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In the Mood for Wiping out Vaccine-Preventable Diseases Ciro De Quadros Has Led Some of the Most Successful Immunization Campaigns in the History of Public Health

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In the Mood for Wiping out Vaccine-Preventable Diseases Ciro De Quadros Has Led Some of the Most Successful Immunization Campaigns in the History of Public Health News In the mood for wiping out vaccine-preventable diseases Ciro de Quadros has led some of the most successful immunization campaigns in the history of public health. He tells Fiona Fleck why, in some ways, it’s harder to eliminate vaccine-preventable diseases today than it was in the past. Q: How did you become interested in immunization? Ciro de Quadros is the executive vice president of the A: After I got my MD degree in Sabin Vaccine Institute, where he heads the vaccine 1966, I worked at a health centre in a advocacy and education programme. Before he small town in the Amazon region, then took up that post in 2003, he held leading positions studied epidemiology and got involved in immunization at the World Health Organization in a new national centre for epidemiol- ogy, a kind of “Brazilian CDC” (Centers (WHO)/Pan American Health Organization (PAHO) for Disease Control and Prevention). between 1970 and 2002, including as the first head But the centre never took off because of the American region’s Expanded Programme on Courtesy of Ciro de Quadros Courtesy of Ciro people working there were accused Ciro de Quadros Immunization. From 1970 to 1976, he served as WHO’s of being communists by the military chief epidemiologist for the smallpox programme in dictatorship. Through the centre, I got Ethiopia. He holds several academic posts, has published extensively in peer- involved in the smallpox campaign reviewed journals on immunization and related issues and serves on many expert which had started in Brazil. health committees. He completed his medical and public health studies in Brazil. In 1969 three other colleagues and I did some of the first trials of the sur- veillance and containment strategy. The smallpox programme in Brazil was with the smallpox patients, you could el to the health centre and spend one based on mass vaccination but did not stop the chain of transmission. That is day a week with us. They reported the have enough resources to mass vaccinate how surveillance and containment works. births in their areas and we recorded people in every state. So we chose four In Brazil, surveillance and containment close to 100% of these, then gave the states where we set up surveillance and proved to be a fantastic strategy and it attendants sterilized materials to use containment units. I was in charge of the was tested in studies in West Africa and in their next deliveries. We had a good unit in Paraná, a state of some eight mil- India with the same success. That’s why system for recording and follow-up lion people and where in 7 or 8 months we it became the final strategy of the global and if kids didn’t come for a second identified over 1000 smallpox cases and smallpox programme. or third dose, the nurse or sanitarian vaccinated their contacts, about 30 000 would visit the family to make sure people. As a result, transmission was Q: Today Brazil is struggling to fill phy- they got it. We also sent the sanitarian interrupted. We published the research in sicians’ posts in remote areas. What to people’s homes to improve sanitation this journal. That was my first experience motivated you to work in such places? by building latrines and connecting the with an immunization programme. A: When I applied to study at the water supply. National School of Public Health, a Q: What is surveillance and containment professor there advised me to work in Q: This year marks 40 years of the Ex- and how did you help to develop this the field first. A foundation called the panded Programme on Immunization approach? Special Service for Public Health (Serviço (EPI). In 1977, you went to work at PAHO A: The smallpox programme in Especial de Saúde Pública) was working in to launch the programme in the Ameri- Brazil started in 1966 with mass vaccina- remote areas of Brazil and needed doc- cas, how did you begin? tion campaigns, which aim to vaccinate tors. They sent me to head a health centre A: When the programme was ap- every single person. But when Donald A in the Amazon Region, in a town called proved by the World Health Assembly Henderson came to Geneva to head the Altamira of about 4000 people in Pará (WHA) in 1974, nothing happened for WHO Smallpox Eradication Programme state. All we had was a community nurse, three years. Vaccination coverage was – before I worked on smallpox – he and a laboratory technician, a sanitarian and very low, below 10% in many parts of his team realized that some countries an administrator to take care of the health the developing world and only three with high levels of vaccination coverage of that community. Vaccine coverage rates vaccines were in use in most countries still had smallpox outbreaks and that were not very high, maybe about 50% – DTP, tetanus toxoid and BCG. Most mass vaccination was not working ev- or 60%, and we only had a few vaccines: countries in the region didn’t even have erywhere. They knew that people with diphtheria–tetanus–pertussis (DTP), tet- an immunization programme and were smallpox had pock marks on their faces anus toxoid and bacille Calmette–Guérin just responding to outbreaks. My task and that these people usually knew where (BCG) [for tuberculosis]. In the early was to get the countries to organize they got infected, because they had seen 1970s, the picture was similar all over the themselves. First, we asked them to someone else like that. They said that if developing world. Still, our small team appoint an immunization manager to you could trace the chain of transmis- managed to increase coverage to nearly run their programmes. Within a year sion from one patient to another over 100% during my first year. they had done this. Then we trained several generations and vaccinate all of We identified the traditional birth the managers so that they could train the people who had come into contact attendants in the area, who would trav- their staff. 236 Bull World Health Organ 2014;92:236–237 | doi: http://dx.doi.org/10.2471/BLT.14.030414 News Q: The Americas was the first WHO region partners and with conflict groups to afford these vaccines. They need new to be certified polio-free in 1994, and it find a resolution. We were lucky that mechanisms to make these vaccines has kept measles at bay since 2002. we could broker peace days between available, such as the PAHO revolving Why has the Expanded Programme on the warring factions. The first one was fund, created in 1979 and that today Immunization been so successful in the in El Salvador in 1985, when everybody has a capitalization of about US$ 100 Americas? participated in the national immuniza- million, and they get reduced prices by A: We had meetings to introduce tion day – even the guerrillas – and that purchasing in bulk. countries to the concept of the Expanded became known as a “day of tranquillity”. Programme on Immunization and soon Dr [Carlyle Guerra de] Macedo, who Q: You are on the Polio Independent all of them started moving in that direc- headed PAHO at the time, called this “a Monitoring Board and have led the Glob- tion. We brought together all the country bridge for peace” because we overcame al Vaccine Action Plan (GVAP) process in managers and everyone else from the problems through the discussion of the past. Why is the Decade of Vaccines governments working in epidemiology, health issues. Today, the situation in and the GVAP making slow progress? primary health care, maternal and child Nigeria, and particularly in Afghanistan A: The GVAP represents a fantastic health, financing and so on, and we asked and Pakistan, is more complex than in initiative, but follow up has been weak. them: “What are the problems that you Latin America. I know that the Global WHO’s regional offices need to prepare have when trying to implement immu- Polio Eradication Initiative is dealing or finalize their “regional vaccine action nization programmes in your countries with those issues, and it’s not easy. plans” and countries need to be support- and what are the solutions?” We listed ed in the preparation of their “national the problems – how to improve cover- Q: What challenges does the Expanded vaccine action plans”. Hurdles to imple- age, do surveillance and organize the Programme on Immunization face today? mentation need to be overcome, such as cold chain – and analysed them. Then A: We launched the polio cam- insufficient budget allocation and lack of we produced a publication called Im- paign in 1985 and had the last case in coordination among partners. munization and primary health care: 1991 in the Americas. The target was problems and solutions (PAHO Scientific 1990 – we were eight months late. We Q: Why the delay? Publication No. 417) and started working didn’t encourage independent pro- A: First you need to transform the on those problems and solutions. PAHO gramme initiatives, like those you see GVAP into regional and national vaccine still does this today. today on the global level. For example, action plans. For example, at a recent a Global Polio Eradication Initiative meeting of the Expanded Programme on Q: You were criticized in the early years that is not part of the Expanded Pro- Immunization managers from Africa, I of the Expanded Programme on Im- gramme on Immunization or a Measles asked how many of them had read the munization, how did you win over your & Rubella Initiative that may work GVAP that was approved two years ago detractors? independently of this programme.
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