The 1947 Smallpox Vaccination Campaign in New York City, Revisited
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LETTERS The 1947 Smallpox Two days later, epidemiologic contrast, the Army and Navy had investigation indicated that all given almost 800,000 doses, and the Vaccination patients with diagnosed cases were city’s public health laboratories had Campaign in New related and that, in all likelihood, the made the remaining 400,000. York City, Revisited outbreak had been successfully halted During the shortage, the Times through tracing the movements of the noted, “hundreds of eager men, To the Editor: In 1947, millions of various patients and vaccinating any- women, and children queued up at New Yorkers received smallpox vacci- one who had contact with them, so- Bellevue Hospital at dawn, although nations, an accomplishment still appro- called “ring” vaccination (4). Despite vaccinations were not scheduled to priately held up as an example of pub- this halt of the outbreak, the city begin until 10 a.m. At some stations, lic health planning and mobilization. pushed forward. The campaign to “Be the crowds did not take kindly to the Although now mythological, a review sure, be safe, get vaccinated!” had news that the doctors had run out of of the events of April 1947, from proven successful. By city estimate, vaccine and the police had a little dif- copies of The New York Times (1–9), >600,000 persons had received vac- ficulty dispersing a crowd of several tells of a more recognizably human cine in the first week. hundred” outside one vaccine station response: pushing, jawing, deceit, Vaccine side effects, which domi- (5). shortages, surpluses, and perhaps a nate coverage of today’s vaccination On April 17, the situation bright- unusual way of counting vaccinees. program, were seldom discussed in ened, when more than a million doses In March 1947, a patient who had 1947. Dr. Weinstein assured residents, suddenly arrived from private labora- recently visited Mexico traveled by “Vaccination is painless. The skin is tories, and 500,000 persons were vac- bus to New York City. He became ill, not even broken by the needle. cinated (6). As the crisis slowly less- was hospitalized, and, after his death, Sometimes a soreness develops in the ened, doctors were recruited at US$8 found to have had smallpox. The occa- armpit. If the arm becomes very sore, (US$64 in today’s market) for a 3- sional case of smallpox had been seen apply an icebag” (4). This advice is hour session (or US$24 for all day; in the area for decades since the last simple compared to the depth and US$192 in today’s market) to admin- big outbreak in 1875, which had killed breadth of information given today to ister vaccine, but few volunteered. 2,000 New Yorkers. However, in a potential vaccinee. Now, volunteers Public health authorities in 1947, a second case and then a third are given several informational lec- Westchester County chided local appeared, and authorities became con- tures and a protracted individual inter- physicians for charging $35 per vac- cerned. On April 4, Israel Weinstein, view to discuss lingering questions, cine (7), and a 29-year-old woman, the New York City Health Com- and they are required to sign a docu- dressed up as a nurse, vaccinated 500 missioner, urged all New Yorkers who ment confirming adequate compre- people with water to impress her had not been vaccinated since child- hension and acceptance of the risks. “man companion” until she was sent hood to receive another vaccination. In the 1947 campaign, trouble to the Bellevue psychiatric ward for The program worked at the outset. began on April 16, when (no longer evaluation (8). Free vaccine clinics were established on page 1), the Times announced, Continued complaints about side throughout the city, and doses were “Vaccinations Stop; Drug Supply effects were dismissed by Dr. given to private physicians for admin- Gone; Thousands Turned Away” (5). Weinstein, who again advised those istration. During the first week, sur- With little warning, and at the height whose arm ached that they only need- prisingly little public attention was of the program, the vaccine supply ed to place an icebag in the armpit for captured (Times articles typically vanished, something that was never relief. Within a week, the program had were brief and confined to page 21). explained. After spending days gear- wound down and been proclaimed “a The story hit page 1 on April 13 (3), ing up citizens to receive the vaccine miracle” (2) by all involved. after a second person died from the quickly, the mayor and Dr. Weinstein The claim of 5 or 6 million vacci- disease. Mayor William O’Dwyer now had to downplay the urgency of nations administered cannot be recon- urged all 7.8 million New York resi- receiving vaccination. They assured ciled against the daily tally reported in dents to receive the vaccine. Then he New Yorkers that a delay of a few the Times. If one assumes that day-to- rolled up his sleeve and was vaccinat- days or more represented “no health day numbers reported in the newspa- ed by Dr. Weinstein. The city swiftly hazard” (5). per were roughly accurate, a simple swung into full crisis mode. Police, Of the 1.2 million doses distrib- calculation places the number of vac- fire, and health departments and hos- uted by April 16, 1947, 42,000 had cinees closer to 2.5 million, far short pitals were mobilized to provide addi- been supplied by private laboratories, of the announced total. For example, tional space for the effort. far short of the promised number. In on April 21, a grand total of 3.45 mil- 960 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 5, May 2004 LETTERS lion recipients were reported; the next Address for correspondence: Kent A. of cardiac or coronary deaths in 1947 day, after noting that only 200,000 Sepkowitz, Infectious Disease Service during the 2-week estimated risk peri- additional persons had received vac- Memorial Sloan-Kettering Cancer Center, New od after vaccination was 1,545. While cine, the total swelled to 4.4 million York, NY 10021, USA; fax: 212-717-3021; the denominator (number vaccinated (9). email: [email protected] in the previous 4–17 days) was not These data reflect the difficulties reported, a total of 6.4 million persons intrinsic to managing such a massive were vaccinated during the 4 weeks of program. The discrepancy may sim- the vaccination program. The 4-week ply be a case of not adding columns of vaccination period would result in a 6- numbers in a systematic way; howev- Smallpox week period of susceptibility for car- er, the fuzzy numbers do have a cer- diac death according to the 4–17 day tain appeal to the modern, more cyni- Vaccination and latency period. Thus, we extrapolate cal reader. Adverse Cardiac that the denominator for the 2-week Whatever occurred, understanding Events observation period is approximately the specifics of “the great vaccination 2.1 to 6.4 million vaccinees at risk miracle” of 1947 is important for To the Editor: The incidence of during the study period. This would maintaining equilibrium during our adverse cardiac events related to mean that approximately 240 to 720 current smallpox vaccination program smallpox vaccinations administered cardiac deaths occurred per million and any future programs directed at during the National Smallpox vaccinees. now-unanticipated infections. Not Vaccination Program (NSVP) in 2003 Suppose that the 1947 smallpox just New York City’s, but the entire has received widespread attention. vaccine indeed caused serious cardiac country’s sense of confidence that it From January 24 through August 8, disease, including myopericarditis can handle a major rapid vaccination 2003, suspected or probable myo- or and myocardial infarctions, with 10 or pill distribution campaign leans pericarditis was reported in 22 of fatal cases per million. Viewed in per- very heavily on the apocryphal vac- 38,257 civilian vaccinees (1); as of spective, this would approximate the cine campaign of April 1947. Yet, as November 4, 2003, suspected or prob- historic rate of vaccine-induced described above, there may be much able myo- or pericarditis was reported encephalitis and would be well in less to the miracle than meets the eye. in 63 of 515,000 military vaccinees excess of the historic rate of progres- (2). Additionally, cases of coronary sive vaccinia. In this scenario, at a artery disease, including myocardial hypothetical incidence of 10 per mil- Kent A. Sepkowitz* infarction and cardiac death, were lion, from 21 to 64 of the 1,545 car- *Infectious Disease Service, New York, reported in the weeks after vaccina- diac deaths (1.4% to 4.1%, respective- New York, USA tion although no causal link has been ly) would have been caused by the established. vaccine. This magnitude of effect References An October 3, 2003, MMWR arti- would have been very difficult to 1. Smallpox in city, inoculation urged. The cle, “Cardiac deaths after a mass detect in this study. Thus, the results New York Times. 1947 Apr 5. p. 21. smallpox vaccination campaign— of such investigations must be consid- 2. Curb of smallpox a ‘miracle,’ says city New York City, 1947” states that the ered in the context of power limita- health commissioner. The New York Times. NYC experience suggests “…that car- 1947 Apr 26. p. 15. tions. Further, studying death rates 3. Second smallpox death spurs vaccination. diac deaths observed in 2003 might sheds no light on cardiac illness such The New York Times. 1947 Apr 13. p. 1. have been unrelated to smallpox vac- as myo- or pericarditis. 4. One more smallpox case found; lone source cination.” While the causes of these The proper interpretation of these of infection traced.