DXIEIJMECIX: CENTER FOR DISEASE CONTROL ATLANTA, GEORGIA 30333 VOLUME 11, NO. 10

Zero Smallpox Issue This issue of DATELINE: CDC is devoted to the story of the eradi­ cation of smallpox and CDC's in­ volvement. Inside stories include: • Historical vignettes • Pictures of field work • The last case of U.S. smallpox • An early campaign to eliminate the disease • Technology of eradication • Future of the smallpox virus • Chronology of smallpox, and others

ft#***#*####*#****#*#*********** Throughout this issue are scattered stories o f "unsung heroes" from many nations who worked with CDC staff in V A R IO LA MAJOR'S last case Rahima Banu, AFTER RECOVERY, Ali Maow Maalin, the fight against smallpox. We have a little girl in Bangladesh who survived. will have chance for normal life. asked the staffers who worked with them to write about them, and all Global Effort Pays Off.. represent true stories o f the eradica­ tion battle. Smallpox at Target "Zero" -ft****************************** The last documented, naturally occurring case of smallpox was diagnosed in Physicians Challenged Merka, Somalia, in 1977. On October 26, 1979, the world celebrated its second anniversary free from smallpox transmission. Smallpox in 1844 A li Maow Maalin, then 23, was a of confidence among a trained army of The WHO campaign against small­ cook in Somalia when he came down smallpox fighters from most of the pox wasn't the first time war had been with smallpox. When he recovered, nations of the world — confidence that declared on the disease. he became the last recorded case of they could be successful in combat In 1844 the progress of a vaccina­ variola minor, a less severe form of with an old enemy. tion program in India was summarized the viral exanthem. In 1967 WHO launched the global in this way: Variola major was snuffed out Smallpox Eradication Programme to rid "...It was absolutely necessary earlier in 1975 with the recovery of the world of the disease within 10 to the final establishment of Rahima Banu, aged 3, of Bhola Island, years. vaccination, that it should be Bangladesh. The program followed several less carried to the doors of the people The campaign against smallpox was extensive, but notable successes. Eight —too lazy, too poor, or too igno­ made possible by many things — years earlier, WHO had suggested the rant, to come in search of it. He perhaps most important was the program to the council of nations at (the Hon. Mounstuart Elphinstone) mustering of international will to the instigation of the Soviet Union. At was well aware that the presence of conquer a common pestilence. The that time, several nations began a European officer thoroughly international w ill to eradicate small­ vaccination programs and in many, versed in the manners and habits of pox was assisted by new developments endemic transmission of smallpox the natives, would do more to in technology and by the development (See page 5) (See page 16) d xteunecix: Technology, Determination Win Against Implacable Enemy Monthly publication for employees of the Center for Disease Control, Public Health Service, U.S. Department of The conquest of smallpox has primarily been a human accomplishment — a Health, Education, and Welfare dramatic example of the good that can be done whenever enough people turn toward a single goal. Editorial and Distribution inquiries to But any review of this medical people at one time, particularly in the DATELINE:CDC R o o m 2 0 7 1 milestone must also note the impor­ military. B u ild in g 1 tant role played by technology. But it received major use in small­ Center for Disease Control Atlanta, Georgia 30333 Three technological tools were pox in the early days of the smallpox Ext. 3444 or 3286 particularly vital: the jet injector gun, eradication program. Injections against the bifurcated needle, and freeze-dried smallpox, measles and other diseases vaccine. were given at an average cost of Texas Man Survives The Jet Injector Gun 7/1 Oths of a cent, in West Africa. In The jet injector gun traces its Brazil more than 90 million smallpox Last U.S. Smallpox beginnings to a 19th century industrial vaccinations were given by jet gun. No one knows for sure when and accident. But it took half a century The Bifurcated Needle where the last case of smallpox in the for it to evolve from mechanic's tool While the jet injector gun was United States occurred. to medical instrument. effective in administering smallpox The best guess, based on a retro­ French workmen of the 1890's, vaccine to large numbers of people at spective look at national reporting, in­ who used grease guns in factories, collected points, it was unsuitable dicates that it probably was in 1949 complained about injecting themselves for house-to-house vaccination pro­ during an outbreak of smallpox in the instead of their intended targets with grams. The guns required maintenance lower Rio Grande Valley, Texas. grease. and repair that could not always be Small numbers of smallpox cases Later, biomedical researchers went provided. were reported in the early 1950's, to work to find a practical, portable, In 1967 the program began experi­ but these did not have laboratory con­ and effective variation on the principle menting with the new bifurcated — or firmation, and are believed to have of the grease gun to inject a jet of im­ forked — needle. (See illustration.) been an illness that was clinically munizing liquid at high pressure and This was one of the simplest items of suggestive of smallpox, such as velocity through the skin. medical technology, but it was to play chickenpox. For more than 20 years, in this a major role in delivering vaccine. country, the jet injector had been used The bifurcated needle has two •ft**-»*******#*******#*********** to give shots to large numbers of (See page 8) Abdel Gadir el Sid by Dr. Stanley O. Foster Abdel Gadir el Sid, a Sudanese smallpox operations officer, arrived in Somalia at a time when smallpox case hiding by the public was the rule. Giving his translator the after­ noon o ff and communicating in his native Arabic, Abdel Gadir moved from village to village searching for smallpox. Suddenly he found a single case. When villagers denied other cases, Abdel Gadir had an idea. He told his driver that he would drive and purposely drove the vehicle into two feet of mud. Villagers poured out of the houses to push the mired vehicle. Among them five more cases of smallpox. The hidden cases had been detected. VIC T O R Y SMILES for four who were prominent in smallpox eradication when last case occurred in India: Dr. J.D. Millar, Jim Hicks, Dr. William Foege, and Billy Griggs. At center *********** *'* ****************** is smallpox god, also defeated.

2 Ah Historic Chronology of Smallpox and Its Final Eradication

SOMETIME The practice of variolation developed in several areas; 1806 Thomas Jefferson wrote to Jenner: “Future nations B.C. scabs ormatter taken from pustules were rubbed on the will know by history only that the loathsome small­ skin of normal individuals, causing a mild infection. pox has existed and by you has been extirpated."

910 A.D. The first complete medical report on smallpox, Trea­ 1813 Congress authorized President James Madison "to tise on Smallpox and Measles, was published by an appoint an agent to preserve the genuine vaccine Arabian scholar, R hazes. matter, and to furnish the same to any citizen of the United States." EARLY Smallpox was probably introduced to the New World 1500's by slave ships. 1832 Congress passed an act ordering the Secretary of War to supply pure vaccine to Indian agents for vaccination 1618 The first smallpox epidemic to strike the Indians in programs. American colonies north of Mexico occurred in the area surrounding Boston. 1834 Negri in Naples produced good quality calf lymph by infecting healthy cows. This made human-to-human 1682 Thomas Sydenham, British physician, in a treatise on vaccination unnecessary. smallpox criticized the widely used heat treatment that made patients miserable, and observed that the 1900 By the turn of the century, the widespread use of vac­ survival rate was higher in the untreated than in those cines had turned smallpox from a major threat into a kept in a "hot bed." minor one in the United States and most of Europe, except Russia. 1721 Lady Mary Wortley Montagu, who learned about vario­ lation while in Turkey as wife of the British ambassa­ 1923 The Russian government made smallpox vaccination dor, introduced variolation to England. Princess mandatory. Caroline accepted it for her children, and the practice BEFORE The Dutch and the French were using vaccines in their became widespread. 1930's colonies. 1746 Renewed interest in variolation led to the establish­ ment of the Smallpox and Inoculation Hospital in 1947 An imported case of smallpox in New York City led to England. Improved procedures lowered the mortality five cases and vaccination of 6,000,000 in New York. rate. The practice spread to Europe and Russia. Surrounding areas also had vaccination campaigns. It Robert and Daniel Sutton, father and son, further re­ was the first smallpox in New York City since 1939. fined the variolation technique, in part through selec­ 1949 The last known case of smallpox in the United States tion of healthy patients. occurred in Rio Grande valley, Texas.

1776 The American colonial army lost a battle for Quebec 1950's Freeze-dried vaccine was developed by Leslie Collier to the British, largely because of smallpox. The British of the Lister Institute in England. The vaccine was were immune. The Americans were not, and came frozen in a vacuum and reconstituted with glycerol down with smallpox. solution. This was an important step in making a worldwide eradication program possible, because the 1796 Sarah Nelmes, a milkmaid, contracted cowpox. When vaccine could last two years at body temperature. the sores on her hand were at the worst, Edward Jen­ ner vaccinated a boy, James Phipps, with material 1958 WHO received, at a World Health Assembly meeting in from the sores. James became permanently immunized Minneapolis, Minnesota, a Russian resolution that against smallpox. smallpox could theoretically be eradicated.

1798 Dr. Jenner published his findings on vaccination;A n 1959 Meeting in Geneva, the World Health Assembly passed Inquiry Into the Causes and Effects of the Varlolae the Russian resolution. A few nations began eradica­ Vaccinae; A Disease Discovered in Some o f the West­ tion programs, but it was to be several years before a ern Counties o f England, Particularly Gloucestershire, concerted worldwide program would get underway. and Known by the Name o f the Cow Pox. 1961 CDC began smallpox surveillance and began consider­ 1802 Benjamin Waterhouse, a Boston physician, proved the ing how to handle a possible epidemic if one occurred. safety and effectiveness of the smallpox vaccine. He vaccinated a large number of children, and later ex­ 1962 A boy traveling from Brazil to Canada passed through posed them to smallpox. None became infected with New York City. He came down with smallpox in smallpox. Canada. CDC coordinated a wide-reaching immuniza­ tion effort to vaccinate all possible contacts. 1802 Thomas Jefferson, who had been interested in Jenner's and Waterhouse's work, wrote that the practice of 1962 CDC started studies of the smallpox vaccination status inoculation should be brought "to the level of com­ of hospital workers. mon capacities." He allowed the use of the White House for distribution of smallpox vaccine and made 1963 CDC established a smallpox unit in its Bureau of special efforts to ensure vaccination of American Epidemiology. Indians. 1963 CDC sent a vaccination team to Tonga in the South 1802 King Carlos IV of Spain agreed to finance an expedi­ Pacific to test the U.S. Army's hydraulic jet injector in tion to vaccinate the Indians in Central America. Led a population that had not received smallpox vaccina­ by Francisco Xavier de Balmis, the expedition brought tion. The jet injector proved capable of giving the vaccine to hundreds of thousands of Indians and later vaccine intradermally at the rate of 1,000 injections to the Philippines and other Spanish colonies. Per hour- (See page 4)

3 An Historic Chronology of Smallpox and Its Final Eradication (Continued from page 3)

1963 The Bureau of Biologies tested a new measles vaccine 1970 The last case of smallpox occurred in West Africa. in Upper Volta, using jet injectors to vaccinate over 10,000 children. This program and later measles pro­ 1971 The last case of smallpox occurred in Brazil. grams in African nations were sponsored by the Agency 1971 The Public Health Service accepted the recommenda­ for International Development (AID). tion of its Advisory Committee on Immunization Practices that routine smallpox vaccination be discon­ 1964 CDC began investigating the question of whether or tinued. For most people in the United States, the not to continue smallpox vaccinations in the U.S. probability of contractor smallpox was so small that Smallpox was gone in the United States, and there the risk of complications from vaccine outweighed the was a need to determine the extent of reactions or benefits derived from it. deaths from smallpox vaccine. 1971 A decision was made to spend HEW funds to further 1965 CDC proposed a joint smallpox eradication and mea­ smallpox eradication. Previously all money was from sles control program in West Africa to AID. the Agency for Internationa! Development.

1965 After a representative of one African nation praised 1972 A pilgrim returning from Mecca is believed to have im­ the measles programs to President Lyndon Johnson, ported smallpox into Yugoslavia. An epidemic fol­ the President issued a statement to the World Health lowed, involving 174 cases, with 36 deaths. CDC Assembly pledging more U.S. assistance to vaccination assisted in vaccination of an estimated 16 or 17 mil­ programs in Africa, and the eradication of smallpox. lion people in a population of 21 million. This paved the way for the 20-nation smallpox eradica- 1973 The Indian government requested the states to start tion/measles control program that CDC had proposed. offering rewards to individuals who reported cases of 1966 CDC began organizing and training teams of medical smallpox. Rewards were eventually extended to health officers and operations officers for two-year tours of workers. The rewards were necessary and helped prove duty in 20 West African nations with an estimated to those reluctant to report that the government really population of 150 million. did want cases reported.

1966 Lagos, Nigeria, was selected as the West African head­ 1973 Surveillance and containment was begun in India. quarters of the project. This led to such an improvement in reporting that many thought India was having a smallpox epidemic. 1966 The World Health Assembly voted to establish a Worldwide Smallpox Eradication Programme, appro­ 1975 Saiban Bibi, a young woman from Bangladesh, was the priating $2 million to get started. last case of smallpox to occur in India. She became infected in Bangladesh and traveled to India. She left 1967 The first vaccinations began in the West African in her wake thousands of searches for cases among project. possible contacts, and hundreds of vaccinations, but no more cases of smallpox. She recovered and re­ 1968 After mass vaccination failed to eradicate smallpox in turned home. some areas, the CDC group developed a surveillance and containment system. They used this system in 1975 The last case of smallpox in Asia, and the last case of eight countries: Nigeria, Togo, Dahomey, Mali, Upper variola major, occurred in Bangladesh. The victim, Volta, Niger, Guinea, and Sierra Leone. who recovered, was a little girl, Rahima Banu.

1968 Surveillance and containment was introduced into a 1977 On October 26, the last case of variola minor to occur WHO-sponsored smallpox eradication program in in the world, occurred in Somalia. The victim, who Indonesia. recovered, was Ali Maow Maalin.

TRAINEES AND FACULTY at CDC before launching West African Program.

4 ft**#*****#**##*#***«***#*#*#*** Dr. Foli Georges Glokpor by Andrew N. Agle In the spring of 1969, Dr. Foli Georges Glokpor, director of the smallpox program in Togo, sub­ mitted a carefully researched report on cultural resistance to smallpox vaccination in Togo. The report, prepared at the request of CDC, was expected to detail the pagan activities of the Sakpate cult whose members considered smallpox sa­ cred (and, by logical extension, presumably regarded vaccination as a threat). Dr. Glokpor presented a detailed exposition of the cult's history and tenets. He traced the cult's activit­ ies right up to the date of his report. He concluded that, although there were indeed some Sakpate adherents who had avoided being vaccinated, the only modern day ''cultural resistance" on a village­ wide scale had occurred (on two occasions) in villages whose inhab­ itants had been proselytized by an PEOPLE IN LINE for vaccine in 1967 at Ghana Trade Fair. obscure Christian sect. ******************************* "Zero" (From page 1) which surveillance/containment with the local governments. They was interrupted. Smallpox remained were the principal components. assisted in planning the program and where there were large rural popula­ The campaign and its success have worked closely with the Ministry of tions, poverty, poor transportation, special meaning for CDC. In 1966 the Health in seeing that each country had and poor communications. U.S. supported eradication projects on a plan suited to its own human, Vaccination had eliminated small­ a regional and bilateral basis with 20 financial and other resources. pox from Europe and North America, countries in Africa. Under contract "It seems to me that this early part but it was still a major problem in with AID (Agency for International of the program was pivotal from the parts of South America, Africa, and Development), CDC was designated to standpoint of CDC," said Dr. J. Asia, and thus posed a continued provide personnel and orientation pro­ Michael Lane, one of the Center's lead threat to smallpox-free areas. In 1966 grams for a preliminary skirmish against people in the smallpox effort. " I t smallpox was endemic in 30 countries the disease in West and Central Africa. was Dr. David Sencer's decision to and afflicted more than 2.5 million That year it was estimated that commit CDC resources and people people. some 200,000 to 400,000 cases of to the smallpox program that made all In 1965 the U.S. pledged its sup­ smallpox occurred in West Africa in of the rest possible." port of the eradication concept and most years. Obstacles to the eradica­ Dr. J. Donald Millar, director of the other vital developments came along tion program included lack of ade­ African Program, emphasized that the soon thereafter to make the time right quate transportation and communica­ success in Africa was largely because it for eradication. According to those tion systems, insufficient medical or­ was an African program. It was plan­ who worked in the program, those ganization and personnel in many ned by the Africans and carried out by developments were: countries, and cultural differences. Africans except for the input of the 1. The pooling of international re­ The jet injector gun was used in the American officers in each country. sources in a coordinated effort African campaign and was a new, It is estimated that about 4,000 2. Improvement of the technique sometimes frightening tool to villagers Africans worked in some capacity. of vaccination wary of vaccination of any kind. In In Africa an important tactical 3. Introduction of high quality each of the 20 countries of West and change was made—a change which freeze-dried vaccine Central Africa, an American medical was to set the example for the global 4. A change of strategy from one officer and/or American operations attack on smallpox. Previously fighters of mass vaccination to one in officer were responsible for working (See page 6)

5 efficient tool made vaccination pro­ Brazil set up weekly reporting systems "Zero" (From page 5) of smallpox had believed that the ans­ cedure in the field more successful and surveillance networks and helped wer to eradication lay in mass vac­ than ever before. train physicians to set up surveillance/ cination of populations—saturation or But always, it is the international containment units throughout the "herd" immunity. cooperation which smallpox fighters country. remember and which most talk about. This approach had been used in Brazil invested $1.2 million in the " I f vaccinators from one country Jamaica, Tonga, and parts of Brazil in smallpox eradication program, during needed to cross the borders of other an earlier project supported by WHO which 94 million people were vacci­ countries in pursuit of smallpox, they and the Pan American Health Organi­ nated between 1967 and 1971. By were permitted to do so w ithout any zation (PAHO). It had been used for 1969, when 7,000 cases were reported, problem," said Jim Hicks, regional most of the 170 years since develop­ the strategy changed from mass administrative officer in Lagos. ment of smallpox vaccine. vaccination w ith jet injector to surveil- The smallpox eradication program But, in Africa epidemiologists lance/containment and use of the learned interesting new things about in Africa was completed in 1970, bifurcated needle. After the change, smallpox. Among them: three-and-a-half years after it began smallpox was stopped in one state 1. Smallpox spread more slowly and ahead of schedule. after only 50,000 people out of seven from person-to-person than had By the 1950's, smallpox had been million had been vaccinated. been believed traditionally. This eradicated from North and Central Brazilian physicians, trained in their meant that if smallpox can be America. In 1966, when WHO was own nation's program, later assisted found in a community, there is calling for its global program and the WHO program in Ethiopia, India, time to stop its spread. international support, Brazil was the and Bangladesh. By that time, much of 2. Smallpox struck only certain only remaining country in Latin the vaccine being used in the program villages in any one year, and America with smallpox. As a result, it was produced in Brazil. even during epidemic periods became the focal point of a concen­ Indonesia, which had eradicated often fewer than 1 percent of all trated effort to eradicate the disease smallpox under the Dutch prior to villages were involved. in the Americas. World War II, had it reimported by the 3. Smallpox outbreaks occasionally Brazil's population of 100 million Japanese after 1942. A t the time of occurred in well vaccinated pop­ people equals that of the countries of the Indonesia phase of the WHO ulations. West and Central Africa. In 1967 the campaign. Dr. Lane was actively 4. Smallpox outbreaks could often campaign to eradicate variola minor, participating there. be controlled with very small the type of smallpox found in Brazil, "Communication was one of our numbers of vaccinations. was begun. major hurdles," he said. "There were This led to the strategy of surveil- That year, 4,000 cases of the no standardized reporting forms for lance/containment. Through surveil­ disease were reported. Leo Morris, smallpox among the islands before lance, villages with smallpox were who served as a consultant with the 1968. It made it difficult to know identified. Patients with smallpox in Brazilian government on the program, where smallpox cases were located." the villages were isolated, and people later estimated that the number of in surrounding villages were vaccinated cases of smallpox was closer to When reports were simplified and so smallpox would not spread to them. 200,000 than 4,000. The team in standardized, they came in regularly With this technique, transmission was interrupted. Dr. William H. Foege, in Africa at the time, conceived and developed the strategy initially because of a shortage of vaccine and resources. According to Dr. D. A. Henderson, assigned by CDC to WHO, where he directed the inter­ national eradication effort: "There was a delay in the delivery of supplies for the mass-vaccination program in eastern Nigeria, and an energetic U.S. advisor, William H. Foege, organized an interim program: he searched out smallpox cases and vaccinated thor­ oughly in a limited area surrounding each case." Another major technical change came later with the introduction of the bifurcated needle. The practical.

6 and if containment had stopped the spread. WHO had international epidemiolo­ gists working under the direction of the Central Government of India. The government also provided epidemiolo­ gists and six or seven central appraisal officers to work with the states; actual responsibilities for the program were vested in state and district health officials. The Indian Minister of Health requested frequent status reports from the states and his smallpox program director or central appraisal officers attended all state meetings. "A n equal level of dedication would be hard to find," said Dr. RECOVERING CASE (center) with Dr. Ronald Waldman and Dr. Stephen Jones. William H. Foege, who headed the and accurately. When reports were not 2. The lower income groups were India program from 1973-1975. received, the Indonesia Communicable not reached in many cases. During 1974 when over 100,000 Disease Center in Jakarta delegated 3. The vaccine being used was not cases of smallpox were reported, someone to find out why and do stable enough to give adequate India's Central Government decided to something about it. Such reporting protection. continue and intensify efforts during made the surveillance/containment In 1973 India was successfully the monsoon season — declaring that phase possible in Indonesia. using surveillance/containment proce­ no village was inaccessible. "The Indonesians were enthusiastic dures in some states and was in the Dr, Mary Guinan, assigned to the about their work," said Dr. Lane. process of switching the rest of the state of Uttar Pradesh, one of the "They have a strong tradition of national program from mass vaccina­ worst smallpox areas of the country, epidemic and disease control." One tion to surveillance/containment. visited out-of-the-way villages during group of young Indonesian workers Among the first steps of the over­ the 1974 monsoon season. In one was given large credit for eradicating hauled program was to set up training village, reportedly free of disease, she smallpox from the Riau Islands, a task programs to get unified surveillance once thought impossible by some. By found an unreported outbreak. After a systems working in high-risk areas — 1974 no cases were reported and WHO round-trip journey through many West Benegal, Uttar Pradesh, and obstacles to Lucknow, she reported declared Indonesia free of smallpox. Bihar. It, too, sent technical aid and experts the outbreak and collected supplies to Team members talked to school to other parts of the world to continue be taken back to the field the next children and teachers, people in the day. Returning to the village with the global battle. market place, and in other key areas. The story of smallpox eradication food, supplies, vaccine, needles, and By late 1974 surveillance teams were sleeping bags, she and the Indian in India is one of cultural nuances, conducting house-to-house searches economic stringencies, and dogged health workers vaccinated everyone for smallpox, averaging 30-million within 24 hours and searched all determination on the part of Indian houses per month in high-risk areas. and WHO health officials. In 1975, houses within a 10-mile radius. after an eight-year campaign, India Each district medical officer listed "Travel during the rainy season was high-risk areas and people in his reported its last case of smallpox. a challenge," she said. "We sometimes In 1962 a mass vaccination cam­ district, including minority groups, rented camels for 24 cents to take our paign was begun and more than 500 and lower socioeconomic groups. Each supplies across the river. Sometimes I million people were vaccinated in five month a special team then went into was carried on the shoulders of two years. In 1967, when WHO began its these locations to search for smallpox. villagers while I still sat on my bicycle. India push, there was as much small­ When an outbreak was discovered, We used ox carts and often carried pox as before in spite of the previous all households within a 10-mile radius supplies on our shoulders so as not to vaccination program. Among the were searched. get them wet." reasons: To assess the effectiveness of the Commenting on the reactions of 1. The same people had been vac­ surveillance/containment program, a the villagers, Dr. Guinan said, "They cinated over and over the first team was sent out a few days or a were so busy just surviving that they time around. Some school chil­ week later to see if villages had been couldn't see the grand plan of small­ dren were vaccinated three and searched and to determine if the pox eradication." four times. source of infection had been found (See page 9)

7 Scientific Community Must Proceed with Technology (From page 2) Research about Smallpox, Related Viruses prongs that can be dipped into the vaccine. They hold the right amount Reprinted from New York Times by Harold Schmeck of vaccine in a space between the two ATLAN TA—In three drab freezer chests in a laboratory near Atlanta are more prongs by capillary action. As long as than 300 specimens of the most bizarre and malevolent endangered species on the person using the needle always earth. vaccinates with a perpendicular mo­ The laboratory, at the Federal than four, perhaps only two, labora­ tion, people with a minimum of train­ Government's Center for Disease Con­ tories in the world as repositories for ing can get 95 percent "take" rates trol, is one of the last refuges of a the virus. One w ill be at the Center for consistently. living thing that has killed millions of Disease Control, which has played a The bifurcated needle was devel­ humans and has spread panic and major role in the world eradication oped by Wyeth Laboratories, Phila­ destruction for thousandsof years. It is effort. Another will probably be a delphia, which allowed the eradication laboratory in Moscow. If there are the virus that caused smallpox. program to use it w ithout patent costs. four, the remaining two w ill be in Stored in little glass vials at 94 It became a basic tool in the program, degrees below zero are specimens from London and Tokyo. A t present, and enabled a vaccinator to give up to many different years and places, from scientists at the Center for Disease 1,500 vaccinations a day. deadly outbreaks in which almost half Control do most of the world's labora­ Freeze-Dried Vaccine of the patients died and from others tory diagnostic work on sm allpox- Potent vaccine which is stable at that were relatively mild. testing each new suspect sample to high temperatures is an essential The Center for Disease Control has determine whether it is really smallpox element in any effective immunization samples from the last smallpox out­ virus. campaign. The provision of such vac­ break in Bangladesh, in 1975; from the The preserved virus samples are cine for the smallpox eradication pro­ last outbreak in India, the same year, kept under lock and key in a labora­ gram was particularly difficult because and from what may prove to have tory that few people are allowed to of special problems related to tem­ been the last case of smallpox on enter. When no one is in the labora­ perature, storage, and transportation. earth—in Merka, Somalia, last October. tory, the whole area is bathed in the Freeze-dried vaccine seemed ideal Eradication Believed Likely baleful blue glow of ultraviolet light for this program since it did not Public health experts think it likely, intense enough to kill an escaped virus. require refrigeration. The technique though not proved, that the smallpox Vaccinations Required for producing freeze-dried smallpox virus has already been eliminated on vaccine had been devised in the early No one may enter the laboratory earth. 1950's at the Lister Institute in w ithout proof of a successful vaccina­ Even if the disease proves to be (See page 21) finally eradicated, however, research tion in the last three years. Those who will continue. Experts will also need to work there regularly are vaccinated refer to laboratory specimens in the yearly. event of some future outbreak similar The air is filtered continuously and to smallpox. the air pressure is kept slightly below In view of the possibilities of new that of the outside atmosphere so that smallpox outbreaks, the World Health air flow, except through the filters, is Organization, which has run the always inward. decade-long campaign to eradicate the Nothing leaves the enclosure w ith­ disease, has asked nations to maintain out being carefully disinfected. Every stockpiles of vaccine. person who goes in must shower The United States already had before leaving and blow his or her nose almost enough bulk vaccine stockpiled to eliminate anything lodged in the at Wyeth Laboratories facilities in nasal passages. Only laboratory clothes Marrietta, Pa., to protect 200 million can be worn inside, and every garment people. Kept at low temperature in a is sterilized after use. freezer room, the vaccine is believed to The dread virus has not been found have an almost indefinite lifetime. In anywhere outside a laboratory since an emergency more vaccine could be the case in Somalia, a young man who prepared fairly quickly. has recovered. But no one can be A year ago, at least 17 laboratories certain that he was indeed the final throughout the world kept the small­ victim, and specialists at the C.D.C. pox virus. Since then the World Health say the war over the Ogaden has Organization has persuaded many to hampered surveillance, especially on destroy their specimens. the Ethiopian side. IN DACCA headquarters — Dr. Stan Foster The objective is to have no more (See page 14) communicates by radio with field staff.

8 "Zero" (From page 7) After that monsoon season, the tide began to turn against smallpox in India. "The real praise goes to the army of Indians — in excess of 100,000 people — who in one way or another partici­ pated directly in the smallpox pro­ gram," said one CDC epidemiologist. "There was such intensity and dedica­ tion to the program. It was a joy to observe ...." "People do what they think they can do. It was an impossible dream — but it was finally perceived as becom­ ing possible — and that made it possi­ ble," said Dr. Foege. Between 1974-76 29 different nationalities participated in the pro­ gram. The Indian Government wel­ comed their assistance, for they IN BANGLADESH MEETING — Dr. Jay Weisfeld (center) of CDC with Dr. Ollie Ringertz (left) of Sweden and Dr. Bert Van Ramshorst of Holland. considered smallpox eradication a global problem — not just a domestic it***#»******#*#***##*#*##*#*******#*************#**«****«******** problem." Simon Pierre N’dengueby Robert J. Baldwin As the countdown against smallpox One of the unsung heros of the the team and to assure that vaccina­ neared its close, Bangladesh and smallpox eradication effort in the tion sessions, which frequently Ethiopia became the last strongholds United Republic of Cameroun was bordered on the hectic, always of the disease. Simon Pierre N'dengue. Simon went smoothly. He would and In 1975 Bangladesh was thought served as the Program Manager dur­ often did perform the job of each to have had its final case. However, ing my stay in the country between team member from registrar to house-to-house searching found cases 1970 and 1972. crowd controller to vaccinator. of the disease in villages of Bhola, Simon, who had been with the In addition to French and a remote island in the Ganges Delta. program since its initiation, was one Pidgin, Simon spoke Ewondo, Bassa Refugees returning to Bangladesh of the most versatile and resource­ and several other tribal dialects and from India, following the war between ful persons with whom I've ever was always quite resourceful in East and West Pakistan, brought worked. He was literally a jack of attempting to communicate with smallpox into the country again. all trades. He could repair almost those whose language we did not Superimposed upon a cumbersome any Ped-O-Jet or vehicle brought to speak. national health superstructure, this him and was quite imaginative in There are those who, after situation made the second eradication adapting when parts were either in reading the above, might question project more complicated. short supply or were non-exist­ the uniqueness o f Simon's contribu­ The Bangladesh campaign suffered ent. In addition to persistence and tions and be inclined to dismiss from the floods of 1974, too. "Those ingenuity in this area, he was able them with the remark that that was floods caused much of the problem," to effectively teach these skills to what the man was being paid to do. said Dr. Stanley Foster, team leader of other persons in country as well as In my opinion, Simon's daily the WHO effort in Bangladesh. "They to those from other countries performance far exceeded the forced many people, including small­ who were sent to Cameroun for bounds of the conventional work pox patients, to move from one area instruction. He was effective in relationship. The dedication with to another. The people traveled to the maintaining a cold chain for vaccine which he worked, his steadfast food-distribution centers and these preservation and in convincing manner, his desire to succeed and places often became the smallpox- those in rural areas of the impor­ accomplish in the face of what at distribution centers." tance of this procedure. In addi­ times appeared to be countless "Our first efforts were to improve tion, he established and maintained frustrations, served as an inspiration surveillance and reporting systems," an effective and equitable vaccine to those of us who worked with said Dr. Stanley I. Music, who served distribution system. him, and w ithout a doubt signifi­ in Bangladesh from 1973-1975. When in the bush, Simon could cantly, contributed to the eradica­ Working through the existing Ben­ be relied upon to totally manage tion of smallpox in Cameroun. gali health structure, the WHO team ***************************************************************** (See page 11)

9 What about Future For Variola Virus? Monkey pox was first recognized as a Reprinted from New England Journal of Medicine human disease in Zaire in 1970, nine Even before the last case of naturally occurring smallpox was recorded in months after the last case of smallpox Merka Town, Somalia, in October, 1977, appeals were made in the scientific and had occurred in that region. Since popular news media for "to ta l" eradication of the smallpox virus, including the then, 37 cases have been identified in destruction of all strains being kept in laboratory freezers throughout the world. six African countries: Zaire, Liberia, Such strains were perceived to be the only remaining source of virus and the last Nigeria, Ivory Coast, Benin and Sierra deterrent to eradication of the disease, which for centuries had caused disfigure­ Leone. It is possible that other cases ment and death. These concerns were heightened by the unfortunate events in of monkey pox go undetected in the Birmingham, England, in August, 1978. Two persons became ill, one fatally, ap­ remote rain-forest regions, but the parently the result of a laboratory-associated smallpox infection. The events in reporting of 37 isolated cases of rash Birmingham clearly illustrated the danger of working with smallpox virus in inade­ disease in West and Central Africa quately equipped facilities. However, they also reinforced the experience of the provides reassurance that the surveil­ last decade showing that smallpox outbreaks can be quickly contained if an acci­ lance system would detect outbreaks if dent occurs. smallpox still existed. Most of the The World Health Organization demand for diagnostic tests is increas­ cases of monkey pox have been in (WHO) very early recognized the ing. During the month of January, children. Five persons have died, the potential danger of laboratory-associ­ 1979, the laboratory received over 450 mortality rate being not unlike that of ated outbreaks and several years ago specimens from 13 African countries, smallpox in West and Central Africa. began a campaign of persuasion mostly as a result of the WHO certifi­ There is little evidence of secondary to reduce the number of laboratories cation program, which includes a spread among close contacts, and no retaining the virus. In 1976, 76 labora­ $1,000 reward for a confirmed case of evidence of tertiary spread. tories were known to have stocks of smallpox. To be certified as small­ There is much about the pox smallpox viruses. In January, 1979, pox free, each country must have been viruses, smallpox-like viruses in partic­ the number of laboratories with free of disease for at least two years, as ular, that we still do not understand. smallpox virus was nine. By 1980, the determined by extensive surveillance We have yet to determine the ecology WHO expects the number to be four designed to track down all exanthems of monkey-pox virus. Could monkey or less. Three laboratories are to be that clinically resemble smallpox. pox be a progenitor of epidemic designated WHO Collaborating Centers Fortunately, none of the specimens smallpox in human beings? for Poxvirus Research: St. Mary's since October, 1977, have contained Also unresolved is the origin of Hospital, London; Research Institute smallpox virus. Most specimens were white-pox virus, a virus biologically of Viral Preparations, Moscow; and the from patients with chickenpox with indistinguishable from smallpox virus. Center for Disease Control (CDC) unusual clinical manifestations. Other Since 1964, six viruses designated as Atlanta. cases were herpes simplex infection, white pox have been isolated from two WHO safety standards for smallpox vaccinia, scabies and skin diseases of captive cynomolgus monkeys, a chim­ are high. For approval, such labora­ unknown cause. Each specimen, how­ panzee, a sala monkey and two ro­ tories must meet a long list of require­ ever, must be considered to contain dents captured in areas where cases of ments and undergo inspections by an smallpox virus until laboratory tests human infection with monkey pox international team. A t present, only prove otherwise. In some cases a valid have been discovered. The origin of three laboratories — St. Mary's, the laboratory test requires smallpox virus this virus is puzzling. Is it of animal or Institute fur Schiffs und Tropenkrank- as a control. human origin? Several viruses from heiten in Hamburg and CDC — meet The WHO w ill convene a group of nonprimates, such as camel-pox and these standards. Only one of them, experts this year to evaluate the need gerbil-pox viruses, are biologically CDC, is actually working with small­ to retain smallpox viruses once global difficult to distinguish from smallpox. pox virus. smallpox eradication has been certi­ There are also reports of human case The strict WHO requirements for fied. Many questions still remain. For of buffalo-pox. How closely related laboratory containment reduce the example, some of the suspected cases are these viruses to human strains of risk o f accidental infection to very low of smallpox over the past few years smallpox? How likely are they to be levels, but the questions must still be have been shown to be caused by pox transmitted to human beings? Could asked, "Why take any risk? What is the viruses other than smallpox. Differen­ these pox viruses fill the ecologic niche need to undertake experiments with tiation of these viruses from smallpox vacated by smallpox virus? Answers to smallpox viruses now that the disease requires critical comparison. Within these and other questions require is eradicated?" the last two months, two cases were comparative studies with smallpox We believe the disease is gone, but diagnosed in the CDC laboratory as strains. the search for the virus continues. being monkey pox, a disease that in The extent of activity of some pox During the last 12 months, CDC's man is clinically indistinguishable from viruses has become apparent only after smallpox laboratory performed diag­ smallpox. The virus was first isolated elimination of smallpox virus as a nostic tests on nearly 4000 specimens in 1958 from captive monkeys, but source of human disease. Newer pox in suspected cases of smallpox, and the has never been isolated in the wild. (See page 16)

10 ***************************************************************** workers modified the surveillance A Santhali Vaccinatorby Dr. James Nakano systems themselves," said Dr. Music. A 21-year-old native of Chhot- an initial appearance of lesions, and "Their active information gathering anagpur, Bihar, India, may be a near recovery, a second crop of was particularly effective in their own remembered as the last of many lesions appeared, instigating a sec­ districts." health workers in history to con­ ond and worse appearance of the In 1975 CDC epidemiologists Jerry tract occupation-related variola rash. Wheeler and Pat McConnon had their major while fighting an epidemic of Some four months after his first experience with urban smallpox smallpox. He deserves a special initial bout wiith smallpox, he was when they saw between 60 and 70 place in the history of mankind's admitted to the hospital with serum people with the disease in hospital effort to conquer the terrible hepatitis. On the fourth day after wards in Dacca. disease. his admission, the patient died of In the field, they covered up to 30 In 1974, the young man was liver failure. to 40 outbreaks a week, vaccinating admitted to the Tata Main Hospital Epidemiologic studies and labo­ people and supplying money for food. in Jamshedpur with fever and a ratory work on the young man's Guards were posted to keep track of smallpox-like rash. case were done at CDC. The course contacts and all people were vacci­ For the previous three months of his illness seems to suggest a nated w ithin a half-mile radius of the he had been in daily and intimate constitutional abnormality in his outbreaks. contact with smallpox patients as immune system. In 1971 Ethiopia became the last he located them, vaccinated them, He was apparently able to nation to join the WHO campaign and assisted in the Chhotanagpur respond to vaccine by antibody against smallpox. In spite of civil war, Smallpox Eradication programme. production, but did not retain difficult mountain terrain, poor roads, His own protection should have “ immunologic memory" and treat­ rain six months of each year, over 70 been complete. He had been ed each subsequent vaccination languages and 200 spoken dialects, the vaccinated as an infant, revacci­ as a new challenge. smallpox program made good head­ nated one week before becoming a The vaccinator worked in in­ way. vaccinator, and twice more during fected villages and probably had an Ethiopia, too, repeated the story of his three months in the smallpox unusually intense exposure to dedication and perseverance that had program, It was not uncommon for smallpox virus. It is possible that become the trademark of the global vaccinators to administer vaccine to the vaccination site of the young effort, When two smallpox cases were themselves in front of villagers to vaccinator became contaminated by found in southwest Ethiopia, a runner allay fears of those about to be physical contact with a case of ran two days during the wet season to given vaccine. His most recent smallpox. It is also possible that the get the message cabled to Addis vaccination—given for “ demonstra­ vaccination needle itself was con­ Ababa. A surveillance officer, who tio n "—was 13 days before smallpox taminated with variola, and the then visited the area, had to walk for lesions appeared on his left arm. result was variolation followed by 15 days to reach his destination. He The vaccinator's case was un­ systemic smallpox. covered the 300-mile area in two usual. First, because smallpox vac­ Whatever the answer, it is clear weeks. cination is one of the most effective that the young vaccinator was one Dr. David J. Sencer, former Direc­ of all immunizations. It provides of many devoted health workers tor of CDC, played a major role in nearly complete protection to all who risked infection in order to committing CDC to the smallpox who have been successfully vac­ pave the way for a smallpox-free eradication campaign. In a 1976 cinated. Second, because following world. interview for "War on Hunger," a *********»•*•*•*****••«#*•*•***# # ****************************** * publication of the Agency for Inter­ "Zero" (From page 9) national Development, he said of the established a system of weekly small­ program: pox reports from "thanas," the basic "Anyone who has had an oppor­ administrative unit in Bangladesh. A tunity to participate in the smallpox report was expected even in the eradication program w ill never forget absence of smallpox. It also incorpo­ the thrill of the achievement of rated for the first time the concept of eradication — to see that people can an "outbreak" in Bengali reporting. work together — all colors, all reli­ In addition to improving an existing gions, and all political beliefs — to passive reporting system, the team bring about the complete destruction inaugurated an aggressive, active of a disease. It is a very thrilling thing system to search for smallpox. The to have been a part of this campaign. I search was conducted by Bengali don't think that anyone who has had REWARD IN HAND, this girl reported a health workers. anything to do with the program will verified case of smallpox. "Some of our Bengali health ever forget it."

11 IN THE FIELD—Smallpox Program Photos

REQUIRED BOOSTER for Dr. J.D. Millar In Bihar State, India CALLING DACCA by radio from operations in Bangladesh is Dr. Stan IV -'■er

IN EARLY DAYS (1966), Mali’s Minister of Health, Dr. Somine Dolo (3rd from left) and Dr. Cheick Sow, director of endemic diseases service visit CDC to confer with Dr. D.A. Henderson (left), director of Smallpox Eradication Program, and CAMEL RIDER Jay Friedman in Timbuktu. Dr. David Sencer, CDC director.

READY FOR ACTION — vaccination team in Bangladesh SM.

12 3ASIC ENGINE REPAIR was subject of study for early CDC group preparing to go to Africa as medical officers and operations officers.

EVALUATIO N IN M ALI — Jay Friedman, Dr. David Sencer, Surgeon General William H. Stewart, Dr. Pascal J. Imperato, Dr. J.D. Millar, Dr. George Lychott, and Ben Blood of the Office of International Health.

B R A ZILIA N GIRL vaccinated with early model, spring-operated jet injector EADQUARTERS in Dacca, Bangladesh by Bill Dial. Possibilities of Reappearance Presumably the most likely emerg­ ency would be the accidental release of virus from a laboratory, but other possibilities, including terrorism have been considered. There is no known "animal reser­ voir" of smallpox virus, although it is possible that one exists, where the disease could linger after the last human case is past. Monkey pox, caused by a closely related virus, has proved capable of infecting humans. But experts at the Center for Disease Control say it does not seem to pass readily from person to person the way smallpox does. In addition to smallpox and mon­ key pox, the pox family includes vaccinia-virus, from which smallpox vaccine is made, whitepox, cowpox, what the infection is. But when the orf, milker's nodule, tanapox and the Community (From page 8) virus nears extinction, every single virus of molluscum contagium. Each The center gets a steady flow of suspect case must be tested, including causes a characteristic infection in specimens from suspect cases: blood many that may be only remote possi­ humans or animals, but none ap­ samples that might show antibodies bilities. The success of the whole proaches smallpox as a menace. against smallpox, as well as bits of venture depends on finding every Asked to Keep Vaccine tissue that might harbor the virus smallpox victim. itself. In view of the possibilities of new More Time-Consuming Specialists are particularly concern­ smallpox outbreaks, the World Health From the laboratory worker's view­ ed about three new samples from Organization, which has run the point the work is more difficult and Somalia because one of their own men decade-long campaign to eradicate the time-consuming when there is no in that country said the patients disease, has asked nations to maintain smallpox virus to be found. In many looked like smallpox cases to him. The stockpiles of vaccine. cases it only takes minutes to recog­ specimens were expected to arrive Dr. Lane said the United States nize a reall smallpox virus under the today. already had almost enough bulk electron microscope. Dr. Nakano said, More Diagnostic Work vaccine stockpiled at Wyeth Labora­ but there are other viruses in the pox Meanwhile, as the number of tories facilities in Marrietta, Pa., to group that look much like it. Each smallpox cases has diminished, the protect 200 million people. Kept at such sample has to be grown in ferti­ press of laboratory diagnostic work low temperature in a freezer room, the lized eggs or tissue culture and often has increased. vaccine is believed to have an almost put through a whole battery of tests to "We have had to stop work on indefinite lifetime. In an emergency prove that it is not smallpox virus but almost everything else," said Dr. James more vaccine could be prepared fairly something else. H. Nakano, head of the laboratory at quickly. As the laboratory work seems to be the center that studies smallpox. In A year ago at least 17 laboratories writing the final paragraphs of the old ordinary times, he said in a recent throughout the world kept the small­ story of smallpox, public health interview, the laboratory tested about pox virus. Since then the World Health officers are taking steps to prevent any 300 specimens a year to confirm or Organization has persuaded many to epilogue. The center has prepared a rule out cases of smallpox. destroy their specimens. detailed plan, titled Comprehensive Since eradication of the disease has Action in a Smallpox Emergency, for The objective. Dr. Lane said, is to come close, the number has been rising dealing with any reappearance of the have no more than four, perhaps only steeply. Last year the laboratory disease. two, laboratories in the world as tested about 3,000 specimens, so far The plan took months to put repositories for the virus. One w ill be this year almost 1,300. All of the 1978 together and fills a large loose-leaf at the Center for Disease Control, specimens have been negative. notebook. Dr. Michael Lane, director which has played a major role in the The increase in workload is easy to of the center's Bureau of Smallpox world eradication effort. Another will explain. In a real outbreak of smallpox Eradication, said that it had been sent probably be in a laboratory in Mos­ it is hardly necessary to do virus tests to every state health department in the cow. If there are four, the remaining on every victim. It is all too obvious country. two will be in London and Tokyo.

14 Reasons for Preservation The scientific methods and tools Dr. Nakano and other experts say necessary for such studies have only there are three reasons to preserve a recently been developed. Furthermore virus that has nothing to offer human­ the smallpox virus is large and com­ ity but death and disfigurement. plex as viruses go—it is 20 times the The first is that, if there is a future size of the polio virus arid three times epidemic that appears similar to the size of the flu virus. smallpox, doctors will need to know The third reason cited for preserv­ whether it is a reappearance of the old ing the smallpox virus is more philo­ virus or the appearance of something sophical and, in Dr. Nakano's words, else that has emerged to fill the old "perhaps humanitarian.” disease niche. Public health reaction to the swine Even though it has always been an flu virus of 1976 might conceivably enemy of man, the smallpox virus is have been far different, for example, part of the immense skein of life on had samples of the old 1918 flu virus earth. Now, through human efforts, it been available for comparison. faces extinction. Dr. Nakano thinks The second reason is research. that man should not push it through Common as smallpox was, said Dr. the final step to oblivion. It would Walter Dowdle, head of the center's make no more sense to do so, he division of virology, the virus was suggested, than to eliminate every relatively little studied. other deadly living thing. CANADIAN BOY who traveled from Brazil to Canada through New York in 1962

U.S. Saved Dollars By "Pox" Demise Prevention of human suffering and death is the most important measurement of the significance of smallpox eradication. But there are also economic benefits. During the 12 years of the eradication campaign the United States provided $27 million in assistance. This amount is saved in this country every three months because routine smallpox vaccina­ tion is no longer required. The U.S. no longer requires proof of smallpox vaccination from arriving international travelers, thus allowing additional resources to be directed toward other health activi­ ties. With the removal of the need for smallpox vaccination, the U.S. now has no routine vaccination requirements for persons entering this country. Savings in dollars or convenience are small in comparison to the prevention of human suffering and death. In 1966, millions of cases of smallpox occurred in the world. Death and disfiguration were com­ mon. Today, a disease which has plagued mankind throughout his­ tory is no longer a threat. TAUREG G IR L in Mali pauses for vaccination against smallpox.

15 a#*#*'#**#***#******#**#****#*#* •****•******#*•*•***••*****#•«• Abu Yusuf 1844 (From page 1) Dr. Gerald Wusang by Dr. Stanley 0 . Foster smooth away prejudices than the by Dr. J.. Michael Lane Abu Yusuf, a legendary leader o f best native vaccinator. During the smallpox eradication the Bangladesh smallpox field force, “ Actuated by these views he efforts in Indonesia, it was generally frequently, because o f his excellence, divided the whole of the territories of difficult to get local medical officials drew the most difficult field assign­ the Presidency into four grand divi­ interested and actively involved in the ments. Spending 25 or more days a sions, and to each of these divisions he work. They were usually content to let month In the field, he often ended upappointed a European vaccinator, with the vaccinators work w ithout field walking 20 to 30 miles through mud an establishment of native vaccinators supervision. and rice paddy to Investigate a rumor under him. The European vaccinator Dr. Gerald Wusang was a young or supervise a containment. was exempted from all local control, physician working in Bantang, a Abu Yusuf also had a warm sense civil, military, or medical, and was at remote part of the southern Celebes o f humor. One day we found ourselves liberty to carry on his operations in Island. Because of his Chinese ances­ supervising a group o f workers de­whatever part of his district he might try, he was not able to obtain a ployed at Chittagong railway station, think proper, reporting monthly, to prestigious urban post, and was living a to detect smallpox importations com­ the medical board at Bombay. The life of intellectual exile as a rural ing from the heavily infected bastees salary was liberal, so that the vac­ government physician. He had done an o f Dacca. Walking along the platform, cinator could at any time take a rapid excellent job of remodeling his clinic / passed a mother and Infant, the latter journey, and come suddenly on his and house, and was providing excellent showing a fresh primary take. Feeling native assistants to ascertain the medical care in his community, but he progress was being made, / moved on. fidelity o f their reports, settle quarrels, had no background or interest in A t the end o f the platform, / turned to etc. and, in addition to the duties of public health. Since there was no see Yusuf bending over the young superintending the vaccination, the public accommodation in his jurisdic­ mother. She was in the first day of vaccinator was provided with a supply tion, I was billeted in Dr. Wusang's smallpox rash, the most Infectious of medicines and ordered to give house when I worked in the Bantang period, and / had missed her. We advice and medical assistance to any of area. He had taught himself English by picked up the patient and carried herthe natives who might apply to him. listening to Australia short-wave news­ to our Landrover for the trip toHe was also furnished with from six to casts, and we were able to communi­ Isolation. eight peons, to assist himself and his cate. As we drove on, Yusuf turned andnative subordinates in collecting the I sent vaccination teams to several suggested that we share the 250 Taka inhabitants, transmitting orders, pro­ outbreaks of smallpox around Ban­ ($20) reward for detecting the new ducing supplies, etc." tang, with detailed instructions about smallpox outbreak. That program did not eradicate ft****************************** smallpox from India. the need to remain during the night, to vaccinate villagers who were away during the day. understanding of their genetic rela­ Future (From page 10) From previous experience in Indo­ tions and to provide a basis for better nesia and elsewhere in the Celebes, I viruses may yet be discovered. Since prediction of disease potential. For doubted that the teams would actually some of these viruses may have the this purpose, the smallpox virus is remain during the night, although Dr. potential to cause human disease, it is required. clear that we can no longer rely on The greatest impediment to the Wusang assured me they would do currently used biologic methods for total eradication of smallpox is not the whatever he ordered. I invited him to differentiating pox viruses. More remote chance that a virus might visit some of the villages with me at sophisticated methods are both needed escape from one of the several tightly night, and as expected, the teams were and possible. A major effort is supervised WHO-approved laboratories nowhere in sight. The villagers were under way at the CDC laboratory to but, rather, premature complacency surprised and delighted that we had construct a catalogue and map viral and the failure to achieve a full under­ arrived to complete the promised DNA by restriction endonuclease standing of the relation of smallpox vaccinations. analyses of the dozens of strains of virus to the rest of the pox-virus The field visit, the obvious impact smallpox and related pox viruses. In family. Sometime during the next few of smallpox on the villages, and the addition, research is under way to years DNA studies of the pox viruses realization that the vaccinators were define biochemically the antigenic will probably make it possible to not as reliable as he had assumed, had nature of each strain. Attempts thus establish a definitive diagnosis without a tremendous impact on Dr. Wusang. far to characterize pox viruses through direct use of the smallpox virus. That He became an overnight smallpox biochemical studies of their DNA have may be a more appropriate time to fanatic. He kept up his busy clinical been encouraging. Additional work consider total destruction of all live work but took on an active role in the is necessary with appropriate human smallpox-virus stocks. supervision of outbreak containment and animal strains to develop a greater —William H. Foege, M.D. and case tracing and investigation. I

16 was shortly able to leave his area and move on to less well organized jurisdic­ Smallpox Successes Changed tions, and he maintained prompt and efficient work while I was away. U.S. Vaccination Policy, 1971 Indeed, he independently rediscovered all of the basic cannons of smallpox During the 1960's, several physicians in the United States and the United epidemiology; the close and prolonged Kingdom questioned the need to continue routine smallpox vaccination, which contact necessary for spread, the causes a slight, but definite rash of severe side effects. efficacy of vaccination during the This became official Public Health those conditions, it was a rational, incubation period, the ploys to be Service policy on October 1, 1971, necessary procedure, and legal regula­ used in contact tracing, etc. Dr. with the publication of new recom­ tions were passed to ensure vaccina­ Wusang is in fact responsible for much mendations of the Advisory Commit­ tion of the public." of the smallpox eradication work in tee on Immunization Practices (ACIP). The announcement recognized that the southern Celebes, but because it Noting that no documented case of implementation of the recommenda­ was outside his usual duties, his role smallpox had occurred in this country tion would require legal changes in has never been recognized. since 1949, the ACIP statement of many areas. To help accomplish this, ******************************* 1971 declared; and to better understand the rationale "F o r most people in the United for this decision, state and local health •jut-**#********#*********»##*#**# States, the probability of contracting authorities were provided with de­ Dr. Kamarul Huda smallpox is so small that the risk of tailed information on the current complications from vaccination out­ by Dr. Stanley 0 . Foster assessment of risks and benefits weighs the benefits..." regarding smallpox vaccination in the Dr. Kamarul Huda, Sub-Divisional Announcement of the PHS decision Medical Officer of Health for Chitta­ United States. noted, as an example, that in 1968 Much of the information sent to gong District in Bangladesh, became a there were nine deaths associated with colleague and friend during 1973, states related to the risk of smallpox routine smallpox vaccination in the when for 1 week each month we being imported into the U.S. The would work together to improve United States. ACIP, in preparing its statement, smallpox outbreak case detection and This official recommendation, concluded that the risk of importation while influential, did not have the control in his division. Initially admin­ of a case was unlikely. immediate effect of stopping wide­ istering from his desk. Dr. Huda However, to minimize concern learned to lead his teams in the field inspread vaccination in this country. about this remote possibility, the States and many local governments had outbreak investigation, training, and ACIP described the national smallpox supervision. On Sunday, March 2, we legal requirements for smallpox vac­ surveillance system, as well as emer­ reviewed on the phone the progress cination. Said the ACIP: gency procedures to be followed for toward smallpox zero. He passed on a "The policy of nonselective vacci­ management of contacts and prevent­ telegraphic report o f smallpox from nation... began when smallpox was ing spread of the disease. Sandwip, an off-shore island in thewidespread and uncontrolled. Under (See page 21) Bay o f Bengal. He would leave at daybreak. The following morning, the sched­ uled steamer failed to sail. Dr. Huda climbed on board an overloaded country boat for the dangerous trip SÜ across open water. Approaching Sandwip the boat overturned and Dr. Huda drowned, leaving a wife and two young children. Dr. Huda was honored by his colleagues with the words o f the Bengali poet Rabindranath Tagore: You brought a deathless life with you which you made gift at your death. In his death and the collective efforts o f colleagues, suffering and death for many has been prevented. ******************************* SYMBOL of West African program displayed by Bernard Challinor.

V POSTERS LIK E THESE played an important part in motivating people to get smallpox vaccinations in Africa and Asia.

18 REPUBLIQUE OE COTE D'IVOIRE MINISTERE DE LA SANTÉ PUBLIQUE JEKA KAYfl ET DE LA POPULATION GHANA LAUNCHES DRIVE AGAINST SMALLPOX AND MEASLES AS A PART OF NEW 19-NATION WEST AFRICAN CAMPAIGN TSAGA + PLAN NATIONAL YAU l'ÉRiDICITIOI DE U VARIOLE

L'Action entreprise contre la variole se poursuit. La Côte d'ivoire déclarée Zone d'endémicité^ les utontés Sanitaires sont habilitées à prescrire et pratiquer elon opportunité vaccinations et re vaccinations’ . LA VACCINATION EST OBLl ¿ fii Put an I t i f fr«

CAMPAGNE ONTRE LA VARIOLE ET A ROUGEOLE

19 **************** ***************************************'ft*****#******#**************.***.».)!.**.,'..**.».*.,'..*.* Surveillance in Southern Sudanbeing made to transfer personnel from At the end of the next month / by David C. Bassett other provinces, as necessary, toreceived a cable from m y counterpart / arrived in Sudan in early 1973 to enable a maximum effort in campaign saying that the second campaign was work with the Smallpox Eradication areas. completed, that no fresh smallpox Program there. The last known small­ As WHO Advisor to the Sudan cases had been found, but that some pox case in Sudan had occurred inSmallpox Program, / helped with the old cases possibly occurring in April, early December, 1972, in Southern planning o f a series o f 3 — 4 week 1973, had been found. Since April, Sudan. But it was thought very likely surveillance campaigns. / knew / would 1973 cases would mean a previously that smallpox still existed in Southern not be able to personally participate inunknown foci, I cabled back my Sudan because in 1973 transportation each o f them, but / decided that / congratulations on a job well done and and communications were very d iffi­ would participate in the first one, toasked my counterpart to wait for me cult, making large areas o f the South take place in the eastern-most district in Juba so that we could go together almost inaccessible. Also, many people o f the Southern-most province. / could to re-visit the site where the old cases were still in hiding from the military set the example, / reasoned, and then were found. hostilities which had ravaged the areahope that it would be followed. The subsequent journey to the for 17 years up to March 1, 1972. To The first surveillance campaign was South and the visit to the old cases be sure that there was no more small­ a field effort o f 3 weeks that involved made it dear to me that smallpox pox in Southern Sudan, it would beabout 15 people travelling in convoy surveillance in Sudan could proceed necessary to plan and execute a special (three vehicles). My counterpart was awith a minimum of direct involvement smallpox surveillance campaign. Sudanese with whom / had not prev­ by myself. The old cases had been There were no paved roads. Many iously worked, so we spent the firstfound in an extremely remote moun­ o f the existing roads were motorable few days feeling each other out. Withtainous area some 60 miles o ff the for only 5, maximum six months o f each passing day we formed a stronger main road. It was dear to me that my the year, November — April. Fuel for bond o f mutual respect. The 3-week counterpart and his colleagues had vehicles was in short supply. It was not campaign was completed without been following my instructions to the possible to find food for purchase inproblems. No evidence o f recent letter and that / did not need to worry the countryside, so food had to besmallpox was found. that any thoroughness was being collected at Juba, the regional head­ A second campaign was planned forsacrificed because / was not there. quarters. Yet even in Juba food the following month. As/ would not The fact that the old cases found were supplies were d ifficult to obtain. be able to participate in this campaign, probably infected in A p ril 1972 rather May to October, 1973 was spent / placed my counterpart in charge andthan 1973, did not detract from this. planning a series o f surveillance went over the strategy with him inMy counterpart and his colleagues campaigns for the coming dry season. great detail, listing the places to go,were proud o f what they had done and A t the same time, supplies o f fuel andthe people to visit, and the informa­/ knew that the rest o f the surveillance food stuffs were being accumulated tion to gather. / then le ft for Khar­ campaign in Southern Sudan was in and stored, and arrangements weretoum, hoping for the best. good hands. **************************************************************************************************

ROTARY LANCET formerly widely used.

2 0 Technology (From page 8) England. Vaccine produced remained potent for two years when stored at body temperature, so it seemed to meet the unusual needs o f the small­ pox eradication effort. But during the early days of the eradication campaign, there were se­ vere problems in supply and quality of freeze-dried vaccine. Only a small percentage of the freeze-dried vaccine in countries where smallpox was endemic met the potency and stability requirements of the World Health Organization. Another critical problem was the lack of a central laboratory for testing vaccine. To meet this need, two major laboratories, in Canada and the Neth­ erlands, agreed to serve as interna­ tional vaccine reference centers. In the early stages, most vaccine used was provided by Russia or the United States. Gradually, production of quality vaccine increased in the endemic countries. By 1970 all vaccine used met accepted international stand­ ards of potency and stability.

Policy (From page 17) These procedures were described in detail in a manual entitled "Compre­ hensive Action in a Smallpox Emer­ gency." It was written to assist the health official in each state (usually the State Epidemiologist) who would be responsible for taking appropriate action. Implementation of the recommen­ dations to halt routine vaccination moved smoothly, but some areas of the country continued to require smallpox vaccination for school entry beyond 1971. None require it today. ACIP recommendations have been further modified since the 1971 announcement. The only persons recommended to receive smallpox vaccination today are the few labora­ tory workers likely to come in contact with the virus, and travelers to coun­ tries requiring vaccination as a condi­ tion of entry. Despite widespread adoption of the recommendation to stop most small­ pox vaccination, many people in the (See page 22)

21 HISTORICAL VIGNETTES • The first medical pamphlet pub­ lished in North America was written by a minister over 300 years ago on the subject of smallpox. • From 1617 to 1619 an outbreak of what was probably smallpox killed about 90 percent of the Indians on the Massachusetts coast making it easy for the pilgrims to land in 1620. Miles Standish wrote, "Smallpox was the blessing in disguise that gave our immigrant ancestors an opportunity to found the State." • In 1730 seven percent of the resi­ dents of New York City died in a 3-month period of time from small­ pox. • Some of the earliest vaccine in this country was carried by Lewis and Clark. Thomas Jefferson, scientist, man of curiosity, obtained vaccine in 1801 and took it to Monticello to vaccinate his family and neighbors. Levyis and Clark were given the vaccine specifically to encourage its use among American Indians. Smallpox among the American tribes was more influen­ tial than the U.S. Army in neutralizing opposition. • In 1716 Lady Mary Montagu, wife of the British ambassador to Turkey, saw variolations or inoculation in Turkey and described how 15 or so people would be taken at one time to be isolated in a farm house. They EMIR OF ZA R IA receives vaccination in northern Nigeria. In center background is Dr. Deane would then be inoculated simultane­ Hutchins, who was medical officer for smallpox eradication program. ously and kept in isolation for several weeks so that the mild smallpox which occurred in many of them would not met with a hostile reception. Attempts princes stricken in their prime. Among spread to the community. She con­ were made to fire bomb his house and the royal victims are Prince Baltasar vinced the British royal family of the a storm of opposition developed. Carlos of Spain; Queen Ulrika Eleo­ procedure's usefulness. The royal nora of Sweden; Queen Mary II of • In 1776 the American colonial army family in turn tested the procedure on England; Louis XV of France and lost Quebec, and consequently all of prisoners and then on their own Joseph I of Austria. K'Ang-Hsi, Canada, to the British. The British children. By the 1720's inoculation emperor of China, is depicted on the army, outnumbered two or three to was an accepted technique for some cover of his autobiography with one, were variolated. The American practitioners in England. smallpox scars clearly visible. troops were not, and came down with • Cotton Mather, the distinguished smallpox. third generation American minister in Policy (From page 21) In January 1777 as the result of the Boston, learned that slaves in the U.S. U.S. still are vaccinated. Latest esti­ defeat at Quebec, Congress provided were using inoculation, a technique mates indicate that more than four General Washington sanction to vario­ they had brought from Africa. In 1721 million doses of the vaccine were late members of the military. a ship docked in Boston introduced distributed in the U.S. in 1978. smallpox to the 11,000 residents of • The Royal Houses of Europe and But, for all practical purposes, Boston. Within 6 months 6,000 had Asia were hosts to smallpox from age smallpox vaccination in the U.S. has become ill. Cotton Mather began to to age. In many ways history has been ended, thus ending risks and discom­ preach the value of variolation, but changed because of monarch's or fort for millions.

2 2 Countries in which CDC Personnel Participated in Smallpox Investigation/Control Activités

EUROPE Guinea England Sierra Leone Sweden Liberia Yugoslavia Ivory Coast Ghana ASIA Togo Burma Benin India Nigeria Bangladesh Cameroon Nepal Chad Pakistan CAR Afghanistan Gabon Indonesia Equatorial Guinea Mali Niger LATIN AMERICA Upper Volta Brazil Congo Zaire AFRICA Sudan Mauritania Somalia Senegal Ethiopia REWARD POSTER has been widely used re­ SMALLPOX GOD with monkey Gambia Djibouti cently in search for any possible case. skull.

2 3 Smallpox Warriors Battle Other Diseases from CDC The following list includes the names of those CDC staffers who worked abroad fighting smallpox. It also includes those who worked in the eradication program through Foreign Quarantine, and in the Smallpox Laboratory at CDC. Hundreds of others played vital support roles in the campaign and we regret that because of space limitations we have not included all of their names. Those listed gave credit to many more who stayed state-side to "make their Jobs possible." With a list of this size, it is likely that names which should have been included have not been. If ommissions are called to our atten­ tion, we will include them in any future use of the list.

Adams, Vernon, M.D. Farer, Laurence, M.D. Klssee, Ben Paz, Elizabeth Adcock, David E. Feld, Bernard Kloth, Theodore I., M.D. Perry, Samuel R. Agle, Andrew N. Ferrazano, Gabriel, M.D. Koplan, Jeffrey P.f M.D. Peters, Bruce F., M.D. Alexander, Charles Fischman, Paul, M.D. Pifer, John M., M.D. Alfaro, August A. Fitzgerald, Stephen A. LaForce, F. Marc, M.D. Pope, R andall S. Allman, Kenneth Flanders, G erald P. Landrigan, Philip J., M.D. Post, Clarence J. Alter, Annabelle H. Foege, William H., M.D. Lane, J. Michael, M.D. Pratt, David, M.D. Andrews, John S., M.D. Folland, David, M.D. Langmuir, Alexander O., M.D. Pust, Ronald E., M.D. Appleton, Fred Fontaine, Robert E., M.D. Lantz, Samuel A. Arnold, Richard B., M.D. Forney, David L. LaPointe, Mark D. Quinn, Michael J. Forrester, Willis R. Baldwin, Robert J. Larry, Daryl, M.D. Foster, Stanley O., M.D. Larson, Edward Barbour, Alan, M.D. Raines, David Francis, Donald P., M.D. Lather, George Barry, William Ramirez, Robert Freedman, George ). Leggln, Phillip Bassett, David C. Reiman, Sol Freemont, James M. Lenz, Catherine E. Vaughn Bentley, Jean C. Rich, James A. Friedman, Jay S. Berall, Jonathan, M.D. Leonard, Thomas A. Richardson, John H., M.D. Lessln, Philip Robbins, Gordon E. Berg, George M., M.D. Garcia, Luis A. Bernier, Roger H. Leutzinger, Craig Roberto, Ronald R., M.D. Garrett, Woodrow A. Berry, Frank Lewis, James O. Romm, Frederick J., M.D. Gelfand, Henry M., M.D. Lichfield, Paul Lantz Bingham, Patricia G. Roots, Logan H., M.D. Gibson, James, M.D. Lichfield, Paul R. Rosenberg, Mark L., M.D. Bloeser, Carl H. Giordano, Joseph F. Lincoln, Burton J. Rosenbloom, Arlan L., M.D. Blumenthai, Daniel, M.D. Godfrey, Harry R. Loggins, Mary S. Rosenblum, Bernard, M.D. Bond, Paul A. Goidsby, James B. Loher, Bernard J. Bourke, Anthony T., M.D. Rothsteln, Nathaniel Goldstein, Joel A., M.D. Long, Gary W., M.D. Roy, Jeannel A. Boyd, Barbara A. Grazis, Peter A. Lorenz, Rodney A., M.D. Roy, Muriel T. Boyd, Robert A. Greenberg, Richard, M.D, Lourie, Bernard, M.D. Ruben, Frederick L., M.D. Bradley, Martin R., M.D. Greenley, John W. Lythcott, George I., M.D. Brar, Mukhtiar Griggs, Billy G. Breman, Joel G., M.D. Scaliy, Francis J. Grigsby, Margaret E., M.D. McBean, A. Marshall, M.D. Scardaci, Anthony M. Brink, Edward W., M.D. Guinan, Mary, M.D. B rix , Jack McConnon, Patrick Schade, Charles, M .D. Gunter, David L. M cE n a n ey, John P. Sencer, David J., M.D. Broske, Stuart P., M.D. Gunter, Dupree Mack, Thomas M. Shoemaker, William D.t Jr. Brown, Denise R. Guyer, Bernard, M.D. Brown, Larry K. Malberg, Donald R. Sllvernail, Carl Marino, Frank A. Smith, Edward W. P., M.D. Brown, Robert Helmholz, Robert C. Martin, William E. Smith, James Bunn, Jack C., M.D. Hemmert, Wynn, M.D. M a rty , M ich ael J. Soiter, Steve, M.D. Burger, Ronald Henderson, Donald A., M.D. Masso, Anthony R. Sparks, Larry Burk, John R., M.D. Henderson, Ralph H., M.D. Staehling, Norman W. Burke, Ralph Herrmann, Kenneth L., M.D. Meehan, Leo J. Melchinger, David B., M.D. Stapp, Joy H. Herron, Charles A., M.D. Carvell, Delbert Melewicz, Frank M., M.D. Stetler, Harrison C., M.D. Hess, James P. Challenor, Bernard D., M.D. Meschievltz, Carlton, M.D. Stiso, Frank Hicks, James W. C h arter, Russell S. Stroh, George HUI, Carl C. Millar, J. Donald, M.D. Claquin, Pierre, M.D. Miller, David C.. M.D. Hogan, Robert c. Connell, Fred, M.D. Miller, Donna L. Hogelin, Gary Tapia, Robert Conrad, Gary Miller, Joe Holloway, Brian P. Teller, Benjamin E., M.D. Copeland, Wallace Miller, Richard Hopkins, Donald R., M.D. Thieme, Martha L. Crankshaw, Richard L. Mitchell, William H. Thomas, Elaine A. Crippen, Peter H. Horne, Thomas Mize, James W. Thompson, David M .t M.D. Curtis, Gerald Howard, Richard D. Huber, Charles Monath, Thomas P., M.D. Thornton, James Moore, Donald J., M.D. Huber, William Tulloch, Roger Moore, Joseph N. D'Agnese, John J. Hudgins, Michael P., M.D. Morgan, Kenneth H. D ’Amanda, Christopher, M.D. Hughes, John, M.D. VanBuskirk, Arthur Davis, Constance, M.D. Hull, Harry F. Morris, Leo Vanderhook, Ray, M.D. Moser, Claude R., Jr. Davis, Daniel Hutchins, Deane L., M.D. VanPatten, Harold Davis, Elmer Mosley, James W., M.D. Vastine, David, M.D. Davis, Hillard Imperato, Pascal J., M.D. Murphy, Kevin Veazey, James M., M.D. DesPrez, William L. Musante, Edward Music, Stanley I., M.D. Deubner, David, M.D. Jackson, Richard J., M.D. Wade, Lloyd W. DeWeese, Luther E. James, W illiam Waldman, Ronald Dix, Dennis J. Jenkins, Lesley M. Nakano, James H. Wanner, Rudolf C., M.D. Donoho, James E. Johnson, Deane Neff, John M., M.D. Watkins, Charles H. Drake, Thomas Jones, Clara J. Nelson, John W., Jr. Watson, William C., Jr. Drescher, John J. Jones, John Nelson, William Q. Weisfeld, Jason S., M .D. Drotman, Peter, M.D. Jones, T. Stephen, M.D. Newberry, David M. W est, G ary Duerden, Edward F. Jones, Warren R. Newport, Frank E. West, James W. Jordan, Wilbert C., M.D. Nlchaman, Milton Z., M.D. Wheeler, Jerry Economidis, Thomas Karzen, Jerome B. Noble, John, Jr., M.D. Whipple, David Eddins, Donald L. Kay, Dale E. Noonan, Allan S., M.D. White, William J., Jr. Ellis» Robert J. Keenlyslde, Richard A. Wilder, Michael, M.D. Emerson, Robert Kelly, John O'Connor, Richard Williams, Eugene Evans, Harmon H. Kimmet, Thomas R. Olsen, Dennis G. Wilson, John E. Evans, Robert N. King, Leiand Orensteln, Walter, M.D. Ewen, Neal H. Klngma, Frederick S. Osborne, Arthur, M.D. Zyler, Laurence D,

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