Immunisation Against Infectious Disease 1996
"The Green Book"
This 1996 edition of Immunisation against Infectious Disease (the Green
Book) almost exactly coincides with the bicentenary of Jenners
remarkable demonstration that an individual could be rendered immune to
smallpox by the inoculation of James Phipps with material obtained from
a cowpox vesicle. Recent changes in immunity brought about by immunisation
have been equally remarkable. The 1992 edition of the Green Book
coincided with the introduction of Haemophilus influenzae b vaccine
(Hib). Haemophilus influenzae meningitis, epiglottis and other
serious infections from this organism have now virtually disappeared from
In 1992, the changing age distribution of measles was noted and some
modification in immunisation strategy anticipated. Mass measles-rubella
immunisation to prevent an epidemic of measles in school-age children
was conducted during November 1994. The Measles/Rubella Immunisation Campaign
reached over 8 million children and necessitated an enormous exercise
in planning and implementation throughout the UK. It also involved a vast
number of doctors, nurses and other health personnel, particularly in
the school health service, and we are greatly indebted to them for its
success. Susceptibility to measles in this target population has dropped
dramatically and the few cases of measles since the campaign occur mostly
in adults or infants too young to have been protected by immunisation.
The inclusion of rubella vaccine has greatly reduced the susceptibility
to rubella in males and therefore the risk to susceptible pregnant women.
It is logical to follow up this campaign by introducing a two-dose strategy
for MMR vaccine to prevent further accumulations of susceptible children
which could sustain future epidemics of measles, and to allow the termination
of the schoolgirl rubella immunisation programme. Other changes reflect
the continuing importance of surveillance and of monitoring the epidemiology
of infection not only in this country but world-wide: the outbreaks of
diphtheria in eastern Europe and the resurgence of tuberculosis are two
problems of particular concern.
The Joint Committee on Vaccination and Immunisation (JCVI) continues
to pay close attention to vaccine safety. Particular care was taken to
monitor and investigate the apparent adverse reactions that occurred during
the Measles/Rubella Immunisation Campaign. In this edition separate chapters
are devoted to adverse reactions and to the problem of anaphylaxis; and
information is provided on the vaccine damage payments scheme. It is always
difficult to distinguish true vaccine reactions from coincidental events
in a childs life, but doctors are urged to be meticulous in reporting
reactions and in obtaining the details and appropriate specimens that
will help in their thorough investigation.
I should like to record my gratitude and that of my colleagues on the
Joint Committee to all those who worked on this Handbook, but particularly
to the editors Dr David Salisbury and Dr Norman Begg, their contributors
in the Department of Health, and to Mrs Maureen Ambler.
A G M Campbell MB FRCP(Edin) DCH
Chairman, Joint Committee on Vaccination and Immunisation (JCVI)
Two hundred years ago, Edward Jenner was able to demonstrate that vaccination
with material from cowpox provided protection against smallpox, which
at that time was one of the most feared infectious diseases. Before then,
few people reached adulthood without having caught smallpox and the case
fatality rates were often around 10%. At the end of the eighteenth century,
smallpox caused one fifth of all deaths in Glasgow and nine out of ten
people who died of smallpox were under 5 years of age. One hundred and
seventy years later, smallpox virus was extinct. Through that course of
events, we have seen all of the key lessons of immunisation, and hopefully
learnt from them. Few medical procedures or treatments can compare with
the enormous benefit to humanity from immunisation, one of the safest
and most cost effective of interventions.
Within a remarkably short time of Jenners first publication of
his observations, thousands of people were being vaccinated. By the beginning
of the nineteenth century, vaccination was being undertaken in many European
countries. Yet an anti-vaccination lobby was already making its efforts
felt. A cartoon by Gillray in 1802 shows vaccine recipients growing cowlike
parts, and spurious information about the risks of vaccination was often
quoted as if it were true. To overcome such resistance, vaccination was
encouraged through the Vaccination Acts of 1840, 1841 and 1853 making
vaccination successively universal, free, and finally compulsory. The
Acts of 1861, 1867 and 1871 made vaccination enforceable by the appointment
of Vaccination Officers and ultimately parents were liable to repeated
fines until their children were vaccinated.
Legislation to make immunisation compulsory was widely unpopular and
all legislation enforcing compulsion was finally withdrawn in 1948.
The last large epidemic of smallpox (variola major) was in London in
1901- 02. After that time, importations continued, notably from Africa
and Asia, a pattern that has been repeated with poliomyelitis and measles.
By the mid 1970s, it was clear that the risk of death from the complications
of smallpox vaccination outweighed the predicted number of deaths that
would follow importations, because of the success of the global programme
of smallpox eradication. Smallpox vaccination was then abandoned, apart
from the requirements for international travel. The worlds last
naturally occurring case of smallpox was in Somalia in October 1977. In
May 1980, the World Health Assembly accepted that smallpox had been eradicated
worldwide. The principles of its eradication - the use of an effective
vaccine, with a strategy that focused on surveillance, along with a global
coalition towards a concerted action, fulfilled a prophecy made by Jenner
that the annihilation of the Small Pox, the most dreadful scourge
of the human species, must be the final result of this practice.
We are now in a position to expect the global eradication of poliomyelitis
within a few years, and hopefully, measles eradication will follow.
Two hundred years after Jenners first observations, we are seeing a new era beginning for vaccines. With the application of genetic manipulation techniques, better understanding of processes of infection and immunity, and a widespread recognition that investment in disease prevention is one of the best uses of resources, we can expect ever more vaccines, and ever more diseases eradicated.
Sir Kenneth Calman
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