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On the eve of the Second World War, an average of 5,000 hospital beds in England and Wales were occupied at any one time by diphtheria patients, and the annual costs of their treatment was £1 million. Within two decades, a central, UK Government-funded, national immunisation programme had resulted in the effective elimination of the disease and its societal and economic costs. This paper explores the spatial retreat of diphtheria in England and Wales under the force of immunisation, from the early adoption of  ad hoc  immunisation schemes in the 1920s, through the implementation of a state-sponsored programme of childhood immunisation in the early 1940s, to effective elimination by the 1960s. Analysis at a variety of spatial scales, from the national to the local, illustrates the generalised collapse of diphtheria activity in the 1940s and,  inter alia , the substantial economic savings that accrued from this development. The epidemiological pattern of retreat followed an ordered spatial sequence that began almost simultaneously in rural areas and smaller towns, progressing to include ever-larger towns and cities and ending in the largest urban agglomerations. The effective elimination of diphtheria in England and Wales can therefore be conceptualised as an intrinsically spatial process of shrinking disease reservoirs that took two decades to achieve.

Geographical Aspects of Diphtheria in England and Wales: Immunisation and the Spatial Sequence of Retreat to Effective Elimination, 1921 to 1964