574 SMALLPOX AND ITS ERADICATION Instructions for Smallpox Vacc<strong>in</strong>ation with Bifurcated Needle Given <strong>in</strong> each Box of Vacc<strong>in</strong>e 1. Method for <strong>vacc<strong>in</strong>ation</strong>-multiple puncture technique. 2. Site of <strong>vacc<strong>in</strong>ation</strong>-outer aspect of upper arm over <strong>the</strong> <strong>in</strong>sertion of deltoid muscle. 3. Preparation of sk<strong>in</strong>-none. If site is obviously dirty, a cloth moistened with water may be used to wipe <strong>the</strong> site. 4. Withdrawal of <strong>vacc<strong>in</strong>e</strong> from ampoule. A sterile bifurcated needle (which must be cool if flamed or completely dry if boiled) is <strong>in</strong>serted <strong>in</strong>to <strong>the</strong> ampoule of reconstituted <strong>vacc<strong>in</strong>e</strong>. On withdrawal, a droplet of <strong>vacc<strong>in</strong>e</strong> sufficient for <strong>vacc<strong>in</strong>ation</strong> is conta<strong>in</strong>ed with<strong>in</strong> <strong>the</strong> fork of <strong>the</strong> needle. 5. Application of <strong>vacc<strong>in</strong>e</strong> to <strong>the</strong> sk<strong>in</strong>. The needle is held at a 90° angle (perpendicular) to <strong>the</strong> sk<strong>in</strong> [see Plate 11.141. The wrist of <strong>the</strong> vacc<strong>in</strong>ator rests aga<strong>in</strong>st <strong>the</strong> arm. For both primary <strong>vacc<strong>in</strong>ation</strong> <strong>and</strong> re<strong>vacc<strong>in</strong>ation</strong>, 15 up-<strong>and</strong>-down (perpendicular) strokes of <strong>the</strong> needle are rapidly made <strong>in</strong> <strong>the</strong> area of about 5 mm <strong>in</strong> diameter. The strokes should be sufficiently vigorous so that a trace of blood appears at <strong>the</strong> <strong>vacc<strong>in</strong>ation</strong> site. If a trace of blood does not appear, <strong>the</strong> strokes have not been sufficiently vigorous <strong>and</strong> <strong>the</strong> procedure should be repeated. Although it is desirable not to <strong>in</strong>duce frank bleed<strong>in</strong>g, <strong>the</strong> proportion of successful takes is not reduced if bleed<strong>in</strong>g does occur. 6. No dress<strong>in</strong>g should be used after <strong>vacc<strong>in</strong>ation</strong>. 7. Sterilization of needle may be done by flam<strong>in</strong>g or boil<strong>in</strong>g. (a) Flam<strong>in</strong>g-<strong>the</strong> needle is passed through <strong>the</strong> flame of a spirit lamp. It should not rema<strong>in</strong> <strong>in</strong> <strong>the</strong> flame for more than three seconds. The needle must be allowed to cool completely before <strong>in</strong>sert<strong>in</strong>g <strong>in</strong>to <strong>vacc<strong>in</strong>e</strong> ampoule. (6) Boil<strong>in</strong>g-<strong>the</strong> needle is sterilized by boil<strong>in</strong>g for 20 m<strong>in</strong>utes. Subsequently, <strong>the</strong> needle must be dried thoroughly to ensure that <strong>the</strong> fork of <strong>the</strong> needle does not conta<strong>in</strong> a drop of water when <strong>in</strong>serted <strong>in</strong>to <strong>the</strong> <strong>vacc<strong>in</strong>e</strong> ampoule. 8. Unused, reconstituted freeze-dried <strong>vacc<strong>in</strong>e</strong> should be discarded at <strong>the</strong> end of each work<strong>in</strong>g day. bifurcated needles were also used, especially <strong>in</strong> of childhood, immuniz<strong>in</strong>g antigens o<strong>the</strong>r rural areas <strong>and</strong> where only small numbers of than <strong>smallpox</strong> <strong>vacc<strong>in</strong>e</strong> were adm<strong>in</strong>istered people required <strong>vacc<strong>in</strong>ation</strong>. In Brazil, <strong>the</strong> with syr<strong>in</strong>ges <strong>and</strong> needles. At that time, before programme was highly organized <strong>and</strong> <strong>the</strong>re disposable equipment had been <strong>in</strong>vented, was no shortage of skilled ma<strong>in</strong>tenance <strong>and</strong> sterilization between <strong>vacc<strong>in</strong>ation</strong>s was timerepair staff for <strong>the</strong> jet <strong>in</strong>jectors. In western <strong>and</strong> consum<strong>in</strong>g, but necessary if serum hepatitis central Africa <strong>the</strong>re was a special reason for was to be avoided. The jet <strong>in</strong>jector overcame us<strong>in</strong>g <strong>the</strong> jet <strong>in</strong>jector-namely, <strong>the</strong> simulta- this difficulty. It consisted, <strong>in</strong> essence, of neous programmes of <strong>vacc<strong>in</strong>ation</strong> aga<strong>in</strong>st a piston which forced a measured dose <strong>smallpox</strong> <strong>and</strong> tuberculosis <strong>in</strong> Zaire <strong>and</strong> of <strong>vacc<strong>in</strong>e</strong>, under high pressure, through aga<strong>in</strong>st <strong>smallpox</strong> <strong>and</strong> measles <strong>in</strong> western a narrow orifice, <strong>the</strong>reby achiev<strong>in</strong>g sub- Africa. In o<strong>the</strong>r areas, <strong>in</strong> which only <strong>smallpox</strong> cutaneous <strong>in</strong>oculation without <strong>the</strong> need for <strong>vacc<strong>in</strong>e</strong> was be<strong>in</strong>g adm<strong>in</strong>istered, <strong>the</strong> bifur- syr<strong>in</strong>ge <strong>and</strong> needle. cated needle, by virtue of its simplicity <strong>and</strong> H<strong>in</strong>gson et al. (1 963) had used jet <strong>in</strong>jection advantages <strong>in</strong> field use, had been universally to adm<strong>in</strong>ister local anaes<strong>the</strong>tics, <strong>in</strong>sul<strong>in</strong> <strong>and</strong> adopted by 1969 <strong>and</strong> had replaced jet <strong>in</strong>ject- various antibiotics s<strong>in</strong>ce 1947, <strong>and</strong> after 1954 ors where <strong>the</strong>se had earlier been used <strong>the</strong> procedure had been used on military experimentally. recruits for <strong>the</strong> subcutaneous <strong>in</strong>jection of <strong>in</strong>fluenzavirus <strong>and</strong> poliovirus <strong>vacc<strong>in</strong>e</strong>s. By History 1962, <strong>vacc<strong>in</strong>ation</strong> aga<strong>in</strong>st cholera, DPT (diph<strong>the</strong>ria, pertussis <strong>and</strong> tetanus), typhoid In immunization campaigns <strong>in</strong> developed <strong>and</strong> yellow fever was be<strong>in</strong>g carried out with countries, undertaken to control <strong>the</strong> diseases jet <strong>in</strong>jectors <strong>in</strong> Central <strong>and</strong> South America. All l'
11. VACCINATION IN THE INTENSIFIED PROGRAMME 575 ;d B : pulled <strong>the</strong> Gston was released forc<strong>in</strong>g a f<strong>in</strong>e highpressure jet of <strong>vacc<strong>in</strong>e</strong> <strong>in</strong>to <strong>the</strong> epidermis. B: Assembled <strong>in</strong> case for transport. U"
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