– 220 Years Ago Smallpox Vaccine introduced in Mauritius from India
Mauritius received from India the first consignment of AstraZeneca (Covishield) vaccine against COVID-19 in January 2021. A donation from India, one of the biggest vaccine producers of the world. Covishield was produced by the Serum Institute of India after obtaining licence from British pharma company. Mauritius then purchased a quantity of another Indian product, Covaxin, which was a source of controversy – although approved by Indian regulators, but not yet by WHO. Two more consignments landed, one from the Covax Facility, another from China. More doses are expected to arrive from Russia. The vaccination campaign in Mauritius, starting on 26 January, is underway and a reasonable coverage of about 70% of the population is expected later this year. This target may be compromised, unless sufficient doses are available in the coming weeks, and the vaccine, not mandatory, is accepted by a large percentage of the population.
In 1803, in a totally different context, the first vaccine against smallpox was introduced in Mauritius from the colonial state of India. Developed in England in 1798, the vaccine against smallpox was soon adopted in Europe, and in a short time, it had reached India in 1802, and colonies as far as Australia in 1804. This brief account relates the bold but complex story of vaccination in Mauritius, reflecting events in most parts of the world, accepted by many and rejected by others, available or not, voluntary or mandatory, its success or failure. The same pattern has marked the entire history of vaccine up to now. History is repeating as COVID-19 is unfolding in real time, marked by vaccine hesitancy alternating with enthusiasm, trust and distrust, rich and poor countries divide, diplomatic and commercial considerations…
COVID-19 pandemic, causing a worldwide health crisis since 2020, was followed by a race against time to find safe and effective vaccines, in the hope of saving lives and restoring socio-economic normalcy of yester years. In a record period of time, vaccine candidates were announced by mid-2020, in Russia, Europe and China. Each vaccine candidate undergoes the process of clinical trials to assess safety and efficacy, before it is recommended by regulatory bodies for mass production by pharmaceutical companies.
Vaccines, having different degrees of efficacy, were announced, all of them requiring double doses, except Johnson and Johnson requiring only one. Most of them, except one, can be stored in normal fridge temperature. More vaccine candidates, going through clinical trials, are expected soon. With mass production, issues such as cold chain storage, transportation and distribution, and pricing have to be addressed. The speed with which Pfizer and Moderna vaccines were developed and rolled out the U.S, ‘did not compromise at all safety nor did it compromise scientific integrity! But rather indicated extraordinary scientific progress.’ (A. Pauci, NIAID).
A Beacon of Hope
The vaccine is a beacon of hope against a backdrop of successive waves of infection, and countries opening and closing lockdowns. In a hurry to be out of the prevailing socio-economic crisis, rich countries have pre-ordered and have shown a tendency to hoarding. However, production being slow, equitable distribution did not happen according to expectation. Vaccination, first rolled out in Russia, was followed by the UK, while the largest campaigns started in India and China. Countries such as Israel and U.K are well in advance. Meanwhile, variants of the first virus appeared. AstraZeneca, unable to combat a new variant, was halted in South Africa; adverse effects were also noted in Europe. The vaccine from Johnson and Johnson too has been paused in the U.S. Moreover, manufacturing countries, Europe and India, put export of vaccine on hold to enable them meet domestic demand. According to experts, about 70% of the world population needs to be immunised to contain transmission. For vaccines to be available free in low-income countries, WHO established the Covax Facility. From February, over 100 countries are benefiting from it, while others are still waiting for the first dose, a delay caused by a lack of stock. Hence, the call from WHO to rich countries having surplus doses to donate to less fortunate countries. (WHO 10/4/2021)
Investigations are also under way about the interchangeability of different vaccines. Until results of findings will be known, WHO recommends the use of the same product for the first and second dose. More reports on side effects, the duration of immunity and impact of variants on vaccines etc. are expected. Scientific information and statistics continually updated will dictate policy changes.
Paradoxically, about 220 years ago, when the first vaccine against smallpox was developed in England, nothing was known about the immune response system and its role in preventing infections. Nor the existence of viruses had been found out yet. Many diseases were attributed to miasmas, poisons in the air (mal air), emanating from rotting plants and animals or from putrid water. In 1796, Edward Jenner, an English country-doctor, initiated the use of cowpox matter ‘vaccinia’ to prevent smallpox. This idea had its origins in folk medicine. Country folks observed how milkmaids suffering from cowpox infection were hardly affected by smallpox, or else they only had a mild infection. Jenner inoculated a boy with matter drawn from the cowpox pustule of a dairy maid, and six weeks later he inoculated him with smallpox virus, he found that no infection followed. It was the first clinical trial ever. Jenner published his findings in 1798 and received the support of the royal court. Vaccination became popular, although it met strong resistance from religious bodies. At first, the arm-to-arm method was used, and only much later, the vaccine was prepared in vials. Vaccination gradually replaced inoculation (or variolation), another form of folk medicine existing for ages in India, China and Africa.
From England, Jennerian vaccine spread to Europe, and soon reached colonies in Asia and America, crossing political barriers and transcending enmity among nations. Napoleon, while warring against England, ordered his army to be vaccinated by the Jennerian method. Since the cold chain did not exist, how the vaccine was transferred overland and at sea to distant colonies was indeed an extraordinary feat. At the request of the East India Company to send the vaccine to India, Jenner despatched to Paris some lymph, which was sent to Vienna and then to Constantinople, from there to Bagdad and then to the port of Basra, and finally it reached Bombay by ship in May 1802. In each place, fresh lymph was raised by vaccinators. The lymph preserved in cloth or threads was kept in a sealed container, which was immersed in wax and dried to protect the content from high temperatures. In India, the vaccine, at first meant for European troops and officials, became over the years, a mass preventive measure including the Indian population.
From India, in 1803, the smallpox vaccine was transferred by ship to the French colony of Isle de France (Mauritius), by the arm-to-arm method, involving a number of children vaccinated in succession. After 1810, the British enforced vaccination by legislation on all white inhabitants and slaves, adults and children. Some people throughout the nineteenth century resisted, believing that the vaccine caused leprosy. Indian immigrants were vaccinated before they embarked at Indian ports. Vaccination Certificates were delivered and these were required for school admission. From Mauritius, the vaccine was introduced in the Seychelles and Madagascar. Whenever, there was a shortage or loss, sharing of smallpox vaccine was common between Mauritius and Reunion, although they were colonies of rival European states. By the early 20th century, vaccination covering a large section of the Mauritian population, the threat of smallpox died down.
Vaccination and surveillance programmes
By the late 19th century, medical science had evolved in Europe and the scientific basis of vaccine and immunology were established. With the development of bacteriology, the existence of different viruses and bacteria was known and modern vaccination therapies developed. Louis Pasteur, in honour of Edward Jenner, adopted the word ‘vaccine’ (vaccinia, poison of the cow). Since then, that term has been used for any virus prepared for immunization purpose.
Over the years, the colonial government in Mauritius introduced vaccines to curb tuberculosis and eliminate polio. The last case of polio was recorded in 1967. The creation of the World Health Organization was a turning point, as the eradication of infectious diseases, especially those affecting children, was prioritized. Vaccination and surveillance programmes were established firmly in Mauritius with the collaboration of WHO and UNICEF. After Independence, vaccines, such as BCG, OPV, Hepatitis B, MMR (against measles, mumps and rubella) etc have been provided free at public vaccination centres within reach of the population.
Vaccination is a preventive measure to protect an individual from serious infection by activating the immune system. A large coverage of the world population will be required to create a collective immunity to contain COVID. At the rate vaccination is taking place in the world, experts say that it will take two years before 50% is reached,(WHO January 2021;CEO, Serum Institute India, BBC HARDtalk 15/3/2021). It is feared that the longer the virus will circulate in the world, the risk of the emergence of new variants will be greater, and the updating of vaccine products can become problematic.
During this World Immunization Week 2021, it is apt to remember that vaccination is the most cost effective measure in public health. Millions of lives have been saved by the initiatives of WHO. Smallpox has been eradicated globally in 1980, while polio is prevalent in only two countries. Infant diseases have been checked. A vaccine against malaria is on trial in Africa. For viruses that mutate all the time, such as influenza, vaccines are produced on a yearly basis. Similarly, the development of one vaccine being difficult to combat HIV, antiretroviral drugs are used. Recently, new diseases, such as Ebola, have emerged, old diseases are becoming resistant to vaccines. The urge to develop new drugs is always there, but investments in research and development of new vaccines are often scarce.
For vaccination campaigns to succeed, both science and technology are required. Countries need active health infrastructures and emergency preparedness plans, rigorous surveillance systems, and diagnostic laboratories with modern equipment. Lessons from anti-smallpox and polio campaigns prove that success depends largely on world cooperation and concerted efforts. Past pandemics have also shown that distinction between national and international health cannot exist. Considerations of individual countries to contain infections and save lives, and re-activate local economy are understandable and legitimate. However, opening borders to international travel and restarting a global economy will largely depend on world safety from COVID-19.
Raj Boodhoo, Infectious Disease and Public Health, Editions Le Printemps, 2019.