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VOL. 38 JANUARY 5, 1923 No. 1
THE EFFECT OF VACCINIA ON LEPROSY.
By H. E. Hasseltine, Surgeon, United States Public Health Service; l'irector, I.eprasy Investigation
Station, Honolulu Hawaii.
It has been reported that vaccination of lepers is followed by a more or less acute outbreak of leprous manifestations.1 The following account of the vaccination of a number of lepers in the Kalihi Hospital apparently confirms this report.
At the time when these vaccinations were begun there were 219 patients, including suspects, in the hospital. Examination of these patients showed that 163 had vaccination scars, 49 had no vaccination scars, and 7 (6 Filipinos, 1 Portuguese) had had smallpox. The number showing evidence of previous vaccination was much greater than was anticipated.
Before the virus for the vaccinations arrived, 20 patients had been paroled, 4 of these having no scars, thereby reducing the number having no evidence of previous vaccination to 45. Twenty-seven of tbese were vaccinated on August 23. The remaining 18 served as controls; though one case should not be considered, as she was showing an acute leprous outbreak at the time.
The type of the 27 cases vaccinated is recorded as follows: Nodular 16; anesthetic, 4; mixed, 7. Vaccination was successful in 19 cases (9 nodular, 4 anesthetic, 6 mixed) and unsuccessful in 8 cases (7 nodular, 1 mixed). In the cases unsuccessfully vaccinated no evidence of any change of the leprous lesions was noted. Of the 19 successfully vaccinated cases, 11 (6 nodular, 5 mixed) developed acute leprous eruptions in the two weeks following date of vaccination. Eight (3 nodular, 4 anesthetic, 1 mixed) showed no evidence of any increased activity of their leprosy.
In character the eruption seen in these cases was like that seen at variable intervals in the course of leprosy under treatment. It consisted of a red, infiltrated rash, frequently beginning as small areas and then growing larger, sometimes coalescing to involve large areas. When it first appeared, the lesions were very painful under pressure. As the eruption progressed, the color, a bright red at first, changed
i Denney, Oswald E., and Hopkins, Halph: Specific Leprous Reactions and Abnormal Vaccinia Induced in Lepers by Smallpox Vaccination. Public Health Reports, Vol. 3", No. 51, Dec. 22,1922, pp, 3141-3 U9. Reprint No. 805.
2«96''-23 1 (1)
to a purplish hue. About the time the vaccinia began to decline, the leprous eruption showed signs of beginning abatement. The first sign noted was a fine wrinkling of the tense shining skin over the infiltrated areas, indicative of a slight lessening of the local swelling. The color disappeared quite rapidly when the decline of the eruption started, and more slowly in the later stages. Desquamation of the epidermis followed in some cases, especially on the face when the eruption had appeared there.
With the appearance of the leprous activity there arc constitutional symptoms in most cases, such as chilliness, fever, and general malaise. The fever may reach as high as 40° C, though usually it remains at 38° to 39° C. Some of the constitutional symptoms may be due to vaccinia.
The most severe eruption occurred one week after vaccination (Aug. 30); whereas the least severe eruptions were delayed until the latter part of the second week. The lightest eruptions appeared on September 4, and September 7 (thirteenth and sixteenth days, respectively).
One case (No. 2084) has had frequent outbreaks of this kind; and had this been the only case showing an eruption, no significance would be attached to it. Cases 1963 and 2003 had shown very slight eruptions from time to time, but the eruption following vaccinia was so much more severe than that usually seen, that it points very strongly to vaccinia as the agent exciting the eruption. Cases 2117 and 2168 had shown no eruption for a long period. Case 2194, a relatively recent admission, and a severe nodular case, showed one of the lightest, and the longest delayed, eruptions observed in the whole group.
Cases 2116, 2129, 2080, and 2095, though having shown but little recent activity, were cases that would be expected to show eruptions, if vaccinia would excite such an outbreak. Nevertheless these cases have shown no evidence of any increased activity. Of these four cases, B. lepne is demonstrable in all except No. 2080.
It appeal's that the anesthetic cases are affected very little, if at all, by vaccinia, whereas, in these vaccinations, the mixed cases have shown the highest percentage of increased activity.
Of the 18 controls (unvaccinated, without vaccination seal's), one, as stated above, was suffering from a leprous outbreak at the time that the examinations for the presence of scars were made, and, therefore, should not be considered. In the remaining 17, no outbreak has occurred, though as a group the}* are comparable to the vaccinated group.
Of 149 lepers having vaccination scars or evidence of having had smallpox, who were confined in the hospital at the time of the vaccinations, two have shown temporary increased activity, evidenced by eruptions, during the same period.
After observing this small series of cases, one can not escape the conviction that vaccinia had something to do with the appearance of the leprous manifestations in the successfully vaccinated cases. This phenomenon may also explain some of the opinions held by the older Hawaiian laity, that in many cases vaccination was the cause, or at least the exciting cause, of leprosy. During the days of armto-arm vaccination the possihility of the spread of leprosy by this procedure must he admitted. It is more probable, however, that the vaccination served to bring to light latent or unrecognized leprosy. It certainly can not bo said to have caused the disease in the subjects of the test reported herein, the diagnosis having been established before the vaccination was done. The virus was produced by a regularly licensed firm in an eastern State and was obtained from the San Francisco branch office of the firm. Special care was taken to see that the virus was kept on ice during the voyage to Honolulu.
These patients will be observed further to determine whether there is any remote deleterious or beneficial effect shown in those vaccinated.
At the date of writing, September 23. one month after vaccination, all cases that showed eruption have returned to normal, except for some desquamation at the former site of the eruption. Eight of the vaccination ulcers are not completely healed. Six of these showed eruptions, and two did not. As in all vaccination ulcers, the healing has been slower in thoso cases showing some loss of tissue at the site of vaccination. The leprous eruption does not seem to have had any direct effect on the course of vaccinia.
I desire to acknowledge the courtesy of Surg. N. E. Wayson, who procured the vaccine for me, and of Dr. Charles Fowler, surgeon of the steamship Wilhelmina, of the Matson Navigation Co., who kept the virus under proper conditions on the voyage to Honolulu.
No. 1885, G. K.. Hawaiian, age 27, male, single, farmer. Admitted 12/29/19; type, nodular; B. Icprx present; duration, 10 years prior to admission. First symptom, •white areas on body; last bacteriological examination, 5/20/22, B. lepra? present. This is an advanced case of leprosy with much destruction of tissue in the nose and one eye.
Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Large vesicle at site of vaccination.
Aug. 31: The vaccination has developed a rather extensive "take'' and there is a Luge zone of redness and infiltration about the site of inoculation. A leprous eruption is evident on the arms and legs, the spots being large, red, indurated, and tender.
Sept. 1: The eruption has extended to the face and ears. Both ears much enlarged. Confined to bed. Has chill and fever.
Sept. 5: The ears are smaller but several very large, red, indurated spots are present on the back.