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Explanation  Each column shows the extent to which I diagnosed cases in my community compared with cases officially notified in the whole country, taking into account population sizes, in each year. For instance, in 1977 I diagnosed forty times as many cases as were officially recognized, but the next year only four times as many.  In 1977 England had not experienced whooping cough outbreaks for 25 years, so when it came along few people recognized it and the ratio was large.  Over the next 15 years it was quite common and people started recognizing it again, so the ratio got smaller.  As it has become less common again in the last 6 years, less people are recognizing it through lack of familiarity, and the ratio has climbed again.  In 1996 I diagnosed 100 times more than nationally.  Another reason for the ratio being even higher recently is the fact that a higher proportion of cases are now occurring in older children and adults, and doctors are even more reluctant to make a diagnosis of whooping cough outside childhood.  You have to remember that there is no really satisfactory test for whooping cough (no longer true since about 2005 when blood tests were devised), and doctors are reluctant to notify a disease without proof.