Do you have a scar on your arm and you aren’t sure why it is there?
Is it from the smallpox vaccine?
Recognizing Old Vaccine Scars
Classically, there are two vaccines that can leave a scar – the ones that protect us against smallpox and tuberculosis.
“BCG scar is a surrogate marker of vaccination and an important index in the vaccination program.”
Dhanawade et al on Scar formation and tuberculin conversion following BCG vaccination in infants: A prospective cohort study
And there are a few easy ways to tell if you have a smallpox scar.
When were you born? Remember, the smallpox vaccine hasn’t been used in the United States since the early 1970s and its use stopped everywhere in 1986.
And where were you born?
The BCG (bacille Calmette-Guerin) vaccine, on the other hand, is still in use in many countries, and is given at birth to prevent tuberculosis disease, including meningitis and disseminated tuberculosis. It isn’t routinely used in the United States though “because of the low risk of infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against adult pulmonary TB, and the vaccine’s potential interference with tuberculin skin test reactivity.”
In general though:
the BCG vaccine scar has a raised center
the smallpox vaccine scar is depressed, with lines that radiate to the edges
Complicating matters is the fact that you can have multiple scars from each vaccine…
“In 1972, the National Advisory Committee on Immunization in Canada recommended that routine immunization of infants for smallpox be stopped. Very few Canadians born after 1972 have been immunized against smallpox. Those, like me, who were immunized prior to that date have little or no immunity left. Nothing, but a small scar as testimony to a grand global achievement.”
It seems to be a big surprise to many folks, but kids can get most vaccines when they are immunosuppressed. In fact, they sometimes get extra some extra vaccines, like Pneumovax, because the “incidence or severity of some vaccine-preventable diseases is higher in persons with altered immunocompetence.”
They should also get all of their vaccines if they are around someone who is immunosuppressed.
Vaccines While Immunosuppressed
Which vaccines your kids can get while they are immunosuppressed is going to depend greatly on the reason why they are immunosuppressed.
Were they born with a specific immunodeficiency, like X-linked agammaglobulinemia, selective IgA deficiency, severe combined immunodeficiency, or chronic granulomatous disease?
Whatever the reason, they likely won’t get a medical exemption to skip all of their vaccines.
“Killed vaccines will not cause infection in immunodeficient or any other children. The fear of increased community-acquired vaccine-preventable diseases should lead to adherence to and completion of recommended immunization schedules in the community to reinforce herd immunity, such that all vaccine-preventable diseases become exceedingly rare.”
Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts
In most cases, immunocompromised kids can get all inactivated vaccines. It is only live vaccines that could pose a problem. Even then, it depends on the specific immunodeficiency as to whether avoiding live vaccines is necessary.
For example, after chemotherapy and a stem cell transplant, kids can usually get live vaccines.
Your doctors can review the latest guidelines to come up with a safe vaccination plan for your child with an immune system problem. If necessary, consultation with an infectious diseases or immunology specialist can also be helpful.
Don’t overlook other causes of possible immunosuppression when getting vaccinated, like taking daily oral steroids for more than two weeks, certain biologic immune modulators, or other medications like methotrexate, azathioprine, 6-mercaptopurine.
“Limited evidence indicates that inactivated vaccines generally have the same safety profile in immunocompromised patients as in immunocompetent individuals. However, the magnitude, breadth, and persistence of the immune response to vaccination may be reduced or absent in immunocompromised persons.”
2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
And keep in mind that just because they can and should get vaccinated, it doesn’t mean that their vaccines are going to work as well as in someone who isn’t immunocompromised.
Vaccines for Close Contacts of Immunocompromised People
What about people who come into contacts with kids and adults who are immunocompromised?
Can they get vaccines?
“Close contacts of patients with compromised immunity should not receive live oral poliovirus vaccine because they might shed the virus and infect a patient with compromised immunity. Close contacts can receive other standard vaccines because viral shedding is unlikely and these pose little risk of infection to a subject with compromised immunity.”
Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts
Yes, close contacts can get vaccinated, especially since we don’t use the oral polio vaccine in the United States anymore.
There are some exceptions for the smallpox vaccine, which few people get, and Flumist, but only in very specific situations, including a recent hematopoietic stem cell transplant.
And one, the adenovirus vaccine, you can only get if you join the military.
Which Vaccines Do You Get When You Join the Military?
But don’t folks get a lot of vaccines when they join the military?
Whether you join the Army, Navy, Air Force, Marine Corps, or Coast Guard, health personnel will evaluate your immunity status by checking your titers to routine vaccine-preventable diseases. So no, if you were wondering, it doesn’t seem like they just check the vaccine records that you might bring from your pediatrician.
And then once they assess your immunization or immunity status, you will get vaccinated:
upon accession – adenovirus, influenza, meningococcal, MMR, Tdap, and chicken pox
during the first or second half of collective training – hep A, hep B, and polio (if needed) and other vaccines based on risk
So, in addition to getting caught up on all routine vaccines that they might be missing, there are other “military vaccines” that they might need, including:
Anthrax vaccine – only military personnel with extra risk, although some civilians can get this vaccine too
Smallpox vaccine – only military personnel who are high risk and smallpox epidemic response team members, although some civilians can get this vaccine too
Like the recommendations for civilians, other vaccines are mainly given to military personal if they have extra risk based on where they are being deployed.
Cholera – only military personnel with extra risk based on deployment or travel to endemic areas
Japanese encephalitis – only military personnel with extra risk based on deployment or travel to endemic area in Eastern Asia and certain western Pacific Islands
Rabies vaccine – pre-exposure vaccination is only for military personnel with animal control duties or with extra risk based on deployment, including special operations personnel
Typhoid vaccine – only military personnel with extra risk based on deployment or travel to typhoid-endemic areas and other areas with poor sanitation.
Yellow fever vaccine – only military personnel with extra risk based on deployment or travel to yellow-fever-endemic areas in sub-Saharan Africa and tropical South America.
These are the same vaccines that we would get if we traveled to high risk areas.
Military Vaccines in Development
It shouldn’t be a surprise that the military does research on infectious diseases and vaccines.
Members of the military are often put at great risk for known and emerging diseases, like Ebola, Zika, and malaria.
That’s why some vaccines might have been given as an investigational new drug in special situations, typically when “individuals who have a high occupational risk – laboratory workers, facilities inspectors, vaccine manufacturers and certain military response teams.”
These vaccines, which were initially developed at US Army labs, are no longer being produced, but have included:
Argentine hemorrhagic fever (Junin virus) vaccine
Chikungunya fever vaccine
Eastern equine encephalitis vaccine
Q fever vaccine
Rift Valley fever vaccine
Venezuelan equine encephalitis vaccine
Western equine encephalitis vaccine
Today, the Walter Reed Army Institute of Research (WRAIR) “is a leader in global efforts against the world’s most pervasive and high impact infectious diseases.”
WRAIR is working on vaccines for HIV, Ebola, MERS, and Zika.
What to Know About Military Vaccines
You will need some extra vaccines when you enlist in the military, but how many will depend on if you are up-to-date when you join and your area of responsibility. So there is no one-size-fits-all military immunization schedule.
And we have known it for a long time. In Leicester, for example, it was known that folks weren’t vaccinated were much more likely to die of smallpox than those who were. In fact, the fatality rate in Leicester in the late 19th century and early 20th century was 1 to 2% for those who were vaccinated. What was it for folks who were unvaccinated? It was 8 to 12%!
And like many other diseases, if they did get sick, those who were vaccinated against smallpox often got a very mild case, especially as compared to those who were unvaccinated. We can see that even now thanks to photographs taken by Dr. Allan Warner, the Resident Medical Officer to the Isolation Hospital in Leicester.
Dr. Warner’s photos have been published time and again, but they can originally be found in the New Sydenham Society’s Atlas of 1904.
There are many photos and many stories from the time that were testament to the fact that vaccines work.
“A boy, aged 14 years, unvaccinated, sickened with small pox on April 14th. He was removed to hospital on April 18th, where he had a severe confluent attack. The father consented to his wife and three children being vaccinated, stating that personally he would not be vaccinated, but would be a “test,” to see if there was anything in it.
Ten days later his daughter, aged three years, developed a small-pox eruption she had less than one hundred spots and never appeared ill. No other person in the house suffered from small-pox except the father, vaccinated in infancy, his eruption appearing fourteen days after the son had been removed to hospital. A photograph of the father and daughter, taken on the twelfth day of the father’s eruption, may be seen in Plate VI. [see below] and requires no comment.”
And there are also stories of folks skipping vaccines already. Remember, the anti-vaccine movement is even older than the first vaccines. It started with variolation. By the time these photos were taken, anti-vaccine folks had already marched on Leicester. A march that didn’t turn folks away from getting vaccinated.
For those who think getting smallpox was all about poor nutrition and hygiene, how do you explain these photos? Why such different outcomes for people in the same family, if it wasn’t their vaccine?
No, I’m not talking about the “crude brew” that was the original DTP vaccine.
This older vaccine used more antigens than the DTaP vaccine that replaced it, so could cause more side effects. Even before that though, there was less oversight of vaccine manufacturers in the early 20th century. This could lead to vaccines that were contaminated or which simply didn’t work.
That certainly was a problem with the early smallpox vaccine, which is typically considered to be the most dangerous vaccine ever routinely used.
Variolation and Smallpox
But even before the smallpox vaccine was developed by Edward Jenner in 1796, we had variolation.
While the smallpox vaccine involved the cowpox virus, variolation actually infected someone with smallpox. The idea was to give the person a milder form by exposing them to a weaker, or attenuated, form of the virus.
They got this weakened virus from the smallpox scabs of someone who had already recovered and:
blowing dried smallpox scabs into their nose
applying pus from smallpox scabs to a small puncture wound on their skin
Variolation worked, giving the person immunity to smallpox – if they survived.
Unfortunately, about 1 to 3% of people who underwent variolation died.
And people who had recently undergone variolation could be contagious, leading to smallpox epidemics.
So why did folks undergo variolation if they had a chance of dying from the procedure?
A natural smallpox infection was so much more deadly. Up to 30% of people who got smallpox died, and many people eventually got caught up in the regular smallpox epidemics that plagued people in the pre-vaccine era.
The Hospital Rock Engravings of Farmington, Connecticut
We don’t have to worry about smallpox anymore.
Well, not about natural smallpox infections, since smallpox was eradicated back in 1980.
And there are many other diseases that we get vaccinated against, with it being extremely easy to get that protection, especially compared to what folks did in the old days.
Do you know how far folks went to make variolation safer?
“Every year, thousands undergo this operation, and the French Ambassador says pleasantly, that they take the small-pox here by way of diversion, as they take the waters in other countries. There is no example of any one that has died in it, and you may believe I am well satisfied of the safety of this experiment, since I intend to try it on my dear little son. I am patriot enough to take the pains to bring this useful invention into fashion in England…”
Lady Mary Wortley Montagu On Small Pox in Turkey (1717)
They actually went to smallpox hospitals to get vaccinated, remaining in quarantine for up to three weeks so that they wouldn’t get others sick.
In Farmington, Connecticut, two doctors established the Todd-Wadsworth Smallpox Hospital and had a lot of success with variolation.
Patients were no longer starved before inoculation, and many had begun to doubt the efficacy and safety of vomiting, sweats, purges, mercurials (toxic mercury salts such as calomel), and bleeding which had previously weakened both inoculees and those who “took the pox in the natural way.”
Charles Leach, MD on Hospital Rock
There, up to 20 patients at a time stayed in quarantine to get variolated, as a smallpox epidemic hit nearby Boston.
Between 1792 and 1794, many who got variolated wrote their names on what is now known as Hospital Rock.
“Many have supposed that the names on this rock were those who had did of the small-pox, but this is a great mistake. Every name on the rock is that of a person who was living when the name was placed there. Norris Stanley lived to own ships which were captured in the war of 1812 by Algerian pirates and still later to receive from the United States an indeminity therefor amounting to a large sum.”
James Shepard on The Small Pox Hospital Rock
The nearby town of Durham seemed to go a different way.
Instead of an inoculation hospital, they had a pest house to quarantine folks with natural smallpox infections.
Adding to the history of smallpox in Connecticut – a smallpox burying ground in Guilford.
Why wasn’t variolation popular everywhere? Folks didn’t have to wait for the first vaccine for the anti-vaccine movement to get started.
What to Know About Smallpox and the Hospital Rock Engravings
Hundreds of people got safely inoculated against smallpox and left their names on Hospital Rock near Farmington, Connecticut just before Edward Jenner discovered the first smallpox vaccine.
We should know that vaccine-preventable diseases were rarely mild, natural immunity comes at a cost, and that those who died from smallpox, diphtheria, measles, and polio aren’t around to talk about their experiences on Facebook (survivorship bias).
We should never forget that vaccine-preventable diseases were once big killers, and the only reason some folks have grown to fear the side effects of vaccines more than the diseases they prevent, is because we don’t see those diseases very much any more. If more people skip or delay getting vaccinated, we will though.
Mostly though, parents in North Texas do a good job of getting their kids vaccinated and protected.
The Plano Smallpox Outbreak of 1895
Of course, that’s not what’s keeping smallpox away.
Routine smallpox vaccination, which was typically given when children were about 12 months old, ended in 1972 in the United States. And smallpox was declared eradicated in 1980.
“Today, Preston Lakes is a quiet, manicured neighborhood in an affluent area of Plano. Almost 120 years ago, it was the site of one of Plano’s darkest hours.”
Plano Smallpox Outbreak of 1895
Driving around Plano now, it is hard to imagine that this city once battled smallpox.
While that is probably true of any modern city, the curious thing is that the area in and around Plano wasn’t settled until the early 1840’s, at which time an effective smallpox vaccine had been available for over 40 years.
“On May 6, 1895, Plano City Council called an emergency meeting, establishing a strict quarantine “to protect our citizens from this loathsome disease.” Anyone within the area between what is now Spring Creek Parkway, Park Boulevard, Coit and Preston Roads was forbidden to leave. An armed guard patrolled the border.”
Plano Smallpox Outbreak of 1895
Farwick Collinsworth, whose family owned large portions of what is now West Plano, lost his 11-year-old granddaughter in the smallpox outbreak.
Next, his wife and two sons died.
Then two more grandchildren and a nephew.
All together, at least 15 people died in the smallpox outbreak of 1895 in Plano, Texas.
“In 1806 the first smallpox inoculations were administered in San Antonio de Béxar. After initial resistance to the experiment, the townspeople came to accept the procedure, and the threat of smallpox was lessened for a time.”
Texas State Historical Association Public Health
While the Plano outbreak is certainly sad, it is truly tragic that smallpox was already a vaccine-preventable disease at this time.
History of Smallpox in Texas
Still, as late as 1900, 894 people died of smallpox in the United States. Globally, at least 300 million people died of smallpox during the 20th century.
So why weren’t folks vaccinated against smallpox in the late 19th century in North Texas?
While some people talking about issues with vaccine availability, remember that this is just after almost 100,000 people participated in the Leicester Demonstration March of 1885 to protest the smallpox vaccine.
While Leicester is quite a ways from Plano, a little bit closer to home we had the Laredo Smallpox Riot.
“When he realized that Laredoans were not fully embracing the quarantine program, especially the mandatory inoculation, he asked the governor to send in Texas Rangers. A contingent of rangers under Captain J.H. Rogers arrived on March 19, 1899, and began enforcing the health official’s orders more vigorously than some of the city’s residents thought proper. Milling protestors pelted rangers and health workers with harsh words and harder rocks, leading to a couple of minor injuries.
The next day, when the rangers got word that someone had telephoned a local hardware store to order 2,000 rounds of buckshot, the officers began a house-to-house search of the part of town where the order had come from. The situation soon deteriorated into a riot, with the rangers killing two citizens and wounding 10 others. It took cavalry from nearby Fort McIntosh to restore order.
The inoculation and fumigation program continued, and by May 1, Dr. Blunt lifted the quarantine in the border city.”
Frontier Medicine: Texas Doctors Overcome Disease and Despair
It maybe shouldn’t be surprising that the last smallpox outbreak in the United States was in Texas – in 1949. Eight people got sick, and one person, Lillian Barber, died.
But Texas wasn’t at the center of the anti-vaccine fight against protecting kids against smallpox. In Utah (the McMillan bill), Minnesota, and California, laws were passed banning mandatory vaccination for attending school. While the governors of Utah and California vetoed their bills, in Utah, legislators overcame the veto.
What came next?
Outbreaks of smallpox.
In 1906, AMA President William J. Mayo, a Minnesota physician, charged that his state’s “inability to enforce vaccination” had unleashed a smallpox epidemic, infecting 28,000 of the state’s citizens – “all due to a small but vociferous band of antivaccination agitators.”
Pox: An American History
That was over a hundred years ago.
What comes next?
Will we let today’s “vociferous band of antivaccination agitators” guide vaccine policy and put our kids at risk for vaccine-preventable diseases, as they push the same old anti-vaccine propaganda and fight against vaccine mandates, which are only necessary because they scare parents away from vaccinating and protecting their kids?
Let’s hope not.
What to Know About the Plano Smallpox Outbreak of 1895
Fifteen people died in Plano, Texas in 1895, even though a smallpox vaccine was available at the time that could have prevented this and most other smallpox outbreaks and epidemics. Tragically, the fight against its use mirrors much of what we see in today’s anti-vaccine movement.