Tag: smallpox vaccine

Should I Be Worried That My Kids Didn’t Get the Smallpox Vaccine?

Routine vaccination with smallpox vaccines ended in the US in 1972, a short time before smallpox was declared eradicated (1980).

Do you have a smallpox vaccine scar?
Do you have a smallpox vaccine scar?

It was also before the last case of wild smallpox was found (1977).

Why?

Because smallpox had been declared eliminated in North America long before (1952), following the last natural outbreak of smallpox in the United States (1949).

Should I Be Worried That My Kids Didn’t Get the Smallpox Vaccine?

Although smallpox has been eradicated, some folks still worry about it.

“There are now only two locations where variola virus is officially stored and handled under WHO supervision: the Centers for Disease Control and Prevention in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia.”

CDC on History of Smallpox

Of course, the concern now is not naturally occurring smallpox, but instead bioterrorism.

Could the smallpox virus be made into a weapon to be used in a bioterrorist attack?

We hope not, but if it was, none of us would be immune, not even the folks who were vaccinated long ago. The smallpox vaccine doesn’t provide life-long immunity.

So should you be worried?

“Some people have been vaccinated through the military or because they were part of Smallpox Response Teams that were formed after the 9/11 terrorist attacks.”

CDC on Why is Smallpox a Concern?

Almost certainly not.

Plans are in place if there ever was a smallpox attack and if necessary, there is actually enough smallpox vaccine stockpiled to vaccinate everyone in the United States!

More on Smallpox Worries

Recognizing Old Vaccine Scars

Do you have a scar on your arm and you aren’t sure why it is there?

Having a smallpox vaccine scar makes you a part of history.
Having a smallpox vaccine scar makes you a part of history.

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.”

Do you have a vaccine scar on your arm?
Do you have a vaccine scar on your arm? Photo by Earl Hershfield

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.”

Diane Kelsall on A Small Scar

Do you have any vaccine scars?

More on Recognizing Old Vaccine Scars

Vaccines While Immunosuppressed

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.

Surprised?

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.

Are they getting chemotherapy?

Did they just get a stem cell transplant?

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.

That’s why herd immunity is so important for these kids.

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.

Johns Hopkins Medicine, which includes the Johns Hopkins University School of Medicine and the The Johns Hopkins Hospital and Health System went out of their way to correct this anti-vaccine misinformation.
Johns Hopkins Medicine, which includes the Johns Hopkins University School of Medicine and the The Johns Hopkins Hospital and Health System went out of their way to correct this anti-vaccine misinformation.

Worried about shedding?

You should be worried about getting a vaccine-preventable disease and giving it to those around you with immune system problems. That’s the real risk!

This is the modern anti-vaccine movement - taking an immoral stand against vaccines and putting sick kids at risk for life-threatening disease.
This is the modern anti-vaccine movement – scaring parents and taking an immoral stand against vaccines and putting sick kids at risk for life-threatening disease.

And no, you are not being selfish to expect those around you to get vaccinated.

Vaccines are safe and necessary – for all of us.

More on Vaccines While Immunosuppressed

Which Vaccines Do You Get When You Join the Military?

The oral adenovirus vaccine is approved to prevent adenovirus infections in military populations.

Believe it or not, many vaccines are available that we don’t routinely get.

Some we only get if we travel, like vaccines for yellow fever and typhoid. Others we only get in high risk situations, like if you get exposed to a bat with rabies.

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?

It depends…

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:

  • Adenovirus vaccine – given to enlisted soldiers during basic training
  • 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

Which vaccines you get in the military might be determined by where you are getting deployed to.
Which vaccines you get in the military will likely be determined by where you get deployed.

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
  • Tularemia 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.

More on Military Vaccines

 

Vaccinated vs Unvaccinated – Smallpox Edition

Anti-vaccine folks really like comparing vaccinated and unvaccinated kids.

Why?

They think that unvaccinated kids are healthier, even though we know that they aren’t, they simply get more vaccine-preventable diseases.

Vaccinated vs Unvaccinated – Smallpox Edition

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.

Vaccinated vs unvaccinated with smallpox.

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.

Vaccinated vs unvaccinated sisters with smallpox.

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.”

This father was the only one in the family who skipped getting vaccinated, and he got smallpox.
This father was the only one in the family who skipped getting vaccinated, and he got smallpox.

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.

The Vaccination of Contacts part of the Leicester Method is usually left out by anti-vaccination folks.
Folks were still getting vaccinated using the Leicester Method in Leicester.

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?

The smallpox vaccine clearly worked.
It was the vaccine, as this report on an outbreak of smallpox in 1903 clearly showed.

And that’s why the anti-vaccine movement “slowly faded from view” in the early 20th century.

Too bad we let them come back…

What to Know About Vaccinated vs Unvaccinated with Smallpox

It should be clear that in the era of smallpox, like with other vaccine-preventable diseases, you clearly wanted to be vaccinated.

More on Vaccinated vs Unvaccinated with Smallpox

The Hospital Rock Engravings of Farmington, Connecticut

Vaccines are a lot safer than they used to be in the old days.

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?

It’s simple.

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.

Patients engraved their name on Hospital Rock in the late 1700s near Farmington.
Patients engraved their name on Hospital Rock in the late 1700s near Farmington. Photo by Keith Wilkens

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.

More on the Hospital Rock Engravings

Grave Reminders of Life Before Vaccines

Need a reminder of just how serious vaccine preventable diseases can be?

Don’t remember the pre-vaccine era?

That could be why some folks are so quick to think that skipping or delaying vaccines is a safe option for their kids.

Vaccines are necessary.

Without them, we will see even more outbreaks of measles, mumps, and pertussis and kids will continue to die of rabies, tetanus, and other now vaccine-preventable diseases.

The South Park Cemetary was begun in 1891 during a diphtheria epidemic.
A diphtheria cemetery in Wyoming.

Isolation hospitals and pest houses were commonly used to quarantine folks with smallpox.
Isolation hospitals and pest houses were commonly used to quarantine folks with smallpox and other now vaccine-preventable diseases.

Even mild smallpox, as depicted on this WHO Smallpox Recognition Card, included flu like symptoms, a few weeks of pustules, and then waiting for the lesions to scab over...
Even mild smallpox, as depicted on this WHO Smallpox Recognition Card, included flu like symptoms, a few weeks of pustules, and then waiting for the lesions to scab over…

People continued to die of smallpox well into the 20th century, even though an effective vaccine was developed in 1796.
People continued to die of smallpox well into the 20th century, even though an effective vaccine was developed in 1796.

In the pre-vaccine era, we had outbreaks of polio, and other, now vaccine-preventable diseases.
Outbreaks of polio would once isolate entire towns, as parents feared their kids would get sick too.

Fight Polio Poster
When was the last time you saw a child with polio?

Before wide use of the Hib and Prevnar vaccines, infants with fever would routinely get spinal taps and you would hope for clear fluid (cloudy fluid could be a sign of a bacterial infection).
Before wide use of the Hib and Prevnar vaccines, younger infants with fever would routinely need spinal taps and you would hope for clear fluid (cloudy fluid could be a sign of a Hib or Strep pneumo infection).

In the pre-vaccine era, Hib caused epiglottitis, meningitis, and pneumonia - all life-threatening diseases that are now prevented by the Hib vaccine.
In the pre-vaccine era, Hib caused epiglottitis, meningitis, and pneumonia – all life-threatening diseases that are now prevented by the Hib vaccine.

Before the 1990s, when the Hib vaccine available, hospitals had an epiglottitis team on call and always available.
Before the 1990s, when the Hib vaccine available, hospitals had an epiglottitis team on call and always available.

News of the Newark kids going to Paris to get Pasteur's rabies vaccine made the front page of the New York Times.
In 1885, several boys from Newark went all of the way to Paris to get Pasteur’s new rabies vaccine, as the disease had always been fatal up until that time.

Even if they survive, kids can lose fingers, toes, or even arms and legs to meningococcemia.
Even if they survive, kids can lose fingers, toes, or even arms and legs to meningococcemia.

Roald Dahl's daughter died of measles in 1962, the year before the development of the first measles vaccine.
Roald Dahl’s daughter died of measles in 1962, the year before the development of the first measles vaccine.

Nationwide, at least 123 people died in the United States during a large measles epidemic from 1989 to 1991, during a time that we had good sanitation, nutrition, and medical care.
Nationwide, at least 123 people died in the United States during large measles epidemics from 1989 to 1991, a time when we had good sanitation, nutrition, and medical care, but some folks weren’t vaccinated and we weren’t yet giving a second dose of MMR.

A papilloma caused by HPV on the vocal cords of a child with recurrent respiratory papillomatosis.
A papilloma caused by HPV on the vocal cords of a child with recurrent respiratory papillomatosis. (CC BY 4.0)

You don't have to go back to the pre-vaccine era to know that pertussis kills.
You don’t have to go back to the pre-vaccine era to know that pertussis kills. Ten infants died in 2010 in California from pertussis infections.

We should never forget what life was like before vaccines.

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.

immunization-program-stages
As more people are vaccinated and diseases disappear, they forget how bad those diseases are, skip or delay getting their vaccines, and trigger outbreaks. Photo by WHO

Vaccines are safe and vaccines work.

Get vaccinated and protected.

Outbreaks of vaccine-preventable diseases belong in the past.

What to Know About Life Before Vaccines

Forgetting the pre-vaccine era and the benefits of vaccines makes folks susceptible to anti-vaccine talking points and scares them away from vaccinating and protecting their kids.

More on Remembering Life Before Vaccines