tag:theconversation.com,2011:/us/topics/diptheria-626/articlesDiptheria – The Conversation2023-04-26T12:28:46Ztag:theconversation.com,2011:article/2042632023-04-26T12:28:46Z2023-04-26T12:28:46ZChallenging the FDA’s authority isn’t new – the agency’s history shows what’s at stake when drug regulation is in limbo<figure><img src="https://images.theconversation.com/files/522817/original/file-20230425-28-sxmbmf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2048%2C1370&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In addition to evaluating new drug applications, the FDA also inspects drug manufacturing facilities.</span> <span class="attribution"><a class="source" href="https://flic.kr/p/bCZpCD">The U.S. Food and Drug Administration/Flickr</a></span></figcaption></figure><p>Political pressure is nothing new for the U.S. Food and Drug Administration. The agency has <a href="https://theconversation.com/the-fdas-big-gamble-on-the-new-alzheimers-drug-162396">frequently come under fire</a> for its drug approval decisions, but attacks on its decision-making process and science itself have increased <a href="https://www.statnews.com/2020/08/27/trump-has-launched-an-all-out-attack-on-the-fda-will-its-scientific-integrity-survive/">during the COVID-19 pandemic</a>.</p>
<p>Recent challenges to the FDA’s authority have emerged in the context of reproductive rights.</p>
<p>On Nov. 18, 2022, a group of anti-abortion doctors and medical groups <a href="https://adflegal.org/sites/default/files/2022-11/Alliance-for-Hippocratic-Medicine-v-FDA-2022-11-18-Complaint.pdf">filed a lawsuit</a> against the FDA, challenging its approval from more than 20 years ago of <a href="https://theconversation.com/mifepristone-is-under-scrutiny-in-the-courts-but-it-has-been-used-safely-and-effectively-around-the-world-for-decades-204163">mifepristone</a>, a drug taken in combination with another medication, misoprostol, to <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">treat miscarriages</a> and used to induce <a href="https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions">more than 50% of abortions</a> in early-stage pregnancies in the U.S.</p>
<p>It is widely believed that the plaintiffs filed the lawsuit in the Northern District of Texas so District Judge Matthew J. Kacsmaryk, a <a href="https://www.nytimes.com/2023/04/07/us/politics/texas-judge-matthew-kacsmaryk-abortion-pill.html">well-known abortion opponent</a>, could oversee the litigation. While Kacsmaryk did issue a preliminary injunction ruling that the FDA lacked the authority to approve mifepristone, an appeal <a href="https://storage.courtlistener.com/recap/gov.uscourts.ca5.213145/gov.uscourts.ca5.213145.183.2_1.pdf">partially reversed</a> the decision and the Supreme Court <a href="https://www.supremecourt.gov/opinions/22pdf/22a901_3d9g.pdf">stayed Kacsmaryk’s order</a>. The case now sits at the 5th U.S. Circuit Court of Appeals and will likely return to the Supreme Court.</p>
<p>The FDA is the government’s oldest consumer protection agency. The effects of this lawsuit could reach far beyond mifepristone – undermining the agency’s authority could threaten its entire drug approval process and change access to commonly used drugs, ranging from amoxycillin and Ambien to prednisone and Paxlovid.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=Yeg0EUgAAAAJ&hl=en">legal scholar</a> whose research focuses in part on the law and ethics of the FDA’s drug approval process. Examining the FDA’s history reveals the unprecedented nature of the current challenges to the agency’s authority.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chart titled 'Data for Decisions' depicting sources the FDA considers in its decision-making" src="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Then FDA Commissioner George Larrick used this chart during 1964 Senate testimony to illustrate the range of sources the agency uses in evaluating proposals.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/dv6CFV">The U.S. Food and Drug Administration/Flickr</a></span>
</figcaption>
</figure>
<h2>Events shaping FDA’s focus on safety</h2>
<p>In its early years, the FDA focused primarily on balancing the competing goals of consumer safety with access to experimental treatments. The priority was strengthening consumer protection to prevent tragedy from recurring. </p>
<p>For instance, at the turn of the 20th century, Congress passed the <a href="https://ncjolt.org/articles/volume-23/volume-23-issue-4/fdas-accelerated-approval-emergency-use-authorization-and-pre-approval-access-considerations-for-use-in-public-health-emergencies-and-beyond/">Biologics Control Act of 1902</a>, providing the federal government the authority to regulate vaccines. This law was introduced after 13 children died from inadvertently contaminated diphtheria antitoxin, which was made from the blood of a horse infected with tetanus. </p>
<p>A few years later, after investigative journalists publicized the unsanitary conditions and food-handling practices in meatpacking plants, Congress passed the <a href="https://ssrn.com/abstract=3237889">Pure Food and Drug Act of 1906</a>, which prohibited the marketing and sale of misbranded and contaminated foods, drinks and drugs.</p>
<p>Similarly, in 1937, approximately 71 adults and 34 children died from ingesting <a href="https://doi.org/10.7326/0003-4819-122-6-199503150-00009">S.E. Massengill’s antibacterial elixir</a>, which contained a poisonous raspberry flavoring added to sweeten the taste. In response, Congress passed the <a href="https://www.fda.gov/about-fda/fda-history/milestones-us-food-and-drug-law">Federal Food, Drug and Cosmetic Act of 1938</a>, requiring manufacturers to show that drugs are safe before they go on the market. This act marked the beginning of modern drug regulations and the birth of the FDA as a regulatory agency. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/4wIBCoxuOJ0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">FDA scientist Frances Oldham Kelsey’s decision to not approve thalidomide for use in the U.S. protected Americans from the birth defects that swept newborns in other countries.</span></figcaption>
</figure>
<p>Then, in 1962, Dr. Frances Oldham Kelsey, a pharmacologist, physician and medical officer working at the FDA, <a href="https://www.fda.gov/about-fda/fda-history/milestones-us-food-and-drug-law">refused to approve thalidomide</a>, a drug marketed in Europe, Canada, Japan and other countries to alleviate morning sickness in pregnant women but later found to cause severe birth defects. Shocking revelations of children born without limbs or suffering from other debilitating conditions motivated Congress to pass the <a href="https://theconversation.com/could-thalidomide-happen-again-46813">Kefauver-Harris Drug Amendments of 1962</a>, which ushered in a more cautious approach to the drug approval process.</p>
<h2>FDA’s turn toward expanding access</h2>
<p>During the 1970s, questions about the limits of safety versus an individual’s right to access arose when cancer patients who wanted access to an unapproved drug derived from apricots, Laetrile, sued the FDA. The agency had blocked the drug’s shipment and sale because it was not approved for use in the U.S. At that time, the Supreme Court <a href="https://tile.loc.gov/storage-services/service/ll/usrep/usrep442/usrep442544/usrep442544.pdf">upheld the FDA’s protective authority</a>, holding that an unproven therapy is unsafe for all patients, including the terminally ill.</p>
<p>The 1980s, however, marks the FDA’s shift toward increasing access following reports of an emerging disease – AIDS – which primarily affected gay men. In the first nine years of the AIDS epidemic, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00001880.htm">over 100,000 Americans died</a>. AIDS patients and their advocates became <a href="https://dx.doi.org/10.2139/ssrn.2739121">vocal critics of the FDA</a>, arguing that the agency was too paternalistic and restrictive following events like the thalidomide scare.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="ACT UP protestors lying on the ground with tombstone-shaped signs demanding the FDA allow access to experimental HIV/AIDS drugs" src="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=518&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=518&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=518&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protests from HIV/AIDS activists like ACT UP spurred the FDA to develop expedited drug approval tracks to meet urgent public health needs.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protesters-close-the-federal-drug-administration-building-news-photo/1213566352">Mikki Ansin/Peter Ansin via Getty Images</a></span>
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<p>After massive protests, Dr. Anthony Fauci, then director of the National Institute of Allergy and Infectious Diseases, proposed a <a href="https://www.washingtonpost.com/outlook/2020/04/29/fight-against-aids-has-shaped-how-potential-covid-19-drugs-will-reach-patients/">parallel track program</a> allowing eligible patients access to unapproved experimental treatments. This, along with other existing FDA mechanisms, helped lay the path for other alternative approval pathways, such as <a href="https://theconversation.com/what-are-emergency-use-authorizations-and-do-they-guarantee-that-a-vaccine-or-drug-is-safe-151178">Emergency Use Authorization</a>, which played a large role in permitting use of vaccines and medications pending full FDA approval during the COVID-19 pandemic.</p>
<h2>Future of the FDA</h2>
<p>Despite the FDA’s shift toward increased access, the <a href="https://www.statnews.com/2018/05/31/right-to-try-ron-johnson/">political right has in recent years argued</a> that the agency remains too bureaucratic and paternalistic and should be deregulated – an argument seemingly contrary to the reasoning underlying Kacsmaryk’s recent order that the FDA did not sufficiently evaluate the safety of mifepristone in its approval.</p>
<p>Mifepristone, which has <a href="https://www.ama-assn.org/delivering-care/public-health/ama-court-don-t-overturn-fda-approval-mifepristone">overwhelming data supporting its safety</a>, could remain available to some people in some states regardless of the outcome of this lawsuit. While the FDA approves drugs for consumer use, it does not regulate the general practice of medicine. Doctors can <a href="https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label">prescribe FDA-approved drugs off-label</a>, meaning they could prescribe a drug with a different dose, in a different way or for a different use than what the FDA has approved it for.</p>
<p>The mifepristone case has broad implications for the FDA’s future and could have devastating effects on health in the U.S. Due in part to FDA involvement, public health interventions have led to a <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm#">62% increase in life expectancy</a> in the 20th century. These include vaccines and medications for childhood illnesses and infectious diseases such as HIV, increased regulation of tobacco, and <a href="https://theconversation.com/fda-approval-of-over-the-counter-narcan-is-an-important-step-in-the-effort-to-combat-the-us-opioid-crisis-198497">over-the-counter Narcan</a> to combat the opioid crisis, among others.</p>
<p>The FDA needs to be able to use its scientific expertise to make data-driven decisions that balance safety and access, without the ability of a single judge to potentially gut the system. The agency’s history is an important reminder of the need for strong administrative agencies and ongoing vigilance to protect everyone’s health.</p><img src="https://counter.theconversation.com/content/204263/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Coughlin is affiliated with the Foundation for Prosecutorial Accountability.</span></em></p>As the government’s oldest consumer protection agency, the FDA has long butted up against drugmakers, activists and politicians. But undermining its work could be harmful to patient health and safety.Christine Coughlin, Professor of Law, Wake Forest UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1619132021-06-11T15:31:18Z2021-06-11T15:31:18ZWe discovered what’s killing the world’s rarest penguin – and it could help us make a vaccine<figure><img src="https://images.theconversation.com/files/405667/original/file-20210610-19-19zcvem.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4437%2C2955&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Yellow-eyed penguins are endemic to New Zealand.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-portrait-endangered-yellow-eyed-penguin-573212221">Michael Smith ITWP/Shutterstock</a></span></figcaption></figure><p>Yellow-eyed penguins are the most endangered penguin species in the world, with just <a href="https://www.doc.govt.nz/nature/native-animals/birds/birds-a-z/penguins/yellow-eyed-penguin-hoiho/">4,000 left in the wild</a>. Found only in New Zealand and its outlying islands, these birds can grow up to <a href="https://www.biologicaldiversity.org/species/birds/penguins/yellow-eyed_penguin.html">79cm tall and weigh 8.5kg</a>, which is similar to a one-year-old child. They’re easily identified by the pale-yellow band of feathers that extends from their eyes and around the backs of their heads.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A map of New Zealand with yellow-eyed penguin colonies highlighted in red." src="https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405669/original/file-20210610-13-voq3iq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The locations of yellow-eyed penguin colonies (red) in New Zealand.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Yellow-eyed_penguin#/media/File:Yellow-eyed_Penguin_distribution_map.png">Nrg800/Wikipedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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</figure>
<p>Their shrill calls during the mating season earned them their local name Hoiho, which means “<a href="https://www.yellow-eyedpenguin.org.nz/penguins/about-the-yellow-eyed-penguin/">noise shouter</a>” in Māori. Yellow-eyed penguins are great divers and mostly catch their food – small fish, molluscs and crustaceans – from the seabed. Unlike most of their kin, yellow-eyed penguins are not very social and often nest away from other penguins.</p>
<p>These withdrawn breeding pairs have been in <a href="https://www.doc.govt.nz/nature/native-animals/birds/birds-a-z/penguins/yellow-eyed-penguin-hoiho/#disease">sharp decline</a> for the last two decades, especially on islands to the north of their distribution where the population has declined by 65%. The primary cause is outbreaks of diphtheria-like infections that are particularly fatal to young chicks between one and 28 days old. The mouth and tongue of infected chicks are covered by a thick membrane, pus and ulcers that stop them from eating. The infection can spread to the entire body, resulting in sepsis.</p>
<p>Even when treated with a combination of antibiotics, infected birds often die. Up to 93% of yellow-eyed penguin chicks contract avian diphtheria every year in the northern population and <a href="https://www.stuff.co.nz/environment/135521/Mystery-illness-strikes-penguins">up to 70% of them die</a>, threatening the future of the species.</p>
<p>Despite the alarming situation, scientists knew very little about the cause of avian diphtheria. But in our <a href="https://journals.asm.org/doi/10.1128/mSystems.00320-21">recently published study</a>, we identified the bacterium causing these infections, how it infects penguin chicks and how it might be treated to save the species from extinction. </p>
<h2>A familiar foe</h2>
<p>To identify the bacterium, my colleagues from the New Zealand Department of Conservation, University of Otago and Massey University collected swabs from the mouths of chicks in infected nests on the Otago peninsula on the east coast of New Zealand’s South Island. My colleagues and I isolated the bacteria in the laboratory and sequenced its DNA to create a family tree that showed how this bacteria is related to other species.</p>
<figure class="align-center ">
<img alt="An adult penguin with yellowish face lying down with a black chick tucked into her side." src="https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=601&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=601&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=601&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=755&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=755&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404130/original/file-20210602-17-4rzebr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=755&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nesting mother and chick on the Otago Peninsula.</span>
<span class="attribution"><span class="source">Megan Abbott</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The results were fascinating. The strains from these penguins belong to a new species which has not been reported before, within a group of bacteria called <a href="https://emedicine.medscape.com/article/215100-overview"><em>Corynebacterium</em></a>.</p>
<p>This group includes another species that causes <a href="https://www.sciencedirect.com/science/article/abs/pii/S1567134816302489?via%253Dihub">diphtheria</a> in humans. Diphtheria once killed up to <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/dip.html">20,000 people a year</a> in the US alone, many of them children, before a global vaccination campaign in the 1940s. Outbreaks are still reported globally which kill thousands of people every year.</p>
<h2>Potential vaccine</h2>
<p>Fortunately, we also found unique DNA sequences in the bacteria that helped us develop a simple test to identify the infection rapidly and more reliably than other methods. Being able to quickly detect these strains will help conservationists start early treatment of infected chicks, improving their chances of survival.</p>
<figure class="align-center ">
<img alt="A pink microscope slide with purple bacterial cells." src="https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405663/original/file-20210610-23-omrd5k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Species of Corynebacterium can be deadly pathogens for humans and other animals.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Corynebacterium_diphtheriae#/media/File:Corynebacterium_diphtheriae_Gram_stain.jpg">Center for Disease Control and Prevention's Public Health Image Library</a></span>
</figcaption>
</figure>
<p>The disease-causing genes in the bacteria from yellow-eyed penguins are similar to those in the species which cause human diphtheria. This helped us understand how this bacteria attaches and invades cells in the mouth of penguins.</p>
<p>One of these genes produces a protein called Phospholipase D that helps the bacteria survive once inside the host. This protein can be modified to protect animals from bacterial infections. This is very exciting, as it could help us develop a vaccine for the world’s most endangered species of penguin, and possibly, save it from extinction.</p><img src="https://counter.theconversation.com/content/161913/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vartul Sangal does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The bacteria which causes the infection in yellow-eyed penguins is closely related to a human pathogen.Vartul Sangal, Senior Lecturer in Cellular and Molecular Sciences, Northumbria University, NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1477332020-12-02T13:28:00Z2020-12-02T13:28:00ZCicely was young, Black and enslaved – her death during an epidemic in 1714 has lessons that resonate in today’s pandemic<figure><img src="https://images.theconversation.com/files/369846/original/file-20201117-15-sppuek.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C1280%2C960&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over 1.4 million people have died from COVID-19 so far this year. How history memorializes them will reflect those we most value.</span> <span class="attribution"><span class="source">Author provided</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>What I believe to be the <a href="https://www.brown.edu/news/2020-03-23/acre">oldest surviving gravestone</a> for a Black person in the Americas memorializes an enslaved teenager named Cicely. </p>
<p>Cicely’s body is interred across from Harvard’s Johnston Gate in Cambridge, Massachusetts. She died in 1714 during a measles epidemic brought to the college by a student after the summer recess of 1713. Another tombstone in the same burial ground remembers Jane, an enslaved woman who died in 1741 during an outbreak of diphtheria, or “throat distemper.” </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An old grave marker sits in a grassy burial ground" src="https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A grave marker for an enslaved woman named Jane uses the archaic ‘1740/1’ Julian calendar notation to denote her death in early 1741.</span>
<span class="attribution"><span class="source">Nicole Maskiell</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>When diseases struck in the Colonial era, many city residents fled to the safety of the country. Poor and enslaved people, like Jane and Cicely – the essential frontline workers of the time – stayed behind. </p>
<p>Why were Cicely and Jane memorialized when so many other enslaved people were not? The archival record doesn’t provide a clear answer, but the question of <a href="https://theconversation.com/will-there-be-a-monument-to-the-covid-19-pandemic-146827">who should be remembered</a> with monuments and commemorations is timely. </p>
<p>Throughout the United States, as COVID-19 affects frontline workers and communities of color <a href="https://www.epi.org/publication/black-workers-covid">far more than other demographic groups</a>, and protesters agitate for racial justice, American society is wrestling with its racial memory and judging <a href="https://abcnews.go.com/US/historians-debate-americas-sordid-history-racism-confederate-monuments/story?id=71486827">which monuments and memorials</a> deserve a place. </p>
<p>Against this backdrop, I believe it’s important to look back at how a few marginalized and oppressed people who served on the front lines of prior epidemics have been treated and remembered. After all, those whom society chooses to memorialize reflect what accomplishments – honorable or horrific – <a href="https://www.gothamcenter.org/blog/monuments-roundtable-stuyvesant-and-hudson">society values</a>.</p>
<h2>Unsung sacrifices</h2>
<p>The lives, labor and sacrifices of women and girls of color have been overlooked for centuries. Of the 3.5 million books in Widener Library – the <a href="https://gsas.harvard.edu/student-life/harvard-resources/libraries">centerpiece of Harvard’s vast library</a> system – I found that not one was devoted to Cicely or Jane, and few focus on women like them. </p>
<p>For early-American <a href="https://www.nicolemaskiell.com">historians of Northern slavery like me</a>, such fragmentary and untold stories are both intriguing and challenging. But this particular story was also personal, because when I first stumbled on Cicely’s tombstone, I was also a Black teen. </p>
<p>I was a sophomore studying history at Harvard when I came upon the headstone while wandering in the Colonial-era graveyard adjacent to campus. It had a carving of a <a href="https://www.boston.gov/departments/parks-and-recreation/iconography-gravestones-burying-grounds">death’s head</a> on top and winding vines down the sides. It was both ordinary and extraordinary – it looked like other tombstones in the graveyard, but this one memorialized a young Black girl.</p>
<p>I wondered about Cicely. She most likely did domestic work in and around Harvard, as <a href="https://www.colonialsociety.org/node/2055">her enslaver</a> was a Cambridge minister and a tutor at the college. But what else did she do during her short life, and why did her enslavers memorialize her with a tombstone? These questions and the mystery of her life inspired me to become a historian. Over the years, I have been passionate about piecing together fragments of her and Jane’s lives. </p>
<p>Jane’s enslaver kept <a href="https://hollisarchives.lib.harvard.edu/repositories/4/resources/4254/collection_organization">a diary</a> that provided some details about her life, but I found little written about Cicely beyond her <a href="https://play.google.com/books/reader?id=Iufi5eVXCGoC&hl=en&pg=GBS.PA134">adult baptismal record</a>, dated just two months before her death.</p>
<h2>Racial unrest and disease</h2>
<p>Cicely lived and died during a time of racial unrest and disease. A slave revolt in 1712 in New York City led to several brutal <a href="https://www.gilderlehrman.org/sites/default/files/inline-pdfs/AppenC.pdf">executions and deportations</a>. News of the revolt spread throughout the Colonies, stoking concerns of a wider uprising. <a href="https://infoweb.newsbank.com/apps/readex/openurl?ctx_ver=z39.88-2004&rft_id=info%3Asid%2Finfoweb.newsbank.com&svc_dat=EANX&req_dat=0D0CB4F0E6B93180&rft_val_format=info%3Aofi%2Ffmt%3Akev%3Amtx%3Actx&rft_dat=document_id%3Aimage%252Fv2%253A1036CD221971FE08%2540EANX-1056625160187997%25402346459-1056625196BEC5B4%25401-10566251F0040E27%2540New-York%25252C%252BApril%252B7th%2Fhlterms%3A">Colonists armed themselves</a> in fear. </p>
<p>Slavery existed in every Colony, including the North. At the time of the revolt, the Northern Colonies – from Nova Scotia down to Delaware – were home to around <a href="https://www2.census.gov/library/publications/1960/compendia/hist_stats_colonial-1957/hist_stats_colonial-1957-chZ.pdf">9,000 enslaved people</a>, representing a third of the enslaved population of the British mainland colonies. New York City had 5,841 residents, of which 975 were <a href="https://babel.hathitrust.org/cgi/pt?id=umn.31951000005142w&view=1up&seq=203&size=125">held as slaves</a>. Boston had roughly <a href="https://www2.census.gov/prod2/statcomp/documents/CT1970p2-13.pdf">400 enslaved people</a>.</p>
<p>Racial unrest was quickly followed by contagion. A measles outbreak the next year followed the same path up the coast as news of the revolt had traveled. </p>
<p>The <a href="https://www.google.com/url?q=https://www.usdeadlyevents.com/1713-oct-1714-measles-epidemic-boston-ma-also-ct-ri-ny-nj-nh-pa-109/&sa=D&source=hangouts&ust=1604992342010000&usg=AFQjCNFwXheWqyP12QgBg_xB8iGm91rKqg">epidemic</a> started in Newport, Rhode Island, in the summer of 1713 and hit Cambridge, Massachusetts, that September. It broke out at Harvard before spreading to Boston. More than 400 Bostonians died – about <a href="https://docs.newsbank.com/s/HistArchive/ahnpdoc/EANX/105662B6683AE209/0D0CB61A15FF3EC0">18% of them people of color</a> – at a time when <a href="https://www.jstor.org/stable/3491467">Black people</a> were only <a href="https://www.census.gov/history/pdf/colonialbostonpops.pdf">4% of the total population</a>.</p>
<p>Racial discord and disease continued throughout the Colonial period. Between Cicely and Jane’s deaths in 1714 and 1741, a smallpox crisis gripped Boston, <a href="https://www.wgbh.org/news/2016/07/03/local-news/slave-who-transformed-cotton-mather-witch-hunter-science-innovator">inflaming racial tensions</a>. An enslaved person named Onesimus helped introduce <a href="https://www.nlm.nih.gov/exhibition/smallpox/sp_variolation.html">an early form of inoculation called “variolation.”</a> This technique was practiced on both white and Black Bostonians, to the consternation of many. On its heels, a five-year diphtheria outbreak ravaged New England, <a href="https://www.newenglandhistoricalsociety.com/great-throat-distemper-1735">killing 5,000 people</a>, including Jane. </p>
<h2>History repeats</h2>
<p>Much like today, Colonists received mixed messages during disease outbreaks, with some leaders touting the <a href="http://resource.nlm.nih.gov/2546057R">value of inoculations</a> while others <a href="http://sitn.hms.harvard.edu/flash/special-edition-on-infectious-disease/2014/the-fight-over-inoculation-during-the-1721-boston-smallpox-epidemic">stood fast against them</a>. As Jane toiled in the shadow of Harvard in 1740, the male landowners of Cambridge held a contentious election that saw <a href="https://docs.newsbank.com/s/HistArchive/ahnpdoc/EANX/1056660DD83DF255/0D0CB61A15FF3EC0">very high voter turnout</a> amid a diphtheria epidemic.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>.]</p>
<p>History can show us how diseases disproportionately harm vulnerable and marginalized populations; how discord and strife lead to racial antipathy; and how epidemics are managed and mismanaged. </p>
<p>Cicely’s and Jane’s lives mattered outside of the value they provided to their enslavers. In a time of disease and racial unrest that echoes the experiences of generations past, the lives of oppressed people like Cicely and Jane are worthy of remembrance.</p><img src="https://counter.theconversation.com/content/147733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole S. Maskiell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>US monuments and memorials have overlooked frontline workers and people of color affected by past epidemics. Will we repeat history?Nicole S. Maskiell, Assistant Professor of History Peter and Bonnie McCausland Fellow of History, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1221912019-10-06T18:52:10Z2019-10-06T18:52:10ZPharmacists can vaccinate adults against whooping cough, measles and the flu, but it might cost you more<figure><img src="https://images.theconversation.com/files/293703/original/file-20190924-54782-1fazeoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacist immunisers are gradually being allowed to give more types of vaccines.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1385453168?src=jkf9PEdb4d2ziEPJcyShBw-1-85&size=huge_jpg">FotoDuets/Shutterstock</a></span></figcaption></figure><p>Vaccines have long been available from GPs and nurses. But in recent years, laws have changed to add pharmacists to the list of health professionals who can give select vaccines without a prescription. </p>
<p>This may improve vaccination coverage against the flu, whooping cough and measles. But there’s a chance it could cost you more than if your saw your GP for the same shot.</p>
<h2>Overcoming resistance</h2>
<p>Before 2014, pharmacists couldn’t give vaccinations in Australia. Then <a href="https://eprints.qut.edu.au/91903/1/QPIP%20Final%20Report%202015%20.pdf">a pilot study</a> allowed a select group of Queensland pharmacies to offer the flu vaccine. </p>
<p>By this time, pharmacists had been giving certain vaccines in <a href="https://www.opatoday.com/professional/advocacy/scope-of-practice">Canada</a>, <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-programme-decisions/pharmacist-vaccinators">New Zealand</a>, the <a href="https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/pharmacists-role-immunization.ashx">United States</a> and the <a href="https://psnc.org.uk/services-commissioning/advanced-services/flu-vaccination-service/flu-vaccination-training/">United Kingdom</a> for some years. </p>
<p>But in Australia, pharmacists didn’t have the skills and the law didn’t allow it. Another barrier was <a href="https://theconversation.com/how-rivalries-between-doctors-and-pharmacists-turned-into-the-turf-war-we-see-today-122534">the attitudes of other health professionals</a>, such as doctors, that pharmacists couldn’t or shouldn’t give vaccinations. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-rivalries-between-doctors-and-pharmacists-turned-into-the-turf-war-we-see-today-122534">How rivalries between doctors and pharmacists turned into the 'turf war' we see today</a>
</strong>
</em>
</p>
<hr>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/28894312">Queensland pilot study</a> concluded pharmacists could safely and effectively administer certain vaccines to adults, once they were trained. This training included how to administer injections and what to do if something went wrong, such as managing <a href="https://immunisationhandbook.health.gov.au/resources/publications/managing-anaphylaxis">anaphylaxis</a> and performing CPR. </p>
<p>State and territory regulations have changed since 2014 and <a href="http://www.ncirs.org.au/new-resource-getting-vaccines-your-local-pharmacy">pharmacist vaccination services</a> have quickly grown. <a href="http://www.healthconsult.com.au/wp-content/uploads/pharmacist-administered-vaccination-program-evaluation.pdf">In Victoria</a>, for example, the number of pharmacies registered to give vaccines grew, from 36 in 2017 to 489 in July 2019. </p>
<h2>What vaccines can you get at the pharmacy?</h2>
<p>The rules <a href="http://ncirs.org.au/sites/default/files/2019-08/NCIRS%20Information%20Sheet-%20Vaccines%20from%20community%20pharmacy_August%202019_Final_0.pdf">vary in each state and territory</a>. Generally, if you’re 16 and over, pharmacist immunisers can give you the following three vaccines:</p>
<ul>
<li>influenza (flu)</li>
<li>diphtheria, tetanus and pertussis (whooping cough) – except Tasmania</li>
<li>measles, mumps and rubella (MMR) – except Tasmania and the ACT.</li>
</ul>
<p>These are important vaccines that are sometimes needed if adults missed doses earlier in life or have waning immunity. The influenza vaccine needs to be given every year in a short time frame.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-are-you-up-to-date-with-your-vaccinations-116510">Health Check: are you up to date with your vaccinations?</a>
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<hr>
<p>There are some further exceptions. </p>
<p>In the <a href="https://www.health.act.gov.au/sites/default/files/2019-04/Pharmacist%20vaccinations.pdf">Australian Capital Territory</a>, pregnant women can’t be vaccinated by a pharmacist. </p>
<p>In <a href="https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/340860/Tasmanian_Vaccination_Program_Guidelines_-_September_2019_.pdf">Tasmania</a> and <a href="http://www.healthywa.wa.gov.au/%7E/media/Files/Corporate/general%20documents/medicines%20and%20poisons/Word/Pharmacist_vaccination_code.ashx">Western Australia</a>, the flu vaccine can be given by a pharmacist to those aged ten and over. </p>
<p>Pharmacist immunisers are gradually being allowed to give more types of vaccines. In Western Australia, for example, pharmacists can now deliver the <a href="https://www.mediastatements.wa.gov.au/Pages/McGowan/2019/08/WA-pharmacists-able-to-administer-greater-range-of-vaccines.aspx">meningococcal ACWY</a> vaccine to those aged 16 and over. This vaccine protects against <a href="https://theconversation.com/what-is-meningococcal-disease-and-what-are-the-options-for-vaccination-88769">around half of the strains that cause meningococcal disease</a> in Australia. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-meningococcal-disease-and-what-are-the-options-for-vaccination-88769">What is meningococcal disease and what are the options for vaccination?</a>
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</em>
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<h2>It might cost you more</h2>
<p>Some vaccines that would be free from your GP, practice nurse or immunisation clinic will need to be paid for if given at a community pharmacy. That’s because pharmacist immunisers <a href="https://www.psa.org.au/pharmacist_administered_vaccinations/">aren’t able to access</a> the government-funded vaccines that your clinic can. </p>
<p>Victoria is an <a href="http://www.ncirs.org.au/new-resource-getting-vaccines-your-local-pharmacy">exception</a> – pharmacists can give select government-funded vaccines. And in the ACT and WA, the over-65s can access government-funded flu vaccines at pharmacies. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacists can’t usually access government-funded vaccines, aside from in Victoria.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1385081492?size=huge_jpg">Dragana Gordic/Shutterstock</a></span>
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<p>The cost of vaccines at pharmacies varies. In <a href="http://www.healthconsult.com.au/wp-content/uploads/pharmacist-administered-vaccination-program-evaluation.pdf">Victoria</a>, for example, the total fee charged for people not eligible for a government-funded vaccination is around A$20 for influenza and A$43 for pertussis (whooping cough). </p>
<p>Even if the vaccine is free, the pharmacy may still charge <a href="https://ajp.com.au/news/flu-vax-charges-under-scrutiny/">a consultation fee</a>. </p>
<p>If you see your GP, they may either bulk bill you for the appointment or charge a consultation fee. </p>
<p>The best thing is to check ahead about any out-of-pocket expenses for vaccination when you make your booking.</p>
<h2>Do you need to see a GP?</h2>
<p>Pharmacy vaccination <a href="https://bmjopen.bmj.com/content/6/9/e011948">increases access</a> to preventative health care, especially for those living in rural and remote areas, where it’s <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">difficult to visit a doctor or clinics are infrequent</a>.</p>
<p>Having pharmacists as immunisers also increases the immunisation workforce capacity for public health responses. To help address an outbreak of meningococcal disease last year in Tasmania, <a href="http://www.premier.tas.gov.au/releases/supporting_pharmacies_to_deliver_meningococcal_vaccines">pharmacist immunisers administered the meningococcal ACWY vaccine</a> to people aged 10 to 21. </p>
<p>Going to the pharmacist for some vaccines may take some <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">pressure off family doctors</a> and free GPs to <a href="https://grattan.edu.au/wp-content/uploads/2017/03/886-Cutting-a-better-drug-deal.pdf">deliver more complex care</a> that only they can perform. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-role-of-pharmacists-should-be-overhauled-taking-the-heat-off-gps-73905">The role of pharmacists should be overhauled, taking the heat off GPs</a>
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</em>
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<hr>
<p>But there may be instances when it’s better to go to your GP for a vaccination, for example, if you’re pregnant, have a chronic health condition or need some blood tests related to vaccination. Or you might have other things to discuss with your doctor other than vaccines.</p><img src="https://counter.theconversation.com/content/122191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Tran is an employee at the National Centre for Immunisation Research and Surveillance (NCIRS). NCIRS receives service contract funding from the Australian Government Departments of Health, NSW and other state government Departments of Health. Catherine Tran has not personally received any relevant external funding, including from any governments, foundations, or research council grants.</span></em></p><p class="fine-print"><em><span>Clayton Chiu is a public health physician and employee at the National Centre for Immunisation Research and Surveillance (NCIRS). NCIRS receives service contract funding from the Australian Government Departments of Health, NSW and other state government Departments of Health. Clayton Chiu has not personally received any relevant external funding, including from any governments, foundations, or research council grants.</span></em></p><p class="fine-print"><em><span>Kristine Macartney is the Director of the National Centre for Immunisation Research and Surveillance (NCIRS). NCIRS receives funding from the Australian Government, NSW and other state government Departments of Health. She also receives funding from the National Health and Medical Research Council (NHMRC).</span></em></p>You no longer have to go to your GP to get your flu shot or catch up on vaccinations you missed earlier in life or have waning immunity to. But they’re unlikely to be free.Catherine Tran, Senior Research Officer and Pharmacist, National Centre for Immunisation Research and Surveillance, University of SydneyClayton Chiu, Public Health PhysicianKristine Macartney, Professor, Discipline of Paediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/749582017-04-19T22:34:51Z2017-04-19T22:34:51ZWhy your child still needs vaccines, even if you may not know someone with the disease<figure><img src="https://images.theconversation.com/files/163924/original/image-20170404-5736-dgqnb8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleeping Beauty's castle at Disneyland, where a measles outbreak in 2015 led to children being sickened in several states. </span> <span class="attribution"><span class="source">Jae C. Hong/AP</span></span></figcaption></figure><p>At the turn of the 21st century, the Centers for Disease Control and Prevention published an article about the 10 greatest public health achievements <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm">over the past 100 years, from 1900-1999</a>. One of them was vaccination, which likely has saved millions of lives over the past 100 years. </p>
<p>Yet, in more recent years, some parents of infants and children have questioned the necessity and safety of vaccines. Grossly inaccurate information that wrongly linked vaccination to autism was a key factor. That claim has now been thoroughly <a href="https://www.cdc.gov/vaccinesafety/vaccines/mmr/mmr-studies.html">debunked</a> by countless high-level studies, but there is still skepticism about vaccination.</p>
<p>In addition to misinformation about safety, vaccination today faces questions from a new corner. Some parents have begun to question whether children still need vaccination for diseases that many of us never even see. </p>
<p>This reasoning is inaccurate and can be dangerous. The viral and bacterial pathogens that cause these diseases still exist. Only one disease – smallpox – has ever been eliminated from Earth.</p>
<p>Bottom line: We have vaccines that have prevented misery in millions of children. Vaccination not only works; it is a godsend. Why is there resistance to these? As a professor of pharmacy who specializes in pediatrics, I will try to explain. </p>
<h2>When things get good, we forget when things were bad</h2>
<p>Ironically, vaccines have been the victim of their own success. </p>
<p>When was the last time that you met or heard of someone in the United States with polio? Diphtheria? Rubella? Likely, never. However, morbidity statistics indicate that in the 20th century, each year in the United States, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm">more than 16,000</a> were ill from polio, more than 21,000 were ill from diphtheria and more than 47,000 were ill from rubella. </p>
<p>In 2015, 0 cases of polio (a 100 percent reduction), 0 cases of diphtheria (a 100 percent reduction) and 10 cases of rubella (a more than 99 percent reduction) <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm">were reported</a> in the U.S. These dramatic differences are a testament to the <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6552md.htm">effectiveness and importance of vaccines in improving public health.</a></p>
<p>Many of the diseases listed in the <a href="https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html">2017 pediatric immunization schedule</a> have not been so dramatically reduced, however. In 2012, <a href="https://www.cdc.gov/pertussis/downloads/pertuss-surv-report-2012.pdf">48,277 cases of pertussis</a> (whooping cough) were reported in the U.S., resulting in 20 deaths, with 18 of these deaths occurring in infants and children. In 2014-2015, <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6552md.htm">855 cases of measles</a>
were reported. </p>
<p>A decline in the number of cases of a disease does not mean that the diseases do not exist, as shown by the measles outbreak and others. </p>
<h2>Vaccine skepticism gets a presidential booster shot</h2>
<p>What should be a settled scientific matter – that vaccines prevent disease and that they do not cause autism – still arises from time to time as a contentious, emotional issue. Nonscientists are usually the ones fueling the confusion.</p>
<p>President Trump has stated repeatedly that he thinks there <a href="https://www.washingtonpost.com/politics/trump-to-meet-with-proponent-of-debunked-tie-between-vaccines-and-autism/2017/01/10/4a5d03c0-d752-11e6-9f9f-5cdb4b7f8dd7_story.html?utm_term=.5e3ca08ec5d8">could be a link</a> between vaccines and autism. </p>
<p>Trump even hosted perhaps the most vocal critic of vaccines, whose controversial study that falsely claimed a link between vaccines and autism was later retracted – at an <a href="https://www.statnews.com/2017/01/21/andrew-wakefield-trump-inaugural-ball/">inaugural ball</a>. That author, Andrew Wakefield, said the night of the ball that a <a href="https://www.statnews.com/2017/01/21/andrew-wakefield-trump-inaugural-ball/">“huge shakeup”</a> is needed at the Centers for Disease Control and Prevention. </p>
<p>Wakefield, incidentally, was additionally investigated for ethical violations and professional misconduct, and has since lost his license to practice medicine in the United Kingdom. <a href="https://www.statnews.com/2017/01/21/andrew-wakefield-trump-inaugural-ball/">He</a> currently lives in Texas, and he continues to promote the false premise that the MMR vaccine causes autism.</p>
<p>When I began my career in 1989, the bacterial pathogen <a href="https://www.cdc.gov/mmwr/PDF/rr/rr6301.pdf">Haemophilus influenzae type b</a> (Hib) was one of the most common causes of bacterial meningitis in children 5 and younger. I can recall young children admitted for meningitis to the pediatric hospital I was associated with. </p>
<p>Thousands of children in the U.S. were similarly treated then for meningitis resulting from Hib. In 2015, only <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6552md.htm">29 cases of serious illness</a> from Hib were reported in children 5 and younger. Effective vaccines to prevent serious illness from Hib were licensed for use at about the time I began my career. They are now routinely recommended. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-young-children-running-towards-camera-284519324?src=88CwbbaCfizsiB9HTURnvg-1-3">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Mercury misunderstanding contributes to confusion, too</h2>
<p>Another scapegoat for a cause of autism has been thimerosal, a preservative agent that had been used in some vaccines, but never in MMR vaccines. Thimerosal contains ethylmercury and differs chemically from methylmercury, the form of mercury commonly found in the environment, including some fish. </p>
<p>Although mercury can be dangerous to humans in high amounts, ethylmercury differs, as it is eliminated from the body quicker than methylmercury. </p>
<p>Although some had suggested that thimerosal was a cause of autism, a 2013 review of the <a href="https://www.cdc.gov/vaccinesafety/concerns/thimerosal/faqs.html#5A">scientific literature has demonstrated that this is not true.</a>. Even so, pharmaceutical companies removed thimerosal from the majority of pediatric vaccines in 2001, and it remains in only a few multi-dose influenza vaccine products.</p>
<h2>Vaccine safety is carefully studied</h2>
<p>Vaccine products, similar to other pharmaceutical products, are evaluated for safety and efficacy over many years, prior to their public use as allowed by the Food and Drug Administration (FDA). </p>
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<img alt="" src="https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/business-technology-internet-network-concept-man-536764612?src=IVXx7rePnZ50zzf8iPxpwg-1-26">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Because of their therapeutic importance for disease prevention, vaccines are additionally evaluated for safety after the FDA has granted their approval for public use. Several monitoring systems carefully track vaccine product safety, including the Vaccine Adverse Events Reporting System, the Vaccine Safety Datalink and the Post-Licensure Rapid Immunization Safety monitoring system. These programs help ensure that <a href="https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx">vaccine products remain safe,</a> once they have been made available for public use.</p>
<p>Because of the importance of vaccines in preventing many serious infectious diseases, the medical community has carefully and thoroughly reviewed the science of vaccines and their potential adverse effects. Vaccines, as any pharmaceutic drug product, have risks – a potential to result in adverse effects, such as a sore arm or leg. The majority of these adverse effects are not serious. The benefits of vaccines – the prevention of fatal infectious diseases – greatly outweigh their risks for the vast majority of infants and children. </p>
<p>As a parent, if you have concerns about giving a vaccine to your child, talk with your child’s pediatrician or physician. Ask specific questions and express your concerns. Good internet sites, with accurate, easy-to-read information you can additionally read, are the Centers for Disease Control <a href="https://www.cdc.gov/vaccines/index.html">website on vaccines</a>; the <a href="https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunization/Pages/default.aspx">website</a> for the American Academy of Pediatrics; and the <a href="http://www.immunize.org">Immunization Action Coalition</a>. Pediatric health care professionals, such as myself, desire infants and children to be as healthy as possible. This includes your children. Vaccines are a safe and effective means to accomplish this.</p><img src="https://counter.theconversation.com/content/74958/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edward Bell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>You may not know anyone with an infectious disease covered by the immunizations on the 2017 list of recommended vaccines. Here’s why that doesn’t matter, and why children still need to be protected.Edward Bell, Professor of Pharmacy Practice, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/431482015-06-12T10:04:09Z2015-06-12T10:04:09Z‘Strangling angel’ of diptheria caught Spain off guard – here’s how<figure><img src="https://images.theconversation.com/files/84740/original/image-20150611-11427-apng62.jpg?ixlib=rb-1.1.0&rect=0%2C23%2C1000%2C694&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is a vaccine.</span> <span class="attribution"><span class="source">Vaccination by Shutterstock</span></span></figcaption></figure><p>The return of diphtheria in Spain after nearly three decades highlights the challenges posed by infectious diseases that had been mostly eliminated from Europe. </p>
<p>Falling vaccination rates, complex population movements, and the disappearance of international health practices perceived as redundant, all contribute to the emergence and spread of infectious diseases that were thought forgotten. At the same time, such public health crises throw light on the delicate relationship between state and citizens, and competing concepts of responsibility for health.</p>
<p>A six-year-old boy from the Catalan town of Olot was admitted to hospital suffering from <a href="http://elpais.com/elpais/2015/06/02/inenglish/1433262397_622650.html">diphtheria</a> last week. This was the first case of the disease recorded in Spain for 28 years. The boy, who is in a critical but stable condition in a Barcelona hospital, had not been vaccinated due to his parents’ concerns about the safety of the vaccine. They now say <a href="http://elpais.com/elpais/2015/06/05/inenglish/1433512717_575817.html">they feel tricked</a> by the anti-vaccination groups which had originally stoked their fears.</p>
<p>Diphtheria, now a rare disease in Europe, is a serious, potentially fatal disease caused by bacteria that can cause heart failure, pneumonia and paralysis of the muscles used for swallowing. Up until the 1920s it was one of the leading cause for death in children, sometimes referred to as “strangling angel”, because the bacteria can create a pseudo-membrane in the airways, causing death by choking. </p>
<p>It was widespread in Spain during the first half of the 20th century, particularly following the physical and economic devastation caused by the Spanish Civil War. <a href="http://www.msssi.gob.es/ciudadanos/proteccionSalud/vacunaciones/docs/recoVacunasAdultos.pdf">Over 27,000 cases</a> of diphtheria were recorded in 1940 alone. Improving infant health was officially a priority for the new Franco regime, and cases did reduce significantly in the post-war era. However, Spain’s impoverished and fragmented public health system failed to make the rapid progress towards eradication achieved by its western European neighbours, with almost 250 new cases a year still reported in the late 1960s. A comprehensive vaccination programme was finally implemented in 1966 and until last week, there had been no diphtheria cases recorded since 1987.</p>
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<img alt="" src="https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84819/original/image-20150612-1456-1dfgyad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Franco meets nurses in 1939.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/49093093@N02/4638912322/in/photolist-84VD1W-f27S4e-g5MR5K-eyNSen-84SvZT-7UaYLq-nd2UNi-nd3dt6-25xKXF-7VpvSe-2ezD3N-nd3dZt-c8mc6d-7VsLiN-8FDcjq-8FDcUs-sLHYoD-su8HHh-sLJpt2-su8E1s-8FHnvV-m5tzpR-5LBtKA-cj71N5-sbWRpC-dET2wS-86iFw6-7UaYN5-2UrYXZ-64kATp-2UrYXM-sJoQZ5-sJoMb3-sLwios-su9zoS-sLwnob-rPV192-sLwLHY-8qRfKU-nX9XGN-9UAQ9w-6qP5Hb-7eh9Lj-bJADqk-2bQY2D-2kmPqQ-2kmgHU-romPP5-djqs9Q-7UdtjX">Teresa Avellanosa</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Russia to the rescue</h2>
<p>As diphtheria had been eliminated in Spain for the last three decades, stocks of the anti-toxin needed to treat the disease are no longer available in the country. This anti-toxin, listed as an “essential medicine” by the World Health Organisation, is increasingly unavailable due to the disease’s rarity and because, as a blood-derived product, its production is highly regulated. </p>
<p>For instance, in the US there are <a href="http://www.cdc.gov/diphtheria/downloads/protocol.pdf">no licensed anti-toxin products available</a> in the whole country, and in case of diphtheria an unlicensed Brazilian product is used by the CDC under investigational new drug status, which basically provides an exemption from federal regulation. In Europe, <a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20830">some public health experts have called</a> for the establishment of a central EU stockpile that all countries can access in times of emergency.</p>
<p>This time, Spanish health authorities were forced to look abroad for supplies, which were personally flown in from Moscow by the Russian ambassador to Madrid. The difficulties in locating and supplying the relevant anti-toxins highlight how quickly international structures can break down once a disease has been eliminated in a particular country and has disappeared from the authorities’ radar. </p>
<p>The recourse to diplomatic channels and the ad hoc supply of medication echoes the chaotic situation more usually associated with times of war and international emergency. A look into the Spanish government archives reveals that during the World War II, for example, Spain’s small West-African colony in what is now Equatorial Guinea faced a dangerous outbreak of Yellow Fever. Facing the collapse of its economy and wartime disruption to international supply, the Spanish government struggled to secure basic medication and to distribute the relevant vaccines both at home and in its overseas colonies. </p>
<p>Help eventually arrived from the local British Consul who agreed to fly to Lagos and bring back supplies of the vaccine in thermos flasks. While these kind of ad hoc solutions may have been a necessary during a time of international conflict, they seem profoundly out of place in today’s apparently more orderly international system.</p>
<h2>A lingering presence</h2>
<p>It was no coincidence that the anti-toxins were available in Russia. Diphtheria cases had begun to fall in the Soviet Union following the introduction of universal childhood immunisation in 1958. By the mid-1970s they had plummeted to an all-time low, approximately the same level as the US. However, changing immunisation schedules contributed to a rise in diphtheria in the 1980s, partly because of reduced levels of public support stoked by <a href="http://wwwnc.cdc.gov/eid/article/4/4/98-0404_article">a strong anti-vaccination movement</a> that channelled distrust in the state during the period of perestroika. With the collapse of the Soviet Union and much of its public health services, especially in the newly independent states, a severe epidemic broke out in 1993. </p>
<p>Shortages in vaccine supply, economic hardship and mass population movements all contributed to the outbreak and the difficulties authorities faced in controlling it. Eventually diphtheria in Russia and the former Soviet states was brought under control through international cooperation between governments, NGOs and UN agencies. Since then, the former Soviet republics and Russia have remained the only area of Europe where diphtheria is still a public health concern. Although no longer in epidemic proportions, the lingering presence of the disease led Russian authorities to keep stocks of diphtheria anti-toxin readily available.</p>
<h2>Spain’s fascist past complicates the debate</h2>
<p>Long-forgotten diseases that make a comeback also bring to light problematic relationships between citizens and the state. Recent American anti-vaccination movements <a href="https://gendersociety.wordpress.com/2014/09/02/neoliberal-mothering-and-vaccine-refusal/">highlight conflicting ideas of individual and public health</a>, while Spain’s authoritarian legacy has coloured the vaccination debate in the country. This week Luis Garciano, economic spokesman for Spain’s new centrist party Ciudadanos (Citizens), said that <a href="http://www.huffingtonpost.es/2015/06/03/garicano-vacunados_n_7502664.html">unvaccinated children</a> should be withdrawn from school and their parents fined and stripped of benefits. </p>
<p>Garciano’s comments have been denounced as “neofascist”, and <a href="http://antivacuna.blogspot.co.uk/">anti-vaccination campaigners</a> have frequently drawn parallels between the idea of obligatory vaccination and Spain’s fascist past. For them, the right to reject vaccination is a freedom that should be protected in the era of democracy.</p>
<p>The return of diphtheria to Spain mirrors the <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/official-warning-measles-endemic-in-britain-851584.html">measles</a>, <a href="http://www.nhs.uk/news/2010/12December/Pages/tb-tuberculosis-cases-rise-london-uk.aspx">TB</a> and other <a href="http://time.com/27308/4-diseases-making-a-comeback-thanks-to-anti-vaxxers/">infectious diseases</a> in Europe and the US. When diseases disappear due to high vaccination coverage, the national and international public health infrastructures needed to deal with them often also whither away. </p>
<p>When distrust in public health organisations and practices or the break-down of relationship between state and citizens give way to faltering vaccination rates (whether through anti-vaccination movements or through lack of access to vaccines), forgotten diseases can make a quick comeback. The case of diphtheria reminds us of the very real stakes at hand when infectious diseases re-emerge and throw light on the personal, national and international consequences of declaring the end of a disease.</p><img src="https://counter.theconversation.com/content/43148/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dora Vargha receives funding from the Wellcome Trust</span></em></p><p class="fine-print"><em><span>David Bryan receives funding from the Wellcome Trust</span></em></p>Spain’s fascist past has complicated the state’s relationship with anti-vaccination groups, now a rare disease has appeared again after 28 years.Dora Vargha, Postdoctoral Research Associate, Birkbeck, University of LondonDavid Brydan, PhD Candidate, Birkbeck, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/3302011-06-14T21:01:24Z2011-06-14T21:01:24ZBraving the jab for community immunity<figure><img src="https://images.theconversation.com/files/1064/original/Sanofil_Pasteur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If most people in a community are vaccinated, others are also protected. </span> <span class="attribution"><span class="source">Sanofil Pasteur</span></span></figcaption></figure><p>Let’s be clear: immunisations matter. They matter a lot.</p>
<p>We all have a complex and ever-changing ecology of microorganisms and parasites inside our bodies and in our community.</p>
<p>A <a href="http://www.couriermail.com.au/news/fatal-return-of-diphtheria/story-e6freomx-1226048663339">recent</a> fatal case of diphtheria in Brisbane and an <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr026.htm">ongoing grumbling epidemic</a> of <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Whooping_cough">pertussis</a> (whooping cough) around Australia are reminders of our interdependence in relation to infectious diseases.</p>
<p>Community immunity, often referred to as herd immunity, is the protection individuals gain from others in their community being protected against an infectious disease. </p>
<p>This immunity can come after exposure to natural infection (“wild” organisms), from exposure to related organisms which provide some level of cross-protection, or from immunisation.</p>
<h2>Vaccine protection</h2>
<p>Vaccines protect against disease by presenting parts of “pathogenic organisms” or “subdued whole organisms” to our immune system. This allows our bodies to develop protective immunity against the disease, without paying the price of the disease the full-blown wild organism can cause. </p>
<p>Some vaccines provide stronger immunity than the wild virus – the human papilloma virus (HPV) <a href="http://theconversation.com/the-case-for-vaccinating-boys-as-well-as-girls-against-hpv-6">vaccine</a> given to girls to prevent cervical cancer, for instance. </p>
<p>Even if we’re susceptible to a disease, our chances of being exposed to a disease-causing pathogen are substantially reduced if the people we’re in close contact with have immunity. </p>
<h2>Diphtheria</h2>
<p>The role of vaccinations and community immunity differs from bug to bug. </p>
<p>For <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Diphtheria?open">diphtheria</a>, the organism causes severe and commonly fatal disease only when a particular toxin is present. </p>
<p>The diphtheria vaccine protects against the toxin, not infection with the organism per se, which can occur in the skin, throat or airways. </p>
<p>It is estimated that in a fully susceptible population, a person with diphtheria is likely to infect six or seven other people. </p>
<p>Based on how readily diphtheria spreads, around 85% of a population need to be immune in order to effectively control the disease. </p>
<p>Experience bears this out. In many countries, coverage rates for diphtheria immunisation of around 90% have reduced the number of cases by more than 99.99%. </p>
<p>But while toxin-producing diphtheria strains are around in some regions and can be imported, the disease can recur if high levels of immunisation aren’t maintained. </p>
<p>Following the break-up of the former Soviet Union, disruption to immunisation led to an epidemic of more than 150,000 cases and spread to other regions. </p>
<p>The <a href="http://www.couriermail.com.au/news/fatal-return-of-diphtheria/story-e6freomx-1226048663339">reportedly</a> unimmunised 22-year-old Brisbane woman who recently died of diphtheria is likely to have been infected by a friend who had recently returned from overseas.</p>
<h2>Whooping cough</h2>
<p>Pertussis, or whooping cough, typically occurs in cyclical epidemics every three to five years, when population immunity wanes enough for an outbreak to be sustained. </p>
<p>The current Australia-wide epidemic began in 2008 and has caused the deaths of four infants so far; it shows little sign of waning. </p>
<p>Pertussis is one of the most highly contagious diseases. </p>
<p>For a susceptible population, each infected person infects around 12 to 17 others. More than 92% of people need to be immune for community immunity to be strong enough to provide protection to the remainder of the population. </p>
<p>But pertussis vaccines are typically 80-90% effective in preventing disease. So pertussis can’t be eradicated through immunising children alone. </p>
<p>Nevertheless, if an immunised person is infected with pertussis, the cough and illness tend to be milder and shorter than in the unimmunised.</p>
<p>Unfortunately, immunity against pertussis (from both natural infection and vaccine) wanes after a decade or so. This is why pertussis occurs in people of all ages. </p>
<p>In adolescents and adults, it is one of the most common causes of cough illnesses lasting more than three weeks. </p>
<p>Infant pertussis immunisation (in a combination vaccine) is scheduled at two, four and six months of age, and it takes two doses before protection becomes substantial. </p>
<p>But most severe pertussis infections and almost all deaths occur in infants under three months, before they can be protected through immunisation.</p>
<p>Parents and other household contacts are the most frequent sources of pertussis infection for infants. That’s why governments recommend boosting parental immunisation: to “cocoon” young infants and provide protection against the disease. </p>
<h2>Hib and pneumococcal bacteria</h2>
<p>There are other diseases for which community immunity powerfully augments individual protection. </p>
<p>The <a href="http://www.who.int/mediacentre/factsheets/fs294/en/index.html">Hib bacterium</a> (Hemophilus influenzae type b) causes severe infections in young children, such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Meningitis">meningitis</a>. </p>
<p>Following introduction of Hib vaccine in the Gambia in Africa, Hib disease almost disappeared despite only 60% of children receiving the three vaccine doses that provide full immunity.</p>
<p><a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pneumococcal_disease">Pneumococcal bacteria</a> also causes meningitis and other serious infections. Worldwide, these bacteria are the most common cause of severe and fatal pneumonia at all ages. </p>
<p>Within a few years of the US introducing its infants pneumococcal conjugate vaccination program, the number of severe infections in young children plummeted, as hoped. But by reducing transmission of the bacteria across the community, more than twice as many infections were prevented in older people – who did not receive the vaccine – as in children who did. </p>
<p>Vaccines against Hib, pneumococci and meningococcal bacteria are so effective in building community immunity because they reduce carriage of the organisms in the nose and throat (where they normally live), thereby reducing transmission.</p>
<h2>Hepatitis A</h2>
<p>One of the most powerful examples of the benefits of herd immunity is the story of hepatitis A in Queensland. </p>
<p>The deaths of several indigenous children from hepatitis A in north Queensland prompted the introduction of hepatitis A immunisation for Indigenous toddlers in north Queensland in 1998. </p>
<p>Despite only 15% of children there being Indigenous, cases of hepatitis A rapidly plummeted, not only among the whole population of north Queensland (Indigenous and non-Indigenous) but across the state.</p>
<h2>Personal responsibility</h2>
<p>By contrast, one disease where community immunity plays no role is tetanus. </p>
<p>Tetanus spores are widespread in soil and the gut of animals, such as horses. Disease occurs when the causative bacterium grows in contaminated wounds and produces a potent toxin. </p>
<p>We can only be protected against tetanus if we are immunised ourselves. Even having tetanus disease doesn’t protect against subsequent attacks.</p>
<p>But for most diseases targeted by vaccines, immunisation substantially reduces not only our individual vulnerability but also our shared exposure. </p>
<p>Keeping our immunisations up to date, at home and when we travel, not only protects ourselves but helps protect our children, partners, friends, patients, work colleagues and wider community.</p><img src="https://counter.theconversation.com/content/330/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tilman Ruff does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Let’s be clear: immunisations matter. They matter a lot. We all have a complex and ever-changing ecology of microorganisms and parasites inside our bodies and in our community. A recent fatal case of diphtheria…Tilman Ruff, Associate Professor, Disease Prevention & Health Promotion Unit, Nossal Institute for Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.