Heaf Gun Research Articles

Reduced tuberculin reactions with a single-use Heaf gun

The Heaf test was conventionally undertaken with a re-usable gun that required disinfection between subjects. Concern with cross-infection led to the development of a gun with a disposable head attached to a re-usable handle (Bignall Surgical Instruments) and, more recently, a single-use device (UniHeaf, Owen Mumford). Promotional literature states that the guns, respectively, contain pressure mechanisms that ensure proper skin penetration before needle release, or correct needle penetration even with the application of excessive pressure by an inexperienced operator. Both guns are recommended for Heaf testing as they avoid the need for disinfection, cleansing and maintenance. Pontypridd and Rhondda (PR) NHS Trust has an uninterrupted history of tuberculin testing on

The BCG scar after percutaneous multiple puncture vaccination may help establish the nationalities of unidentified cadavers

BCG vaccination using the multiple puncture device (the Heaf gun) has been used in Japan and in the United Kingdom. The appearance of the BCG scars therefore differs from that caused by the conventional intradermal BCG vaccination, which is used throughout the world. The aim of this study was to investigate the usefulness of examining BCG scars to identify the nationalities of unidentified cadavers. We investigated the BCG vaccination program not only in Japan, but also in other countries, along with the relation between the BCG scar and nationality. The results showed that the countries which domestically make and use the Heaf gun are Japan (where it is the only method that has been in use since 1968), the United Kingdom (where it has been used, in part, since 1982), and South Africa (where it has been used, in part, since 1972). In addition, for the past 10 years, the Japanese Heaf gun method has been partially applied in the Republic of Korea and in Brazil. The Heaf gun scar can be clearly distinguished from the intradermal scar, and is visible throughout a person’s life when good technique is used to administer the vaccination. If the Heaf gun scar is found on the left upper arm of an unidentified Asian cadaver, it is sure to be that of a Japanese. The findings of this present study indicate that the Heaf gun scar can be examined to identify the nationalities of unidentified cadavers.

Administration of the BCG vaccination using the multipuncture method in schoolchildren: a comparison with the intradermal method

BACKGROUNDBCG vaccination using the multipuncture device (the Heaf gun) is recommended in the UK for infants and very small children only. The aim of this study was to investigate the...

Route of administration of BCG in a school population outcome of an audit of clinical practice in North Bedfordshire

Following findings of variations in policies and practices of BCG (Bacillus Calmette-Gúerin) administration in different parts of England and Wales, recommendations were made for BCG vaccination to be administered intradermally using disposable equipment. Intradermal methods were used for BCG in Bedfordshire until 1981 but it was changed in 1982 to percutaneous method using the reusable modified heaf gun. Suggestion to revert from percutaneous to intradermal method caused anxiety amongst health professionals with anecdotal reports of scar formations and keloids causing disfigurement at injection site. An audit was therefore carried out to assess the outcome of intradermal BCG administration initially by doctors and then by nurses. The outcome did not justify initial anxieties.

Route of administration of BCG in a school population: outcome of an audit of clinical practice in North Bedfordshire

Following findings of variations in policies and practices of BCG (Bacillus Calmette-Gúerin) administration in different parts of England and Wales, recommendations were made for BCG vaccination to be administered intradermally using disposable equipment. Intradermal methods were used for BCG in Bedfordshire until 1981 but it was changed in 1982 to percutaneous method using the reusable modified heaf gun. Suggestion to revert from percutaneous to intradermal method caused anxiety amongst health professionals with anecdotal reports of scar formations and keloids causing disfigurement at injection site. An audit was therefore carried out to assess the outcome of intradermal BCG administration initially by doctors and then by nurses. The outcome did not justify initial anxieties.

Effect of inadvertent intradermal administration of high dose percutaneous BCG vaccine.

In the United Kingdom it is recommended that all children receive BCG vaccination to prevent development of tuberculosis.1 2 The standard route of administration is intradermal. In neonates a 10 times more potent percutaneous preparation is used, a small volume being injected to a depth of 2 mm with a modified Heaf gun. The two preparations have similar packaging and labelling and so may easily be confused.3 We report the outcome of inadvertent intradermal administration of the stronger percutaneous product and define the relation between the development of skin lesions and the dose of vaccine. Thirty two school children aged 11-14 received 0.1 …

Effect of inadvertent intradermal administration of high dose percutaneous BCG vaccine.

In the United Kingdom it is recommended that all children receive BCG vaccination to prevent development of tuberculosis.1 2 The standard route of administration is intradermal. In neonates a 10 times more potent percutaneous preparation is used, a small volume being injected to a depth of 2 mm with a modified Heaf gun. The two preparations have similar packaging and labelling and so may easily be confused.3 We report the outcome of inadvertent intradermal administration of the stronger percutaneous product and define the relation between the development of skin lesions and the dose of vaccine. Thirty two school children aged 11-14 received 0.1 …

A comparison of fixed and disposable head Heaf guns

The objective of the study was to compare the newly introduced Model 2000 disposable-head Heaf gun with the currently used fixed-head gun. The study simultaneously Heaf-tested 1410 school children on both forearms using a different gun on each arm; the tests were read blind. The results were similar for both Heaf guns. The fixed-head gun gave a stronger reaction in 202 (14%) children by one Heaf grade. The disposable head gun gave a stronger reaction in 116 (8%) children, by one Heaf grade in 113 and 2 Heaf grades in 3 children. κ = 0.607 (95% confidence interval [CI] = ± 0.038), indicating good agreement between the tests. χ 2 = 0.177, d.f. = 1, P = 0.7 NS. Given the practical advantages of Heaf skin testing for primary screening, it is likely that practitioners will replace the fixed-head gun with one that avoids sterilisation problems. The small variation between the tests was not considered clinically important, while the advantages of the new test were considerable. It is therefore recommended that the Model 2000 Heaf gun replace the fixed-head gun for primary screening.

A comparison of the relative sensitivity of two types of Heaf gun

A total of 696 secondary school children were given a Heaf test in one forearm with a magnetic head Heaf gun and in the other forearm with a fixed head gun. One week later the results were read blind. In 333 (48%) children the fixed head gun gave a more strongly positive result than the magnetic head gun, while in only 27 (496) children did the magnetic head gun gives a more strongly positive result. These findings are statistically highly significant (p < 0.001).

BCG immunisation of infants by percutaneous multiple puncture.

The safety, efficacy, and ease of administration of percutaneous multiple-puncture gun immunization of infants with BCG was compared with intradermal injection with a syringe. 214 consecutive infants scheduled for BCG were alternately given percutaneous or intradermal injections over the left deltoid muscle by 1 of 3 doctors. The Modified Heaf gun with 20 needles set to penetrate 1 mm, or a syringe with a 24 gauge short beveled needle was used. Doctors recorded bleeding and ease of administering the vaccine. The intradermal method was recorded as difficult in 36 cases, very difficult in 4, and the percutaneous method was deemed difficult in 1 case. Of the 200 infants remaining in contact 3-7 days later, 141 were read as positive. There were no significant differences in amount of bleeding or seroconversion. A difference in seroconversion was observed, however, between the different doctors using the intradermal technique. The percutaneous method resulted in less ulceration and scarring, gave consistent seroconversion, and was easier to administer.

False negative tuberculin tests: check your Heaf gun.

False negative tuberculin tests: check your Heaf gun.

Intermittent combination chemotherapy with or without bacillus Calmette-Guérin for treatment of acute lymphoblastic leukemia of childhood.

Seventy-four children ranging in age from 6 months to 17.5 years with acute lymphoblastic leukemia newly diagnosed between 1976 and 1979 were entered on a study incorporating intermittent chemotherapy with or without the addition of bacillus Calmette-Guérin (BCG). The chemotherapy program consisted of induction with vincristine, dexamethasone, and intrathecal methotrexate, intensification with adriamycin and asparaginase, central nervous system treatment with cranial irradiation and intrathecal methotrexate, and continuation treatment with 5-day courses of combination chemotherapy administered every three weeks. The first phase of continuation therapy incorporated vincristine, adriamycin, 6-mercaptopurine, and dexamethasone. In the second phase, oral methotrexate was substituted for the adriamycin in non-T-cell patients; in T-cell patients, cytosine arabinoside or cyclophosphamide and methotrexate in alternating cycles were substituted for the adriamycin and asparaginase was added. Total duration of therapy was approximately 2.5 years. Connaught BCG was administered by Heaf gun on days 8 and 15 of each 3-week cycle for the first 8 months of treatment in approximately one-third of the patients. Actuarial disease-free survival with a median follow-up of 59 months shows no difference in outcome between the BCG and non-BCG poor-risk patients. However, there is an improvement in disease-free survival of BCG-treated good- and average-risk girls (P = 0.04). While patients were actively receiving BCG there was also a trend toward the development of fewer significant infections than when patients were not receiving BCG (P = 0.85). Toxicities from BCG administration included satellite rashes, local tenderness, lymphadenopathy, secondary infection, and residual scars. Overall disease-free survival by actuarial analysis is 60% at 6 years; for patients with unfavorable prognostic features it is 40%. In this trial the addition of BCG prolonged the disease-free survival of girls with good- and average-risk prognostic features and also may have decreased the susceptibility to infection while it was being administered. However, the benefit does not appear sufficient to warrant its routine use, especially in view of the toxicities encountered.

Adjuvant reactivity predicts survival in patients with "high-risk" primary malignant melanoma treated with systemic BCG. EORTC Malignant Melanoma Cooperative Group Writing Committee.

We report the prognostic importance of strength of reaction to BCG, tumor histology and clinical factors in patients with previously untreated high-risk (Clark, III, IV and V) primary malignant melanoma. One hundred and one such patients receive high-dose BCG (1 x 10(8) viable units) by Heaf gun as an adjuvant to standardized primary surgery according to EORTC Protocol 18741. Univariate analysis of disease-free interval (DFI) indicates that the degree of maximum reaction to BCG (p = 0.0003), Breslow thickness (p = 0.0003) and Clark level (p = 0.002) are highly significant prognostic factors. When a multivariate model using Cox's proportional hazard regression was used for DFI, the degree of maximum reaction to BCG and Breslow thickness were by far the most significant criteria. A prognostic equation wa obtained to predict DFI from maximum BCG reaction and Breslow thickness. From analysis of the "scores" calculated in this way it appears that the two variables act independently. This technique permits the determination of values that are predictive of DFI and discriminate between subgroups of patients with different DFI characteristics (5 groups, p less than 0.0001). This exercise was repeated for survival and similar results were obtained. The degree of a patient's immune reaction to BCG administered therapeutically is of paramount importance in determining the likelihood of survival. This factor and the Breslow thickness can be integrated to produce a mathematical equation which accurately predicts survival for appropriately treated melanoma patients.

Adjuvant immunotherapy in acute nonlymphocytic leukemia

Of 112 patients (maximum age 70 years) with acute nonlymphocytic leukemia, 62 (55%) went into remission on an induction therapy of cytosine arabinoside and daunorubicin. 20 patients were randomized for maintenance treatment consisting of chemotherapy only and 22 patients for combined chemo-immunotherapy. The chemotherapy consisted in 5-day courses of daunorubicin and cytosine arabinoside and of thioguanine and cytosine arabinoside, alternating every month. The chemo-immunotherapy group also received weekly intracutaneous injections of 109 allogeneic nonirradiated leukemic myeloblasts and 106 BCG organisms (Glaxo) by Heaf gun.

Immunologic monitoring and immunotherapy in Ewing's sarcoma

Serial immunological monitoring was performed on 31 patients with Ewing's sarcoma who were on a randomized immunotherapy trial with BCG administered by dermal scarification with a Heaf gun. Patients were skin-tested for delayed hypersensitivity reactions (DCHR) to recall antigens and extracts of tumor cells, and with keyhole limpet hemocyanin (KLH). In vitro testing consisted of lymphocyte counts, percentages of cells forming rosettes with sheep erythrocytes at 29° C and at 4° C, and leukocyte migration inhibition to tuberculin (PPD) and to 3 M KCl extracts of tumor cells. At the time of diagnosis, nearly all patients had positive DCHR to mumps and streptococcal antigens and were negative to PPD. Neither the skin tests nor the lymphocyte counts at this time gave useful prognostic information. In tests during and after therapy, the patients who responded and remained free of detectable disease had a higher incidence of DCHR to KLH and of rosette values in the normal range than did the patients who developed recurrent disease. The BCG immunotherapy had no apparent effect on immunologic parameters except for conversion of reactions to PPD.

BCG Therapy in Acute Non Lymphoid Leukaemias

The survival of patients with acute non-lymphoid leukaemias (ANLL) receiving chemotherapy (32 patients) or chemotherapy plus BCG (31 patients) has been compared in a randomized trial which started in Nov 1974. Fresh BCG (Institut Pasteur, Paris) was administered by Heaf gun in the interval of chemotherapy cycles. The overall survival was better in the chemo-immunotherapy group (median duration of survival of 25 months compared to 16 months in the chemotherapy group). However, the first remission duration did not differ (median duration of the 15 and 12 months, respectively). Plateau survival curves were not obtained in either group. A second complete remission was obtained in 7 out of 12 patients with bone marrow relapses in the chemo-immunotherapy group, and only in 2 out of 15 in the chemotherapy group (P less than 0.05). BCG seemed more efficient in patients older than 40 years; no difference was observed according to sex.

MAINTENANCE OF REMISSION IN ACUTE MYELOGENOUS LEUKÆMIA BY A MIXTURE OF B.C.G. AND IRRADIATED LEUKÆMIA CELLS

Thirty patients with acute myelogenous leukæmia (A.M.L.) in full hæmatological remission were allocated alternately to two groups of fifteen patients each. All patients received immunotherapy, given weekly as intradermal and subcutaneous injections of killed allogeneic A.M.L. cells, plus Glaxo B.C.G. given by Heaf gun at a separate site. One group also received a mixture of A.M.L. cells and B.C.G. on 4 occasions early in remission. Four patients in this group have remained in remission for 92 to 134 weeks, whereas all patients in the other group had relapsed by 68 weeks. The findings suggest that cells mixed with B.C.G. may be effective in prolonging remission.

Chemoimmunotherapy for maintenance in acute myeloblastic leukemia.

Of 30 adult patients with acute myeloblastic leukemia, 14 achieved complete remission. Eight of these were given chemoimmunotherapy for maintenance. The immunotherapy consisted of intradermal pooled allogeneic leukemic cells (snap-frozen irradiated) and BCG vaccine given by Heaf gun, given twice in 4 weeks. The chemotherapy was given for 1 week in 4 weeks. The median duration of remission in these eight patients was 115+ weeks and the median duration of survival was 147+ weeks. The other six patients who were given chemotherapy only for maintenance had a median duration of remission of 15 weeks and a median survival of 52 weeks. The two groups cannot be compared properly, however, as allocation of patients was not random, and the chemotherapy differed significantly.

Immunotherapy with chemotherapy in the maintenance of remission in acute myeloblastic leukaemia.

Thirteen patients with acute myeloblastic leukaemia or one of its variants in remission have been given maintenance treatment with a combination of chemotherapy and immunotherapy. Chemotherapy was given for one week in four, and immunotherapy was given during the intervening three weeks. The immunotherapy consisted of BCG vaccine given by Heaf gun, and snap-frozen pooled allogeneic irradiated leukaemic cells. The median duration of survival was 147 weeks, and the median duration of the first complete remission was 76 weeks. It is difficult to compare these results with other figures reported, but they add to the evidence which suggests that immunotherapy is of value in the maintenance treatment of patients with this disease. Further controlled trials are necessary.

Immunotherapy for acute myelogenous leukaemia.

One hundred and seven untreated patients with acute myelogenous leukaemia (AML) were admitted to St Bartholomew's Hospital between 10 October 1970 and 31 January 1973. Before receiving drugs to induce remission they were allocated alternatively into 2 groups to decide their remission treatment—a group to receive chemotherapy alone and a group to receive the same chemotherapy with immunotherapy. The patients were then given induction chemotherapy and 45 of them attained complete remission. All patients in remission then received chemotherapy consisting of 5 days treatment every 28 days. Patients receiving immunotherapy were also given multiple weekly intradermal injections of irradiated stored AML cells and Glaxo B.C.G. using a Heaf gun. There were 19 patients in the group which received only chemotherapy during remission; 7 of these patients remain alive (median survival after attaining remission 303 days) and only 5 are still in their first remission (median remission length 188 days). Twenty-three patients were allocated to receive immunotherapy during remission in addition to chemotherapy and 16 remain alive (median 545 days) and 8 are in their first remission (median 312 days). The difference in survival of the two groups is significant with a P value of 0·003.