PUBLIC HEALTH, THEN AND NOW

Feb 14, 2017 by

PUBLIC HEALTH THEN AND NOW
|
American Journal of Public Health
Hendriks and Blume
|
Peer Reviewed
|

Jan Hendriks, MSc, and Stuart Blume, PhD, MA

At the beginning of the 1960s, it was clear that a vaccine against measles would soon be available.
Although measles was (and remains) a killer disease in the developing world, in the United States
and Western Europe this was no longer so. Many parents and many medical practitioners considered
measles an inevitable stage of a child’s development. Debating the desirability of measles immuniza-
tion, public health experts reasoned differently. In the United States, introduction of the vaccine fit
well with Kennedy’s and Johnson’s administrations’ political commitments. European policymakers
proceeded cautiously, concerned about the acceptability of existing vaccination programs. In Sweden
and the Netherlands, recent experience in controlling polio led researchers to prefer an inactivated
virus vaccine. Although in the early 1970s attempts to develop a sufficiently potent inactivated vaccine
were abandoned, we have argued that the debates and initiatives of the time during the vaccine’s
early history merit reflection in today’s era of standardization and global markets. (
Am J Public Health
.
2013;103:1393–1401. doi:10.2105/AJPH.2012.301075)
clinical trial had gained in Britain.
We have looked in detail at the
introduction of the measles vac-
cine, focusing not only on the
United States and Britain but on
two other European countries (the
Netherlands and Sweden) as well.
Responses to the development
of the first measles vaccines con-
firm Baker’s contrast between
American and British styles, the
one marked by a sense of
urgency, the other by a cautious
insistence on randomized trial
data. But our analysis suggests
that, in addition, two other con-
siderations influenced policymak-
ers: one was the national
experience with polio vaccination
just a few years previously, which
differed in these four countries;
the other was the European pub-
lic health authorities’ concern
with the implications of introduc-
ing a new vaccine for the national
immunization program, as a
whole, and for popular confi-
dence in it, in particular.
THE SEARCH FOR A
MEASLES VACCINE
By the early 1960s the epide-
miology of measles was well
understood. It was known that the
disease occurred throughout the
world, generally in regular peri-
odic cycles. With the exception of
Before the Measles-Mumps-Rubella Vaccine
EXAMINING THE INTRODUCTION
of four pediatric vaccines (diph-
theria antitoxin and the pertussis,
polio, and measles vaccines),
Baker has argued that the middle
years of the 20th century dis-
played distinctive national styles
of vaccine innovation
1
: whereas
US vaccine development and im-
plementation were marked by a
“current of urgency,” the more
cautious British set much higher
standards for the evidence re-
quired to p
rove
the safety and ef-
fectiveness of a new vaccine be-
fore deciding on its introduction.
This, in turn, could be attributed
to the influence that the statisti-
cal pioneers of the randomized
V
ACCINATIO
N
MEASLES
MEASLES
M
PUBLIC HEALTH THEN AND NOW
August
2013, Vol 103, No. 8
|
American Journal of Public Health
Hendriks and Blume
|
Peer Reviewed
|
Public Health Then and Now
|
1393
|
Jan Hendriks, MSc, and Stuart Blume, PhD, MA
At the beginning of the 1960s, it was clear that a vaccine against measles would soon be available.
Although measles was (and remains) a killer disease in the developing world, in the United States
and Western Europe this was no longer so. Many parents and many medical practitioners considered
measles an inevitable stage of a child’s development. Debating the desirability of measles immuniza-
tion, public health experts reasoned differently. In the United States, introduction of the vaccine fit
well with Kennedy’s and Johnson’s administrations’ political commitments. European policymakers
proceeded cautiously, concerned about the acceptability of existing vaccination programs. In Sweden
and the Netherlands, recent experience in controlling polio led researchers to prefer an inactivated
virus vaccine. Although in the early 1970s attempts to develop a sufficiently potent inactivated vaccine
were abandoned, we have argued that the debates and initiatives of the time during the vaccine’s
early history merit reflection in today’s era of standardization and global markets. (
Am J Public Health
.
2013;103:1393–1401. doi:10.2105/AJPH.2012.301075)
clinical trial had gained in Britain.
We have looked in detail at the
introduction of the measles vac-
cine, focusing not only on the
United States and Britain but on
two other European countries (the
Netherlands and Sweden) as well.
Responses to the development
of the first measles vaccines con-
firm Baker’s contrast between
American and British styles, the
one marked by a sense of
urgency, the other by a cautious
insistence on randomized trial
data. But our analysis suggests
that, in addition, two other con-
siderations influenced policymak-
ers: one was the national
experience with polio vaccination
just a few years previously, which
differed in these four countries;
the other was the European pub-
lic health authorities’ concern
with the implications of introduc-
ing a new vaccine for the national
immunization program, as a
whole, and for popular confi-
dence in it, in particular.
THE SEARCH FOR A
MEASLES VACCINE
By the early 1960s the epide-
miology of measles was well
understood. It was known that the
disease occurred throughout the
world, generally in regular peri-
odic cycles. With the exception of
Before the Measles-Mumps-Rubella Vaccine
EXAMINING THE INTRODUCTION
of four pediatric vaccines (diph-
theria antitoxin and the pertussis,
polio, and measles vaccines),
Baker has argued that the middle
years of the 20th century dis-
played distinctive national styles
of vaccine innovation
1
: whereas
US vaccine development and im-
plementation were marked by a
“current of urgency,” the more
cautious British set much higher
standards for the evidence re-
quired to p
rove
the safety and ef-
fectiveness of a new vaccine be-
fore deciding on its introduction.
This, in turn, could be attributed
to the influence that the statisti-
cal pioneers of the randomized
V
ACCINATIO
N
MEASLES
MEASLES
M
PUBLIC HEALTH THEN AND NOW
August
2013, Vol 103, No. 8
|
American Journal of Public Health
Hendriks and Blume
|
Peer Reviewed
|
Public Health Then and Now
|
1393
|
Jan Hendriks, MSc, and Stuart Blume, PhD, MA
At the beginning of the 1960s, it was clear that a vaccine against measles would soon be available.
Although measles was (and remains) a killer disease in the developing world, in the United States
and Western Europe this was no longer so. Many parents and many medical practitioners considered
measles an inevitable stage of a child’s development. Debating the desirability of measles immuniza-
tion, public health experts reasoned differently. In the United States, introduction of the vaccine fit
well with Kennedy’s and Johnson’s administrations’ political commitments. European policymakers
proceeded cautiously, concerned about the acceptability of existing vaccination programs. In Sweden
and the Netherlands, recent experience in controlling polio led researchers to prefer an inactivated
virus vaccine. Although in the early 1970s attempts to develop a sufficiently potent inactivated vaccine
were abandoned, we have argued that the debates and initiatives of the time during the vaccine’s
early history merit reflection in today’s era of standardization and global markets. (
Am J Public Health
.
2013;103:1393–1401. doi:10.2105/AJPH.2012.301075)
clinical trial had gained in Britain.
We have looked in detail at the
introduction of the measles vac-
cine, focusing not only on the
United States and Britain but on
two other European countries (the
Netherlands and Sweden) as well.
Responses to the development
of the first measles vaccines con-
firm Baker’s contrast between
American and British styles, the
one marked by a sense of
urgency, the other by a cautious
insistence on randomized trial
data. But our analysis suggests
that, in addition, two other con-
siderations influenced policymak-
ers: one was the national
experience with polio vaccination
just a few years previously, which
differed in these four countries;
the other was the European pub-
lic health authorities’ concern
with the implications of introduc-
ing a new vaccine for the national
immunization program, as a
whole, and for popular confi-
dence in it, in particular.
THE SEARCH FOR A
MEASLES VACCINE
By the early 1960s the epide-
miology of measles was well
understood. It was known that the
disease occurred throughout the
world, generally in regular peri-
odic cycles. With the exception of
Before the Measles-Mumps-Rubella Vaccine
EXAMINING THE INTRODUCTION
of four pediatric vaccines (diph-
theria antitoxin and the pertussis,
polio, and measles vaccines),
Baker has argued that the middle
years of the 20th century dis-
played distinctive national styles
of vaccine innovation
1
: whereas
US vaccine development and im-
plementation were marked by a
“current of urgency,” the more
cautious British set much higher
standards for the evidence re-
quired to p
rove
the safety and ef-
fectiveness of a new vaccine be-
fore deciding on its introduction.
This, in turn, could be attributed
to the influence that the statisti-
cal pioneers of the randomized
V
ACCINATIO
N
MEASLES
MEASLES
M

 American Journal of Public Health
Hendriks and Blume
|
Peer Reviewed
|
Public Health Then and Now
|
|
Jan Hendriks, MSc, and Stuart Blume, PhD, MA
At the beginning of the 1960s, it was clear that a vaccine against measles would soon be available.
Although measles was (and remains) a killer disease in the developing world, in the United States
and Western Europe this was no longer so. Many parents and many medical practitioners considered
measles an inevitable stage of a child’s development. Debating the desirability of measles immuniza-
tion, public health experts reasoned differently. In the United States, introduction of the vaccine fit
well with Kennedy’s and Johnson’s administrations’ political commitments. European policymakers
proceeded cautiously, concerned about the acceptability of existing vaccination programs. In Sweden
and the Netherlands, recent experience in controlling polio led researchers to prefer an inactivated
virus vaccine. Although in the early 1970s attempts to develop a sufficiently potent inactivated vaccine
were abandoned, we have argued that the debates and initiatives of the time during the vaccine’s
early history merit reflection in today’s era of standardization and global markets. (
Am J Public Health
.
2013;103:1393–1401. doi:10.2105/AJPH.2012.301075)
clinical trial had gained in Britain.
We have looked in detail at the
introduction of the measles vac-
cine, focusing not only on the
United States and Britain but on
two other European countries (the
Netherlands and Sweden) as well.
Responses to the development
of the first measles vaccines con-
firm Baker’s contrast between
American and British styles, the
one marked by a sense of
urgency, the other by a cautious
insistence on randomized trial
data. But our analysis suggests
that, in addition, two other con-
siderations influenced policymak-
ers: one was the national
experience with polio vaccination
just a few years previously, which
differed in these four countries;
the other was the European pub-
lic health authorities’ concern
with the implications of introduc-
ing a new vaccine for the national
immunization program, as a
whole, and for popular confi-
dence in it, in particular.
THE SEARCH FOR A
MEASLES VACCINE
By the early 1960s the epide-
miology of measles was well
understood. It was known that the
disease occurred throughout the
world, generally in regular peri-
odic cycles. With the exception of
Before the Measles-Mumps-Rubella Vaccine
EXAMINING THE INTRODUCTION
of four pediatric vaccines (diph-
theria antitoxin and the pertussis,
polio, and measles vaccines),
Baker has argued that the middle
years of the 20th century dis-
played distinctive national styles
of vaccine innovation
1
: whereas
US vaccine development and im-
plementation were marked by a
“current of urgency,” the more
cautious British set much higher
standards for the evidence re-
quired to p
rove
the safety and ef-
fectiveness of a new vaccine be-
fore deciding on its introduction.
This, in turn, could be attributed
to the influence that the statisti-
cal pioneers of the randomized
VACCINATION MEASLES
MEASLES
MEASLES
PUBLIC HEALTH THEN AND NOW
American Journal of Public Health
|
August
2013, Vol 103, No. 8
1394
|
Public Health Then and Now
|
Peer Reviewed
|
Hendriks and Blume
some isolated population groups,
almost all children contracted
measles before they reached ado-
lescence. No nonhuman sources
of infection were known.
By 1960, thanks to the use of antibi-
otics and imp
rovements in living
conditions, measles mortality was
declining steadily in industrialized
countries (although not in the
developing world). For example,
in the United Kingdom deaths
from measles had fallen from 307
in 1949 to 98 in 1959.
3
Parents
largely came to see measles as an
unpleasant, although more or less
inevitable, part of childhood.
Many primary care physicians
shared this view.
In the early 1960s researchers
in numerous US and European
laboratories were, nevertheless,
trying to develop a measles vac-
cine. Building on their earlier
success with the poliovirus, in
1954 John Enders and his Har-
vard colleagues succeeded in cul-
turing the measles virus. Because
their initial sample was taken
from a boy named David
Edmonston, the strain became
known as the Edmonston strain.
By 1960, Katz, Enders, and Hol-
loway had shown that their
Edmonston strain, suitably atten-
uated, stimulated production of
measles antibodies in susceptible
children.
4
Because it was found to be too
reactogenic, Enders and his col-
leagues set about attenuating it
further. Enders wanted to
encou
rage other investigators and
made the strain freely available.
Very soon numerous other
researchers (including Anton
Schwarz at American Home Prod-
ucts and Maurice Hilleman at
Merck) were also working at
attenuating it further.
5
In addition,
inspired by Salk’s earlier develop-
ment of an inactivated polio vac-
cine, other laboratories were
developing inactivated (killed
virus) vaccines. One or more safe
and effective vaccines seemed
within reach. But were they
needed and would they be used?
Although measles claimed the
lives of 1 to 2 million children
annually in developing countries,
few of these countries had ade-
quately organized immunization
programs at this time.
6
In the
United States and Western
Europe, which did, measles mor-
tality was low and declining and
parents seemingly accepted it as
an unpleasant part of childhood.
What reasons could there be for
introducing a measles vaccine?
In March 1963 the first two
measles vaccines were app
roved
for use in the United States: a
live vaccine produced by Merck
(
Rubeovax
) and a formalin-inacti-
vated one produced by Pfizer
(
Pfizer-Vax Measles–K
).
7
In Sep-
tember 1963 the US Surgeon
General Luther Terry published
a statement on the status of mea-
sles vaccines.
8
The live vaccine
had by this time been given to
some 25 000 people in the
United States. A single dose pro-
duced an effective antibody
response in more than 95% of
susceptible children—a response
that trials had shown persisted
for at least three years. Although
30% to 40% of these children
showed signs of temporary high
fever and a rash after vaccina-
tion, side effects could be
reduced by coadministration of
γ
globulin. The inactivated vac-
cine was generally administered,
in field trials, on a three-dose
monthly schedule. Although this
produced no side effects, anti-
body levels were lower than
with the live vaccine, and it was
not known whether they per-
sisted beyond six months.
9
A
combined schedule had also
been tried. If a dose of inacti-
vated vaccine was given a month
or so before the live vaccine,
reactions caused by the live vac-
cine were greatly reduced. The
surgeon general recommended
that children without a history
of measles be immunized at
approximately aged nine
months.
10
There seemed to be
no reason to begin a mass immu-
nization program; the decision
to immunize could be left to
individual medical practitioners
and parents.
The situation in the early
1960s was thus that live attenu-
ated vaccines appeared to offer
long-term protection against
measles. Their side effects, how-
ever, were a matter of concern,
and attempts to develop further
attenuated, less reactogenic
strains continued. (The Schwarz
strain would be licensed in 1965,
and Merck’s more attenuated
“Moraten” strain in 1968.) Inacti-
vated vaccine produced no side
effects, but it was unclear
whether it could provide protec-
tion of adequate duration. If pro-
tection was of too short duration,
there was a risk of measles infec-
tion being postponed to an older
age, when its effects could be
more serious.
US AND UK IMMUNIZATION
POLICY, 1963–1968
Any decision to begin mass
measles vaccination in the early
1960s thus involved numerous
The situation in the early 1960s was thus that
live attenuated vaccines appeared to offer
long-term protection against measles. Their
side effects, however, were a matter of
concern, and attempts to develop further
attenuated, less reactogenic strains continued.

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