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Anti-Vaccination Fever

The Shot Hurt Around the World

Sensationalist media, religious fanatics, and alternative medical practitioners fanned the fires created by questionable research to spawn worldwide epidemics of a disease that had almost been forgotten.

William John Hoyt, Jr.

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When pertussis takes hold, the infected person makes horrid, whooping sounds as he inhales. When he gets a chance to inhale. Which isn't often during the torturous "paroxysmal phase," characterized by sudden attacks of repetitive, severe coughing. The disease's Latin name, pertussis, translates as "intensive cough." But whooping cough, the common name, does a far better job of describing the unique whooping sound the disease's victim makes when, finally, he gets a chance to breathe.

Neither the common nor the Latin name give any indication that the hacking cough and haunting whoop are often followed by vomiting. Nor does either name indicate that this distressing paroxysmal phase can last up to four weeks, and that this phase, in which the victim most clearly needs constant assistance, cruelly is also the phase in which this deadly disease is the most highly contagious. Since highly and deadly are relative terms, I should tell you that pertussis infections occur in 70 to 100 percent of all unimmunized household contacts that have been exposed to an infected person (CDNANZ 1997). In 1931, before immunization, pertussis was responsible for 1.3 percent of all deaths in England and Wales (Research Defence Society 1999).

Figure 1. United Kingdom's pertussis rate (per 100,000 population).

You have probably imagined an adult victim while reading thus far. In fact, before an effective vaccine became available, pertussis had been a worldwide leading cause of infant deaths. Before the 1940s, it was a major cause of infant and child morbidity and mortality in the U.S. (CDC 2002). From 1890 to 1940, in New South Wales, whooping cough killed more children under five than diphtheria. It was second only to gastroenteritis as a cause of infant deaths (Hamilton 1979).

In Sydney, Australia's, Royal Alexandria Hospital for Children alone, eighty-five died in 1940: "A whole 30-bed ward was filled for months with these poor little ones. Most of those admitted were young. The older ones were not in great danger and stayed at home, going on for seemingly endless weeks with their distressing spasms of breath-robbing cough ending in a vomit or choking whoop" (Hamilton 1979).

The force of pertussis coughing is so severe that many patients develop facial suffusions (discolorations), and small hemorrhages in the skin or conjunctivae. The coughing alone can also lead to hernias, rectal prolapse (protrusion of the rectal mucous membrane or sphincter muscle through the anus), or even hypoxic encephalopathy (degenerative disease of the brain). An adult can literally cough his way into a proctologist's or neurologist's office. Vomit, food particles, or mucous aspired while whooping can result in secondary pneumonia infection. Some children even become malnourished because they literally can't stop coughing long enough to eat. And some, usually infants, die (Malleson et al. 1977; CDNANZ 1997).

Fear and Loathing on the Vaccine Trail

In 1906, researchers discovered that the Bordatela pertussis bacterium caused pertussis. Within twenty years of that discovery, the first whole-cell pertussis vaccine was developed (Research Defence Society 1999). After two decades of testing and refinement, many countries accepted varying versions of a whole-cell pertussis vaccine, established vaccination protocols, and began to vaccinate their citizens. Many of the vaccine manufacturers produced a combined diphtheria-tetanus-whole cell pertussis (DTP) vaccine.

For most countries, as vaccination coverage increased, both the frequency and severity of pertussis epidemics markedly declined. Ironically, this success actually may have been the vaccine's undoing, as presaged in this pointed 1960 British Medical Journal commentary: "When immunization results in the virtual elimination of a disease it is inevitable that some will question the continued need for routine inoculation of all infants" (Editors 1960).

Figure 2. Sweden's pertussis rate (per 100,000 population).

The first hint of a problem came from Sweden in 1960, less than ten years into its vaccination program. Sweden had previously seen pertussis incidence rates as high as nearly 300 per 100,000. By 1960, the incidence rates were merely a third of that and falling (Gangarosa et al. 1998). It was at this time that Justus Ström, an influential Swedish medical leader, questioned the continuing need for pertussis vaccines. In his British Medical Journal paper, he claimed pertussis was no longer a serious disease because of economic, social, and general medical progress. Furthermore, he cited thirty-six cases of neurological conditions that he attributed to the whole cell pertussis vaccine, calculating an alarming neurological complication rate of 1 in 6,000 (Ström 1960).

Ström first presented his paper at a meeting of the Swedish Medical Association, where it evoked lively discussion, including some severe criticism of both his methods and conclusions (Malmgren et al. 1967). Nonetheless, Ström's twin suggestions, that the vaccine had little to do with the control of pertussis and that the vaccine may do more harm than good, shook Swedish pediatricians' faith in the vaccination program. Shortly thereafter, the Swedish Royal Medical Board appointed a special committee to investigate the matter. The committee found that Ström's adverse reaction rate calculation was off by an order of magnitude, and corrected it to 1 in 50,000 (Malmgren et al. 1967). Apparently, Ström never accepted the Royal Medical Board's corrections to his data. In 1967 he published new data claiming that neurological reactions had increased to 1 in 3,600 vaccinated children (Ström 1967). This claim further eroded confidence in the vaccine's safety. Fortunately, and perhaps owing to the Royal Medical Board's criticism of the paper, Swedish reaction was slow to take hold.

Then in the United Kingdom, in 1974, Kulenkampff and his colleagues published a paper citing another thirty-six cases of neurological reactions that they attributed to the whole cell pertussis vaccine. The paper's evidence was weak on several fronts acknowledged by the authors. They clearly stated they "do not know either the prevalence of natural infection or the frequency of inoculation encephalopathy (brain diseases resulting from vaccination) in the population we serve" (Kulenkampff et al. 1974). And they noted that "in as many as a third of our patients there were contraindications to inoculation with pertussis vaccine, in that there was a previous history of fits, or family history of seizures in a first-degree relative; reaction to previous inoculation; recent intercurrent infection; or presumed neurodevelopmental defect" (Kulenkampff et al. 1974).

Despite the authors' appropriately cautious approach to their paper, the anti-vaccination advocates seized upon it, and the media ran with it. Soon after the paper's publication, British television aired a program on the whooping cough vaccine. Focusing on the anecdotal evidence of terrible adverse reactions supposedly caused by the vaccine, it presented little of the clear good the vaccine had done historically.

The negative press and television coverage persisted for years. Other doctors came forward to tell the public of the alleged horrors of whole-cell pertussis vaccination (Gangarosa et. al 1998). These included Gordon Stewart, a prominent public health academic, who claimed that the little protection pertussis vaccination afforded did not outweigh the risks (Stewart 1977). The British medical community, however, maintained a healthy skepticism. Immediately following Stewart's paper, the Lancet published an article concluding that "fewer immunised children were admitted [for pertussis infection] than would be expected if immunization were ineffective" (Malleson et al. 1977). Nonetheless, vaccination rates fell precipitously. Before the brouhaha, vaccination uptake rates in the UK were about 81 percent. Between 1974 and 1978, the rates plummeted to 31 percent (Gangarosa et al. 1998; Research Defence Society 1999). The control over pertussis, which had taken the UK nearly two decades to achieve, quickly was being lost. As seen in figure 1, per capita pertussis rates rose about ten-fold during these four years (Gangarosa et al. 1998).

Meanwhile, back in Sweden, where Ström's paper had already set the stage, pertussis incidence rates had crept back up, causing Swedish physicians to further lose confidence in the vaccine's efficacy. To put this perceived problem in proper light, however, recall that Swedish pertussis rates in the 1940s and early 1950s, before the vaccine had been introduced, often hovered around 300 per 100,000. The 1975 pertussis rate (figure 2) was around 50 per 100,000 (Gangarosa et al. 1998). The backdrop had been set, though, and the physician's lack of confidence, combined with the news from the UK, prompted the Swedish medical society to abandon whole-cell pertussis vaccination in 1979. Between 1980 and 1983, pertussis among pre-schoolers skyrocketed to 3,370 per 100,000. In the years following, more than 10,000 cases per year were reported (Gangarosa et al. 1998; Cherry 1996).

Figure 3. Japan's pertussis rate (per 100,000 population).

The Kulkenkampff paper spread quickly to Japan as well, but the Japanese response was swifter. Japan's already active anti- vaccination proponents seized upon both the UK pertussis scare and a national debate on adverse smallpox vaccination events to alarm the public. With a growing public clamor, and the unfortunate deaths of two infants within a day of vaccination, the Okayama Prefectural Medical Association eliminated pertussis vaccination altogether in 1975. Within two years, the pertussis vaccination rate for Japanese infants nose-dived from nearly 80 percent to 10 percent. Five years into this mushrooming fiasco, Japan experienced a pertussis epidemic (figure 3) with more than 13,000 cases and forty-one deaths (Gangarosa et al. 1998).

Figure 4. Australia's pertussis rate (per 100,000 population).

The land down under was next to react to the news of alleged neurological reactions to pertussis vaccination. The Australian public began to fear vaccine reactions more than pertussis itself, and a passive anti-vaccination movement began to grow. Australian doctors slowly stopped pertussis vaccination. A study conducted by McIntyre and Nolan in the early 1990s found over half of the Australian physicians surveyed would give diphtheria-tetanus (DT) shots when DTP was indicated (McIntyre, et al. 1994). In 1993, Lester and Nolan wrote of Australia's coming catastrophe: "[G]eographically clustered populations of children who have inadequate pertussis protection . . . could promote epidemic outbreaks" (Lester, et al. 1993).

That ink was barely dry when the first wave struck. Australia's 1994 epidemic logged more than 5,000 cases. The second wave reached Australian shores three years later. This time, nearly 10,699 cases and nine infant deaths were reported. In the 2000-2001 Australian epidemic (figure 4), by November 6, 2001, 7,185 cases and two infant deaths had been recorded (Gangarosa et al. 1998, Kingsley 2001). In this latest outbreak, the Hunter Public Health Unit in Hunter Valley, New South Wales, reported, "About 30 percent of cases in Hunter Valley have been among 10 to 19 year olds." Australian children past eight years old aren't vaccinated against pertussis "because of concerns about the possible side effects of the vaccine beyond this age" (ABC Science Online 2000).

Figure 5. Russia's pertussis rate (per 100,000 population).

During the 1970s and into the 1980s, the Soviet Union maintained control of pertussis through compulsory immunization. Perestroika changed all that. Its anti-government bias spawned an active anti-vaccination movement, one of whose targets was the pertussis vaccine. Soviet virologist Galina Chervonskaya inspired the Soviet media to launch a campaign to discredit vaccination, and DTP vaccination coverage rates fell by 30 percent. Not surprisingly, the Russian Federation (figure 5) also began to experience pertussis epidemics (Gangarosa et al. 1998).

Returning to the Status Quo Ante Botchum

The epidemics shocked many of the nations that experienced them, although official and public responses have varied. Many countries introduced acellular pertussis vaccine as a "safer" alternative to the whole-cell vaccine. Some have also tried to control the problem by introducing more vaccination boosters to the protocol. But other countries, those whose vaccination programs were unaffected by anti-vaccination movements, haven't experienced these epidemics at all. These countries include Portugal, Hungary, Norway, the former East Germany, Poland, and, until recently, the U.S.

Japan's reaction to its epidemic was swiftest and strongest. By 1981, Japan resumed vaccination with an acellular pertussis vaccine and pertussis incidence rates returned to their pre-fiasco levels. The United Kingdom's vaccine uptake rate began slowly climbing, and by the 1990s reached levels exceeding those prior to the hysteria. English and Welsh pertussis incidence rates declined accordingly.

Sweden, however, remains plagued with high pertussis rates. As recently as 1996, and despite continuing epidemics, Sweden had yet to resume vaccinations (Cherry 1996). Australia's efforts to halt pertussis continue to be thwarted by a passive anti-vaccination movement. The 2001-2002 epidemic bears witness to that. The Russian Federation has also failed to regain control and today has one of the highest pertussis incidence rates in the developed world.

Distorted numbers, confusion of correlation with causation, and statistical innumeracy certainly played roles in this sad story. Sensationalist media campaigns fanned the glowing embers. But in each of the countries that experienced the raging fires of epidemics there were other forces at work. Most prominent in passive anti-vaccination movements were religious groups whose opposition was based on religious or moral grounds. Prominent in both passive and active anti-vaccination movements are followers and practitioners of homeopathy, chiropractic, and natural and alternative medicine (Gangarosa et al. 1998).

Despite the compelling case for vaccination that the anti-pertussis vaccination movement has inadvertently made, the Ström, Kuhlenkampff, and Stewart papers are still frequently cited in anti-vaccination literature. Speaking to Science News, Eugene Gangarosa, of Emory University, had this to say of anti-vaccine movements: "There's no question these movements undermine, collectively and individually, the benefits of vaccination" (Christensen 2001).

When anti-vaccination alarm takes hold-characterized by sudden attacks of the media, mistaken researchers, fervent religious groups, and alternative medicine quacks-the infected society begins to make horrid, whoppingly bad decisions. There is, as yet, no Latin name for this peculiar social disease.

Acknowledgments

I wish to thank C.R. "Skip" Wolfe, from the Centers for Disease Control, for providing raw pertussis data from the Gangarosa et al. paper cited, which he co-authored. Figures for this article were derived by combining data previously reported in Gangarosa et al., with pertussis incidence data from the World Health Organization (WHO 2002) and the U.S. Census Bureau's IDB Summary Demographic Data (U.S. Census Bureau 2002).