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The Incidence and Control of Smallpox Between 1900 and 1958

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The Incidence and Control of Smallpox Between 1900 and 1958 CHAPTER 8 THE INCIDENCE AND CONTROL OF SMALLPOX BETWEEN 1900 AND 1958 Contents Page Introduction 316 Variations in the incidence of variola major and variola minor 316 The elimination of smallpox from Europe by 1953 317 United Kingdom 324 Russia and the Union of Soviet Socialist Republics 326 Germany 326 France 326 Portugal and Spain 327 Scandinavia 327 The elimination of smallpox from North America, Central America and Panama by 1951 327 Central America and Panama 327 United States of America 328 Canada 332 Mexico 333 Smallpox in South America, 1900-1 958 333 Brazil 333 Other countries 335 Smallpox in Asia, 1900-1 958 335 Eastern Asia 335 China 339 Japan 343 Korea 344 Indonesia 344 Philippines 344 Malaysia 345 Burma 345 Thailand 345 Indochina 345 The Indian subcontinent and Afghanistan 346 India 346 Pakistan and Bangladesh 346 Afghanistan 347 Sri Lanka 348 South-western Asia 348 Smallpox in Africa, 1900-1 958 349 31 5 316 SMALLPOX AND ITS ERADICATION Page North Africa 350 Western, central and eastern Africa 351 Western Africa 351 Central Africa 353 Eastern Africa 357 Southern Africa 359 Angola and Mozambique 359 Malawi, Zambia and Zimbabwe 359 South Africa and adjacent countries 359 Madagascar 361 Smallpox in Oceania during the 20th century 361 Australia 361 New Zealand 362 Hawaii 362 Summary : the global incidence of smallpox, 1900-1 958 363 INTRODUCTION land. Viruses that differed from alastrim virus in several biological properties (see Chapter 2) As has been described in Chapter 5, by the caused variola minor in Africa, and their end of the 19th century variola major was spread is more difficult to trace. African endemic in most countries of the world and in variola minor was endemic in southern Africa every inhabited continent except Australia ; until 1973, and a similar disease was reported and a new mild variety of smallpox, variola from time to time in many countries of minor, was endemic in South Africa and the eastern and central Africa, usually coexisting USA. with endemic variola major. It is not clear The present chapter explores the situation whether its extension in Africa was due solely between 1900 and 1958 in greater detail than to spread from the southern African focus or was given in the survey of the global inci- whether there were other places in Africa in dence of smallpox in Chapter 4, drawing for which a similar mutant form of the virus the earlier data on Low (191 8), Simmons et al. emerged, or indeed whether some outbreaks (1944-1 954), Hopkins (1983a), various pa- followed importations of alastrim from the pers published in scientific journals, and homelands of the European colonial powers. records produced by national health authori- One of the most interesting epidemiologi- ties in several countries. It also traces in some cal features of smallpox during the period detail the elimination of endemic smallpox in 1920-1958 was the relation between variola several countries in each continent in the major and variola minor in countries in which years before 1958, which provided the ratio- both varieties occurred. An important factor nale for the decision by the World Health affecting their relative incidence was the Assembly to embark on a global smallpox attitude of the public at large and public eradication programme in 1959. Inevitably, health workers to smallpox control; in gen- because of the absence of reliable data from eral, both were much more tolerant of variola many countries and the inadequacy of the minor than of variola major. This was evident record even in those with the best data, the in many countries-for example, Switzer- treatment of the subject is far from complete. land, in which variola minor was endemic between 1921 and 1926. When variola major occurred in Basle in 1921 (44 cases ; 7 deaths) VARIATIONS IN THE INCIDENCE it was promptly controlled, whereas it took 6 OF VARIOLA MAJOR AND VARIOLA years to eliminate variola minor from Swit- MINOR zerland (Sobernheim, 1929), leading to a pronouncement by the Swiss delegate to the As Fig. 5.8 (Chapter 5) illustrates, the 1926 International Sanitary Conference of American strain of variola minor (alastrim) the Office international d’Hygi6ne publique : virus spread from the USA to Canada, South “[Smallpox] has, in reality, no place in an America, Europe, Australia and New Zea- international convention. It is not a pestilential 8. INCIDENCE AND CONTROL, 1900-1958 317 disease in the proper sense of the term: it is, in nation was poor and the health services effect, a disease that exists everywhere. There is ineffective, such as India and Mexico, variola probably not a single country of which it can be major predominated because of its greater said that there are no cases of smallpox.” (Cited by capacity to infect and spread. Howard-Jones, 19?5.) (4) In some African countries such as Three other factors were operative: the Ethiopia, in which at that time there was infectiousness of individual patients; the virtually no vaccination, endemic variola number of contacts with susceptible subjects ; minor replaced variola major, probably dur- and the degree of protection afforded by ing the 1950s. In this country of sparse vaccination, if it had been carried out many population and very poor communications, years earlier. Patients with variola major the major factor favouring variola minor was usually excreted more virus and were thus probably its capacity to persist in small more infectious than patients with variola nomadic groups, among whom the transmis- minor, and variola major was more likely sion of variola major would have been inter- to overcome the effects of slight residual rupted spontaneously (see Chapters 4 and 21). immunity due to vaccination. On the other Its persistence was probably helped by the hand, the severity of systemic symptoms from widespread practice of variolation (see the prodromal stage onwards was so great in Chapter 21). For much of the period under variola major that most patients were con- review variola major and variola minor co- fined to bed and thus their contacts were existed in many central, eastern and southern greatly limited. Patients with variola minor African countries. usually had such a mild systemic illness that Brazil does not fit readily into this classifi- they were often ambulant throughout the cation. Although its health services were course of the disease, and therefore made probably no better than those of Mexico many more close contacts. during the 1920s and 1930s, alastrim replaced These four factors, and the element of variola major in Brazil during the 1920s but chance, in relation to viral mutation or impor- never became endemic in Mexico. tation, interacted to produce four patterns of endemicity : (1) In very well vaccinated communities, THE ELIMINATION OF SMALLPOX such as in many countries of continental FROM EUROPE BY 1953 Europe in the 1930s, the level of immunity of the population was so high that variola minor One of the factors which led to the decision could not become established. Any smallpox by the Twelfth World Health Assembly, in that did occur was variola major associated 1959, to adopt global eradication of smallpox with importations. as a major goal of the World Health Organiza- (2) In countries such as the United King- tion (see Chapter 9) was the fact that by this dom and the USA, with highly organized time eradication had been achieved in all the health services but without properly enforced countries of Europe and of Central and North compulsory vaccination, outbreaks of variola America. Tables 8.1 and 8.2 set out the major were rapidly brought under control by incidence of reported cases of smallpox isolation and selective vaccination, whereas between 1920 and 1958, in selected countries variola minor evoked no such reaction from of western and eastern Europe respectively. the health authorities. For example, in De- The gradual elimination of endemic small- troit, Michigan, in 1923, at a time when pox from the countries of Europe is illustra- variola minor was epidemic (710 cases in 6 ted in Fig. 8.1-8.3. In the following pages the months), the Health Department conducted overall position in Europe between 1900 and vigorous propaganda for vaccination, but 1958 is described first, drawing on Low achieved only about 6000 vaccinations per (1918) for data before the First World War. month. Soon afterwards variola major was Stowman (1945), Fabre (1948), Murray imported from Canada ; the vaccination rate (1 95 1) and the Epidemiological and vitalstatistics increased very greatly, half a million persons report (1953) provide useful summaries of the being vaccinated within 1 month and 800 000 incidence during both the First and the (about 70% of the population) within 5 Second World Wars and the inter-war period. months. Following this summary, the situation in (3) In populous countries in which vacci- selected European countries for which more Table 8. I. Western Europe: numbers of reported cases of smallpox in selected countries, 1920- I958a ew m Germanyb United France ltalyc Spainc Belgium Netherlandsc, Austria Portugalc Switzerland Kingdom 1920 population (millions) 62 44 39 37 21 8 7 6 6 4 I950 population (millions) 68 51 42 47 28 9 10 7 8 5 I920 2 IIS I007 392 26 453 3 285 91 50 253 I209 2 1921 689 442 34 I 4 644 2 097 21 I 18 267 596 I922 215 980 I72 534 I 325 23 0 4 425 I 153 1923 17 2 507 I95 495 525 31 2 17 660 2 145 I924 16 3 801 210 432 I217 31 3 I 75 I I234 I925 24 5 367 456 I95 849 12 2 0 468 329 I926 7 10 147 565 112 I12 13 15 0 3 94 54 I927 4 14921
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