What can we learn from the history of vaccines fancy

From cows to coronavirus and the museum's collection: the history of vaccine development shaped our ability to respond to worldwide pandemics. As COVID-19 is recorded into history what will it teach societies of the future?

Banner image: Copyright Doherty Institute for Infection and Immunity 2020
Photographer: Dr Jason Roberts; Electron Microscopist: Dr Andrew Leis

Please note: this article features graphic images of people suffering from smallpox and measles.

A world without vaccines would be very different to the one we have today—and more dangerous.

Vaccines are ‘our single most important medical intervention that has saved more lives than anything else,’ says Professor Marc Pellegrini, joint division head of infectious disease and immune defence at WEHI.

In a nutshell, vaccines educate your immune system by stimulating an immune response without giving you the full disease.

This allows your immune system to recognise, and fight against, the real invader if you are ever exposed to it.

It is easy to take for granted just how vital these medical marvels have been for humankind in reducing child mortality and improving our quality and longevity of life.

When we really need vaccines, but don’t have them, we are incredibly vulnerable—a situation acutely felt with the outbreak of COVID-19.

With no other option, those early days of the pandemic necessitated a return to masks and physical distancing to reduce disease transmission.

It was a similar story 100 years ago during the 1918 influenza pandemic, commonly (but unfairly) referred to as the Spanish flu.

Bank tellers wearing face masks. — MM 135982 – Bank Tellers Wearing Face Masks, Victoria, 1919
View in MUSEUMS VICTORIA COLLECTIONS

The major difference, though, is that scientists today know what they are fighting against.

Part of the vaccine history collection at Museums Victoria. Photo: Photographer: Michelle McFarlane/Museums Victoria

Influenza

When the influenza pandemic first emerged at the end of World War I in 1918, no one understood what caused it.

‘Cinemas, schools, racecourses and even state borders were closed in an unsuccessful attempt to halt the spread,’ says Dr Johanna Simkin, senior curator of human biology and medicine at Museums Victoria.

‘Hospitals were overwhelmed, and Melbourne’s Royal Exhibition Building was turned into a temporary hospital.’

Hospital beds line the Exhibition Building's great hall during the influenza pandemic in 1919.

A vaccine was quickly developed, but scientists at this time didn’t know that influenza was caused by a virus.

The vaccine was instead made to target secondary bacterial infections and was not effective.

It was not until 1933 that scientists first identified the flu virus in an H1N1-type strain.

H1N1 viruses have been behind everything from worldwide pandemics (including in 1918, 1977 and 2009) to seasonal flu.

‘The flu is one of those that is able to mutate quite easily,’ says Dr Simkin.

a woman in a laboratory — Dr Johanna Simkin manages Museum Victoria's health and medicine collection.

Scientists constantly monitor outbreaks at worldwide surveillance centres and alter vaccines accordingly: ‘That's why we all need to get our vaccines every year.’

And, as we will later learn, mutation of a pathogen can work both for and against us.

While it is impossible to know exactly how many died in the 1918-19 pandemic, estimates vary between about one and five per cent of the world’s population of 1.8 billion people.

If the same thing were to happen today, that would equate to nearly 400 million deaths—the combined populations of France and the USA.

So, it is a good thing we have become a lot better at making flu vaccines.

But that’s not to say all vaccines before the 1918 flu were impotent; the first vaccine ever created was so successful that we no longer have to worry about that disease at all.

Hospital beds line the Exhibition Building's great hall during the influenza pandemic in 1919. Photo: Museum Victoria

Small Pox

COVID-19 nearly brought the world to a standstill and has dominated daily aspects of our lives.

But as horrible as this disease is, smallpox was worse.

A girl covered in sores — A girl with smallpox in 1890.

Once the ‘scourge of the human species’, the earliest physical evidence for smallpox is found in scars of mummified Egyptian pharaohs 3,000 years ago but it is believed to be much more ancient.

Patients would come down with a fever, flu-like symptoms and a distinctive skin rash that progressed to fluid-filled blisters.

It killed nearly a third of everyone it infected, and left survivors badly scarred.

But when Europeans introduced smallpox to Australia in the late 1700s it was much more lethal to First Peoples, who had no previous exposure.

Messengers from First Peoples clans travelled to warn their neighbours of the disease but, in doing so, unknowingly spread smallpox themselves.

It devastated entire communities, particularly along river systems.

Elderly people told European observers the death toll was so high in some cases that their dead could not be buried.

The first real attempt to fight against smallpox came in the form of variolation—the precursor to vaccination.

It involved exposing someone to a mild dose of smallpox, to give their body the chance to develop immunity.

But this process carried its own risks.

So, when an English doctor named Edward Jenner discovered a more effective, and safer way, people really took notice.

‘Like all good scientific discoveries, it came about by accident,’ says Dr Simkin.

Jenner observed that milkmaids who had been infected with cowpox appeared immune to smallpox.

He tested this theory in 1796 by inoculating an eight-year-old farm hand, James Phipps, with cowpox before exposing him to smallpox.

Fortunately for James, and the rest of us, it worked.

Jenner named the treatment vaccination (from vacca, Latin for cow) and in 1801 wrote: ‘The annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice’.

And Jenner was right in his prediction but it took 179 years and a concerted effort to get there.

His vaccine quickly spread around the world, replacing variolation as the preferred method of combatting smallpox.

Dr Jenner performing his first vaccination on James Phipps on 14 May, 1796, as painted by Ernest Board. Source: Wellcome Collection

‘That vaccine was incredibly brilliant,’ says Professor Pellegrini.

Keep in mind, this was more than 60 years before scientists established that disease was caused by microbes invading the body (germ theory).

Jenner himself had no idea of the minute scale on which his invention worked.

Scaling the invisible. Animation by Len Doublet.

Australia’s first doses of Jenner’s smallpox vaccine were delivered in 1804, the same year that Napoleon was crowned Emperor of France.

Victoria introduced a Compulsory Vaccination Act in 1854, which largely mitigated the threat and prevented major outbreaks.

The country’s last confirmed case of smallpox was during World War I, but Australians continued to be vaccinated for decades thereafter—many people alive today still carry the tell-tale scar from their immunisation.

‘It’s really important to keep up vaccination levels until you're sure that the disease does not exist anymore,’ says Dr Simkin.

‘There’s a reason that we still have vaccine regimens for all kids and adults.’

The disease remained a serious problem for many nations throughout much of the 1900s but in May 1980, the World Health Organisation announced the death of smallpox to the world.

Smallpox is so far the only human disease we have managed to conquer and this was only possible through vaccination.

We are close to eradicating other diseases, but as Professor Pellegrini says: ‘We've been saying we’re close to [eliminating polio] for the last 20 years.

‘To actually eliminate a virus requires virtually 100 per cent immunisation.’

This Spanish advertisement from the 1940s reads 'get vaccinated against smallpox'. Source: Wellcome collection

Polio

Like smallpox, there are few people alive in the developed world today who truly know the horrors of polio, again, thanks to vaccination.

Many people who survived polio required the use of an iron lung for the rest of their lives.

A man encased in a large metal box. His head is exposed and a nurse is smiling down at him — An iron lung surrounded the patient’s body, except for their head, creating a vacuum that pumped air in and out of their lungs. A mirror mounted above the head allowed patients to see their surroundings.

Polio, or poliomyelitis, is highly infectious and predominantly affects children under the age of five.

Most people infected show no symptoms but in one in every 200 cases the virus attacks the nervous system, causing permanent paralysis.

Up to one in ten of those paralysed die because their breathing muscles have stopped responding.

The saviour of many polio patients came in the shape of a coffin-like machine, known as an iron lung.

Small boy on crutches with legs in callipers

a black and white photo of a man wearing glasses and a white coat sits at a desk holding a pen

There was a time when thousands of them filled hospitals across the world but fortunately, the most likely place you’ll find an iron lung now is in a museum.

One of the biggest issues with the development of vaccines for any disease, explains Dr Simkin, is funding.

‘Even back then—can you get media coverage to get people interested enough to give researchers the money, so they can actually do the research?

‘If a rich population is being particularly affected by something, generally that rich population puts money into developing a cure.’

In the case of polio, that population was the United States of America and among those diagnosed was a president.

a man in a wheelchair and a dog on his lap smiles at a small girl beside him — Roosevelt was rarely seen in his wheelchair, but he publicly championed the cause of polio patients.

Franklin D Roosevelt was paralysed below the waist at age 39 and it was his advocacy and fundraising efforts that led to the development of two vaccines.

Some children with polio suffered muscle paralysis. Crutches and braces took on the work of paralysed muscles to keep legs straight. Photo: Winton Irving/Copyright Northcott Disability Services

American virologist Dr Jonas Salk was the first to develop a safe and effective vaccine against polio, using an inactivated virus—a technique he learned from researching the flu virus.

At the time, the most prominent view was that only a live virus could stimulate the immune system to recognise and fight the disease.

But Salk didn’t want to risk infecting the patient and took the unusual step killing the virus in a formaldehyde solution.

He announced his vaccine was ready for trials in 1953 but it took two years before it was finally approved for use.

Before the vaccine’s release in the US, there was an average of 45,000 cases every year but by 1962 there were just 910—Salk was hailed as a hero.

The vaccine arrived in Australia in 1956 and in that year alone more than one million Victorians rolled up their sleeves.

It reduced the number of cases 20-fold in the space of 12 months.

But Salk’s vaccine had its limitations.

In Australia herd immunity was not reached quickly enough and by 1961 there was another outbreak.

Jonas Salk Photo: Theodore Hall Collection/San Diego Air and Space Museum Archive

A rival of Salk’s, Dr Albert Sabin, developed his own attenuated live virus vaccine that could be administered orally, provided longer-lasting immunity, and was much cheaper to manufacture.

It took over as the preferred vaccine in global eradication efforts and is responsible for much of polio’s decline.

Australia hasn’t had a case since 1979, while the USA has been polio-free since 1994.

However, in extremely rare cases (one in 2.7 million doses) the live virus in Sabin’s vaccine can mutate and cause a case of a paralytic polio.

It is for this reason that the World Health Organisation has recommended a return to using the killed virus vaccine.

Salk’s vaccine is still being used in Australia, where more than 95 per cent of children aged five and under are immunised.

The reason for that, explains Dr Simkin, is that there are still two remaining strains of polio yet to be eradicated.

‘It’s still around the world, and [there is still a risk of polio] because of the huge amount of movement of humans around the globe.’

Albert Sabin. Source: Courtesy Hauck Center for the Albert B. Sabin Archives, Henry R. Winkler Center for the History of the Health Professions, University of Cincinnati Libraries

In 1988, the Global Polio Eradication Initiative was launched by over 200 participating countries.

In 1994, Polio was declared eradicated from the Americas.

Polio cases have dramatically declined across the world since 2014 but the disease persists in parts of central Africa, Afghanistan and Pakistan.

The number of cases has increased in recent years, in part because vaccination efforts have been set back by the COVID-19 pandemic.

According to the World Health Organisation: ‘Failure to eradicate polio from these last remaining strongholds could result in as many as 200,000 new cases every year, within 10 years, all over the world.’

And we have reason to be concerned about that possibility because when vaccination rates drop, some diseases come back with a vengeance.

Whooping Cough

Pertussis (or whooping cough) is wildly infectious, debilitating, and difficult to treat but, importantly, preventable.

It is most dangerous, and even deadly, to infants but coughing from pertussis can be so violent that adults lose control of their bladder, pass out or even break ribs.

An effective vaccine was first produced the 1940s and has been steadily improved since—it is now found in a combined vaccine with diphtheria and tetanus.

Unfortunately, the whooping cough vaccine has also been the target of the anti-vaccine movement which has caused the disease’s resurgence in several countries.

A young boy is presented to a clinic suffering from what was diagnosed as pertussis. Source: Centers for Disease Control/Public Health Image Library

Whooping cough continues to circulate around the world. Animation by Len Doublet.

Pertussis seemed well under control up until the 1970s, when a report linked the vaccine to neurological damage in children—a condition later proven not to be related to vaccines but infantile epilepsy.

The United Kingdom, Sweden and Japan subsequently decreased their vaccination programs and all experienced whooping cough epidemics.

Australia’s vaccination rates followed suit, not because of a change in government policy but, because of misinformation.

Doctors also expressed concern at the safety of the vaccine, despite the evidence.

It was enough to give whooping cough a foothold and now Australia has one of the highest rates of pertussis in the world, despite its vaccination rates returning to high levels.

Because the virus has been allowed to circulate in a large population, it has given it the opportunity to mutate and adapt.

The vaccine that was designed to work against the previous strain is no longer as effective and a new one is now needed to get on top of it again.