Smallpox target zero [full issue]

WORLD HEALTH The magazine of the World Health Organization October 1972 UK: 20p USA: 0.50 smallpox target zero

TARGET ZERO This month, smallpox workers throughout the world begin the final phase of the WHO global campaign against one of mankind's most feared and ancient enemies. The target : zero cases—a world free from smallpox. While at one time smallpox was a universal scourge, exacting a fearful toll by death, blindness and disfigurement, it has gradually been beaten back. Today, the disease continues to spread in only seven countries—last year, less than 200,000 cases are estimated to have occurred. However, so long as smallpox persists anywhere in the world, no country can relax its vigilance— vaccination programmes must continue and in many situations vaccination certificates must be required. With jet travel, an infection today in Karachi or Delhi or Addis Ababa can mean an outbreak next week in Santiago. Control of smallpox is but a temporary and uncertain measure—its eradication, the only effective solution. This issue of World Health describes the devastation of smallpox, known mainly to past generations, and the efforts now being made in WHO's inten- sified global eradication campaign, at present in its sixth year. As articles from Ethiopia and Nepal attest, the success of the programme relies ulti- mately on the persistence and dedication of a comparatively small band of workers who, in these and other endemic countries, have to contend not only with smallpox but with mountains and uncharted desert wastes, with storms and floods, with abject poverty, with superstition and unreasoning hostility. And the problem changes when the disease suddenly escapes from its recog- nized habitat to countries from which it has long been absent—it happened this year in Yugoslavia, which had had no cases for more than four decades. The global eradication programme this year, for the first time, extends into every state and province of every country where the disease exists. The final phase of the campaign is beginning. The eradication of smallpox would be a milestone in the history of medicine, and would demonstrate what true international co-operation can achieve. ■ smallpox target zero Cover design by Peter Davies. Contents Target zero 3 A grim saga, by L. Thapalyal 4 The global strategy, by Dr D. A. Henderson 8 The anger of a goddess, by N. Willard 18 Great expectations, by Dr M. Brooke 22 Every country pays 26 Conquest of an epidemic, by D. Egli 28 Training aids 32 Around the world 34 World Health appears in Arabic, English, French, German, Hindi, Japanese, Portu- guese, Russian, and Spanish. The face of smallpox. (Photo WHO/L. Matlovsky) DOWN THE AGES A GRIM mac by L. Thapalyal From the earliest chronicles of ancient civilization, smallpox has written across the pages of recorded time an unparalleled history of death, blindness and disfigure- ment throughout the world. Its existence was described in the earliest Chinese texts and the sacred Sanskrit writings of India; physical evidence of its presence in Egypt more than 3,000 years ago is preserved in the mummy of the Pharaoh Ramses V, who appears to have died of smallpox about 1160 B.C. Mys- teriously absent from the world of the ancient Greeks and Romans, it was again chronicled in Arabia during the Elephant War of 569 A.D., when a smallpox epi- demic among Abyssinian troops besieging Mecca saved the city and its handful of defenders. This dramatic event and the all too visible symptoms of smallpox were transformed by popular imagination into a myth: "Large birds appeared, which dropped stones the size of a pea on to the people, and they were killed." In succeeding years, the dreaded scourge spread over the continents of Europe and then Africa, affecting rich and poor alike and, in the process, changing the course of history. Such was the dread of the disease that many cultures in Africa and Asia created deities to which, even today, sacrifices and supplication are made. Lord Macaulay in his History of England wrote: "This disease was one of the most terrible of all ministers of death. The havoc of the plague had been far more rapid, but the plague visited our shores only once or twice within living memory; but the small- pox was always present, filling our church- yards with corpses." Epidemics regularly swept the cities and towns of Europe, causing the death of 20 to 40 per cent of those afflicted. In the early 18th century, it is estimated, two out of every ten children born eventually died of smallpox. In Europe, at the same time, smallpox was said to be the leading cause of blindness. During the Franco-Prussian war, 200,000 soldiers were struck down by smallpox and over 25,000 died; at the same time, in Paris, more than 18,000 of the civilian population died. Introduction of the disease into the more isolated areas of the world was frequently devastating. Instruments for variolation, first practised in ancient times in China and India. The powder ground from smallpox scabs was kept in the receptacle (top), placed with the spatula in the silver tube (bottom) and blown into the nostril of the person to be variolated. (Photo Wellcome Museum) In Iceland in 1707, as many as 18,000 people died in a population of only 57,000. Royal families were no more exempt than the common man. The disease attacked King Louis XV of France, William II of Orange, Queen Mary II of England, Emperor Joseph I of Germany, and Tsar Peter II of Russia. Queen Elizabeth I of England, who had severe smallpox when she was 29, became bald and thereafter wore a red wig and worried over the disfiguring marks of smallpox on her face. Exploration and settlement in the Americas was soon followed by smallpox and the devastation of entire Indian tribes and communities in North, Central and South America. Particularly catastrophic was the introduction of smallpox into Mexico in 1520, resulting in the death of some 3.5 million people. In North America smallpox was descri- bed as the worst enemy of the native popu- lation. In a devastating epidemic which raged from 1617 to 1619, almost nine- tenths of the Amerindian population living along the Massachusetts coast were destroyed. The town of Eastham had a population of 1,331 in 1763; the census returns two years later recorded only four inhabitants. Commenting on this "decay of Indians—a subject of melancholy interest," the Reverend Frederick Freeman in his History of Cape Cod ( 1858-62) says: "The numerous and powerful Nau- sets were soon to be, like the mammoth, only known to have existed." While nothing can be done, even today, in the specific treatment of the disease, methods for protection against smallpox were developed over 2,500 years ago in China and India. Ancient practitioners found that, by inoculating material from scabs or pustules into the nose or skin, a less severe disease could be produced which would subsequently prevent the person inoculated from developing the often fatal natural disease. This process, called variolation, appears to have been well known in western Asia and Africa over many centuries and was introduced into Europe and America in the 17th and 18th centuries. While perhaps one to two per cent of the recipients died following variolation, this still was recognized to be a considerable improvement over the 4 A smallpox fetish of the Sopona cult of Dahomey and Western Nigeria. (Photos WHO) The mummified head of the Pharaoh Ramses V ( 1160 B.C.), with lesions thought to be those of smallpox. Mary II of England died of smallpox in 1694 at the age of 32. Louis XV of France, born in 1710, died o smallpox in 1774. 5 expected fate of those experiencing the natural disease. Unfortunately, however, the infected person, although inoculated artificially, can readily transmit infection to susceptible persons with whom he is in contact. Variolation is frequently fol- lowed by outbreaks of the natural disease and thus the practice was highly contro- versial. In the late 18th century, Edward Jenner, an English country doctor, altered the history of smallpox by discovering vac- cination. Many observers had noted that milkmaids who had had cowpox seemed strangely insusceptible to smallpox. It remained for Jenner to take material from a sore on the hand of a milkmaid and on 14 May 1796 to inoculate it into the arm of a healthy eight-year-old boy. On the seventh day, a small sore developed similar to that produced by modern vaccination. Two months later, he tried to inoculate the child with smallpox. The infection did not take. Jenner had dis- covered smallpox vaccine. Within a decade, vaccination had begun in countries throughout Europe. But transfer of the new vaccine virus to America and Asia was not so easily accomplished. On one expedition, com- missioned by the King of Spain, 22 unvaccinated children were placed on a frigate and two were vaccinated imme- diately before departure. When the vac- cination pustule developed, two additional children were vaccinated with material from their pustules. Each week this was done until the expedition arrived in Venezuela, where it divided to spread vaccination to Central and South America. Part of the expedition picked up 26 addi- tional children to continue propagating the vaccinia virus in a living chain and so it was carried to the Philippines, Macao and China. Yet even after vaccination had been demonstrated to be a successful preventive measure, epidemics continued to rage in many countries, since the concept of widespread and eventually compulsory vaccination developed slowly. In Britain, for example, the first Vaccination Act was not passed until 1840, after a three-year epidemic that caused 41,000 deaths. With increasing use of vaccine, small- pox in many parts of the world gradually declined in intensity, but not until 150 years after Jenner's epic discovery did the continent of Europe itself finally stop its continuing spread. Under the impact of the global programme for smallpox eradi- cation, the end of this historical saga is now rapidly approaching. ■ 6 • /K47,43,`40 Edward Jenner (left), the English country physician who discovered smallpox vaccina- tion in 1796. Popular resistance to the idea of vaccination was caricatured by the English artist Rowlandson early in the 19th century (right). However, in the face of successful results, scepticism could not last. In Sicily, the arrival of the "blessed vaccine" was greeted with religious processions (above). But even the country where vaccination was discovered continued to experience smallpox. Hospital ships in the river Thames near London (below) were used for isolation of patients during smallpox epidemics around 1900. Buildings were erected on deck to house the sick. (Photos WHO) SMALLPDX ERADICATION THE GLOBAL STRATEGY by Dr Donald A. Henderson, Chief, WHO Smallpox Eradication Unit History, myth and religion bear witness to man's age-old struggle against smallpox. Soldiers, pilgrims, primitive tribes, whole populations of large cities, royal families —all were attacked by this terrifying and disfiguring disease for which there was, and still is, no cure. Until the discovery of vaccination, the smallpox virus knew no frontiers, and no amount of potions, incantations or magic amulets could stop its relentless spread. Eventually, smallpox became endemic throughout the world. By the nineteen-fifties, however, it had been eliminated from Europe and North America through vaccination, and had been brought under effective control in a number of countries in South Ameri- ca, North Africa and Asia. Yet smallpox was still a major threat, not only to coun- tries where it was endemic but also to those freed from it; its reintroduction was an ever-present possibility. It was truly a world problem, requiring a multi- national approach. In 1958, WHO, then in existence for 10 years, called for a global eradication programme against smallpox. During the years that followed, several countries began systematic vaccination programmes aimed at eradicating the disease, but only a few were successful. It soon became evident that technical and material assis- tance to member countries needed to be stepped up, and programmes streamlined regionally as well as on a world-wide basis. WHO's nineteenth yearly Assembly in 1966 therefore adopted a resolution proposing intensification of the eradica- tion programme. The new strategy came into effect at the beginning of 1967. In that year, smallpox was considered to be endemic in 30 countries—in Africa, most countries south of the Sahara; in Asia, Afghanistan, India, Indonesia, Nepal, and Pakistan; in South America, only Brazil. Twelve additional countries reported cases believed to have been imported. Smallpox transmission had already been successfully interrupted in many developing countries in Asia and the Americas where health services were limited and communications difficult. This was an indication that the objective of global eradication was both technically and operationally feasible. A vital need for the success of the pro- gramme was adequate supplies of high- quality freeze-dried vaccine. Surveys showed that not more than 10 to 15 per cent of the freeze-dried smallpox vaccine in use in the endemic countries in 1967 met standards recommended by WHO. The Organization assisted vaccine-producing countries by providing equipment, fel- lowships to train their workers abroad, and consultants to advise them on improv- ing quality and raising output. A detailed manual on vaccine production was pre- pared and two WHO Reference Centres for Smallpox Vaccine were designated, one in Utrecht, Netherlands, and the other in Toronto, Canada. The responsi- bilities of these Centres included the testing of vaccines from other laboratories, the training of national laboratory workers in vaccine production, and the evaluation of new techniques of vaccine production. Both the quality and the quantity of vaccines steadily improved. Several of the originally endemic countries—including Brazil, Bangladesh, Guinea, Indonesia and Kenya—began to produce sufficient vaccine of acceptable quality for their own needs. Other laboratories in Asia and South America did the same. But in addition to indigenously produced vac- cine, a futher 150 million doses were required annually to carry out the pro- gramme; these were donated by 20 Member States, the largest contributors being the USSR and the USA. By 1969, more than 95 per cent of all vaccine in use in the endemic countries was freeze-dried vaccine conforming to the requirements laid down by WHO. A second consideration in the develop- ment of the programme was the technique of vaccination. Previously, most vaccina- tions had been administered by the easily performed scratch technique. Under field conditions, this method was found less effective than the more difficult multiple- pressure technique. Alternative tech- niques were sought. Newly developed jet injectors were introduced into programmes in Africa and South America, where teams vaccinated large numbers of people col- lecting at particular points. The proportion of successful vaccinations was as satis- factory as that obtained with the multiple- pressure method and less vaccine was required to obtain an adequate response. However, problems were encountered in maintaining and repairing the injectors and they were found to be unsuitable for house-to-house vaccination programmes in Asia. The introduction of the bifurcated or forked needle around this time came as a great boon. WHO began to experiment with the bifurcated needle in 1967—it soon proved to be as revolutionary a device as 8 Samples of vaccine from different countries (right) and vaccine production in Bangladesh. Adequate supplies of high-quality freeze-dried vaccine, easily preserved in tropical areas, are vital to success in eradicating smallpox. Today, nearly all vaccine conforms to WHO requirements. Much of it is produced in the endemic countries themselves. The balance is provided by twenty other nations, the main do- nor being the USSR. (Photos WHO' .1. Mohr) Vaccination techniques have been re- fined considerably during the last five years. Previously, vaccine was adminis- tered by the scratch technique with one of a variety of vaccinostyles (right). The jet injector (below), introduced for routine field use in 1967, was more rapid and effective but presented main- tenance problems. Most recent is the bifurcated needle (left), first employed in 1968. The needle is simply dipped into vaccine and the skin pricked rapidly about 15 times. The bifurcated needle has proved to be as revolutionary a device as the safety-pin in its time. With it, a single vaccinator can perform as many as 1500 vaccinations a day. (Photos WHO) the safety-pin in its day. With the needle, the rate of successful vaccination was found to be superior to that obtained by other devices, and the amount of vaccine required was reduced to one fifth. A vaccinator could learn to work with it in an hour or less. The needles could be sterilized easily and repeatedly, and there was no question of breakage or main- tenance. Teams using the needle in Rwanda were able to do 1,000 to 1,500 vaccinations per day per vaccinator. Once the vaccination technique had been sim- plified, the programme went into full swing. While these problems of vaccine and vaccination were being resolved, WHO co-operated with health authorities to plan smallpox eradication programmes in each of the endemic countries and in many countries particularly vulnerable to the introduction of smallpox owing to their geographical situation. Some programmes began in 1967, but most started in 1968 and 1969. The last of the endemic coun- tries to begin was Ethiopia, in 1971. In all, WHO assisted programmes in more than 50 countries. The strategy and operational techniques have been adapted in national program- mes to existing health structures and patterns of vaccination activities. Every programme has two principal compo- nents: 1) surveillance, including disease notification and field investigation and containment of outbreaks; and 2) syste- matic vaccination, including assessment of the results achieved. In the past, eradica- tion programmes consisted almost solely of mass vaccination; with the present strategy, surveillance is the keystone. There are several reasons for this. The objective of the programme is a zero incidence of smallpox—no cases at all, anywhere. When the characteristics of people who contract the disease are known, vaccination programmes can be aimed at high-risk groups. Analysis of surveillance data indicates that in most countries more than 85 per cent of cases occur among those who have never been vaccinated, and more than 80 per cent among children less than 15 years old. In many areas a disproportionate number of cases occur in lower socio-economic groups in the cities, and frequently it is individuals belonging to these groups who introduce the disease into rural areas. Accordingly, vaccination programmes now place more stress on primary vaccination of children and on the vaccination of poorer city-dwellers. In addition to being a highly useful device to define high-risk groups, surveil- lance plays an even more important role in interrupting the transmission of small- pox. In some areas, despite a high rate of vaccination coverage, smallpox trans- mission persists at low levels, the disease continuing to spread from one person to another among a very small number of susceptible individuals. Active measures to identify and contain outbreaks, however, have sometimes caused transmission to be interrupted even where less than half the population had been vaccinated. The remarkable efficacy of surveillance and containment measures can be explained by the epidemiological behaviour of smallpox, elucidated through the surveil- lance programme and in special studies. Smallpox is an unusual disease, as its presence in an area can be readily detected. Each person infected with the virus deve- lops the characteristic rash and can transmit infection until his scabs disap- pear. There are no silent or subclinical infections and the virus is not present in animals or insects. If the virus is to persist in an area, the infected person must transmit the virus to a second person and he to a third person in a continuous chain. If the infected person does not transmit the virus to anyone, the chain is broken and the outbreak stops. In remote villages and nomadic population groups, this may occur even though no specific mea- sures are taken. Furthermore, if the source of infection of the first case in a village can be determined, previously unrecognized or unreported foci can be detected and similarly contained. The key role in all smallpox eradication programmes is therefore played by two or three national or provincial surveil- lance teams, headed by a physician or health inspector. The teams consist of two to four people who travel constantly. They feed the reporting system, search for cases, investigate reports of any out- breaks and take measures to contain them. One team can normally do all that needs to be done in a population of two to ten million people. Experience has shown that all outbreaks can be investigated and contained by one to five teams based centrally or—in the case of large coun- tries—at provincial or state headquarters. As a supporting measure, systematic vaccination is being carried out in virtually all countries. By increasing the proportion of immune people, vaccination creates a partial barrier to transmission and reduces the number of chains of transmission that require the attention of surveillance teams. Whether vaccination is performed by special teams or individual vaccinators, efforts are always made to obtain the maximum participation of the existing health services. Where programmes are 11 Fishermen and migrant groups (see back cover) Special programmes are required to assure a photographs were taken in Bangladesh. (Photos conducted by teams, an assessment unit evaluates the coverage and rate of success- ful vaccination in a sample of the popula- tion one to two weeks later. If 80 per cent or more of all age groups, particularly the 0-4-year-olds, show a vaccination scar, and if at least 95 per cent of primary vaccinations are successful, the perfor- mance of the vaccination team is consider- ed satisfactory. Since 1967, both the incidence of small- pox and the number of countries reporting cases have decreased significantly. In 1967, the number of cases reported was 131,418. Surveys conducted since 1967 suggest that less than 5 per cent of all cases were then being reported : the actual number of cases is thus estimated to have been at least 2.5 million. Despite increasingly complete reporting, smallpox incidence declined each year until 1970, when 33,318 cases—the fewest on record— were reported. In 1971, however, the reported incidence rose to more than 52,000 cases. Half of these were accounted for by Ethiopia which, beginning in 1971, developed a highly effective eradication programme (see page 22). In the rest of the world, smallpox incidence decreased by more than 25 per cent for the fourth consecutive year. With all endemic coun- tries engaged in eradication programmes, at least one third of all cases are now believed to be notified. The actual number of cases in 1971 is thus estimated to be less than 200,000, in contrast to the 2.5 million cases estimated for 1967. The number of countries reporting `requently transfer smallpox from area to area. sigh level of immunity among such people. These WHO/J. Mohr) smallpox decreased from 42 in 1967 to 16 in 1971. Of the 42 countries reporting smallpox in the former year, 30 were considered to be endemic, whereas the remaining 12 notified imported cases. At present, continuing transmission is believed to be limited to 7 countries : Bangladesh, Botswana, Ethiopia, India, Nepal, Pakistan and Sudan. In addition, 9 other countries have reported indigenous cases within the past two years. Since these cases were not known to have been imported, the interruption of transmission in these countries must still be regarded as provisional. With the decrease in smallpox incidence, importation of the disease into Europe has become less frequent. During the first two years of the programme, 1967 and 1968, smallpox was imported into Europe on six different occasions but in the four years subsequently, only three times— twice in 1970 and once in 1972. The last introduction occurred in April 1972, when a Yugoslav pilgrim, infected in Iraq, brought the disease back to his own country (see page 28). No cases have been imported into North America since 1962. In 1967, the smallpox endemic coun- tries were considered to fall within four regions : South America, Indonesia, Africa and the mainland of Asia. It was consider- ed unlikely that smallpox would be transmitted between any two of these regions. And, indeed, during the last five years, no such transmission has been detected. Thus, when smallpox transmiss- ion is interrupted in one of the regions, it will probably remain free from smallpox. Two of the four regions, South America and Indonesia, now appear to be small- pox-free. In South America, more or less exten- sive smallpox eradication programmes have been conducted in various countries during the past 20 years. By 1967, endemic smallpox was being reported only in Brazil, which began an eradication pro- gramme in that year. During the next four years, 83.3 million out of a popula- tion estimated in 1971 at 94 million people were vaccinated in a well organized and carefully assessed programme. Surveil- lance activities were begun in July 1969 and the smallpox incidence subsequently rose precipitously as the detection and notification of cases improved. During 1970, a steady decline in incidence occur- red until mid-November, when zero inci- dence was first recorded. Subsequently, a single localized outbreak of 20 cases was detected in suburban Rio de Janeiro and lasted until April 1971, when the last known case of smallpox in South America was reported. Surveillance units in each of the states of Brazil and more than 3,800 reporting posts throughout the country are continuing their activities. Several other countries in South America have intensified their vaccina- tion programmes in the past five years. Cases were imported into three countries during this period and in each instance Brazil was shown to be the source of infection. Since the last case was reported from Brazil, an intensive search for possible residual endemic foci has been undertaken in that and in neighbouring countries. None has been found. Thus, 450 years after smallpox was first intro- duced into the Americas, transmission appears to have been interrupted. Inten- sive surveillance, however, will be needed for at least two years before interruption can be definitely confirmed. In Indonesia, the second of the target areas, an eradication programme began in July 1968 in Java and Bali, and was subsequently extended to include the outer islands. Surveillance and contain- ment measures were primarily emphasized although routine vaccination was also improved. During the first three years of the programme, between 10,000 and 18,000 cases were notified annually but, in 1971, the number decreased sharply to 2,000. In 1972, only 34 cases were reported, all of which occurred in west Java during January. A national search for cases was conducted over the succeed- ing months and special surveillance teams are continuing this activity. No cases, however, have been detected. The results are encouraging but, as in South America, it is too early yet to be absolutely certain that transmission has been stopped. In 1967, smallpox was widely endemic throughout most countries of Africa south of the Sahara. During the past five years, eradication programmes have been undertaken by most of the African countries. Except in Botswana, Ethiopia and Sudan, reported smallpox incidence has now decreased to zero. In 20 countries of western and cen- tral Africa, with a total population of 120 million, reported smallpox incidence declined to zero in October 1969. One additional outbreak was detected in Nigeria in March 1970, the last known case occurring in May 1970. Surveillance and vaccination programmes are conti- nuing throughout this sub-region. In the countries of eastern and southern Africa, outside of Ethiopia and Sudan, smallpox incidence declined steadily during the course of the programme, apparently reaching zero incidence following the occurrence of two cases in Zaire in September 1971. Subsequently, it was discovered that Botswana, previously smallpox-free, became infected almost at the time the last cases were occurring in South Africa. There were 1,000 cases before the epidemics could be controlled. Introductions of smallpox from Ethiopia and Sudan also occurred into the French Territory of the Afars and Issas, as well as into Uganda, but were successfully contained. The two countries of main concern in Africa are Ethiopia and Sudan. In Ethio- pia, the programme started in January 1971 is based on a strategy consisting chiefly in surveillance, vaccination in conjunction with containment activities, and systematic vaccination in the largest towns and along the main roads. During 1971, over 25,000 cases were detected, compared with only 722 in 1970. Over six million people have been vaccinated to date in a population in which few had previously been vaccinated. Since March 1972, the number of reported cases has decreased, and programme officials now believe that transmission in 9 of the 14 provinces can be interrupted by the end of the year. In Sudan, more than 1,000 cases were reported both in 1970 and 1971—the highest incidence recorded in 15 years. A somewhat larger number of cases is expected to be recorded in 1972. Present information suggests that Sudan succeeded in interrupting transmission in the early 1960's. The disease appears to have been reintroduced in 1968 and, in the absence SMALLPDX '67 Countries considered endemic for smallpox in 1967 numbered 30: Afghanistan, Brazil, Burundi, Cameroon, Congo ( Dem. Rep.), Dahomey, Ethiopia, Ghana, Guinea, India, Indonesia, Kenya, Liberia, Malawi, Mali, Mozambique, Nepal, Niger, Nigeria, Pakis- tan (East and West), Southern Rhodesia, Rwanda, Sierra Leone, South Africa, Swa- ziland, Tanzania, Togo, Uganda, Upper Volta and Zambia. Cases throughout the world when the intensified eradication pro- gramme began are estimated at 2.5 million. SMALLPDX '72 After 5 years, the endemic countries have been reduced to 7: Bangladesh, Botswana, Ethiopia, India, Nepal, Pakistan and Sudan. The arrows indicate importations into non- endemic countries: from Botswana to South Africa, from Ethiopia to the French Terri- tory of the Afars and the Issas, from Iraq to Syria, from Iraq to Yugoslavia, from Pakistan to Sri Lanka, from Sudan to Uganda, and from Yugoslavia to the Fede- ral Republic of Germany. Importations of unknown origin occurred in Iran and Iraq. 14 ENDEMIC COUNTRIES AND IMPORTATIONS 1972 ENDEMIC COUNTRIES 1967 DD- 3ABA APUSSI 84 L E — B EGEi;IDIR E PI TREA E A.1 GO-F- G OJJA SMALLPDX ERADICATION PROGRAMME IN 19D WE WEEKLY RE-PORTE 0 CASES BY PROVINCE -1972 mmarancestuaritunna 1111111111111 11111m The global strategy JAN FEB 4- The smallpox eradication programme in Ethiopia: a WHO epidemiologist at the wall-chart which shows weekly numbers of cases in each province. A member of a surveillance team investigates an outbreak of smallpox in the province of Sidamo. He seeks to determine from whom and where the child contracted the disease, and to find his contacts since he became ill. (Photos WHO/ P. Almasy) ltelegrarril • of effective surveillance, spread through- out the country during the next two years. Since 1968, a partially effective eradica- tion programme has been in progress in the northern and central provinces, but activities have only begun in the three southern provinces, from which more than three-quarters of all cases are now being reported. As more intensive efforts are being applied in Ethiopia and Sudan, other African countries are remaining alert to prevent possible importations. Vaccina- tion programmes are continuing in order to maintain a high level of vaccination immunity. Since 1967, the only known endemic countries on the mainland of Asia have been Afghanistan, Bangladesh, India, Nepal and Pakistan. China is reported to have become smallpox-free after inten- sive vaccination campaigns in the 1950's. Burma, Iraq, Iran, Syria and countries of the Arabian peninsula have recorded only infrequent importations of smallpox from the endemic countries in Asia. In the fourth year of a well-executed programme, Afghanistan experienced a considerable decrease in incidence during 1972 and since February all cases have been among immigrants from Pakistan and their contacts. The first round of a systematic vaccination programme was completed early in 1972 and a second round has begun to assure that high levels of vaccination immunity are maintained. Special surveillance teams are continuing to move systematically through the country searching for cases. Most cases reported by India during 1971 and 1972 occurred in its northern states. With improving surveillance acti- vities and better notification, the number of reported cases increased from 12,000 in 1970 to 16,000 in 1971. The total in 1972 is expected to approach the 25,000 mark. After 10 years of intensive vaccina- tion programmes throughout the country, immunity everywhere is comparatively high. However, smallpox has continued to spread, primarily among unvaccinated people, who are estimated to constitute no more than 10 per cent of the popula- tion. Efforts are now being made to improve the reporting system as well as the efficacy of surveillance and contain- ment activities in order to interrupt the chains of infection. Much, however, still remains to be done. Bangladesh, which became free of smallpox in August 1970, experienced a recrudescence at the time of return of infected refugees from India early in 1972. Major outbreaks occurred in 5 of the 19 Districts and, despite emergency measures, it has not yet been possible to control them. Pakistan began an eradication pro- gramme in 1968 in its largest province and subsequently extended it to the remaining three provinces in 1971. As in India, vaccination immunity is com- paratively high and, with the develop- ment of an effective surveillance pro- gramme, transmission should soon be interrupted. Nepal has been conducting a steadily expanding and effective programme over the past four years. Most outbreaks during the past year have occurred near the Indian border and have been shown, or are suspected, to have originated from importations from India. The problems of smallpox eradication in Nepal are inseparably linked with those of neigh- bouring India, whose principally afflic- ted areas are on or near the Nepalese border. The amazing reduction in smallpox cases in only five years—from 2.5 million to 200,000—is due to the dedication and perseverance of national and WHO staff alike, working in the field under difficult conditions. Their efforts have been indi- rectly recognized by the governments of the United States and the United Kingdom, who have made smallpox vaccination no longer a routine procedure. They believe that the risk of importation is now slight, and that an eventual out- break could easily be contained. In the two countries, vaccination is now reserved for people travelling to endemic areas and for health service staff in contact with patients. It is too soon for all other governments to do the same, since not all countries are so far from endemic areas nor do all have such advanced health services. But if special efforts in the WHO smallpox eradication campaign are made during the next two years, smallpox incidence throughout the world could reach zero or near-zero levels. With a final effort and the mobilization of re- sources, mankind's most feared killer, as well as smallpox vaccination itself, could be relegated to history. ■ 16 - ?ow - NEPAL THE ANGER OF A GODDESS by Nedd Willard The day begins with walking. Through the cold morning mists the people of Nepal set off for the fields where their work awaits them. Each foot of good land has been carefully cultivated and its border marked by the sculpted edge of a terrace. Even the roads are allowed barely enough space through which to pass. The fields begin high up in the hills and crowd to- gether as they step down the terraces into the valley. In comparison to its neighbours, Nepal is a small country, only about 800 km long and 240 km wide at its broadest plane, and good land is scarce. It runs along the fringes of the Himalayas, whose snowy bulk is picturesque but scarcely able to sustain life. In this land, which lies like an oblong tablecloth covering the place where the flat plains of India rise to meet the world's highest mountains, people are cheerful, yet they are still subject to most of man- kind's crippling and killing diseases. Life expectancy is not high, about 39 years, but the population is expanding: there are more than eleven million people in this country about the size of England. One quarter of Nepal's landlocked territory is made up of sterile mountains and rocky plateau. Until recently, smallpox, malaria, cholera, leprosy and tuberculosis spread unchecked by any serious medical effort. It was only in the 1950's that Nepal broke out of its isolation from the rest of the world. Its unique culture and spon- taneity had been preserved by isolation but, at the same time, its people were deprived of techniques other nations had devised to protect health and stave off death and disease. The popular image of Nepal remains that of a land of sherpas and hippies, with Mount Everest at one end and the en- chanted valley of Kathmandu at the other. To many people the very word Kathmandu suggests a faraway place of strange temples, friendly people, mystic lore and cheap drugs. Like all legends, this one contains both truth and fantasy. Mount Everest does lie partly in Nepal; the other half is in Tibet. Sherpas do help mountaineers, as they did in the conquest of Everest, but moun- taineering forms only a small part of Nepal's way of life—mountain farming is much closer to it. Hippies do still come to Kathmandu, but they are comparatively few in number and many are merely enjoying their equivalent of a middle-class holiday. Nepal for visitors is perhaps only a few colour-slides to be projected on the wall when they get back home. The real Nepal is something quite different. It must face problems of ill health and poverty, and it is determined to do something about them. The climate ranges from the arctic cold of the semi-desert Himalayan slopes to the sticky heat of the Terai plain and jungle region that borders India. In spite of jungle growth, wild animals and malaria, the rich lowlands always attracted more and more people down from the less hospitable heights. But though the jungle could be cleared, no large-scale settlement could take place until malaria had been vanquished. This made malaria eradica- tion one of the first health targets of the Nepalese Government. The campaign was a success. By 1971, with help from Nvxo, malaria had prac- tically disappeared from Nepal except for isolated cases. Ending malaria meant freeing large fertile tracts of land for settlement. Ending smallpox, the next key target, will mean freeing children and adults from a major cause of mutilation and death. But difficulties abound in a country with a low average income, incred- ibly rugged terrain, a low rate of literacy and a developing national health system. Pilot project In 1962, the Government of Nepal and WHO signed an agreement to set up a pilot project to see whether smallpox could be eradicated in Kathmandu Valley. En- couraged by success, they extended the agreement in 1966 and a countrywide plan was drawn up and signed in 1967. No one underestimated the difficulties, but the goal was still set high: to end the transmission of smallpox throughout Nepal. A national smallpox eradication project headquarters was established with offices near Kathmandu. The first step was to plan a comprehensive strategy, setting out by stages what was to be carried out and by whom. Nepal is a rural country—about 96 per cent of its population still live in villages— so the smallpox campaign had to reach out into the country to find cases and provide vaccination. Nepal's population is young: 40 per cent of its peOple are under 14. This is the age group most vulnerable to small- pox and which needs vaccination most. In the beginning, the harsh facts of geography hindered plans to wipe out smallpox. Maps were lacking for many parts of the country, or were not suffi- ciently accurate or detailed to be of much use. Where roads are few and poor, news of an outbreak travels slowly. Help travels slowly too. In the entire country, there are probably not more than 800 km of all- weather, hard-surfaced roads. There were even less in the 1960's when the campaign began. During the monsoon season, from June to August, rains scour the hillsides and flood the lowlands. Land communica- tions come to a halt in most areas. Air links, too, are frequently broken as land- ing strips are lost under muddy sheets of water. Any active campaign is therefore confined to the dry months of the year. Statistics were also missing at the start of the campaign. Except in a few major centres, births and deaths were infre- quently registered. The collection of vital statistics is further hindered by the fact that Nepalese people are often on the move, migrating great distances in search of work, going on religious pilgrimages, helping with harvests. In some groups of the population there persists a belief in a smallpox goddess who must be propitiated by a certain number of cases each year. Believers are convinced that vaccination would anger her. Small- pox victims covered in pustules are still found by doctors lying on a wooden bed with a sword nearby to give them courage and a few leaves from the neem tree under the bed as an aid to recovery. Bad roads, isolated villages, poverty and superstition— this picture was what the first planners had to face in the early sixties when the cam- paign to clear Nepal of smallpox was get- ting under way. The Nepalese Government and WHO adapted their campaign to the land, to the 18 . `It - Yftit, Dr P. N. Shrestha (above) directs eradica- tion operations in Nepal. On the map in his office in Kathmandu he points out areas where smallpox cases have been reported recently. In Patan (below), a township near Kathmandu, a nurse questions children about suspected smallpox. Children are often a good source of information for surveillance teams looking for cases. (Photos WHO/J. Mohr) - INIFF`c. , traditions and to the way of life of the Nepalese people. Formerly, the standard practice was to try to vaccinate everyone. However, in a land of isolated valleys, where the newborns may amount to 4 per cent of the population, in a country criss-crossed by pilgrimages and migra- tion, a more sophisticated approach had to be worked out. In October 1969, the vaccination tech- nique was changed to the multiple- puncture method with the bifurcated needle. In some districts, vaccinations seem in the past to have been performed almost at random on any part of the upper or lower arm, including the wrist. This complicates surveillance when large num- bers of people must be examined quickly to find out whether they have been vac- cinated. Rather than trying to separate the vaccinated from the unvaccinated, it was often considered preferable to vac- cinate everyone living near an outbreak. Smallpox reporting presented difficulties and was far from covering all cases. Of those reported in 1968, age, sex and vac- cination status were. mentioned only occasionally In 1969, the proportion of cases estimated to be reported reached 60 per cent, which was a great improvement on previous years. Only fast, accurate reporting can tell vaccinators to go where they are needed. Two years ago, it hap- pened that the first notification of an out- break in a Terai village was made by a newspaper. Vaccinators arrived at the vil- lage some eleven days later, did their best, and left. When an assessment team visited the area later they discovered that new cases were continuing to appear, and that the actual number of cases was almost a third higher than had been officially reported. Gradually, a general picture of smallpox in Nepal emerged. The number of cases has declined sharply, reaching an all-time low in 1971. Most outbreaks in recent months have been traced to introductions from India. The Terai remains the major problem for smallpox in the country. As it borders on parts of India where small- pox is still endemic, reintroduction of the disease remains possible. In 1972, routine vaccination and re- vaccination are continuing throughout the country, with emphasis on the Terai. An approach in efforts being made to improve the reporting and the contain- ment of smallpox is to use the same people in a given district to look out for both smallpox and malaria. The vaccinators in the field remain the backbone of the cam- paign. It is important to use dedicated and well-trained personnel. In fact, vaccinators in field work today often need to be helped to fill in gaps in their knowlege of small- pox, and to improve their vaccination technique and their ability to track down cases. A recent seminar, sponsored by WHO in 1971, showed this clearly. A preliminary test given to vaccinators brought in from the field showed that though a majority of the participants answered most the ques- tions correctly, some of them scored only 40 to 55 per cent in the preliminary examinations. If you do not know what to do, it is very hard to do it correctly. Knowing how long the incubation, period lasts, for example, is vital to discovering future sources of infection. An improved strategy now being put into use is based on alerts. Whenever a case appears, a team tries to make its way to the village to carry out vaccinations within 48 hours of the time of notification. They do not skimp on vaccinations. Every- one who may have been in contact with the disease is vaccinated, whether or not he has been vaccinated before. Even if a person is already infected with smallpox, vaccination during the incubation period lessens the severity of the disease. This is important, since the more severe a case, the more infectious it is. The new strategy also lays strong em- phasis on tracking down the source of infection. Patients are questioned about their whereabouts during the previous two weeks: "Where were you?" "Whom did you see?" "Where did you eat away from home ?" If carried out thoroughly, this questioning can lead to the source of infection. In addition to back-tracking, vaccinators try to find out whether any of the infected people have visited friends and relatives in other villages or have gone to market during the incubation period of the disease. Most people in Nepal live in small houses. An estimated 6.6 persons share each two-room household. This helps spread infection since smallpox, like the common cold, is usually communicated by droplets that patients exhale. In the present campaign, Nepalese patients are kept at home, for not only are the hos- pitals distant but, under the old system, some of the patients admitted were actually misdiagnosed cases. They came in suffering from chicken-pox and left the hospital carrying smallpox infection back to their village. Now, a suspected smallpox case is kept at home and everyone in the family is vaccinated. Daytime has not proved suitable for reaching everyone. The men may be away tending a flock; some of the women may be in the fields or marketing, and it is hard to know where all the children are. So it has been discovered that it is a good idea for the vaccinator to return in the evening when everyone is at home. What is more, December, January, February and March are the only months when he can be sure to find everyone, since many Nepalese travel. Each summer, many of the people in the mountain regions go down to the plains of the Terai to help in the harvest. They are joined by workers who arrive from the Indian border states of Uttar Pradesh and Bihar, known to be endemic areas for smallpox. Pilgrims also gather in Nepal from near and far, some coming down from the high mountains, others trudging in from the dusty plains in India. Each year thousands of them attend fairs and religious festivals in Kathmandu valley, Lumbini and other sacred sites. The best strategy seems to be intensive vaccination where there are large concentrations of people, rather than spending too much time and energy trying to track down and vaccinate everyone individually in remote areas. It is partic- ularly difficult to ensure that all babies are vaccinated soon after birth in a country where a valley may be only 100 km as the crow flies from a vaccination centre, but is cut off by mountains and can be reached only after two days of bone-shattering journey by jeep or motorcycle. Of course, helicopters can play an important role in fighting the disease, but they are expensive. Even when people are assembled it often takes time, patience and cunning to win them over to the idea of vaccination. The help of local dignitaries is sought. Vac- cinators may have to overcome a variety of strange ideas and superstitions : "Don't vaccinate in hot weather—it's dangerous" is one. Some villagers want to appease the goddess. Many people do not consider a smallpox outbreak as requiring imme- diate action, unlike a cholera outbreak. As the number of cases has declined in Nepal, greater emphasis has been placed on containment and surveillance. Priority is also being given to locating and vaccin- ating infants as early as possible. Attempts are being made to see that the primary vaccination is given on the left upper arm. This will make checking easier and reduce the present confusion with scars left by variolation. Practitioners of variolation have been contacted and persuaded to change over to modern vaccination tech- niques—the National Eradication Pro- gramme in Nepal supplies them with modern vaccine free of charge. The materials for the programme are available, the plan has been drawn up and is being carried out. Everything is geared now to put an end to the chain of smallpox transmission that has gone on uninter- rupted in Nepal for many centuries. ■ In the Terai region, a vaccinator works with the bifurcated needle. (Photo WHO/J. Mohr) ETHIOPIA GREAT EXPECTATIONS by Dr Marcus Brooke The third largest population in Africa, difficult mountain terrain with few good roads, six months of rain every year, over 70 languages and 200 dialects, strongly rooted traditional beliefs and customs— this is Ethiopia as the smallpox team sees it. Yet despite the many problems of this vast and varied country, the small- pox programme in Ethiopia has been one of the most successful ever undertaken. In January 1971, when Ethiopia first joined in wHo's world programme for the eradication of smallpox, she had reported less than 2,000 cases in the preceding four years. At the end of 1971, the yearly total in the records rose to more than 25,000 cases—the highest incidence of any country in the world—and while this year's figures are decreasing due to the success of the programme, Ethiopia still accounts for a third of the world's total of cases. To understand the apparent paradox whereby smallpox increased after the programme began, one must examine the policy behind WHO's efforts to eradicate this much- dreaded disease. The keystone of the global programme is surveillance—the detection of cases through reporting and constant search. Hand-in-hand with surveillance goes con- tainment: once a case is discovered, the surveillance team proceeds immediately to the region—a village, a school, a suburb—to seek other cases and to vac- cinate all the people there. Vaccination is intensive rather than extensive, seeking to immunize all the people within a restricted area rather than many people in a diffuse area. This approach is based on the observa- tion that smallpox spreads much more slowly than was formerly believed. Since cases are found around single focal points rather than randomly distributed through- out a province or country, the disease can be contained by vaccinating a relatively small group of contacts of the index case. Instant investigation and prompt contain- ment have become the major elements in smallpox eradication today, rather than the earlier method of mass vaccination alone. All the same, in the course of the sur- veillance-containment operation in Ethi- opia, over six million people have been vaccinated since the programme began. Vaccination is done with a forked needle which is used to make multiple punctures. The vaccine, made available by will:), is high-quality freeze-dried vaccine produced by laboratories in more than 30 countries. In the programme, conducted under the administrative control of the Ethiopian Ministry of Health, three WHO epidemiol- ogists have a key role. The base of the pyramid is composed of some 70 field workers. About half of these are Ethiopian health officials and the rest American Peace Corps volunteers. Additional volun- An Ethiopian surveillance officer and an American volunteer (above) discuss team operations. The WHO poster behind them warns against the dangers of smallpox. Travelling by horse, mule or camel, the surveillance team can cover up to 50 km a day, searching for cases and vaccinating people they meet en route. (Photos WHOI P. Almasy) teers from Japan and Austria have recently joined the programme. Simple as the concept of surveillance- containment may seem, its execution is no easy task. The magnitude of the prob- lem of smallpox eradication in Ethiopia becomes evident only when one takes a close look at the country and the life-style of its peoples. Ethiopia is believed to have, after Nigeria and Egypt, the third largest population in Africa—about 25 million people. There are only two cities with more than 100,000 inhabitants—more than 92 per cent of the population is rural. These include many groups such as the Afars and the Nuers, who are nomads moving from place to place with their cattle. There are more than 100 different tribes in the country, each with its own ethnic and religious customs. Some of these customs may, on occasion, run counter to Ministry of Health efforts. Some Amharas, for instance, strongly resent vaccination but take much pride in their own age-old ceremonies to ward off smallpox. When the disease appears, the dwelling of the patient is decorated with fresh green leaves, grasses and flowers, and filled with the fragrance of burning incense. Sheep, goats and hens of different colours are sacrificed, and ritual play-acting and singing is organized. This is done in the hope that the disease will take a milder form. Actually, the disease in Ethiopia is quite mild and those who resist vaccina- tion might be more compliant if it were more severe. Deaths are comparatively few. In 1971, only 522 people died out of 25,000 cases—about 2 per cent. (The type of smallpox virus found in Asia kills 15 to 40 per cent of its victims.) However, in Ethiopia, as in other countries, the highest number of deaths occurs among infants below the age of one—about 12 per cent of those developing smallpox die of the disease. In some regions one may find an attitude of welcome to the disease. A surveillance team once found a tukul (mud hut) in which six of the seven children had small- pox. They attempted to vaccinate the one healthy child but the mother clung desper- ately to it: she did not want it to be dif- ferent from the others. It is in the northern part of the country that the major problem is encountered: the still-prevalent practice of variolation. This consists in taking pus from a smallpox patient and injecting it into a scratch on the forearm of a healthy person to immu- nize him. The technique is many centuries old, and was at one time the only known method of protection against smallpox. Its use is, however, no longer justified since the discovery of vaccination. With variolation, the recipient develops active smallpox and may act as a focus of the disease, spreading it to others. The Nuers, one of the Nilotic tribes along the Sudanese-Ethiopian frontier, are eager to be vaccinated but also have their own rites against the disease. When small- pox breaks out, their prophet calls for a ceremony. With a celebration of joy and a show of strength, the people ask the "god of the sky" to relieve them from the sick- ness. The prophet leads them through the fields and down to the river bank, where goats are sacrified to the "mother of the gods", who lives in the river. The crowd then bathes in the water. Many people of the south, such as the Gallas, are very co-operative and some- times even over-eager to be vaccinated. The problem here is to prevent people coming back three or four times. Often, on a lonely country track, teams come across crudely scribbled notes asking them to come to such and such a village, 40 or 50 km away in the bush, where the villagers are waiting expectantly for them. Ethiopia has a surface area of about 1,220,000 square km, more than France, Italy and the Federal Republic of Germany put together. Most of it is a massive high- land complex of mountains, with occa- sional plateaus lying between 1,500 and 4,250 metres. Thousands of years of ero- sion have produced numerous valleys flanked by steep hills. Some of these are more than a kilometre in depth and several in width, criss-crossed by rivers which become impassable during the long rainy season. Though most of the country is mountainous, it also contains the northern part of the Rift Valley, which descends to a depth of about 120 metres below sea level. Here is a land of sand, of burning basalt rocks, of boiling hot springs and of salt flats, where some of the highest temperatures in the world are recorded. The scene changes again in the south-west, where the vegetation is sometimes lush and tropical, and the climate humid. Big game abounds—there are large herds of buf- falo, elephant, kudu, oryx and topi, to name but a few. The rivers are full of crocodiles. This vast country with its varying landscape has little more than 8,000 km of all-weather roads and only about one- third of these are bituminized. There are about 16,000 km of second-class roads and about 20,000 km of what are little more than trails, both of which are impas- sable during the wet season, lasting in general almost half the year. One third of the population lives more than 25 km from the nearest road, while more than 75 per cent of the arable land is more than one day's walk from the nearest all-weather road. Even with rugged, four- wheel-drive vehicles, the teams are able to reach less than half the population. However, riding on horses and mules, climbing, hiking and fording streams, the teams have managed to penetrate to the most inaccessible areas of the country. With a blanket roll, a tent, emergency food rations and vaccine, teams disappear into these vast reaches for days and weeks on end—searching, constantly searching, for smallpox. There are also communication problems of another kind. The many languages and dialects spoken in Ethiopia mean that sometimes a member of the smallpox pro- gramme can communicate only through two or even three interpreters. In northern Ethiopia, for example, an English-speak- ing epidemiologist once wished to question a peasant who spoke only Tigre. The ques- tion was put first to an English-Amharic speaker. He relayed it to someone who spoke Amharic and Tigrinya, but not English or Tigre. The last interpreter, from Tigrinya into Tigre, then put the question to the person for whom it was intended. The reply travelled back along the same channel in reverse. The time needed to obtain vital information is considerable; so are the possibilities for confusion. In spite of these difficulties, however, it is becoming increasingly apparent that the strategy employed in the Ethiopian small- pox eradication programme is sound and that even with a staff of less than 70 people interruption of the transmission of smallpox is feasible. Indeed, in the eight southern provinces it is hoped to achieve this goal by the end of this year. By the end of 1973, the disease may be under control in the entire country. This must be followed by very active surveillance for at least another two years to ensure that there are no hidden foci. After that, smallpox may well be a thing of the past in Ethiopia. ■ Great expectations Market days are particularly busy for the smallpox team. Using loud-hailers, they exhort the population to come to be vaccinated. Usually the response is immediate and a large crowd quickly gathers. Sometimes the team gives BCG as well as smallpox vaccine. While they are working, they gather informa- tion about possible cases of smallpox in the area. (Photos WHO/P. Almasy) EVERY COUNTRY PAYS FOR SMALLPDX The cost of smallpox throughout the world is very high. In most countries the expenditure is for preventive measures, in others for eradication. Some idea of the annual cost of small- pox prevention in the USA is given by the figures below worked out by investigators in the course of a study of vaccination patterns and complications. Over a three-week period in the winter of 1961-62, five people reached England from Pakistan and shortly after arrival developed smallpox. The disease spread, and before it could be controlled 62 other people had been taken ill. Twenty-four of them died. To fight the outbreak, more than 5.5 million doses of vaccine were distributed and no less than eleven special smallpox hospitals were opened during a period of six weeks. Special measures cost the country £1.4 million ($3.9 million). A Swedish sailor on return from an Asian tour in 1963 was taken ill with smallpox. It was the first case in Sweden in 30 years. Twenty-five additional cases, including four deaths, occurred before the outbreak was controlled. More than one million doses of vaccine were distributed and more than a thousand people who had been in contact with the patients were placed in isolation. These are examples of what smallpox can mean to countries that have freed themselves from the disease. For good reason, public health author- ities fear the introduction of a case of smallpox more than any other disease. First, the smallpox virus can be trans- mitted readily from person to person in any country and in any season. By con- ESTIMATED ANNUAL COST OF SMALLPDX PREVENTION IN THE USA IN 1968 Vaccine production and physicians' services in vaccination $ 92,800,000 Vaccination complications— medical care, time lost from work and mortality $ 42,856,000 International vaccination certificates, inspection and national surveillance $ 6,462,000 Maritime industry losses in waiting for clearance of vessels $ 8,000,000 $150,118,000 WARNING SMALLPDX HOSPITAL THE PUBLIC ARE REQUESTED TO KEEP AWAY FROM THIS ROAD On a public road in Yorkshire during an outbreak in England, 1953. The necessity for inspection of vaccination certificates often causes lengthy delays for travellers arriving from areas still endemic. (Photo WHO/T. Takahara) 27 trast, yellow fever or malaria, for example, require for their transmission mosquitos of particular species to bite both the patient and susceptible people, and such mosquitos are not present everywhere nor in all seasons. Likewise, cholera, which is spread mainly in conditions of poor sani- tation, is no significant threat to countries with adequate water supply and waste disposal services. The second reason for the concern caused by smallpox is that there is no cure for the disease. Among patients who acquire the type of smallpox virus present in Asia, one case in three may die, while the others are left disfigured or perhaps blind. The serious concern of health author- ities is reflected in the fact that countries throughout the world, even those where no cases have occurred for many decades, have continued their vaccination pro- grammes. In many areas, children are not permitted to attend school unless they can present evidence of having been vaccinated or have a valid medical reason for not being vaccinated. The cost of such pro- grammes is considerable. While vaccina- tion programmes are themselves expensive, adverse reactions sometimes occur follow- ing vaccination and, although infrequently, treatment in a hospital may be required. In recent years in the USA, complications have accounted for over 3,000 total days of hospitalization each year and between 6 and 10 deaths. To prevent smallpox from being trans- mitted from infected to smallpox-free areas, travellers throughout the world must carry a certificate of vaccination. This causes not only expense and inconve- nience to the traveller but a burden to the health services, which must provide a staff of health inspectors to examine the certi- ficates at points of entry and departure. And yet these measures, necessary as they are, are not infallible. Travellers from infected areas manage to cross interna- tional borders without proper vaccination. Some are vaccinated with impotent vaccine or improper technique, others acquire false vaccination certificates. When small- pox is introduced into a smallpox-free country, it is frequently misdiagnosed by the medical staff, who may not have seen cases of smallpox for many years, or per- haps ever. Sometimes, four to six weeks may elapse before the first case is properly diagnosed. In the meantime, the disease spreads among people who have not been vaccinated for many years or at all. The global programme of smallpox eradication has as its objective the elimi- nation of smallpox throughout the world. Achievement of this goal would make it possible to discontinue smallpox vaccina- tion everywhere. International travellers would no longer require certificates. Even though this goal has not yet been achieved, smallpox incidence has fallen to such low levels that importation of cases has become infrequent. Only three cases, in fact, have been introduced into Europe in more than four years and none into North American countries in over ten years. Because of the success of the eradication programme and the sharp decline in the risk of smallpox importation during the past five years, two countries, the United States and the Unit- ed Kingdom, decided in 1971 to discon- tinue routine vaccination in their coun- tries. At the same time, the countries of Europe and North America agreed that international certificates of vaccination would no longer be routinely required for travel between and within these areas. The annual savings already being realized by the USA alone are now estimated to be almost equivalent to the entire budget of WHO. As the programme progresses more countries will benefit from this programme and be able to divert badly needed funds from smallpox prevention to other health priorities. ■ EPIDEMIC YUGOSLAVIA CONQUEST OF AN by David Egli In February 1972, the first case of small- pox in over four decades occurred in Yugoslavia, brought by a pilgrim infected while in Iraq. His illness was mild and he did not seek medical help. The presence of smallpox was detected only after cases had developed among people with whom he had been in contact. Health authorities mobilized rapidly, and worked day and night to contain its spread. By April the outbreak was over but not before 175 people had developed the disease and 34 had died. The story of this as of other outbreaks in European countries where the disease has long been absent is one of rumour, panic, heroic sacrifice by health authorities, and finally success in again vanquishing this ancient enemy. As this was the first significant outbreak in the country in 42 years, inevitably there had been a relaxation in performing rou- tine vaccination in Yugoslavia, even among hospital staff. Some doctors and nurses, who should have been totally immune to the disease through regular vaccination, finally ended up as patients in the Thousand Roses makeshift isola- tion hospital. In the population at large, the level of immunity is reported to have been lower than that of still heavily in- fected India. Despite this general picture, the outbreak was brought under control within less than a month after its detection. On 14 March a physician in Prizren, some 300 km south of Belgrade, in the autonomous province of Kosovo, notified the Federal health authorities of his suspicions concerning three recently ad- mitted patients. Specialists were flown in to examine the patients and to take sample crusts for laboratory tests. The diagnosis was confirmed by the Belgrade Institute of Immunology and Virology. By 17 March, containment measures were in operation and a widespread vaccination programme was started. The last known case in the epidemic occurred on 10 April. In the early days following recognition of the disease, the country was in turmoil. People were afraid to walk the streets or frequent public places until they were satisfied that they and their families were protected through successful vaccination. Some citizens had themselves vaccinated several times to make quite sure; others put through urgent calls to friends and relatives in other countries to supply them with quantities of gamma-globulin, thought to provide added protection. Initially, trucks carrying food and even loads of bricks from Kosovo province were turned back before reaching other areas of Yugoslavia; market produce was allowed to rot if suspected of having originated in a contaminated area. The deep-rooted but sometimes irrational fears of the population were difficult to quell. Early-season tourist-bookings were can- celled, other countries closed their borders to Yugoslays and advised their nationals not to visit the country, and the entire hotel industry took a dismal view of what would happen during the summer holiday period. With the epidemiologists hard at work it was rumoured and later confirmed that the disease had been introduced by a pil- grim. On his way back to Yugoslavia, the pilgrim had visited various places in Iraq, including Baghdad, where there were smallpox cases at the time. With discovery of the source came a greater feeling of security and a recognition that the health authorities were bringing the epidemic under control. The sense of relief was great. The Kosovo province in Serbia, close to the border with Albania, is one of the less developed areas of Yugoslavia. The farm- ing community tenaciously maintains lan- guage, traditions and religious obser- vances passed on from previous genera- tions. Each villager's house is his fortress and the women in the family are protected from the prying eyes of strangers by high mud and brushwood walls, steadily added to in spare moments between harvests. Despite the efforts of the authorities, the women, after compulsory schooling, are still closeted away, hidden behind heavy veils should they need to appear in a public place, and betrothed by arrange- ment. During the smallpox epidemic, the work of the Serbian health authorities was not easy in this traditional setting, and it is perhaps fortunate that many of the 380 teams handling the mass vaccination pro- gramme were "no-nonsense" army units. Soldiers in uniform were able to penetrate into houses from which civilian teams might have been barred. While the popular response to the vaccination programme both in the infected area and in the rest of Yugoslavia was positive, take-rates, in the early stages of the programme at least, 28 During the recent Yugoslavian epidemic, the authorities set up hundreds of road check- points around the infected areas. Travellers were required to show valid vaccination certi- ficates. (Photos WHO'D. Egli) were reportedly very low. There was a need for constant checking and re-checking in the villages. The local population co-operated well, and bore with stoicism the necessary restrictions of quarantine under which entire villages were cut off from the out- side world. In certain families, however, there was a superstitious reluctance to turn to the hospitals for treatment. By tradition, the sick are treated at home with all members of the extended family group trooping past the sick-bed as well-wishers. A handful of smallpox cases, including children, were discovered by the vaccina- tion teams and had not been spontaneously reported. In the belief that the local isola- tion hospital spelled death, they had been hidden away by their families. By a stroke of bad luck, the disease was carried to the Yugoslav capital by a patient with the hard-to-diagnose haemor- rhagic form of smallpox. The carrier patient first became ill in early March, before identification of the epidemic, and was hospitalized in the town of Novi Pasar. Because of the apparent severity of his undiagnosed infection he was trans- ferred to a second hospital in Cacak. As his condition deteriorated further it was decided to send him on to Belgrade. On 9 March, this patient was admitted to a dermatological clinic where he was pro- visionally diagnosed as a case of "unusual drug reaction secondary to penicillin". Twelve hours later he was again trans- ferred, this time to an intensive care unit at a surgical hospital, where he died twenty-four hours after admission. His body was returned to Novi Pasar and only days later, when his brother came down with classic smallpox symptoms, was the alarm raised. On 22 March the diagnosis of haemorrhagic smallpox was established. The Novi Pasar case set a record in the number of others he infected : two patients and a visitor at the Novi Pazar hospital, eight secondary cases following his brief stay in the Cacak hospital, eight cases in the dermatological clinic in Belgrade, and eighteen cases in the surgical hospital's intensive care unit, including all thirteen patients there at the time, plus a doctor, a nurse, a hospital technician and a wardrobe man who took care of the patient's clothing—a total of 37 people. Although the risks of a spread of the epidemic in Belgrade were enormous, the swift and thorough action of the health authorities successfully snuffed out the disease before it could do further substan- tial damage. In four days, starting on 23 March, approximately 1,200,000 per- sons in the Belgrade area were vaccinated. Some 2,500 vaccination posts were manned continuously, 24 hours a day. Everyone in the two Belgrade hospitals visited by the Novi Pazar patient was quarantined Some staff in emergency smallpox hospitals wore protective clothing. (Photo WHO/D. Egli) and four hotels were set aside for the iso- lation of all known contacts—visitors, friends and relatives of the hospital patients. Of the several thousand who came forward in response to radio appeals, 180 were finally retained in quarantine. An indication of the success of these measures is that only four secondary cases occurred in the Belgrade area, all among home contacts of those who had acquired the disease from the Novi Pazar patient. Serbian authorities estimate that by the end of the campaign between 95 and 98 per cent of the total population of Bel- grade and the Kosovo region had been successfully vaccinated. Vaccination certi- ficates were distributed and controlled at road check-points, railway stations and post offices. On 24 March, the Yugoslav government decided to go a step further and vaccinate the entire country. Thirteen nations to- gether with the World Health Organiza- tion responded to an appeal for vaccine, contributing more than 15 million doses. Yugoslavia added to this quantity through local production, reserves and additional purchases. In terms of disease control, nation-wide vaccination such as this is usually un- necessary. However, authorities stressed the dangers of the free movement within the country both of nationals and the six or seven million expected tourists, plus transit traffic. They noted additionally that the global smallpox eradication campaign could at best succeed only in several years' time and they wished to make absolutely certain that Yugoslavia was adequately protected during the cam- paign's final stages. Whatever the reason, the decision may have been an important psychological factor in encouraging tourists to maintain their Yugoslav holiday plans. In any case, for most Europeans the out- break, once finally eliminated, was forgot- ten almost as quickly as it had occurred. What became of the smallpox patients? After the initial period during which patients and staff at both major hospitals visited by the Novi Pazar patients were isolated, smallpox cases in the Belgrade area were transferred to a motel on the outskirts of the town. The public quickly rebaptized the Thousand Roses Motel the "Thousand Pocks". The medical staff here did its best to make the patients as com- fortable as possible. In the Kosovo region, the staff began work at the Hospital in Dakovica on 18 March with eight smallpox cases. At the height of the epidemic they had more than 100 patients. To begin with, they reported difficulties in keeping the appre- hensive local staff on the job. But the doctors were later joined by nurses from Belgrade and seeing that they were not afraid the local staff gradually returned to work. For serious cases the treament prescribed was intensive but conventional. Broad spectrum antibiotics were admin- istered to prevent secondary infections. A close watch was kept on the cardio- vascular system. Skin hygiene and efforts to prevent eye infections were insisted upon. Those patients too sick to eat were fed intravenously and given up to eight litres a day of liquid food. In April, the last case, a ten-year-old boy, was brought in by one of the vaccin- ating teams after being hidden by his family. With his recovery, villagers in nearby Ratkovac celebrated the lifting of quarantine and the new victory over smallpox with a feast of fish, lamb and plenty of slivovica. ■ 30 More than 380 health teams, some of them army medical units, took part in the vaccination drive. (Photo WHO'D. Egli) -'

SMALLPDX RECOGNITION AND DIAGNOSIS The training aids, manuals, and visual material illustrated here have been prepared by the World Health Organization for use in countries engaged in smallpox eradication programmes as well as in those at risk of importation. They are designed to facilitate immediate recogni- tion and diagnosis of the disease, essential elements in quickly controlling outbreaks. AKA I fomc, ,, ∎ . PROGRAMNFS WHO EXPERT COMMITTEE ON SMALLPDX ERADICATION Second Report WHO Technical Report Series No. 493, 1972, 64 pp. (English, French, Spanish, Russian) GLAD!' TO THE I BORATORY DIAGNOSIS OF SMALLPO \ GUIDE TO THE LABORATORY DIAGNOSIS OF SMALLPDX WHO, 1969, 48 pp. (English, French, Russian) DIAGNOSIS OF SMALLPDX Two Coloured Slide Series Fifty-one slides with accompanying text illus- trating the development and clinical characteristics of the disease in African patients and showing the differential diagnosis between smallpox and chickenpox (English and French) A teaching series of 36 slides with accompanying text. Photos of Asian patients illustrate the develop- ment of the disease and its comparison with chickenpox. (The last five slides are designed to test the viewer's ability to identify the disease.) (English and French) SMALLPDX RECOGNITION CARDS Two cards illustrating in colour the most obvious clinical manifestations of the disease. The larger (left) is 21 x 30 cm and sealed in a protective plastic jacket. It has proved a useful tool for smallpox workers in the detection of cases. The smaller (below), also in colour, is postcard-size. It is usually distributed to medical workers not directly connected with the smallpox eradica- tion programmes in order to encourage notifica- tion of the disease. SMALLPDX CHICKENPDX chickenpox SMALLPDX — CHICKENPDX A full colour wall chart, 88 x 112 cm, illustrating the phases of the rash on four different areas of the body from days 2 to 25 for small- pox and days 2 to 10 for chickenpox. A brief text characterizes the clinical features of the two diseases and diagrams show the dis- tribution of rash on the body. (English, French, Portuguese) SMALLPDX POSTERS Full-colour photos of a mother holding her child suffering from smallpox. Designed for distribu- tion in African and Asian coun- tries. The margins of these posters (60 x 40 cm) have been left blank so that information concerning vaccination activities and notifi- cation of the disease may be printed in any language. smallpox chickenpox A PICTORIAL GUIDE TO DIAGNOSIS An eight-page brochure in full colour (22 x 30 cm) illustrating the development of the disease in African patients and including a comparison with chickenpox. A brief text and diagram give ad- ditional information on diagnosis and the difference between the two diseases. (English and French) 33 AROUND THE WORLD New premises for WHO in Europe Her Majesty Queen Margrethe of Den- mark, His Royal Highness Prince Henrik and the Director-General of WHO, Dr M. G. Candau, attended the official open- ing on 18 September 1972 of WHO's new Regional Office building in Copenhagen. Placed at WHO's disposal by the Danish Government, the new building faces the sea near the Copenhagen residential district of Hellerup. It was designed by Eske Kristensen, Inspector of Royal Buildings, and comprises three-storey office accommodation for 185 staff mem- bers, a conference hall, a library, a print- ing-shop and garage space. The WHO Regional Office for Europe moved from Geneva to Copenhagen in 1957. Directed by Dr Leo Kaprio, it serves Europe as well as Morocco, Algeria and Turkey. The other WHO Regional Offices are located at Washing- ton for the Americas, Brazzaville for Africa south of the Sahara, Alexandria for the Eastern Mediterranean countries, New Delhi for South-East Asia, and Manila for the Western Pacific. The aim of this decentralization is to enable WHO to adapt its work more closely to the needs of its Member States. The inauguration of the new Copen- hagen premises took place at the 22nd Session of the WHO Regional Committee for Europe, which is composed of govern- ment representatives. Maternity centres offer family planning advice In Egypt, maternal and child health services have played a significant part in lowering infant mortality rates from 169 per 1,000 live births in the 1940's to 117 per 1,000 in recent years. Egyptian experts are convinced that pregnancy spacing, by ensuring a higher survival rate for both babies and their mothers, will lead to a still greater improvement. Family planning advice is available at 3,000 centres throughout Egypt, all set up since 1964. In the rural areas, where two- thirds of them are situated, there is a greater resistance to birth control than in the towns. Health workers offering care to mothers and their young children use the opportunity for family planning education. Home visitors also approach as many married women as possible, encouraging them to keep their families at a manageable size. Family planning services set up at the Karkh and Alwiyah Maternity Hospitals in Baghdad, Iraq, have proved to be in great demand. A WHO adviser sent at the Government's request recommends the establishment of similar facilities in other health centres as quickly as possible. The Iraq programme uses a "maternity- centred" approach and works on the prin- ciple that women are most highly motivated to plan their families when they are pre- gnant or have just had a child. Family planning services integrated with mother and child health work can reach all women who take their children for medical care but who would not present themselves specifically for family planning advice. The Government's long-term intention is to extend family planning services to every maternity department, maternal and child health centre, and basic health service unit throughout the country. WHO's approach to family planning is based on the improvement that pregnancy spacing can bring about not only in the health and strength of mothers and babies but in the well-being of the whole family. Vaccination at birth in Somalia Somalia, now stepping up its drive against tuberculosis with WHO's assistance, provides BCG vaccination for all babies delivered in hospital. Freeze-dried, heat- stable BCG vaccine is administered to every newborn by hospital nurses who receive special training in the technique at Mogadishu's Tuberculosis Centre. With gloomy uniformity, local records show a sharp leap in infection rates from infancy to adolescence, with significant "ups" when children start school and are more exposed to infection. From an average 20 per cent at the age of 5, the infection index climbs to 50 per cent at 10, and 60 per cent at 15; hence the need for vaccinating children systematically, preferably at birth. Hospital-delivered babies in Somalia are given a reduced dose of BCG, while children starting school get a normal dose. Both provide prolonged protection. Direct BCG vaccination—without previous tuberculin-testing, as recommended by WHO—has already proved a rational, and safe, public health procedure in a country with meagre medical resources. Somalia's all-out drive against m, still in its early stages, is being gradually expanded as more staff and treatment facilities become available. The blueprint calls for systematic BCG vaccination, country-wide case-finding to locate infec- tious sources, and supervised out-patient treatment of infectious cases. Preliminary steps in this direction include case-finding by direct microscopy, referral for treatment, house-to-house vaccination, and orientation courses in simple control procedures for auxiliary personnel. Despite such efforts to put TB control on the right track, the present drive leaves wide areas of Somalia uncovered. Over a million nomads roam the country, fol- lowing the seasons, the rains, the growth of grass. Reaching them is expected to confront the health workers with great difficulties. ■ 34 Smallpox (back cover and right) A travelling smallpox worker vaccinates a nomad family in their tent in Afghan- istan. Nomads, migrating with the sea- sons in search of food for their animals, are a special problem for eradication teams. (Photo WHO/P. Almasy) WHO in Europe (left and below) The new building complex of the WHO Regional Office for Europe in Copenha- gen, Denmark. Left, the main entrance to the new building. Below, an aerial view. The red-roofed building is the original office building, now outgrown but still in use and connected by a linking building to the main office block, foreground. Behind the office block, right, is the conference hall. The new European complex is placed at WHO's disposal by the Danish government. (Photos WHO) nies S.A. Lausanne prinleries a • *"*• • I I