Cover: For ten years the world has been spared such a sight~a baby suffering from smallpox. Photo WHO IX ISSN 0043-8502 World Health is the officia l il lu strated magazine of the World Hea lth Organization Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten trmes a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. The German edition is obtainable from · German Green Cross, Schuhmarkt 4, 3550 Marburg, FRG. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necess­ arily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Ten years of freedom from an ancient scourge Smallpox: never again ! by Halfdan Mahler . 3 In the aftermath of "target zero" byZdenekJezek . 4 The lessons learnt by Donald A. Henderson . 8 Progress in the right direction by lsao Arita. 12 The poorest had most to gain by Jarl Tranaeus. 14 A world freed the threat of smallpox. 16-17 Can smallpox return? by Frank Fenner. 18 Surveillance and research by Svetlana Marennikova . 22 Getting your money's worth by John F. Wickett . 24 Spin-off from space travel by Silvia Michanie and Frank L. Bryan . 26 • Department Health Manpower Development Meeting health needs by Abdul Rahman AI-Awadi 28 News Page ... 30-31 2 ·rEN YEARS OF FREEDOM FROM AN ANCIENT SCOURGE Smallpox: never agai1n! by Dr 'Halfdan Mahler Director-General of the World Health Organization en years have now elapsed since pull together in a venture that will the world's last case of endemic benefit not only our generation but that Usmallpox was detected, in of our children and our children's chil­ Somalia. Ten years are surely enough dren. When the history of the twentieth to convince even the most hardened century comes to be written from the sceptics-and there were many-who standpoint of the twenty-first, this said that smallpox was too insidious a achievement will undoubtedly rank disease to oe really eradicated .from the. alongside such wonders as the mastery planet. Surely it would turn up again to of flight and the landing of men upon plague mankind as it has done since the moon. time immemorial? We at WHO are proud of the part we Nevertheless smallpox has gone from played in this achievement-but we are the world. Throughout the past decade, not resting on our laurels either. The the alarm bells have rung many times. next step is to harness the same inter­ Smallpox has been "definitely diag­ national will and energy to bring about nosed" inthis country or that.. But the whole package of educational, en­ WHO's meticulously kept "international vironmental,social, behavioural, medi­ rumour register" proves the value of cal, organizational and managerial ac­ unremitting surveillance: every alarm tions that we call Health for all by the has turned out on investigation to be a year 2000. And in so doing, we shall false one-the result of chickenpox or make good use of the lessons we learnt I measles or skin disease or erroneous in those stirring years when the pock­ press reporting. marked map of the globe was gradually The eradication of smallpox is a truly cleansed until the last vestige of small­ sensational example of what can be pox was wipe9 away for ever. done when all the nations of the world W oR LD HEALTH, Aug ./Sept. 1987 3 n October 1977, health staff their Organization to ensure that several countries of North America, working in the small port of this situation remained permanent. Europe and the Western Pacific. UMerka, in southern Somalia, Recommendations formulated by Even so, 133 countries were still diagnosed a case of smallpox in a the Global Commission for the Cer­ continuing routine vaccination 23-year-old hospital cook named tification of Smallpox Eradication programmes. Ali Maow Maalin. He was isolated, and the newly-established special With the certification of the eradi­ and his friends and eo-workers who WHO Committee on Orthopoxvirus cation of smallpox in May 1980, the had been in close contact with him Infections assisted WHO to map out representatives of WHO's Member were located, examined and vacci­ a post -eradication "insurance pol­ States endorsed the recommenda­ nated. Health teams then fanned icy " focusing on the main goal : tion that routine vaccination against out in search of every case of chick­ public safety by maintaining the smallpox was no longer justified enpox and skin rash they could find. world permanently free from and should be discontinued in every No more smallpox was discovered. smallpox. country. By the end of 1984, all Mankind had seen its last case of countries had ceased smallpox vac­ this endemic disease. Smallpox ••••••••••••••••••••••••••• cination of the general public . " target zero" had now indeed been • • Routine vaccination did not cease • Dr Zdenek JEZEK heads • achieved. The ancient scourge, . instantly, as appropriate instruc­ which had killed millions since the : WHO's Smallpox Erad1cat1on : tions were not always transmitted dawn of civilization, was finally : Programme. : throughout the health services. In eradicated. This fact was certified, •••••••••••••••••••••••••••• • some places, smallpox vaccine con­ in a historical session, by the Thirty­ tinued to be made available on third World Health Assembly of the Vaccination policy: The modern request. Health staff in these coun­ WHO in May 1980. world had built up an elaborate tries had to explain to anxious pa­ But the job was not yet finished. system of defence against smallpox rents that the risks posed by vacci­ It was necessary to convince the which included compulsory vacci­ nation for their children stood world community that the disease nation and constant checks on in­ against "zero" benefits. There was had gone forever, to ensure that ternational travellers. Already part no disease to be feared. Some phy­ advantage was rapidly taken of the of that system was being dismantled sicians had to be persuaded that benefits of this achievement. De­ by 1977, when worldwide eradi­ smallpox vaccination has no value spite the overwhelming evidence cation became imminent. By that in treating or preventing recurrent that the world had been freed from time, routine vaccination, which herpes infections, warts and so smallpox, measures needed to be had been in existence for over 175 forth, and that, furthermore, misuse taken by the Member States and years, was no longer required in of smallpox vaccine for such treat- 4 W oRLD HEALTH . Aug ./Sept. 1987 ment is associated with the risk of Facing page: Helicopters helped to severe complications. close the net on smallpox in Somalia. WHO In 1983, contacted govern­ Photo W HO/E. Shafa ments and vaccine producers and urged them not to distribute vaccine Right : Health workers summoned peo­ to civilians. Nevertheless, military ple to come forward for vaccination, personnel have continued to be vac­ offered cash rewards for anyone report­ cinated in some countries, resulting ing a smallpox case, and stuck up post­ in the accidental vaccinal infection ers to explain the campaign. Eradication of their civilian contacts. In 1983 , in meant savings in time and money for order to prevent such incidents, the everyone at airport health control Committee on Orthopoxvirus In­ points. Photos WHO/P. Almasy. WHO/E. Shafa. fections recommended that " milit­ WHO/P. Almasy and W HO/Novosti ary personnel who have been vacci­ nated be confined to their bases and prevented from contacting unvacci­ could reach any country m the nated persons for a period of two world within 24 hours. weeks following vaccination". And At the end of last year the stock in 1986 the Committee proposed amounted to more than five million that smallpox vaccination of milit­ ampoules which, with the use of ary personnel be terminated. Small­ bifurcated needles, would be suffi­ pox vaccination is now only re­ cient to vaccinate about 250 million quired for the small number of lab­ persons. Considering that nearly oratory workers who handle variola ten years had elapsed since the last virus or closely related orthopox­ endemic case of smallpox and that viruses in their laboratories. Vast human monkeypox had not proved sums taken from scarce health to be a significant health problem, resources and spent on smallpox the Committee on Orthopoxvirus vaccination in the past are now Infections considered iri March diverted to other pressing public 1986 that there was no further need health problems. for WHO to maintain the global Checks on international travel­ vaccine reserve. lers: In May 1980, the Member Reports on smallpox prove false: States agreed to withdraw require­ We had no doubt that reports of ments for valid smallpox vacci­ suspected cases of smallpox would nation certificates for international reach WHO for several years after travellers, and the following year the declaration of its eradication. smallpox was formally struck from The thorough and prompt investi­ the International Health Regu­ gation of such reports, backed up lations. Despite health administra­ by laboratory examination and sub­ tions withdrawing such require­ sequent disclosure of results, would ments, international travellers and be a very important element of crews of ships and aeroplanes were post-eradication surveillance. Any occasionally asked for such certifi­ report of a suspected case is re­ cates at ports and airports, when garded as a public health emergen­ applying for visas, or simply by cy and has to be promptly investi­ travel agencies. WHO cooperated gated. Since 1980, WHO has coordi­ with national health authorities to nated the investigation of 131 clarify reports of such incidents, rumours of suspected cases, re­ which had virtually ceased by 1986.