Smallpox is dead! [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION MAY 1980 WORLD HEALTH e, 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. For centuries, variola virus stalked the world with im- punity causing unmeasured 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 are 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. (Photo WHO) population 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 Contents A victory for all mankind by D.A. Henderson ....... 3 A windfall for development by James Magee 5 A job well done by Marcella Davies An effort of will by V.T. Herat Gunaratne India's "war plan" by Jitendra Tuli 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? by Donald R. Hopkins ... 22 Decline and Fall of the Smallpox Empire . 24 Can we stop smallpox vaccination ? by Isao Arita 27 The closing stages by Svetlana Marennikova 30 How can we be sure? by Frank Fenner 35 A victory for all mankind Brought about by hundreds of thousands of health workers from all over the world, eradication is a triumph of international cooperation and of preventive medicine by D. A. Henderson 6 11 12 that all countries would give the pro- gramme a high priority. Some delegates optimistically proposed setting a 10 years goal for eradication, but most believed realistically that better control of small- pox was the best that could 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 virtually all countries south 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 contributors. 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 programmes throughout the countries of western and central Africa and Brazil. In 1968, field studies conduc- ted by WHO showed that the newly devel- oped bifurcated needle could be used to administer vaccine by a new technique— multiple puncture vaccination. The bifurcated needle soon became the stan- dard method for vaccination. A second concern from the start was the question of an appropriate strategy. Mass vaccination designed to reach 80 or even 100 per cent of a population had succeeded only in some smaller countries and those with more developed health services. For most of the still endemic countries, a different strategy was required. The decision to emphasize surveillance as an important component of the strategy proved to be the much- needed critical breakthrough. The new strategy called for a systematic two- to three-year vaccination campaign de- signed to reach 80 per cent of the popu- lation in each country. During this time, it was planned for a nationwide reporting system to be developed which would be sensitive enough to detect such smallpox foci as remained and to eliminate them. Soon after the programme began, it was discovered first in Nigeria, then in Indonesia and Brazil, that effective reporting systems could be developed in months rather than years. By isolating the patients and vaccinating their con- tacts, outbreaks could be rapidly con- tained. Even in areas where vaccination coverage was poor, smallpox transmis- sion could often be stopped quickly. So now increasing emphasis was placed on the surveillance-containment component of the strategy. Special surveillance 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 contain the outbreaks, and they visited schools and public places to inquire about The end of smallpox in Asia meant that more resources could be made available in Ethiopia. The net was closing on the last places on earth where the disease lurked. (WHO/E. Shafa) rumours of smallpox. A special "WHO Recognition Card" showing a picture of a smallpox patient was printed and dis- tributed to help them in their search. The first campaigns started in 1967 and, by 1969, all countries except Ethio- pia had started eradication programmes. Ethiopia's programme began in 1971. In 20 countries of western and central Afri- ca, a USA-assisted programme of small- pox eradication and measles control suc- ceeded in eliminating 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 than 700 million persons, presented a special problem. Surveillance-containment mea- sures such as had been successful in Afri- ca and South America proved far less ef- fective in these densely populated areas where people travel frequently and far. A different approach was required. During the summer of 1973, Indian health au- thorities with WHO staff planned a dif- ferent surveillance strategy. All health personnel were asked to undertake an in- tensive search of each village, and later each house, to detect smallpox cases. This would need to be done rapidly to be successful and so the search was planned to be completed during a seven- to ten- 4 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 facilitate 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 developnrient 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 Magee 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. The 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 $112 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 job well done Today, a new lease of life is at hand for one out of every ten children in West Africa who used to be either killed, left mentally retarded or blinded by smallpox by Marcella Davies In Sierra Leone, the WHO-sponsored smallpox eradi- cation programme was unique not only because it was a joint venture between that country's Govern- ment and the United States, but because it was a major public health effort on the part of 20 West African coun- tries closely coordinated with worldwide WHO efforts to rid the world of smallpox by 1975. This was a gruelling exercise demanding watchfulness and speed for its success, but all the same it was worth the effort. Up to some 15 years ago, the whole country was virtually lit- tered with cases of smallpox. All districts, with the possible ex- ception of Kailahun, reported high attack rates. The last severe outbreak, documented for 1957, resulted in 4,246 reported cases with 228 deaths. This trend continued and the situation remained tense until 1965, when there were severe sporadic outbreaks. In November 1967, Sierra Leone experienced a high incidence of the disease in the aftermath of the previous year's epidemic. According to WHO figures, the whole country had more smallpox for its population in 1967—with 1,636 reported cases and 248 deaths than any other place in the world. Most of the victims were scattered in remote places with little or no medical facilities. Living conditions were generally poor and the teams had to trek for miles across hilly terrain, marshy swamps and ferryless rivers in order to reach some villages. Although small-scale vaccination programmes were in prog- ress all over the country, their impact had not been sufficient to change the trend of the infection rate nor the attitude of most people to vaccination. It was commonplace to see a whole village deserted whenever a vaccinator loomed in sight. The four-year programme developed for Sierra Leone in collaboration with USAID (the United States Agency for Interna- tional Development) had two aims : the complete eradication of smallpox, and the control of measles by immunizing all susceptible children aged between six months and two years. The first (attack) phase of the campaign for the fiscal years 1968/69 was devoted to mass immuniza- tion against smallpox, with a follow-up assessment to ensure 90 per cent cover- age. An improved surveillance system was also instituted, with the immediate aims of detecting and containing any 6 In Africa, the eradication campaign was ac- complished by a kind of cooperation that transcended all language barriers and local traditions. (Photo WHO/J. Ryst) case of smallpox, and reducing measles morbidity and mortality. The first step was to arrange meetings with local representatives of medical bodies, other government agencies and volunteer groups as well as influential personalities. Advance teams contacted local chiefs and village heads to establish the places and times of vaccinations and to motivate people to get themselves immunized. Radio broadcasts, mobile address systems, street banners, personal letters and placards were all part of the publicity machinery. The teams generally used jet injectors to "blitz" major populations, while smaller roving teams using the multiple pressure method were reserved for mop- ping up as the crowds became thinner. Each person vaccinated was shown how to avoid infection, and had to dip the finger of the right hand in a harmless solution of silver nitrate to facilitate id- entification by the assessment teams. To control outbreaks, a fire-fighting team was formed, to throw a vaccination cordon around smallpox cases in areas already vaccinated, or to mop up areas which had been poorly covered. A monthly bulletin, "The Eradicator", gave up-to-date information about the campaign's progress. A pilot project to document the safety and efficacy of the simultaneous admin- istration of smallpox, BCG and measles vaccine was carried out in Freetown be- tween January and February 1968. The Endemic Disease Control Unit in itself was completely overhauled in an effort to develop team spirit and self-discipline. 7 Then followed a series of highly intensi- fied training courses to qualify team members as experts in mass vaccination techniques, health education and the care and use of the jet injectors. In the southern town of Bo, I was closely involved with the inaugural cere- mony in my dual capacity as Principal Medical Officer, Southern Province, and Acting Senior Medical Officer, Endemic Diseases Control Unit, Bo. Held on 8 15 March 1968, the ceremony was a most impressive and colourful event. Shops and markets closed for the occasion and all the roads were choked. There were floats of every description, and most of the paramount chiefs were present res- plendent in their native costumes. The vaccination team members wore their field uniforms and displayed their jet in- jector guns for the public to see. The merriment, dancing and feasting that accompanied this ceremony paid very good dividends. It gave the campaign a good start and acted as a stimulus for the team members. In the subsequent months we noted that, time and again, explosive outbreaks followed funeral ceremonies of notable people in the villages. At such times large numbers of people converged on the home of a smallpox victim, to pay their last respects. Some took part in washing Above: In Ivory Coast ; the hanged bird was a macabre warning to travellers: "We have smallpox in this village stay away." Left: One phase in the local production of small- pox vaccine in West Africa. r Photos WHO and WHO/D. Henrioud) the body while others were in close con- tact with the victim's family. It was usually after they dispersed to their own homes that these contacts themselves became victims of the disease. It is an accepted fact that field work of any kind, particularly in countries with a poor road system and difficult terrain, is most strenuous—and Sierra Leone was no exception. On the whole the working conditions were unpredictable and hazardous. Teams were sometimes called upon to perform burdensome and demanding tasks. In Kagboro Chiefdom, Moyamba District, team members nar- rowly escaped drowning and lost all their belongings when the boat in which they were sailing capsized. At Nomo Faama, terror-stricken campaigners fled for their lives when they sighted an elephant strid- ing through the dark forests. To suit the convenience of peasant farmers during the farming season and to cover areas far from the nearest motorable road, vaccinators were willing to walk up to 35 miles. Two factors helped to keep the team spirit and morale high; firstly, the feeling of the campaigners that their interests were well looked after by their imme- diate seniors, and secondly the sense of gratitude and cooperation demonstrated by villagers wherever they went. They were often accorded courtesies usually reserved for distinguished visitors, with entertainment in the form of big feasts and native dancing. From the start we realized that this type of work could only succeed with good supervision, particularly in the field. We recruited four officers from the health inspector cadre who had received good formal training in public health, and they were given the necessary addi- tional training. They turned out to be very dedicated field leaders. Throughout the campaign I made unannounced visits to the areas where teams were working, to see for myself how they performed and to boost their morale. It was quite rough going during those travels as Sier- ra Leone had just gained her indepen- dence and most of the roads were not motorable. When all is said and done, it was these young heroes who conquered smallpox, and they deserve recognition for a job well done. Today, a new lease of life is at hand for one out of every ten children in West Africa who used to be either killed, left mentally retarded or blinded by small- pox. In Sierra Leone, the fear of vaccina- tions which formerly impeded the suc- cess of immunization programmes has given way to universal acceptance of the benefits to be derived from vaccines. The experience of the Endemic Disease Con- trol Unit in that campaign has welded them into a strong unit which now forms a sound basis for future prevention and control of the more acute communicable diseases in the country. The successful eradication campaign has been accom- plished by a kind of cooperation that transcended language barriers and tradi- tions, working for the good of Africa in particular and all the nations of the world in general. ■ + * An effort of will by Dr V. T. Herat Gunaratne Regional Director of WHO's South-East Asia Region The will and determination of the people of South-East Asia and their governments, O combined with unpreced- ented international support, succeeded in achieving the goal of small- pox eradication in this Region. The certi- fication, on 14 December 1977, of small- pox eradication in Bangladesh—the last country in Asia to be freed from the dis- ease—was the finale to a decade-long battle. Burma reported the last case in 1969, Indonesia in 1972, Nepal and India in 1975, while Bangladesh reported the last historic case, Rahima Banu, who happily survived, on 16 October 1975. The other countries in the Region had achieved smallpox-free status earlier. In the past, most of the Region's coun- tries had been reservoirs of the disease. In Indian folklore, it was personified by a deity, Shitala Mata ; her annual spring visits were so much a part of Indian life that the disease was often referred to as the "Spring Disease". By the beginning of this century, governments were trying to extend im- munization against smallpox throughout the countries of Asia. This work was in- tensified after the Second World War. In 1949, the WHO Regional Committee for South-East Asia urged all Member countries to make primary vaccination and periodic re-vaccination compulsory. Through strengthened immunization programmes, Thailand, Sri Lanka and Burma had interrupted indigenous trans- mission by the late 1950s. Large epidemics still continued, however, in other countries of the Region. In 1958, one of the peak epidem- ic years, India had a morbidity rate of 39 per 100,000 population, and in East Pakistan (now Bangladesh), the inci- dence was reported to be five times as high. The reintroduction of the disease into countries that had arrested trans- mission still posed a real threat. Thanks to the combined efforts and dedicated work of national and interna- tional health workers, supported by the determined will of the Member govern- ments and substantial external support obtained from international organiza- tions and bilateral agencies, the number of foci of the disease gradually decreased in 1973-1975. By November 1975, there were no cases of smallpox in this part of Asia. WHO assumed a principal role in orga- nizing and coordinating country pro- grammes in smallpox eradication. The Regional Office assisted Member coun- tries in implementing the programme, and cooperated in obtaining resources, Will and determination were the keys to success—sometimes quite literally when the smallpox team's vehicle became stuck. Left: In 1975, three-year-old Rahima Banu became the last smallpox case in Bangladesh and in the Indian sub-continent. She was also the world's last case of variola major. ( Photos WHO/T. S. Satyan and WHO/D. Tarantola) supplying vaccine, and providing techni- cal advice and consultant services in all managerial and technical matters related to the eradication campaign. This success reflects the principles of sound management and practical imple- mentation. The campaign had set precise objectives and definite plans of action, and it developed easily applicable techni- ques for concurrent and independent evaluation. All levels of staff maintained a spirit of dedication, tirelessness, imagi- nation, leadership and acceptance of field work under the most difficult circumstances. The programme provided valuable les- sons in the effectiveness of collaborative efforts between the national health ser- vices and international agencies and oth- er organizations. National will and effort were undoubtedly basic requirements and a solid foundation for external inputs. This success also underscores the im- portance of maintaining a flexible ap- proach, enabling strategy to be changed in mid-stream, if need be. Thus, instead of pursuing a policy of mass vaccination in an attempt at universal coverage, we adopted the more practical approach of concentrating on problem areas. The unstinting support in terms of men and material by the governments concerned in the face of resources con- straints, the remarkable motivation shown by all those engaged in eradica- tion work, and the unfailing support from international agencies—all these were essential ingredients in what has proved to be the most outstanding achievement in international public health. It shows the way towards imple- menting other important public health programmes aimed not necessarily at era- dicating particular diseases but at effec- tively controlling them, so that they cease to be public health problems. I had the privilege to preside over the 1967 World Health Assembly, and in my address to that august body I said : "On smallpox eradication, we have decided to strengthen our resolve to make individ- ual and collective efforts to intensify the fight against this dreaded disease. The eradication of smallpox is within our reach. The achievement of this important undertaking now depends exclusively on our will and determination." It is indeed very gratifying to note that our Member States showed such a decisive example of will, determination and collaboration, and succeeded in eradicating this age-old scourge from the face of the earth. ■ 11

Victory was only possible if everybody concerned put all they had into the efforts. In fact, everybody at the Central, State and district, even village levels, put in more than they had It was on a hot, blistering June afternoon in 1973 that the "war plan" that eventu- ally spelt victory over smallpox in India was set in motion. Till then, the relentless war against an enemy that knew no mercy had not been going on too well. If anything, it had become a general's nightmare. Though there was no dearth of "troops" or "ammunition", the prob- lem was to get them to the right place at the right time. Naturally, the casualties were heavy—over 16,000 reported dead and more than five times this number maimed and disabled. It was a desperate situation and, ob- viously something drastic had to be done, and done soon. This dark and des- olate scenario was what a small group of officials studied that afternoon in June. Present at the meeting in Nirman Bha- wan, the Central headquarters of India's Health Ministry in New Delhi, were rep- resentatives from the four most badly af- fected States, senior officials from the Health Ministry itself and WHO. "We decided then that instead of expending our resources against the entire enemy forces simultaneously, we would concen- trate on their strongholds", explains Dr R. N. Basu, now Assistant Director- General of Health Services, Government of India, who in 1973 was the National Smallpox Eradication Programme Offic- er. And that was how the "war plan" and final campaign against smallpox was launched. Recollecting those anxiously hectic days (and nights), Dr Basu says that the core of the plan consisted of establishing 28 mobile teams, very much like com- mando units that would strike at "enemy" strongholds at short notice. These teams consisted of one medical officer, one paramedical worker and a driver. Since the available resources were limited, WHO was requested to provide 14 epidemiologists while the Govern- ment of India agreed to take care of the rest. "If you see a case like this, tell your teacher." Schoolchildren too were recruited to the cam- paign by visiting members of the mobile teams. ( Photo WHO/A. Kochar) Within three months of this decision, the first mobile teams were already in action in Uttar Pradesh and Bihar, two of the worst affected States, as well as in Madhya Pradesh and West Bengal. These teams were a welcome addition to the over 28,000 "troops" already in the field against smallpox, and the regular health staff in primary health centres all over the country. Even before the "war plan" and inten- sive campaign went into action, the country was spending over 80 million rupees (US$ 10 million) annually to com- bat smallpox. The expenditure, largely on personnel, was equally divided be- tween the Centre and the States. What this meant roughly was that there were three or four vaccinators in each primary health centre, and one vaccinator for 25,000 population in the urban areas. The biggest bottlenecks were bureau- cratic procedures, which hindered mobil- ity, delaying teams from reaching an affected area from another district or State. With the mobile teams in action, this drawback was soon overcome. Thus, in the first week of October 1973, the mobile teams organized visits to every village in the four selected, endemic States. These were reconnaissance trips; having identified the "enemy" areas, the troops went into action shortly after. When an active case was found, the en- tire village was vaccinated and "sealed". The intensive campaign saw many innovations. Not willing to take any chances, the health workers would insist that nobody from an infected village could go beyond the village precincts, not even to work in the fields. "But how will we eat?" demanded the villagers. Their fears were allayed by the health teams, which saw to it that nobody went hungry in the village while their vigil was on. As a result of the campaign between October and December 1973, the num- ber of reported cases went up sharply and cynics were quick to attribute this to the failure of the campaign. But it had been expected by the campaigners, as their aim was to search for smallpox outbreaks and then to contain them. The results of the search operation only helped to strengthen the Govern- ment's belief that the campaign not only had to continue but had to be intensified. It was at this juncture that WHO assis- tance also increased considerably, and the Government decided to divert from other programmes to this campaign some of the existing manpower and other resources. The next six months, until June 1974, were the most crucial, when a systematic, house-to-house search was carried out in all the villages of the vast country. By then victory seemed a distinct possibility, but only if everybody concerned was willing and able to put all they had into the efforts. "And here I must say that everybody at the Central, State and dis- trict, even village levels, put in more than they had", adds Dr Basu. During the intensified campaign, be- tween 1974 and 1977, the Indian Govern- ment contributed more than $ 19 million and the various States and Union Territ- ories another $ 21 million. During the same period, WHO provided $ 11 million, mainly through a contribution by the Swedish International Development Authority. As for the lessons learnt, Dr Basu says that the foremost was that jointly, and with determination, one can achieve goals, whatever the odds. The second was the need to concentrate resources in problem areas, instead of attempting mass, universal coverage. The third, "and certainly not the least important lesson", was the realization that "managers" who can take an overview of the situation and tackle it with some innovative solutions were necessary for such programmes. But the key factors in this most remarkable achievement in the annals of international public health were the determination of the health staff and close collaboration between governments and international organizations and agencies. In this instance, collaboration was both in the letter and in spirit, with international staff working shoulder to shoulder with the local health teams. ■ 13

A goddess defied "Often, before uneducated villagers would agree to submit, the vaccinators would have to jab themselves in front of the entire community, to prove thattherewas nothing harmful!" by Arun M. Chacko Late in May 1975, at the sleepy little eastern border town of Karimganj, Indian smallpox field workers zero- ed in on the railway station and successfully isolated a victim of the disease—Saiban Bibi, aged 30, a woman migrant from Bangladesh. That was the last time any of the several thousand people employed by India's Smallpox Eradication Programme had occasion to use their skills. It had been far from smooth sailing, and at the outset there was a critical shortage of manpower. Mr L. R. Tiwari, a former vaccination inspector who spent 20 years combating smallpox, told me: "Before 1960, Delhi with 2.5 million people had just one vaccination superin- tendent and 35 vaccinators. (And the capital has always been more fortunate than the rest of the country.) When the Smallpox Pilot Project was started in 1960, staff strength was raised to 37 in- spectors and 176 vaccinators. This per- mitted a door-to-door survey of the entire population, and every individual got his or her primary vaccination." But the primary task was not so much reaching individuals as overcoming ignorance and prejudice. Shitala Mata has for centuries been worshipped as the goddess of smallpox, and temples dedi- cated to her are dotted around the coun- try. Some devotees believed she spilled Left: So rooted was smallpox in the everyday life of India that the disease had its own goddess, Shitala Mata. Right: Freeze-dried vaccine being prepared from virus grown on the skin of a living animal—a calf. (Photos WHO and WHO/J. Mohr) grain from a basket on her head every time she shook it, and each grain turned into a smallpox pustule. Victims survived if she used water from the pitcher in one hand to clean the spilt grain, but did not survive if she used the broom which was in the other. Some people worshipped smallpox cases as being blessed by the goddess. Relatives and friends would come miles to pay homage—and merely succeeded in spreading the infection. So it was not surprising that many refused to be vaccinated against what was considered to be the goddess's generosity. Another vaccination inspec- tor, Aman Hussain, recalled : "When we first went into the field, people got agitated and soon became violent. The police had to intervene." But that solved few problems. "The people were agitated about the vaccine, which was believed to come from the cow and was therefore against the Hindu religion", said Mr C. B. Shar- ma. "Religious groups like the influen- tial business-oriented Jains and the Namdhari Sikhs even started heated campaigns against it. Villagers claimed that their kids died following vaccina- tions, and undoubtedly some did. However this was because they would rub cow-dung on the fresh vaccination, thus causing tetanus. Or they would im- mediately suck out the vaccine. But the blame was invariably put on the vaccina- tor, who received an extremely hostile reception whenever he returned." Often the vaccinators would first have to jab themselves in front of the entire community, to prove that there was nothing harmful. Mr Tiwari himself did not complain. But he did remark : "I had to give myself smallpox vaccinations four to five times a year. And every time it worked. We would persuade freshly vaccinated cases to stand around for 15 minutes so the vaccine would dry, and we warned them of the grave conse- quences of applying cow-dung. When protected kids didn't die in any of the post-1959 smallpox epidemics, opposi- tion to vaccination faded away. There has been no smallpox in those villages and slums for the last 20 years, even though some devotees to Shitala Mata began worshipping the inflamed vaccina- tion scab on the eighth day!" Over the years, conditions and aware- ness throughout the country underwent a sea-change. Back in 1958 it would take hours to persuade just one man to take his shot. Field workers would travel miles to track down a case, who might be The "bullets" that helped to exterminate a killer disease. Serried ranks of freeze-dried vaccine doses in an Indian laboratory. ( Photo WHO) carried from village to village just in order to dodge treatment. "Today when we go into the fields, we're welcomed", Dr N. K. Gupta, Delhi's Medical Officer for Communicable Diseases, said with evident satisfaction. Most crucial to eventual success was the new voio strategy implemented from 1973. Rather than vaccinate every individual—an impossibility with 650 million people—it was decided to concentrate available resources on areas with smallpox cases. Detection was a critical feature, achieved largely through publicity, with the offer of rewards for anyone finding a sufferer, and house- to-house searches for cases of fever with rash. "We have now started taking imme- diate containment measures on the report of any case of infectious disease", Dr Gupta told me. "Patients are removed by flying squad to the Infec- tious Diseases Hospital, and their homes and surroundings are immediately disin- fected. Anyone who came into contact with the case and those living around are given prophylactic immunization. The area is investigated to find out any source of infection or any additional case. We wait and then try to delimit the area in the event of secondary cases." In the light of long years of experience in the field combating smallpox, what would the field workers do to contain the menace of infectious diseases? They un- animously acclaim the measures spelled out by Dr Gupta—not for the sake of agreeing with a superior, but out of a genuine belief in the superiority of the successful WHO strategy. ■ 16 Libre de la Viruela flow reartems. contra ta .iruel. per eon,. derarla snaccesaria Illtiel n. lope rues Mahler' MO use ee la . hutna.L. fee Dermot.. ma ahem cle. ad. I. melon, de *Cares A rhean 4 vas etp...dad mood. que padre n des r r.mto intflooth 4e mirce c oho. Prod... , lot espeembalas pen ape dire Orr.. manners ma... Or l• 'Ted' . eaedan I be /growled* dos rra det wee ea. d,pues. de que se in del mar el Director for(tmre nn' td . oreen.a,op Unto raw dr sin., t de le haled ) ma, Des-de crooners mat de to Hasler die IC fatale.. ha sudo oda,ts able en Arra tedo el mut.' au par te el der for hares.. i on es. de la t•MS que area I Inch, en la re.. elle. Ceara Driboint Ma. el entmo reeturto Wavle. dlr., • la eon Per primers set aorta de ta he Ilea.° • la erre de um en...dad enade eon moo.. le a.. Es. ta thatnruo mar pees lado el on MS raromendare en onos metes a todo. ■ex rot/osier. our G. is iscunrcro. Ld IJCIACt contre Ia variole sets md eader Per ea; /es passe b da de r ego she 17•77•1 ma a la redid ds,I three de el La da per anegoo an. an. Og erratrices de a ate gagnee W Sabina alibi GENEVE 1AFFI --- Le comment La •Royal Society. de Londres n sfricain a gam. In Satellite de la va. toutelois pas estime. k renegue. gut role el In monde tidier se trouve do- la cation du nadecin sur la sormais !there de ce (lean nolleualre premiere vaccination de tous les qui • fait plus de millions de marts temps naritait qu'on lei Base grand que n Minoru quell. epidemic ou w. Ce n'est que ISO ate awes la de- ni:amine quell. guerre L'acipanisatthomenthale de la san- te a en Wet stamina i Nairobi. ma la coarse de EAfrique• on avail ell entegistre lee derniers cat -- daharresser C!...... ,SWIttrlui: ,ee" couverte 'erenner que le continent comedian . a &Maar la trans mission de la variole. La peso, le cholera et le fiat,, oune qui lion!. jamais une I cidence aussi univereelle perste. DEATH Or A woe the dew again. Puna., dm. homital ...eon a. Mmiet.triel Mere..ve ended kri ll her hmek *Mena okan bill of he tr alth. No 1.144 belle emo. Me emotennal tragedy of Iming her daughter end Mies. d in trie outbreak World' Demo. officials believed tieeId berpeo She can new pay mM milk• men tete... go to the and entertain Mem, but she har paid highly :a the, f lake soutane, most people lake for gran., Signs Endlich frei Als letzter Kontinent n 174CE C, ALTMAN, MD. 11.0 aher I bocamor ae lologia at the Chasm Par we Canna ea Adana in . aid of my bones. Dr. Don- lama, startled me 41 0011 0.0 aa taws. tang taut viral dote., vacated it way new paihrsc easement trier.% vivre nob tradable.. vaecuw . a fahmaram, thallesomo an epidemic ■ ritecocn that tbe course a haamy. it had and had warned and ray more. Media, abuda I ...meat d douse, not No polessor eyed d of eracherusen y tart *mated the ath anal PhY- Mtathani and hoer entes he accompiained by min , owned( , dmease ems my NZ,: Of In my knot edge of entteepox • sow searbothe Mdboagn rrole en ende-Bretagne : erte passee name. .1 atter. de .., est lore du eetteCe Amen, le 22 mirtemb4 19,8 HearneWaved m que hullle. cuteness. el ate at rad ':••Eleartn .Li:" rtrt'oso7 La survedience P(h toe. le, sopts en cont. les deux reeled*, SS cum.,* que 4 ha.ee ore t•ereld..14 DQ Sormmgnarn s fin. Les autortlis canclaires oth un ensemble It rnesures nyiactmum err hate,. puts. Se. gm cost pro A cert. l'OMS Teo. O. denier Cri vartoot mu dans 4 monde On dahors c.tanonatton du laboratode Irande-Bretagne) ram.. au etobre 1977. A Merl. (Soma. on 14 40441 is dormer raw 2.11.01,011591.*<-21.100 d‘24'.1. -0i0inv9, 51.219 4241111-4..th*Wht 2 1-02 2.2112;d21-,241.5'045' PdsliPA07 ow S ;140.SPirfer gd wail MK MAW =0 %RUM GWaSM31 tV.2.4P.DP.W..e 1 td 55 50080 - Odhitel£91420011991.b I • 441103" -1/1DrirD fig tagatilaX,AWM3..4-* 0Pliffia's-As-eD. ts• MINSTaD.0,7141D3.1041) Q.D.P.T.INS1O8641M1 MOCI.V52Mr,*( 4.2.1 uriatsM0z4toisi. ir...L.401PRalaara3aU 14.98r SennLaMaiae 040- Th.D.Nernaefiell 3E,Dxishairm04:41.3OD 1.4.7 -b0.1141111.542P211094 2 .11.21Z-0.1*h 2 L9 dditif WNW 1141Q Li 42' glinesd, Di3e0<E3413 6219KE5.022.Y.Aill.590 fT cle..0.1 0.VSeEh< 51 Friday the director-general of the World Health aanIsation, Dr. Hattrian Mahler, confirmed in Nairobi It smallpox has finally been eradicated throughout I world. The virus is beina preserved in seven >oratories, in the Soviet Ur gin, the Netherlands, Chin( Le mythe 10 recommend the preserve dangereux smallpox vaccine for two y de ('eradication ■uld decide whether or not t Mahler described the Apt/ - Log 421M+KCP4 ItS4The-, a 81 41 is Ern..MataSeres3Mso 5-44D6'0.-.01. trigatigitiCrak 3....adeb,k0Waitert.73 Wiit=0113413 K.201F4firdi100 20' 41211-00.21: =moon Div SirSJ6Wilik LDIMMaladariv IM.30Mtr...Ce tiOlgra „POW 003NE1 alletRedated' a41121:113K+316. ,datin,-; 00 IN 413.0 R94-004 9/, it lagg3=DaC.X. AKPUillaidetAL DInW"Esd,t3O' 0313,10D4r41 V.P.D.VSettAiDsi NIPO.D.LagiSila 4:zar MS30#0 2i1i400',2594 <01 leadirfdir i102g 1.1 al isCI,;;AIL. 7.1) new. o4:0. VfaesifilKif tIRL S.PMSCE-1311Er: WEN NeVt. +gistdDielnitP. 101n1' b-i4' Ii 4500r ...r0. IMPWaDe. 414 511856 1c` KtisMIEDN,E; She ennobled unalmea herFeu la variole ? aim huh 41al ot the dam.. WASMNOTON - ro de laborat. A va1101.9. gut consti- marupulava o tutu grave problema de t artola tot re, sande pabltca durable 76 pars sett *tidos, tot tinalrnente O rtsco erradicada do plane la. cape de Maus segundo 1ntormaram redo r,a10 ontern funmonanos eta assign. .1600 Organtgacgo !Notariall mss perms do Sande. depots de 11 guardados no anon de urn intenso pro- tonos pare ea grams de combats a mo medtda cis doe ne a. utra yes de ca. caso a doe' remnantsas de yam.- a se manliest cAo e tsolamento dab ea tonna Esc pessoas atIngidas pet° e Bova Dent reel reserve de van ' A Ultima resnan do 200 11111hDes CI mundo atetada pelt re, more t posstve moist 101 o Contlnente ca se0t airman°. byre da enter- 0 anunc rn Wade dots anon de- dl erradleacl pots do ultimo caso re. MM, no ens. gistrado no Somata. tetto somente Segundo os menUstas de 1980. dun do 0131S. urn dos recen- sembleia Hera les canon remstrad.101 A prOsuna o de torn traba1hador de ganWacgo 0 a um laboratOno de BIT- mondial de mingham. na Inglaters contra tuber, rot. que morreu em con- nortueltte. dU secinencla de um virus Kano em cad que escapou em 1968. 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S.Ddighlat =0 I' KCVO SaMidatt Mil I Sell irersArs-v I 4444,11- *6Y9;4i; ZVI 41161/R1,44-P W I **COMA ;I:* ildts2 Aar 40116.14:4101i iwt0.,{21riao.14/4 *1,1.30:1 CVX-VrAP Vgliffr Ittie•gd• WV( le I +.0 0' S.33.331,' 510,214e2 10505POWV5M5W1 H11 70 din 7,•L'tht9 Ser(C-..9. • fim da rarioi em todo o mu: ILLER EFReit'M TIM atr4 WI* wt.". he, de.h(er craitiart wound prim ow e 9 1119919.0 999990.111, pm pour mew.. ioneenoe mat ma anent mew etie niriningbam Uit-ow wail.. oat caolmted • brampaians At le vulterlence ...I se p.n.n the disease ,„ un an dans Oorne ref Kenya .ua Yemen, poor wide... striae seem= . our kl amen Wis.. ow. On .ure pie.. mon. wan i as s„,„ twat, wan litmeti. wont dletwation line.. ulapent.n de Y vimic M quarantine'. .dan TOSS., eas wiwts We la ...ion atiorrionens. mat . v... le connea et le Iltsnw ..anent une drpwte ann.. p.ele de dace , .Erradicada la viruela 711'"?'"trar; 4'"'ta T . l'r'Isret* m-it"r. "el ' NAIROBI. ZS Oct tUPi. - Ea 0,01a gentile.r due el Cuerno de Africa to 3,1* nova lo nonPlage one cause la muerte de minions ...Mr litre CM vimnls as Mr wr rm. ve a very ,,, It personas. tow-entente,. ha skin 11.1. Este pasty b.ocratko . preckseha Para coma er. Whet e 1 f i 0 i 1 n t ", mune arra:Ikeda. sell. Mr.. boy fun. all., el cam1no y smier hater el anunclo ,. ,,,,,, ,•,....., ,w disc.. pc .clon4r1Ines, la Organnaid. m.o. de , Or que lad AMC. y pod to Unto tom el c„. 7 ,,,,,,,,..' ,,,,,,,, mundo, ea. Ilbre tel ssal. stable net be Made. woclra to ma rerenam. "Ede .uerdo final no 1.1.11", deClara S.ie MOM. 1', one of the nor ,„,,,,,, , ,,,-,,,, ,--- --- ------- too de los runctonartes. anomie +Wes, sue • arl.r. a'r'm/ n7 --n-- en - capita! de Kaye, 06.46 W os se caleiga que se present.. ..awes ,.__ ' ., declarer/3 woe Africa. y por 10 wan two el d.,,,,,,,,,,, ,,,,,,,,,,,,, , ,...,,,,,,,...„..., e-er S-nt row r Humanklad, El Callow caso de alruela se regletra hare Postamente des arica en Somalia, caste clue autorldadm.ollartas de les cuatro nes perteneclentea al llamado Cuero . Africa -Somalia, Kenya, Etienne y J tbutl- Am. con la OMS, recOrrieron Ia region en Mime de nuevos Des.rs de una ,ere de re.lonen que celebraron este .mana en este capital, las autoridegat tle la sated ...Moque nose d.cuhrleron nuev. ea. de ...la mollpox virus escapes in England;' ;; , virus. The =the .] case Is described as waged a global our against smallpox' , era( Center for Disease Control in At , been I total mores. There has been ' "nib' Iv the brief report from the Fed- widely believed that the °mango I nest plus obligatoire 'extinct' disease rears its ugly head as N.Y. Timm News Service Don certificates for thy f, Alen who .the th' *ern 7.5t° specialued Inna.ilabo.rattone.cLILI, "Seba Wye beep in Bh"*41'n E4'"6. laboratorim In the world that kept .rnall- mk". pox has des-sloped in England following Some oationS have extended the ov pox vim; (Cday Owe are 14. the accamtal escape of the deadly drus garment to all travelers from BMA from a Laboratory there, United States There is no malls. vaccination maul ''''''''''''""th''''''""r*' ''''''''''''''th'emWS'-''". 1 Vaccinations : l'antivariolique first patient to te tilt by the laboratory physicians and public-health experts In NEW YORK -Seemed case of mall. within the testi...ad The nee victim is the nether of the For more t an a decade, attend/ '".....C'...'"'...-I'Asth'u... ......0- ... 1. 1 44.1.14 at... 1. la • la mamma max 0 1 lasts. The daughter, a medical knows naturally occurring nee d photographer who became infected late in dangerous drus Infection anywhere mats les autres seront renforcees August, dledgepf II. earth since last October, when a coot them M":, than Z" ."'',..., ssis"seusg'' al l /It '''''Uncle" rb.'"'peccidindrkof the World Rea ,,,,,aoes. so orcew o• to. s...aows ilea ....co... ''...'ne ". ir.'"°' I'''. ''...'".. ° r adophon . h Con., 0. ....au wow.. 4 4 rim. con. 4 .10414 011 4 And her husband. Fred aced `d ad of a mg.*. Men atck trade ander smaII om Pedereree liOryinismon de U .'S. *scene... raeawital I. varois •nent ea teen At her nanoin Myrtle -.orients un (in limt en eller Mottle tam caimem Avenue, Meg, ficath stn. blerriet eel Nora dommucun ere pert ea it mei.* .4 Seem. Mein. 411 Me lend... og. Mr rouraxe meded to overanme . tr.... of rser du ...o leterteers au rtmede creCanornser Ms d wconno... :au, - Is rataew a, 915 911' sill 011.9 deux nate.. ashes oar an. Ulnae.. oweer. Her fare betray. little of p lies e wept,. m..nmeope - h sib (raw brew etrthe et ram) enraer I P017 0 1.11I in' alas tit aft Fewer waterers( or F. Sr waf rose WIT to aft cf.4 .ee e te nor sonata ward wart aA arewhi ed gar ROW or memo owner at mra r I New mwas hst dl wri row TIM erfTWE d WW*1 N We watt tew * Mao det mere 41 ori er ow* el 'brae armor lior• *PINTA * itc warZ rent tr• eat t ferM3 fader *Woo sa1 rt lease as** el tog I teat' Orr 13 r 4.‘ arta Mat a culairc riaridencr d, maladies in• feetetees ii en re...redo...lament l eaps rnion dun untimem- to Wear. 111441•11 qui conduit micliger les ilk- redetaire, des ...rifted.. quoi bon a '44 contra de. m.o., qui 44 114 ol disparu7 P. Leann-. ,..munication raced.. de ...rine dr Paris. cr. arrears sou encore encourage, per 10 re, the 11.0- du dam I, milieus *bele], et amp', lOrgeuidtion ...kale de la Same dr la lendable ere... definitive des malad maladies Wert.. rota rat de 1.1 ies (h. II Mal hien ad... cue la ada.. modern., nor fait encore di. pan.. meted. epidenuque II s quelques scone., TOSIS am. en. nonce l'enidiret.n du paludisme; or re INri nous name.. Europe a Inner. la Turquk it wk. de Mire one rentree brut. M.. nous mon.. stars non ...au de n'amtir pas mh ea. I l'eradication du paladin.. mats probablement reel. reran tune COMM C1114 inf.tton plus diflicile en- core dam les rem.. na elk se r.n i . feste stun form, ales R(... Le titan, We encore Meta,. trop de p.m., et l'on pet. a (shire gull en w de mt. pour Ia diva/pie. Per.onne ne Mere ape la ...nation corms la polionnelite a rapes,. ant own& Wooire; rualhmreusement It diwipline en maniere eh 1acciaation n'exime Cretan. pa.• trui uot reu pan. unman l'iredication de la p ct. litamselift par tine dm, rsoilm.Ma. de saccinatio. genecalisees nni su Pepper.. la malache qui, en rtfri- qtk par evemple est aujoiardlui ding lots plus frequente ore !Weak au moment on Eon a commerick les sae.- mai.. in Haien. , on ca.. eh joard'hui au. de gem can de lite de, une commo.u. relight.. qui refuse la weein.ion Des ea, isett Ni . Au Canasta .4421 la .isite de pa- rentseu des e.umts atm les rue. l(ollandah: 144111 ICS 11111/4411950.1th specialist, annencrient la fin des atidadics vine- riesnev on ale on revs en moon, au, Murd'hui. En annomant premeturinhot le di.- petition de rertaine. rnaladies Infect., se; les or.... officials concern, JES toqu. Dna. ore dt mundo, to queaado fibre del mad qte Se huro0me a ogigeo de la vpunia, peep rya TWA swan divante sligas the la metal.do In la el caw se ventied en la cabe. momitkada de, (arena egawto Ramses V. quIen rethO * ■, tr► 117 (ea w e Ingle.. en 1614 dee. 16•6 a 167S. war a- murleron centenaresde mdeede perm.* twat sr r• g. Coo el cart de koe Melon. canteneres de perinea De 'skint courier. de druela. pero en Ma fldeo MM. Edward !toner 'oar,' 70 fa wow Met descubrio una vac.a Los ult.. loc. de reststeocia sisa and ireat programa de erraMethian de la vIntela. pop, fuer. unt.dos en el Cuerode Afrka Y - k (;> Larar‘ I Mild 1h6 Ia.. WORLD SUPPORT FOR THE CAMPAIGN The mass communications media-press, radio and television-lent powerful backing to the campaign. As a result, the public in developed and developing countries alike rallied wholeheartedly to the support of smallpox eradication wwitanws pawameaton M S retobilaw so coats ae - land. walamol.ep It de enhoware et Wale la meet de Mem pm. h.. do P.3.3•33 ••3 js• inn oota dew de 150A00 lad- Iwit. lb JAS. edema...a.. mum .t estbs,, In - ashes kr manche. tocurinue en la paws. de weannomder Pots-Ben l'U RS S Ewe. *ma 1 360, et dig. la midge de kr mortherbo. trre- Mel redeemer, Anermem 1971 et d'Asse en tainatiqua. con les Hama. deI3-AN ennowita ou'elle Ois ne eau ea el* iouroore 197S nvmd. &Wan 1976 - - ...to in Mapco, an • s . ' 'Disease has ode. we'd, a-noshes. ate le awl (Rama if kibmineties quo Oda Awes de west, raw era own de ce • a mablorf. wd Ia aroma. dee 11. it014 gado se waft encore cm orl:,57741.1,, At bad IA rice tEssta.Usa.). Bilthavea ( Max ou LecskerhEcr Tee. Lo Chan. rat nohow nu AL a se mos Jana wins toins• (her the tentunes. smallpox killed. braided labored.. coma or perettenentl.' scarred hundreds or millions pair ham when an apodemie began. people could do ,n n'innn.n.' little neat than watt for the lever. the sorniting w, ananantaaa. nnn 'nnn`nd the pasta. to sat.. Lnolt. physician %hard Jena. Wm/met, • frre,mWMme 'arcane 1.0..005 ago but there nes never a rare WHO Ready to Declare Eradication of Smallpox NAHIC2121. Kenya (AP) - R probably lolled Pharaoh Ramses V of Egypt 3,000 years ago . Africans and Lantana worshipped a. n 1971. a Somali rook named Ab Maw Mae. became the 14.4 person known lea catch 0 maw* a Whereto- hindered detection and matron of virus out- brealm. But WHO teams have completed intensive wrveys In the Horn or Africa regioa and the four .untneswill bet..ed next welt. AccorMng to publh health officials. the viede ry over smallpox marks the first time scene has eliminated a dowse. The campaign cost llama el dollars. soh WHO contribuong 5100 =Mon 'After Iwo yea.. without • smolt case. there is as dunce setallpus will return.' Dr. Lao/ Warn. WHO's Mseasehaerroi officer te (11.1.11 Africa. said m ore 111114fSKW imam-to-asaa Infection, with au stage in Un alto sin un solo caso de viruela en el mundo G119h012. 21 WPM. La Clegarshachm hi..al de la Salad rOAS) Marne eekbrate tin 've tie WU el primer alks sin ea•OX I. vlocelem el shad. El anion east de .heels se deo a onnocer el 211 Moe neer .1 ano pew . es et retede de Africa. 111 ent, nuts* del mama sett, IP coal today. hi man.. ettplancra. bin la OWS CR0155107 .. AVEC LES PRIORITES PURE, PROGRAMMES D'IMMUNISATION, IMPUTABLES A DES CARENCES NUTRIT: MEDICAMENTS ESSENTIELS AUX PAYS t QUART A L'ACCIDENT 5089150 NU PLUS GRAND RISQUE VARIOLIQUE EST DE VIRUS DES LABORATOIRES. POUR NESERONT PLUS DETENUS QUE DANS 1 ATLANTA (ETATS-UNISI, LONDRES ET E0/0C AFP 230145 Sam. olkahe de la OMS, la An M virus. represents. ma Maar. de ream. pan todo el mem. an maws 0.111 asMasts de serlares Refirienekise a la retieote spar.oa de la vim. ea Gran 405,4.. ape eas. meet. • ana per.. en 0441414 la tHiS dijo ant me. se prod., debido a comaistirosion por parte de as talionne. y este hoca- (4,4) VARIOLE recompense de 100 000 F, D. 1 t le Doctor's WI Eradication of Smallpox roce< my Waking SIM,. weal that day did 1 dream redo( Mem.d a alien to hosed wipe pea a disewe caw inhistury 16011111441. M 141141 Dr Hem me to Mrs. to lath runs owandmin Worowal 19 Se Intensetamal Develop. arether duets. though las ...gm. sere onwa as poembee about an dad not awe boa mat C Nhould play • lay nee al Organ.tton p ersdkaresmaDpoa On 0. ths Hen rat.v wprthed9si deed cab. erselscatedtme3 dee It ca Sanaa, th hurw•totanuse *lame) o sea beeten ow years ago marred in Englthd 11/2 atistana ewe armored I IrDen Mnmsearc owned huh the erne I Fcc the tho wars after in ar-lected C144111 .e.s. worker. ease wert rim sme,tes ga,ea AE, HOW MUCH DID IT COST to send a man to the Moon ? Between 1961, when President John Kennedy gave a directive to set a man on the Moon and bring him back "before this decade is over", and the successful landing in August 1969 of two men in the Sea of Tranquillity and their safe return to Earth, the US space agency NASA is estimated to have spent US $24,000 million to wipe out smallpox from the Earth? Between 1967, when WHO ordered its inten- sified Smallpox Eradication Programme into action, and 1980, when the Thirty-third World Health Assembly endorsed the final disappearance of this disease from the Earth, the total cost of eradication was US $300 million HOW MUCH WILL IT SAVE? The estimated saving every year to all coun- tries when smallpox vaccination is abolished worldwide is US $1,000 million HOW MANY VICTIMS WERE THERE? In the one year 1967, official health statistic returns showed there were 131,697 cases of smallpox. But the figures showed only a tiny fraction of the real suffering. It is estimated that in that year there were over 10 million cases of smallpox in the world HOW MANY PEOPLE DIED? It is estimated that, in 1967, the death toll was about two million people HOW MANY PEOPLE WORKED TO SAVE THE WORLD FROM SMALLPDX? • The total number of national staff, in over 40 coun- tries, who worked in the Smallpox Eradication Pro- gramme was 200,000 men and women The total number of international staff, from more than 70 countries, was about 700 men and women HOW MANY SHOTS OF VACCINE ? Estimated total number of doses of smallpox vaccine used in the global programme: Total produced by endemic countries: Total distributed by WHO: HOW MANY BIFURCATED NEEDLES? Between 1967 and 1976 WHO supplied over 40 mill- ion needles to the programme. The needle was inspired by the basic sewing machine needle, the loop being ground down to produce the pronged fork. The advent of the bifurcated needle brought major savings in the quantity of vaccine required. 2,400 million 2,000 million 400 million ( Photos Len Sirman ©, WHO, and WHO/Center Disease Control, Atlanta, USA) Towards the year 2000 by Dr Halfdan Mahler Director-General of the World Health Organization The end of smallpox—but for WHO it is only the end of the beginning. -It has been said that if we O had known beforehand "the heart-aches and the thousand natural shocks" that awaited us, we would never have undertaken the smallpox eradication programme. Yet no one drew back, neither the leaders of governments, nor the hundreds of thousands of national field workers, nor the small WHO army of international med- ical and technical officers that went forward like a bright spearhead in country after country against this vicious foe. For many of those people, the battle against smallpox may prove to be the most significant and uplifting event of their lives. The elements that contributed to final victory are discussed by the men and women, veterans of the campaign, who have written the articles for this special commemora- tive issue of World Health. Those contributors include scien- tists, public health experts, epidemiologists, managers. Each of them approaches the subject in a slightly different way : leadership, evolving strategy and tactics, effective deployment of scarce resources, active search, accurate case reporting, watertight containment of outbreaks, close sur- veillance, unstinting administrative backup and round-the- clock laboratory support. What is common to all is a sense of fulfilment, pride of participation in what can justly be called a noble and historic endeavour. Victory over smallpox has implications that go far beyond the individuals directly concerned, however. It reasserts our ability to change the world around us for the better, through mutual collaboration and mobilization of resources, allied to human energies and the will to succeed. It comes like a freshening wind for a vessel too long becalmed, creating hopeful new impetus as we set our course towards Health for All by the Year 2000. The present realities of the Third World are simply unac- ceptable. There is little joy in life nor any kind of justice for a child condemned to disease or early death because of the accident of birth in a developing country. Nor is there any rationale that can defend a system that continues to with- hold the gift of health and care from nine-tenths of a nation's population. Smallpox eradication is a sign, a token of what can be achieved in breaking out of the cycle of ill-health, disease and poverty. It comes as a glimpse into the future, an intimation of a viable new order of things, in which world health, meaning health for the world, will have central significance in an upward spiral of economic and social progress. ■ (Photo WHO/P. Almasy) 19 SMALLPDX IS DEAD! October 1979: Jubilant young Kenyans perform a dance of triumph in Nairobi at the ceremony marking the end of smallpox in all Africa. (Photo WHO) YEAR OF CERTIFICATION BY INTERNATIONAL OR GLOBAL COMMISSION 1E1973 III 1974 1.1976 11977 1978 MI 1979 Official statement of freedom from smallpox for two or more years received 1978 — 1979 How the seal was set on eradication Countries reporting smallpox cases in 1967 Ramses V Earliest known victim? by Donald R. Hopkins Finally, there he was: Live Horus, Migaty Bull, Repulser of Millions, Golden Horns, Sovereign, Protector of Egypt, King of Upper and Lower Egypt, Lord of the Two Lands, Son of Re, Ramses V, Pharaoh. After a long flight from Atlanta, Georgia, USA, and a restless night, I had reached the culmination of a three-year-long quest. Permission had finally been granted for me to collect and examine specimens from the mummy of the Pharaoh Ramses V for scientific evidence that would prove he had died of smallpox. Standing in the Mummy Room of the Cairo Museum, I was almost too excited to take photographs. Soon after it was discovered in 1898, the mummy of Ramses V, who died in 1157 isc, was recognized as bear- ing evidence of a rash which resembled smallpox. According to Dr C. W. Dixon, this Pharaoh died of "an acute illness at the age of forty". But it was the rash on Ramses' embalmed and shrouded corpse thaz made it probable that he had died of smallpox. Previous electron-microscopic studies of non-royal Egyptian mummies by Dr Peter K. Lewin, of tae Hospi- tal for Sick Children in Toronto, Canada, and others had revealed sub-cellular structures in some rehycrated tis- sues with extraordinary clarity. Now there was a new pro- ject, to see if there were poxviruses that cou:d still be recognized in the skin of the ancient Pharaoh. Besides Dr Lewin and myself, it was undertaken by Dr Erskine Palmer and Dr James Nakano of the Center for Disease Control's Special Viral Diagnostic Branch and Viral Ex- anthems Branch, Professor Mourad A. Sherif of Cairo's Ain Shams Faculty of Medicine, and others. By special permission of President Anwar el-Sadat, (Photo WHO) Professor Snerif and I were allowed to examine Ramses V's mummy en 8 November 1979. Since this is one of the best pres erved royal mummies in the Cairo_ Museum, museum authorities were understandably reluc- tant tc permit us to actually cut a riece of skin containing one or more of the apparent blisters or pustules. Instead, we collected tiny pieces of skin on the shroud. On examining the front of the mummy from the waist up, we saw a rash of yellowish blisters or pustules, each of between one tc five mm :n diameter. The rash is most strikir g over the lower face, neck and shoulders, and is also visible on the arms, but there is no rash on the chest and upper part of the abdomen Earlier photographs, published by G. Elliot Smith, show that the rash is also prominent on the lover part of tae abdomen and scro- tum. We could not see the palms and soles. Despite the limited areas accessible for inspection, the rash is quite striking and is remarkably similar to smallpox. Electron-mizrosconic studies of the pieces of skin we obtained did not reveal evidence of poxvirus. Intact layers of skin and cl_s were clearly visible in some sec- tions. Thus, the specimens examined appear to be of nor- mal intervening skin rather than of directly affected skin. Ordinarily, the virus is concentrated in the pustules, blisters or scabs of smallpox victims. Other immunologic and v_rologic studies also did not yield the hoped-for clear evidence of variola virus. But our failure to see poxvirus in these specimens obviously does not mean that Ramses V did not die of smallpox. And after seeing at first hand the rash on this remarkable mummy I am almos -: as convinced that he did indeed have smallpox as if [ had actually seen a 3000-year-old poxvirus. • 22 50, v..* FRIBUllUETOGOLAIS REPUBIJOUITOGOIAISE REM IyI F F ■ )1,1)1 \I-I REPUBLIQUE TUNISIENNE ' 4,-111., I- DECLINE AND FALL OF THE EMPIRE 1519 AD: The ships of Hernan Cortes landed in Mexico, carrying something more deadly than 500 Conquistadores and 23 cannons: the smallpox virus. More than three mil- lion people died when a series of epidemics erupted, finally toppling the centuries-old Aztec Empire. 1694: Queen Mary II of England fell a victim to smallpox and died at the age of 32. 1721: Deliberate inoculation (variolation) with smallpox virus had been practised in Africa, China and India for centuries, before being introduced to Europe and North America by Lady Mary Wortley Montagu. The wife of the British ambassador in Turkey, she had observed variolation in Constantinople. The Reverend Cotton Mather learned of the practice from his African slaves and introduced it in Boston. 1774: King Louis XV of France died of smallpox, aged 64. Benjamin Jesty, an English farmer, inoculated his wife and two sons with cowpox to protect them against a smallpox outbreak. 1796: An English country doctor, Edward Jenner, took material from a cowpox sore on the hand of a milkmaid and inoculated it into the arm of an eight-year-old boy on 14 May 1796. Two months later he tried to inoculate the boy with smallpox—and the infection did not take. He an- nounced his findings in 1798; by 1801 more than 100,000 persons had been vaccinated in England and Jenner's pamphlet on the subject had been translated into five languages. 1801 : Jenner predicted that "the annihilation of the small- pox the most dreadful scourge of the human species must be the final result of this practice". 1803: Efforts were made to promote vaccination through- out the world. One of the most spectacular efforts was made by Charles IV of Spain who in 1803 dispatched vac- cine to his dominions around the globe by means of chil- dren vaccinated arm-to-arm in succession during the voyages. 1807: Five Red Indian Chiefs wrote a letter of thanks to Dr Jenner. It said : "Brother: Our Father has delivered to us the book you sent to instruct us how to use the discovery which the Great Spirit made to you, whereby the smallpox, that fatal enemy of our tribe, may be driven from the earth. ... We send with this a belt and string of wampum (beads used for money) in token of our acceptance of your pre- cious gift." 1870: During the Franco- Prussian war in Europe a small- pox epidemic broke out. The French army lost 23,400 sol- diers to the disease. But the German army had been vacci- nated, and only 278 died. 1948: At its first meeting in July 1948, the World Health Assembly (WHA) paid special attention to the problem of smallpox in its deliberations. 1958: The Eleventh WHA, following a motion by the Soviet delegation, decided to step up efforts to eradicate smallpox. The Soviet resolution pointed out that the funds devoted to vaccination against smallpox throughout the world exceeded those necessary for the eradication of the disease. 1967: WHO launched an intensified smallpox eradication programme. A unit set up at WHO's Geneva headquarters began work with WHO Regional Office teams and with national smallpox programmes. 1971: In South America between 1950 and 1967, endemic smallpox was eradicated in all countries except Brazil. In Brazil a huge programme of mass vaccination and case searching, which included the vast Amazon basin, culmi- nated in victory over smallpox in 1971. 1975: In Asia, the campaign strategy had evolved from the concept of mass vaccination to an even more success- ful approach based on improved case investigation and searches and containment of outbreaks. The last case on the vast Indian subcontinent was Rahima Banu, a three-year-old girl in Bangladesh. 1977: From Asia the focus of the campaign shifted to the Horn of Africa, the last foothold of the disease in Africa and in the world. The last endemic case in Africa, and worldwide, was located in Somalia on 26 October 1977. The patient, 23-year-old hospital cook Ali Maow Maalin, made a complete recovery. 1979: In December, the Global Commission for Certifica- tion of Smallpox Eradication—an independent body which consisted of scientists from 19 nations—confirmed that smallpox eradication had been achieved throughout the world. 1980 The Thirty-third World Health Assembly meeting in Geneva officially declares that smallpox has been com- pletely eradicated from the planet. ■

Can we stop smallpox vaccination? The cessation of vaccination will not only save thousands of patients who would otherwise have suffered from complications but will also save the world community some $1,000 million a year by lsao Arita As early as 1801, Edward Jenner, the discoverer of smallpox vaccination, wrote O that "the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice". He was probably the first person ever to predict smallpox eradication, yet one wonders whether even he considered that the practice of smallpox vaccination would come to an end if his prediction came true. The first official indication that wiping out the disease would also spell the end of smallpox vaccination appeared in 1958, in a resolution of the Eleventh World Health Assembly. This proposed the start of the global eradication pro- gramme and suggested that "... with the eradication of smallpox, vaccination and all expenditures involved in its applica- tion will be redundant". The Global Commission for the Certi- fication of Smallpox Eradication, an in- dependent group convened by WHO to consider all issues related to the pro- gramme, has delivered its formal judge- ment that smallpox has now been eradi- cated and that there is no evidence that it will return as an endemic disease. It recommended that "smallpox vaccina- tion should be discontinued in every country, except for investigators at spe- cial risk". And it added that "interna- tional smallpox vaccination certificates should no longer be required of any traveller". These recommendations were made because the risks of complications from vaccination, however small, certainly exceed the risk of smallpox infection, which is negligible. The only instance in which smallpox vaccination is justified is for personnel who are directly engaged in work that involves handling variola virus or related viruses. Understandably, VACCINE INOCULATION. By EDWARD JENNER, M.D. F.R.S. PlIDTED BY D. N. COCCI. bE6wtca saucEr, ,ottu, !W. [ to ] benefits throughout Europe and other parts of the Globe are in calculable: and it now becomes too rnanifeft to admit of coon,. verfy, that the annihilation of the Small Pox, the mon dreadful feourge of the human (pecks, muff be the final refult of this praCtice. Facing page: A little girl being vac- cinated in Colombia. Now the need is no longer there. Inset: Dr Edward Jenner, the discoverer of vaccination, who actually forecast the eradication smallpox. ( Photos WHO/P. Almasy and WHO) however, there may be some hesitation about abandoning a practice which has been shown over a long period of time to bring great benefits. So let us look at a few of the major issues bearing on the decision to terminate smallpox vaccination. Has smallpox really been eradicated? Minutely detailed documentation of the eradication programme and conti- nued investigation of smallpox suspects has been carried out in 79 countries, in- cluding those where smallpox had recently been endemic, where there had been a risk of importations leading to the possible establishment of endemic foci, or where information was inadequate to permit confirmation of freedom from smallpox. All these investigations failed to detect any evidence of continuing smallpox transmission, since the world's last endemic case of smallpox occurred in Somalia in October 1977. In 1978 and 1979, no fewer than 9,170 specimens were collected for labo- ratory confirmation by WHO Collaborat- ing Centres from suspected cases in the Horn of Africa and elsewhere through- out the world; not one of them contained the smallpox virus. Furthermore, all the remaining 121 countries and areas sub- mitted to WHO a declaration of freedom from smallpox. These were the countries which had not had endemic smallpox for at least the last ten years and which had effective surveillance systems. This was the evidence that convinced the Global Commission that the WHO programme had indeed reached its goal. Could virus stocks cause epidemics? Variola virus stocks in laboratories can be considered to be a potential danger for the introduction of a new 27 Can we stop smallpox vaccination? Left : This child reacted badly to vaccination and suffered severely from eczema. The Global Commission has now recommended discon- tinuing vaccination because the risks of complications, however small, certainly exceed the risk of smallpox infection, which is negligible. ( Photo Royal College of General Practi- tioners, UK) Right : The humble hen's egg had a part to play in the campaign. Vaccines were quality-tested by being inoculated into the outer membrane of embryonated eggs; if the vaccine was effec- tive, the membrane would develop character- istic pocks two days later. ( Photo WHO(J. Molfr) infection of smallpox. The occurrence of smallpox in Birmingham, UK, in 1978 demonstrated this risk. Scientists have been aware of this danger and in recent years, under WHO's coordination, efforts have been made to reduce the number of laboratories retaining variola virus. In 1976, there were 76 laboratories retain- ing variola virus, but the number has now been reduced to six—one each in China, Netherlands, South Africa, USSR, United Kingdom and United States. All of these laboratories have been inspected by WHO teams of biosafe- ty experts, virologists and epidemiolo- gists. Adequate containment measures have been established by these laborato- ries and by the national health authori- ties concerned, and the WHO inspections will continue periodically. In two years' time, when the current priority research projects have been completed, a review will be made to evaluate whether the retention of variola virus is still scientifi- cally justified. Meanwhile, a further reduction in the number of such laborat- ories is anticipated. Is there an animal reservoir? Since the intensified programme began in 1967, there has been an active research programme looking into the question of whether an animal reservoir of variola virus exists. All epidemiological investi- gations of smallpox outbreaks in tropical areas of Africa, Asia and South America turned up no evidence that such out- breaks originated from a source other than man. In the course of these investigations, a disease called human monkeypox was first detected in West and Central Africa in 1970. Up to February 1980, 48 cases had been discovered. This disease resem- bles smallpox clinically, but infected per- sons do not easily transmit the disease to others. Only four patients seem to have caught the disease from primary cases, and there has been no evidence of spread to a third case. The causative agent is monkeypox virus, which is related to but distinct from variola virus. It appears to be maintained by some monkeys and possibly other animals; it very infre- quently causes an infection in humans. The Global Commission indicated that monkeypox does not constitute a threat to the permanence of smallpox eradica- tion. As a further precaution, however, close surveillance of human cases will continue as part of a collaborative study between WHO and countries in Africa to investigate further the natural history of this disease. Do scabs pose a threat? It has been shown that variola virus in the scabs of smallpox cases become non-infectious quickly in a tropical cli- mate when they fall off the skin and remain in the patient's home or else- where. A similar query arose about the specimens maintained by variolators- people who inoculated material from the skin lesions of smallpox patients into oth- er persons in order to immunize them; this ancient practice was still being carried out recently in some countries of Africa and Asia. Forty-five specimens of scabs were collected from variolators 28 in Afghanistan, Ethiopia and Pakistan. Only on four occasions was variola virus isolated from these specimens. There was no positive result from specimens which were collected more than nine months before testing. These findings suggest that within a year of collection, variola- tion material probably becomes inactive. In those countries where variolation was practised, there have been no smallpox cases detected for more than three years despite continued vigorous surveillance. Can animal poxviruses mutate into smallpox? Past studies on orthopoxviruses, the group of viruses to which variola virus belongs, have indicated that there has been no evidence that an orthopoxvirus has been or can be transformed into variola virus. Current genetic studies on poxviruses support this observation, and show that, because of the substantial dif- ference between the genetic structure of variola virus and those of other individ- ual poxviruses, mutation of other known poxviruses into variola virus appears to be unlikely. All these considerations indicate that the risk of smallpox being still present or re-emerging in the world is most unlikely. What about the risk of complications if vaccine is given? Very severe complica- tions that may occur following smallpox vaccination include encephalitis (a fre- quently lethal disease involving the brain), eczema and necrosis of skin tissue at the vaccination site. The frequency of complications in the past varied accord- ing to the type of vaccine virus used, the age of persons receiving the vaccination and the state of health of each individual. However, a very conservative estimate is that, among one million persons vacci- nated for the first time, one or two per- sons will die, and 10 to 20 persons will suffer severe illness. By the middle of April 1980, 64 coun- tries had already stopped their vaccina- tion programmes, and it is anticipated that all the remaining countries will fol- low suit. Fourteen countries still required vaccination certificates from interna- tional travellers. It is hoped that, by the time this issue of World Health is pub- lished, many more countries will have stopped vaccination and those requiring certificates may have fallen to very few. The universal termination of smallpox vaccination will not only save thousands of patients who might otherwise have suffered from complications but will also result in enormous savings in the health budgets of the world community, rough- ly estimated at around US$1,000 million a year. Finally, it is reassuring to note that, despite the overwhelming evidence that the world has been freed of smallpox, measures are being taken by countries and by WHO to assure the permanent status of smallpox eradication. The "insurance policy" includes continuing surveillance for suspected cases of smallpox, promotion of research on orthopoxviruses in laboratories and in the field, and the maintenance of a WHO vaccine reserve sufficient to vaccinate 200 million persons in case of an unexpected emergency. ■ 29 The closing stages As smallpox diminished, the need for laboratory diagnosis became more acute. While the disease was widespread, it could easily be diagnosed from typical clinical data, but rare outbreaks required specific attention that could only be provided in the laboratory by Svetlana Marennikova In 1966, the Smallpox Pro- phylaxis Laboratory of the Moscow Research Institute for Viral Preparations be- came the first of WHO's International and Regional Centres, later to be known as wHo Collaborating Centres. This lab- oratory was chosen not only for the high qualifications of its staff but also because it was one of the laboratories which had been working on the smallpox eradication programme for many years. One of the first steps undertaken by wHo after the programme was initiated in 1958 was to draw up the "minimal in- ternational requirements" for smallpox vaccine. This involved making detailed tests of the dry vaccines produced in various countries of the world. For these trials, wHo chose a number of laborato- ries including our own, which was then part of the Mechnikov Research Insti- tute of Vaccine and Serums in Moscow. The trials resulted in a reference prepara- tion of smallpox vaccine which later proved of great importance for vaccine testing and for ensuring that the programme received only high quality vaccines. Similar trials were held to select a reference preparation for smallpox antibodies. Further studies showed that a number of the important properties of smallpox vaccine (such as neuropathogenicity and reactogenicity when humans are inocu- lated) do not depend on the techniques used to produce the preparation but on the strain itself. The work done by the Moscow Centre made it possible for WHO to recommend one of the three Soviet poster illustrating the role of vaccines in eradicating smallpox. Facing page: Technicians at work in the Moscow Smallpox Prophylaxis Laboratory a scientific unit which has been closely associated with the small- pox eradication programme for mares years. (Photo WHOINovosti) strains with low or moderate reactoge- nicity and the best possible combination of other properties, instead of permitting a multitude of poorly studied local strains. The key role played by laboratory ser- vices was acknowledged from the start of the programme, but its significance grew as time went on. When the incidence of smallpox began to diminish, the need for laboratory diagnosis became more acute. This is easy to explain. So long as the dis- ease was widespread, it was not hard, as a rule, to diagnose it from the typical clinical and epidemiological data. On the other hand, rare outbreaks or single cases required specific attention that could only be provided in the laboratory. Laboratory diagnostic investigations reached their high point once the certifi- cation of smallpox eradication had begun; from then on, virtually all sus- pected smallpox cases were investigated. In 1971, for instance, the number of spe- cimens we investigated totalled 203, but in 1979 there were 2,949. The principle underlying the diagnos- tic work was not merely to confirm a smallpox diagnosis or otherwise, but also to clarify the origin of the agent that had caused the infection. This approach required the use of at least two techni- ques : electron-microscopy of the spe- cimens, which made it possible to estab- lish whether the agent was of the pox or herpes group; and inoculation into the 30

chorio-allantoic membrane of chick em- bryos. The latter technique had some particular advantages when viruses of the pox group were isolated, since its very high sensitivity offered us an oppor- tunity to differentiate between closely related members of this group which can cause infection in humans. The unprecedented upsurge in diag- nostic investigations that took place during the certification period, when we sometimes received 318 to 420 specimens a week, required from every person in- volved not only intense exertion and physical effort but also real self-sacrifice. Just the electron-microscope scanning of material prepared from one patient takes up to 20 minutes, to say nothing of the routine tasks of treating the material, in- oculating the chick embryos and estimat- ing the inoculation results. We fulfilled this work thanks to a high sense of re- sponsibility and an awareness of the work's importance. Above: One of several cases found in Zaire in 1970 which the Moscow laboratory was able to diagnose as monkeypox in humans. ( Photo WHO/ H. Steniowski ) Facing page: Vaccine production in the USSR. The centrifuge separates out all foreign matter and ensures that the vaccine is pure. (Photo WHO/Novosti) Diagnostic work calls for a great deal of caution, since all sorts of surprises can occur. A vivid illustration of this was the detection of human monkeypox. In Au- gust 1970, in a village of the Equatorial Province of Zaire where smallpox trans- mission had been interrupted for more than a year, the programme staff unex- pectedly discovered a case that, by all its symptoms, was indistinguishable from smallpox. This case caused considerable alarm, since no visible source of infection had been found. Results obtained in the laboratory 48 hours after the inoculation of embryos promised nothing unusual: lesions on the membrane looked like those of smallpox virus. After 72 hours, however, the picture had changed : hard- ly visible haemorrhages had appeared in the centre of the pocks. Incredible diagnosis These changes could easily have been overlooked. Only our previous ex- perience combined with the caution men- tioned above, made it possible to estab- lish the diagnosis—a seemingly incre- dible one : human monkeypox, of which the epidemiology was fully investigated by WHO and national staff at that time. It was incredible because this virus had been generally considered harmless to man. Further investigations with a long series of tests, intended to distinguish monkey- pox virus from other poxviruses, subse- quently confirmed the diagnosis. This discovery had three important consequences: the possibility of a spon- taneous return of the infection to territo- ries from which it had been eliminated was excluded; a previously unknown human infection had been found ; and a number of new scientific and practical questions appeared in connection with this new human infection, and were reflected in appropriate recommenda- tions and subsequent WHO research projects. The post-eradication period we are now entering, which will be accompanied by the ending of smallpox vaccination and a gradual loss of smallpox immunity in the population, will require vigilance with respect to other poxviruses of potential danger to man. This applies, above all, to the cowpox virus. Our studies have already enabled us to consi- derably expand the available knowledge about the ecology of this virus. One of the most important factors is its detec- tion in rodents, which we now believe to be a natural reservoir of the cowpox virus. We have also established that a wide range of animals are susceptible to this virus, and in some of them, such as the cat family, it may cause fulminating pulmonary infection, with lethal effect. Our investigations into the ecology of the cowpox virus are of importance not only for this infection. They will un- doubtedly be useful for understanding many unclear questions relating both to the monkeypox virus and to other poxviruses. ■ 32 itv

Now can we be sure ? It is difficult to prove that a disease no longer exists on earth. But a mass of carefully compiled evidence has convinced the Global Commission that Smallpox Target Zero has in truth been attained by Frank Fenner The claim that smallpox has been totally eradicated from O the earth is a broad one. "How do you know ?" and "How can we be sure?" are questions that many people may well ask, particularly those health administrators who are re- sponsible for vaccination programmes. From the outset of the Intensified Smallpox Eradication Programme, WHO has been aware of the importance of these questions, firstly for the countries where smallpox was endemic as they moved towards eradication, and then for the world as a whole as country after country signalled the all-clear. The mechanisms devised to give the answers are novel ones, simply because mankind has never before faced such questions. Given the essential tools, namely a good vaccine and an adequate surveil- lance network, two concepts were of out- standing importance for the achievement of global smallpox eradication. Firstly, international cooperation and, secondly, assessment or quality control. Many in- dividual countries could and did wipe out endemic smallpox without interna- tional help, but global eradication could not even have been contemplated without the involvement of WHO as the instrument of international cooperation in health matters. The role of assessment is less obvious, but it was just as essential. It had to be Those who survived smallpox carried scars for the rest of their lives. Surveys of such pockmarks helped to determine when the disease had last occurred in a certain area. (Photo WHO/ L. Dale) applied to all phases of the programme, from the quality control of vaccines, so that the vaccinator could have potent material for his work, to the overseeing of work in the field, so that full coverage of the population by vaccination could be assured in the early stages of the cam- paigns, and the adequacy of surveillance could be guaranteed in the later stages. (Photo WHO/P. Almasy) As country after country achieved the goal of Smallpox Zero, the question arose as to how the world community itself could be assured of the reality of these achievements. Later, with ap- proaching global eradication, the ques- tion took on a new urgency and involved other considerations; for instance, how to maintain variola virus stocks in labo- ratories, and what measures to take after global eradication. To answer these new questions the same two concepts were evoked, international cooperation and assessment. A system for certifying smallpox eradication in countries or in groups of countries was introduced in 1973 and became ever more elaborate as the programmes proceeded, reaching a peak of intensity with the two most difficult strongholds of the disease—the Indian subcontinent and the Horn of Africa. This system depended on a series of International Commissions for the Certi- fication of Smallpox Eradication, 21 of which examined the situation successive- ly in 61 countries, beginning in South America in 1973 and ending with Soma- lia in October 1979. Although the Inter- national Commissions were convened by WHO, it was realized from the outset that they must be, and must be seen to be, independent of WHO yet of high standing in international health matters. WHO therefore sought for service on the International Commissions a group of people from several different countries, each a respected authority in public health, epidemiology or virology, and each with at least some experience in smallpox control. The response of scientists and admi- nistrators was enthusiastic; rarely was a request from WHO for service on an International Commission refused. The next important matter to be determined was when the commissions should assess the situation in relation to the last reported case in a country or region, and what preparations should be made. As the situation developed, two different kinds of response seemed necessary. In countries where smallpox had been 35 How can we be sure? recently endemic, it was decided that a minimum of two years should elapse be- tween the last known case of smallpox and the visit of the Commission. During this time intensive active surveillance for smallpox should be carried out, and special reports on the situation and on post-eradication surveillance should be prepared for the Commission. In other countries, such as those adjoining highly endemic regions, smallpox had been eliminated by national programmes with little assistance from WHO; in many of these certification was delayed for several years after the last known case, but wHo-assisted surveys were carried out before the Commis- sion's visit. Intensive preparations Especially in countries where smallpox had long been a scourge, the visit of the International Commission was an im- portant event and preparations were as intensive as the activities of the last few years of the eradication programme itself. Detailed "Country Reports" were drawn up, based on the history of the eradication campaign but supplemented by the results of special searches and surveys carried out during the post- eradication period. Active surveillance for fever-and-rash cases continued and intense publicity campaigns made sure that everybody knew about the reward offered for the notification of smallpox cases. Country-wide "special searches" were sometimes carried out, and as the pro- gramme evolved two special kinds of survey developed. One was the facial pockmark survey, especially suitable in countries that had experienced severe smallpox; the other was the chickenpox survey, which proved invaluable in coun- tries where variola minor—the less serious form of smallpox—had occurred. Severe smallpox can leave two serious legacies in those who survive : blindness and pockmarks. About 70 per cent of people who have recovered from severe smallpox have more than five facial pockmarks that they carry for the rest of their lives. By examining large , numbers of persons in various age groups in a population, particularly school and pre- school children, and recording histories of the date of the smallpox attack in each pockmarked person, it proved possible to get a retrospective estimate both of the amount of smallpox that had occurred and, most importantly, when it had last occurred. The facial pockmark survey Above: Somalia—Rewards were offered to anyone notifying a smallpox case. Left: Bangladesh—Quality control of local production of vaccines. Right: USSR—Millions of vaccine doses contributed to the success of the worldwide eradication campaign. (Photos WHO/E. Shafa, WHO/ P. Claquin and WHOINovosti). was particularly valuable in the Indian subcontinent, some parts of Africa and China. Variola minor, which has a mortality rate of one per cent or less compared to up to 40 per cent for variola major, leaves much less facial scarring—only about seven per cent of known cases in Somalia had facial pockmarks a year later. However, this form of smallpox can be mistaken for chickenpox, so that surveys of this disease provided a useful indicator of the presence or absence of =r=s ,•"-r-3 -1=±":1 mild smallpox. In such chickenpox surveys, specimens for laboratory exami- nation were sought from a selection of cases of chickenpox; one from each sep- arate chickenpox outbreak, from severe or fatal cases, and from chickenpox in unvaccinated individuals, as well as from all suspected cases of smallpox. The specimens were sent to Geneva and examined at the WHO Collaborating Centres in Moscow or in Atlanta, USA. More than 5,200 specimens were examined in the periods leading up to certification in Ethiopia and Somalia, without variola virus being detected. When it was clear that these prepara- tions had been adequate, an Interna- tional Commission was convened to visit the selected country or region. On ar- rival, the members conferred with the national health authorities and discussed all the evidence that had been assembled to show that there had been no case of smallpox for at least two years, and then 37 made field visits. These were designed to assess the efficiency of the surveillance system for smallpox. The question that the International Commission sought to answer was : If there had been a case in the last two years, would it have been detected? The field visits concentrated on difficult or "problem" areas, the location of the last reported case, border districts, and inaccessible areas with poorly devel- oped health services. Then the members met again to go over the country reports once more, with the added information gleaned from the field visits, and the Commission produced its report. In every case the preparations had been so thorough, or such a long period had elapsed since the last known case, that the International Commission was able to certify the country or region free of smallpox. Global certification By 1977, when worldwide eradication appeared to be imminent, it was clear that some independent authoritative group was needed to map out the strate- gies for certifying global eradication of smallpox, to assess the results of Interna- tional Commissions and other enquiries, to consider such implications of global eradication as the cessation of smallpox vaccinations among the general public and the significance of variola virus stocks in laboratories, and to map out a post-eradication "insurance policy". The Director-General of WHO called a Consultation on worldwide certification of smallpox eradication in October 1977, consisting of 17 experts from 16 coun- tries, most of them being epidemiologists and virologists experienced in the eradi- cation programme operations and cer- tification procedures. The Consultation made detailed recommendations for a programme for the following year, and recommended the setting up of an "In- ternational Commission for the Global Certification of Smallpox Eradication" to provide consultative assistance and to verify this unique event. The Global Commission, as it was subsequently called, was formed early in 1978 and met in December of that year and again in December 1979. That first meeting of the Global Com- mission, in December 1978, considered the situation relating to smallpox in every inhabited country and area in the world, and drew up a programme of work which was designed to result in cer- tification of freedom from smallpox from every country by December 1979. It also addressed itself to several problems of special importance in a world free of smallpox : vaccination policy, stocks of variola virus in laboratories, and the pos- sibility that there might be an animal reservoir of variola virus. The year 1979 was one of intense and carefully orchestrated activity, which succeeded in laying before the December 1979 meeting of the Global Commission reports on the smallpox situation in every country in the world, an expert opinion on the justification and extent of the retention of stocks of variola virus in laboratories, and ideas for a post-small- pox-eradication "insurance policy". In addition to considering all this informa- Left: October•1979: Members of the Global Commission travelled iriddy in the Horn of Africa to make certain that nobody knew of one single case of the disease. Right: December 1979 : Dr P. N . Sh•eshta, a Nepalese member of the Global Commission, formally signs the document declaring "that small- pox has been eradicated in every country in the world - . ( Photos WHO/J. Breman and WHO/L. Blanco) tion, the 1979 meeting completed a final report on its activities. And it concluded its intensive four days of work by wit- nessing the signature, by all members, of a document bearing the words, in six lan- guages: "We, the members of the Global Commission on Certification of Small- pox Eradication, certify that smallpox has been eradicated in every country in the world." The report, which is about 120 pages long, summarizes the campaigns that led to the eradication of smallpox and the certification of eradication, by country, by groups of countries, and throughout the world as a whole. It also outlines in some detail an insurance policy for the post-eradication era. The report and its recommendations were considered by the Executive Board of WHO in January 1980, and figure on the agenda of the World Health Assembly this month. It is difficult—perhaps impossible—to "prove a negative", that is, to prove that smallpox no longer exists on earth. But evidence provided by the careful work of national health authorities in every coun- try, of WHO expert consultants and advis- ers, and of the staff of the Smallpox Eradication unit at WHO headquarters in Geneva, has convinced all members of the Global Commission that transmis- sion of this disease from person to per- son has been interrupted everywhere in the world. The last case of endemic smallpox occurred in Somalia in October 1977. Smallpox Target Zero has now indeed been reached, and the Global Commission has formally certified that the world is at last free of this appalling disease. ■ In the next issue The June issue of World Health, pub- lished of the eve of the World Confer- ence of the UN Decade for Women, in Copenhagen, will look at the role of women in the closely interrelated fields of development and health. Contributors from many parts of the world emphasise some of the most striking aspects of women's situation in different cultures and settings. Authors of the month Dr D.A. H usDERsoN. formerly vato's Chief of Smallpox Eradication, is now Dean of the School of Hygiene and Public Health at the Johns Hopkins University, Baltimore, Maryland, USA. Mr J. MAGEE is the Information Officer of the Smallpox Eradication unit at WHO headquarters, Geneva. Dr Marcella DAVIES is the WHO Pro- gramme Co-ordinator for Sierra Leone. Dr V. T. H. GUNARATNE is the Regional Director for WHO'S South-East Asia Region. Mr J. Tuu is the Public Information Officer for WHO'S South-East Asia Re- gion, based in New Delhi. Mr A.M. CHACKO is a freelance jour- nalist based in New Delhi. Dr H. MAHLER is the Director-General of the World Health Organization. Dr D.R. HOPKINS is the Assistant Director for International Health at the Center for Disease Control; Atlanta, Georgia, USA. Dr I. ARITA is the Chief of the Smallpox Eradication Programme at WHO head- quarters in Geneva. Professor S. MARENNIKOVA is Chief of the Smallpox Prophylaxis Laboratory, Moscow Research Institute for Viral Preparations. Professor F. FENNER, until recently Director of the Centre for Resource and Environmental Studies of the Australian National University, is the Chairman of the Global Commission for the Certifi- cation of Smallpox Eradication. WORLD HEALTH 1980 Subscription Rates US$ Sw. fr. One year 12.50 25.— Two years 22.50 45.— Three years 30.— 60.— ORDER FORM Please enter my subscription to "Wolld Health" as follows: One year ❑ Two years ❑ Three years ❑ I enclose cheque / international postal order in the amount of • Name Street • City • Country World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and subscription agencies. For payment in natio- nal currencies, please contact your usual bookseller. Of the smallpox god Sopona, worshipped by the Yorubas of Nigeria, it was said that "being a very stubborn deity, he would not heed any appeasement." (Photo WHO)