WORLD HEALTH ORGANIZATION REGIONAL COMMITTEE
REGIONAL OF.FICE~FOR THE WEsrERN PACIFIC
Seventh Session Manila
WP /RC7 /9 Add. 2 12 November 1956
7-13 September 1956 ORIGINAL: FRENCH
Agenda Item 15
CAMPAIGNS AGAINST SMALLPOX
Attached a.r.e",reporte received from the Governments of Macau and Timor with regard to their campaigns against smallpox.
REPORT OF THE GOVERNMENT OF MACAU CAMPAIGN AGAINST SMALLPOX
The recommendations contained in Dr. C.W. Dixon's report would ultimately result in overcoming the difficulties mentioned and would permit unified procedure and action in the very delicate field of prevention of smallpox and control of the disease. However, these principles cannot be adopted rigidly when the conditions for their practical application do not exist. The Health Services of Macau have tried to follow the recommendations put forward by Dr. Dixon, but there has almost always been a need to adopt a different procedure in vit;!w of the abnomaJ. circUI:lStances found in the Orient. Through mass vaccination - using vaccines of good quality and an appropriate technique as far as ~ossible - we have tried, without however assessing the results in each case, to maintain the highest possible degree of immunity within the population and in spite of the fact that we were not able to reach a hundred per cent, we think that these techniques also adopted by public health administrations of neighbouring territories, which have the same enormous movements of population and the same abnormal. conditions, contributed to a great extent to the total or quasi-total. absenoe of smallpox. In 1946, the smallpox epidemic in Hongkong recorded 1998 cases and 1365 deaths. In Macau, during the same period, we counted 41 recognized cases of smaJ.lpox without any deaths. Owing to the intense movement of Chinese between Hongkong and Macau during that year, we think that we would have had many deaths if the population, or at least a great part of it, had not been submitted to mass vaCCination. As a result of the lack of co-operation on the part of the Chinese population 'Which is unwilling to go to the vaccination centres which are permanently opened, and the impossibility of requesting all persons entering the Province to bring eVidence of such vaccination, periodic general vaccination campaigns have had to be carried out. The magnitude of this complex problem - the health problem being one of the most important - caused by a very intense movement of population under most precarious health, economic and social conditions can neither be assesse~? nor fully understood by people who do not face the facts. In 1953-19)4-1955, 491 211, 485 170 and 703 072 Chinese, respectively, entered the already overcrowded Province of Macau, and only 408 098, 436 182 and 612 452 left. Therefore, during the same years 83 113, 48 988 and 90 620 remained in the territory. If the movement of the Chinese between Macau and Hongkong does not give too much trouble with respect to the import of communicable diseases, since we are aware of the public health measures taken in the Colony, we are quite concerned about the population coming from other parts, i.e., from Cont1nentaJ. China. During these same years 350 000 Chinese came from China and only 300 000 left. Therefore, some 50 000 remained in the Province.
- 2 -
The diagnosis of smaJJ.pox cases is always assessed by the health authority and the isolation and treatment of the cases made by the health services and in the state hospital. Based on information obtained, cases of variola minor have been classified as non-acute smallpox; such a designation gives however, only an idea of the clinical foro and uO indication of a different epidemiological behaviour, since the same measures have been used in these cases as for variola major. In spite of all measures taken upon declaration of smallpox, we are still being informed too late of certain cases, since the people try first - and this is the traditional approach of a large portion of the population to call upon quack or herb doctors, and also to avoid the isolation of the patient from his family. It is, however, extremely difficult to change the mentality, customs, beliefs and habits which are the basis for this behaviOur. Vaccination limited to families, to those living with the family or to possible contacts, is the procedure Which is adopted in all cases 'Where such a method is to be used. But the fact that these cases are generally known too late forced us to apply this measure to larger or smaller portions of the population as the case occurred. Vaccination is not compulsory but the health authorities inform the population through all possible means of the need and benefit of getting vaccinated as early as possible. These appeals have not yielded satisfactory results and we are therefore forced to organize periodic vaccination c~aigns. The school population is being vaccinated in the schools by teams of the health services and it is to be noted that certain schools have already made requests for the vaccination of their pupils. The staff used for this vaccination is cOIlq)osed of excellently trained health visitors 'Who use the latest vaccination technique. These health officials also deaLwith the prevention of diseases and carry out health education in the families. This work will be intensified with a view to having the small children successfully vaccinated. A£ far as the vaccination technique goes, one should as far as possible avoid washing the skin with alcohol. However, this method is preferable to washing with soap and water, since the first method enables the skin to be washed more thoroughly and to dry more quickly. Parallel and short inCisions will be used in the future instead of the cross inciSions since the latter may II' oduce a large scar. It is not possible to obtain vaccine in Canton. The one we use is produced in IIongkong and sent directly through the producing laboratory, maintained in refrigerators at the health centres, that is to sa::/, placed under conditions 'Which ensure safe handling. The results obtained flom these vaccines are satisfactory, a fact 'Which is ascertained periodically through tests performed on small children. So far, the results of vaccination and re-vaccination have not been assessed and this has been a great gap in our system. We realize that without these assessments, it is hardly possible to evaluate. the results obtained or the
- 3 inmrunity rate of the various portions of the popuJ.ation. One year ago, however, systematic incision vaccination was introduced with a view to having the resuJ.ts on record. We have appreciated the objective and open manner in which Dr. Dixon has observed and assessed in his remarks. It is aJ.ways agreeable to discuss problems and to know the expert t s point of view in order to find a. solution. The suggestions and recommendations of Dr. Dixon are useful. and some of them will be taken into consideration with a view to eliminating the gaps mentioned. others, however, will only be taken into consideration each time circumstances penni t.
REPORT OF THE GOVERNME!NT OF TIMOR CAMPAIGN AGAINST SMALLPOX
Smallpox vaccinations are performed annually and intensively allover the Province, the time selected being that when the census is taken as the population of the Province gathers in certain places. Since 1951, we have not had one case of smallpox in the Province but we do not want to pretend that this is due to constant smallpox vaccination and re-vaccination services. These duties are performed by medical officers and nurses "Who work in the fifty-three health stations allover the ProVince. Dry vaccine in tubes of fifty doses provided by Portugal or imported from other countries is used for vaCCinations.
WORLD HEALTH ORGANIZATION REG IONAL COMMITrEE
REG IONAL OFFICE FOR
THE WESTERN PACIFIC WP/RC7/9 Add.1 23 July 1956 ORIGINAL: ENGLISH
Seventh Session Manila 7-13 September 1956 Agenda Item 15 CAMPAIGNS AGAINST SMAIJ..POX
Attached is a report received from the Government of China (Taiwan) 'Wi th regard
to its campaign against smallpox.
REPORT OF THE GOVERNMENT OF CHINA (TAIWAN) CAMPAIGN AGAINST SMALLPOX (From 1946 to May 1956 A Brief History Taiwan is an island in the Western Pacific, less than 150 kilometres from the South China coast, with an area of 35,961 square kilometres and a population of about 9,000,000. The climate is sub-tropical and products are chiefly agricultural. Taiwan is one province of the Republic of China. On the provincial level, there is the Provincial Health Administration which is responsible for the health problems of the whole population. The island is divided into 17 counties and 5 cities, and in each unit, there is a health centre. At the basic level, there are 360 villages and towns, and there is one health station in each village or town which is in charge of the health problems of the inhabitants. The island was occupied by the Japanese for fifty years and during that time, smallpox was prevalent for a number of years. During the last few years, however, of the Japanese occupation, smallpox was almost entirely under control with none or very few cases each year. Since October 1945, Taiwan has been restored to China. Due to the large population movement and the bad situation after the war, various kinds of communicable disease have been prevalent and, among these, smallpox used to be the most serious. The highest epidemic was in 1947, when there were 5,193 cases and 1,725 deaths of smallpox among the population of about 6,500,000. However, after the carrying out of the mass immunization campaign, both the incidence and the mortality rate have been considerably reduced since 1948, and we have not had any case of smallpox since 1955. The cases and deaths of smallpox in Taiwan from 1947 to May 1956 are shown in Table I, and the age distribution of smallpox cases from 1946 to May 1956 is shown in Table II. It is interesting to note that the cases of smallpox have been more concentrated among the adult group rather than among the youngsters. This may be partly due to the fact that the soldiers have played an important role in the incidence of smallpox during the last few years, and partly due to the fact that the immunization campaign among the infants has been quite successful while the immunizing rate of the campaign among the adults has not been entirely satisfactory. Control Programme There are three important parts in the smallpox control programme in this country, namely: 1. 2. To vaccinate all the infants (primary vaccination) every year. To revaccinate the whole population every three years. To revaccinate the inhabitants of the area where smallpox cases are reported.
3.
The programme is essentially considered to be a governmental rospo~si bility, all the vaccine, supplies, and personnel for the smallpox control programme being provided by the government at various levels to the people, free of charge. 1. To vaccinate all the infants every year.
, As in other parts of the world, smallpox vaccination has been quite popular in this country even in the most remote villages. The Government conducts the smallpox vaccination campaign for the infants twice a year-once in the spring and once in the autumn. The parents of the infants are notified by the health stations and are asked to bring their babies within a certain time to a certain place where the medical personnel will vaccinate the babies free of charge, Most of the practitioners are asked to participate in this campaign with or without charge to the people. The reactions of the vaccination are read by the person who has done the vaccination and those who show no reactions will be revaccinated. The percentage of the infants who receive primary vaccination ranges from 95 to 98 each year. (See Table III) 2. To revaccinate the whole population every three years.
Since the duration of immunity after smallpox vaccination has not yet been fully understood, it is difficult to decide within what period of time a person should be revaccinated. In order to increase the immunity level among the population as far as possible, the policy since 1950 has been'that the mass vaccination campaign should be carried out every other year. This was done in 1950, 1952 and 1954. The number of people who were vaccinated in the past three campaigns was 6,649,065, 6,773,595,'and 5,758,538, respectively, among the population of about 9,000,000. The percentage of the people who were vaccinated in each mass campaign was 88.02, 83.94 and 67.18, respectively. (See Table III) As the number of smallpox cases has become very few in recent years, the frequency of the mass vaccination campaign will be changed from every other year to every three years starting this year. Also, for the sake of administrative convenience, one third of the population will be revaccinated within three years, The dividing of the population will be done at the village level, that means, suppose there are 15 hamlets in a village, the health officer in the health station of the village (there is one health station in every village) will vaccinate the people of 5 hamlets each year.
3. To revaccinate the'inhabitants of the area where smallpox cases are reported. Whenever there is a suspected smallpox case reported to the health centre, the responsible officer will go to the place to check the diagnosis and carry out the routine work such as, isolation of the case, disinfection, and quarantine of the contacts if it is a highly suspected case. The specimen of the Ekin lesion will be sent to the central laboratory for the laboratory diagnosis (this was not done until 1955). In addition, a smallpox vaccination campaign will be immediately organized in the region where the case originated. As the people of this island are quite aware of smallpox, there is no difficulty in doing this.
Table I - Cases and Deaths of Smallpox in China (Taiwan) (From 1947 to May 1956)
. ;
. Population Cases
i
Cases per
j
. , Deaths
Deaths per
Year
100,000
DODulation
100,000
nonulation .....
1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 Jan-May
6,097,117 6,497,734 6,807,601 7,396,131 7,554,399 7,869,247 8,069,959
1,561 5,193 288 625 78
25.60 79,91 4.23 8.45 1.037 0.090 0.470 0.160 0.10 0 !
315 1,725 50 173 27 0 0 0 1 0 0
5.16
-
26.54 0.73 2.33
_ .....__.
-_..._-
-
7 37 14 9 "
0.35 .-. 0 ,._0 0 0.01 ... ~--~.
I I i
8,369,404 8,578,567 9,020,938 (Feb. )
.-
0
0 0
---_ , ..1
9,123,797
I
0
0
I
Age Group 1194611947\194811949 " 1950 11951' 1952 1953 '1954 1955 Mly I
•
t
'
,
j
!
r
Jan-
----. Total
1
0-:-4 years 171 l1206 5-9 years 10-14 years 15-19 years 68 29 49 258 123 199 344 614 657 517 475 335 204 136 84 31 20
I
64 17
113 35 12
29 7 4 2 6 9 7 5 3 2 3 1 !
~
1956 9 1 , j
1 5 1 2 1 1 1 1
1583 ~,-
-..'".
..
9 3
400 172 _ ..1. 2-
-
12 28 35 30 30 18 25 16 7 5
39 60 64
1 2 2 2
3 2 5 4 2 2
308 592 960 994 806
20-24 years 147 25-29 years 230 30-34 years 230 35-39 years 192 40-44 years 141 45-49 years 138 50... 54 years 55-59 years 60-64 years 65-69 years 70 years and over Total .
--
1 1 1
61 58 67 59 33 12 6 3i 3
706 1 1
---
560 ._., 335 192 118
-"
78 36 23 26 3
"~.--
a_·,
1
1
"-'-'26 .•.-_ 0'/
62
1561 5193 .
288
625
78
-
.
, .
7
39
14
9 .-
I
I
0
I
7814
Table III - Number of People ,.rho were Vaccinated from 1946 to 1955 i , ,
Year 1946 1947 1948 1949 1950 1951 1952 1953 1954
Population 6,097,117 6,497,734 6,807,601 7,396,131 7,554,399 7,869,247 8,069,959 8--t.16~404
No. of people received vaccination 2,120,312 6,399,,768 856,,726 1,,709,146 6,649,065 529,715 6,773,595 1.130.611 i ~
Percentage received vaccination
*** .. ** 98.49
-.~,
-
*** ***
* it-
88.20
*** 83.94 f ,
~
8,578,567
5,758,538
*
*** 67.13
o-
.......
* Mass *** The
campaign of smallpox vaccination for the whole population.
** Mass campaign of smallpox vaccination during the epidemic period. number of people who were vaccinated included: (1) infants of primary vaccination, (2) infants whose vaccinations showed no reaction last year, (3) people who were revaccinated due to the fact that they lived in the area where smallpox cases were reported. So there is no need to calculate the percentages.
WORLD HEALTH ORGANIZATION REGIONAL COMMITTEE Seventh Se ssion Manila 7-13 September 1956 Agenda Item 15 CAMPAIGNS AGAINST SMi\LLPOX
REGIONAL OFFICE FOR THE WESTERN PACIFIC WP/RC7/9 2 July 1956 anGINAL: ENGLISH
The Regional Committee at its sixth session, having considered the report of the Regional Director on the smallpox survey carried out in tha Regionl and the resolution of the Eighth World Health Assembly relating to 2 the conduct of campaigns against smallpox , adopted a resolution? urging the health administrations of the countries and territories concerned to report at the seventh session of the Committee on the steps they had takQn to implement the recommendations made as a result of the regional survey. While two territorie s, Hong Kong and Sarawak, replied that their representatives did not intend to present a report on this matter, information on the implementation of the recommendation has been received from North Borneo, the Philippines, Singapore and Viet Nam, the reports of which are appended herewith. as addenda to this document. Any additional reports received will be issued
lUnpublished document WP/RC6/16 2Resolution WHA8.38, Off. Rec. Wld Hlth Org. 63, 38 3Resolution WP/RC6.R15
WP/RC7/9 APPENDIX
REPORT OF THE GOVERNMENT OF NORTH BORNEO CAHPAIGN AGAINST SMALLPOX
The Report of the WHO Ccnsultant on Smallpox, Dr. C.W. Dixon, was received with great interest and has been closely studied. All modical officers in the service of the Government have been circularised with a copy of the Consultant's report and particularly instructed to take action in regard to the technique of vaccination and the methods by which the case of smallpox, if introduced, can be isolated and the public protected from the spread of the disease. 2. A special hospital for the treatment of tuberculosis will shortly be constructed in Jesselton and a similar hospital is anticipated in Sandakan. Although primarily intended for the reception and treatment of tuberculosis patients, these hospitals could in emergency be applied to the purposes of an isolation hospital for smallpox patients.
3. The various other recommendations in the Report relating to the methods of storage of vaccine lymph, the use of the international forms and the training of multi-purpose public health workers are being implemented insofar as local conditions permit.
WP/RC7/9 APPENDIX REPORT OF THE GOVERNMENT OF THE PHILIPPINES CAMPAIGNS AGAINST SMALLPOX The campaign agains t smallpox in the Philippine s is an integral part of the Public Health Program of the Department of Health. This phase of the program is being carried out directly under Program I, - Rural Health Services of the Bureau of Health. Since 1948 there has been no known case of smallpox in the Islands; during that year a small smallpox outbreak was registered in the province of Mindoro. It started in March 1948 and was put under control barely four weeks after, with very few residual cases. The source of infection was traced to be a Chinese mestizo who returned to the Philippines from Arnoy, China, and spread the disease in that province, the population of which were susceptible to the disease because of the effects of World War II, which disturbed and altered the vaccination campaign in that province and rendered t he general population vulnerable to this disease. Since then no case of smallpox was registered in the Philippines inspite of the prevalence of this disease in the neighboring countries. This can be attributed to properly organized and systematic mass vaccination and re-vaccination of the people every five years, and rigid enforcement of quarantine control rreasures. This five-year smallpox vaccination program is carried out by the different health agencies of the Bureau, like the 27 Vaccinating Parties composed of 270 Vaccinators and Sanitary Inspectors, and the 53 Provincial Health Officers and 27 City Health Officers and their corresponding sanitary personnel which started vaccination work as early as 1916. From July 1, 1948 up to June 30, 1951, the said health agencies performed a total of 16,717,355 Vaccinations with 13,213,374 inspections and 9,067,123 positive (Primary and Accelerated takes only) or a total of 44.90% positive in relation to ~he population of the Philippines. From July 1, 1951 up to March, 1956, the health agencies accomplished 17,772,428 positive (Primary and Accelerated takes only) or a total of 38.54% in relation to the total population. This apparently low percentage of positive takes in relation to the total population for the two five-year periods was due to our conservative polic.y of reading vaccination reactions. We consider a reaction as positive only when the result is found to be either ItAccelerated Type" and "Primary Reaction", while the "Immune Reaction" is read and recorded as negative. This policy finds support in the opinion of Dr. Dixon, WHO Consultant and Senior Lecturer on Preventive Medicine of the University of Leeds, who maintained and recommended that the so-called "Immune Reaction" should be recorded as negative and only those found with true vesiculation of the "Primary" and "Accelerated Type" occuring after 48 hours and usually from 3-7 days after vaccination should be regarded as positive. (Page 8, Survey Report on Smallpox in the Philippines, November 11, 1955).
W P/RC 7/9 APPENDIX Page 2 In order to increase our vaccination work and systematize operation procedures and put more scientific supervision on the vaccination and immunization activities of this Bureau, all Vaccinators with the exception of those belonging to Mobile Vaccinating Party I and II, and other personnel who are performing vaccination work will be integrated with the Rural Health Services effective this Fiscal Year 1957. With this integration, all the sanitary personnel under the Provincial Health Officers and City Health Officers which have to do with vaccination work, would be required to perform a total of 4,800,000 vaccinations every year, so that in five years or by 1960 all population should have been vaccinated. The latest move towards an effective campaign against smallpox is the plan of the Bureau to send beginning June 1, 1956, two Special Teams of Vaccinators and Sanitary Inspectors for Sulu Archipelago to effectuate the immunization and vaccination of the people in that area. This plan would at the same time bolster the status of immunity against smallpox, cholera, dysentery, typhoid and paratyphoid to a level commensurate with accepted public health standards, particularly considering the fact that the area of campaign comprise of the outlying groups of Islands and Islets considered vulnerable to the introduction of smallpox from without due to its proximity to Borneo and the Malay States. With the cooperation of the Philippine Navy and the Bureau of Quarantine we hope to vaccinate or immunize at least 85-90% of the 120,000 people living in the six groups of islands in the Sulu Archipelago, thus insuring these Islanders immunity against smallpox.
WP/RC7/9 APPENDIX REPCR T OF THE COLONY OF SI NGAPORE CAMPAIGN AGAINST SMALLPOX Geographically Singapore is surrounded by numerous endemic centres of smallpox. It is also the centre of distribution trade for South East Asia, and is consequently one of the greatest ports in the British Commonwealth. These two circumstances - one, providing nodal centres of the disease and the other, immense facilities for the entrance of infected persons and virue to the Colony - expose Singapore peculiarly to visitations of both epidemic and endemic consequences. Since the epidemic of smallpox which prevailed from May 1946 to March 1947 contributing 152 cases with 42 deaths and a further 5 cases in 1948, the Island has not witnessed any endogenous quarantinable disease. Nevertheless 12 cases of variola arriving from without were isolated in the quarantine station at St. Johns Island since that period. Singapore depends for its imrnuni ty from the di sease mainly on two measures: (a) prevention of entry of disease and (b) the maintenance of a high level of herd immunity in the popUlation. Singapore maintains an efficient Port Health Service responsible for maritime and air quarantine work, and also has a quarantine station in St. Johns Island for the isolation of infected cases. New arrivals are subjected to inspection and, if necessary, to vaccination before release into the Colony. All ships arriving from infected areas must anchor at the quarantine anchorage and only leave after clearance by the Port Health Officer. It is compulsory for all travellers coming into Singapore to be in possession of valid certificates of vaccination. Infant vaccination is carried out systematically and it is probably an under-statement to claim that 85% of the children born in the Colony have been imrnunised against the disease. Re-vaccination is done in the schools. In addition vaccination campai gns are conduc ted ani gener ally the response to such campaigns has been satisfactory. The last such campaign was towards the end of 1952 when within a period of 3-1/2 months some 600,000 persons over the age of three years were vaccinated in a population which was then 1,077,000. Another campaign is due to be started next year. The Colony does not possess a sufficient number of medical practitioners (Government or private) and there is no system of panel service. Consequently the early detection of any domestic case must still be largely a matter of chance. There is also reason to believe that while the population is much in dread of the disease it is never very anxious to report cases. It is therefore suggested that Singapore1s immunity from this disease for over seven years has been due mainly to the two factors mentioned above - and not to early detection and consequent suppression of an outbreak.
WP/RC?/9 APPENDIX Page 2 Once the disease has come in, machinery does exist for its control. The Port Health staff and t1edical Officers of Health, both of Government and the City Council as well as their Sanitary Inspectors have high professional ability and a number of them are specially trained in the control of smallpox. Singapore is largely in agreement with Dr. Dixonts General Report, and in fact has in the past used precisely the methods he recommends in dealing with smallpox outbreaks; nevertheless we still believe that vaccination campaigns are of value. Every effort is made to stress the importance of early diagnosis; in the absence of the disease itself it is doubtful how effective theoretical instruction aided by photographs etc. would be when these men and women face actuality should it ever arise.
WP/RC7/9 APPENDIX ORIGINAL: FRENCH
MEASURES TAKEN BY THE VIETNill~SE HEALTH ADMINISTRATION FOR THE I MPLEMEN'rATI ON OF 'lliE SVlALLPOX CONTROL CAMPAIGN There are two kinds of measures: - prophylactic - curative I 1.
PROPHYLACTIC MEASURES Elimination of insanitary slums which are propagation centres for smallpox. Improving the sanitation of highly populated town districts and urban centres by periodical DDT spr~ing with a view to destroying the pathogene carrying insects. Mass education by means of conferences and talks, showing of pictures and films, circulation of pamphlets, etc. on hygiene in the house, collective, personal and other hygiene. Compulsory notification of all smallpox cases. Prohibition of person to person inoculation. Case finding and isolation of smallpox patients. Disinfection of the rooms in which smallpox patients were found, of bedding and personal belongings. Compulsory smallpox vaccination during epidemics and optional vaccination during normal p8riods. Setting-up of mobile vaccination teams once every six months .• Owing to the endemicity of smallpox in Viet Nam, an international certificate of smallpox vaccination is required from travellers leaving the country and from those coming from contaminated areas. Creation of sanitary cordons in cases of possible epidenics.
2.
3.
4. 5. 6. 7.
8.
9.
10.
These preventive measures proved to be so efficient that in spite of the promiscuous way of life following migration of the population from the northern part of the country, smallpox is only to be found sporadically and has been controlled each time it tended to spread.
WP/RC?/9 APPENDIX Page :2
II
CURATIVE MEASURES
Treatment of smallpox patients with all the neans provided by modern therapeutics. The smallpox patients are isolated in special pavilions reserved for contagious cases and they remain there until completely recovered.