An Historical Examination of Smallpox Vaccinations:
Past and Present Immunization Challenges
Chris J. Hong, BHSc, MD Candidate 2016
Faculty of Medicine
University of Ottawa
Summer 2014
This research was sponsored by the Geza and Caroline Hetenyi Memorial Studentship for
the Study of History of Medicine at the Faculty of Medicine, University of Ottawa.
Keywords: vaccination, smallpox, epidemics, Jenner, anti-vaccinationists, Canada
Corresponding Author
Chris J. Hong
Faculty of Medicine, University of Ottawa
451 Smyth Road, Ottawa, Ontario
K1H 8M5
Email: [email protected]
Word Count: 6,685
2
Table of Contents
Acknowledgements ............................................................................................................ 3
Introduction ........................................................................................................................ 4
A Brief History of Smallpox .............................................................................................. 6
Variolation and Early Preventions ..................................................................................... 9
Brief History of Edward Jenner and Discovery of Smallpox Vaccine ............................ 12
How Do Vaccines Work? ................................................................................................ 13
The Spread of Vaccinations ............................................................................................. 14
Claims of Anti-Vaccinationists and Rebuttals ................................................................. 18
Case Study of Dr. Thomas Smellie .................................................................................. 25
Ontario Vaccination Laws and Legislation ...................................................................... 27
Ongoing Controversies with Compulsory Vaccinations .................................................. 28
Conclusions ...................................................................................................................... 31
3
Acknowledgements
First and foremost, I would like to thank the Geza and Caroline Hetenyi Memorial
Studentship at the University of Ottawa for allowing me to undertake this project. Their
support provided me with a tremendous opportunity to explore, and learn about, the
history of vaccinations and ongoing barriers to their widespread use. In addition, I would
like to express my sincere appreciation to my supervisor, Dr. Toby Gelfand. His guidance
and support enabled me to complete this work on time and on target.
4
Introduction
Are vaccines benign or do they pose possible health risks? Are the benefits, real
or imagined, greater than the dangers? These questions have been of continuing public
concern since the development of vaccination programs. Although vaccines have
improved the quality of life for most people, there have been, and continue to be, pockets
of resistance. As I prepare this paper, critics still challenge the safety and efficacy of
vaccines and actively resist mandatory vaccination programs. Although causal links to
diseases like colitis and autism spectrum disorders have been discredited, there remains a
vocal minority that campaigns against vaccinations.
Arguments that compulsory vaccinations violate civil rights are tenuous at best.
Section One of the Canadian Charter of Rights and Freedoms “guarantees the rights and
freedoms set out in it subject only to such reasonable limits prescribed by law as can be
demonstrably justified in a free and democratic society.”1 In cases of disease outbreaks,
like SARS, society demands that victims be sequestered in order to limit or contain the
contagion. The greater good overwhelms individual rights and freedoms. Following the
same logic – infected persons are not allowed to resist or disobey quarantine orders –
why should individuals be allowed to refuse vaccinations? Simply because vaccines can
reduce the burden of disease, does it mean that vaccines should be compulsory and
mandated? The answer must be resoundingly in the affirmative. This is a matter that calls
for leadership from the medical community; it must be removed from the political arena
as the science behind vaccination programs is incontrovertible: vaccinations are
beneficent and necessary and they must be compulsory.
1
Canadian Charter of Rights and Freedoms, R.S.C, 1985 see also Part I (ss. 1 to 34) of the Constitution
Act, 1982.
5
It is important that the long-established, scientifically corroborated benefits of
vaccination campaigns be re-asserted in order to promote their ongoing success. It is, in
fact, worrisome that immunization rates today are declining despite available and
effective vaccination strategies. There continue to be alarming outbreaks of vaccinepreventable diseases.2,3,4
Figure 1: Global outbreaks of vaccine-preventable diseases since 2008. Each disease type identified
by a color (measles, mumps, rubella, polio, whooping cough, other) and larger circles represent more
infections. Courtesy of the Council on Foreign Relations.
The purpose of this project is to support compulsory immunization programs
across Canada. The current decline in vaccination rates makes compulsory immunization
a medical issue rather than a political issue. The medical community needs to lead a
compulsory vaccination campaign notwithstanding the resistance or opposition that may
2
Public Health Agency of Canada. Measles (July 15, 2014). Available online at: http://www.phacaspc.gc.ca/im/vpd-mev/measles-rougeole/professionals-professionnels-eng.php. Accessed July 29, 2014.
3
Public Health Agency of Canada. Mumps (October 24, 2013). Available online at: http://www.phacaspc.gc.ca/im/vpd-mev/mumps-eng.php. Accessed July 29, 2014.
4
Cherry JD. Epidemic pertussis in 2012—the resurgence of a vaccine-preventable disease. N Engl J Med
2012;367:785-7.
6
be encountered. It is hoped that this paper will inspire public confidence and improve
health outcomes.
A Brief History of Smallpox
Epidemic diseases have shaped human history. Among epidemics from the past,
smallpox is often considered one of the greatest scourges. It is a highly contagious
disease and is spread by droplet nuclei. Its mode of transmission is close face-to-face
contact, which makes people who have close contact with an infected person (e.g. family,
healthcare workers) highly susceptible to infection.5 Smallpox claimed millions of lives
over 3,000 years. People suffered from grotesque symptoms that began with a distinctive
rash and quickly progressed to suppurating blisters that caused gross disfigurements,
blindness and, in many cases, death.6
Figure 2: Distinctive rash and progressive suppurating blisters causing gross disfigurement from
5
U.S. Department of Health and Human Services, National Institutes of Health, National Institute of
Allergy and Infectious Diseases. Smallpox—Transmission (March 6, 2009). Available online at:
http://www.niaid.nih.gov/topics/smallpox/pages/transmission.aspx. Accessed August 1, 2014.
6
Perlin D, Cohen A. The Complete Idiot’s Guide to Dangerous Diseases & Epidemics. 1st edition. Alpha
Books, Penguin Group (USA) Inc., 2002.
7
smallpox infection
It first appeared in northeastern Africa around 10,000 BCE and spread to other
parts of the world as travel, trade and migration routes developed. Our earliest evidence
of smallpox lesions is found on the faces of mummies dating back to Egyptian
dynasties.6,7 Ramses V, for instance, is suspected to have died young from smallpox in
1157 BCE. The first recorded smallpox epidemic occurred in 1350 BCE during the
Egyptian-Hittite War.6,7
Smallpox subsequently spread to India and China. Some scholars speculate that
the disease existed in India from “time immemorial” and that it was mentioned in the
most ancient of Sanskrit writings, the Atharva Veda.8 However, others argue that
smallpox appeared in India early in the Common Era and flourished along the Ganges
valley where settlements were dense.8 Smallpox also had deep roots in China. Although it
was likely present before the Common Era, it appeared in Chinese literature as early as
the first century CE.8
In Europe, an epidemic in Athens during the Peloponnesian War (431-404 BCE)
generally considered smallpox killed more than 30,000 people and reduced the general
population by twenty percent.9 Thucydides, an Athenian aristocrat who survived
smallpox, wrote a historical account describing: “… the dead lying unburied, temples full
of corpses, and the violation of funeral rituals.”9 He was the first European scholar to
speak to the idea of acquired immunity; he noted that those who survived smallpox
became immune to recurrences. Although Athens was the only Greek city hit by the
7
Arnott R. The Archaeology of Medicine. Oxford: British Archaeological Reports, 2002.
Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its Eradication. Geneva: World
Health Organization; 1988. pp. 212-67.
9
Thucydides, Warner R, Finley MI. History of the Peloponnesian War. Penguin Books, 1972.
8
8
smallpox epidemic, Rome and many other Egyptian cities were also affected.9
Smallpox epidemics appeared frequently during the Common Era and affected the
development of Western civilization. In 108 CE, for instance, a large-scale epidemic – the
plague of Antonine – accounted for the deaths of about seven million people and led to
the early stages of the decline of the Roman Empire.10 Another early epidemic infected
the Ethiopian invaders of Mecca in Arabia in 568 CE. Also known as the “Elephant War”,
the plague virtually destroyed the Ethiopian army and ended their rule in Arabia.11
In 570 CE, Bishop Marius of Avenches of Switzerland introduced the word
variola. It derived from the Latin varius, meaning “stained”, or from varus, meaning
“mark on the skin”.12 The term small pockes was first used in England at the end of the
fifteenth century in order to distinguish the disease from syphilis, which was known as
the great pockes.12
A notable scientific work on smallpox dates to Alexandra in 622 CE. It is by
Ahrun a Christian priest who described smallpox:
The most curable sort [of smallpox] is the white and red; the most
dangerous is the black, then the greenish, and the next to that the yellow.
When you see that the fever is lessened upon the breaking out of the SmallPox or Measles, it is a favorable sign; but when the fever is aggravated, it
is fatal.13
The most notable record, however, was that of Rhazes (Abu Bakr Muhammad Bin
Zakariya Ar-Razi, 865-925 CE) who provided the first medical description of smallpox.
He said the disease was transmitted from person to person and that survivors of smallpox
do not develop the disease a second time. His work was translated into Latin and Greek
10
Littman RJ, Littman ML. Galen and the Antonine plague. Am J Philol 1973;94:243-55.
Barquet N, Domingo P. Smallpox: the triumph over the most terrible of the ministers of death. Ann Intern
Med 1997;127:635-42.
12
Moore J, C. The History of the Smallpox. London: Longman, 1815.
13
Razi AB, Greenhill WA. A Treatise on the Small-Pox and Measles. London: The Sydenham Society,
1848.
11
9
and influenced European physicians down through the Renaissance; it was the first theory
of acquired immunity.13
Nevertheless, smallpox continued to ravage the globe. It spread from Africa and
Asia to Europe and later to the Americas.6 By the end of the eighteenth century, the
disease accounted for nearly 400,000 deaths per year in Europe.6,14 Estimates suggest that
thirty percent of cases ended in death and most survivors suffered some degree of
disfigurement that often led to suicide. Many were also blinded when smallpox infected
corneas.15 The death tolls were staggering and are alleged to have accounted for more
than three hundred million fatalities around the globe by the end of the twentieth
century.15
Variolation and Early Preventions
Despite advances in understanding of the pathology of smallpox, no effective
treatment strategies emerged; bloodletting, purging and cooling techniques remained in
effect. Leeches were commonly used to treat smallpox until the late 1700s.16 It was one
of the doctors’ standard remedies; it did nothing to mitigate the disease but made patients
feel like something was being done for them. Competing beliefs, like the ameliorative
properties of the colour red, also remained popular.16
Since no effective treatment strategies appeared, there was a shift in attitudes from
treating to preventing smallpox. Early attempts at prevention are reflected in the
14
Hays JN. Epidemics and Pandemics: Their Impacts on Human History. ABC-CLIO, 2005. pp. 151.
The College of Physicians of Philadelphia. The History of Vaccines—History of Smallpox. Available
online at: http://www.historyofvaccines.org/content/timelines/smallpox. Accessed August 1, 2014.
16
Williams G. Transcript for “From Jenner to Wakefield: The long shadow of the anti-vaccination
movement.” (September 28, 2011). Available online at: http://www.gresham.ac.uk/lectures-andevents/from-jenner-to-wakefield-the-long-shadow-of-the-anti-vaccination-movement. Accessed August 1,
2014.
15
10
eighteenth century practice of variolation.17 The process involved taking a small amount
of smallpox, called variola, from an infected patient and inoculating a healthy person
with the disease. The individual developed smallpox-like symptoms, which were usually
less severe (i.e. the fever was milder, the disease was of shorter duration, and there were
fewer pustules).18 The hope was to induce a milder infection that could be resisted and
confer long-term immunity on the patient. Originating in China, it spread slowly to the
Middle East then to Europe and North America.11
Variolation in Europe was introduced by travelers who witnessed the technique in
Istanbul. In 1714 and 1716, Emanuel Timoni and Giacomo Pilarino wrote letters to the
Royal Society of London describing variolation.19 However, English physicians did not
change their ways. It was Lady Mary Wortley Montagu – wife of the British ambassador
to the Ottoman Empire – who played an important role in disseminating variolation in
England.20 After observing the process in Istanbul she treated her son and daughter in the
presence of English physicians. Her initial success led to the experimental inoculation of
six inmates of Newgate Prison in London. That also succeeded and promoted variolation
programs for the royal family and the English population generally. Variolation had a
greatly reduced death rate: only two percent in the first eight years to 1729.21 This was
much better than the twenty to thirty percent mortality rate from naturally occurring
smallpox.8
17
Variolation was likely practiced in China, India and Africa long before the eighteenth century when it
was introduced to Europe. (Gross CP, Sepkowitz KA. “The myth of the medical breakthrough: smallpox,
vaccination, and Jenner reconsidered.” Int J Infect Dis 1998;3:54-60.)
18
U.S. National Library of Medicine, National Institutes of Health. Variolation (July 30, 2013). Available
online at: http://www.nlm.nih.gov/exhibition/smallpox/sp_variolation.html. Accessed July 30, 2014.
19
Riedel S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent)
2005;18:21-5.
20
Halsband R. “New light on Lady Montagu’s contribution to inoculation.” J Hist Med 1953;8:390-405.
21
Behbehani AM. “The smallpox story: life and death of an old disease.” Microbiol Rev 1983;47:455-509.
11
In Boston, Puritan minister Cotton Mather began using variolation in 1721 after
learning about it from his African servant. With the help of a local doctor, named Dr.
Zabdiel Boylston, they managed to reduce the death toll from smallpox.22 Mortality
among the inoculated was significantly lower compared to the non-inoculated (2% versus
20%-30%).8,21 In subsequent years, variolation was endorsed by philosophers who hoped
to promote good health.
Benjamin Franklin became one of the main proponents of variolation in the
United States following the death of his four-year-old son.23 In Franklin’s autobiography,
he regretted foregoing smallpox inoculations:
In 1736 I lost one of my sons, a fine boy of four years old, by the smallpox
taken in the common way. I long regretted bitterly and still regret that I had
not given it to him by inoculation. This I mention for the sake of the
parents who omit that operation, on the supposition that they should never
forgive themselves if a child died under it; my example showing that the
regret may be the same either way, and that, therefore, the safer should be
chosen.24
In 1759, with help from Franklin who added an introduction documenting the success of
variolation in Boston, English physician William Heberden prepared pamphlets that
encouraged parents to inoculate their children against smallpox.25 These materials were
distributed in the American colonies. The practice spread quickly and by the end of the
American Revolutionary War, it was popular in many cities and towns.25 Although
variolation had a two percent mortality risk, it was effective in lowering the overall death
rates from smallpox. The following table demonstrates the efficacy of variolation on the
22
Celebrate Boston. First Inoculation in America (1721). Available online at:
http://www.celebrateboston.com/first/inoculation.htm. Accessed August 1, 2014.
23
Best M, Katamba A, Neuhauser D. Making the right decision: Benjamin Franklin’s son dies of smallpox
in 1736. Qual Saf Health Care 2007;16:478-80.
24
Franklin B. Autobiography. New York: Modern Library, 1950. pp. 113-4.
25
Heberden W. Some Account of the Success of Inoculation for the Small-Pox in England and America:
Together with Plain Instructions by which any Person may be Enabled to Perform the Operation and
Conduct the Patient Through the Distemper. London: W. Strahan, 1759.
12
death rate from smallpox during three epidemics in Boston.26
Year
General Population
Cases
Deaths
Deaths/1,000 Cases
Cases
Deaths
Deaths/1,000 Cases
1721
1764
10,700
15,500
Natural Smallpox
5,759
699
842
124
146
177
Smallpox FollowingVariolation
130
4,977
2
46
15
9
1792
19,300
232
69
297
9,152
179
20
The first known use of variolation in Canada was in 1765.27 In 1769, James
Latham, a British military surgeon, variolated 303 people, including prominent English
and French families in Quebec City. He later treated 200 in Montreal, without a fatality.
By 1770, Latham had variolated 1,250 inhabitants.28 In 1796, the authorities allowed the
variolation of Mohawk Indians in Upper Canada, and more near Kingston. Variolation
continued for over half a century after the introduction of smallpox vaccines. 27,28
Brief History of Edward Jenner and Discovery of Smallpox Vaccine
Edward Jenner – an English physician and scientist from Gloucestershire – is
credited with pioneering the world’s first smallpox vaccine.29,30,31 Although there were
earlier theories and experiments testing whether or not cowpox offered immunity against
smallpox, it was not until Jenner’s experiment and self-publication that the procedure was
26
Blake, J.B. Public Health in the Town of Boston, 1630-1832. Harvard University Press, 1959.
Heagerty, J.J. Four Centuries of Medical History in Canada. Vol 1. Toronto: Macmillan, 1928. pp. 17-65.
28
Tunis B. Inoculation for Smallpox in the Province of Quebec, a Reappraisal. In: Roland CG, editor.
Essays in Canadian History. Toronto: The Hannah Institute for the History of Medicine, 1984. pp. 171-93.
27
29
LeFanu, W.R. A Bio-Bibliography of Edward Jenner, 1749-1823. London (UK): Harvey and Blythe,
1951. pp. 103-8.
30
Baxby D. Jenner’s Smallpox Vaccine: The Riddle of Vaccinia Virus and Its Origin. London: Heinemann
Educational Books, 1981.
31
Baxby D. Vaccination: Jenner’s Legacy. Berkeley, UK: Jenner Educational Trust, 1994.
13
widely adopted. A milkmaid in Chipping Sodbury told Jenner that milkmaids were
generally immune to smallpox once they had contracted cowpox.16 Jenner brought this
idea to the Convivio-Medical Society. It was rejected and maligned by his colleagues
who refused to offer any credence to the observations of milkmaids, who belonged to the
lower classes.16 Nevertheless, Jenner persisted; he believed that cowpox offered
protection against smallpox. In 1796, Jenner tested his hypothesis by inoculating James
Phipps – the eight-year-old son of Jenner’s gardener – with cowpox taken from the hand
of a milkmaid named Sara Nelmes.11 The boy reacted positively to cowpox: he developed
a mild fever and some uneasiness, but did not develop a full-blown infection. Jenner later
found that young Phipps was immune to smallpox when injected with an active sample.11
The word vaccine derives from Jenner’s work. Its root comes from the Latin
vaccinus, meaning “pertaining to cows, from cows”.32 By the end of 1800, more than
5,000 people in England and over 100,000 in Europe were successfully vaccinated using
cowpox sera. Smallpox was sharply curtailed after a massive vaccination program was
undertaken. Variolation quickly fell into disuse and was eventually banned in England in
1849 because of the risk of spreading the contagion.33
How Do Vaccines Work?
Vaccines are powerful tools that prevent contagious, epidemic diseases by
introducing attenuated viruses into hosts who develop antibodies that resist the infections
of similar strains. This confers long-term immunity. The immunological mechanism of
vaccinations involves a macrophage activation that results in a series of events
32
33
Ayto, J. Dictionary of Word Origins. New York. Arcade Publishing. 1990. p.553
Wolfe, R.M, Sharp LK. Anti-vaccinationists past and present. BMJ 2002;325:430-2.
14
specifically designed to kill the engulfed microorganisms.34 Phagosomes, containing
microorganisms, fuse with lysosomes – referred to as “phagosome maturation” – which
quickly allow nascent phagosomes to transform their composition to yield
phagolysosomes, where most of the killing, degradation and digestion of microorganisms
occur.34 Once the microorganisms have been consumed and their antigens processed,
macrophages carry them to lymph nodes where lymphocytes, namely T cells and B cells,
reside. Exposure to the antigens results in “programming” or “maturation” of T cells and
B cells, which cause them to destroy infected cells and produce new viral antibodies.
After the weak or dead viruses are eliminated from the body, the microorganism-fighting
B cells and T cells convert to memory cells; re-exposure to the same infections results in
a quick recognition and effective prevention.34
Individuals are protected from diseases at the social level when a significant
portion of the population is vaccinated. Also known as “herd immunity” or plural effects
of immunization, this theory argues that there is less probability for disease transmission
between infected and susceptible individuals if the majority have vaccine-conferred
immunity.35 This mechanism is particularly useful in reducing the spread of infectious
diseases from a public health perspective. It provides a level of protection to the
susceptible who cannot be safely vaccinated due to medical conditions.
The Spread of Vaccinations
After Jenner’s discovery, vaccinations gained rapid acceptance across Europe and
34
U.S. Department of Health and Human Services. How Vaccines Work (July 23, 2013). Available online
at: http://www.vaccines.gov/more_info/work/. Accessed July 30, 2014.
35
U.S. Department of Health and Human Services. Community Immunity (“Herd Immunity”) (November
27, 2013). Available online at: http://www.vaccines.gov/basics/protection/. Accessed July 30, 2014.
15
elsewhere. In North America, John Clinch, a medical missionary in Trinity,
Newfoundland, is recognized as the first vaccinator.36 On December 1, 1796, after
hearing about cowpox vaccines, Clinch sent a letter to Jenner, his old classmate and
colleague, asking for further information. Clinch then started vaccinating Newfoundland
residents and by the end of 1801 he had vaccinated seven hundred people.36 By bringing
smallpox vaccinations to the New World, Clinch saved many lives. Following Clinch,
Benjamin Waterhouse vaccinated his children and two servants in July 1800 and
popularized vaccinations in Boston.37 Also in July of 1800, President Thomas Jefferson
vaccinated his family and neighbors and endorsed Jenner’s findings:
Yours is the comfortable reflection that Mankind can never forget that you
have lived. Future generations will know you by history only that the
loathsome smallpox has existed, and by you had been extirpated.38
In 1803, after gaining royal approval, the Royal Jennerian Institute was
established in London to promote vaccinations, especially among the poor.39 In Berkeley,
Jenner established a clinic – known as the “Temple of Vaccinia” – where he gave free
vaccinations to the poor.40
Cowpox matter was easily transported from one continent to another via an armto-arm transfer method so vaccination programs spread throughout the world. In 1803,
King Charles IV of Spain rounded up a number of Madrid orphans (who served as an
arm-to-arm transfer chain) and sent the Balmis Expedition to the Americas to introduce
36
Davies, J.W.” A historical note on the Reverend John Clinch, first Canadian vaccinator.” CMAJ
1970;102:957-61.
37
To Slay the Devouring Monster—The Vaccination Experiments of Benjamin Waterhouse. Rare Books and
Special Collections, Francis A. Countway Library of Medicine, Harvard University (2000).
38
Hopkins, D.R. The Greatest Killer: Smallpox in History. Chicago: University of Chicago Press, 2002.
39
Royal Jennerian Society for the Extermination of the Smallpox (2013). Address of the Royal Jennerian
Society for the Extermination of the Small-Pox. London: Forgotten Books. (Original work published 1803)
40
Edward Jenner and his “temple of vaccinia”. Br Med J 1996;2:946.
16
smallpox vaccinations to the colonies.41 Within several decades of Jenner’s discovery
millions were protected.
Following Jenner’s findings, governments took an interest in vaccines. Although
vaccines were initially regarded as a matter of national pride and prestige, they soon
became an essential component of disease prevention.42 During the nineteenth century,
for instance, European governments passed laws making vaccinations compulsory. The
first smallpox vaccination law was passed in 1807 in the Grand Duchy of Hesse; it was
soon copied by Bavaria and Denmark in 1810.43 During an epidemic in Rome in 1814,
Pope Gregory XVI supported vaccination as “a precious discovery, which ought to be a
new motive for human gratitude to Omnipotence.”44 In 1852, the English parliament
passed a compulsory vaccination law, requiring the first steps to eliminating smallpox to
begin. Vaccines “quickly became integral to utilitarian and public health notions of
societal security, productivity, and protection.”42 Gratitude to Jenner for one of the
greatest discoveries in medical history was nearly universal.
In Canada, endemic smallpox persisted until 1946. Nova Scotia had a suspected
case in 1949 but through rigid quarantines the disease was confined.45 The final
documented case in Canada was in 1962: Jimmy Orr, the fifteen-year-old son of a
missionary in Brazil, returned to Toronto with an active case of smallpox.46,47 It produced
41
Rigau-Perez, J.G. The introduction of smallpox vaccine in 1803 and the adoption of immunization as a
government function in Puerto Rico. Hispanic American Historical Review 1989;69:393-423.
42
Stern, A.M, Markel, H. The history of vaccines and immunization: familiar patterns, new challenges.
Health Affairs 2005;24:611-21.
43
Persson S. Smallpox, Syphilis and Salvation: Medical Breakthroughs that Changed the World. Exisle
Publishing, 2010.
44
Henderson, D.A. “Smallpox—the death of a disease: the inside story of eradicating a worldwide killer.”
Am J Epidemiol 2010;171:384-5.
45
McIntyre, J.W.R, Houston, S. “Smallpox and its control in Canada.” CMAJ 1999;161:1543-7.
46
Jarvis, E. “A contagious journey within a culture of complacency: the smallpox scare of 1962 in New
York and Toronto.” CBMH/BCHM 2007;24:343-66.
47
Brown, J.R. McLean, D.M. Smallpox—a retrospect. CMAJ 1962;87:765-7.
17
a flurry of medical and media attention as public health officials tried to limit the spread
using selective ring vaccinations (a strategy in which contacts of cases are identified and
vaccinated). This situation led to a re-examination of immigration health procedures and,
more importantly, highlighted the potential threat to public health as a consequence of
low level of immunity among the North American population. Complacency and apathy
surrounded a disease that most assumed was extinguished.
Vaccination programs continued to spread and in 1967, the World Health
Organization (WHO) announced that they could eradicate smallpox once and for all.48
They set out on a concerted global campaign to eradicate smallpox through mandatory
mass vaccinations.
Figure 3: Smallpox global eradication program of the WHO
In retrospect, the smallpox eradication program of the WHO turned out to be an
impressive achievement. Since its inception in 1967, the final smallpox case was
48
Bhattacharya, S. “The World Health Organization and global smallpox eradication.” J Epidemiol
Community Health 2008;62:909-12.
18
diagnosed in Somalia on October 26, 1977, and, consequently, smallpox was officially
deemed eradicated.21 The entire program cost $112 million and now saves one billion
dollars annually in global health expenditures.21
Claims of Anti-Vaccinationists and Rebuttals
Figure 4. Example of an article published by anti-vaccinationists
Notwithstanding evidence confirming the efficacy of vaccines, there has been
active and persistent resistance to them. The majority of anti-vaccination claims have
been superficial. In the early days, opposition was rooted in simple conservatism, inertia
or apathy. Others feared that vaccinations would eventually lead to minotaurization: the
19
development of cattle-like features in humans.16,49 Some anti-vaccinationists also claimed
that vaccines would cause tuberculosis, syphilis, blood poisoning, and diabetes, amongst
a host of other diseases.16,50,51 Noted philosopher Immanuel Kant speculated that it was
not a good idea to put animal materials into human bodies. Ernest McCormack built on
Kant’s idea and suggested:
It takes a human twenty-one years to reach maturity and it takes a cow
three years to reach maturity. Therefore cow cells divide seven times faster
than human cells. Therefore if you put cow stuff into man, man’s cells are
suddenly going to start dividing seven times faster than they should do.
Therefore you will get cancer.16
The specious nature of these arguments does not hold any value today.
Many people came to oppose compulsory vaccinations through direct experience
with suffering. There were rumors that the outcomes of victims of vaccinations were
devastating, even from those who “claimed” to be former advocates of vaccination. In
1810, a report from the Medical Observer noted 535 cases of smallpox after vaccination,
ninety-seven fatal cases and 150 cases of vaccine injuries.52 In Musselburgh, Scotland,
Dr. Thomas Brown (1818) published an article revealing his disappointment with
vaccinations. He stated that he was in favor of vaccinations at first that no one “could
outstrip [him] in zeal for promoting vaccine practice”; however, after vaccinating 1,200
individuals, he observed that many people still contracted fatal smallpox outbreaks.53
Serious opposition was based on concerns about infections. Bacterial
contamination of the vaccines, or the equipment used to apply them, commonly led to
infections, which resulted in some morbidities and mortalities.16 This was at a time when
49
Rowley, W. Cox-Pox Inoculation No Security Against Small-Pox Infection. London: J Harris, 1805.
Creighton, C. The Natural History of Cowpox and Vaccinal Syphilis. London: Cassell, 1887.
51
Wilder A. History of Medicine. New England Eclectic Publishing Company, 1901.
52
Vaccination by Act of Parliament. Vol 131. Westminster Review 1889. pp. 101.
53
Brown, T. “On the Present State of Vaccination.” Vol. 15. The Edinburgh Medical and Surgical Journal
1819. pp. 67.
50
20
scientists had limited knowledge of how infections spread. There is evidence that some
early cowpox inoculations proved fatal for these reasons.16 Anti-vaccinationists spoke of
the poor quality of the vaccines and the unhygienic conditions of administration, both of
which led to secondary infections and deaths. In some instances these fears were merited.
The Anti-Vaccination League of Canada argued:
Has any civilized Government moral sanction for compelling wholesale
inoculation of a filthy and highly dangerous disease upon its healthy
subjects, professedly for the purpose of preventing the incidence of another
disease, which not one in a thousand of them may ever take and which
does not, in these days, slay one per cent of those who do take it?54
They maintained that sanitation, hygiene and isolation were the best weapons against
smallpox.54 In light of the disorganized, unsupervised conditions under which
vaccinations were delivered in the late nineteenth and early twentieth centuries some of
these charges were valid. By the latter part of the twentieth century, however, both the
quality of the vaccines and the sanitary processes that informed inoculation programs
were no longer an issue.42
Other resisters used the “not-in-my-backyard” approach; they believed that
vaccinations were unnecessary where smallpox was not present. A more reasoned
argument was based on the risk of substantial adverse events attending vaccinations.
These included viral encephalitis, vaccinia necrosum (rare progressive necrosis and
ulceration of the skin), and generalized vaccinia (generalized eruption of skin lesions that
may occur 6-9 days after vaccinations); they corresponded to an overall rate of severe
adverse events in 1.3 per 1,000 vaccinations.55 Despite these marginal risks, compulsory
smallpox vaccinations were important because the benefits outweighed the overall
54
55
Anti-Vaccination League of Canada, Vaccination in Canada, pp. 41.
Hoey, J. “Smallpox vaccination advice.” CMAJ 2002;167:1148.
21
dangers.
In Canada, smallpox vaccinations ceased in the 1970s when the disease was
eradicated.55 However, recommendations must change should the disease re-emerge in
the future. For these reasons, there should be mandatory preventive vaccinations for
diseases such as measles, mumps and rubella.
Some anti-vaccinationists did not believe the data and added a number of
“conspiracy theory” arguments to buttress their causes. When mandatory vaccinations
were first introduced, opponents alleged that public health officials used the programs as
a “ploy to avoid sanitary measures”, which were invariably more expensive.56 In her
book Crimes of the Cowpox Ring (1906), Lora C. Little proposes the idea that
vaccinations were inflicted on the children of America through a consortium that included
manufacturers of cowpox vaccinations, government officials and doctors who profited
from effecting the treatments.57 Such non-falsifiable hypotheses, however, carry little
weight. It is like arguing that physicians support workplace injuries and the proliferation
of diseases in order to earn a living. The measurable health benefits of vaccinations are
ignored in favour of unsupported aspersions of profiteering. The absence of the disease is
testimony to the effectiveness of vaccinations.
Additionally libertarian arguments have made their way into the fight against
mandatory vaccinations.58 They argue that compulsory immunization legislation
encroaches on the rights of individuals to manage their personal health autonomously.
They believe that vaccinations should not be compulsory any more than any other
56
Anti-Vaccination League of Canada, Vaccination in Canada (Toronto, 1907), pp. 46.
Little, L.C. Crimes of the Cowpox Ring: Some Moving Pictures Thrown on the Dead Wall of Official
Silence. Minneapolis: Liberator Publishing Co., 1906.
58
Blum, J.D. “Balancing individual rights versus collective good in public health enforcement.” Medicine
and Law 2006;25:273-81.
57
22
medical measures. One of the most notable cases adjudicated at law is found in Jacobson
versus Massachusetts: a resident of the city of Cambridge refused to be vaccinated for
smallpox because he believed that the law violated his right to care for his own body.
However, by a 7-2 majority, the American Supreme Court upheld the right of states to
enact compulsory vaccination laws:
[T]he liberty secured by the Constitution of the United States to every
person within its jurisdiction does not import an absolute right in each
person to be, at all times and in all circumstances, wholly freed from
restraint. There are manifold restraints to which every person is necessarily
subject for the common good. On any other basis organized society could
not exist with safety to its members. Society based on the rule that each
one is a law unto himself would soon be confronted with disorder and
anarchy.59
The Court’s decision set a precedent for subsequent challenges of vaccination laws. It
also outlined the terms for state interventions to limit individual liberties affecting other
health issues such as fluoridation of municipal water supplies. This leveraged state
powers to control the spread of contagions using compulsory measures such as isolation
and quarantine. The utilitarian philosophy – the greatest good for the greatest number –
states that societies are collectives, not simply a multitude of individuals. In order for
vaccinations to work, everyone – sick, healthy, young, old - needs to be vaccinated in
order to prevent disease (i.e. herd immunity). All citizens must have equal access and
exposure to all rights and one person’s rights cannot overwhelm another’s. There are
many examples of limiting the rights of individuals in favor of protecting the greater
good of society.
When compulsory vaccinations came to Ontario (1887), critics were angered by
the fact that treatments were disproportionate: they reflected ethnicity, gender, race, age,
59
Jacobson v Massachusetts, 197 US 11, pp.26 (1905).
23
class and income biases. During the Montreal smallpox epidemic of 1885, the upper class
was able to escape compulsory vaccinations.60 Local newspapers inflamed public
opinions by claiming that vaccines disproportionately targeted French-speaking children,
women, immigrants, and low-income French-speaking families.60 Heightened by media
attention, this led some to believe that vaccinations were a sham and that everyone should
not be required to be vaccinated. Moreover, the public did not appreciate the autocratic
nature of health officials; they wanted doctors to convince them of the value of
vaccinating rather than forcing them to submit to compulsory programs without
informing them of the potential risks.60
Since Jenner’s time, religion has played an important role in anti-vaccination
campaigns. People sought quotes from The Bible to show that vaccinations were
blasphemies. Based on the story of Job, they argued that the curse of boils that Satan left
on Job looked like vaccination scars.16 According to this sophistry, it “proved” that Satan
was actually the first vaccinator. Developing the same theme, John Birch argued against
vaccinations because it interfered with divine birth control among poor families: it was
God’s will that these poor children should die from smallpox.16 The idea of a Divine Plan
persisted into the 1900s.
More recently, some opponents have focused on other religious principles and
beliefs to promote resistance. Their objections are largely based on: 1) ethical dilemmas
associated with using human tissue to create vaccines and 2) xenophobic beliefs that the
body is sacred and should not receive “foreign” chemicals, blood or tissues from
60
Dr. Alexander M. Ross, Toronto News (October 20, 1888). Quoted in Heather MacDougall, Activists and
Advocates, pp. 122.
24
animals.61 In essence they want healing to take place through God or by natural means.
Although these groups represent a small proportion of the population, exemptions based
on religious grounds have risen in recent years.62
Religion should not exempt anyone from being vaccinated. Policies that allow
these exceptions encourage potentially dangerous outbreaks. For instance, in 1990, a
major measles outbreak occurred in Philadelphia.63 It was located predominantly among
unvaccinated school children who were members of two fundamentalist churches that
relied on prayers and opposed vaccines. Among 892 unvaccinated church members, 486
cases and 6 measles-associated deaths occurred between November 4, 1990 and March
24, 1991.63 In 1994, a measles outbreak occurred in two communities that objected to
vaccinations.64 The outbreak originated in a teenage girl who lived with her family in
Illinois and attended a Christian Science boarding school in Missouri. From April 16
through May 19, her illness contributed to 190 measles cases in Missouri and Illinois.64
Control measures included offering measles vaccines to students in affected communities
and isolating those with rashes as well as those considered susceptible to measles. In
2005, a measles outbreak occurred among members of a religious community in Indiana
who opposed vaccinations.65 When an unvaccinated teenager returned ill from a trip s/he
infected those attending a church gathering. As shown in these cases, diseases are
61
The College of Physicians of Philadelphia. The History of Vaccines—Cultural Perspectives on
Vaccination. Available online at: http://www.historyofvaccines.org/content/articles/cultural-perspectivesvaccination#Source%202. Accessed August 2, 2014.
62
USA Today. “Parents Use Religion to Avoid Vaccines.” (October 18, 2007). Available online at:
http://usatoday30.usatoday.com/news/health/2007-10-18-religion-vaccines_N.htm. Accessed August 2,
2014.
63
Rodgers, D.V. Gindler, J.S. Atkinson, W.L. Markowitz, L.E. “High attack rates and case fatality during a
measles outbreak in groups with religious exemption to vaccination.” Pediatr Infect Dis J 1993;12:288-92.
64
Centers for Disease Control and Prevention (CDC). “Outbreak of Measles Among Christian Science
Students: Missouri and Illinois.” 1994;43:463-5.
65
Centers for Disease Control and Prevention (CDC). “Import-Associated Measles Outbreak—Indiana,
May-June 2005." 2005;54:1073-5.
25
indiscriminate and democratic. They pay no attention to social or religious systems and
can quickly infect hundreds or thousands. Religious exemptions imperil the health of the
general public and therefore should not play a significant role in vaccination programs.
There are many examples where religious dogmas are interrupted for the benefit of
society at large such as when physicians transfuse against a family’s will in emergency
situations.
Case Study of Dr. Thomas Smellie
The case study of Dr. Thomas Smellie of Thunder Bay presents a strong argument
for mandatory vaccinations. In 1883, a navvy from Winnipeg brought smallpox to a
shanty about forty miles from Port Arthur, Thunder Bay.66 The news quickly spread and a
number of citizens fled the town before proper quarantine and vaccination measures were
taken. As demonstrated in the doctor’s report, everyone who left eventually became a
locus of infection while many of those who were quarantined and vaccinated escaped the
disease’s most serious effects. From the full reports received from Dr. Smellie and Dr.
James Clark (sheriff of Thunder Bay), the following points were made clear:
1) That close relations exist between Chicken-pox and Small-pox,
probably owing to the fact that the conditions favourable for the one
are those serving for a free development of the other.
2) That danger of Small-pox becoming epidemic arises either from a false
diagnosis of the first case or from the selfish interest of those whose
business may be unfavourably affected, and who are ready to accuse
the physician of creating unnecessary alarm. This fact will also be seen
in the report of the case as Claremont.
3) That isolation and disinfectant precautions, thoroughly enforced, are
sufficient to stamp out an outbreak of the disease, if applied to the first
cases.
4) That vaccination modifies, in a very definite manner, the susceptibility
to the disease; and that it greatly lessens its severity.
66
Provincial Board of Health of Ontario. Annual Report of the Provincial Board of Health of Ontario
Being for the Year, 1884. pp. 21-22. London: Forgotten Books, 2013 (Original work published 1884).
26
5) That the mortality from the disease, in outbreaks at the present day,
does not seem to be less than in former times, at any rate in persons
who have not previously been vaccinated, since a very large proportion
of those first affected, and who were unvaccinated, died.66
Similarly, in 1892 an immigrant train arrived in Port Arthur from the east.67
Several of its occupants were infected with smallpox so the train was quarantined outside
the limits of Fort William. Armed guards kept watch over the cars so that no smallpox
victims could escape and infect the town. As Fort William’s Medical Officer of Health,
Dr. Smellie attended upon all aboard. He relocated the train to the countryside where the
eighty immigrants were able to move about more freely. He cared for the patients
personally and lived among them for the duration of the epidemic during which time he
too became infected.67 He wrote to the Department of Health and sought a sufficient
supply of vaccines to treat everyone put at risk. They were vaccinated accordingly and
the disease was contained. He also organized a major relief effort by convincing
townsfolk to donate food, blankets, and clothing and treated the sick until quarantine was
lifted.67
Dr. Smellie’s leadership was exceptional: he set the example for the medical
community to follow and delineated the importance of proper quarantine and vaccination
measures for the prevention of infection. His heroic efforts reflected in the end result
where only one young girl died; everyone else recovered.67 This case reveals the need for
compulsory participation and the need for physicians to be at the vanguard of
vaccinations. Dr. Smellie did not entertain objections; there was no opportunity to “opt
out” of the quarantine or the vaccinations he ordered. Following the aforementioned case
it makes sense to implement compulsory vaccination programs in order to limit the
67
Banks, C.J.” Care of the Sick in Fort William.” Daily Times-Journal, April 17, 1908.
27
chance of vaccine-preventable disease outbreaks.
Ontario Vaccination Laws and Legislation
In the wake of the Montreal smallpox epidemic of 1885-86, the Ontario
government passed the Vaccination Act (1887).68 It stipulated that parents must have their
children vaccinated against smallpox within three months of birth and re-vaccinated
when necessary.69 The Act empowered municipalities to pass general vaccination orders
in the face of smallpox outbreaks. The law also encouraged local school boards to pass
by-laws demanding that each pupil provide a vaccination certificate before being
admitted to classes.69
The first organized opposition to vaccinations in Ontario was in response to an
1894 by-law, passed by the Toronto Board of Education.69 On January 18, 1900, the AntiVaccination League of Canada was formed. Modeled on the efforts of British antivaccinationists, and using much of their “argumentation, methods and publications”,70 the
League set out to secure the repeal of all compulsory vaccination legislation in the form
of a mass movement. Its members and supporters included individuals ranging from
politicians and businessmen as well as some physicians.70
Initially the League failed to force the Toronto Board of Education to rescind its
regulations. Nevertheless, on March 1, 1906, the League successfully repealed it by
presenting a petition of five thousand names. By a vote of ten to two, the Board agreed to
remove the vaccination certificate requirement.69 After securing this victory the League
68
Government of Ontario. An Act Respecting Vaccination and Inoculation. Vol 2. Revised Statutes, 1887.
pp. 2294-301.
69
Arnup, K. “Victims of Vaccination?” Opposition to Compulsory Immunization in Ontario, 1900-90*.
CBMH/BCHM 1992;9:159-76.
70
Bator, P. The health reformers versus the common Canadian: the controversy over compulsory
vaccination against smallpox in Toronto and Ontario, 1900-1920. Ontario History 1983;75:348-73.
28
attempted to overturn the provincial legislation.71 The politicization of the issue denies
the impolitic nature of diseases. Sensitivities to re-election cannot be permitted to
compromise public health. It should be a matter that transcends politics and laws; it
should be about physiology and science.
In 1914, the Ontario government re-enacted the Vaccination Act.69 It empowered
local Medical Officers of Health to require vaccination certificates of all pupils in their
jurisdictions. Following the outbreak of a mild strain of smallpox in 1919, compulsory
vaccinations became stricter, leading to mass inoculations at city halls.69 The League
continued to fight, documenting the dangers of vaccinations. It urged people to resist
compulsory treatment. By 1920, Toronto’s Public Health Department was a powerful
bureaucracy; the League was a large, well-organized opponent. Throughout the mid and
late 1900s, the battles between the Department and the League72 continued. Despite their
efforts, however, the League was unsuccessful. Even a conscientious objector clause was
defeated.69 Despite dramatic improvements in vaccinations and an official World Health
Organization declaration of the global eradication of smallpox on May 8, 1980, the
Medical Liberty League of Canada’s opposition to compulsory vaccination persists.73
Ongoing Controversies with Compulsory Vaccinations
Despite the proven benefits of vaccines, their efficacy is still being challenged.
Besides libertarian, religious and philosophical oppositions, there are false scientific
71
72
Anti-Vaccination League of Canada. Vaccination in Canada. Toronto, 1907. pp. 46.
The Anti-Vaccination League of Canada changed its name to the Anti-Vaccination and Medical Liberty
League of Canada on October 12th, 1927 and changed its name again to the Medical Liberty League of
Canada on January 20th, 1964
73
Industry Canada. Federal Corporation Information – 0517399 (June 20, 2014). Available online at:
https://www.ic.gc.ca/app/scr/cc/CorporationsCanada/fdrlCrpDtls.html?corpId=0517399. Accessed August
2, 2014.
29
claims against vaccines. In 1998, Andrew Wakefield published a paper in The Lancet
linking vaccines to autism spectrum disorders.74 This sparked a storm of controversy
about the safety and side-effects of vaccines. In his patent application, he stated:
It has now also been shown that use of the MMR vaccine (which is taken
to include live attenuated measles vaccine virus, measles virus, mumps
vaccine virus and rubella vaccine virus, and wild strains of the
aforementioned viruses) results in ileal lymphoid nodular hyperplasia,
chronic colitis and pervasive developmental disorder including autism
(RBD), in some infants.75
His ideas lowered public confidence in vaccinations. His claim was quickly discredited
for “ventur[ing] to profit from the measles, mumps and rubella (MMR) vaccine scare,”76
His paper was retracted but the damage was already done.
Individual experience and the suffering allegedly associated with vaccinations
have played an important role in opposition, but their effects are much greater today. In
the past, anti-vaccinationists recruited celebrities like George Bernard Shaw and Alfred
Russel Wallace. Shaw claimed that vaccination is “a particularly filthy piece of
witchcraft.”77 Wallace stated that vaccination is “probably the cause of greater mortality
than smallpox itself” and that it “cannot be proved ever to have saved a single life.”77 In
recent years, media outlets and celebrities have played a significant role in influencing
public views by rejecting vaccinations out-of-hand. One of the most well-known celebrity
critics of vaccinations is Jenny McCarthy. She has carried her anti-vaccination campaigns
to radio, television, Internet websites, newspapers and magazines. According to
74
Wakefield, A.J, Murch, S.H, Anthony.,A. et al. “Ileal-lymphoid-nodular hyperplasia, non-specific colitis,
and pervasive developmental disorder in children.” Lancet 1998;351:637-41.
75
Wakefield, A.J. “Pharmaceutical composition containing transfer factor for treatment of inflammatory
bowel disease and regressive behavioural disorder.” (publication #: WO1998055138 A1), 1998.
76
CNN Health. “Vaccine study’s author held related patent, medical journal reports.” Available online at:
http://www.cnn.com/2011/HEALTH/01/11/autism.vaccines/?hpt=Sbin. Accessed July 30, 2014.
77
Rhodes, J. The End of Plagues: The Global Battle Against Infectious Disease. Palgrave Macmillan Trade,
2013.
30
McCarthy:
Time magazine’s article on the autism debate reports that the experts are
certain ‘vaccines don’t cause autism; they don’t injure children; they are
the pillars of modern public health.’ I say, ‘that’s a lie and we’re sick of
it.’… Almost all kids get – injected toxins – very early in life, and our own
government clearly acknowledges vaccines cause brain damage in certain
vulnerable kids.78
She claims that her son developed autism following MMR vaccinations and that
chelation therapy for mercury in vaccines cured him. Despite scientific dismissals, her
high profile has sustained media attention and discouraged some parents from having
their children vaccinated. Besides McCarthy, there are websites that use fear to dissuade
others from inoculating. As in other fields, there are outrageous claims of conspiracies
behind mass vaccinations.
Vaccination rates have dropped in recent years.79 This is due in part to the
phenomenal successes of global vaccination programs. The absence of epidemic diseases
however does not mean that vigilance must cease. Coupled with vocal minority
opposition and reduced incidents of infections there have been some preventable
outbreaks. In Quebec, 725 confirmed measles cases were recorded in 2011, following a
2007 outbreak that affected ninety-four individuals.80 During the Vancouver Olympics,
which brought together people from all over the world, eighty cases of measles were
diagnosed.80 More recently, in April 2014, there were more than 375 cases in British
78
McCarthy J. Who’s Afraid of the Truth about Autism? (March 9, 2010). Available online at:
http://www.huffingtonpost.com/jenny-mccarthy/whos-afraid-of-the-truth_b_490918.html. Accessed July
30, 2014.
79
NBC News. Vaccination rates drop, putting more kids at risk—Recent outbreaks of whooping cough,
measles and mumps may point to loss of ‘herd immunity’. Available online at:
http://www.nbcnews.com/id/40280560/ns/health-infectious_diseases/t/vaccination-rates-drop-puttingmore-kids-risk/. Accessed August 2, 2014.
80
CBC News. Measles outbreaks in Canada outsize U.S.—Americans more aggressive at tracking every
case, implementing control measures, doctor says. Available online at:
http://www.cbc.ca/news/health/measles-outbreaks-in-canada-outsize-u-s-1.2605628. Accessed July 30,
2014.
31
Columbia’s Fraser Valley area.80 Moving forward, there must be more vigilant and
rigorous vaccination efforts in order to prevent such outbreaks in Canada.
Conclusions
In the future, strict rules and regulations must be considered to improve
immunization rates. Hospitals and medical schools mandate the vaccination of their
employees and students. It is worthwhile to consider implementing such strategies in
other workplaces as well. Although this might deny people a right and freedom to choose
vaccination, it is our duty as responsible caretakers of society to recognize that vaccines
are effective and safe in preventing diseases. They have been proven to lower morbidities
and mortalities arising from diseases and can significantly improve health outcomes.
Although some adverse events may result from vaccinations, we must accept them for the
greater good of society. This has certainly been the case for the automobile, which
pollutes and kills but there is widespread understanding that these drawbacks are offset
by travel benefits. The only exceptions to participation must be when the risks attending
vaccine complications far outweigh the actual infection.
This was the case with smallpox; since the last outbreaks in the United States and
Canada in 1949 and 1962 respectively, the dangers associated with vaccine complications
were deemed to far outweigh the risk of smallpox infection, which is why mandatory
vaccinations against smallpox came to an end. In Canada, smallpox vaccinations among
the general population were stopped in 1972 and of healthcare workers in 1977.55,81
Today, however hospital workers must be vaccinated – and maintain the integrity
81
Ministry of Health and Long-Term Care. Diseases: Smallpox (January 2003). Available online at:
http://www.health.gov.on.ca/english/providers/pub/disease/smallpox.html. Accessed July 31, 2014.
32
of their vaccinations – in order to work in such facilities. There is no opting out and there
are no active protests against such policies. Would it not therefore be wise and expedient
to vaccinate all patients?
There needs to be renewed vaccination campaigns by municipal Public Health
officials, Health Canada and the provincial governments. They must introduce new
measures to maintain mandatory vaccination programs at the community and individual
levels. By increasing the awareness of the benefits and consequences of vaccinations and
demystifying fear-based beliefs and unsupported claims, Canada will improve
immunization rates and reduce opposition that exposes the population to scourges that
need to remain silent. In addition, there must be stronger interventions by the medical
community to repudiate claims that are harmful or dangerous since they undermine
public confidence. Vaccination campaigns set out by WHO, namely the smallpox
eradication program, required everyone to be vaccinated and it, in turn, resulted in the
global eradication of smallpox. It is now time to do the same for other vaccinepreventable diseases such as measles, mumps and rubella and bring them to an end, once
and for all.