It is 1957. In a tiny apartment in married student housing in Raleigh, N.C., boy cousins, six and five, sit on their bunk beds, ill and bored, quarantined with the mumps.
I remember this illness vividly and the quarantine I shared with Jimmy. It was one of the UCHD of the past, “usual childhood diseases,” which we all seemed to have during our youth in the ’50s.
The mumps vaccine was not licensed until 1967 and the MMR (Measles/Mumps/Rubella) in 1971. Our generation received tetanus shots and a scarring smallpox vaccination on the upper arm (this was stopped as a routine immunization by the CDC in 1971), as well as an innocuous-appearing sugar cube that our moms said prevented polio.
Some of our classmates and their parents wore large heavy steel and leather braces. Dr Blackmon, my grandparents’ physician, made house calls wearing his braces and crutches. Later, in medical school (1976), I lined up with the other medical students, nurses and house staff in the auditorium to receive the vaccine against the “swine flu,” which The New England Journal of Medicine editorialized would likely cause a pandemic on a scale of the post-World War I influenza.1 This never materialized, and comics of the time called the swine flu vaccine the only cure for which there was no disease. Forty-five percent of the U.S. population (about 98 million people) received the vaccination and sadly there were 450 cases of Guillain-Barré Syndrome in patients who had received the vaccine.2
The long history of preventing contagious illness by injecting a weaker or altered version of the cause of the illness began probably in India and China, as did many of the advances in science and philosophy of the ancient world3. In the 15th century, childhood mortality was 33% by age 15. An immunization to prevent smallpox, called “variolation,” involved grinding up scabs of smallpox and blowing the material into the nose (or rubbing it into scratched areas of skin). This practice reached Constantinople, first tried in the sultan’s harem and then on his family members and finally made its way to Europe.
In the 18th century, there were 400,000 deaths from smallpox in Europe annually, and one-third of the survivors were left blind. Infants had an 80% mortality. In the Boston smallpox epidemic of 1721, Cotton Mather advocated for variolation and saw a 14% mortality in those who were not variolated and 2% mortality in those who were. In England, orphans and prisoners were variolated in trials in the mid-18th century. Both Napoleon and George Washington (1777) had their soldiers variolated after they were convinced of evidence of effectiveness.
Widespread acceptance of immunization against smallpox remained elusive until the work of Edward Jenner in 1796.4 Sir Francis Galton, English polymath (including statistician, inventor, Social Darwinist) 1822-1911, put it this way: “In science credit goes to the man (sic) who convinces the world, not the man (sic) to whom the idea first occurs.”
Like the story of George Washington and the cherry tree, the popular notion that Jenner was the originator of immunization is false. He did, however, call the process “vaccination” and the substance a “vaccine” from the Latin “vacca,” or cow, since he used biomaterial from the lesion of cowpox to inject into the human subject. He started with the eight-year-old son of his gardener. It had been “social knowledge” among milkmaids that those who had experienced cowpox did not get smallpox. Jenner overheard a milkmaid say: “I shall never have smallpox for I have had cowpox. I shall never have an ugly pockmarked face.”
Jenner injected the eight-year-old on May 14, 1796. The boy developed mild fever and axillary discomfort. He felt cold and had anorexia nine days after vaccination, but the next day felt well. In July 1796, Jenner challenged the boy with a small amount of smallpox, and the boy remained well. He had soon vaccinated 23 more subjects. He sent a short paper regarding vaccination to the Royal Society the next year. He continued to vaccinate hundreds more and received from Parliament grants totaling 30,000 pounds for more widespread vaccination.
Acceptance was not universal. Edward Jenner was the object of scorn and ridicule. Contemporary political cartoonists depicted Jenner’s patients with small cows sprouting from their bodies. Critics of our time, including a medical anthropology professor at Stanford University, Lachlann Jain, argue against the validity of the “Great Man” theory and cite the questionable ethics of Jenner doing research on his employee’s son.5 Critics of vaccination have been with us always.
Jenner remains a hero to some; this is augmented by the story of what Jenner called “The Temple of Vaccinia,” a one-room hut in his back garden where he vaccinated his impoverished patients at no charge.4
Over the next two centuries, vast progress in immunization against many infectious diseases was made. Critics and side effects persisted.
Efficacy varies depending on the vaccine. It is estimated that the influenza vaccine is only 44% protective, whereas chickenpox vaccine is 92%, measles vaccine 97% and the polio vaccine 99%.
Despite these advances, there remains a large minority who shun immunizations. In 2019, the World Health Organization (WHO) identified “Vaccine Hesitancy” as one of the 10 threats to global health.6 They cite three factors: complacency, inconvenience of access to vaccine and lack of confidence in vaccines. The WHO estimates worldwide vaccination prevents 2-3 million deaths per year (2019) and that with improvement in vaccine rates, we would be able to save another 1.5 million lives.
The MMR vaccine was the cause of great controversy after a pediatric clinic in the United Kingdom published a paper in The Lancet in 19987 describing 12 children (11 boys from 3-10 years old) previously healthy and with normal development who presented with diarrhea, abdominal pain and developmental disorders. Eight of 12 had recently received the MMR. Nine of the 12 had autism and one had disintegrative psychosis.
All of the children underwent colonoscopy with biopsies, MRI, EEG, LP and barium studies. Lymphoid nodular hyperplasia and aphthous ulceration was noted, along with patchy chronic colitis.
This study was retracted from The Lancet after it was found the lead author, A.J. Wakefield, manipulated the data and had conflicts of interest. There were no subsequent data to support the findings. Despite retraction, the anti-vaccination movement remains fueled by this paper.
Some countries have created legislation to counteract vaccine hesitancy. For example, Australia helps reduce their antivaccination problem with a “No Jab, No Pay” Bill, mandating that only parents of immunized children can receive credits such as the Child Care Benefit, the Child Care Rebate and the Family Tax Benefit ( https://www.scientificamerican.com/custom=medical).
The global COVID-19 pandemic and the long-awaited arrival of effective vaccines has, once again, put the spotlight back on vaccine hesitancy in countries with a surplus of vaccine struggling to vaccinate hesitant individuals to stem the spread, sadly in contrast to other areas of the globe where vaccine supply is limited and precious. While the science of vaccine manufacturing has morphed significantly from its first days to now, many of the social constraints remain the same.
A Vaccine Timeline
Below is just a partial list of the significant dates in vaccine history. A wonderfully detailed and complete timeline can be found at immunize.org/timeline.
1879 Louis Pasteur creates live attenuated bacterial vaccine against cholera in chickens
1884 Pasteur develops live attenuated virus vaccine for rabies using formaldehyde- inactivated brain tissue, with first use in 1885
1888 Emile Roux discovers diphtheria toxin – passive serum therapy developed – refinement by Emil von Behring and Paul Ehrlich
1896 Cholera and typhoid vaccines developed
1897 Alexandre Yersin at the Pasteur Institute develops anti-plague horse serum and takes the vaccine prepared from this to an epidemic in China
1901 22 children in the United States develop tetanus from contaminated vaccines; the Biologic Control Act of 1902 is passed
1908 First County Health Departments formed in the U.S.
1914 Tetanus toxoid; rabies and typhoid vaccines licensed in the U.S.
1915 Pertussis vaccine licensed
1918 “Spanish Flu” causes 50 million deaths out of 500 million cases worldwide
1923 Diphtheria toxoid licensed
1927 Albert Calmette and Camille Guerin create live attenuated Mycobacterium bovis for M. tuberculosis immunization
1942 U.S. Armed Forces use Influenza A/B vaccine in military personnel
1945 Influenza vaccine released to civilian population
1952 Worst polio epidemic occurs, where out of nearly 58,000 cases reported that year, 3,145 people died and 21,269 were left with mild to disabling paralysis, most being children
1953 Adult Td licensed
1955 Jonas Salk’s inactivated polio vaccine licensed
1957 “Asian flu” H2N2 kills 70,000 in U.S.
1961 Albert Sabin’s oral polio vaccine licensed
1963 Live measles vaccine licensed (Rubeovax, Merck)
1964 Rubella epidemic of 12.5 million cases; 20,000 newborns with congenital newborn syndrome and fetal and neonatal deaths in the thousands
1967 Mumps live vaccine licensed (Mumpsvax, Merck)
1968 “Hong Kong flu” epidemic H3N2; 34,000 deaths in the U.S.
1971 CDC discontinues recommendation for routine smallpox vaccination
1980 World declared free of naturally occurring smallpox
References
- N Eng J Med 294: 1058-1960
- https://www.discovermagazine.com
- https://newint.org/feature/2021/04/06/
- Proc (Bayl) Univ Med Center2005 Jan;18(1)21-25
- https://news.stanford.edu 2020/06/25
- https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
- https://www.thelancet.com/journals/lancet/article/PII/50140-6736(97)11096-0
Lancet 1998 Feb28; 351(9103):637-41
Dr. T. Kirkland Garner
Dr. Garner is a recently retired general internist who practiced for 40 years at Piedmont Atlanta. He graduated from the University of Florida, Gainesville and the University of Florida College of Medicine. He was a resident in the Emory–Grady, Atlanta VA program and chief resident in medicine at the VA. In his practice and publications, he was particularly interested in general medicine topics involving the medical interview.
