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Artefacts from the HKMMS Member oftheEducationandResearchCommittee,HongKongMuseumMedicalSciencesSociety trained several Chinese employees of the British British the also of he employees Chinese and several Chinese, trained into translated was which vaccination, of technique the on pamphlet a wrote the other three orthopoxviruses can infect both both infect animals. can and humans virus, orthopoxviruses variola three the other by the caused is disease Variola monkeypox. only infects virus humans, while e and cowpox, vaccinia, variola, orthopoxviruses: four are There orthopoxvirus. of family the to belonging countries. affected in death and a of worldwide major cause had spread smallpox during the firstAD. century By themid-18th century, as to early was carried as The1500 BC. disease India ancient from writings medical in documented 50%. as high as be can fatality Case development. of stage same the at vesicles pustules or deep-seated firm, by The rash. characterised is a rash of appearance exceed the or by to followed increase is 38.3°C can smallpox that fever of a with onset acute The or objects. fluids bodily contaminated infected with contact direct by or individual infected an with contact via droplets by spread is that disease infectious highly a is Smallpox Moira Chan-Yeung, Vaccination knife Pearson, a surgeon to the East India Company. India Alexander East the to by surgeon a Pearson, and Macao via 1805 in safer than variolation and soon replaced the latter. the replaced soon and variolation than safer immunity but a only caused much was mild reaction, effective produced which Vaccination, smallpox humans. to in ‘vaccine’, immunity produce called to he inoculation which for lesion, cowpox a from the material the used and first , doctor Gloucestershire, a in Europe, Jenner, Edward 1796, England, In America. North in practised became widely variolation result, a As England. to return her on proponent enthusiastic an became Empire, Ottoman the in stay her during variolation observed Reminiscence:variolation. with occurred sometimes reactions child with smallpox a for cotton of 2 to undergarment 3 days. unwashed of Nonetheless severe the wearing or child, pledget a a of nose the into scabs placing smallpox with impregnated or scabs smallpox powdered blowing including used were inoculation of methods Several century. 10th late the in China vaccination. and variolation of principle basic the is which forms, other all immune against became virus who the of person form a one that contracted recognised was it virus, the of Th S Je I V n 1718, Lady Mary Wortley Montagu, who who Montagu, Wortley Mary Lady 1718, n mallpox is an ancient disease, first first disease, ancient an is mallpox ariolation against smallpox was introduced in smallpox was introduced against ariolation nnerian vaccination was introduced in China introduced was vaccination nnerian Hong Kong Med J J Med Kong Hong FRCP, FRCPC 2 Long before the discovery discovery the before Long ⎥ Volume 23 Number 6 6 Number 23 Volume 1 ⎥ December 2017 2017 December 3 3

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community because of the extensive vaccination vaccination extensive Tung by out Wah. carried work the of because community Chinese the for his programme a have not under did he care, patients and community European the vaccinated he Although vaccination. in efforts its for Hospital Wah Tung Colonial praised accepted Ayers, (1873-1897), PBC Surgeon Dr became community. local the vaccination by that vaccinators Chinese employed that 1872 in Hospital TungWah colony British a became Kong extensively Hong hen was variolation performed. traditional 1842, in infection, rigid guards, shields, or cages were placed placed were cages or shields, guards, rigid infection, it a family business. family a it making grandchildren and children his the to technique on passed and vaccinator a as wealthy became factory. One of his first trainees, Qiu Xi ( Xi Qiu trainees, first his of One factory. even provided aftercare using traditional Chinese Chinese He medicine. traditional liberated. using aftercare being provided toxin” even “fetal as pustules the explaining and made to be were incisions where arm the on points meridian the naming acupuncture, of language the using Pearson of method the described

hpd ie lne blade. lancet a like shaped vaccine The points ivory using incisions the onto introduced was points. acupuncture of meridian the along arms on both incisions two by making method his modified Qiu in arm. one incision one only made in the Figure. He a illustrated as using lancet method scabs. buffaloes young of human through with the smallpox powdered nostrils inoculation including produce to lymph ways transmission improvised vaccinators arm-to-arm this method, by leprosy as diseases such transmitting of possibility the of vaccinated. Because be to child the on applied directly was lesions resultant the from extracted lymph the vaccinated and were vaccination children “charitable poor the where dispensary”, by ensured was days vaccinators. early other of those and efforts his of result a as century 19th early the in China Southern in accepted widely became vaccination this, Despite practice. medicinal traditional Chinese of rules the breaking thus body, into a and substance the foreign introducing incision on Morrison Hill, Morrison on Hospital Society Medical the at children Chinese doctor, vaccinate tothe first was missionary W Q P L 3 ymph supply throughout the year in those those in year the throughout supply ymph earson practised the single linear cut/scratch cut/scratch linear single the practised earson u i ulse hs w bo i 11. He 1817. in book own his published Xi iu ⎥ www.hkmj.org 3 Qiu performed vaccination by making an an making by vaccination performed Qiu 4 lhuh ejmn osn a Hobson, Benjamin Although 5 it was only after the founding of of founding the after only was it 3

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performed with the flat of an instrument such as the flat of a blade or a Hagedorn needle, that was flattened on the sides and firm pressure was applied to the skin of the upper forearm where a drop of vaccine was placed. The pressure tore the stratum corneum slightly and the inoculum was deposited in the epidermis.7 Hong Kong ran many major vaccination campaigns during the early 20th century in an attempt to reduce the severity and mortality from smallpox epidemics. The Vaccine Institute (1892- FIG. Short vaccination knife, made in France in the 19th century, 1906) and the Bacteriology Institute, built in 1906, was acquired in 2009 by the Hong Kong Museum of Medical produced smallpox vaccine lymph for use locally Sciences Society from the Pasteur Institute, Paris. It has a steel and in neighbouring areas such as Guangzhou. lancet (3.3 x 0.8 cm) with tortoise shell guards (6.2 x 0.8 cm) The massive vaccination campaigns involved not only Tung Wah Hospital but all other hospitals and Chinese public dispensaries.8 Vaccination campaigns continued after the Second World War. During the over the vaccination sites to allow natural healing. It post-war years, the government hired inoculators is likely that the vaccinators of Tung Wah Hospital trained in China to carry out smallpox vaccination used Qiu’s method as they were trained in South and other immunisation in the field. According China by Qiu’s descendants or by trainees of the to Patricia Ko-Woo, Chief Nursing Officer at the early vaccinators taught by Pearson. Department of Health in the 1950s and 1960s, Other more complicated instruments were the most common method employed then was to designed such as a spear-pointed lancet with a produce two to three abrasions on the skin of the groove for holding the vaccine, or spring-loaded upper arm, or upper thigh and occasionally on the lancet. These gave way to simpler, easily sterilised sole of the foot, using a small blade similar to a later and/or dispensable instruments such as surgical version of one shown in the Figure. Only one site needles or even darning needles used with special was inoculated at one time. Later on, needles were handles. The incision method was widely used as it used to produce five to six pricks on the skin. In both was simple and rapid, and could be used for multiple methods, the drawing of blood was to be avoided. site inoculation.4 Revaccination was recommended every 2 to 3 years. Another method of vaccination was by The last case of smallpox in Hong Kong was puncture, a stabbing action at a right angle or acute recorded in 1952 and Hong Kong was declared free angle to the site. A variety of mechanical, spring- of smallpox in 1979.9 In 1967, the World Health loaded devices that could control the depth of Organization set in motion a global Smallpox penetration were developed but they were difficult to Eradication Programme using intensive vaccination, clean. In 1961, a bifurcated needle was introduced; it surveillance, contact tracing, and isolation/ was simple and could be used by auxiliary workers quarantine. The Programme succeeded and the last after minimum training. This method saved 75% of naturally occurring case of smallpox was reported the volume of the vaccine and was widely used in on 26 October 1977. On 8 May 1980, the World the Eradication Programme against Smallpox of the Health Assembly announced that the world was free World Health Organization in the 1960s and 70s.7 of smallpox and recommended that all countries The third was the multiple pressure method, cease vaccination.9

References 1. Riedel, S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent) 2005;18:21-5. 2. Rao AR. Smallpox. Bombay: Kothari Book Depot. 1972. OCLC 723806. 3. Leung AK. The business of vaccination in nineteenth-century Canton. Late Imperial China 2008;29:7-39. 4. Hobson B. Report of the Medical Missionary Society’s Hospital at Hong Kong under the care of Benjamin Hobson. Chinese Repository 1844: 380. 5. Bowman ML. and the Chinese classics: a brilliant Scot in the turmoil of colonial Hong Kong. 1st ed. Victoria, BC, Canada: Friesen Press; 2016: 159. 6. Colonial Surgeon’s Report of 1876, Tung Wah Hospital. Hong Kong Blue Book 1876. 7. Baxby D. Smallpox vaccination techniques: from knives and forks to needles and pins. Vaccine 2002;20:2140-9. 8. Medical and Sanitary Report 1917. Tung Wah Smallpox Hospital. Hong Kong Administrative Reports 1917: 48. 9. Lee SH. Infectious disease surveillance. Hong Kong: Department of Health; 1994: 43-5.

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