Transcript Document

Two recent, good books on
smallpox
 Pox Americana: The Great Smallpox
Epidemic of 1775-1782, Elizabeth A.
Fenn (pb.)
 The Eradication of Smallpox, Hervé
Bazin
 (and a 3rd not so good: Demon in the
Freezer, Richard Preston)
Earliest recorded case, 1157 BC:
Egyptian Pharaoh Rameses V, died
Last case of smallpox, Oct. 26, 1977:
Ali Maow Maalin (Somalia), survived
Smallpox at day 3 and 7
Smallpox at day 9 and 20
Permanent scarring
Blindness
Monkeypox—not as contagious nor as deadly.
Erupting now that vaccination no longer
practiced
The spread and success of
vaccination,
1798 (Jenner published An Inquiry)
–1966 (global eradication campaign
begun)
The spread and success of
vaccination, 1798-1966
 Jenner’s bold experiment: infecting children
with cowpox, then variolation with “artificial”
smallpox
 With widespread use of vaccination smallpox
mortality decline, but was not eliminated
 Opposition to vaccination
 Franco-Prussian war (1870-1) proved why
vaccination should be compulsory
 Public health campaigns to prevent outbreaks
among high-risk groups (migrants, immigrants,
uneducated, native peoples, Asians, Africans)
Jenner’s bold experiment:
observation + experimentation
 Observing that milk maids infected by cowpox
did not get smallpox
 1796: Infecting a child with cowpox, then
variolation with “artificial” smallpox
 Royal Society rejected Jenner’s manuscript
 1798: experiments with 4 children
 Published privately: An Inquiry into the Causes
and Effects of Variolae Vaccinae…
Vaccination
at 14 days
(cowpox
vaccine)
...
Variolation
at 14 days
(smallpox
virus)
Morality <1
per 100,000
Morality
1-3 per 100
Variolation vs. Vaccination
» Variolation spread the disease,
» except where it was “universal”
» or quarantine was faithfully practiced.
» Vaccination contained the pox and reduced
fatalities
» even without universal practice
» because the vaccinated did not spread the pox.
The curious history of inoculation:
preventive for the individual, threat
to the public
 In 18th century Europe (1718) & America
(1721), “artificial” smallpox began to be used
as a preventive
 Principal opposition: inoculation (“artificial”
smallpox) spread “natural” smallpox to others
 Proponents ignored the risks of spreading the
“natural smallpox” to innocents as well as the
patient’s risk of dying (greater than 1%)
Opposition to inoculation was
based on science, not religion—
the debate in Boston, 1721:
 Mather, Increase. Several reasons proving that
inoculating or transplanting the small pox, is a
lawful practice, and that it has been blessed by
God for the saving of many a life.
 The critic, Dr. William Douglass: “A Pious &
Charitable design of doing good,” but “his
mischievous propagating the Infection in the
most Publick Trading Place of the Town”
should be “construed as Propagating of
Infection and Criminal.”
London: Inoculation spread smallpox
(1747-1800)
general inoculation
Poor
data?
ceiling
floor
vaccination
“the longer a society lived with smallpox, the less
severe its demographic impact became” —Tucker, 8
NOT!!
general inoculation
ceiling
floor
Vaccination
was truly
effective in
reducing
smallpox
mortality
From 1798, vaccination quickly replaced
variolation as the preferred method for
protecting against smallpox
 Treatise translated and published in German,
French, Dutch, Latin, Spanish and Italian
 1802: Pres. Jefferson charged the Lewis and
Clark expedition with vaccinating Indians
 1804: Charles IV sponsored a world-wide
expedition to vaccinate through-out Spanish
colonies
 Before 1820: Compulsory vaccination laws in
provinces of Italy, Denmark and Sweden
Moore, History of Smallpox, 1815
» “Had it been possible formerly to have persuaded
every human being to have submitted to
inoculation, a great saving of human lives would
have ensued: but this was impracticable; and the
experience of a century has shewn, that partial
inoculation, by diffusing contagion, multiplied
deaths.” (p. 303).
Moore, History of Smallpox, 1815
» 303: “All the benefits of inoculation, without the
mischiefs, might however have then been
obtained, by precluding the inoculated, while the
infection was upon them, from intercourse with
persons who had not already passed through the
Small Pox. But instead of this salutary
precaution being even now adopted, there are
miscreants of the medical profession, so
stimulated by avarice, and so divested of
humanity, as to disseminate the contagion of
Small Pox through the most populous quarters of
London.”
Sweden:
inoculation did not work (1750-1800);
vaccination did (1801-)
death rate from smallpox per million pop.
inoculation vaccination
<1800
smallpox
mortality =
2-4 per
thousand;
>1800
nearly zero
Sweden:
Vaccination
worked; Deaths
per
compulsory million
vaccination
worked
better,
1770-1843
With widespread use of
vaccination smallpox mortality
decline, but was not eliminated
 Vaccination was not universal
 Re-vaccination was needed ~10 years to
provide maximum protection
 Parents and public health authorities
were not zealous in protecting with
vaccination
 Compulsory vaccination laws were not
enforced; variolation continued to spread
the disease
Opposition to vaccination
persisted in 19th century England
 Religious: against God’s will
 Variolationists: 1840, England—
variolation banned, and vaccination
made compulsory
 “Scientific”: anti-contagionists (blamed
atmospheric conditions and unsanitary
environment)
 Libertarian: opposed public health
authorities enforcing vaccination laws
Franco-Prussian war (1870-1) proved
why vaccination should be compulsory
 A “perfect” demonstration
 France, no vaccination policy: 1 million soldiers;
Country
Soldiers (at risk)
ill
Case fatality rate
125,000 ill; 23,470 died
France
1,000,000
.125
.20
 Germany, compulsory vaccination, re-vaccination:
Germany
800,000
.001
.05
800,000 soldiers; 8,463 ill; 459 died
France had no compulsory vaccination for soldiers
Germany had compulsory vaccination for soldiers
 French POWs in Northern Germany sparked
epidemics among the civilian population (low
vaccination rates)
 Epidemic spread world-wide
 Tightened vaccination laws (England, 1871;
Germany, 1874; Italy, 1920; etc.)
Why vaccination works, even after an
epidemic breaks out:
Smallpox is slow to develop (12th day)
vaccination ‘takes’ quickly (by 9th day)
Smallpox
Body
temp
Cº
Vaccination
Days after infecction
Public health campaigns to
prevent outbreaks:
migrants and immigrants
 New York City, 1866-1901
 Epidemics 1866-75: ~1,000 died in worst years
 1875: Vaccination mandatory for entry into public
schools
 1875: costly public health efforts to vaccinate
migrants and immigrants (600,000 vaccinations in 6
weeks)
Public health campaigns to
prevent outbreaks
 Montreal, Boston, Philadelphia, Mexico City,
Rio de Janeiro
 Until 1885, many French Canadians opposed
vaccination
 Education was an important factor
 Riots in Rio against vaccination (1904)
Public health campaigns:
native peoples, Asians, Africans
 America: native peoples, 1802-1898
 1802: Lewis and Clark Expedition
 1837: Quarantine and vaccination often ignored
 1853: Hawaii, 6-8% died; 1854 law, mandatory
vaccination for residents and visitors.
 1896: When vaccination failed, “care” made the
difference among the Pueblos
 Asians and Africans
 Persistence of variolation and burial customs that
spread the disease
 Continued epidemics, notwithstanding colonial
powers efforts to vaccinate