2 Websites on smallpox Center for Disease Control

2 Websites on smallpox § Center for Disease Control (CDC): www. bt. cdc. gov/agent/smallpox/index. asp § Institute of Medicine Report: books. nap. edu/books/NI 000489/html

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 3 rd 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 18 th 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 19 th 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. 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 (12 th day) vaccination ‘takes’ quickly (by 9 th 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