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Smallpox 1947: "People were terrified"

Public health officials averted an outbreak with the largest mass vaccination in U.S. history.

By Victoria Stagg Elliott, AMNews staff. June 23, 2003.

In February 1947, Eugene Le Bar, a healthy, 47-year-old merchant, got on a bus in Mexico City, and five days later, arrived in New York City with a rash and a mild headache. It didn't prevent him from sightseeing all over the Big Apple. But a few days later, he was sick enough to be admitted to a hospital.

This tale is the first chapter in the story of how smallpox made its last appearance in New York City.

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It is a classic public health saga: An infectious disease was carried in by travel and spread throughout the community. Intervention was delayed by a mistaken diagnosis. But a rigorous response effectively stopped it.

LeBar had been vaccinated against smallpox as a child, so doctors initially thought his symptoms were the result of an adverse reaction to the aspirin and other pain killers he took for his headache. But on March 10, LeBar died. By the end of the month several other patients and hospital workers who had contact with him developed smallpox, according to the November 1947 American Journal of Public Health.

Ultimately, the outbreak killed two and sickened 12. It was not the last smallpox appearance on U.S. soil -- that would be in Texas' Rio Grande Valley two years later. But what makes New York's 1947 episode notable is the massive and unprecedented public health measures that effectively contained it. Contacts were traced aggressively. People were told to get vaccinated. And they did.

"It's amazing what they managed to do," said Alexandra Lord, PhD, staff historian for the U.S. Public Health Service.

An outbreak in Seattle two years earlier had killed 20 and shut down the city . A previous 1901 New York outbreak killed hundreds and sickened thousands. And according to the public health journal article, without New York's mass vaccination efforts in 1947, more than 4,000 people would have been infected and nearly a thousand would have died. Instead, there were two deaths from the virus and six deaths linked to the vaccine.

"Tragic as these incidents were, it must be borne in mind that had vaccination not been carried out on such a large scale, there very likely would have been thousands of cases and hundreds of deaths," noted Israel Weinstein, MD, then-commissioner of health for New York City, who authored the journal article.

With today's renewed focus on smallpox as a potential weapon of bioterrorism, consumer publications and public health officials have frequently mentioned the 1947 outbreak as a possible model for how the United States could respond in a worst-case scenario.

A model from the past

In 1947, more than 6 million of the city's 7 million residents volunteered to be vaccinated in less than a month. According to 1947 New York Times coverage, public and private hospitals vaccinated 1.6 million. Public health clinics and police stations jabbed another 1.9 million. Workplace clinics got 1.2 million, and 650,000 were vaccinated at school. Private physicians vaccinated 1 million.

People showed up for the vaccine, and the health department arranged for staff to take care of them. In addition to city employees, 1,100 physicians, 242 clerks and 3,000 other civilian volunteers were recruited to meet the challenge.

"There was a little more urgency then, than there is now," said Theodore Tuller, MD, regional medical consultant for the Social Security Administration, who was in his first year as a general practice physician in 1947. "People lined up all over the place. If they heard you had vaccine, they were there. ... People were deeply concerned about it."

The process, according to newspaper accounts and memories of doctors working in New York City at the time, was far from smooth, although it was successful. Diagnosis of Le Bar, the index patient, was completed retrospectively, and public health historians say this situation would be difficult to avoid.

"Early on in smallpox, the clinical diagnosis is difficult," said Judith Leavitt, PhD, professor of medical history at the University of Wisconsin in Madison. "And a lot of the doctors had never seen a case."

But once the diagnosis was made, an extensive information campaign was launched. In post-World War II America, health officials were able to recall recently dismissed air-raid wardens and other civilian defense workers to canvas door-to-door and convince people to get vaccinated.

The health department passed out buttons with a simple message: "Be safe. Be sure. Get vaccinated." The word also went out over the radio and in newspapers. Mayor William O'Dwyer posed for photos while he received the vaccine. Even President Harry S. Truman publicly received his vaccination before visiting the city.

How they did it

Health centers, city hospitals and police stations -- 179 sites citywide -- were open almost nonstop to give the vaccine, which was free. Students could get their shots at school. Workers could get it on the job.

"It was very, very convenient," said Dr. Lord. "People didn't have to travel or make an appointment."

Thousands of vaccinations were provided per day, with a half-million on April 17 alone.

"We worked around the clock, 24 hours a day, giving smallpox vaccinations," said David Annunziato, MD, who was an intern at St. John's Hospital in Brooklyn and worked three or four 24-hour shifts providing vaccinations in April 1947. "When you're a young house officer nothing is boring."

His hospital alone processed 40 to 50 people an hour. Dr. Annunziato remembers working fast. Recipients were prepped by nurses and rapidly filed through the clinic.

"They were all prepped by nurses, sleeves rolled up, arms prepped with acetone, and the nurses would hand you a vial of vaccine and a needle," said Dr. Annunziato, who also sits on the historical archive committee of the American Academy of Pediatrics. "You do it, and it's gone. It was an assembly line."

The vaccine, however, required more skill to deliver then, and the city was constantly putting out the call for doctors to come forward and help. Special needles that made the procedure easier and more efficient had not yet been introduced. In the 1940s, a drop of vaccine was placed on the recipient's arm and then scratched into the skin with a regular needle.

"Until the development of the bifurcated needle in the 1960s, vaccinating for smallpox was very difficult and required a fair amount of training and knowledge," said Dr. Lord.

But in some ways, the process was simpler. There wasn't the extensive screening process that exists today. Many immune-compromising conditions that now can make the vaccine deadly were unknown or didn't exist.

"We did a very minimal screening. We asked them if they had eczema, and most of them said no," said Dr. Annunziato, who is now director of pediatric education at Nassau University Medical Center in New York state. "We didn't ask if they had AIDS. There was no AIDS."

Recipients were not called back to determine if the vaccine actually "took." And nearly all were re-vaccinees -- they just hadn't received the vaccine recently.

But while the city had the facilities and the message, it did not have enough vaccine. It started out with 250,000 doses and ordered large amounts to arrive as soon as possible. Doses couldn't be made fast enough, and the city quickly ran out. The Army, Navy and Public Health Service sent several thousand units, and manufacturers were granted special permission to package in 50-dose vials rather than the usual 10-dose vials. Drug companies kept their factories running nonstop.

Clinic shortages were brief because the city focused on fulfilling their needs, sometimes to the detriment of solo physicians, who had a hard time getting the vaccine. The 50-dose vials were reserved for the large temporary clinics.

"I remember having difficulty getting the vaccine," said Dr. Tuller. "Someone helped me out and got me some, and I did vaccinate employees of a few businesses in the area."

There were also instances of fraud. The Times said a nurse was sentenced to six months for vaccinating 500 people with water. In addition, some clinic patients gave false names or contact information, making follow-up impossible.

"Even in those days, we had illegal aliens," said Dr. Annunziato.

But while modern public health officials look to successful campaigns like this to plan how to do it again, historians say the factors that converged to make it possible may not be easy to duplicate. In 1947, the anti-vaccine movement was not powerful. And, despite the end of the war, many people were still in the military or linked to war-effort volunteer organizations. They could be called on to run the clinics. And in the post-war era, people were also more willing to follow government advice.

"If it had to happen and you had to vaccinate a population, the 1940s was probably the right period to do it," said Dr. Lord.

Local public health officials got everyone involved in the process, including federal and state governments, aid organizations such as the Red Cross, drug companies and community organizations. They also used education and volunteerism rather than coercion. And they didn't make getting the vaccine mandatory.

The public health system was strong, backed by law enforcement, when necessary, and kept the public informed. When they had vaccine, the health department told people to line up. When they ran out, they announced that too.

"The health department really respected the public's need to know," said Dr. Leavitt, "They weren't putting a spin on it. And the public health infrastructure was in extremely good shape and gained support by reaching deep into community networks."

Physicians working at the time credit the success of the effort to something much simpler: fear. Smallpox hadn't been seen in New York City in decades, but it was still a very real threat and endemic in much of the world.

"People were terrified," said James Dick, MD, who was a resident at the Postgraduate Medical School and Hospital in New York. He administered the vaccine to his regular patients at the time, although he did not participate in the mass vaccinations. "People went and got [vaccinated.]"

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