How to Defeat COVID-19? Some Lessons from the Global Smallpox Eradication and the Polio-Free Effort in the Americas

How to Defeat COVID-19? Some Lessons from the Global Smallpox Eradication and the Polio-Free Effort in the Americas Patricio V Marquez, Betty Hanan, Giovanni S Marquez “Humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future” ---William H. Foege, House on Fire: The Fight to Eradicate Smallpox, 2011 With the advent of 2021, the hope shared by the global community is that we can turn the page after the challenging year 2020 and reclaim some normalcy. The COVID-19 pandemic has disrupted and changed our lives in multiple ways, extracting a high human, social, and economic cost across the world. In large measure, the emergency approval of the first COVID-19 vaccines (Pfizer/BioNTech and Moderna, and in the UK of AstraZeneca), and the promise of an additional pipeline of vaccines that may be approved in the upcoming months, is fueling this hope. But, as was anticipated, the massive deployment and administration of new vaccines for entire populations in countries is a complex task. It has encountered severe bottlenecks that are delaying the achievement of ambitious vaccination targets, even in rich countries such as the United States, the United Kingdom, and nations in the European Union. While a crisis poses challenges, it also offers opportunities to learn and evolve. In that sense, perhaps we need to pause, look back, and learn anew from public health history to avoid being condemned to repeat past mistakes, by adapting methods that worked well in the past to deal with similar public health challenges. Some of us have been blessed for having been exposed during our formative years to historical public health leaders such as Prof. D.H. Henderson, who led at the World Health Organization (WHO) the international effort to eradicate smallpox, before becoming the dean of the Johns Hopkins School of Hygiene and Public Health, and Dr. Ciro de Quadros, a Brazilian epidemiologist who was part of the smallpox eradication effort in Ethiopia and later led the Pan American Health Organization (PAHO)-driven polio eradication program in the Americas. Their work offers us some lessons that are highly relevant for ensuring that COVID-19 vaccination roll-out is effective. 1. Lessons from the eradication of smallpox More than 40 years have passed since the last naturally occurring case of smallpox, marking the “death of a disease.” This landmark global public health victory was the result of a 10-year smallpox eradication plan approved in 1966 by the World Health Assembly. It built upon the failed efforts over 1957-1975 to eradicate hookworm, yellow fever, yaws, and malaria. The plan included two components: (i) systematic vaccination and (ii) a new concept—surveillance and containment. First, it called for continuous, routine collection of data about cases and deaths due to infectious diseases; the regular analysis and interpretation of this material; and its regular distribution to those responsible for disease control. Second, the containment of outbreaks by special containment teams required that vaccines be administered in the area where outbreaks were occurring, to break the chain of transmission by vaccinating possible contacts in areas where there were cases. As explained by Prof. D.H. Henderson in an interview, an interesting historical aspect was that the plan was approved during the time that the Cold War between the US and the Soviet Union was at its peak. Both superpowers put aside their political differences to support and fund the smallpox eradication campaign. A lesson from this experience for successfully dealing with the ongoing COVID- 19 pandemic, is that all countries should cooperate and participate in a global effort to control SARS-Cov2 under the technical lead of WHO and support from institutions such as the World Bank Group. This will require mobilizing financing resources to fund the vaccination effort at the country level, complemented by contributions from high income countries to COVAX to subsidize the purchase of vaccines for low-income and low-middle income countries under its Advance Market Commitment-92 (AMC-19) arrangement. There are three additional lessons for the COVID-19 control effort that can be derived from the smallpox eradication experience, as recently highlighted in a Lancet commentary: 1. well-defined, time-bound, programs need to be prepared and adopted, with clear, measurable objectives for extinguishing community transmission; 2. equitable access and distribution of vaccines among countries, ramping up vaccine production, and ensuring quality control of laboratories making the vaccines; 3. it is of critical importance to: undertake country vaccination readiness assessments to identify gaps in the system to inform policy and programmatic decisions; allocate adequate financial resources for strengthening logistical and operational capacity, including cold chain systems, to vaccinate entire populations in accordance with the results of the readiness assessments; have a cadre of well-trained personnel to administer the vaccines; involve local communities; and, support continuous research and feedback in the field. 2. Lessons from Polio-Free Americas Program The Americas was the first WHO region to be certified polio-free in 1994. This historical public health achievement in the region, was the product of work led by Dr. Ciro de Quadros between 1970 and 2002, serving as PAHO's first head of the Expanded Program on Immunization (EPI). The polio campaign in the Americas was launched in 1985, and the last case was reported in 1991. In accordance with EPI guidelines, the polio campaign was not run as an independent initiative but was part of an effort to integrate all programs for vaccine-preventable diseases. Thereby, national polio campaigns included other vaccines, such as measles, DPT, and tetanus toxoid. Cuba provided the early signs that polio eradication was possible in the Americas. In 1962, Cuba launched a nationwide annual polio vaccination campaign with the oral polio vaccine (OPV) as part of a comprehensive national polio elimination program. The campaign and follow-ups, which targeted children 1 month – 14 years of age, with two doses given 4 weeks apart, and which were implemented twice a year, were characterized by high vaccination coverage achieved through week-long drives, surveillance of suspected cases, and outbreak investigation and control, when necessary. This strategy effectively halted polio transmission in Cuba, with the last case being recorded in May 1962. The essential components of the polio-free effort in the Americas, that are highly relevant for the COVID-19 vaccination effort nowadays, were: At the country level: Political will, local alliances, and community involvement are absolutely necessary to take on the goal of interrupting/controlling disease transmission. In the Americas, the regional campaign against polio was spearheaded by governments, international organizations, and nonprofits. As noted by Sir George Alleyne, the Director Emeritus of PAHO, the region became the first to defeat the once lethal childhood infection and has been able to sustain its infectious disease control programs since, because “the countries of the region accepted the need to eliminate polio and infectious diseases in general and there was commitment to a regional (Pan-American) approach to solving the problem.” In large measure, however, the success was due to the widespread support of local communities. For instance, in El Salvador, at the height of the country’s civil conflict in the mid-1980s, it was necessary that agreements be negotiated between the government and guerrilla forces, a painstaking process that involved PAHO, UNICEF, the Red Cross, and the Catholic Church, to observe cease-fires during national immunization days. Extraordinary social mobilization efforts accompanied the immunization campaigns, as well. Radio and television announcements and newspaper articles highlighted the importance of immunization, and people throughout Central America responded positively to these massive media campaigns. The number of staff responsible for the EPI, should be strengthened through additional human resources and training. The Plan of Action spearheaded by PAHO emphasized personnel training as a critical component of the program’s success. PAHO prepared training manuals and materials, and assisted countries with customizing these to fit the local context and circumstances. Training activities also bolstered the commitment of health workers and national governments towards the regional goal of polio eradication. High coverage, active surveillance, and lab networks are essential components for controlling disease outbreaks. Enhanced surveillance was a critical component for the success of this initiative, as inaccurate surveillance can hinder the timely implementation of early control measures. A reporting system with standard procedures and definitions was implemented to ensure that no cases were missed. Moreover, every case was regarded as a public health emergency and investigated immediately; its chain of transmission was used to determine the extent of virus circulation in the community. Increased laboratory support was critical since with the decrease in the number of cases and the increase in vaccination coverage, it became more important to determine if a poliovirus isolate was a wild virus. Gaps in the logistics

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