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Immunisation has always had its opponents and professional reactions to them have not always been exemplary. The last epidemic of smallpox in Boston, Massachusetts began in 1901 and lasted for almost two years. A recent article (New England Journal of Medicine2001;344:375–9) has described some of the excesses of medical fervour displayed in an attempt to control it. The epidemic began in May 1901 and when it ended in March 1903 there had been 1596 cases and 270 deaths. Almost half (47%) of the cases had been vaccinated and in these the fatality rate was 11% whereas in unvaccinated patients it was 22%. In “public” (state) schools vaccination had been compulsory since 1855 and during the epidemic the rate of infection in children aged 6–10 years was about one sixth of that in pre-school children. Initially, voluntary vaccination was offered but compulsory vaccination was introduced in December 1901. The penalty for refusing to be vaccinated was a $5 fine or 15 days in prison. Homeless and destitute people were thought to constitute a major risk to the rest of the population and men in cheap boarding houses were vaccinated forcefully by “virus squads”, often including three policemen to hold down the resisting tramp. An active minority considered compulsory vaccination to be an unacceptable offence against civil liberties and it was challenged unsuccessfully in the courts in January 1902. In an incident offensive by modern ethical standards, the chairman of the Boston Board of Health challenged those opposed to vaccination to allow themselves to be exposed to smallpox deliberately while unvaccinated. The challenge was taken up by one Dr Pfeiffer, who was taken on a tour of the smallpox hospital on 23 January 1902; by 8 February he had severe smallpox from which he recovered unexpectedly. The last case of smallpox in Boston was in 1932 and the last case in the United States in 1949. Routine vaccination against smallpox ceased in the USA in 1971.
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