GLOBAL PUBLIC HEALTH Osher Lifelong Learning Institute at
GLOBAL PUBLIC HEALTH Osher Lifelong Learning Institute at Berkshire Community College Winter Session 2021, Katherine M. Kidd, Ph. D
Class Objectives • To consider the factors that led to the smallpox eradication campaign • To examine the characteristics that led to its success • To analyze two case studies – Eastern Nigeria and India • To consider the benefits of the eradication effort • To understand the lessons learned • To consider the way in which this campaign has shaped subsequent global health efforts
Pharaoh Ramses V DOD 1157 BCE
Smallpox and vaccine innovations • Variolation, using a little virus from an infected person, was in use in the 18 th century. Onesimus, an African-born enslaved person in Boston, introduced Cotton Mather to variolation • Zabdiel Boylston, an uncle of John Adams, advocated variolation during smallpox epidemic in 1721 • Used by George Washington during Revolutionary War for American troops • Edward Jenner, championed vaccination, taken from cowpox in 1796, and proved the efficacy of the cowpox vaccine • By early 19 th century Thomas Jefferson created a National Vaccine Institute to promote national vaccination program
Smallpox in the 1950 s • Vaccines were widely used worldwide • Smallpox had ended in many industrialized countries but still endemic in 63 countries with 60% of global population. Estimates of death from smallpox was 1. 5 -2 million annually. • Smallpox virus varied by region, South Asian version most deadly with 30 -40% deaths, approximately 10% of survivors were blinded and scaring often made women not eligible for marriage • There was no cure so total cases were widely underreported • Even where smallpox was no longer a threat, vaccination was generally required for all children since virus could spread from smallpox endemic regions
Smallpox Eradication • 1958 Russian delegate to the World Health Assembly (WHA), Viktor Zhdanov, proposed a 10 year eradication campaign • USSR offered 25 million doses of vaccine • 1959 WHA endorsed eradication campaign • WHO created a special unit but did not put its energy and leadership into movement for first 5 years • Depended almost exclusively on national vaccination efforts • By 1965, WHO realized that without data and leadership, eradication would falter
Why smallpox and why the 1960 s? • Smallpox is infectious but not highly contagious • Has no non-human vector • New vaccines required no cold chain, could be easily stored for long periods • New bifurcated needles more effective, less painful and used less vaccine • Smallpox is easily diagnosed and does not need a physician for accurate diagnosis • Vaccination did not require a physician – community health workers could be trained in 15 minutes
Smallpox cases 1950
1965 Turning Point • The US, largest WHO funder, committed to the campaign with funds and staff • President Johnson looking for something doable in the International Cooperation Year • Dr. Henderson at CDC saw smallpox as the least expensive, best choice for a global campaign, not measles or malaria • WHO created a dedicated fund for smallpox which made fundraising much easier • 1966 WHA adopted the Intensified Smallpox Eradication Program
Messaging and Management Matters • WHO acknowledged need to learn from mistakes of malaria projects and built in more open communication • Reports came out bi-weekly and were distributed worldwide • WHO provided guidelines but they were flexible and modifications were encouraged as needed • Research and data collection was considered essential • Case reporting system was required
Mass vaccination to surveillance and containment • Mass vaccination campaigns had not been successful in many countries • Poorest most remote people did not get vaccines • Incentives to over report number of vaccines administered • Revaccination was easier than finding those who hadn’t gotten vaccine • Making community health worker responsible for reporting cases for vaccination and containment led to underreporting of cases • Many people refused vaccination, especially in India, due to religious beliefs
Surveillance and containment • 1966 – CDC in partnership with USAID took lead for smallpox • • • eradication in 20 West African countries 1967 Biafran Civil War breaks out in Nigeria Mass vaccination became very difficult. S&C came out of necessity of working in a war zone but proved more effective than mass vaccination Vaccination within 7 -10 days was still effective even if someone was exposed to smallpox Mapping of smallpox showed disease moved from north to south. By containing outbreaks in the north, chain of transmission could be broken. Within two years, S&C resulted in eradication of smallpox in the Eastern Zone of Nigeria – completed during a horrific famine and civil war
William Foege, MD
Rolling out the S&C Approach • Once S&C had been proven effective in Nigeria, it was rolled out for all of West Africa • Within 12 months, smallpox had been eradicated in all 20 countries of West Africa • CDC and WHO agreed that S&C was more effective than mass vaccination and it became the first line approach for the 33 countries that still had endemic smallpox • S&C was effective even with a poor health infrastructure and in conditions of extreme poverty and conflict • Creative adjustments to local culture was essential to success
Smallpox in India 1973 • By 1973, smallpox had been eradicated in most countries except in South Asia – India, Bangladesh, Pakistan, and Nepal where it was still endemic • Foege sent by the CDC and WHO to help India implement the S&C approach • Three mass vaccination campaigns in 10 years had not resulted in eradication in 6 of India’s largest and poorest states – especially Uttar Pradesh and Bihar • S&C was resisted by top health authorities as not Indian but local health workers embraced it
The Indian Campaign
The Indian Campaign
The Indian Campaign
Why 1973? • Indira Gandhi’s government was committed • Increased resources – WHO/CDC staff, vaccines, money • More vaccination staff • More quality vaccine • Bifurcated needles • Timely accurate reporting system • Cross notification system between states in India
Adjusting to India • 80% mass vaccination goal left hundreds of thousands exposed in every district • Massive training of village level workers • Reporting and containment roles were separated • Actual smallpox incidence was 100 times higher than all previous reports • Introduction of guards – up to 100, 000 needed • Three critical lessons after three months • Knowing the truth was essential to success • More containment staff was needed • Team work – treating everyone equally – was essential
Mobilizing additional resources • WHO/CDC provided 235 additional epidemiologists on three month rotations • Integration in the field • Integrity • Cultural sensitivity • Optimism • Hospitals, universities, businesses provided additional volunteer staff – Tata Industries in Bihar provided 100 top staff. Tata partnership was the first of many formal business-public health partnerships. • Non-hierarchical monthly staff meetings to share data, best practices and encourage competition became key to success
Maintaining Political Will • “You get what you inspect, not what you expect” • Success of containment involved a lag of 21 days from report of outbreaks • Chief Minister of Bihar threatened to withdraw support – house on fire response • National Minister of Health threatened to return to mass vaccinations – top medical team threatened resignation • Within one year of S&C campaign, India was smallpox free in May, 1975. Succeeded where 175 years of vaccination had not.
The Indian Campaign
The Final Steps • Bangladesh • Ethiopia • Somalia – 1977 last reported cases of smallpox reported
Lessons Learned • Seeking the truth is essential • Diverse teams, based on trust, work • Develop a tool kit and then adjust it based on actual experience • Each disease and culture require different approaches • Social will – a “we” that people understand • Social will must be transformed to political will • Public health solutions require good management plans • Leaders must be optimistic, humble, and ready to go the full distance • Clear, honest communication among and between all sectors of the community is essential
Questions and Answers
- Slides: 26