ACTIVE IMMUNIZATION: CURRENT CONSIDERATIONS Margaret H. D.

Smith Pediatrics 1963;32;444

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/32/3/444

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1963 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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REVIEW

ARTICLE

ACTIVE
Department of

IMMUNIZATION:
Margaret
Pediatrks and Epidemiokgy,

CURRENT
H. of D. Smith,
Tulane Louisana

CONSIDERATIONS
M.D.
School Orleans of Medicine, an(i

University at New

The Charity

Hospital

T
are
ously.

HE

PRAC1ICAL

ASPECTS

of

immunization

outbreaks

of diphtheria

among

olden

people

have changed in the last few inevitably destined to change

Not only does modern

years, and continukeep

in institutions,3 among certain reason behind

and for cases in recent years skid row groups.4 It is tile the long schedule of diphin of

science

producing but the tnibution epidemiologic and zation need

newer vaccines of disease

and more themselves agents expressed is pattern have

potent alter and it:

vaccines, the disthe As Batson Immunisubject in

thereby

thenia toxoid inoculations recommended the so-called Red Book of the Academy Pediatnics. That the Red Book schedule
may, in a future edition, require modifica-

of disease. a dynamic

Christie procedure of constant

tion with diphtheria recent

reinoculated

respect booster by
with

to the stimuli Volk

DT

need for repeated is suggested by co-workers,

a 7 group

a
of

evaluation. DIPHTHERIA

article subjects

and

who 13 years cononly imnot and diphto

toxoid

young seem of imessential,

inoculated The booster units of antitoxin

to

Nowhere
more clearcut

does
than against

this
in the

phenomenon
case of diphtheria.

previously.6 tamed were mediately 2 Lf good but

inoculation

Whereas
munization

25 years natural to boost childhood

ago

a basic

course
was

each toxoid; not levels achieved had, 2 years later, bacilli, of levels. diphtheria injections

diphtheria

they

repeated upon later the

exposure that immunity and adolescence. has become

areas

could

be

relied

throughout Nowadays so relatively

need to we

fallen to prebooster Exposure to live perhaps also repeated thenia toxoid, the diphtheria in subsequent the Hence to be would diphtheria
otherwise

disease

itself
in many

uncommon

that

bring on bacillus doses advisability of

hypersensitivity protein contained diphtheria of a special toxoid. toxoid

be reminded Heath, and

PEDIATRICS

by articles Sherman2 that 900 in the

in

like that a recent of

of Doege, issue of do and States,

cases

diphtheria

occur

annually

United

used in adolescents contain only very toxoid,

present, for

and adults, which small amounts of tile for of necessity,

a following Moperforming

that these cases tend where immunization of the very

for

to be grouped programs lag. in most

exposure,

in states Because of opis an

to obviate skin
his

scarcity,
natural

places,
there

loney
ity.7

or Zoeller
Edsall and

test

hypersensitivCanadian largely and respon-

pontunity

collaborators,

appreciable adults
childhood,

number who,
has

of though

adolescents immunized
fully become

and in
sus-

the Danish

pioneer

observations have been

even
again

workers,

ceptible diphtheriae. with

to infection This age

by a talk of the Grant

with falling must

Corynebacterium off account

2E-207 of Academy the

sible for the development of the labelled TD, i.e., tetanus-diphtheria adult usual
Institute

preparation toxoid contains the contained

of

immunity for small

National Status of of Pediatrics,

type. amount
of Allergy presented Illinois,

This of
and

material tetanus
Infectious in 31,

increasing
in upon Meeting part

toxoid
Diseases.

Aided
Based Annual

entitled American

Current

Old

Vaccines, Chicago,

a Symposium 1962.

at Dr.

the

1962 will Tulane 1963

October

Geoffrey which

Edsalls talk on Passive Immunization appear in PEDIATRICS for October. ADDRESS: (M.H.D.S.) Department
Avenue,
New Orleans

to the
of Pediatrics,

same

Symposium
Tulane University

is the

basis
School

of his
of

Review,

Medicine,

14:30 Septemiwr

12,

Louisiana.
PEDIATRICS,

444

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REVIEW
in preparation munization
start

ARTICLE
ported in fifth due birthday to tetanus who and had of which not yet 32 more 99 occurred reached of these part
in the

445

recommended of children. Whether this in children

years, is difficult

for of
to

basic imone should toxoid or

It say.

children

their people lived of the

face of

employing doses
or 12

type

for 10
de-

in young

booster
years,

of 8 years,

of 5 to 19 years in the southern

country. This

of age.11 Most and southeastern

situation exists

pends really on the amount of experience which a particular child is likely to have had with diphtheria; if he has been brought up in South Louisiana, where diphtheria is endemic, ica,
would

our most agents, cidence

having, nearly whether

in

tetanus perfect one reactions, been

how

toxoid, of all considers or the

maybe the immunizing the long low indunaof inrecent

im-

or in most in the Middle

surely be

parts

of Latin

Amen8 years age limit

of side immunity. have

learning

or the
other

almost

East, then the upper of the

in

tion of vestigators
years in

Several groups interested in

long after basic

for
the

safe type

routine of
the

use diphtheria

more If,

conon

centrated lives
where

toxoid.

munization uals
type

previously display response. If

immunized a recall one tests and an adults

individafter

hand,

youngster

question

would of

or anamnestic also Looney excellent reafter 13 years, associates,14 one response; and if Goldsmith

in one many
type

of the areas clinical diphtheria years,

of the United States has not been seen

for
seem dilute

a logical

than the age of 12 would time to start employing the years toxoid to the with
has

of toxoid.

Again fluid
of

in

recent versus
adjuvant

question some
been to raised,

of form

10 years, as did Stafford2 and associates13 one finds sponse; if one tests children as did Peterson and his finds an equally excellent one waits 14 to 18 years,

toxoid
aluminum

as did

either with of unpleasant adjuvant

cause the

regard
side

a higher and
seemed

incidence
aluminum

reactions

and his associates, and also McCarnoll and associates6 the response is still splendid. Indeed, the findings mentioned above suggest

in adolescents
alum toxoids

adults,
to

or
provoke

be-

that

the

interval

between could well it basic been dose

tetanus be not

toxoid greatly seem out, to toxoid the pawithin toxoid the is such or alum

booster

injections the
once

paralytic tile fluid chusetts attempted I think,

Young adjuvant

poliomyelitis more readily than toxoids. Studies from the MassaPublic Health Laboratories have to answer answered
adults, does the not

lengthened. This being

necessary,

case,
the

does carried of tetanus provided injection tetanus

immunization

this question and it for adolescents

answer show being any that striking

have, and
alum effect

against administer

tetanus has a booster

at the time of each injury, tient has received a toxoid the in past year. of the one can use equal years
untoward

on

the

primary On
Council Toxoid

response the other Report

by seem doses its to

at least hand,
Committee have of even

to tetanus findings Medical

on Diph-

If, for

however, a fresh fluid

toxoid. a recent
search thena that
(l;IV

the

is administered rapidity that toxoid For

laceration, response toxoid that

occurred

British

to the

Re-

anamnestic either

demonstrated the present

very

large

with some
no

effectiveness. it was thought

reaction

pracwith

purified
diphtheria basic

preparations
toxoid are

of not
of children

formol
as effective as toxoid

on

tically

fluid
for
vith

booster adults. shown

with

doses

of

tetanus

toxoid,

even

in

immunization

a mineral

adjuvant.b0

However, further experience has that individuals repeatedly injected

tetanus toxoid do have a higher in-

TETANUS
Turning now to the tetanus component of

DPT we learn volume on the States, that

from Vital

the most Statistics year 283

recent of the (leatlls

(1959) United
were re-

cidence of this MeComb occurred that they

of unpleasant phenomenon, concluded in previously were age

reactions. In a study Levine, Ipsen, and that these reactions immunized persons, dependent, rising mark-

in that

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446
edly tically Their vations,
lowering

ACTIVE
after data and,
of the

IMMUNIZATION
pracobserto a toxoid the Concerning moment we may convulsions pertussis a year
type

the may

twenty-fifth below at or

year 20 years

but

be that

preferred far smaller

to

the doses

animal should

antisera, suffice.

and

insignificant

of age.8

well lead to further some future time,

amount of toxoid

PERTUSSIS
pertussis no startling not recently vaccine there development. have read is at Almuch folpoll of the showed

contained

in

the

TD,

tetanus administration

diphtheria of to of few to base

use of toxoid

adult type. Intradermal toxoid has for booster tions.7 in but antibody unfortunately data (The other of been
vaccines,

though tetanus been doses, in the recommended, in order must majority there on which
for the

especially avoid reaca rise individuals, thoroughly a formal

in this

about lowing conducted

and encephalopathy vaccine, an informal or two ago is still is more high

cough.

by

one

It undoubtedly

produce

manufacturers that this Apparently signed

munity

of pentussis of reaction the public a rather

whooping

vaccine

are

occurring.21 or less reprice for

One

satisfactory recommendation

to paying
against

imcan

fashion. eral
fluenza

same

comment such
where the

applies as typhoid has from

to sevand time be the effecinto

vaccines administration recommended:

only tion

hope that current will lead to a type

laboratory investigaof immunizing agent different

intradermal

route time

against pertussis fundamentally from any now available. QUADRUPLE ANTIGEN

it must

tive, but precise data are wanting.) To give a clear cut outline for dling of tetanus-prone wounds sible. Several discussion of The using Proper with
trivial

VACCINES new developantigen vacthe Massacame out to the efof

decrease

hanp05-

is not

Nor is there any startling ment with regard to quadruple cines. As all of us know Department 1960 with the
vaccine

recent articles the problems at present antitoxin of

for all

give a good involved.1820 to avoid possible. together toxoid,

with where even the

by now, of Health a statement component

a rapid

tendency tetanus cleansing administration

tetanus-prone

is to try whenever

chusetts in August feet

quadruple

that

pertussis
suffered

the later

the wound, of tetanus

individuals wounds;

is

in potency

upon

standing.22

This

was

recommended

shown to be due in part, servative used in the is where substituted deleterious The set Division a higher benzethonium for to

at least, quadruple chloride

to the prevaccine, had been latter being component. has initial the now antinamely 6% or and to from Unfortunecessary render the four the

wound more above

antimicrobial

has severe, treatment

been
drugs

present
should

several infected,
be added

days, suitable
to the

or obviously and in the where

merthiolate, the the poliovirus Standards for the standard

continued previously the wound recommended

for

at least

of Biologic

a week. Only nized, and only is tetanus tion to the to whether

units

unimmuis serious, in addivary as of 1,500

recorded

antitoxin

pertussis 14 instead more has months of

potency of the vaccine, of 12 units, to offset deterioration the the cold rigorous expiration date of storage.23 standards, public, date issue

above regime. the time-honored

(despite

Opinions dose
numerous

monthly shortened from

in potency;

is optimal

instances quent
10,000

where

tetanus

developed or whether should be that

of the

subsedoses preferred this

toxoid

to such a dose); to 40,000 units the

the

manufacturers nately, these for the protection

of the

(despite
blanket

possibility
booster effect

may
ad-

ministered one would antitetanus

simultaneously). agree globulin that,

Probably whenever is available,

everyhuman it should

vaccine economically lem add the increasing of polio vaccine, and matters a vaccine will have could again

unsound. To this probuse of tile oral type

it is clear that several

to be

settled

before on the

such market.

appear

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REVIEW SITE OF DPI

Diphtheria,
gens, singly or

ARTICLE
with bryo-denived
state

447
assurance. vaccine viruses,
2O,

INJECTION
and pertussis
all site recently for been have

tetanus,
in

antiin

Because chick is theoretically by bacteria it is

by preferable

emless or unto be

combination,

subject desirable
preferred Vaccine would

to contamination

common muscularly.
cular ject of little

that
Tile inoculations

they
has

are
optimal

administered
the

intraintramussub-

perhaps

preserved certainly seem

lyophilization to liquid

considerable
question that

debate.
the

There

seems the
where

to

be

recommendation
. . .

vaccine, region
lies
is as

which This

must

be to

so

carefully preserve true, its its

kept po-

of 40 years of the
tile great

ago
vastus

is still
of

valid:
the

at
in ties sion

freezer
warm

temperature is particularly immune

the indications climates.

outer

side

thigh,
muscle,

tency.

of course, potentialiuse were

externus tile

nearly
types nals damage in of

as

possible
intramuscular

ideal
injection.21

place in medical
serious injections,

for At

all least jour-

Vaccinia
and of

globulin,
for

its

15 articles
recent

have
following

appeared
years reporting intragluteal
2. 2;

described
ins

in of the

1959
receiving

by

Kempe
tile

on

the

occa-

nerve es-

Award

Academy discussed immunity an attack protection, in of

Mead Johnson of Pediatnics. Anilis

peciallv of the to be
bacterial

in
thigil

infants. and
contamination

tile

The deltoid gluteal

of

anterior areas
the or skin

aspect are also The

is apt

otiler matter duration of tion: confers shorten Armed while long-lasting

address

is tile

following smallpox vaccination probably practice

suffices

vaccinaconfers also for a much in the U.S. at least every

to maintain

preferred less
by

to these
major

the sites,
nerve

region. they
blood

to be
versed

at
no

and

are

tra-

vessel.

protection, but time. Current Forces

which probably

is to revaccinate solid level Asia,

annual

SMALLPOX The field

widely ingenious manufacturer

3
in are
reported called by (manufactured

years,

more of smallpox
known.

recent
Kravitz

developments vaccination
has gadget,

the
an the

a reasonably However, tinental

New Guinea,

of herd proceeding Africa,

revaccination

immunity. to conIndonesia,
is ne-

probably
on

for Europe, For

personnel

plastic

Mono-Vacc

quired.

civilians for

a similar

plan to he

would aware genby in dysagamcorti-

by
)lify

Lincoln vaccination

Laboratories,
by seem tile

Inc.,
multiple

only) and

to simpuncture

appear wise. It is well

that smallpox

pediatricians
vaccine, wilen

method.27
so tllat

It is presterilized
it would to deserve

disposable,
widespread

administered

to

a pregnant

woman,

may

produce

use.
vaccine

If,

at onto
indeed

some the
be

future
satisfactorily

time,
be

the

smallpox
lyophilized

could

enalized abortion, it the crasias,

vaccinia in the as attested by Medical

and

fetus, followed a recent article Blood and

with

(lirectly
would

points
convenient.

of the primary

apparattis, vaccination

British

Journal. leukemia
therapy

particularly hormones, to

The
is still

optimal

age

for

maglobulinemia,

eczema
takes, inure

tinder discussion. vaccinatum

progressive common under

It seems clear that and unduly severe

vaccinia, etc., are all

costeroid traindications

constitute vaccination.

absolute

con-

the

age

of one is more

year; cornAll been

one be to

CLINICAL
of the discussed that more than

EFFECTIVENESS
immunizing up they and a field to have important, test) agents this been found we

VERSUS
which point tested ilave by which have have in in the some to

and mon the

would

that after optimal

vaccinial tile

encephalitis

LABORATORY

TESTING

age of time for

lie

two years; therefore primary vaccination

the vaccine vaccine, ages should is hard of

seem

to

between

common field, but

test

and

two years.8 Whether calf lymph used, or chick embryo

so to speak, even (other

to be effective;

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448

ACTIVE
effectiveness,
other test (skin

IMMUNIZATION
that
diphpreferably four injections at intervals of

measure
this

and
reaction

we

know
after

thenia tests, thenia

and

smallpox

vaccination, in the case intracerebral

serologic of diphmouse

to 10 days should be followed dose 1 to 5 months later, mended dogcatchers, for veterinarians, with subsequent animal

by

a booster as recomhandlers, every

flocculation test and tetanus, for illness the

and

boosters

challenge effectiveness
venting

pentussis), of tile vaccine from of the test infection. next exists,

vaccines,

truly mirrors the on toxoid in prethree and

and

In agents,
rabies

case no

immunizing I refer
to BCG.

few years on on the occasion of possible exposune. While on the subject of rabies, we would like to mention that the antinabies horse serum Lederle ardized
serum

such
typhoid

to

for

passive Laboratories by
by

immunization only) with

the Division

is

(made by now standa reference

of Biologic

comparison

RABIES
The
vaccine,

furnished

brain the

tissue

containing Semple supplanted embryos From we is, it in a does tests have general, recent
between

type

of rabies vaccine, is

so-called

Standands,41 in terms previously.

of

that the dosage units rather than

is expressed milliters,

as

rapidly made Company in lieve vaccine, turbing

able

being from duck only). mammals, this although in

antigenic
tilat

by a vaccine (Eli Lilly and of effectiveness reason an report to effective is considerbatches.

BCG
bedishas ing under and Council. agreed relatively The incidence been a recent the effectiveness of proven one auspices severe of BCG forms in many conducted of the in lowering of tuberculosis includBritain Research are
with a

other that

the

studies,42 in Great Medical authorities like ours of the

describe by

variability

The
Ilis

elegant
coworkensb6

demonstration
that none of

Gibbs
the 22

mdi-

that,

However most in countries low incidence

viduals veloped whereas

vaccine

immunized

with

duck

vaccine changes,

de-

disease,

electroencephalographic 10/69 vaccinated did, should prove physicians who 7 or

So of

BCG
Research should to greater elude with been
North

with brain tissue extremely reassurfind it necessary vacto

fol-

(available in the Foundation, be reserved for than usual risk.4 all children adults wilose arrested
American

U.S. only from the Chicago, Illinois) those individuals at This in would inhouseholds disease has 5 years:
to live

ing

to

administer the cine recommended

a rabid one animal. report only

14 doses of rabies for persons exposed

far there is on transverse myelitis

who live tubenculous no more

children

record

for

than
going

also
in

lowing adult We

duck who must

embryo ultimately all perforce

rabies recovered).7 be aware

vaccine of the

(an ap-

areas

of

the

world

where have vaccine

tuberculosis in not
tile

is
sug-

endemic. Various
gested
tilat

authorities

past

parently increasing the epidemiology

state is the

role played by of rabies in almost Particularly

bite is not a bat

bats in every

BCG

be

used

in

of the
fact

union.8
that

disturbing
necessary

newborn higher lesions,

response

infants, incidence because and

because of a relatively of prolonged vaccination of presumed poor antigenic the vaccine might infection reports5 are there BCG,
of

for has
Now

infection been that

: aerosol proven in a relatively rabies vaccine

its

transmission bat-inhabited safe, albeit is

prophylactic caves,

of rabies caves. somewhat we

use trap Under in live

because

be

discredited if a true were superimposed. show

tilat tilat untoward

tuberculous Recent incidents rate is good;

to fear

painful,
should Youngsters

available,

rare

and seems where

consider who

the
ilO

conversion
further

explore

then

reason

intradermal

wild
world

animals,
where

or
rabies

go

to

live course

in parts of

of the
such

inoculation
tile

of newborns of tuberculous
tile

with infection
strains

is endemic.

risk

is high. bovine

circumstances

a basic

three,

or

Unfortunately,

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RE\TIEW tul)ercle \(re Thus

country,

ARTICLE Fronl
to

449 tile thC area, start efficacy i)tlt potency co-operated tile Listen in London
Institute of of

i)acilh all, until it was

to

fronl

wiiicii

13CC to
still is

is made
iSOilidZid.
in

it was of the

importailt vaccine lai)oratory would

riot

only

recciltlv,
necessary, choose

sensitive
1I1(l between

test

in an

entests

this child,

(ICifliC

11s() to fiuid which

a(llllinistening

for clinical

vaccine

reflect in many inReReed that vaccine ac was was used to vac-

prophylactic thus giving

duration;

isoniazid him or instant giving

to an

exposed

effectiveness.

Laboratories in the

protection of limited Ilim BCG, where but starts only after the detubencle agonizing Unger,
On

countries eluding search Army

The

evaluation,

protection interval velopment

an

is longlasting

Insitute of Medical and the Walter

Research in Washington.

of 2 to 4 months. With of a strain of bovine to isoniazid,

110

results

the
in

field
about

study
70%

showed of those vaccine disturbing presently consistently of the

tile presence

bacilli
cilOice

resistant
is

this necessary.

the
gave

heat-killed
protection

phenol-preserved tile alcohol

longer

Thomas

on the
sistant
tile same

and Muggleton reported laboratory investigations

BCG,
issue

in 1961 INH
in

cinated, not the

wilereas

and
of

Gaisford

and

Gniffiths

effective.5 fact that tests

Particularly none of the was found

the

British

ivil several
of

on

a successful ilundred is iiot pediatricians and observe it presents

clinical

Medical Jourtrial involving

laboratory

BCG

newborns.#{176} While this type available in the United States, who need great where disease. travel to be promise tuberculosis abroad acquainted for large is the to

reflect the degree cine in tile of the so-called demonstrated

soever.

of effectiveness Nor was Vi antigen in

the

vaccine what-

tilOse

to be of any
absence of

importance

teach with

it:

In
tests test

tile

adequate

laboratory impossible to for potency, schedule for any contain

for some

areas of tile world leading infectious

for

potency,

it

becomes of vaccine optimal on to make doses. vaccines

although,

or

different to work

batches out the for booster

TYPHOID
Last typhoid ral)ies oratory
ments

basic of of some

immunization, of the
reason,

recomparaob-

of all we vaccine. and BCG measure

have

come to a consideration Here, as in the case vaccines, there of its effectiveness. for by Sir decades-even Almroth War-as Review this it was is no

mendation

Moreover,

typhoid Salmonella

labArguit at

typhoid
scure

A antigen,
completely

panatyphi from this

A has country.

disMy

raged

since Wright

appeared

was the was rate feeling

best.

developed time any

of the Boen good or not. left maybe

field studies

to Viletiler it of many sepawith effective

out in

own feeling is that cilildren wilo live typhoid then plain To

would

in the United States only in the household with a be given or are

the

carrier with typhoid a vho infections

recommend

should heat-killed, vaccine live

immunized, phenol-preserved subcutaneously. where

vaccine,

and

incidents that
The

reviewer 75%
carried

tile at
the

those

travel
triple

SalI
lleat-

British Army this century that time, that they standards. which led Yugoslavian but are It

in India in the were considered

early years convincing

of at

monelia killed the

is not

hyperendemic, In either the they case

Cockburn showed in 1955 not acceptable by modern is this general uncertainty to co-operate authorities with the in a field

and family
very

phenol-preserved. should
potent,

be its

told

that

W.H.O. health

not

challenge

and that effectiveness.

vaccine had best

trial of typhoid typhoid fever designed namely vaccine a heat-killed to

tile

vaccines, is endemic. test two alcohol-killed one hand; and phenol

in an area wilere Tile trial was types and and preserved on of vaccine, preserved the other vaccine.

INFLUENZA As
neither

a comes field

sort
a very

of
old

postscript,
vaccine,

because
nor a very

it
new

is

one, ous have

influenza trials over

virus the the

vaccine. last twenty

Numeryears

on

the

demonstrated

efficacy

of influenza

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450
virus vaccines, and the laboratory

ACTIVE
tests

IMMUNIZATION
do

seem lie

to between

correlate of effective 40 and

with

clinical protection 96% with

results.0 seems to an averthe has the in

at

tamed, to be

and, in countries where in contact with smallpox, Nigeria, should

1 to 3 years.

ofle e.g.

is likely
. Congo,

The range
age around polyvalent several high
young

India, Indonesia, pox revaccination

intervals of

Pakistan, smallbe practiced at

Routine ty-

78 to 80%. Unfortunately vaccine ordinarily employed

37

phoid tions, world,

immunization, is indicated in \Vhere as is BCG. (i.e. rabies,

despite many rabies

its parts

imperfecof the

serious incidence
children,

of
which

untoward
has been

such as reactions
estimated

is prevalent, consider provaccination

8 to 40%,

the

short

duration

of tile

immunity

I personally phylactic
against with

would seriously preexposure) using duck

conferred for booster

mutation

by this vaccine with the need doses each autumn, the ongoing
of influenza viruses with

embryo

vaccine type of yelalso to

three-or-four-dose-and-booster

bility

that

existing immunity to appear

of

vaccines against on the

showing

may

the confer

possiless-

than-usual virus yet

the number

the strains of scene. Finally

that the ef-

schedule. Special inoculations low fever, cholera, plague, be indicated, or even required

against etc., may by law. and

It is well
warn

to

remember,

Ilowever,

studies

fective preschool cination This reserve fluenza

from

clinical protection children by is very limited. being the situation immunization vaccine for chronic heart

conferred anti-influenza it seems with

upon vacwise to

patients, effective 100% are

that no immunization of the time. Our only perhaps they which 90% confer varies

is 100% very best effective. falls gradfrom per-

vaccines

The immunity ually along son from or

which a curve

those

polyvalent inchildren suffering disease, such or those insuffimetadisvaccine

in

to person; persons another disease, or pregnant, to may be infection.

already suffering in surgical shock, more tile

time of

debilitating disease, disease incipient

as hy-

physiologically Moreover at tile important. play the

rheumatic

congenital (particularly cardiac

susceptible of the posure even thing, genie of the

size
ex-

pentensive heart with frank or ciency); bolic, orders. Ideally,

should be

infective dose is tremendously when fully

In

short, every-

chronic bronchopulmonary, renal disease; or neurological a dose followed later. of polyvalent

subcutaneously,

immunized

against

one still should not viruses and bacteria childrens you come game over.

with pathocounterpart Red Rover,

Rover,

administered

I dare

early
tion

autumn, about

by

a second

injec-

2 months

REFERENCES
1. Batson, R., and
and T. C.,

Christie,
matetrials.

GENERAL
It seems recommendations means parts the worthwhile

COMMENTS
to point of the Red out that are the by no in and also
2.

methods 1958. Doege, 1960.

A. : Immunization J. Pediat., 53:51,

W.,

Heath,

C.

Book

I. L. : Diphtheria
PEDlAnucs,

in the
30: 194,

Jr., and Sherman, United States, 19591962. to diph-

always applicable of the world other United States, and with special consideration
doses

to conditions than Canada that they care must

3. Brainerd,

H. D.,
among New

et

a!.:

Susceptibility

thetria
by the
oid.

be interpreted patient under abroad,

particular, booster

when the has lived abroad. In

tox-

elderly intracutaneous
Engi.

persons. Immunization administration of tox247:550, 1952.

J. Med.,

or in preparing for when

to travel
of

diphtheria

oid are superfluous many places and, cated, ployed Tetanus the TD for children immunity

older children they do seem should be

in mdiemabove. main-

adult

type

of 8 years and should be carefully

C. W., Jr., and Zusman, J. : An outbreak of diphtheria among skid-row men. New Engl. J. Med., 267:809, 1962. 5. Report of the Committee on the Control of Infectious Diseases, American Academy of Pediatrics, Evanston, Illinois, 1961. 6. Volk, V. K., et al.: Antigenic response to booster dose of diphtheria and tetanus toxoids-seven to thirteen years after primary 4. Heath,

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REVIEW
iflOClllltiOn
PIll).

ARTICLE
23. of Pittman, M. : Instability of pertussis-vaccine

451
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of

noninstitutionalized 77:185, et toxoid 52:353, McComb, and and 1962. ci.:

children.

health

Rep., following

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Pappenheimer,
reactions and purified L., Ipsen, population.

A. NI., Jr.,
diphtheria Amer.

A
in

study of an 1950. crude adult

administration

in quadruple and tetanus poliomyelitis

1962.

antigen toxoids vaccines. for

1920.

vaccine. and perJ.A.M.A.,

J. Hyg., J., Jr.,

fluid Preparation

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A.: 25.

Turner,
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G.

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The
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intramuscular

8.

Levine, Adult

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immunization.

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tion
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Procedures

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premature

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Lesions. inoculation and to the of in primary Brit. of Vital 2:60, E. 1959. S. :

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ATRICS,

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smallpox vaccination.

Cabasso,

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44:194,

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anitoxin van254:6, Williams, 32. 33. re-

smallpox
calf

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after

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adults,
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452
41. Atanasiu,
body
serum

ACTIVE
P.,
response and 1961. et (11.: to vaccine Rabies different inoculations neutralizing schedules in

IMMUNIZATION
antiof non-

pital. 50.
Ungar,

Lancet,
j., Freeze-dried

2:902,
V.,

1959.
and : a \Iiiggleton, vaccine laboratory 1961. 1: 1498, from P. an inB.C.G. strain

Thomas,

w.
51.

exposed
103, 42. Ruegsegger,

persons:

Part

3. Bull.

W.H.O.,

25:

isoniazid-resistant

J.
Rev. T.

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Personal
past,
76:715,

communication.
present, and
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vestigation. Gaisford, W.,

Brit. and
clinical 1961.

Med. J., Griffiths,

from investigation. Early Roy.

M.

I. : A freezeBrit. of Med. Med. typhoid Corps,

43.
44. 45.

Wallgren,

A. : BCG
M. :

future.

dried
B.C.G. 52. to Cockburn,

vaccine : a W.

isoniazid-resistant

Amer.
Pollock,

BCG

vaccination Advisory

J.,1:1500,
vaccination.

Tubercle,
Tuberculosis

40:399,
Control

1959.

C. :

history Army

J. 1955.
B.
Amer.

46.

the Public Health Service: Use of BCG vaccine. Public Health Rep. 77:680, 1962. Lorber, J. : Freeze-dried BCG vaccination of newborn infants by the multiple puncture method. Tubercle, 40:21, 1959.
Moodie, A. S., and Cheng, G. K. : Con-

101:171,
53. Cvjetanovic,
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B. :

Field

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with typhoid

trial of Health, Field

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typhoid 47:578, and laboBull.

54.

Yugoslav
ratory

Typhoid
studies

47.

48.

current BCG and smallpox vaccination in newborn babies. Tubercle, 43: 155, 1962. Mount, F. \V., and Ferebee, S. H. : The effect
of isoniazid prophylaxis on tuberculosis

WHO.,

16:897,

1957.

Acknowledgment

morbidity viously 49. Dormer,

protection

among household contacts known cases of tuberculosis.

of preAmer.
isoniazid: hos-

The
for his

author
constructive

is

indebted criticism, Karzon,

to and in

Dr. also to the

Geoffrey to Dr. Drs. Jorge preparation

Edsall John Escoof

Rev. Resp.

Dis., 85:821, 1962. B. A., et al: Prophylactic

of infants in a tuberculosis

Fox
bar

and
Melguizo

David
for

assistance

the

manuscript.

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ACTIVE IMMUNIZATION: CURRENT CONSIDERATIONS Margaret H. D. Smith Pediatrics 1963;32;444

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1963 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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