THE MASS BCG VACCINATION CAMPAIGN IN JAMAICA*? (October 1951-June 1953)
1. THE CAMPAIGN WHO scholarship to Ecuador for training with the “International Tuberculosis Cam- 1. The Joinf Agreement between WHO, paign” BCG vaccination teams in that UNICEF and the Govemment of Jamaica country. In September 1951 they, in turn, for a Mas-s BCG Caynpaign trained four junior medical officers and eight Early in 1951 it mas agreed between repre- nurses in Jamaica. At the onset of the sentatives of the Jamaican Government, programme, Dr. Knut Osvik, WHO Regional the World Health Organization and the BCG adviser, was present during one month United Nations Children’s Fund (UNICEF) to instruct and advise the local personnel. that a tuberculin testing and BCG vaccina- The chief of the campaign was Dr. J. 1. tion campa@ should be started in Jamaica Rerrie, Chief of Tuberculosis Division, during 1951. An agreement was reached Island Medical Department, Jamaica. Cam- concerning details about the objectives of paign organizer was Dr. R. G. Lampart, the project, the organization, method and Jamaica. extent, the training of personnel and the Four teams, each consisting of one as- proposed commitments of WHO, UNICEF sistant medical officer and two nurses plus and the Government of Jamaica. a chauffeur, were working during the whole The campaign was expected to cover the campaign. During June 1952 two of the whole island and to last for at least two doctors working as team leaders were re- years. The population LO be examined was placed by the two senior nurses who were hmited to persons O-20 years of age in the trained in Ecuador and two new nurses were urban areas and O-30 years of age in the appointed. The personnel in the central rural areas. The field work was planned to BCG Office in Kingston were one supply be done by four teams, each consisting of officer, one statistician, two clerks, a chauf- one doctor, two nurses and one driver. feur and a messenger. The Office consisted It was estimated that about 600,000 of three rooms plus a store room. persons would thus be examined in the A team consisting of one doctor and two campaign. Name-lists of the positive tuber- nurses arrived in November 1951 from culin reactors should be made for the local Trinidad for two months’ training in BCG health authorities’ use in their case-finding work. A similar team from Paraguay arrived programmes. one month later for a short visit.
2. Training, Personnel and O$îce 3. Equipment In February 1951, Dr. R. G. Lampart All the equipment: 6 Willys station wag- and two nurses, Miss P. Manahan and Miss ons, vaccination kits, propaganda material, V. Skeffery, mere sent on a three months etc., was supplied by UNICEF and arrived in July 1951 in good condition. The tuber- * Campa@ carried out under the joint auspices of the Government of Jamaica, World Health culin and vaccine were paid for by UKICEF Organization and the United Nations Children’s and sent weekly by air-freight from Mexico Fund. This report-mas prepared under the direc- City to Kingston. Yc tion of Dr. J. 1. Rerrie, Tuberculosis Officer, ’ Jamaica, with the assistance of Mr. Truls Zeiner- 4. Propaganda and Planning Hendriksen, Statistician, World Health Organisa- tion. During September and October 1951 t Manuscript received in July, 1956. extensive propaganda was carried out 61 62 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA
through press and radio and public meetings. tested even though they were over 30 years Before the campaign teams were scheduled of age. Refusal to test such persons was diffi- to arrive in a district, meetings were held cult and perhaps unnecessary. Accordingly, with local doctors, health workers, sc&hool- almost everyone up t’o about 50 years of age teachers and other authorities, pamphlets who carne to the vaccination centres was distributed and propaganda films with accept’ed. It was derided not to test or popular lectures shown for the public. The vaccinate babies under one year of age in schools were visited, and sites were selected the campaign, because of t,he often difficult as vaccination centres. Before and during working ronditions for at,tending new-borns the examinations, loud-speaker propaganda in the field. was made from the team cars. This proved Name-lists of positive reactors were pre- to be very effective, and good contact was pared for the lora1 health authorities. obtained with the public. Table 1 shows the progress of the cam- paign in terms of the number of persons 5. Progress of Worlc tested and the number vaccinated each The vaccination teams generally worked month from October 1951 through June together in the same district and covered 1953. one entire parish before proceeding to another. 6. Tuberculin Testing and BCG Vaccination The campaign started in Kingston on 22 B single 5 T‘C’ intradermal tuberculin test October 1951, with vaccination in schools was used throughout the rampaign. This and later in some offices and factories. The meant that people only had to be seen twice: four teams continued to work in Kingston once to be given the test and a second time and St. Andrew parish through November, three days later to have the reaction read December and January. The next parishes and to be vaccinated, if considered “nega- to be covered were St. Thomas and Portland tive”. With few except’ions the tuberculin in the eastern part of the island. In April tests were given on Mondays, Tuesdays and 1952 the campaign proceeded to the parish Wednesdays; the reactions were read and of St. Mary. During May, June and July the “negatives” were vaccinated on Thurs- the parishes of St. Mary, St. Ann and days, Fridays and Saturdays. Trelawny, al1 on the north coast, were Tuberculin for the campaign was the covered. St. James and Hanover in the purified protein derivative (PPD) identified north-western part of the island were cov- as RT XX11 from the State Serum Institute, ered in September; Westmoreland and St. Copenhagen. Stock solutions sent from Elizabeth in the south-western part of the Copenhagen were diluted at the Laboratorio island in November and December. In del BCG in Mexico City, and the ready-to- January 1953, the campaign had reached use dilutions were forwarded weekly (as a Manchester and proceeded to Clarendon, rule), by air, in 100 CC. bottles packed in where vaccination was done until May. The specially const,ructed ice-containers. The parish of St. Catherine was also finished tuberculin test’ mas given by intradermal during May. In June some additional injection of approximately 0.1 CC. of the 5 vaccination was done in Kingston, and one TU dilution into t,he dorsal aspect of the team was sent to the island of Grand Cay- left forearm. man where vaccination was done until the Reactions with indurations measuring 6 end of June 1953. mm. or more in transverse diameter were The age-range considered in the campaign considered “positive”, those with indura- was changed from what had been set out in tions of 5 mm. or less were considered the agreement. It was found difficult to hold “negative”. Only persons with “negative” the oldest age limit, as adults coming to reactions were offered BCG vaccination. the centres with their children wanted to be The time interval between injecting the July 195?] BCG VACCINATION IN JAMAICA 63
TABLE I.-Number of. .persons tuberculin-tested and vaccinated with BCG during October 1951-June 1953, by month. - - - Number with test read Month and year Number I l Number given test - vaccinated Total Positive Negative -- -- _- October 1951 15,971 15,279 6,007 9,272 9,190 November 1951.. 54,237 50,138 25,427 24,711 24,681 December 1951 : : 39,242 37,817 22,462 15,355 15,330 January 1952.. 28,767 26 >852 14,163 12,689 12,655 February 1952..
tuberculin and reading the reaction was tuberculin testing programmes were carried usually three days, in a few cases two or out: the first from 2 June to ll July 1952, four days. The vaccination was made by the second from 8 September to 15 October injecting approximately 0.1 CC. of BCG 1953. Under the supervision of WHO per- vaccine intradermally into the deltoid region sonnel, both programmes were done in of the left shoulder. selected school-groups vaccinated with dif- Vaccine for the campaign was prepared ferent lots of vaccine at different periods in at the Laboratorio del BCG in Mexico City different parts of the island (see section IV: and sent by air, together with the tuber- Post-Vaccination Testing). culin, packed in ice-containers. The tuber- culin and the vaccine were stored in refriger- 8. Continuation of BCG Vaccination ators either at the BCG Office in Kingston Final decisions regarding the continuation or at the temporary field stations. Vaccine of BCG vaccination under national auspices lot numbers 141 to 216 were used during had not yet been made when the campaign the campaign. * ended in June 1953. Instruction and training of public health nurses in the different par- 7. Post-Vaccination Testing ishes were to be done by a BCG nurse during For the purpose of getting some informa- the first months of 1954, and plans had been tion about the allergy obtained after the made to obtain necessary equipment for mass vaccination, two post-vaccination supplying the public health nurses through- * The following lots were not used: 150, 151, out the island so that BCG vaccination 161, 166, 170, 181, 182, 195, 199, 201-204, 208, 212. could become a part of the parish public . 64 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA health nurses’ routine programme in the by t,he WHO Tuberculosis Research Office School Health Service. Vaccination is to be in 1951 for WHO/UNICEF mass BCG given to the lower classes in the schools, and vaccination campaigns. According to this it is hoped that by 1955 the BCG programme system, three kinds of statistical record will be organized throughout the island. forms are used: (a) an individual card for selected groups; II. THE STATISTICAL MATERIAL (b) a group card for recording the daily 1. Method counts of the tested and vaccinated; Records of tuberculin tests and BCG (c) a monthly statistical report form. vaccinations were made in accordance with The individual card (Fig. 1) is used only a simplified statistical system recommended for “selected groups” such as schools, etc.,
FIG. l.-Individual card
1 1 SURNAME 3 DATE OF BIRTH 4 AQE 9 INSTITUTION DhY MOHTH; YE*I IN YEARS
/Is_ ! ’ 2 FIRST NAME 5 SEX
MALE q FEMALE q
6 House NO.. STREET
7 TOWN/VILLAGE
13 RE-TESTINQ
15 RE.YACCINATION DATE q CG NO. VACCIN*TOR REMARKS
1 I July 19573 BCG VACCINATION IN JAMAICA 65
where details of identification can be ob- provide records of the campaign in the tained with a view to possible follow-up general population and is not intended as a examinations. Space is provided for identi- basis for follow-up examinations. It is filled fication data, tuberculin test results, BCG out each day by the teams, giving informa- vaccination (if given) and, on the reverse tion about the location of the group exam- side, details about post-vaccination exami- ined, the vaccine lot used, date of testing nations. and reading; records of the total number of The group card (Fig. 2) is designed to persons with test given, “positives”, vacci- 66 BOLETIN DI? LA OFlCIN.4 SANITARIA PANAMERICANA
FIG. 3.-Monthly statislical report form MONTHLY STATISTICAL REPORT Country. District Month 195 Tuberculin test & dose used. Form filled by -
_. _.
-. _.----_ ~___--
_.------. ----_- -
-. _.----___--___
_.___------. -__------_-
-. _.----_-- --l---I------_----___ -1-1-1-l-/7-l, mil I nated, and “negatives not vaccinated” by local statistician at the central BCG Office the three age-groups: O-6,7-14 and 15 years along with group cards and individual cards. and more are collected by tallying in the After the statistician had verified the data, space provided for this purpose. Totals and the report was typed and sent to the WHO identification information for the “selected Regional Office in Washington through the groups” are also filled in on group cards WHO Caribbean Field Office, to UNICEF after counting of the individual cards. Area Office in Guatemala, and to the Tuber- The monthly stalistical repart form (Fig. 3) culosis Research Office in Copenhagen. A gives summary data on the number of copy was also given to the Director of persons tested and vaccinated by the three Medical Services, Kingston, Jamaica. age-groups and by place of examination, in A “summary report” with monthly totals correspondence with the group cards. and accumulated t’otals was sent regularly With few exceptions, the schools al1 over to the same institutions plus the WHO the island were examined as “selected Tuberculosis Section, Geneva, the WHO groups” with individual cards. Individual Caribbean Field Office, and the WHO cards were also used for some other institu- Regional BCG Statistician. tions and for some factories and offices in The WHO Tuberculosis Research Office in Kingston. Results in al1 other groups, re- Copenhagen has reviewed the monthly ferred to as the “general population”, were stat’istical reports, caomputed the records by recorded by tallying directly on the group month and parish, and puhlished the card. monthly and accumulated totals. Records of the testing and vaccination were made by the teams in the field. The 2. Completeness and Accuracy of the Material identification information for the school- The same products of tuberculin and children was, as a rule, filled in on the indi- vaccine and a uniform technique of testing vidual cards by the teachers before the first and vaccination were used during the whole visit of the vaccination team. campaign. The readings of the tests were The monthly statistical report was drafted always done by the campaign doctors or by the field personnel and forwarded to the nurses. The measurements of indurations in TABLE II.-Number oj persons tuberculin-tested and vaccinated with BCG by age-group and parish.
Number of persons - With test read Positive Vaccinated Parish - T Age ~roup (years) Age group (years) / Total I Total - Total O-6 1-14 15+ O-6 1-14 15+ O-6 7-14 15+ ------__ Kingston and St. Andrew Urban.. 128,322 16,094 30,088 74,704 120,886 1,364 9,457 54,807 65,628 55,258 14,692 20,607 19,804 55,103 St. Andrew Rural., 13,240 1,628 4,258 6,137 12,023 63 411 3,684 4,158 7,865 1,565 3,835 2,449 7,849 St. Ann. 53,524 8,965 15,859 23,487 48,311 301 1,659 12,731 14,691 33,620 8,655 14,194 10,741 33,590 St. Catherine. 48,245 6,509 15,186 22,144 43,839 495 3,658 16,005 20,158 23,681 6,004 11,514 6,133 23,651 9 St. Elizabeth. 48,638 7,851 15,149 21,764 44,764 328 2,143 11,746 14,217 30,547 7,448 12,534 9,868 29,850 St. James.. 35,601 5,109 9,739 18,713 33,561 239 1,510 11,827 13,576 19,985 4,867 8,224 6,854 19,945 St. Mary. , 37,660 4,925 11,673 18,030 34,628 255 1,918 10,829 13,002 21,626 4,660 9,739 7,192 21,591 St. Thomas 35,345 4,726 9,295 18,961 32,982 246 1,618 12,493 14,357 18,625 4,477 7,673 6,466 18,616 Clarendon. 63,275 10,090 18,307 29,211 57,608 639 3,660 19,170 23,469 34,139 9,375 14,526 9,861 33,762 Hanover . 25,192 4,001 8,072 11,407 23,480 123 973 6,365 7,461 16,019 3,872 7,095 5,034 16,001 Manchester., 53,320 9,208 15,751 23,950 48,909 429 2,125 14,281 16,835 32,074 8,770 13,617 9,660 32,047 Portland. : 21,932 3,166 6,811 9,540 19,517 130 922 5,755 6,807 12,710 3,020 5,858 3,780 12,658 Trelawny 25,137 3,820 7,393 11,856 23,069 83 668 6,137 6,888 16,181 3,736 6,724 5,703 16,163 Westmoreland . 42,282 6,513 12,626 19,771 38,910 273 2,272 11,954 14,499 24,411 6,238 10,345 7,801 24,384 Grand Cayman. . . . 3,708 699 817 2,011 3,527 34 132 1,028 1,194 2,333 665 685 983 2,333 _- _- -- __- -- -__ _- Total. 635,421 !33,304 181,024 311,686 586,014 5,002 33,126 198,812 236,940 349> 074 88,044 147,170 112,329 147,543* ------* In addition to this, 117 persons were vaccinated without previous testing. 68 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA
FIG. 4.-Number of persons with test read and III. RESULTS OF STATISTICAL TABULATION number vaccinated in each of the three age-groups: AND ANALYSIS l-6 years, 7-14 years and 15 years and more. 1. The Population Tested and Vaccinated In al1 635,421 persons carne for a tuber- culin test and 586,014 (92%) returned for the second visit to have the test read. Of these 40.4 % were considered “positive”. A total of 347,660 persons or 99.6 % of the “negatives” were BCG vaccinated. The persons with test read had the following age-distribution: l-6 years 15.9 %, 7-14 years 30.9 % and 15 years and more 53.2 %. The vaccinated had the following age-dis- tribution l-6 years 25.3 %, 7-14 years 42.4 % and 15 years and more 32.3 %. Total figures for tested and vaccinated by the three age-groups and by parishes are given in table II; see also Fig. 4. 2. Completeness of Testing and Vaccination The last census in Jamaica was in 1943, AGE IN YEARS but population figures for 31 December 1952 have been calculated from birth, death and mm. for the “selected groups” were done migration since the census and may be used carefully. However, many different nurses for making rough estimates of the complete- and doctors made the readings, and personal ness of the campaign. (A sample census in errors in the measurements are likely to 1953 is not yet published, but the first have occurred. results indicate that the calculated figures In the “general population” the persons for 1952 are usable.) were asked their age on the first and again The total number of persons with test on the second visit in case it was not obvious read is close to 40 % of the total 31 December to which of the three broad age-groups they 1952 population (1,478,078). Including those belonged. Persons of 5-7 and 14-16 years who were given test but did not return for may have been grouped in different cate- the reading the percentage is 43. This is a gories on the two visits, with some small high coverage compared with similar cam- discrepancies between the numbers tested paigns in many other countries (1). For the and read in each age-group as a result. For three age-groups the proportion of persons ‘(general population” in the cities some with test read among the estimated total persons may have had their reactions read population of the same age-groups is 37% twice, or a person may have had his reaction (l-6 years), 65 % (7-14 years) and 35 % read in another examination centre than the (15 years and more) .* one where he was tested. For the school- The adult population seems to have been children age information was generally covered almost as well as the population of taken from the school registers. children under 6 years of age, but the cover- Only the selected group material contains * Population in the three age-groups is esti- information about sex and sizes of reactions mated as 17, 19 and 60.5yo of the total population in mm. Tabulation by sex is not included in figures, as obtained from a modification of the age this report. distribution in the 1943 census. Juìy 19571 BCG VACCINATION IN JAMAICA 69
age was highest in the school-aged group. TABLE IV.-“Positive” reactors (6 mm. or more All the schools on the island were visited by induration to 6 TU) in percentage of the total num- the campaign-teams, and many school-age ber of persons with test read (positive plus negative reactors) by age-group and parish. children were also examined in the “general - population” at the vaccination centres. Percentagesof “Positives” Population coverage in the different par- Parish Age-group (years) ishes varies, as shown in table III giving - i Total figures for the number of persons with test l-6 7-14 15+ -- read and the estimated population, by parish. Kingston and St. An. drewurban. ,._ _, 8.5 31.4 73.4 54.3 The campaign worked all over the island, St. Andrew Rural 3.9 9.7 60.0 34.6 including small villages with difficult com- St. Thomas. 5.2 17.4 65.9 43.5 munications from the main routes. The only Portland. 4.1 13.5 60.3 34.9 parish where the population appeared to St. Mary. 5.2 16.4 60.1 37.5 St. Ann. offer some resistance to the campaign was 3.4 10.5 54.2 30.4 Trelawny 2.2 9.0 51.8 29.9 Portland; this parish shows the lowest St. James. 4.7 15.5 63.2 40.5 percentage, only 29.0 %, of the population Hanover . 3.1 12.1 55.8 31.8 to have completed test. The next lowest Westmoreland 4.2 18.0 60.5 37.3 percentage is found in St. Andrew Rural, St. Elizabeth. 4.2 14.1 54.0 31.8 Manchester. 4.7 but this may in fact reflect some error in 13.5 60.0 34.4 Clarendon 6.3 20.0 65.6 40.7 the population figures, as Urban St. Andrew St. Catherine.. 7.6 24.1 72.3 46.0 is included with Kingston, and only a rough Grand Cayman 4.9 16.2 51.1 33.9 estimate of the St. Andrew urban and rural -- -- population has been available. The parish Total 5.4 18.3 63.8 40.4 - - of St. Catherine had a coverage percentage of only 30.6 and this may be because the parish was reached in the last months of the campaign when the work was somewhat TABLE III.-Number of persons with test read rushed. For all the other parishes the per- in percentage of total- population,- by parish.- centage participation is between 37 and 45, PeNXlS except for the island of Grand Cayman PeWXX Estimated with test Parish with tPst population read in where 57 % of the population were tested read 31 Dec. 1952! 6‘YFge and read. Fmpulation -. One of the difficulties in a mass BCG Kingston and St campaign is to get persons to return for the Andrew Urban 1120,886 274,778 44.0 second visit for reading of the tuberculin St. Andrew Rural.. 12,023 39,670 30.3 test and for vaccination. Yet the percentage St. Thomas. 32,982 72,636 45.4 of persons who were tuberculin tested and Portland. 19,517 67,267 29.0 returned for the reading was 92.2, in average, St. Mary. 34,628 93,066 37.2 St. Ann.. 48,311 111,824 43.2 for the entire campaign. The parish of Trelawny 23,069 57,454 40.2 Portland, which showed the lowest coverage St. James _. 33,561 77,265 43.4 of the population, also had the lowest Hanover 23,480 58,455 40.2 percentage of tested persons returning for Westmoreland.. 38,910 104,878 37.1 the secoqd visit. The highest percentage St. Elizabeth. 44,764 119,126 37.6 Manchester. 48,909 104,878 46.6 (95.1%) was on the island of Grand CIarendon. 57,608 147,572 39.0 Cayman. St. Catherine. 43,839 143,073 30.6 Grand Cayman 3,527 6,136 57.5 3. Tuberculin Sensitivity -- .- .- The statistical material givés the number Total. .5 86,014 1 ,478,078 39.6 - of “positives” and “negatives” by three 70 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA
age-groups, for each locality and group of districts and groups within the same parisl-c persons examined. The percentages of are compared. Some of the variation may, “positive” reactors (6 mm. or more of indura- of course, reflect differences in age-distribu- tion to 5 TU) of the total number with test tions, especially within the youngest and read (positives plus negatives) for each of oldest age-groups. For parish to parish the 14 parishes and the island of Grand Cay- comparisons, however, the variation in age man are given in table IV. distributions within the three age-groups These percentages are calculated from should be rather small and of little impor- the total number of persons (selected groups tance. and general groups) with test read during Tabulation of percentage of “positives” the entire campaign. by age in single years has been done for a Kingston, including St. Andrew Urban, group of schools where the children were has the highest percentage of “positives” retested in 1952. For 12 schools in Kingston in each age-group, and St. Catherine has (4,902 tested and read), 6 schools in St. the next highest. Clarendon, the parish Andrew (1,075 tested and read) and 6 west of St. Catherine, ranks as number three schools in St. Thomas (3,861 tested and in the age-groups l-6 and 7-14 years, and read), the percentages of ‘Lpositives” for as number four, after St. Thomas, in the ages 7-14 are illustrated in Fig. 6. The oldest age-group. The lowest percentages of tuberculin sensitivity increases with increas- “positives” are found in the parishes of ing age. Trelawny, St. Ann, Hanover, St. Elizabeth For the same schools the distributions of and the island of Grand Cayman. The high- the sizes (in mm.) of induration to 5 TU est percentages in the three age-groups, are given in table V. See also Fig. 7. represented by Kingston, are: 8.5, 31.4, 73.4 The distributions show quite high pro- while the lowest on the island of Jamaica portions of small reactions and do not show are 2.2, 9.0, 51.8 represented by the parish the two fairly distinct concentrations of of Trelawny. The average percentages of reactions reported from European countries. “positives” among school-aged children Similar distributions may be found in other (7-14 years) in the different parishes are districts in Jamaica, though only samples of illustrated in Fig. 5. the statistical material have been analysed The parishes are rather large units for in this respect. Accumulations of reactions computing percentages of “positives”, and read as “round” numbers, as 10, 12, 15 and much variation is found when different 20 mm., are also quite obvious-an indica-
FIG. 5.-Geographical distribution by parishes of percentages of “positives” (persons reacting with 6 mm. or more induration to Mantoux 6 (TU) among unvaccinated persons r-14 years old examined during the mass campaign. July 19571 BCG VACCINATION IN JAMAICA 71 tion that the reactions were not measured FIG. 6.-Percentages oj “positives” (persons re- too carefully in the mass campaign. More- acting with 6 mm. or more induration to Mantoux 6 TU) among groups oj unvaccinated school children over, there is an accumulation on 6 mm. in Kingston, St. Andrew and St. Thomas parishes, probably owing to a tendency to read by single years of age. doubtful small reactions as 6 mm. to avoid the possible vaccination of naturally infected - KINGSTON ---- ST ANDREW persons. 30 - ---- ST THOMAS There are other limitations in using the w percentage of “positives” as an expression 2 of the prevalence of tuberculosis infection. 5 20. It ís doubtfu1 what proportion of the small E ti! 10 - z but definite indurations to 5 TU may repre- i’ r._cI/-x, /’ .*‘,’ N.’ sent specific tuberculosis infection or a non- / specific kind of sensitivity: the larger non- Oo-7 8 9 10 II 12 13 14 specific reactions cannot be distinguished AGE IN YEARS from the smaller specific reactions with the tuberculin products in use today. Although FIG. 7.-Freguency distributions by size oj in- duration of reactions to Mantoux 5 TU among very little is known about the presente or groups of unvaccinated school children in Kingston, prevalence of non-specific tuberculin sensi- St. Andrew and St. Thomas parishes. tivity in Jamaica, it is likely that a substan- tial proportion of the “10~ allergy reactors” KINGSTON among the “positives” have not had a NUMBER. 4,902 virulen‘t tuberculosis infection.
IV. POST-VACCINATIOR’ TESTING 1. Method Two post-vaccination tuberculin testing projects were carried out to obtain informa- 819 ST. ANDREW tion about the allergy developed among W NUMBER: 1,075 ” those vaccinated ín the campaign. The first 4 project was in June and July 1952, after t- z the campaign had been in progress for nine ” 0 months; the second in September and Octo- 05 ber 1953 after the finish of the campaign. w CL Retesting was done in samples of the vaccinated school population. Various vac- cine lots used for vaccination in different 76.2 ST. THOMAS parts of the island were selected. About NUMBER: 1,861 300-500 children, preferably from severa1 schools, were retested for each vaccine lot; the retesting was also intended to cover vaccination done by the different teams in schools including both sexes, rural and urban populations and differing living conditions. 4 8 12 16 20 24 28 Z3C But practica1 considerations regarding trans- INDURATION in mm. portation, co-operation and attendance in the schools had, of course, to be made. ment schools, generally comprising boys Most of the groups retested were govern- and girls 6-14 years old, although some 72 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA
TABLE V.--Size of induration of reactions to could be found. Tuberculin testing of the Mantoux 6 TU test among unvaccinated school chil- non-vaccinated was done in order to get dren examined in Kingston, St. Andrew and St. some information about the allergy among Thomas, October 1961 to March 1962. natural reactors and at the same time to Pre-vaccination 5 TU Test obtain a mixed group of vaccinated and - - - - - unvaccinated to obtain biased readings. The 6: ,, 6 sichools St. Total % nurse reading the reactions did not see the KE A T homas _- _- - _- individual cards and therefore could not 0 38,080 874 1 ,419 15,373 know the child’s vaccination status. 68.8 1 14 6 0 20 Al1 post-vaccination tuberculin tests were 2 170 30 28 228 5.3 made with 5 TU of the same tuberculin 3 129 23 34 186 4 176 18 33 227 used for the mass campaign: the PPD iden- 5.2 5 123 20 37 180 tified as RT XX11 from the State Serum 6 193 8 31 232 Institute, Copenhagen, diluted at the Labo- 4.3 7 70 13 21 104 ratorio del BCG in Mexico City and used 8 95 3 21 119 2.8 within a month of preparation. The tuber- 9 79 4 20 103 10 157 37 201 culin injection technique, the reading of 4.0 11 88 F, 12 109 reactions and the statistical recordings were 12 135 9 30 174 done in a uniform manner throughout the 3.0 13 56 3 5 64 retesting programme and were similar to the 14 66 8 16 90 3.2 procedures used in the campaign, with the 15 106 14 31 151 16 38 3 7 48 following exceptions : 1.1 17 29 6 10 45 In 1953, the reactions were read after two 18 26 6 16 48 days instead of after three days. This was 0.9 19 15 1 ll 27 of considerable practica1 advantage for the 20 38 8 19 65 0.9 work, and comparative readings in two 21 0 0, 4 4 22 2 2 3 7 schools of second and third day reactions 0.2 23 4 0, 4 E had shown that the difference in reaction 24 1 Cl 1 2 sise on the two days was very small. This is 0.2 25 8 Cl 8 lf also in accordance with studies reported by 26 0 C1 1 1 0.0 the Tuberculosis Research Office (2). The 27 1 C1 0 1 retest examinations were recorded on the 28 0 c) 0 ci 29 0 C) 0, (1 same individual cards that had been used 30 0, I 1 0l (1 in the vaccination campaign. In 1952 these >30 3 C) 2 1í 0.1 cards were forwarded together with pro- _ ------visional tabulations and work reports to Total 4,902 1,07!i ,861 7,8383 100.0 - - - - TRO for punching and tabulating; in 1953 complete tabulations were made with the kindergarten and higher schools were also help of the Medical Department in Kings- included. With very few exceptions, al1 the ton. vaccinated pupils present in school during Everyone retested was also examined for the retesting visits were tested. In severa1 vaccination lesion, and the measured sise schools, tuberculin tests were also given to of the.lesion (scar) was noted on the individ- children whose reactions had been “positive” ual card. or “not read” according to the mass cam- The 1952 retesting team comprised the paign secords, as well as to new pupils who WHO Regional BCG Adviser, Dr. K. Osvik, had entered school since the time of the the WHO Regional BCG Statistician, Mr. campaign. Children in the latter group were T. Zeiner-Henriksen, and one of the nurses considered non-vaccinated if no BCG scar from the mass campaign, Miss A. Thompson. July 19573 BCG VACCINATION IN JAMAICA 73
In 1953 Mr. Zeiner-Henriksen and two been expressed as the percentage of persons campaign nurses, Miss P. Manahan, and with a tuberculin reaction larger than a Miss 1. Jones, made up the team. Both certain sise (usually 5 mm. of induration). retesting projects were set up in co-operation This implies that a reaction of 5 mm. or more with the Campaign Organizer, Dr R. G. indicates a successful vaccination, a smaller Lampart. The work, which was planned in reaction an unsuccessful vaccination. More- accordance with suggestions made by the over, the percentage of “positives” after WHO Tuberculosis Research Office, was vaccination gives little information about done carefully and with special attention to the degree of tuberculin sensitivity induced accurate measurements of reactions. by the vaccine. On the other hand, in every part of the world, vaccinated groups tested 2. Resulta for post-vaccination allergy show unimodal The main statistics for the retesting pro- distributions by size of induration (3). The gramme are given in table VI. A total of arithmetic mean (average) of al1 the reac- 6,000 children attending 43 schools, repre- tions in a group is, therefore, a meaningful senting BCG vaccination with 16 different expression of the allergy produced by the lots of Mexican vaccine, completed retest vaccination and may be used for comparing during the two projects. Thus, 1.7% of al1 results from one group to another. those vaccinated during the campaign and The distributions of post-vaccination 5 TU 4.1% of those vaccinated in the age-group reactions by size of induration are shown in 7-14 years were retested. In addition to the Fig. 8A for the schools retested in 1952 and examination of children vaccinated in the in Fig. 8B for the schools retested in 1953. mass campaign, 640 previously “positive”, Both distributions form a smooth, fairly 250 previously “not read” and 1,300 new symmetrical dome-shaped curve-the uni- pupils were also retested. modal curve commonly found in vaccinated In most of the schools where retesting groups. The reactions in both distributions was done, the children had been vaccinated cover about the same range on the size early in the campaign: 26 of the 43 before scale and have about the same mean value: March 1952. Only in 12 schools had mass ll.4 mm. for the groups retested in 1952 vaccination been done after June 1952. and 10.5 mm. for those retested in 1953. Most of the schools were located in Kingston Children in three schools vaccinated in and the surroundings of Kingston, but re- Kingston during the first month of the mass testing was done al1 over the island, covering campaign and retested in 1952 showed a schools in the mountainous area as well as high proportion (more than 10%) of reac- the coast and swamp land. The campaign tions at 0 mm., although the bulk of re- records showed that 10,5UOchildren had been actions centered at lo-12 mm. vaccinated in the 43 schools. Of these, about When the results are analysed according 70 % were given a tuberculin test by the to vaccine lot number, some variations retesting team, but some 1,300 failed to among the various lots are found, as shown return to have the test read. Retesting was by the unweighted averages for each lot in thus completed in 58 % of those vaccinated table VI. The mean size of reactions by lot in the 43 schools selected for the retesting varies from a low average of 8.8 mm. of programme. Many pupils had left school induration obtained with lot 143 to a high since the vaccination campaign, and many average of 16.0 mm. with lot 156. The were absent: during the retesting in 1953 children in the two schools vaccinated with heavy rains during the last two weeks re- lot 156 had higher means than found from duced the school attendance and in 1952 any of the other vaccine lots retested. The the “mango season” had the same effect. vaccination scars were also considerably Results of BCG vaccination have often larger (7-8 mm. as compared to 3-6 mm. 74 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA
TABLE VI.-Results of testing children vaccinated in the mass campaign with 6 TU, by school and vaccine lot. - I I l - vkan size of 5 ‘U reactions of Date of Jac- 1Completing nd. in mm. by :ine retest School Parish accinatior lot (month, lexi- - year) can VX- T khaol cine 1ot* .- -__ S$ Geqrges Kingston x-51 141 VI-52 290 35 10.1 “ x-51 141 IX-53 2: 431 131 8 ll.7 Rousseau LL x-51 141 VI-52 199 51 I‘ “ 141 IX-53 283 400 50 13 8.70 10.2 Al1 Saints “ $1;: 141 VII-52 215 14:2 Elco Pract. “ x-51 141 IX-53 292 277 1:: : Alvernia “ XI-51 142 VI-52 245 20 10.: ‘< ‘L XI-51 142 IX-53 273 464 125 24 7:9 9.3 CZ%;!tt&h Park “ 142 VI-52 257 141 13 “ g: 143 VI-52 ; 405 E Wincl+rard R.9. “ XI-51 143 VI-52 PE 52 11:2 “ XI-51 143 IX-53 27 438 142 1: 8.9 8.8 Wolmer Boys “ XI-51 143 VII-52 221 124 26 7.4 Rolliffgton Tyyn L‘ XII-51 146 VII-52 ; 186 6 11.4 “ XII-51 146 IX-53 22 292 103 4 Alpha Infant “ 146 VI-52 130 3 12:: 11.3 “ “ “ g: 146 262 330 3 ll.7 Providence “ XII-51 148 ;g;; 6 145 iii1 13.7 Swallowfield “ XII-51 148 VI-52 182 104 2 13.7 jba;;;nce Tavern St. Andrew 154 VI-52 5 317 123 5 z.7 ‘< “ “:-gj 154 VI-52 5 83 29 - 13:7 Gordon Town “ “ I-52 154 VI-52 1 ll.6 ll.6 Mannings Hill I‘ “ I-52 154 VII-52 i 19’; 105 ll.4 Stony Hill “ <‘ I-52 154 IX-53 19 44 1; Mt. Fletcher St. Thomas II-52 “ “ 156 VI-52 5 29435 115 - 17:; 16.0 gh&ent Gap II-52 VI-52 70 g.;: “ <‘ II-52 :57” VI-52 4 14: 4 12.3 “ “ II-52 158 VI-52 470 12:3 W&e Hall <‘ LL II-52 VI-52 4 213 98 3 13.9 Wilmington “ “ II-52 :5: VI-52 1 4 132 77 - 15.0 13.7 Cedar Valley ‘L “ II-52 158 VII-52 1 246 100 2 13.7 Yallahs “ L‘ II-52 VII-52 4 392 241 1 14.2 Aeolus Valley II-52 :59 VII-BI 128 64 - 12.0 13.1 Highgate G. $. MF;; v-52 168 IX-53 1:: 229 114 4 Carron Hall G. 168 IX-53 177 102 3 :“2:7 12.0 Carron H. J. ‘< <‘ ;:g; 168 :7’ 34 - 12.9 Port Maria “ I‘ 169 :g;; 42;: 250 20 7.7 Hillside “ “ TI;; 169 IX-53 ::: 302 159 5 10.2 9.0 Falmouth Trelawny VII-52 179 14 180 4 10.6 Clarks Town “ VII-52 179 :$zg 2: 59 - 12.5 11.7 Granville “ VII-52 179 :4 115 62 1 11.9 Lances Bay Hanover IX-52 187 :& , 105 2 ll.4 Green Island “ IX-52 187 :2 170 ii 11.2 ll.8 Lucea IX-52 187 :grg 1 290 150 i 12.8 Ballards Valley St. Elizabeth XI-52 196 I$$ :1 185 129 - 11.1 “ “ XI-52 Mayfie!d “ “ 196 3 223 131 1 11.6 12.3 Tneyoy XI-52 196 x-53 , :: 201 2 14.1 Manchester 207 IX-53 , 168 10: 3 9.7 :::g; 1 ; “ 207 353 139 1 11.1 10.6 II-53 207 :“x:g c, 7 268 124 2 11.1 - -- Total. II0,513 61,042 366 11.1 - * Unweighted average.
for 80 % of the schools), which suggests that vaccine lot given to children in different this lot has in fact been stronger than the schools in the same area at the same time the others. Variability within the same was also found. Lot 141, for example, pro- July 1957] BCG VACCINATION IN JAMAICA 75
FIG. 8.-Frequency distributions by size of induration of reactions to Mantoux 6 TU among BCG vac- inated children.
8. RETEST 1953 - NUMBER. 2,758 MEAN: 10.5 25 SCHOOLS t 7-23 MONTHS AFTER VACCINATION ‘OI-
l-----T- Z” C. 6 SCHOOLS RETESTED 1952-1953 NUMBER. 1,308 MEAN, 10.4 RESULTS 1952 6-8 MONTHS AFTER Io r VACCINATION w a 2 = 0 w ” E 20 p. 1 D SAME GROUP AS C NUMBER. 635 MEAN: 9.8 I RESULTS 1953 I
A: Al1 groups (24 schools) retested in 1952 B: All groups (25 schools) retested in 1953 c: Groups (6 schools) retested both in 1952 and 1953; results 1952 D: Same groups as C; results 1953 duced mean reactions ranging from 7.7 to vaccination allergy were vaccinated in the 14.2 mm. of induration; and mean reactions first months of the campaign when the to lot 154 ranged from 7.4 to 13.7 mm. This destructive effect of sunlight on BCG vaccine indicates that variation in the strength of had not yet been brought to the attention the different vaccine lots is not the only of the teams. In two of these schools (Rous- cause of the varying results obtained in the seau and Calabar), it was learned that retesting programme. vaccination was in fact done outdoors and Four of the schools with lowest post- the exposure to sunshine may thereby have 76 BOLETIN DE LA OFICINA SANITARIA PANAMERICANA reduced the vaccine’s allergy-producing of any fading with time of the allergy in- potency. Children in schools vaccinated duced by BCG vaccination ; the somewhat after the first months of the mass campaign lower average for the 1953 retesting may show very few instances of a mean post- reflect diff erences in various technical vaccination allergy of less than 10 mm. of factors in the vaccination. induration. In about 33 % of al1 the schools Unvaccinated persons-new pupils, stu- the children retested showed mean reactions dents with reactions previously “not read” of 11-12 mm., and about 40 % had mean or “positive’‘-were retested together with reactions of more than 12 mm. the vaccinated persons. The degree of allergy In six schools, retesting was done in 1952, found among the naturally positive, presum- and repeated 15 months later during the ably tuberculosis-infected children could retesting project in 1953. The distributions thus be compared with the degree of BCG- of the reactions for both retestings are induced allergy in the vaccinated. The 640 illustrated in Fig. 8C and 8D, where the mean siee of induration for the 1952 retest is previously positive persons had an average 10.4 mm, for the 1953 retest 9.8 mm. The reaction of 14.5 mm. of induration; of the reactions are a little larger for St. George 500 unvaccinated new pupils, the 280 react- school in 1953 than in 1952, unchanged for ing with 8 mm. or more of induration had schools Rousseau and Alpha Infant, and an average reaction of 13.6 mm. These somewhat smaller in average sizes for the figures show that although some vaccinated other three schools, Alvernia, Windward groups have an allergy comparable to that Road and Rollington. 635 children were of the natural reactors, on the average the retested both in 1952 and again in 1953, tuberculin allergy induced by BCG vaccina- giving mean sizes of induration of 10.9 and tion in Jamaica is 33 mm. smaller than that 9.8 mm. There is, however, no indication of the natural positives.
REFERENCES (1) Mass BCG Vaccination Campaigns 1948-1961. lin reaction size on five consecutive days. (Reports from 17 countries.) The Interna- Bull. Wld. Hlth. Org. 12:189-196, 1954. tional Tuberculosis Campaign, Copenhagen, (3) WHO Tuberculosis Research Office. Further studies of geographic variation in naturally 1954. acquired tuberculin sensitivity. Bull. Wld. (2) WHO Tuberculosis Research Office. Tubercu- Hlth. Org. 12:63-83, 1954.