Vaccinations

VACCINATIONS, prophylactic and therapeutic, are the introduction of vaccines, sera, or non-specific substances into the organism for prophylactic or therapeutic purposes. Vaccinations are performed either for the purpose of prophylactic vaccination and serovaccination, when vaccines or sera are introduced into the organism, or for the purpose of specific treatment, when sera or vaccines are used, or, finally, for the purpose of non-specific protein therapy (see). Historically, the first vaccine used for a prophylactic purpose was Jenner's vaccine (see Smallpox Vaccination); the next stage in the development of the issue was the work of Pasteur (see Pasteur vaccinations). Behring and Roux, who used antitoxic serum for the treatment of diphtheria, are the founders of serum therapy. Behring, moreover, began to use a mixture of diphtheria toxin and serum for vaccination against diphtheria and thus laid the foundation for serovaccination. The latest stage in the history of vaccinations is the use of convalescent sera for the purpose of immunization (Degkwitz—for measles). Vaccinations are based on the fact that immunization confers upon the organism a more or less pronounced immunity to a given disease (active immunization, vaccination) or—in the case of passive immunization—neutralizes microbial products (toxins) present in the organism; the basis of protein therapy lies in the fact that non-specific substances introduced into the organism (mainly proteins) increase its resistance in general (Much's non-specific immunity). Vaccinations are widely used for the purpose of prophylactic vaccination against various infectious diseases. Most effective are those vaccinations in which live attenuated microbes or viruses—the causative agents of the given infection—are used as the vaccine; but even when using such vaccines, the acquired immunity does not have an absolute character and is not maintained throughout life. The use of live vaccines is hindered by the circumstance that such vaccines are not absolutely harmless; in view of this, for some diseases, killed cultures of microbes are used for the purpose of vaccination; killed vaccines are harmless, but the immunity they confer is even less robust and durable than the immunity resulting from the introduction of live attenuated vaccines. Due to this, both when using attenuated vaccines and when using killed vaccines, it is necessary to resort not only to vaccination but also to revaccination, i.e., repeated vaccination. For some infectious diseases that leave behind antitoxic immunity (diphtheria), anatoxin (see) is used as a vaccine. Prophylactic vaccination is of the greatest importance for smallpox (live attenuated vaccine), for intestinal infections (cholera, typhoid fever, paratyphoid—killed vaccines), and for diphtheria (anatoxin). Vaccinations for therapeutic purposes are performed predominantly for those infections in which the causative microbes secrete a toxin that poisons the organism; serum treatment of diphtheria, tetanus, botulism, and gas gangrene is of the greatest importance. Such antitoxic sera can also be used for prophylactic purposes (passive immunization) in cases where infection has already occurred or must inevitably occur due to close contact with a highly contagious infection; thus, in the presence of wounds with crushed tissues, it is appropriate to inject anti-tetanus and anti-gangrene sera for the purpose of preventing the development of tetanus and gas gangrene. Serum treatment is also used for some infectious diseases whose causative agents do not secrete a true toxin; such sera are antibacterial; their action is based partly on the fact that they possess bactericidal properties, partly on the fact that they increase the content of opsonins and other antibodies in the organism, and partly on the fact that they exhibit a non-specific effect. Such sera are used for epidemic cerebrospinal meningitis, for streptococcal diseases, for tuberculosis, etc. Vaccinations of vaccines (vaccinotherapy), proteins, and other non-specifically acting substances (protein therapy, non-specific therapy) are also performed for therapeutic purposes. Vaccination materials (vaccines, sera, proteins) are most often introduced subcutaneously; along with this, introduction into the skin (into a superficial incision of the skin or into the thickness of the skin), into the bloodstream, into the muscles, and into the spinal canal is also used; besides these parenteral methods of introducing vaccination material, its introduction per os is also used (vaccination against cholera, typhoid fever, dysentery). Vaccinations performed parenterally are usually accompanied (if it concerns the introduction of vaccines, proteins, etc.) by a reaction consisting of local phenomena at the site of vaccination (pain, infiltrate) and general phenomena (increase in temperature, general weakness, malaise). When using sera, one must always reckon with the possibility of anaphylaxis phenomena (see Serum sickness). The place occupied by vaccinations in the system of prophylactic and therapeutic measures in the fight against infectious diseases is currently very significant. For some diseases (smallpox, rabies, diphtheria, tetanus), vaccinations are the main measure of control; for other infections (cholera, typhoid fever, paratyphoid), their importance is less, but even here they are an essential link included in the system of measures for combating these diseases. The effectiveness of therapeutic and prophylactic vaccinations against many infections has been proven by a sharp decrease in morbidity and mortality. Such results have been obtained, for example, with vaccination against smallpox and with serum treatment of diphtheria. By means of vaccination, it is possible to completely eliminate smallpox and reduce the incidence of typhoid fever, paratyphoid, dysentery, cholera, etc. The effectiveness of other vaccinations is either controversial or not yet fully clarified (plague, epidemic meningitis, scarlet fever, etc.). In individual cases, after various vaccinations, different complications are observed, for example, with the use of anti-rabies vaccinations—paralysis, with smallpox vaccinations—post-vaccinal encephalitides.

V. Lyubarsky. Organization of mass preventive vaccinations. The main indication for conducting mass preventive vaccinations is the presence of a threatening or beginning epidemic when it is impossible or difficult to eliminate it quickly or reliably prevent it by more radical means—by carrying out sanitary-hygienic measures. Smallpox vaccinations stand apart, as they are carried out systematically year after year, regardless of the threat or presence of a smallpox epidemic (see Smallpox vaccination). Occupying a definite place in the system of anti-epidemic measures, preventive vaccinations are carried out mainly according to a plan, which constitutes a part of the general operational plan for fighting epidemics. In annual plans for conducting vaccinations, the following elements must be provided for: 1. A list of populated areas where vaccinations must be performed. This list is compiled on the basis of available data on the epidemiological state of populated areas in a given district, region, or territory. Regarding smallpox vaccinations, all populated areas without exception are entered into this list; regarding other vaccinations—only points that are endemic for the corresponding infections or that present favorable conditions for their development due to their sanitary state, especially with the simultaneous danger of the introduction of infection from outside (e.g., high population turnover). 2. Contingents of the population subject to vaccination in each of the designated populated areas. Such contingents are: a) specific age groups (e.g., in relation to vaccinations against childhood infections—children under the age of 12-15); b) specific professional groups most threatened by the corresponding infections: military personnel, transport workers and employees, students, etc.; in relation to vaccinations against gastrointestinal infections, additionally workers and employees of communal institutions and food enterprises; c) moving masses of the population (migrants of all categories); d) in individual cases—the entire population of a given point or district (smallpox and cholera vaccinations—in the presence of even single cases of these diseases; vaccinations against typhoid fever and paratyphoids—in the event of a threat of their sharp epidemic development). 3. Control figures for vaccinations for each populated area and district are established by an approximate count of all contingents subject to vaccination. Necessary information is obtained from the relevant statistical bodies, as well as institutions, enterprises, schools, etc. 4. Timing of conducting vaccinations. When establishing these dates, it is necessary to take into account both epidemiological considerations and living conditions. Smallpox vaccinations, since they provide immunity for a number of years, can be performed throughout the year; due to living conditions, mass smallpox vaccination campaigns are more convenient to perform in the spring and late autumn. Immunity after vaccinations against typhoid fever and paratyphoids reaches its maximum 2 weeks after the last vaccination and holds, without weakening, for at least 6 months; therefore, mass vaccinations against typhoid fever and paratyphoids are recommended to be started approximately no earlier than April and finished by June 1. Immunity after vaccinations against diphtheria occurs relatively late (3-4-5 months after immunization with mixtures and 4-5 weeks after immunization with toxoid) and lasts for many years; immunity after scarlet fever vaccinations (with combined vaccine and toxin) occurs 2-3 weeks after the last vaccination and lasts for about a year. Mass vaccinations against diphtheria are therefore more convenient to perform in the 4th and 1st quarters, vaccinations against scarlet fever—in the 1st and 2nd quarters. 5. The need for vaccination material is determined based on the planned control figures for vaccinations and the consumption norms of this material per vaccinated person. These norms can be accepted on average as follows: a) for smallpox detritus—2.5 doses per vaccinated person (understanding by dose the amount of detritus consumed for 3 scarifications, i.e., approximately 0.01 cm³); b) for cholera, typhoid, and paratyphoid vaccines (as well as di-, tri-, and tetra-vaccines)—4 cm³ per vaccinated person; c) for diphtheria toxoid and scarlet fever vaccine—2.5 cm³ per vaccinated person. Vaccines, like all bacterial preparations, are produced in bacteriological institutes, from where they are obtained by health departments and their pharmacy administrations. One should avoid shipping mass vaccines (except smallpox detritus) in the cold season in unheated railway cars to avoid freezing the vaccines, which makes them unfit for use due to the formation of non-dissolving flakes and bacteriolysis in the thawed vaccine. (Regarding the shipment and storage of smallpox detritus—see Smallpox detritus.) Mass vaccines should be stored in dry and cool premises. The shelf life of vaccines with proper storage is established by the People's Commissariat of Health of the RSFSR at 2 years for mass vaccines and 3 months for detritus (counting from the day of release). Upon expiration of these periods, the vaccine is subject to destruction, and smallpox detritus—to preliminary verification by way of vaccinating newborns. Prices for vaccines and smallpox detritus are established by the People's Commissariat of Health. 6. Need for and preparation of vaccination personnel. Vaccinations are performed both by existing medical personnel of hospitals, outpatient clinics, children's consultation clinics, etc., and by special personnel. Systematic smallpox vaccinations are carried out through cadres of smallpox vaccinators. Vaccinations against cholera, typhoid fever, and paratyphoids should be performed if possible by doctors, and in their absence—by mid-level medical personnel under the guidance of doctors. Vaccinations against childhood infections are performed exclusively by doctors. The output norm for subcutaneous vaccinations for one vaccinator with a registrar assistant (vaccination squad or brigade)—from 100 to 300 vaccinations per working day. It is most convenient to conduct the preparation of vaccination personnel by organizing short-term courses at bacteriological institutes and large laboratories. 7. Need for instrumentation for vaccinations. Each vaccination point or squad must be supplied with instrumentation and accessories according to the following approximate calculation: 2 Record syringes (1 and 2 cm³), 2 dozen needles for them (No. 15 and 16), 5 smallpox lancets (or 12 smallpox pens), 1 sterilizer, 1 primus stove, 1 alcohol lamp, 2 Petri dishes for needles, 1 enameled tray for syringes, 2 tweezers, 1 pair of scissors, 5 files, 1 cork borer, 2-3 small cups or beakers for pouring vaccines, 2 pairs of watch glasses or 5 glass slides for pouring detritus, 1 maximum thermometer, absorbent cotton, bandages, denatured alcohol (for burning), ether (100 g per 1,000 vaccinations), gasoline (the same), iodine tincture, collodion, 3% solution of carbolic acid, soap, kerosene (for the primus), 2 brushes for washing hands, hand towels, medical gowns, oilcloth for covering the table, valerian drops (30 g), ampoules with adrenaline, camphor, and caffeine for injections (5 pieces each), registration forms, clean paper, ink, pencils, etc. 8. Need for sanitary-educational aids. This includes the advance ordering or printing on the spot of leaflets, brochures, slogans, and posters on vaccinations and, in general, on the fight against the corresponding infectious diseases. 9. Procedure for performing vaccinations. A part of the vaccinations can be performed in permanent medical institutions: outpatient clinics, health posts, children's consultation clinics. Another part of the vaccinations is performed at specially opened vaccination points. Finally, the remaining part of the vaccinations (usually the largest) is performed at the place of residence of those being vaccinated (house-to-house or barrack-to-barrack) or at their place of work or occupation (in institutions, at enterprises, in schools, kindergartens, nurseries, etc.). The most complete coverage of the population with vaccinations is achieved by a combination of all these methods. 10. Persons responsible for the execution of the vaccination plan must be designated for each city and district. Besides vaccinations carried out in a planned manner, the need for conducting mass vaccinations outside the plan may always arise—during epidemic outbreaks of one or another infection; to ensure such unplanned vaccinations, every health department must have a certain reserve of vaccination material and instrumentation. In accordance with the plan, an estimate of expenses for conducting vaccinations is compiled. The mandatory nature of vaccinations is established throughout the USSR only in relation to smallpox vaccinations. The conducting of other vaccinations in a mandatory manner by way of issuing corresponding mandatory decrees is carried out through the corresponding executive committees. The success of vaccinations as a mass measure largely depends on the organization of the population and on the organization of the vaccination campaign itself. The organization of the population is achieved by attracting broad public attention to this issue, mobilizing public and professional organizations, and deploying mass agitation and explanatory work among the population. The organization of the vaccination campaign itself comes down to conducting vaccinations in the shortest possible time, without lowering the quality of work, and in such a way that the vaccinations are accompanied by the least inconvenience and loss of working time for the population.

A convenient choice of place and time for vaccinations, the elimination of queues at vaccination points, an attentive attitude toward those being vaccinated, speed and precision of work, and the accurate and impeccable execution of the methodology and technique of vaccinations constitute a necessary condition for the success of this work and ensure mass coverage of the population with vaccinations. To achieve high rates and high quality of vaccination work, the best means is the application in this work of methods of socialist labor (shock work and competition between vaccination brigades, public support, etc.), as well as the introduction into the practice of this work of the principles of economic accountability (payment of vaccination brigades in accordance with the volume and quality of the work performed). Accurate registration of those vaccinated, carried out best by a card system, is of great importance for the correct conduct of vaccinations. Completed registration cards, upon completion of vaccinations, are submitted to the health department and serve as material for accounting for the results of vaccinations. This accounting is necessary for the accumulation of data that can serve to improve the methodology of vaccinations. The analysis of all materials on vaccinations thus has, besides scientific, also great practical interest and should be entrusted to bacteriological institutes and laboratories. Technique of subcutaneous vaccinations. Subcutaneous vaccinations must be performed under aseptic conditions. The vaccinator's hands are washed with warm water and soap and wiped with a solution of mercuric chloride in alcohol; syringes and needles are sterilized in boiling water for at least 15 minutes, and each needle after use is again thrown for 5 minutes into a sterilizer with boiling water; the skin at the injection site is disinfected by smearing with iodine tincture or wiping with alcohol and ether; the vaccine from vials or ampoules is poured into a sterile cup covered with paper; the room for vaccinations must be kept clean. Before opening a vial or ampoule with vaccine, they are carefully inspected and vigorously shaken until a uniform turbidity appears. Vaccine containing non-dispersible flakes must not be used. The same must be done with vials whose airtightness is clearly violated and there is reason to assume contamination of the vaccine. The best places for subcutaneous vaccinations are the back (under the lower angle of the scapula) and the subclavicular region (between the clavicle and the nipple); one should not inject the vaccine into muscles, and in particular, its injection into the thickness of the skin is unacceptable. Contraindications. Every person being vaccinated must be questioned before vaccination about their state of health and previously suffered diseases. Contraindications in relation to all subcutaneous vaccinations are: acute diseases; pronounced forms of nephritis, tuberculosis, and diabetes; uncompensated heart defect; all cachectic states; pregnancy in the second half. Special caution is required when vaccinating those with tuberculosis: here one must individualize each case. When vaccinating those with malaria, it is recommended to give them small doses of quinine (0.3-0.5) to prevent malaria attacks. The reaction after subcutaneous vaccinations in most cases is absent or expressed in insignificant local phenomena (redness, swelling, soreness at the injection site) and in some increase in temperature. More severe phenomena, both local and general (temperature up to 38.5-39° and even 40°, malaise, joint pain, gastrointestinal disorders, strong edema at the site of vaccination), are usually observed in 3-5-10% of cases (rarely higher) and are accompanied by temporary loss of ability to work for 1-2 days. Usually, the reaction after vaccination begins 6 hours after vaccination and lasts up to 1.5-2 days. In individual cases, especially with vaccinations against scarlet fever and diphtheria, phenomena of anaphylactic shock were observed in the first half-hour after vaccination. Cases of extremely severe complications during vaccinations, up to and including fatal outcomes, belong to the rarest phenomena and were observed exclusively when vaccinating persons suffering from severe degeneration of internal organs and especially sharply pronounced status thymico-lymphaticus. Special technique and methodology for certain vaccinations - see Bacteria, Calmette-Guérin bacillus, Rabies, Typhoid fever, Degkwitz vaccinations, Dysentery, Diphtheria, Measles, Smallpox, Smallpox vaccination, Pasteur vaccinations, Scarlet fever, Tetanus, Cholera, Plague. Oral vaccinations (see Vaccination) have practical significance only for dysentery. Oral vaccinations against typhoid fever and cholera are at the present time in the stage of study and are being conducted as a broad scientific experiment in populated areas that present favorable conditions for setting up this experiment (probability of a seasonal rise in the corresponding infections and the settled nature of the population), with the selection of control groups homogeneous in epidemiological conditions (vaccinated subcutaneously and not vaccinated at all) and with accurate accounting of the results. The technique of oral vaccination is relatively simple and boils down to giving the person being vaccinated on an empty stomach (6 hours after a meal and no earlier than 1 hour before the next meal) 1 tablet or 10 cm³ of liquid vaccine for three days in a row. Contraindications are acute diseases and gastrointestinal disorders. There is usually no reaction at all. Therapeutic vaccinations - see Vaccine therapy and Serum therapy. Vaccinations for animals - see Vaccination.