A World Without Vaccines

A young girl gasps desperately for air, her face contorted and purple as a distinctive whooping sound emits from her severely restricted airways. A once-active toddler stares blankly at the ceiling with only his head protruding from a cylindrical metal container — the “iron lung” where he will spend the rest of his short life. Elsewhere, an entire town succumbs to a deadly infection that begins with a high fever and leaves its victims covered in painful pustules; those who survive remain permanently disfigured. These images may sound like plots from an apocalyptic movie, but the reality is these scenes represent a snapshot of world history. As recently as a century ago, vaccine-preventable diseases like pertussis (whooping cough), polio and smallpox ran rampant in big cities and small towns alike. Literally no one was immune, since vaccines for these infectious maladies had yet to be invented. It was a world without vaccines — a time vastly different from the world we live in today.

It’s been said that those who cannot remember the past are condemned to repeat it. For many in the industrialized world, horrific diseases such as these seem obscure and unreal — the lore of times gone by. It could be described as a situation where lack of familiarity breeds complacency; if you’ve never seen someone crippled by polio, perhaps it’s not a real threat. This false sense of security has public health experts worried. Are we looking at a future generation doomed to relive its disease-ridden past?

What a Difference a Century Makes

In the early 1900s, life in the United States bore little resemblance to today. There was no Internet, email or Facebook. U.S. roads were populated by a mere 8,000 cars, and only one in 14 homes even had its own bathtub. Birth control was nonexistent, and more than 95 percent of all births in the U.S. took place at home.¹ As a result, families tended to be larger, and for good reason, but many children did not survive past the age of 5. The U.S. infant mortality rate was a shocking 20 percent, and the childhood mortality rate prior to age 5 matched it at 20 percent.² While it can be argued that healthcare standards were far from what they are today, these dismal statistics were frequently the result of common childhood killers such as measles, diphtheria and smallpox. Today, many of these devastating diseases have been contained, thanks to the development and distribution of safe, effective and affordable vaccines.

Paul Roumeliotis, MD, Medical Officer of Health at the Eastern Ontario Health Unit, stated the following in his article Should My Child Be Vaccinated: “Vaccines have proven extremely effective in controlling and even eradicating some major childhood diseases. Indeed, smallpox — a severe and often fatal disease, which used to be common among children — has been entirely wiped out by worldwide immunization.”³

When it comes to saving lives, vaccines have been called the most transformative public health achievement of our time. Routine vaccination programs have prevented the deaths of hundreds of millions of people and saved billions of dollars in public health expenditures. Yet in recent years, the contribution vaccines have made to public health has been questioned and even criticized. The reasons behind the backlash are complex, but one contributing factor may be that people simply don’t remember what the world was like when vaccines were not yet available.

Life Before Vaccines

In the 21st century, certain diseases like cancer, acquired immune deficiency (AIDS) and Alzheimer’s are universally recognized and feared. But 100 years ago, a very different lineup of illnesses were considered the most fearful and potentially deadly:⁴

• Smallpox: This is a contagious, disfiguring and often deadly disease that has affected humans for thousands of years. Naturally occurring smallpox was eradicated worldwide by 1980. Before vaccines, smallpox was responsible for an estimated 300 million to 500 million deaths in the 20th century alone, more than double the number of people killed during the wars of that same period.
• Measles: Far more contagious than smallpox, measles can cause deafness, blindness, encephalitis and death. Between 2000 and 2007, measles deaths dropped by 74 percent worldwide. However, more than 18 million people continue to be infected by measles each year, resulting in 197,000 deaths in 2007, primarily among children. Before measles immunization was available, nearly everyone in the U.S. got measles. An average of 450 measles-associated deaths were reported each year between 1953 and 1963.
• Polio: In the years following World War II, polio was the most feared disease among parents in the U.S. Before polio vaccine was available, 13,000 to 20,000 cases of paralytic polio were reported each year in the U.S. These annual epidemics of polio often left thousands of victims — mostly children — in braces, crutches, wheelchairs and iron lungs.
• Haemophilus influenzae type b (Hib): This serious disease is caused by bacteria. Before Hib vaccine became available, Hib was the most common cause of bacterial meningitis in U.S. infants and children, and there were approximately 20,000 invasive Hib cases annually. Hib meningitis once killed 600 children each year and left many survivors with deafness, seizures or mental retardation.
• Rubella (German measles): Although rubella is a mild childhood illness, it can cause severe birth defects in children born to mothers who contract the disease in the early stages of pregnancy. The introduction of a rubella vaccine in 1969 has greatly reduced the incidence of congenital rubella syndrome (CRS) in the developed world, but the disease still causes approximately 110,000 cases worldwide each year. Before rubella immunization was used routinely in the U.S., there was an epidemic of rubella that resulted in an estimated 20,000 infants born with CRS, with 2,100 neonatal deaths and 11,250 miscarriages. Of the 20,000 infants born with CRS, 11,600 were deaf, 3,580 were blind, and 1,800 were mentally retarded.
• Diphtheria: This disease was once one of the most common causes of death in children. While it is now rare in the U.S., diphtheria is re-emerging in some areas of the world and is responsible for about 5,000 deaths each year in developing countries, primarily among children. Before diphtheria immunization was available in 1921, 206,000 cases and 15,520 deaths were reported. With vaccine development in 1923, new cases of diphtheria began to fall in the U.S., until in 2001, only two cases were reported.
• Pertussis (whooping cough): This disease causes spasmodic, uncontrollable coughing that persists for weeks. Although global rates have fallen significantly since the arrival of the vaccine, pertussis still kills almost 300,000 people annually. Recent outbreaks of pertussis are thought to be related to parental resistance to immunization. Before pertussis immunization was available, nearly all children developed whooping cough. In the U.S., prior to pertussis immunization, between 150,000 and 260,000 cases of pertussis were reported each year, with up to 9,000 pertussis-related deaths.

Vaccines: A Brief History

Although the earliest smallpox vaccine was developed in 1796, widespread vaccination remained sporadic until the 20th century. The golden age of vaccine development began following World War II, when several new vaccines were developed in a relatively short period of time. Their success in preventing diseases such as polio and measles was considered revolutionary, and large-scale vaccination campaigns soon followed.

Even with the vaccine backlash today, vaccination is considered a routine medical intervention. But decades ago, vaccinating various population groups was a daunting task, requiring tremendous push and collaboration on the part of scientists, manufacturers, public health officials and government agencies. Following such efforts, success depended largely on a skeptical public’s willingness to actually show up and get vaccinated. Still, when efforts were successful, results were dramatic. In 1967, for example, the World Health Organization (WHO) spearheaded a massive immunization campaign against smallpox. Just 10 years later, a disease that had plagued mankind for thousands of years had been virtually eliminated. Wild-virus polio, a disease that once circulated globally, is now present in only a handful of countries, and no cases have been diagnosed in the U.S. since 1979. Measles, mumps, rubella, diphtheria and pertussis were also reduced from epidemic ranges to contained outbreaks within a matter of a few decades.

The Success Paradox

A generation ago, childhood vaccination was considered a normal rite of passage. Today, many take for granted that children will be born and raised without the threat of paralysis, brain damage, blindness and death associated with childhood disease.

Over the years, diminishing outbreaks of once-terrifying diseases also have decreased the fear associated with them.Public awareness regarding the value of vaccines has begun to fade. As infectious disease rates fell, concerns began to grow over vaccine risks and side effects, which led some to question the wisdom of mass vaccination. This public scrutiny did lead to some positive outcomes, including improved oversight of vaccine manufacturing processes and better vaccine technology. The irony is, current vaccines are safer than ever before, yet more and more people question their efficacy. Because people do not fear diseases as they used to, vaccine rates have dropped in many regions, causing many once-eradicated diseases like measles and pertussis to stage unwelcome comebacks.

As of this writing, the U.S. is experiencing the highest number of measles cases in 15 years, according to a recent report by the Centers for Disease Control and Prevention (CDC). Between 2001 and 2008, the median number of cases has been 56 per year. By May 20, 2011, that number had more than doubled.⁵ Additionally, documented cases of pertussis are on the rise. In 2010,California faced the state’s biggest outbreak of pertussis since 1958, with public health officials declaring it an epidemic.⁶ In early 2011, the CDC issued a health alert when the outbreak spread to other parts of the country.

The Indiscriminate Nature of Disease

Vaccine-preventable diseases are equal-opportunity attackers, affecting people from all walks of life. A look back in history shows some very well-known people whose lives were changed because a vaccine was either refused or simply not available:⁷

• Princess Alice of Hesse, a daughter of Queen Victoria, died of diphtheria in 1878 at age 35; her daughter Princess Marie had died of it a few weeks prior.⁸
• Benjamin Franklin was initially against vaccination but became an advocate after his unvaccinated 4-year-old son died of smallpox. It was recorded in his autobiography that he bitterly regretted not vaccinating his child.
• Thomas Jefferson’s daughter Lucy died of whooping cough at the age of 2.
• In 1850, Abraham Lincoln’s 3-year-old son died of diphtheria. In 1904, the daughter of President Grover Cleveland died of the same disease. The diphtheria vaccine became available in 1923.
• Franklin D. Roosevelt, president of the United States from 1933 to 1945, was a wheelchair-bound polio victim. The first polio vaccine became available in 1955.
• In 1962, a measles infection killed the 7-year-old daughter of Roald Dahl, the author of Charlie and the Chocolate Factory. Dahl later became a strong supporter of vaccines.

The above cases just highlight that these infections could affect almost anyone and that the vaccination debate has been around as long as many of the diseases themselves.

A World at Risk

Vaccine research and innovation is a rapidly developing field. It is anticipated that in the next decade and beyond, many conceptual and scientific advances will provide extraordinary opportunities to expand our current portfolio of immunizations. Major efforts are under way to develop new vaccines against pneumonia, HIV, tuberculosis, malaria and diarrheal diseases like rotavirus. Vaccines such as these obviously have the potential to save millions of lives. Without them or their predecessors that paved the way for current vaccine development, the world our children inherit could be a vastly different and more dangerous place.

WHO compares vaccination to clean water in terms of its ability to reduce the spread of infectious diseases. Few of us in the U.S. can envision life without access to clean drinking water; perhaps a paradigm shift is required to begin to view life without preventive vaccines in the same light. The benefits of vaccination extend far beyond individual or even community health and well-being. Reducing global infant mortality rates is a moral obligation for those in developed countries, and a major public health concern now and for the indefinite future.