Smallpox

"Its decline in the later decades of the nineteenth century was at one time almost universally attributed to vaccination, but it is doubtful how true this is. Vaccination was never carried out with any degree of completeness, even among infants, and was maintained at a high level for a few decades only. There was therefore always a large proportion of the population unaffected by the vaccination laws. Revaccination affected only a fraction. At present the population is largely entirely unvaccinated. Members of the public health service now flatter themselves that the cessation of such outbreaks as do occur is due to their efforts. But is this so? The history of the rise, the change in age incidence, and the decline of smallpox rather lead to the conclusion that we may here have to do with a natural cycle of disease like plague, and that smallpox is no longer a natural disease for this country."

"One of the most significant and serious current examples of the harm that can be set into motion by eliminating a disease-bearing pathogen from the human environment is associated with the present status of smallpox. The 23 year-long, global eradication of smallpox that has been achieved is a public health and medical triumph of the late twentieth century. However, the freedom attained from this infectious and contagious disease, and the suspension of smallpox vaccination that it has made possible, have rendered the world population highly vulnerable to the intentional or unintentional release of the variola virus that causes smallpox. This has heightened the anxiety that now exists about the threat of biological warfare and terrorism, and the possibility that the smallpox variola might be used as a weapon. In the United States, the government has responded with a plan to reintroduce smallpox vaccination, beginning with the vaccination of members of the military, hospital workers and health professionals, and firefighters and police who, in the instance of a biological warfare attack, would be most likely to have “front-line” contact with the persons who have diagnosed or undiagnosed smallpox. This plan has ignited debate about how many and which persons to vaccinate, about the risk of the adverse effects that will result from vaccination (ranging in gravity from diffuse skin eruptions to brain damage and death), and about how to monitor and minimize them."

"it is clear that it [smallpox vaccines] was not the cause of the disappearance of smallpox from England or Europe."

"Public health and vaccination programs rest on one central story: that they were crucial to the elimination of one of history’s greatest killers, smallpox. As we’ve seen, this is not true."

"In a wide-scale emergency in which a vaccine is available or potentially available, a large supply of vaccine would be necessary and needed quickly. Currently, the U.S. Strategic National Stockpile (SNS) has enough smallpox vaccine to vaccinate every person in the country in the event of a bio-weapon attack."

"In the case of smallpox, PEP is likely to be effective when given within four days of exposure to the virus. Plans provide for the smallpox vaccine to be shipped starting on the first day of an attack, and it would continue to be shipped from the stockpile to the rest of the country as needed in the five to six days following the attack."

"Several accounts from the 1500s describe smallpox inoculation as practices in China and India (one is referred to in volume 6 of Joseph Needham’s Science and civilization in China). Glynn and Glynn, in the The Life and Death of Smallpox, note that in the late 1600s Emperor K’ang His, who had survived smallpox as a child, had his children inoculated. That method involved grinding up smallpox scabs and blowing the matter into nostril, inoculation may also have been practiced by scratching matter from a smallpox sore into the skin. It is difficult to point when the practice began, as some sources claim dates as early as 300 BCE."

"Individual versus public health priorities were first argued in the U.S. Supreme Court more than 100 years ago. In Jacobson versus Massachusetts, a Cambridge resident refused to be vaccinated for smallpox, because he believed the law violated his right to care for his own body how he knew best. The Court rejected Jacobson’s challenge. This seminal 1905 ruling has served as the foundation for state actions to limit individual liberties to protect the public’s health.."

"The first human vaccines against viruses were based on using weaker or attenuated viruses to generate immunity, while not giving the recipient of the vaccine the full-blown illness or, preferably, any symptoms at all. For example, the smallpox vaccine used cowpox, a poxvirus similar enough to smallpox to protect against it, but usually didn’t cause serious illness."

"Vaccines are responsible for many global public health successes, such as the eradication of smallpox and significant reductions in other serious infections like polio and measles."

"In the United States, state policies mandate certain immunizations, including school entry requirements, which cover significant numbers of children. The first school vaccination requirements were enacted in the 1850s to prevent smallpox."

"Military research programs throughout history have made significant contributions to medicine and, in particular, to vaccine development. These efforts have been driven primarily by the effects of infectious disease on military conflicts: smallpox devastated the Continental Army in 1776, as well as troops on both sides of the United States Civil War; typhoid fever was common among soldiers in the Spanish American War. More person-days were lost among U.S. soldiers in malaria-endemic regions to malaria than to bullets throughout the entire 20th century; indeed, malaria continues to sap military strength into the current century."

"The history of medical research and human experimentation reveals both great successes and horrible abuses. Plagues like smallpox were rampant and capable of wiping out entire cities. People were desperate for relief and would try anything that could help ward off the horrible plagues, even experimenting. English aristocrat Lady Mary Wortley Montague introduced the idea of variolation to the gentry in 1715. In variolation, ooze from the sores of smallpox victims with mild cases was scratched into the skin. During the French the Indian War, General George Washington was convinced that his most formidable for was smallpox and he subjected his men to forced variolation to stop its spread. Many of the soldiers had only mil reactions, but some became seriously ill and died. The European press, especially among the antivaccine society, bitterly criticized Washington for forcing his men into possible harm without their consent, Hessian soldiers, who fought alongside the British, were captured and imprisoned in Frederick, Maryland, where they may have been subjected to variolation experimentation—a safety precaution before Washington would order to the procedure for his own army. When British physician Edward Jenner (1749-1823) introduced the use of cowpox sores to make a vaccine against smallpox, he was subjected to the same criticism. In the 1700s principles of individualism, self-determination, and consent of the governed formed the establishment of the United States. Ethicists all this idea the principle of “respect for persons.” Therefore, informed consent is a human right and an outgrowth of life, liberty and the pursuit of happiness."

"During the French Indian War, General George Washington was convinced that his most formidable for was smallpox and he subjected his men to forced variolation to stop its spread. Many of the soldiers had only mild reactions, but some became seriously ill and died. The European press, especially among the antivaccine society, bitterly criticized Washington for forcing his men into possible harm without their consent, Hessian soldiers, who fought alongside the British, were captured and imprisoned in Frederick, Maryland, where they may have been subjected to variolation experimentation-a safety precaution before Washington would order to the procedure for his own army."

"We used to think, for example, that smallpox vaccine gave you a permanent immunity just like the disease does. Actually it doesn't. It falls. ... The same with yellow fever vaccine. I don't know how many years. That's never been quite worked out, although it's a longer-lasting immunity than just giving a dead antigen."

"Today’s best known vaccination success story is the global campaign of the World Health Organization (WHO) to eradicate smallpox. In 1967, the WHO began its coordination of 200,000 health workers who took 10 years to vaccinate the world’s population in its remotest corners. Between 1976 and 1979, only one case of smallpox was recorded, leading to the declaration in 1980 that smallpox had been officially eradicated (Plate 14-1). A similar global immunization program against rinderpest is currently pushing this pathogen toward extinction (Box 14-2)."

"One of the first accounts of variolation — an ancient form of smallpox prevention — was from an 11th century Buddhist nun, who blew ground smallpox scabs into the noses of her patients."

"During the 1960s and early 1970s health workers applied epidemiologic methods to eradicate smallpox worldwide. This was an achievement of unprecedented proportions for applied epidemiology."

"The idea of attenuation of virulent infections developed slowly over the course of centuries. Variolation was analogous to the use of small amounts of poison to render one immune to toxic effects. Jenner's use of an animal poxvirus (probably horsepox) to prevent smallpox was essentially based on the idea that an agent virulent for animals might be attenuated in humans."

"It has been recognized for centuries that some diseases never reinfect a person after recovery. Smallpox was the first disease people tried to prevent by intentionally inoculating themselves with infected matter. Inoculation originated in India or China some time before 200 BC. The concept of immunization, or how to artificially induce the body to resist infection, received a big boost in 1796, when physician Edward Jenner inoculated a young boy in England and successfully prevented him from getting smallpox. Jenner used a lancet to scratch some infected material from a woman with cowpox (similar to smallpox) under the boy’s skin."

"“This history of vaccines is an incredibly interesting history of social relationships, colonial relationships, global relationships, and relationships between animals and humans,” said Jain, a professor of anthropology in the School of Humanities and Sciences. For example, when British physician Edward Jenner developed the smallpox vaccine in the late 18th century, he used his gardener’s 8-year-old child as one of his test subjects – an action that demonstrates both the loose ethical standards and social hierarchies of Georgian England. Jain also pointed out that Jenner’s idea for inoculation came from countryside folklore that dairymaids’ exposure to cowpox made them immune to smallpox. “Although Jenner is known as the father of vaccinations, the idea didn’t come from nowhere. He built on social knowledge of the time,” said Jain."

"While Jenner discovered a preventive measure against smallpox, it took over 150 years for his method to be administered in a way that was safe to vaccine recipients. For example, early experiments exposed test subjects to the virus to make sure the vaccine worked, which sometimes led to infection and even death from the very illness one was being inoculated against. In other instances, early doses of the vaccine were sometimes contaminated with other harmful agents, such as the bacterium that causes syphilis. “This history raises a host of questions about how we think about what is effective,” said Elliott M. Reichardt, a PhD student in anthropology, who took the class. “It challenges this history that we have of Edward Jenner and that the development of the smallpox vaccine was just perfect. No – it was quite dangerous for a lot of people.”"

"For millennia, humans have sought and found purpose, solace, values, understanding, and fellowship in religious practices. Buddhist nuns performed variolation against smallpox over 1000 years ago. Since Jenner developed vaccination against smallpox in 1796, some people have objected to and declined vaccination, citing various religious reasons."

"Religious concerns about immunization have a long history, reaching back to those who rejected Edward Jenner’s 1796 mode of smallpox vaccination as contrary to God’s will. In the United Kingdom, the Anti-Vaccination League formed in 1853 in London to oppose compulsory vaccination acts. Similar events occurred in the Netherlands and elsewhere. In the United States, several Boston clergymen and devout physicians formed the Antivaccination Society in 1879. In contemporary cases, such objections involve blood products, porcine or bovine pharmaceutical excipients, or the remote fetal origins of cell-culture media and rubella strain RA27/3. In contrast, it is also worth remembering that some of the earliest descriptions of variolation to prevent smallpox involved the proponency of Buddhist religious women."

"The first written account of variolation describes a Buddhist nun (bhikkhuni) practicing around 1022–1063 CE. She ground scabs taken from a person infected with smallpox (variola) into a powder, and then blew it into the nostrils of a non-immune person to induce immunity. Continuing this tradition, the 14th Dalai Lama participated in poliovirus immunization programs personally. Jains may drink boiled water, cook food, use paper or soap, and take necessary antibiotics, but perhaps with some regret. When considering vaccination, Jains may benefit from an explanation of the seriousness of the diseases to be prevented, to explain the rationale for killing microorganisms in the course of vaccine production. Jains agree with Hindus that violence in self-defense can be justified."

"Judaism traditionally expects certain actions of its believers to maintain health. Pikuakh nefesh, acting to save one’s own or another’s life, is a primary value, a positive commandment (mitzvah aseh). Judaic principles emphasize the community benefits of disease prevention in a manner superior to individual preference, based on scriptures such as Leviticus 19:16 (Table 1C) that counsel not to stand idly by while a neighbor is in trouble. Jewish scholars applied this directive to encourage smallpox vaccination in previous eras."

"Rabbi Abraham Nanzig, writing in London in 1785 in the era of smallpox outbreaks, described the halachic basis for exposing a child to variola virus (variolation) to induce immunity against smallpox: “One who undergoes this treatment while still healthy, God will not consider it a sin. Rather, it is an act of eager religious devotion, and reflects the Commandment to ‘be particularly careful of your well-being”’(Deuteronomy 4:15, Table 1C). In the 1850s, distinguished Rabbi Yisroel Lipshutz described Edward Jenner as a “righteous gentile,” for his efforts in developing smallpox vaccination."

"Members of certain traditional reformed (bevindelijk gereformeerden) Christian denominations in the Netherlands, founded in the 1570s CE, have a tradition of declining immunization that dates back to concerns about adverse events after smallpox vaccination from 1823 onward. These communities were the epicenters of paralytic poliomyelitis, measles, congenital rubella syndrome, and mumps outbreaks between 1971 and 2008. Members of these denominations have familial and cultural ties to associated Christian communities in other countries (e.g., Canada, United States), where immunization rates may also be low. These ties have resulted in international transmission of vaccine-preventable diseases (e.g., measles, poliomyelitis, rubella) with multiple outbreaks in locations otherwise free of circulating disease."

"Health and medical scholars have described vaccination as one of the top ten achievements of public health in the 20th century. Yet, opposition to vaccination has existed as long as vaccination itself. Critics of vaccination have taken various positions, including opposition to the smallpox vaccine in England and the United States in the mid to late 1800s, and the resulting anti-vaccination leagues; as well as more recent vaccination controversies, such as those surrounding the safety and efficacy of the diphtheria, tetanus, and pertussis (DTP) immunization, the measles, mumps, and rubella (MMR) vaccine, and the use of a mercury-containing preservative called thimerosal."

"Widespread smallpox vaccination began in the early 1800s, following Edward Jenner’s cowpox experiments, in which he showed he could protect a child from smallpox if he infected him or her with lymph from a cowpox blister. Jenner’s ideas were novel for his time, but they were met with immediate public criticism. The rationale for this criticism varied, and included sanitary, religious, scientific, and political objections. For some parents, the smallpox vaccination itself induced fear and protest. It included scoring the flesh on a child’s arm, and inserting lymph from the blister of a person vaccinated about a week earlier. Some objectors, including the local clergy, believed the vaccine was “unchristian” because it came from an animal. For other anti-vaccinators, their discontent with the smallpox vaccine reflected their general distrust in medicine and in Jenner’s ideas about disease spread. Suspicious of the vaccine’s efficacy, some skeptics alleged that smallpox resulted from decaying matter in the atmosphere. Lastly, many people objected to vaccination because they believed it violated their personal liberty, a tension that worsened as the government developed mandatory vaccine policies. The Vaccination Act of 1853 ordered mandatory vaccination for infants up to 3 months old, and the Act of 1867 extended this age requirement to 14 years, adding penalties for vaccine refusal. The laws were met with immediate resistance from citizens who demanded the right to control their bodies and those of their children.[The Anti Vaccination League and the Anti-Compulsory Vaccination League formed in response to mandatory laws, and numerous anti-vaccination journals sprang up."

"Toward the end of the 19th century, smallpox outbreaks in the United States led to vaccine campaigns and related anti-vaccine activity. The Anti Vaccination Society of America was founded in 1879, following a visit to America by leading British anti-vaccinationist William Tebb. Two other leagues, the New England Anti Compulsory Vaccination League (1882) and the Anti-vaccination League of New York City (1885) followed. The American anti-vaccinationists waged court battles to repeal vaccination laws in several states, including California, Illinois, and Wisconsin. In 1902, following a smallpox outbreak, the Board of Health of Cambridge, Massachusetts, mandated all city residents to be vaccinated against smallpox. City resident Henning Jacobson refused vaccination on the grounds that the law violated his right to care for his own body how he knew best. In turn, the city filed criminal charges against him. After losing his court battle locally, Jacobson appealed to the U.S. Supreme Court. In 1905 the Court found in the state’s favor, ruling that the state could enact compulsory laws to protect the public in the event of a communicable disease. This was the first U.S. Supreme Court case concerning the power of states in public health law."

"The history of vaccines did not begin with Jenner's smallpox vaccine. It will not end with the recent vaccines against the novel coronavirus, which caused the COVID-19 pandemic. The history of vaccines begins before the first vaccine, with an immunizing procedure called "inoculation" by some and "variolation" by others. According to researchers, inoculation with materials from smallpox lesions to trigger immunity against smallpox dates back to antiquity in China. And the first written account of the procedure was written in 1549."

"Secret or not, the practice of inoculation traveled west toward the Ottoman Empire in the 1500s, reaching Constantinople (modern day Istanbul, Turkey) in the mid-1600s. From there, inoculation traveled to Europe and Northern Africa. From Northern Africa, the practice traveled to the Massachusetts Colony through an enslaved man named Onesimus. He told Reverend Cotton Mather -- of Salem Witchcraft Trials fame -- about being inoculated by enslavers to resist smallpox and get better pay for his enslavement. Cotton Mather, together with a local doctor in Boston, adopted and promoted inoculation as a deadly smallpox epidemic arrived in Boston in 1721. Around the same time, Lady Mary Wortley Montague, a British socialite living in Constantinople with her diplomat husband, had her son inoculated by a local physician. She then asked her daughter -- back home in Scotland -- to be inoculated. By 1723, the evidence was clear that inoculation in a controlled setting and under the supervision of a physician was preferable to catching smallpox "the natural way." After his son died from smallpox in 1736, Benjamin Franklin became a champion of inoculation. He wrote several introductions to written works of the time about the procedure. In one such document written in 1759, Benjamin Franklin even included some numbers on the death rates of those who were inoculated (also known as "variolated"). The numbers gave even more proof that the risk of death was lower in those who were inoculated, cementing the practice in Europe and North America. Such was the adoption of variolation that General George Washington ordered the American troops to be inoculated as part of their intake into the Continental Army during the American Revolutionary War."

"By the late 1700s, Edward Jenner observed that milkmaids and others previously infected with cowpox were immune to smallpox. Cowpox caused lesions similar to smallpox, but the lesions were localized, and the disease was much milder and not considered deadly. Building on the world and observations of other physicians at the time, Jenner devised a series of experiments in which a person who had not previously acquired smallpox nor cowpox would be inoculated first with cowpox and later with smallpox. The gambit paid off. The subjects of these experiments showed a mild reaction to cowpox, and no reaction nor disease to smallpox inoculation. The first vaccine was born. For almost eighty years, cowpox vaccination against smallpox remained the only vaccine in use around the world. Science and technology were not yet there to create vaccines against other disease-causing organisms, though many tried."

"One version of smallpox variolation involved drying the material extracted from smallpox lesions before giving it to someone. It was believed the drying caused the material to be less virulent, so Pasteur tried this with the brains and spinal cords of infected rabbits."

"The 1950s and 60s also brought great cooperation among the nations in eliminating and then eradicating smallpox. That old adversary, the one that got the whole science of vaccination started, was on the retreat through programs in developed nations to vaccinate every individual starting at a young age, not allowing for any exceptions except medical ones. Those who did not want to be vaccinated faced stiff fines and the inability to participate in public spaces like schools, or even in certain jobs. Through a worldwide effort to vaccinate every person alive, smallpox became the first human virus to be eradicated when the last case was detected in 1978. Since its eradication, the smallpox vaccine is only used in personnel working with the smallpox virus and in military members as part of readiness against an intentional release of the virus."

"Smallpox is said to be “eradicated globally” since late 1977, success that has rendered the vaccine itself normally unnecessary and even inadvisable since the risks associated with this vaccine are greater than the risk of contracting smallpox."

"The success of vaccines remains impressive despite the fact that all vaccines themselves present health risks of one kind or another.11 The health risks associated with vaccinations have been the basis of rare but sometimes vigorous opposition to vaccinations at least from the beginning of this century (in Jacobson v. Massachusetts, concerning mandatory smallpox vaccinations) and have reappeared more recently, leading, for example to the National Childhood Vaccine Injury Act of 1986, designed to compensate individuals for reactions to federally approved and, in some cases, legally mandated vaccines."

"See Peter, “Childhood Immunizations,” 1799, for recognition of this. 16Cf.: “To our knowledge, no one argued that it would be morally wrong to eradicate smallpox through vaccination and other public health measures,”"