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The Global Eradication of Smallpox

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The Global Eradication of Smallpox THE GLOBAL ERADICATION OF SMALLPOX Final Report of the Global Commission for the Certification of Smallpox Eradication, Geneva, December 1979 WORLD HEALTH ORGANIZATION GENEVA 1980 HISTORY OF INTERNATIONALPUBLIC HEALTH, No. 4 ISBN 92 4 156065 7 © World Health Organization 1980 Publications of theWorld Health Organization enjoy copyright protection in accordance with the provisionsof Protocol 2 of the Universal Copyright Convention. For rightsof reproduction or translation of WHO publications in part or in toto, application should be made to the Office of Publications, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of theDirector-General of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. PRIN1ED IN SWITZERLAND 80/4790- Alar- 5500 Foreword On 8 May 1980, the 155 Member States of the World Health Organization, represented by their delegates to the Thirty-third World Health Assembly, unanimously accepted the conclusions of the Global Commission for the Certification of Smallpox Eradica­ tion-namely, that: "1. Smallpox eradication has been achieved throughout the world. "2. There is no evidence that smallpox will return as an endemic disease." Because of the uniqueness of the achievement and the effect it has already had, and will continue to have, on the lives of people throughout the world, it is important that public health officials, historians and future generations should have access to the evidence upon which these conclusions are based. This book, The Global Eradication of Smallpox, which is the report of the Global Commis­ sion, carefully presents and discusses that evidence. It also includes recommendations on policy for the post-eradication era to ensure that this achievement is permanent. The eradication of smallpox has shown that resounding victories can be attained by international cooperation when the objectives are well focused, plans are realistically constructed, and the necessary resources are made available in time. Let this final report of the Global Commission stimulate us all to reflect not only on the eradication of one disease but on how this experience can help us to attack more effectively other health problems with the same enthu­ siasm, optimism, and sheer hard work that characterized the success­ ful crusade against smallpox. H. MAHLER, M.D. Director-General MEMBERS OF THE GLOBAL COMMISSION FOR THE CERTIFICATION OF SHALLPOX ERADICATION Left to right. Front row: Dr Marennikova; Dr Azurin; Dr Burgasov; Dr Fenner; Dr Kostrzewski; Dr Henderson; Dr Koinange Karuga; Dr Zhang. Back row: Dr \i'ehrle; Dr Basu; Dr Aashi; Dr Lundbeck; Dr Rodrigues; Dr Dumbell; Dr Netter; Dr Tagaya; Dr Hoeti; Dr Kalisa; Dr Shrestha; Dr Deria. Dr J. Aashi Dr D.A. Henderson Dr I. Tagaya Assistant Director-General Dean, School of Hygiene and Public Health Director-, Department of Enteroviruses Preventive Medicine The Johns Hopkins University National Institute of Health Ministry of Health 615 North Wolfe Street Murayama Annex Riyad Baltimore Gakuen Saudi Arabia Maryland 21205 Musashi-Murayama USA Tokyo 190-12 Dr J. Azurin Japan Under-Secretary of Health Dr Ka lisa Ruti Department of Health Director, Expanded Programme on Dr P .F. Wehrle (Rapporteur) Manila I:mmunization Hastings Professor of Pediatrics Philippines P.O. Box 1899 Pediatric Pavilion Kinshasa Los Angeles County - University of Dr R.N. Basu Zaire Southern California Medical Center Assistant Director-General of 1129 North State Street Health Services (Smallpox) Dr W. Koinange Karuga Los Angeles Directorate General of DirectOr of Medical Servic�s California 90033 Health Services Ministry of Health USA New Delhi P.O. Box 30016 India Nairobi Dr Zhang Yi-hao Kenya Deputy Director Dr P.N. Burgasov National Serum and Vaccine Institute Deputy Minister of Health Dr J. Kostrzewski (Vice-Chairman) Beijing of the USSR Secretary, Medical Section China Ministry of Health of the USSR Polish Academy of Sciences R.:-,hmanovskij per. 3 Palac Kultury i Nauki Dr R. Netter Moscow 00-901 Warsaw Director-General USSR Poland Laboratoire national de la Sante 25 Boulevard Saint-Jacques Dr A. Deria Dr H. Lundbeck Paris 75014 National Programme Manager Director France Smallpox Eradication Programme National Bacteriological Laboratory c/o WHO Programme Coordinator lOS 21 Stockholm Dr Bichat A. Rodrigues P.O. Box 374 Sweden Executive Secretary of National Mogadishu Council of Health Somalia Dr S.S. Marennikova Ministry of Health Chief, Smallpox Prophylaxis Department Brasilia 70.000 Dr K.R. Dumbell Research Institute of Virus Preparation Brazil Head, Department of Virology 1st Dubrovskaya ul. 15 The Wright-Fleming Institute � Dr P.N. Shrestha USSR of Microbiology Chief, Planning Division St Mary's Hospital Medical Institute of Medicine School Dr J.S. i:1oeti Haharajgunja London W2 lPG Chief Medical Officer of Health Kathmandu United Kingdom �inistry of Health Nepal Gaborone Botswana Dr F. Fenner (Chairman) Director, Centre for Resource and 1 Dr C. Mcfidi Environmental Studies Apartment �o. 249, Block 1 The Australian National University Behjatabad Building P.O. Box 4 Teheran l5 Canberra, A.C.T. 2600 Iran 1 Australia unable to attend page 5 C 0 N T E N T S PREFACE 9 1. S l)M}"JARY 10 2. CONCLUSIONS AND RECOMMENDATIONS 12 2. 1 Conclusions 12 2.2 Recommendations : Policy for the post-eradication era 12 Vaccination policy Reserve stocks of vaccine Investigation of suspected smallpox cases Laboratories retaining variola virus stocks Human monkeypox Laboratory inve stigations Documentation of the smallpox eradication programme WHO headquarters staff 3. HISTORY OF SMALLPOX, VARIOLATION Ju�D VACCINATION 16 3.1 Possible origin of smallpox and history of its glob al spread 16 3.2 Early efforts at control 17 3.2.1 Variolation as a method of control 3.2.2 Vaccination as a method of control 4. CLINICAL FEATURES AND DIAGNOSIS OF SMALLPOX 19 4.1 Clinical course 19 4.1.1 Case fatality rate 4.2 Clinical differentiation from other diseases 20 4.3 Laboratory diagnosis 20 5. EPIDEHIOLOGY OF SMALLPOX 22 5.1 Infectivity 22 5.2 Immunity 22 5. 3 Spread 22 5.4 Age incidence 23 5.5 Seasonal incidence 23 6. INTERNATIONAL INVOLVEYffiNT IN CONTROL AND ERADICATION 1924-1966 23 6.1 1924-1947 23 6.2 1948-1957 24 6.3 1958-1967 24 page 6 7. THE ESTABLISHMENT OF THE INTENSIFIED SMALLPOX ERADICATION PROGRAMME 25 7.1 Headquarters 25 7.2 Regional offices 26 7.3 Nat ional programmes 26 8. STRATEGIES IN THE INTENSIFIED ERADICATION PROGRAMHE 27 8.1 Provision of a sufficient amount of potent and heat-stable va ccine 27 8.1.1 Freeze-dried vaccine 8.1.2 Production 8.1.3 Quality control 8.1.4 Provision of consul tant services, fellowship training and vaccine testing by WHO 8.1.5 Techniques of vaccinat ion 8.1.6 Complications of vaccination 8.2 The mas s vaccination strategy 30 8.2.1 Rat ionale 8.2.2 Vaccination coverage 8.2.3 As sessment 8.2.4 Successes and failures 8.3 Changing strategies 31 8.3.1 Lessons from the field 8.3.2 Characteristics of smallpox facilitating eradication 8.4 The surveillance and containment strategy 33 8.4.1 Routine reporting systems 8.4.2 Active surveillance 8.4.2.1 Special searches 8.4.3 Containment 8.4.4 Special prob lems 8.4.4.1 Concealment of outbreaks 8.4.4.2 Variolation 8.5 Research 36 8.5.1 Epidemi ology and public health 8.5.2 Virology page 7 9. IMPLEMENTATION OF THE INTENSIFIED ERADICATION PROGRAMME 36 9.1 The period from 1967 to 1972 37 9.1.1 West and central Africa 9.1.2 South America 9.1.2.1 Brazil 9.1.2.2 Other countries 9.1.3 Other central African countries 9.1.4 South-eastern Africa 9.1.5 Sudan and Uganda 9.1.5.1 Uganda 9.1.5.2 Sudan 9 .1.6 Indonesia 9.2 Southern Asia 42 9.2.1 Burma 9.2.2 Afghanistan 9.2.3 Pakistan 9.2.4 Nepal 9.2.5 India 9.2.6 Bhutan 9.2.7 Bangladesh 9.3 The countries of the Arabian peninsula 46 9.4 Countries in the Horn of Africa 46 9.4.1 Djibouti 9.4.2 Ethiopia 9.4.3 Kenya 9.4.4 Somalia 9.5 Mi ssed outbreaks 49 10. OUTBREAKS OF SMALLPOX IN NON-ENDEMIC AF.EAS 50 10.1 Importations of smallpox 50 10.1.1 International quarantine 10 .1. 2 Importations into Europe , 1950-1977 10.2 Lab oratory-associated outbr eaks 51 11. THE CERTIFICATION OF ERADICATION 51 11.1 International Commi ssions 51 11.2 Preparations for certification 52 page 8 11.2.1 In recently endemic and adj acent countries 11.2.1.1 Effectiveness of the routine reporting system 11.2.1.2 Active searches 11.2.1.3 Pockmark surveys 11.2.1.4 Chickenpox surveillance 11.2.1.5 Rumour register 11.2.1.6 Specimens for laboratory diagnosis 11.2.1.7 Publicity, knowledge about smallpox, and rewards 11.2.2 In countries free from smal lpox for several years 11.3 Certification by international commi ssions 57 11.4 Certification by the Global Commi ssion 59 11.4.1 Rationale 11.4.2 Action by the Global Commi ssion 11.4.2.1 Countries already certified by international commissions 11.4.2.2 Countries designated for special reports and/or visits 11.4.2.3 Formal statements by countries and areas 11.5 International smallpox rumour register 59 12.
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