John Albert Kolmer.

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used among the British troops in India in ever-increasing quantities,
with uniformly good results.

Antityphoid vaccination was begun in the United States army in
1908, the vaccine being prepared by Major Frederick F. Russel. Its
value has been established so clearly that vaccination is now compulsory.
The results obtained in the army have had considerable influence in
establishing a wide-spread general confidence in antityphoid inoculation.

Preparation of Typhoid Vaccine. — Based upon general principles,
the vaccine should be prepared of typhoid bacilli as little changed by
heat or chemicals as possible. Russel has prepared the army vaccine
with a single avirulent culture which proved by animal experiments
and laboratory methods capable of producing large quantities of immune
agglutinins and bacteriolysins. As a general rule, however, the vaccine
should be polyvalent, and particularly in view of the experiments of
Hooker, 4 who has shown by complement-fixation tests consistent anti-
genic differences among some strains of Bacillus typhosus.

1 Deutsch. med. Wchnschr., 1896, xxii, 735.

2 The Lancet, London, September 19, 1896, 907; Brit. Med. Jour., January 30,
1897, 16.

3 Jour. Roy. Inst. * Jour. Immunology, 1916, 11, 1.



PROPHYLACTIC IMMUNIZATION OR VACCINATION 689

The preparation of the vaccine is comparatively simple. The bacilli
are grown on agar for twenty-four hours, washed off with sterile normal
salt solution, standardized by counting the bacilli, and killed by heating
to 56° C. for one hour. As a matter of safety, 0.25 per cent, of tricresol
is then added (Russel) . The details of the technic are given in Chapter
XIII.

Metchnikoff has never fully accepted the belief in the value of heat-
killed vaccines, and at present is actively concerned with vaccines pre-
pared of living bacilli sensitized with their immune serum (sensitized
vaccines). Injection of these vaccines into chimpanzees is not followed
by any untoward effects, and apparently the bacilli so administered are
destroyed at once, as they have not been found in the blood, urine, and
feces. Metchnikoff and Besredka have immunized persons according
to these methods and report excellent results. Obviously, there is some
reluctance in using a vaccine of living bacilli until extended animal
experiments have proved that they are harmless and more efficient than
the vaccines of killed bacilli.

As a general rule, the vaccine is prepared in two strengths: 500,000,-
000 bacteria per cubic centimeter for the first dose, and 1,000,000,000 for
the second and third doses.

Method of Inoculation. — The vaccine is best administered at about
4 o'clock in the afternoon, so that the reaction appears during the night
and is least likely to be disturbing. It is well to administer a cathartic
the day before the inoculation is made. Inoculations should not be
given during the menstrual period, as the general reaction is likely to be
somewhat severer at this time.

• The skin over the insertion of the deltoid muscle is touched with
tincture of iodin and the injection given subcutaneously . Intramuscular
injections should be avoided, as the reactions are more unpleasant and
accompanied by unnecessary pain on movement. In making deep
injections there is also danger of striking a nerve, a proceeding that may
be followed by disagreeable neuritis.

After the injection has been given the iodin is wiped away with a
pledget of cotton and alcohol; no dressing is necessary.

The syringe and needle should be sterile. Commercial firms have
placed the prophylactic on the market in syringes with sterilized needles,
accompanied with full instructions as to the technic of administration.
The vaccine should be well shaken before the injection is given.

When a large number of injections are to be given at one time, a
single syringe may be used with a large number of sterile needles, a
44



690



ACTIVE IMMUNIZATION



separate needle being used for each person. The vaccine may be put
up in individual ampules or in a stock bottle, the former being preferable.

Dosage. — Three injections are given at intervals of one week. For
adults (150 pounds) the doses used in the army have been as follows:
First dose: 500,000,000 bacilli.

Second dose: 1,000,000,000 bacilli.
Third dose: 1,000,000,000 bacilli.

These amounts are contained in 1 c.c. (about 15 minims). Children
receive doses in proportion to their weight; if the dose cannot be divided
evenly, it is better to give a little more rather than a little less, for chil-
dren tolerate the injections remarkably well.

Reactions. — Persons in poor physical condition are more likely than
the robust to experience disagreeable after-effects.

The local reaction consists of a small red and tender area lasting about
forty-eight hours. Occasionally the edema and pain may be more
marked, but abscess formation is practically unknown.

The general reaction, when present, gives rise to headache, malaise,
and sometimes to fever, chills, and occasionally to nausea, vomiting, or
diarrhea. The severe reactions are not alarming and disappear quickly.

The inoculated person should abstain from severe exercise for the
following twenty-four hours and rest; in the great majority of instances
our soldiers have not been inconvenienced and were able to continue
with their routine duties.

The following tables, compiled by Major Russel, 1 show the propor-
tion of reactions in adults and children:

TABLE 24.— PERCENTAGE OF GENERAL REACTIONS IN ADULTS

(128,903 DOSES)



Dose


None


Mild


Moderate


Severe


First


68.2
71.3
78.0


28.9
25.7
20.3


2.4
2.6
1.5


0.3
0.2


Third


0.1







TABLE 25.— PERCENTAGE OF GENERAL REACTIONS IN 359 CHILDREN,
TWO TO SIXTEEN YEARS OF AGE



Dose


None


Mild


Moderate


Severe


First

Second

Third


1

! 73.54
86.26
92.56


24.51

11.99

0.38


1.67
1.75
1.06


0.28



Jour. Amer. Med. Assoc, 1913, lx, 344.



PROPHYLACTIC IMMUNIZATION OE VACCINATION 691

A comparison of these tables shows that the general reaction is much
more infrequent or milder in children than in adults, even after the first
dose; after the second and third doses the difference is more marked.

In former years considerable stress was laid upon the possibility of
a negative phase following the inoculation, during which a person was
believed to be more susceptible to infection. This is now believed by
Leishman, Russel, and others of extended experience to be incorrect,
the more general belief being that inoculations may be made and are
especially indicated during epidemics of the disease.

Duration and Degree of Typhoid Immunity. — It should be empha-
sized that immunity following typhoid immunization is not absolute,
and an immunized person cannot afford to neglect ordinary precautions-
against infection. A lowered state of general body health or a large dose
of infectious material may at any time result in infection.

The prophylactic treatment should be used in conjunction with
well-known sanitary precautions in order to obtain the best results.

The immunity is apparently manifest soon after the first and second
doses have been given. The duration is not known definitely. From
the rich experience of the British army in India Colonel Firth 1 concludes
that immunity begins to decline in about two and one-half years after
inoculation. However, even after four and five years the typhoid rate
among the inoculated is, estimated roughly, one-fourth that of unpro-
tected troops.

Sensitized Typhoid Vaccine of Gay and Claypool. — Gay and Clay-
pool, 2 who have made an extended and extensive study of typhoid im-
munization, have advocated a polyvalent, sensitized typhoid vaccine
sediment for prophylactic immunization against typhoid fever, as being
superior to other forms of typhoid vaccine. Force 3 has found that this
vaccine produces less reaction and Sawyer 4 has found it more protective
than several other types of commercial vaccine. Gay's vaccine consists
of the ground sediment of a mixed polyvalent vaccine that has been
sensitized by an antityphoid serum and then killed and precipitated
by alcohol. From this ground culture the endotoxins are extracted
by carbolated saline solution and the remaining sediment of bacteriaL
bodies alone used for prophylaxis and in the treatment of typhoid fever.

For prophylactic purposes Tt mg- of dried bacteria, which corresponds

1 Jour. Roy. Army Med. Corps, 1911, xvi, 589.

2 Archiv. Int. Med., 1913, xii, 613; 1913, xii, 622; 1914, xiii, 471; 1914, xiv, 662:
1 914, xiv, 662, 669, and 671 ; 1916, xvii, 303.

3 Amer. Jour. Pub. Health, 1913, iii, 750.
1 Jour. Amer Med. Assoc, 1915, lxv, 1413.



692 ACTIVE IMMUNIZATION

to an original bacteria count of about 750,000,000, is administered by
subcutaneous injection every other day until three or four doses have
been given. This vaccine is claimed to produce a better and more prompt
immunity response than other vaccines. It has also been used in the
treatment of typhoid fever by intravenous injection.

Results. — The value of the typhoid prophylactic therapy is best
shown in the army, where conditions are better controlled than is possible .
in civilian life. In 1911, of a division of United States troops, about
20,000 men along the southern boundary, only two cases of typhoid
fever developed and both recovered. During this same period of time
49 cases were reported in the city of San Antonio, with 19 deaths. The
soldiers mixed freely in the city, ate of fruits and vegetables, drank of
the same water, and in this manner were freely exposed, although the
sanitary conditions in the camp were excellent.

In 1898, during the Spanish War, there were assembled at Jackson-
ville, Florida, 10,759 troops, among whom there were certainly 1729
cases of typhoid, and including the suspected cases, this figure reached
2693 cases, with 248 deaths. This camp continued about as long as
that in 1911, the climatic conditions and water supplies being practically
the same, but the sanitary conditions were bad. The remarkable dif-
ference in the typhoid rate cannot, however, be reasonably explained by
perfect camp sanitation, and the results in 1911 leave no doubt as to the
value of antityphoid vaccination.

Excellent results have been reported by Spooner, Hachtel and Stoner,
and others as to the prophylactic value of typhoid immunization in
hospital-training schools for nurses, insane asylums, and other public
institutions.

Recommendations. — In view of the satisfactory results obtained in
the army, typhoid vaccination is now obligatory on all members of the
army and navy corps. Protection of the individual by immunization
is the only measure of protection independent of surroundings and
effective under all conditions.

Typhoid inoculation in civilian practice cannot be as wide-spread
or as readily performed as vaccination against smallpox, as the prophy-
lactic must be administered subcutaneously and more than one dose is
necessary.

1. Our various State and city boards of health should endeavor to
educate the laity, and, if necessary, offer the prophylactic free of charge
in order to build up a vaccinated community as far as this is possible.

2. Persons coming in intimate contact with typhoid patients, such



PROPHYLACTIC IMMUNIZATION OR VACCINATION 693

as physicians, nurses, and attendants in hospitals, should be immunized.
Hospital authorities are justified in making typhoid vaccination ob-
ligatory on all applicants for admission to training schools.

3. All inmates of asylums, homes, and other public institutions
under forty-five years of age should be immunized and the State should
be ready, if necessary, to furnish the vaccine.

4. The physician and nurse should urge vaccination upon all the
members of a family when there is a typhoid patient among them.

5. The physician should especially advise immunization of those
about to leave their homes for a vacation in some neighboring seashore
or mountain resort.

6. In times of epidemics of typhoid fever the physician should urge
vaccination of all over whom he has influence. Thorough vaccination
with proper sanitary conditions offers the best hope of eradicating this
dreaded disease.

Paratyphoid Fever
According to recent experiences in the European armies prophy-
lactic immunization with typhoid vaccine does not afford protection
against infections with Bacillis paratyphosus A and Bacillis paraty-
phosus B. In this country various investigators have estimated that
about 2 to 4 per cent, of the cases of so-called "clinical typhoid fever"
are due to paratyphoid infections; apparently the majority of these are
with Bacillis paratyphosus B. It would appear advisable therefore to
immunize with these microorganisms in addition to Bacillis typhosus,
and particularly members of the Army, Navy, National Guards, and all
volunteer organizations called into service in time of war. For over a
year I have been using routinely a mixed vaccine prepared in the same
manner as the typhoid vaccine, each cubic centimeter of which contains
500,000,000 typhoid bacilli of the army strain and 250,000,000 each of
Bacillis paratyphosus A and B, the latter strains being selected from a
number on the basis of stimulating the production of agglutinins to a
well-marked degree in persons and rabbits. The first dose of this mixed
vaccine is § c.c. ; three more injections are made at intervals of a week of
1 c.c. each, making a total of four injections. In the Army a mixed
vaccine of paratyphoid bacilli is generally administered after the usual
course of three injections of typhoid vaccine, and in the same manner.
Three doses are given; the first dose contains 500,000,000 Bacillus para-
typhosus A and 300,000,000 Bacillus paratyphosus B; the second and
third doses are the same, and contain 1,000,000,000 Bacillus paraty-
phosus A and 600,000,000 Bacillus paratyphosus B.



694 active immunization

Typhus Fever
Preliminary studies upon prophylactic immunization of persons with
Bacillus typhi exanthematici, a Gram-positive pleomorphic bacillus
secured in blood-cultures from persons suffering with typhus fever by
Plotz, Olitsky and Baehr, 1 seem to indicate that a vaccine of this bacillus
is capable of reducing the incidence of the disease, although it does not
produce an absolute immunity to typhus fever (Plotz, Olitsky, and
Baehr). 2 The vaccine is polyvalent and is sterilized by heating to 58°
to 60° C. for from half an hour to one hour. The suspension is so diluted
that each cubic centimeter contains about 2,000,000,000 bacteria, and
is preserved with 0.5 per cent, phenol or tricresol. Three injections con-
sisting of 0.5, 1, and 1 c.c, respectively, have been given in five- or six-
day intervals. The subject is in the experimental stage.

Pneumonia
In the prophylaxis • of lobar pneumonia by active immunization
Wright 3 has had an unusually rich experience in the Rand mining
district of South Africa where a severe type of pneumococcus pneu-
monia has claimed a high morbidity and mortality among the natives.
After a considerable amount of experimentation the administration of
a single large dose of stock vaccine containing 1,000,000,000 cocci was
generally employed. Wright thinks that this vaccine reduced the inci-
dence of pneumonia among the natives during the first three months
following inoculation. Later reports of this work have failed to establish
the efficacy of active immunization in preventing the development of
pneumonia or materially lowering the mortality. Since, however, re-
cent investigations by Lister 4 have shown the existence of different
serologic types of pneumococci on the Rand, an improvement in the
efficiency of Wright's vaccine may have been made by using a mixed
vaccine of these special strains; if a vaccine is employed as a prophy-
lactic measure in pneumonia, it should be prepared of a number of
strains belonging to types I and II at least and several injections should
be given at intervals of five or seven days. The protection is likely to be
of short duration, but the method would appear worthy of trial under
these conditions and particularly during the seasons when pneumonia

is prevalent.

Plague

In view of the frightful infectiousness and mortality of plague,
prophylactic measures are highly desirable. Extermination of rats and

1 Jour. Infect. Dis., 1915, xvii, 1. 2 Jour. Amer. Med. Assoc, 1916, lxvii, 1597.

3 Drugs and Vaccines in Pneumonia, 1915, Paul B. Hoeber, New York.

4 South African Inst, for Med. Res., Johannesberg, Dec. 22, 1913.



PROPHYLACTIC IMMUNIZATION OR VACCINATION 695

ground squirrels, especially of the former, about the wharves of seaport
cities and towns is highly essential, as the disease is transmitted by the
fleas of these rodents. Aside from sanitary measures, plague vaccine,
especially that of Haffkine, has now been used extensively, with encour-
aging results.

Preparation of Plague Vaccine. — The Haffkine prophylactic is pre-
pared by growing pure cultures of Bacillus pestis in flasks of neutral
bouillon to which a few drops of sterile olive oil or butter-fat have been
added, to serve as floats from which the surface growth of the bacilli
can take place. The flasks are cultivated at from 25° to 30° C. for five
to six weeks, and are shaken every two or three days, by which the hang-
ing, stalactite-like colonies are thrown down, so that a new crop of the
bacilli can develop in contact with the air.

After growing for six weeks the purity of the culture in each flask is
tested by subcultures on agar and by direct smears. The masses of
bacilli are broken up by shaking, and the material is sterilized by heating
at 65° C. for from one to three hours. Phenol is added to the point of
0.5 per cent., and the fluid is tested for sterility by culture. If it is
found sterile, it is finally poured into small vials of from 10 to 30 c.c.
capacity.

Kolle prepares a vaccine by cultivating the bacillus for two days .in
flasks of agar measuring 10 by 9.5 cm. Each surface of agar equals
about 15 ordinary agar slant cultures, and an agar slant holds about
15 loopsful of culture (4 mm. loop). A loop of this size holds about 2
mg. of organisms, and, accordingly, a flask of agar contains about 225
loopsful of culture, or 225 doses of 2 mg. each. Kolle prepares the
vaccine in amounts of 0.5 c.c. per dose (2 mg. of bacilli), and the growths
in each flask are removed with 112.5 c.c. of sterile normal salt solution.
The emulsion is shaken to break up clumps, heated for one hour at 70°
C, and tested for sterility. It is then preserved with phenol or tricresol
and placed in ampules containing 0.5 c.c. each.

The German Plague Commission strongly recommended the use of
twenty-four- to forty-eight-hour-old agar cultures instead of the old
bouillon cultures employed in the preparation of Haffkine's vaccine.

Kolle and Strong have also employed living cultures of greatly re-
duced virulence for the immunization of man.

Lustig and Galeotti prepare a vaccine of the toxic precipitate pro-
duced by dissolving the bacilli in a 1 per cent, solution of caustic soda
and neutralizing with 1 per cent, of acetic acid. This precipitate is
dried in vacuo and redissolved in a weak solution of sodium bicarbonate,
the dose for, adults being 0.0133 gm. of solid substance.



696 ACTIVE IMMUNIZATION

Terni and Bandi inoculate rabbits or guinea-pigs intraperitoneally
with the bacillus, and just preceding or directly after death they collect
the peritoneal exudate, in which the organisms are allowed to continue
growing for twelve hours more. The bacilli are then killed at a low
temperature, and the fluid thus obtained, after a preservative has been
added, constitutes the vaccine.

Dosage. — The ordinary dose of Haffkine's prophylactic for adult
males is from 3 to 3.5 c.c; for adult females, from 2 to 2.5 c.c. Haffkine
himself has injected larger quantities without resulting harm. He
recommends giving a second injection after from eight to ten days.
The injections are given subcutaneously, with a sterile syringe, into the
upper arm or elsewhere in areas where the skin is not tightly bound down.

The local and constitutional effects are similar to those in typhoid
except that they are slightly intensified. The inoculation is followed
by redness and swelling at the seat of inoculation, and general symp-
toms in the form of rise of temperature and a feeling of illness. The
latter pass off in twenty-four hours, but the patient should rest during
the first day after inoculation.

Duration of Immunity. — The immunity is apparent a few days after
inoculation, but is of short duration. In India the protection is believed
to last at least three months and possibly longer. In times of epidemic
the inoculations should be repeated at least two or three times a year.
The brief duration of the immunity is probably one reason why better
results are not secured. Best results are observed during epidemics when
protection is afforded for a short time, or until the danger is past. In
countries or localities where the disease is endemic, persons may refuse
repeated inoculation and thus become susceptible to infection.

Results. — In the pneumonic variety of plague the prophylactic does
little or no good, a finding that has also been shown experimentally by
Strong and Teague. 1

In the bubonic variety Haffkine's vaccine has in general yielded
encouraging results. The protection is not absolute; the immunity
is of relatively short duration, and therefore good results are not so
readily appreciated when the disease is endemic. The mortality among
the inoculated is much lower, i. e., 11 to 41 per cent., as compared with
50 to 92 per cent, among the non-immunized. Haffkine summarized
his results a few years ago as follows: Among 186,797 inoculated
persons there were 3999 attacks, or 1.8 per cent.; among 639,630 un-
inoculated persons there were 49,433 attacks, or 7.7 per cent., with 29,733,
or 4.7 per cent, of deaths.

1 Philippine Jour. Sci., 1913, vii.



PROPHYLACTIC IMMUNIZATION OR VACCINATION 697

The Indian Plague Commission a few years ago reported as follows:

1 . Inoculation sensibly diminishes the incidence of attacks of plague.
It is, however, not an absolute protection against the disease.

2. The death-rate is markedly diminished by its means, not only
the incidence of the disease, but also the fatality, being reduced.

3. The protection is not conferred on those inoculated for the first
few days after the injection.

4. The duration of the immunity is uncertain, but it seems to last
for a number of weeks, if not for months.

After the disease has once developed, vaccination is of no avail.
When there is eminent danger of infection, vaccine and antiserum should
be given together.

Cholera

Protective inoculation against cholera was first practised by Ferran,
a Spaniard, in 1884, although little definite knowledge as to the value
of the procedure resulted from his work. He is said to have used impure
cultures of bacilli isolated from the feces of cholera patients. Broth
cultures were prepared, and the living organisms injected subcutane-
ously, using eight drops for the first and 0.5 c.c. for the second and third
doses, the injections being given at intervals of six or eight days. While
his method and results have been questioned, he was, however, the
first to use a method employed later, with some modifications, by Haff-
kine in India with good results.

Preparation of Cholera Vaccine. — Haffkine, following Pasteur's
method with anthrax, uses two vaccines, — a weaker and a stronger, —
living microorganisms being used in both and injected subcutaneously.
Vaccine No. 1 is weaker, and is obtained by growing the bacilli on agar
at a temperature of 39° C. Vaccine No. 2 is composed of more virulent
organisms, prepared by passing the vibrios through a series of guinea-
pigs until a strain is obtained which is invariably fatal to these animals
within twelve, or at least twenty-four, hours. Cultures are grown on
agar, washed off with 8 c.c. of sterile bouillon or saline solution, and
administered in doses of 1 c.c, which is equivalent to about two loopsful
(4 mm.) or 4 mg. of living bacilli.

Kolle has shown, however, both by animal experimentation and in
the human being, that heat-killed cultures are equally good, and that
living cultures are unnecessary and may be undesirable.

By this method the vaccine is prepared by cultivating a virulent
strain on flasks of agar for twenty-four hours, as described in the pre-



Online LibraryJohn Albert KolmerA practical text-book of infection, immunity, and specific therapy, with special reference to immunologic technic → online text (page 70 of 101)