Tuesday, August 14, 2012

History of Infectious Disease and Vaccination in the United States

History of Infectious Disease and Vaccination in the United States

By Marcella Piper-Terry, M.S., founder of VaxTruth
This article presents an overview of the history of infectious disease in the United States as it relates to the development of U.S. policy regarding mandatory vaccination in general, and the requirement that children must be vaccinated prior to attendance in school.
History of Smallpox
Examination of the establishment of the United States’ policies on vaccination begins with the devastation caused by a single infectious disease:  smallpox.  Smallpox appears to have been endemic in many countries throughout the world, dating back to ancient history (1).
Smallpox is mentioned in ancient Sanskrit from China (1122 BC), and the mummified remains of Ramses V bears scars suggesting the Egyptian pharaoh’s death in 1156 BC may have resulted from smallpox (2).  Smallpox epidemics were responsible for bringing about the end of at least three empires (3) and its potential for use as a biological weapon dates back to the French-Indian War (1754-1767) when a British commander suggested using the virus to reduce the Indian population (4).
Smallpox was first brought to the New World by conquistadors from Spain and Portugal, and later by European settlers to the
northeastern coast of North America.  The virus had devastating effects on populations of Native Americans, including the Inca and Aztec tribes.  The slave trade contributed to the incidence of smallpox in America because the disease was endemic in many of the regions of Africa from which slaves were captured (2).
Smallpox is not easily spread through casual contact (5), but conditions of overcrowding and poor sanitation contributed to epidemics in the Northeast during the 1890s and into the early 1900s (6).  Estimates of the virulence of smallpox vary widely, and appear to be related to particular populations and environmental conditions of the time.  Throughout the course of history, it is estimated that approximately 30% of those who contracted the virus died from it (7), though estimates of mortality rates range from 12% (6) to as high as 60% (3).  Recovery from smallpox granted lifelong immunity, but survivors were often left with disfiguring scars that were especially prominent on the face.  Many people were rendered blind by smallpox due to scarring of the cornea (7).
History of Vaccination
The history of vaccination begins with attempts to reduce the number of people who died as a result of smallpox infection
(3, 8).  The process of inducing immunity to a disease by exposing a non-immune person to the virus that causes it began centuries ago and was known as “inoculation” (2).  Inoculation against smallpox involved using a knife, lancet, or scalpel to make a cut in the arm or leg of the patient and then transferring biological matter taken directly from the oozing pustule of an infected person (9).  This process, called arm-to-arm inoculation, resulted in the inoculated person developing a form of the illness, but the course tended to be shorter in duration and milder in symptoms.  Some people died as a result of inoculation, but those who recovered were immune to smallpox for life (2).
As the incidence of smallpox increased in North America during the 1700s, inoculation (or variolation, as the procedure had come to be known) against the virus became more widely used (2).  Two of the most well-known proponents of variolation were Rev. Cotton Mather and Dr. Zabdiel Boylston.  Mather and Boylston performed and promoted the procedure among the citizens of New England, beginning in 1721 (1).  Their activities were well-received by some but many people were suspicious of the practice and
believed variolation was as dangerous as contracting smallpox naturally.  Using statistical analysis to compare the death rate among the approximately 6,000 citizens of Boston who contracted smallpox during the 1721 epidemic, Mather and Boylston demonstrated that among those who were variolated the death rate was 2%.  Among those who contracted the naturally-occurring form of smallpox, the death rate was 14%. (2)
The success of Mather and Boylston’s use of variolation in New England led to wider acceptance of the process in Europe, where smallpox had resulted in the deaths of more than a few young members of the ruling class (2).  Variolation grew in popularity and was practiced widely among the European aristocracy during the mid-to-late 18th century.  However, despite the success
and popularity of the procedure, there were well-founded concerns about safety, due to the number of people who developed not only smallpox, but other blood-borne diseases including syphilis and tuberculosis as a result of undergoing variolation (2).
In the late 1700s, a young English physician named Edward Jenner began experimenting with using cowpox virus to inoculate
humans against smallpox (8).  Jenner collected data in controlled experiments and wrote articles publishing his findings among his peers in the medical societies of Europe.  Jenner coined the term “vaccination” to refer to his procedure, taking the Latin vacca(cow) and vaccinia (cowpox) as the root (2).
Jenner not only shared his knowledge through published literature, he also shared the vaccine itself, giving samples to other physicians and anyone else who requested it. Use of the cowpox vaccine grew as those who received it from Jenner passed it on to others.  In 1800, Dr. John Haygarth was responsible for the introduction of the vaccine in the United States when he sent some of Jenner’s cowpox vaccine to a physics professor at Harvard University.  After introducing the vaccination in New England, professor Benjamin Waterhouse convinced Thomas Jefferson to try the vaccination in Virginia.  It was this contact between Waterhouse and Jefferson that led to the establishment of the National Vaccine Institute and the implementation of the United States’ first national vaccination program (2).
The first mandatory vaccination law in the United States was enacted in 1809 in Massachusetts, giving the government the power to enforce mandatory vaccination or quarantine in the event of a disease (smallpox) outbreak that posed a threat to the public health (10).  Throughout most of the 1800s vaccination against smallpox in the United States was voluntary, though coercion wasoften used to convince citizens to receive the procedure.  During the 19th century the widely held belief that those who suffered the ravages of poverty were responsible for their own circumstances due to a lack of moral fortitude contributed to the success of
“the vaccinators.”  Outbreaks of smallpox, and other highly contagious diseases such as scarlet fever, measles, and diphtheria almost always originated in populations of impoverished immigrants living in overcrowded conditions characterized by poor sanitation and lack of access to heat, clean water, or nutritious food.  Because illness and poverty were so frequently and closely
linked, proponents of vaccination promoted acceptance of the procedure on moral grounds to increase the numbers of those who were willing to accept vaccination against smallpox, even as the incidence of the disease continued to decline in the general population (6).
Two outbreaks of smallpox in New York’s German and Italian immigrant communities around the turn of the century set the
stage for the establishment of policies for compulsory vaccination. In response to the increasing number of infections, Brooklyn’s Republican Mayor, Charles Schieren, appointed Dr. Z. Taylor Emery to head the city’s health department.  Emery was charged with increasing vaccination coverage, particularly among the city’s immigrants.  To achieve this goal, Emery was granted the power to mandate vaccination and enforce quarantines for anyone who refused.  The number of health department employees responsible for delivering vaccines (e.g., “vaccinators”) was increased, eventually numbering more than 200, and teams of vaccinators fanned out across the city enforcing the procedure in tenements and apartment buildings that housed mainly poor, immigrant families.  Colgrove (6) reports that according to the official “Rules for Vaccinators” quarantines could be ordered and enforced by the Sanitary Police only if there had been a confirmed case of smallpox infection in the vicinity.  However, according to reports published in the Brooklyn Daily Eagle newspaper (cited in Colgrove, 2006), as time went on, it became increasingly common for families to be quarantined without cause, even in the absence of any identified cases of infection.  According to Colgrove’s review, families who were quarantined were denied access to employment or even food deliveries until they eventually acquiesced to the demands of the vaccinators (6).
The city’s homeless population was targeted by the vaccinators, who descended on the rooming houses where the 2,400 homeless members of Brooklyn’s society congregated.  Colgrove (2006) reports on the language of a health department publication, which reveals the attitudes toward those who lived in poverty.  According to Colgrove, the report discussed the importance of targeting Brooklyn’s 72 lodging houses, stating, “In them are gathered nightly a large proportion of those homeless and vagrant ones
in our population whose unwholesome heredity and unsanitary lives render them liable not only to the commission of crimes, but to the contraction of disease” (Colgrove, 2006, p. 25).
To ensure the highest possible rate of vaccination among the city’s homeless population, the proprietors of the lodging houses were forced to require their tenants to produce proof of vaccination status as a condition of receiving a room for the night. Proprietors who failed to comply with the mandate were threatened with loss of licensure (6).
As the aggressiveness of Emery’s teams of vaccinators continued to increase, they began targeting businesses and enforced mandatory vaccination on employees who were threatened with losing  their jobs if they did not comply.  In his review of the social context of Brooklyn in the 1890’s, Colgrove (2006) reports that the fact that the city was in the middle of a severe depression most likely had a significant impact on the willingness of employees to accept vaccination rather than risk unemployment.  Colgrove also notes that the effects of the depression most likely contributed to the zeal with which the vaccinators pursued their prey, as the administrators of the smallpox vaccine were paid thirty cents for each person they vaccinated.
As public complaints against the vaccinators increased, one letter published in The Daily Eagle newspaper charged that paying the
vaccinators in this manner “created an incentive for them to ‘terrorize or intimidate healthy people to be revaccinated by them under penalty of quarantine for refusal’” (Colgrove, 2006, p 23).
During the smallpox outbreak of  1893-1894 resistance against compulsory vaccination increased and several legal challenges were filed by the Anti-Vaccination League, which was a grass-roots organization based in Brooklyn and comprised largely of homeopathic physicians.  Throughout the mid-to-late 1890s, the Anti-Vaccination League filed several lawsuits against the local government and Emery, asserting that the actions of the vaccinators were infringing on the Constitutional rights of United States
citizens.  In addition, there were frequent allegations that the vaccinators falsified death records in an effort to cover up the fact that their zealous activities were resulting in death for a percentage of those citizens they were charged with protecting (6).
Despite multiple challenges from the Anti-Vaccination League during the 1890s in Brooklyn, the conflict leading to the seminal legal ruling regarding compulsory vaccination did not begin until the winter of 1902 and it took place in Boston, Massachusetts. The case of Jacobson v. Massachusetts involved an adult, Henning Jacobson, who refused smallpox vaccination and also refused to pay the $5.00 fine imposed for not complying with the health board’s order of compulsory vaccination.  At trial, Jacobson presented evidence that vaccination was dangerous and frequently caused serious injury or death, and that he himself had been harmed by vaccination as a child.  The case went all the way to the Supreme Court, which ultimately ruled that The State (in this case, Massachusetts) was not unreasonable and had not violated Jacobson’s Constitutional rights because in the midst of the smallpox epidemic, laws enacted by the state had a “real and substantial relation to the protection of the public health and safety”
(10; Welborn, 2005, p. 1-2).
The ruling of the Supreme Court affirmed the sovereignty of individual states to enact and enforce laws to protect the public health and safety, with the only provision being that in doing so, state laws did not violate the United States Constitution or infringe on rights granted by it (10).
Mandatory Vaccination as a Condition of School Attendance
Many states had laws on the books regarding compulsory vaccination against smallpox as a prerequisite for school enrollment, beginning in the early 19th century (11).  The first recorded mandate in the U.S. was in 1827 when smallpox vaccination became a
requirement for entry into public school (12).  However, the laws were not widely enforced or challenged until the smallpox epidemic of 1893-1894 (6).  In 1894 a lawsuit was filed against the principal of a public school in Brooklyn, seeking admittance of the two children of a physician, Charles Walters. Dr. Walters was involved with the Anti-Vaccination League and his children had not been vaccinated against smallpox (6).
Despite the fact that court rulings had generally been decided in favor of the civil rights of adults who had challenged mandatory vaccination (6), the earliest cases involving school attendance were decided in favor of the state and local authorities. In the case of Walters v. Public School No. 22, The Court ruled that compulsory vaccination could be enforced through city and state laws as long as they did not violate the U.S. Constitution in doing so.  The basis for the judge’s decision was that attendance in a public school was a privilege and not a right.  Colgrove reports the findings of the case, quoting the judge’s ruling, “A common school education, under the existing constitution of the State of New York, is a privilege rather than a right… It follows that the State can certainly exercise this discretion by debarring from attendance at the public schools such persons as are unwilling to adopt a precaution which, in the judgment of the legislature, is essential to the preservation of the health of the large body of scholars” (6; Colgrove, 2006, p. 28-29).
The question of whether mandatory vaccination against smallpox as a condition of attendance in public school violated Constitutional rights was heard again by the Supreme Court in 1922,  and again The Court ruled that mandatory vaccination was legally enforceable, basing its decision on precedent established by the Jacobson v. Massachusetts case of 1905 (11).
The Expansion of the Childhood Vaccination Schedule
During the first half of the twentieth century there was a great expansion in vaccine research, leading to the development of new vaccines for pertussis, diphtheria, and tetanus in 1902, 1926, and 1938, respectively (9).  The polio vaccine was licensed in 1955,
followed by the development of the measles, mumps and rubella vaccines in the late 1960s (9).  Although smallpox vaccination had been a requirement of school attendance for decades, it was during the late 1930s that compulsory vaccination against other illnesses began to be instituted for children enrolling in public school (11).  By 1942, nine states had adopted laws requiring immunization against diphtheria, in addition to smallpox vaccination for school children (11).  It was not until the 1980s that laws regarding vaccination of children in public school were expanded to include more than one or two vaccines.  Many of the laws concerning mandatory vaccination of school children sprang up as a result of measles outbreaks in the 1960s and 1970s (10).
Examination of the childhood immunization schedules from the CDC’s Advisory Committee on Immunization Practices (ACIP) reveals that in 1983, children vaccinated according to the schedule received eight injections against seven illnesses by the time they were 18 months old.  Vaccinations were administered beginning at two months of age and were said to protect against diphtheria, tetanus, pertussis (DTP), polio, measles, mumps and rubella (MMR) (13).
By 1994, the ACIP’s recommended childhood schedule included 21 injections against nine diseases by the age of fifteen months, more than doubling the recommendations made in 1983 (14).  The major difference between the 1983 schedule and the 1994 schedule involved immunizing infants against Hepatitis B, and against Haemopholis Influenza type B (HiB).  The series for immunization against hepatitis B was begun within hours of birth for infants born to mothers who tested positive for the hepatitis B virus, and at two months of age for those whose mothers were not infected (15).
The current (2010) childhood vaccination schedule from the ACIP recommends 27 injections (many of them containing multiple vaccinations) against fourteen illnesses by the age of eighteen months.  An additional ten or eleven injections (depending on the child’s birth date), against eleven illnesses are recommended prior to school entry (16).
Currently, a child living in the United States must be vaccinated fifty times prior to entering kindergarten in public school, according to the ACIP recommendations.  Because the laws regarding compulsory vaccination prior to enrollment in public school are based on acceptance of recommendations from the CDC, and because the Supreme Court has upheld the legality of individual states to enforce laws mandating vaccination as a requirement for receiving education through the public school system, parents of children attending school in the U.S. are now “required” to vaccinate their children against hepatitis B and chicken pox, even though neither illness has ever been associated with significant mortality in children living in the United States (17, 18, 19).  (Please note that the term “required” is in parentheses because that is what mainstream media and those who take a pro-vaccine stance would have us believe.  All parents in the U.S. have the legal right to declare exemptions from vaccination.  Please see information posted on VaxTruth regarding your legal right to Medical, Religious, or Philosophical exemptions.)
Problems with the Current Vaccination Policy
The United States’ policies mandating vaccination against infectious diseases began in response to the serious threat of illness and death posed by the smallpox virus.  Smallpox was eradicated during the 20th century and mandatory vaccination against this
particular threat has since been eliminated (20) as a requirement for entrance by children in the public school environment.
Public policy that mandated vaccination against infectious diseases was initiated at a time when the threat of death from smallpox was a genuine concern, especially for persons living in conditions of overcrowding, poor sanitation, and poverty (6).  Review of the results of early court cases challenging the right of local jurisdictions and state governments compelling citizens to vaccinate against smallpox reveals that judges deciding those cases took into account the seriousness of the illness not only in terms of immediate harm to the individual, but with regard to the threat to the community and the capability of the public health authorities to respond to the threat (6, 10, 11).  Notably, the earliest court case regarding compulsory vaccination was decided in favor of the school system and the local government, but in his remarks, the judge in that case specifically mentioned that his decision was based on the fact that at that time (1894) attendance in public school was a “privilege” and not a right. This distinction would seem to be of import to current advocates facing increasingly zealous attacks from mainstream media and attempts to alter legislation to eliminate currently available exemptions for parents who object to the one-size-fits-all vaccination schedule.
Several of the vaccines that are currently required before a child is allowed to attend school or even daycare are known to cause serious side effects and in some cases, death, for a segment of the population receiving them (21, 22, 23, 24).  Proponents for vaccine safety argue that mandatory vaccination of all infants and children with vaccines that have not been proven to be effective at eradicating serious illness or death, and which have resulted in serious illness or death for a percentage of children makes no sense.  In short, the cost (in human life and suffering) is too high.
Proponents of vaccine safety often advocate for individuality in the vaccine schedule, asserting that decisions about what vaccines a child should receive (or not) should be based on careful consideration of the risks of that child contracting a particular illness, the possible harm to that child as a result of having contracted the illness, and the possible threat to the community if others should become infected.  The argument has been made that since a large percentage of the population of the United States does not object to vaccination and willingly complies with the recommendations of the CDC, even if the number of parents filing exemptions and “opting out” of vaccinations were to increase considerably, there would be little chance of outbreaks of disease in school settings, as the vast majority of children would continue to be fully vaccinated.  If the vaccines do indeed work, children who are fully vaccinated should not be at risk of contracting illnesses for which they have received vaccinations.  As one popular mantra among advocates for more thoughtful vaccination states, “Saying my unvaccinated child is a risk to your vaccinated child is like saying my child must take birth control pills so your child doesn’t get pregnant.”  If you’re protected, you’re protected.
Attitudes about parents who are concerned about the safety and necessity of so many vaccinations are often disparaging and downright nasty.  This has been the case since the beginning of the vaccine controversy, dating back to the 1890s when those who refused vaccination were accused of being morally corrupt and lacking in a sense of responsibility for the health and welfare of the public at large (6).  At present, mainstream media outlets contribute to the divisiveness among parents, with figures as prominent as Dr. Nancy Snyderman declaring on The Today Show that the majority of parents who claim religious exemptions are lying about their beliefs and putting the general public at risk (25).  Dr. Snyderman stated on national television that parents who refused vaccination were responsible for the recent deaths of eight babies in California from pertussis.  During her rant, Dr. Snyderman stated that parents who choose not to vaccinate their children according to the CDC’s recommended schedule are guilty of neglect and should have their children removed from their custody.  Dr. Snyderman went so far as to suggest that such parents should be held liable and criminal charges should be filed against them, holding them responsible for the children that died.  With a daily viewership numbering in the millions, Dr. Snyderman’s opinion carries a lot of weight and rhetoric such as hers is contributing to the chasm between concerned parents and their neighbors, school systems, and personal physicians.  What the
majority of the public does not know is that more than two-thirds of the pertussis infections in California this year have occurred in individuals who were fully vaccinated and in the majority of cases the illness occurred as a result of vaccine failure (25).
Dr. Snyerdman’s rhetoric is insignificant when compared to the activities of Dr. Paul Offit. Dr. Offit is without debate the single-most vocal pro-vaccine voice in the United States.  He is the chair of infectious diseases at Children’s Hospital of Philadelphia and
was a member of the Institute of Medicine (IOM) committee that reviewed the evidence regarding the association between vaccines and autism.  The IOM’s 2004 report of findings announced there was insufficient evidence at this time to determine a causal association between vaccines and autism.  This review was based on the results of 14 studies that evaluated one vaccine (MMR) and one vaccine ingredient (thimerosal).  The committee further concluded that future research funding for autism should go to the areas that show the most promise, in effect declaring that further research regarding vaccines and autism should not be pursued.
Advocates for vaccine safety argue that there are significant conflicts of interest that prevented the IOM from delivering a balanced report, chief among them being Paul Offit’s membership on the committee.  Dr. Offit is not only the Chief of Infectious Diseases at
Children’s Hospital of Philadelphia, he is the recipient of an annual $1.5 million dollar research award from Merck pharmaceuticals, which is a major manufacturer and distributor of vaccines.  Dr. Offit is also heavily involved in vaccine research on a personal level, having developed a vaccine against rotavirus (Rotateq).  During the time Dr. Offit was serving on the IOM committee to review vaccine safety, he was the patent-holder for Rotateq vaccine, a patent that was since sold, for a reported sum of $182 million.
When evaluating the risks of vaccination versus the benefits to society, there are a number of issues that must be considered.  As this review of the history of infectious disease in the United States shows, the early development of vaccine policy was in response to outbreaks of smallpox, a highly contagious disease that carried a high rate of mortality.  Even so, when the first court cases objecting to mandatory vaccination for school attendance were decided in favor of the state and local governments, the ruling judge tempered his decision, stating that mandatory vaccination was not a violation of Constitutional rights because at the time, school attendance was not considered a right, but was a privilege.
Given that school attendance is now not only a right, but is compulsory, the factors mitigating The Court’s ruling in those cases that set precedence have changed.  It is the opinion of this writer that just as times have changed, so must the law.

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