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WORLD HEALTH ORGANIZATION A33/3 ORGANISATION MONDIALE DE LA SANTÉ 13 March 198о THIRTY-THIRD WORLD HEALTH AssEMBLY 11VüEJCLD Provisional agenda item 21 REPORT OF THE GLOBAL COMMISSION FOR THE CERTIFICATION OF SMALLPDX ERADICATION The Director -General has the honour to transmit to the Thirty -third World Health Assembly the final report of the Global Commission for the Certification of Smallpox Eradication. WORLD HEALTH ORGANIZATION А33/3 VV«�г� .' V! ORGANISATION MONDIALE DE LA SANTÉ ANNEX WHO/SE/79.152 THE ACHIEVEMENT OF GLOBAL ERADICATION OF SMALLPDX FINAL REPORT OF THE GLOBAL COMMISSION FOR THE CERTIFICATION OF SMALLPDX ERADICATION GENEVA DECEMBER 1979 The issue of this document does not constitute Ce document ne constitue pas une publication. formal publication. It should not be reviewed, Il ne doit faire l'objet d'aucun compte rendu ou abstracted or quoted without the agreement of résumé ni d'aucune citation sans l'autorisation de the World Health Organization. Authors alone l'Organisation Mondiale de la Santé. Les opinions are responsible for views expressed in signed exprimées dans les articles signés n'engagent articles. que leurs auteurs. WHO /SE/79.152 page 2 The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city, or area, or concerning the delimitation of its frontiers or boundaries. WHO /SE/79.152 page 3 MEMBERS OF THE GLOBAL COMMISSION FOR THE CERTIFICATION OF SMALLPDX ERADICATION Dr J. Aashi Dr F. Fenner (Chairman) Assistant Director -General Director, Centre for Resource and Preventive Medicine Environmental Studies Ministry of Health The Australian National University Riyad P.O. Box 4 Saudi Arabia Canberra, A.C.T. 2600 Australia Dr J. Azurin Under -Secretary of Health Dr D.A. Henderson Department of Health Dean, School of Hygiene and Public Health Manila The Johns Hopkins University Philippines 615 North Wolfe Street Baltimore Dr R.N. Baru Maryland 21205 Assistant Director -General of USA Health Services (Smallpox) Directorate General of Dr Kalisa Ruti Health Services Director, Expanded Programme on New Delhi Immunization India P.O. Box 1899 Kinshasa Dr P.N. Burgasov Zaire Deputy Minister of Health of the USSR Dr W. Koinange Karuga Ministry of Health of the USSR Director of Medical Services Rzhmanovskij per. 3 Ministry of Health Moscow P.O. Box 30016 USSR Nairobi Kenya Dr A. Deria National Programme Manager Dr J. Kostrzewski (Vice -Chairman) Smallpox Eradication Programme Secretary, Medical Section c/o WHO Programme Coordinator Polish Academy of Sciences P.O. Box 374 Palac Kultury i Nauki Mogadishu 00 -901 Warsaw Somalia Poland Dr K.R. Dumbell Dr H. Lundbeck Head, Department of Virology Director The Wright -Fleming Institute National Bacteriological Laboratory of Microbiology 105 21 Stockholm St Mary's Hospital Medical Sweden School London W2 1PG Dr S.S. Marennikova United Kingdom Chief, Smallpox Prophylaxis Department Research Institute of Virus Preparations 1st Dubrovskaya ul. 15 Moscow USSR WHO /SE/79.152 page 4 Dr J.S. Moeti Dr I. Tagaya Chief Medical Officer of Health Director, Department of Enteroviruses Ministry of Health National Institute of Health Gaborone Murayama Annex Botswana Gakuen Musashi-Murayama Dr C. Mofidil Tokyo 190 -12 Apartment No. 249, Block 9 Japan Behjatabad Building Teheran 15 Dr P.F. Wehrle (Rapporteur) Iran Hastings Professor of Pediatrics Pediatric Pavilion Dr R. Netter Los Angeles County - University of Director -General Southern California Medical Center Laboratoire national de la Santé 1129 North State Street 25 Boulevard Saint -Jacques Los Angeles Paris 75014 California 90033 France USA Dr Bichat A. Rodrigues Dr Zhang Yi -hao Executive Secretary of National Deputy Director Council of Health National Serum and Vaccine Institute Ministry of Health Beijing Brasilia 70.000 China Brazil Dr P.N. Shrestha Chief, Planning Division Institute of Medicine Maharajgunja Kathmandu Nepal 1Unаblе to attend WHO /sE/79.152 page 5 C O N T E N T S PREFACE 9 1. SUMMARY 10 2. CONCLUSIONS AND RECOMMENDATIONS 12 2.1 Conclusions 12 2.2 Recommendations : Policy for the post -eradication era 12 Vaccination policy Reserve stocks of vaccine Investigation of suspected smallpox cases Laboratories retaining variola virus stocks Human monkeypox Laboratory investigations Documentation of the smallpox eradication programme WHO headquarters staff 3. HISTORY OF SMALLPDX, VARIOLATION AND VACCINATION 16 3.1 Possible origin of smallpox and history of its global spread 16 3.2 Early efforts at control 17 3.2.1 Variolation as a method of control 3.2.2 Vaccination as a method of control 4. CLINICAL FEATURES AND DIAGNOSIS OF SMALLPDX 19 4.1 Clinical course 19 4.1.1 Case fatality rate 4.2 Clinical differentiation from other diseases 20 4.3 Laboratory diagnosis 20 5. EPIDEMIOLOGY OF SMALLPDX 22 5.1 Infectivity 22 5.2 Immunity 22 5.3 Spread 22 5.4 Age incidence 23 5.5 Seasonal incidence 23 6. INTERNATIONAL INVOLVEMENT IN CONTROL AND ERADICATION : 1924 -1966 23 6.1 1924-1947 23 6.2 1948-1957 24 6.3 1958-1967 24 WHO /SE/79.152 page 6 7. THE ESTABLISHMENT OF THE INTENSIFIED SMALLPDX ERADICATION PROGRAMME 25 7.1 Headquarters 25 7.2 Regional offices 26 7.3 National programmes 26 8. STRATEGIES IN THE INTENSIFIED ERADICATION PROGRAMME 27 8.1 Provision of a sufficient amount of potent and heat -stable vaccine 27 8.1.1 Freeze -dried vaccine 8.1.2 Production 8.1.3 Quality control 8.1.4 Provision of consultant services, fellowship training and vaccine testing by WHO 8.1.5 Techniques of vaccination 8.1.6 Complications of vaccination 8.2 The mass vaccination strategy 30 8.2.1 Rationale 8.2.2 Vaccination coverage 8.2.3 Assessment 8.2.4 Successes and failures 8.3 Changing strategies 31 8.3.1 Lessons from the field 8.3.2 Characteristics of smallpox facilitating eradication 8.4 The surveillance and containment strategy 33 8.4.1 Routine reporting systems 8.4.2 Active surveillance 8.4.2.1 Special searches 8.4.3 Containment 8.4.4 Special problems 8.4.4.1 Concealment of outbreaks 8.4.4.2 Variolation 8.5 Research 36 8.5.1 Epidemiology and public health 8.5.2 Virology WHO /SE/79.152 page 7 9. IMPLEMENTATION OF THE INTENSIFIED ERADICATION PROGRAMME 36 9.1 The period from 1967 to 1972 37 9.1.1 West and central Africa 9.1.2 South America 9.1.2.1 Brazil 9.1.2.2 Other countries 9.1.3 Other central African countries 9.1.4 South -eastern Africa 9.1.5 Sudan and Uganda 9.1.5.1 Uganda 9.1.5.2 Sudan 9.1.6 Indonesia 9.2 Southern Asia 42 9.2.1 Burma 9.2.2 Afghanistan 9.2.3 Pakistan 9.2.4 Nepal 9.2.5 India 9.2.6 Bhutan 9.2.7 Bangladesh 9.3 The countries of the Arabian peninsula 46 9.4 Countries in the Horn of Africa 46 9.4.1 Djibouti 9.4.2 Ethiopia 9.4.3 Kenya 9.4.4 Somalia 9.5 Missed outbreaks 49 10. OUTBREAKS OF SMALLPDX IN NON- ENDEMIC AREAS 50 10.1 Importations of smallpox 50 10.1.1 International quarantine 10.1.2 Importations into Europe, 1950 -1977 10.2 Laboratory -associated outbreaks 51 11. THE CERTIFICATION OF ERADICATION 51 11.1 International Commissions 51 11.2 Preparations for certification 52 WHO /SE/79.152 page 8 11.2.1 In recently endemic and adjacent countries 11.2.1.1 Effectiveness of the routine reporting system 11.2.1.2 Active searches 11.2.1.3 Pockmark surveys 11.2.1.4 Chickenpox surveillance 11.2.1.5 Rumour register 11.2.1.6 Specimens for laboratory diagnosis 11.2.1.7 Publicity, knowledge about smallpox, and rewards 11.2.2 In countries free from smallpox for several years 11.3 Certification by international-commissions 57 11.4 Certification by the Global Commission 59 11.4.1 Rationale 11.4.2 Action by the Global Commission 11.4.2.1 Countries already certified by international commissions 11.4.2.2 Countries designated for special reports and /or visits 11.4.2.3 Formal statements by countries and areas 11.5 International smallpox rumour register 59 12. HUMAN MONKEYPDX 60 12.1 Discovery and properties of moпkеypoх virus 60 12.2 Human infections with monkeypox virus 61 13. POSSIBLE SOURCES FOR A RETURN OF SМALLPDX 62 13.1 Laboratory stocks of variola virus 62 13.2 Deliberate release 62 13.3 Natural reservoirs of variola virus 62 13.3.1 Virus in crusts 13.4 An animal reservoir 62 13.4.1 Whitepox virus 13.4.2 White pock variants of monkeypox virus 14. INTERNATIONAL RESOURCES FOR THE INTENSIFIED ERADICATION PROGRAMME 63 14.1 Financial 63 14.1.1 1958 - 1966 14.1.2 1967 - 1980 14.2 National and locally recruited personnel 64 14.3 International personnel 64 14.4 Vaccine 65 14.5 Transport 65 ANNEXES 1 -19 66 WHо /SE/79.152 page 9 PREFACE At the beginning of the twentieth century smallpox affected every continent and virtually every country in the world at one time or another. Over the first half of the century it was eliminated from most countries of Europe, North America and Oceania, but it remained endemic in most of Africa, Asia and South America. When the World Health Organization was set up in 1948 it singled out smallpox as the first disease whose control should be sought by all countries, but it was not until 1958 that there was an explicit call from the World Health Assembly for the worldwide eradication of smallpox.
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