[Music] [Immunization Against Infectious Diseases] [Originally Prepared by The Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Under the Supervision of Harry A. Towsley, M.D., Including Photography by Harry A. Towsley, M.D., C. Roland Burd, Alfred P. Lane] [Approved by The Committee on The Control of Infectious Diseases of the American Academy of Pediatrics] [Produced with the support of Lederle Laboratories Division, American Cyanamid Company] [Revised by Fordel Films, Inc. New York] [Narrator:] In the short time since the discovery of sulfonamides and then penicillin, the world has witnessed greater progress in the control of infectious diseases in man and animals than has previously occurred in medical history. The scene is changing with such rapidity that what is known today is frequently invalid tomorrow. The practitioner must ever keep abreast of late clinical evidence in order to exercise sound judgment in employing antimicrobial agents available to him. It is the purpose of this film, therefore, to say, in effect, this we know, but there is more to learn. Since the introduction of broad-spectrum antibiotics, the dramatic changes in morbidity and mortality statistics have established antimicrobial agents as one of the major avenues of attack against infectious diseases. Tetracycline, demethylchlortetracycline, chlortetracycline, oxytetracycline, chloramphenicol, streptomycin, the sulfonamides, or penicillin have been shown to be effective in the control of brucellosis, pertussis, Rocky Mountain Spotted Fever, scarlet fever, tuberculosis, tularemia, typhoid and paratyphoid fever, and typhus. But valuable as antibiotics are, they cannot replace accurate diagnosis, therapeutic judgment, and skilled surgery. Infections must be properly treated and anatomic abnormalities corrected. Even though many infectious diseases may be controlled by antimicrobial agents, many others will either not respond to them, or of are such nature that it is desirable to prevent their occurrence by immunization. [Active Immunization is Practicable Against: Cholera, Diphtheria, Influenza, Measles, Mumps, Pertussis, Plague, Poliomyelitis, Rabies, Rocky Mt. Spotted Fever, Smallpox, Tetanus, Typhus, Typhoid-Paratyphoid A & B, Tularemia, Tuberculosis, Yellow Fever] [Passive immunization is practicable against: Diphtheria, Gas Gangrene, Hepatitis, Measles, Pertussis, Tetanus, Rabies] [Infectious Hepatitis, Mumps, Poliomyelitis] Passive immunization against these diseases may be of value in decreasing the severity of the symptoms. Combined immunization against diphtheria, pertussis, and tetanus should be started at one to two months of age. Polio vaccine may be started at the same time as the other immunizations. The initial course should consist of three injections of triple antigen, given at intervals of not less than one month and preferably not more than three months. It is recommended that a fourth injection be given a year following the third injection. Injections should consist of .5 ml made into either the deltoid or the gluteus maximus muscles. Injections should not be made more than once at the same site during the primary course of immunization. Those states having the largest number of diphtheria cases are shown in the darkest color. [Map of US titled Diphtheria-Reported Cases-1965] Reported cases of diphtheria, as might be expected, have shown a steady decrease during the last 15 years. [Line graph of US reported cases of diphtheria, 1950-1965] Diphtheria infection sources are discharges and secretions from the surfaces of the nose, throat, nasal pharynx, skin, and other lesions of infected persons. A diagnostic test consists of culture rapid growth of bacteria in four hours on horse serum-impregnated cotton swab kept at 37 degrees centigrade in Loeffler's or Tellurite media. Strains isolated should be tested for virulence. For older children and adults, diphtheria toxoid as a single antigen is indicated in reduced dosage for primary immunization and booster injections. In primary immunization of children in the preschool age, the use of diphtheria toxoid alone is recommended only when there is some specific contra-indication to the use of the triple antigens. For individuals over 10 years old, diphtheria toxoid in doses exceeding two hundredths to five hundredths ml should not be given without a preliminary Schick test, together with a Moloney or [Zella?] toxoid sensitivity test as a control. For primary immunization of children less than 10 years of age, give three intramuscular injections of five tenths ml at intervals of at least one month, but preferably not more than four months. For individuals more than 10 years of age who are Schick-positive reactors with negative sensitivity tests, the primary immunization course is the same as for children under 10. Individuals showing positive reactions to both the Schick test [Positive Schick Test, 5 days] and the toxoid sensitivity test should not be given further toxoid. Negative reactors to both the Schick and toxoid sensitivity tests require no further toxoid as the tests themselves serve as small boosters. But if immunization practices including recall injections at three-year intervals are carried out as previously outlined, repeated use of the Schick test to determine individual susceptibility seems unwarranted. Passive immunity may be obtained for about 10 days with diphtheria antitoxin in doses of from 1,000 to 2,000 units intramuscularly. A careful history and adequate sensitivity testing should be done before any animal serum product is administered. However, serum sickness may occur in individuals who had no sensitivity prior to serum administration. [Map of US titled Whooping Cough-Reported Cases-1965] Whooping cough sources of infection are from discharges from pharyngeal and bronchial mucus membranes of infected persons. Pertussis vaccine as a single antigen is indicated for attempted rapid primary protection of infants in the presence of epidemics, for primary immunization of children who have been inoculated against diphtheria and tetanus, and for recall injections following exposure. Pertussis vaccine, saline suspended, is useful in attempted rapid protection of exposed individuals during epidemics. A total of 12 NIH units divided into three equal doses should be injected subcutaneously at intervals of one week. [Line graph of pertusis (whooping cough) reported cases 1950-1965] Pertussis vaccine, alum-precipitated or aluminum phosphate- or hydroxide-absorbed are preferred for infants less than six months when there is no need for rapid protection, and when he has already received diphtheria and tetanus inoculations, or a contra-indication to the triple antigen exists. Twelve NIH units should be injected intramuscularly in three equal doses at intervals of four to six weeks. Recall injections of four NIH units should be given a year later, then in two years, and thereafter every three years if the danger of whooping cough infection exists. [US map titled Tetanus-Reported Cases-1965] Against tetanus, active immunization is indicated in all children, adults subject to abrasions, and in adults who are exposed to frequent accidents where tetanus spores may contaminate the wound. Primary immunization is obtained by two intramuscular injections of .5 ml each of alum-precipitated or aluminum hydroxide-adsorbed tetanus toxoid at an interval of between one and four months. Recall injections are advised in one year and every five to 10 years thereafter, or after potential exposure. The effectiveness of emergency boosters is dependent on the time relationship between the injection and the potential development of infection so that toxoid alone may not be adequate. When the individual already has had previous toxoid, added protection is afforded if, in addition to the booster, he is given hyperimmune gamma globulin in the muscles of a different extremity using the usual precautions. Where the possibility of gas gangrene coexists, a gas gangrene antitoxin is also available. [Map titlted World Distribution of Small Pox] Although smallpox is endemic in various parts of the world, it has virtually been eliminated from the United States. [Line graph of reported cases of smallpox 1950-1965] Individuals suspected of smallpox should be isolated strictly, pending definite diagnosis. Diagnosis on clinical evidence is generally possible and preventive measures should be instituted without waiting for results of laboratory tests. Primary vaccination is recommended in the first year of life unless the child is not thriving or is suffering from allergic eczema or dermatologic disorders, with revaccination every three years thereafter. The multiple pressure method should be used over the skin of the left deltoid muscle or the posterior aspect of the arm over the triceps muscle. These are the stages of successful primary vaccination: maculation second day; papulation fourth day; vesiculation sixth day; pustulation tenth day; scabbing or crusting thirteenth day; scarring twentieth day. This is an early or immediate reaction. [US map titled Tuberculosis-Reported Cases-1965] Tuberculin-negative individuals who are potentially exposed to tuberculosis can be immunized with the BCG vaccine. [Line graph of reported cases of tuberculosis 1950-1965] Tuberculin sensitivity is determined by means of the intracutaneous injection of OT or PPD or by the use of the tuberculin tine test shown here. As soon as possible after completing the tuberculin test, .1 ml of material equal to .1 mg BCG vaccine should be injected intracutaneously as superficially as possible over the deltoid muscle. BCG vaccine should not be given to infants who are markedly underweight at birth or who are premature, nor should it be given when the person is suffering from infectious diseases. Although the vaccine may be given at the same time with other antigens, it should never be administered simultaneously with smallpox vaccination. [US map titled Typhoid Fever-Reported Cases-1965] Typhoid fever sources of infection are the feces and urine of patients and carriers. [Line graph of reported cases of typhoid fever, 1950-1965] Immunization is indicated for residents in rural areas of the United States and Canada where the disease is prevalent. For adults, a total dose of 1 ml standard typhoid vaccine should be given in two equal doses one to four weeks apart, by the subcutaneous route. Infants less than one year of age should receive correspondingly small doses. Sharp febrile reactions are not uncommon. Recall injections of .1 ml intracutaneously every one to two years depending on probability of exposure. [US map titled Scarlet Fever-Reported Cases-1965] Active immunization against scarlet fever, streptococcal pharyngitis, and arrecipolis is no longer attempted since the advent of effective chemotherapy of streptococcal diseases. [Line graph of reported cases of scarlet fever, 1950-1965] Adequate treatment of streptococcal infections with one of the penicillins has become most important, since the development of acute glomerulonephritis and rheumatic fever may be prevented in this way. Passive immunization has been practiced in the past, but the advent of antibiotics makes the procedure unnecessary. In certain circumstances, it may be desirable to culture exposed individuals and treat those with positive cultures, especially if the index case developed nephritis. Antimicrobial therapy should be seriously considered for administration to hospitalized patients as well as to close contacts of cases. The importance of careful investigation and adequate treatment of any contact having a history of rheumatic fever is well-known. Prophylactic use of penicillin and other antimicrobial agents is often necessary. [US map titled Poliomyelitis-Reported Cases-1965] Satisfactory immunity against poliomyelitis has been conferred in several large mass vaccination programs by the administration of two feedings [Line graph of reported cases of poliomyelitis, 1950-1965] of trivalent Sabin vaccine at intervals of one to two months or by the feeding of monovalent vaccine at intervals of one month. The precise need for boosters has not yet been clearly shown, although recent evidence indicates that it may be prudent to administer booster feedings to children three years after the primary series. [US map titled Measles-Reported Cases-1965] In the case of measles, passive immunization may be attempted when conditions render it advisable, such as in infants under 12 months, children ill with or closely exposed to other diseases such as tuberculosis and rheumatic fever. [Line graph of reported cases of measles, 1950-1965] Killed vaccine or gamma globulin is advised for such patients. Passive immunization may be used in institutions to avoid epidemics. Clinical experience indicates that .02 ml of human gamma globulin per pound of body weight is satisfactory for modification, while .1 ml per pound of body weight is considered sufficient for prevention. [US map titled Hepatitis-Reported Cases-1965] Passive immunization against, or attenuation of, infectious hepatitis may be attempted in cases where infection is likely or exposure is known to have occurred. Human gamma globulin injected subcutaneously or intramuscularly is thought to give protection for six to eight weeks. Effective dosage range has been found to lie between .01 ml and .06 ml per pound of body weight. [Temporary Immunity Against Mumps] Temporary immunity can be obtained by injection of gamma globulin prepared from donors who have been hyperimmunized with mumps vaccine. Active immunization can be accomplished by means of subcutaneous injections of inactivated vaccines. The recent attenuation of the mumps virus may make routine immunization of infants and children possible. [US map titled-Brucellosis-Reported Cases-1965] [Line graph of reported cases of brucellosis, 1950-1965] Brucellosis infections in man should be prevented through pasteurization of all dairy products, separation of hogs from milk-producing cattle, and veterinary measures to eliminate brucellosis from cattle and hogs. [US map titled Rocky Mountain Spotted Fever-Reported Cases-1965] Active immunization against Rocky Mountain Spotted Fever is advised only for individuals working in highly endemic areas. [Line graph of reported cases of Rocky Mountain Spotted Fever, 1950-1965] Protection from vaccination is not long-lasting. Stimulating doses must be given annually to maintain a high level of protection. Three subcutaneous injections of .5 ml each of inactivated Cox yolk-sac vaccine should be given at five to seven day intervals. The case you have seen here is typical of the disease. [US map titled Tularemia-Reported Cases-1965] Active immunization against tularemia is advised only for laboratory workers and those handling wild rabbits and other susceptible animals. Individuals should be skin-tested prior to vaccination [Line graph of reported cases of tularemia, 1950-1965] using one to 1,000 dilution of vaccine and saline. Positive reactors should not be immunized as they may develop severe reactions. Negative reactors should be given three doses of vaccine subcutaneously at two-day intervals in the following amounts: .1 ml, .5 ml and .5 ml. [Line graph of reported cases of rabies in man, 1950-1965] Rabies in man has decreased in recent years to the point that only six cases have been reported since 1961. After exposure to rabies, patients with bites about the trunk or extremities with no extensive tissue damage should be given rabies vaccine in .5 ml doses subcutaneously daily for 14 days. In cases of extensive tissue damage, multiple bites, injuries about the head, or where treatment has been delayed, 2.5 ml doses should be given daily for the next seven days. Anti-rabies serum is a useful adjunct to therapy with rabies vaccine for the prevention of rabies, but should not be used as a substitute for the vaccine. It is of vital importance that the dog be caught. If it dies after showing signs of rabies, its brain should be examined for the presence of Negri bodies or fluorescent antibodies. [Map showing World Distribution of Cholera] Cholera, an important disease in the United States until 1893, is now confined to southeastern Asia, China and the near east. A killed vaccine is available for people entering endemic zones, but the immunity conferred thereby is of relatively short duration. Immunization is obtained in adults with a .5 ml injection of inactivated cholera vaccine subcutaneously followed a week later by an injection of 1 ml. [Chart displaying Dosage Schedule for Cholera Vaccine] For children under 11 the following doses are recommended. Booster injections of from .1 ml to 1 ml according to age may be required every six months. [Map showing World Distribution of Plague] Plague occurs in wild rodents and/or in man in many parts of the world. In the United States, the endemicity in wild rodents is slowly moving eastward. Human cases are rare, about 500 cases having been reported since 1900. This is a bubo showing extensive necrosis and bubo pasteurella pestis in large numbers. Plague immunization may be obtained in adults with a .5 ml injection of plague vaccine subcutaneously, followed by 1 ml given 7 to 28 days later. [Chart displaying Dosage Schedule for Plague Vaccine] For children under 11, 3 subcutaneous injections at 7- to 10-day intervals should be given as shown. Re-immunization may be required not more often than every four to six months where plague is a hazard. [Map of US titled Typhus-Reported Cases-1965] Basic typhus immunization may be obtained in adults by a one ml subcutaneous injection of typhus vaccine followed by a second injection of one ml given in one to three weeks and a third in the same amount a year later. [Line graph of reported cases of typhus, 1949-1965] Children under 11 should be given equal doses of vaccine one to three weeks apart. The dose for a six-month old child to a two-year old should be .1 ml; three to six years .25 ml; seven to ten years .5 ml. Boosters are from .12 ml to 1 ml according to age should be given annually to retain immunity. [Map showing World Distribution of Yellow Fever] This is the reported distribution of human cases of yellow fever. Cases in jungle animals are important because they may under certain circumstances feed urban epidemics among man. Immunization for all age groups is obtained by a single subcutaneous injection of .5 ml of a one to 10 dilution of concentrated yellow fever vaccine. Containing an attenuated strain of virus, a similar dose as a booster may be required every six years. These are intranuclear inclusion bodies in liver cells. [Precautions and Contraindications] The administration of an injection for immunization against an infectious disease is a simple procedure, but to avoid infecting the patient, it is essential that asepsis be maintained at all times. Store vaccines and serum products under refrigeration. Reconstitute live attenuated vaccines just prior to use. Rubber stoppers of the antigen containers must be disinfected. The physician should be familiar with recent medical literature and with package literature before administering any biological product, and every precaution must be taken for the prevention and arrest of untoward reactions. Serum therapy should be employed only when definitely indicated and only when the physician is equipped adequately to combat such reactions as may occur. [Music] [Statistical information supplied by Epidemiology Branch, Communicable Disease Center, Public Health Service, U.S. Dept. of H.E.W. and the Epidemiological and Vital Statistics Report World Health Organization] [The End]