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The Emergency campaign for smallpox eradication from Somalia (1977–1979)—Revisited
Vaccine 29S (2011) D36–D40
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
The Emergency campaign for smallpox eradication from Somalia (1977–1979)—Revisited Abdullahi Deria ∗ Former National Manager of the Campaign, 28 Claudia Place, London SW19 6ES, UK
a r t i c l e
i n f o
Article history: Received 29 October 2010 Received in revised form 29 April 2011 Accepted 13 May 2011 Available online 18 December 2011 Keywords: Smallpox Virology Vaccination Disease eradication Somalia
a b s t r a c t The historical significance of smallpox eradication from Somalia lies in the fact that the country was the last to record the last endemic smallpox case in the world. Before 1977 the programme was mismanaged. In the mid-1970s, the programme was plagued with concealment. Confirmation of smallpox outbreak in Mogadishu in September 1976 delayed global smallpox eradication. The Government maintained that there was no ongoing smallpox transmission in the country after the Mogadishu outbreak and frustrated independent attempts to verify its claim. In February 1977 the Government allowed World Health Organization (WHO) epidemiologists to search, unhindered, for smallpox outside Mogadishu. Soon widespread smallpox transmission was detected. The Government appealed for international support. The strategy to stop the smallpox transmission was based on surveillance and containment. The WHO took the leading role of the campaign which, in spite of the Somalia/Ethiopia war of 1977/78, culminated in the eradication of smallpox from the country. Somalia was certified smallpox-free on 19 October 1979. © 2011 Elsevier Ltd. All rights reserved.
1. Introduction In the colonial era, there were the British Somaliland in the north and the Italian Somalia in the south in the Horn of Africa. Somaliland became independent on 26 June 1960 and Somalia became independent on 1st July 1960 and, on the latter date, the two countries joined to form the Somali Republic (commonly known as Somalia). The Somalis are of single ethic unit and practise the Sunni Muslim religion. The population was estimated, in 1979, at 4 million, roughly composed of 35% urban and 65% rural/nomadic. The land area of the country is 627,339 sq.km. The country is sparsely populated and the average population density in 1979 was about 6 persons/sq.km. Administratively, the country comprised 16 Regions divided into 83 Districts. 2. The programme before 1977 2.1. Poorly run programme (a) The programme, before 1977, had a chequered history. In 1960/62, the country reported 304 smallpox cases. For the following 9 years (1963/71) only 2 cases were reported in 1966. In 1972/76, Ethiopia, with porous border with Somalia, experienced frequent smallpox epidemics. Almost in the same
∗ Tel.: +44 2087883244. E-mail address: a [email protected] 0264-410X/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2011.05.039
period, 1972 to mid-1976, Somalia reported 42 cases, 38 of them reported as importations from Ethiopia and only 4 cases reported as secondary cases in a single household. Smallpox importations from Ethiopia into Somalia could have occurred. However, inadequate surveillance and case investigation made it difficult to distinguish between genuine imported cases from cases of ongoing smallpox transmission in Somalia. Amazingly, of 30 of the 38 imported cases for which the interval between rash onset and detection was available: 8 cases were detected on the same date as the date of rash onset, 12 cases within 4 days, 5 cases within 7 days and 5 cases within 8–22 days of rash onset [1]. (b) Bearing in mind the then poor health services infrastructure of the country and the scarcity of health personnel knowledgeable about the epidemiology and the clinical evolution of smallpox, it seems barely credible that the country could so quickly detect imported cases and contain the outbreaks so efficiently that there would only be 4 secondary cases resulting from the 38 cases reported as importations! It would appear that the country found it convenient to label detected cases as importations to conceal ongoing smallpox transmission in the country and, as subsequent events showed, that indeed was the case. 2.2. Smallpox outbreak in Mogadishu The outbreak was confirmed in September 1976 and it occurred at the most critical time in the history of the global smallpox eradication. Then the WHO was poised to declare global smallpox
A. Deria / Vaccine 29S (2011) D36–D40
eradication, but the outbreak threw a spanner in the preparations for that event. The outbreak, which resulted in 39 cases, was reported to the WHO and the cases isolated in a hospital in the capital, Mogadishu. The Government claimed that the source of infection of the outbreak was in Ethiopia and also denied that the source of infection of an outbreak detected in Kenya in January 1977 was in Somalia. In fact, the source of infection of both outbreaks was in Somalia itself! The Mogadishu outbreak, as discovered later, represented hitherto undeclared ongoing smallpox transmission in the country. 2.3. Government in denial At the beginning of 1977, the Government was in denial about the truth of the smallpox situation in the country and, in the process, created problems for the documentation of the eradication activities, e.g. the sources of infection of 13 of the 39 declared cases could not be determined. That was the situation of the eradication programme at the beginning of 1977 and it was not really fit for purpose. It was devoid of the concept of disease eradication and it was nothing more than ad hoc activities without proper planning. 3. The eradication campaign of 1977/79 3.1. Smallpox rumour outside Mogadishu In1976, I was abroad for studies and returned to the country in January 1977. Then there were rumours of smallpox transmission outside Mogadishu. The activities of a few WHO epidemiologists working with the Ministry of Health were limited to Mogadishu, even though they were not allowed to search the whole hospital in which the declared smallpox cases were isolated. It was also rumoured that, on the few occasions when the epidemiologists were sent to the field, with national minders, they were steered away from localities where there were smallpox cases. Information that came to light later revealed that the isolation hospital in Mogadishu admitted over 500 smallpox cases not reported to the WHO [2] (Chapter 22, page 1048). 3.2. My appointment I was appointed in February 1977 as the National Manager of the Emergency Smallpox Eradication Campaign. I informed the Minister of Health about the rumours I was hearing about smallpox transmission in the country and I accepted the appointment on condition that the WHO epidemiologists would be allowed to go the Regions to search, unimpeded, for smallpox and to report their findings to the WHO. The Minister accepted my proposal except that he stipulated that cases which occurred before January 1977 should not be reported. The Minister was adamant about this point. I reported my discussions with the Minister to the WHO and advised the Organization not to make an issue of the Minister’s position, for fear that the Government might become more intransigent and might even refuse to open up the country for international epidemiologists. The stakes were high and I thought it was a case where the end justified the means! We hurriedly prepared country-wide search plan, established 200 Somali Shillings reward for any person who reported unknown smallpox case and mobilized as many nationals as could be spared by the Ministry of Health. 3.3. First coordination meeting of the Horn of Africa countries The WHO convened, for the Horn of Africa countries, the 1st coordination meeting in Nairobi, Kenya, 14–16 March 1977 and the
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following countries participated in the meeting: Sudan, Ethiopia, Kenya and Somalia. The Horn of Africa countries proper (i.e. Kenya, Ethiopia, Djibouti and Somalia) were collectively considered as one epidemiological block for the purposes of smallpox eradication and certification. That was because the boundaries between the countries were (and still are) porous where nomads crisscrossed without control. Also the Horn of Africa was the last area in the world where smallpox transmission was occurring or recently occurred. The meeting recommended that the Horn of Africa countries should adopt similar strategies in surveillance and should notify, through the WHO/HQs in Geneva, rumours of smallpox in each other’s countries. The meeting also recommended to hold similar coordination meetings on 6-monthly basis. 3.4. Smallpox discovery outside Mogadishu No sooner had the Somalia participants returned from the Nairobi meeting that the first smallpox outbreak outside Mogadishu was detected on 18 March 1977 in Bakool Region and the outbreak was immediately reported to the WHO [1]. Soon after, reports of smallpox cases came in thick and fast and the smallpox situation in the country dramatically changed overnight. The search plan had to be quickly revised to cope with the epidemic. Thus the year 1977 marked a watershed in the history of smallpox eradication from Somalia and the campaign of 1977/79 began in earnest. The campaign benefited from recent experiences in smallpox eradication elsewhere and, right from the start, active surveillance and containment to interrupt smallpox transmission – as distinct from mass immunization – formed the strategy of the campaign. The superiority of this strategy over mass vaccination was first demonstrated in West Africa, as documented in [3]. 3.5. International support (a) In May 1977, the World Health Assembly (WHA) in Geneva discussed the smallpox epidemic in Somalia. During the WHA, Jimmy Carter, then the President of USA, was visiting Geneva and he wished to know how the USA could assist Somalia in health matters. In this regard, it is worth mentioning that then the world was in the cold war and Somalia and the USA were in different ‘camps’. Thus, the diplomatic relations between the two countries were at their lowest ebb. Dr William Foege, then Director of CDC, Atlanta, arranged a meeting between the Somalia Minister of Health and Dr Peter Bourne, Special Assistant to President Carter for health issues. The Minister asked me to accompany him to the meeting. When Dr Bourne asked the Minister how the USA could help Somalia in health matters, the Minister replied that such proposals should come through the Somali Embassy in Washington, DC. The meeting was almost over. I then chipped in with a suggestion for help in the smallpox epidemic and Dr Bourne asked me how. Convinced that Somalia would not accept epidemiologists direct from the USA Government, I suggested USA epidemiologists recruited through the WHO. Both Dr Bourne and the Minister agreed to the suggested arrangement. In retrospect, one might say that smallpox eradication played its small part in helping the strained relations between two countries to thaw a little! Dr I. Arita, Chief of the Smallpox Unit in the WHO/HQs, and Dr Foege, Director of CDC, were closely working together and on 8 June 1977 five CDC epidemiologists arrived in Mogadishu for the campaign [2]. (b) The Government, unable to cope with the smallpox epidemic, had to first declare the epidemic as an emergency before it could appeal, through the WHO, for international support. The WHO took the leading role in mobilizing resources for the smallpox epidemic. The appeal launched by the United Nations Disaster Relief Office (UNDRO) on 27 May 1977 yielded US$ 459,750.00.
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A. Deria / Vaccine 29S (2011) D36–D40
With that money, the WHO purchased, for the campaign, transport and other supplies and equipment which were airlifted to Mogadishu in June 1977. Also more WHO epidemiologists were recruited for the campaign. The WHO alone spent US$ 3,823,984.00 on local costs (i.e. at country level) during the period 1977/79 [1,2].
or Asia and introduced into the campaign tried and tested technical techniques in smallpox eradication (see also Section 3.12 below). (d) Simplified management: the campaign management in Mogadishu corresponded directly with the Smallpox Unit in Geneva and vice versa, without going through any intermediary level.
3.6. Campaign under pressures 3.8. Further coordination meetings At its peak in June/July 1977, more than 3000 nationals, 24 WHO epidemiologists and over 50 vehicles were engaged in the field operations. All along, the campaign was under two pressures: (a) First, the late confirmation of smallpox outbreak in Somalia in September 1976 was a serious setback in the global smallpox eradication and the world was eagerly waiting for the date when the smallpox transmission in Somalia would be interrupted. (b) Second, tension had been building up all along the Somalia/Ethiopia border and it was not if but when fighting would break out between the two countries. As it happened, Somalia invaded Ethiopia on 13 July 1977 and by August overran the eastern regions of Ethiopia. However, in the end, events turned against Somalia and in March 1978 Ethiopia recaptured all the territory it lost to Somalia which suffered a shattering defeat. That, in my view, marked the beginning of the end of the military regime in Somalia and heralded the failure of the Somali State itself. Although the 1977/78 Somalia/Ethiopia war added to the cost of the campaign, it did not hamper the field operations. None of the WHO staff engaged in the campaign were evacuated from Somalia nor their movements in the country restricted at all. While the war was on, the Ethiopian and Somali smallpox workers continued to meet and compare notes at the Nairobi coordination meetings.
The 2nd coordination meeting of the Horn of Africa countries was held in Nairobi, 26–28 September 1977. The meeting recommended, inter alia, that ‘current international cooperation should be sustained for the Somalia eradication campaign so that transmission can be interrupted in the shortest possible time – the target being the end of 1977’ [1]. Within 4 weeks after the meeting, the last case of endemic smallpox in Somalia occurred on 26 October 1977 [4]. While containing what proved to be the last endemic smallpox case not only in Somalia but also in the world, the Somali pilgrims were travelling to the Holy places in Saudi Arabia where millions of Muslims from different countries were to congregate during the Muslim pilgrimage season of October/November 1977. All the Somali pilgrims were vaccinated against smallpox and a team of surveillance agents accompanied them. The disease did not spread but died out in Somalia. Because of visa problems, Somalia did not participate in the 3rd coordination meeting held in Nairobi, 17–19 April 1978. 3.9. Maintaining smallpox-free status During 1978/79, the eradication activities were surveillancedriven and focused on active surveillance and/or special searches for “fever with rash” to exclude any possible smallpox transmission and also to fulfil the WHO criteria for smallpox eradication, i.e. at least 2 years should have elapsed after the last known endemic case and continued surveillance sensitive enough to detect smallpox outbreak if it occurred before the eradication of smallpox was certified [1].
3.7. Facilitating factors 3.10. The results The combined effects of several factors, the main ones listed below, facilitated the rapid build-up of an effective campaign: (a) Once the Government opened up the country for international epidemiologists, it’s political commitment to the success of the campaign was total. The Government’s commitment was expressed in different forms, e.g. waiving parts of the Labour Law, so that we could hire and fire national staff without going through the time-consuming procedures of clearing every recruitment/dismissal with different Government committees; waiving some customs formalities to give priority to speedy clearance of supplies and equipment imported for the campaign and last, but not least, instructing the regional administration and health authorities throughout the country to facilitate and not to hinder or interfere with the campaign operations. The Government commitment was acknowledged in [1], pp. 7 and 8. (b) Generous and timely international support, ably coordinated by the Smallpox Unit in the WHO/HQs, Geneva. (c) Availability, at short notice, of ‘battle-hardened’ international epidemiologists with extensive experiences in smallpox eradication in different countries – since, by then, all the other countries in the world already eradicated smallpox. All the 76 international epidemiologists who participated in the campaign in 1977–1979 had already worked either in West Africa
Within the short period of March to October 1977, the campaign interrupted the smallpox transmission and also reported 3229 cases occurring in 947 smallpox outbreaks and 13 deaths, (a case fatality rate of 0.4%). This success was achieved as a result of the concerted efforts of dedicated national and WHO field staff, supported by no less dedicated management at the Smallpox Unit in the WHO/HQs. Summary of number of reported smallpox cases and deaths in Somalia: 1967–1978. Years
1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 Total cases and deaths
Cases 0 Deaths 0
0 0
0 0
0 0
0 0
5 0
7 0
11 0
14 0
39 1
3229 13
0 0
3528 14
Source: Extracted from page 1041 in bibliography [2].
3.11. Eradication certification In October 1979, four separate International Commissions simultaneously assessed the 4 smallpox eradication programmes of the 4 Horn of Africa countries. In the case of Somalia, the International Commission, during 2–19 October 1979, assessed the eradication campaign and on 19 October, in a simple ceremony in the capital, Mogadishu, the Chairman of the Commission declared that Somalia eradicated smallpox and the country was certified smallpox-free. The International
A. Deria / Vaccine 29S (2011) D36–D40
Commission also recommended that, if Kenya, Ethiopia and Djibouti were also certified smallpox-free in October 1979, Somalia should terminate smallpox vaccination forthwith.
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a Sh.200 reward for reporting a case of smallpox is scanned into page 6. As a result of the public’s literacy in the Somali language, the overall public awareness about the campaign was very high.
3.12. The workforce 3.14. Eradication legacy During the campaign (1977/79), for different periods of time, 36 national regional epidemiologists, 73 national district team leaders, 1000s national surveillance agents, together with76 WHO epidemiologists and 5 WHO administration-cum-finance officers from 23 countries participated in the campaign [1]. I acknowledge the invaluable contribution of everyone of them, not forgetting the drivers and the secretaries. However, Dr I. Arita and Dr Z. Jeˇzek were the linchpin of the successful execution of the campaign. Dr Arita, Chief of the Smallpox Unit in the WHO/HQs, tirelessly mobilized resources for the campaign and closely followed up the progress of the field operations. Dr Jeˇzek, WHO Officer, joined the campaign on 10 May 1977 and stayed on until the closure of the campaign at the end of December 1979. He acted as Field Coordinator of the campaign and played a leading role in the documentation of the eradication activities. 3.13. The Somali language The language was written, for the first time, in 1972 in the Latin script. Thus, the population became literate in the language which played an important role in the campaign. The population could read the publicity material about the campaign, in Somali, which was widely distributed in the country. The search forms used in the campaign were printed in both English and Somali- the latter for the benefit of the surveillance agents whose English was limited (forms in annexes 11–15 in [1]). Also a poster, in Somali, which announced
Regarding the legacies of smallpox eradication, Somalia shares with the rest of the world the two enduring legacies, i.e. freedom from what was a killing or blinding or disfiguring disease for millennia and the resources freed up, as a result of the absence of the disease. For Somalia, another legacy is the expanded programme on immunization (EPI).
3.15. Laboratory-held smallpox virus Thirty years after smallpox eradication, the smallpox virus is still kept in laboratories and I see no valid justification why that should be so. In order not to discredit disease eradication, no smallpox virus (or infectious material thereof) should any longer exist in the world.
4. Conclusion The success of the smallpox eradication from Somalia came about at a cost. It would have been less costly had the Government been open about the disease earlier before it became epidemic and also the one-year delay in the global smallpox eradication would have been avoided.
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Conflict of interest statement: The authors wish to confirm that there are no known conflicts of interest associated with this publication. The authors participation in the SEC2010 Symposium was sponsored by the Steering Committee of the Symposium. References [1] Jeˇzek Z, Al Aghbari M, Hatfield R, Deria A. In: Tulloch J, editor. Smallpox eradication in Somalia. Alexandria: WHO Regional Office for the Eastern Mediterranean and Somali Democratic Republic, Ministry of Health; 1981.
[2] Fenner F, Henderson DA, Arita I, Jeˇzek Z, Ladnyi ID. Smallpox and its eradication. WHO; 1988. [3] Hopkins DR, Lane JM, Cummings EC, Thornton JN, Millar JD. Smallpox in Sierra Leone. II. The 1968–1969 eradication programme. Am J Trop Med Hyg 1971;20(5):697–704. [4] Deria A, Jeˇzek Z, Markvart K, Carrasco P, Weisfeld J. The world’s last endemic case of smallpox. Bull World Health Org 1980;58(2):279–83.
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
The Emergency campaign for smallpox eradication from Somalia (1977–1979)—Revisited Abdullahi Deria ∗ Former National Manager of the Campaign, 28 Claudia Place, London SW19 6ES, UK
a r t i c l e
i n f o
Article history: Received 29 October 2010 Received in revised form 29 April 2011 Accepted 13 May 2011 Available online 18 December 2011 Keywords: Smallpox Virology Vaccination Disease eradication Somalia
a b s t r a c t The historical significance of smallpox eradication from Somalia lies in the fact that the country was the last to record the last endemic smallpox case in the world. Before 1977 the programme was mismanaged. In the mid-1970s, the programme was plagued with concealment. Confirmation of smallpox outbreak in Mogadishu in September 1976 delayed global smallpox eradication. The Government maintained that there was no ongoing smallpox transmission in the country after the Mogadishu outbreak and frustrated independent attempts to verify its claim. In February 1977 the Government allowed World Health Organization (WHO) epidemiologists to search, unhindered, for smallpox outside Mogadishu. Soon widespread smallpox transmission was detected. The Government appealed for international support. The strategy to stop the smallpox transmission was based on surveillance and containment. The WHO took the leading role of the campaign which, in spite of the Somalia/Ethiopia war of 1977/78, culminated in the eradication of smallpox from the country. Somalia was certified smallpox-free on 19 October 1979. © 2011 Elsevier Ltd. All rights reserved.
1. Introduction In the colonial era, there were the British Somaliland in the north and the Italian Somalia in the south in the Horn of Africa. Somaliland became independent on 26 June 1960 and Somalia became independent on 1st July 1960 and, on the latter date, the two countries joined to form the Somali Republic (commonly known as Somalia). The Somalis are of single ethic unit and practise the Sunni Muslim religion. The population was estimated, in 1979, at 4 million, roughly composed of 35% urban and 65% rural/nomadic. The land area of the country is 627,339 sq.km. The country is sparsely populated and the average population density in 1979 was about 6 persons/sq.km. Administratively, the country comprised 16 Regions divided into 83 Districts. 2. The programme before 1977 2.1. Poorly run programme (a) The programme, before 1977, had a chequered history. In 1960/62, the country reported 304 smallpox cases. For the following 9 years (1963/71) only 2 cases were reported in 1966. In 1972/76, Ethiopia, with porous border with Somalia, experienced frequent smallpox epidemics. Almost in the same
∗ Tel.: +44 2087883244. E-mail address: a [email protected] 0264-410X/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2011.05.039
period, 1972 to mid-1976, Somalia reported 42 cases, 38 of them reported as importations from Ethiopia and only 4 cases reported as secondary cases in a single household. Smallpox importations from Ethiopia into Somalia could have occurred. However, inadequate surveillance and case investigation made it difficult to distinguish between genuine imported cases from cases of ongoing smallpox transmission in Somalia. Amazingly, of 30 of the 38 imported cases for which the interval between rash onset and detection was available: 8 cases were detected on the same date as the date of rash onset, 12 cases within 4 days, 5 cases within 7 days and 5 cases within 8–22 days of rash onset [1]. (b) Bearing in mind the then poor health services infrastructure of the country and the scarcity of health personnel knowledgeable about the epidemiology and the clinical evolution of smallpox, it seems barely credible that the country could so quickly detect imported cases and contain the outbreaks so efficiently that there would only be 4 secondary cases resulting from the 38 cases reported as importations! It would appear that the country found it convenient to label detected cases as importations to conceal ongoing smallpox transmission in the country and, as subsequent events showed, that indeed was the case. 2.2. Smallpox outbreak in Mogadishu The outbreak was confirmed in September 1976 and it occurred at the most critical time in the history of the global smallpox eradication. Then the WHO was poised to declare global smallpox
A. Deria / Vaccine 29S (2011) D36–D40
eradication, but the outbreak threw a spanner in the preparations for that event. The outbreak, which resulted in 39 cases, was reported to the WHO and the cases isolated in a hospital in the capital, Mogadishu. The Government claimed that the source of infection of the outbreak was in Ethiopia and also denied that the source of infection of an outbreak detected in Kenya in January 1977 was in Somalia. In fact, the source of infection of both outbreaks was in Somalia itself! The Mogadishu outbreak, as discovered later, represented hitherto undeclared ongoing smallpox transmission in the country. 2.3. Government in denial At the beginning of 1977, the Government was in denial about the truth of the smallpox situation in the country and, in the process, created problems for the documentation of the eradication activities, e.g. the sources of infection of 13 of the 39 declared cases could not be determined. That was the situation of the eradication programme at the beginning of 1977 and it was not really fit for purpose. It was devoid of the concept of disease eradication and it was nothing more than ad hoc activities without proper planning. 3. The eradication campaign of 1977/79 3.1. Smallpox rumour outside Mogadishu In1976, I was abroad for studies and returned to the country in January 1977. Then there were rumours of smallpox transmission outside Mogadishu. The activities of a few WHO epidemiologists working with the Ministry of Health were limited to Mogadishu, even though they were not allowed to search the whole hospital in which the declared smallpox cases were isolated. It was also rumoured that, on the few occasions when the epidemiologists were sent to the field, with national minders, they were steered away from localities where there were smallpox cases. Information that came to light later revealed that the isolation hospital in Mogadishu admitted over 500 smallpox cases not reported to the WHO [2] (Chapter 22, page 1048). 3.2. My appointment I was appointed in February 1977 as the National Manager of the Emergency Smallpox Eradication Campaign. I informed the Minister of Health about the rumours I was hearing about smallpox transmission in the country and I accepted the appointment on condition that the WHO epidemiologists would be allowed to go the Regions to search, unimpeded, for smallpox and to report their findings to the WHO. The Minister accepted my proposal except that he stipulated that cases which occurred before January 1977 should not be reported. The Minister was adamant about this point. I reported my discussions with the Minister to the WHO and advised the Organization not to make an issue of the Minister’s position, for fear that the Government might become more intransigent and might even refuse to open up the country for international epidemiologists. The stakes were high and I thought it was a case where the end justified the means! We hurriedly prepared country-wide search plan, established 200 Somali Shillings reward for any person who reported unknown smallpox case and mobilized as many nationals as could be spared by the Ministry of Health. 3.3. First coordination meeting of the Horn of Africa countries The WHO convened, for the Horn of Africa countries, the 1st coordination meeting in Nairobi, Kenya, 14–16 March 1977 and the
D37
following countries participated in the meeting: Sudan, Ethiopia, Kenya and Somalia. The Horn of Africa countries proper (i.e. Kenya, Ethiopia, Djibouti and Somalia) were collectively considered as one epidemiological block for the purposes of smallpox eradication and certification. That was because the boundaries between the countries were (and still are) porous where nomads crisscrossed without control. Also the Horn of Africa was the last area in the world where smallpox transmission was occurring or recently occurred. The meeting recommended that the Horn of Africa countries should adopt similar strategies in surveillance and should notify, through the WHO/HQs in Geneva, rumours of smallpox in each other’s countries. The meeting also recommended to hold similar coordination meetings on 6-monthly basis. 3.4. Smallpox discovery outside Mogadishu No sooner had the Somalia participants returned from the Nairobi meeting that the first smallpox outbreak outside Mogadishu was detected on 18 March 1977 in Bakool Region and the outbreak was immediately reported to the WHO [1]. Soon after, reports of smallpox cases came in thick and fast and the smallpox situation in the country dramatically changed overnight. The search plan had to be quickly revised to cope with the epidemic. Thus the year 1977 marked a watershed in the history of smallpox eradication from Somalia and the campaign of 1977/79 began in earnest. The campaign benefited from recent experiences in smallpox eradication elsewhere and, right from the start, active surveillance and containment to interrupt smallpox transmission – as distinct from mass immunization – formed the strategy of the campaign. The superiority of this strategy over mass vaccination was first demonstrated in West Africa, as documented in [3]. 3.5. International support (a) In May 1977, the World Health Assembly (WHA) in Geneva discussed the smallpox epidemic in Somalia. During the WHA, Jimmy Carter, then the President of USA, was visiting Geneva and he wished to know how the USA could assist Somalia in health matters. In this regard, it is worth mentioning that then the world was in the cold war and Somalia and the USA were in different ‘camps’. Thus, the diplomatic relations between the two countries were at their lowest ebb. Dr William Foege, then Director of CDC, Atlanta, arranged a meeting between the Somalia Minister of Health and Dr Peter Bourne, Special Assistant to President Carter for health issues. The Minister asked me to accompany him to the meeting. When Dr Bourne asked the Minister how the USA could help Somalia in health matters, the Minister replied that such proposals should come through the Somali Embassy in Washington, DC. The meeting was almost over. I then chipped in with a suggestion for help in the smallpox epidemic and Dr Bourne asked me how. Convinced that Somalia would not accept epidemiologists direct from the USA Government, I suggested USA epidemiologists recruited through the WHO. Both Dr Bourne and the Minister agreed to the suggested arrangement. In retrospect, one might say that smallpox eradication played its small part in helping the strained relations between two countries to thaw a little! Dr I. Arita, Chief of the Smallpox Unit in the WHO/HQs, and Dr Foege, Director of CDC, were closely working together and on 8 June 1977 five CDC epidemiologists arrived in Mogadishu for the campaign [2]. (b) The Government, unable to cope with the smallpox epidemic, had to first declare the epidemic as an emergency before it could appeal, through the WHO, for international support. The WHO took the leading role in mobilizing resources for the smallpox epidemic. The appeal launched by the United Nations Disaster Relief Office (UNDRO) on 27 May 1977 yielded US$ 459,750.00.
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A. Deria / Vaccine 29S (2011) D36–D40
With that money, the WHO purchased, for the campaign, transport and other supplies and equipment which were airlifted to Mogadishu in June 1977. Also more WHO epidemiologists were recruited for the campaign. The WHO alone spent US$ 3,823,984.00 on local costs (i.e. at country level) during the period 1977/79 [1,2].
or Asia and introduced into the campaign tried and tested technical techniques in smallpox eradication (see also Section 3.12 below). (d) Simplified management: the campaign management in Mogadishu corresponded directly with the Smallpox Unit in Geneva and vice versa, without going through any intermediary level.
3.6. Campaign under pressures 3.8. Further coordination meetings At its peak in June/July 1977, more than 3000 nationals, 24 WHO epidemiologists and over 50 vehicles were engaged in the field operations. All along, the campaign was under two pressures: (a) First, the late confirmation of smallpox outbreak in Somalia in September 1976 was a serious setback in the global smallpox eradication and the world was eagerly waiting for the date when the smallpox transmission in Somalia would be interrupted. (b) Second, tension had been building up all along the Somalia/Ethiopia border and it was not if but when fighting would break out between the two countries. As it happened, Somalia invaded Ethiopia on 13 July 1977 and by August overran the eastern regions of Ethiopia. However, in the end, events turned against Somalia and in March 1978 Ethiopia recaptured all the territory it lost to Somalia which suffered a shattering defeat. That, in my view, marked the beginning of the end of the military regime in Somalia and heralded the failure of the Somali State itself. Although the 1977/78 Somalia/Ethiopia war added to the cost of the campaign, it did not hamper the field operations. None of the WHO staff engaged in the campaign were evacuated from Somalia nor their movements in the country restricted at all. While the war was on, the Ethiopian and Somali smallpox workers continued to meet and compare notes at the Nairobi coordination meetings.
The 2nd coordination meeting of the Horn of Africa countries was held in Nairobi, 26–28 September 1977. The meeting recommended, inter alia, that ‘current international cooperation should be sustained for the Somalia eradication campaign so that transmission can be interrupted in the shortest possible time – the target being the end of 1977’ [1]. Within 4 weeks after the meeting, the last case of endemic smallpox in Somalia occurred on 26 October 1977 [4]. While containing what proved to be the last endemic smallpox case not only in Somalia but also in the world, the Somali pilgrims were travelling to the Holy places in Saudi Arabia where millions of Muslims from different countries were to congregate during the Muslim pilgrimage season of October/November 1977. All the Somali pilgrims were vaccinated against smallpox and a team of surveillance agents accompanied them. The disease did not spread but died out in Somalia. Because of visa problems, Somalia did not participate in the 3rd coordination meeting held in Nairobi, 17–19 April 1978. 3.9. Maintaining smallpox-free status During 1978/79, the eradication activities were surveillancedriven and focused on active surveillance and/or special searches for “fever with rash” to exclude any possible smallpox transmission and also to fulfil the WHO criteria for smallpox eradication, i.e. at least 2 years should have elapsed after the last known endemic case and continued surveillance sensitive enough to detect smallpox outbreak if it occurred before the eradication of smallpox was certified [1].
3.7. Facilitating factors 3.10. The results The combined effects of several factors, the main ones listed below, facilitated the rapid build-up of an effective campaign: (a) Once the Government opened up the country for international epidemiologists, it’s political commitment to the success of the campaign was total. The Government’s commitment was expressed in different forms, e.g. waiving parts of the Labour Law, so that we could hire and fire national staff without going through the time-consuming procedures of clearing every recruitment/dismissal with different Government committees; waiving some customs formalities to give priority to speedy clearance of supplies and equipment imported for the campaign and last, but not least, instructing the regional administration and health authorities throughout the country to facilitate and not to hinder or interfere with the campaign operations. The Government commitment was acknowledged in [1], pp. 7 and 8. (b) Generous and timely international support, ably coordinated by the Smallpox Unit in the WHO/HQs, Geneva. (c) Availability, at short notice, of ‘battle-hardened’ international epidemiologists with extensive experiences in smallpox eradication in different countries – since, by then, all the other countries in the world already eradicated smallpox. All the 76 international epidemiologists who participated in the campaign in 1977–1979 had already worked either in West Africa
Within the short period of March to October 1977, the campaign interrupted the smallpox transmission and also reported 3229 cases occurring in 947 smallpox outbreaks and 13 deaths, (a case fatality rate of 0.4%). This success was achieved as a result of the concerted efforts of dedicated national and WHO field staff, supported by no less dedicated management at the Smallpox Unit in the WHO/HQs. Summary of number of reported smallpox cases and deaths in Somalia: 1967–1978. Years
1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 Total cases and deaths
Cases 0 Deaths 0
0 0
0 0
0 0
0 0
5 0
7 0
11 0
14 0
39 1
3229 13
0 0
3528 14
Source: Extracted from page 1041 in bibliography [2].
3.11. Eradication certification In October 1979, four separate International Commissions simultaneously assessed the 4 smallpox eradication programmes of the 4 Horn of Africa countries. In the case of Somalia, the International Commission, during 2–19 October 1979, assessed the eradication campaign and on 19 October, in a simple ceremony in the capital, Mogadishu, the Chairman of the Commission declared that Somalia eradicated smallpox and the country was certified smallpox-free. The International
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Commission also recommended that, if Kenya, Ethiopia and Djibouti were also certified smallpox-free in October 1979, Somalia should terminate smallpox vaccination forthwith.
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a Sh.200 reward for reporting a case of smallpox is scanned into page 6. As a result of the public’s literacy in the Somali language, the overall public awareness about the campaign was very high.
3.12. The workforce 3.14. Eradication legacy During the campaign (1977/79), for different periods of time, 36 national regional epidemiologists, 73 national district team leaders, 1000s national surveillance agents, together with76 WHO epidemiologists and 5 WHO administration-cum-finance officers from 23 countries participated in the campaign [1]. I acknowledge the invaluable contribution of everyone of them, not forgetting the drivers and the secretaries. However, Dr I. Arita and Dr Z. Jeˇzek were the linchpin of the successful execution of the campaign. Dr Arita, Chief of the Smallpox Unit in the WHO/HQs, tirelessly mobilized resources for the campaign and closely followed up the progress of the field operations. Dr Jeˇzek, WHO Officer, joined the campaign on 10 May 1977 and stayed on until the closure of the campaign at the end of December 1979. He acted as Field Coordinator of the campaign and played a leading role in the documentation of the eradication activities. 3.13. The Somali language The language was written, for the first time, in 1972 in the Latin script. Thus, the population became literate in the language which played an important role in the campaign. The population could read the publicity material about the campaign, in Somali, which was widely distributed in the country. The search forms used in the campaign were printed in both English and Somali- the latter for the benefit of the surveillance agents whose English was limited (forms in annexes 11–15 in [1]). Also a poster, in Somali, which announced
Regarding the legacies of smallpox eradication, Somalia shares with the rest of the world the two enduring legacies, i.e. freedom from what was a killing or blinding or disfiguring disease for millennia and the resources freed up, as a result of the absence of the disease. For Somalia, another legacy is the expanded programme on immunization (EPI).
3.15. Laboratory-held smallpox virus Thirty years after smallpox eradication, the smallpox virus is still kept in laboratories and I see no valid justification why that should be so. In order not to discredit disease eradication, no smallpox virus (or infectious material thereof) should any longer exist in the world.
4. Conclusion The success of the smallpox eradication from Somalia came about at a cost. It would have been less costly had the Government been open about the disease earlier before it became epidemic and also the one-year delay in the global smallpox eradication would have been avoided.
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Conflict of interest statement: The authors wish to confirm that there are no known conflicts of interest associated with this publication. The authors participation in the SEC2010 Symposium was sponsored by the Steering Committee of the Symposium. References [1] Jeˇzek Z, Al Aghbari M, Hatfield R, Deria A. In: Tulloch J, editor. Smallpox eradication in Somalia. Alexandria: WHO Regional Office for the Eastern Mediterranean and Somali Democratic Republic, Ministry of Health; 1981.
[2] Fenner F, Henderson DA, Arita I, Jeˇzek Z, Ladnyi ID. Smallpox and its eradication. WHO; 1988. [3] Hopkins DR, Lane JM, Cummings EC, Thornton JN, Millar JD. Smallpox in Sierra Leone. II. The 1968–1969 eradication programme. Am J Trop Med Hyg 1971;20(5):697–704. [4] Deria A, Jeˇzek Z, Markvart K, Carrasco P, Weisfeld J. The world’s last endemic case of smallpox. Bull World Health Org 1980;58(2):279–83.