2 Websites on smallpox

1. 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/NI000489/html

2. 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)

3. Earliest recorded case, 1157 BC: Egyptian Pharaoh Rameses V, died Last case of smallpox, Oct. 26, 1977:Ali Maow Maalin (Somalia), survived

4. Smallpox at day 3 and 7

5. Smallpox at day 9 and 20

6. Permanent scarring

7. Blindness

8. Monkeypox—not as contagious nor as deadly. Erupting now that vaccination no longer practiced

9. The spread and success of vaccination, 1798 (Jenner published An Inquiry) –1966 (global eradication campaign begun)

10. 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)

11. 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…

12. Morality <1 per 100,000 Vaccinationat 14 days(cowpox vaccine) ...Variolationat 14 days(smallpox virus) Morality1-3 per 100

13. 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.

14. 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%)

15. 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.”

16. London: Inoculation spread smallpox (1747-1800) general inoculation vaccination ceiling Poor data? floor

17. “the longer a society lived with smallpox, the less severe its demographic impact became” —Tucker, 8 NOT!! Vaccinationwas truly effective in reducing smallpox mortality general inoculation ceiling floor

18. 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

19. 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).

20. 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.”

21. Sweden: inoculation did not work (1750-1800); vaccination did (1801-) death rate from smallpox per million pop. <1800smallpox mortality = 2-4 per thousand;>1800 nearly zero inoculation vaccination

22. Sweden:Vaccination worked; compulsory vaccination worked better, 1770-1843 Deathsper million

23. 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

24. 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

25. Franco-Prussian war (1870-1) proved why vaccination should be compulsory • A “perfect” demonstration • France, no vaccination policy: 1 million soldiers; 125,000 ill; 23,470 died • Germany, compulsory vaccination, re-vaccination: 800,000 soldiers; 8,463 ill; 459 died • 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.) CountrySoldiers (at risk)illCase fatality rateFrance 1,000,000 .125 .20Germany 800,000 .001 .05France had no compulsory vaccination for soldiersGermany had compulsory vaccination for soldiers

26. Why vaccination works, even after an epidemic breaks out:Smallpox is slow to develop (12th day)vaccination ‘takes’ quickly (by 9th day) Smallpox BodytempCº Vaccination Days after infecction

27. 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)

30. 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)

31. 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