Case Studies in Public Health

2018

Chapter 1

James Lind and Scurvy

Abstract

Scurvy is a disease that results from lack of fresh fruit and vegetables, now known to be caused by vitamin C (ascorbic acid) deficiency, causing symptoms of fatigue, lethargy, limb pains, swollen and bleeding gums, joint pain, shortness of breath on exertion, skin bruising, and, if untreated, death. Identified as a disease in the 16th century and widely attributed to infection, it was common among seamen with disastrous loss of life on long voyages. In 1747, James Lind, a young naval surgeon, conducted a clinical trial of comparing nutritional treatment of sailors with scurvy, which showed the cure to be citrus fruit, and reported on his finding to the Royal Society. The Royal Navy later made consumption of lemon juice mandatory to preserve the health of sailors and to allow ships to stay at sea longer. Lind’s study is considered a first in epidemiology as a case-control study opening the field of nutritional epidemiology with vital public health implications that continue today. Scurvy gradually passed from public health consciousness but vitamin C has recently attracted attention as a common micronutrient deficiency globally with dietary intake of fruit and vegetables daily, and vitamin C fortification of basic foods as public health nutritional intervention.

Keywords

James Lind; scurvy; public health; Royal Navy; vitamin C deficiency; nutritional epidemiology

James Lind (1716–1794) a 30-year-old surgeon’s mate on HMS Salisbury in 1746 conducted the first documented randomized controlled clinical-epidemiologic trial using various nutritional regimens for sailors sick with scurvy, and reported: "They all in general had putrid gums, skin spots and lassitude, with weakness of their knees. Two others had each two oranges and one lemon given them every day. These they ate with greediness, at different times, upon an empty stomach. The consequence was, that the most sudden and visible good effects were perceived from the use of oranges and lemons; one of those who had taken them, being at the end of 6 days fit for duty." Source: James Lind–Quotes. Available at: http://www.sciencemuseum.org.uk/broughttolife/people/jameslind.

Background

Studies in nutritional sciences began in the early 18th and 19th centuries with identification of the basic food elements - carbohydrates, protein and fats. Revolutionary developments that enabled identification of the elements led to the development of methods of testing with chemical analysis, quantitative analysis and new scientific approaches to nutrition. Development of studies in chemistry and physiology advanced the field, which today is still dynamic and productive of information vital to public health.

The practice of nutrient supplementation of foods dates back to the year 400 BCE when the Persian physician Melanpus suggested adding iron filings to wine to increase soldiers’ potency. In 1831, the French physician Boussingault urged adding iodine to salt to prevent goiter. In 1912, Casimir Funk identified vital amines as essential trace elements for human health. With the development of nutritional sciences from the early part of the 20th century, knowledge grew rapidly of the vital role of vitamins and minerals, now called essential micronutrients, and they became part of the public health arena.

Scurvy was a common illness and cause of death for ship crews on long sea voyages during the 17th and 18th centuries. Although no scientific knowledge of the cause of scurvy existed, in 1617, John Woodall, a surgeon and author of Surgeon’s Mate, described the disease. He listed lemon juice as the cure, which was subsequently adopted by the East India Company, which started providing lemon juice for its sailors. The famed round-the-world voyage of a Royal Navy fleet of eight ships led by Commodore George Anson in 1740–44 lost a majority (145 men survived out of a total of nearly two thousand, most dying of scurvy), of the sailors who died from the great sea plague as scurvy was then called.

James Lind (1716–1794) was born in Edinburgh in 1716, the son of an Edinburgh merchant with family medical connections. In 1731 he was apprenticed to an Edinburgh surgeon supplemented by studies at Edinburgh University Medical School. He joined the Royal Navy in 1738 as a surgeon’s mate and in 1740 was posted to the 50-gun vessel HMS Salisbury. His major works included "Treatise of the Scurvy published in Edinburgh in 1753, An Essay on the Most Effectual Means of Preserving the Health of Seamen. (1762), and An Essay on Diseases Incidental to Europeans in Hot Climates" (1771).

On a ten-week voyage in 1746 scurvy struck 80 out of 350 sailors on the Salisbury. Lind then at age 30, with little academic education, undertook an investigation of the problem by randomly assigning 12 sailors sick with scurvy to different dietary regimens. Each group of two received a different diet of frequently recommended regimens for a two week period while Lind monitored progress of the clinical picture. One group was given oranges and lemons, others seawater, cider, vinegar, or various medications thought to be effective against scurvy. This study is recognized as the first recorded experimental randomized controlled clinical trial, which became a hallmark of general and nutritional epidemiology.

The sailors in Lind’s study who received lemon and other citrus fruits showed dramatic clinical improvement within several days, in such a way that one was able to help care for the other group of sailors in the trial who did not improve. Lind reported in his book Treatise of the Scurvy that in a short time this group was fit for duty. Lind further concluded that "experience indeed sufficiently shows that green or fresh vegetables with ripe fruit were the best remedies for it (scurvy), so they prove the most effectual preservatives against it, and oranges are the most effectual preservatives against the distemper." Lind also promoted hygienic improvements in ventilation, regular bathing, changes of clothing and bedding for sailors to reduce infectious diseases including typhus.

Lind found difficulty convincing naval authorities of the importance of these findings. Captain James Cook (1728–1779), one of the greatest sea explorers of all time, took great efforts to maintain the health of his seamen on his circum-navigation voyages with ventilation and mandatory hygiene and antiscorbutic foods. During his second voyage, a companion ship, whose captain paid less attention to diet and hygiene of the sailors, experienced many cases of scurvy, while Cook’s crew members were free of scurvy. Cook documented the benefits in health of sailors on his ship as compared to the companion ship which ignored these requirements in his official logbook of the voyage.

Further efforts by experts on scurvy, such as Gilbert Blane (1749–1834) and Thomas Trotter (1760–1832), and the documented experience of seasoned sailors such as Captain Cook on the efficacy of dietary discipline in preserving the health of his crews on long sea voyages, helped convince the British Admiralty. In 1796, the Admiralty mandated daily issuing lemon juice to all sailors at sea to prevent scurvy. Application of the new dietary regulations eliminated scurvy from the Royal Navy, allowing voyages to go beyond the previous 6–8 week limit of sea time without replenishment of supplies of fresh vegetables, shore leave, or both. A naval expert of the time noted that this effectively doubled the fighting strength of the Royal Navy at sea during the Napoleonic wars of 1797–1814, in a common saying of the time that Lind, as much as Nelson, broke the power of Napoleon. In 1867, the British Parliament mandated provision of a daily lime ration to sailors in all ships of both the Royal Navy and the Merchant Navy to prevent scurvy. This resulted in the use of the term limey for British sailors and British people generally in America.

Lind’s study was the first clinical-epidemiologic study, and is considered the first randomized control trial (RCT). It was also the first documentation of effective intervention in a nutritional-occupational disease. Identification of an active nutritional factor led to cure and prevention of a well known clinical disease of major public heath importance. Lind anticipated the discovery of vitamins by 150 years, describing "various qualities, of which all vegetables possess one or more in various degrees, and do from thence accordingly become more or less antiscorbutic."

Vitamin C was isolated from lemon juice in 1932 by Hungarian and British scientists. The Nobel Prize for Physiology or Medicine was awarded to Albert Szent-Györgyi for his studies of the biological functions of L-ascorbic acid (vitamin C). In 1937 the Nobel Prize for Chemistry was awarded to two scientists. Norman Haworth received the Prize for his investigations on carbohydrates and vitamin C and for determining the structure of ascorbic acid Paul Karrer received the Prize for his investigations on carotenoids, flavins and vitamins A and B2. Further studies of the nutritional and public health importance of vitamin C are ongoing. Examples of these are studies on how to enhance the nutritional value of ascorbic acid in agricultural crops, for prevention of heart disease, stroke, and cancer.

Current Relevance

Nutritional sciences in the 19th century focused mainly on calories, carbohydrates, protein, and fats. Early in the 20th century, the identification of other essential or vital amines, later shortened to vitamins, became part of the field of study. Lind’s demonstration that specific foods that could cure and prevent a serious disease of sailors on long voyages proved to be a prescient change in nutritional science, and pioneered the development of the vital research methods of the clinical trial.

Today, micronutrient deficiencies (MNDs) of vitamins and minerals that are necessary for health, especially for pregnant women, children and adults, are considered to affect some 2 billion persons globally. Vitamins are organic compounds that are essential in small amounts for specific functions and health of the body, such as growth, reproduction, and resistance to infection. They differ in physical and chemical properties and in biological functions. Vitamins function in highly specific metabolic processes. They cannot be synthesized in sufficient quantity by the body alone, and must therefore be obtained from the diet, from fortified foods and supplements and, in the case of vitamin D, from skin exposure to the sun. Vitamin C is readily available in diets including regular and adequate amounts of fruit and vegetable intake at all ages but this is not universally available nor part of all dietary cultures.

Many diets in low-, medium-, and high-income countries are in fact deficient in more than one of these needed elements and, along with trace minerals, should be added to foods commonly eaten by most people such as flour, rice, cooking oils, milk, salt, and sugar. Fortification of common basic foods has become increasingly justified in science and in practice over the past century with successful experience in fortification of basic foods with iodine, iron, vitamin B complex including folic acid, vitamin D and others to prevent many micronutrient deficiency conditions. Moreover, supplements are essential for certain groups in the population who need higher doses than that made available by food fortification.

Vitamin C is the primary antioxidant in the diet. It is available in balanced diets with vegetables and fruit, but can be deficient in the usual diets of many persons. A dietary lack of vitamin C adversely affects the general health of individuals, especially when under stress of infections such as the common cold or chronic illness.

Vitamin C is water-soluble and not synthesized in the human body thus adequate dietary intake is essential for maintaining health, especially for children, pregnant women, chronically ill and elderly people. As an antioxidant it is essential for absorption of iron and for collagen formation to maintain the skin and connective tissue, as well as for bones, blood vessels, wound healing, and facilitating recovery from burns. Vitamin C is widely available in fruit (especially grapefruit, lemons, limes, blackcurrants, oranges, berries and kiwi fruit) and vegetables (e.g., broccoli, green and red peppers, tomatoes, cabbage, sprouts, and sweet potatoes). It is also found in milk, fish, and some meats, such as liver.

Vitamin C deficiency still occurs as part of the general problem of undernutrition, associated with trauma and surgical care, refugee and migrant populations, people living in isolation, persons with chronic disease, poor nutrient absorption (such as with smoking, alcoholism, gastroenteric diseases), and inadequate nutrition among people living in high-, medium- and low-income countries. Symptoms include fatigue, lethargy, depression, gingivitis, and bleeding from the gums, skin petechiae (rash), internal bleeding, reduced resistance to infections, impaired wound healing, and mental illness. Patients on renal dialysis and anticoagulation therapy require vitamin C supplements. The required amount of vitamin C varies with the state of health and thus supplements are recommended to prevent or shorten the duration of common acute illnesses and are necessary in long-term illnesses such as for cancer patients, HIV/AIDS, and others.

People in categories considered at risk for deficiency, and therefore requiring regular vitamin C intake, include infants fed on cow’s milk only; cigarette smokers; pregnant and lactating women; anorexia nervosa and bulimic patients; type 1 diabetes; immune-deficient patients; chronically ill patients; patients with enteric diseases and malabsorption such as celiac disease; and patients on restrictive diets due to allergies. Others at risk include a wide variety of people who lack regular access to fresh fruit and vegetables including elderly people living on poor diets (tea and toast syndrome); residents of remote, geographically isolated locations without access to diverse foods needed for healthy diets; poor families without financial or physical access to fresh fruit and vegetables; people eating primarily at fast food restaurants; alcoholics; refugees dependant on food donations; homeless people; drug addicts; institutionalized patients with poor eating habits; and people who have extreme dietary practices. Other groups in need of vitamin C and micronutrient support needs are HIV/AIDS and cancer patients, as well as patients on chronic renal dialysis or coumadin anticoagulation therapy. In total, these groups constitute a substantial segment of societies, even in high-income countries.

Scurvy prevention and control is a vital consideration in major emergency situations, such as following natural or man-made disasters with mass refugee situations, or homeless populations. Prevention of vitamin C deficiency along with prevention of thiamine deficiency, pellagra, and iron deficiency anemia are vital measures for disaster preparation and management with nutritional support policies for supplements, especially for infants, pregnant women and other vulnerable groups.

Vitamin C deficiency may be a comorbid condition among patients with other MNDs (e.g., iodine deficiency, iron deficiency/anemia, rickets), and those with psychotic and mental illness, chronic renal failure, cancer, and chronic illness. Refugees, minorities, and aboriginal populations are vulnerable to vitamin C and other multiple micronutrient deficiency conditions. The use of vitamin C and other antioxidants to treat severe trauma and burn patients is an ongoing area of clinical research. Additionally, many other potential benefits have been claimed and are under continuing review.

Vitamin C deficiency is still a global problem, with recognition that MNDs usually include more than a single vitamin or mineral. Deficiencies of iodine, iron, selenium, and vitamins B, C, D, and others are now considered to be multifactorial. From treating poorly fed pregnant women with iron and folic acid as practiced for decades we are now also recognizing the need for iodine, selenium, zinc, magnesium, vitamins A, B group, C, D and B12. The public health issue of improving pregnancy and neonatal outcomes will require multivitamin supplementation as well as fortification of basic foods.

Ethical Issues

The importance of vitamin C deprivation must be taken into account for ethical health policies. Undernutrition with MNDs and calorie deprivation are worldwide issues. Underlying morbidity and mortality are frequently associated with poverty and social deprivation. Vitamin C deficiency is a special problem for vulnerable groups of people in every society, including:

• the elderly and other groups unable to maintain a healthful diet in poor health, or due to lack of access to healthful foods for social and economic reasons;

• people with acute trauma, fractures, burns;

• people with chronic medical conditions;

• people with dependency on smoking, alcohol, and drugs;

• people with low income; and

• people with mental illness.

Yet interventions to reduce the high prevalence of subclinical MNDs, such as vitamin C, are not sufficiently recognized and promoted as national and international public health priorities. Routine supplementation of chronically ill and other high-risk groups is sporadic, and fortification of basic foods with vitamin C and other micronutrients is essential for population health. This applies in high-income as well as in medium- and low-income countries.

The lessons learned from Lind’s study, and many others who followed in nutritional epidemiology, should lead those who deal with population health policy to address MNDs. This should be considered in modern times as part of clinical care and population health, and in disaster situations, including those in which people are displaced as a result of conflict in regions or countries in wartime conditions, and suffer from physical harm and nutritional deprivation. In disaster situations with uncertainty of healthful food supplies it is even more important to ensure vitamin C and other micronutrient adequacy. Scurvy is uncommon, but can occur in chronically ill and debilitated people; but subclinical vitamin C deficiency is occurring in vulnerable population groups on a global basis.

Ascorbic acid is an antioxidant that seems to have protective effects against free radicals, which are potentially harmful derivatives of food and environmental factors. Antioxidants include vitamin C, beta carotene, selenium, vitamin E, and others. Free radicals can damage strands of DNA, leading to effects such as assisting absorption of low-density lipoprotein (LDL, i.e., bad cholesterol) molecules into artery walls, causing atherosclerosis. Moreover, this DNA damage may contribute to cancer and other chronic conditions. The protective effects of antioxidants are under intense research scrutiny since the 1990s but have not been definitively proven to be as effective in disease prevention as originally thought. However, high fruit and vegetable intake are highly recommended as important measures to reduce risk of cardiovascular diseases and cancer as seen in lower mortality from cardiovascular disease and cancer of the lung in a high fruit and vegetable consuming country such as Italy, Greece and Israel.

The World Health Organization (WHO) recommends a daily intake of 45 mg of vitamin C for healthy adults and 25–30 mg for infants. The US National Institutes of Health (NIH) recommend between 40–50 mg/day for infants, 15–75 mg/day for toddlers to adolescents, and 75–90 mg/day for adults, depending on age, gender, pregnancy status, and up to 120 mg/day for lactating mothers.

Some advocates, including Linus Pauling, a 1954 Nobel Prize laureate for chemistry, promoted mega doses of vitamin C for prevention of many diseases. This advocacy has fallen out of acceptability, with evidence of harmful effects of massive overdosage.

While frank scurvy is rare, except in severe environmental or national disaster situations, the prevalence of mild deficiency worldwide may be high. Data from the US National Health and Nutrition Examination Survey (NHANES) of 1988–94 indicated marginal deficiency in 9 percent of women and 13 percent in men, resulting from dietary deficiency in vegetable intake and chronic disease conditions.

Defining which foods belong to fruits and which ones to vegetables varies between European countries and no common definition exists, leading to difficulties in comparisons of the member countries. The United Nations Food and Agriculture Organization (FAO) provides data that indicate a marked north-south gradient in fruit and vegetable consumption in Europe. Countries in northern and eastern Europe have low consumption of vitamin C, while southern European countries, such as Italy, Greece, and Israel have high levels of vitamin C in the Mediterranean diet. The European Region of the WHO reports that fruit and vegetable consumption can vary widely and affect population health such as between European Region countries, as seen in Figure 1.1.

Figure 1.1 Average amount of fruit and vegetables available per person per year (kg) in selected European countries. Source: World Health Organization European Region. Health for All Data Base, July 2016. Available at: http://data.euro.who.int/hfadb/ (accessed 24 June 2017).

Economic Issues

MNDs rarely occur alone and are often associated and interactive with chronic illness, thus adversely effecting treatment outcomes and associated costs, such as in patients with cancer, AIDS, renal dialysis, and others. The economic consequences of MNDs, including vitamin C deficiency, are also related to low work capacity and productivity. Economic growth requires improved health of adults in work, children in development, and education capacity. The World Bank and other economic agencies place nutritional security high in priority for economic progress in low- and medium-income countries. The Food and Agriculture Organization of the United Nations (FAO) suggests that "investing US$1.2 billion annually in micronutrient supplements, food fortification and biofortification of staple crops for five years would generate annual benefits of US$15.3 billion, a benefit-to-cost ratio of almost 13 to 1." (FAO, 2017). The benefits from investing in micronutrient supplements, food fortification, and biofortification of staple crops would generate better health, fewer deaths, and increased economic growth.

Agriculture policies in high-income countries, where farmers' unions and corporate farming are politically powerful, provide high levels of subsidies to the traditional commodity crops, mainly wheat, corn, beans, cotton, dairy, sugar and meat agriculture. Support for specialty crops which include fruit and vegetables are much more limited, for specific programs such as crop insurance, disaster assistance, pest and disease protection, and research. These policies, common in the United States, Canada, and Europe, provide subsidies to the least healthful foods. But much less support is available for fruit and vegetables, the healthiest component for national consumption. This limits availability at affordable costs for large sectors of the population even in high income countries. Such policies are counterproductive for health; they promote low nutritional value products at low cost increasing their consumption, while deterring healthful nutrition by cost and availability factors. This policy paradox is a contributor to growing obesity especially among the poorer sectors of society.

Malnourishment includes subclinical conditions where one or multiple vitamins and essential minerals are missing from the regular diet or, in the case of vitamin D, when sunlight exposure is inadequate to produce sufficient amounts of this essential vitamin in the skin to meet the needs of bone health. Lowered vitamin C intake can occur in the elderly and chronically ill with cancer, AIDS, renal disease, or in common situations where there are low levels of vegetable and fruit consumption. Chronic illness aggravated by lethargy, poor appetite and difficulty in chewing vegetables can be a factor for susceptibility to infection and avoidable prolongation of lengthy and costly stay in acute care hospitals.

WHO addresses scurvy, along with pellagra and thiamine deficiency, as serious problems in emergency situations, where adequate nutrition is not available or absorbed. Fortification of basic foods is a widely practiced public health measure to protect vulnerable populations or situations. National and international aid agencies need to recognize multivitamin supply as crucial for preventive care in refugee, disaster, and war situations. International refugee agencies, donors, and national governments should prioritize nutritional support for the most vulnerable i.e., pregnant women, infants, and children with essential vitamin and mineral supplements. This is a major global ethical challenge when donor fatigue is reducing resources available, and refugee populations have soared to reach 66 million persons globally in 2017.

Conclusion

Lind’s pioneering study showed that citrus fruit in the diet cures and prevents scurvy. As a result, this practice was adopted as a standard method of preserving the health of late 18th century British sailors on long voyages. As knowledge of nutrition gained momentum in the 20th century, vitamin C in adequate amounts was found to be an important component of health promotion. Healthy diets with regular consumption of vegetables and fruit prevent vitamin C deficiency and frank scurvy. But low levels of vitamin C can be masked, especially in vulnerable populations, and may cause serious manifestations after 2–3 months. Frank scurvy in adults manifests symptoms such as lassitude, weakness and irritability, swollen bleeding gums, vague muscle or joints pain in legs and feet, weight loss, peripheral edema, and impaired work capacity. Moreover, internal bleeding can be fatal. In infants, scurvy leads to irritability, leg tenderness, and paralysis. Additionally, vitamin C deficiency impairs resistance to infections.

Cultural and traditional dietary patterns are important factors in the epidemiology of many important health conditions such as stroke, coronary heart disease, and cancer of lung and other cancers. Vegetable and fruit consumption are one of the key factors in the health benefits of the Mediterranean diet, compared to many traditional and current diets in Eastern Europe, or in the southern region of the United States sometimes called the Stroke Belt.

Prevention of vitamin C deficiency depends on a healthful diet of vegetables and fruits, which are also effective in preventing cardiovascular diseases and cancer. Along with regular exercise, regular vegetable and fruit consumption is considered among the most effective public health measures of self-care and population health.

Lind’s pioneering investigation opened policy issues around the prevention of a specific dietary deficiency disease that led to new energies, explorations, studies, and recognition of nutritional sciences, epidemiology and policy. With 2 billion people estimated to have hidden hunger with MNDs globally, the public health challenges are enormous, but thanks to Lind and his successors we have the knowledge to reduce this burden on global health.

Food and nutrition security is not only an individual problem but also a national and global issue. FAO and WHO emphasize that the societal cost of undernutrition (and overnutrition) in terms of health, societal, and economic is high. Investing in solutions can improve long-term nutritional outcomes. Improved policies for education, monitoring and food systems of production, and marketing can greatly improve nutritional security as part of the food security. National agricultural policies and subsidies to promote low cost fruit and vegetable production at least comparable to farm subsidies to dairy, meat and sugar production are important to increase their affordability, popularity and consumption. This not only requires both physical and financial access to nutritious foods at affordable prices but also enhanced nutritional value of basic foods and supplementation of essential vitamins and minerals to vulnerable populations. Many of these food system changes must be directed by well-coordinated nutrition policies from governments, the private sector, and families themselves. Today, there is wide knowledge and many tools are available such as community-wide education for better dietary practices, in schools, homes, workplaces, institutional settings and others. Poverty reduction to improve access to healthy diets, essential micronutrient supplements, and fortification of basic foods are vital public health policy issues globally.

Recommendations

International organizations, national, state and local governments, private donor agencies and the private sector should undertake population based nutrition policies for implementation globally:

1. Promote fruit and vegetable consumption in home, school, work, catering, public eating places, and institutional settings.

2. Promote education for fruit and vegetable consumption in education and health system programs.

3. Promote policies and implementation of well regulated fortification of basic foods with vitamin C and other essential micronutrients, including iron, iodine, magnesium, selenium, folic acid, vitamin B complex, vitamin D and others.

4. Promote adoption of policies and implementation of vitamin C and multivitamins supplements for high-risk population groups such as pregnant and lactating women, infants and toddlers, chronically ill persons, homeless and other deprived or institutionalized groups.

5. Promote fruit and vegetable marketing in poor urban neighborhoods and isolated remote communities.

6. Promote national and international agriculture policies with subsidies to encourage fruit and vegetable production and marketing at low cost in preference or at least as are provided to other agriculture sectors such as dairy, sugar and meat production.

7. Promote surveys on fruit and vegetable consumption as a regular component of nutrition monitoring.

8. Disaster preparation should include provision of vitamin C and multivitamins for situations of long-term deprivation of normal societal conditions of supply and home economics.

Student Review Questions

1. Why is Lind’s study of scurvy considered a pioneering epidemiologic study?

2. What is a randomized clinical trial? What are its strengths and weaknesses?

3. Give three examples of current nutritional deficiency conditions in your own country.

4. What are the options for preventing these deficiencies in your country?

5. How does vitamin C deficiency affect people with chronic diseases?

6. Describe a study that could demonstrate an effective intervention to prevent that deficiency condition.

7. Describe high-risk situations in which vitamin C and other micronutrient supplements should be part of health care.

8. Explain why multivitamin supplements are preferred for pregnancy and elderly care rather than a few individual vitamins and minerals.

9. What preparation should be taken for prevention of frank or subclinical micronutrient deficiency conditions in emergency situations?

10. How do agricultural policies affect national fruit and vegetable consumption and relate to population health?

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Chapter 2

Edward Jenner, Vaccination and Eradication of Smallpox

Abstract

In 1796, Edward Jenner (1749–1823), a country physician in Gloustershire, England, investigated local beliefs that milkmaids were immune to smallpox because of their exposure to cowpox. He took matter from a cowpox pustule of a milkmaid and applied it with scratches to the skin of a young boy named James Phipps, who was later inoculated with smallpox and did not develop the disease. Smallpox continued to be a periodic pandemic worldwide with millions of sufferers and deaths. In 1953 the World Health Assembly (WHA) the governing body of the World Health Organization (WHO) rejected the notion that smallpox should be selected for eradication. But gradual expansion of smallpox vaccination globally during the 20th century led WHO in 1966 to declare eradication of smallpox as a global health target. In 1967 a year with more than 10 million smallpox cases and 2 million deaths in 43 countries, implementation of the eradication campaign was launched. The campaign was conducted by the WHO in cooperation with many agencies and countries, with combined strategies of mass vaccination and focal eradication based on case reporting and localized vaccination to prevent spread of the disease. The campaign was assisted by many innovations and use of volunteer community health workers. The last known case was identified in Somalia in 1977, and the WHO declared that global eradication of smallpox was accomplished in 1980. This enormous achievement has set precedents for global eradication of other infectious diseases including poliomyelitis, measles, and many others.

Keywords

Edward Jenner; smallpox; vaccination; Donald Henderson; World Health Organization; smallpox eradication; disease eradication

Background

Smallpox, a devastating and disfiguring epidemic disease, ravaged all parts of the world and has been known since the third century BCE (Before the Common Era). Described first by Rhazes, a Persian physician, in the tenth century CE (Common Era), the disease was confused with measles and was widespread in Asia, the Middle East, and Europe during the Middle Ages. It was clearly designated as a cause of death in the London Bills of Mortality in 1629. Smallpox epidemics occurred throughout the 17th, 18th, and 19th centuries primarily as a disease of childhood, with mortality rates between 25 percent and 40 percent or more and disfiguring sequelae. Smallpox was also a key factor in the near elimination of the Aztecs and other societies in Central and South America following the Spanish invasion. The disease was spread deliberately as an act of war in North America in the late 18th century and naturally by person to person transmission and on contaminated personal contact materials such as bedding.

Edward Jenner (1749–1823)

The first experiment to test this theory involved milkmaid Sarah Nelmes and James Phipps, the 8 year-old son of Jenner's gardener. Dr. Jenner took material from a cowpox (variola) sore on her hand and inoculated it into Phipps' arm. Months later, Jenner exposed Phipps a number of times to variola virus, but Phipps never developed smallpox. More experiments followed, and, in 1801, Jenner published his treatise "On the Origin of the Vaccine Inoculation, summarizing his discoveries and expressing hope that the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice." Source: Photo courtesy of the National Library of Medicine. Available at: https://www.cdc.gov/smallpox/history/history.html (accessed 11 August 2017).

Donald Ainslie Henderson