Reactions and serologic responses to monovalent acetone-inactivated typhoid vaccine and heat-killed TAB when given by jet injection*

TYPHOID Reactions and serologic responses to monovalent acetone-inactivated typhoid vaccine and heat-killed TAB when given by jet injection* EARL A. EDWARDS,' DAVID P. JOHNSON,2 WILLARD E. PIERCE,8 & ROBERT 0. PECKINPAUGH 4 Monovalent acetone-inactivated typhoid vaccine and heat-killed TAB caused local reactions in 82-88 % of volunteers vaccinated by jet injection, whereas they caused local reactions in only 24 % of volunteers injected by means of a conventional syringe. Both vaccines induced a high seroconversion rate to typhoid H antigen, but neither proved significantly immunogenic to antigens 0 and Vi. There was no increase in the occurrence of local reactions when a second jet injection was given S weeks after the first. Serologic response to typhoid vaccines has been used as an indicator of vaccine effectiveness. Al- though the validity of using the levels of the in- dividual 0, H, and Vi antibodies as a measure of immunity has been questioned (1-5), both volun- teer (6) and field studies (7) have unquestionably demonstrated a higher level of protection in those who received typhoid vaccine than in the controls. The most common and consistent characteristic of antibodies resulting from vaccination was H ag- glutinin. The cost and slowness of administering vaccines with the conventional syringe and needle have been deterrents to mass immunization, especially in devel- oping countries. Since the use of an automatic jet injection apparatus would make mass immunization against typhoid quicker and less costly, it was decided to compare reactions caused by jet and conventional vaccination. * From Naval Medical Research Unit No. 4, Great Lakes, IL, USA. The opinions expressed are those of the authors and are not to be construed as official or as necessarily reflecting the views or carrying the endorsement of the Navy Department. 1 Chief, Immunology Division. Present address: Biolog- ical Sciences Division, Naval Health Research Center, San Diego, CA 92152, USA. 'Head, Epidemiology Division. 'Head, Biometric Division. 'Commanding Officer. MATERIALS AND METHODS Vaccines The vaccines used were: a monovalent, acetone- inactivated dried typhoid vaccine (AKD, Wyeth Laboratories, Marietta, PA, USA) containing no more than 109 Salmonella typhosa Ty2 organisms perml; and the polyvalent typhoid-paratyphoid aque- ous vaccine (TAB, Pittman-Moore, Indianapolis, IN, USA), containing 109 S. typhosa, 25 x 107 S. paratyphi, and 25 x 107 S. schottmuelleri organ- isms per ml. The AKD vaccine was reconstituted with the diluent supplied (0.02 mol/l phosphate- buffered saline with 0.5% phenol as preservative) immediately before use. Sterile saline without pre- servative was used as the control. All doses were 0.5 ml given intramuscularly, whether by jet or by syringe. The jet injection apparatus was an automatic hypodermic injection gun with a hydraulic power source and a bottle holder. Conventional injection was by syringe and 23-gauge needle. Study population The subjects were men aged 19-25 years who were undergoing recruit training at the Naval Training Center, Great Lakes. A total of 306 men volunteered for the study after they had been fully informed of its nature. 3295 - 501 - BULL. WORLD HEALTH ORGAN., 1974, 51 EARL A. EDWARDS ET AL. Iv *r- lq N N- N- N N N 0 N1s N- N _N N 00 I0 00 0 CM I ' 'It l~~~~~ I I I C) -t t LO N 'I v- l N w w 00oV LO w- LO N4 N4 co r- N v- 0) C') o 0) CY) 1 0 co U) 0 V- 0) cD N lq C') DCD 0 CO oo w oo 19 14 'I I V) 0) .4t O LI~ ~ I I 0 00 qtN C') co 00 000) C') oo O CO 0o N 0o qt 0 L o - M tD U) N CD le -i q w U) > C') C') 0ID 0 0 0E E CoE ~ CA .. 0'- 0 U)0- 0 --a (0 E .r % U)a 502 C E 0 C ._ 94 r.':0 F a he 0 C co a id r, CO Nr Mt 200a. CL4 N f- 0 al. N N 00 N 0 OD N N N 0 NN 00 N 0 N N N 0 a C14 r- 00 r- U) C14 r-0) C14 C14 U) CN U) C14 C14 N le U) N Ul) cn) N U) CD4 00 E CD0 a) Z lo CO -o C cn C2 CD co a 0)0. 0 co 0 .0 a) E 1- 0C. cD E U) U a) Co C. Nt 110, JET INJECTION OF TYPHOID VACCINES Clinical assessment Each volunteer was interviewed and examined immediately before and 1, 2, and 3 days after immunization. Oral temperatures were taken and local reactions (pain, tenderness, swelling, erythema, and induration) were noted. Systemic symptoms of malaise, headache, chills, and fever were also re- corded. The study was double-blind: neither the volunteers nor the investigators knew which vaccine was administered in each case, neither were the investigators told of the method of injection used in each case. Serologic studies The macroscopic slide agglutination test (8) was used to determine antibody to 0, H, and Vi anti- gens. The serum was tested without heating. Samples were screened at a dilution of 1: 20; those that showed a reaction of 2+ or greater were retested at higher dilutions. The titre was the reciprocal of the highest dilution showing a complete (4+) agglutina- tion. The antigens were commercially prepared (Difco). Acceptability and antigenicity studies In phase 1 of the study, volunteers were assigned at random to one of 6 treatment groups each comprising 26-35 men. Each group received 1 of 6 treatments comprising AKD or TAB vaccine or control saline injected either by jet or by syringe. Blood samples were taken before vaccination and 14 and 35 days following vaccination. In phase 2, designed to investigate local and systemic reactions following a second dose of vac- cine, volunteers were randomly assigned to one of 3 groups and received AKD or TAB vaccine or saline by jet injection. Thirty-five days later all the men were given a dose of AKD vaccine by jet to determine whether sensitivity to the vaccine had been increased by the first injection. RESULTS Phase I Local and systemic signs and symptoms following inoculation with AKD, TAB, and saline are shown in Table 1. Systemic symptoms, which could have been caused either by acute respiratory disease or by vaccination, were present in all the groups after treatment, although less so in the groups treated with saline. Symptoms of acute respiratory disease were present in 20-25% of the volunteers before treatment, and the systemic symptoms are therefore more difficult to evaluate than the local reactions. There were striking differences in the occurrence of local reactions between the groups given vaccine and those given saline. Eighty-eight and 82%, re- spectively, of AKD- and TAB-treated men showed one or more local reactions 24 h following jet injection, whereas only 24% of those who received vaccine by syringe, and none of those injected with saline by either method, showed local reactions. These reactions, which were mainly erythema and tenderness, were less frequent 48 h and 72 h after treatment. There was no significant difference in antibody response between those injected with AKD or TAB by jet and those inoculated by syringe (an average of 81% seroconversion to the H antigen). There was little difference in the titres of blood samples taken 35 days after treatment compared with those taken 14 days after treatment. The AKD vaccine was no better than the TAB in stimulating Vi antibody production (less than 13 % seroconversion irres- pective of the method of administration). Phase 2 Local and systemic reactions to a jet injection of AKD vaccine 35 days after the first jet injection are shown in Table 2. There were fewer of both types of reaction in the volunteers receiving their second dose of vaccine compared with those receiving their first dose. When evaluated 48 h after treatment the number of local reactions was significantly smaller in those who had received 2 doses of vaccine than in those who had received vaccine 35 days after an injection of saline; the difference was not significant, however, 24 h after treatment. The occurrence of erythema was significantly less frequent in those given their second dose of vaccine than in those given their first, both 24 h and 48 h after treatment (P = 0.05 and <0.001, respec- tively), whereas the occurrence of edema or indura- tion did not differ significantly. The difference be- tween the 2 groups in the frequency with which tenderness occurred was highly significant (P = <0.001). DISCUSSION The administration of typhoid vaccines by jet produced more local reactions than when the vac- cines were given by conventional syringe and needle. 503 EARL A. EDWARDS ET AL. Table 2. Percentage of men showing local reactions and systemic symptoms imme- diately before (pre) and 24 h, 48 h, and 72 h after jet injection with AKD vaccine, administered 35 days after the first jet injection Initial treatment AKD TAB saline pre 24 48 72 pre 24 48 72 pre 24 48 72 No. of men examined 52 49 48 49 49 45 42 49 50 47 45 50 systemic symptoms(oneormore) - 24 8 6 4 24 4 2 6 36 6 10 malaise - 4 2 - - 9 - - - 13 - - headache - 12 6 6 4 11 2 2 6 21 6 8 chills &fever - 14 6 2 - 16 2 - - 15 2 - febrile (>37.8'C) 6 16 4 4 2 18 - - 2 23 - 4 local reactions (one or more) - 80 40 - - 78 33 - - 87 69 6 pain - 2 erythema - 61 25 - - 69 26 - - 81 64 2 calor - 14 - - - 11 - - - 28 - - swelling - 14 - - - 18 - - - 34 - - tenderness - 71 16 - - 51 21 - - 83 53 6 induration - 39 23 - - 31 19 - - 53 40 2 nodes - 10 - - - 10 - - - 19 2 - This difference can probably be attributed to the greater diffusion into the tissues of vaccine admin- istered by jet injection, and to the intradermal deposition of some of the vaccine. There was, how- ever, no enhancement of local reactions when a second dose ofAKD vaccine was given 35 days after the first jet injection. The 2 vaccines were equally capable of inducing the production of serum antibodies to H antigen, irrespective of the method of administration. Al- though field studies have demonstrated that AKD vaccine is superior to TAB in protecting against natural chaUenges of typhoid (7, 9), this study has not shown AKD to be more capable of stimulat- ing 0, H, or Vi agglutinins. If the effectiveness of typhoid vaccines depends on their ability to raise 0 and/or Vi antibody levels, neither vaccine used in this trial could be expected to be reliably protective. Either H agglutinins play a significant role in protec- tion or other, as yet unidentified serum factors or other types of host defence mechanism are respon- sible. RESUMt REACTIONS ET REPONSES SEROLOGIQUES A UN VACCIN ANTITYPHOIDIQUE MONOVALENT INACTIVE PAR L'ACtTONE ET A UN VACCIN TAB TUA PAR LA CHALEUR, INOCULES AU MOYEN D'UN INJECTEUR SANS AIGUILLE Le cout et la lenteur de la vaccination classique au moyen d'une seringue et d'une aiguille constituent un obstacle a l'immunisation de masse, surtout dans les pays en voie de developpement. Etant donn6 l'economie de temps et d'argent que permet l'emploi d'un injecteur A pression automatique, il a ete d6cid6 de comparer les r6actions provoqu6es par l'une et l'autre techniques. Un vaccin antitypholdique monovalent inactive par 504 JET INJECTION OF TYPHOID VACCINES 505 l'acetone et un vaccin TAB tu6 par la chaleur ont pro- voqu6 des reactions locales chez 82-88% des volontaires vaccines au moyen d'un injecteur a pression, mais ils n'ont cause de telles reactions que chez 24% des sujets vaccin6s au moyen d'une seringue et d'une aiguille. Les deux vaccins ont induit des taux eleves de seroconversion a l'egard de I'antigene H, mais ne se sont pas montr6s significativement immunogenes I'e'gard des antigenes 0 et Vi. II n'y a pas eu plus de reactions locales lors de la seconde innoculation par injecteur a pression pratiquee 5 semaines apres le premiere. Cette etude permet de conclure a la securite de la vaccination antitypholdique au moyen d'un injecteur a pression sans aiguille, methode qui a l'avantage d'etre rapide et bien adapt6e a la vaccination de masse. REFERENCES 1. CLASENER, H. A. L. Immunization of man with Salmonella vaccine and tetanus-diphtheria vaccine. Dose-response relationship, secondary response, and competition of antigens. Journal of hygiene, 65: 457- 466 (1967). 2. HORNICK, R. B. & WOODWARD, T. E. Typhoid fever vaccine-yes or no? Medical clinics ofNorth America, 51: 617-623 (1967). 3. BENENSON, A. S. Serological responses of man to typhoid vaccine. Bulletin of the World Health Organi- zation, 30: 653-662 (1964). 4. TULLY, J. G. & GAINsS, S. H antigen of Salmonella typhosa. Journal ofbacteriology, 81: 924-932 (1961). 5. TULLY, J. G. ET AL. Studies on infection and immunity in experimental typhoid fever. Journal of infectious diseases, 112: 118-124 (1963). 6. HORN1CK, R. B. ET AL. Study of induced typhoid fever in man. I. Evaluation of vaccine effectiveness. Transactions of the Association of American Physi- cians, 79: 361-367 (1966). 7. CvJETANovIC, B. & UEMURA, K. The present status of field and laboratory studies of typhoid and para- typhoid vaccines. Bulletin ofthe World Health Organi- zation, 32: 29-36 (1965). 8. COLEMAN, M. B. Salmonella and Shigella. In: Muckenfuss, R. S., ed. Diagnostic procedures and reagents, 3rd ed. New York, American Public Health Association, 1950, pp. 212-235. 9. AsHcRoFr, J. T. ET AL. A seven year field trial of two typhoid vaccines in Guyana. Lancet, 2: 1056-1059 (1967).