The smallpox vaccine, first introduced by Jenner in 1796, was administered to subjects either through scoring the skin on a person’s arm and injecting into it the pus from a cowpox blister or injecting lymph from a person who had been recently vaccinated. Issues concerning hygiene and contagion were not as well understood then as they are
now, so it was not uncommon for persons to develop a secondary bacterial skin infection during the process. It was also possible for the recipient to come down with some other infectious disease being carried by the individual from whom the lymph was taken. This potential to develop sickness from the process of prevention was understandably worri-some to many and led people to view the vaccination process as unclean.

Today, we have much higher standards for the purity and safety of our vaccine supply and its administration, though these have come, in some cases, as a direct result of lessons learned from past mistakes. Chapter 1 discusses the deaths from tetanus that occurred in Camden, New Jersey, following vaccination with a contaminated small-pox vaccine and in St. Louis, Missouri, from contaminated diphtheria antitoxin. We learned about the Cutter incident in which the polio vaccine from Cutter Laboratories was incompletely inactivated and children were unintentionally injected with live polio virus. These are significant dark spots in vaccine history, but response to these tragedies resulted in the much more robust system of oversight, safety testing, and monitoring that we enjoy in our vaccine manufacturing process today.

Yet, concerns about the cleanliness and purity of vaccines still exist. In today’s anti-vaccine climate, these commonly take shape in one of two ways; either in the form of the often faulty assumption that a vaccine can actually give you the disease against which it was meant to protect, or the concern over alleged toxins used in modern-day vaccines that are somehow going to poison us and cause sickness. We can counter the first assertion by explaining the difference between a killed virus and a live-attenuated virus vaccine and by cautioning patients about the normal revving up of their immune system that happens after vaccination, which can sometimes make them feel under the weather. We can also appropriately select patients to vaccinate with live-attenuated vaccines so that we aren’t putting those with a suppressed immune system at unnecessary risk. The concern over “toxins” is a bit more difficult to tackle.

Thimerosal (containing ethyl mercury), as one example of a “toxin” frequently cited, was used for many years to prevent bacterial and fungal contamination of multidose vials of vaccine, ironically to help them stay more clean and pure. However, the thimerosal content of vaccines has been a concern for the anti-vaccine movement, specifically those who buy into the vaccines/autism link suggested by Wakefield. As a result of growing public concern, the Public Health Services agencies, the American Academy of Pediatrics, and vaccine manufacturers agreed to reduce or eliminate thimerosal in vaccines.³ In 2001, thimerosal was removed from all but the multidose vial of influenza vaccines, not because of any reproducible evidence of harm, but just to take it off the table as an issue. However, in doing so, we have only contributed to the rising cost of vaccines, each dose of which now has to be individually packaged. And, when there were no significant safety problems with thimerosal to begin with, we have fed the suspicions of some anti-vaccine advocates that vaccines weren’t safe from the start. See chapter 9 for discussion of other purported toxins in vaccines and why these are, in reality, not harmful to us in the concentrations present in vaccines.

In England, the Vaccination Act of 1853 made it mandatory for infants up to 3 months old to receive vaccination for smallpox. The Vaccination Act of 1867 expanded this to include all persons up to 14 years of age. Both acts penalized parents who refused vaccination. These mandates were felt by some to have violated their personal liberties to
control their own bodies and the bodies of their children. Consequently, the first Anti-Vaccination leagues were founded, protests were held, and court battles ensued. The most memorable anti-vaccine protest was the Leicester Demonstration March of 1885 during which more than 80,000 people marched through the streets carrying children’s coffins, banners, and a burning effigy of Edward Jenner. As a result of these and other similar demonstrations, a commission designed to study vaccination was formed. In 1896, the commission supported the recommendation for vaccination against smallpox, recognizing its protective benefit to the population, but suggested removing penalties. The Vaccination Act of 1898 then created a “conscientious objector” clause that allowed parents to apply for an exemption certificate if they desired not to vaccinate their children.⁴

The United States saw similar movements with the formation of the Anti-Vaccination Society of America in 1879 after a visit by the prominent British anti-vaccinationist William Tebb (more than 100 years later we would see a similar tour of the United States by anti-vaccinationist Andrew Wakefield). Other leagues, such as the New England Anti-Compulsory Vaccination League and the Anti-Vaccination League of New York sprang up. These organizations were active in trying to repeal vaccination mandates through the courts in California, Wisconsin, Illinois, and others.⁴ The most important court case in the early battles over mandatory vaccination came in 1902 after an outbreak of smallpox in Cambridge, Massachusetts. The board of health ordered vaccination of all residents of the city, and a man named Henning Jacobson refused on the grounds that it violated his right to control what happened to his body. The state filed criminal charges against him and he lost his local court battle. Jacobson appealed the decision to the US Supreme Court, making it the first and most famous Supreme Court case concerning the states’ power in public health law. The Court found in the state’s favor, granting that the state could enact mandatory laws to ensure protection of the public in the event of a communicable disease.⁵ The Court’s decision continues to be used today as a foundation against which states’ rights versus individual rights claims can be judged. As stated by Justice John Harlan, Associate Justice presiding over Jacobson v Massachusetts:

In the 19th century, at the time of the smallpox vaccine introduction and at the beginning of mandatory vaccination programs, the understanding of how disease spreads was in its infancy, with much debate among scientists and doctors about whether there was a specific etiology of disease (such as an infectious organism). Many at the time believed in an atmospheric theory of disease causation, suggesting that disease was pro-duced from “noxious emanations from decaying organic matter.”⁷ Jenner’s vaccine, the
existence of which was based upon the theory of a specific etiology of smallpox, ran counter to this commonly held belief about disease. It is no wonder that the average person was confused and fearful of Jenner’s methods when even scientists and doctors were at odds about how this approach could work. Study of the anti-vaccine movement in the 19th century suggests that the movement was “part of a wider public distrust of scientific medicine and ‘new science’ and a cherishing of ‘natural’ methods of treatment and ’sanitary’ methods of prevention.”⁸ Again, this feels familiar. Just as it was back then, the introduction of any new vaccine (or for that matter, any new treatment or medication) that is unknown or poorly understood can be confusing and frightening.