THE CERTIFICATION OF ERADICATION: CONCEPTS, STRATEGY … 24.pdf · Anopheles gambiae, from Brazil in 1940 (Soper & Wilson, 1943). With these programmes of vector eradication came

CHAPTER 24

THE CERTIFICATION OFERADICATION : CONCEPTS,STRATEGY AND TACTICS

Contents

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PageIntroduction 1104Historical development of the concept of certification 1104Eradication : definition and criteria 1108

Definition in terms of vaccination programmes (1962) 1108Definition in terms of the interruption of transmission(1968-1980) 1108

Development of strategies for certification 1110South America 1110Indonesia 1111Western Africa 1112Coordination of certification activities 1113

National preparations for certification 1114Effectiveness of the routine reporting system 1115Active searches for unreported cases 1115Pockmark surveys 1117Chickenpox surveillance 1118Rumour register 1118Specimens for laboratory diagnosis 1118Publicity campaigns and rewards 1122Documentation 1123

Operation of international commissions 1123Membership 1126Mode of operation 1126

Procedures for global certification 1127Consultation on the Worldwide Certification of Small-

pox Eradication 1127Establishment and responsibilities of the GlobalCommission 1130

Chronology of certification 1130Declaration of the global eradication of smallpox 1134

Annex 24 .1 . Membership of international commissions forthe certification of smallpox eradication 1140

Annex 24.2. Participants in the Consultation on theWorldwide Certification of Smallpox Eradicationand members of the Global Commission 1146

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SMALLPOX AND ITS ERADICATION

INTRODUCTION

world's most heavily populated country,China (Chapter 27) .

On 8 May 1980 delegates to the Thirty-third World Health Assembly, representingall 155 Member States of the World HealthOrganization, unanimously accepted the con-clusions of the Global Commission for theCertification of Smallpox Eradication (WorldHealth Organization, 1980), namely that :

(1) Smallpox eradication

had beenachieved throughout the world .

(2) There was no evidence that smallpoxwould return as an endemic disease .

The first conclusion was based on thefindings of a series of independent inter-national assessments, undertaken underWHO's auspices, of the efficacy of smallpoxeradication programmes and surveillance incountries throughout the world, especiallythose in which smallpox had been endemic in1967 and others at special risk. These activi-ties constituted the programme for the "certi-fication" of smallpox eradication . The secondconclusion was founded on epidemiologicalinvestigations and research studies carried outduring the course of the Intensified SmallpoxEradication Programme and summarized inChapter 30 .

Certification of the eradication of smallpoxwas possible because the virus had no animalreservoir, subclinical infections were rare anddid not result in subsequent transmission, andlatent infections did not occur. Just as thestrategies and tactics used in the eradicationof smallpox in different countries evolvedover time (see Chapters 9 and 10), so also didthe strategies adopted for certification in-crease in rigour and sophistication .

The present chapter describes these chang-ing strategies and tactics, culminating withthe declaration of global smallpox eradicationat the World Health Assembly in 1980 . Theactual operations involved in the 79 countriesin which special measures were taken aredescribed in the following three chapters,which deal in turn with the activities ofinternational commissions for the certifica-tion of smallpox eradication between 1973and 1977 (Chapter 25), the varied activitiesoutlined by the Consultation on the World-wide Certification of Smallpox Eradication in1977 and supervised by the Global Commis-sion for the Certification of Smallpox Eradi-cation (Chapter 26), and the final certificationoperations in the world's last stronghold ofsmallpox, the Horn of Africa, and in the

HISTORICAL DEVELOPMENT OFTHE CONCEPT OF CERTIFICATION

As outlined in Chapter 9, programmes toeradicate specified human diseases from parti-cular localities, and eventually globally, datefrom the early years of the 20th century . Apartfrom Jenner's prophetic but hardly practicalpronouncement in 1801 (see Chapter 6, Plate6.8), the first explicit statement about thepossible large-scale eradication of a humandisease was a comment by Gorgas (1911 a) onthe eradication of yellow fever, a disease later(1915) nominated for global eradication bythe International Health Commission of theRockefeller Foundation (see Chapter 9) . Withthe realization in the mid-1930s that therewas an animal reservoir of the yellow fevervirus (Soper, 1936), global eradication of thatdisease ceased to be a tenable objective . It wasreplaced by the idea of eradicating its urbanvector, Aedes aegypti, from countries in theAmericas, a concept that gained acceptance in1942 partly because of the successful eradica-tion of the imported African malaria vector,Anopheles gambiae, from Brazil in 1940 (Soper& Wilson, 1943) . With these programmes ofvector eradication came the need for somemeans of assessing whether the mosquito inquestion had indeed been eliminated fromparticular localities, regions and countries .The first "certification" procedures for Aedesaegypti eradication were developed by the PanAmerican Health Organization in 1954, re-vised in 1960, and issued in a definitive formin 1971 (Pan American Health Organization,1971b). The criteria called for the absence ofAedes aegypti from a region for a period of atleast 1 year, during which 3 surveys confirm-ing the absence of the mosquito had beenmade. The final survey had to be carried outwith the cooperation of the Pan AmericanHealth Organization, which provided thetechnical personnel needed for the task . If thesurvey confirmed the absence of Aedes aegyptimosquitos, the country was entered on thePan American Health Organization's registryof countries considered free of this species .

When the malaria eradication programmewas begun by WHO in 1955, it was realizedthat some mechanism was needed for con-vincing those outside the regions and coun-

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Plate 24.1 . Poster produced in the 6 official languages of WHO on the occasion of thecertification of the eradication of smallpox from the Horn of Africa on 26 October 1979,exactly 2 years after the world's last case of endemic smallpox occurred in Somalia.

1106 SMALLPOX AND ITS LRADICA'I'ION

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION - MAY 1980

Plate 24 .2 . A complete issue of the WHO magazine World health was devoted to smallpoxeradication at the time of the Thirty-third World Health Assembly's formal declaration thateradication had been achieved .

tries concerned that they were free of thedisease . In 1960, the Thirteenth World HealthAssembly requested the Director-General ofWHO "to establish an official reister listingareas where malaria eradication' had beenachieved, after inspection and evaluation by aWHO evaluation team". The methodologyand procedures for certification were laiddown in 1961 (WHO Expert Committee onMalaria, 1961) and amplified in 1966 and1974. The essential feature of the assessmentprocedure was that a regional WHO evalua-tion team would visit the area for whichregistration had been requested by a govern-ment, analyse the epidemiological and oper-ational data collected during the consolida-tion phase (a period of 3 consecutive years,during which no evidence of transmissionhad been found and during the last two ofwhich no general measures of anophelinecontrol had been practised), and examine theorganization, methodology and quality of thesurveillance operations and the plans for theirmaintenance. Each WHO evaluation teamincluded at least one member of the WHOExpert Committee on Malaria, together withstaff from the relevant WHO regional office orshort-term consultants appointed by it .National experts from the country beingassessed were not included, but the teamrelied heavily on briefing by them . The team'sreport was first reviewed at the WHO re-gional office and later by the WHO ExpertCommittee on Malaria, and on the latter'srecommendation the area was entered in theofficial register .

With the imminent eradication of small-pox from South America in 1971, it becamenecessary for WHO, through its SmallpoxEradication unit, to develop procedures forthe assessment of the claim that smallpox hadbeen eradicated from the Americas . Theearlier eradication programmes had estab-lished the important principle that it was notpossible for any independent authority, suchas a team of WHO experts, acting entirely onits own, completely to confirm the status of acountry or region in respect of Aedes aegypti ormalaria for any definite period of time .Instead, it was necessary for it to depend onrecords compiled by the national authorities,the quality of which could then be deter-mined by field appraisal undertaken by a teamof experts from outside the country .

The global eradication of smallpox, if itcould be achieved, would be uniquely differ-ent from that of Aedes aegypti or malaria since

24. CERTIFICATION : CONCEPTS, STRATEGY AND TACTICS 1107

two valuable but expensive public healthmeasures could then be abolished : routinevaccination of populations in all countriesand the requirement that international tra-vellers had to be vaccinated. For this to bepossible, however, the world community ofpublic health officials and medical scientistswould have to be convinced that globaleradication had really been achieved . Assess-ment of the situation in each country there-fore needed to be carried out by teams ofhighly respected scientists and health offi-cials, independent both of the national auth-orities of the country being assessed and ofWHO, which might be regarded as having avested interest in the results . Having estab-lished the goal of global eradication never arealistic objective in the case either of Aedesaegypti or of malaria the Smallpox Eradica-tion unit saw that the independence of theassessment teams needed to be placed beyondall possible doubt.

With these requirements in mind, a strat-egy for the certification of smallpox eradica-tion was developed by the unit . This consistedfirst of the preparation of detailed "countryreports" by the national health authorities ofthe countries concerned, assisted by WHOstaff and consultants . The reports outlinedthe procedures by which it was believed thatsmallpox had been eliminated and describedthe capability of the surveillance system todetect cases of suspected smallpox . When theSmallpox Eradication unit judged that thesepreparations had reached an appropriatestage, arrangements were made for a group ofindependent international experts, who con-stituted what came to be called an "inter-national commission for the certification ofsmallpox eradication", to visit the country orcountries concerned . Their task was to studythe country report, make visits wherever theythought necessary, assess carefully the capa-bility of the surveillance system to detect casesof smallpox should they have occurred, andmake recommendations about public healthactivities relevant to smallpox . This was a newstrategy designed to solve the novel problemof convincing the international communitythat smallpox, formerly a universal disease,had been eradicated from particular countries,regions, continents and finally the world . Onthe basis of experience of the best tactics forparticular situations, the certification processwas modified and improved, but the essentialfeatures-adequate preparations and detaileddocumentation of the evidence of freedom

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from smallpox for at least 2 years, andthe independence and authority of thecertification team remained unchangedthroughout .

ERADICATION: DEFINITION ANDCRITERIA

To understand the way in which certifica-tion of smallpox eradication evolved, it isnecessary to examine the definition of, andcriteria for, eradication developed in 1967 bythe WHO Scientific Group on SmallpoxEradication (1968) and ratified and slightlyelaborated in 1971 by the WHO ExpertCommittee on Smallpox Eradication (1972) .

From the time of WHO's foundation in1948, the control of smallpox had been amatter of concern both to the World HealthAssembly and to the WHO Secretariat . Theconcept of the global eradication of smallpox,as distinct from control within MemberStates, was first enunciated by WHO in 1958and accepted as WHO policy by the TwelfthWorld Health Assembly in 1959 (see Chapter9). The Intensified Smallpox EradicationProgramme was launched in 1967 (seeChapter 10). Between these two dates, 1959and 1967, the concept of the way in whicheradication could be achieved underwent avery important change .

Definition in Terms of VaccinationProgrammes (1962)

In 1962, in his report on smallpox eradica-tion to the Fifteenth World Health Assembly(document A15/P&B/18 ; unpublished), theDirector-General of WHO defined eradica-tion by stating that : "From a practical view-point, countries in which smallpox has re-cently been persistently present may considerthe disease to be eradicated when no cases ofsmallpox occur during the three years follow-ing the end of a satisfactory vaccination pro-gramme." In suggesting a period of 3 years,the Director-General was probably in-fluenced by the use of this period in certifica-tion procedures for malaria eradication .

Definition in Terms of theInterruption of Transmission

(1968-1980)

The first meeting of the WHO ExpertCommittee on Smallpox was held in Geneva

in 1964. The WHO smallpox eradicationprogramme was discussed (WHO ExpertCommittee on Smallpox, 1964), but no at-tempt was made to define specific criteria foreradication . However, in 1967 a meeting ofthe WHO Scientific Group on SmallpoxEradication (1968) specified the basic defini-tion of, and the criteria for, eradication .Meeting in 1971, with 4 years' experienceof the Intensified Smallpox Eradication Pro-gramme, the WHO Expert Committee onSmallpox Eradication (1972) confirmed boththe definition and the criteria, although itstated them in slightly different terms .

The definition produced by the ExpertCommittee was subsequently endorsed with-out change by the Consultation on theWorldwide Certification of Smallpox Eradi-cation in 1977 and by successive meetings ofthe Global Commission for the Certificationof Smallpox Eradication in 1978 and 1979 .Because they were formulated later, we shalluse the 1971 definition of the criteria foreradication (WHO Expert Committee onSmallpox Eradication, 1972) as the basis fordiscussion

"Eradication of smallpox is defined as theelimination of clinical illness caused by variolavirus . Since smallpox is transferred direct fromman to man in a continuing chain of transmission,and since there is no human carrier state ofepidemiological importance and no recognizedanimal reservoir of the disease, the absence ofclinically apparent cases in man may be assumed tosignify the absence of naturally occurringsmallpox .

"In order to be able to confirm the interruptionof smallpox transmission an effective surveillanceis needed so that clinical infections can be detected.Recent experience indicates that, in all countrieswith a reasonably effective surveillance pro-gramme, residual foci can be detected within 12months of apparent interruption . Thus, in coun-tries with active surveillance programmes, at least2 years should have elapsed after the last knowncase excluding well-defined and contained im-portations before it is considered probable thatsmallpox transmission has been interrupted .

"Because of the ease with which smallpox can betransmitted from one country to another, theconcept of `eradication' can apply only to acontinent . Thus, although smallpox may be con-sidered to have been eradicated from certain conti-nents, it cannot yet be said to have been eradicatedfrom Africa, Asia, or South America .

"On the basis of epidemiological and technicalconsiderations and the considerable experience

acquired so far, the Committee believes that theglobal eradication of smallpox, as defined above, ispossible ."

Since the foregoing formulation of "eradi-cation" became the basis of the whole certifi-cation process, several aspects of it warrantcomment and explanation .

Disease or virus

In the first paragraph the phrase "Eradica-tion of smallpox is defined as the eliminationof clinical illness . . ." provides the most im-portant criterion ; this could be used because,as already pointed out, there was no animalreservoir, subclinical infections were rare andepidemiologically unimportant, and latentinfections did not occur . It was thereforelogical to base a certification programme onthe results of campaigns of active surveillance,which could detect only manifest disease. Itwould be impossible to use such a criterion fordiseases such as plague or tuberculosis .

Furthermore, this criterion took into ac-count the difference between interruptingperson-to-person transmission of smallpoxand supplementing this by the destruction ofall variola virus stocks, as some experts hadurged. Achievement of the interruption ofhuman transmission throughout the worldwas a practical and verifiable goal ; ensuringthe destruction of all variola virus stocks, inthe deep-freeze cabinets of every laboratory inevery country of the world, was impracticableand unenforceable.

Period of freedom from smallpox

In the second paragraph, the stipulationthat " . . . in countries with active surveillanceprogrammes, at least 2 years should haveelapsed" before certification could be under-taken, proved to be a conservative but man-ageable criterion for determining the timingof certification activities, although the choiceof a period of 2 years was an arbitrary one . Ithad been adopted by the 1967 meetingwithout much discussion, and by 1971 furtherexperience of eradication programmes sug-gested that it was realistic . In all countries inwhich WHO-assisted programmes were im-plemented, the surveillance systems improvedgreatly during such programmes and, in thegreat majority of countries, no outbreaks ofsmallpox had occurred after transmission wasthought to have been interrupted . Therewere, however, a few exceptions . In Brazil,


Indonesia and Nigeria, outbreaks were disco-vered 10-34 weeks after transmission wasthought to have been interrupted, but in nocase was the stipulated period of 104 weekseven remotely approached . After these inci-dents, countries in which national eradica-tion programmes were still in progressfurther strengthened their surveillance sys-tems. The effectiveness of such systems wasalways evaluated by WHO before a date wasfixed for the visit of an internationalcommission .

In a practical sense, the reliability ofcertification was related to two factorsnamely, the lapse of time since the last knowncase and the intensity of surveillance . If theintensive surveillance in operation during theeradication campaign had been maintainedfor 2 years thereafter, this period was morethan long enough to judge whether or noteradication of the disease had been achieved .Where longer periods had elapsed, a lesssensitive surveillance system was sufficient todetect the serial transmission of smallpoxsince many hundreds of cases would need tooccur to maintain the chains of transmission .Because the supply of susceptible subjectswould soon be exhausted, smallpox could notpersist for prolonged periods in sparselypopulated inaccessible regions ; and in townsand cities, in which the population densitywas high enough to support continued trans-mission, large numbers of cases could not gounobserved. After eradication had beenachieved in the Indian subcontinent, theSmallpox Eradication unit believed that, incountries in which active surveillance hadbeen maintained after an energetic eradica-tion campaign had been successfully com-pleted, the interval could well be reducedfrom 2 years to 1 . However, to makeassurance doubly sure, it was decided toadhere to the earlier decision .

Importations and laboratory-associated outbreaks

The second paragraph of the definition oferadication excludes "well-defined and con-tained importations". Apart from importa-tions by travellers from endemic countriesinto countries in which transmission hadbeen interrupted, as occurred in Europe, theAmericas, Africa and Asia (see Chapter 23),this exclusion was used by the Global Com-mission as a basis for its decision regarding thestatus of the last cases of smallpox in theworld. This outbreak, which occurred in

1110


Birmingham, England, in August-September1978, was associated with variola virus beingused for experimental work in the virologylaboratory of the University of Birmingham(see Chapter 23) . The United Kingdom hadbeen free of endemic smallpox since 1934,although there had been a number of impor-tations from the Indian subcontinent afterthat date . This event, like the well-containedlaboratory-associated outbreak in London in1973, was regarded in the same manner as animportation into a country that had long beenfree of endemic smallpox. It was a tragic andpotent reminder of the risks of working withvariola virus with anything except the stric-test containment facilities (see Chapter 30),but it was in no way a threat to the eradicationprogramme .

The outbreaks in China in the mid-1960s,which resulted from the activities of variola-tors but were not reported to WHO until1984 (see Chapter 27), could be regarded inthe same light as a laboratory-associatedoutbreak .

Eradication as a "continental" concept

In the third paragraph, the statement that"the concept of `eradication' can apply only toa continent" meant that the eradication ofsmallpox should not be certified when theendemic disease was absent in a singlecountry or even a group of adjacent countries,but only on a continental or global basis. Thepractice developed of using the terms "inter-ruption of transmission of smallpox" or"elimination of smallpox" to signify theachievement of smallpox-free status by indi-vidual countries.

In fact, the certification of eradication in anentire continent was possible only in theAmericas. In Asia and Africa it provedimpracticable to delay national certificationuntil smallpox was eradicated throughoutthese continents . Thus in Asia, since there hadnot been a recorded importation of smallpoxinto Indonesia since 1949, certification wasarranged in 1974, 2 years after the lastreported case but before other Asian countrieswere smallpox-free. Certification of eradica-tion in Africa posed special problems becauseof the persistence of smallpox in Ethiopialong after freedom from the disease had beenachieved in western Africa . Certificationactivities were therefore not started in west-ern Africa until 1976 and certification in

other areas was undertaken in stages, bothbecause of the shortage of personnel and timeand because of the differing eradicationprogrammes of African countries .

DEVELOPMENT OF STRATEGIESFOR CERTIFICATION

The occurrence of what was believed to bethe last case of smallpox in Brazil (and thus inthe Americas) in April 1971 forced theSmallpox Eradication unit to plan immedi-ately the steps to be taken before eradicationof smallpox from the Americas (in practicefrom South America) could be certified foracceptance by the international community,in 1973, 2 years after the last case . Twooperations new to the unit needed to beplanned and implemented : (1) the collectionin South America of basic data for theassessment of the smallpox status of eachcountry ; and (2) the selection and mode ofoperation of the international assessmentteam, which in 1973 would examine theevidence collected during the preceding 2years. The way in which these operationsdeveloped can best be appreciated by aconsideration of certification procedures in 3areas of the world-South America, Indo-nesia and western Africa .

South America

National preparations

In 1971 a general plan of work was outlinedby agreement between WHO Headquartersand the Regional Office for the Americas . Itcalled for specific reports on the smallpoxstatus of all countries in South America ex-cept Chile, which, because of its geographicalisolation, was judged to be at only slight riskof importations from Brazil or elsewhere,following its last case in 1954. WHO staff andconsultants were assigned to visit the variouscountries, for most of which little informa-tion had previously been available, and wereinstructed to prepare detailed reports in linewith requirements specified prior to theirvisits. While these assessments were beingmade, it became apparent that the surveil-lance systems in some of the countries wereimproving, and the data gathered becameincreasingly valuable as time progressed . Spe-cial programmes were undertaken for the

areas of greatest concern-e .g., the Amazonbasin .

Because of the paucity of established healthunits in the Amazon basin and the inaccessi-bility of many of the areas of interest, specialinvestigations were undertaken in parts of thebasin within Bolivia, Colombia, Ecuador,Peru and Venezuela. The Brazilian parts ofthe basin were systematically and thoroughlysearched by smallpox teams working with themalaria service ; these teams progressed sys-tematically through the entire area, vacci-nating people wherever they were found andinquiring about smallpox. Other measures,outlined in Chapter 25, were also taken .Because only variola minor had been presentin South America in recent decades, pock-mark surveys would have been of littleassistance, and none was attempted .

A mechanism of international assessment

Drawing primarily on the precedent ofassessment of the malaria status of countriesin which that disease was thought to beeradicated, the Smallpox Eradication unitproposed that the results of the reportsprovided by national authorities and WHOconsultants should be evaluated by what cameto be called an "International Commission forthe Certification of Smallpox Eradication" .The first such commission to be established,that for South America, suffered from defectsin both its composition and its performance,which were largely remedied when the nextone (for Indonesia) was set up and did notrecur . In the first place, the Commission forSouth America included several persons whohad been involved in the eradication pro-gramme in South America including as chair-man, at the insistence of the Brazilian govern-ment, Dr Alfredo Bica, Secretary of PublicHealth of Brazil and formerly Director of theCommunicable Diseases Division of the PanAmerican Sanitary Bureau/WHO RegionalOffice for the Americas. The Smallpox Eradi-cation unit, for its part, failed to provide adetailed plan of action for the Commission. Asa consequence, procedures and records andthe history of smallpox eradication pro-grammes in various countries were examinedin a rather cursory and superficial manner .Finally, when the Commission framed itsrecommendations, it showed little apprecia-tion of the significance of the eradication ofsmallpox from the Americas, calling forcontinued routine vaccination throughout

24. CERTIFICATION: CONCEPTS, STRATEGY AND TACTICS

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the continent, as before. Fortunately for thereputation of the Commission, the SmallpoxEradication unit and WHO as a whole,subsequent history showed that smallpox hadindeed been eradicated from South America .

Indonesia

The last case of smallpox in Indonesiaoccurred on 23 January 1972 . Since there wasno record of a case of smallpox having beenintroduced from the nearby endemic coun-tries in Asia since 1949, it was judgedappropriate to proceed with arrangements tocertify eradication in Indonesia (as an isolatedcountry) in 1974 . In the light of the experi-ence in South America, the methods ofpreparation for certification and for fieldactivities by the members of the InternationalCommission were strengthened .

National preparations

Like many other governments, that ofIndonesia was not enthusiastic about contin-uing active surveillance after it was believedthat smallpox had been eliminated and had tobe persuaded of its importance. Then, suffi-cient data would need to be collected to satisfythe Commission that smallpox had beeneradicated . Dr Paul Wehrle, an experiencedsmallpox consultant, therefore visited Indo-nesia in order both to identify weaknesses inthe surveillance system, and to work with thegovernment and WHO advisers to develop aplan which in his opinion would provide suchdata. Subsequently, health staff carried outintensive precertification activities, includ-ing an active search in high-risk areas and thecollection of separate written declarations bythe chiefs of tens of thousands of villages,stating that they had searched for smallpoxthroughout the area under their authority andhad failed to find any cases .

Two factors which facilitated the prepara-tions in Indonesia, compared with those inSouth America, were that pockmark surveyswere useful because the prevailing variety ofsmallpox had been variola major, and that areward was offered to anyone reporting a caseof smallpox .

Selection of members of the International Commission

Profiting from the experience in SouthAmerica, the Smallpox Eradication unit

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modified the procedure for the selection ofmembers of the International Commission,adopting an approach that was applied in theformation of all subsequent commissions . Themajor problem with the constitution of theSouth American Commission was that anational of the major country under examin-ation, Brazil, was appointed chairman . Thismistake was never repeated, but after a gooddeal of debate Dr Julie Sulianti Saroso,Director-General for the Control and Preven-tion of Communicable Diseases in the Indon-esian Ministry of Health, was made a memberof the Indonesian Commission. Subsequentlynationals of the country concerned wereappointed to an international commissiononly in special circumstances as in India,where this was necessary to enable the Com-mission to have access to Bhutan. Govern-ments of neighbouring countries (Australiaand Malaysia) were asked to nominate repre-sentatives, on the grounds that these coun-tries were most at risk of importations shouldsmallpox still be present in Indonesia sotheir nationals might be expected to beespecially critical of the material presented . Ingeneral, the Smallpox Eradication unit tookthe view that the certification process wouldbe best served by the appointment to eachcommission of individuals (whether fromgovernments or universities) respected bytheir own governments so that their opinionson smallpox eradication would also be re-spected. Great care was exercised in theappointment of the chairman, and the prece-dent set in Indonesia, whereby Dr Wehrlevisited the country during the preparatoryperiod and subsequently acted as chairman ofthe International Commission, was followedin other countries in which certification wasof great importance e.g ., Ethiopia and India.After eradication had been certified in Indo-nesia, the Smallpox Eradication unit tried toinclude in each new international commis-sion one or two members who had already hadexperience with an earlier commission .

This Commission and all subsequent com-missions were asked to reach one of twoconclusions : either that they were satisfiedthat eradication had been achieved, or thatthey would be satisfied that eradication hadbeen achieved if certain specific measureswere undertaken. At the initial briefingsession in Jakarta, the Australian and Malay-sian members of the Commission were ex-tremely doubtful whether eradication hadbeen achieved in Indonesia. One observed


that he had recently heard rumours of cases innorthern Sumatra and the other believed thatcases were almost certainly occurring in theslum areas of Jakarta itself. Such scepticismwas welcomed by the Smallpox Eradicationunit since, if these members were persuadedby the evidence presented in the course of theactivities undertaken by the Commissionitself, their conclusions would be more con-vincing to the international community .

A feature of the work of the IndonesianCommission was that Dr Sulianti Saroso,speaking as Director-General for the Controland Prevention of Communicable Diseases inthe Indonesian Ministry of Health, concludedher opening remarks at the first session bysaying that Indonesia was convinced that itwas free of smallpox. Consequently, she in-vited members of the Commission to feel freeto "go anywhere, with anyone, and make anyinquiries" they chose to. This statement washonoured and provided an important prece-dent for other international commissions .

Western Africa

The last case of smallpox in western Africaoccurred in Nigeria in May 1970 and UnitedStates bilateral assistance was terminated in1972. At that time, however, smallpox wasstill endemic in many other parts of Africaand certification was therefore postponed .Smallpox was progressively eliminated fromone African country after another, but thestipulation that eradication was a continentalconcept made the Smallpox Eradication unitreluctant to undertake certification in Africa.However, by 1975 endemic smallpox ap-peared to be limited to the Horn of Africa, andit was decided to initiate the certificationprocess in the African continent in phasedgroups of countries so as to reduce logistic andadministrative problems . The epidemiolog-ical situation in different parts of the Africancontinent was nevertheless borne in mind . Agroup of 15 countries in western Africa wascertified first because transmission had firstbeen interrupted there and because they werefurthest away from the areas in which small-pox was still endemic . Surveillance had beenintensive in these countries for 2 years afterthe presumed elimination of smallpox, buthad then very largely declined . Documenta-tion on activities carried out since 1972 wascomparatively sparse in most countries in theregion. On the other hand, the long period of

time that had elapsed since smallpox had beenseen in any country of western Africa pro-vided good grounds for believing that thedisease had been eliminated and had not beenreintroduced . While notification systemswere not as well developed as might have beendesired, they had been capable of detectingcases of monkeypox in human beings in 1970and succeeding years, as well as outbreaks ofunusual and extremely serious diseases, suchas Lassa fever or Ebola virus disease, whichhad come to the notice of local health staffwithin 6 months and of central health person-nel within 12 months of their occurrence . Ifsmallpox, especially variola major, had oc-curred in western Africa after 1970, it seemedreasonable to expect that the health staff ofthe country concerned would have knownabout it within a year . The 6-year intervalsince the last case thus provided a very largesafety margin .

Because the Commission's visit took placeso long after the last known case, manynational smallpox eradication staff, as well asUnited States epidemiologists who hadworked in the programme, had long since leftand taken up other employment . Moreover,the Commission had to deal with 15 countriescovering a vast area-almost two-thirds ofthe size of the USA-in which the healthservices infrastructure was much less welldeveloped than in South America or Indone-sia. To cope with this situation, WHO re-gional staff and consultants made frequentvisits to these countries and two importantchanges were made in the procedure . First,preparations for certification were simplified,compared with the elaborate precertificationsearches and detailed documentation thatwere used in Indonesia and subsequently inthe Indian subcontinent . Preparation of thecountry reports was based on a standardizedquestionnaire developed by the SmallpoxEradication unit ; when completed, this pro-vided essential information about the na-tional eradication campaign . Secondly, a newmethod of active search was developed for usein all areas in which variola major hadoccurrednamely, large-scale facial pock-mark surveys in children (see later in thischapter). It was reasoned that, if these surveysincluded all children up to 15 years of age,there would be some who had had smallpoxwhen it was still endemic and would havepockmarks which the teams should detect .This served as an internal control in thesurvey, in that failure to detect any individ-


uals with pockmarks would call into questionthe work of the team concerned . Whenchildren with pockmarks were detected, ef-forts were made to find out in which year theyhad contracted the disease that had caused thescarring . Such information was surprisinglyeasily obtained from most villagers . The age ofthe youngest pockmarked child also providedobjective evidence as to when smallpox hadlast occurred .

Western Africa was certified to be free ofsmallpox on 15 April 1976, and in May 1976the Twenty-ninth World Health Assembly,commenting for the first time on the certifi-cation process, endorsed "the procedures de-veloped by the Director-General in the use ofgroups of international experts in the certifi-cation of eradication and [asked] for the fullcooperation of all countries concerned incarrying out these procedures, so that coun-tries throughout the world may have confi-dence that eradication has been achieved"(resolution W HA29 .54). The successful carry-ing out of certification in western Africaprovided the experience necessary for the staffof WHO and various national health authori-ties to proceed with certification in otherareas of Africa as well as in south-western Asia .

Coordination of Certification Activities

In consultation with staff from the appro-priate regional office and the national small-pox eradication programme, the SmallpoxEradication unit was responsible for decidingwhether a particular country was ready toreceive an international commission and, ifso, when. This obviously required frequentvisits by WHO smallpox eradication staff and,on occasion, by WHO consultants, to coun-tries preparing for certification . Thus, eventhough smallpox had been eliminated from allcountries except Somalia by the end of 1976, anumber of WHO smallpox eradication staffwere retained or recruited to assist in thecertification process . From 1977 onwards, theSmallpox Eradication unit in Geneva con-sisted of Arita, who replaced Henderson afterhis departure in February 1977, Dr Joel G .Breman, an epidemiologist from the Centerfor Disease Control, Atlanta, USA, withextensive experience in smallpox and tropicaldiseases, Dr Alexander Gromyko, Dr JamesTulloch and Mr John Wickett. Dr CelalAlgan, Dr Ziaul Islam, Jezek, Dr DanielTarantola and Dr Lev Khodakevich assisted

1114


the programme as WHO staff members in theregional offices .

Certification of smallpox eradication wasnot solely a technical matter but also involvedmany managerial and political questions .Ladnyi, who had acted as WHO intercountrysmallpox adviser in eastern Africa from 1965to 1971, returned to WHO Headquarters in1976 as an Assistant Director-General andremained in this post until 1983. In thiscapacity he was able to help to solve some ofthe political problems that inevitably aroseduring the organization of certificationactivities .

The support provided by WHO staff andconsultants was of two types. First, in acountry in which an eradication campaignhad been developed and executed with theactive participation of WHO staff epidemi-ologists or consultants, some internationalpersonnel continued to work with nationalstaff after eradication in organizing andassessing the active searches for unreportedcases of smallpox, as well as in pockmarksurveys or in the surveillance of chickenpoxcases. The last-named activity was carried outin a number of countries, being of specialimportance where variola minor had beenendemic, since this disease rarely left pock-marks and was readily confused with chicken-pox. Secondly, in countries of western, centraland southern Africa, in which the eradicationcampaign had been organized many yearsbefore certification and in which WHO oroutside epidemiologists were not involved incontinued surveillance, special arrangementswere made to assign experienced WHO con-sultants or staff epidemiologists from eitherinside or outside the country to assist thehealth services in precertification activities .

In countries from which smallpox hadrecently been eradicated great interest wasshown in certification, whereas in those inwhich the disease had been eliminated manyyears before, certification was not consideredby the national health administrators to be ofhigh priority. In some countries, nationalhealth officials who had taken part in thenational smallpox eradication campaign hadrisen in the local health service hierarchy andwere important in persuading senior govern-ment administrators of the importance ofcertification. The assignment of special WHOconsultants and epidemiologists also helpedto promote certification activities .

To persuade governments to mobilize ade-quate numbers of staff to prepare properly for

Plate 24.3 . Joel G . Breman (b . 1936) was a medicalofficer with the WHO Smallpox Eradication unit,1977-1980, during the most active part of the certi-fication programme, and participated in monkeypoxsurveys in western and central Africa . He alsoworked as an epidemiologist in the eradicationcampaign in western Africa, 1967-1969 .

certification, several approaches were used(1) WHO regional office and Headquartersstaff communicated with countries by letteror memorandum, emphasizing the impor-tance of certification if the final achievementof smallpox eradication was to be accepted bythe world community ; (2) further encourage-ment was provided through coordinationmeetings with representatives of the coun-tries concerned and through visits by staff ofthe Smallpox Eradication unit ; and (3) WHOfunds were frequently provided to cover fueland vehicle repair costs and the living ex-penses of national surveillance teams .

NATIONAL PREPARATIONS FORCERTIFICATION

The methodologies employed in nationalpreparations for certification (precertifica-tion activities) differed according to thevariety of smallpox present in the countriesconcerned and whether eradication was fol-lowed immediately by post-eradication sur-veillance and preparation for certification, orprecertification activities were carried outmany years after the occurrence of the lastknown case of smallpox . In most cases thefinal product was a "country report" that was

assessed by the appropriate internationalcommission or the Global Commission .

The WHO Scientific Group on SmallpoxEradication (1968) had pointed out the needfor an effective surveillance system capable ofdetecting and investigating suspected small-pox cases in order to demonstrate that small-pox transmission had been interrupted . Al-though all countries in which smallpox hadbeen endemic continued some form of small-pox surveillance after the date of onset ofwhat they considered to be the last case, itsintensity differed substantially from countryto country. In the last countries to be affectedby smallpox, such as Bangladesh, Ethiopia,India and Somalia, the national programmescontinued active post-eradication surveil-lance that was even more intensive thanduring the eradication campaign itself . Thedocumentation in such countries was morecomplete than that available elsewhere andthese countries could be visited by interna-tional commissions just 2 years after they hadreported their last case . On the other hand, inmost countries of Africa, special surveillanceprogrammes had ceased long before certifica-tion was undertaken . In all cases, countryreports covered the following items, whichare described more fully later :

(1) a description of the routine reportingsystem ;

(2) an account of special active searches,both in high-risk areas and throughout thecountry, including the methods of assessingthe quality of the searches ;

(3) the results of pockmark surveys, ifappropriate ;

(4) a description of chickenpox surveil-lance, wherever it was undertaken ;

(5) the status of rumour registers, in whichall suspected cases of smallpox were recorded,and sometimes also cases with fever and rash ;

(6) a list of specimens sent for laboratoryinvestigation and the test results ;

(7) an account of the publicity given to theneed for reporting smallpox cases, the rewardsoffered for finding a case (where appropriate),and public awareness of such rewards ;

(8) documentation on other precertifica-tion activities .

Effectiveness of the Routine ReportingSystem

Each country provided data on the numberand distribution of health units, including the

24. CERTIFICATION: CONCEPTS, STRATEGY AND TACTICS

1115

number and types of hospitals, health centresor stations and peripheral health units, withmaps showing their distribution throughoutthe country, and on the regularity and com-pleteness with which they reported . Thenumber of monthly or other periodic reportscalled for was compared with the numberactually received . Data were also supplied onthe reporting of cases of chickenpox, especi-ally those with a fatal outcome. Finally,records of the action taken when a suspectedsmallpox case was reported were examined .During visits by WHO consultants in pre-paration for certification, action was taken toincrease awareness among health personnel ofthe need to report immediately any caseswhere smallpox was suspected .

Active Searches for Unreported Cases

In most countries, specially organized mo-bile teams conducted field surveys in order toobtain up-to-date information regarding acti-vities in connection with smallpox. The teamswere organized and directed by the nationalsmallpox eradication programme (when stilloperative), by those who had been involvedin the eradication programme during itsactive phase, or by those responsible for thecommunicable diseases programme.

Special investigations were carried out inlocalities in which the risk of unreportedsmallpox was thought to be greatest . Theseincluded areas in which the last knownoutbreaks had been notified, those in whichsuspected smallpox cases or chickenpoxdeaths had been reported after the last knownoutbreak of smallpox, and those in whichhealth coverage and communications werepoor. Areas bordering on countries in whichsmallpox had recently been endemic, or inwhich there had been recent extensive popu-lation movements, were also included . Specialattention was given to the villages in whichthe last known cases had occurred . Suchinvestigations provided information as to theeffectiveness of control measures and casedetec ion during the concluding phase of theprogramme in the country. If it was foundthat all cases in an outbreak had been detectedand containment was satisfactory, this in-creased confidence in the efficacy of thesurveillance-containment activities .

A general survey was usually planned forcities, towns, and larger villages, since experi-ence had shown that, if smallpox had per-

1116

The Absence of Evidence is not Evidence of Absence

From the beginning of the global eradication programme, steps were taken to encouragethe submission of all reports of smallpox in any country thought to be free of the diseaseand to investigate all such reports . There had always been serious doubts with smallpox, aswith cholera, whether the absence of reported cases really meant that the disease was absentfrom the country concerned. Reports of suspected cases of smallpox in non-endemiccountries had been queried by the Smallpox Eradication unit since the IntensifiedSmallpox Eradication Programme began, in order to determine definitely whether or notthey were imported cases or whether they represented continuing endemic transmission .As the campaign progressed, such reports took on a greater significance and eventually in1978 an international rumour register was established in Geneva (see Chapter 28) .Rumours were very important . Thus, although no cases were officially reported from Iranafter 1963, information that smallpox might be occurring there in 1971 was drawn to theattention of WHO by a WHO consultant as well as by a number of international staffworking with other health agencies . Reports of imported cases in Somalia before 1976 werealso received from embassies long before being notified officially by the government .Similarly, the serious outbreaks which occurred in the Salt Lake refugee camp in WestBengal in 1971 were unknown to the government and to WHO until reported by anAmerican epidemiologist who had observed cases of smallpox in a television news filmtaken at the camp (see Chapter 15) .

sisted in smaller villages or nomadic groups, itwould ultimately reach the larger populationcentres. The localities to be visited wereselected so as to include communities withhealth units and primary schools, since theseattracted people from a large area who mightreport suspected cases . The usual objectivewas to reach a sufficient number of communi-ties to ensure that at least 20-25% of theentire population of the country was coveredby the survey .

In the countries which were the last tobecome free of smallpox Bangladesh, Ethio-pia, India, Nepal, Pakistan and Somalia-country-wide house-to-house searches todiscover possible cases were conducted onseveral occasions . A large number of healthstaff, volunteers and temporarily recruitedsearchers were deployed so that the searchcould be completed within a period of 3-4weeks .

Search teams were organized in order toobtain information about cases of smallpoxand chickenpox, actual or rumoured, in pri-mary schools, health units, markets and otherplaces at which people congregated, fromnomadic and other migratory groups, and onsome occasions from all households in select-ed villages or urban areas. Their trainingcovered the following aspects :


(1) The status of smallpox eradication inthe country, including details of the lastoutbreaks, suspected cases, and deaths fromchickenpox, and an indication of particularlocalities requiring special investigations andfield surveys .

(2) The characteristic features wherebyfacial pockmarks caused by smallpox could bedistinguished from scars caused by otherconditions. In this connection, it was empha-sized that only persons with facial pockmarkscaused by smallpox or suspected smallpoxwere to be investigated and the findingsdocumented .

(3) Techniques for the epidemiologicalinvestigation of suspected cases, includingthe collection of specimens for laboratoryinvestigation .

(4) Methods to be used in selecting theitinerary for field visits and the recording andreporting of data .

The organization of active searches invarious countries is described in detail insubsequent chapters . One universal and im-portant feature on which WHO consultantsand staff preparing for certification insisted,however, was that the effectiveness of thesearchers themselves should be properly as-sessed by follow-up staff whose task was to

evaluate the work done by visiting houses andvillages selected at random from among thosepreviously visited by the search teams . Specialassessment teams directed by national pro-gramme staff were organized for this purposeand each month visited up to 10°.0 of theplaces previously visited in the course of thesearches.

Pockmark Surveys

Permanent facial pockmarks were found inabout 70°° of those who survived Asianv ariola major, the rates being slightly lowerafter infection with the somewhat less viru-lent forms of variola major virus found insome parts of Africa . Heavy diffuse facialscarring, readily observed at a distance of 5metres, was seen on the faces of many victims,but others had lesser degrees of scarring thatcould be detected only by close inspection .Residual pockmarks, which tended to flattenout over time, were found less frequentlyamong those infected during the first fewyears of life. The presence of 5 or moredepressed facial scars 2 mm or more indiameter at the base was accepted as indicat-ing a probable previous attack of smallpox

24. CERTIFICATION: CONCEPTS, STRATEGY AND TACTICS 1117

Plate 24 .4 . Facial pockmarks . A: Moderately severe in a Nigerian girl 7 years after an attack of smallpox .B : Severe, in an Afghan who had suffered from smallpox many years before .

(see Plate 24.4) and such persons were care-fully interrogated to determine the time ofoccurrence of the illness and its cause . Con-trary to what might be expected, it was foundthat, as mentioned before, most villagersgenerally remembered precisely when anindividual had acquired the disease whichcaused the scars . Chickenpox also sometimesleaves residual scars, but it was unusual to find5 or more scars on the face . Facial scarring orpitting resulting from other causes, such asburns and acne and other skin diseases, couldusually be distinguished by experienced ob-servers, but these cases too were investigatedby interrogation and, where possible, byreview of the medical records .

Variola minor, which was prevalent inBrazil and in several parts of Africa during theperiod of the Intensified Smallpox Eradica-tion Programme, caused far less scarring. Acareful follow-up study in Somalia (Jezek &Hardjotanojo, 1980) showed that 5 or morefacial pockmarks could be detected in only7°0 of patients seen 1 year after recovery .Pockmark surveys were of little use and werenot carried out in countries such as Brazil,Ethiopia and Somalia, in which only variolaminor had occurred in recent years. A numberof African countries had experienced both

1118

variola major and variola minor and in manythe pockmark surveys were supplemented bysurveillance of cases of chickenpox (seebelow) .

When a pockmarked person was found, thedating of his illness became a matter ofimportance ; if it was more recent than the lastknown case of smallpox, the adequacy of thesurveillance system was open to question . Thesurveys concentrated on the examination ofchildren, as their illnesses were usually morerecent than those of adults . Failure to findpockmarks in any children born since theoccurrence of the last known case in thecountry provided important evidence thattransmission of variola major had beeninterrupted .

A widely varying incidence of pockmarkswas observed in pockmark surveys carried outby national teams in 34 African and 5 Asiancountries. A relatively high incidence wasfound in schoolchildren in some countries,particularly where large outbreaks of variolamajor had occurred a few years before trans-mission had been interrupted. However,when the date of illness of each case wascarefully investigated, no children werefound whose illness was more recent than thelast reported case .

In many countries the members of theinternational commission also carried outpockmark surveys during their field visits .The prevalence of facial pockmarks whichthey observed was often higher than thatrecorded during the national surveys, sincethey tended to focus on high-risk areas, suchas those in which the last known cases ofsmallpox had occurred .

Chickenpox Surveillance

Where variola minor was prevalent andresidual pockmarks were uncommon, empha-sis was placed on the surveillance of chicken-pox cases, which were sometimes clinicallyconfused with smallpox . It was thought that asurveillance system sensitive enough to detecta large proportion of chickenpox cases would,in all likelihood, detect smallpox, if it werepresent. Efforts were made to verify thediagnosis of a number of such cases, especiallythose which were severe or fatal, by theexamination of scabs or vesicular fluid in thelaboratories of WHO collaborating centres .

Both the fixed and the mobile health unitssought to discover and report chickenpox


cases. In addition, some countries introducedthe notification of chickenpox during thepost-eradication period where previously thishad not been required . The taking of speci-mens from at least one case in each outbreak,especially if a death had occurred, was re-quested and specimens were also obtainedfrom patients who had not been vaccinatedagainst smallpox and those with an extensiverash involving the palms and soles. In a fewcountries, a small reward was offered for thediscovery of the first case of chickenpox in apreviously unrecognized outbreak .

Rumour Register

In 1974, a new device was introduced inIndia-a register in which all cases of small-pox were recorded, and later all cases of feverwith rash. It was particularly effective incountries in which smallpox was then ende-mic-namely, certain Asian countries and inthe Horn of Africa. Rumour registers (Plate24.5) were maintained at both national andlower levels . At the regional level, healthofficials kept a record of all patients, includ-ing the full name, age, sex, village or locality,presence or absence of a vaccination scar, date,and data relevant to the illness . All casesentered in the register were investigated byqualified personnel. If there was any doubtregarding the diagnosis, a consultation wassought through the national surveillanceorganization and specimens were collected .All the information supplied by the regionswas recorded in national registers.

Specimens for Laboratory Diagnosis

Relatively few specimens were collectedwhen smallpox was widespread because thediagnosis was usually obvious ; if there wasany doubt, cases were treated as smallpox . Asthe incidence fell to low levels, increasingnumbers of specimens were taken and, astransmission came closer to being interrup-ted, specimens were collected from eachsuspected case .

In countries in which variola minor hadbeen endemic, preparing for certificationrequired the collection of large numbers ofspecimens from patients with chickenpox andwith other types of fever with rash, and fromother patients in whom smallpox was sus-pected . They were sought over a wide geo-graphical area and especially in population


W.eksEnding

(day)M O N T H L Y RASH WITH FEVER REPORT

S Number of rash w11h 1.004 cases dotodod Ih 11ta mo0h !

Iq jjem

I

Form 'B'S

n $

(rea r)(Month)

M wL.cv,r ..nl

ISipnad

,PN~nrcTei1~.61

naT-NOT? i Ons copy of this report to 10 a subs tiled to the Olstrl,1 Health Off- Orery last weak of the moam b[

trt . M .dlcal O1%cw tic . PHC(Slod) or MordUpal He0h ORrtwr and a duplrcala copy should amain,arn.d at the PHC or M .niclpallly Me" ORION to' :000.dlon .

A

1119

Plate 24 .5 . Forms (rumour registers) used for reporting cases of fever with rash in India . A: At primaryhealth centres . B : At district offices ; the district reports were consolidated at the state level on similar forms .

To

The District Health Officer

From : PHC/Mo..c .pSitr CNC4Nn w.an 0- r. .n.n!! ~ rer

-re. . Muwaw N .~..sre Iwee.I4 .1!sure .wxre M .r . ..w. .e.we e • .cureun Iw r .u .l

~.

• a o.yn . . ..

aq-

pe..,uis' -AN

(.! w.. u.Omcw

SI 01.., .ane. -1 .- Ore.. ..a I.wr I.a..N I. . ..mw . .Pwwl arrr .e

.. RuwMr .r •u. will le, e.w .. rn Mw . eared

..wNw aw. .t w.MM .•N w .w .. .rreenN . ..wl

OO4EREYEMT OF INDIA

WORLD HEALTH 010ANITC+ICI :

,.local Sr11poo Eradication

Global SM111POK Fradiootdur

Proerarea

Praeramne

D I S T R I C T MONTHLY REPORT OF FEVER W I T H RASH CASES

i.TSTRICT

STATE

MONTH

197

IEEE NO :___ TO NO

REPORTING OFFICER, NAME

TOTAL NUMBER OF REPORTING

POSITION

NUMBER OF REPORTS RECEIVEDUNITS :

TIMBER OF CASES OF RASH-17N FEVt]1 ENTERED INN

SMALL-FOE NUMBER OF CIIIIKE:TON M'MBER OF I£1SLES NHCL' : •I ,YFI( w .i l, -

N1IN FI'0 .7RDMDUR REGISTERRa .C REPORTINr.

UNITS(PAC . MunicipS-lit.hospital .,oIt .)

o

u!~

y ee

-Wrrokorllied

Outbreakratified

ou . :.r : .rr[ :ilicd __

~

I ~ . I

i'

I

1

_

_'_

-

iTOTAL

NOTF : Ibnth should Include the woks • ordina [o tncer . .ae .onal ell-[ion ofwake (mold, of front corer of to yell . rrpartinA booklet) .

Within fl •c dye of, ., the Ice day of .onrh, •end a copy of this report to Sure MSEF Office .

B

Table 24.1 Country of origin and number of specimens tested by the WHO collaborating centres in Atlanta and Moscow between 1969 and I 979a

NO

Number of specimens received (and number positive for smallpox)Country

1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979

AfricaAngola 0 0 0 0 0 0 0 0 1 98 23Botswana 0 0 18(14) 107(56) 14(5) 9 8 2 41 211 54Burundi 0 3(2) 0 5 4 3 1 0 0 0 0Cameroon 0 6 3 0 21 12 9 19 10 I 146Central African Republic 0 0 0 3 0 0 0 0 0 0 5Chad 0 6 4 0 0 0 0 0 0 0 0Congo 0 0 0 70 0 0 0 0 2 I 0Cbte d'lvoire 0 0 10b 4 32 5 4 1 0 0 0

9Dahomey (Benin)Djibouti

300

I0

20

I0

013 (9)

07(2)

00

20

017

12 667

0

rro75Ethiopia 0 0 0 24(23) 22(5) 39(9) 113(33) 434(60) 582

1 153 1042

O

Ghana 30 IS 15 12 0 0 0 0 0 0 0 9Guinea 4(l) I 0 0 0 0 0 0 0 0 0

zKenya 0 0 12(12) 6 2 9(3) 2 1 147(5) 126 1 473

C7Lesotho 0 0 0 0 0 0 0 0 0 32 27

HLiberia 1 32b 143 5 0 1 1 3 0 0 0Malawi 0 0 0 0 2 2 0 3 295 24 1

mMali 0 2 I I 0 0 0 0 0 0 a0

9Mauritania 0 0 0 0 0 0 1 2 1 2 0Mozambique 0 0 0 0 0 0 4 0 62 14 1

nNamibia 0 0 0 0 0 0 0 0 0 9 99

HNiger 22(11) 8 8 4 2 0 0 1 0 0 0

ONigeria 250(87) 108(54) 187b 21 4 2 1 3 0 0 0

zRwanda 5(5) 10(9) 0 0 2 0 0 0 3 0 0Senegal 0 0 0 0 0 0 0 1 0 0 0Sierra Leone 5 246 0 0 0 0 1 3 I 0 1Somalia 0 0 0 0 0 0 0 56(32) 865 (265)

1 623 1 271South Africa 0 0 0 0 0 0 0 0 0 48 103Southern Rhodesia

(Zimbabwe) 0 0 0 0 0 0 0 0 0 23 0Sudan 0 0 2(l) 2(l) 9 22 9 18 15 34 5Swaziland 0 0 0 0 0 0 0 0 1 38 3Togo 14(2) 2 2 0 0 0 0 0 0 0 0Uganda 0 0 0 S(3) 0 0 1 1 0 119 0United Republic of Tanzania 2(I) 12(5) 0 0 1 0 2 0 3 75 0Upper Volta

(Burkina Faso) 4 5 24 3 72 5 I 0 I 0 0Zaire 0 23b(9) 167(4) 142b 78b 63b 136b 104 6 98b IOIb 125bZambia 0 0 0 0 0 0 I 0 50 42 0

Benin I), 1979 (Zaire 4, Cameroon 2).

AmericasBolivia I 0 4 0 0 0 0 0 0 0 0Guyana 0 I 0 0 0 0 0 0 0 0 0Nicaragua 0 0 0 0 I 0 0 0 0 0 0Venezuela 0 0 4 I 0 0 I 0 I 0 0

AsiaAfghanistan 0 0 0 0 4(l) 0 I 0 4 0 0Bahrain 0 0 0 0 0 0 0 0 0 51 IBangladesh 0 0 0 2(l) 9 1 (1) 18(3) 162 625 0 0Burma 0 0 6 18 0 0 0 II 0 0 0Democratic Yemen 0 0 0 I 0 0 0 1 0 30 7Dubai 0 0 9(7) 1 0 0 0 0 0 1 0 NIndia 0 0 7(5) 20(15) 24(14) 27(20) 395 (126) 354 904 I 0 ?Indonesia 0 12 8(6) 22(9) 3 3 0 1 0 0 0 mIran 0 0 0 0 0 0 0 0 0 347 0Iraq 0 0 0 0 0 0 0 0 0 13 1Kuwait 0 0 0 0 0 0 0 0 0 78 4Lebanon 0 0 0 0 I 0 0 0 0 0 0 nMalaysiaNepal

00

00

10

04(l)

037(27)

048(40)

016(8)

05

03

00

00 p

Oman 0 0 0 0 0 0 0 0 0 57 5 Z

Pakistan 0 6(5) I 7(6) 10(5) 22(11) 49 109 7 2 2 nQatar 0 0 0 0 0 0 0 0 0 23 0 0Saudi Arabia 0 0 7 0 1(1) 0 0 0 24 105 0 nSri Lanka 0 0 0 0 1 (1) 0 0 0 0 0 0Syrian Arab Republic 0 0 0 3 (3) 0 1 0 0 0 9 4 -1United Arab Emirates 0 0 0 0 0 0 0 0 0 52 1Viet Nam 0 0 0 0 0 1 0 0 0 0 0Yemen 0 0 1 2 7 6 3 2 2 28 22

9

EuropeBelgium 0 0 0 0 0 0 0 0 0 0 I

C<Italy 0 0 0 0 0 0 0 0 I 0 0

YSwitzerland 0 0 0 0 0 0 0 I 0 0 0 z

C7Total 368 (107) 277(84) 646(49) 496(118) 376(68) 288(86) 778 (170)

1 300(92) 3766(270) 4 650 42809n

a Recorded by date of receipt in Geneva . Includes only specimens for which testing results were reported . Includes multiple specimens from the same individual if taken . Excludes serum, animal, -1variolation and other specimens associated with special studies .

b of which positives for monkeypox by year numbered : 1970 (Zaire 1, Liberia 4, Sierra Leone 1), 1971 (Cote d'Ivoire 1, Nigeria 2), 1972(5), 1973(3), 1974(1), 1975(3), 1976(3), 1977(7), 1978 (Zaire 8,r)

1122

5000-

4000-

1000 -

118

Positive for variola virus

778

1300


3766

4650

4280

496376 288

2700 68 86 ~ .70 92

1972 1973 1974 1975 1976 1977 1978 1979

Fig . 24 .1 . Number of specimens collected fromcases of smallpox, suspected smallpox, chickenpox,or suspected monkeypox and tested by WHO col-laborating centres, 1972-1979 .

groups and regions considered most likely toharbour smallpox . Specimens were forwardedto Geneva and from there sent either to theWHO collaborating centre in Atlanta or tothat in Moscow. The specimens were shippedand tested with the least possible delay andthose given priority were dealt with immedi-ately, the results being cabled to the field .

Table 24.1 shows the national origin ofspecimens tested between 1969 and the end of1979. The number tested rose from 288 in1974 to over 4200 in 1978 and 1979 (Fig .24.1) . The percentage of specimens in whichvariola virus was found was relatively largeduring the earlier years, but none was positiveafter October 1977 . About three-quarters ofthe specimens collected in 1978 and 1979came from Ethiopia, Kenya and Somalia,which had reported their last cases (of variolaminor) in 1976 and 1977 and were preparingfor certification in 1979 . Most specimenscame from cases of chickenpox, the virus ofwhich does not grow on the chorioallantoicmembrane of the chick embryo . However,electron microscopy showed that many ofthem contained herpesvirus particles (vari-cella virus) .

Publicity Campaigns and Rewards

Publicity campaigns aimed at encouragingpeople to report suspected cases and inform-

ing them that they would receive a reward ifany of the cases turned out to be positive hadbeen a feature of the eradication campaigns inthe Indian subcontinent and the Horn ofAfrica and they continued until formal certi-fication had occurred. In large urban centres,use was made of radio, newspapers, andtelevision . In smaller villages and remoteareas, leaflets and posters showing pictures ofsmallpox patients were more frequently used .Health unit personnel were encouraged toinquire about smallpox and other illnesseswith fever and rash, and mobile teams repeat-edly visited schools, markets and other places,where they informed the public about thedisease, either in conversation or by loudhailer . In several countries so many postersand signs were fixed to walls that the smallpoxteams were asked to desist because they weredefacing the buildings .

The rewards were initially small but weregradually increased until they ultimatelyreached the sum of US$1000, offered by WHOin 1978 (Plates 24 .6 and 24.7). In theircontacts with schoolchildren or other seg-ments of the population, active search teamsshowed the smallpox recognition card, askedpeople what the disease was, when cases hadlast been seen, and whether there were anyreports or rumours of smallpox or chickenpoxin the area . The teams also inquired whetherpeople knew where to report if they did knowof such a case and also whether they knewabout the reward and its value . Since the valueof the reward was changed at intervals, thereplies provided an indication of how re-cently information had been received aboutthe campaign.

The reward system was not readily acceptedin all countries, since some national healthauthorities feared that it would establish aprecedent with regard to the reporting ofother diseases, although in fact no evidence ofthis was subsequently found. In westernAfrica, for example, the offering of rewardswas discussed at the coordination meeting in1975, during preparations for certification,but was finally rejected . However, rewardsbecame an important method of surveillance,especially in Asian countries.

For smallpox transmission to have contin-ued without detection when a large propor-tion of the population knew about the diseaseand the reward appeared highly unlikely .Thus, many countries conducted surveys toassess what proportion of the populationknew about smallpox and where to report a

Rewards for Reporting Smallpox

The idea of offering a reward for information on cases that were proved to be smallpoxoriginated in Indonesia, following the discovery that information on known smallpoxcases had been suppressed by local officials because they feared punishment for failure tocontrol the disease . It was taken up in most Asian countries in which smallpox was stillendemic, and in some African countries . The reward was important in several areas ofIndia, in which the reporting of cases by a health officer was taken as prima facie evidencethat the vaccination campaign for which he was responsible had not been sufficientlythorough and he was punished for this by transfer or other means . By announcing that areward would be given for reporting a case, the government made it quite clear that itwanted cases to be reported. Moreover, if health officers continued to suppress reports,lower-level staff anxious to receive the money bypassed them and reported the cases .

The size of the reward increased as the likelihood of finding a case of smallpox declined .The existence of a reward proved to be most effective in two ways : it increased thereporting of suspected cases of smallpox and, during active searches, questions aimed atdiscovering whether people knew of the reward proved an excellent method of assessingthe effectiveness of search teams .

In April 1978, a coordination meeting was held in Nairobi, Kenya, to discusspreparations for the certification of the Horn of Africa . At that time 5 months had elapsedwithout a reported case of smallpox despite continuing surveillance in the Horn of Africa,as well as elsewhere in the world . One of the proposals discussed during the meeting wasthat a global WHO reward should be established to promote the reporting of smallpox .Reporters covering the meeting enthusiastically supported this idea. As a result of arecommendation from this meeting, the Thirty-first World Health Assembly in May 1978,in its resolution on smallpox (WHA31 .54), requested the Director-General

. . to establish a reward of US$1000 for the first person who, in the period preceding finalcertification of global eradication, reports an active case of smallpox resulting from person-to-person transmission and confirmed by laboratory tests, in the belief that such a reward willstrengthen worldwide vigilance for smallpox as well as national surveillance in priority countries" .

Thereafter, the reward was widely publicized through radio, newspapers, television, etc .,and a specially designed poster (Plate 24 .7) was distributed to all countries. Immediatelyafter the announcement of the award, many suspected cases were reported to WHOHeadquarters, not only from developing but also from developed countries, includingFrance and the USA . All proved to be false alarms. The reward was never collected .

case, or had heard about the reward . Thesurveys were often combined with activesearches for cases of unreported smallpox . Inthe more populous and more recently ende-mic countries these campaigns reached a veryhigh proportion of the people.

Documentation

Each country expecting to be visited by acommission was asked by WHO to prepare acomprehensive report ("country report")containing demographic data, informationon its notification and surveillance system, adescription of its smallpox eradication pro-gramme, information about the most recent


outbreaks and data on precertification sur-veillance activities. These reports were sub-mitted to the international commission at thebeginning of its visit and provided the basicinformation needed for the planning of itsfield trips.

OPERATION OF INTERNATIONALCOMMISSIONS

The membership of all the internationalcommissions is set out in Annex 24.1 and theiroperation is described in Chapters 25-27 .General features of the method of selectingcommission members, as developed after thecertification of Indonesia, and their usualmode of operation, are outlined below.

1124 SMALLPOX AND ITS ERADICATION

wkly E/idw . Rrr . - ReNrd dpdim, hrbd.: 1978 . S5, 221-228

28 JULY 1978

WORLD HEALTH ORGANIZATION

GENEVA

WEEKLY EPIDEMIOLOGICAL RECORDRELEVE EPIDEMIOLOGIQUE HEBDOMADAIRE

Epdrmbdeelcd S-111- of(7--ekt, DL,,-,,Ta48roeMc Address : EPIDNATIONS GENEVA Trlea 27821

Automatic Telex Reply ServiceTelex 28150Gems. with ZCZC and ENGL for . reply in English

Service aulomatique de repotmTeks 28150 Geneve suivi de ZCZC et FRAN pour um repome en f aocnir

SMALLPOX SURVEILLANCE

A reward has been established by the Director-General ofWHO for the first person who, in the period preceding finalcertification of global eradication, reports an active case ofsmallpox resulting from person-to-person transmission andconfirmed by laboratory tests .

(Resolution WHA31 .54, World Health Assembly, 1978)

SMALLPOX-FREE WEEKS WORLDWIDE

SURVEILLANCE DE LA VARIOLE

REWARD US$ 1000 RECOMPENSE

Le Directeur general de I'OMS a institue une recompense 8altribuer a la premiere personne qui, au tours de la periodeprecedant la certification definitive de ('eradication mondiale,signalerait un cas actif de variole resultant de In transmissiond'un elre humain a I'autre et confrme par des essais delaboraloire .(Resolution WHA31 .54, Assemblee mondiale de la Sante, 1978)

39 SEMAINES SANS CAS DE VARIOLEDANS LE MONDE

LABORATORIES RETAINING VARIOLA VIRUS

With the interruption of transmission of smallpox in the worldpopulation, the only remaining possible source of infection will belaboratories still retaining stocks of the causatise virus .Accordingly, the Thirty-first World Health Assembly (1978) has

requested that all laboratories retaining sariola sirus, except WHOCollaborating Centres . destroy their stocks or transfer them to aWHO Collaborating Centre. Of at least 76 laboratories identifiedby WHO to have sariola virus since all countries and areas werepolled from 1975 to 1977, 57 had voluntarily transferred or des-troyed their strains by the end of 1977 . In 1978 file additionallaboratories have disposed of their strains :

Instituto Adolfo Lutz, Sao Paulo (Brazil)Laboratoire national de Ia Santo publique . Paris (France)Microbiological Research Lstabluhment, Porton Down, Salisbury(United Kingdom)

Virus Instituto Salud Publica, Lima (Peru)Walter Reed Army Institute of Research, Washington (USA)Currently there are at least 14 laboratories with sariola sires

(Table l) . China reports that more than one laboratory has thisvirus.Security measures for such laboratories were recommended by a

"Workshop Meeting on Safety Measures in Laboratories RetainingVariola Virus", convened by WHO in August 1977 . With con-tinued cooperation the number of laboratories retaining variolavirus will be further reduced to not more than four WHO Collabor-ating Centres by 1980.

53rd YEAR - 53e ANNEE

Srrvicr dr to Su..111enee dplddmloloelasa des Melodic, rrwwmmlbtaaAd,.,,. tdldgr,pi~gu.. EPIDNATION5 GEM EVE T14+27821

No. 30

ORGANISATION MONDIALE DE LA SANTE

GENEVE

28 JUILLET 1978

LABORATOIRES DETENANT ENCORE DU VIRUSVARIOLIQUE

Asec I'arrdl do la transmission do la variole clans la populationm ondiale . la scale source possible d'infection sera eonstituee par leslaboraloires detenant encore des stocks de virus pathogene .

Aussi la Trente et Unieme Assemblee mondiale de la Sante (1978)a-i-vile demands a tous Its laboratoires, autres quc les centrescollaboratcurs de TOMS, detenant du virus variolique de detruire(curs stocks ou de Its Iransferer a un centre collaborateur . Sur aumoins 76 laboratoires identifies par TOMS comme detenant dus irus sariohquc depuis Fenquctc conduite de 1975 a 1977 sur tour lespays et circonscri pitons, 57 asaicnt solonlairement transfers oudetrun (curs souches a la fin de 1977. En 1978, cinq autres labo-ratoires se soot defaits de lours coaches, soil :

Instituto Adolfo Lutz, Sao Paulo (Bresil)Laboratoirc national de la Santc publique, Paris (France)Microbiological Research Establishment, Porton Down, Salis-

bury (Rovaume-Uni)Virus Instituto Salud Pubhca, Lima (PSrou)Walter Reed Army Institute of Research, Washington (EUA)Actuellement . d exists au moms 14 laboratoircs qui possedent du

virus variolique (T hleau 1) . La Chine signale que plus d'un labo-ratoire de cc pays deticnt le vrus en question .

Un atelier sur (es mesures de securite a appliquer dans les labo-raloires conservant des stocks de virus variolique reuni par TOMSen aoul 1977 a recommande Ies mesures de securite A appliquer dansIts laboratoires en cause . Grace a on esprit de collaboration deroutes Is parties, it n'v aura plus en 1980 quc quatre laboratoiresqw conserveront des stocks de virus variolique, it s'agira dans Iesquarry cas de centres collaborateurs de I'OMS.

Epidemioioeieel outer eona.ned .n his number :Adenovines Infections, Legionnaire's Disease, Neisseria go-norrhoea., Poliomyelitis Surveillance, Smallpox Surveillance,Surveillance of Animal Rabies, Surveillance of NosocomialInfections, Viral Diseases Surveillance .

List of Newly Infected Areas, p . 228,

W--.- epidem,otoeique -ten- dans ce numere .Infections a adenovirus, Maladie de I'Anrcncan Legion,Neisseria gonorrhoeae, surveillance de In poliomy6lite, sur-veillance de In rage animate, surveillance de In variole, sur-veillance des infections nosocomtales, surveillance des mala-dies a virus.Liste des zones nouvellement infectees, p . 228.

Plate 24.6 . The Weekly epidemiological record was used extensively to promote the certification activities bypublishing pertinent information . The front page of the issue for 28 July 1978 announced the offer of a rewardof US$ 1000 for reporting an active case of smallpox and recorded that 39 weeks had passed since the last casein the world. The front-page article reported on laboratories that had disposed of their stocks of variola virus ;such stocks were by then considered the only possible remaining source of infection .


11nWoddHoefCr

onoft sUS$1000mthefirstpersonreportingforsctiveamsNpoxcoos

horn humantransmi~ionandootrfirttt.e by

YMd globsI iseadieation is cwtifisd

4

tr$pnmondlale deb San" otlro um recompense de US $1000C 1a pwsiies pooonos epd signalers urr cas actII d . voricM tdadtant Oweba

oian d'un dho humain ;t un subs et

err 1

e Catteoffre eat vslabts jusqu'a Is certification do rep a fon mondisle

Plate 24.7 . Poster produced by WHO in mid-1978, publicizing the reward ofUS$ 1000 for finding a confirmed case of smallpox .

1125

1126


Membership

The timing of the visits to the countries byinternational commissions and their member-ship were decided by WHO in the course ofdiscussions with national health authorities .Individuals were selected who would becritical in their assessments and whose viewsas experts would be respected both nationallyand internationally. Some of those selectedwere experts in communicable disease con-trol, others in virology or health manage-ment. On each commission, one or twomembers were appointed from the countriesmost at risk of importation of smallpox fromthe country or countries to be certified . Astime passed a deliberate effort was also madeto include in the international commissionsexperts from as many different countries aspossible, so that the nature and extent of theefforts made to document the interruption oftransmission would be widely known . Specialcare was taken in the selection of the chair-man. Apart from the first international com-mission, in South America, the chairman wasnot a national of any country under reviewand, after the certification of Indonesia,officials from the country concerned were,with few exceptions, excluded from theinternational commissions . Exceptions weremade for the single group of experts who, asmembers of separate international commis-sions, certified Bangladesh and Burma respec-tively, by including a Burmese member in thecommission assessing the adjacent country ofBangladesh and a Bangladeshi as a member ofthe commission assessing Burma . In addition,a senior Indian military medical officer wasincluded in the Indian commission, so thatvisits could be made to areas to whichforeigners did not have access at that time .

After the appointment of the Global Com-mission for the Certification of SmallpoxEradication early in 1978, its members servedas chairmen or members of almost all of theinternational commissions . In this way mem-bers of the Global Commission becamefamiliar with the certification process at thecountry and regional levels . In all, 76 expertsfrom 48 countries served on internationalcommissions (see Annex 24 .1) .

Mode of Operation

The principal aim of a commission's visit toa country was to evaluate the reliability of

Plate 24 .8 . Holger B . Lundbeck (b . 1924), Directorof the National Bacteriological Laboratory, Stock-holm, participated in several international com-missions for the certification of smallpox eradicationand was an influential member of the Global Com-mission . He is shown here signing the scroll certifyingeradication which is reproduced as the frontispieceof this book .

that country's report by interviewing healthpersonnel and examining records at bothcentral and peripheral levels, so as to ascertainwhether smallpox transmission had beeninterrupted as claimed. It was recognized thatno commission could expect to examine evena small proportion of the population of acountry in order to confirm that none hadsmallpox. Moreover, if experts of the rightcalibre were to participate, it was appreciatedthat they would be unable to spend more than3-4 weeks away from their normal place ofwork. The objective of an international com-mission was to assess the quality of the localsurveillance programme and to determinewhether cases of smallpox would have beendetected if transmission had occurred duringthe preceding 2 years. In doing so, commis-sion members themselves usually carried outtheir own, rather limited surveys .

In most instances preliminary visits by oneor two of the commission's members (often

the chairman) were arranged by WHO so thatthey could examine the state of the documen-tation and recommend any additional mea-sures which they thought were indicated .

After arrival in the country to be certified,the commission usually spent 2-3 days in thecapital reviewing the country report. Ifseveral countries were involved, the com-mission selected a conveniently situatedcapital city for its initial meeting, duringwhich it scrutinized all the country reports ; itthen divided up into several groups to visitindividual countries, and finally reassembledto assess the findings and prepare a report . Ineach country, in order to visit as many areas aspossible, the commissions usually dividedthemselves up into teams consisting of one ortwo members, the areas selected being thoseidentified as having the least satisfactorydocumentation or as being at unusual risk .Members of the commission had both the rightand the responsibility to decide exactly whichareas, villages and health units they would visiteach day. The teams travelled extensively in thefield for 1-3 weeks before reconvening .

PROCEDURES FOR GLOBALCERTIFICATION

By June 1977, international commissionshad already visited or were preparing to visitall the previously endemic countries andcountries at special risk . However, there wereother countries in which there was a need todetermine what measures should be taken inorder to certify that the transmission ofsmallpox had been interrupted for at least 2years. Furthermore, there were several coun-tries China, Democratic Kampuchea, Iran,Iraq, Madagascar, Namibia, South Africa,Southern Rhodesia (Zimbabwe), the SyrianArab Republic, Thailand and Viet Nam forwhich the staff of the Smallpox Eradicationunit needed outside advice on how best to dealwith the situation . Clearly, countries such asMadagascar and Thailand would not beexpected to undertake the same kind ofprecertification activities as had been carriedout in the countries of western Africa, yetthey could not be ignored . Others, such asDemocratic Kampuchea, Namibia, SouthAfrica and Southern Rhodesia (Zimbabwe),were not readily accessible to WHO staff .

Another important matter was the inter-national credibility of a claim that smallpox


1 127

had been eradicated throughout the world .The problem was that, if the staff of theSmallpox Eradication unit themselves were todecide as to the data to be provided inconfirmation of eradication, such a decisionwas open to criticism by government officialsand health professionals around the world,since those responsible for a programmeobviously have a stake in its success . Howeverobjective their judgements might be, otherscientists would be justified in questioningthat objectivity .

As has already been pointed out, thepractical implications of the global eradica-tion of smallpox were substantial . If theWorld Health Assembly were to accept thatsmallpox had been eradicated, this wouldmean that all preventive measures against thedisease, including routine vaccination andinternational certificates of smallpox vacci-nation, could be abandoned. However, it wasclear that these changes in well-establishedpublic health practices and the consequentfinancial savings would materialize only if theinternational community confidently ac-cepted the assertion that smallpox had indeedbeen eradicated, first from countries, regionsand continents and, finally, from the world .To gain such acceptance would not be asimple matter, for disbelief in the feasibility ofsmallpox eradication was common through-out the duration of the Intensified SmallpoxEradication Programme .

Consultation on the Worldwide Certifica-tion of Smallpox Eradication

The practical solution to the problemsdescribed above was to set up a globalcommission of respected scientists which, asone of its functions, could advise WHO as towhat data should be collected, for clearly thiswas a matter of judgement . Eventually, whensuch outside experts were fully satisfied thatglobal eradication had been achieved, thisconclusion would have been reached, not byWHO itself or by putting together the reportsof a series of international commissions eachdealing with one or a few countries, but by aninternational group of senior scientists andadministrators capable of taking a global viewof the problem .

To obtain advice on how best to achievethe certification of global eradication, theDirector-General of WHO convened a con-sultation which was held in Geneva on 11-13

1128

Category I Formal certification by international commissions of experts visiting thecountries concerned and assessing their smallpox-free status by examining recordsand making field visits to determine whether surveillance activities would have beenadequate to detect a case of smallpox if one had occurred during the previous2 years .

Category 2 Certification by the visit of selected experts to verify and document thesmallpox incidence since 1960, the last known outbreak and control measuresemployed, and procedures for handling suspected cases .

Category 3

Certification through submission of detailed country reports .

Category 4 - Official statements by countries declaring their smallpox-free status duringthe previous 2 years and signed by government health authorities .

Fig . 24 .2 . Methodologies used for the certification of smallpox eradication in various categories of countries .

October 1977. The participants (Annex 24.2)included 17 experts on epidemiology, virol-ogy and public health administration from 15countries : 3 from Africa, 3 from the Ameri-cas, 4 from Asia, 6 from Europe and 1 fromOceania. During the succeeding 2 years,most of the participants in the consultationserved on the Global Commission for theCertification of Smallpox Eradication . Docu-mentation for the meeting had been preparedby the staff of the Smallpox Eradication unit,and the consultation made important recom-mendations (WHO/SE/77.98) as to how cer-tification should proceed so that the stagecould be reached, as quickly as possible, atwhich it could be certified that smallpox hadbeen eradicated globally. For this purpose, thecountries of the world were divided into threecategories ; a fourth was subsequently added


by the Global Commission (Fig . 24.2). Thevarious categories are discussed below .

Category 1 Formal certification by internationalcommissions

The most stringent assessment was re-quired in countries in which smallpox wasendemic at the inception of the IntensifiedSmallpox Eradication Programme in 1967, orhad become endemic since then. For suchcountries, the consultation recommendedthat the established procedure of formalcertification by designated internationalcommissions should be carried out . In Oct-ober 1977, when the consultation met, thisformal certification had already been per-formed in South America (1973), Indonesia(1974), 15 countries in western Africa (1976),

Afghanistan and Pakistan (1976), 5 countriesin south-eastern Asia (1977) and 9 countriesin central Africa (1977) (see Plate 24.11). Theadditional countries scheduled for formalcertification from November 1977 onwardswere

South-eastern Asia : Bangladesh and Burma(scheduled for November-December 1977) .

South-eastern Africa : Malawi, Mozambique,the United Republic of Tanzania and Zambia(scheduled for March 1978) .

Eastern-central Africa : Sudan and Uganda .Southern Africa, group I : Angola, Botswana,

Lesotho and Swaziland .Southern Africa, group II : Namibia, South

Africa and Southern Rhodesia (Zimbabwe) .Because of political complexities (see Chapter26) it was apparent by 1978 that it would beboth difficult and time-consuming to organ-ize the certification of these countries byinternational commissions . Instead they wereinvestigated as set out for Category 2 coun-tries (see below) and certified by the GlobalCommission .

The Horn of Africa and neighbouring countries :Democratic Yemen, Djibouti, Ethiopia,Kenya, Somalia and Yemen .

Category 2 - Certification by the visit of selectedexperts

The consultation considered that somecountries in which smallpox was not endemicin 1967 required special consideration, shortof a visit by an international commission,because of the inadequacy of surveillanceand/or their proximity to areas in whichsmallpox had recently been endemic. For suchcountries, it was suggested that visits by inter-national experts (subsequently Global Com-mission members or WHO consultants)and/or WHO epidemiologists should bearranged during 1978 in order to verify anddocument their smallpox eradication status .The countries in this category are discussedbelow .

China . Although it was widely believed thatsmallpox transmission had been interruptedin China in about 1960, the country did notbecome a member of WHO until 1972 . Evenas late as 1977, little information was availableto WHO as to what had been achieved, orhow, or when, except that smallpox had beeneradicated in China in 1960 or thereabouts .Since it was the most populous country onearth, and one in which smallpox had beenwidespread for over 1800 years, the consulta-


1 129

tion believed that special investigations wereneeded to assure the international communitythat smallpox was no longer endemic there .

Iran, Iraq and the Syrian Arab Republic .Although endemic smallpox had been elimin-ated from these countries in 1963, 1959 and1957 respectively, variola major had becomeestablished again in all of them between 1970and 1972. Smallpox was first reintroducedinto Iran from Afghanistan and subsequentlyspread into Iraq and the Syrian Arab Republic(see Chapter 23). Because of the extent andduration of the outbreak, the consultationsuggested that each of these countries shouldbe asked to submit a detailed report of itssurveillance programme and smallpox eradi-cation activities during at least the past 5years, after which members of the consulta-tion or its successor, the Global Commission,would visit each country to review thesituation .

Thailand. Although smallpox had ceased tobe endemic in Thailand in 1962, the goodcommunications with Bangladesh and Indiaindicated the need for special evaluation,particularly in the border area of Thailand,Burma and the Lao People's DemocraticRepublic, which was notoriously inaccessible .

Category 3-Centfcation through submission ofdetailed country reports

WHO was requested by the consultation toask certain countries to provide detailedreports, including but not limited to data onthe incidence of smallpox since 1960, anaccount of the last known outbreak and thecontrol measures employed, and the methodof approach to be adopted should a suspectedcase of smallpox be found . Several countriesabout which detailed information was notavailable to the Global Commission fell intothis category and are discussed below .

Gulf States : Bahrain, Kuwait, Oman, Qatar,Saudi Arabia and the United Arab Emirates .These countries had been free of endemicsmallpox since 1963 but had experi-enced sporadic importations up to 1971 . TheSecretariat-General for the Ministers ofHealth of the Arab States of the Gulf wasasked to coordinate the preparation of specialcountry reports from these States .

South-east Asian countries . Because fightinghad been going on for so long, detailedinformation was lacking from DemocraticKampuchea, the Lao People's DemocraticRepublic and Viet Nam . A special report was

1130


also requested from China (Province ofTaiwan) .

Madagascar. Although the last reported caseof smallpox in Madagascar occurred in 1934,rumours had reached the consultation ofoutbreaks of a disease that might have beensmallpox. A special report was thereforerequested.

Category 4 Official statements by countries

In addition to these more stringent require-ments, it was decided that every country andarea should provide WHO with a signedstatement that smallpox had not been presentin that country or area during at least thepreceding 2 years. Certification of freedomfrom smallpox by an international commis-sion was considered to constitute such astatement.

Establishment and Responsibilities of theGlobal Commission

Finally, the consultation recommendedthat, since smallpox eradication was an unpre-cedented achievement, it should be promptlycertified and appropriately recognized . Forthat reason, " . . . To assist in this effort and toprovide authoritative endorsement, a for-mally constituted International Commissionfor the Global Certification of SmallpoxEradication (Global Commission) should beestablished by WHO to provide consultativeassistance and verification of this event"(WHO/SE/77.98). Early in 1978 most of theparticipants in the consultation were desig-nated by the Director-General of WHO asconstituting the Global Commission for theCertification of Smallpox Eradication and atthe same time a few new members wereintroduced (Annex 24 .2 ; Plate 24 .10).

Fenner, who had been Chairman of theconsultation, was elected Chairman of theGlobal Commission, and acted in this capacityat the meetings in 1978 and 1979 (see below) .Dr W. Koinange of Kenya was the Vice-Chairman at the 1977 consultation and Dr JanKostrzewski of Poland was Vice-Chairman atboth meetings of the Global Commission .Arita, as Chief of the Smallpox Eradicationunit, served as secretary both of the consulta-tion and of the Global Commission . As hasalready been mentioned, Global Commissionmembers were included in almost all of the 11international commissions which met in 1978

DECLARATIONOF SMALLPOX-FREE STATUS

The Government of

L - : 7

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hereby declares that no case of smallpox hasoccurred in its territory during the previous two years

The last case occurred inr,... ;t r e.el

IN WITNESS THEREOF I have signed this declara-tion for submission to the World Health Organization

Done at. ..YK~ . .T_K

onFGy1F RP 2 , 1 , 7'

For the Government of

Title .

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Signotnre :

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Plate 24.9 . Official statements, like this one fromIceland, were received from 121 countries and terri-tories declaring they had not had a case of smallpoxfor at least 2 years . They were accepted by theGlobal Commission for all countries other than the79 where special measures were deemed necessary .

and 1979 to deal with specific geographicalareas, an experience which further strength-ened the assessment by the Global Commis-sion of the progress of eradication as a whole.

The Global Commission met in Geneva inDecember 1978 and again in December 1979to review certification activities in variouscountries in the four categories defined by theconsultation and to consider other issuesrelevant to global certification. At the 1979meeting, the Global Commission debated andapproved its final report (World HealthOrganization, 1980), which was submitted tothe Thirty-third World Health Assembly .

CHRONOLOGY OF CERTIFICATION

As has previously been noted, special mea-sures had to be taken in 79 countries beforethe declaration of global smallpox eradicationcould be made . Between 1973 and 1979,


therefore, the status of smallpox in thesecountries was assessed by WHO and byindependent groups convened by the WHOSecretariat (Fig . 24 .3) . The eradication ofsmallpox in 63 of these countries was certifiedby international commissions ; the situationin the other 16 (No. 53-64, 66-67 and 78-79)was evaluated by other means .

Of the 79 countries concerned, 31 had beencertified by international commissions be-tween 1973 and 1976 (see Plate 24 .11), butfrom 1977 onwards certification activitieswere much accelerated in view of the fact thatglobal eradication was imminent . The 1977Consultation on the Worldwide Certificationof Smallpox Eradication and the establish-ment of a Global Commission substantiallypromoted the prompt completion of theseactivities, since these bodies were a source ofadvice and recommendations.

Plate 24.10 . Participants at the meeting of the Global Commission for the Certification of Smallpox Eradi-cation, 6-9 December 1979 . Left to right, front row : Yemane Tekeste (Ethiopia), Z . Jefek (WHO), I . D . Ladnyi(WHO), I. Arita (WHO), Z . Islam (WHO), S. E. Woolnough (WHO), C . I . Sands (WHO); second row :S. S. Marennikova (USSR), J . Azurin (Philippines), P . N. Burgasov (USSR), F . Fenner (Australia),J . Kostrzewski (Poland), D . A. Henderson (USA), W . Koinange (Kenya), Jiang Yutu (China) ; third row :A. I . Gromyko (WHO), R. N. Basu (India), J . M . Aashi (Saudi Arabia), B . A. Rodrigues (Brazil),R. Netter (France), J . S. Moeti (Botswana), Kalisa Ruti (Zaire), P. N . Shrestha (Nepal), B. C. Dazo(WHO), M . C. de Souza (WHO), Zhang Yihao (China), J . Magee (WHO) ; back row : G . Meiklejohn (USA),P. F. Wehrle (USA), J . G . Breman (USA), H. B. Lundbeck (Sweden), K . R. Dumbell (United Kingdom),I . Tagaya (Japan), A. Deria (Somalia), J . L . Tulloch (WHO), R . N. Evans (WHO), J . F . Wickett (WHO) .The names of the Commission members are in bold type .

In May 1978, when 49 of the 79 countrieshad already been certified, a document en-titled Methodology for Preparation of AppropriateData for the ]30] Countries Remaining to beCertified Free of Smallpox (SME/78.6) wasprepared by the staff of the Smallpox Eradica-tion unit. On the basis of experience gainedwith previous certifications, the document setout the minimum requirements for thecountry reports, guidelines and standardforms for field activities such as pockmarksurveys and chickenpox surveillance, andprocedures for the collection and dispatch oflaboratory specimens . It was distributed to allcountries still to be certified and proved to beextremely useful for both health planners andfield workers in their preparations forcertification .

Despite the existence of many politicallyinsecure areas in the late 1970s and the large

0Vz

m

1132 SMALLPOX AND ITS ERADICATION

e

v

Plate 24 .11 . Chronological progress of certification in the 79 countries where special measureswere necessary. All other countries provided an official statement that smallpox had not occurredin their country during the preceding 2 years .

Plate 24.12 . Smallpox eradication, and its certification between 1973 and 1979, were conductedwhen the numbers of refugees in the world were growing constantly . This map shows the countryof origin of refugees assisted by the Office of the United Nations High Commissioner forRefugees in 1972 and in 1982 (the purple shading indicates countries common to both years) .Although it clearly depicts the magnitude of this distressing problem, it does not show some areasin which, before or between those years, the conditions that caused people to become refugeesalso made eradication work particularly difficult - e .g ., Nigeria (1967-1968), Bangladesh(1970 -1971), and the Horn of Africa (1974 -1978) .

Year of certification by International or Global Commission1

1973 1976 19781974 1977 1979

Official statement of freedom from smallpox received

I 11978-1979

Country

1966 1


1 133

Last endemic 1970

1971

1972

1973

1974 11975 11976 1 1977

1978 11979 11967

1968

1969

Endemic smallpox until year indicated

• Importation

Fig . 24 .3 . Countries requiring special procedures for the certification of smallpox eradication . The yearwhen the country ceased to be endemic, the year of the last known case, and the year and method of certifi-cation are also shown .

1 ARGENTINA

19662 BOLIVIA

1960 Mode of certification :3 BRAZILCHILE

1954 International Commission56

COLOMBIA

1965ECUADOR

1963 I

1 Visit or detailed7B

FRENCH GUIANA

1 904GUYANA

1 951 country report9 PARAGUAY

1 96010 PERU

1966II SURINAME

1 92012 URUGUAY

195713 VENEZUELA

1956

14 INDONESIA

15 BENIN1 6 GAMBIA

196617 GHANAIB GUINEA19 GUINEA-BISSAU

195720 COTE D'IVOIRE

196621 LIBERIA22 MALI23 MAURITANIA

196224 NIGER25 NIGERIA26 SENEGAL

196327 SIERRA LEONE28 TOGO29 UPPER VOLTA (BURKINA FASO)

30 AFGHANISTAN I31 PAKISTAN J

32 NEPAL33 BHUTAN

192034 INDIA

35 BURUNDI36 CAM EROON i37 CENTRAL AFRICAN REPUBLIC

196338 CHAD

196539 CONGO

196540 EQUATORIAL GUINEA

1 96041 GABON

196542 RWANDA43 ZAIRE

44 BURMA

196545 BANGLADESH

46 MALAWI47 MOZAMBIQUE48 UNITED REPUBLIC OF TANZANIA49 ZAMBIA

50 SYRIAN ARAB REPUBLIC

1950

aI

51 UGANDA52 SUDAN

1962

I, .53 BAHRAIN

195754 IRAN

196355 KUWAIT

1 95756 LAO PEOPLE'S DEMOCRATIC REPUBLIC

195357 NAMIBIA

before 195558 OMAN

196259 QATAR

196160 SAUDI ARABIA

1 96161 SOUTHERN RHODESIA (ZIMBABWE) _ . J62 THAILAND

196263 UNITED ARAB EMIRATES

Nev64 VIET NAM

1959

65 IRAQ

195966 SOUTH AFRICA67 MADAGASCAR

before 1918

68 ANGOLA

19S969 BOTSWANA

196470 LESOTHO

196271 SWAZILAND

1966

72 DEMOCRATIC YEMEN

196073 YEMEN

74 DJIBOUTI

19597 5 ETHIOPIA I76 KENYA77 SOMALIA

1962 •

• • • c'7879

CHINA

1961DEMOCRATIC KAMPUCHEA

1 959 f

I

1134


number of refugees, of whom there were tentimes more in 1982 than in 1972 (see Plate24.12), certification activities, including fieldvisits by outside experts where necessary,proceeded surprisingly well, perhaps owingto the interest of the international com-munity in this unprecedented event in thehistory of medicine .

Certification activities were strongly sup-ported by a vigorous information campaign .From March 1978 to August 1980 a specialinformation officer, Mr James Magee, wasrecruited to ensure good communicationswith major media agencies as well as medicalperiodicals. The goal of the informationcampaign was to reach beyond the scientificcommunity with the news that

(1) the world's last naturally occurring caseof endemic smallpox had been found inSomalia on 26 October 1977 ;

(2) this was being confirmed globally bycertification procedures involving an inten-sive search for cases ; and

(3) it was expected that, if all went well, thetarget date for the declaration of globaleradication, 26 October 1979 i.e ., 2 yearsafter the case in Somalia would be met .

The benefits of eradication to the inter-national community were stressed, includingthe end of the misery caused by this diseasethroughout human history and the enormousfinancial savings to the public health sectorwith the universal discontinuation of small-pox vaccination and associated controlmeasures . Those with doubts wereencouraged to speak out well in advance ofthe final global certification and countrieswere urged to change their legislation onsmallpox vaccination at an early date .

The last certification activities by inter-national commissions took place in October1979 in the Horn of Africa-Djibouti, Ethio-pia, Kenya, and Somalia, where, as has justbeen mentioned, the world's last case ofendemic smallpox was discovered in October1977. The 4 commissions that visited thecountries of the Horn of Africa in October1979 subsequently met in combined session inNairobi, where they considered the region as awhole. On 26 October 1979, exactly 2 yearsafter the onset of rash in the last case ofendemic smallpox in the world, smallpoxeradication was certified for Africa at aceremony in which the Director-General ofWHO and the directors of the Regional Offices

Plate 24 .13 . Gordon Meiklejohn (b . 1911), Pro-fessor of Medicine at the University of Colorado,Denver, USA . Worked with Dr A . R . Rao in Madrasin the early 1960s and served as a WHO consultanton smallpox almost every year from the mid-1960s,and for a full year in 1968-1969 . He was a member ofseveral international commissions for the certificationof smallpox eradication and was responsible for thepreparation of the first draft of the Final Report ofthe Global Commission .

for Africa and the Eastern Mediterraneanparticipated .

Certification of the Horn of Africa left only2 countries uncertified, China and Demo-cratic Kampuchea. However, in November1979, a report prepared after the visit of aWHO team to China became available and thesmallpox situation in Democratic Kampu-chea was clarified . On 9 December 1979, at itslast meeting in Geneva, the Global Commis-sion agreed to certify smallpox eradication inthese 2 countries .

By the end of 1979 all other countries-i .e .,excluding those visited by the inter-national commissions or certified by theGlobal Commission on the basis of otherevidence-had submitted to WHO theirsigned declarations that no cases of smallpoxhad occurred during at least 2 years . Therequirements for global certification recom-mended by the 1977 Consultation on theWorldwide Certification of Smallpox Eradi-cation had thus been met .

DECLARATION OF THE GLOBALERADICATION OF SMALLPOX

The ultimate responsibility of the GlobalCommission, once it was satisfied that world -


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The Thirty-third World Hralth Aesembly, on this the 8th day of May 1980 ;

H .rvInl± considered the 1rvr-lopments and results of the global progreniesmallpoxx eradication initiated by WHO 111 1458 and intensified since 1967 ;

DECLARES SOLEMNLY THAT THE WORLD ANN ALL ITS PEOPLES HAVE WONFREEDOM FROM SMAI .LPUX, WHICH WAS A MOST DFV'ASIATING DISEASE SWEEPING INEPIDEMIC FORM 'CHROUGH MANY COUNTRIES SINGS SURLIEST TIKE, LEAVING DEATH,BLINDNESS AND DISFIGURF[ENT IN ITS WAKE AND WATCH ONLY A DECADE AGO WASRAMP.ANI" IN AFRICA, ASIA AN'f) SOUTH AMERICA ;

EXPRESSES ITS DEEP GRATITUDE TO ALL FUSIOHS AND INDIVIDUALS WHOCDNTRIBO'TED TO 'L1 SUCCESS OF THIS NOBLE AND HISTORIC ENDEAVOUR;

CALLS T11IS UNPRECEDENTED ACHUEVEMENT T4 THE HISTORY OF PUBLIC HEALTHTD THE ATTENTION OF ALI . NATIONS, WHICH SY THEIR COLLECTIVE ACTION HAVEFREED MANKIND OF THIS ANCTENT 55(515GE AND, IN SO DOING, HAVE DEMONSTRATEDHOW NATIONS WORKING TOC'PHFR IN A LOSE-HIS CAUSE MAY FURTHER HUMAN PROGRESS .

Plate 24.14 . Resolution WHA33 .3, the formal declaration of the eradication of smallpox, based onthe report of the Global Commission to the Director-General of WHO, was adopted unanimouslyby the Thirty-third World Health Assembly on 8 May 1980 .

1135

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Plate 24 .15 . As the President of the Thirty-third World Health Assembly, Dr A-R . A . Al-Awadi,and the Director-General of WHO, Dr Halfdan Mahler, signed resolution WHA33 .3, the Presidentremarked: "While doctors sign the death certificates of people, today we are signing the deathcertificate of a disease" .


Plate 24 .16 . The ceremony of the declaration of global eradication of smallpox, on 8 May 1980, during theeighth plenary meeting of the Thirty-third World Health Assembly . A: Dr Frank Fenner (inset), Chairman ofthe Global Commission, addressed the Assembly and handed to the President the scroll that had been signed bythe members of the Commission (see frontispiece) . B: The President of the Assembly, Dr A-R . A. Al-Awadi,signing resolution WHA33 .3, with the Director-General of WHO, Dr Halfdan Mahler, looking on .

1138

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Plate 24.18 . Signatures of the delegates of Member States, from Malawi to Zimbabwe, appended to resol-ution WHA33 .3 .

1140


wide eradication of smallpox had beenachieved, was to document the reasons for itsdecision in a way that would allow the WorldHealth Assembly to declare that smallpox hadbeen eradicated . In addition, it was importantthat a post-eradication strategy should beplanned and machinery developed to imple-ment it .

During 1979, with the help of Dr GordonMeiklejohn, a WHO consultant, the SmallpoxEradication unit drafted a report for consi-deration by the Global Commission . This wasreviewed in detail by the 12 members of theGlobal Commission present in Nairobi inOctober 1979 (see Chapter 27), and therevised report was the main subject of discus-sion at the 4-day final meeting of theGlobal Commission in December 1979 . Thefinal report (World Health Organization,1980) outlines the criteria on the basis of

which all members of the Global Commissionsigned a document proclaiming the globaleradication of smallpox (see frontispiece) . Italso contained 19 recommendations coveringall aspects of a post-eradication strategy (seeChapter 28) designed to ensure that all thecountries of the world could remain confidentthat smallpox had indeed been eradicated .

On 8 May 1980 the Thirty-third WorldHealth Assembly reviewed the Global Com-mission's report and declared that smallpoxhad been eradicated throughout the world .There were two resolutions : resolutionWHA33.3 (see Plates 24 .14-24 .16) declaredthat the global eradication of smallpox hadbeen achieved and resolution WHA33 .4 en-dorsed the Global Commission's recommen-dations on policy for the post-eradication era(see Chapter 28) .

ANNEX 24.1 . MEMBERSHIP OF INTERNATIONAL COMMISSIONS FOR THECERTIFICATION OF SMALLPOX ERADICATION

The positions held by members at the time of the international commissions give someindication of their standing and expertise . Members of the Global Commission who were alsomembers of international commissions both before and after the establishment of the GlobalCommission are indicated by the letters GC in parentheses after their names .

1 . SOUTH AMERICA : 12-25 August 1973 (PAHO document CD22/19)Dr A. N. Bica

Secretary of Public Health, Ministry of Health, Rio deJaneiro, Brazil (Chairman)

Dr F. J . C. Cambournac

Director, Institute of Hygiene and Tropical Medicine,Lisbon, Portugal

Dr E. Echezuria

Chief, Department of Demography and Epidemiology,Ministry of Health, Caracas, Venezuela (Rapporteur)

Dr J. D. Millar

Director, State and Community Services Division, Centerfor Disease Control, Atlanta, GA, USA

Dr R. J . Wilson

Chairman, Connaught Medical Research Laboratories Ltd,University of Toronto, Canada

2 . INDONESIA : 15-25 April 1974 (WHO/SE/74 .68)Dr N. McK. Bennett

Specialist Physician and Deputy Superintendent, FairfieldHospital, Melbourne, Australia

Dr J . J. Dizon

Chief of Disease Intelligence, Disease Intelligence Centre,Department of Health, Manila, Philippines

Dr J . S . Gill

Assistant Director, Health and Epidemiology, Ministry ofHealth, Kuala Lumpur, Malaysia (Rapporteur)

Dr S. Kumarapathy Senior Registrar, Quarantine and Epidemiology, Environ-mental Public Health Division, Ministry of Environ-ment, Singapore


1 141

Dr J. Sulianti Saroso Director-General for the Control and Prevention of Com-municable Diseases, Ministry of Health, Jakarta,Indonesia

Dr I. Tagaya (GC)

Director, Department of Enteroviruses, National Instituteof Health, Tokyo, Japan

Dr P. F. Wehrle (GC)

Hastings Professor of Pediatrics, Los Angeles CountyUniversity of Southern California Medical Center, LosAngeles, CA, USA (Chairman)

3 . WESTERN AFRICA : 23 March-15 April 1976 (AFR/Smallpox/80)Countries included : Benin, Cote d'Ivoire, Gambia, Ghana, Guinea-Bissau, Liberia, Mali,Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Togo and Upper Volta (Burkina Faso) .

Dr S. Bedaya-Ngaro

Inspector General of Health Services, Bangui, CentralAfrican Republic

Dr W. Koinange (GC)

Director, Division of Communicable Disease Control,Ministry of Health, Nairobi, Kenya (Chairman, Abidjan)

Dr I. D. Ladnyi

Chief, Central Board of Quarantinable Diseases, Ministry ofHealth, Moscow, USSR

Dr Lekie Botee

Director-General, Department of Public Health, Kinshasa,Zaire (Chairman, Brazzaville)

Dr R. Netter (GC)

Director-General, National Health Laboratory, Paris,France

Dr M. I. D. Sharma

Director (retired), National Institute of CommunicableDiseases, New Delhi, India

Dr P. F. Wehrle (GC)

Hastings Professor of Pediatrics, Los Angeles CountyUniversity of Southern California Medical Center, LosAngeles, CA, USA (Rapporteur)

4. AFGHANISTAN : 22-29 November 1976 (WHO/SE/77 .89)and

5 . PAKISTAN : 6-18 December 1976 (WHO/SE/77 .90)

Dr H. S. Bedson

Professor of Medical Microbiology, University of Bir-mingham, Medical School, Birmingham, England

Dr N. McK. Bennett

Specialist Physician and Deputy Superintendent, FairfieldHospital, Melbourne, Australia

Dr A. I . Idris

Director-General, Epidemiology, Ministry of Health, Khar-toum, Sudan (Chairman, Pakistan)

Dr G. Meiklejohn

Professor of Medicine, University of Colorado MedicalCenter, Denver, CO, USA (Rapporteur, Afghanistan andPakistan)

Dr N. Kumara Rai Director, Planning Department, Directorate General forCommunicable Disease Control, Ministry of Health,Jakarta, Indonesia

Dr P. N. Shrestha (GC)

Chief, Smallpox Eradication Project, Department of HealthServices, Kathmandu, Nepal (Chairman, Afghanistan)

6 . CENTRAL AFRICA : 6-30 June 1977 (AFR/Smallpox/86)Countries included : Burundi, Cameroon, Central African Republic, Chad, Congo,Equatorial Guinea, Gabon, Rwanda and Zaire .

Dr P. Agbodjan

Chief, Major Endemic Diseases Service, General Directoratefor Health, Lome, Togo

Dr J . G. Breman Epidemic Intelligence Officer (Michigan Department ofPublic Health), Bureau of Epidemiology, Center forDisease Control, Atlanta, GA, USA

1142


Dr E. Coffi

Director, Institute of Hygiene, Ministry of Public Health,Abidjan, Cote d'Ivoire

Dr F. Dekking

Health Science Laboratory, University of Amsterdam,Netherlands

Dr A. K. M'Baye Chief Medical Officer, Major Endemic Diseases Service, andDeputy Director of Public Health, Dakar, Senegal(Chairman)

Dr R. Netter (GC)

Director-General, National Health Laboratory, Paris,France (Rapporteur)

Dr M. Yekpe

Chief, Communicable Diseases Service, Ministry of PublicHealth, Cotonou, Benin

7 . INDIA : 4-23 April 1977 (SEA/Smallpox/78)NEPAL : 4-13 April 1977 (SEA/Smallpox/80)BHUTAN : 28 March-1 April 1977 ; 22 April 1977 (SEA/Smallpox/80)India and BhutanDr J. Cervenka

Chief (Epidemiology), Institute of Epidemiology and Micro-biology, Bratislava, Czechoslovakia

Dr W. A. B. de Silva

Deputy Director (Planning), Ministry of Health, Colombo,Sri Lanka

Dr F. Fenner (GC) Director, Centre for Resource and Environmental Studies,The Australian National University, Canberra, Australia(Rapporteur)

Dr H. Flamm

Institute of Hygiene, University of Vienna, AustriaLt.-Gen. R . S . Hoon

Director-General, Armed Forces Medical Services, NewDelhi, India

Dr T. Kitamura

Chief, Division of Poxviruses, National Institute of Health,Tokyo, Japan

Dr W. Koinange (GC)

Director, Division of Communicable Disease Control,Ministry of Health, Nairobi, Kenya

Dr J. Kostrzewski (cc)

Secretary, Medical Section, Polish Academy of Sciences,Warsaw, Poland (Chairman)

Dr H. B. Lundbeck (GC)

Director, National Bacteriological Laboratory, Stockholm,Sweden

Dr A. M. Mustaqul Huq

Director of Health Services (Preventive), Ministry ofHealth, Dhaka, Bangladesh

Dr D. M. Mackay

Ross Institute of Tropical Hygiene, London School ofHygiene and Tropical Medicine, London, England

Dr M. F. Polak

Scientific Officer, Faculty of Medicine, Catholic University,Nijmegen, Netherlands

Dr R. Roashan

President, Foreign Relations Department, Ministry ofPublic Health, Kabul, Afghanistan

Dr D. J . Sencer

Director, Center for Disease Control, Atlanta, GA, USADr U Thein Nyunt

Director, Disease Control, Ministry of Health, Rangoon,Burma

Dr V. M. Zhdanov

Director, Institute of Virology, Academy of MedicalSciences, Moscow, USSR

NepalDr T. Kitamura

Chief, Division of Poxviruses, National Institute of Health,Tokyo, Japan

Dr J. Kostrzewski (cc)

Secretary, Medical Section, Polish Academy of Sciences,Warsaw, Poland (Chairman)

Dr D. M. Mackay Ross Institute of Tropical Hygiene, London School ofHygiene and Tropical Medicine, London, England(Rapporteur)

8. BURMA : 21-30 November

Dr S. Jatanasen

Dr A. D. Langmuir

Dr C. LercheDr H. von Magnus


Dr I. F . Setiady

Dr M. I. D. SharmaDr P. N. Shrestha (GC)

Dr U Thein Nyunt

9. BANGLADESH : 1-14 December 1977 (SEA/Smallpox/84)

Dr S. Jatanasen

Director, Division of Epidemiology, Ministry of PublicHealth, Bangkok, Thailand

Dr A. D. Langmuir Professor, Harvard University Medical School, Departmentof Preventive and Social Medicine, Boston, MA, USA(Chairman)

Dr C. Lerche

Director, National Institute of Public Health, Oslo, NorwayDr H. von Magnus

Head, Department of Epidemiology, State Serum Institute,Copenhagen, Denmark (Rapporteur)



Dr I . F. Setiady

Director, Epidemiology and Quarantine, Ministry ofHealth, Jakarta, Indonesia

Dr M. I. D. Sharma

Emeritus Medical Scientist, New Delhi, IndiaDr P. N. Shrestha (GC)

Chief, Smallpox Eradication Project, Department of HealthServices, Kathmandu, Nepal

Dr U Thein Nyunt

Director, Disease Control, Ministry of Health, Rangoon,Burma

24 . CERTIFICATION : CONCEPTS, STRATEGY AND TACTICS

1143

1977 (SEA/Smallpox/83)Director, Division of Epidemiology, Ministry of Public

Health, Bangkok, ThailandProfessor, Harvard University Medical School, Department

of Preventive and Social Medicine, Boston, MA, USA(Secretary)

Director, National Institute of Public Health, Oslo, NorwayHead, Department of Epidemiology, State Serum Institute,Copenhagen, Denmark (Rapporteur)


Director, Epidemiology and Quarantine, Ministry ofHealth, Jakarta, Indonesia (Chairman)

Emeritus Medical Scientist, New Delhi, IndiaChief, Smallpox Eradication Project, Department of Health

Services, Kathmandu, NepalDirector, Disease Control, Ministry of Health, Rangoon,Burma

10. MALAWI, MOZAMBIQUE, UNITED REPUBLIC OF TANZANIA and ZAMBIA : 6-29 March 1978(AFR/Smallpox/87)

Dr M. Davies

Chief Medical Officer, Ministry of Health, Freetown, SierraLeone

Dr Z. M. Dlamini

Senior Medical Officer of Health, Ministry of Health,Mbabane, Swaziland

Dr J. A. Espmark

Department of Virology, State Laboratory of Biology,Stockholm, Sweden

Dr F. Fenner (GC)

Director, Centre for Resource and Environmental Studies,The Australian National University, Canberra, Australia(Rapporteur)

Dr J. S. Moeti (GC)

Director of Medical Services, Ministry of Health, Gaborone,Botswana (Chairman)

1144


11 . IRAQ : 5-15 October 1978 (WHO/SE/78 .127)and

12 . SYRIAN ARAB REPUBLIC : 15-22 October 1978 (WHO/SE/78 .126)Dr R. Netter (GC)

Director-General, National Health Laboratory, Paris,France (Chairman)

Dr M. Chamsa

Assistant Director, Organization of Medical Services, RedLion and Sun Society of Iran, Teheran, Iran

13. UGANDA : 11-27 October 1978 (AFR/Smallpox/88)

Dr A. Deria (GC)

Director, Department of Public Health, Ministry of Health,Mogadishu, Somalia (Chairman)

Dr Kalisa Ruti (GC)

Medical Director, Expanded Programme on Immuniza-tion, Department of Public Health, Kinshasa, Zaire(Rapporteur)

Dr Y. P. Rikushin

Chief, Department of Epidemiology, Pasteur Institute,Leningrad, USSR

14. SUDAN : 15-29 NovemberDr A. M. FerganyDr W. Koinange (GC)

Dr C. Lerche

Dr S. S. Marennikova (GC)

Dr G. Meiklejohn

Dr D. A. Robinson

Ato Yemane Tekeste

15 . ANGOLA : 5-16 February 1979 (AFR/Smallpox/89)Dr Kalisa Ruti (GC) Medical Director, Expanded Programme on Immunization,

Department of Public Health, Kinshasa, Zaire (Co-Rapporteur)

Dr Bichat A . Rodrigues (Gc) Regional Coordinator for the South-East Region, Ministryof Health, Brasilia, Brazil (Chairman)

Dr Cabral A . J. Rodrigues National Director of Preventive Medicine, Secretariat forInternational Cooperation, Maputo, Mozambique (Co-Rapporteur)

16. BOTSWANA, LESOTHO AND

Dr D. Chilemba

Dr A. Deria (GC)

Dr P. E. M. Fine

Dr W . Koinange (GC)

Dr G. Meiklejohn

1978 (WHO/SE/79.134)Adviser, Ministry of Health, Oman (Chairman)Chief Deputy Director of Medical Services, Ministry of

Health, Nairobi, KenyaDirector, National Institute of Public Health, Oslo, Norway

(Vice-Chairman)Chief, Laboratory of Smallpox Prophylaxis, Moscow Re-

search Institute for Viral Preparations, Moscow, USSRProfessor of Medicine, University of Colorado Medical

Center, Denver, CO, USA (Rapporteur)Community Physician, Communicable Disease Surveillance

Centre, London, EnglandProject Manager, Smallpox Eradication Programme,

Addis Abeba, Ethiopia

SWAZILAND : 5-23 March 1979 (AFR/Smallpox/90)Chief Medical Officer, Ministry of Health, Lilongwe,

MalawiDirector, Department of Public Health, Ministry of Health,

Mogadishu, SomaliaRoss Institute of Tropical Hygiene, London School of

Hygiene and Tropical Medicine, London, EnglandChief Deputy Director of Medical Services, Ministry of

Health, Nairobi, Kenya (Chairman)Professor of Medicine, University of Colorado Medical

Center, Denver, CO, USA (Rapporteur)


1145

Dr E. A. Smith

Director of Medical Services, Federal Ministry of Health,Lagos, Nigeria

Dr I. Tagaya (GC)

Director, Department of Enteroviruses, National Instituteof Health, Tokyo, Japan

17 . DEMOCRATIC YEMEN : 3-11 June 1979 (WHO/SE/79 .140)Director of Epidemiology and Quarantine, Directorate

General of Preventive Medicine, Ministry of Health,Baghdad, Iraq

Chief, Division of Poxviruses, National Institute of Health,Tokyo, Japan (Chairman)

Chief, Department of Tropical Diseases, PostgraduateSchool of Medicine, Prague, Czechoslovakia

18 . YEMEN : 2-10 June 1979 (WHO/SE/79 .139)Dr J. M. Aashi (GC)

Dr T. J . Geffen

Dr R. Netter (GC)

Dr F. Jurji

Dr T. Kitamura

Dr V. Sery

19. DJIBOUTI : 9-18 October 1979 (WHO/SE/79 .147)

Assistant Director-General of Preventive Medicine, Minis-try of Health, Riyadh, Saudi Arabia (Co-Chairman)

Director, Communicable Diseases Division, Departmentof Health and Social Security, London, England(Rapporteur)

Director-General, National Health Laboratory, Paris,France (Co-Chairman)

Epidemiologist, Douvaine, France ; formerly Regional Ad-viser for Smallpox Eradication in the WHO RegionalOffice for South-East Asia, New Delhi, India(Rapporteur)

Dr T. Nacef

Director, Department of Preventive and Social Medicine,Ministry of Public Health, Tunis, Tunisia

Director-General, National Health Laboratory,France (Chairman)

Dr N. C. Grasset

Dr R. Netter (GC)

20. ETHIOPIA : Preliminary(WHO/SE/79.148)

Dr R. N. Basu (GC)

Dr Z. M. Dlamini

Dr K. R. Dumbell (GC)

Dr J. Kostrzewski (GC)


Dr T. Olakowski

Dr N. A. WardFinal visit : 1-19 OctoberDr K. R. Dumbell (GC)

Dr D. A. Henderson (GC)

Paris,

visit : 3-18 April 1979 ; final visit : 1-19 October 1979

Assistant Director-General of Health Services, DirectorateGeneral of Health Services, New Delhi, India

Director of Medical Services, Ministry of Health, Mbabane,Swaziland

Head, Department of Virology, The Wright-FlemingInstitute of Microbiology, St Mary's Hospital MedicalSchool, London, England

Secretary, Medical Section, Polish Academy of Sciences,Warsaw, Poland


Deputy Director, National Tuberculosis Institute, Warsaw,Poland

Save the Children Fund, London, England1979

Head, Department of Virology, The Wright-FlemingInstitute of Microbiology, St Mary's Hospital MedicalSchool, London, England (Rapporteur)

Dean, School of Hygiene and Public Health, The JohnsHopkins University, Baltimore, MD, USA (Rapporteur)

1146


21 . KENYA : 1-19 October 1979 (WHO/SE/79 .149)Dr R. N. Basu (GC)

22 .

Dr J . Kostrzewski (GC)


Dr I. Noormahommed

Deputy National Director of Preventive Medicine, Ministryof Health, Maputo, Mozambique

Dr D. A. Robinson

Epidemiologist, Communicable Disease SurveillanceCentre, London, England

Dr A. A. Stroganov Assistant Professor, Central Institute for Advanced MedicalTraining, Communicable Disease Department, Moscow,USSR

Dr Kalisa Ruti (GC)

Dr S. S. Marennikova (GC)

Dr G. Meiklejohn

Dr J . S. Moeti (GC)

SOMALIA : 1-21 OctoberDr J. M. Aashi (GC)

Dr Z. M. Dlamini

Dr T. J . Geffen


Dr J . D. Millar

Dr P. N. Shrestha (GC)

Assistant Director-General of Health Services, DirectorateGeneral of Health Services, New Delhi, India (Chairman)

Medical Director, Expanded Programme on Immunization,Department of Public Health, Kinshasa, Zaire

Chief, Laboratory of Smallpox Prophylaxis, Moscow Re-search Institute for Viral Preparations, Moscow, USSR

Professor of Medicine, University of Colorado MedicalCenter, Denver, CO, USA (Rapporteur)

Senior Medical Officer of Health, Ministry of Health,Gaborone, Botswana

1979 (WHO/SE/79.146)

Assistant Director-General of Preventive Medicine, Minis-try of Health, Riyadh, Saudi Arabia

Director of Medical Services, Ministry of Health, Mbabane,Swaziland

Director, Communicable Diseases Division, Department ofHealth and Social Security, London, England(Rapporteur)

Director, National Bacteriological Laboratory, Stockholm,Sweden (Chairman)

Assistant Director for Public Health Practice, Center forDisease Control, Atlanta, GA, USA

Chief, Planning Division, Tribhuvan University Institute ofMedicine, Kathmandu, Nepal

ANNEX 24.2. PARTICIPANTS IN THE CONSULTATION ON THEWORLDWIDE CERTIFICATION OF SMALLPOX ERADICATION AND

MEMBERS OF THE GLOBAL COMMISSION

The numbers in parentheses have the following significance :(1) participated in the 1977 Consultation ;(2) attended the 1978 meeting of the Global Commission ;(3) attended the 1979 meeting of the Global Commission .

Participants in the Consultation and Members of the Global Commission

Dr J . M. Aashi (1, 2, 3)

Assistant Director-General of Preventive Medicine, Minis-try of Health, Riyadh, Saudi Arabia

Dr J . Azurin (1, 2, 3)

Under-Secretary of Health, Department of Health, Manila,Philippines

Dr R. N. Basu (1, 2, 3)

Assistant Director-General of Health Services, DirectorateGeneral of Health Services, New Delhi, India

Deputy Minister of Health, Moscow, USSRDirector-General, Ministry of Health, Quito, EcuadorDirector, Department of Public Health, Ministry of Public

Health, Mogadishu, SomaliaHead, Department of Virology, The Wright-Fleming

Institute of Microbiology, St Mary's Hospital MedicalSchool, London, England

Chairman : Director, Centre for Resource and Environmental Studies,The Australian National University, Canberra, Australia

Dean, School of Hygiene and Public Health, The JohnsHopkins University, Baltimore, MD, USA

Medical Director, Expanded Programme on Immunization,Kinshasa, Zaire

Head, International Health Division, Department of Healthand Social Security, London, England

Director, Division of Communicable Disease Control,Ministry of Health, Nairobi, Kenya



Chief, Laboratory of Smallpox Prophylaxis, Moscow Re-search Institute for Viral Preparations, Moscow, USSR

Senior Medical Officer of Health, Ministry of Health,Gaborone, Botswana

Minister of Higher Education and Science, Teheran, IranDirector-General, National Health Laboratory, Paris,

FranceExecutive Secretary, National Council of Health, Brasilia,

BrazilChief, Planning Division, Tribhuvan University Institute of

Medicine, Kathmandu, NepalDirector, Department of Enteroviruses, National Institute

of Health, Tokyo, JapanHastings Professor of Pediatrics, Los Angeles County

University of Southern California Medical Center, LosAngeles, CA, USA

Dr Zhang Yihao (3)

Deputy Director, National Serum and Vaccine Institute,Beijing, China

Dr P. N. Burgasov (2, 3)Dr H. Corral (1)Dr A. Deria (1, 2, 3)

Dr K. R. Dumbell (1, 2, 3)

Dr F. Fenner (1, 2, 3 ;1, 2, 3)

Dr D. A. Henderson (1, 2, 3)

Dr Kalisa Ruti (3)

Dr J. Kilgour (1)

Dr W. Koinange (1, 2, 3 ; Vice-Chairman : 1)

Dr J. Kostrzewski (1, 2, 3 ; Vice-Chairman : 2, 3)

Dr H . B. Lundbeck (1, 2, 3)

Dr S. S. Marennikova (1, 2, 3)

Dr J . S. Moeti (1, 2, 3)

Dr C. Mofidi (1, 2)Dr R. Netter (1, 2, 3)

Dr Bichat A. Rodrigues (3)

Dr P. N. Shrestha (2, 3)

Dr I. Tagaya (2, 3)

Dr P. F. Wehrle (1, 2, 3 ;Rapporteur : 1, 2, 3)

Dr H. Corral (1)Dr W. H. Foege (2)Dr T. J . Geffen (2)

Dr N. C. Grasset (2)Dr Jiang Yu-tu (3)Dr G. Meiklejohn (2, 3)

Dr W. Nicol (2)Dr A. G. Rangaraj (2)Dr Parviz Rezai (2)

Ato Yemane Tekeste (2, 3)


1147

WHO Advisers

Director-General, Ministry of Health, Quito, EcuadorDirector, Center for Disease Control, Atlanta, GA, USADirector, Communicable Diseases Division, Department of

Health and Social Security, London, EnglandEpidemiologist, Douvaine, FranceMilitary Academy of Medical Sciences, Beijing, ChinaProfessor of Medicine, University of Colorado Medical

Center, Denver, CO, USAArea Medical Officer, Birmingham, EnglandEpidemiologist, Nilgiris District, Madras, IndiaDeputy Director-General, Communicable Diseases Control

and Malaria Eradication, Ministry of Health and Welfare,Teheran, Iran

Programme Manager, Smallpox Eradication Programme,Addis Abeba, Ethiopia

1148


WHO Regional Office Staff

AfricaDr A. H. Abou-Gareeb (3), Director, Disease Prevention and Control, Brazzaville, CongoDr C. Algan (1, 2), Medical Officer, Health Services, Brazzaville, CongoDr Z. Islam (2, 3), Medical Officer, Epidemiological Surveillance of Communicable Diseases

Project, Nairobi, KenyaDr L. N. Khodakevich (2, 3), Interregional Medical Officer, Smallpox Eradication Project,

Addis Abeba, EthiopiaAmericasDr J. Bond (3), Medical Officer, Communicable Diseases, Washington, DC, USADr C. H. Tigre (2), Scientist, Communicable Diseases, Washington, DC, USADr K. A. Western (1, 2), Chief, Communicable Diseases, Washington, DC, USA

South-East AsiaDr L. N. Khodakevich (1), Medical Officer, Smallpox Eradication, New Delhi, India

EuropeDr M. R. Radovanovic (1, 2), Medical Officer, Epidemiological Surveillance of Communicable

Diseases, Copenhagen, Denmark

Eastern MediterraneanDr P. Chasles (1), Medical Officer, Communicable Diseases Prevention and Control, Alexandria,Egypt

Dr F. Partow (2), Medical Officer, Communicable Diseases Prevention and Control, Alexandria,Egypt

Western Pacific :Dr B. C. Dazo (3), Scientist, Communicable Diseases, Manila, PhilippinesDr R. R. Lindner (1), Medical Officer, Communicable Diseases, Manila, PhilippinesDr Chin Wentao (2), Consultant Medical Officer, Communicable Diseases, Manila, Philippines

WHO Headquarters Staff

Dr I. D. Ladnyi (1, 2, 3), Assistant Director-GeneralDr A. Zahra (2, 3), Director, Division of Communicable DiseasesDr I. D. Carter (2, 3), Epidemiologial Surveillance of Communicable DiseasesDr H . J. Schlenzka (2), Legal DivisionDr E. Shafa (1, 2), Expanded Programme on Immunization

Smallpox Eradication unitDr I. Arita (1, 2, 3), Chief Medical OfficerDr J. G. Breman (1, 2, 3), Medical OfficerMr R. N. Evans (2, 3), Technical OfficerDr A. I . Gromyko (1, 2, 3), Medical OfficerMr R. O. Hauge (1), Consultant Technical OfficerDr Z. Jezek (2, 3), Medical OfficerMr J. Magee (2, 3), Information OfficerDr J . L. Tulloch (2, 3), Consultant Medical OfficerMr. J . F. Wickett (1, 2, 3), Administrative Officer

THE CERTIFICATION OF ERADICATION: CONCEPTS, STRATEGY … 24.pdf · Anopheles gambiae, from Brazil in 1940 (Soper & Wilson, 1943). With these programmes of vector eradication came

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