̽��ֱ�� of Cambridge - Stephen Mawdsley

Call to arms: how lessons from history could reduce the ‘immunisation gap’

lw355 — Mon, 25 Apr 2016 08:00:04 +0000

An outbreak of measles in Disneyland sounds like a fairytale gone bad. Yet, in January 2015, states across the USA began reporting measles among individuals who had visited the Disneyland Resort in California the month before. All because a visitor to the resort had unwittingly carried the virus into the ‘Happiest Place On Earth’.

̽��ֱ��virus is so contagious that 90% of those close to ‘patient zero’ had been at risk of being infected if they were not already immune. Epidemiologists later concluded that “substandard vaccination compliance” was likely to blame for the outbreak. Six months later, the state of California made vaccination mandatory: from July 2016, all children enrolling in school must be fully vaccinated.

Measles and other vaccine-preventable diseases have been on the rise globally in recent years. France, for instance, seemed close to eliminating measles in 2007, but in the following four years, reported a dramatic outbreak of more than 20,000 cases, with 80% of reported cases occurring in unvaccinated people.

These recent events have highlighted the ‘immunisation gap’ – the trend for parents not to have their child vaccinated because of anxiety about unforeseen health consequences. But without a certain threshold of vaccination in a community – so-called herd immunity – the unvaccinated become especially vulnerable.

Yet, vaccinations are considered to be one of the greatest public health achievements in history. Perhaps that’s part of the problem, says historian Dr Stephen Mawdsley: “We have largely forgotten what it’s like to face an epidemic sweeping through a population.” Vaccinations, it seems, have become a victim of their own success.

But this isn’t the first time that ‘vaccine hesitancy’ has threatened public health. “During the first half of the 20th century, America faced a terrifying disease – polio,” he adds. “As many as 57,000 new cases were being reported every year in the early 1950s. Not only was this a painful illness, it had grave economic consequences. Thousands of survivors required expensive acute and convalescent care, and many suffered from lasting paralysis.”

Although the polio virus could strike anyone, young children were particularly affected, inspiring the term ‘infantile paralysis’. Despite a vaccine being available, few teenagers and adults sought its protection because they believed they were not sufficiently at risk to warrant paying for the course of three inoculations.

Mawdsley’s research, just published in the Journal of Cultural and Social History, has uncovered how young people themselves became the answer to the problem, in what might be the first, largest and most successful case of teen health activism of the time. This fight waged against vaccine noncompliance in 1950s America, he suggests, could provide important lessons for the world today.

It was while hunting through the archives of the March of Dimes (MOD) – a fundraising campaign set up by polio survivor President Franklin D. Roosevelt and his law partner Basil O’Connor – that he made the discovery. “Who’d have thought that, after suffering terrible epidemics and fear, Americans would have a very mixed reaction towards polio vaccination? Or that those in the ‘vaccination gap’ would help to fill it.”

A range of social, economic and political factors complicated the delivery of a comprehensive vaccination programme. Teens, in particular, were a demographic group that was difficult to reach. Two years after the vaccine was licensed in 1955, as many as 30% still had no inoculations, and a third of all new cases were in teens. ̽��ֱ��public health message wasn’t getting through, and new strategies were needed.

Celebrities helped the cause. ‘Presley Receives a City Polio Shot’ proclaimed the New York Times in 1956, as the King of Rock ‘n’ Roll offered his arm for vaccination before appearing on the Ed Sullivan Show. But the real drivers of the message were a group of teenagers gathered together by the MOD-financed National Foundation for Infantile Paralysis (NFIP).

“Growing consumerism and rising purchasing power and recreational time spurred the emergence of an assertive teen culture by the late 1950s,” explains Mawdsley. “Many national organisations began to recognise teens as important consumers with cultural influence. By tapping into this segment of society, the NFIP hoped to inspire a new wave of vaccination driven by peer approval.”

̽��ֱ��relationship was reciprocal. For the hundreds of young people brought together by the NFIP from all over the USA for a conference, this was a chance to challenge negative stereotypes about juvenile delinquency, and gain recognition and appreciation through grassroots activism.

Officials and teenagers debated strategies to improve vaccination, as well as how to break down race, ethnicity and gender stereotypes. ̽��ֱ��underlying ethos was that the vaccination message could penetrate teen culture only if it came from within its ranks. After the conference, the teenagers established county chapters across the country under the motto ‘Teens Against Polio’ (TAP), each chapter recruiting yet more teens to promote vaccination.

Some canvassed door to door or gave talks at schools; others organised car washes and peanut sales, or visited polio wards and rehabilitation centres. “No shots, no dates” was a recurring phrase, and teens were often asked at school dances to prove they were immunised before gaining entry. “By using exclusive dances as a tactic, young volunteers were able to exploit the fear of missing out as a means to increase vaccine uptake among teens,” he says.

“I interviewed some former TAP volunteers, and they said that looking back it was surprising that some of these tactics were so acceptable – it showed the power of teens understanding and connecting with their own demographic.”

̽��ֱ��creativity and audacity of teens were acknowledged as cornerstones to the marketing strategy by adults, as one NFIP chapter chairman recalled: “ ̽��ֱ��youngsters did have enterprise and nerve. They went in offices, stores, restaurants, hotels – any place there was a person. They barged in on bank presidents, dentists, janitors, even the jail.”

Although teen health activists could not solve all the challenges facing vaccination, their strategies had a remarkable effect. As teen vaccination increased, fewer cases of polio emerged. By 1960, the annual incidence of polio had decreased by nearly 90% compared with 1950.

Mawdsley believes that lessons might be learnt from the history of the fight against polio by public health communication campaigns today. “Yes, their approaches and language were very much the product of 1950s America, but the lesson here is that a hard-to-influence group can be reached. This could be by tapping into new forms of communication such as social media, or clever approaches to promoting vaccination to people opposed to vaccination.

“TAP reinvigorated a failing public health campaign by addressing the fears, access restrictions and misinformation about polio. ̽��ֱ��teen polio crusaders were a Trojan horse in the battle for public support and donations for polio.”

This research was funded by Clare Hall, Cambridge, and Cambridge Infectious Diseases.

A rise in the number of outbreaks of vaccine-preventable diseases has highlighted the growing trend for parents not to have their child vaccinated. Could the activities of a group of teenagers in 1950s America inspire a fresh look at the effectiveness of pro-vaccine public health information campaigns?

Who’d have thought that, after suffering terrible epidemics and fear, Americans would have a very mixed reaction towards polio vaccination? Or that those in the ‘vaccination gap’ would help to fill it.

Stephen Mawdsley

Teens Against Polio

̽��ֱ��New York City Municipal Archives

Elvis Presley receives a polio vaccination

̽��ֱ��text in this work is licensed under a Creative Commons Attribution 4.0 International License. For image use please see separate credits above.

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Polio provocation – the health debate that refused to go away

sj387 — Tue, 03 Sep 2013 14:00:00 +0000

In 1980, public health researchers working in West Africa detected a startling trend among children diagnosed with paralytic polio. Some of the children had become paralyzed in a limb that had recently been the site of an inoculation against a common paediatric illness, such as diphtheria and whooping cough. Studies emerging from India seemed to corroborate a similar association between diagnosis of polio and recent immunisation.

These reports reignited a debate known as the theory of polio provocation that has waxed and waned since the early 1900s – and, at times, shaped immunisation policy. ̽��ֱ��theory of polio provocation argued that paralytic polio can be provoked by medical interventions, such as injections or tonsillectomy. ̽��ֱ��controversy that surrounded the debate forced medical professionals into the uncomfortable position of considering whether programmes and practices intended to prevent some illnesses might be also causing another.

In a blog published today by Oxford Journals, Cambridge ̽��ֱ�� historian Dr Stephen Mawdsley looks at the ways in which the theory of polio provocation was debated in the US and beyond throughout the 20th century. His blog draws on his historical research, published in the Social History of Medicine, into the polio provocation debate.

Polio is a terrifying disease. Most infections of polio pass unnoticed but, in a small percentage of cases, the virus can enter the blood stream, where it targets the motor neurons of the spinal cord. Depending on the severity of the infection, the disease can cause paralysis of the limbs and respiratory muscles, which can lead to further complications or death. For those who survive the acute phase, the rehabilitation process is lengthy and some are left with lasting paralysis and health complications.

After over 50 years of debate, medical researchers have shown that polio provocation can occur in certain circumstances. Although the current danger of contracting the disease through this route is likely to be slight, health professionals need to consider safeguards to reduce the risks even further. “Worldwide uptake of the polio vaccine is important since only through building herd immunity can the disease be eradicated. Research indicates that people who are not immunised against the disease and are living in polio endemic regions may face the risk of polio provocation,” said Dr Mawdsley.

“Awareness of this risk informs health policy today. Increasingly, health professionals are considering the importance of immunisation sequence (the order in which injections against childhood diseases are given), the type of vaccine to use, and the age at which children should be immunised. We will never know precisely how many people were exposed to polio provocation in the past, or how many contracted polio by this route, as there is no reference point from which we might measure a correlation.”

Dr Mawdsley’s research, based on records from the March of Dimes Archives in New York and historical medical journals, shows how successive generations of public health officials and policy makers made decisions with far-reaching consequences for the population. These professionals were obliged to debate whether polio provocation existed, and decide how best to balance the risks to individuals against the benefits of herd immunity, at a time when the mechanism behind the theory had yet to be understood.

Polio, which was first identified in the 19th century, was (and still is) a feared disease: haunting images of polio survivors with withered limbs or children housed in respirators (iron lungs) serve as potent reminders of the suffering caused and underline the importance of polio vaccination. In the US, outbreaks often peaked in the summer and children were particularly vulnerable. One Minnesota physician remembered the 1948 epidemic: “ ̽��ֱ��people of Minneapolis were so frightened that there was nobody in the restaurants. There was practically no traffic, the stores were empty. It just was considered a feat of bravado almost to go out and mingle in the public.”

̽��ֱ��first vaccine against polio, developed by Dr Jonas Salk at the ̽��ֱ�� of Pittsburgh, was field tested in 1954 and subsequently licensed for use in mass immunisation programmes by April 1955. Polio incidence in the US and other developed countries plummeted from that time and polio was slowly eradicated from the list of life-threatening children’s illnesses. Immunisation offered protection and the debate about polio provocation slipped from public consciousness.

While parents in developed countries no longer fear polio, the disease remains a threat in some developing countries – such as Afghanistan, Pakistan and parts of Africa. Growing concerns raised by major aid organisations prompted a team at the State ̽��ֱ�� of New York to unravel the mechanism behind polio provocation. In 1998 scientists Drs Matthias Gromeier and Eckard Wimmer were able to show that tissue injury caused by certain injections gives the polio virus easy access to nerve channels, thereby increasing its ability to cause paralysis.

“In the light of this discovery it is fascinating to look at how polio provocation, which some experts contested simply did not exist, migrated from being a theory to a clinical model – and trace its history and the waves of debate about it, both in the US and beyond,” said Dr Mawdsley.“At various junctures during the 20th century, health professionals were divided in opinion, which meant that it was difficult to establish a coherent public health policy. Medical scientists were also frustrated by the difficulties this debate posed to anyone conducting field trials using injections.”

One of the first procedures to be implicated as provoking polio was tonsil surgery. In 1910, doctors observed that children who underwent throat surgery during a polio epidemic faced an elevated risk of contracting polio within seven to 14 days of the operation. Supporters of the polio provocation theory warned fellow clinicians that operations to the nose and throat should not be performed during epidemics when the risk of contagion was highest. Medical opinion, however, remained split: while the US Army and some leading public health officials advised against tonsil and adenoid operations during polio outbreaks, other health professionals continued to assure clinicians that the danger was minimal.

Anxiety about the hypothesis peaked in 1950 when a rise in tonsillectomy operations coincided with a spike in the diagnosis of polio. Once again, although clinical evidence suggested that tonsillectomies appeared to treble the risk of children contacting polio, not all doctors agreed – though many heeded the advice to postpone procedures until the summer polio season was over. In the absence of a consensus, doctors made decisions on a case-by-case basis.

Shifts in notions about the causes of polio outbreaks – which was first considered to be an infection spread by immigrants or poor hygiene, and later as an affliction targeting prosperous, active people – were accompanied by changing theories about the possible causes of polio provocation.

Along with tonsillectomy, implicated at different times were injections of a wide range of drugs and paediatric immunisations. By 1952, leading medical and health organisations in the US agreed that injections against common infectious diseases such as diphtheria, whooping cough and tetanus should be postponed during periods of high polio incidence, while other injections such as vitamins and hormones were thought to be safe.

“ ̽��ֱ��decision to reform public health policy in the US was handled differently in various areas, but appears to have been taken with great care, since it was clear that withholding certain immunisations would jeopardise herd immunity,” said Dr Mawdsley. “Delaying injections until after polio epidemics subsided was an expedient means to achieve a compromise.”

Dr Stephen Mawdsley is the Isaac Newton-Ann Johnston Research Fellow in History at Clare Hall, ̽��ֱ�� of Cambridge. His article ‘Balancing Risks: Childhood Inoculations and America’s Response to the Provocation of Paralytic Polio’ is published in the OUP journal Social History of Medicine. A blog by Dr Mawdsley ‘Polio Provocation: A Lingering Public Health Debate’ appears today.

For more information about this story, contact Alex Buxton, Office of Communications, ̽��ֱ�� of Cambridge, amb206@admin.cam.ac.uk 01223 761673

Dr Stephen Mawdsley's blog

Dr Stephen Mawdsley's historical research

For much of the 20th century, health professionals were locked in debate about one possible cause of paralytic polio. Some argued that the viral infection could be provoked by medical interventions; others hotly contested this theory. Historian Dr Stephen Mawdsley looks at the unfolding story of polio provocation.

It is fascinating to look at how polio provocation, which some experts contested simply did not exist, migrated from being a theory to a clinical model

Dr Stephen Mawdsley

History of Medicine (NLM)

A Clinical Center physician prepares an injection for a young patient

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