Vaccination

VACCINATION (vaccinatio), the artificial inoculation of humans with live cowpox vaccine virus (see).-The vaccination process in the vaccinated person is accompanied by active immunization and the development of insusceptibility to smallpox. The protective power of the first vaccination (vaccination) lasts for several (7-10) years, after which a second vaccination-"revaccination" is necessary.-The beginning of modern V. was laid by the English physician Jenner (Edward Jenner; 1749-1823). In his time, cases of dairy cows contracting smallpox were quite common, and cases of the pustular rash transferring from the udder to the hands of the milker were frequently observed. In the people, there existed an ancient belief that whoever once, even in youth, had cowpox on their hands, was protected for many years or even for a lifetime from contracting human smallpox. Through long-term experimental trials and observations, Jenner became convinced of the validity of this fact. This led him to the thought of the possibility of achieving the same results through artificial inoculation of cowpox in humans. This idea proved to be correct and feasible: on May 14, 1796, Jenner introduced into small incisions on the arm of an 8-year-old boy some material taken from pustules on the hands of a milkmaid who had been infected while milking cows with smallpox. After a few days, the boy developed typical cowpox vesicles. The variolation test performed by Jenner on July 1 remained without result. This brilliant discovery of Jenner quickly spread to all countries of the world. Since Jenner's time, vaccination has undergone significant improvements. Initially, there were several methods for obtaining vaccine material. Until the middle of the 19th century, the most common method was vaccination with the humanized vaccine introduced by Jenner ("from hand to hand"). Pustule crusts forming on the dried pustules of children were also used. However, this did not ensure the constant availability of vaccine material. In addition, with the humanized vaccine, syphilis, erysipelas, pustular rashes and other dangerous diseases were sometimes transmitted. These disadvantages are absent from "animal vaccine", cultivated for V. purposes on calves and cows (see Scab of smallpox). Proposed by Negri in 1842, this method by 1865 had become widespread in almost all European countries. Initially, vaccinations were performed with the contents of pustules taken directly from a calf. A serious disadvantage of this method was the impossibility of prior bacteriological control of the vaccine material. For preservation, calf lymph was dried on plates made of bone, wood, or celluloid. The use of glycerin for the same purpose, introduced in 1866 by Müller, was a turning point in "animal" vaccination. The smallpox scraping not only retains its specific strength in glycerin for a long time but is also quickly cleansed of accidental admixture of ordinary microbes. At present, glycerin scab is used almost exclusively for V. In recent years, the question of standardizing smallpox vaccine in relation to the upper and lower limits of its specific virulence and the permissible number of contaminating microbes has been intensively developed. Thanks to successes in this field, smallpox laboratories can now at any time provide medical organizations with a sufficient amount of impeccable smallpox vaccine, highly active and completely free from admixture of pathogenic germs. The brilliant successes of V. have been overshadowed in recent years by the appearance of "vaccinal encephalitis" [especially in Holland and England (see Encephalitides)]. This complication has deeply alarmed not only medical but also public and political circles abroad, where in many governments commissions of experts have been established to clarify the nature of this complication and measures for its prevention. Voices are being raised demanding the removal of highly virulent vaccine, reduction in the number and depth of vaccination incisions, and generally a review of all details and a radical reorganization of V., if this proves necessary to guarantee the safety of smallpox vaccinations. The very necessity of vaccination and revaccination is however almost universally uncontested. "There are no grounds," concludes the expert to the British government Dr. Andrews (Andrews), "to reject V., which remains the most reliable means against smallpox that we possess". Practice of V. in the USSR is regulated by orders of the People's Commissariat of Health, issued in implementation of the decree of the Council of People's Commissars on compulsory V. (see below). In the RSFSR, vaccination is compulsory for all citizens in the 1st year of life and revaccination in the 11th and 21st years. According to the experience of Germany, triple vaccination of the population is a quite reliable guarantee against the epidemic spread of smallpox. The actual achievement of this ideal is however possible only under certain conditions. The main ones are: 1) rational_ch organization of V., 2) good vaccination technique, 3) impeccable vaccine quality.- Choice of vaccine. At present, glycerin dermavaccine, or smallpox scab, is the generally accepted normal preparation for V. It is considered sufficiently active with a titer of not less than 1:1,000 when tested by one of the control methods in use. In the hands of an experienced vaccinator, it should give no less than 98% success in vaccinating children. Vaccine preserved for more than 3 months sometimes loses virulence even with proper storage (in an icehouse), so it is useful to test any vaccine older than 3 months before mass use by vaccinating several children. In appearance and method of application, it is identical to neurovaccine, proposed for V. by Levaditi and Nicolau and tested in Spain by Gallardo. However, the latter cannot be recommended. Vaccine cultivated for a long time in rabbit brain undergoes biological changes and acquires new properties: the percentage of successful vaccination is relatively low (85-90%), necrotic processes in the vaccinated are not rare, there is an increased tendency to generalization and apparently also a tropism for the central nervous system. These changes in biological properties are accompanied by a decrease in immunizing strength: it has been experimentally proven that neurovaccine protects less against vaccine (and therefore against smallpox) than the dermavaccine commonly used in V. practice. In Spain, only about 100,000 vaccinations have been made with the Gallardo strain, with according to sanitary inspectors not entirely successful results. Technique of V. The act of vaccination, very simple in technique, has its indications and contraindications. Non-observance of these, as well as other precautions necessary for this minor operation, sometimes leads to serious complications and even fatal outcomes. In view of the compulsory nature of V., the rule "nil nocere" must be observed with special strictness. The most convenient age for vaccination should be considered from 3 months to 1 year. At this time, children tolerate vaccination well without particularly strong general reactions, are not inclined to scratch the pustules, and are calm, which cannot be said of older children. Children under 3 months have thin and unclear skin, are very susceptible to erysipelas and purulent infections, and are unable to develop high and stable immunity. Newborns and infants of the first weeks of life are less susceptible to vaccine than older children. Vaccine in such children often does not "take", or in case of success, the vaccination is accompanied only by transient insusceptibility. Since vaccinal encephalitis occurs almost exclusively in children over 1 year old, in some countries (England) vaccination is recommended starting from 2 months of life, with revaccination in primary school age and then before leaving school (advantage: observation of the vaccinated by school doctors). The time of year for vaccinations is in principle indifferent, as vaccinations succeed well all year round. In Bulgaria, for example, vaccination is preferred in winter due to the lesser danger of complications and spoilage of the scab than in warm weather. During strong summer heat, vaccine fever is poorly tolerated by small children, in addition gastrointestinal diseases, very dangerous for them, are more frequent in summer. In view of all this, in many localities of the USSR, spring, late summer and early autumn with their moderate, warm, stable weather are the preferred times for V. Since Jenner's time, vaccinations have been performed on the front-outer surface of the shoulder in the area of attachment of the deltoid muscle: this area of skin is accessible, easy to keep dry and clean, very convenient for various medical interventions, applying bandages, etc. For persons wishing to hide scars, vaccination can be done on the lower third of the thigh on the outside, or on the calves. V. is performed while observing the usual rules of surgery (clean gown, washing hands with soap and warm water, etc.). Before vaccination, the child must be bathed, dressed in clean underwear and a dress with spacious sleeves, nails must be cut short. The field of operation before vaccination is wiped with cotton or gauze soaked in 70% alcohol (residual alcohol is removed with ether). The choice of instruments for vaccination is left to the discretion of the vaccinator.

The most convenient instrument is the Hubert plate needle made of nickel-plated steel, one end of which is shaped like a spear, while the other end is elongated and provided with a small depression for convenient detritus capture. After each vaccination, the instrument is disinfected by wiping with alcohol and ether or by boiling. Contraindications to vaccination are almost always temporary and conditional. Vaccinations are only performed on completely healthy children. The sick, weakened, with a sharp decline in nutrition, febrile, convalescents, etc. are temporarily excluded from vaccination. Vaccination is also contraindicated in all acute infectious diseases, in open tuberculosis, acute rickets, scrofula, in diseases of the respiratory and digestive organs. Impetigo, psoriasis are usually contraindications, as well as purulent inflammation of the middle ear and furunculosis (possibility of secondary infection of the pustules). It is very dangerous to transfer the vaccine to eczematous skin, especially facial skin; vaccination in these cases is postponed until complete recovery. Severe hemophilia and pernicious anemia are almost absolute contraindications to vaccination. During epidemics of measles, scarlet fever, diphtheria, whooping cough, vaccinations are performed only at home; they are postponed with significant development of acute infectious diseases of the central nervous system (encephalitis, poliomyelitis, etc.). During smallpox epidemics, vaccinations are performed universally. Vaccination technique. The child is carefully examined before vaccination, and anamnestic information about his health is collected. Having ascertained the absence of contraindications, vaccination is begun. At present, vaccination is performed almost exclusively by incisions. The operator with his left hand grasps the shoulder in the area of the deltoid muscle, stretches the skin, and, holding the needle moistened with detritus, perpendicular to the skin, makes three incisions, arranging them at the vertices of an isosceles triangle. The incisions should not be more than 7 mm in length, the distance between them not less than 3-4 cm. They should be superficial, not deeper than the papillary layer of the skin, and not bleeding. The vaccinated person remains with the shoulder exposed until the blood and lymph that have emerged from the incision coagulate. The question of the number of vaccination incisions has been vigorously debated in recent times. In view of the alleged danger of encephalitis complications, it is recommended to reduce the length (to 1-2 mm), depth of incisions and to limit their number to one. It has been proven, however, that encephalitis complications are not associated with the virulence of the vaccine, with the strength of the reaction and the number of vaccination incisions. Much more important is the question of how many incisions are needed to ensure solid immunity to smallpox. According to statistics from the Stockwell Hospital in London, out of 703 smallpox patients without a vaccination scar, the mortality rate was 47%, out of 516 patients with an indistinct scar-25%, out of 632 patients with 1 distinct scar-5.3%, out of 677 patients with 2 distinct scars-4.1%, out of 259 patients with 4 or more scars-1.1%.

There are objections that the size and depth of the scar depend not only on the virulence of the vaccine but also on the influence of secondary infections. This does not however diminish the significance of the data presented. They very clearly show that the chances of acquiring immunity to smallpox are the higher, the greater the number of scars. Reducing the number of incisions to one threatens to make the effect of vaccination illusory. In some countries (Austria) intradermal and subcutaneous vaccination is still practiced. Both of these methods cannot be recommended. They are troublesome, painful, require the use of diluted vaccine, and this dilution (usually 1:100) must be proportional to its virulence. The vaccine must also be free from foreign germs. Intradermal vaccination is accompanied by an infiltrate that does not disappear for 6-8 weeks or more. The danger of generalized vaccinia and encephalitis by this method of vaccination is not excluded. Due to the absence of scar formation, the result of intradermal and especially subcutaneous vaccination is almost impossible to control, and the strength and duration of immunity are less than with the ordinary method of vaccination. Recently, the question has been raised of developing a method by which the degree of immunity achieved could be determined in vitro or experimentally on animals and in vitro. Care of the vaccinated person in the normal course of vaccination consists in observing the following rules: keep the child clean, keep the vaccination site dry and cool, do not touch the pocks unnecessarily, and protect them carefully from damage. For the first 3 days after vaccination, the child can be bathed; starting from the 4th day, only local washing is limited, avoiding wetting the pocks. Nutrition and the entire lifestyle of the child remain normal. It is necessary to carefully protect the child from contact with persons suffering from acute infectious diseases, skin rashes, erysipelas, etc. Unvaccinated children must be kept away from contact with vaccinated children and in no case should they sleep with them in the same bed. With proper development of pocks, applying a bandage is superfluous. Clinic of vaccination. During the first minutes after vaccination, only slight redness and swelling are observed at the site of vaccination—"traumatic reaction". Only by the end of the 3rd or beginning of the 4th day does a small, raised, reddish nodule appear, which increases the next day and becomes flat. On the 5th day, a narrow rim of redness, or areola, forms around the nodule. This is followed by the transformation of the nodule into a pock: at its apex, fluid exudes, forming a multi-chambered vesicle, which, gradually increasing, reaches its greatest development on the 7th day. A developed pock is about 8-9 mm in diameter, of a beautiful pearl-pink color, with even, steeply raised edges and a navel-like depression in the center. By the 8-10th day, a second rim of redness appears around the pock—a wider and lighter one, merging without a sharp boundary into the surrounding healthy skin (areola) [see separate table (Vol. XXII, pp. 439-440), Fig. 2]. The intensely red tint of the areola sometimes gives rise to confusion with erysipelas. With the development of pocks, certain general phenomena also gradually become apparent. On the 4-5th day, there may already be a slight increase in temperature, but the fever characteristic of the vaccinal process appears only between the 7-10th day. At the same time, swelling and pain in the axillary lymph glands appear. From the 9-10th day, the reverse development of pocks begins. From the 11th day, the pock begins to dry, turning into a brown, then black crust, which falls off spontaneously on the 4th week. At the site of the pocks, a white, shiny, radially structured scar remains. Vaccinated persons are usually examined on the 7-8th day to determine the results of vaccination. Vaccination is considered successful even with the presence of one properly developed pock. Due to the danger of encephalitis, a double examination is recommended: between the 7-10th day and between the 14-17th day after vaccination (England). Clinic of revaccination. In contrast to the uniform stereotyped course of vaccination in primarily vaccinated persons, revaccination shows extreme diversity in the clinical picture: the entire range of transitions from a red spot or nodule to a typical pock is observed. All the variety of forms of revaccination, according to Pirke's terminology [see separate table (pp. 39-40), Fig. 4], can be divided into 3 groups. 1. Allergic, or early reaction. From the 2nd day, itching is felt at the vaccination site. On the 2-3rd day, and sometimes earlier, a slight swelling or even a nodule sitting on a reddened base appears. The reaction is characterized by rapid appearance and equally rapid reverse development (within 2-3 days). 2. Modified pocks. After 3-5 days, a small vesicle develops, surrounded by an areola of varying size. The development of the pock proceeds slowly, with the formation of a clearly expressed areola, which sometimes has a hemorrhagic character. 3. Typical revaccination pocks. The reaction closely resembles the development of pocks in primarily vaccinated persons, but the entire process and its individual periods are shorter than in vaccination. In the state statistics of the RSFSR, the formation of at least one nodule or vesicle surrounded by a clearly expressed areola is considered a sign of successful revaccination. The nature of the reaction depends on the degree of immunity retained by the vaccinated person from previous vaccination. The highest degree of immunity, together with the presence of increased sensitivity, is expressed in the "early reaction"; the development of typical pocks indicates a complete loss of non-susceptibility. Duration of immunity after vaccination. As experimentally proven, e.g., by Sacco's experiments with variolation of vaccinated individuals, immunity after primary smallpox vaccination arises on the 6-10th day with a maximum on the 11-13th day. Over time, it gradually fades. On average, in Europeans it lasts about 8 years with quite significant individual variations (from 4 months to 10 years and more). As observations during smallpox epidemics show, the protective power of vaccinations weakens in many cases after only 4-5 years, after 5-10 years it significantly decreases or ceases altogether; according to Koyamada, 4% of vaccinated individuals lose immunity after one year, 83% after 4 years. At the same time, non-susceptibility to the vaccine also decreases. The older the age of the vaccinated person (vaccination in childhood), the higher the percentage success of revaccination. On the basis of very extensive material, the health authorities in Germany conclude that vaccination protects against infection with smallpox for 10 years, and against fatal disease for 20 years. The duration of immunity after smallpox vaccination depends mainly on the amount and virulence of the vaccine introduced (number and size of vaccination scars—see above), and then on individual characteristics of the vaccinated. It has been experimentally proven that with a small number of isolated pocks in a rabbit, only slight immunity to the vaccine develops. According to Voigt, fresh, strong variola vaccine protects much more reliably against smallpox than old vaccine weakened by long cultivation on calves. Apparently, decisive importance belongs to the biological peculiarities of individual vaccine strains. The variability inherent in other microbes is also highly characteristic of the smallpox virus. Depending on the method of vaccination, on conditions of stay in various animal tissues, the biological properties of the smallpox virus change to a sharp degree, and with them the immunizing ability also changes (decreases). For example, vaccine introduced under the skin of a rabbit causes a specific reaction but loses the ability to vaccinate the skin of another rabbit. Therefore, proposals to use for human vaccination neurovaccine, orchivaccine, etc., must be treated with great caution. The role of individual and racial "predisposition" to smallpox and to the vaccine is little clarified in essence. In many people, under the influence of a single vaccination, non-susceptibility to smallpox is created for life. In others, with repeated vaccination after 1-2 years, complete success is obtained each time. According to some authors, the black and yellow races are especially predisposed to smallpox, as well as Eskimos, natives of Siberia, and some other peoples. In childhood, immunity to smallpox is lost sooner than in mature age, which is probably explained by the greater rapidity of tissue metabolism in children. Abnormalities and complications of the vaccinal process in humans. When performed lege artis, with observance of indications and contraindications, smallpox vaccinations almost always proceed only with the minor painful phenomena described above. Sometimes, however, vaccination is accompanied by "vaccinal harms," sometimes distressing and even dangerous. All cases belonging here are divided into 2 groups according to etiological criteria: 1) abnormalities related to biological peculiarities of the vaccine virus, 2) complications with secondary infections of wounds. 1. Abnormalities related to the vaccine. With accelerated development of vaccination, a mature pock is already present on the 7th day, sometimes of a waxy color. This abnormality is observed predominantly in summer, in children suffering from scrofula, rickets, and lethargy.

Delayed development of the vaccine is described, when pustules appear only on the 7th, 10th, 14th day after vaccination and even later; it is observed in vaccinated individuals with intercurrent diseases (diarrhea, childhood infections, etc.). In very exhausted children, the vaccine takes the form of the so-called 'cachectic reaction.' The pustules are soft and easily subject to mechanical damage. The areola is absent or appears late as a narrow ring. Between the 8th-12th day, rashes similar to measles or rubella may appear on the face and trunk. They last 2-3 days and disappear, leaving rapidly passing pigmentation. In other cases, the rash resembles urticaria, exudative erythema, or scarlet fever. The cause of vaccinal exanthems is not clarified. They are most often observed in primarily vaccinated children during hot summer weather. With delayed immunity development, creeping vaccination (vaccina serpiginosa) is observed. The growth of pustules continues beyond the normal period, they reach a large size, and secondary or satellite pustules develop in the same manner. Recovery can be delayed for several months. This anomaly represents a transitional stage to the rarely observed vaccina generalisata—a general eruption of pustules over the entire surface of the skin, occurring through the hematogenous route. Generalized vaccination is usually detected on the 8th-10th day. The pustules only rarely reach full development (on the 10th-13th day) and resolve without scar formation; sometimes, however, recovery is delayed for several months. Fatal complications with septicemia and vaccina generalisata hemorrhagica with fatal outcome have been described. Sometimes after 7-9 days of normal development, the pustules undergo necrosis, and deep crater-like ulcers form in their place. The cause of this phenomenon is not clarified. Apparently it lies in the increased toxicity of certain strains of the smallpox virus. This anomaly is relatively often observed after vaccination with neurovaccine and in very weakened, cachectic children. Recovery occurs slowly, and a deep, irregularly shaped dense scar remains at the site of the ulcer. 2. Complications of the vaccinal process. Vaccination incisions, like any other violation of skin integrity, can give rise to various wound infections. Secondary infection occurs either due to contamination of the fresh incision, e.g., through contact with dirty linen, clothing, etc., or later—usually on the 8th-9th day, when, due to the developing itching, scratching of the pustules most often occurs. Erysipelas belongs to the very rare complications. Early and late vaccinal erysipelas are distinguished. The first appears on the 2nd-4th day after vaccination, the second—from the fifth day and later. The cause is external contamination of the vaccination site. Late erysipelas (when it appears on the 8th-9th day) is sometimes difficult to distinguish from the normal vaccinal areola, especially in cases of revaccination. Prevention of erysipelas consists in careful observance of aseptic rules during vaccinations and in maintaining the utmost cleanliness in the child's entire environment. In children suffering from impetigo contagiosa, vaccination is often complicated by this infection, which almost always leads to the purulent breakdown of the pustules. Complications with other acute infectious diseases. The disease of scarlet fever contributes to a severe course of vaccination; measles, on the contrary, has a suppressing effect. Diphtheria is somewhat aggravated under the influence of vaccination, while whooping cough takes a more favorable course. A special group of complications consists of cases of transfer of the smallpox virus from vaccination pustules to other parts of the body. They sometimes lead to serious disturbance of health (e.g., when the organ of vision is affected). Mostly it is a matter of autoinoculation: when scratching the pustules, the vaccinated individual contaminates the fingertips with lymph and, by scratching various areas of the skin with the nails, transfers the smallpox virus there. Sometimes the vaccinated individual becomes a source of transferring vaccination to others (when sleeping together, using common linen, baths, etc.). Cases of transfer to the genitals, eyes, etc., have been described. Very dangerous (up to 40% mortality) is the transfer of vaccination to eczematously altered areas of skin—eczema vaccinatum (it also often occurs through the hematogenous route). The surface of the affected skin acquires a dirty-gray color, and numerous confluent or separate eruptions with all the signs of typical pustules form along its periphery. Fever appears, the height and duration of which correspond to the size of the affected area. In the most severe cases, especially in infants, death may occur with signs of general infection (delirium, loss of consciousness, rapidly increasing cardiac weakness). With severe hemophilia, the vaccination incision may be accompanied by fatal bleeding, and with pernicious anemia, leukemia—it can exacerbate these diseases and cause death. Complications in vaccination are a great rarity. They cannot influence the assessment of vaccination, which remains the only means against the development of smallpox epidemics. Organization of Vaccination. Legislation. The first law on compulsory vaccination in the USSR was issued on April 10, 1919, signed by V. I. Lenin. The main requirements of the resolution of the Council of People's Commissars of the RSFSR of October 18, 1924, are as follows. 1) All without exception citizens residing on the territory of the RSFSR are subject to compulsory vaccination (vaccination) during the first year of life and again (revaccination) at ages 10 to 11 years and at ages 20 to 21 years. 2) 'In case of an outbreak of smallpox... executive committees are obliged to take measures to organize mass compulsory vaccination of the entire population of the affected area or of separate groups of it.' Further orders of the People's Commissariat of Health of the RSFSR have significantly expanded the contingents of citizens subject to compulsory revaccination (those entering educational institutions, state service, etc.). Similar laws have been enacted in almost all union Soviet socialist republics. In Belarus, according to the decree of April 10, 1925, vaccination is compulsory in the 1st year of life, revaccination in the 11th year and in the 21st year. In Ukraine, according to the decree of January 20, 1925, compulsory vaccination is required for 1) all children during the 1st year of life, 2) all citizens of other ages who have not yet been vaccinated. Revaccination is compulsory for all citizens at ages 7-8 years, 14-15 years, and 20-21 years. From the Transcaucasian union republics, compulsory vaccination was introduced in Georgia in 1923, and in Azerbaijan and Armenia in 1925. The terms of compulsory vaccination are established: in Azerbaijan and Georgia in the 1st year and upon reaching 7 years, in Armenia in the 1st year, upon reaching 10 years and upon reaching 20 years. In these 3 republics, compulsory revaccination is also established for students, Red Army soldiers, workers and employees, etc. General guidance of vaccination belongs to the People's Commissariat of Health (development of legislative proposals, control over vaccination, supply of vaccine virus, etc.). Executive committees are granted the right to issue regulations establishing the compulsory nature of revaccination for certain groups of the population. The responsibility for conducting vaccination through health departments lies with the executive committees. The latter are tasked with developing a vaccination plan, supplying vaccination points with vaccine virus, forms, sanitary-educational literature, and compiling and implementing budgets for vaccination. Direct management of vaccination and responsibility for it is entrusted to sanitary and district physicians according to their jurisdiction. Smallpox vaccination and issuance of certificates in this regard are provided free of charge. All official institutions and individuals are supplied with vaccine free of charge from state smallpox institutes and laboratories. Almost everywhere a mixed, household-by-household and point system of vaccination has been adopted. In rural areas, it is conducted mainly through household visits. Unlawful evasion of vaccination is punished in accordance with Article 219 of the Criminal Code (fine up to 300 rubles or compulsory labor up to 3 months, by decision of the people's court). Statistics of Vaccination and Forms of Record Keeping. Planned organization of vaccination is possible only with the necessary statistical information for this purpose. The procedure for collecting it, forms of record keeping are provided by the relevant orders of the People's Commissariat of Health. The most important are: 1) systematic accounting of contingents subject to compulsory vaccination, 2) accounting of persons who received vaccination, 3) accounting of vaccination results (separately for primary vaccination and revaccination); accounting of births is carried out on the basis of information available in the departments of registration of civil status (ZAGS), by agreement with them; accounting of persons subject to compulsory revaccination is carried out through police and housing management authorities in cities and through district and rural soviets in rural areas. In vaccination statistics, 2 types of records are usually used: an ordinary list and individual-card registration. The advantage of the latter is that it facilitates both obtaining information and especially its further processing. Name lists are compiled in alphabetical order of surnames, with indication of first name, patronymic, age, and place of residence of persons subject to vaccination. The existence of such lists greatly facilitates the compilation of a calendar plan for vaccination, routes, etc.

Regarding the vaccination performed, examination, etc., the vaccinator makes appropriate notations on the lists, then enters data about each vaccinated person onto individual cards, counts them, and based on them compiles a summary report on the work and sends it for further detailed development to the person (sanitary doctor, district doctor) or institution (rayzdrav) in charge of the matter of V. The name lists remain in the vaccinator's archive as reference, control, and justifying material about the work performed. The ultimate goal of V. is a 'successful' vaccination. It is therefore very important to consider not only the fact of vaccination for a given person, but especially the result of this operation. Verification of V. with appropriate statistical accounting is absolutely necessary and mandatory. Any statistical report on V. is completely devalued by the absence of the columns 'verified' and 'result of vaccination.' The examination of vaccinated persons is performed on the 8th day after vaccination, of revaccinated persons - somewhat earlier, on the 5-6th day. Organization of V. abroad. a) Legislation. The most significant data on legislation regarding vaccination in European countries are grouped in Table 1. Sample card for vaccinated persons. 1. Serial number..........2. Vaccination, revaccination. 3. Sex: male, female.4. Year and month of birth....... 5. Surname, name, patronymic....:.............................................................. 6. Place of residence: city..........street...........house # apartment..... 7. District........................................., village........................................... 8. Occupation: student, worker, employee, unemployed, pre-conscription.................................................................... 9. Time of previous successful vaccination........................ y...........month...........date................................................... 10. Time of having had smallpox..............y..... month........... A. Vaccination performed.............. month........date........193.. Lymph from..............Institute, series JY»..................... Signature of vaccinator............ B. Verification performed....................month...... .......... date........... 193.......y. , Results of vaccination: Successful, number of pustules developed____ unsuccessful.............. Revaccination: no reaction, early, modified, typical pustules. Complications: Signature of examiner................................ Countries where V. is conditionally mandatory: England, Holland, Norway, Belgium, Austria. Characteristic of them is such a wording of Table 1. Country Name Date of law on mandatory V. Content of law on mandatory V. Bulgaria . . Hungary . . . Germany . . Denmark .... Spain . . . Italy. . . . Latvia .... Luxembourg Poland . . . Portugal Romania . . . Finland . . . France . . . . Czechoslovakia Sweden . . . . Estonia . . . . Yugoslavia . . . 1845, 1904 1876, 1887 10/ IV 1875 1810 and 2/IV 1871 1815, 1891, 1903, 1919, 1921 22/XII 1888, 30/XII 1923 17/I 1928 27/VI 1906 19/VII 1919 2/III 1899, 26/V 1911 1847, 1874 22/XII 1879, 17/XI 1883, 1920 15/II 1902 1816 and 7/V 1926 1924 14/Ш 1925 Vaccination is mandatory for children within the first year of life. Revaccination is mandatory upon entering school and at age 21 Vaccination is mandatory within the 1st year of life. Revaccination - within the 12th year Those subject to vaccination: 1) every child within the calendar year following the year of birth, 2) every pupil of a public educational institution or private school within the year in which they turn 12. A certificate of V. is required upon entering school. Everyone who has not had smallpox must be vaccinated before reaching 7 years of age. Admission to schools, to marriage, to confirmation is conditional upon presenting a certificate of V. V. is mandatory: 1) for all children within the first 6 months of life, 2) for all not vaccinated within the last 6 years; 3) for all entering educational institutions and child care institutions All children are subject to vaccination within the first 6 months of life. Revaccination is mandatory at age 9 Vaccination is mandatory within the 1st year of life, revaccination - at age 12 Vaccination is mandatory for children in the 1st year of life, revaccination - within the 11th year The entire population of Poland must be vaccinated against smallpox: primarily - all children within the 1st year of life, secondarily - all children up to 6 years; in addition - all persons who for some reason have not yet been vaccinated Vaccination and revaccination every 7 years is mandatory Vaccination is mandatory for all children over 3 months, revaccination - upon reaching 10 years of age. A certificate of V. is required upon entering school Vaccination is mandatory. Revaccination is mandatory only in certain cases: during smallpox epidemics and in the event of a smallpox epidemic threat, all who have not been vaccinated within the last 5 years must be revaccinated Smallpox vaccination is mandatory within the 1st year of life, revaccination - within the 11th and 21st year Vaccination is mandatory in the 1st year of life and revaccination within the 7th and 14th year Smallpox vaccination is mandatory no later than within the calendar year in which the child turns 6. Revaccination is mandatory only for military personnel, customs officials, doctors and other medical personnel, and for the entire population during smallpox epidemics Vaccination is mandatory All children over 3 months are subject to vaccination. Revaccination is mandatory for all children over 10 years attending educational institutions law, which allows many to evade its execution without punishment, making the 'mandatory' nature of V. illusory (Table 2). incisions by the latest decree is prohibited; only a 1-inch linear incision not longer than ¹/₂ inch is prescribed. Table 2. ! Country Name Date of law on V. Content of law on V. 9/IV 1892 1867, 12/VIII 1898, 1907 18/IV1818, 4/II 1895, 31/VII 1897, 1/III 1906 4/XII 1872, 1919 3/IV 1810 V. is indirectly mandatory for certain population groups. It is particularly strictly controlled in schools. Revaccination is mandatory in the army (since 1876) Parents or guardians are obliged to vaccinate the child within the first 6 months of life, but they are exempt from any punishment if within 4 months from the child's birth they officially declare that in their opinion vaccination will harm the child's health A certificate of V. is required from all entering school. V. is mandatory for certain population groups: for workers sorting wool - vaccination, for entering school and army - vaccination and revaccination V. is mandatory for schoolchildren and those entering school. The effect of this law has been temporarily suspended (since 1/1 1929) V. is mandatory for students of all higher schools, for military personnel, for those wishing to confirm in the Lutheran church, for those marrying In Switzerland V. is mandatory only in some cantons. Of non-European countries, Japan deserves mention, where V. is mandatory by law of 1864. All regulations on V. were codified in 1885 and 1909. By virtue of them vaccination is mandatory for every child under 6 months, revaccination - within the 10th year of life. A certificate of V. is required from all entering school. Of non-European countries V. is also mandatory in: Egypt, Brazil, Bolivia, Venezuela, Haiti, Guatemala, Mexico, Peru, Uruguay, Ecuador. The picture of V. in the USA is characterized by great originality and variety. Along with general mandatory V. (Columbia, Kentucky, Maryland), there are numerous forms of indirectly mandatory and conditionally mandatory V. (mostly requiring a certificate of V. for school entry). In California, by law of 1911, 'conscientious objection' was introduced on the English model. Finally, in the states of Arizona, Minnesota, North Dakota and Iowa, any form of mandatory V. is prohibited by law. Practice of V. abroad. In Germany, all federal states are divided into vaccination districts. Each is under the supervision of a doctor who performs smallpox vaccinations annually from May 1 to the end of September. Vaccination points are chosen so that any populated place in the vaccination area is no more than 5 'vaccination hours' away. V. is performed exclusively by doctors. Extensive propaganda for V. is carried out (reports, demonstrations, cinema, press, school teaching). Making vaccinations in hospital institutions is prohibited by special decree. Examination of vaccinated persons and performance of revaccination is prescribed to be done in separate rooms. In England V. is entrusted to the poor guardians. Each administrative council appoints the necessary number of vaccinating doctors and non-medical personnel (vaccination officer), whose duty is to implement the requirements of the vaccination law. Vaccination is performed almost exclusively at home. Making, as was previously established, 4 vaccination incisions Accounting and control of V. In many countries (Germany, Yugoslavia), control and accounting of V. are facilitated by the fact that municipal authorities, directors of educational institutions, etc. are obliged to present to vaccinators lists of persons subject to vaccination and revaccination.

In Bulgaria, lists of births are compiled twice a year: at the beginning of March and at the beginning of September. On the basis of these lists, a plan for vaccination is drawn up, the required amount of vaccine is obtained, etc. The place and time of vaccination and inspection are strictly recorded. The registration of vaccination results is carried out by a special commission with the participation of representatives of local authorities. In Mexico, the hygiene bureau has mobile (automobile) vaccination teams that perform vaccinations at home, in schools, workers' centers, railway stations, etc. The bureau maintains a daily record of vaccinations and revaccinations and issues certificates free of charge. In Norway, each vaccination is entered in a special register and is subject to mandatory inspection on the 8th day, carried out by the district physician. In Sweden, the inspection is carried out by the vaccinator himself. However, in rural areas, another person--an inspector ('examiner') for checking vaccination results--is sometimes appointed for this purpose, trained for this role in special courses for checking vaccination results. In England, the person registering a birth is obliged no later than 8 days from the registration of an unvaccinated child to send the parents or guardian of this child a summons with an offer to perform vaccination. A certificate of vaccination indicating its results is sent by the vaccinator to the official responsible for conducting vaccination (vaccination officer). In Czechoslovakia, vaccinations are performed in the presence of a) a vaccinating physician, b) a representative of state authority (duties: maintaining order during vaccinations, ascertaining the reasons for children's failure to appear at the vaccination point, etc.), c) a community secretary (duties: checking lists, filling in statistical categories according to the physician's instructions, etc.). At the end of the session, the physician and secretary review the lists, identify the absentees, etc. The physician informs the municipal authorities of the absentees to request an explanation from the parents of the child for the absence. Vaccination inspection is carried out on the 8th day in the presence of the aforementioned persons. Vaccination is considered successful if there are at least 2 well-developed pustules. By checking the lists, the following is determined: 1) the number of vaccinated persons, 2) the number of successful and unsuccessful vaccinations, 3) the number of children permanently exempt from vaccination, 4) the number of children temporarily exempted from vaccination, 5) the number of children unlawfully evading vaccination, 6) the number of children who came for vaccination from other communities. Those unlawfully evading vaccination are entered in a special list. The municipal authority is obliged to bring these children for vaccination with a fine imposed on the parents in case of evasion. In case of unsatisfactory vaccination results in a given district (high percentage of evaders, etc.), the vaccinating physician again schedules a vaccination session in this district. For disobedience to the vaccination law in France, a fine of 1-5 francs is imposed; in case of relapse--from 1 to 3 days in prison; in Sweden a fine up to 20 kronor, in Germany a fine up to 50 marks or arrest up to 3 days, in England a fine up to 20 shillings, in Bulgaria a fine from 25 to 500 leva, in Spain a fine from 5 pesetas (in special cases up to 500-1,000 pesetas), in case of relapse--imprisonment in a correctional prison with a fine corresponding to the severity of the offense. In Mexico, those evading vaccination are fined 1-10 piastres, then subjected to vaccination. In case of refusal--they are arrested for 36 hours at the hygiene bureau. If they agree to vaccination, the arrested person is immediately released, if they persist--they are detained until the 36 hours have expired and are fined again (in case of non-payment--additional arrest for 1 day). Owners and directors of factories, plants, workshops, industrial enterprises, etc. are obliged to ensure compliance with the vaccination law by workers and employees. For non-compliance--a fine from 5 to 50 piastres, for the first relapse--double, for the 2nd and subsequent--up to 500 piastres. Despite the absence of mandatory vaccination, the population of some Western European countries is well immunized against smallpox: thus, in Belgium and Austria the population is virtually universally vaccinated and enjoys complete freedom from smallpox. Among 22 European countries for which reliable statistical data are available, in 1928 there was not a single case of smallpox in Austria, Bulgaria, Denmark, Gibraltar, Norway, Holland, Sweden, and Yugoslavia. In Austria, no case of smallpox has been recorded since 1923, in Denmark and Sweden since 1925. M. Morozov.