The history of vaccination in the United States dates to the colonial period, continuing a longer global tradition of using exposure to disease to protect people from contracting it. The practice of smallpox variolation – deliberate exposure to the disease to build immunity – originated in ancient times. Inoculation, variolation using a lancet or needle, was introduced in Europe in the early 1720s. Around the same time in the American colonies, Boston conducted the first mass inoculation in what would become the United States amidst a smallpox outbreak. West Africans had long practiced inoculation, and through their enslavement and transport to America, brought their knowledge to the colonies. Onesimus, one of these enslaved Africans, shared the technique with his owner, the influential minster Cotton Mather. A leader of the Puritan community in Boston, Mather publicized and promoted inoculation during this outbreak. Despite Mather’s influence within the community, many Bostonian clergymen opposed inoculation, arguing that the epidemic was divine punishment and thus should not be interfered with. The controversy was so great that opponents to inoculation threw explosives into the homes of Mather and Dr. Zabdiel Boylston, the surgeon pioneering inoculation. Attached to the bomb thrown into Mather’s house was a note: “Cotton Mather, You Dog, Dam[sic] you, I’ll inoculate you with this, with a Pox to you.”[1]
"Rev. Cotton Mather (Son of Increase) Using His Powerful Influence to Overcome the Prejudice Against Inoculation for Smallpox in Boston, 1721." Bronze Casting by Sally James Farnham, 1915 (courtesy of the Art Institute Chicago).
By the time of the American Revolution in the 1770s, inoculation had become more accepted in New England. Through the 1760s, future Revolutionary War leader Dr. Joseph Warren operated an inoculation clinic on Castle Island in Boston Harbor. His patients included prominent figures such as John Adams, who was inoculated during the 1764 outbreak, and Thomas Hutchinson, the governor of Massachusetts Colony on the eve of the Revolution (when he was treated by Dr. Warren, Hutchinson was serving as the colonial lieutenant governor). While Dr. Warren died in 1775 during the Battle of Bunker Hill, other doctors continued the tradition of inoculation. Abigail Adams and her children received their inoculations on July 12, 1776. As she wrote her husband, “Such a Spirit of inoculation [sic] never before took place; the Town and every House in it, are as full as they can hold. I believe there are not less than 30 persons from Braintree [the Adams’ community]… God Grant that we may all go comfortably thro [sic] the Distemper.”[2]
While many citizens received their smallpox inoculations, until 1777, many soldiers in the Continental Army were susceptible to the disease, greatly harming American campaigns. In late 1775, as Continental soldiers led by Benedict Arnold approached Quebec, smallpox crippled his forces. The enlistment of many of Arnold’s soldiers ended on January 1, 1776. A majority of these men preferred to desert the Patriot cause and not reenlist rather than risk death by smallpox. As such, Arnold and General Richard Montgomery rushed their assault on Quebec, launching it on December 30. Only about eight hundred men in their army were able to fight, resulting in a devastating failure where Arnold was wounded, Montgomery killed in action, and hundreds of Continental soldiers captured by British forces. As the campaign in Canada continued, soldiers began self-inoculating without the assistance of a doctor. However, many made the consequential mistake of not quarantining after inoculation, spreading the disease rapidly throughout the northern division of the Continental Army. As infection rates increased in the army, even more men inoculated themselves, compounding the spread of the disease. In February 1776, Arnold, attempting to curb the rampant spread of the disease, forbade inoculation under penalty of death. Despite this harsh punishment, many soldiers still secretly inoculated themselves, preferring to risk the consequences of violating Arnold’s ban than the disease.[3]
Throughout the spring of 1776, smallpox continued to harm the American war effort in the north. In March, Congress sent Major General John Thomas to take command of Continental forces in Canada. Though Arnold had reconsidered his ban, Thomas refused to allow inoculation out of concern that his soldiers would not recuperate from the sickness contracted via exposure to the inoculated disease quickly enough to defend themselves from British attack. In solidarity with his soldiers, Thomas, who had never had the disease, refused to get inoculated despite recommendations from political leaders. Tragically, this resulted in his own death from the disease, which he contracted shortly after his arrival in Canada in May 1776. After General Thomas’s death, Continental forces in Canada lacked a strong leader, ultimately ending the campaign in the north. History professor Ann Becker argued that smallpox, rather than military conditions, resulted in the American failures in Canada. John Adams agreed with this sentiment, writing to Abigail on June 26 that “Our Misfortunes in Canada, are enough to melt an [sic] Heart of Stone. The Small Pox [sic] is ten times more terrible than Britons, Canadians and Indians together. This was the Cause of our precipitate Retreat from Quebec, this the Cause of our Disgraces at the Cedars [a series of battles around Montreal in late May 1776, resulting in decisive American losses].”[4]
In response to the failures in Canada, George Washington ordered the mass inoculation of his troops. In January 1777, he enacted the first medical mandate in American history, requiring all troops to be inoculated. To offset the manpower deficit created by inoculation-related illness, military doctors exposed divisions to the disease in five-day intervals, utilizing private homes and churches to quarantine soldiers and control the spread of disease. Despite the attempt to mitigate the loss of troops during this initiative, the Continental Army still had to keep these inoculations secret to prevent the British from learning of the mass variolations and launching an attack on the weakened American forces. Washington urged his subordinates to complete the inoculations as soon as possible so that soldiers could fight by the summer “campaigning season,” although several generals and governors, including Virginia Governor Patrick Henry, remained resistant to inoculation. This limited the number of soldiers Washington had for his summer campaigns. On April 13, 1777, he wrote Henry, urging him to vaccinate Virginian soldiers because “I know [smallpox] is more destructive to an Army in the Natural way, than the Enemy’s Sword, and because I shudder when ever [sic] I reflect upon the difficulties of keeping it out.” By late 1777, however, the procedure of inoculation had been well-established in the Continental Army, significantly diminishing the risk of the disease within American forces.[5]
Shortly after the end of the Revolutionary War, a revolutionary discovery was made in medical research. Edward Jenner, a British physician, developed the smallpox vaccine in the late 1790s. Utilizing the less virulent strain of cowpox (the word “vaccine” comes from the Latin word vacca, meaning cow), Jenner developed his revolutionary treatment. Unlike variolation, which required direct exposure to the disease, vaccination utilized a weaker variant to build an immunity, making it far less dangerous.[6]
Dr Jenner performing his first vaccination on James Phipps, a boy of age 8. May 14th, 1796. By Ernest Board, c. 1910. (Wikimedia Commons)
Vaccination came to America soon after Jenner’s discovery of the vaccine. Dr. Benjamin Waterhouse, the first Professor of Physic at Harvard Medical School introduced the vaccine in America near the end of the eighteenth century. In 1799, a friend of Waterhouse’s, London physician John Coakley Lettsom, sent the Boston doctor a copy of Jenner’s An Inquiry into the Causes and Effects of the Variolæ Vaccinæ, which contained Jenner’s studies. Waterhouse was so impressed with Jenner’s work that he began writing to the British doctor and soon received thread containing the vaccine matter. He was so confident in the safety and efficacy of vaccination that he used this matter to inoculate his household in 1800. Thus, the first vaccinations in the United States occurred.[7]
After vaccinating his own household to prove the safety of the vaccine, Waterhouse published the results of his own work, which popularized the Jenner vaccine, known as kinepox, across the U.S. Even President Thomas Jefferson received the vaccine, becoming the highest profile advocate of inoculation. He allowed his name to be used as an endorsement, giving legitimacy to vaccination initiatives across the new republic. Throughout the summer of 1801, Jefferson forced the enslaved workers on Monticello to be inoculated in addition to vaccinating his sons-in-law and some neighbors- approximately 200 people in total. He began with vaccine material received from Dr. Waterhouse but then was able to collect his own vaccination material from those who had been inoculated. This newly acquired material was sent to other parts of Virginia, including Richmond and Petersburg, and Washington, D.C. Jefferson was such a proponent of the vaccine that he instructed the Lewis and Clark expedition to carry kinepox vaccination matter and encourage any Native Americans they encountered to receive inoculation. In 1806, the President wrote to Edward Jenner, describing the discovery of the vaccine as the greatest medical discovery in history: “Medecine [sic] has never before produced any single improvement of such utility... you have erased from the Calendar of human afflictions one of it’s[sic] greatest.”[8]
The first state and federal policies regulating inoculation date back to this period, likely encouraged by the high-profile proponents of the vaccine. In 1809, Massachusetts enacted the first vaccine mandate law in America, giving local health boards the authority to require immunization within their jurisdictions. This was soon followed by the federal 1813 Vaccine Act, which appointed an agent to distribute vaccines to anyone who requested it and allowed for them to be mailed for free, without postage. This law was repealed in 1822 after infectious variolous matter was mailed accidentally, inadvertently causing a smallpox epidemic.[9]
While federal vaccination laws stalled for a brief period after the repeal of the 1813 Vaccine Act, municipalities across the United States enacted local vaccination laws, especially in schools, throughout the Antebellum period. The first city to require the immunization of schoolchildren attending public schools was Boston, in 1827. In 1855, the State of Massachusetts passed a law requiring vaccinations for all children statewide. Through the rest of the nineteenth century, vaccine mandates continued being implemented throughout the United States.[10]
Despite significant public opposition to these laws, the Supreme Court upheld the authority of states to pass and enforce vaccine mandates in the 1905 case Jacobson v. Massachusetts. This case was decided shortly after the 1901-1903 Boston smallpox epidemic, which infected nearly 1,600 people and killed 270. The epidemic brought the issue of public health to the forefront in Boston, where antivaccinationists and pro-vaccinationists debated the merits of compulsory vaccination after the state required all adults to be inoculated under penalty of a $5 fine (approximately $180 today). In 1902, Pastor Henning Jacobson refused to be vaccinated or to pay the fine, arguing that previous vaccines had injured him and his son. The Massachusetts Supreme Judicial Court ruled against him, so Jacobson appealed to the United States Supreme Court, arguing that the “compulsion to introduce disease into a healthy system is a violation of liberty.” In a 7-2 ruling, written by Justice John Marshall Harlan, the Supreme Court also rejected his arguments. Harlan wrote that states had police power to regulate public health: “The good and welfare of the Commonwealth, of which the legislature is primarily the judge, is the basis on which the police power rests in Massachusetts... Upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”[11]
Illustration from the Boston Globe, January 28, 1902 as the state moved to vaccinate its citizens for smallpox.
The power of states to regulate vaccination was strengthened in another court case nearly twenty years later. In 1922, the Supreme Court ruled in Zucht. v. King that governments had the power to mandate vaccination as a condition of attendance in both public and private schools. Like many municipalities across America, San Antonio, Texas, city ordinance required children to get vaccinated before attending school. Rosalyn Zucht was barred from attending both a public and a private school because she was unvaccinated. This was challenged in state court, arguing that there was no epidemic and therefore no reason for requiring vaccination; thus, Zucht’s liberty was infringed upon. In a unanimous ruling written by Justice Louis Brandeis, the Supreme Court decided that both states and municipalities had the power to mandate vaccinations: “a state may, consistently with the federal Constitution, delegate to a municipality authority to determine under what conditions health regulations shall become operative.” [12]
Following these two landmark cases, government’s power to implement vaccination mandates increased. By 1915, fifteen states and Washington, D.C. had vaccine mandates for schoolchildren, and twenty-one other states, including West Virginia, had laws or regulations allowing localities to issue mandates. This only increased throughout the twentieth century, as states either enacted new mandates or, like WV, passed new laws to strengthen their existing policy. By 1980, every state had laws pertaining to the vaccination of children before they attended school. By the turn of the twenty-first century, all but four states had vaccine mandates for students entering kindergarten through 12th grade, and thirty had vaccine requirements for college students as well. As of 2022, all states required vaccination as a condition for attending school. In every state, the law stipulates that children must receive the DTaP (diphtheria, tetanus, and pertussis), polio, and varicella vaccines before entering kindergarten. Furthermore, all states besides Iowa require that children receive an MMR (mumps, measles, and rubella) vaccine; Iowa requires measles and rubella immunization but not mumps. Many other states require students to receive other vaccinations for their entrance into later grades, often 7th grade, and college.[13]
While these mandates require vaccination, all states have medical exemptions and most offer religious or philosophical exemptions to parents as well. As of 2024, West Virginia is one of five states, along with California, Connecticut, Maine, New York, and Washington, D.C., with no non-medical exemptions to vaccination laws. Of these five, WV is the only state to never have had non-medical immunization exemptions.[14]
The lack of a non-medical exemption in West Virginia reflects the strong tradition of vaccination in the Mountain State. In some of the first legislation passed by WV in 1863, the state hired an agent to distribute vaccines across the Mountain State. As the state grew, several new laws were passed to strengthen and provide WV’s vaccination policy. In 1872, after the state formation of county boards of education, the state delegated the power to these local institutions to require vaccination. The following year, the state amended existing law to hire two additional vaccine agents, stationing one in Charleston, one in Martinsburg, and one in Wheeling.[15]
West Virginia passed its first statewide vaccine law in 1905. This law gave county courts the power to institute smallpox vaccine mandates or compulsory quarantine, allowing only medical exemptions. These courts could only do so upon the petition of 100 voters within the county in the case of an epidemic, giving the ultimate power to the people. When these mandates were implemented, any person refusing vaccination who did not have proof of vaccination or a certificate from a physician demonstrating medical exemption would be placed under quarantine. Furthermore, during these periods, no children were allowed into public schools without vaccination or a physician’s certificate. To contain smallpox within the locality, any person that contracted smallpox had to present a certificate of being “properly cleansed and disinfected” to the county health officer in charge of the county that they wanted to visit. This travel restriction was in place for up to three months after their infection. Any physician that gave false certificates of vaccination was found guilty of a misdemeanor and subject to a fine between $20 and $100. Any other violations of this act were misdemeanors punishable by a fine between $10 and $50.[16]
West Virginia recodified all of its laws in 1931, updating and modernizing its legal code. Included in this revision was an updated vaccination law that enabled municipalities, rather than local courts, to implement vaccine or quarantine mandates. WV code was amended again in 1937 to enact a statewide smallpox and diphtheria vaccine mandate for schoolchildren. This policy remained the same throughout the 1940s, 1950s, and most of the 1960s. However, the development of new vaccines throughout the 1950s and 1960s resulted in two more updates to the legal code in 1967 and 1971. Immunizations for polio, measles, pertussis, and tetanus (1967) and rubella (1971) were required for students before children were allowed to enter school.[17]
Among these vaccines, the polio vaccine was the most significant and represented one of the largest public health initiatives in American history, ending the threat of one of the worst childhood diseases. Throughout the early twentieth century, polio raged through the United States, killing or paralyzing thousands. Residual childhood paralysis from polio in southern West Virginia was so common that Morris Memorial Hospital in Cabell County was built in 1936 to care for them. Since water therapy was a common treatment for polio victims, the hospital had three saltwater pools on-site. It also had eight iron lungs to treat the children and assist their breathing.[18]
Throughout the 1940s and 1950s, doctors developed a vaccine to protect children from such a terrible disease. In 1947, Dr. Jonas Salk was appointed the director of the Virus Research Laboratory at the University of Pittsburgh School of Medicine. At Pitt, Salk developed an inactive polio vaccine, consisting of a “dead” polio virus, which he believed could immunize children without infecting the patient. The first clinical trials of the Salk vaccine were performed in 1952 at the D.T. Watson Home for Crippled Children (now the Watson Institute), in Sewickly, Pennsylvania. Salk began mass nationwide tests of his vaccine in 1954, resulting in over a million schoolchildren becoming “polio pioneers.” In 1955, full rollout of the Salk vaccine began nationwide, including in West Virginia. At around the same time as Salk, Albert Sabin, a Cincinnati scientist, developed a live vaccine that was ingested rather than injected. The Sabin vaccine was distributed through America beginning in the 1960s. Across West Virginia, “Sabin Oral Sundays” were held to promote this vaccine. Because of the bitter, salty taste of Sabin’s oral vaccine, it was often given to children on a sugar cube or in a spoonful of syrup- in fact, the song “A Spoonful of Sugar (Helps the Medicine Go Down)” from Mary Poppins was inspired by the composer’s five-year-old son’s story of his polio vaccination at school that day. The last reported case of polio in West Virginia occurred in 1970.[19]
"Sabin Oral Polio Vaccine Sundays, Kingwood, Preston County, W. Va." (West Virginia & Regional History Center)
Another significant public health triumph was marked with another 1973 amendment to West Virginia code. This time, the state removed the requirement for the smallpox vaccine, reflecting its eradication. Despite the final case of smallpox occurring in the U.S. in 1949, it took until 1972 for the American government to discontinue routine vaccination of children. The eradication of smallpox was one of the greatest public health triumphs in history, fueled by advances in medical technology. The 1950s saw the development of heat-stable and freeze-dried smallpox vaccines that could be stored without refrigeration, enabling widespread vaccination across the world. The World Health Organization called for the global eradication of smallpox in 1958, starting a global initiative that transcended Cold War-era international divisions. Smallpox was eradicated in North America in 1952, Europe in 1953, and South America in 1971. The final natural cases of smallpox occurred in 1975 in Bangladesh and 1977 in Somalia, and the World Health Organization declared the disease fully eradicated in May 1980.[20]
In West Virginia, the vaccination schedule remained consistent for about four decades. While the law was altered to add a requirement that informed parents about vaccine mandates and potential adverse effects (1985) and provided provisional enrollment for students with at least one dose of the vaccine (1987), no new vaccine requirements were added until 2015. In 2015, the law was updated to include chickenpox, hepatitis B, meningitis, and mumps immunizations, requiring these vaccinations in all public, private, and parochial schools and state regulated day cares. This remains the most recent vaccination law in West Virginia’s legal code.[21]
Vaccination in the United States has come a long way from the days of Cotton Mather, Zabdiel Boylston, and variolation. As medical technology has advanced, new breakthroughs have enabled doctors to protect children from new and deadlier diseases across West Virginia, the United States, and the world. As science continues to progress, hopefully, vaccination initiatives will eradicate many other diseases, just as they did smallpox.