Immunity and Community Part One
This article appeared in Ceylon Today on Tuesday April 7 2015
I had most of the childhood illnesses without too many problems. I remember measles as being soporifically pleasant. I slept endlessly, wrapped up in a tartan blanket in front of a roaring fire in the kitchen of my grandparents. Mumps was painful but I survived. I had a bout of whooping cough. Chickenpox was an itchy scalp and I still have some scars. My abiding memory of that illness is that while I was still off school my father took me to the cinema (perhaps before I was fully recovered) to see Laurence Olivier’s Richard III. This was strong meat for an eight year old. I was morally confused. Olivier’s Richard was clearly bad because he was killing many people to get his political way. However, he was funny, charismatic, and occasionally likeable. The scary thing was that during the soliloquies, he was speaking directly to me and I could not escape. I feigned boredom and pleaded to go home. I had nightmares in which Richard was the dressing gown hanging on my bedroom door.
I also had a respiratory attack – I panicked when I could not breathe. The GP diagnosed it as bronchitis but it sounds more like asthma. My mother decided I was allergic to feather pillows and I have avoided them ever since and have had no further attacks. My mother may have been somewhat overprotective but she had been severely ill as a child with rheumatic fever and had known people who died of diphtheria and scarlet fever.
These days one can get vaccinations to protect against measles (rubeola), whooping cough (pertussis),mumps (parotitis), chickenpox (varicella), asthma, diphtheria, scarlet fever (scarlatina) and tetanus.
The Fever Van
In 1901, Emil von Behring won the first Nobel Prize in Physiology or Medicine for his work developing serum therapy for a diphtheria vaccination. Thanks to (among other factors) vaccination, scarlet fever and diphtheria, which were common in the 1930s, are now almost unknown in the UK.
These diseases occurred mainly in children between the ages of two and eight and spread rapidly because children would often continue to play with friends in the street and to mix with neighbours despite symptoms. Social stigma sometimes caused families to conceal the illness and an outbreak on a farm could lead to a ban on the sale of dairy products and hence loss of income. LS Lowry’s painting The Fever Van recalls those times. These vehicles operated throughout Britain from around 1910 to the 1950s transporting patients with infectious diseases from their homes and isolated them in special fever hospitals for up to six weeks. This allowed time for their own immune system to fight off the infection and limited the risk of contamination between patients and family. However, there was a strong likelihood of never returning, such was the high mortality of scarlet fever and diphtheria.
Nietzsche wrote: “What does not kill you makes you strong”. The body often provides its own immunity. I did not get vaccinations against measles, mumps, chickenpox or asthma but I survived. “Natural” immunity results from the body defending itself against an infectious illness. Vaccines provide immunity without a potentially dangerous infection.
Although measles was a fairly pleasant experience for me, it has killed more children than any other disease in history. Complications range from the mild, such as diarrhoea, to the serious, such as pneumonia, otitis, acute brain inflammation, subacute sclerosing, panencephalitis, and corneal ulceration.
Between 1855 and 2005, measles killed about 200 million people worldwide. Measles killed 20 percent of Hawaii’s population in the 1850s. In 1875, measles killed over 40,000 Fijians, approximately one-third of the population. In the 19th century, the disease killed 50% of the Andamanese population. Seven to eight million children died from measles each year before the vaccine was introduced. Measles still affects about 20 million people a year mainly in Africa and Asia.
In 2011, the WHO estimated that there were about 158,000 deaths caused by measles. This is down from 630,000 deaths in 1990. As of 2013, measles remains the leading cause of vaccine-preventable deaths in the world. In 2012, the number of deaths due to measles was 78% lower than in 2000 due to increased rates of immunization among UN member states.
One in every twenty children with measles will develop pneumonia; one in every thousand will develop encephalitis, which can leave a child deaf or brain-damaged. Measles is airborne and extremely contagious; a virus transmitted by a sneeze can still infect people an hour later. A community generally needs more than ninety per cent of its members to be immunized against the virus in order to protect everyone.
Recent Measles Epidemics
In 2013–14, there were almost 10,000 cases in 30 European countries. Most cases occurred in unvaccinated individuals. In 2014, a review by the Centers for Disease Control concluded: “the elimination of endemic measles, rubella, and CRS has been sustained in the United States.” However, an outbreak that started in February 2015 in California, has now spread to 14 states and there is fear that it will spread throughout the nation, particularly in places where parents have sought legal exemption from vaccination. California is one of nineteen states that allow people to opt out not only for religious and medical reasons but also because of a loosely defined “personal belief.” Antii-vaccination sentiment decreased the community immunity afforded by public health programmes. Currently, eight percent of children in California kindergartens are not adequately vaccinated.
The infection has now spread beyond California to Utah, Washington, Oregon, Colorado, and Mexico. Last year, California made the “personal belief” exemption law more stringent, requiring parents to submit a form signed by a health professional. Governor Jerry Brown, at the last minute, added a religious exemption, so that parents who object to vaccination as a matter of faith do not need a physician’s signature.
Outbreaks of pertussis (whooping cough) were first described in the 16th century. The bacterium that causes it was discovered in 1906. Throughout the world, pertussis affects 16 million people every year and there were 61,000 deaths in 2013 – down from 138,000 in 1990. It strikes people of any age. Two per cent of children under one who get it will die. Most cases occur in the developing world
A vaccine became available in the 1940s. In the latter 20th century, vaccinations helped to reduce the incidence of childhood pertussis in the US. However, reported instances increased twenty-fold in the early 21st century, causing many deaths. Many parents declined to vaccinate their children for fear of side effects from the vaccine itself. There have been concerns that DPT, a class of combination vaccines against diphtheria, pertussis and tetanus caused brain damage.
As long ago as 1990, the Journal of American Medical Association called the fear a “myth” and “nonsense”. No studies showed a causal connection. The alleged vaccine-induced brain damage proved to be an unrelated condition, infantile epilepsy. Scepticism endures – in 2012, more than forty-eight thousand pertussis cases and twenty deaths were reported to the Centers for Disease Control, the greatest number since 1955.
I did get vaccinations against polio and TB. Diphtheria was seen as a disease of poverty but the aristocratic president of the USA, Franklin D Roosevelt, was struck down with polio. I remember the shock in 1959 when Jeff Hall died of polio. He was a young and fit footballer, playing with distinction at full-back for Birmingham City and England. Hall’s last match for Birmingham was away to Portsmouth on 21 March 1959. He became ill two days later and was admitted to hospital where he was diagnosed with polio. Over the next twelve days, his condition deteriorated; he became paralysed and lost his speech before dying on 4 April, aged 29.
Polio had been a comparatively rare disease in Britain. However, at its peak in the 1940s and 1950s, polio would paralyze or kill over half a million people worldwide every year. In 1952, during the worst recorded epidemic, 3,145 people, including 1,873 children, in the United States died from polio. It was feared because of its capacity to maim young and healthy bodies. The consequences of the disease left polio victims marked for life, in wheelchairs, crutches, leg braces, or iron lungs. One sees many victims in Sri Lanka. Rock poet Ian Dury was severely disabled by childhood polio. Booker Prize winner JG Farrell contracted the disease when he was at Brasenose College Oxford and was partially disabled, sometimes needing an iron lung. There is a strong suspicion that his death by drowning in County Cork was suicide. Anxious parents kept their children away from swimming pools where the disease was thought to spread, but take-up of the Salk vaccine was slow.
In the weeks following Hall’s death, and after his widow, Dawn, spoke on television about her loss, demand for immunisation surged. Emergency vaccination clinics were set up and supplies of the vaccine flown in from the United States to cope with the demand.
The last case of natural polio infection acquired in the UK was in 1984. Between 1985 and 2002, 40 cases of paralytic polio were reported in the UK. In Sri Lanka, the incidence of poliomyelitis has decreased steadily along with the rapid increase in the immunization coverage of infants. Sri Lanka has not reported any cases for the last 15 years and the last virologically confirmed case of polio was detected in Sri Lanka in 1993.
Vaccination and the concept of “herd immunity” raises civil liberties issues which I will discuss in next week’s column.