The scientist who led the smallpox eradication campaign weighs in on the current crisis in West Africa.
In May 1980, the World Health Assembly (the ruling body of the World Health Organization), declared smallpox eradicated. We have the WHO’s highly successful smallpox eradication campaign to thank for that.
From 1966-1977, the team led by D.A. Henderson (who at the time was working for the US Centers for Disease Control and Prevention) navigated numerous hurdles. They persuaded countries where the virus was still endemic to support the global effort including the logistically difficult task of mass vaccinating hard-to-reach communities in Asia and particularly Africa. The team developed new strategies, training programs and educational materials for countries where the basics—telephones, running water, electricity—were sparse or nonexistent. The smallpox eradication program is often perceived largely as a mass vaccination campaign, but in the countries where the virus was still rampant it also introduced the idea of surveillance-containment strategy; symptomatic smallpox cases were sought and isolated and their contacts traced and vaccinated. The strategy became the cornerstone to success.
Today, smallpox exists as the only disease to have been eradicated by vaccination (though polio has a decent shot of being added to the list.) So on wonders, are there strategies to be applied in the current Ebola crisis devastating countries in West Africa. Ebola is a much rare, more complicated virus that makes the development of therapeutics particularly challenging. There are no approved vaccines at the moment and the experimental drugs available for compassionate use are hard to make. The countries decimated by Ebola are recipes for disaster: not enough hospital beds, health care workers, facilities, supplies or protective gowns and head masks. Fear is rampant and the global response scattershot. But there recently have been signs of a more coordinated global response.
Dr. Henderson, a Founding Director of the Johns Hopkins Center for Civilian Biodefense Strategies and currently Distinguished Scholar at the UPMC Center for Health Security, offered his own unique perspective on what needs to be done immediately to quell the escalating crisis. Here are excerpts of an Oct. 1 telephone conversation Regina McEnery, the senior scientific writer at Charles River, had with Dr. Henderson for the Eureka blog.
What has made this Ebola outbreak so much more severe than earlier Ebola outbreaks?
“The first outbreaks in 1976 were found almost simultaneously in southern Sudan and Northern Congo. Supplies were scarce but these were rural areas and people didn’t travel far, if they traveled at all. Communities were able to contain the outbreaks fairly effectively, There have been a number of other outbreaks, most in areas in central Africa, and they have all been fairly limited. What is different here is that Ebola has gotten into two very large cities—Monrovia [capital of Liberia] and Freetown [capital of Sierra Leone]. People move around mor. There isn’t sufficient space to [quarantine] patients and so when a patient would come down with Ebola, families would bundle them up in a taxi, with relatives mixed in, and go from site to site to see which facilities might be taking patients. Cases multiplied. Then you also had an ill- founded effort in Monrovia to contain people in slum areas where cases were occurring. The difficulty there was they didn’t have enough food. So you have 40,000 people, milling around, who can’t get food. This has led to a lot of turmoil and a rapid increase in cases with little in the way of resources. The question is why aren’t the resources there?”
So what needs to be done?
“During the smallpox eradication program, the key was to try and identify cases, keep the individuals in their home and vaccinate the family. We also wound up hiring [unarmed] guards from the village to prevent visitors from entering the homes of sick people, which was the custom in rural Africa, until they were vaccinated. With Ebola we have no vaccine, of course, but some of the same principals apply. You still want the patient to be in a situation where [they] are kept isolated, in a special treatment center or at home, so they are not able to transmit the disease. Supplies are limited, but people handling the sick should be provided protective gear. It is also quite clear that the dead are spreading disease. In many countries in Africa, when a person dies it is customary for relatives and friends to come and touch the body, stroke it and wish them well. The idea of trying to disrupt a funeral procedure, which has been so long present, is difficult, but outbreaks are occurring this way. So right now, you have large numbers of patients still basically roaming free or not being able to be housed in restricted quarters. And you have teams made up of ordinary laborers burying the dead. Protective equipment is limited and it has been hard trying to convince these burial teams to keep the equipment one, but the message is sinking in that is necessary.
What about using contact tracing?
This is hard to do generally. The manpower needed is considerable. You have to identify for any given patient how many people they have been in contact with. This would be easier if most patients, when they got sick at home, went straight to hospital, but it is apparent that they aren’t immobile. So if you take one person with 10 contacts you could soon have 100 to 200 people at a given point that you need to keep track of for 21 days. In circumstances like this you are dreaming. So my advice would be to keep your eye on what has to be done, keep patients alone, in a room, apart from others, have as few as people in contact with the patient as possible, and change the burial practices.
How has the WHO’s response been thus far?
“The WHO used to have a really good program that seemed to be working quite well that permitted and encouraged global reporting and response to emerging diseases. And they took the lead quickly after the Severe Acute Respiratory Syndrome (SARS) broke out in 2002. But the WHO budget got cut way back and staffing for the program was cut from 75-80 to around 30 people, which was devastating. Ebola is now recognized as a major problem by the UN Security Council and the WHO, and the US government and other governments are taking action.”