A victory for all mankind Brought about by hundreds of thousands of health workers from all over the w orld, eradication is a triumph of international cooperation and of preventive medicine by D. A. Henderson For centuries, variola virus stalked the world with im- punity causing unmeasured 0 suffering, death and blind- ness. Today it is confined to glass vials kept under high security in six laboratories. To those who vividly recall the suffering of its victims, to health staff who so diligently conducted vaccination programmes, to quarantine inspectors who carefully examined vacci- nation certificates, it is difficult to believe that " sporadic" cases are not still occur- ring somewhere. However, convincing data, diligently assembled by tens of thousands of health staff, now demon- strate that smallpox is a disease which can be consigned to history- the first disease ever eradicated by man. It was little more than two decades ago, in 1958, that the Soviet Union pro- posed to the Eleventh World Health As- sembly that the countries of the world cooperate in a globally coordinated ef- fort to eradicate smallpox. In that year, 63 countries reported 280,000 cases. This is itself a substantial number of cases but, because of incomplete reporting, it would need to be multiplied by 100 or more to describe the true magnitude of the problem. Data regarding deaths a re likewise incomplete, but it is reasonable to assume that at least 20 per cent of those infected died and tens of thousands were permanently blinded. There was, and is, no treatment for smallpox; pre- vention through vaccination was the only way to cope with this disease. After further study of the Soviet pro- posal, the Assembly in 1959 agreed that a global smallpox eradication programme should be undertaken as a matter of urgency. It was thought that, by "vacci- nating or revaccinating 80 per cent of the This was smallpox. The world will never again witness the suffering that was caused by the variola virus. ( Pboto WHO) populat ion within a period of four to five years", smallpox could be eradicated from endemic areas. During the following eight years, WHO encouraged governments to undertake programmes, solicited contributions of vaccine, encouraged and coordinated studies of vaccine strains, and assisted laboratories in starting vaccine produc- tion. Many countries started pro- grammes and some succeeded in inter- rupting transmission. But not all did or could embark on eradication with their own limited resources. Contributions were far less than the funds required and many countries which interrupted trans- mission were reinfected by their neigh- bours. Of greater concern was the dis- covery that, even when vaccinations were administered to 80 per cent of a popula- tion, smallpox often persisted. Health authorities became discouraged and pes- simistic. It was one thing to eliminate the disease from countries with a developed health infrastructure, but could this be done in the numerous countries, so recently independent, whose limited health services scarcely extended beyond their urban centres? And could these many countries coordinate their efforts sufficiently for smallpox to be eliminated from large geographical areas? It was a concerned and less confident World Health Assembly which in 1966 decided that WHO should undertake an intensified eradication programme. Ap- proximately US $2.5 million was in- cluded in the Organization's regular bud- get to provide for overall programme coordination and for assistance to those countries requiring it. This was a small sum indeed to provide support in some 50 countries with a population of more than one thousand million persons. But it represented almost five per cent of WHO's total budget that year. Hopes were expressed that more substantial vol- untary contributions would be made and Smallpox is dead! Cover design by Peter Davies IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor : John Bland Deputy Editor : Christiane Viedma Art Editor : Peter Davies News Page Editor : Lalit Thapalyal World Health appears in Arabic. English. French. German. Italian. Persian. Portuguese. Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization Signed articles do not necessarily reflect WHO's views. World Health. WHO. Av. Appia. 1211 Geneva 27. Switzerland Contents A victory for all mankind by D. A. Henderson A windfall for development by James Magee A job well done by Marcella Davies An effort of will 3 5 6 by V.T. Herat Gunaratne .. . . . 11 India's " war plan" by Jitendra Tuli 12 A goddess defied by Arun M. Chacko 15 How much did it cost? 18 Towards the year 2000 by Halfdan Mahler 19 Ramses V : earliest known victim 7 · by Donald R. Hopkins 22 Dec line and Fall of the Smallpox Empire 24 Can we stop smallpox vacc ination 7 by lsao Arita 27 The closing stages by Svetlana Marennikova How can we be sure? by Frank Fenner 30 35 lhat all countries would give the pro- gramme a high priority. Some delega tes optimistically proposed setting a I 0 yea rs goa l for erad ication, but most believed rea listically that better contro l of small - pox was the best that cou ld be expected . The intensified programme began in January 1967. That year, 46 countries recorded 131,697 cases, a number repre- senting perhaps one per cent of the true number of cases. Four endemic areas were present. A major reservoir was Africa where virtua lly all countries sout h of the Sahara were infected. A second important reservoir of smallpox was in Asia, extending from Bangladesh through India , Nepal, Pakistan and Af- ghanistan . The third was the Indonesian archipelago and the fourth was Brazil, it- self comprising half a continent. Of primary concern as the programme began was the need for sufficient vacci- nation devices and vaccine- the guns and bullets of the campaign. Large con- tributions were made initiaLly by the Soviet Union and the USA; eventually 26 countries became con tribu tors. A de- tailed manual on vaccine production was produced and vaccine batches were rou- tinely tested to ensure that they met in- ternational standards . By 1971, all vaccine in use in the programme met accepted standards and by 1973, fully 80 per cent was being produced in the endemic coun- tries, some of which supplied vaccine to others . In 1967, the jet injector was intro- duced in progTammes throughout the countries of western and central Africa and Brazil. In 1968, field stud ies conduc- ted by WHO showed that the newly devel- oped bifurcated needle could be used to administer vaccine by a new technique- mu ltiple puncture vaccination. The 4 bifurcated needle soo n became the stan- dard method for vacc inat ion. A second conce rn from the sta rt was the question of an appropriate strategy . Mass vaccination designed to reach 80 o r even lOO per cent of a population had succeeded on ly in some sma ller countries and those with more developed hea lth services . For most of the still endemic countries, a different strategy was required . The decision to emphasize survei llance as an important component of the strategy proved to be the much- needed critical breakthrough. The new strategy cal led for a systematic two- to three-year vaccination campaign de- signed to reach 80 per cent of the popu- lation in each coun try. During this time, it was planned for a nationwide reporting system to be developed which would be sensitive enough to detect suc h smallpox foci as remained a nd to e liminate them. Soon after the programme began , it was discovered first in Nigeria, then in Jndo nes ia a nd Braz il , that effective reporting systems could be developed in months rather than yea rs. By isolating the patients and vacci nating their con- tacts, outbreaks could be rapidly con- ta ined. Even in areas where vaccination coverage was poor, smallpox transmis- s io n could often be stopped quick ly . So now increasing emphasis was placed on the surveillance-containment component of the strategy. Specia l surveil lance teams were recruited and trained. They visited each health unit in an area to en - sure that each week it submitted a report indicating the number of cases seen. When cases were reported, the teams worked with local health staff to conta in the outbreaks, and they visited schools and public places to inquire about The end of smallpox in Asia mea m 1 hm more resources could be made available in Ethiopia. The net ll 'C/S closing on the last places on earth Hhere the disease lurked. ( WHO/E. Shafa ) rumours of small pox . A special "wHO Recognit ion Card'' showing a picture of a smal lpox patien t was printed and dis- tribu ted to help them in their search. The nrst campaign s started in 1967 and, by 1969, all countries except Ethio- pia had started eradication programmes. Ethiopia's programme began in 1971. [n 20 countries of western and centra l Afri- ca, a USA-assisted programme of small- pox eradication and measles contro l suc- ceeded in eliminat ing smallpox in just three and a half years . Brazil 's last case was detected in 1971 and Indonesia's in 1972. By the summer of 1973, small- pox transmission had been interrupted throughout the whole of Africa, except in Ethiopia. That country plus five coun- tries in Asia remained as the only small- pox infected countries. However, India, Pakistan and Ban- gladesh, with a population of more t.han 700 million persons, presented a special problem. Surveillance-conta inment mea- sures such as had been successfu l in Afri- ca and South America proved far less ef- fect ive in these densely populated areas where people travel frequently and far. A different approach was required . During the summer of 1973, India n health au- thorities with WHO staff planned a dif- ferent surveillance strategy. All health personnel were asked to undertake an in- tensive sea rch of each village, and later each house, to detect smallpox cases. Th is would need to be done rapidly to be successfu l and so the search was planned to be completed during a seven- to ten- day period. In heavily infected areas this was done each month and, in less infect- ed areas, every second or third month. During the first search in October 1973, thousands of unreported cases were detected. But once discovered, the out- breaks could be contained. Through careful planning, training and assessment, the searches became in- creasingly thorough. Between searches, surveillance teams visited schools and markets seeking to learn about cases of smallpox. Containment measures were strengthened . As the numbers began to decrease, a reward for the detection of a case was offered to the first person reporting it and to the health worker in- vestigating it. Similar approaches were soon employed in Bangladesh, Pakistan and Nepal. On 16 October 1975, only two years after the start of this new strategy, the last case of smallpox oc- curred in Asia- on Bhola Island in Ban- gladesh. This marked the end of variola major, the severe form of the disease. As 1975 drew to a close, only Ethiopia remained with smallpox. There, variola minor was prevalent, a form of smallpox which killed only one per cent of its vic- tims in contrast to variola major which killed 20 per cent or more. Ethiopia's programme, besides being the last to begin, faced incredibly diffi- cult problems. Although the country is larger than France and Spain together,. the available staff numbered little more that 100 persons. There was almost no health infrastructure. Roads were few and it was estimated that half the popu- lation lived more than a day's walk from any accessible road. Civil war and famine compounded the problems. However, with the interruption of small- pox transmission in Asia, more resources could be made available to Ethiopia. Vil- lage residents were recruited and trained to serve as surveillance workers and vac- cinators; more transport was provided ; helicopters were laid on to faci litate supervision. Less than one year later, on 9 August 1976, the last case occurred there. Unfortunately, coincident with the last outbreak in Ethiopia, smallpox was in- troduced into neighbouring Somalia. Before fully effective surveillance sys- tems could be established, nomads dis- seminated the disease throughout the southern part of the country. In May 1977, a national emergency was declared, additional staff were recruited and special assistance was provided by WHO. An intensive surveillance-contain- ment and vaccination programme conti- nued throughout the summer months. More than 3,000 cases occurred, the last of them on 26 October 1977. Nevertheless, surveillance teams and search workers continued for two years and more in their efforts to discover cases . In many countries, a reward was A windfall for development Already the international community is starting to collect part of the health legacy-and it is likely to be huge-- that smallpox eradication will bequeath. Calculations indicate that in the post- smallpox era a sum of nearly US $1,000 million . annually will be released, or some $10,000 million over a decade. The cost to the world of a disease like smallpox included production or purchase of vaccine, maintenance of vaccination programmes, the treatment of vaccination complications, spending to maintain national surveillance and frontier controls, and the cost involved in handling the emergencies caused by sudden outbreaks. Thus in the United Kingdom, an outbreak sparked by an imported case in 1961 involved a bill for an estimated $3.6 million. United States experts calculate that smallpox protec- tion was costing the American taxpayer about $150 million a year- or about half the total cost of the global eradica- tion programme which was just over $300 million. The release of money that has hither - to been tied up for smallpox could have massive impact- provided it is diverted to development programmes. In one recent year, 1975, total funds available for the health sector (including water supplies) as bilaterial aid from the Or- ganization for Economic Cooperation and Development (OECD) and from the European Economic Community (EEC), or as multilateral aid via the UN specia - lized agencies, amounted to $1 ,500 million. The new resources could therefore make a massive addi - tion to the funds available. In the view of WHO, these funds would have their greatest strategic im- pact in the area of primary health care. They could be applied to a combination of health development activities, incl- uding clean water and sanitation, immu- nization programmes, action to pro- mote correct and adequate nutrition, particularly for infants and young chil- dren, maternal and child care, and pro- grammes for the supply of oral rehydra - tion kits to combat diarrhoea! diseases and to ensure the availability of essen- tial drugs to all who need them. James M agee offered and tens of thousands of cases of chickenpox, measles and other rash dis- eases were reported by villagers in hopes of collecting a reward. Thousands of spe- cimens were taken and sent to WHO Diagnostic Centres in Moscow and At- lanta, USA. None proved to be small- pox. For the disease to persist in a popu- lation, it must be passed from one person to another in a continuing chain of infec- tion. Since there is no animal reservoir and no asymptomatic carrier (person having the disease but showing no symp- toms), each person who is a link in this chain must experience the characteristic illness. During the programme, it was found that smallpox never persisted for more than eight months in a country without being detected by the surveil- lance network. Continuing search during a two-year period, that is, three times this eight-month period, provided addi- tional assurance that the spread of small- pox had stopped. To confirm that transmission had been interrupted , specially constituted WHO International Commissions visited each country. In 1978, the Director-General of WHO appointed a Global Commission to review the experience in all countries. The Commission completed its work on 9 December 1979, at which time it agreed that there was sufficient documentation to certify worldwide eradication. T he eradication of smallpox means that vaccination everywhere can be stopped and that travellers will no longer need vaccination certificates. The savings throughout the world are estimated to be $1,000 million anually. The cost of this achievement was only $1 12 million in international assistance, or $9 million spent annually during the 13-year period 1967-1979. This includes all funds spent by WHO plus bilateral and multilateral contributions from 42 countries. It is es- timated that globally the endemic coun- tries spent perhaps twice this amount but, in fact, few spent much more than they had hitherto been spending on never- ending smallpox control programmes. Now the chapter entitled "smallpox" is closed- let us hope for ever. The achievement of eradication is a victory for hundreds of thousands of health workers in many different countries. WHO staff alone were drawn from 73 dif- ferent countries . It is a triumph of inter- national cooperation and of preventive medicine. With coordination, coopera- tion, dedication and imagination it is clear that much can be achieved at minimal cost. • 5
A victory for all mankind Brought about by hundreds of thousands of health workers from all over the w orld, eradication is a triumph of international cooperation and of preventive medicine by D. A. Henderson For centuries, variola virus stalked the world with im- punity causing unmeasured 0 suffering, death and blind- ness. Today it is confined to glass vials kept under high security in six laboratories. To those who vividly recall the suffering of its victims, to health staff who so diligently conducted vaccination programmes, to quarantine inspectors who carefully examined vacci- nation certificates, it is difficult to believe that " sporadic" cases are not still occur- ring somewhere. However, convincing data, diligently assembled by tens of thousands of health staff, now demon- strate that smallpox is a disease which can be consigned to history- the first disease ever eradicated by man. It was little more than two decades ago, in 1958, that the Soviet Union pro- posed to the Eleventh World Health As- sembly that the countries of the world cooperate in a globally coordinated ef- fort to eradicate smallpox. In that year, 63 countries reported 280,000 cases. This is itself a substantial number of cases but, because of incomplete reporting, it would need to be multiplied by 100 or more to describe the true magnitude of the problem. Data regarding deaths a re likewise incomplete, but it is reasonable to assume that at least 20 per cent of those infected died and tens of thousands were permanently blinded. There was, and is, no treatment for smallpox; pre- vention through vaccination was the only way to cope with this disease. After further study of the Soviet pro- posal, the Assembly in 1959 agreed that a global smallpox eradication programme should be undertaken as a matter of urgency. It was thought that, by "vacci- nating or revaccinating 80 per cent of the This was smallpox. The world will never again witness the suffering that was caused by the variola virus. ( Pboto WHO) populat ion within a period of four to five years", smallpox could be eradicated from endemic areas. During the following eight years, WHO encouraged governments to undertake programmes, solicited contributions of vaccine, encouraged and coordinated studies of vaccine strains, and assisted laboratories in starting vaccine produc- tion. Many countries started pro- grammes and some succeeded in inter- rupting transmission. But not all did or could embark on eradication with their own limited resources. Contributions were far less than the funds required and many countries which interrupted trans- mission were reinfected by their neigh- bours. Of greater concern was the dis- covery that, even when vaccinations were administered to 80 per cent of a popula- tion, smallpox often persisted. Health authorities became discouraged and pes- simistic. It was one thing to eliminate the disease from countries with a developed health infrastructure, but could this be done in the numerous countries, so recently independent, whose limited health services scarcely extended beyond their urban centres? And could these many countries coordinate their efforts sufficiently for smallpox to be eliminated from large geographical areas? It was a concerned and less confident World Health Assembly which in 1966 decided that WHO should undertake an intensified eradication programme. Ap- proximately US $2.5 million was in- cluded in the Organization's regular bud- get to provide for overall programme coordination and for assistance to those countries requiring it. This was a small sum indeed to provide support in some 50 countries with a population of more than one thousand million persons. But it represented almost five per cent of WHO's total budget that year. Hopes were expressed that more substantial vol- untary contributions would be made and Smallpox is dead! Cover design by Peter Davies IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor : John Bland Deputy Editor : Christiane Viedma Art Editor : Peter Davies News Page Editor : Lalit Thapalyal World Health appears in Arabic. English. French. German. Italian. Persian. Portuguese. Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization Signed articles do not necessarily reflect WHO's views. World Health. WHO. Av. Appia. 1211 Geneva 27. Switzerland Contents A victory for all mankind by D. A. Henderson A windfall for development by James Magee A job well done by Marcella Davies An effort of will 3 5 6 by V.T. Herat Gunaratne .. . . . 11 India's " war plan" by Jitendra Tuli 12 A goddess defied by Arun M. Chacko 15 How much did it cost? 18 Towards the year 2000 by Halfdan Mahler 19 Ramses V : earliest known victim 7 · by Donald R. Hopkins 22 Dec line and Fall of the Smallpox Empire 24 Can we stop smallpox vacc ination 7 by lsao Arita 27 The closing stages by Svetlana Marennikova How can we be sure? by Frank Fenner 30 35 lhat all countries would give the pro- gramme a high priority. Some delega tes optimistically proposed setting a I 0 yea rs goa l for erad ication, but most believed rea listically that better contro l of small - pox was the best that cou ld be expected . The intensified programme began in January 1967. That year, 46 countries recorded 131,697 cases, a number repre- senting perhaps one per cent of the true number of cases. Four endemic areas were present. A major reservoir was Africa where virtua lly all countries sout h of the Sahara were infected. A second important reservoir of smallpox was in Asia, extending from Bangladesh through India , Nepal, Pakistan and Af- ghanistan . The third was the Indonesian archipelago and the fourth was Brazil, it- self comprising half a continent. Of primary concern as the programme began was the need for sufficient vacci- nation devices and vaccine- the guns and bullets of the campaign. Large con- tributions were made initiaLly by the Soviet Union and the USA; eventually 26 countries became con tribu tors. A de- tailed manual on vaccine production was produced and vaccine batches were rou- tinely tested to ensure that they met in- ternational standards . By 1971, all vaccine in use in the programme met accepted standards and by 1973, fully 80 per cent was being produced in the endemic coun- tries, some of which supplied vaccine to others . In 1967, the jet injector was intro- duced in progTammes throughout the countries of western and central Africa and Brazil. In 1968, field stud ies conduc- ted by WHO showed that the newly devel- oped bifurcated needle could be used to administer vaccine by a new technique- mu ltiple puncture vaccination. The 4 bifurcated needle soo n became the stan- dard method for vacc inat ion. A second conce rn from the sta rt was the question of an appropriate strategy . Mass vaccination designed to reach 80 o r even lOO per cent of a population had succeeded on ly in some sma ller countries and those with more developed hea lth services . For most of the still endemic countries, a different strategy was required . The decision to emphasize survei llance as an important component of the strategy proved to be the much- needed critical breakthrough. The new strategy cal led for a systematic two- to three-year vaccination campaign de- signed to reach 80 per cent of the popu- lation in each coun try. During this time, it was planned for a nationwide reporting system to be developed which would be sensitive enough to detect suc h smallpox foci as remained a nd to e liminate them. Soon after the programme began , it was discovered first in Nigeria, then in Jndo nes ia a nd Braz il , that effective reporting systems could be developed in months rather than yea rs. By isolating the patients and vacci nating their con- tacts, outbreaks could be rapidly con- ta ined. Even in areas where vaccination coverage was poor, smallpox transmis- s io n could often be stopped quick ly . So now increasing emphasis was placed on the surveillance-containment component of the strategy. Specia l surveil lance teams were recruited and trained. They visited each health unit in an area to en - sure that each week it submitted a report indicating the number of cases seen. When cases were reported, the teams worked with local health staff to conta in the outbreaks, and they visited schools and public places to inquire about The end of smallpox in Asia mea m 1 hm more resources could be made available in Ethiopia. The net ll 'C/S closing on the last places on earth Hhere the disease lurked. ( WHO/E. Shafa ) rumours of small pox . A special "wHO Recognit ion Card'' showing a picture of a smal lpox patien t was printed and dis- tribu ted to help them in their search. The nrst campaign s started in 1967 and, by 1969, all countries except Ethio- pia had started eradication programmes. Ethiopia's programme began in 1971. [n 20 countries of western and centra l Afri- ca, a USA-assisted programme of small- pox eradication and measles contro l suc- ceeded in eliminat ing smallpox in just three and a half years . Brazil 's last case was detected in 1971 and Indonesia's in 1972. By the summer of 1973, small- pox transmission had been interrupted throughout the whole of Africa, except in Ethiopia. That country plus five coun- tries in Asia remained as the only small- pox infected countries. However, India, Pakistan and Ban- gladesh, with a population of more t.han 700 million persons, presented a special problem. Surveillance-conta inment mea- sures such as had been successfu l in Afri- ca and South America proved far less ef- fect ive in these densely populated areas where people travel frequently and far. A different approach was required . During the summer of 1973, India n health au- thorities with WHO staff planned a dif- ferent surveillance strategy. All health personnel were asked to undertake an in- tensive sea rch of each village, and later each house, to detect smallpox cases. Th is would need to be done rapidly to be successfu l and so the search was planned to be completed during a seven- to ten- day period. In heavily infected areas this was done each month and, in less infect- ed areas, every second or third month. During the first search in October 1973, thousands of unreported cases were detected. But once discovered, the out- breaks could be contained. Through careful planning, training and assessment, the searches became in- creasingly thorough. Between searches, surveillance teams visited schools and markets seeking to learn about cases of smallpox. Containment measures were strengthened . As the numbers began to decrease, a reward for the detection of a case was offered to the first person reporting it and to the health worker in- vestigating it. Similar approaches were soon employed in Bangladesh, Pakistan and Nepal. On 16 October 1975, only two years after the start of this new strategy, the last case of smallpox oc- curred in Asia- on Bhola Island in Ban- gladesh. This marked the end of variola major, the severe form of the disease. As 1975 drew to a close, only Ethiopia remained with smallpox. There, variola minor was prevalent, a form of smallpox which killed only one per cent of its vic- tims in contrast to variola major which killed 20 per cent or more. Ethiopia's programme, besides being the last to begin, faced incredibly diffi- cult problems. Although the country is larger than France and Spain together,. the available staff numbered little more that 100 persons. There was almost no health infrastructure. Roads were few and it was estimated that half the popu- lation lived more than a day's walk from any accessible road. Civil war and famine compounded the problems. However, with the interruption of small- pox transmission in Asia, more resources could be made available to Ethiopia. Vil- lage residents were recruited and trained to serve as surveillance workers and vac- cinators; more transport was provided ; helicopters were laid on to faci litate supervision. Less than one year later, on 9 August 1976, the last case occurred there. Unfortunately, coincident with the last outbreak in Ethiopia, smallpox was in- troduced into neighbouring Somalia. Before fully effective surveillance sys- tems could be established, nomads dis- seminated the disease throughout the southern part of the country. In May 1977, a national emergency was declared, additional staff were recruited and special assistance was provided by WHO. An intensive surveillance-contain- ment and vaccination programme conti- nued throughout the summer months. More than 3,000 cases occurred, the last of them on 26 October 1977. Nevertheless, surveillance teams and search workers continued for two years and more in their efforts to discover cases . In many countries, a reward was A windfall for development Already the international community is starting to collect part of the health legacy-and it is likely to be huge-- that smallpox eradication will bequeath. Calculations indicate that in the post- smallpox era a sum of nearly US $1,000 million . annually will be released, or some $10,000 million over a decade. The cost to the world of a disease like smallpox included production or purchase of vaccine, maintenance of vaccination programmes, the treatment of vaccination complications, spending to maintain national surveillance and frontier controls, and the cost involved in handling the emergencies caused by sudden outbreaks. Thus in the United Kingdom, an outbreak sparked by an imported case in 1961 involved a bill for an estimated $3.6 million. United States experts calculate that smallpox protec- tion was costing the American taxpayer about $150 million a year- or about half the total cost of the global eradica- tion programme which was just over $300 million. The release of money that has hither - to been tied up for smallpox could have massive impact- provided it is diverted to development programmes. In one recent year, 1975, total funds available for the health sector (including water supplies) as bilaterial aid from the Or- ganization for Economic Cooperation and Development (OECD) and from the European Economic Community (EEC), or as multilateral aid via the UN specia - lized agencies, amounted to $1 ,500 million. The new resources could therefore make a massive addi - tion to the funds available. In the view of WHO, these funds would have their greatest strategic im- pact in the area of primary health care. They could be applied to a combination of health development activities, incl- uding clean water and sanitation, immu- nization programmes, action to pro- mote correct and adequate nutrition, particularly for infants and young chil- dren, maternal and child care, and pro- grammes for the supply of oral rehydra - tion kits to combat diarrhoea! diseases and to ensure the availability of essen- tial drugs to all who need them. James M agee offered and tens of thousands of cases of chickenpox, measles and other rash dis- eases were reported by villagers in hopes of collecting a reward. Thousands of spe- cimens were taken and sent to WHO Diagnostic Centres in Moscow and At- lanta, USA. None proved to be small- pox. For the disease to persist in a popu- lation, it must be passed from one person to another in a continuing chain of infec- tion. Since there is no animal reservoir and no asymptomatic carrier (person having the disease but showing no symp- toms), each person who is a link in this chain must experience the characteristic illness. During the programme, it was found that smallpox never persisted for more than eight months in a country without being detected by the surveil- lance network. Continuing search during a two-year period, that is, three times this eight-month period, provided addi- tional assurance that the spread of small- pox had stopped. To confirm that transmission had been interrupted , specially constituted WHO International Commissions visited each country. In 1978, the Director-General of WHO appointed a Global Commission to review the experience in all countries. The Commission completed its work on 9 December 1979, at which time it agreed that there was sufficient documentation to certify worldwide eradication. T he eradication of smallpox means that vaccination everywhere can be stopped and that travellers will no longer need vaccination certificates. The savings throughout the world are estimated to be $1,000 million anually. The cost of this achievement was only $1 12 million in international assistance, or $9 million spent annually during the 13-year period 1967-1979. This includes all funds spent by WHO plus bilateral and multilateral contributions from 42 countries. It is es- timated that globally the endemic coun- tries spent perhaps twice this amount but, in fact, few spent much more than they had hitherto been spending on never- ending smallpox control programmes. Now the chapter entitled "smallpox" is closed- let us hope for ever. The achievement of eradication is a victory for hundreds of thousands of health workers in many different countries. WHO staff alone were drawn from 73 dif- ferent countries . It is a triumph of inter- national cooperation and of preventive medicine. With coordination, coopera- tion, dedication and imagination it is clear that much can be achieved at minimal cost. • 5
Uma vitória para toda a humanidade Resultado do empenho de centenas de milhares de profissio- nais da saúde em todo o mundo, a erradicação da varíola é um triunfo da cooperação internacional e da medicina preventiva D. A. Henderson Durante séculos, o vírus da varíola assolou impune- mente o mundo, deixando um rastro inenarrável de sofrimento, morte e ce- gueira. Hoje, em seis laboratórios, o ví- rus está confinado em frascos, mantidos sob um sistema de alta segurança. Para aqueles que gravaram na memó- ria o sofrimento das vítimas da varíola, para o pessoal de saúde que, com tanta diligência, realizou programas de vacina- ção, para os inspetores de quarentena, que examinavam cuidadosamente os cer- tificados de vacina, é difícil de acreditar que já não ocorrem casos "esporádicos" em um ou outro lugar. Contudo, dados cuidadosamente compilados por dezenas de técnicos em saúde demonstram con- vincentemente que a varíola é uma doença que passou para a história - a primeira doença que o homem conseguiu erradicar. Em 1951, durante a Décima Primeira Assembléia Mundial da Saúde, a União Soviética propôs que os países do mundo cooperassem num esforço global coorde- nado para erradicar a varíola . Naquele ano, foram registrados 280.000 casos em 63 países. Por si só, esse número já seria significativo ; contudo, dada a imperfei- ção do sistema de registro, seria necessá- rio multiplicá-lo por 100 ou mais para descrever a verdadeira magnitude do problema. Os dados referentes a óbitos também são incompletos, embora seja razoável supor que pelo menos 20% das pessoas inf ectadas morreram e dezenas de milhares ficaram cegas para sempre. Não existia e ainda não existe trata- mento para a varíola. A prevenção por . A varíola era assim. O mundo nunca mais verá o sofrimento causado pelo vírus da varíola . ( Foto OMS) meio da vacinação é a única forma de combatê-la. Depois de estudar a proposta formu- lada pela União Soviética, a Assembléia acordou, em 1959, quanto à urgente ne- cessidade de lançar u~ programa global de erradicação da varíola. A conclusão foi de que, "mediante a vacinação ou a revacinação de 80% da população num período de quatro a cinco anos" , a va- ríola poderia ser erradicada de áreas en- dêmicas. Durante os oito anos seguintes, a OMS instou os governos a preparar progra- mas, solicitou contribuições de vacina, estimulou e coordenou os estudos de ce- pas de vacina e prestou assistência aos la- boratórios que iniciavam a sua produ- ção. Muitos países lançaram programas e alguns conseguiram interromper a transmissão. Contudo, nem todos quise- ram ou puderam dedicar-se à erradica- ção com recursos próprios limitados. O montante das contribuições era muito in- . ferior aos recursos necessários, e muitos países que interromperam a transmissão voltaram a ser inf ectados por países vizi- nhos. Muito preocupava a constatação de que, mesmo no caso de vacinações de 80% da população,· a varíola muitas ve- zes persistia. Desanimadas, as autorida- des de saúde assumiram uma atitude pes- simista. Uma coisa era eliminar a doença dos países dotados de infra-estrutura sa- nitária desenvolvida, e outra era supor que isso pudesse ser feito nos numerosos países que acabavam de obter a sua inde- pendência e cujos escassos serviços de saúde quase não passavam dos centros urbanos. Poderiam esses. países coorde- nar suficientemente os seus esforços de modo a poder eliminar a varíola de gran- des áreas geográficas? Apreensiva e menos confiante, a As- sembléia Mundial da Saúde de 1966 deci- A varíola está morta! Desenho de Peter Davies IX ISSN 0043-8502 A Saúde do Mundo. Revista ilustrada oficial da Organização Mundial da Saúde. Editor: John Bland Editora Assistente: Christiane Viedma Editor de Artes: Peter Davies Editor de Noticias: Lalit Thapalyal A Saúde do Mundo é publicada em alemão. árabe. espanhol. francês. inglês. italiano. persa. português e russo . Ê permitida a reprodução. com menção da fonte. de artigos e fotos sem reserva de direitos autorais. Organização Mundial da Saúde (OMS) Av. Appia. 1211 Genebra 27. Suíça . indice Uma vitória para toda a humanidade D. A. Henderson . . . . . 3 Um legado para o desenvolvimento James Magee . . . . . . . 5 Trabalho bem feito Marcella Davies Força de vontade 6 V. T. Herat Gunaratne 11 O "plano bélico" da lndia Jitendra Tuli . . . . . . . 12 O crepúsculo de uma deusa Arun M. Chacko . 15 Quanto custou 7 . . 18 Rumo ao ano 2000 Halfdan Mahler. . . Ramsés V: a primeira vitima conhecida 7 19 Donald R. Hopkins . . . . . . 22 Decadência e queda do império da varíola . . . . . . 24 Podemos suspender a vacinação 7 lsao Arita . . . . . . . . . . . . 27 Os estágios finais Svetlana Marennikova . . . . . . . 30 Como ter certeza 7 Frank Fenner. . . . . . . . . . . 35 diu que a OMS aplicaria um programa in- tensificado de erradicação. Foi incluída no orçamento ordinário da Organização uma verba de aproximadamente US$2,5 milhões, destinada à coordena- ção geral do programa e à prestação de assistência aos países que a solicitassem. Esse montante era claramente insu- ficiente para prestar apoio a cerca de 50 países necessitados, com uma popu- lação superior a um bilhão de habitantes. Proporcionalmente, porém, representava quase 5% do orçamento total da OMS para aquele ano. Havia esperanças de substancial aumento das contribuições voluntárias e de que todos os países atri- buiriam alta prioridade ao programa. Delegados mais otimistas propuseram o prazo de dez anos como meta para a er- radicação; contudo, a maioria preferiu ser mais realista, limitando-se a esperar que o programa resultasse, no máximo, em melhor controle da varíola. O programa intensificado começou em janeiro de 1967. Naquele ano, 46 países registraram 131.697 casos, total que re- presentava talvez 1 % do número real de casos. Havia quatro áreas endêmicas. A África era um importante reservatório, estando infectados virtualmente todos os países ao sul do Saara. O segundo reser- vatório em importância era a Ásia, onde a varíola se espalhava de Bangladesh através da Índia, do Nepal e do Paquis- tão, até atingir o Af ganis tão. O terceiro reservatório era o arquipélago da Indo- nésia e, o quarto, o Brasil, país de dimen- sões semicontinentais. Preocupação fundamental ao início do programa era a necessidade de suficiente material de vacinação e da própria va- cina - as armas e a munição da cam- panha. A União Soviética e os EUA fize- ram grandes contribuições iniciais; o número de contribuintes aumentou final- mente para 26 países. Começaram tam- bém as pesquisas de instrumentos deva- cinação que requeressem menos vacina do que a exigida pelo método quase uni- 4 versai da laceração. Em 1968, estudos de campo realizados pela OMS demonstra- ram a possibilidade de usar a agulha bi- furcada, recentemente aperfeiçoada, para administrar vacina por meio de uma nova técnica: a vacinação por punc- turas múltiplas. Não tardou que a agulha bifurcada fosse promovida a método pa- drão de vacinação. Desde o início da campanha, também preocupava a questão da estratégia mais adequada. A vacinação em massa, desti- nada a cobrir 80% ou até 100% de uma população dada, só tivera êxito em al- guns países menores e nos países com serviços de saúde mais desenvolvidos. Na maioria dos países ainda endêmicos, era necessário adotar uma estratégia di- ferente. A decisão de encarar a vigilância como importante componente estraté- gico mostrou ser · o avanço decisivo de que muito se necessitava. A nova estraté- gia previa uma campanha de 2-3 anos de vacinação sistemática destinada a cobrir 80% da população de cada país. Durante esse período, planejou-se o desenvolvi- mento de um sistema nacional de notifi- cação suficientemente sensível para de- tectar e eliminar os focos remanescentes de varíola. Logo após o início do programa, cons- tatou-se a possibilidade de desenvolver, já não mais em anos, mas em meses, efe- tivos programas de notificação. Me- diante o isolamento de pacientes e a vaci- nação de seus contatos, os surtos pode- riam ser rapidamente contidos. Mesmo em áreas com deficiente cobertura deva- cinação, muitas vezes seria possível con- ter rapidamente a transmissão da va- ríola. Assim, passou-se a dar ênfase cada vez maior ao componente vigilância-con- tenção da estratégia. Procedeu-se ao re- crutamento e ao treinamento de equipes especiais de vigilância, que visitavam cada unidade de saúde de uma área a fim de assegurar a preparação e o envio se- manal de relatórios indicativos do nú- mero de casos detectados. Havendo noti- O desaparecimento da varíola na Ásia resultou na canalização de maiores recursos para. a Etiópia. Fechava-se o cerco em torno dos últimos redutos da doença. (OMS/E. Shafa) ficação de caso, as equipes, em conjunto com o pessoal de saúde do campo, trata- vam de conter os surtos e investigavam, em escolas e outros locais de reunião, ru- mores e boatos a respeito de casos de va- ríola. Para ajudá-los nessa busca, foi im- primido e distribuído, para fins de reco- nhecimento, um cartão especial da OMS com a foto de um paciente de varíola. As primeiras campanhas foram inicia- das em 1967. Dois anos mais tarde, com excepção da Etiópia, todos os países ha- viam iniciado programas de erradicação. O programa da Etió(>ia começou em 1971. Em 20 países da Africa Ocidental e Central, um programa de erradicação de varíola e de controle do sarampo: patro- cinado pelos EUA, conseguiu eliminar a varíola em apenas três anos e meio. No Brasil, o último caso foi detectado em 1971 e, na Indonésia, em 1972. Em mea- dos de 1973, a transmissão da varíola fora interrompida em toda a África, ex- ceto na Etiópia. Apenas cinco países da Ásia, além da Etiópia, continuavam in- fectados pela varíola. Contudo, a Índia, o Paquistão e o Ban- gladesh, com uma população superior a 700 milhões de habitantes, apresentavam um problema especial. Medidas de vigi- lância e contenção semelhantes às que haviam sido aplicadas com êxito na América do Sul e na África revelaram-se menos eficazes naquelas áreas densa- mente povoadas, cujos habitantes viajam com frequência e para muito longe. Im- punha-se uma abordagem diferente. Em meados de 1973, as autoridades sanitá- rias da Índia prepararam, com o pessoal técnico da OMS, uma nova estratégia de vigilância. Todo o pessoal de saúde foi instruído no sentido de proceder a bus- cas intensivas em cada aldeia e, mais tarde em cada domicílio, para detectar casos de varíola. O êxito dessa operação exigia rapidez, motivo pelo qual as bus- cas deveriam estar completadas em 7- 1 O dias. Em áreas de alta infecção as bus- cas se repetiam mensalmente e, em áreas menos infectadas, cada dois ou três meses. Durante a primeira busca, reali- zada em outubro de 1973, foram detec- tados milhares de casos não notificados. Mas, uma vez descobertos, havia possi- bilidade de conter os surtos. Mediante cuidadoso planejamento, treinamento e avaliação, as buscas eram cada vez mais completas. Entre as bus- cas, equipes de vigilância visitavam esco- las e pontos de mercado, procurando in~ formar-se a respeito de casos de varíola. As medidas de contenção foram fortale- cidas. Com a redução das cifras de mor- bidade, instituíram-se recompensas ao primeiro informante de um caso e para o sanitarista que o investigasse. Métodos similares não tardaram a ser empregados no Bangladesh, no Paquistão e no Ne- pal. Em 16 de outubro de 1975, decorri- dos apenas dois anos do início da nova estratégia, registrou-se o último caso de varíola na Ásia, ocorrido na ilha Bhola, no Bangladesh. Foi este o fim da vario/a major, a forma severa da doença. Em fins de 1975, somente existia varíola na Etió- pia. A forma prevalente era a vario/a mi- nar, cuja taxa de mortalidade é de apenas 1 %, em contraste com a vario/a major, cuja mortalidade é de pelo menos 20%. Além de ser o último a começar, o pro- grama da Etiópia enfrentou problemas incrivelmente dificeis. Embora a área do país seja maior do que a área conjunta da França e da Espanha, havia pouco mais de 100 profissionais de saúde disponíveis. Quase não havia infra-estrutura sanitá- ria. As estradas eram poucas, calcu- lando-se que metade da população vivia a uma distância superior a um dia de ca- minhada de qualquer estrada acessível. A guerra civil e a fome compunham os problemas. Mas com a interrupção da transmissão da varíola na Ásia foi possí- vel destinar maiores recursos à Etiópia. Nas aldeias, os próprios moradores fo- ram recrutados e treinados para servir como agentes de vigilância e vacinado- res. Além de mais veículos de transporte, utilizaram-se helicópteros para facilitar a supervisão. Em 4 de agosto de 1976, me- nos de um ano depois de iniciada a cam- panha, ocorreu o último caso na Etiópia. Infelizmente, na mesma época em que ocorria o último surto na Etiópia, a So- mália, país vizinho, era invadida pela va- ríola. Antes de se poder estabelecer siste- mas totalmente eficazes de vigilância, os nômades disseminaram a doença na re- gião sul da Somália. Em março de 1977, foi declarada uma emergência nacional. Além do recrutamento de pessoal adicio- nal de saúde, a OMS passou a prestar as- sistência especial. Durante os meses do verão, continuou a ser aplicado um pro- grama intensivo de vigilância e conten- ção e de vacinação. Foram detectados mais de 3.000 casos, o último dos quais em 26 de outubro de 1977. Não obstante, por mais de dois anos as equipes de vigilância e o pessoal de Um legado para o desenvolvimento A comunidade internacional já começa a usufruir parte do legado de saúde -que, pro- vavelmente, será imenso- a ser deixado pela erradicação da varíola. Indicam os cálculos que, na era pós-variólica, serão liberados para outros fins cerca de US$1 bilhão por ano, vale dizer, aproximadamente US$10 bi - lhões em dez anos. Incluíam-se no custo mundial de uma doença como a varíola a produção ou aqui- sição de vacinas, a manutenção de progra- mas de vacinação, o tratamento de compli- cações causadas pela vacinação, as despe- sas de manutenção da vigilância nacional e de controles de fronteiras e o atendimento de emergências causadas por irrupções de surtos. No Reino Unido, por exemplo, um surto causado em 1961 por um caso imRor- tado de varíola exigiu a aprovação de uma lei especial que autorizou verbas no valor apro- ximadp de US$3,6 milhões; em 1978, o epi- sódio ocorrido num laboratório de Birming- ham resultou uma vez mais na oneração da despesa pública. Técnicos dos Estados Uni- dos calculam que a proteção contra a varíola vinha custando aos contribuintes america- nos cerca de US$150 milhões por ano - montante equivalente a metade do custo to - tal do programa de erradicação global. A liberação dos recursos até agora vincu- lados à varíola poderá exercer grande im- pacto - desde que estes sejam orientados para programa de desenvolvimento. Há pouco tempo -em 1975- os recursos desti- nados ao setor da saúde (incluindo o abas- tecimento de água) na forma de ajuda bila- teral da Organização para a Cooperação Económica e o Desenvolvimento (OCED) e da Comunidade Económica Européia (CEE), ou de ajuda multilateral através das agências especializadas das Nações Unidas, totaliza - ram US$1,5 bilhão. Portanto, os novos re- cursos poderiam reforçar maciçamente os fundos disponíveis. Na opinião da OMS, tais recursos exerce- riam impacto estratégico máximo sobre seguintes áreas essenciais da atenção pri- mária em saúde. Estima-se, por exemplo, que 80% de todas as doenças nos países do Terceiro Mundo guardam relação com a poluição da água, implicando em 250 milhões de novos casos anuais de doenças transmitidas pela água e em muitos milhões de óbitos. A febre tifóide e a cólera são exemplos típicos. Entre outras, são doenças transmitidas pela água a es- quistossomlase, a malária, a filarlase, a onco- cerciase e a tripanossomlase. Em 1981, será proclamada a Década do Abastecimento de Agua e Saneamento. Nos cinco anos iniciais da Década, uma quantia anual de US$1 bi- lhão ajudaria a prover adequadamente de água e saneamento muitos milhões de habi- tantes de áreas rurais no mundo em desen- volvimento, assim gerando um novo e vasto ciclo de progresso social e econõmico ba- seado em melhores padrões de saffl:le. James M e busca envidaram esforços para descobrir novos casos. Em muitos países, com a oferta de uma recompensa por informa- ção, os aldeões deram conta de dezenas de milhares de casos de varicela, sa- rampo e outras doenças pustuliformes. Milhares de espécimes foram enviados aos Centros de Diagnóstico da OMS em Moscovo e em Atlanta, EUA. Nenhum deles correspondia a varíola. Para que persista numa população, a doença deve ser transmitida de uma pessoa para outra, em contínua cadeia de infecção. Por não existir reservatório animal nem portador assintomático, cada pessoa que seja elo dessa cadeia deve revelar sinais e sintomas característicos. Durante o pro- grama, constatou-se que a varíola nunca persistia por mais de oito meses num país sem ser detectada pela rede de vigilância. A busca contínua durante dois anos, ou seja, por período três meses superior a esses oito meses, propiciava uma garan- tia a mais de q_ue o alastramento da va- ríola fora contido. Para confirmar a interrupção da trans- missão, Comissões Internacionais espe- ciais da OMS visitaram cada país. Em 1978, o Diretor Geral da OMS formou uma Comissão Mundial para revisar a experiência de todos os países. A Comis- são completou seu trabalho em 9 de de- zembro de 1979, data em que conveio quanto à existência de documentação su- ficiente para certificar a erradicação em escala mundial. A erradicação da varíola significa que a vacinação pode ser interrompida em qualquer lugar e que não mais serão exi- gidos certificados de vacinação dos via- jantes internacionais. As poupanças mundiais são estimadas em US$1 bilhõe por ano. O custo dessa proeza não pas- sou de US$ l 12 milhões em assistência in- ternacional, ou em US$9 milhões por ano durante o período 1967-1979. In- cluem-se nesse total todos os recursos aplicados pela OMS e as contribuições bi- laterais e multilaterais de 42 países. Se- gundo as estimativas, os países endêmi- cos talvez tenham aplicado o dobro desse montante. Contudo, poucos foram os que fizeram despesas superiores às que vinham fazendo até então em interminá- veis programas de controle da varíola. Portanto, está encerrado - e, espere- mos, para sempre- o capítulo intitulado "Varíola". A erradicação é uma vitória de centenas de milhares de profissionais da saúde em numerosos países. Somente a OMS recrutou pessoal em 73 diferentes países. Trata-se de um triunfo da coope- ração internacional e da medicina pre- ventiva. Ficou comprovado que, com coordenação, cooperação, dedicação e imaginação, os resultados serão máxi- mos e os custos serão mínimos. • 5