Immunization, Then and Now

What lessons can history teach us about eradicating disease?

Edward Jenner is smiling and thinking about immunizing his son

Inoculation — seeking to immunize against a deadly disease through deliberate exposure to a weaker pathogen — has been practiced for at least 400 years, but the world’s first vaccine was developed in the late 18th century, using cowpox to immunize against deadly smallpox.

Thanks to the crusading efforts of English physician Edward Jenner — who coined the term “vaccination” (from “vaccinia,” the Latin name of cowpox) and published the first scientific paper about the procedure in 1798 — vaccination was widely adopted throughout Europe, replacing older and more hazardous forms of inoculation such as variolation.

Sliding Backwards

Jenner’s work paved the way for the many other successful vaccines that followed. Cowpox vaccination was effective enough that the French emperor, Napoleon Bonaparte, ordered all of his troops to be vaccinated, even though France and England were then at war. Over the next two centuries, vaccines have made it possible to bring under control or even eliminate deadly and debilitating illnesses like polio.

So, how does this centuries-long history relate to our current situation? As everyone waits anxiously for their COVID-19 vaccine, it’s vital that we not lose too much ground on other important vaccinations. Unfortunately, there are signs that’s already happening.

Many immunizations were delayed earlier last year due to the pandemic, especially in the early months of March and April, when outpatient clinics and medical offices were only open for emergency care. Now, many facilities are back to a semblance of business as usual, but delayed immunizations remain delayed. This is especially disruptive of vaccinations that require multiple doses spaced out by weeks or months.

It is essential that children receive their required vaccinations and receive them on time. While the pandemic remains the No. 1 public health concern, it would be unconscionable if a child died of measles or another vaccine-preventable disease because of COVID-19. It’s no less important that adults, particularly vulnerable elders, stay up to date on crucial immunizations.

Hesitancy and Resistance

Pandemic-related delays may compound the growing global problem of vaccine hesitancy. The percentage of the population that will actually refuse all vaccinations for themselves and their children is relatively small — perhaps 2.5 to 4 percent — but misinformation about vaccines is widespread.

Although all current childhood vaccines have decades of solid medical evidence demonstrating their effectiveness against diseases, some recent studies suggest that as many as one in every five adults have misconceptions about vaccination. (The World Health Organization’s Global Vaccine Safety Initiative addresses and debunks some of the most common misconceptions, based on information originally developed by the CDC.)

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Ironically, most parents who refuse vaccines for their kids were themselves vaccinated as children, but have chosen to deny their own children the same benefits they themselves enjoyed. The resulting resurgence of vaccine-preventable diseases hurts other families, worsens population health and means higher healthcare costs for all of us.

Vaccination has been an invaluable public health tool for two centuries, but many of the gains it has made possible may be lost if not enough people receive the necessary shots, causing dangerous resurgences of preventable diseases that had been all but eliminated not long ago.

Thinking Beyond the Pandemic

COVID-19 vaccines are in development around the world, but the process is fraught with complications, both political and medical. At this point, no one can predict when a vaccine will be widely available, who will get it and who may refuse it for themselves or their children. We also don’t know if any COVID-19 vaccine will be effective long-term.

Edward Jenner’s smallpox vaccine was much safer and more effective than the crude inoculation practices it superseded, but the vaccine didn’t provide lifelong immunity. It took another 184 years for smallpox to finally be eradicated worldwide.

What we can do to improve public health and child healthcare right now is advocate that all children receive their other recommended vaccinations — including flu shots, if they haven’t already been vaccinated this season.

On the positive side, the masking, distancing and sanitation precautions most of us continue to practice to avoid COVID-19 may also reduce the incidence of other communicable diseases, such as influenza and measles.

Vaccine Advocacy

Even if pediatrics is not your specialty, the nonprofit National Foundation for Infectious Diseases reminds us that all healthcare providers can play an important role in encouraging people to stay up to date on immunizations, whether it’s helping to dispel misconceptions, connecting patients with appropriate information or just encouraging them to make sure their children receive important vaccinations.

As a nurse and pediatric nurse practitioner for many decades, this isn’t simply an academic issue for me. Caring for children, well or ill, has given my professional life purpose, and drives my passion for enhancing wellness and preventing disease.

Not long ago, the Institute for Healthcare Improvement developed a framework for optimizing health system performance. The framework is quite modest: Strive to improve the patient experience of care (even though shots may still hurt), improve population health and reduce the costs of healthcare.

Providing immunizations to children — often available at low or no cost thanks to programs like Vaccines for Children — accomplishes all these goals.

Nursing Education

RUTH K. ROSENBLUM, RN, DNP, PNP-BC, is an associate professor of nursing at San Jose State University, a practicing pediatric nurse practitioner and a Public Voices Fellow with The OpEd Project.



This primitive smallpox inoculation was used for centuries before vaccines

Today, if someone told you the surest way to protect your patients or loved ones from a deadly disease was to apply pus from the lesions of an infected patient to open cuts on each uninfected person’s arms and legs, you would recoil in horror. However, for centuries, this nauseating procedure, known as “variolation,” was the best protection medical science could offer against smallpox .

Science or Superstition?

Although crude and dangerous, variolation was based on a sound scientific theory: If surviving an infectious disease conveys immunity from reinfection, it may be possible to immunize other patients through deliberate exposure to a milder form of the same disease.

Did this primitive form of inoculation actually work? The answer is “sometimes.” Some patients were lucky, and came away immune to smallpox with no lasting ill effects. Roughly one in every 30–50 variolated patients died, either of smallpox or of some other disease contracted through the inoculation. Even patients who eventually recovered were often bedridden for weeks. Worse, a variolated patient could develop a mild but still contagious case of smallpox. Since such patients often felt fine, they would resume their normal routines, infecting everyone they encountered.

Useful Risks

Despite its hazards, variolation was often worth the risk. Smallpox epidemics could infect whole populations. Well into the 20th century, case-fatality rates for non-inoculated patients were typically around 30 percent.

By the mid-18th century, variolation was widely practiced in the Ottoman Empire, Europe, Britain and colonies in the Americas. Many wealthy and powerful families inoculated their children in this way, and some military commanders variolated entire armies to prevent smallpox outbreaks.

In the 19th century, variolation was gradually superseded by vaccination using cowpox, which didn’t provide permanent immunity to smallpox, but was much safer than variolation. The far more effective modern smallpox vaccine was developed in the 1950s, and by 1980 had finally eradicated wild smallpox across the globe.


Vaccination Pioneer Edward Jenner (1749–1823)

This English physician even coined the term “vaccination”

While he didn’t actually invent the form of inoculation he dubbed “vaccination,” English physician and scientist Edward Jenner was one of the practice’s most important pioneers and early advocates.

As early as the 1760s, when Jenner was a teenage apprentice to a county doctor in South West England, many rural people believed that farmworkers exposed to vaccinia (cowpox) — a zoonotic infection common among dairy cattle — were much less susceptible to smallpox. There had even been a few attempts to use cowpox to inoculate humans against smallpox, although it wasn’t yet a common practice.

Controversial Methods

In May 1796, Jenner decided to test these theories, convincing his gardener to allow him to inoculate the gardener’s 8-year-old son with cowpox extracted from the lesions of a local dairymaid. Later that summer, Jenner deliberately exposed the boy to smallpox and found that the child was now apparently immune.

Jenner self-published his findings in 1798 and began a tireless campaign to promote vaccination for the prevention of smallpox.  His work remained highly controversial throughout his lifetime, but Jenner’s efforts helped to establish vaccination’s effectiveness as a means of preventing disease.Today, vaccinia inoculation is still used for short-term immunization and post-exposure prophylaxis for people exposed to smallpox.

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