Global CS 1: Eradicating Smallpox

What was the suggested global cost, both indirect and direct, of smallpox in the late 1960's?

$1.35 billion

What was spent per year on endemic countries?

$10 million, even though 50 million was estimated originally

How much money came from endemic countries?

$200 million

What was the annual cost of the smallpox campaign between 1967 and 1979?

$23 million

In total, how much did international donors provide for the campaign?

$98 million

By using existing health care systems for the program, what did this do?

-forced some countries to bring their systems up to standard -staff training important in hospital based health systems that had no experience in setting up preventative campaigns helped develop immunization services more generally- health staff helping with the campaign receibed training in vaccination and this could be applied to other campaigns and reduce traingn cost

What characteristics of the vaccination gave reason for optimism?

-freeze dried vaccines eliminated reliance on cold chain -if stored properly, vaccine maintains its strength for many years -single vaccine can prevent infection from smallpox for at least a decade, some studies show even up to 30 years -even when vaccine fails to prevent infection, resulting disease tended to be milder and have lower fatality rate

Why was the new breakthrough Bifurcated needle so awesome?

-reduced costs -1000 needles cost $5 to make -made vaccinating easier -could boil or flame each needle and reuse hundreds of times -one vial provided enough vaccine for 4 times as many people because smaller amount required -very easy to use, a villager could be trained in 15 minutes

What is the timeline for presentation of the disease.

-remain apparently healthy for up to 17 days -infectious stage includes onset of flu-like symptoms -2-3 days later fever reduces and characteristic rash appears- face first, then hands, then forearms, then trunk -ulcerating lesions in nose and mouth and virus released into throat

What virus causes smallpox? How is it spread?

-variola virus -between people, through the air, mainly from face to face contact and to a lesser extent by clothes and bedding

However, during the first few years of the campaign, what portion of the WHOs regular budget was spend?

.2 .5 milllion a year

What was smallpox costing developing countries as a whole per year?

1 billion dollars each year at the start of the intensified eradication campaign

Explain the smallpox eradication program?

1. 1965, Smallpox Eradication Unit at WHO and a pledge of more support from the largest donor, US 2. endemic countries supplied with vaccines and kits for collecting and sending specimens 3. bifurcated needle made vaccination easier 4. intensified effort in 5 remaining countries in 1973 5. concentrated surveillance and containment of outbreaks

What were the things that made smallpox a good candidate for eradication?

1. disease passed directly between people, without intervening vector, so no reservoirs 2. distinctive rash made it easy to diagnose 3. survivors gained lifetime immunity 4. the long time between contracting and getting sick meant people would take to their beds with symptoms by the time they were infectious and infect few others 5. where an outbreak occured, the natural course of the disease gave health workers time to isolate victims, trace contacts, and vaccinate the population

What 7 diseases have global efforts tried to eradicate?

1. hookworn 2. yellow fever 3. malaria 4. yaws 5. smallpox 6. guinea worm 7. polia

What are the 2 main benefits of eradicating a disease?

1. monetary and other resources can be redirected 2. surveillance, logistics, and administrative support are invigorated to achieve a higher standard of performance, improve quality and quantitiy of health workers, bolster health infrastructure, foster coordination among donors

What are the 6 preconditions for disease eradication?

1. no animal reservoir for the virus known or suspected 2. sensitive and specific tools are available for diagnosis and surveillance 3. transmission from one individual to another can be interrupted 4. nonlethal infection or vaccination confers lifelong immunity 5. the burden of disease is important to international public helath 6. political committment to eradication effort exists

The WHOs general director, Gandau, was compelled to reenergize the smallpox camapign. What elements figured into the director general's proposal?

1. the budget was divided so that one part remained in the main WHO budget and the other in a dedicated fund -- allowed countries committments to be guaged while at the same time safeguarding the WHO's core budget 2. the general approach was designed to learn from the problems with the malaria program-- rather than setting out strict set of rules, the program articulated principles to allow for flexibility 3. the case reporting system was to be developed right at start of program and guide its progress 4. research was encourgared ---all WHO member countries would be required to participate, and their efforts would need to be coordinated

In 1966, there were approximately 10 million to 15 million cases of smallpox in more than 50 countries and how many people died from the disease per year?

1.5-2 million

Of those who contract the major form, how many die?

1/3

In 1958, what did the deputy health minister of the Soviet Union and delegate to WHA, Prof Viktor Zhdanov, propose? What did he promise?

10 year campaign to eradicate the disease worldwide based on compulsory vaccination and revaccionation promised that the SU would donate 25 million vaccine doses to initiate the program

How long did it take to eradicate smallpox?

10 years, 9 months, 26 days after start of intensified campaign

Jan 1967, about how many cases were there worldwide? How many died each year? How many endemic countries and where were they?

10-15 million 1.5-2 million died each year 31 endemic countries -many sub-Saharan Africa, 6 asia, 3 S. America

When did mass vaccination programs become theoretically viable? Why?

1920s improved vaccine

When did world eradication become a practical goal? What made it more practical?

1950s developed vaccine that did not require cold storage and could be produced as a consistently potent product in large quantities

When did word that the smallpox eradication campaign was working really spread among donors?

1974 just 5 endemic countries remained this triggered large donations and more funds

By what year was the las endemic case of smallpox recorded in Somalia?

1977

When was the last new case of smallpox reported?

1978

What efforts have been taken to prepare for outbreaks of smallpox?

1997 BioReliance: 300,000 doses of improved smallpox vaccine ($70 per dose) 2000 OraVax 40 million doses 2002 Bush admin set aside money to procure 300 million doses 2003: 291,000 doses released by CDC to vaccinate first responders in US against smallpox $42 million for Smallpox Vaccine Injury Compensation Program

Who did the staff consist of for the Smallpox Eradication Unit?

4 medical officers 1 administrator 1 technical officer 4 secretaries strong support from CDC to produce epi report every 2-4 weeks

Until 1966, how many full time employeees were assigned to field programs?

5

In 1959, it has been estimated that smallpox remained endemic in ______ countries containing about ______% of the world's population.

59 countries 60% of world's pop

In 1959, how many countries reported a total of how many cases of smallpox?

63 countries reported 77,555 cases -thought to be underestimate and closer to 100,000

By 1990, what percentage of children throughout the developing world were receiving childhood vaccines against 6 childhood killers, compared with only 5% when the program started?

80%

Of the survivors, how many have deeply pitted marks especially on face and even blindness?

80%

At the start of the campaign what was the esitmated cost of the efforts?

977 million people estimated live in endemic areas cost 10 cents per person $98 million

What countries were already on he verge of interrupting the transmission of the disease in 1950's?

China, Iraq, Thailand, and Algeria

Who was chief medical officer of the Smallpox Eradication Unit?

D.A. Henderson

Who created a vaccine in 1798 and claimed it was successful in vaccinating people against smallpox?

Edward Jenner

Which countries were the last to eradicate?

Ethipopia was thought to be last then smallpox again in Somalia because of refugees. Ethiopioa eradicated then the last endemic case in Somalia October 1977

Where were supplies like vaccine jet injectors, kits for collecting specimens, and training aids stored?

Geneva Switzerland

What is the expanded program on immunization?

UNICEF supported, 1980's, add a host of other vaccines (diptheria, tetanus, pertussis, polio, and measles vaccines to the routine smallpox and BCG (to prevent TB))

In 1953, who rejected the notion that smallpox should be selected for eradication?

World Health Assembly (WHA),, the highest governing body of the WHO

New appointments to WHO in 1964 revived the conviction that smallpox was beatable and created the impetus to set up what?

a separate Smallpox Eradication Unit, which provided focused leadership for international efforts

Rather than the measles and smallpox campaign program, what was proposed?

al alternative smallpox eradication campaign, which was eventually put on the Us agenda, and finally, US support for the global effort

September 1973, intensified campaigns began in five remaining endemic countries, which were?

bangladesh, india, nepal, pakistan, ethipopia

How is the threat of smallpox still an issue?

bioterrorism -questioning whether strains should be kept alive in specific labs

In the 1700s in Europe, one third of all cases of ______ were attributed to smallpox?

blindness

What other campaign was the WHO distracted by at the time, giving little funds to smallpox campaign?

campaign against malaria (given a go ahead 4 years before smallpox)

When the wHO announced a mass vaccination program in India in 1963, what happened?

campaign ran into trouble when it failed to generate sufficient donations of freeze dried vaccines

In May 1980, after two years of surveillance and searching, the World Health Assembly...?

declared that smallpox was the first disease in history to be eradicated

In India, who did vaccination programs focus on? What did this achieve?

easiest targets -achieved 90% coverage in some districts but outbreaks still occurred in remote villages and slums, among traveling workers, and even in heavily vaccinated areas

What is a short term pitfall of eradication campaign?

focused efforts to deal with one ailment detract from a health system's ability to deal with many other causes of human suffering

For the national programs, what did success hinge on?

having someone who was responsibble , preferably, solely for smallpox eradication. this individual woul dbe the primary contact in the country and could be held accountable

What is another really important, general transferrable lesson learned?

importance on monitoring better surveillance and evaluation activity (how many vaccines given) is not necessarily an indicator of success

In 1970, the SmallPox Eradication Unit proposed an Expanded Programme on Immunization to do what?

increase the number of vaccinations administered during a single patient interaction

How did teams go out and use the surveillance and containment strategy and search for cases?

jeeps and motorbikes

Each year, the wHO director general told the WHA that eradication wasn't going as well as planned because why??

lack of funds for vehicles, supplies, and equipment, each year asking for more funds

What is a long term risk of eradication campaign?

may be impossible to obtain all the promised benefits because vaccination and other preventative serivces, must continue

For several years, who were the only full time employees on the smallpox campaign?

medical officer and secretary

In 1965, the US government, the WHOs largest contributor, promised what?

more technical and material support to the campaign

Once there were a few countries with smallpox, how did the campaign change?

move away from general vaccination campaigns to focusing on actively seeking out cases and constraining outbreaks with quarantine and vaccination of local people

In the early days of eradication, who was in charge of eradication efforts? What role did the WHO play?

national campaigns leaving cost and human resources on the national governments providing technical assistance where called for and helping out by ensuring produciton of the vaccine

In 1964, an expert committee was set up and realized that case reporting was running at 5% or less of actual cases, closer to 1% in fact. What did this mean?

no one could tell where progress was being made or where there was a problem -because success in some places was not being tracked, there couldn't be proof to rally for more support for the campaign

What does eradication mean?

permanantly reducing the number of new infections worldwide to zero, with interventions no longer needed

What is hoped to be the 2nd eradicated disease?

polio

What is much of the program's success attributed to?

political committment and leadership, in this case from WHO and CDC, specific funds, staff, and a unit withoverall accountability and responsibility for the program

What is elimination?

reducing the number of new infections to zero in a defined geographical area, with continued interventions required to prevent reestablishiment of transmission

What might be one of the greatest contributions from the smallpox eradication campaign?

routine imunization in the developing world

How much does the US save because it does not have to vaccinate or treat smallpox?

saves the total of all its contributions every 26 days

Why were the estimates so off?

some countries only reported cases that surfaced in major urban hospitals and some failed to report, also lacked info from countries not members of WHO, like China

A year after Zhdanov's proposal, what did the WHO do?

suggested that eradication could be achieved by vaccinating or revaccinating 80% of the people in the endemic areas within 4-5 years -russion proposal passed in 1959

What compelled the WHO director general, Gandau, to reenergize eradication campaign?

support from Us and the long standing campaign from the soviet union

What interesting idea, now taken for granted, was disovered during the smallpox campaign?

that more than one vaccine could be given at a time

In 1966, the WHA finally agreed to back the objective adopted the previous year for what?

the Intensified Smallpox Eradication Programme

In 1964, what did the WHO recommend to solve the problem of quota meeting and vaccinating some people multiple times?

the entire population be vaccinated to achieve eradication

No two national campaigns were alike, whcih points to one important lesson...?

the need for a flexible approach important that funds raised didn't come with conditions that prevented their use in certain areas

Why were outbreaks still happening in heavily vaccinated areas in India?

the quota system led to some people, like schoolchildren, to receive the vaccine multiple times to meet the quotas, while those not in school wre never vaccinated

When was the western hemishpere declared free of smallpox?

April 1971

When did the Intensified Smallpox Eradication Programme begin and what was the total budget? Budget per country?

Jan 1, 1967 $2.4 million divided among 50 countries to be about $50,000 per country

Why did the US start giving more support to smallpox eradication?

LBJ was searching for an initiative to mark International Cooperation Year in 1965. Favored a measles and smallpox control campaign in western and central Africa but measles expensive to vaccinate so the CDC and D.A. Henderson doubted the sustainability of that program

What month and year was smallpox finally declared eradicated?

May 1980