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Vaccine Preventable Diseases in Fiction and in Reality

By 

René F. Najera, DrPH

January 4, 2023

I got the chance to listen to the audio book version of The Ballad of Songbirds and Snakes, a prequel novel to The Hunger Games series from a few years back. The story in Ballad is all about how Coriolanus Snow begins his rise to power. By the time of Hunger Games, he was President of a post-apocalyptic nation named “Panem for some time.

Without spoiling the story too much for those of you who’ve not read the books, the titular “Hunger Games” are a yearly battle royale where children fight to the death until only one is left standing. The children are drawn from the 12 districts in Panem, districts controlled by the authoritarian government seated at the “Capitol.” Each year, on July 4th, a boy and a girl from each district are chosen to fight in the games. Up until the 74th games, presented in 2008’s The Hunger Games, there had only been one victor from each game. In those games, Katniss Everdeen and Peeta Melark are co-victors because they hatched a Romeo and Juliet-type plot to be either co-victors or die by suicide. This embarrasses the authorities, and they are thrown back into the games for the 75th offering. More on that in a second.

In The Ballad of Songbirds and Snakes, which takes place 65 years before the events of Hunger Games, we are told some of the backstory of how Panem came to be, and how a civil war was won by the Capitol at the expense of many lives and treasure, and the apparent annihilation of “District 13.” In the aftermath of that civil war, The Ballad describes the Capitol through the eyes of Coriolanus, talking about rubble from air strikes, people resorting to cannibalism of corpses for food, and continued terroristic attacks from the rebels. Because he is from a reputable family, Coriolanus is asked to be a mentor to recruits coming into the Capitol for the 10th Hunger Games.

Tuberculosis

Among the children taken for the 10th Hunger Games are two who die, not from the Hunger Games events themselves, but from infectious disease. “,” from District 11, is described as “a girl with similar coloring but a skeletal frame and a hacking cough.” Later in the book, during the games, she is described as having signs and symptoms of the disease that has consumed her. Not long into the games, she is taken out to the sun by her district ally, refused to drink water, and dies after coughing up blood.

Mycobacterium tuberculosis, a rod-shaped bacterium, causes . While the main symptoms are associated with the bacterial infection of the lungs, tuberculosis can also infect other parts of the human body. For example, leads to deformations of the vertebrae. According to the World Health Organization, , with millions more infected and not yet showing symptoms. Since 1921, the Bacille Calmette–Guérin (BCG) vaccine has been given to prevent spinal tuberculosis in children. In the United States, and other developed countries, the BCG vaccine has been discontinued in favor of a screen-and-test approach to tuberculosis due to the availability of screening tests and antibiotics to treat the infection. In developing countries, children still receive the BCG vaccine.

We can speculate about Dill’s infection being tuberculosis, because of how she is described physically and how she dies coughing up blood. We also know that Panem is in North America, primarily in what used to be the United States. We can then speculate that the test-and-treat plan is no longer in place after whatever war ended the United States and brought about Panem. And, of course, antibiotics are probably not available to her. Even if antibiotics were available, it could be possible that Dill has multi-drug resistant tuberculosis (), a form of tuberculosis that survives most tuberculosis treatments.

Rabies

Rabies is another disease that seems to make an appearance in the 10th Hunger Games. In the book, the tribute from District 11, known as “,” dies after taking a fall while running away from bottles of water being dropped on him. Why bottles of water? Because rabies causes hydrophobia, fear of water, from , and from the brain damage the virus causes. Essentially, the person with rabies is not themselves, and they act strangely, with the fear of water being . In the book, Jessup is assumed to have been infected after contact with an animal at the decommissioned zoo where the tributes were held before the games.

Rabies has been around in humans for thousands of years. Most modern-day exposures in developed countries come from accidental encounters with bats or raccoons. It is not as common in dogs in developed countries as it used to be, thanks to strict vaccination requirements for house pets. In developing countries, contact with rabid dogs is still a major source of human rabies cases, with .

Back in the mid-1800s, as those cities expanded into the wilderness around them. Dogs from the city would go into the forest and get rabies from other mammals, and then return to the city. They would bite people in the city, whether they were their owners or people on the street. Days to weeks later, those exposed to rabies would develop the disease and inevitably die. (Even today, rabies is 100% deadly once the symptoms begin).

In the late 1800s, Louis Pasteur and his team worked on a vaccine against rabies by inoculating rabbits with rabies, taking their brains, drying the brains, then inoculating other rabbits with those brains. This process would continue until an attenuated (weakened but not dead) form of the virus was recovered from the rabbits. It was that attenuated virus approach that served as the first human vaccine against rabies, when Joseph Meister was given the vaccine after being bitten by a rabid dog.

When given shortly after an exposure, the rabies vaccine is nearly 100% effective at preventing rabies. This is because the vaccine triggers an immune response that reacts not only against the vaccine virus, but also against the wild rabies virus from an exposure. That response is faster than the proliferation of the wild virus, leading to a prevention of the disease even when the infection sets in.

As with many vaccines, not all countries have access to rabies vaccines for domesticated animals, or for people exposed to rabies through contact with rabid animals. This places the global burden of rabies on developing nations and their people. In the United States and most developed countries, . In 2021, (likely a bat). He died a month later, with symptoms similar to what Jessup Diggs was described as having.

On A Knife’s Edge

Later in the timeline of the Hunger Games, readers find The Capitol did not annihilate . Instead, the two sides made a deal to make it seem that District 13 was destroyed in exchange for The Capitol leaving District 13 alone, and District 13 not launching a nuclear strike against The Capitol. Toward the end of the timeline, as the heroes rally in District 13 to take on The Capitol once and for all, one of them mentions the lack of children in District 13. It is then that a character mentions a “pox” that killed many people, young and old.

In the real world, in modern times, vaccination is largely a function of the government or can be found in functioning states. This is because governments license and regulate vaccine products to ensure their safety. (Though non-governmental organizations, such as academic centers and competing vaccine manufacturers, also look into vaccine safety and effectiveness.) Governments also establish rules requiring certain vaccinations to allow people to receive or participate in public programs. And governments also fund the distribution networks for vaccines to reach their citizens.

Absent a government (due to war, social unrest, or natural disasters, among other reasons), it is difficult for vaccines and other medical treatments to reach populations at risk of epidemics of vaccine-preventable and other diseases. In Ukraine, the current invasion by Russia has triggered a mass displacement of people away from conflict zones and mostly into the rest of Europe. This has brought the threat of MDR-TB traveling with refugees into population centers where tuberculosis is currently not a problem, but where the BCG vaccine is not used, either. If those refugees are not screened for tuberculosis (and other communicable diseases), they may trigger an epidemic.

In like and , cholera has made an appearance because the potable water infrastructure has been compromised. Fragile states in Africa continue to suffer from Ebola epidemics, and t (most of them children) year after year. In the Americas, while most Latin American countries have strong childhood vaccination programs, vaccination rates have dropped in many areas due to economic downturns, the COVID-19 pandemic, social unrest (e.g. ), and local absence of government due to drug cartels’ violent acquisition of territory. And many of the people being persecuted “over there” are seeking refuge in more developed nations.

Of course, a nation can have a working government and still face issues with vaccine-preventable disease and vaccine inequity due to social factors. In the United States, lies and misinformation from anti-vaccine groups . This has led to recent epidemics of measles in Ohio. Furthermore, the polarization seen around COVID-19 pandemic restrictions has eroded the trust in public health authorities by the public from different sides of the political spectrum. If stronger vaccination requirements are imposed, Conservative-leaning Americans lose trust in public health authorities. If vaccination requirements or other COVID-19 containment measures are relaxed, then it is the Liberal-leaning Americans who express mistrust.

At the end of the day, vaccines will only be as effective as the presence, strength, and credibility of the institutions charged with the protection of the public’s health and the delivery of vaccination. Vaccines can be 100% effective at preventing a disease, but they are worthless if no one takes them. Or their effectiveness toward reaching herd immunity is eroded if enough people avoid or oppose vaccination. So the containment of vaccine-preventable diseases truly balances on a knife’s edge, even in a resource-rich nation with a strong central government when trust for the 20th century’s most successful public health intervention wanes.

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