The Dangers of Vaccination

Vaccination against smallpox is almost 200 years old, yet it is still far from being an invariably safe procedure. Although production methods have become more sanitary, the vaccine itself has changed little since Edward Jenner scraped it from sores on the hand of a cowpox-infected dairymaid. It causes severe and even fatal reactions in a small but appreciable number of people, with an average of seven deaths reported annually in the U.S. since 1950. Also, it probably leaves a greater number of victims with permanent mental damage from spread of the cowpox virus to the brain. Yet the U.S. has had no death from smallpox itself since 1949 and not one case of the disease since 1954. What the country now needs, argues the University of Colorado's Dr. C. Henry Kempe, is protection not against smallpox but against vaccination.

Routine vaccination has become an American fetish. There is no doubt that in its first 150 years vaccination was enormously effective in virtually eliminating smallpox from the developed countries of Europe and much of the Americas. But it is deceptively easy to assume that the current U.S. immunity to the disease is the result of continuing mass vaccinations. Probably far more significant is effective border control, which keeps out infected travelers. Changes in vaccination policy are resisted, says Tulane University's Dr. Margaret H.D. Smith, because of "an emotional investment in the traditional role of smallpox vaccination."

First Year Worst. Nor is this cautious attitude limited to oldtimers. Dr. Samuel L. Katz, 42, Duke University's brilliant pediatrician who worked with Harvard's great virologist John F. Enders, is chairman of the American Academy of Pediatrics committee that is drawing up vaccination schedules for children. In its next revision, Katz insists, there will be "no recommendation banning mass vaccination programs for smallpox." That means no widespread change in the current practice of vaccinating infants between six and nine months of age. However, vaccination is three times as likely to cause severe illness in the first year of life as it is in the second. So, says Tulane's Dr. Smith, vaccinators should at least postpone their needling until the second year.

Colorado's Kempe would go much farther. He would totally abolish routine vaccination of children, and of all stay-at-home Americans except those engaged in health services that might bring them into contact with an accidentally imported case of the disease. He would, however, continue to vaccinate young men entering the armed forces and maintain the presently required vaccination for any traveler to areas where smallpox is still rife.

The government-appointed vaccination authorities at the National Communicable Disease Center in Atlanta (a branch of the U.S. Public Health Service) are divided. The current official recommendation is for vaccination between the first and second birthdays. Some N.C.D.C. experts favor abandoning the routine vaccination of children at any age. On the liberalizing side, Dr. J. Michael Lane and three N.C.D.C. colleagues have analyzed 572 vaccine reactions reported in 1968. Their study, published in the New England Journal of Medicine, says that 68% of the patients had serious complications after being vaccinated for the first time (only 7% after repeat vaccinations). No fewer than 20% of the patients had never been directly vaccinated at all: they were mostly children with eczema who picked up the vaccinia (cowpox) infection accidentally from contact with somebody else's sore arm. In the entire group surveyed there were nine deaths, while three survivors appear to have suffered brain damage and a fourth is paralyzed in both arms and legs. In all likelihood, say the N.C.D.C. investigators, complications are many times as numerous as the reports indicate.

Give with VIG. While health authorities are unlikely soon to adopt Kempe's proposal for a near-total halt to mass vaccination, potent agents for reducing its ravages are already available. One is a safer vaccine that Kempe has devised. Before that, or something like it, comes into general use, doctors can still use a VIG gamma globulin extract, vaccinia immune globulin (VIG), which contains antibodies from recently vaccinated blood donors, to protect the very young and those in poor health who have to be vaccinated. The value of VIG is well established; it has been stocked for years in 15 Red Cross regional blood banks for distribution to doctors in emergencies after a severe reaction to vaccination has developed.

One point on which all the warring factions agree is that doctors should be far more careful before giving the present vaccine. Children with leukemia, or on steroid drugs that depress the immune reaction, obviously should not be vaccinated. Nor should a child with eczema or a history of recent eczema be vaccinated--certainly not without VIG --because cowpox may cause a fulminating and occasionally fatal exacerbation of eczema. But doctors and nurses often do not take the time to ask the right questions.

While vaccinators insist that with more care the number of bad reactions could be sharply reduced, this is a counsel of perfection never yet and unlikely ever to be fully observed. Clearly, new and safer vaccines and revised vaccination schedules are needed.

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