Tag Archives: Smallpox

Eradicating smallpox: the global vaccination push that brought the world ‘arm-to-arm’

Edward Jenner vaccinating his son, held by Mrs Jenner; a maid rolls up her sleeve, a man stands outside holding a cow. Coloured engraving by C. Manigaud after E Hamman. The Wellcome Collection.

Michael Bennett, University of TasmaniaAs the roll-out of COVID vaccines proceeds, it’s worth looking back on the challenges and successes of the early global spread of smallpox vaccination.

Smallpox (also known by its scientific name, variola) was a horrible, highly infectious disease, with a case fatality-rate of 30%. In 1798, Edward Jenner, an English country doctor, published data on cowpox (or “vaccine”, a term derived from the Latin for cow and increasingly preferred by Jenner; modern scientific name vaccinia). His data suggested this pustular disease found on dairy cows protected people from smallpox.

He detailed experiments in which he inoculated children with cowpox (usually by nicking the arm and inserting cowpox pus under the skin), and presented the inoculation of cowpox as a safe and effective way to prevent smallpox.

Jenner’s claims were initially met with scepticism. Even in Britain, vaccination was not taken up on any scale until 1800. By this time, though, cowpox samples were being dispatched overseas and attracting great interest as a way to protect people against smallpox. By 1805, at the height of the Napoleonic Wars, people were already being vaccinated all around the world. By 1815, several million people, half of them outside Europe, had been vaccinated.

Sadly, however, the global eradication of smallpox was not achieved until the late 1970s.

Read more:
Four of the most lethal infectious diseases of our time and how we’re overcoming them

The wonder of cowpox

Smallpox was universally feared but people had learned to live with it. It was easy enough to recognise; victims became visibly ill before they became infectious. Crucially, people knew that if they survived the attack, they could be confident of lifelong immunity.

Learning to live with smallpox sometimes involved deliberately exposing children to the disease in the hope of a mild outcome. In Britain, it was found smallpox inoculation — that is, making a light cut in the arm and applying smallpox pus to the wound — resulted in far fewer deaths than in cases of naturally acquired smallpox.

It was as a practitioner of smallpox inoculation (which was also known as variolation) that Jenner found evidence people who had been casually infected with cowpox appeared to be immune to smallpox infection.

He put the theory to the test by inoculating a boy with cowpox lymph — taken not from the cow but from a vesicle or blister on a milkmaid’s hand — and demonstrating his resistance to smallpox by variolation.

Jenner’s presentation of cowpox as a safe and effective substitute for smallpox found corroboration in trials in London in 1799. It wasn’t easy to allay doubts among parents. Still, people were even more scared of smallpox, and recognised smallpox inoculation involved significant risk to the patient and the community. Cowpox was a game-changer.

More diaspora than roll-out

Although hailed as a boon, the new approach got off to a shaky start. Cowpox was rare, appearing only sporadically in dairy farms. The supply of vaccine depended from the outset on its propagation on human bodies. If the vaccine “took” on the child’s arm then, nine or ten days later, the ripe pustule was pricked to provide fresh vaccine.

Children of the poor were immunised at no charge and, on returning to clinics for examination, were put arm-to-arm with the next batch of children. Some vaccine was dried, often on cotton threads, as a future supply. Quality control was a major problem. In 1800, a cowpox institute was set up in London to propagate and distribute vaccine and in 1803 the Royal Jenner Society was established to promote the practice.

Cowpox was a rare disease, appearing only sporadically in dairy farms.
J. Pass, Public domain, via Wikimedia Commons

The spread of the first vaccine was more diaspora than roll-out. Samples of cowpox on cotton threads were sent in the post, in Britain and overseas, rather in the manner of plant seeds.

Many samples proved useless on arrival, but by sending them in some profusion, it proved relatively simple to seed the practice in Europe and North America. Improvements in packaging even made it possible to send vaccine from Vienna to Baghdad, where it was propagated for onward transmission to India in 1802. Viable vaccine was even delivered, after a 154-day voyage, to Sydney in 1804.

The world arm-to-arm

Another approach to conquering the tyranny of distance was to move patients under vaccination. Early in 1802, Tsar Alexander approved an expedition to establish vaccination through Russia in which children vaccinated in one province were escorted to go “arm-to-arm” with children in the next. In 1803, King Carlos of Spain launched an even grander expedition that, by vaccinating a succession of children, delivered live vaccine to Spanish America and then across the Pacific to Manila and Macao.

Vaccination literally brought the world arm-to-arm. The rapid global spread of the vaccine itself owed a lot to the universal dread of smallpox but also to humanitarian enthusiasm and international collaboration.

A range of measures were used to embed the practice. In Berlin, children were given trinkets and medals. Poor mothers in Mexico and India were bribed to have their children vaccinated. In Austria, mothers whose children died of smallpox were named and shamed.

Some states moved rapidly along the road to compulsion. In France, where Napoleon was a great advocate of the practice, vaccination was urged as a civic duty but not made mandatory. In Denmark, a vaccination certificate was rapidly made a requisite for schooling, public employment and even marriage.

Complacency and lack of resolve

Aware of vaccine’s global success, Jenner and his colleagues deplored the loss of momentum in Britain itself. In London, the practice was under challenge from a noisy anti-vaccination lobby led by old-style inoculators.

A smallpox epidemic in 1805, while showing the value of vaccination, disclosed some failures arising from poor early practice. In claiming vaccination was for life, Jenner had set the bar too high. To the end of his life in 1823, he was reluctant to concede the need for periodic re-vaccination.

The major problem in Britain and elsewhere was complacency. The early success in suppressing smallpox, and indeed eliminating it in some places, led parents to neglect vaccination.

Outbreaks in the 1830s were a major shock and pushed the British government to fund vaccination in 1840 and to make it mandatory in 1853. Victoria — though not New South Wales — followed this lead. Although it was controversial and fuelled anti-vaccination sentiment, compulsory vaccination, with some provision for conscientious objection, played a vital role making the practice routine. This kept smallpox at bay, prompted improvements, and helped inspire the development of new vaccines.

From the outset, vaccination was seen as a means of eradicating smallpox. It saved countless lives, kept communities safe for as long as vaccination was maintained, and limited the severity of outbreaks.

The permanent elimination of smallpox required governments to provide the infrastructure and resources, and show the political will to incentivise if not mandate vaccination.

Although the disease was largely brought under control in the West, millions were still dying from smallpox elsewhere in the middle of the twentieth century when the World Health Organization committed itself to the global eradication of smallpox.

Read more:
Four of the most lethal infectious diseases of our time and how we’re overcoming them

The Conversation

Michael Bennett, Professor in School of History and Classics, University of Tasmania

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Coronavirus vaccine: lessons from the 19th-century smallpox anti-vaxxer movement

English physician and scientist, who was the pioneer of smallpox vaccine, Edward Jenner sees off the anti-vaccinators.
Wikimedia/Wellcome Collection

Steven King, Nottingham Trent University

There is hope a coronavirus vaccine might be ready by the end of the year. But for it to eliminate COVID-19 a critical mass of people must be vaccinated. And if the protective benefits of a COVID-19 vaccine fall off rapidly (as seems to happen with naturally acquired antibodies) maintaining immunity will require multiple vaccinations. So unless people keep renewing their jabs, the critical mass will decline quickly.

How will politicians ensure critical mass and renewal? For UK prime minister Boris Johnson (who labels those who oppose vaccination as “nuts”) and others, vaccination is a matter of duty. There is a logical case (we know people who have died or suffered badly from COVID-19) and a moral case (to protect others if not yourself).

Yet anti-vaccination sentiment focused on the rights of citizens not to act is clear. A recent poll of 2,000 people across the UK found that 14% would refuse to take a vaccine.

The rights of citizens not to act mean that compulsory vaccination cannot be (and has not been) ruled out. The history of other vaccination programmes, particularly the first truly national campaign against smallpox, shows how difficult the balancing of rights and duties will be.

A disappearing act

The 19th-century invention of vaccination created a new national imperative for the UK to combat endemic smallpox. The risk of dying from smallpox for those who contracted it was substantially higher than that for COVID-19 today. Survivors gained immunity but often at the cost of physical scarring and long-term health problems.

Vaccination and subsequent elimination should have been a no-brainer. Yet local and regional outbreaks persisted across the 19th century.

Governments of this period assumed (sometimes incorrectly) that the middle-classes would realise the value of vaccination. The poor and marginal were different. For them, mass compulsory vaccination awaited.

The result was an explosive atmosphere. Rumours of deaths after vaccination and of the rounding up of the poor like animals generated a sustained popular backlash, with some organising under the umbrella of the National Anti-Vaccination League.

19th century cartoon of people marching in protest
An attack on smallpox vaccination and the Royal College of Physicians’ advocation of it, 1812.
Wikimedia/Wellcome Collection

Yet even after vaccination became compulsory in 1853, there were many ways in which, by accident or design, ordinary people citizens avoided the jab. Some people simply disappeared from the records or failed to appear when asked. Those most prone to doing so (those in crowded households or immigrants, for example) were also the groups most susceptible to disease.

Census data consistently undercounts the national population. Undercounting in the 1800s may have missed around 10% of some communities. Even for the 2011 census, around 6.1% of the population is believed to have been missed. Achieving vaccination critical mass is difficult where you do not know the true size of the mass and the most vulnerable are the least detectable.

The poor also “clogged up” the vaccination system. Sometimes they agreed to participate and then did not turn up, a common feature for systems of compulsion where there is no ultimate sanction. On other occasions, as for instance at Keighley in 1882, people would supplement this activity with the sending of anonymous hate mail in an attempt to disrupt the work of local vaccinators.

Fight for their rights

Taking advantage of local tensions was also a useful avoidance technique. “Smallpox riots” in the face of attempts at crude compulsion were frequent and sustained.

Sometimes organised by local agitators, and sometimes spurred on by instances of children dying after vaccination, such unrest varied on a spectrum from small and localised to community-wide and sustained. Riots at Ipswich, Henley, Leicester and Newcastle were particularly notable.

Nor should we forget that vaccination opponents spread rumours about and caricatured vaccines and vaccinators, undermining the credibility of the system in the public imagination. These included one cartoon from the 1880s in which helpless children are shovelled into the mouth of a diseased cow while, at the other end, a doctor portrayed as the devil incarnate shovels dead children excreted by the cow into a cart bound for mass graves.

In July 2020 public figures stand accused of using Twitter to the same effect for COVID-19 vaccination.

Cartoon of children being fed to a disease-ridden cow creature, representing vaccination.
Children are fed to a disease-ridden cow creature, representing vaccination.
Wikimedia/Wellcome Collection

Most forcefully, while politicians used the law in order to force vaccination, the law could also be turned against them. Penalties against parents for failing to vaccinate children, introduced in 1853 and strengthened in 1867, were routinely ignored by courts. Compulsory child vaccination was removed in 1898 and the freedom to refuse introduced.

Long-standing opposition to vaccination by some scientists as well as ordinary people crystallised in 1885 with a huge demonstration at Leicester (ironically the recent focus of a British local lockdown). This and ongoing smaller protests across the country forced the government to introduce a Royal Commission to reflect on the whole question of compulsion. The verdict ultimately fell on the side of the rights of the individual.

It is not hard to imagine the 2021 human rights case in which a court must decide on the balance of the legal and collective duty of citizens to get vaccinated against COVID-19 nd the individual right to choose.

Our political and medical elites believe that people will accept moral responsibility: “get vaccinated”. Yet little thought has gone into how a mass vaccination programme works.

We will see some of the lessons of 20th-century vaccination schemes repeated, with public information campaigns and elements of coercion via vaccination programmes in schools and care homes. Nonetheless, the lack of serious credence given to anti-vaccination “nuts” and the resistance that a vaccination programme may generate feels oh so 19th-century.The Conversation

Steven King, Professor of Economic and Social History, Nottingham Trent University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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