on io March 1947 andapproved a final draft of the proposed classifica-tion.

2. First Session of the InternationalCommittee in Ottawa,

Canada, 10-21 March 1947.

A. Arrangement of Session.

It was considered advisable for the first sessionof the International Committee to be convened onio March in Ottawa, since it would thus be pos-sible to arrange combined meetings with the UnitedStates Committee on Joint Causes of Death,meeting there for the final revision of its document.These combined meetings were arranged, upon theinvitation of the Executive Secretary of theInterim Commission to the United States Com-mittee to take part in the discussions of the sessionand thus to give the International Committee thebenefit of its wide experience.

In addition, two members of the United StatesCommittee - namely, Dr. Selwyn D. Collins, HeadStatistician, Public Health Service and Secretaryfor Morbidity Code ; and Dr. Halbert L. Dunn,Director, National Office of Vital Statistics andSecretary for Mortality Code - were invited toparticipate in the work of the International Com-mittee during its first session, as Rapporteurs ofthe United States Committee. The same invitationwas extended to Dr. A. H. T. Robb-Smith, NuffieldReader in Pathology, University of Oxford, andalso member of the United States Committee, totake part in the session as Rapporteur of the abovementioned Medical Advisory Committee in theUnited Kingdom.

B. Persons attending the First Session of the Inter-national Committee.

International Committee:

Dr. Percy Stocks (elected Chairman),W. Thurber Fales (elected Vice-Chairman),J. E. Backer,Dr. S. T. Bok,Dr. Dario Curiel,Dr. J. Wyllie.(Dr. M. Kacprzak and the expert in medical

statistics from the USSR were unable to attendthe first session.)

Rapporteurs: Dr. S. D. CollinsDr. H. L. DunnDr. A. H. T. Robb-Smith

Secretaries: Dr. Marie CakrtovaJ. T. Marshall.

United States Committee on Joint Causes of Death:

Dr. George Baehr, Mount Sinai Hospital, NewYork ;

Dr. F. S. Burke, Chief of Blindness Control,Department of Health and Welfare, Ottawa,Canada ;

Dr. Edwin L. Crosby, Director, The JohnsHopkins Hospital, Baltimore, Maryland ;

Dr. Paul M. Densen, United States Veterans'Administration, Washington, D.C. ;

Dr. Harold F. Dorn, United States Public HealthService, Bethesda, Maryland ;

Eugene L. Hamilton, United States War De-partment, Washington, D.C. ;

Dr. Lowell J. Reed, Professor of Biostatisticsand Vice-President, The Johns Hopkins Uni-versity, Baltimore, Maryland (Chairman) ;

Dr. Edward S. Rogers, Dean, School of PublicHealth, University of California, Berkeley,California ;

Dr. Robert L. Ware, United States Navy Depart-ment, Washington, D.C. ;

Dr. Iwao M. Moriyama, United States PublicHealth Service, Washington, D.C. ;

Winifred O'Brien, Vital Statistics Branch, Do-minion Bureau of Statistics, Ottawa, Canada ;

as well as Dr. Percy Stocks, Dr. W. T. Fales, Dr. JWyllie, Mr. J. T. Marshall, Dr. S. D. CollinsDr. H. L. Dunn, and Dr. A. H. T. Robb-Smithalready listed under the International Committee'

Dr. Yves M. Biraud, Deputy Executive Secre-tary of the Interim Commission, and Dr. J. C.Meakins, Professor of Medicine and Dean of theFaculty of Medicine, McGill University, Montreal,Quebec, Canada, also members of the United StatesCommittee, were unable to attend the session.

C. progress of the Session.As stated in the draft Minutes 1, the session

consisted of twenty-two meetings, the first beingattended by the International Committee only,to elect its officers ; the second to the sixth meetingswere also attended by the full United StatesCommittee ; and the seventh to the twenty-second by the Working Sub-Committee of the

1 Documents WHO.IC/MS/Min/I-22, unpublishedworking documents.

OF DISEASES AND CAUSES OF DEATH - 19 -

United States Committee, which was authorizedby its parent body to continue in session with theInternational Committee.

D. Summary of the Work of the Session, andRecommendation to the Interim Commission as to

Action to be taken.

The International Committee and its Chairmansummarized the work of the session as follows :

" The International Committee for the Pre-paration of the Sixth Decennial Revision ofInternational Lists of Diseases and Causes ofDeath was entrusted by the Interim Commissionthrough its Chairman and Executive Secretarywith the responsibility of :

" (a) reviewing the developments as regardsmorbidity and mortality classificationwhich have taken place since the FifthDecennial Revision in 1938 ;

" (b) formulating proposals to be submittedthrough the Interim Commission toGovernments ;considering suggestions from Governmentsand agencies interested in the problem ofmorbidity and mortality classification ;

" (d) preparing recommendations to the Inter-national Conference for the Sixth Decen-nial Revision of International Lists ofDiseases and Causes of Death."

During the first session of the InternationalCommittee held in Ottawa, Canada, from io-21 March 1947, parts (a) and (b) of the abovefunctions were fulfilled.

" (c)

(a) Review and Study of Developments since 1938.

The Chairman of the International Committee,in order to carry out the responsibility as listedunder (a), asked the Chairman of the UnitedStates Committee on Joint Causes of Death tomake the work of his Committee available forreview and study by the International Committee.

The Chairman of the United States Committeeon Joint Causes of Death took action to transferthese documents to the International Committee :

(i) Proposed Statistical Classification of Diseases,Injuries and Causes of Death (Introductionand List of Categories) in its final form, asapproved by the United States Committeeat its meeting in Ottawa, io March 1947.

(ii) Tabular List of Inclusions (Tentative Edi-tion) under the respective categories of theclassification in provisional form as preparedby the United States Committee.

The International Committee, during its firstsession, reviewed and amended the List of Cate-gories and reached agreement on the final version.It also prepared a Preface, revised the Introductionand adopted for the classification the followingtitle : " International Statistical Classification ofDiseases, Injuries and Causes of Death ".

In combined meetings with the working sub-committee of the United States Committee,discussions on the Tabular List of Inclusions have

been carried out on the tentative version, givingproper consideration to amendments suggestedfrom various sources.

The International Committee considered thedesirability of preparing a list of Latin equivalentsof the terms appearing in the Tabular List, andappointed a sub-committee to prepare such a list.

The International Committee also devoted timeto consideration of the need for intermediate andabridged lists for use where tabulations based onthe detailed list were not practicable. A sub-committee was appointed to prepare such listsduring the session.

The International Committee summarized itswork and deliberations during the session in thefollowing statements :

(i) There is an ever-increasing need for a uni-form classification of causes of sicknesssimilar to the International List of Causesof Death.

(ii) A single statistical classification applicableto both causes of sickness and causes ofdeath would permit parallel presentationof morbidity and mortality statistics.

(iii) In order to achieve comparable morbidityand mortality statistics, there should alsobe available a uniform list of inclusionterms for each title of the list.

(iv) There should be agreement on condensedforms of the list suitable for comparativetabulations of morbidity and mortalitystatistics by such characteristics as ageand geographical region.

In view of these conclusions, the InternationalCommittee is submitting to the Interim Commis-sion the following documents prepared during thefirst sessions :

List of Categories (including the Prefaceand Introduction) of the InternationalStatistical Classification of Diseases, Injuriesand Causes of Death.1

(ii) Tabular Lists of Inclusions, in an amendedversion.2

(iii) Drafts of an Intermediate and an AbridgedList, as prepared by the Sub-Committeeand submitted to the International Com-mittee.3

(b) Recommendations to Interim Commission as toaction to be taken.

The International Committee proposes to theInterim Commission that :

(i) The List of Categories of the InternationalStatistical Classification of Diseases, In-juries and Causes of Death should be sub-mitted to Governments, with the recom-mendation that this classification beadopted as a basis for the Sixth DecennialRevision of the International List ofCauses of Death.

Document WHO.IC/MS/x,document.

2 Document WHO.IC/MS/7,document.

3 Document WHOJC/MS/8,document.

unpublished working

unpublished working

unpublished working

- 20 - REVISION OF INTERNATIONAL LISTS

(ii) The amended version of the Tabular Listof Inclusions should be circulated amongparticipants in the Ottawa session forstudy and further consideration.

(iii) The amended version of the Tabular Listof Inclusions should be forwarded to theGovernments of Canada and the UnitedStates, with the recommendation that thisversion be used as the basis in the prepa-ration of an alphabetical index of inclusionterms. This recommendation is based onbelief that the highly technical work ofpreparing an index should be entrusted tothose agencies which, having producedsuch alphabetical lists in the past, areequipped with machinery and personnelto perform this task.

(iv) In view of the above recommendation, aTechnical Sub-Committee for the prepa-ration of an alphabetical index should beestablished, which would include personsin these two countries actually in chargeof such work. This Sub-Committee shouldbe given the responsibility of co-operatingwith representatives of governmental andother agencies in the two countries in orderto produce a uniform index in English, toreport to the International Committeeabout the progress of the work, and submitadditional terms for inclusion in the tabularlist or index.

(v) Early action should be taken in effectingtranslations of the List of Categories intoFrench and Spanish.

The International Committee further proposesthat :

(vi) Drafts of the intermediate and abridgedlists should be circulated among partici-pants in the Ottawa session for study andfurther consideration.

(vii) The second session of the InternationalCommittee should be convened in Sep-tember or October 1947, in order to :

(1) fulfil part (c) and (d) of the functionsas outlined by the Interim Commis-sion ;

(2) receive a report of the Sub-Committeeon the preparation of an alphabeticindex and discuss further steps ;

(3)

(4)

(5)

(6)

discuss action as to translations ofthe Tabular List and Index intoFrench and Spanish ;consider the list of Latin equivalentsprepared by the Sub-Committee ;further study the problem of inter-mediate and abridged lists ;deal with any other pertinent pro-blems arising.

(viii) The second session should be held inGeneva.

E. Assistance given to the Session by the CanadianGovernment.

The International Committee is deeply indebtedto the Canadian Government for the excellentservices rendered by the secretarial staff of theDominion Provincial Relations Organization andby the Dominion Bureau of Statistics in the pre-paration of the numerous documents during thesession, the duplication of the final documentsand their distribution to Governments.

3. Documents referring to the Session. 1

WHO.IC/MS/Min. I-22 - Draft Minutes of theMeetings ;

WHOIC/MS/i - International Statistical Clas-sification of Diseases, Injuries and Causes ofDeath ;

WHO.IC/MS/2 - Agenda of the First Meeting ;WHOJC/MS/3 - Provisional Technical Agenda

of the Session ;WHOIC/MS/4 - Composition of International

Committee ;

WHO.IC/MS/5 - Composition of United StatesCommittee on Joint Causes of Death ;

WHO.IC/MS/6/Rev. i - Amendments to List ofCategories of United States Document ;

WHOJC/MS/7 - Tabular List of Inclusions (Ten-tative Edition) ;

WHO.IC/MS/8 - Drafts of two forms of Abbre-viated Lists.

1 Unpublished working documents.


(b) REPORT ON THE SECOND SESSION

Held 21-29 October 1947, Palais des Nations, Geneva,

in combined meetings with the Index Sub-Committee

(presented to the Interim Commission at its fifth session). 1

Outline

1. Arrangement of the Session.2 . Persons attending.

3 . Documents presented at the Session.4. Summary of Developments since the First Session.5 . Discussions and Progress.

6 . Summary of Work.7 . Documents resulting from the Session.

8 . Recommendations :A. Sixth Decennial Revision Conference.B. Permanent Expert Committee on Health and Vital Statistics.C. Other.

1. Arrangement of Session.

The Expert Committee for the Preparation ofthe Sixth Decennial Revision of the InternationalLists of Diseases and Causes of Death (hereinaftercalled the " Committee ") held its second sessionfrom 21 to 29 October 1947, in Geneva.

It was found desirable to arrange for combinedmeetings with the Index Sub-Committee, in orderto receive the report on its work and to discusssteps in the preparation of the final AlphabeticalIndex. The Index Sub-Committee, having hadtwo previous meetings in Washington and NewYork,2 held its third meeting in Geneva, on 18 and20 October 1947, prior to the session of the Com-mittee.

Dr. H. L. Dunn, Director of the National Officeof Vital Statistics, Washington, D.C., was askedto attend the session as adviser, especially in viewof the Joint Cause Problem included in the pro-gramme of the second session.

2. Persons attending.

Chairman: Dr. Percy Stocks, Chief Statistician(Medical), General Register Office of Englandand Wales, London, United Kingdom.

Members :

J. E. Backer, Sc.D., Chief, Demographic Section,Central Bureau of Statistics, Oslo, Norway ;

Dr. S. T. Bok, Professor of Medicine, Univer-sity of Leiden, Chief, Section for Statistics,Institute for Preventive Medicine, Leiden,Netherlands ;

Off. ReC. WHO, No. 7, pages 16, 35-36.2 Document WHO.IC/MS/2o-WHO.IC/MS/Index/2,

unpublished working document.

[WHO . IC/128]io December 1947

Dr. P. F. Denoix, Chef des Services techniqueset de la Section du Cancer, Institut Nationald'Hygiéne, Paris, France ;

W. Thurber, Fales Sc.D., Vice-Chairman, ResearchAssociate. School of Hygiene, Johns HopkinsUniversity, Baltimore, Md., United States ofAmerica ;

Dr. M. Kacprzak, Professor of Hygiene, Director,State School of Hygiene, President, NationalHealth Council, Warsaw, Poland.;

Dr. J. Wyllie, Professor of Preventive Medicine,Queen's University, Kingston, Ontario, Ca-nada.

Index Sub-Committee:S. D. Collins, Sc.D., Chairman, Head Statisti-

cian, United States Public Health Service,Bethesda, Md., United States of America ;

J. T. Marshall, Assistant Dominion Statistician,Ottawa, Canada ;

Iwao M. Moriyama, Ph.D., Chief, MortalityAnalysis Section, National Office of VitalStatistics, United States Public Health Ser-vice, Washington, D.C., United States ofAmerica ;

Winifred O'Brien, R.N., Supervisor, NosologySection, Vital Statistic Branch, DominionBureau of Statistics, Ottawa, Canada ;

Dr. A. H. T. Robb-Smith, Nuffield Reader inPathology, University of Oxford, Oxford,United Kingdom.

Adviser :Dr. H. L. Dunn, Chief, National Office of Vital

Statistics, United States Public Health Ser-vice, Washington, D.C., United States ofAmerica.


Observers :

Lucien Feraud, Ph.D., Actuarial Consultant,International Labour Organization, Geneva,Switzerland ;

Forrest Linder, Ph.D., Chief, Population andVital Statistics Section, Statistical Office,United Nations, Lake Success, N.Y., UnitedStates of America.

Secretariat :

Dr. Yves M. Biraud, Director of the Division ofEpidemiology and Public Health Statistics ;

Dr. Marie Cakrtova, Medical Officer, Secretaryto Expert Committee.

(Dr. Dario Curiel, Medical Chief, Division ofEpidemiology and Vital Statistics, Caracas, Vene-zuela, was not able to attend.)

3. Documents presented at the Session. 1

WHOJC/MS/i - International Statistical Classi-fication of Diseases, Injuries and Causes ofDeath. Introduction and List of Categories.

WHOJC/MS/i Corr. i - Corrigendum to Intro-duction and List of Categories.

WHOJC/MS/7 - International Statistical Classi-fication of Diseases, Injuries and Causes ofDeath. Tabular List of Inclusions (TentativeEdition).

WHO.IC/MS/8 - Draft Minimum List of 150Selected Categories for International Tabulationof Diseases and Causes of Death by Demo-graphic Characteristics and Abbreviated List of6o Selected Categories for Tabulation of Diseasesand Causes of Death for Geographic Subdivisions.

WHO.IC/MS/8 Corr. i - Corrigendum to DraftMinimum List and Abbreviated List.

WHO.IC/8iWHO. IC/MS/9 Report on the First Session.

WHOJC/MS/io - Report on the PreparatoryWork.

WHOJC/MS/io Add. 1.WHOJC/MS/ii - Problem of Joint Causes of

Death, Preliminary Report of the United StatesCommittee on Joint Causes of Death.

WHOJC/MS/r I Add. 1.WHOJC/MS/ii Add. 2.WHOJC/MS/ii Add. 3.WHOJC/MS/12 - Intermediate and Abridged List

(Analysis of Comments).WHOJC/MS/r2 Add. 1.WHOJC/MS/13 - General Comments by Govern-

ments on the International Statistical Classifi-cation of Diseases, Injuries and Causes of Death.

WHOJC/MS/13 Add. 1.WHOIC/MS/I4 - General Recommendations sub-

mitted by Governments.WHOJC/MS/15 - Proposed Amendments to

Introduction and List of Categories.WHOJC/MS/15 Add. 1.WHOJC/MS/i6 - Problem of Joint Causes of

Death, Recommendation submitted by Canada.

Unpublished working documents.

WHOJC/MS/r7 - Draft Agenda.WHOJC/MS/i8 - List of Persons attending.WHOIC/MS/I9 - List of Documents (Provi-

sional).WHO . I C/MS/2 oWHOJC/MS/Index/2 - Report of the Sub-

Committee on the Preparation of an AlphabeticalIndex.

WHOJC/MS/2oWHO.IC/MS/Index/2 Add. 1.WHOJC/MS/Index/i - Alphabetical Index (Ten-

tative Edition).WHOJC/MS/Index/3 - Additional Terms for

Alphabetical Index and Tabular List of Inclu-sions, submitted by the National Office of VitalStatistics, United States Public Health Service.

WHOJC/MS/Index/4 - Additional Terms forAlphabetical Index and Tabular List of Inclu-sions, submitted by the General Register Office,England.

4. Summary of Developments sinceFirst Session.

As given in the Report on the PreparatoryWork,2 action had been taken on all recommenda-tions resulting from the first session.3

(1) Circulation of Introduction and List of Categories.

The Introduction and List of Categories of theInternational Statistical Classification of Diseases,Injuries and Causes of Death 4, available in bothEnglish and French, had been given wide circula-

were asked to initiateaction which would enable competent adminis-trations to exchange views on the usefulness of theClassification and to formulate co-ordinated pro-posals. A supplementary distribution of thedocument had been carried out to national healthadministrations, to central statistical offices andsocial insurance agencies, in order to facilitatediscussion of the proposal. Copies of the Spanishedition, prepared on the recommendation of theCommittee, were put at the disposal of the WorldStatistical Congress held in September 1947, inWashington.

(2) Response.

Comments and suggestions had been receivedprior to the second session from thirty-three Govern-ments and were correlated and analyzed.6 Twoadditional replies arrived during the session intime to be considered by the Committee.7 Theviews of the competent authorities of Poland werepresented by Dr. M. Kacprzak during the sessionitself.

(3) Problems referred to the Committee.

In addition to the items outlined at Ottawa forthe programme of the second session,8 two other

2 Document WHO.IC/MS/ro.3 See Report on the First Session, pages 17-20.4 Document WHO.IC/MS/x.5 Document WHOJC/MS/ro Add. r.6 See documents WHOJC/MS/r3, 14 and 15.7 Documents WHO.IC/MS/r3 Add. r and 15 Add. 1.8 See Report on the First Session, pages 17-20.


problems were referred to the Committee in the.interval between the two sessions :

(a) Cancer registration and statistics, as outlinedin the resolution adopted by the Conferencton Cancer Statistics, Copenhagen, in Sep-tember 1946 1 ;

(b) Joint Cause Problem, as presented in thePreliminary Report of the United StatesCommittee on Joint Causes of Death.2

5. Discussions and Progress.

The session, consisting of sixteen meetings,proceeded in accordance with the adopted draftagenda.3

6. Summary of Work.The Expert Committee and its Chairman sum-

marized the work of the session as follows :The Expert Committee for the Preparation of

the Sixth Decennial Revision of the InternationalLists of Diseases and Causes of Death was entrustedby the Interim Commission with the responsibilitiesof :

(a) reviewing the developments as regardsmorbidity and mortality classification whichhave taken place since the Fifth DecennialRevision in 1938 ;

(b) formulating proposals to be submittedthrough the Interim Commission to Govern-ments ;

(c) considering suggestions from Governmentsand agencies interested in the problem ofmorbidity and mortality classification ;

(d) preparing recommendations regarding theInternational Conference for the SixthDecennial Revision of the InternationalLists of Diseases and Causes of Death.

The Expert Committee, during its first sessionat Ottawa, io to 21 March 1947, carried out parts(a) and (b) of the entrusted responsibilities.4

During the second session, the Expert Com-mittee continued in fulfilling parts (c) and (d) ofthe terms of reference. The Expert Committee alsodealt with problems arising from the discussionsduring the first session and with additional sub-jects referred to it by the Interim Commission andits Secretariat. Specifically, the Expert Com-mittee :

List of Categories. - (I) Considered the commentsfrom Governments and agencies on the generalstructure of the International StatisticalClassification of Diseases, Injuries and Causesof Death. The objections concerned, on onehand, the extent of the Classification as to thefourth-digit subdivisions2 and, on the otherhand, the lack of useful meaning in some two-digit titles!' The Committee, in view of theseobservations, agreed on the following modifi-cation of the general structure :

1Off. Rec. WHO, No. 5, pages 77-78.Documents WHO.IC[MS/ii and II Add. 1-3.

3 Document WHOIC/MS/i7. For summary of thediscussions, see document WHOIC/MS/3I.

See Report on the First Session, pages 17-20.5 Document WHOJC/MS/13.6 Document WHOJC/MS/i2.

(a) deletion of the two-digit list 7 and repla-cement of the two-digit cross-headings inthe Classification itself by significantgroup titles of three-digit categories ;

(b) presentation of the detailed list in twosections, including, respectively :

(i) a list of three-digit categories forobligatory use in classification ofmorbidity and mortality data ;

(ii) a list of four-digit categories for op-tional use by countries, to be shownas subdivisions of three-digit titles,together with the inclusion terms andwith all necessary explanatory notes ;

(2) Considered the amendments to the Inter-national Statistical Classification of Diseases,Injuries and Causes of Death ; Introductionand List of Categories 8, proposed by Govern-ments and experts 2, as well as otherssubmitted verbally during the session ;

Tabular List of Inclusions.

(3) Authorized the Chairman, Vice-Chairman,Secretary of the Committee and MissO'Brien, member of the Index Sub-Com-mittee, to revise the Tabular List of Inclu-sions " according to those amendments tothe List of Categories which were acceptedby the Committee ;

Alphabetical Index.

(4)

(3)

Adopted the Report of the Index Sub-Committee. 11

Approved the general structure of theAlphabetical Index (Tentative Edition) tothe Tabular List of Inclusions," as preparedby the Index Sub-Committee ;

(6) In discussion on the preparation of the finalAlphabetical Index, the Committee :

(a) considered the problems outlined by theIndex Sub-Committee 13;

(b) authorized the working group mentionedin paragraph 3 to clear problems as setout in the Report of the Sub-Com-mittee," and any problems of a similarnature ;

entrusted the Index Sub-Committeewith the responsibility of incorporatinginto the final version of the AlphabeticalIndex diagnostic terms not already inthe provisional documents 15 ;

(e)

7 Given on pages 1-4 of document WHOJC/MS/I.8 Document WHOJC/MS/I.As given in documents WHOJC/MS/15 and 15

Add. 1.1° Document WHOJC/MS/7." As given in document WHOJC/MS/2oWHO.

IC/MS/Index/2." Document WHOJC/MS/Index/i.13 In document WHOJC/MS/2oWHO.IC/MS/

Index/2 (VII, items 4(a)-(e).)" Appendices I-III of document WHOJC/MS/2o

WHOIC/MS/Index/2.15 Documents WHOJC/MS/7 and WHO.IC/MS/

Index/i.A preliminary list of such terms is given in docu-

ments WHOJC/MS/Indices/3 and/4.


(d) considered the recommendation of theIndex Sub-Committee concerning thepublication of the International Statis-tical Classfication 1 ;

(e) instructed the Index Sub-Committee toproceed with the preparation of the finalIndex so that a complete version wouldbe available for use by 31 December1948 ;

(7) Re-stated its policy as to the inclusion ofLatin equivalents of diagnostic terms in theTabular List and in the Alphabetical Index.The discussion revealed that the need forLatin equivalents in certain countries couldbe satisfied in two ways, by :

(a) providing Latin equivalents for termsin the English version which are notanglicized Latin expressions and thusnot easily recognizable in the Englishform ;

(The Committee decided that suchterms, being few, could be easily blendedinto the English version, and instructedthe Sub-Committee on Latin Equiva-lents, consisting of Dr. Backer and Dr.Bok,2 to supply such terms to the IndexSub-Committee for incorporation intothe final Index.)

(b) translating all English terms for whichthere are available Latin terms incommon usage.

(The Committee felt that the inclusionof such equivalents would lead to anundesirable inflation of the EnglishIndex without offering the benefit offully satisfying any particular nation,in view of the quantitative differencesin the usage of Latin terms, andadopted the suggestion of the Sub-Committee that countries not able toutilize the English, French and Spanisheditions should be asked to preparenational versions incorporating theLatin terms used in these countries.)

(8) Recognized the need for lists of selected cate-gories for certain tabulations of mortality andmorbidity data, and defined the respectiveuses of the detailed and shorter lists for suchpurposes ;Revised, accordingly, the draft Intermediateand Abbreviated Lists,3 taking into consider-ation various suggestions and comments.4Revised the Selected List of Causes of Mor-bidity for Social Security Purposes, as adoptedprovisionally by the Inter-American Com-mittee on Social Security 5 and submitted tothe Expert Committee for study 6 ;

(II) Expressed satisfaction with the action of theSecretariat of the Interim Commission on therecommendation of the first session, concern-

1 As indicated in document WHO.IC/MS/2o-WHO.IC/MS/Index/2 (VII, item (3)).

2 Document WHOJC/MS/9.3 Document WHO.IC/MSM.4 GiVell in document WHO.IC/MS/I2.5 Document WHOJC/MS/i2, Appendix D.Ibid., page 7.

(I2)

(13)

ing the translation of the Introduction andList of Categories into French and Spanish.7It further stressed the need for preparingFrench and Spanish versions of the TabularList of Inclusions and Alphabetical Index,such versions not being literal translations ofthe English document but including synony-mous terms used in French- and Spanish-speaking countries ;

Considered the problem of joint causes ofdeath presented in the Preliminary Report ofthe United States Committee on Joint Causesof Death and submitted to the Committeefor review and study.8 The Committee dis-cussed in detail the recommendations of theUnited States Committee,3 and endorsedparticularly the following :

(a) the adoption of a standard internationalform of medical certificate of cause ofdeath ;

(b) the adoption of the principle of selectingthe underlying condition as the maincause ;

(c) the formulation of uniform rules forselecting the underlying cause of death ;

(d) tabulation and publication of multiplecauses.

The Committee entrusted a Sub-Committee,consisting of the Chairman, Vice-Chairman,Dr. Moriyama and Mr. Marshall, with the taskof preparing by correspondence a draftOutline of Rules for Selecting the UnderlyingCause of Death.

Studied recommendations as to problems ofhealth and vital statistics either put forwardby Governments in response to the circulatedClassification 10 or referred to the Committeeby the Interim Commission :

(a) considered the request made by certainGovernments for international co-ordina-tion of definitions of stillbirth andimmaturity and for uniform methods inthe residence allocation of vital data ; 11

(The Committee agreed on the desira-bility of international co-operation onthese and similar problems.)

(b) discussed the recommendation on cancerresearch and registration.12

(The Committee felt that this problemcould not, in the time available andwithout the co-operation of cancer expertsreceive the full consideration it deserved.)

The Committee concluded its delibera-tions on the above-mentioned items with theconviction that there should be a permanentcommittee available to deal on an interna-nal level with the statistical aspects of cancerand of any other problem of public healthimportance.

7 Document WHOJC/MS/mo.8 Documents WHO.IC/MS/ii and Adds. 1, 2 and 3.9 Document WHOJC/MS/II, page 5.

10 Document WHOJC/MS/i." Document WHOJC/MS/i4."Off. Rec. WHO, No. 5, pages 77-78.


(14)

The Committee suggested that, pendingpermanent provision to this effect, theExecutive Secretary request the health andstatistical authorities of Denmark, Englandand Wales, France and Norway and anyother country which had signified interest inthe problem of cancer registers and statistics :

(a) to undertake preliminary investigationsalong the lines indicated by the Confer-ence on Cancer Statistics held in Copen-hagen in September 1946, and

(b) to make available to the Expert Com-mittee the results of their work for studyand consideration ;

considered, in fulfilling item (d) of the termsof reference, further steps in the internationalclearance of the International StatisticalClassification of Diseases, Injuries and Causesof Death.

The Committee was convinced that aninternational conference such as the onealluded to in the International Agreement of7 October 1938 provided a useful means forinternational collaboration in the field ofhealth and vital statistics. Such a conferencewould contribute to the widespread adoptionof International Lists of Diseases and Causesof Death and, generally, to improvement inthe international comparability in health andvital statistics.

The Committee felt even more the desir-ability of bringing together at an internationalconference representatives of general statis-tical offices and health administrations, inview of the fact that the International Agree-ment signed in New York on 22 July 1946entrusted the international responsibility andleadership in this field to the World HealthOrganization alone, instead of to a jointbody composed of representatives from sani-tary and statistical institutions, as in previousrevisions.

The Expert Committee agreed that theConference be convened in the spring of 1948,in order to ensure that manuals incorporatingthe new lists and procedures would be in thehands of vital registrars in time for their usein coding deaths as from i January 1949.

Further, the Committee was of the opinionthat the Sixth Revision Conference shouldnot only consider the proposed new lists asto their adoption but should devote specialattention to other subjects bearing directlyon the international comparability of healthand vital statistics which have been largelyneglected in previous conferences.

In view of the new purpose of the proposed" Detailed List of Categories " (three-digitclassification) to serve as the basis for bothmortality and morbidity statistics, the Com-mittee concluded that provision should bemade for the presentation of its viewpointto the Conference and that the task of incor-porating and editing the changes should beleft to the Expert Committee, which shouldhold a third session immediately after theRevision Conference.

7. Documents resulting from the Session.

The Expert Committee submitted to theInterim Commission the results of the secondsession in the following documents :

Adopted Amendments to the List of Cate-gories (WHOJC/MS/22) ;Suggested Uses of Detailed and Shorter Listsof Categories (WHOJC/MS/23) ;Intermediate List of 150 Selected Categoriesfor Tabulation of Diseases and Causes ofDeath (WHOJC/MS/24) ;Abbreviated List of 50 Selected Categoriesfor Tabulation of Causes of Death (WHOJC/MS/25) ;Selected List for Tabulation of MorbidityStatistics for Social Security Purposes(WHO.IC/MS/26) ;Preparation of a Final Alphabetical Index(WHO.IC/MS/27) ;Suggested Form of Medical Certificate ofCause of Death for International Adoption(WHO.IC/MS/28) ;Suggested Form of Multiple Cause TabulationAround the Census Year (WHO.IC/MS/29) ;International Statistical Classification of Dis-eases, Injuries and Causes of Death ; Intro-duction and List of Categories (Amended)(WHO JC/MS/i/Rev.i) ;International Statistical Classification of Dis-eases, Injuries and Causes of Death ; TabularList of Inclusions (Amended) (WHO.IC/MS/7/Rev. 1) ;Report on the Second Session (WHO.IC/MS/3o) ;Summary of Discussions (WHOJC/MS/31) ;Final List of Documents (WHO.IC/MS/32).

8. Recommendations.As a result of its deliberations, the Expert

Committee proposes to the Interim Commissionand its Secretariat a series of recommendationsgrouped under three broad headings :

A. International Revision Conference ; B. Per-manent Expert Committee on Health andVital Statistics, and C. Other specificrecommendations.

A. International Revision Conference.

(1) that arrangements be made for convening anInternational Conference for the Sixth Decen-nial Revision of the International Lists ofDiseases and Causes of Death, said Conferenceto be held not later than the end of April1948;

that the International Statistical Classificationof Diseases, Injuries and Causes of Death,2 asamended during the second session of theExpert Committee, be placed on the agenda ofthe Revision Conference as the Committee'sproposal for the Sixth Revision ;

(2)

1 Unpublished working documents.2 Documents WHOJC/MS/ and 7.

REVISION OF INTERNATIONAL LISTS 26 - OF DISEASES AND CAUSES OF DEATH

(3)

(4)

(5)

that the agenda of the Revision Conferenceinclude consideration of the following items,in addition to the review and adoption of theproposal for the Sixth Revision ;(a) Medical certificate of cause of death ;(b) Joint-cause problem ;(c) Structure and uses of Intermediate and

Abbreviated Lists ;(d) Uniform definitions of stillbirth and

immaturity ;(e) Size of age-groups for tabulation of vital

data ;(1) Methods for standardization of rates ;(g) Residence allocation of vital data ;(h) Technical machinery for future revision of

the International Classification of Dis-eases, Injuries and Causes of Death ;

that the viewpoint of the Expert Committeebe presented to the Conference by its Chairman,Vice-Chairman and Rapporteur ;

that a third session of the Expert Committeebe held immediately after the Revision Con-ference in order to incorporate and edit thechanges in the Lists as approved by theRevision Conference ;

(6) that the International Statistical Classificationof Diseases, Injuries and Causes of Death, asadopted for the Sixth Revision by the RevisionConference, be published in two parts, con-sisting of :

Part I. - 1. Introduction and Detailed Listof Three-digit Categories.

2. Tabular List of Inclusionsunder the Three- and Four-digit Categories, together withexplanatory notes.

3. Appendices containing selec-ted lists for Tabulations ofMortality and Morbidity Dataand Rules for Joint CauseSelection.

(7)

Part IL - Alphabetical Index.that the Executive Secretary draft " Inter-national Regulations " under which the WorldHealth Organization may put into practicethe recommendations of the Expert Committeeand the International Revision Conference.

B. Permanent Expert Committee on Health and VitalStatistics.

(8) that the Interim Commission propose to theWorld Health Assembly the establishmentwithin the WHO of a permanent ExpertCommittee on Health and Vital Statistics ;that the scope of work of this Committee be :

(a) to provide technical advice to Govern-ments, health and other administrationsinterested in the practical applicationand possible developments of the Inter-national Lists of Diseases and Causes ofDeath ;

(9)

(io)

(II)

(b) to make interim adjustment and preparefor future revision of such lists ;

to stimulate, co-ordinate and directstudies required for the improvement ofthe international comparability of healthand vital statistics ;

(d) to act as the consulting body to the WHOand its various technical committees andSecretariat on statistical methods whichmay facilitate their work and better theresults ;

that the members of the proposed committeeof experts and advisers be so selected asto include experience and specialized know-ledge in the following fields :

(a) scientific statistical methods (includingsampling) applicable to medical researchand public-health work ;

(b) medical nomenclature and statistics ;(c) vital registration and other statistical

administrations ;

that the proposed committee be in a positionto recommend the formation of sub-com-mittees through the adjunction of specializedexperts, to deal with special subjects such asthe definition of stillbirths, hospital statisticsand cancer registration.

C. Other Specific Recommendations.

(u) That the amended Introduction and List ofCategories and the amended Tabular Listof Inclusions 2 be republished before theRevision Conference.

that the amended List of Categories be cir-culated to Governments prior to the Inter-national Revision Conference, and that theamended Tabular List of Inclusions be dis-tributed for information at the Conferenceitself ;

that the work of the Index Sub-Committeecontinue according to a time schedule whichwill make available a complete Index by31 December 1948 ;

that financial assistance be given to the Sub-Committee on Latin Equivalents for securingexpert advice and covering secretarial ex-penses ;

The Expert Committee further proposes thepreparation of the French and Spanish ver-sions of the final complete document, withthe recommendations that the help of VitalStatistics Offices of the South Americancountries be enlisted through the Pan Ame-rican Sanitary Bureau and the Inter-AmericanStatistical Institute for the Spanish versionand that co-operation be established with theInstitut National d'Hygane of France for thepreparation of the French version.

(I3)

('4)

(I5)

(i6)

1 Document WHOIC/MS/I/Rev. 1.2 Document WHOJC/MS/7/Rev. 1.

- 27 -[WHO.IC/i261

16 October 1947

N. EXPERT COMMITTEE ON QUARANTINE


Held 13-16 October 1947, Palais des Nations, Geneva

(presented to the Interim Commission at its fifth session).1

The Expert Committee on Quarantine met atGeneva from 13 to 16 October 1947. The sessionwas attended by :Chairman: Dr. P. G. Stock, Medical Adviser,

Ministry of Health, London, United Kingdom.

Members:Dr. Dujarric de la Rivière, Sous-Directeur de

l'Institut Pasteur, Paris, France ;Dr. G. L. Dunnahoo, Medical Director, Chief,

Foreign Quarantine Division of the UnitedStates Public Health Service, Washington,D.C., United States of America ;

Dr. G. D. Hemmes, Inspector of Public Health,Utrecht, Netherlands ;

Dr. Mohammed Nazif Bey, Under-Secretary ofState for Quarantine, Ministry of PublicHealth, Cairo, Egypt ;

Dr. W. W. Yung,2 Director, Department ofEpidemic Prevention, National Health Admi-nistration, Nanking, China.

Observer:Dr. M. Gaud, Président de la Commission des

Finances et du Transfert, Ogce Internationald'Hygiène Publique, Paris, France.

Secretariat:Dr. Y. Biraud, Director of Epidemiology and

Public Health Statistics ;Dr. G. Stuart, Chief of the Sanitary Conventions

and Quarantine Service, Secretary of theCommittee.

Dr. C. Mani (New Delhi), Professor G. H. dePaula Souza (Sao Paulo), the USSR memberand the observer from the International CivilAviation Organization were unable to attend.

Dr. Biraud, on behalf of the Executive Secretary,welcomed the members and explained that thecholera epidemic in Egypt, in its internationalaspects, had necessitated the advancement of thedate of the Committee's first meeting from24 November to October.

The Committee, on the proposal of Dr. Dujarricde la Rivière, seconded by Dr. Nazif Bey, electedDr. Stock as Chairman.

The Committee adopted the agenda prepared bythe Secretariat,3 adding as a further item " thedisinfection of aircraft ".

1. Cholera Epidemic in Egypt.The Committee heard from Dr. Nazif Bey a

comprehensive statement on the origin, develop-

1 Off. Rec. WHO, No. 7, pages 16, 18, 33-34.2 Attended as from 15 October.3 Document WHO.IC/Q/7, unpublished working

document.

ment and present state of the cholera epidemic,which, making its first appearance on 22 Sep-tember 1947 in El Qurein village, Sharkiya Pro-vince, had, by II October, extended to severalprovinces in the Nile Delta, more particularly toDakahliya and Kaliubiya. 4

Dr. Nazif Bey detailed the measures taken toprevent the spread of the disease throughout Egyptand to other countries.

The Committee was impressed by the extentand thoroughness of the action taken by theEgyptian public-health authorities.

With regard to the Mecca Pilgrimage now takingplace, Dr. Nazif Bey informed the Committee that7,000 Egyptian pilgrims had already left Egyptby ship before the outbreak, but that 15,000 othershad been prevented from sailing. Foreign pilgrimswere allowed to proceed by ship through the SuezCanal in quarantine, medical inspection beingcarried out at Port Said and Suez. Foreign pil-grims arriving in Egypt in transit by air wereallowed to proceed after the sixth day followinganticholera vaccination.

Dr. Nazif Bey invited opinion on the source ofthe outbreak and stressed the need for a hundredambulances to transport patients and suspectedcases to isolation hospitals. He sought the adviceóf the Committee on measures against the epidemicin general and on dosage of anticholera vaccine inparticular. There were apparently considerabledifferences in the concentration of the vaccinesreceived by Egypt from the various countries.

While the Committee considered that for prac-tical purposes, and in view of the urgency, indica-tions given by the producing institutes as regardsdosage of the vaccines should be followed, itrecommended that the question of the standardi-zation of anticholera vaccines be referred to theExpert Committee on Biological Standardizationof the WHO. It further suggested that the Egyp-tian health authorities should test the antigenicefficacy of the various vaccines received.

Among other points considered by the Com-mittee as requiring scientific elucidation were thelength of the cholera vibrio's viability :

(a) on flies ; and the latters'. potentialities asvectors, particularly when carried by air-craft.

(b) in sewage, whether crude or during treat-ment on sewage-farms, due regard beingpaid to the presence or absence of thecholera bacteriophage as well as the vibrio.

The Committee decided to bring to the attentionof Governments, of the League of Red Cross

4 Document WHO.IC/Q/I2, unpublished workingdocument.

- 28 - QUARANTINE

Societies and the general public, the urgent needof Egypt for ambulances.

The Committee considered the statement pre-pared by the Secretariat on the quarantine mea-sures imposed by various countries on travellersfrom Egypt, and noted that in many cases suchmeasures greatly exceeded the provisions ofexisting international sanitary conventions. TheCommittee was, however, unanimously of theopinion that these provisions-Articles 29 to 34of the 1926 and 1944 Maritime Sanitary Conven-tions and Articles 30 to 33 of the 1933 and 1944Conventions for Aerial Navigation-were in everyway adequate.

The Committee emphasized the fact that Ar-ticle 15 of the 1926 and 1944 Maritime Conventionscould not be construed as empowering countries toimpose quarantine measures more rigorous thanthose laid down in the previously mentionedarticles dealing specifically with cholera control :

(i) surveillance for travellers adequately pro-tected by vaccination ;

(ii) surveillance and medical examination forthose unvaccinated ; medical examinationin revealing suspected cases enables healthauthorities to submit them to any supple-mentary investigation necessary (includingbacteriological examination of the stools)and to observation.

The Committee agreed that the fears whichinspired excessive quarantine measures largelyarose from insufficient knowledge of the trueepidemic situation, and that one of the bestmethods of allaying such fears was for infectedcountries promptly to provide information to theWHO-the international body responsible for thedissemination of epidemiological intelligence tonational health-authorities.

2. Disinfection of Aircraft.The Committee, after an exchange of views on

the practical difficulties of disinfecting aircraft,decided to ask the Secretariat to obtain technicalinformation on the subject.

Pending an international agreement on standardmethods of disinfecting aircraft, the Committeeadvised that as a routine :

(i) Water-tanks should be periodically cleanedout and disinfected.

(ii) Aircraft should carry disinfecting tablets(e.g., halazone) for the treatment of anywater taken on at an infected port.

The Committee recommended that in the eventof a true or suspected case of cholera on board,the following measures should be taken, in additionto those specified in the International SanitaryConventions :

(a) Steam or other appropriate sterilization ofmovable furnishings ;

(b) Incineration or sterilization of excreta andof vomitus and its receptacles ; sterilizationof excreta receptacles by means of a strongdisinfecting solution ;

(c) Thorough disinfection of toilets and wash-rooms with a strong disinfecting solutionsuch as 4% cresol, and

(d) Swabbing with a strong disinfecting solutionall parts of the aircraft's interior whichmight have been contaminated ;Sterilization or incineration of all unsealedfoodstuffs ;Disinfection of all water ;Sterilization of all galley (kitchen) equip-ment, crockery, etc.

The above measures of disinfection are additionalto the routine disinsectization of aircraft comingfrom cholera infected areas.

It was decided that the subject of disinfectionof aircraft should remain on the Committee'sagenda.

(e)

(g)

3. International Certificates of Inoculationand Vaccination.

The Committee considered the protest by theGovernment of India in regard to the demandmade by the health authorities of Hongkong,Singapore and the Malayan Union, that all smallpoxvaccination certificates should be countersigned bya medical officer in government or muncipal ser-vice.1

The Committee could but observe that Article 42of the 1926 and 1944 Maritime Conventions leaveto the health authorities of the country of arrivalthe decision as to whether a traveller has beenadequately vaccinated or not ; it is therefore inthe interest of the traveller to present as trust-worthy a certificate as possible.

The Committee recommended that health author-ities accept as valid, and consequently exemptingthe bearer from further revaccination and quaran-tine restrictions, the form of " InternationalCertificate " when completed or authenticated bya medical offcer in government or municipalservice or in a government-approved institution.

The Committee recommended that certificatesnot ,so authenticated are not to be consideredinvalid but may be accepted, under the terms ofArticle 42 of the 1926 and 1944 InternationalSanitary Conventions, by the health authoritiesof the port of arrival.

The Committee further recommended that theforms of international certificates and the questionof their endorsement should be referred to theExpert Committee on International EpidemicControl and that the question of simplifying thevarious forms of international certificates shouldbe considered during the revision of the SanitaryConventions.

The Committee agreed that no photograph orthumbmark should be required on the certificateswhen the holder was in possession of a passport oridentity card.

The Committee considered it permissible for theforms of certificates to be drawn up in both thelanguage of the issuing country and one of theofficial languages of the 1944 Conventions (Englishand French).

Taking into account the confusion arising fromthe use of the terms " reaction of immunity and" no reaction " in the international form of smallpoxvaccination certificate, the Committee considereda proposal made by Dr. Stock for an amended

1 Off . Rec. WHO, No. 6, pages 184-185.

QUARANTINE - 29

form of certificate designed to overcome this con-fusion.1 The proposed form consists of three partscertifying respectively : I. Vaccination ; IL In-spection of the results ; and III. Revaccination andits results in the event of the first vaccination'sproving unsuccessful.

This text of the proposed triple certificate wasadopted, with the following amendments : 2

(i) " If any " to be inserted after the words" Official position " of the certifying per-son, in the three parts of the certificate.

(ii) " if possible " to be inserted before " BatchNo. of vaccine ", in parts I and III of thecertificate.

(iii) " and in my opinion he is immune to vac-cinia " to be deleted from part III.

With one member dissenting, the Committeedecided to submit the said certificate as amendedto the Interim Commission, with a view to thelatter recommending to Governments its recogni-tion and adoption, pending the revision of theInternational Sanitary Conventions in force.

The dissenting member was of the opinionthat, should there be no reaction after two vacci-nations, any certificate to that effect should notbe incorporated in the " International Certificate "but could be issued as a separate document.

The Committee decided against the issue ofinternational interim certificates of inoculation orvaccination to persons travelling on urgent busi-ness.

The Committee endorsed the action taken bythe Secretariat in printing fresh editions of " Inter-national Certificates " in response to requestsreCeived from public-health administrations.

4. Inoculation against Plague and Typhus.The Committee endorsed the action taken by

the Interim Commission on the protest by theGovernment of India against the restrictionsimposed by the Government of Iraq against passen-gers from India on account of plague 3.

The Committee stressed the fact that inoculationagainst plague or typhus cannot be required underexisting Conventions, and observed that suchmeasures had little value for the protection ofcountries receiving travellers from infected areas.

In its opinion, disinsectization of the travellersand their belongings by means of DDT or otherefficient insecticides would be more efficacious inpreventing the importation of these diseases.

The Committee asked the Secretariat to bringthese facts to the notice of any health authorityrequiring incoming travellers to be in possessionof certificates of inoculation against plague ortyphus.

5. Standard Method for Disinsectizationof Aircraft.

The Committee considered the proposal for astandard method put forward by Dr. Mani 4, the

1 Document WHOJC/Q/I 1, unpublished workingdocument.

2 The amended text is reproduced as Appendix I.3 Off. Rec. WHO, No. 6, pages 185-186.4 Document WHOJC/EQ/23, unpublished working

document.

report of the ad hoc sub-committee of the BritishWest Indian Quarantine Conference 5 and otherdocuments.

The Committee accepted the recommendationsof that Conference as a basis for further study, butfelt that more technical information was necessarybefore laying down definite standards for interna-tional use. It therefore requested the Secretariatto obtain from Governments and other agenciesas full information as possible, and decided to keepthe subject on its agenda.

The Committee also emphasized the importanceof keeping aerodromes and their surroundings freefrom mosquitos and other insect vectors of disease.

6. Authorities for the Issue of ValidInternational Certificates of Inoculation

against Yellow Fever.

The Committee recommended that the Secre-tariat should obtain from Governments completeinformation on authorities empowered to issueyellow-fever certificates and in due course shouldpublish such information.

7. Yellow Fever.

(a) Laboratories approved for testing the Activityof Y ellow-fever Vaccines.

The Committee approved acceptance by theInterim Commission of the laboratories alreadyapproved by UNRRA for testing the activity ofyellow-fever vaccines :

Bogotá (Colombia) - Yellow Fever Laboratory,National Yellow Fever Service.

Dakar (Senegal) - Pasteur Institute.Entebbe (Uganda) - Yellow Fever Institute.Hamilton (Montana, United States of America)-

Rocky Mountain Laboratory (United StatesPublic Health Service).

Johannesburg (Union of South Africa) - South-African Institute for Medical Research.

Lagos (Nigeria) - Yellow Fever Research Ins-titute.

London (England) - Wellcome Research Ins-titution.

New York (United States of America) - Labor-atories of the International Health Division,Rockefeller Foundation.

Paris (France) - Pasteur Institute.Rio de Janeiro (Brazil) - Yellow Fever Research

Institute.

(b) Laboratories approved for the Preparation ofY ellow-fever Vaccine.

With regard to vaccines, the Committee recom-mended that those produced by the institutesalready approved by UNRRA and listed belowshould continue to be so recognized ad interimunder the same conditions, but that the measuresalready decided upon by the Interim Commissionfor a systematic international testing of yellow-fever vaccines should be put into force as soon aspossible, so as to ensure maintenance of the activity

5 See " Report of the British West Indian Quaran-tine Conference ", held in Port-of-Spain, Trinidad,from 15-19 November, 1943, Advocate Co., Ltd. -Printers to the Government of Barbados, pages 78-80.

- 30 - QUARANTINE

of all vaccines in international use, to permit fullapproval to be granted to those institutes havingat present only interim approval and to providefor other institutes being added to the list ofapproved :vaccine-producing laboratories.

International Health Division of the RockefellerFoundation.'

National Institute of Health of the United StatesPublic Health Service 1,

Pasteur Institute, Dakar 2.South-African Institute of Medical Research,

Johannesburg 1.Wellcome Research Institution, London 3.Yellow Fever Laboratory, Brazilian National

Yellow Fever Service, Rio de Janeiro 3.Yellow Fever Laboratory, Colombian National

Yellow Fever Service, Bogotá 3.

(c) Development of Immunity after Inoculationagainst Y ellow Fever.

In considering the period required for the develop-ment of immunity following prophylactic inocula-tions, the Committee noted that, while the Inter-national Sanitary Conventions regard ten days assufficient for the development of effective immunityafter yellow-fever inoculation, some countries basetheir quarantine requirements on a period offifteen days.

The Committee decided to request the InterimCommission to entrust the Yellow-fever Panel ofthe WHO with the task of making the studiesnecessary to determine objectively the timerequired for obtaining effective immunity.

(d) Inoculation of Infants against Y ellow Fever.

On the evidence furnished by the experts of theWHO Yellow-fever Panel, the Committee agreedthat infants and young children could be safelyinoculated against yellow fever provided 17 Dvaccine were used.

(e) Delimitation of Yellow-fever Endemic Areas.

After considerable discussion, the Committeedecided to postpone any decision until the nextsession, and in the meantime asked the Secretariatto obtain further information.

8. Application of the 1926 Convention.

(a) Deratization Exemption Certificates.

On the definition of " home ports ", the Com-mittee reaffirmed the decision taken by the Perma-nent Committee of the Office International d' Hy giMePublique at its April session 1932, which reads asfollows :

" The term 'home port' should not be restrictedto mean the 'port of registration of the ship'but should be applied equally to the port inwhich the ship is in fact at home-i.e., whereits crew is paid off at the termination of thevoyage (port terminus), where the necessaryrepairs are carried out, where its crew is usually

Fully approved.2 Approved, provided vaccine is administered by the

scarification method of the Dakar Pasteur Institute.3 Approved, for the time being, for quarantine

purposes.

enrolled prior to sailing-such port correspondingto the French meaning of 'port d'armement'(fitting port).

" Thus, a ship may not indefinitely have thesame 'home port' (port d'attache), particularlyif engaged on sea routes different from those onwhich it normally plies ; it may claim the benefitof the extension provided for in Article 28 of the1926 International Sanitary Convention, soas to be able to make the port which temporarilyfulfils the conditions stated above." 4The Committee requested the Executive Secre-

tary to bring this decision to the attention of anyGovernment concerned.

(b) The Committee reaffirms the previous deci-sions of the Permanent Committee of the OfficeInternational d'Hygane Publique in regard to theundesirability of issuing deratization exemptioncertificates to ships with loaded holds.

(c) The Committee noted the memorandumprepared by Dr. M. T. Morgan on estimating therat population on ships.5

9. Abolition of Bills of Health and ConsularVisas.

The Committee reviewed the terms of Article 49of the 1926/1944 Conventions and unanimouslyagreed that, as an effective epidemiological servicehad now been established by the WHO, bills ofhealth and consular visas should be abolished.

The Committee accordingly requested the Secre-tariat to bring this decision to the notice of Govern-ments and do everything in its power to acceleratethe abolition of these obsolete documents.

10. International Quarantine Directory.While the Committee felt that the issue of such

a Directory was not pressing, it requested theSecretariat to prepare, when opportunity per-mitted, forms of questionnaires on sea- and air-ports for consideration by the Committee at asubsequent session.

11. Inoculation of Infants against Plagueand Typhus.

The Committee felt that the value, for quaran-tine purposes, of inoculation against plague andtyphus had not been established, and in any casecould not advocate as a general measure suchinoculation of infants under one year of age.

The Committee agreed that the Secretariatshould in due course obtain the views of membersof the expert panels on pestilential diseases aboutto be set up for the revision of existing InternationalSanitary Conventions.

12. " Polyglot Medical Questionnaire ".The Committee agreed that it could not recom-

mend the establishment and use of a Polyglot(Multilingual) Medical Questionnaire for quaran-tine purposes.

Translated from the Procés-verbaux de l'OfficeInternational d'Hygigne Publique, April-May 1932,page 123.

5 See Bulletin of the WHO , 1, pages 63-67.

QUARANTINE - 31 -

13. Air Disinfection of PassengerAccommodation at International Airports.

The Committee felt that it was not in a positionto recommend the installation of ultra-violet lightor other methods of air sterilization for passengeraccommodation at international airports. TheCommittee, however, emphasized the advantagesof adequate ventilation and a high standard ofenvironmental sanitation.

14. Other Items.The Committee took note of a memorandum

submitted by Dr. Hemmes on post-vaccinal ence-phalitis in the Netherlands 1 and of a time schedulepresented by Dr. Dujarric de la Rivière, of inocu-lations and vaccinations applicable when multipleimmunization is required.2

Appendix I.

EXTRACT FROM DOCUMENT WHOJC/Q/I 1, AS AMENDEDBY THE EXPERT COMMITTEE ON QUARANTINE

INTERNATIONAL CERTIFICATE OF VACCINATION AGAINST SMALLPDX

I. I CERTIFY THAT (Age Sexwhose signature appears below, has this day been vaccinated by me against smallpox.(Origin and if possible Batch No. of Vaccine

Signature of VaccinatorOfficial Position, if anyPlace Date

OfficialStamp

Signature of Person vaccinatedHome Address

IMPORTANT : A person vaccinated for the first time should be warned to report to a doctor betweenthe 7th and r4th day, in order that the result may be inspected and recorded on certificate II.In the case of revaccination, an accurate assessment of the result is usually possible by inspectionon the 3rd and again on the 6th or 7th day.

II. I CERTIFY THAT I inspected the above vaccination on date(s)and in my opinion the vaccination was [state whether (a) successful or (b) unsuccessful].

OfficialStamp

Signature of DoctorOfficial Position, if anyPlace Date

Signature of Person vaccinatedNOTE The term " successful vaccination " should be used only when vaccinial vesicles develop

In the case of unsuccessful vaccination, the operation must be repeated. If the result is thensuccessful, certificates I and II should be issued. If the result is again unsuccessful, certificate IIImay be issued.

III. I CERTIFY THAT 01:1 [date] I revaccinated(Age Sex

whose signature appears below with vaccine (Origin and, if possible, BatchNo. of Vaccine ) believed to be potent, but vaccinial lesions did not result.

OfficialStamp

Signature of DoctorOfficial Position, if anyPlace Date

Signature of Person vaccinated'

1 Document WHOJC/EQ/16, Add. 3, unpublished working document.2 Document WHO.IC/Q/i4, unpublished working document.

- 32 -

[WHOJC/85]30 June 1947

V. EXPERT SUB-COMMITTEE FOR THE REVISION OF THE PILGRIMAGE CLAUSESOF THE INTERNATIONAL SANITARY CONVENTIONS

(a) REPORT ON THE FIRST SESSIONHeld 16-26 April 1947, Alexandria, Egypt

(presented to the Interim Commission at its fourth session).1

The Expert Sub-Committee appointed to studythe Revision of the Mecca Pilgrimage Clauses inthe International Sanitary Conventions of 1926/38met in Alexandria on 16 April 1947.

The following took part in the work of theSub-Committee :

Experts:Dr. M. Gaud, Directeur de l'Office International

d'Hygiène Publique, Paris, France ;Dr. C. Mani, Deputy Director-General of Health

Services, Government of India, New Delhi,India ;

Dr. M. T. Morgan, Medical Officer of Health,Port of London, United Kingdom ;

Professor J. J. Van Loghem, Professor ofHygiene, University of Amsterdam, Nether-lands ;

Dr. Wasfy Omar, Director of the Pan ArabRegional Health Bureau, Alexandria, Egypt ;

Dr. Yehia Nasri, formerly Director-General ofHealth, Mecca, Saudi Arabia.

Secretariat:Officials of the InterimDr. G. Stuart Commission, World HealthM. G. de Brancion Organization, Geneva.

On the proposal of Dr. Mani, seconded byDrs. Gaud and Yehia Nasri, Dr. M. T. Morganwas unanimously elected Chairman of the Sub-Committee. Dr. Gaud was nominated Rapporteur.

Inter alia, the Committee on Epidemiology andQuarantine had decided that the Expert Sub-Committee had the authority to call in advisers,who, however, would neither be members of theSub-Committee nor have a right to vote.

The Sub-Committee therefore requested the aidof advisers whose qualifications and experiencewould, in the opinion of its Members, serve toelucidate certain special questions.

These advisers, unanimously appointed, wereconsequently individually invited by the Chairmanto attend those meetings of the Sub-Committeein which their advice would prove of particularvalue.

The advisers were :Dr. M. Khalil Bey, Under-Secretary of State for

Quarantine, Ministry of Health, Cairo, Egypt.Dr. Lorenzen, Director of Medical Services,

Anglo-Egyptian Sudan ;Dr. Pridie, Medical Counsellor to the British

Embassy, Cairo, Egypt ;His Excellency Youssef Yassin, Minister for

Foreign Affairs, Mecca, Saudi Arabia.

1 Off. Rec. WHO, No. 6, pages 36, 46, 179, 218 ;No. 7, pages 34-35, 37, 51.

The Sub-Committee met twice daily at Alexan-dria between 16 and 20 April. On 21 and 22 April,it examined the sanitary installations and equip-ment of the Port of Jeddah. Its journey to andfrom Jeddah was made by air. It resumed itsdeliberations at Alexandria on 23 April and con-tinued its discussions until 26 April.

The Committee on Epidemiology and Quaran-tine of the Interim Commission, in its reportdated 26 April 1947,2 had enjoined the ExpertSub-Committee to undertake a study of thefollowing questions :

1. Prophylactic Measures.

" The need for taking, in respect of all pilgrimsleaving their country of origin, adequatemeasures to ensure individual and collectiveprotection in the country of origin, transitcountries and countries of destination, againstthe introduction and dissemination of disease(inoculations and vaccinations), disinfection,disinsectization, biological examinations, etc.),and the need for official certification that suchmeasures have been adequately carried out,both in the country of origin and in thecountry of destination."

The Sub-Committee, desirous of protectingpilgrims against the pestilential diseases mentionedin the International Sanitary Conventions, recog-nized the need for subjecting pilgrims, prior totheir departure from their country of origin, to anumber of prophylactic measures. In particular,it gave its attention to vaccinations, the bacterio-logical examination of stools, the duration ofvalidity of immunization certificates ; and arrivedat the following conclusions :

A. Vaccination.

(a) Smallpox. - Every pilgrim should carry avalid certificate of vaccination against smallpox,the certificate to be in the form prescribed in theInternational Sanitary Conventions of 1944.

(b) Cholera. -Every pilgrim should carry avalid certificate of inoculation against cholera, thecertificate to be in the form prescribed in theInternational Sanitary Conventions of D944.

(c) Yellow Fever.- The Expert Sub-Committeerecommended that, until further definite informa-tion is obtained from the Interim Commission'sYellow-Fever Panel as to the biological conditionsin the Hedjaz vis-d-vis the transmission of yellowfever, all pilgrims coming from zones recognized

2 Off. Rec. WHO, No. 5, pages 126-128.

REVISION OF THE PILGRIMAGE CLAUSES OF - 33 - THE INTERNATIONAL SANITARY CONVENTIONS

internationally as yellow-fever zones should beinoculated against yellow fever prior to theirdeparture from such zones, whether by land, seaor air.

(d) Typhus Fever. - After discussion of everyaspect of immunization against typhus fever byinoculation, the Sub-Committee came to theconclusion that such vaccination is more efficaciousas a measure of individual, rather than of collective,protection. Furthermore, in view of the need forthree inoculations and of the large quantities ofvaccine that would be required if anti-typhusinoculation were to be made internationallycompulsory, the alternative method of disinsecti-zation by the use of an adequate insecticide seemedpreferable from every point of view. The Sub-Committee, therefore, recommended that disinsecti-zation should be obligatory for all pilgrims comingfrom an epidemic typhus area.

(e) Plague : The Sub-Committee was unani-mously of the opinion that obligatory anti-plaguevaccination was unnecessary.

B. Bacteriological Examination of Stools.

There has been no evidence of cholera in theHedjaz for many years. Obligatory inoculationagainst cholera and a period of medical supervisionboth before departure and during the journeyhave been provided for in the present Convention.

It seemed unnecessary, therefore, to add tothese apparently sound measures a measure ofdoubtful value-i.e., the bacteriological examina-tion of stools-until the findings could be moreprecisely evaluated.

Further, the mass bacteriological examinationof the stools of all pilgrims at their place of depar-ture necessitates a complicated organization, anumber of highly trained personnel ; and theresults are not likely to be sufficiently decisive topermit of practical application in the short periodof time available.'

C. Methods of Vaccination and Duration of Validityof Immunization Certificates.

While the Expert Sub-Committee took the viewthat there were numerous points connected withimmunization requiring further consideration andstudy-for instance, the method of vaccinationagainst smallpox and the interpretation of theresults and also the choice of antigen to produceoptimum immunity in the case of cholera-theseare matters which should be dealt with by appro-priate technical committees of the Interim Com-mission-e.g., the Expert Committee on BiologicalStandardization.

Further study on the duration of validity of thecertificates issued following immunization was alsorequired, but the Sub-Committee did not feelcalled upon to express an opinion which might beprejudicial to the strict application of the present

1 Although this resolution had been unanimouslyadopted, Professor Van Loghem pointed out that,under special conditions, the examination of stoolscould be of value, and drew attention also to theimportance of studying epidemic choleriform ente-ritis (Appendix 1). Moreover, Dr. Wasfy Omaragreed with Professor Van Loghem's point of view(Appendix 2).

Conventions. On the contrary, the Sub-Committeefelt it important that the certificates issued topilgrims should not differ in their validity fromthose laid down in the 1944 Conventions, andrecommended that in the revised PilgrimageClauses the certificates referred to should take thesame form as those in force for the time being for allclasses of travellers.

D. Pilgrims' Sanitary Passport.

In accordance with the terms of Article 2 of thepresent draft Convention, pilgrims are requiredto be immunized, before departure, against small-pox and cholera and, in certain circumstancesagainst yellow fever, and must carry with themvalid certificates. These certificates must be of theinternationally recognized form, in effect, thecertificates annexed to the International SanitaryConventions of 1944.

The Sub-Committee recommended that thesecertificates should be incorporated in the pilgrim'spassport or, alternatively, should be printed andbound in the form of a booklet.

2. The Hedjaz and Transit Ports.

" To determine whether the sanitary installationsand equipment of the Hedjaz and transitports are capable of carrying out adequatemeasures and, if necessary, to make recom-mendations."

The Sub-Committee visited Jeddah on 21 and22 April to inspect the sanitary services of the townand port and to examine the work undertaken inconnexion with the provision of an adequate pipedwater-supply to the port. The findings of the Sub-.Committee are recorded in Appendix 3. Dr. YehiaNasri also submitted, in a Report-Appendix 4-an account of the organization and duties of themedical and quarantine services of the Kingdomof Saudi Arabia in general and of the port ofJeddah in particular.

The views of the Sub-Committee may be sum-marized as follows :

1. The Sub-Committee, having visited the portof Jeddah and observed the several activities ofthe Quarantine Service there, appreciated theefforts made to bring about improvements, butwas of the opinion that the Service was not yetsufficiently equipped in personnel, in hospital andisolation accommodation and in sanitary facilitiesgenerally.

2. In the circumstances, the Sub-Committee wasunable to regard the present services in the portof Jeddah as sufficient to warrant the cessation ofactivities at El Tor and Kamaran.

3. Even so, the Sub-Committee felt able torecommend that the terms of the Sanitary Con-ventions now in force should be modified, to thefurthest extent possible, in order to relax thepresent burden of sanitary measures imposed onpilgrims, but without diminishing essential security.

4. The Sub-Committee did not consider that thedraft which it now proposed should be regarded asfinal. As soon as a new quarantine service hadbeen set up, the present mtasures proposed shouldbe reviewed and the transfer to Jeddah of the

- 34 - REVISION OF THE PILGRIMAGE CLAUSES OF

measures of control at present practised by theexisting quarantine stations envisaged.

5. The Sub-Committee hoped that the SaudiArabian Government would put plans of sanitaryreorganization into operation as soon as possibleand that, to hasten their development, it wouldtake advantage of every technical assistancetending to that end.

3. Sanitary Authority.

" By what sanitary authority is the pilgrimageto be declared ' clean ' or infected ' ?

The International Sanitary Conventions dealingwith the Pilgrimage-the Conventions of 1912 andthose of 1926-1938-have never raised the questionof the pilgrimage being " clean " or " infected ",nor of the sanitary authority responsible formaking such declaration. They have concernedthemselves with the measures to be taken, on thereturn of pilgrims, in connexion with the presencein the Hedjaz or in the ports of embarkation, ofplague or cholera.

On the other hand, in the section dealing withsanitary information concerning the pilgritnage,the 1926-1938 Convention provided that the Govern-ments of Egypt and of Saudi Arabia, as well asof all other countries interested in the pilgrimage,should transmit to the Office International d'Hy-giMe Publique, Paris, all notifications and sanitaryinformation coming to their knowledge during thepilgrimage season relative to the sanitary situationin the regions traversed by the pilgrimage.

It had not appeared opportune to the Sub-Committee to alter the existing Convention byintroducing into the new text an official declara-tion on the state of the pilgrimage, whether " clean "or " infected ". On the contrary, the Sub-Com-mittee was of the opinion that, as all Governmentsconcerned should be speedily and continuouslyinformed of the epidemiological situation in theHedjaz before, during and after the pilgrimage,it was desirable to make precise arrangements forthe declaration and notification of Conventiondiseases occurring during those periods so as toenable the said Governments to take all necessarymeasures.

In the draft Convention, this sanitary informa-tion has been the subject of a special article-Article 58-in which the responsibilities of theSaudi Arabian Government in this respect havebeen defined.

4. Red Sea Sanitary Stations." Proposals relating to the Red Sea Sanitary

Stations referred to in the Conventions nowin force."

Inquiries made at the time of its visit to Jeddahhaving demonstrated that the installations andsanitary equipment there did not allow of theapplication of adequate measures of control, theSub-Committee unanimously decided that thesanitary stations on the Red Sea must continueto play the rôle assigned to them by the Conven-tion now in force.

Nevertheless, the Sub-Committee was of theopinion that if no cholera, plague or yellow fever,or smallpox or typhus in epidemic form, had been

notified in the Hedjaz durhg the pilgrimage period,pilgrim ships returning north would not be requiredto undergo at El Tor the measures at presentprescribed. They would merely be visited at Suez,and, if any sanitary measures were considerednecessary, the ships would proceed for such pur-pose to Moses Wells. Thereafter, if free frominfection, they would be allowed to pass throughthe Suez Canal in quarantine, on condition thatfive days had elapsed since tInir leaving Jeddah.

A note prepared by Dr. . Wasfy Omar (Ap-pendix 5) provides all information on the organi-zation of the sanitary station at Moses Wells.

5. Measures for Land or Air Travel." Sanitary measures to be taken in regard to

pilgrims travelling by land or air."The Sub-Committee considered that the sanitary

measures to be taken in regard to pilgrims travel-ling by land or air should form the subject of twonew sections in the draft Convention. These areSections II and III of the draft text prepared bythe Sub-Committee.

* *

In addition to the five points referred by theEpidemiology and Quarantine Committee forinvestigation by the Expert Sub-Committee,Dr. Wasfy Omar requested that the note (Ap-pendix 6) presented by Professor Khalil Bey shouldbe discussed-a note proposing certain amend-ments to the Pilgrimage Clauses in the 1926-1938Convention.

As to this request, the Sub-Committee, on theproposal of the Chairman, decided as follows :

(1) That the note of Professor Khalil Bey wasnot a personal note but one presented officiallyby the Egyptian Delegate, in the name of hisGovernment, at the meeting of the Office Inter-national d'Hygiene Publique, held in April-May1946 ;

(2) That this note, in addition to the technicalmeasures it advocated, included certain proposalswhich seemed to be rather of a political cha-racter ;

(3) That, in the circumstances, the Sub-Committee, composed as it was of technicalexperts, was only qualified to examine proposalsof a technical nature. Such examination hadbeen made during the discussions which hadtaken place on proposed amendments to theConventions at present in force.

Moreover, the Sub-Committee, in agreementwith Dr. Gaud's suggestion, was of the opinionthat, as the note presented to the Office Interna-tional d'Hygiene Publique by Dr. Khalil Bey inthe name of his Government had been officiallytransmitted by the Office to all Governments, suchGovernments could take any stand they wishedin respect of the questions raised.

The Committee on Epidemiology and Quaran-tine had recommended in its Report presented atthe third session of the Interim Commission " thatit should be left to the Expert Sub-Committee tosuggest whether the revision should be an ad hocagreement covering the pilgrimage or should even-tually form part of the Sanitary Conventions ".

THE INTERNATIONAL SANITARY CONVENTIONS - 35 -

This recommendation implied that the Sub-Committee had to propose a revised text of Part HIof the 1926-1938 Convention, dealing with " SpecialProvisions regarding Pilgrimages ".

However, as the 1926-1938 Convention at presentin force did not modify the form of Part III of the1912 Convention, which envisaged only transportby sea, it appeared necessary to the Sub-Committeeto alter the summary of that part reserved forpilgrimages in such a way as to give a logical placeto new prophylactic measures, on the one hand,and to provisions for transport by land and air,on the other.

Thereafter, the 'Sub-Committee examined articleby article the Convention now in force, and deletedor modified such articles as did not appear to beadapted to modern conditions.

In so far as transport by sea is concerned, theSub-Committee has refused to consider the trans-port of pilgrims by sailing ships because of thedifficulty inherent in their medical surveillance-adifficulty amounting to practical impossibility ;the Sub-Committee also has disallowed the cookingof food on board by the pilgrims themselves, byreason of the not inconsiderable risk of fire arisingfrom such practice ; the Sub-Committee has sim-plified and bettered the hygienic conditions ofpilgrim-life on board ship.

In respect of Dr. Mani's proposal submitted tothe Sub-Committee (Appendix 7) in regard to theusage and provision of bunks aboard pilgrim ships,the suggestion has been incorporated in the newtext-viz., that each pilgrim should be furnishedwith a detachable, separate berth, preferably ofmetal construction. The berths could be arrangedin two tiers, provided that the minimum unitiesof surface and of cubic space allowed to eachpilgrim were observed.

Finally, having taken into account the newobligations imposed on pilgrims as regards immu-nizations and the security resulting therefrom, theSub-Committee has reviewed, modified and con-solidated the requisite sanitary measures to betaken for pilgrim ships in the sanitary stations ofthe Red Sea in respect both of outward- andhomeward-bound pilgrims.

In the new text proposed, there have beenadded articles dealing with the compulsory immu-

.mzation of pilgrims, prior to their departure fromtheir country of origin, against smallpox, cholera

and, in certain circumstances, against yellowfever, as well as special sections on the sanitarymeasures to be taken in connexion with transportby air and by land.

In regard to sanitary information, the Sub-Committee considered that he Saudi ArabianGovernment should be responsible for acquaintingall interested Governments with the epidemio-logical state of the Hedjaz before, during and afterthe pilgrimage. The Sub-Committee has detailedthe conditions under which such sanitary informa-tion has to be transmitted. The Saudi ArabianGovernment will receive, in this connexion, sani-tary information and notifications furnished bythe medical missions which accompany the pil-grims.

The Sub-Committee has expressed the desirethat the heads of medical missions should bechosen by their Governments largely on accountof their epidemiological knowledge and experienceand that, in order to facilitate the carrying-out oftheir duties, such heads will, in so far as circum-stances permit, be selected from Moslem doctors.

Thus has been prepared the draft which will besubmitted to the Committee on Epidemiology andQuarantine to the Interim Commission. During itswork, the Sub-Committee has been actuated bythe desire to maintain logical order in its presen-tation of the measures prescribed, to lighten inevery possible way the burden laid on pilgrims,without loss, however, of essential epidemiologicalsecurity, to adapt the new legislation to meet theneeds of modern transport, to bring into line themeasures proposed with the development ofnational and international health organizations.

The Sub-Committee did not discuss the questionof sanitary dues and sanctions, believing such tobe beyond its technical competence.

Lastly, as to whether the revised text should bean ad hoc agreement covering the pilgrimage orshould form part of existing or future Conventions,it has appeared to the Sub-Committee that themost advantageous course to follow would be tomake the present text an Annex to these Con-ventions. Thus would be retained the largelyinternational character of the agreement, as wellas its connexion with a world sanitary code ; atthe same time, possibilities of further modificationsarising out of later developments would be providedfor.

Appendix 1.

REMARKS PRESENTED BY PROFESSOR J. J. VAN LOGHEM

i. Epidemic Choleriform Enteritis.The question has been raised, in connexion with

the pilgrimage, as to whether, in certain articles,mention should not be made of epidemic choleriformenteritis, caused by a non-cholera vibrio. This matteris worth consideration from two points of view :

(a) The El Tor vibrio, found many times since1904 among pilgrims and once in the water of theZam-Zam spring, is without pathogenicity ; itwas found in 1937 in Celebes, where it caused anepidemic of choleriform enteritis.

It is obvious that a serious " El Tor " epidemicamong pilgrims would call for the same measures tobe taken as an epidemic of true cholera. From thispoint of view, it would be advisable to instructdoctors whose duty it is to inform the Saudi ArabianGovernment on the sanitary situation also to reportCases of epidemic choleriform enteritis.

(b) The other point at issue concerns the diag-nosis of vibrios.

Generally speaking, it is agreed that the word" cholera " indicates a pathological entity, a disease

- REVISION OF THE PILGRIMAGE CLAUSES OF

caused by the comma bacillus. This implies thatcholeriform enteritis caused by a vibrio which,according to bacteriologists, belongs to anotherspecies of vibrio is not, according to the Conventions,identical with cholera, even if it proves to be identicalas a pathological and epidemiological entity. Allbacteriologists, however, are not in agreement asregards the differentiation of vibrios agglutinable bycholera serum. This scientific incertitude presents avery real danger, because it tempts any Governmentnot desirous of reporting first cases of cholera toshield itself behind bacteriological controversies.

From this angle, it would be desirable to reflect onthe advisability of rejecting the aetiological conceptionof cholera and of applying the International Conven-tion to all diseases which, caused by vibrios, provepathologically and epidemiologically identical with" cholera asiatica ".

2. Examination of Stools to determine the Presence ofCholera Vibrios and Other Pathogenic Bacteria of theIntestine.

Most members of our Sub-Committee are in agree-ment that the bacteriological examination of stoolsto determine the presence of the " vibrio comma " isnot to be recommended. The Sub-Committee declaredthat " thanks to compulsory vaccination againstcholera and the period of medical surveillance, nocase of cholera has been found in the Hedjaz for manyyears. It would not seem necessary to add to theseapparently adequate measures one of doubtful value-viz., the bacteriological examination of stools."

For my part, I have tried to point out that it is notclear why the Hedjaz has been free from cholera fortwenty-five years. Certainly, vaccination and medicalobservation are useful measures, but their valueappears relative in the face of imperfect knowledgeof the epidemiology of cholera.

From this point of view, it must be admitted thatevery measure which facilitates cholera research anddetection should be included in the programme of theWorld Health Organization. It is evident that thebasis of international measures against the infectionby cholera of the Mecca pilgrimage does not lie in aquarantine system but in sanitary control in thecountries of origin. The greater the number of pre-ventive measures taken before departure, the fewerthe risks of infection during the journey.

In this connexion will be needed sanitary or epi-demiological services operating in the collectingcentres for pilgrims and in the ports of embarkation.It goes without saying that these sanitary servicesshould pay special attention to pilgrims coming fromplaces where cases of cholera or choleriform enteritishave been notified.

I consider that the task of our Sub-Committee isnot limited by the present terms of reference. It isalso our duty to point out the measures leading tofuture improvements.

3. The Dangers of Quarantine Measures.

I propose to express in our resolutions the necessityfor avoiding any quarantine measure not justified byconsiderations of hygiene or preventive medicine.Crowding not only facilitates the propagation ofinfectious diseases of a parasitic nature ; it also favoursthe spread of communal infections, particularly by theaccelerated circulation of commensal microbes, chang-ing the quantitative equilibrium existing betweenthem and their human host.

4. Personal and International Hygiene.

During the discussions of our Sub-Committee, wehave sometimes touched on measures of personalrather than of international importance.

It is obvious that measures which increase thecomfort of the pilgrim or protect him against riskson the journey do not belong to the internationalsphere.

Generally it must be recognized that the regulationand supervision of the conditions under which thejourney is made form part of the duties of the respec-tive Governments. For instance, there is no scientificbasis for the calculation of the minimum of Englishsquare feet to be allocated to each pilgrim.

5. Anti-plague Vaccination.

The members of our Sub-Committee agree not toaccept anti-plague vaccination as a compulsorymeasure. All the same, the danger of plague must notbe forgotten. Pneumonic plague, following on bubonicplague, can become the source of an epidemic ofprimary pneumonic plague.

From this point of view, it may be stated thatliving anti-plague vaccine, studied and utilized byFrench and Dutch scientists, has not yet been givedthe attention it deserves.

Appendix 2.NOTE PRESENTED BY DR. WASFY OMAR

Although having given his approval to the resolu-tion unanimously adopted (see page 33), Dr. WasfyOmar has expressed the wish that the following noteconcerning the question of bacteriological examina-tion for cholera be added to the documentation :

" The question of bacteriological examination forcholera was deferred until the arrival of ProfessorJ. J. Van Loghem, who is an accepted authority oncholera. He has given a favourable opinion as regardssuch an examination (Appendix r), and I wish toassociate myself with his declaration."

Appendix 3.REPORT ON THE QUARANTINE STATION AT JEDDAH

The Quarantine Station comprises :(1) An administrative and technical service, con-

sisting of a Director and Assistant Director of Qua-rantine, together with a certain number of subor-dinate staff.

(2) Quarantine Offices, including a jetty for lightcraft, a large hall for the reception of pilgrims and oneor two small rooms which are used for office adminis-tration, medical examinations, inoculations, etc.Pilgrims may not land other than at the above-


mentioned jetty, although it is doubtful whether thisrule is strictly followed.

(3) Two quarantine islands situated respectively atapproximately half-an-hour's and an hour's runfrom the jetty by motor-launch. It is understood thatthere is good deep-water anchorage close to theseislands.

The Committee visited the more proximate island,on which the following facilities are provided :

(a) A landing-jetty for small craft ;(b) A disinfection and ablution block containing

two steam disinfectors with a coal-fired boiler, notof modern design, which, it is understood, have notbeen used for some years.

(c) Four isolation blocks providing for approxi-mately 300 persons. One of these blocks is intendedfor first-class passengers.

(d) Ancillary buildings, including medical offi-cer's quarters, guardian's house, a kitchen and ashop.

(e) A water-supply, consisting of a condenser,with an output said to be 3 metric tons per diem.

(f) Latrine accommodation, which, save in theablution chambers and the 'block for first-classpassengers, consists only of wooden structures builtout over the sea.

The buildings are all of sound construction and ina good state of repair.

With the exception of a few beds and mattresses,there was no evidence of any equipment, linen,crockery, medical stores, etc.

While this island station might possibly be usefulin an emergency, it is not in any way suitable forroutine use during the pilgrimage season, particularlyon account of its distance from the port and anapproach which must be difficult and even dangerousat times for the small craft usable for this type ofj etty.

It was not possible to visit the second island,which, it is understood, could provide accommodationin at present uncompleted buildings for approximately1, 000 persons.

Hospital accommodation in Jeddah. There is a 54-bedded hospital in the town, which, although appa-

rently of solid construction, is not modern in designand gives the impression of being very inadequatelyequipped.

This hospital forms no part of the port's quarantineservice but caters solely for the local sick.

Water-supply. The present water-supply is of twokinds :

. (a) from a number of brackish wells ; and(b) from a condensing plant (this water, being

very costly, cannot be used by the poorer in-habitants).A piped water-supply from springs situated 62 kilo-

metres away from the town is in course of constructionand is expected to be completed before the nextpilgrimage.

Drainage. There is no drainage or sewerage system.Accommodation for pilgrims. A certain number of

houses in the town are registered for the accommoda-tion of a specified number of pilgrims per house.The Sub-Committee did not visit any of these houdes.

Recommendations.

(1) The Quarantine Service requires reorganizationthroughout.

(2) A new Quarantine Station, with isolation accom-modation and ancillary services adequate to meet theneeds of the pilgrimage, should be constructed.

(3) Meanwhile, the equipment and facilities on thequarantine islands should be brought up to date andkept in running order.

(4) While the piped water-supply should enablea material improvement in the general situation, it isrecommended that a drainage and sewerage schemeshould be immediately drawn up and carried out assoon as possible, in order to take full advantage ofthe water-supply.

It will be appreciated that the port of Jeddah isonly one link in the chain of defence against epidemicdisease ; the measures of control in the interior, thefrontier quarantine posts and the provision of ade-quate isolation arrangements all form part of acomprehensive and efficient plan of defence organi-zation.

A note prepared by the Chief Quarantine Officer on thefunctioning of his service is annexed (see Appendix 4).

Appendix 4.

NOTE PRESENTED BY DR. YEHIA NASRI ON THE SANITARY MEASURES TAKEN ON THEARRIVAL OF PILGRIMS AT JEDDAH PORT

1. On the arrival of the ship at Jeddah, and beforeallowing any contact with the shore, the QuarantineOfficer boards the ship and meets the captain and theship's doctor or doctors.

He examines the bills of health issued by the portof origin and particularly that issued by KamaranQuarantine Station (when the ship comes from thesouth, after having called at Kamaran Station).

The captain fills in and signs the sanitary question-naire submitted to him by the Quarantine Officer,which includes questions as to the sanitary state ofthe ship from the date of its departure from the portof origin to the time of its arrival at Jeddah, thenumber of pilgrims carried by the ship, the ports ofcall during the voyage, the sanitary state of these ports,and whether pilgrims were embarked or disembarkedthere.

The Quarantine Officer also examines all otherdocuments which might interest the quarantineauthorities, such as the fumigation certificate or thecertificate of exemption from fumigation, the certi-ficate relating to the number of pilgrims transported,their names, the names and functions of the membersof the crew, the certificates of inoculation which thepilgrims and members of the crew were subjected tobefore embarkation. In addition to this, the ship'ssurgeon is given three certificates to be filled in andsigned : the first dealing with the sanitary state of theship during the voyage and the inoculations madebefore embarkation ; the second concerning the stateof the sick during the voyage, with their names, thenature of the disease, and all other useful information,(the sick are transported to Jeddah Hospital if theyare in a condition requiring such a measure) ; the


third concerning cases of deaths which have occurredduring the voyage, mentioning the names of thedeceased, the cause of death, etc.

The Quarantine Officer then inspects the ship toascertain the sanitary state of the pilgrims and crew,paying special attention to the drinking-water andthe food of the pilgrims, the sanitary accommodationprovided, so as to ensure sanitary well-being, such ashospital accommodation, isolation quarters, whether .the pharmacy is provided with all the necessaryrequirements, the baths, showers, and latrines, themeans of ventilation. The Quarantine Officer alsoascertains that the ship is not carrying pilgrims inexcess of the number allowed by the certificate ofmeasurement, as well as the state of the rescueequipment (lifeboats, rafts, lifebelts) imposed bythe International Sanitary Convention of 1926 forpilgrim ships. After ascertaining that the ship isfree from any suspicion from the sanitary point ofview, the Quarantine Officer will authorize thedisembarkation of the pilgrims on the special jettythrough which all pilgrims must pass with a viewto undergoing a medical inspection and-as anadditional precaution-a check of the inoculationcertificates they carry. Free pratique is then grantedto the ship.

2. It is a matter of great importance to us thatpilgrims should be subjected-in their country ofdeparture-to compulsory inoculation against small-pox, cholera and the other diseases against whichinoculation is required under the terms of the Inter-national Sanitary Convention. Further, passengers orpilgrims from an area infected with an epidemicdisease, such as yellow fever, cholera or typhus, arenot allowed to disembark unless they have beenpreviously inoculated against the disease prevailingin their country and a sufficient period has elapsedsince that inoculation. Otherwise they will be liableto isolation, with all measures that this isolationinvolves, such as inoculation, disinsectization, disin-fection, etc., etc.

3. If the existence of positive or suspected epidemicdisease is verified among the passengers or membersof the crew, they will be isolated in the special qua-rantine islands, in accordance with the provisions ofthe International Sanitary Convention, and subjectto all the measures required by their sanitary state.Any communication between the ship and theinhabitants of the town will be forbidden, except forthe seamen of Jeddah harbour and the " muza-weriyas ", whose duties require such a contact. Thelatter will be isolated with the passengers for a periodvarying between five and six days. The ship willleave with an unclean bill of health, after inoculationof the members of the crew and transit passengersand a general disinfection of the vessel.

4. Pilgrims are at present landed in motor-launchesor sailing-boats and directed to the special premiseserected on the quay.

Departure of Pilgrims from Jeddah.5. After completion of the pilgrimage, the pilgrims

proceed to J eddah for their embarkation. If thepilgrimage has been declared " clean " by a decisionof the public health organization, they are allowed toleave without restriction. On their embarkation, theyundergo an individual inspection, with the object ofascertaining their general state of health and freedomfrom disease. The ship receives the usual bill of health.

If, on the contrary, the clean state of the pilgrimageis not established, the pilgrims are not allowed toleave unless they have been detained for the period ofincubation and subjected to inoculation, disinfection,etc., as provided for in the International SanitaryConvention. After completion of their quarantineperiod and if they are in a good state of health andfree from diseases, they are allowed to proceed home.

All these measures-and any other complementarymeasures-are applied to all persons, whether arrivingby air or by land, according to the circumstances ofeach case, and in accordance with the clauses of theInternational Sanitary Convention of 1926 modifiedby the International Sanitary Conference of 28 Oc-tober 1938.

[Seal of the Saudi ArabianQuarantine Administration.]

MEDICAL AND HEALTH SERVICES IN SAUDI ARABIA

General Directorate.

Director-General of Public HealthAssistant DirectorInspector-GeneralChief Pharmacist

7 Regional Directors.

Regional Services :A. At Mecca.

Specialists :gynxcologistoculistsurgeondermatologistradiologist

4 internistsr bacteriological chemist

pxdiatristear, nose and throat specialist

2 travelling doctorsdentistsdispenser

2 assistant dispensers

Dispensaries in the Mecca Region :I. Taif : Hospital

2 doctorspharmacistassistant pharmacistdentist

II. Zafire : r doctor

Medical Centres :I. Bahra

II. Wadi FatmaIII. Wadi MohremeIV. ZemaV. Ceil

B. At Riyadh.Royal Palace :

Hospital :

4 doctorsdentistdispensersurgeonoculistradiologistpxdiatrist

2 physicians2 travelling doctors

dentist


Dispensaries in the Riyadh Region :I. Majmaa : x doctor

II. Breda : r doctorMedical Centres :

I. HaryaII. Hafre

III. Dawadmie

C. At Jeddah:Hospital : surgeon

x oculistinternisttravelling doctorbacteriologistdentist

z dispenserDispensaries in the Jeddah Region :

I. Yambo : x doctorII. Wajh : i doctor

Medical Centres :I. Lice

II. RabegueIII. Yambo NaklileIV. DibaV. Omloge

D. At Medina:Hospital : oculist

r surgeonI internist

travelling doctorDispensaries in the Medina Region :

I. Haile : r doctorII. Oula : r doctor

III. Joffe : r doctorMedical Centres :

I. MsegideII. Tabougue

III. Heibare

E. At AssireHospital : 3 doctors

dentistdispenser

Dispensaries in the Assire Region :I. Najran : r doctor

IL Djizane : r doctorIII. Konfonda : r doctor

Medical Centres :

I. ZahraneII. Farassane

III. El BerqueIV. Bicha

F. At Ahssa:

Hospital : 3 internistsdentist

Dispensaries in the Ahssa Region :

I. Katif : r doctorII. Damame :1 doctor

Medical Centre :

Khobare.

G. Quarantine Service:

J eddahYomboWaj ehKonfondaJizanRas TannouraDamameKhobare

doctordoctordoctordoctordoctordoctordoctordoctor

Quarantine Centres :

ToalRabegueUmlogeDibaHakilKhrebaAl UreidBirekFarassanUj ma

Total : ro directors :

A.B.C.D.E.F.G.

17 doctors14

7

76

52

Total : 68 doctors

Appendix 5.

ORGANIZATION OF THE SANITARY STATION AT MOSES WELLSby Dr. Wasfy OMAR

The Egyptian Quarantine Administration main-tains two lazarets at Suez : one at El Shat (not usedsince the construction of the Moses Wells lazaret)and the other at Moses Wells, situated on the Asiaticcoast of the Gulf of Suez, about 5 kilometres south ofSuez.

Moses Wells lazaret is designed for the reception ofpassengers arriving on an infected vessel. It canaccommodate 25 first- and second-class passengersand 500 third-class.

The lazaret is composed of buildings for the accom-

modation of passengers, buildings for the nursingstaff, one ordinary hospital block, one isolation block,kitchens, baths with hot and cold showers, and adisinfecting station including steam stoves.

It is provided with a jetty which vessels canapproach in ordinary weather ; there are a separatesewage-disposal system and an electric light plant.

The station has been used for the isolation ofpilgrims arriving after the closure of El Tor camp andfor that of cases of infectious diseases landed fromvessels.


Appendix 6.

NOTE PRESENTED BY PROFESSOR KHALIL BEY

I should like first of all to thank warmly theSub-Committee for having appointed me as adviseron the pilgrimage question.

My opinion is that a general review of the pilgrimagesitúation will greatly facilitate future discussions.

You have been nominated because the countries towhich you belong are those most interested in theMoslem Pilgrimage, but the country most interestedis, without doubt, Saudi Arabia, for the pilgrimage isa very important matter for Saudi Arabia, moreimportant, perhaps, than mines or oil.

The opinion of the Saudi Arabian Government isthat the measures concerning the pilgrimage figuringin the Convention, such as quarantine at El Tor, etc.,deter people from proceeding on the pilgrimage. Itcomplains also of measures which discriminatebetween Moslems and non-Moslems. As an exampleis quoted the case of a British Moslem returning fromthe Hedjaz accompanied by his Christian wife on thesame ship. The husband was detained in quarantine,whereas his wife was authorized to proceed on hervoyage. Naturally, this discrimination cannot bejustified on any scientific basis. These measures wereadopted because Mecca was, as it still is, inaccessibleto persons other than Moslems, because no reliablesanitary information was received from Mecca or theinland districts of the Hedjaz, only the ports havingforeign consuls, and because there were no organizedmedical staffs or sanitary services in the country.

But conditions have now changed, and it has beenfinally admitted that the Hedjaz is not a source ofcholera or of plague. If cases of these diseases wereformerly observed there, it was because the diseasehad been brought into the country from outside. Itis therefore necessary to take measures in the coun-tries of origin to protect pilgrims, and also the Hedjaz,from cholera, plague and yellow fever. These measuresare dictated by humanitarian motives.

It has to be considered whether the whole questionof measures concerning the pilgrimage should not bereviewed' in the light of scientific progress and of theequality 'of race and religion.

The Conventions at present in force were aimedonly at protecting Europe against these diseases,without any consideration for the pilgrims them-selves ; it is necessary to consider them now, and theprotection of the pilgrimage countries. Moreover,sanitary organization has been considerably developedin the Hedjaz, where the methods of protection againstpestilential diseases are now well known.

It must be added that yellow fever, which in thepast was present in regions situated at more than sixdays' journey from the Hedjaz, has crept considerablynearer the frontier of that country. A few years ago,the countries on the west coast of the Red Sea wereincluded in the endemic yellow-fever zone (Eritrea,British, French and Italian Somalilands, Ethiopia,Sudan). For this reason, when revising the convention,measures to protect pilgrims from that disease mustnot be neglected.

For the last twenty-two years, there has been noepidemic of plague or cholera among the pilgrims.

Thus the measures taken at El Tor have been un-necessary. When the pilgrims return to Jeddah, it ispossible to determine the presence or absence ofcases of cholera, plague or yellow fever ; and if thepilgrimage is declared " clean ", why continue totake at El Tor measures which are only necessary ifthe pilgrimage has been declared " suspect " or" unclean " ?

The measures of surveillance to be applied topilgrims on their arrival in the Hedjaz are a matterfor the Saudi Arabian Government ; it has the rightto decide on the conditions to be fulfilled by the pil-grims in order to enter Arabia.

Finally, on account of the facility afforded by theConvention of concluding agreements between neigh-bouring countries, incredible results have sometimesensued.

The Saudi Arabian Government made an agreementwith Palestine whereby pilgrims travelling by air cantravel directly from Jeddah to Lydda (Palestine)without touching El Tor. Thus a pilgrim can reachhis country of destination in three hours withoutpassing through the quarantine station, whereas, ifhe travels by sea, he must spend three days in qua-rantine at the El Tor lazaret. The case has evenoccurred of a pilgrim being able to return to Egyptwithout passing through El Tor, because he flew fromJeddah to Lydda, whence he continued his returnjourney by air. Similar agreements have been signedwith India, South Africa, Syria and the Lebanon.

When the pilgrimage question was submitted to theHygiene Committee of the Pan Arab League, thelatter was of the opinion that a complete revision ofthe pilgrimage clause of the 1926 Convention shouldbe undertaken immediately.

It is necessary, therefore, to examine scientific andpractical conditions to enable the control of pilgrimson the return journey to be made at Jeddah and toensure that cases of pestilential diseases arrivingthere may not escape notice. As regards the arrivalof pilgrims in the Hedjaz, it is for the Government ofthat country to decide the measures it desires toapply to them before permitting them to enter itsterritory.1

1 In the original report, Appendix 6 was completedby an " Explanatory Note on the Proposed Amend-ments to the Sanitary Convention of 1938 in so faras the Pilgrimage is Concerned ", by Dr. Khalil Bey,and the text of the proposed amendments. Thenote and amendments have already been publishedin Off. Rec. WHO, No. 4, pages 162-163, with theexception of the following paragraphs, which wereadded to the amendments :

" 1. The above measures will not come into forceuntil all the premises and equipment have beeninstalled and placed in working order and alltechnical measures decided upon, in conformitywith regulations to be approved by the experts ofthe Pan Arab Regional Sanitary Bureau of Alex-andria.

" 2. If at any time these measures prove insuf-ficient, the El Tor lazaret will again be utilized.

" 3. It will be the duty of every Government totake the additional measures it considers necessaryin regard to its own nationals."


Appendix 7.

NOTE PRESENTED BY DR. MANI ON THE PROVISION OF BERTHED ACCOMMODATIONIN PILGRIM SHIPS

1. The following extracts from an inquiry carriedout in 1940 by the Government of India are placedbefore the Sub-Committee with a view to recommend-ing the provision of berthed accommodation inpilgrim ships, in the revised clauses relating to thepilgrimage. It is my considered opinion that un-berthed accommodation is not only anti-hygienic butcompletely out-of-date and that all accommodationfor pilgrims should, in future, be of the berthed type.

2. Unberthed passenger traffic is peculiar to Indiaand some of the countries of the East, while Westerncountries do not permit it. Its main advantage liesin low costs and consequently low fares.

3. Many of the suggestions for improving the lot ofthe deck pilgrim involve capital outlay, increasedcost, and lower income for the steamer company, butthere is another aspect of the problem which must notbe disregarded. Unberthed accommodation hasdefects which are inherent in its nature ; improve-ments, therefore, have a natural limit beyond whichthey cannot be carried out without creating incon-gruities. Increased space-allowance, separate markingof blocks, and similar measures intended to givepilgrims comfort to the degree generally desiredmust, if progressively enforced, lead to a point whenit would be more practicable to do away with un-berthed accommodation altogether.

4. It should be clear from what has been said in theforegoing that overcrowding can be prevented onlyby increasing the space-allowance to an extent thatwould entail a very considerable curtailment of thecapacity of the between-deck compartments.

5. Berthed accommodation, if introduced for thelowest class of passengers on pilgrim ships, wouldpossess the following advantages, disregarding thequestion of cost, over the system in force at present :

(a) In the first place, berths add directly tophysical comfort, as sleeping in a berth is morecomfortable than sleeping on the floor, and berthscan also be used for sitting.

(b) The space in area which can be utilized bythe passenger is virtually increased by almost thesurface area of the berths, a small allowance beingmade for supports. The surface of the deck underthe lowest berths remains usable and offers aconvenient place for putting away luggage.

(c) The arrangement of berths by itself intro-duces order in the distribution of passengers andobviates the annoyance of some appropriating moreof the deck than is their due.

(cl) Reservation of accommodation becomespossible.

(e) When berths are arranged in two tiers, aconsiderable amount of space becomes free, inwhich passengers can move about unobstructed.

(/) It should be easier to keep the quarters cleanin berthed accommodation than when the deck iscovered by bedding, mats, carpets, etc., and bypassengers lying about.

The usual size of a small bunk is about 6 feet by2 feet. ThiS area of 12 square feet accrues to the.advantage of every passenger and represents so muchextra horizontal surface that can be used by him.Normally, berths are installed in two tiers, an arrange-ment that is adopted in emigrant ships of the UnitedKingdom.

6. It appears that the berths are often fitted uptemporarily in the between-decks. It is, in fact, notnecessary to have permanent fixtures which wouldprevent the present pilgrim ships from carrying cargoin the between-decks during the off-season. I haveseen on a ship that was preparing to convey Indianseamen wooden bunks being fitted for the occasion,but this arrangement was crude and would not begenerally satisfactory. Steel tubular constructionwould answer the requirements best of all, as suchtake-down berths could be used for many seasonswithout replacement, being very durable and, fromthe point of view of hygiene, the most suitable.

Technically, therefore, it is practicable to use stteltake-down berths on pilgrim ships. To the objectiOnthat permanent attachments on the steel decks h1towhich the supports have to be fitted would damagecargo, it may be said that it is quite feasible to designsockets that would be either countersunk or havebevelled tops to avoid interference with cargo.Technical difficulties are seldom insuperable.

7. The 16 square feet allowance as in force todaywould be sufficient for berthed accommodation.

8. A large class of people who cannot afford totravel in cabins are deterred by what they hear of theunpleasant features of deck passage from venturingout on pilgrimages altogether. Those who go in thedeck class at present are mostly those who would goin any case, whatever the hardships and discomforts.

9. Pilgrim steamers of some foreign countries Withberthed accommodation for the lowest class haste forseveral years regularly called at Jeddah. Unberthedsteamers do not hold the field entirely in this traffic,which caters mainly for Asiatics and Africans. Manypersons and associations who feel that deck passagehas outlived its day have urged the introduction ofberthed accommodation for the lowest class in allpilgrim ships, and it appears that the question islikely to attract increasing attention in future. Thematter is of such fundamental importance that Iconsider it desirable that the possibility of providingpilgrims travelling in the lowest class with berthedaccommodation should be investigated as early aspossible.


[WHO.IC/84]30 June 1947

(b) DRAFT REGULATIONS FOR THE CONTROL OF THE PILGRIMAGE

(presented to the Interim Commission at its fourth session).,

Chapter I. General Provisions.

Chapter II. Special Provisions.

Section I - Transport by sea.

Outline.

Pilgrim ships - general provisions.Conditions applying to pilgrim ships.Measures to be taken before departure for the Hedjaz.Measures to be taken during the voyage.Measures to be taken in the Red Sea.

A. Measures to be taken on the outward voyage :(a) Ships going to the Hedjaz from the south ;(b) Ships going to the Hedjaz from the north.

B. Measures to be taken on the return of pilgrims :(a) Ships proceeding north ;(b) Ships proceeding south.

Section II. - Transport by air.Section III. - Transport by land.

(i) Pilgrims travelling by caravan or individually.(ii) Pilgrims travelling by automobile.

(iii) Pilgrims travelling by rail.

Chapter III. Sanitary Information.

Chapter IV. Sanctions (not examined).

Chapter One. GENERAL PROVISIONS

Article 1.The general provisions and all sanitary measures

laid down in the International Sanitary Conven-tions in force are applicable de plano to the trans-port of pilgrims, whether the transport be bysea, air or land.

Article 2.The following special measures of sanitary

protection will apply to pilgrims prior to theirdeparture from their country of origin :

(I) All pilgrims shall be immunized, before theirdeparture, against smallpox and cholera,whatever their region of origin and thesanitary condition of the region.

(2) Pilgrims coming from regions where yellowfever exists or from zones classified asendemic by international decision shall bein possession of a valid internationallyrecognized yellow-fever certificate of im-munization.

1- Off. Rec. WHO, No. 6, pages 46, 179, 218.

(3)

(4)

If cases of plague, smallpox, typhus or anyother widely diffused communicable diseaseexist in the area of origin or departure of thepilgrims, such pilgrims may not leave, what-ever the means of transport, until they haveundergone the necessary observation, witha view to ensuring that none of them issuffering from these diseases. The local sani-tary authorities will carry out all measures ofdisinfection and disinsectization they con-sider necessary.

Pilgrims coming from localities where casesof cholera have been observed during thesix months preceding the date of departuremay not, in principle, lbe authorized toproceed to the Holy Places. They may bepermitted to leave after a period of five days'observation.

Article 3.

Certificates of immunization will conform withthe international standards in force.

THE INTERNATIONAL SANITARY CONVENTIONS - 43 -Article 4.

Provisions brought by pilgrims may be destroyedif the sanitary authority considers it necessary.

Article 5.

Pilgrims shall, whatever the method of transportmay be, be in possession of a return ticket or shallhave deposited a sum sufficient to pay the returnj ourney, and, if circumstances permit, they shallbe required to show that they possess the meansnecessary for the accomplishment of the pilgrimage.

Chapter Two. SPECIAL PROVISIONS

SECTION I - TRANSPORT BY SEA

(i) Pilgrim Ships - general provisions.

Article 6.

Only mechanically propelled ships shall bepermitted to carry pilgrims.

Article 7.

Pilgrim ships used for short sea transport knownas coasting voyages shall conform with specialregulations made by agreement among the coun-tries concerned. These regulations will be basedon a model drawn up by the World Health Organi-zation.

Article 8.

A ship, which, in addition to ordinary passengers,embarks pilgrims in less proportion than onepilgrim per ioo tons gross shall not be considereda pilgrim ship.

This exemption applies only to the ship. Thepilgrims carried therein, irrespective of class,shall remain subject to all the measures relatingto them set out in this Convention.

Article 9.

The captain or the agent of the shipping com-pany shall, at the discretion of the sanitary author-ity, pay the total of the sanitary charges due inrespect of each pilgrim. Such charges shall beincluded in the price of the ticket.

(ii) Conditions applying to pilgrim ships.

Article io.

The ship shall be capable of accommodating thepilgrims in the between-decks. Over and abovethe space reserved for the crew, the ship shallprovide for each pilgrim, irrespective of age, anarea of 1.5 square metres, equivalent to 16 Englishsquare feet, and a cubic capacity of at least 3 cubicmetres, equivalent to 96 cubic feet.

Each pilgrim should be provided with a separate,detachable berth preferably of metal construction.These berths may be in two tiers, provided thatthe above-mentioned unities of surface and ofcubic space allowed to each pilgrim are used forcalculation of total space provided in any compart-ment reserved for pilgrims.

Pilgrims shall not be lodged on any deck lowerthan the first between-deck below the water-line.

Satisfactory ventilation, augmented by mecha-nical means in the case of decks below the firstof the between-decks, shall be provided.

In addition to the space reserved for pilgrims,there shall be on the upper deck a free area of notless than 0.56 square metre, equivalent to about6 English square feet, for each person, irrespectiveof age, over and above the area upon that deckwhich may be reserved for temporary hospitals,the crew, douches and latrines and for the workingof the ship.

Article

Places screened from view, including a sufficientnumber for the exclusive use of women, shall beprovided on deck.

These places shall be provided with water underpressure in pipes fitted with taps or douches, soas to furnish sea water supply for the use of thepilgrims at all times even if the ship is lying atanchor. Taps or douches shall be in proportionto i per ioo pilgrims or fraction of ioo.

Article 12.

The ship shall be provided, in addition to closetsfor the crew, with latrines fitted with a flushingapparatus or with a water tap.

Some of these latrines shall be reserved exclu-sively for women.

Latrines shall normally be in the proportion of3 per Ioo or fraction of Ioo pilgrims, but in thecase of existing ships where adaptation will notpermit of 3 per cent., a minimum of 2 per Ioo maybe admitteq by the competent authority.

There shall be no latrines in the hold.

Article 13.

Pilgrims are forbidden to cook food on board.

'Article 14.

Hospital quarters, satisfactory from the pointof view of safety and health, shall be reserved forthe accommodation of the sick. They shall besituated on the upper deck, unless, in the opinionof the sanitary authority, an equally healthysituation can be provided in another place.

They shall be constructed so as to allow personssuffering from infectious diseases, and personswho have been in close contact with them, to beisolated according to the nature of their illness.

The hospitals, including temporary hospitals,shall be capable of accommodating not less than4 per ioo or fraction of roo of the pilgrims takenon board, allowing 3 square metres, equivalent toapproximately 32 English square feet, per person.

The hospitals shall be provided with speciallatrines.

Article 15.

Every ship shall carry medicaments, disinfectantsand articles necessary for the treatment of the sick.The regulations framed for this class of ship byeach Government shall specify the nature and thequantity of these medicaments. Each ship shallbe provided, in addition, with the necessaryimmunizing agents, especially anti-cholera andanti-smallpox vaccines, which shall be storedunder suitable conditions. Medicine and attendanceshall be provided for the pilgrims free of charge.

REVISION OF THE PILGRIMAGE CLAUSES OF

Article 16.Every ship taking pilgrims shall carry a duly

qualified medical officer, who shall be recognizedby the Government of the country of the first portat which the pilgrims are embarked upon theiroutward journey. A second medical offiper ful-filling the same conditions shall be carried whenthe number of pilgrims on board exceeds 1,000.

Article 17.The captain shall cause notices, printed in the

principal languages of the countries to which thepilgrims to be embarked belong, to be posted upon the ship in a conspicuous place accessible toall concerned, showing :

(I)(2)

(3)

(4)

The destination of the ship ;The price of tickets ;The daily ration of food and water allowedto each pilgrim in accordance with the regu-lations of the country of origin ;The price of foodstuffs not included in thedaily ration, which may be procured onextra payment.

Article 18.The heavy baggage of pilgrims shall be registered

and numbered. Pilgrims may keep with themonly such articles as are absolutely necessary. Thenature, amount and dimensions of these articlesshall be set out in regulations framed by eachGovernment for its own ships.

Article 19.Extracts from the provisions of Section (i) of

this Chapter shall be posted up, in the form ofregulations, in the language of the country towhich the ship belongs, and also in the languageschiefly spoken in the countries inhabited by thepilgrims to be embarked, in a conspicuous andaccessible place on each deck and between-deckof every ship carrying pilgrims.

(iii) Measures to be taken before departure for theHedjaz.

Article 20.The captain, or, failing the captain, the owner

or agent, of every pilgrim ship shall, not less thanthree days before departure, declare to the com-petent authority of the port of departure hisintention to embark pilgrims. At ports of call,the captain, or, failing the captain, the owner oragent, of every pilgrim ship shall make the samedeclaration twelve hours before the departure ofthe ship. This declaration shall indicate theproposed date of departure and the destination ofthe ship.

Article 21.

On receipt of the declaration prescribed in thepreceding article, the competent authority shallproceed at the expense of the captain to inspectand measure the ship.

Inspection alone shall take place if the captainalready has a certificate of measurement furnishedby the competent authority of his country, unlessit be suspected that the certificate no longerrepresents the actual condition of the ship.

Article 22The competent authority shall not permit the

departure of a pilgrim ship until satisfied :(a) That the ship has been thoroughly cleaned

and, if necessary, disinfected.(b) That the ship is in a condition to undertake

the voyage without obvious danger ; thatit is provided with the necessary gear andapparatus for use in case of shipwreck,accident or fire, particularly a wirelessapparatus for sending and receiving mes-sages, capable of being worked independ-ently of the ship's engine, and that itcarries a sufficient number of boats andlife-saving apparatus ; that it is properlymanned, equipped and ventilated, andprovided with awnings of sufficient size andthickness to shelter that part of the decksreserved for pilgrims and that there isnothing on board that may be or maybecome injurious to the health or safety ofthe passengers.

(c) That there is on board, properly stowedaway, over and above the provision madefor the ship and crew, sufficient fuel andfood of good quality for all the pilgrimsduring the duration of the voyage.

(d) That the drinking-water on board is of goodquality ; that it is in sufficient quantity toensure that not less than 5 litres shall beput each day at the disposal of every pil-grim, irrespective of age, free of charge ;that the tanks for drinking-water are safefrom all contamination and so closed thatthe water can be supplied only by meansof taps or pumps ; fittings for sucking watershall be absolutely prohibited.

(e) That the ship carries a condenser capableof distilling a minimum quantity of 5 litresof water per diem for every person on board,including the crew.

(f) That the ship possesses a disinfectingchamber, ascertained by the sanitary au-thority of the port where the pilgrimsembarked to be safe and efficacious.

(g) That the ship carries a duly qualified medi-cal officer, if possible with up-to-date know-ledge of maritime health conditions and ofthe pathology of tropical diseases, recog-nized by the Government of the countryof the first port at which the pilgrims areembarked upon their outward journey, andthat it carries medical stores as requiredby Article 15.

(h) That the deck is free from merchandise andall encumbrances ;

(i) That the arrangements on board are suchas to allow of the measures prescribed inChapter II, Section I (iv) being carried out.

Article 23.The captain may not start without having in

his possession :(1) A list countersigned by the competent

authority showing the names and sex of thepilgrims who have embarked, and the totalnumber of pilgrims he is authorized to carry.


(2) A document giving the name, nationalityand tonnage of the ship, the names of thecaptain and of the doctor, the exact numberof persons embarked (crew, pilgrims andother passengers), the nature of the cargo,and the place of departure.

The competent authority shall note onthis document whether the number of pil-grims permissible under the regulations hasbeen embarked or not, and, in the lattercase, the additional number of passengersthe ship is authorized to embark at sub-sequent ports of call.

(iv) Measures to be taken during the voyage.

Article 24.During the voyage, the deck allotted to pilgrims

shall be kept free from encumbrances ; it shall bereserved night and day for the passengers andplaced at their disposal without charge.

Article 25.The between-decks shall be carefully cleansed

and rubbed with sand every day when the pilgrimsare on deck.

Article 26.The latrines allotted to the passengers, as well

as those of the crew, shall be kept clean, in goodworking order ; and they shall be cleansed anddisinfected at least three times daily, and morefrequently if necessary.

Article 27.In the case of infectious or other communicable

disease, the ship's medical officer will be respon-sible for all necessary measures of disinfection,which shall be carried out under his supervision.

Article 28.If there be any doubt as to the quality of the

drinking-water or any reason to suspect that itmay possibly have become contaminated, either atits source or during the voyage, it shall be boiledor sterilized, and the captain shall cause it to beemptied overboard at the first port of call at whichhe can procure a purer supply. The tanks shall bedisinfected before taking on a fresh supply.

Article 29.The medical officer shall visit the pilgrims, tend

the sick and see that the rules relating to healthare observed on board. He shall, in particular :

(1) Satisfy himself that the rations issued to thepilgrims are of good quality, that theirquantity is in accordance with contract andthat they are properly prepared ;

(2) Satisfy himself that the provisions of Article22 (d), regarding the distribution of water,are observed ;If there be any doubt as to the quality of thedrinking-water, call the attention of thecaptain, in writing, to the provisions ofArticle 28 ;

Satisfy himself that the ship is always keptclean, and particularly that the latrines arecleansed in accordance with the provisionsof Article 26 ;Satisfy himself that the pilgrims' quartersare kept wholesome, and, in case of the

(3)

(4)

(5)

occurrence of infectious disease, that thenecessary disinfection is carried out ;

(6) Keep a diary of all occurrences relating tohealth during the voyage, and submit thisdiary, on request, to the competent author-ity of the ports of call or the port of finaldestination.

Article 30.

Only the persons charged with the care of patientssuffering from plague or cholera or other infectiousdiseases shall have access to them, and thesepersons shall not come in contact with the otherpersons that have been embarked.

Article 31.In the event of a death occurring during the

voyage, the captain shall enter the fact oppositethe name of the deceased on the list countersignedby the authority of the port of departure, and shallalso enter in the log the name of the deceased, hisage, the place from which he came, the supposedcause of death, according to the medical certificate,and the date of death.

In the event of a death from infectious disease,the corpse, wrapped in a shroud impregnated with adisinfecting solution, shall be committed to thedeep.

Article 32.The captain shall see that all measures taken

against the spread of communicable disease duringthe voyage are entered in the log. The log shall besubmitted by him, on request, to the competentauthority of the ports of call or the port of finaldestination.

At each port of call, the captain shall cause thelist drawn up in accordance with Article 23 to becountersigned by the competent authority.

In the event of a pilgrim disembarking during thevoyage, the captain shall note the fact on the listopposite the pilgrim's name.

In the event of persons embarking, their namesshall be entered on the list in accordance with theprovisions of Article 23. This shall be done beforethe list is countersigned by the competentauthority.

Article 33.Any sanitary document given at the port of

departure shall not be modified during the voyage.In case of failure to observe this regulation, theship may be treated as infected.

It shall be countersigned at each port of call bythe sanitary authority, who shall enter :

(1) The number of passengers disembarked orembarked at the port ;

(2) Anything that has happened at sea affectingthe life or health of the persons embarked ;

(3) The health conditions of the port of call.

(y) Measures to be taken in the Red Sea.A. Measures to be taken on the outward voyage.

(a) Ships going to the Hedjaz from the south.

Article 34.

Pilgrim ships from the south, bound for theHedjaz, shall, in the first instance, put in at theKamaran Sanitary Station, and shall be subjectedto the procedure set out in the following article.


Article 35.

The pilgrims shall be medically examined. Anypilgrim not in possession of a valid certificate ofimmunization against cholera and smallpox and,if the terms of Chapter I, Article 2, apply, yellowfever, shall forthwith be immunized and issuedwith a certificate of immunization.

If there has been no case of Convention diseaseon board during the voyage, the ship shall bepermitted to proceed forthwith to Jeddah.

If there has been a case of plague, cholera oryellow fever on board, the case shall be landed andisolated. The pilgrims shall also be landed and adaily medical inspection carried out. The pilgrimswill be re-embarked, and the ship will be allowedto proceed to Jeddah in the case of cholera, fivedays after the occurrence of the last case, and sixdays after the last case of plague or yellow fever.

If there has been a case of Convention diseaseother than plague, cholera or yellow fever, the caseshall be landed and isolated and the ship allowedto continue the voyage after the necessary measuresof immunization or disinsectization have beencompleted.

Article 36.

Ships to which Article 35 applies shall be subjectto medical inspection on board on arrival atJeddah. If the result is favourable, the ship shallreceive free pratique.

If, on the other hand, the occurrence of definitecases of Convention disease on board during thevoyage, or at the time of arrival at Jeddah, isestablished, the sanitary authority of the Hedjazmay take all necessary measures subj ect to theprovisions of Article 54 of the InternationalSanitary Convention of 1926.

Article 37.

Every sanitary station intended for the receptionof pilgrims shall be provided with a skilled andexperienced staff, in sufficient number, togetherwith all the structures and plant necessary forensuring the complete application of the measuresto which pilgrims are liable.

(b) Ships going to the Hedjaz from the north.

Article 38.

All ships carrying pilgrims and passing throughthe Suez Canal will pass through in quarantine.

Article 39.

If, on medical inspection of the pilgrims at PortSaid, no case of Convention disease has beenobserved, and if the pilgrims are in possession ofvalid immunization certificates, the ship shallproceed forthwith to Jeddah without call at anyintermediate port. Pilgrims not in possession ofvalid certificates shall be immunized.

If medical inspection of the pilgrims at PortSaid reveals a case of plague, cholera or yellowfever on board, the ship shall proceed direct toEl Tor to undergo the measures prescribed inArticle 35. Cases of other Convention diseasesshall be disembarked and isolated at Port Said or atSuez and the ship allowed to proceed to Jeddah

after the necessary measures of immunization ordisinsectization have been completed.

B. Measures to be taken on the return of pilgrims.

(a) Ships proceeding north.

Article 40.

If plague, cholera or yellow fever, or if smallpoxor typhus in epidemic form has not been observedin the Hedjaz during the pilgrimage period, shipswill proceed direct to Suez, where the pilgrimswill undergo medical inspection.

If a case of plague, cholera or yellow fever isfound on board, ships will be sent back to El Tor.

If a case of smallpox or typhus is found on board,it will be disembarked, the ship put in quarantine,and the necessary measures of re-vaccination, ordisinfection and of disinsectization will be takenbefore the ship is authorized to continue its voyage.

If there is no pilgrim found to be suffering fromone of the Convention diseases, the ship will beauthorized to enter the Suez Canal, even at night,provided five full days have elapsed since leavingJeddah.

Nevertheless, if the first three ships returningpilgrims via El Tor are found to be healthy, theSuez sanitary authority may permit the passage ofthe Canal by healthy ships, without requiring thelapse of five days since leaving Jeddah.

Article 41.

Pilgrims wishing to disembark at a port onEgyptian territory may not travel in ships referredto in the preceding Article 40.

Ships carrying pilgrims wishing to disembark atan Egyptian port shall proceed to El Tor or to anyother station prescribed by the Egyptian SanitaryAuthority, there to undergo the sanitary measuresprescribed in the Egyptian Quarantine Regulations.

Article 42.

If plague, cholera or yellow fever, or if smallpoxor typhus in epidemic form has been observed inthe Hedjaz during the pilgrimage period, the SaudiArabian Government will immediately notify allthe diplomatic missions in its territory.

The diplomatic authorities of the countries towhich the pilgrims are going will instruct thecaptains of the ships to proceed to El Tor, there toundergo the measures prescribed in Article 43.

Article 43.

Ships arriving at El Tor in the circumstancesprescribed in Article 42 and carrying pilgrims notwishing to land on Egyptian territory will undergothe following measures :

(r) Medical examination under conditions to bedetermined by the local sanitary authority.

(2) Disembarkation and isolation of cases ofConvention diseases.


(3)

(4)

In the case of plague, cholera and yellowfever, contacts shall be clisembarked andsubmitted to the sanitary measures consi-dered necessary by the sanitary authorities.They shall be isolated for a period not ex-ceeding five days in the case of cholera, andsix days in the case of plague and yellowfever. In the case of plague, the procedurelaid down in Article 25 of the InternationalSanitary Convention of 1926 concerning ratsshall be applied in so far as possible.Contacts with cases of Convention diseasesother than plague, cholera and yellow feverwill undergo the disinfection or disinsecti-zation considered necessary by the sanitaryauthority, after which they will return to theship.

On completion of the sanitary measures referredto in this Article, the ship, having re-embarked itspilgrims, shall proceed without delay to Suez.

Article 44.Ships from the Hedjaz carrying pilgrims bound for

the African coast of the Red Sea shall proceed directto the Quarantine Station appointed by the Govern-ment concerned, for the purpose of undergoing anysanitary measures considered necessary by thelocal sanitary authority.

Article 45.Passengers from the Hedjaz, whoever they are,

who have accompanied the pilgrimage, shall besubject to the same measures as pilgrims. Allpassengers travelling on ships carrying pilgrimswill be submitted to the same sanitary measures asthose applied to pilgrims.

(b) Ships proceeding south.

Article 46.If plague, cholera, yellow fever, or smallpox or

typhus in epidemic form have been observedduring the pilgrimage, the diplomatic authorities ofthe countries to which the pilgrims are proceeding,notified by the Saudi Arabian Government, willinstruct the captains of ships to call at Kamaran,where the passengers will undergo the measuresprescribed in Article 43.

SECTION II - TRANSPORT BY AIR

Article 47.Aircraft transporting pilgrims and pilgrims

transported by air shall be subject to the generalrequirements of international air navigation and tothe provisions of the International SanitaryConvention for Aerial Navigation, 1933, modifiedin 1944. They will, in addition, conform to theconditions laid down in Articles i and 2 of thisConvention and in the following articles.

Article 48.(a) Conditions applying to aircraft. - Aircraft

engaged in the transport of pilgrims shall fulfil allthe health and security requirements laid down bythe international regulations governing the trans-port of passengers by air. No departure from suchregulations in the way of additional passengers orcargo shall be permitted.

(b) Measures to be taken before departure. -The commander of an aircraft carrying pilgrims,or, in default, the agent of the aircraft companyat the aerodrome of departure, shall declare to thecompetent authority of the aerodrome of departure,at least twenty-four hours before leaving, hisintention to embark pilgrims. The said authorityshall immediately warn the competent sanitaryauthority, who shall be responsible for carrying outthe measures provided in Chapter I, Articles 2and 3, of the present Convention.

The competent authority of the aerodrome shallnot permit an aircraft carrying pilgrims to leavewithout being satisfied that the aircraft is in a fitstate to undertake the voyage without obviousdanger, that it is suitably equipped to carry pil-grims and that all safety requirements are ful-filled.

The commander of the aircraft may not takeoff until in possession of a list, signed by the com-petent authority, containing the names of thepilgrims who have been embarked, as well as thetotal number of the pilgrims he is authorized totake on board.

(c) Aircraft carrying pilgrims may only landon designated sanitary aerodromes.

Article 49.Measures as regards pilgrims to be taken on arrival

in or on departure from the Hedjaz.

(a) Immediately the aircraft lands in the Hedjaz,the local sanitary authority will ascertain if thepilgrims fulfil the conditions required to satisfythe sanitary measures provided in Chapter I,Articles 2 and 3.

If these sanitary measures have been compliedwith, the pilgrims will not be subjected to anyfurther sanitary measure.

If the pilgrims have not complied with theprescribed conditions, they shall undergo thenecessary immunizations.

If a pilgrim refuses to undergo these sanitaryrequirements, he shall immediately be sent back.

(b) On return from the Hedjaz, pilgrims notshowing any evidence of Convention disease shallnot, during the voyage, undergo any sanitarymeasures other than those prescribed in Article 52of the International Sanitary Convention for AerialNavigation, 1933, modified in 1944.

On arrival, each country of origin will determinethe sanitary measures to take as regards its ownnationals.

Article 50.

The crew of aircraft carrying pilgrims and allpassengers, whether they be pilgrims or not, shallundergo the same sanitary requirements as thosefor pilgrims.

SECTION III - TRANSPORT BY LAND

(i) Pilgrims travelling by caravan or individually.

Article 51.

Pilgrims entering the Hedjaz by caravan shallpass through the frontier sanitary stations spe-cially designated for this purpose, where they will

REVISION OF THE PILGRIMAGE CLAUSES OF - 48 - THE INTERNATIONAL SANITARY CONVENTIONS

be examined by the sanitary authorities of SaudiArabia. The measures laid down in Article 62of the International Sanitary Convention of 1926will apply.

Article 52.If pilgrims have complied with the immuization

requirements laid down in Articles 2 and 3 of thisConvention, they may continue their voyage. Ifnot, they shall be immunized. If pilgrims incaravans refuse to submit to immunization or tosuch measure of disinfection and disinsectizationconsidered necessary by the local sanitary author-ity, they will be immediately sent back.

Article 53.On leaving the Hedjaz, pilgrims are required to

conform with the regulations of the sanitaryauthorities of the neighbouring countries in accord-ance with the terms of Article 62 of the Inter-national Sanitary Convention of 1926.

Article 54.Pilgrims making the voyage individually are

subject to the same regulations as pilgrims travel-ling in caravan. After medical examination at thefrontier sanitary posts, they will, as far as possible,be grouped together for the continuation of theirvoyage.

(ii) Pilgrims travelling by automobile.

Article 55.Pilgrims arriving in the Hedjaz by automobile

are required to pass through frontier sanitaryposts specially designated for the purpose by theSaudi Arabian Sanitary Authorities, where theywill be visited. The measures laid down in Article62 of the International Sanitary Convention of1926 will be applied.

Article 56.On their return, if cases of plague, cholera,

yellow fever, or smallpox or typhus in epidemicform have been observed in the Hedjaz during thepilgrimage, the pilgrims shall report to the firstsanitary post of the neighbouring country, toundergo observation or surveillance, which theSanitary Authorities may apply according to theterms of Articles 61, 62 and 65 of the InternationalSanitary Convention of 1926.

(iii) Pilgrims travelling by rail.

Article 57.In the case of pilgrims travelling towards the

Hedjaz by rail, the sanitary authorities of thecountries traversed will ensure that the measureslaid down in Chapter I, Articles 2 and 3, are com-plied with.

Special measures in conformity with Articles 62,63 and 65 of the International Sanitary Conven-tion of 1926 may be taken in the case of pilgrimstravelling to and from the Hedjaz by rail.

Chapter Three. SANITARY INFORMATION

Article 58.

(a) The Saudi Arabian Government will keepthe Governments concerned with the pilgrimageregularly informed of the epidemiological condi-tions in the Hedjaz during the pilgrimage and fora period of two months preceding and followingthe pilgrimage.

This information, sent weekly by cable to theWorld Health Organization, will be transmittedby the latter to the various Governments concerned.In addition, the diplomatic missions in the Hedjazwill be immediately informed of these communica-tions by the Saudi Arabian Government.

To this end, the Saudi Arabian Government willtake into account the information supplied and thenotification made to it by medical missions accom-panying the pilgrims.

It rests with °each Government, in the light ofthis information, to decide on the measures to takeon the arrival of pilgrims in their territory.

(b) The Saudi Arabian Government, and thoseof all other countries concerned in the pilgrimage,will send an annual report on the pilgrimage tothe World Health Organization.

The World Health Organization will, as soon aspossible, transmit these reports to Governmentsconcerned, in the form of a collective document.

Chapter Four. SANCTIONS

Not examined.

- 49 -[WHO.IC/95]

8 Viugust 1947

VI. EXPERT COMMITTEE ON TUBERCULOSIS


Held 30 July-2 August 1947, Office International d'Hygiene Publique, Paris

(presented to the Interim Commission at its fourth session).'

Outline.I. Introduction.2. Fields of Activity.3. Techniques for Control.4. Emergency Measures.5. Tuberculosis Secretariat and Finance.6. Dissemination of Information.7. Composition and Functions of the Expert8. Summary.

Committee on Tuberculosis.

At the third session of the Interim Commissionof the World Health Organization, held in Genevain April 1947, it was resolved to set up an ExpertCommittee on Tuberculosis. The Chairman of theInterim Commission and the Executive Secretaryagreed to appoint the following members of thisCommittee, after approaching their respectiveGovernments :

Dr. P. M. d'Arcy Hart, Farm Laboratories,National Institute for Medical Research,Medical Research Council, London, UnitedKingdom ;

Dr. Herman E. Hilleboe, Commissioner of Health,New York State Department of Health,Albany, New York, United States of America ;

Dr. Johannes Holm, Chief, Tuberculosis Division,State Serum Institute, Copenhagen, Denmark.

An invitation to the Government of the Unionof Soviet Socialist Republics to suggest the nameof a Russian member for the Committee was sent.The attendance of an expert was arranged, but hissudden illness prevented his coming to Paris.

The Expert Committee on Tuberculosis ap-pointed by the Interim Commission met in Parisfrom 30 July to 2 August 1947. Dr. Holm waselected Chairman. The Secretary to the ExpertCommittee, Dr. J. B. McDougall, and Dr. W.Gellner (Interim Commission Field Services) werein attendance.

* *

The Committee unanimously agreed to forwardthe following statements and recommendations tothe Interim Commission, with a view to theirsubmission to the World Health Assembly :

1. Introduction.It is recognized that tuberculosis is a world

problem of great magnitude. The Committee is

fully in accord with the decision of the InterimCommission that tuberculosis, malaria and venerealdiseases are infectious diseases deserving thehighest priorities for its activities.

There can be no isolationism in the field ofhealth. The fight against infectious disease is nota national or a racial problem ; it is a task for thewhole of humanity. No nation is safe if anothernation is vanquished by disease. The fortunateand relatively healthy nations, inspired by intelli-gent self-interest and humane considerations, willnecessarily have to come to the aid of strickennations and, through money, professional personneland equipment, distribute existing resources tothe needy and suffering areas of the world.

Tuberculosis-control work of an internationalscope must go forward if present suffering anddisability are to be alleviated and future genera-tions protected. The all-inclusive objective of anysound tuberculosis programme is the preventionand eventual eradication of tuberculosis from thepeoples of the world. Poverty, shortages of foodand housing and the lack of opportunity for gain-ful occupation complicate the task enormouslyand make it necessary for us to share and distri-bute our resources where they will do the mostgood in the shortest possible time.

2. Fields of Activity.There are five well-defined fields of activity in

which we must work and direct our efforts on aplanned basis, if tuberculosis is to be systematicallyeliminated : (1) prevention, (2) case-finding, (3)isolation and medical care, (4) rehabilitation andafter-care, (5) social and economic protection ofafflicted families.

No one of these activities can be effective alone.They all must operate together and in propersequence.

See Off. Rec. WHO, No. 6, pages 13, 55, 182, 219 ; No. 7, pages 25-26.4

TUBERCULOSIS

3. Techniques for Control.

It is not enough merely to recognize and describethe objectives of a tuberculosis-control programme.It is also necessary to have clearly defined andfirmly established techniques for the achievementof those objectives. The following recommenda-tions include eleven principle techniques for tuber-culosis control, which may be used singly, ingroups, and, finally, all together, if the WHOprogramme is to be comprehensive and whollyeffective :

1. The first technique is the determination ofthe extent of the problem of tuberculosis in eachcountry, the present means and facilities at itsdisposal, the manner in which these facilities arebeing used to tackle the problem, and the additionalfacilities required. Countries with little informa-tion available should be encouraged to record atleast simple basic data. It is recommended thatschedules (now being prepared by the ExpertCommittee) be filled in by the experts of theSecretariat who actually go into the countries attheir request ; these schedules should be keptup-to-date at regular intervals.

2. One of the most important techniques thatwork toward the realization of the objectives oftuberculosis control is the recruitment and trainingof professional personnel. In most countries, thereis at present an insufficient number of well-trainedworkers in this field. It is recommended thattravelling fellowships be awarded to countriesmost in need, principally to train medical officers.There are four special fields in which trainedmedical officers are essential for every country :administration, epidemiology, laboratory work andclinical work. It is estimated that one thousandsuch fellowships could be granted by the WHOwith good effect within the next few years. Itwould appear wise to recommend that only fiftyof these be provided in the first year, in order toget the programme under way. To operate thescheme, the Secretariat should survey the teachingfacilities throughout the world and designateacceptable teaching centres. At the same time,the Secretariat should ascertain the needs ofcountries for trained personnel, so that, in consul-tation with them, promising medical officers,especially those who show potentialities of leader-ship, can be selected for fellowships. Countrieswhere the needs are greatest should be chosen first.

It is also recommended that fifteen visitinglectureships of short duration be provided tocountries, especially those with teaching centres,in order to make available the latest knowledgeand viewpoints of outstanding specialists.

3. The provision of physical facilities, suppliesand equipment for all phases of prevention, diag-nosis and treatment is second in importance onlyto the provision for personnel. It is recommendedthat the WHO should be prepared to give expertadvice to the various countries requesting suchinformation, on the number, type and location offacilities needed and on the best means of financingthe construction and maintenance of these faci-ities, drawing on the successful experience of otherountries. Recommendations should be given only

if they are to form a part of a long-range, com-prehensive plan for the nation and its adminis-trative subdivisions.

4. Health education is recognized as an essentialtool in tuberculosis control. The general publicmust know the seriousness of the disease and itscost in human misery and money before it willaccept its responsibility to support the workfinancially. It is recommended that the WHOshould encourage national and international volun-tary organizations to take the major responsi-bilities for informing the public and gaining theirsupport.

To keep the medical profession informed onadvances in tuberculosis, it is recommended thatthe WHO prepare from time to time material onrecent developments of special importance, andthat it provide for the circulation of specialistliterature. The WHO should encourage nationaland international professional organizations todevelop the distribution of tuberculosis literature.

5. The best way to get a new programme startedor to improve a poor one in any country is bymeans of field services for the purpose of demon-strating practical activities in one or more of thespecial fields of administration, epidemiology,laboratory work and clinical work. Well-trainedteams, even with limited supplies and equipment,can demonstrate what should be done to controltuberculosis and how to do it. It is recommendedthat the WHO provide demonstration teams. Thesize of the team and the length of its stay wouldvary with needs, but in any event should be keptto a minimum. Certain supplies and equipmentwill be necessary for these teams. An essentialcondition for the demonstration will be that thecountry agree beforehand to take over the projectas soon as sufficient of its personnel has beentrained to do so. When taken over, these fielddemonstrations should become national training-centres, and in some cases should be designatedalso for international use of travelling Fellows.For example, an international training-centre mightbe established in India for training workers fromvarious parts of Asia, where the problems to besolved are similar in nature. Areas where it isproposed to set up international training-centresshould have first call on demonstrations, if suchare necessary.

The persons charged with these demonstrationscould be either regular staff members of the WHOor professional personnel with temporary appoint-ments. The person to take charge of the workwhen it is taken over by the local group could wellbe one of the persons who had received a travellingfellowship from the WHO.

6. While it is recognized that present budgetarylimitations do not permit grants of money fortuberculosis control to nations at this time, it isrecommended that in future such grants shouldbe made, in order to help nations unable to helpthemselves. Such grants should be made, however,only if great need is demonstrated, and if a com-plete plan is submitted to show the joint use ofnational funds and those from the WHO and toshow that the funds are used solely for tuberculosis

TUBERCULOSIS

control and that the WHO's contributions are notused to replace local funds.

7. The best contribution that can be made bythe WHO in tuberculosis research would appearto be in developing and recommending uniformprocedures. Special problems would require fromtime to time the services of small sub-committeesof experts in highly specialized fields ; where pos-sible, members of other expert committees of theWHO should be used for this purpose. Whenevera problem comes up for the Expert Committee onTuberculosis which involves the responsibilityshared by another expert committee, one of themembers of the second committee should be askedto take part in the deliberations. For example,when the Expert Committee on Tuberculosisconsiders the problem of tuberculin and tuberculin-testing, a member of the Expert Committee onBiological Standardization should be asked toparticipate, and vice versa. It is recommended thatthe Expert Committee for the Preparation of theSixth Decennial Revision of the InternationalLists of Diseases and Causes of Death consultwith the Expert Committee on Tuberculosis beforefinal action is taken on classification of tuberculosis.There are several suggestions which the Committeewishes to make on the first draft prepared by theformer Committee.

The principle problems which need action toestablish uniform procedures are as follows :

(I)

(2)

(3)

(4)

(5)

(6)

Tuberculin and tuberculin-testing ;Preparation and clinical use of BCG ;Classification of tuberculosis ;X-ray interpretation and mass radiography ;Laboratory diagnosis of tubercle bacilli ;Evaluation of new chemotherapeutic agentssuch as streptomycin.

Even during the period of the Interim Commis-sion, it is recommended that action be taken on(1), (2) and (6). Thus, it is urged that sub-com-mittees be appointed on tuberculin and tuberculin-testing, and on BCG, and that a conference becalled early in 1948 on the use and value of strep-tomycin. This conference should bring togetherthose who have been actively engaged in researchon this drug.

8. It is recognized that several other interna-tional organizations have been carrying on activitiesand have contributed in many ways to tuberculosiscontrol. It is recommended that the WHO shouldtake full advantage of these services and shouldestablish working relationships with all groupsgenuinely interested in tuberculosis control. Suchco-operative effort would help to avoid duplicationand would produce harmonious agreement in thiscollective enterprise. The Committee has beeninformed that the International Union againstTuberculosis is about to establish a branch officein Geneva. It is urged that liaison be establishedat once between the WHO and the Union in orderthat their several activities go forward in unison.Co-operation with all private and official agencies,even those only partially engaged in tuberculosis-control activities, should be extended at every

opportunity. Furthermore, this Committee wouldwelcome the opportunity to be consulted by othercommittees of the WHO and of the United Nationswhenever questions and problems involving tuber-culosis arise.

9. Tuberculous cattle still form an importantsource of tuberculosis among human beingsthroughout the world. Infected milk is not the onlysource of spread, for it has recently been demon-strated that farm-workers may contract bovinetuberculosis through direct contact with diseasedcattle. It is recommended that the WHO shoulduse its influence to encourage nations whose herdshave high infection rates to take active steps toeradicate tuberculosis among cattle as quickly aspossible.

io. It is recommended that the WHO shouldbe prepared to give expert advice to nationalGovernments and health departments on soundlaws and regulations pertaining to human andbovine tuberculosis. This Committee proposes tostudy both the legal and epidemiological aspectsof the problem of tuberculosis among migrants.This would form the basis of recommendationsdesigned to prevent the spread of this disease fromone country to another.

1. Modern public-health practice demandsthat public-health programmes have review andevaluation at regular intervals, in order that anyineffective techniques be discarded and that moremodern ones be added as new knowledge is gained.This is particularly true of a new programme.Accordingly, it is recommended that the WHOmake preparation for review and evaluation of itsprogramme at yearly intervals, with the adviceand counsel of the Expert Committee.

4. Emergency Measures.

Because of the epidemic proportions of tubercu-losis in many countries, certain emergency measureswhich require relatively small expenditure shouldbe applied at once. It is recommended that smalldemonstration teams be sent into such countries,even for short periods, for two principle purposes :

(1) To carry on intensive programmes ofBCG vaccination similar to those at present inoperation under the Danish Red Cross in severalEuropean countries which have appealed for aid.

(2) To develop a system of collecting andexamining sputum for tubercle bacilli on allpersons who are coughing and expectorating.Private doctors, dispensaries and hospitals insuch areas should be encouraged to assist in thedemonstrations. In this way, the most infectiouscases can at least be identified.

The Committee wishes to emphasize that thesetwo measures are clearly of an emergency nature.It is hoped that their initiation and successfuloperation will encourage the local groups to developand carry on a more comprehensive programme.

- 52 - TUBERCULOSIS

5. Tuberculosis Secretariat and Finance.In order to accomplish the above proposals, it is

recommended that a permanent TuberculosisControl Office be established within the WHO.This office must be adequately staffed by highlyqualified professional and other personnel, andprovided with sufficient funds to develop the pro-gramme for the international control of tubercu-losis. In addition to this central office, certainother items requiring substantial sums of moneyhave been included in the above proposals.

Under Section 3 (2), funds will be needed forfifty fellowships averaging six months each, andfor fifteen visiting lectureships averaging onemonth each. Under Section 3 (4), funds will beneeded to publish special reports and to purchasepublications for distribution to various countries.Under Section 3 (5), funds will probably be requiredfor twenty demonstration teams, comprising inall approximately fifty to sixty professional per-sonnel, and for their necessary travel expenses,subsistence, supplies and equipment.

Even though no funds are available yet for allthese proposals, which the Committee hopes theWHO will in due course accept, it is recommendedthat some funds be provided immediately by theInterim Commission for the emergency measuresunder Section 4 of this report - namely, to start incertain countries, as soon as possible, programmesfor BCG vaccination and for identifying infectiouscases.

It is further recommended that the InterimCommission provide immediately funds for theexpenses of the sub-committee meetings (on tuber-culin and tuberculin-testing, and on BCG) and forthe conference on streptomycin referred to inSection 3 (7).

6. Dissemination of Information.

If the Interim Commission approves of theproposals of this Committee, it is recommendedthat there should be wide dissemination of infor-mation concerning the services which the WHOcan provide.

7. Composition and Functions of Committeeon Tuberculosis.

It is recommended that :

(1) The terms of reference of the Committeeshould be to act as the advisory experts to theWHO in the field of tuberculosis.

(2) The Committee should consist of from nineto twelve experts, appointed for terms of threeyears and eligible for reappointment. Considera-tion should be given to appropriate geographicalrepresentation.

(3) The Committee should be empowered toappoint its own Chairman, adopt its own rules ofprocedure and call in other experts for temporaryservice on special problems when necessary.

(4) There should be at least two meetings peryear, each lasting approximately five days. Specialmeetings and conferences, other than the regularmeetings, may be requested when special needsarise.

(5) The Chairman of the Executive Board, inagreement with the Director-General, shouldappoint the first nine to twelve members from alist submitted by the Expert Committee on Tuber-culosis of the Interim Commission. As new appoint-ments need to be made, additional lists will beprepared by the Committee.

(6) The time of the next session of the Com-mittee should be determined by the Committeeat the closing meeting of each session. The ExpertCommittee on Tuberculosis would like to have itsnext session not later later than January 1948.

* *

These proposals are respectfully submitted tothe members of the Interim Commission of theWHO for their acceptance and approval. TheExpert Committee strongly feels that with theleadership and support of the WHO, it will bepossible to bring tuberculosis under internationalcontrol within a reasonable period of time.

8. Summary.

The recommendations incorporated in this reportare summarized herewith :

(I) The extent of the problem of tuberculosis ineach country should be determined.

(2) There should be recruitment and training ofprofessional personnel, with provisions for fellow-ships and lectureships.

(3) Expert advice should be given to requestingcountries on the physical facilities for all phases ofprevention, diagnosis and treatment.

(4) Specialist literature on tuberculosis should beprovided by the WHO.

(5) Field services should be provided for thepurpose of demonstrating practical activities.

(6) Grants should be made in the future to helpnations unable to help themselves.

(7) Uniform procedures should be established intuberculin and tuberculin-testing ; the preparationand clinical use of BCG ; the classification of tuber-culosis ; X-ray interpretation and mass radio-graphy ; laboratory diagnosis of tubercle bacilli ;and in the evaluation of new therapeutic agentssuch as streptomycin.

(8) Special sub-committees should be set up atonce on tuberculin and tuberculin-testing and onBCG, and a special conference be called early in1948 to discuss the use and value of streptomycin.

(9) Working relationships should be establishedwith all groups genuinely interested in tuberculosiscontrol.

TUBERCULOSIS - 53 -(io) Nations should be encouraged to take steps

to eradicate tuberculosis among cattle.

(II) The legal and epidemiological aspects of theproblem of tuberculosis among migrants will bestudied by the Expert Committee.

(14 The tuberculosis programme shall be re-viewed and evaluated at regular intervals.

(13) Demonstration teams should be madeavailable at the earliest moment to deal withemergency problems by BCG vaccination and theidentifying of infectious cases.

(i4) A Tuberculosis Control Office should beestablished within the World Health Organization.

(i5) The Committee on Tuberculosis shouldconsist of from nine to twelve members and shouldact as the advisory experts to the WHO, and thereshould be at least two i egular sessions of thisCommittee each year.

(i6) The time of the next session of the ExpertCommittee should be not later than January 1948.

- 54 -[WHO.IC/127]

17 November 1947

VIL EXPERT COMMITTEE ON THE UNIFICATION OF PHARMACONEIAS


Held 13-17 October 1947, Palais des Nations, Geneva


Outline.

1. Introduction.

2. Consideration of the work of the Technical Commission of Pharmacopceial Experts of the HealthOrganization of the League of Nations.

3. Preparatory work for the International Pharmacopoeia undertaken during the session.

4. Programme of future work.

5. Recommendations.

6. Appendices.

1. Introduction.At the third session of the Interim Commission

of the World Health Organization held in Genevain April 1947, it was decided to set up an ExpertCommittee on the Unification of Pharmacopoeiasto continue the work of the Technical Commissionof Pharmacopoeial Experts of the Health Organi-zation of the League of Nations. The Chairman andExecutive Secretary of the Interim Commission,with the approval of the health authorities of theGovernments concerned, appointed the followingfive members :

Professor H. Baggesgaard-Rasmussen, Chairman,Chemical Division of the Danish Pharmaco-poeia Commission, Copenhagen, Denmark ;

Professor E. Fullerton Cook, Chairman, Com-mittee of Revision of the United States Phar-macopoeia, Philadelphia, Pennsylvania, UnitedStates of America ;

I. R. Fahmy, Ph. D., Professor of Pharma-cognosy, Fouad I University, Cairo, Egypt ;

Dr. C. H. Hampshire, Secretary of the BritishPharmacopoeia Commission, General MedicalCouncil Office, London, United Kingdom ;

Dr. R. Hazard, Professeur de Pharmacologie etde Matière médicale h. la Faculté de Médecinede l'Université de Paris, France.

The Expert Committee held its first session inGeneva from 13 to 17 October 1947, at which allthe members were present with the exception ofProfessor Hazard, who was unfortunately preventedby illness from attending. At the opening meeting,a draft agenda was adopted with modifications,and Dr. C. H. Hampshire was elected Chairman.

Dr. R. Gautier and Dr. W. M. Bonne representedthe Secretariat.

The report which follows, prepared by the Chair-man at the request of the Committee, representsthe views and decisions unanimously reached bythe Committee.

2. Consideration of the Work of the TechnicalCommission of Pharmacopoial Expertsof the Health Organization of the Leagueof Nations.

The Committee reviewed in detail the work ofits predecessor, the Technical Commission ofPharmacopoeial Experts set up by the HealthOrganization of the League of Nations, as outlinedin the Minutes of its second meeting 2 and in itsInterim Report 3.

The Committee agreed that the object of itswork should be the same as that of the previousCommissionnamely, to produce a draft Interna-tional Agreement for the Unification of Pharma-copoeias, modifying and extending the existingAgreement for the Unification of the Formulm ofPotent Drugs, and to present the draft Agreementas an International Pharmacopoeia, similar in formto the present-day national pharmacopoeias. Itwis understood that such an International Phar-macopoeia could have no authority in any countryuntil it had been adopted officially by thatcountry.

The Technical Commission last met in May 1939,and its report was examined in the light of changedconditions and in view of the modern developmentsin medical and pharmaceutical knowledge andpractice.

It was decided to continue the main part of thework, the preparation of draft monographs, alongthe lines adopted by the previous Commission.Each member of the Committee agreed to preparemonographs upon specified drugs, and ProfessorBaggesgaard-Rasmussen agreed to supply compa-rative information on the treatment in the differentnational pharmacopoeias.

Off. Rec. WHO, No. 7, pages 30, 58-592 League of Nations document, C.H./Pharm./to8.3 Bull. Hitli. Organ., 1945/46, 12, III-179.

UNIFICATION OF PHARMACOPIAS - 55 -(a) General Rules.

The Chairman agreed to prepare a revised draftextending and completing the General Rules as setout in the Interim Report. The rules of the nationalpharmacopceias would be taken into consideration,and those which had already been published in theInterim Report would be considered for incorpo-ration in the new draft.

(b) Approximate Estimate of Spoonfuls.

After discussion, the Committee decided not toinclude any statement defining standard spoonfuls.

(c) Chemical Nomenclature and Formula.

The Committee decided to include whereverappropriate systematic chemical names in themonographs, and to follow any international rulesthat might be available for chemical formule.The final decision as to the style of graphic for-mule should be taken later with the help of expertchemists.

(d) Botanical Nomenclature.

The Committee decided to describe vegetablesubstances by their scientific Latin names, followingthe International Rules of Botanical Nomenclatureprepared by the International Botanical Congress.In case of difficulty, it was agreed that the Chairmanshould consult with the Director of the RoyalBotanical Gardens, Kew.

(e) Style and Arrangement.

The Committee approved in general, but subjectto minor modifications, the style and presentationof the monographs which had been drawn up andadopted by the previous Commission. ProfessorCook undertook to send copies of the stylebookcompiled for the use of the United States Pharma-copceia Commission, to the members of the Com-mittee.

On the question of the arrangement of thesections in the monographs, the Committee decidedthat it would be preferable for the present to adoptthe arrangements approved by the TechnicalCommission, and to make at a later stage anyrearrangements that might be required.

(f) Synonyms.

The Committee discussed the use of synonymsand the extent to which they should be includedin the monographs. It was decided to defer decisionfor the present, pending consideration of a reporton this subject which Professor Cook agreed toprepare.

(g) Freezing, Melting and Boiling Points.

The Committee was of the opinion that a reporton the methods used for the determination offreezing, melting and boiling points should beprepared. Professor Baggesgaard-Rasmussen statedthat one of his assistants had been engaged on thisproblem, and the Committee accepted his offer tosupply members with a copy of this report. It wasalso decided to adopt the term " range " in allsuitable cases in place of " point ".

(h) Measurement of Colour and Clarity.

After a discussion on the measurement of colourand clarity, especially in regard to the use ofcoloured glasses and the colour-matching fluidsof the United States Pharmacopceia, ProfessorBaggesgaard-Rasmussen reported that Dr. F. Rei-mers, of the Laboratory of the Danish Pharma-copceia Commission, had done valuable work onthis subject, and had found that the colour-matching fluids of the United States Pharmacopceiawith certain modifications gave reliable results.The Committee decided to accept the report ofDr. Reimers on this subject.

(i) Incompatibilities.After a discussion as to whether the interna-

tional pharmacopoeia should include informationon incompatibilities, the Committee decided that,while this information was included in certainnational pharmacopceias, in accordance withnational practices and to comply with nationallegislation, it was not necessary in an internationalpharmacopceia.

(j) Doses.Professor Cook questioned the inclusion in the

monographs of maximal doses, which are notstated in the United States Pharmacopoeia. Afterdiscussion, the Committee agreed, in view of thelegal position in France and some other countries,that maximal doses should be included, in orderto indicate the quantities which must not beexceeded in dispensing, without express instruc-tions from the prescribing physician. 1 It wasdecided not to include the dosage in each mono-graph, but to provide the information in tabularform. Such a table of doses should include mode ofadministration, usual doses, and maximal dosesboth single and daily.

(k) Monographs.The Committee decided that each member

should examine the monographs printed in theInterim Report, and should send any criticismand revision to the Secretariat.

3. Preparatory Work for the InternationalPharmacopceia.

(a) Scope of the International Pharmacopceia.The Committee discussed the scope and content

of an international pharmacopceia. Professor Cookwished it to be extended so as to present to medicalmen a comprehensive list of the drugs consideredto have outstanding value in medical practice.Such a list might be divided into two sections, aprimary list of the essential drugs, and a secondarylist of less important but useful drugs. It wasdecided that, for the present, monographs shouldbe prepared only of the essential drugs.

The inclusion of other material, such as surgicalsutures, dressings, was also discussed. The Com-mittee was of the opinion that international stan-dards and specifications for such material shouldbe established, and thought that, as soon as an

1 See Bull. Hlth. Organ., 1945-46, 12, x19.

UNIFICATION OF PHARMACOPCEIAS

international pharmacopceia proper had beenprepared, the terms of reference of the ExpertCommittee should be extended so as to includeconsideration of the establishment of internationalstandards for such materials.

(b) Arrangement of the International Pharmacopria.

A general discussion took place on the questionas to whether preparations of drugs, such as tinc-tures, etc., should be grouped together, as is thepractice of some national pharmacopceias, orwhether the American practice of placing themunder the name of the drug itself should be adopted.

The Committee felt that, as the internationalpharmacopceia was intended primarily for the useof national pharmacopceia commissions, and onlysecondarily for the use of the medical profession,it would be better to group the preparationstogether. It was decided, however, that any finaldecision should be deferred until the Committeeshould have been enlarged.

(c) Biological Standardization.

After discussion, it was decided to include in theinternational pharmacopceia the preparations stan-dardized by the Expert Committee on BiologicalStandardization.

(d) Patented Drugs and Trade-marks.

The Committee discussed the inclusion ofpatented drugs and the use of trade-mark namesin an international pharmacopceia in view ofpossible legal complications. It was realized thatextensive enquiries would be necessary in orderto ascertain the world position regarding patentrights in the manufacture of drugs, and trade-markrights in names proposed for international use.The Committee decided to request the Secretariatto obtain legal advice on the position which mightbe created by the inclusion, in an internationalpharmacopceia, of a drug the sole method ofmanufacture of which was patented, or by the useof a name which was the subject of a trade-mark.It was suggested that the trade-mark positionmight be met by the inclusion of the followingparagraph in the introduction to the pharma-copceia : " In parts of the world in which any ofthe names used is a trade-mark, this name shouldbe applied only to the product of the particularfirm owning the trade-mark".

(e) Medical Advisory Committee.

The Committee considered the possibility ofestablishing a medical advisory committee toassist the work of the Expert Committee. Afterdiscussion, it was felt that the formal establish-ment of such a committee was unnecessary, andit was agreed that the Secretariat should be askedto provide any necessary medical comment on aswide an international basis as possible.

(f) Reference Sub-Committee on Galenical Pharmacy.

In view of the fact that galenical preparationsare now of less importance in medicine and phar-macy than formerly, their place being taken bythe new synthetics, alkaloidal principles and injec-

table materials, the Committee decided not tore-establish, at the present stage of the work, theReference Sub-Committee on Galenical Pharmacyappointed by the previous Commission.

(g) Provisional International Secretariat of Pharma-copteias at Brussels.

The Committee discussed the relationship of theExpert Committee with the provisional Inter-national Secretariat established at Brussels underthe International Agreement of 1925. It waspointed out in discussion that the Belgian Pharma-copoeia Commission was entrusted with the workon a purely provisional basis, and that the prepara-tion of an international pharmacopceia would begreatly facilitated by the existence of a singleunified Secretariat. The Committee recommendedto the Interim Commission that the ExecutiveSecretary be empowered to enter into negotiationswith the Belgian Government for the establishmentof a single international secretariat under theagis of the World Health Organization. (SeeSection 5, Recommendation II.)

(h) Draft Monographs.

Thirty draft monographs were before the Com-mittee, and during the course of the session allwere discussed and accepted, with amendmentswhere necessary. The list was as follows :

Acidum HydrochloricumAcidum Hydrochloricum DilutumAdrenalinumZEther AnastheticusArseni TrioxydumAspidium Filix MasBelladonna FoliumBelladonna Folium Pulveratum Standard-

isatumBelladonna RadixCascara SagradaChloroformum AnastheticumCoffeinum cum Natrii BenzoateCoffeinum cum Natrii SalicylateColchici SemenDigitalis FoliumDigitalis Folium Pulveratum StandardisatumErgota (except the Assay)Ergota PulverataErgotamini TartrasHyoscyami FoliumIodumIpecacuanhaIpecacuanha Pulverata StandardisataQuinini SulfasScillaStramoniumStrychnos Nux Vomica Pulverata Standard-

isataStrychni Nux Vomica SemenTheophyllinumTheophyllinum et Natrii Acetas.

4. Programme of Future Work.(a) List of Drugs.

The Committee compiled a new and compre-hensive list of drugs which should be consideredfor inclusion in an international pharmacopceia.

UNIFICATION OF PHARMACOPCEIAS - 57 -It was agreed to divide the drugs into three cate-gories, category A being assigned to those drugsdeemed of primary importance for immediateattention and inclusion, category B to drugswhich, though valuable, were not considered ofsufficient importance to justify immediate atten-tion, and category C to drugs which were discussedbut not thought worthy of further attention.543 drugs were considered, 248 of which weremarked category A ; 90, category B ; and 205,category C. Of the drugs in category A, it wasreported that 73 monographs had now been ap-proved by the Committee.

(b) Preparation of Monographs.The Committee decided to allocate the prepara-

tion of the necessary monographs for the drugs incategory A among the members present. It wasagreed that, as Professor Hazard had unfortunatelybeen unable to attend and participate in the dis-cussions, he should be invited to act in the capacityof a general critic for all the draft monographs.The drafting of the monographs was then allocatedamong the members, and the lists of the workundertaken form Appendix 3 of this Report.

(c) Preparation of Reports.The Committee discussed the list of special

reports to be prepared, both those which remainedfrom the work of the Technical Commission andthose the need for which had been shown in thecourse of the Committee's deliberations. The pre-paration of such reports was allocated amongthe members present (see Section 6, Appendix 1).

(d) Experimental Investigations.The Committee considered the draft list of

experimental investigations, which it revised inthe course of discussion (see Section 6, Appendix 2).It was decided that each member should be res-ponsible for any experimental investigationrequired during the drafting of the monographsassigned to him.

(e) International Nomenclature.The Committee discussed the possibility of

introducing international nomenclature for newdrugs so as to avoid the present multiplicity ofnames for the same drug. While the Committeewas fully agreed as to the desirability of and thenecessity for the adoption of an internationalnomenclature for new drugs, it felt that thisquestion should be reconsidered in the light of thelegal advice to be provided by the Secretariat onthe question of patented drugs and trade-marks.

(f) Membership of the Committee.In view of the great amount of work required

in the preparation of draft monographs andreports and of the desirability of providing aswide an international basis as possible, the Com-mittee recommended that its membership shouldbe increased by at least three members (seeSection 5, Recommendation Ia).

(g) Relations with the Secretariat.The Committee considered that its work would

be greatly facilitated by the presence of specializedstaff familiar with the work of pharmacopceial

revision on the Secretariat, and therefore recom-mended the appointment of such staff (seeSection 5, Recommendation Ib).

(h) Date of Next Session.The Committee recommended that its next

session should be held during the latter part ofMay 1948.

The Committee wished to record its thanks tomembers of the Secretariat for their assistanceduring the session.

Professor Cook expressed the thanks of theCommittee to the Chairman for his unfailingguidance during the deliberations of the Committee.

5. Recommendations.

The Expert Committee for the Unification ofPharmacopoeias submits the following recommen-dations for the consideration of the InterimCommission :

Whereas the preparation of draft monographsentails much detailed work on the part of theindividual members of the Committee,

Whereas the additional list of drugs under studyfor inclusion in the International Pharmacopoeiais so comprehensive that it would be impossiblefor the present members to finish the task withina reasonable time,

Whereas it is essential for the InternationalPharmacopoeia to be completed as expeditiouslyas possible,

Whereas it is felt that a more representativeopinion is essential for the establishment of theInternational Pharmacopceia on a truly inter-national basis,

And whereas the work would be greatly facilitatedby the presence of suitably specialized staff on theSecretariat capable of undertaking preparatoryand editorial work,

THE COMMITTEE RECOMMENDS :

I. (a) that the Committee be increased by atleast three members,

(b) that a suitably qualified specialist beadded to the staff of the Secretariat.

Whereas Article 35 of the Final Protocol of theSecond International Conference for the Unifi-cation of the Formulx of Potent Drugs, Brussels,1925, reads as follows :

" The Organizing Committee shall urge theBelgian Government to enter into negotiationswith the League of Nations with a view to thedefinite Constitution of the Permanent Secre-tariat, and of the other Committees which theConference has in principle decided to set up.

" Meanwhile, the Belgian Pharmacopceia Com-mission will, purely provisionally, be entrustedwith the work of the projected Organization soas to lose no time and to enable the Secretariatto continue its work as soon as it has beenfinally set up ",

- 58 - UNIFICATION OF PHARMACOPCEIAS

Whereas the functions of the League of NationsHealth Organization have been transferred to theWorld Health Organization or to its InterimCommission (by the International Acts signed atNew York On 22 July 1946),

Whereas it was clearly indicated in Article 35quoted above that the Secretariat to be set up atBrussels was to be purely provisional,

Whereas the Expert Committee for the Unifi-cation of Pharmacopoeias established by theInterim Commission has been entrusted with thepreparation of an International Pharmacopceia,

Whereas such a task would be greatly facilitatedby the existence of a single unified Secretariat,

THE COMMITTEE RECOMMENDS :

II. that the Executive Secretary of the InterimCommission be empowered to enter into negotia-tions with the Belgian Government for the esta-blishment of a single International Secretariat forPharmacopceias under the gis of the WorldHealth Organization or of its Interim Commission.

6. Appendices.

i. Preparation of Reports.

Professor Baggesgaard-Rasmussen agreed toreport on :

The methods of determining boiling, freezingand melting points (with the assistance ofProfessor Fahmy).

Professor Cook agreed to report on :The use and inclusion of synonyms,The solubility of Theophyllinum et Natrii

Acetas.

Professor Fahmy agreed to report on :The general principles of alkaloidal assays,Standards for the fineness of powders ;

and to assist Professor Baggesgaard-Rasmussenin :

The methods of determining boiling, freezingand melting points.

Dr. Hampshire agreed to prepare :A revised draft of the General Rules,A list of reagents,A list of qualitative and limit tests ; and to

report on :The standardization of ergot,The methods of preparing sterile solutions.

The Secretariat agreed to report on :The legal position on the inclusion of patented

drugs and trade-mark names,The standards for fineness of powders defined

by the Commission Internationale de Stand-ardisation.

2. Experimental Investigations.Professor Baggesgaard-Rasmussen agreed to

investigate :The chemical standardization of Thyroideum,The limits of ash, acid-insoluble ash and

sulphated ash,

The applications of chromatographic methodsto pharmacopoeial work,

The pH of available supplies of Barbital-natrium.

Professor Cook agreed to investigate :The applications of spectrophotometric me-

thods to pharmacopceial work.

Professor Fahmy agreed to investigate :The methods of sampling of vegetable and

animal drugs,The chemical standardization of alkaloidal

crude drugs.

Dr. Hampshire agreed to investigate :The chemical standardization of alkaloidal

salts.

3. Preparation of Draft Monographs (Category A).Professor Baggesgaard-Rasmussen agreed to

prepare draft monographs on :AcriflavinaAmphetaminaAmphetamin SulphasAmyleni HydrasArgenti NitrasArgentum Proteinicum ForteBenzylis BenzoasCalcii GluconasCalcii LactasCarbacholumChiniofonumChloramina TCresolFormaldehydumGlycerylis TrinitrasInjectio Mersalyli et TheophylliniMersalylumNeostigminae BromidumNeostigmin MethylsulphasPentazolPethidin HydrochloridumPhenytoinum SodiumPotassii BromidumPotassii IodidumProflavin HemisulphasSodii BromidumSodii CitrasSodii IodidumSodii SalicylasSuraminum SodiumTetrachlorothylenumThyroideumTribromothanolisUnguentum Hydrargyri

Professor Cook agreed to prepare draft mono-graphs on :

Acidum Nicotinicum/Ether Vinylicus/EthisteronumlEthylis AminobenzoasAmino Acid PreparationsAneurin HydrochloridumButacain SulphasButylis AminobenzoasCalciferolCarbonei Dioxidum

UNIFICATION OF PHARMACOPCEIAS - 59 -Desoxycorticosteroni AcetasDiethylstilboestrolDigitoxinumDigoxinumGonadotrophinum ChorionicumHistamina Phosphas AcidusInjectio Epinephrin (Adrenalina)Injectio HepatisInjectio InsuliniInjectio Insulini Protaminaticum ZincoInjectio OxytociniInjectio Pituitarii PosteriorisInjectio VasopressiniLanatosidum CLiquor Epinephrina HydrochloridiLiquor Hepatis PurificatusMenadionum (Menophthonum)Mepacrin HydrochloridumMethyltestosteronumNitrogenii MonoxidumCEstradiolCEstradiolis MonobenzoasCEstronumOleum HippoglossiOleum MorrhuaOxygeniumPilocarpina HydrochloridumPituitarium PosteriusProgesteronumRiboflavinaStreptomycinTestosteroni PropionasTetracaina HydrochloridumTheophyllina cum lEthylenediaminaTotaquinaTuberculini Derivaturn Proteinicum Purifi-

catumTuberculinum Pristinum

Professor Fahmy agreed to prepare draft mono-graphs on :

lEthylis ChloridumAloeAloinumAmylis NitrisApomorphina HydrochloridumAspidii OleoresinaBarii SulphasBismuthi CarbonasBismuthi SalicylasCarbonei TetrachloridumCodeina PhosphasCodeina SulphasColchicinaEphedrinaExtractum Belladonna SiccumExtractum Cascara SagradaExtractum Nucis VomicaFerri SulphasFerri Sulphas ExsiccatusFerrum Citricum AmmoniatumHyoscyamus MuticusLiquor ArsenicalisLiquor Potassii ArsenitisMorphini HydrochloridumMorphini SulfasOleum ChenopodiiOleum RiciniOpiumOpium Pulveratum Standardisatum

Oxymel ScillaPhenol LiquefactumPicrotoxinumStrophanthin KTheobromina et Sodii AcetasTheobromina et Sodii SalicylasTinctura AconitiTinctura BelladonnaTinctura ColchiciTinctura DigitalisTinctura Hyoscyami MuticiTinctura Hyoscyami NigriTinctura IpecacuanhaTinctura Nucis VomicaTinctura OpiiTinctura Opii BenzoicaTinctura ScillaTinctura Stramonii

Dr. Hampshire agreed to prepare draft mono-graphs on :

AcetarsolAcidum BenzoicumAntimonii et Sodii TartrasAntimonii et Sodii ThioglycollasAntitoxinum DiphthericumAntitoxinum Gas-GangranosumAntitoxinum ScarlatinumAntitoxinum TetanicumCarbasonumChloroformumDichlorophenarsina HydrochloridumEmetina HydrochloridumErgometrina MaleasErgotamina TartrasHeparinumNeoarsphenaminaOxophenarsina HydrochloridumPenicillinumSolutiones IodiSuccinylsulphathiazolumSulphadiazinaSulphadiazina SodiumSulphaguanidinaSuIphamerazinaSulphamerazina SodiumSulphanilamidumSulpharsphenaminaSulphathiazolumSulphathiazolum SodiumThiopentonum SodiumToxinum Diphthericum DiagnosticumToxoida Diphtherica Alumen-PraecipitataToxoida Diphtherica et TetanicaToxoidum DiphthericumToxinum ScarlatinumToxinum Tetanicum DetoxicatumTryparsamidumVaccinum CholeraicumVaccinum Febris FlavaVaccinum PestisVaccinum Typhi ExanthematiciVaccinum Typho-ParatyphosumVaccinum TyphosumVaccinum Vaccina

Finally, Professor Hazard was asked to preparea draft monograph on :

Vaccinum Rabies.

VIII.

- 6o -[WHO.IC/i47]

20 January 1948

EXPERT COMMITTEE ON VENEREAL DISEASES


Held 12-16 January 1948, Palais des Nations, Geneva

(presented to the Interim Commission at its fifth session). 1

1. Introduction.2. Delineation of the Problem.3. Fields of Activity :

(a)(b)

Outline.

Training facilities, fellowships, lectureships ;Serological standardization and laboratory aspects ;Availability of drugs ;Evaluation of treatment ;Health education ;Research ;Venereal-disease information ;Prophylaxis ;Unification of nomenclature for causes of morbidity and deaths ;Relations with other international organizations ;

(1?) Assistance to Governments,

4. International Health Regulations for Venereal Diseases.5. Presentation of the Polish Anti-syphilis Plan.6. WHO Committee on Venereal Infections, a Section in the WHO Secretariat on Venereal Diseases,

and Finance.7. Summary of Recommendations of the Expert Committee.

At the second session of the Interim Commission,a joint resolution by Brazil, France and Norwayrequested that venereal diseases be entered on theagenda of the Interim Commission. At its thirdsession, the Interim Commission decided to carryout a preliminary survey on the nature and theextent of the problem. At its fourth session, theestablishment of an Expert Committee on VenerealDiseases was decided, the terms of reference being :

" that a survey with regard to scientific,practical, and other aspects of the problem bepursued, with a view to developing practicalplans for international combating of venerealdiseases ", and " to prepare a report for consi-deration by the Interim Commission at its fifthsession for eventual recommendation to the firstWorld Health Assembly ".

With the approval of the Chairman of theInterim Commission, the Executive Secretaryappointed, with the consent of the respectiveGovernments, the following members to theCommittee :

1. Professor Waldemar E. Coutts, Chief, Depart-ment of Social Hygiene, Public HealthAdministration, Santiago, Chile ;

1 Oft Rec. WHO, No. 7, pages 26-29.

2. Professor Marian Grzybowski, Chief, Clinic ofDermato-Syphilology, University of Warsaw,Poland ;

3. Dr. John F. Mahoney, Medical Director,Venereal Diseb.se Research Laboratory, UnitedStates Public Health Service, Staten Island,New York, United States of America ;

4. Dr. G. L. M. McElligott, Adviser on VenerealDiseases, Ministry of Health, London, UnitedKingdom.

The participation of a Soviet Union specialistwas invited, but no candidate was suggested tothe Interim Commission Secretariat. The ExpertCommittee on Venereal Diseases met in Geneva12-16 January 1948. All members were present.Dr. J. F. Mahoney was elected Chairman. Dr. G.L. M. McElligott took the Chair during the dis-cussion on the Brussels Agreement. Dr. T. Guthewas Secretary to the Committee. Also presentwere Drs. J. Suchanek and D. Borenzstein, of theVenereal Disease Division of the Polish Ministryof Health, Dr. Hantchef, of the League of RedCross Societies, and Dr. Bor6i6, liaison officer,UNICEF. Dr. W. Burckhardt, liaison officer forthe International Union against the VenerealDiseases, attended the last meeting.

VENEREAL DISEASES

The following report, unanimously adopted bythe Committee, is submitted to the Interim Com-mission of the World Health Organization for itsacceptance and approval. It was agreed to submitrecommendations included in the report forconsideration of the Interim Commission with aview to their submission to the World HealthAssembly.

1. Introduction.

It is recognized that venereal diseases representa world health problem of great magnitude, andthe Committee is fully in accord with the viewsof the Interim Commission that malaria, tuber-culosis and venereal diseases deserve the highestpriorities among the important activities of theWHO, and that in several respects the venereal-disease problem has a distinct international cha-racter, brought out particularly during and afterthe recent war.

The relative importance of many aspects ofvenereal-disease control has undergone majorchanges in the last few years. In the therapy ofsyphilis, penicillin has removed most of the dangersand many of the drawbacks formerly associatedwith arsenic, heavy metal and other therapy, andhas introduced a hopeful outlook for preventionof congenital syphilis in the newborn by treatmentof pregnant syphilitic mothers. Gonorrhcea haslost much of its capacity to injure the human being,and the minor venereal diseases have shown asatisfactory response to chemotherapy. In thefield of diagnosis, better culture techniques haveadded to the recognition of the gonococcus. Thedevelopment of cardiolipin lecithin antigens holdspromise of removing some of the uncertainties inserum diagnoses of syphilis.

In planning for future international activities inthe field of venereal diseases it would appeardesirable to attempt an early evaluation of theimpact which will be exerted on the generalsituation by these advances. These have probablynot been operative for a sufficiently long period oftime or over a wide enough geographic area toexert a demonstrable influence on the world-widevenereal-disease picture. National and internationalvenereal-disease control activities recommendedat the present may become obsolete or mayrequire realignment within the next few years,when a more precise appraisal of the influencelikely to arise becomes possible.

While a hopeful vista is apparent today, thereis not any assurance that the favourable situationwill persist. As long as the therapeutic agents uponwhich reliance is now being placed continue to beeffective, satisfactory progress in control of thecommunicable stages of the venereal diseases maybe anticipated. It is not beyond the range ofpossibility, however, that the present antibioticsmay encounter a progressively increasing resistanceon the part of the causative organisms of gonor-rhcea and syphilis. In that event, the controlforces would be in a discouraging position, unlessand until a replacement for the current agentswould be developed. Although no evidence of -resistance has been observed up to the present, itwould appear provident to press national andinternational control programmes as vigorously aspossible while entirely adequate implements for

the managements of the diseases are available.Action now through public health, scientific, andother measures, in each country and internationally,would gain such advantages, which would contributemost fully to shrink the reservoirs of venerealinfections.

The Committee recognizes that in all countriesvenereal diseases represent a health problem withvast social implications. In view of the terms ofreference of the Committee-to propose plans forinternational combating of venereal infections-the Committee takes notice that many of the socialaspects of the problem are at present under consi-deration by the United Nations and other inter-national organizations. Until such definite pro-grammes have been outlined, the WHO may findit advisable to concentrate on the public healthand medical aspects' of the problem as the essentialbasis for international combating of these infections.

Realizing the responsibility placed on the Com-mittee by the Interim Commission under its termsof reference, and considering the statutory obli-gations of the WHO under its Constitution, aswell as the views of Governments obtained throughthe preparatory work of the Interim CommissionSecretariat, the Committee is of the opinion thatthe activities outlined in the report are essential forthe programme of the WHO in international com-bating of venereal diseases. These activities willrequire a permanent Committee on VenerealInfections;to advise the WHO, and a section onvenereal diseases as part of the administrativeframework of the Secretariat.

2. Delineation of the Problem.

An accurate determination of the magnitude ofthe problem through the conduct of serologicalsurveys and through the medium of other devicesfor collecting information on incidence would con-stitute the desirable approach to the formulationof national and international programmes forthe combating of venereal infections. Countriesshould be encouraged to record at least basic data.It should be one of the activities of the WHOSecretariat to collect data in an effort to mapsystematically the nature and extent of the globalproblem of venereal diseases. In view of the pro-tracted delay entailed by this approach, however,and the weight of the opinion that a basic structureshould now be designed, capable of functioningunder any particular set of circumstances, it isconsidered justified to proceed with the organi-zation of international activities in the field ofvenereal diseases.

The major emphasis of the venereal-diseaseproblem should be placed on the control of syphiliswith gonorrhcea, chancroid, lymphogranulomavenereum and granuloma inguinale, considered inthat order of relative importance. In view ofreports from many countries on the increasingimportance of genito-infections of unclassified orill-defined origin, the possibility of new entities ofvenereal infections being recognized in the futureshould be stressed. Collection of data on theseconditions is desirable.

Although the late manifestations of syphilis areimportant from the standpoint of medical careand should be considered in any extensive inter-

VENEREAL DISEASES

national venereal-disease programme, the earlyinfection is the stage of the disease which primarilywarrants public-health attention. This statementrisks being invalidated by the production ofevidence indicating an active rôle of the late orlatent infections in the transmission of the disease.

In support of the allocation of priorities, theCommittee desires to record the following :

1. Antibiotic therapy appears to have trans-formed gonorrhcea from a disease of great chro-nicity with frequent recurrences, with greattendency to troublesome complications andprotracted disability, to an infection readilyamenable to treatment and with almost com-plete freedom from complications or tendencyto relapse.

2. Chancroid responds promptly to sulphon-amide therapy in the majority of instanceswithout extensive tissue damage and prolongeddisability. Its principal importance apparentlylies in the frequency with which chancroidallesions may harbour evidence of a concomitantlyacquired syphilis.

3. Lymphogranuloma venereum in the acutephase yields readily to sulphonamide therapy.The incidence of the disease is not great exceptin certain geographic areas and certain socialstrata. The degree of disability usually encoun-tered is not great except in chronic stages, asrepresented by a rectal stricture esthiomene andelephantiasis penis et scrota.

4. Granuloma inguinale is a disease of minorprevalence, except in certain geographic areasand certain races. Satisfactory response isreported to streptomycin therapy.

In view of the above; it is recommended thatinternational venereal-disease activities shouldplace major emphasis upon the detection andtreatment of early syphilis, with a proviso thatspecial consideration be given to the remainingmembers of the venereal group of diseases wherespecial geographical or racial considerations per-tain, and in the spread of venereal diseases fromcountry to country.

3. Fields of Activity.

(a) Training facilities, fellowships, lectureships.

The Committee takes notice of the statutoryobligations of the WHO to promote improvedstandards of teaching and training in the health,medical and related professions.

In many countries today, there is an inadequatenumber of trained personneL available in thevenereal-disease field. The diagnosis, prevention,treatment and control of these infections haveundergone major changes in the past decade. Itappears timely to consider the venereal diseases,including their laboratory aspects, as a separateentity within the fields of medicine and of publichealth. An appreciation of the changes in thevenereal-disease field in the last decade is essentialfor the development of effective venereal-diseasecontrol programmes. To this end, it appears ofprimary importance to establish training facilities

in the several departments of control work at theearliest possible moment.

The fields in which medical officers are neededand which would be important nationally andinternationally are : administration and epide-miology, and clinical and laboratory aspects.

The selection of physicians, nurses and labora-tory workers for training should be done with theobject of making available personnel capable ofsubsequently conducting demonstrations and/orestablishing training facilities in countries or ingeographic areas where the need for intensiveactivity is pressing.

In this connexion it is desired to express thewillingness of the United States Public HealthService, in order to start this programme, to makethe training facilities of the United States MarineHospital and the Venereal Disease ResearchLaboratory, Staten Island, New York, availablefor such key medical personnel as may be requiredto launch programmes to be subsequently outlined.

It is recommended that twelve venereal-diseasefellowships be provided in the first year and thattraining facilities in various countries be studiedand designated by the WHO with a view to ex-panding this part of the training programme.

It is further recommended that six lectureshipsbe provided for outstanding specialists in thevenereal diseases, to visit countries at their request.

(b) Serological Standardization and LaboratoryAspects.

An effective control programme is dependent,to a maj or degree, upon the efficient conduct ofserological tests for syphilis. At the present time,a wide variety of distinctive methods, employingas an indicator either the complement fixation orthe precipitation phenomenon, is in use in differentparts of the world. All of these methods havelimitations. No single test or combination of testscompletely covers the field of clinical syphilis.All are capable of being influenced by reacting sub-stances produced by infections and disease condi-tions other than syphilis. A close scrutiny of theentire situation will be required if sound informationis to be the basis for international activities in thefield of serology.

There is a great lack of uniformity in procedureand technique, which has, in the past, had theeffect of producing confusion and of renderingvalueless many studies of the serology of syphilis.It may cause an individual to be considered ashaving syphilis in one country and as being freeof suspicion in another ; as being syphilitic on oneday and normal on the next.

Quantitative determinations of the reactingsubstance are essential to the most advantageoususe of penicillin in the treatment of syphilis,especially in early infections. The serology curveas portrayed by successive quantitative deter-minations conveys to the clinician the degree ofsatisfactory progress, the presence of serologicrelapse or of serologic failure in the individualpatient. The pattern is also helpful in differen-tiating relapse and reinfection. The quantitativeprocedures throw an additional burden of technicalwork upon the serology laboratory and introduceeven greater opportunities for discrepant andinconsistent findings.

VENEREAL DISEASES - 63 -

Very recently, the advantages of the more stableand more uniform mixtures of cardiolipin and leci-thin replacing the lipoidal antigens which havebeen employed in the tests for syphilis are becom-ing apparent. This circumstance may prove tobe of great value to serology in syphilis, as itoffers an opportunity of eliminating some of thevariable factors encountered in the older type ofantigens. Several years of additional experience,however, will be needed before the real value ofthis advance can be estimated.

If the maximum of usefulness is to be obtainedfrom serology in syphilis, the following technicalaspects will require detailed consideration :

(t) The selection and adoption of one technicalmethod to be employed in the laboratory of theofficial health organization of the countries parti-cipating in the WHO programme. This selectionwould not militate against the conduct of anyother test or tests but would stipulate that thisprocedure be employed in the exchange of infor-mation between nations.

(2) A concerted effort to bring the test methodsemployed in various parts of the world into areasonable degree of uniformity as to the levelof sensitivity.

(3) The selection of a uniform method for thereporting of the results of quantitative determi-nations.

(4) The standardization of technical methodsin so far as is possible.

The Committee recognizes the internationalimportance of the efforts of the Health Organi-zation of the League of Nations in the field of sero-logical standardization. This work should againgo forward.

The Committee takes notice of the statutoryobligations of the WHO to standardize diagnosticprocedures where necessary and to call suchtechnical and other special international confer-ences which are within its competence. As a meansof initiating steps to bring the laboratory phasesabreast of clinical work in syphilis, it is recom-mended that an international conference of keyserologists from representative areas be convened,on the model of the Technical Laboratory Con-ferences of the League of Nations and the Sero-logical Standardization Conferences of the UnitedStates Public Health Service.

For the conduct of preliminary studies, and forguidance on the preparation of the technical workessential to such an international gathering, theUnited States Public Health Service has expressedits willingness to make available the facilities ofits Venereal Disease Research Laboratory, NewYork. To undertake other necessary preparatorywork in this highly specialized field, it is furtherrecommended that a sub-committee on serologyto the suggested Committee on Venereal Infectionsbe established. This sub-committee should com-mence to function before the end of 1948, theInternational Serological Conference itself beingcalled not earlier than 1950.

In an international effort towards uniformityof serological tests for syphilis, the WHO musthave at its disposal at least one first-class reference

laboratory, competent to guide inteniational sero-logical work and to teach and keep abreast of newdevelopments. As a temporary measure, it isrecommended that the potential services of existinglaboratories should be explored in this respect.

Laboratory aspects of the other venereal dis-eases-gonorrhoea, chancroid, lymphogranulomavenereum and granuloma inguinale-as well asgenito-infections of ill-defined and unclassifiedorigin, may from time to time require considerationfrom the point of view of establishing interna-tionally uniform procedures.

(c) Availability of Drugs.

Many countries have been lacking anti-venerealdrugs since the war. Sulphonamides are the mostwidely available, but a shortage of arsenicals andbismuth is marked in several areas. Production ofpenicillin is limited to a few countries, and re-quirements for treatment of venereal and otherdiseases cannot be met in many countries owingto limited production and other technical reasons.Whilst penicillin preparations in the past havebeen issued in the amorphous form, demands forpurified crystalline preparations are steadily in-creasing. While it is desirable that crystallinepenicillin should be used for reasons of accuratedosage, tolerance, etc., the purification processresults in as much as 30-50% decrease in the actualyield during manufacture. Crystalline penicillinshould therefore be restricted to syphilis, and theamorphous form to gonorrhoea. It is consideredthat penicillin is often being wastefully used andthat the medical profession should be warned thatcumulative undue expenditure of the drug wouldfurther endanger its availability. All possiblemeasures should be taken by the World HealthOrganization to encourage production and toensure an equitable distribution of the antibioticto all countries, particularly those where it is notnow available. It is recommended that, as a basisfor further evaluation of this problem, the WorldHealth Organization or its Interim Commissionshould study current production capacities, aswell as penicillin requirements in the variouscountries.

(d) Evaluation of Treatment.

The advent of new anti-syphilitic drugs andmethods of treatment during the last few yearshas introduced conditions essentially different fromthose prevailing at the time of the standardizationwork in the field of antisyphilitic therapy by theHealth Organization of the League of Nations.

Developments in recent years have shown that,regardless of penicillin-arsenic-bismuth being usedalone or in any combination, emphasis is put onthe epidemiological aspect by the use of short-term treatment methods to break the chain ofinfection as quickly as possible. A precise optimalform of treatment cannot, however, be laid down,since these methods have not been applied longenough to permit a final evaluation of the results.

It is assumed that, on the basis of availabledata, it may be stated, however, that a minimumtreatment schedule for early syphilis with peni-cillin should consist of not less than 4,o0o,000units, given over a period of eight days, at the

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rate of 6o,000 units every two hours, for a totalof 90 injections, or 24-hourly injections of 500,000units of penicillin in oil beeswax (POB). In gonor-rhcea, the therapy with penicillin should not bechanged because of the danger of aborting ormasking an early syphilis in the advent of the twodiseases being contracted simultaneously ; serologicalfollow-up for six months after penicillin treatmentof gonorrhcea would, however, seem advisable.

It is recommended that one of the tasks of theproposed WHO Committee on Venereal Infectionsshould be, through suitable procedures, to makeavailable future evaluations of treatment methodsand to induce nations to adopt a reasonablyaccurate form of therapy. Evaluation of treatmentschedules might be facilitated by the calling of aninternational meeting of experts on venerealdiseases when sufficient time has elapsed to permitsuch evaluation.

(e) Health Education.

The Committee observes that the statutoryobligations of the WHO provide for assistance indeveloping an informed public opinion amongall peoples in matters of health.

Opinions on the type of health education impor-tant to venereal-disease control programmesappear to vary widely from country to country.If the WHO should establish a section on healtheducation, venereal diseases should be included,to encourage national and international voluntaryorganizations to assume responsibility for inform-ing the public and gaining its support. If such asection is not formed, the Committee would be infavour of considering the recommendation at alater date of a sub-committee to the suggestedWHO Committee on Venereal Infections. Thissub-committee should be composed of trained men,skilled in the art of public enlightenment, tostudy the questions involved and evaluate measuresand procedures currently used in various countries.

(f) Research.

The Committee observes that it is within theprovince of the WHO to promote and conductresearch in the field of health.

There are a number of important investigativeproblems in the venereal-disease field, the solutionof which would be beneficial to national andinternational control work. Special problems mightrequire studies by experts in highly specializedfields, and financial support of such research bythe WHO would appear desirable.

It is recommended that the activities of the WHOin regard to research in the venereal diseases beconfined to financial support to organizations,institutions or individuals who are consideredcompetent to carry to a definite conclusion thestudy of significant problems bearing upon anyof the venereal infections.

Wherever mutual problems arise in other tech-nical committees of the WHO, liaison should bemaintained with them. For example, in serologicand penicillin standardization work, close liaisonshould be maintained with the Expert Committeeon Biological Standardization.

(g) V enereal-Disease Information.

Most existing periodicals in the venereal diseasesare of national character, and there is need for acritical international abstract periodical whichwould provide information to health administra-tions, public health officers and the medicalprofession, and would contribute to liberalizeinternational interchange of medical and publichealth information.

It is recommended that the possibility of es-tablishing a specialized abstract periodical underthe w.gis of the WHO and other internationalorganizations or of co-ordinating existing activitiesin the field be explored by the Secretariat andfurther considered by the proposed WHO Com-mittee on Venereal Infections when it meets.

In many countries, particularly those ravagedby war, great need exists for venereal-diseaseinformation in general, particularly with regard torecent developments in the field of epidemiologyand therapy. Assistance by the WHO in providingvenereal-disease textbooks, monographs, medicalperiodicals, etc., would expedite venereal-diseasecontrol programmes in such countries.

(h) Prophylaxis.

It is the opinion of the Committee that presentavailable personal and per-oral prophylactic me-thods are not suitable for general use in civilianpopulations. There is no reliable evidence thatper-oral prophylaxis based on penicillin is success-ful. Should future developments in this field proveof definite value in the control of venereal diseases,the Committee would favour indicating a prophy-lactic procedure.

(i) Unification of Nomenclature for Causes ofMorbidity and Deaths.

The Committee takes notice of the statutoryobligations of the WHO to establish and revisenecessary international nomenclatures of diseases.In considering the proposed unification list ofcauses of morbidity and deaths, the Committeeapproves the approach embodied in the unificationprinciple. In regard to the proposed groupings forvenereal diseases, it is recommended that liaisonbe maintained between the proposed Committeeon Venereal Infections and the Committee on theInternational Statistical Classification of Diseases,Injuries and Causes of Death, for reciprocalconsultations whenever action on revision is taken.Suggestions will be passed by the Expert Committeeto the Classification Committee.

(j) Relations with other International Organizationsin the Venereal-Disease Field.

It is recognized that several other internationalorganizations are carrying out activities contri-buting to venereal-disease control. The UnitedNations and several other international organiza-tions are considering programmes relating to thesocial hygiene, educational and other aspect of theproblem. Full advantage should be taken of theservices of these organizations, and relations shouldbe established to co-ordinate future over-all planningand action. Elsewhere in this report specificreference has been made concerning mutual


problems appearing to require reciprocal consul-tations and action by such other internationalorganizations.

Relations should also be maintained with non-governmental international organizations. Thesocial implications of venereal diseases representa field where these organizations can contributeto control programmes.

The Committee observes that the Interim Com-mission at its fourth session requested that thereports of the International Union against VenerealDiseases be made part of the Committee's referencematerial. In considering these reports, the Com-mittee approves the purposes and activities of thisorganization and the proposed establishment bythe Union of a liaison committee with the WHO, asset forth in the resolutions passed at the firstpost-war assembly of the Union.

It is recommended that liaison be maintainedby the WHO with other international governmentaland non-governmental organizations carrying outactivities contributing to venereal-disease control,in order that future over-all planning and actionbe co-ordinated.

(k) Assistance to Governments.

The Committee takes notice that, under theWHO Constitution, assistance may be extended toGovernments upon request.

The Committee is of the opinion that, in venerealdiseases, the WHO should be prepared to giveexpert advice to countries requesting informationon the aspects of prevention, diagnosis, treatmentand control, drawing on the experience of othercountries.

It should also be prepared to inform Governmentsand health departments on legal aspects of venereal-disease control and to review periodically recentdevelopments in this field. The Committee takesnotice that the International Union against theVenereal Diseases is presently undertaking asystematic compilation of current venereal-diseaselaws and regulations in all countries and areas ofthe world. It would appear desirable that thisproject be supported by the WHO.

The WHO should be prepared to meet requestsof countries for field services, with a view to de-monstrating practical activities in one or more ofthe special fields of clinical, laboratory or adminis-trative phases of control work. Such consultationand demonstration units should be made available,particularly to areas where knowledge of modernpublic health methods is limited.

The educational value of these teams would beconsiderable, and such equipment should be provid-ed as would permit the authorities of the countryitself, or organizations designated by them, tocarry on the work after an initial demonstrationperiod. Such teams should preferably be com-posed of personnel trained under the fellowshipprogramme. The suggested units should not beput into the field until teams are available capableof carrying out an impeccable job.

Details of the composition of the teams and theminimum equipment required in such field con-sultation and demonstration units should befurther discussed at the next meeting of the experts.

It is recommended that the WHO should beprepared to give advice to Governments on various

aspects of venereal-disease control and should out-line plans for field consultation and demonstrationunits, composed of qualified teams, which, at therequest of Governments, could demonstrate prac-tical venereal-disease control activities, theseactivities to be taken over by the countries them-selves after an initial demonstration period.

4. International Health Regulations forVenereal Diseases, and the Brussels Agree-ment.The Committee is in agreement with the prin-

ciple expressed by the Economic and SocialCouncil of the United Nations, June 1946, on theadvantages of replacing diplomatic conventions intechnical fields by international regulations, andtakes notice of the Constitution of the WHO,authorizing the World Health Assembly to adoptsuch regulations in health matters. The Committeeis further in accord with the views of severalGovernments that the Agreement respecting faci-lities to be accorded to merchant seamen for thetreatment of venereal diseases (Brussels, i Decem-ber 1924) be revised and expanded. In the opinionof the Committee, such revision and expansionshould take place in the form of internationalhealth regulations for venereal diseases, and theAgreement should remain valid until the actualentry-into-force of the new regulations.

The Committee agrees with the views of severalGovernments that expansion of the BrusselsAgreement should include migratory groups otherthan seafarers (such as displaced persons, foreignworkers, emigrants, etc.). It is, however, recognizedthat seafarers are particularly exposed to risks ofvenereal infections, and it is desirable that theprinciples of the Brussels Agreement be preservedin any new health regulations for venereal diseases.Further, due to their international epidemiologicalimportance, seafarers should receive particularattention as regards the question of sick-pay (tothose who might be deterred from undergoing anti-syphilitic treatment for fear of losing their ship).

The Committee takes notice that the UnitedNations, the ILO, and other international organi-zations are at present considering the problemspertaining to migratory groups, including seafarers,owing to the particular characteristics of this group.Revision and expansion of the Brussels Agreementinto international health regulations for venerealdiseases should therefore be made by co-ordinatingthe activities of the organizations concerned.

In such international health regulations, thefollowing basic principles should be embodied :

(r) Medical examination, treatment and drugs,and hospitalization where necessary, should, beprovided, all free.

(2) The services provided should be of thehighest professional quality, and treatmentapplied should, wherever possible, follow suchoptimal treatment schedules as might be recom-mended from time to time by the WHO Com-mittee on Venereal Infections.

(3) An individual treatment book should beprovided free of charge to the patient, wherepertinent data regarding results of examinations,laboratory procedures, treatment, etc., shouldbe entered.

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(4) It would be advantageous to have aninternational list of treatment centres, includingfacilities available in inland towns as well asports. This list should be revised at least everythird year.

(5) The epidemiological necessity for treat-ment of infectious stages of venereal diseases isin the interests of the community concerned.A system of international contact tracing shouldtherefore be established in such a way that eachcountry agrees to communicate confidentially,under the professional seal of secrecy, directlyto the public health authorities of other coun-tries, the names and addresses of persons indi-cated as being a source of infection, so that thepublic health authorities of these countries willbe able to take measures permitted under theirlegislations. To facilitate rapid epidemiologicalinvestigations, such communications should besent by airmail.

(6) In every large port, it is desirable that asocial welfare worker be available, the qualifi-cations for whom should include some knowledgeof venereal-disease treatment and its implica-tions.

It is recommended that the Brussels Agreementbe abrogated and replaced by a wider instrumentin the form of international regulations for venerealdiseases. This instrument should cover variouscategories of migratory groups, including sea-farers, and be based on the principles outlined.

The Expert Committee would be prepared tomake a preliminary draft of such regulations inconsultation with the Committee entrusted withthe revision of sanitary conventions (Committeeon International Epidemiological Control) for theconsideration of the WHO and Governments.

5. Presentation of the Polish Anti-syphilisPlan.

The Committee takes notice of the anti-syphilisplan of the Polish Ministry of Health, as presentedboth by the representatives of the Ministry andin the documents made available to the Committee.After considering its technical and other aspects,the Committee wishes to express its approval ofthe plan as follows :

A mass attack on syphilis on a nation-wide scalewith penicillin has, to the knowledge of the Com-mittee, so far not been attempted anywhere in theworld.

It is the opinion of the Committee that the plan,as presented by the Polish Ministry of Health,appears to be a well-rounded and well-plannedmethod for the control of syphilis in that country.The principles which are embodied in the planshould serve as an effective means of combatinga similar situation in other countries.

6. WHO Committee on Venereal Infections,a Section in the WHO Secretariat onVenereal Diseases, and Finance.

(a) Committee on Veneral Infections and Sub-Committee on Serology.

The international activities outlined, in theopinion of the Committee, can only be accomp-

lished by the establishment of an advisory bodyof experts to the WHO, composed of ten to twelvespecialists in public health, clinical venereology,and other aspects, with power to create specialsub-committees. A Sub-Committee on Serologyand Laboratory Aspects, composed of five members,should be appointed as soon as possible.

Meetings will be required as programmes andactivities develop. The time and place of meetingsshould be tentatively set at the end of each session.

In view of the proposed activities in the field ofserological standardization and the time necessaryto prepare for the proposed international meetingof serologists, the Expert Committee is of the opinionthat a meeting of the Sub-Committee on Serologyshould be held in September 1948 in New Yorkand that the WHO Committee on Venereal Infec-tions should also meet at that time.

(b) A Section in the WHO Secretariat on VenerealDiseases, and Finance.

The proposed Section in the WHO Secretariaton venereal diseases should be adequately staffedby highly qualified personnel. The structure ofthe section should be flexible in such a way as topermit development of the international publichealth and medical activities in the field of vene-reology and to meet particular problems arisingfrom new advances.

Adequate funds for the proposed WHO com-mittees and the activities of the Secretariat shouldbe provided, including funds for the particularproposals outlined. A translation of these activitiesinto budgetary terms will be made at a later date.

7. Summary of Recommendations of theExpert Committee.

(I) Introduction.

Considering the international character of thevenereal-disease problem, the increased prevalenceof venereal infections after the Second World War,the high degree of effectiveness displayed by newantibiotics in the management of these infectionsand the present favourable absence of resistanceon the part of the causative organisms of syphilisand gonorrhoea, organizational programmes ininternational combating of venereal diseases shouldgo forward as soon as possible under the mgis ofthe WHO and its Interim Commission.

Until definite plans on many of the social aspectsof the venereal-disease problem now under consi-deration by the United Nations and other inter-national organizations become available, the WHOmay find it advisable to concentrate on the publichealth and medical aspects in international vene-real-disease activities.

(2) Delineation of the Problem.

In international combating of venereal diseases,major emphasis should be placed on detection andtreatment of early syphilis, special considerationsbeing given to the remaining members of thevenereal group of diseases : gonorrhoea, chancroid,lymphogranuloma venereum and granuloma ingui-nale, in that order of relative importance, where


special geographical or racial considerations pertainand in the spread of venereal diseases from onecountry to another.

The nature and extent of the problem of venerealinfections should be determined, as far as possible,in each country, and countries should be encou-raged to record at least basic data.

(3) Fields of Activity.

(a) The Expert Committee recommends that :there be recruitment and training of profes-sional personnel in the various departmentsof venereal-disease control work under afellówship and lectureship programme ;research in the venereal-disease field, finan-cially supported by WHO, be confined toorganizations, institutions or individualscapable of carrying to a definite conclusionthe study of significant problems ;information on venereal diseases be spon-sored and provided to health administra-tions, public health officers, specialists andthe medical profession in general ;consideration be given at a later date to therequirements regarding health educationand venereal-disease information for thepublic ;the WHO be prepared to give expert adviceon various phases of venereal-disease controlwork ; andplans for field units, consisting of teamsto demonstrate practical venereal-diseasecontrol activities be further studied.

(b) The Expert Committee further recommendsthat :

uniform serological procedures in syphilis besought and that an international conferenceon serological standarclization and labo-ratory aspects be called under the nis ofthe WHO, not earlier than 1950 ;a special sub-committee on serology andlaboratory aspects be established in 1948under the proposed WHO Committee onVenereal Infections, to prepare for such aconference of key serologists ;at least one first-class serological referencelaboratory be at the disposal of the WHO ;andthe potential services of existing laboratoriesbe explored.

(c) It is also recommended that :measures should be taken by the WHO toencourage production of penicillin and toensure an equitable distribution to allcountries ;the WHO or the Interim Commission studycurrent production and requirements ofpeniciffin ;

the medical profession in each country bewarned that cumulative undue expenditurewould endanger the availability of penicillin.

(d) It is recommended that :evaluation of modern treatment methodsbe made available through appropriate pro-

cedure proposed by the WHO Committeeon Venereal Infections when sufficient timehas elapsed to permit such evaluation.

(e) It is finally recommended that :working relationships be established andmaintained with other international govern-mental and non-governmental organizationscontributing to venereal-disease control ;close liaison be established between ExpertCommittees of the WHO where mutualproblems are concerned.

(4) International Health Regulations for VenerealDiseases.

Considering the principle expressed by theEconomic and Social Council of the United Nationson advantages of replacing diplomatic conventionsin technical fields by international regulations, theauthority of the World Health Assembly to adoptsuch regulations in health matters and the viewsof Governments on the desirability of revising andexpanding the Brussels Agreement, it is recom-mended that :

the Brussels Agreement be replaced byinternational health regulations for venerealdiseases ;such international health regulations includemigratory groups other than seafarers ;these regulations be based on the principlesoutlined in the report of the Expert Com-mittee.

(5) Presentation of the Polish Anti-syphilis Plan.

The Expert Committee expresses its approvalof the plan as presented by the Polish Ministry ofHealth, observing that the principles embodiedmight be of interest to other countries.

(6) Committee on Venereal Infections, a Section inthe WHO Secretariat on Venereal Diseases, andFinance.

In order to carry out the programme in inter-national combating of venereal diseases outlined,the Committee recommends that :

an advisory body be established on venerealinfections, with powers to create specialsub-committees ;a Sub-Committee on Serology and Labo-ratory Aspects be appointed as soon aspossible ;

the proposed Committee and Sub-Committeemeet in September 1948, in New York.

It is further recommended that :an adequately staffed section on venerealdiseases be part of the administrative frame-work in the Secretariat of the WHO, tocarry out essential activities, and thatadequate funds be made available for therequirements of the proposed Committee,Sub-Committee, the Section in the Secre-tariat on Venereal Diseases and the specificproposals outlined.

OF EXPERT COMMITTEES TO THE INTERIM COMMISSION

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