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A

SIMPLIFIED

TECHNIQUE

FOR

VACCINATION

AGAINST

SMALLPOX

Harvey Kravitz, M.D.

Department of Pediatrics, University of Illinois, and St. Francis hospital, Evanston, Illinois

ADDRESS: (Office) 2341 Devon Avenue, Chicago 45, Illinois.

219

T

HE PURPOSE of this paper is to describe

a new type of scanifien for performing

vaccination against smallpox.

HISTORICAL

Many attempts have been made to improve

the technique of performing vaccination smce

I

enner’S monumental paper in 1798.1 The lit-erature is filled with publications of various new techniques and improved instruments. A review of the important papers that influenced

the development of the present methods showed that as early as 1805 Bretonneau2

de-veloped a method of sealing vaccine lymph in glass capillary tubes so that the vaccine could be preserved or transported. Unfortunately, this method was not adopted in France and was forgotten for almost 50 years.

Galbiati3 in 1810 artificially inoculated calves

with cowpox virus and used the lymph from

the infected calves to vaccinate his patients.

Negri4 in Italy, Layet5 in France,

Worlo-mount6 in Belgium, and Pissin7 in Germany further advanced the technique of animal vac-cination and made it possible to have large amounts of fresh vaccine lymph which could

be preserved and transported when needed, ob-viating the need for arm-to-arm vaccination.

Husband8 revived Bretonneau’s technique of preserving vaccine lymph in sealed glass capillary tubes in 1851.

Glycerine was used as a preservative for

vaccine lymph in Italy as early as 1830.

Cheyne’ first advocated the use of glycerine as a preservative in England around 1850.

Andrews’#{176} in 1857, and Collins” in 1858

re-ported successfully preserving vaccine lymph

in glycerine using sealed capillary tubes. Germany in 1884, and then England in 1898 took the lead in establishing animal inocula-tions under strict government control. They

established standardized methods for growing the cowpox virus in calves, and the method of collection, preservation and packaging the

vac-cine. Recently, McClean’2 developed a lyophil-ized vaccine which makes vaccination possible

in tropical areas where refrigeration is not avail-able.

There has been no uniformity or agreement regarding the method of administering the

vac-cine or the method of scarification. Numerous

lancets, scalpels, points, needles, rakes and drills of various designs were described in the world literature.

J

enner in his original description of arm-to-arm vaccination used a simple lancet to scratch

or puncture the skin, then coated the tip of the

lancet with vaccine material from a fresh

vac-cination, and introduced the material into the

fresh puncture.’ Later, he modified his tech-nique, and used an ivory tip on which the vac-cine was coated.’

Seaton14 in 1867 in describing the technique of performing vaccination mentioned the use

of needles as well as lancets.

The first attempt at introducing medications under the skin by simultaneous multiple skin

punctures was described by Brown in 1867’s This was never used for performing

vaccina-tions.

Rosenthal in 195236 described a method for

administering BCG by means of a multiple

puncture device. He, also, mentioned its pos-sible use in performing vaccination against

smallpox.

The scanifier employed in this study at-tempts to improve on the multiple pressure

technique described in detail by Leake.’7 This method is used almost uniformly throughout the United States, and has re-cently been adopted as the official method in England. This consists of 6 to 10

succes-sive multiple pressures with the tip of a solid round needle in an area an eighth of an inch in diameter within a drop of vac-cine on the posterior (more protected area)

of the upper arm.

(2)

cm.

O.Ocm.[[1J 11Th

VfEW

(TTPtCPL-ALL V1EW3)

220 SMALLPOX VACCINATION

SUBJECTS AND TECHNIQUES

A total of 354 patients were vaccinated with

the experimental scarifiers, and divided into the

following groups:

Sixty-three unvaccinated infants (Group I) were vaccinated with a new type of scarifier which consists of an adhesive bandage with a stainless steel metal plate inserted and taped in

Pl1ce on the adhesive surface of the bandage.

The surface of the metal plate had nine metal

pOiIltS .15 cm long arranged in rows of threes.

The width of the scarifying surface measured .35 cm, which fits well within a drop of vaccine.

1 he points were mounted on a metal platform

O5 cm

TOP

\‘1.W

Fic. 1

\Vilicll was .07 cm thick. The platform rested on

a metal base .06 cm thick. The width of the

metal base measured .9 cm. (Fig. 1).

A second series of 62 infants (Group II) were vaccinated with a similar device, except

that the length of the points was .21 cm and

the width was .29 cm.’8 (Fig. 2).

The technique of vaccination was as follows:

the skin of the lateral aspect of the upper arm was cleansed with acetone in the routine

man-ner and the liquid vaccine of a licensed corn-pan of the U. S. Public Health Service was squeezed on the skin in the customary manner.

The scarifier, which had been autoclaved for

20 minutes, was unwrapped from its sterile

cover. One end of the adhesive bandage was

taped adjacent to the vaccination site on the arm of the subject. The points of the scarifier were brought directly over the drop of vaccine,

and pressed firmly into the epidermis by

apply-ing pressure with the thumb (Fig. 3). The

ad-hesive bandage with the scarifier was then im-mediately removed, taking care not to scratch

the skin adjacent to the vaccine and not to

smear the drop of vaccine. The drop of vac-cine was allowed to dry in place. No cover was

used over the vaccinated area.

Fic. 2

A third series of 122 unvaccinated infants

constituting Group III were vaccinated with the identical vaccinator used in Group II

(length of the points was .21 cm, and the width was .29 cm) except that the technique

(3)

Fic. 4

ARTICLES

vaccine material was dropped directly on the points of the vaccinator, and the device was

brought in contact with the skin (Fig. 4). The scarifier was pressed into the deep layer of the

epidermis. The scarifier was immediately

re-moved from contact with the skin, leaving a

drop of the vaccine material over the area of scarification.

A fourth series of 50 unvaccinated infants constituting Group IV were vaccinated in an identical manner as described in Group III, above, except that the scarifier was formed from “Lucite” plastic. The size, shape and

length of the scarifying points was identical with the dimensions of the metal scarifying

points used with Group III (Fig. 2).

A fifth series of 40 unvaccinated infants

con-stituting Group V were vaccinated with the

same type of plastic scarifier used in Group IV except that the scarifier was mounted on a

curved piece of “Lucite” plastic which fits about the thumb (Fig. 5A-E). The course of a

typical vaccination as performed in Group V is shown in Figure 6.

The reason for performing a series of tests utilizing a plastic scarifier was to demonstrate the feasibility of an inexpensive, disposable,

mass-produced scarifier utilizing the techniques developed in the Group III series.*

In addition, a series of 17 children and adults (Group VI) who had primary

vaccina-tion takes within 7 years were revaccinated with the scarifier employed in Group IV.

A series of 62 unvaccinated infants were

* A plastic scarifier following the construction utilized in the Group V series is commercially available from Lincoln Laboratories, Decatur, Il-linois, under the proprietary name “MONO-VACC.”

vaccinated with the conventional multiple

pres-sure method, using a needle as scarifier. These cases served as controls.

RESU LTS

The results are completely summarized

in Table I.

DISCUSSION

Satisfactory vaccinations were obtained in

all Groups. No instance of multiple scars

occurred. Repeat vaccinations were

neces-sary in six cases from Group II, compared

with four cases from the control group (see

Table I). The superiority of the techniques

used in Groups III, IV and V is cleanly

indicated by the fact that tile highest

per-centage of “takes” was obtained in these

series. The ease and rapidity of

administra-tion of the vaccine is readily apparent. Scarifying the skin takes only 2 to 3 seconds

in all age groups. In Groups III, IV and V,

no aiming of the scanifier against the drop of vaccine is necessary, as it is in Groups I

and II.

Another important finding was the lack

of smearing of the vaccine material

fol-lowing the scarification. This was seen in all the experimental groups. This is due to

the design of the scanifier in which it should be noted that the points of the scarifien are raised on a metal platform (Fig. 5A).

The author’s experience with the old

(multiple-pressure) vaccination technique

was that a substantial number of reports

would be made by parents that the

vac-cinated infant had a high temperature (103

to 104#{176}F,39.4 to 40#{176}C,rectal). With the new scanifier, telephone reports from

par-ents, reporting a high temperature, were extremely rare.

No secondary infections were

encoun-tered in any of the groups and no instance of active bleeding from the site of the vac-cination was noted in any of the

experi-mental groups. Pinpointed serosanguinous

areas were noted over the area of scarifica-tion in the experimental groups. The scars

(4)

7

B

C

F

1

D

E

222 SMALLPOX VACCINATION

4

V

‘-.‘.‘. 1

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1.ceatlu?i of ,

(rruu/ . 1ijpe ofSear,fjer Iaccuse

I ()n skits Metal-. 13 (Iii I)OiIItS On .$5 cm square base

on adhesive strip

,,,, Range of

_Vurnber IllS/UI! 111,11(11 sr of (511/

(If (i.ses I (1/C I(il/SOC ,,

I /.e

(cm)

63 11 1!) 69.5 .40-70

il;

.lIe(111 .“tuislar! N,:e of

I)ersa-.‘i(ur 11(115

(em) (±)

.31 1.13

6 59.2 . 3))- .50 .36 .67

119 3 97.5 .30-5(1 .35 .72

15 2 96. .3(1 .60 .35 .;

1)) 5) lOUiS .3)) .5)) .36 .74

u;

1 93.0

-93. 1 .30- . 9)) .6)) 1 .9

ittitit tine reaction)

Irols On skits Metal needle 62 55 1

Scars of successful vaccinations measured 2 months afterwards.

SMALLPOX VACCINATiON

TABLE I

SUMMAHY OF RESULTS

On skin Metal-.’fl Cm PiIts 6’2

on .29 cm square base

on adhesive strip

Ill On scantier Metal-.21 Clii points t

points on .29 m square base

Oil adhesive strip

I V On scantier Plastk-.’21 cm points .5fl

I)OilltS OII .29 Ciii qare base

OII adhesive strip

On scantier Plastic-.21 III points LI)

points on .29 CIII square base

OIl plastic thumb unit

VI On scantier Plastic-.21 cm points 17

I)oints (re- On .29 cm square base

vaccination) on adhesive strip

(un-tIII(l Il1OC unifornl in size in Groups I, II,

III, lV and V as compared to the control

group; the scars in Groups III, IV and V

being t11( smallest. The cosmetic appearance of tli(’ scars of the experimental groups was

suI)erior to that of the control group. There

was IR) (lifference in the appearance of scars

resulting from tile Group III, IV and V

series. The scanifiens formed from plastic

material that were used in Groups IV and V

pro(Itlced cosmetic scars that were equally

exeelknt as compared to the cosmetic scans

produced by the metal scarifiens used in Group III.

The percentage of “takes” was

remark-able, considering the fact that the metal

scanifiers were handmade prototype models,

and presumably were used with some

de-crease in the sharpness of the points.

The tpare11t lack of pain was well

(1cm-onstrate(l vhen use(l on ol(ler children

and adults. There was a flOtal)le lack of struggling and 1fltlch less crYing in the

iH-fant group receiving the experimental

ac-cinations. This is probably due to the speed

of the procedure. and the fact that the poilits

do not penetrate into the deep dermis. The determination of the length of the

points was important in obtaining good re-stilts. The width of the base of the

vaccina-ton was also an important factor, since it

was found that too large a width prevented tile points from penetrating the skin. The relatively high percentage of failures in

(7)

epidermis. When the scarifying points were

lengthened, the number of failures in Groups II, III, IV and V was greatly re-duced. The addition of the platform to the

vaccinator served to prevent the smearing of

the vaccine material.

CONCLUSION

In comparing the technique of the use of

the scanifier in Groups II, III, IV and V it

is cleanly evident that the method of

“load-ing” the vaccinator witll the vaccine

ma-tenial prior to scarification (Groups III, IV

and V) is superior to the technique of

at-tempting to scarify through a drop on the

skin (Group II). The loading technique

used in Groups III, IV and V gives a higher

percentage of takes, and is recommended.

Tile specific advantage of the thumb plas-tic scanifier over the scanifier carried by the adhesive bandage is that use of the thumb

unit leaves the vaccinator with one hand

completely free to hold the arm of the

sub-ject. Therefore, in vaccinating a young child

or infant, the doctor may hold the child

steady and vaccinate without need of

assist-ance from a parent or nurse. The

thumb-vaccinating unit is recommended as the

de-vice of choice.

SUMMARY

A new device for performing vaccination

against smallpox has been successfully used in 323 patients.

The percentage of vaccination “takes” of the experimental scanifier “loaded” with

vaccine material (Groups III, IV and V) is

greater than the presently-used multiple-pressure method, although the difference is

not statistically significant.

The new vaccinator provides uniformly

smaller and cosmetically superior scans. Struggling of infants and children is elim-inated by this procedure.

The fear of the sight of the currently

employed vaccinating needle is eliminated

in children by the use of this new procedure.

There is less pain with the proposed method since the points are designed to

press into the epidermis, and pricking of the

dermis is minimized.

A vaccination can be performed in 2 to 3

seconds with ease in all age groups.

Acknowledgment

I would like to express my thanks to

Hay-worth Sanford, M.D., Professor of Pediatrics and Chairman of Department, University of

Illinois, and Ira Rosenthal, M.D., Associate

Professor of Pediatrics, University of Illinois, for their aid in preparing this paper; to Noel

G. Shaw, M.D. and John B. Murphy, M.D. for reviewing the manuscript; to Bernard Block, M.D. for assisting in some of the testing

covered by this paper; to Edward Press, M.D., Public Health Director of Evanston Depart-ment of Health, Evanston, Illinois, and Louis

D. Minsk, M.D., Director of Infant Welfare

Society, Evanston, Illinois, for allowing the testing of the vaccinator on patients in their clinics; to Lawrence Toriello of the Department of Photography, University of Illinois and to

Paul C. Jorgensen and Ada E. Clark of the

Department of Photography, St. Francis

Hos-pital, Evanston, Illinois, for taking the

photo-graphs. I would also like to express my appre-ciation to Nadine Slack, Nancy Glauner, Kay Lowenbach and Karen Berns for their aid in

preparing the vaccinators.

REFERENCES

1. Jenner, Edward: An Inquiry into the Causes and Effects of the Variolae Vac-cinae. London, Law, 1798, p. 13. 2. Bretonneau, M.: Bretonneau’s method is

described in a note to Charroy; observa-tion sur Ia vaccine. Jour. de Med. Cell.

23:385, 1805.

3. Galbiati, G.: Memoria sulla inoculazione collumore ricavato immediatemente

della vacca precedemente inoculata. Naples, 1810.

4. Hime, Thomas W.: Animal vaccination. Brit. Med.

J.,

1:1279, 1896.

5. Layet, A.: Traite pratique de Ia

vaccina-tion. Paris, 1889.

6. Worlomount, E.: Remarks on the different methods of collecting, preserving, and

employing animal vaccine. Brit. Med.

J.,

11:449, 1880.

7. Pissin: Reform den Schutz pocken impfung

durch die vaccination direct von der

K#{252}hen.Berlin, 1868.

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226 SMALLPOX VACCINATION

capillary tubes in vaccination. Journal Medical Serums, London and Edin-burgh, 13:229, 1851.

9. Cheyne, R.: Glycerine lymph. Medical

Times, 227, 1850.

10. Andrews: Amer.

J.

Med. Sci., 561, 1857. 11. Collins, C.: A new method of preserving

vaccine virus. Boston Med. Sung.

J.,

58: 122, 1858.

12. McClean, D.: The use of smallpox vaccine.

Bull. W.H.O., 13:437, 1955.

13. Jenner, Edward: Letter to the Reverend

William Pruen of Fladbury. January 14,

1822.

14. Seaton, Edward C.: A Handbook of

Vac-cination. 1868.

15. Brown, A. R.: Acupuncturation instrument. U. S. Patent No. 84,854, December 15,

1868.

16. Rosenthal, S. R.: Vaccination appliance.

U. S. Patent No. 2,619,962, December

2, 1952.

17. Leake,

J.

P.: Questions and answers on

smallpox and vaccination. Public Health

Rept., 42: 221, 1927.

18. Kravitz, H. and Lettvin, N.: Means for vaccinating. U. S. Patent No. 2,817,336,

December 24, 1957.

PREMATURITY: Trw DiAGNosIs, CAwI AND

DISORDERS OF THE PREMATURE INFANT,

Beryl Corner, M.D., Springfield, Illinois,

Charles C Thomas, Publisher, 1960,

587

pp.,

$21.00.

The publisher states on the fly-leaf, “This

book is an endeavor to meet the need of the whole team of workers”-clinicians, investiga-tors, nurses, social workers, etc. This is an im-possible objective, and it is doubtful that the author hoped to achieve it. However, it is

evi-(lent that he did plan a very complete treat-ment of the subject of prematurity. The result is a large book (587 pages), wealthy in detail and in bibliography, with about one-third

de-voted to physiology in the broad sense and the

rest to the clinical aspects of the premature in-fant. Dr. Corner has put much effort into this

work, and the resulting volume has much to

reward the reader.

However, the attempt to be all-encompassing

was unfortunate. The review of the complete

development of the human fetus is so cursory

as to contribute little of value to the physician.

A more thorough description of the develop-ments that take place from the fifth to the ninth month of gestation would be more pertinent. It would be preferable to delete the superficial

treatment of the placenta and devote more

time and space for example, to the metabolic

response to surgery and how to intelligently approach the postoperative patient. The long section on congenital malformations contributes little to an understanding of the problem of

prematurity, and the material is covered ill

essentially similar fashion in most textbooks of pediatrics. In contrast, the important subject of sepsis is relatively briefly treated. The

“epi-demic staphylococcus,” of such concern to all who care for premature infants, is not

men-tioned. Possibly this threat leaped into

promi-nence too recently to have gained entrance into the book. In similar fashion there is no refer-ence to chloramphenicol toxicity and revised

dosage schedules. The inevitable lag between writing and publication was no doubt extended by the broad, possibility overly-broad, approach to the subject.

Despite these failings Dr. Corner’s book is a most extensive effort, but there remains a need for a more penetrating critical review focussed

sharply on the problems of the premature

in-fant presented to the physician working in the

field, interwoven with sufficient information of basic mechanisms to permit an intelligent evalu-ation of current practices.

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1961;27;219

Pediatrics

Harvey Kravitz

A SIMPLIFIED TECHNIQUE FOR VACCINATION AGAINST SMALLPOX

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(10)

1961;27;219

Pediatrics

Harvey Kravitz

A SIMPLIFIED TECHNIQUE FOR VACCINATION AGAINST SMALLPOX

http://pediatrics.aappublications.org/content/27/2/219

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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