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In the August 1995 issue of theArchives, Woodin et al 1 presented an interesting survey of physicians and parents regarding multiple immunizations given by separate injections at health visits. This is interesting information and should be used accordingly by those who are working on the technology to combine many antigens, so that a single injection would be polyvalent. Until that time, however, if one uses the already available diphtheria-tetanuspertussis toxoids (DTP) plus Haemophilus influenzae type b (Hib) conjugate combination, there is no need for more than two injections per visit, with the sole exception of that after the first birthday, when one might administer the combination of DTP and Hib conjugate vaccine (DTP-Hib) with measles-mumps-rubella (MMR) and varicella-zoster vaccine (VZV). Our neighbors in Canada already have available to them a combined vaccine that includes DTP, Hib conjugate, and inactivated polio (IPV). With the demonstrated success in overseas trials of

In Reply .—Dr Slater writes of the unending debate between the proponents of OPV and those favoring the addition or substitution of the new E-IPV. The exchange of commentaries by Drs Marcuse and me was not such a debate but a presentation of positions both favoring the addition of E-IPV. The question was a matter of timing; whether to make the addition now for the private sector only or to introduce it later when all infants and children would benefit, and when E-IPV could be integrated into our immunization schedule to include DTP and conjugate Haemophilus influenza B for infants. We agree with his conclusion that the need exists for "harnessing the special virtues of both of these excellent products." The combined schedule that eventually will be used in the United States will probably differ from that initiated in Israel (E-IPV at 2, 4, and 12 months; trivalent OPV at

In Reply .—Dr Bader's thoughtful comments merit consideration now and for the future. If, indeed, the state of Washington has a vaccine-associated paralytic polio rate of 1 per 100 000, it differs markedly from the rest of the nation where careful surveillance and annual review of reported alleged cases by an expert committee have consistently disclosed an overall rate of 1 per 2.7 million poliovirus vaccine live oral trivalent (TOPV) doses or 1 per 560 000 first doses of TOPV. From 1975 to 1986, 107 cases were labeled vaccine-associated paralytic disease, of which 37 were in recipients and 48 in contacts. If Washington has a higher rate, it may resemble the unexplained geographic (or possibly genetic) aberrations observed in some other infectious diseases studies such as the unusual results in Minnesota with the initial studies of Haemophilus influenzae type B polyribose phosphate vaccines in contrast to the efficacy studies in

Recent developments in the field of influenza viral infections have received abundant press coverage during the past few months. From five Army recruits at Fort Dix, NJ, ill with acute respiratory disease in February, a strain of virus has been recovered that is indistinguishable serologically from that which is thought to have caused the pandemic of 1918-1919. Human-to-human spread of the virus among recruit personnel and among some of their family members has been confirmed subsequently by serologic techniques. This strain of influenza virus is very similar to that which normally causes respiratory illness among hogs. It is designated, therefore, a "swine-like influenza virus." Because of the unusually severe nature of the epidemic of 1918-1919, and because of the large number of questions generated by the events of the past few months, the following data are presented as a status report of information available at this time. Antibody surveys of

To the Editor.— Although there is certainly a case to be made for the consideration of amantadine as a chemoprophylactic agent, perhaps even a therapeutic agent, in influenza type A virus infections, the commentary by Chanin has some misleading implications. First of all, Chanin recommends a drug dosage that is one half that of the licensed product, yet he presents no data to substantiate the efficacy of his reduced dosage schedule. Secondly, in discussing the effects of influenza vaccine on the pulmonary function of patients with chronic lung disease, he alludes to studies with experimental live influenza virus vaccines but fails to differentiate for the reader that this was an investigative vaccine totally different from the licensed, inactivated vaccines that are used in prophylaxis. This confusion is further compounded by his comment that the immunization leads to adverse effects in the high-risk patient. Finally, he restates the old complaint that

THE DEVELOPMENT of safe and effective vaccines for the prevention of many infectious diseases has had a profound influence on the history of preventive medicine during the past two centuries and especially in the past 35 years. The technology has become available to prepare safe and effective vaccines for the prevention of smallpox, rabies, diphtheria, pertussis, tetanus, yellow fever, poliomyelitis, measles, mumps, and rubella. The extensive use of most of these vaccines is responsible in great part for the substantial decline in morbidity and mortality associated with these diseases. Today, smallpox appears to be a vanishing disease; with the solitary exception of Ethiopia, it has been virtually eradicated from the world. The reported number of cases of diphtheria in the United States has declined from levels of about 350,000 cases per year in the 1920s to approximately 200 to 300 in recent years. During the past 25 years, there has

Dr Nitzkin is quite correct in his approach. Those children whose attendance in health facilities is so sporadic and unreliable that one visit may be their only appearance certainly may receive simultaneously DTP, TOPV, measles, rubella, and mumps vaccine. This is certainly not ideal because the anticipated febrile and other possible responses from each may be additive, and, if there is any illness in the subsequent several days, it is further confusing to delineate its cause—from the vaccines or some intercurrent infection. However, one must be pragmatic, and the ideal can certainly be compromised to meet reality. There is no concern about the antigens interfering with one another in such a mass single administration schedule. The only caution relates to the surveillance of reactions.

To the Editor:— Dr. Tuft is correct in nearly all that he has stated in his reply to my recent answer published in your QUESTIONS AND ANSWERS column. However, I do not think he really takes issue with me, because we seem to be in agreement except for the matter of emphasis. In his discussion of the efficacy of intradermal vaccination he underlines what I had already stated. The only major disagreement would be his comments upon the incidence and severity of reactions after subcutaneous administration of influenza vaccines. The paper which he cites is from a 1962 report and the data would not be tenable with present vaccines. The improvements in technology of vaccine development and production have resulted in influenza antigens which are far less reactigenic, and the presently available vaccines prepared by zonal ultracentrifugation are practically free of reactions in many populations. Nevertheless, I must continue to

Introduction Three years have elapsed since the first trial in susceptible children of an attenuated measles virus propagated in tissue cultures of chick embryo cells.1 During this period of time it has been possible to enlarge our experience with the administration of vaccine to both normal children and those suffering from various disorders, to accumulate further data documenting the clinical and serological responses induced by this material, and to observe the prophylactic efficacy of vaccination in varying environmental situations. The initial study, undertaken in 1958, included only 13 residents of a state institution for the mentally deficient. More than 10,000 children have now received similar vaccine in one fashion or another. In addition to healthy children and a few adults, those vaccinated include individuals with tuberculosis, asthma, cystic fibrosis, rheumatoid arthritis, cerebral palsy, epilepsy, malnutrition, nephrosis, cardiac disease, adrenocortical hyperplasia, nephrogenic diabetes insipidus, phenylketonuria, sickle-cell trait, and leukemia. The age of vaccine

Introduction Attempts to discover safe and effective means of inducing active immunity against measles have extended episodically over a period exceeding 200 years. Francis Home of Edinburgh initiated these studies when in 17581he scarified the skin of susceptible children and applied cotton pledgets soaked in the blood of patients acutely ill with measles. In this way he hoped to induce an immunizing infection unaccompanied by severe respiratory complications that in his time were of major concern. Because the earlier work on active immunization has often been reviewed, I shall restrict this summary to a consideration of investigations on live attenuated virus vaccines which have been reported since 1954, when the application of modern methods of tissue culture provided tools for a fresh approach to this old objective. In so doing I shall first recapitulate researches done in our laboratory and then briefly refer to similar work of others