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Washington, D.C., World Bank, 1991. x, 51 p. (World Bank Technical Paper No. 159)A World Bank report outlines the results of an empirical study. It lists institutional characteristics connected with successful tropical disease control programs, describes their importance, and extracts useful lessons for disease control specialists and managers. The study covers and compares 7 successful tropical disease control programs: the endemic disease program in Brazil; schistosomiasis control programs in China, Egypt, and Zimbabwe; and the malaria, schistosomiasis, and tuberculosis programs in the Philippines. All of these successful programs, as defined by reaching goals over a 10-15 year period, are technology driven. Specifically they establish a relevant technological strategy and package, and use operational research to appropriately adapt it to local conditions. Further they are campaign oriented. The 7 programs steer all features of organization and management to applying technology in the field. Moreover groups of expert staff, rather than administrators, have the authority to decide on technical matters. These programs operate both vertically and horizontally. Further when it comes to planning strategy they are centralized, but when it comes to actual operations and tasks, they are decentralized. Besides they match themselves to the task and not the task to the organization. Successful disease control programs have a realistic idea of what extension activities, e.g., surveillance and health education, is possible in the field. In addition, they work with households rather than the community. All employees are well trained. Program managers use informal and professional means to motivate then which makes the programs productive. The organizational structure of these programs mixes standardization of technical procedures with flexibility in applying rules and regulations, nonmonetary rewards to encourage experience based use of technological packages, a strong sense of public service, and a strong commitment to personal and professional development.
WORLD HEALTH. 1987 Aug-Sep; 8-11.The implications of the fact that it was concerted global effort that eradicated smallpox are discussed. The primary reason why the effort succeeded is that specific measurable goals and time deadlines were built in. The 10-year goal was met in 9 years 9 months 26 days. Universal political commitment, including provision of funds by WHO and by constituent countries, was required. A strategy of 80% vaccination and surveillance and containment of outbreaks, followed by certification of eradication, was adhered to. Whether the smallpox campaign could be used as a template for eradicating other diseases is discussed. The biology of smallpox makes it a unique candidate for eradication, while no other disease shares all of its qualifications, such as having only a human host. Lessons have been learned for control of other diseases, however. With regard to the concept of primary health care for all, the smallpox effort showed that finite, specific programs are better supported than basic health services. The eradication demonstrated the power of good leadership and common goals supported by an international institution.
WORLD HEALTH. 1987 Aug-Sep; 18-21.The possibility that smallpox could be released to infect the world again is considered from the viewpoint of theoretical situations as well as the mechanisms in place to keep the virus out of circulation. Theoretically, smallpox could be stolen from a laboratory, found unknowingly in a lab freezer, manufactured for biological warfare, newly generated by mutation from another virus, emerge from the environment, or be reactivated from the system of a former victim. Laboratory sources have all been destroyed, except for cloned DNA kept in Atlanta and Moscow, which without the virus coat cannot be transmitted. There is no animal reservoir of a virus similar to smallpox. Smallpox is a type of DNA virus that has never been known to be reactivated from people who had the disease. After the publication of the Global Commission for the Certification of Smallpox Eradication in 1979, the WHO maintains an International Rumor Register in Geneva to investigate possible cases of smallpox. All suspected cases have been either chickenpox or measles. There were 2 cases in Britain in 1978 due to a laboratory accident, and 3 incidents of unwitting storage of virus in laboratory freezers. These stocks were immediately destroyed, and it is decreasingly likely that more smallpox virus will be found.
SCIENTIFIC AMERICAN. 1976 Oct; 235(4):25-33.The key events in the eradication of smallpox worldwide are related. Smallpox virus was spread by droplets, only from the appearance of the rash until scabs form, 4 weeks later. It only infected humans, making it a potential disease for eradication. It had been endemic in populous areas, largely China and India in ancient times, appearing in Europe in the 6th century and in America in 1520. Smallpox vaccination was known as variolation before the modern practice of vaccination with cowpox (Vaccinia) was demonstrated in 1796. Success of the 10 year long world eradication campaign depended on production of heat-stable vaccines and a reusable pronged needle that used little material. The U.S.S.R. suggested the campaign in 1959, but the current campaign began in 1976. The 1st strategy was intensive vaccination, with moderate success. Subsequent strategies involved surveillance and containment, along with improved reporting methods. The concept of an infected village was introduced, and house to house searches were instituted. Victims were put under guard and all villagers were vaccinated. The last case of virulent smallpox occurred in Bangladesh in October 1975, and of mild smallpox in Ethiopia in August 1976. The cost of the entire 10-year global eradication was $83 million for foreign assistance, and about $160 million spent by the individual countries. This is small compared to an estimated $2 billion yearly spent to control smallpox. It is ironic that smallpox became an epidemic pestilence upon the growth of populations, yet it played a major role in preventing population growth until variolation and vaccination became common.
NATIONAL GEOGRAPHIC. 1978 Dec; 154(6):796-805.The story of the defeat of smallpox is told from the end back to high points in the effort. In April 1979, the case of the last natural victim of smallpox, a Somalian cook, was documented. Unfortunately there were 2 subsequent cases, due to laboratory exposure in Birmingham, England. The more severe Asian strain killed 20-30% of persons it attacked, and left the survivors scarred and sometimes blinded. A concerted world effort to eradicate smallpox, rather than merely control it, began with WHO in 1959, but succeeded with the WHO campaign instigated in 1966. In 1966 there were 44 countries with uncontrolled smallpox. The number fell to 19 nations in 1972, 5 in 1975, and none in 1978. Asian smallpox was contained in 1976, leaving only variola minor endemic in Ethiopia and Somalia. The 1st plan was mass vaccination. After a shortage of supplies in Nigeria, the strategy of surveillance and containment was found to be far superior and cost effective. In this technique, suspected cases were quarantined under guard, while all contacts and everyone within a 5-mile radius were vaccinated. New stable vaccines and a special needle that saved vaccine material permitted field workers to vaccinate inaccessible populations. Workers used charm, guile, shame or intimidation to get universal cooperation. This feat in world-wide teamwork, creative problem-solving and heroic leadership under severe odds and admonitions of the experts demonstrated that the chain of transmission of a dread disease could be broken.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1975; 52(2):209-22.The history of smallpox eradication in the 20 countries of West and Central Africa from Mauritania to Zaire is recounted, including background, evolution of strategy, assessment, maintenance, costs, and significance of the campaign. Smallpox was endemic in these countries, peaking each year at the end of the spring dry season, usually occurring in isolated villages only periodically. The average case fatality was 14.5%, but twice as high in infants and older adults. Clinical exams showed that those with actual vaccination scars rarely got smallpox. The campaign was made feasible because of lyophilized heat-stable vaccine and bifurcated needles or jet injectors. The initial strategy called for mass vaccination and assessment of achieved vaccination. Between 1967 and 1969 100 million persons were vaccinated at collecting points; by 1972, 28 million more children had been protected. In 1966 an outbreak of 34 cases in Nigeria was blocked within 3 weeks of initiation of surveillance and containment. This effort also demonstrated that actual smallpox transmission was slow and relatively ineffective, and further that vaccination of contacts even after exposure was effective. The strategy was replaced by surveillance-containment begun in the seasonal low. The results were that smallpox disappeared within 5 months in an area of 12 million, and within 1 year in 19 of the 20 countries. Maintenance vaccination to prevent importation of the virus is continuing. The cost of the program was $15 million to the U.S. sponsors, or 1/10 the yearly price of smallpox control in the U.S.