What Happened After the Chicken-Pox Vaccine?
In the COVID era, the success of the varicella vaccine in the nineties is staggering to contemplate.
A boy with chicken pox takes a pill to help relieve itching, in 1960. Before the varicella vaccine, chicken pox killed about seventy children in the U.S. every year.Photograph by Carl Iwasaki / Getty
Last summer, at the Centers for Disease Control and Prevention, an internal presentation on the coronavirus, which was leaked to the press, called the Delta variant of covid-19 “as transmissible as chicken pox.” Although the claim was found to be overstated, it’s easy to see why researchers may have been predisposed to draw parallels between the two diseases. Both varicella-zoster—the proper name for the chicken-pox virus—and the coronavirus are spread through the air, and both can be contagious before any symptoms are evident. Both have relatively mild impacts on most children, with a higher risk of more serious effects in adults. The mostly apocryphal tales of “covid parties”—which almost always turn out to be unintentional spreader events—descend from those of “chicken-pox parties,” where parents knowingly exposed their children to symptomatic peers.
There was also a kind of wistfulness in the comparison. A vaccine for varicella received full approval from the Food and Drug Administration in 1995, and within a decade forty states and the District of Columbia added varicella as a required immunization for enrollment in public elementary schools. Today all fifty states enforce this mandate. (Medical and religious exemptions vary state by state.) Near-universal mandatory immunization against chicken pox virtually eliminated the disease in the space of a generation.
This past October, a coronavirus vaccine for children aged five to eleven received emergency-use authorization from the F.D.A.; since then, a little more than eighteen per cent of eligible children in the U.S. have received the two shots required for vaccination, according to a recent Kaiser Family Foundation report. (The F.D.A. is reportedly close to authorizing a vaccine for children under five.) Several of the nation’s biggest cities are now mulling covid-vaccine mandates for their public-school systems; New York’s Mayor, Eric Adams, has spoken in support of student mandates. But across large swaths of the U.S.—including in states such as Georgia, Indiana, Montana, Tennessee, and Texas, where covid-vaccine mandates for state employees and health-care workers are banned—any large-scale immunization effort is a nonstarter.
It’s also increasingly likely that existing vaccine mandates will collapse. In January, after the D.C. Council voted in favor of a vaccine mandate for eligible public-school students, Ted Cruz, the Republican senator from Texas, introduced a joint resolution to block it. (Cruz cited the Home Rule Act, from 1973, which subjects locally enacted laws in the District of Columbia to congressional review.) A bill introduced in the Georgia General Assembly would prohibit “state and local governments from mandating vaccine passports” for any disease, meaning that children attending public schools in Georgia would no longer be required to receive any immunization at all.
Today the success of the varicella vaccine is staggering to contemplate—partly because, in the vast majority of cases, chicken pox wasn’t a very big deal. It usually meant a week or so of itchy convalescence and maybe a faint, tiny scar or two. (The classic description of chicken-pox lesions is “dewdrops on a rose petal,” although “angry little red zits” would be more apt. “Chicken pox” is also a total misnomer—it’s a herpesvirus, not a pox, and who knows about the chickens.) Before the vaccine, between three and four million people in the U.S. contracted chicken pox every year. Kids were so overwhelmingly likely to catch it that the C.D.C.’s list of “evidence of immunity to varicella” includes “birth in the United States before 1980.”
“People viewed it as part of childhood: you get measles, you get chicken pox, and you move on with your life,” William Moss, a pediatrician and a professor at Johns Hopkins, told me. “When viewed in that individualistic way, it’s analogous to ‘covid is a cold,’ where it’s dismissed as a common infection that’s not serious—you don’t feel well for a few days, you get better, and you’re done with it.”
But, as with covid in children, there were rare and awful exceptions. “We were curing kids of leukemia only to have them die of varicella,” Anne Gershon, a professor of pediatrics at Columbia, told me. Gershon, who led a varicella-vaccine study group funded by the National Institute of Allergy and Infectious Diseases, in the late nineteen-seventies and eighties, said that immunocompromised children, such as those undergoing chemotherapy, were vulnerable to disseminated varicella, a severe form of chicken pox that can manifest as encephalitis, hepatitis, or, most commonly and most fatally, pneumonitis, a pneumonia-like lung-tissue inflammation. Newborns and infants could become seriously ill with chicken pox, and so could older, otherwise healthy children if chicken pox coincided with a staph infection or group A streptococcus, the cause of strep throat.
The Japanese virologist Michiaki Takahashi isolated varicella-zoster in a three-year-old boy, in 1974, in order to create what became known as the Oka vaccine strain (named for the boy’s family); a vaccine was approved in Japan by 1986. In the U.S., however, clinical trials dragged on throughout the nineteen-eighties and into the nineties, in part because researchers worried that the vaccine’s effects would diminish over time. (Once varicella-zoster enters the human body, it never leaves, and instead sleeps within nerve cells; decades later, it can reactivate as shingles, an often debilitating nerve inflammation.) The plodding pace of approval also stemmed from an odd mix of caution and indifference. Speaking to the Times in 1993, Walter Orenstein, then the director of the C.D.C.’s national immunization program, said, “The major controversy is whether the medical consequences of chicken pox are serious enough to warrant a major vaccination effort, whether chicken pox is worth preventing.” Gershon told me that, when she would run into various F.D.A. officials at meetings and conferences, “I would say, ‘When are we going to get this vaccine licensed?’ They would just shrug their shoulders.”
This irresolution persisted, to an extent, after the vaccine was finally licensed. Public hearings on adding varicella to the schedule of required immunizations tended to strike similar notes from state to state: among parents, a small, vocal minority were dismayed by what they viewed as an abrogation of their rights; among pediatricians, there was near-consensus that the vaccine was safe but some uncertainty about whether it was strictly necessary. Charlotte Lewis, who was a pediatric resident in Los Angeles at the time, and who is now a pediatrician in Seattle, told me, “I was one of those people who felt really ambivalent about it, because it was a disease that seemed relatively benign.” Her mixed feelings resolved after she treated a ten-year-old girl with no preëxisting health conditions who landed in the I.C.U. with varicella pneumonia. “I had that one experience, and that’s all it took—I could see now what chicken pox can do even to kids who are healthy,” Lewis said. She still remembers her patient’s long, dark hair, and how the girl, too sick to move for weeks, longed to wash it.
That ten-year-old survived. But William Moss, the Johns Hopkins pediatrician, told me he’d seen a child die of chicken pox in the late eighties, when he was in residency training at Columbia-Presbyterian Hospital. Before the varicella vaccine, chicken pox killed about seventy children in the U.S. every year. By comparison, in the first twenty-three months of the current pandemic, six hundred and sixty-one children under the age of twelve have died of covid.
There have been anti-vaxxers in America since at least 1721, when one, in Boston, threw a bomb into the home of the clergyman Cotton Mather, who advocated for community-wide inoculation against smallpox. (The bomb was a dud.) Two hundred and seventy years later, in the nineteen-nineties, a pediatrician might have had to reason with a few parents who preferred chicken-pox parties over the chicken-pox vaccine, owing to “the underlying idea that natural infection is better,” as Moss put it. In “On Immunity,” Eula Biss writes that this quasi-homeopathic allegiance to “wild-type” immunity is evidence of “a variety of preindustrial nostalgia.”
Still, pediatricians circa 1995 did not operate in a world in which “vaccine hesitancy” was common parlance. It would be three years before the medical journal The Lancet published a fraudulent study by Andrew Wakefield and twelve co-authors implying a link between the measles, mumps, and rubella (M.M.R.) vaccine and autism, and more than a decade before the television personality and vaccine skeptic Jenny McCarthy told Larry King, “It’s an infection and/or toxins and/or funguses on top of vaccines that push children into this neurological downslide which we call autism.” In the pandemic era, vaccine mandates—much like masking policies and library books with Black people in them—have been weaponized in the right-wing culture wars, held up as evidence of an authoritarian plot to subvert parental autonomy. (In introducing his anti-mandate bill, Ted Cruz stated, “covid policies should be based on science and common sense, not the hysterical demands of radical liberal activists and union bosses who have no interest in what’s best for our children.”)
“Social-media platforms have played a large role in spreading misinformation and disinformation about vaccines, reaching an increasingly large audience with repeated false claims,” Moss said. “This in large part accounts for differences in parental views of vaccines from the nineteen-nineties until now. But this is also occurring in a broader cultural context in which there is increasing mistrust in traditional scientific, medical, and public-health expertise.” To reason with a vaccine-skeptical parent, he said, “requires an intense, sustained effort, and you get tired. It’s a battle that has to be fought on a one-by-one level. It’s not a battle we can win at a population level.” Lewis told me that pediatricians can’t give wary parents what they want, and what they can get from other, unsavory sources: absolute certainty. She went on, “The physician and the parent are on different planes, coming from vastly different perspectives, and they don’t fully understand each other.”
The pediatrician’s struggle toward this mutual understanding is made more difficult by the trend, during the past two decades, of consolidation among physicians in private practice, which can anonymize what once might have been lifelong familial connections. “The relationship in which a parent and a child are seeing multiple different providers in a large practice is different from one where they see the same provider over many years. It’s not the same trusting relationship,” Moss said. When I got chicken pox, in the nineteen-eighties, my mother called Dr. Steinhart, whom I’d been seeing since I was born. By contrast, my own children, who are patients at a multi-location pediatrics network, haven’t seen the same doctor twice in a row in years. When I brought my son in recently for his five-year visit, I didn’t even catch the name of the very nice pediatrician who examined him.
Not long ago, I texted about a dozen friends in their thirties and forties to ask for their memories of chicken pox. All but one had had it. The median age of infection was about six. Nobody’s parents had sent them to a bona-fide chicken-pox party, but several recalled chicken-pox playdates. Motifs emerged: Aveeno oatmeal baths (“a strange melding of breakfast and hygiene,” one friend recalled), the smell of calamine, cartoons on the couch, lightly fevered napping, trying not to scratch. A couple of women revealed that having chicken pox marked the first time they’d realized that their undercarriage had an interior—those blisters went everywhere. Several people said they had not even heard about the chicken-pox vaccine until their own children became eligible for it, and felt briefly taken aback that the medical community had gone to so much trouble. (“In my day we had to walk two miles to school in the snow with chicken pox,” one joked.)
I didn’t detect much preindustrial nostalgia in these texts. Yet my correspondents did appear to place a value, however sheepishly, on the distinct, tactile memory of a generationally shared inconvenience—one that is now obsolete, like trying to find your friends at a warehouse party without cell phones. Having had chicken pox places you in a specific before-time, the way that the smallpox-vaccine scar on my father’s upper arm does for him. Perhaps it’s only natural to long, a little, for the before-time of chicken pox, when the question was whether we would be able to wipe out a disease and not, once we had the capability, whether we would choose to do it.
Written by Jessica Winter for The New Yorker ~ February 7, 2022