analysis participation

Further Analysis of National Participationin the inactivated

Poliomyelitis Vaccination Program, 1955-61LEO MORRIS, M.P.H.

AMEASUKE of the acceptance of inacti¬vated poliomyelitis vaccine by various

population segments is important both to thoseconcerned with its effective community applica¬tion and to those concerned with the continuingmeasurement of its effectiveness. A substantialbody of data relating to the acceptance ofinactivated poliomyelitis vaccine has been ob¬tained annually since 1957 through the CurrentPopulation Survey conducted by the Bureauof the Census. An analysis of this data by agegroup alone has been presented by Sirken (1).

Utilizing information from the same source,this paper supplements Sirken's presentationwith a more extensive analysis of the data by a

number of other variables, including age andsex, age and race, geographic region, geographicdivision, type of area (urban or rural), andincome.Although some observations concerning

motivational factors are made, the primarypurpose is to describe the extent of participa¬tion. The sociological and motivational factorsaffecting this participation have been wellrecorded in the literature {2-10).

Study Methods

Trend statistics in this report are based on fivenational household surveys conducted annuallysince 1957. These surveys were sponsored bythe Public Health Service and conducted bythe Bureau of the Census as supplements to itsmonthly Current Population Survey which in¬

cludes 35,000 households. A description of theCurrent Population Survey has already ap¬peared (11). Additional details concerningthe Current Population Survey methods andsample design were included in a report basedon the 1957 survey (12).The reliability of the estimated percentages

derived from these annual surveys is discussedin the statistical note appearing on p. 479. Thefinal table contains the approximate standarderrors of estimated percentages, computed forselected sizes of the population base, which maybe used to make tests of differences between twopercentages.

Definitions

The Current Population Survey covers thecivilian noninstitutional population. Conse¬quently, the Armed Forces and persons resid-ing in institutions are excluded from estimatesin this report. The variables used in the studyare defined as follows:

Age. The age classification was based on theage of the person at his last birthday.

Race. Persons were classified as white or non¬

white in accordance with the U.S. Bureau ofthe Census definitions (13).

Geographic region and division. The fourgeographic regions and nine divisions are those

Mr. Morris is a statistician in the Surveillance Sec¬tion, Epidemiology Branch, Communicable DiseaseCenter, Public Health Service, Atlanta, Ga.

Vol. 79, No. 6, June 1964 469

defined by the U.S. Bureau of the Census (14)

Type of area. Persons were classified as liv¬ing in either (a) a Standard Metropolitan Area(SMA), (6) an urban area, or (c) a rural area.

The definitions of SMA, urban, and rural are

those used in the 1950 census (15).Except in New England, a Standard Metro¬

politan Area is a county or group of contiguouscounties which contains at least one city of50,000 inhabitants or more. In addition to thecounty or counties containing such a city or

cities, contiguous counties are included in a

Standard Metropolitan Area if, according tocertain criteria, they are essentially metropoli¬tan in character and socially and economicallyintegrated with the central city. In New Eng¬land, Standard Metropolitan Areas have beenassigned on a town rather than a county basisand are defined in terms of population density.Areas not included in an SMA may be either

urban or rural. Urban areas are as follows: (a)places of 2,500 inhabitants or more incorporatedas cities, boroughs, and villages; (b) incorpo¬rated towns of 2,500 inhabitants or more except

Figure 2. Percent of persons receiving three ormore inoculations of inactivated poliomyelitisvaccine by age and sex, September 1957 and1961

100-

80H

°60-

;40H

20H

-Male-Female

1961

1957-i.i.i.i-r-5 10 15 20 30

Age40 50

in New England, New York, and Wisconsin,where towns are simply minor civil divisions ofcounties; (c) the densely settled urban fringe,

Figure 1. Nine geographic divisions of the United States

WestNorth Central Northeastf

470 Public Health Reports

including both incorporated and unincorpo-rated areas, around cities of 50,000 or more;and (d) unincorporated places of 2,500 inhabi¬tants or more outside any urban fringe. Theremaining areas are classified as rural.Family income. This variable was used only

in the 1957 survey. Persons in primary fami¬lies (heads of households and household mem¬bers related to the head of the household) were

classified according to family income for thepreceding 12 months.Vaccination status. Persons were classified

as having received none, one, two, three, or fouror more poliomyelitis vaccine inoculations. Forthe purpose of this report, any person with threeor more doses of inactivated vaccine will be con¬

sidered a triply vaccinated or vaccinated person,and the fourth dose may sometimes be referredto as a booster inoculation.

Survey period. The 1957 survey was con¬

ducted in August and the 1958,1959,1960, and1961 surveys in September. For comparison,the month of September is used as a referencepoint for the 1957 survey in some graphs.

Results

Age amd sex. The vaccination status of thepopulation by sex was obtained in the 1957,1960, and 1961 surveys. By September 1961,more than 85 percent of all school age (5-14years) boys and girls had received at least threedoses of inactivated poliomyelitis vaccine, andabout 60 percent had received four or more

doses. The percentage of males and femalesreceiving three or more inoculations of inacti¬vated vaccine is presented in figure 2 by agegroup for the years 1957 and 1961.

Table 1. Poliomyelitis vaccination status of the civilian noninstitutional population under 60years by age and sex, United States, September 1961

1 The estimated population size for each age group has been independently rounded to the nearest population sizegiven in table 6; hence the sum of parts shown may differ slightly from the totals shown. Percentages are basedon unrounded numbers.

Vol. 79, No. 6, June 1964 471

In 1957, the children 5 to 9 years of agerepresented the best vaccinated group for eithermales or females. This was probably the di¬rect result of the vaccine allocation systemrecommended on May 16, 1955, when prioritywas given to children aged 5-9, and each Statewas allocated vaccine in proportion to its popu¬lation in that age group. In 1961, slightlymore of those 10 to 14 years of age were vacci¬nated than those 5 to 9 years old.In both 1957 and 1961, there was no difference

in the proportion of vaccinated males and vac¬

cinated females under 20 years of age. How¬ever, among adults, significantly more women

than men were vaccinated in 1957 and 1961 ineach of the adult age groups.In all age groups under 20 years, the percent¬

age of males and females with exactly threedoses of vaccine in 1961 was essentially equal

(table 1). This was similarly true for four or

more doses of vaccine. A greater proportionof the vaccinated children, 1 through 19 years,of both sexes had received four or more dosesthan three doses. However, among adults 20to 39 years of age, a greater percentage of wom¬en than men had received their fourth inocula-tion.

Race. A greater proportion of white per¬sons than nonwhite have received three or more

inoculations of inactivated poliomyelitis vac¬

cine. By September 1961 (table 2), 55 per¬cent of the white population under 60 years ofage had received three or more doses of vaccinecompared with 43 percent of the nonwhite pop¬ulation. There was a significant difference forall age groups with the exception of infantsunder 1 year of age. For persons under 20years, the proportion triply vaccinated was 81

Table 2. Poliomyelitis vaccination status of the civilian noninstitutional population under 60years, by age and ethnic group, United States, September 1961

1 See footnote to table 1.


Figure 3. Percent of persons receiving three ormore inoculations of inactivated poliomyelitisvaccine by age and ethnic group, September1957 and 1961

100

80 H

.S60H

20 H

White-Nonwhite

-^rl957"1-1-1-1-1-1-1

0 5 10 15 20 30 40 50Age

percent for white persons and 64 percent fornonwhite. At ages 20-59 years, 34 percent ofthe white population had been vaccinated com¬

pared with 20 percent of the nonwhite popula¬tion.This race differential for both the younger

and older age groups was evident in the 1957survey (12) &nd has continued throughout re¬cent years (fig. 3). From 1957 to 1960, theincrease in percentage of persons vaccinatedwas approximately equal for whites and non¬

whites under 15 years of age. However, amongadults, the vaccinated white population in¬creased at a faster rate, producing the greaterdifference seen among adults in 1961.During the 1960 to 1961 interval, the propor¬

tion of the nonwhite population vaccinated in¬creased slightly more than the white popula¬tion for all age groups under 40 years. Thischange was caused largely by nonwhite chil¬dren and adults receiving their third inocula-tion for the first time between 1960 and 1961while the white population had been receivingthe fourth and, in some instances, fifth inocula-tion. Those receiving a fifth dose would notincrease the percentage of persons with three or

more inoculations.The white population 1 through 39 years had

received a greater proportion of fourth doses ofvaccine than third doses (table 2). However,in the nonwhite population, this is true only forschool-age children, and even in this group thedifference is not outstanding.

Geographic regions. The proportion ofpersons who had received three or more doses ofvaccine by September 1957 did not vary greatlybetween the four geographic regions of theUnited States (Northeast, North Central,South, and West). The variation between re¬

gions ranged from 27 percent for the NorthCentral region to 23 percent for the South (12).In September 1960, 3 years later, the West

had the highest proportion of triply vaccinatedpersons, 55 percent with three or more doses ofvaccine. The proportion triply vaccinated inthe North Central and Northeast regions was

virtually the same, 53 percent and 51 percent,respectively. The proportion vaccinated in theSouth was 47 percent, the lowest of the fourregions. There is a clear differential betweenthe West and South, and a difference is alsonoted between the other regions and the South.The Northeast region, followed closely by the

North Central and Western regions, had thehighest proportion of vaccinees among children(table 3). Among adults, the participationwas comparatively equal among all regions ex¬

cept the South. The South had the lowest pro¬portion of vaccinees for all four age groupsshown.For all regions, only the school-age popula¬

tion had received a greater proportion of fourthdoses of vaccine than third doses (table 3).This finding is consistent with the school-agechildren becoming the first group to receivethree doses of vaccine and then being the firstgroup eligible for a booster dose when this wasrecommended in 1959. Among preschool chil¬dren (0-4 years of age), about 40 percent hadnot yet received their third dose of vaccine, andas many as 24 percent of the preschool childrenin the South were still unvaccinated.The proportion of persons triply vaccinated

by region and type of area was also tabulated in1960. For children under 15 years of age, allregions except the West had a higher propor¬tion vaccinated in the Standard MetropolitanAreas than in urban and rural areas. Thesedifferences were greatest for the children under

Vol. 79, No. 6, June 1964 473

5 years of age. This differential was greatestin the South where 62 percent of the preschoolchildren in the SMA's were vaccinated com¬

pared with 51 percent of those in urban andrural areas.

Among adults, only the South and NorthCentral regions exhibited a greater proportionof persons in the SMA's triply vaccinated.The differences were not great for adults in anyregion.The proportion of persons triply vaccinated

by region and race was tabulated in the 1959survey. In all regions and age groups, a

greater proportion of the white population hadbeen vaccinated. For persons under 20 yearsof age, the greatest difference was in the Westwhere 71 percent of the white population hadbeen vaccinated as compared with 44 percent ofthe nonwhite population. Among adults, thegreatest difference was found in the North Cen¬tral region where 43 percent of the white popu¬lation were vaccinated compared with 18 per¬cent of the nonwhite population.

Geographic divisions. Eesults from the 1957survey showed differences among the geo¬graphic divisions within each region to basmaller than those among regions (12). In1960, the geographic divisions comprising theNortheast and Southern regions did show some

differences (table 4).In the Northeast region, the New England

States showed a greater proportion of personsvaccinated in all age groups than the MiddleAtlantic States. This difference was especiallytrue among adults. When the persons who hadreceived four or more doses of vaccine are con¬

sidered, there is a highly significant differenceat all age groups. This may be attributed tosome extent to the 1960 poliomyelitis epidemicin Ehode Island. During the epidemic season

of 1960, from June through September, ap¬proximately 500,000 doses of vaccine were dis-tributed, the greatest proportion in July (16).It is also estimated that 43 percent of the Salkvaccine administered to the population of Provi-dence, R.I., during June, July, and August went

Table 3. Poliomyelitis vaccination status of the civilian noninstitutional population under 60years by age and geographic region, United States, September 1960



to persons receiving their fourth, fifth, sixth,and seventh doses (17).In the southern region, there was a greater

proportion of vaccinated persons in the WestSouth Central division. This was especiallytrue among preschool age children and the 15-to 39-year age group. A significantly higher

proportion of individuals in this division hadreached their fourth inoculation compared withthe East South Central and South AtlanticStates.In all age groups, the New England States

had the highest proportion of persons vacci¬nated.

Table 4. Poliomyelitis vaccination status of the civilian noninstitutional population under 60years, by age and geographic division, United States, September 1960

Age and geographic divisionPopulationcategory(millions)

Percent distribution by number of inoculations

4 or more

Total under 60 years:New England_Middle Atlantic_East North Central.West North CentralSouth Atlantic_East South CentraLWest South Central.Mountain_Pacific_

0-4 years:New England_Middle Atlantic_East North Central_West North Central_South Atlantic_East South Central_West South Central_Mountain_Pacific_

5-14 years:New England_Middle Atlantic_East North Central_West North Central_South Atlantic_East South Central_____West South Central_Mountain_Pacific_



103030102010155

20

134132312

255353424

310104104525

21010353425

32.142. 139.437.345.847.839.437.635.0

15.317.418.318.924.328.621.916.617.4

2.85.06.77.58.811.810.17.87.5

25.439. 136.832.047.949.639.835.331.5

74.084.482.980.688.392.784.482.675.4

2.92.72.42.03.02.42.72.64. 1

7.46.46.75.66.56.56.46.99.0

3.65.45.23.97.75.34.46.46.0

1.01.51.91.63.02.82.52.42.3

3.83.02.52.02.81.93.02.15.2

3. 12. 11.41.3.9.91.21.43.4

14.012.012.911.014.513.511.313.015.4

3. 14.85.34.37.47.45.85. 17.9

9.27.98.16.76.67.07.08.610.3

5. 13.22.62.91.81.02.52.75.0

22.925.026.026.725.525.623.927.327.4

27.135. 135.238.931.630.929.340.634.5

25.836.035.032.841. 143.829.935.236.7

28.629.529.731.226.725.827.429.730.9

10.76.68.39.36.03.87.28. 19.9

34.723.725.528.519.217.727.525.624.4

40.030.128.427.221.921.733.123.326.7

67.452.751.153.939.734.151.649.645.7

33.020.522.928.116.015.822.824.322.0

7.23.74.85.93.01.54.75. 16.3


Vol. 79, No. 6, June 1964 475

Type of area. The proportion of personsunder 60 years of age who had received threeor more doses of vaccine was slightly greaterin Standard Metropolitan Areas than in urbanor rural areas (fig. 4). The proportion vac¬

cinated was 55 percent for SMA's comparedwith 52 percent for urban and 51 percent forrural places. In general, the differences be¬tween the three types of areas are somewhatgreater when age is held constant. For eachage group, residence in the Standard Metro¬politan Areas corresponded to the greatestparticipation in the vaccine program. Thiswas true for 1957,1960, and 1961.The vaccination status by age and type of

area is tabulated in table 5 for September 1961.For each age group from 1 through 39 years,and in each type of area, more than half of thepersons with three or more doses of vaccine hadalready received their fourth dose. This re¬

sponse to the fourth or booster inoculation,recommended in 1959, was not evident in anygreat degree until the 1961 survey. Through1960, only those from 1 through 14 years in theSMA and the urban areas had received a greaterproportion of fourth doses than third doses.In the rural areas, only those vaccinees from 1through 9 years had received a greater pro¬portion of booster inoculations.

Figure 4. Percent of persons receiving three or

more inoculations of inactivated poliomyelitisvaccine by age and type of area, September1961

100n

80H

£60-

8 40-

20H

SMA- Urban

Rural

Family income. The participation of personsby income and selective population character¬istics was tabulated only in the 1957 survey(12). Participation in the vaccination pro¬gram was strongly associated with family in¬come. This association between participationand income held for each geographic regionand area of residence. The relationship wasmuch more marked for the white populationthan for the nonwhite population; in fact,among nonwhite children of school age, partic¬ipation was not correlated with family income.Persons and families with a yearly income lessthan $3,000 received most of their inoculationsat work or school. Those in higher income fam¬ilies received most of their inoculations fromprivate physicians.Other surveys measuring levels of vaccination

by socioeconomic status have been conductedsince 1957 (18,19). In these, the highest levelsof vaccination status have been associated withthe upper socioeconomic groups.

Discussion

It is clearly evident that well-defined seg-ments of the population have not participatedin the poliomyelitis (inactivated) vaccinationprogram as well as others. The response ofadult males, preschool children, and the non¬

white population has been well below the par¬ticipation of adult females, school-age children,and the white population.The higher rate of vaccination among females

undoubtedly reflects the fact that pregnantwomen were one of the more important targetgroups in the vaccination program. In addi¬tion, the mothers were available for vaccinationwhen they brought their children to the physi¬cians' offices and clinics for inoculations.During the 5-year period 1957-61, the dif¬

ference between vaccinated men and women

grew larger, as the following figures show.

h.i.i.r.0 5 10 15 20

i.30Age

40 50 60


As a result of this widening difference, theSurgeon General's Committee on PoliomyelitisControl in January 1961 laid the groundworkfor a "Babies and Breadwinners" poliomyelitisvaccination campaign (20). This proposal wasaimed at unvaccinated men and the preschoolchildren who have never attained the degree ofvaccination that the captive school populationhas. Although the vaccination status of men

has improved slightly from 1960 to 1961, therelative proportions of vaccinated men andwomen has not changed.The better vaccination status of women has

altered the epidemiologic pattern of paralyticpoliomyelitis among adults. In 1955, the lastyear before widespread immunization with in¬activated poliomyelitis vaccine, women betweenages 20 and 39 experienced higher attack ratesthan men in the same age group (21). Beforewidespread immunization, women were prob¬ably at greater risk than men because of closercontact with infants and young children. Dur¬ing 1960, in contrast to 1955, the age-specificattack rates were higher for men than women

in this 20- to 39-year-age group (22).It is notable that 13 percent of the preschool

Table 5. Poliomyelitis vaccination status of the civilian noninstitutional population under 60years, by age and type of area, United States, September 1961

See footnote to table 1.

Vol. 79, No. 6, June 1964 477

children (1 through 4 years) and 45 percent ofthe infants under 1 year were still unvaccinatedin September 1961. During the 4-year period1958-61, an average of 43 percent of the para-lytic cases of poliomyelitis were in preschool-age children and an average of 63 percent of allcases in this age group had received no inacti¬vated vaccine (23).The results of the September 1962 survey

show that this situation is not being remedied(24). As of that date, 14 percent of the pre¬school children and 50 percent of the infantsunder 1 year were still unvaccinated.The problem in reaching preschool children

is evident once again when looking at the greaterproportion of white population vaccinated com¬pared with the nonwhite population. Twenty-six percent of the nonwhite preschool childrenwere unvaccinated along with 11 percent of thewhite preschool children. In addition, roughlyhalf of the white and nonwhite infants under1 year of age were also unvaccinated.

Since the advent of inactivated vaccine, ithas been well documented that urban epidemicshave produced higher attack rates of paralyticpoliomyelitis among the nonwhite than amongthe white population (25-29). It is suggestedthat this change in the epidemiologic patternof paralytic poliomyelitis can in large part beattributed to the difference in vaccination levelsof the two populations under discussion.

Estimates of the effectiveness of three or moredoses of inactivated poliomyelitis vaccine, as

studied in four recent epidemics, have rangedfrom 77 to 82 percent (16, 28, 30). The sharpdrop in poliomyelitis incidence since 1955 can

be attributed largely to the use of the inacti¬vated vaccine. The reason that the decrease inparalytic poliomyelitis has not been greater maybe the poor immunization status of the afore-mentioned population groups.

SummarySince 1957 the Public Health Service has

sponsored annual surveys to determine nation¬wide participation in the inactivated poliomye¬litis vaccination program which began in April1955. These vaccination surveys were conductedin 5 successive years by the Bureau of the Censusas supplements to the monthly Current Popu¬lation Surveys.The significant results of the five surveys were

analyzed according to various segments of thepopulation. The proportion of the popula¬tion adequately immunized has progressively in¬creased since the licensure of Salk vaccine inApril 1955. By September 1961, 77 percent ofthe population under 40 years of age had re¬

ceived at least one inoculation, about 67 percenthad received three or more inoculations, and 40percent had received the fourth or booster inoc-

Table 6. Sampling variability of estimated percentages

Population base of thepercentage

Standard error of estimated percentages1

2or98

5or95

10or90

15or85

20or80

25or75

30or70

40or60

50

250,000...500,000...1,000,000.2,000,000.3,000,000.4,000,000.5,000,000.10,000,00015,000,00020,000,00025,000,00030,000,00040,000,00050,000,000

1.51.0.7.5.4.4.3.2.2.2. 1. 1. 1. 1

2.31.61.2.8.7.6.5.4.3.3.2.2. 2.2

3.22.21.61.1.9.8.7.5.4.4.3.3.2.2

3.82.71.91.31. 1.9.8.6.5.4.4.3.3.3

4.23.02.11.51.21. 1.9.7.5.5.4.4.3.3

4.63.22.31.61.31. 11.0.7.6.5.5.4.4.3

4.83.42.41.71.41.21. 1.8.6.5.5.4.4.3

5.23.62.61.81.51.31.2.8.7.6.5.5.4.4

5.33.72.61.91.51.31.2.8.7.6.5.5.4.4

1 The chances are 67 out of 100 that the true percentage is within plus and minus the standard error, and 95out of 100 that it is within plus and minus twice the standard error.


ulation. Approximately 60 percent of school-age children had four or more doses of inacti-vated poliomyelitis vaccine by September 1961,but less than half of the preschool children andyoung adults and less than one-quarter of themen had reached this level.In summary, the response of preschool chil-

dren, adult males, and lower socioeconomicgroups has been well below the participation ofschool-age children, adult females, and highersocioeconomic groups respectively. Since theadvent of the inactivated poliomyelitis vaccinein 1955, poliomyelitis has attacked these poorlyimmunized groups with greater frequency.

Estimates of the effectiveness of three or moredoses of inactivated poliomyelitis vaccine, asstudied in four recent epidemics, have rangedfrom 77 to 82 percent. The sharp drop in polio-myelitis incidence since 1955 can largely be at-tributed to the use of the inactivated vaccine.That the decrease in paralytic poliomyelitis hasnot been greater may be attributed to the popu-lation groups who have remained poorly im-munized.

Therefore, outbreaks of poliomyelitis willcontinue unless more extensive vaccination iscarried out in preschool children, adult males,and lower socioeconomic groups.

STATISTICAL NOTE

In this paper, the statistics are expressed principallyas percentages of the population that received three ormore doses of inactivated poliomyelitis vaccine. Sincethese statistics are based on a sample, they are subjectto sampling variation. Although the sampling varia-tion of the Current Population Survey was fully dis-cussed in the report of the 1957 survey results (12),the more important details are repeated here for clarityand convenience.Table 6 presents the approximate standard errors of

estimated percentages computed for selected sizes ofthe population base. Estimates of sampling error pre-sented in table 6 depend on both the size of the per-centage and the size of the age group on which it isbased. The chances are 67 out of 100 that the per-centage based on a complete enumeration of the popu-lation group would be within the interval representedby the estimated percentage plus and minus the stand-ard error of the estimate.These errors pertain to the estimates derived from

the 1957, 1960, and 1961 surveys, each of which utilizedthe entire monthly Current Population Survey sampleof 35,000 households. The 1958 and 1959 estimateswere based on information from a subsample of one-half the 35,000 households in the Current Population

Survey sample. The sampling errors for these esti-mnates are roughly 40 to 50 percent larger than theerrors shown in table 6.In addition to sampling variation, the estimates in

this report are subject to nonsampling errors such asthose caused by nonresponse and to response bias. Theexisting evidence, however, does not indicate that thesemeasuring errors materially affect the data. The popu-lation willingly cooperated in providing the informa-tion in the household interviews, and with few excep-tions (less than 1 percent), the respondents were ableto report the number of inoculations received.Table 6 can be used to make rough significance tests

of differences between two percentages. Assuming thecorrelation between the two percentages to be negli-gible, the standard error of the difference between thetwo percentages is equal to the square root of the sumof the squared standard errors of each percentage.Thus, if the difference between the two percentages ismore than twice its sampling error, or more than threetimes if a more conservative test is desired, the differ-ence is considered significant. In this paper, the moreconserva-tive test of three times the error has been used.

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(21) Hall, W. J., Nathanson, N., and Langmuir, A. D.:The age distribution of poliomyelitis in theUnited States in 1955. Amer J Hyg 66: 214-234 (1957).

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(23) Poliomyelitis Surveillance Unit, U.S. Communi-cable Disease Center: Surveillance of polio-myelitis in the United States, 1958-61. PublicHealth Rep 77: 1011-1020, December 1962.

(24) U.S. Communicable Disease Center: U.S. polio-myelitis vaccination survey results. Polio-myelitis Surveillance Report No. 275, Feb. 15,1963.

(25) Nathanson, N., et al.: Epidemic poliomyelitisduring 1956 in Chicago and Cook County,Illinois. Amer J Hyg 70: 107 (1959).

(26) Molner, J. G., and Agate, G. H.: Final report ofpoliomyelitis epidemic in Detroit and WayneCounty, 1958. Public Health Rep 75: 1031-1043, November 1960.

(27) Marine, W. M., Washburn, A. M., Gravelle, C. R.,and Chin, T. D. Y.: Epidemiology of polio-myelitis in Arkansas-1959. Southern Med J54: 962-968, September 1961.

(28) Chin, T. D. Y., and Marine, W. M.: The changingpattern of poliomyelitis observed in two urbanepidemics. Public Health Rep 76: 553-564, July1961.

(29) Gresham, G. E., Joseph, J. M., Farber, R. E., andSilverman, C.: Epidemic of type 3 paralyticpoliomyelitis in Baltimore, Maryland, 1960.Public Health Rep 77: 349-355, April 1962.

(SO) Timothee, R. A., Morris, L., Feliberti, M., andMainardi, L. E.: Epidemic of poliomyelitis inPuerto Rico, 1960. Public Health Rep 78: 65-76, January 1963.

Resources for Mentally Ill ChildrenA "Directory of Resources for Mentally Ill Children in the United

States, 1964," is designed to assist professionals in the referral andplacement of seriously disturbed children.

Recently pablighed by the National Association for Mental Healthin cooperation with the National Institute of Mental Health, the publi-cation is a guide to 147 public and private treatment centers, schools,and hospitals providing specialized care for emotionally disturbedchildren up to the age of 18 as a service distinct and apart from adultcare. Inclusion in the directory does not imply endorsement or ap-proval by either organization.

Copies of the 93-page indexed directory are available at $2 each fromthe National Association for Mental Health, Inc., 10 Columbus Circle,New York, N.Y.


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