Resolution on Smallpox Eradication at the Eighteenth World Health Assembly, Lecture notes of English Literature

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WORLD WEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE BUREAU R ~ G I O N A L

FOR THE EASTERN MEDITERRANEAN FOUR LA M~MTERRANEs,ORIENTALE 1

D r. S. Falkland l ~ e d l c a lO f f i c e r

D r. I. Arlta

Fredlcal I?ff xcer

. J. Copland

Admlnlstratrve Off leer

~ / S Pm / 3

13 a p r x l 1967

ENGLISH O N E

D r. ?I. 9 l a m Reglonal Idviser on Cmmu?icable Dlseases

D r. R. Huerta

Reglonal 'idv-~seron Cornmun~cable Diseases

D r. B. Rcdrxguez

Reglorn1 Adviser on Smallpox

Sradlcatxon D r. 2. ~. Hamam i'ubllc q e a l t h , i d m n ~ s t r a t o r (C?)

D r. T. a p e s

Publlc E e a l t h J - d m n l s t r a t m (iL!L) 3r. F .I. 3 u s s e i n l Xegsonal A d v ~ s e ron Health Laboratory Services D r. :,. Koarefi Iiegional Advxser on Health Cducatlon D r. E. Shafa i e g l o n a l ?,dviser on S m l l p a x J r a d l c a t i o n

D r. R. I g n j a t o v i c

Regsonal ildvlser on C o m i c a b l e

3lseases

D r. C.R. Yen

Reglanal Advlser on C ommunlcable

Dlseases

TEW. FmO ADVISERS

D r. ( s. S .S. Marennikwa

D r. D.A. Bltllar

The attiached draft docuaerrts am i n the first stage of pmparatlan only. They baw been prepared as d r a f t uorkiq doouwnts for review ly a nmter of W O staff anq ac)visers a& thua a m aubject ta subetaafial change, Quits alearlg, they ale not a t t h i s stage ready for field application or evaluatitm,

D, A. Hendsmn, N. 3.

Chief, Smallpox Emdiaation

Thls Manual has been developed zs a gulde for WHO staff and senlor s t a f f of National

Smallpox Eradlcatlon Programes. T h e prmclples s e t forth and the p c e d u r e s suggesbd

have been based on extenslve s t a f f and collsultant experiences m f l e l d epidemiology and m different types of vaccxnatlon campaigns, a s well a s on recent experiences w i t h

smallpox eradlcatlon pogrammes I n several parts of the world.

To date, however, no programme of the magnitude srvl general character of t h e present

project has ever been undertaken a d thus there ui much whch 1s y e t unknown. It is

also evldent t h a t no manual could prnvlde a satisfactory slngle blue-prmt whlch would be

uluversally applicable, coniilderlng the riiany smallpox endemlc countrles and the vast

dFfferences m present health structures, personnel and polxcles, population charader-

l s t i c s and attitudes, geography and climate. Further, ~t 1 s clear that the many

countrles whlch have thus f a r become s ~ ~ l l p c x - f r e ehave achleved this s t a t u s by a number of d i f f e r e n t approaches. The Manual, therefore, k s been developed not a s a r l g i d text

but as a descriptxon of baslc principles nhlch, m the Informed judgement of t h e mtIY who

partlcipataCrSn ~ t spreparation, should f a c l l ~ t a t ethe progress of era6icakon wh~le, a t

the s a m tire, s e w t o strengthen the general hezlth s e r n c e s m each country.

ikny of the pnnclples and procedures proposed have been well-tested u d e r f i e l d

circllmstances, some have not. Nore defmltlve, c r l t l c a l experlence ~sneeded. A

Nanual such a s t h i s must m n t i n u a Q evolve a s the global p r o g r a m progresses and rmst

constantly be subjected to query and crltzclsm. I n cogumnce of the f a c t t h a t the

most vlgorous t e s t l n g and scrutmy of the principle s s e t f o r t h w l l l take place during

t h s , the f u s t year of the programme, the K n u a l has been d i s t r h t e d u u b a l l y i n

"draftr1 form w l t h the expectabon t h a t a more deflnltlve t e x t would he developed a f t e r a

year's experlence.

From a l l concerned, comments an3 suggestions wlth rrspect to the Manual, a r e welcome.

"The Eighteenth FJorld Health Assembly, H a v ~ n gexammed t h e r e p o r t of t h e Dlrector-General on the present s t a t u s of smallpox

in t h e world, an3 t h e r e s u l t s achieved,

N o t u g m t h concern t h e t , though some r e c e n t l y enriemlc c o u n t r l e s have eradicated

t h e d i s e a s e a s a r e s u l t of well-orgarmed campzlgns, progress I n generzl 1s slow and

major endemlc f o c l remam m A s l a , A f r l c a ard t h e Americas;

N o t u g t h a t t h e D l r e c t o r 4 e n e r a l h.is estlrnated t h a t s m l l p e x mmlght be eradicated m t h n 10 y e a r s f o r an estimated ~ n t e r n a t l o n a lexpenditure of US$ 23.5-31.0 m l l l c n in a d d l t l o n t o t h e p r a v l s ~ a nwhlch t h e countrles havlng erdemlc smallpox themselves can make;

Bellevlng t h a t strong r e a f f l r m a t l r n of t h e l n t e n t to eradicate smallpcx would present a challenge and a stlmulus t o the world t c rncblllze resources t c achieve t h e objective, and tht t h e support r e c p l r e d 1s available r l t h l n-- --- the international --- and national programmes devoted t o world s o c l a l and ecmomlc dev?lspme,it, and Recognlzlng t h e need t l r r e n e w t h e technical a d aadml~ustratlverequirements of programes, t o ensure the extensive use of freeze-dried vaccine and t h e d e v e l o p n t of

~ t sprqductlen m endemlc a r e a s and t o p r o v d e annually f o r the rmss phase of tk

campalgn up t o 50 milhm dcses of freeze-&led v a c c m e m a d d l t l s n t o s u p p l l e s lecblly

produced o r a l r d d y belflg provlded m b l l a t e r a l agreements, or through voluntary cun- t r l b u t l o n s ,

1. DECURES^ t h e^ world-mde^ e r a d i c a t m n^ of^ smallpox t o be one of^ the^ m^ J^ o r^. ~ b j e c t l v e s

of t h e Orgarmatlon,

2. RF,dUESTS^ t h e^ c c u n t r l e s^ bring^ smallpox^ an3^ w ~ t h o u te r a d l c a t l o n^ p r o g r a m e s^ In

i n f l a t e them and tk c o u n t r ~ e sm t h programms t o l n t e n s m them;

3. REGUESTS Menher S t a t e s t o glve t h e prcgramme g r e a t e r suppert then m t h e p a s t and

t o provlde t h e s u b s t a n t l e l w n t r l b u t l o n s essential f o r ~ t sexecuc.lm,

4 RELUESTS^ governments which carry^ cn^ h l l a t e r a l^ programmes^ of^ zald^ t o^ m c l u d e^ s m l l p o x e r a d i c a t l a n l n t h e l r programmes of assistance,

5. REdUESTS guvernments t o t a k e e a r l y s t e p s t o e s t a h l l s h b a s l c h e a l t h s e r v l c e s far t h e

maintenance phase whlch would a l s o s e r v e t h e e r a d l c a t l o n of e t h e r commurncable diseases;

6. (^) REQUESTS t h e Director-General to seek anew the necessary f m n c l a l a r d vther resources r e q u l r e d t o achleve world-wde srmllpox er2dlcatlon wrth s p e c l a 1 r e f e r e n c e t o resources t h a t rmght be made n v a l l s b l e through voluntary c o n t n b u t l e n s and b i l a t e r a l

p r o g r m e s , a s w e l l a s through progremmes such a s those cf UKICEF ard t h e Uruted rIatlons

Exparded Programme of T e c h n ~ c a lAss= tance, and

7. IZEQ,UESTS^ t h e^ Duector-General^ t o make a v a i l a b l e t h e^ increased^ amount o f^ tec-cal guldance z r d advlsory s e r v l c e s m order t o a c c e l e r a t e t h e programme a s wen a s a s s i s t

the countries I n obtallung t h e necesw-lgr a a a c u m. , ~ ard ~ ta~ ~

r e p c r t on t h e progress achleved t o f u t u r e s e s s l o n s of t h e Iniorld Health A s ~ e r n b l y. ~

Durlng t h e Nineteenth World Xealth Assembly, a sum of over US* 2 m l k c n was a l l o c a t e d from t h e R e g u h r Budget f o r t h e purposes of smallpox eradlcatlon. A t^ t h e

same tlme t h e Assemhly requested "Member S t a t e s and m u l t l - l a t e r s l and bilateral agencles

t o ,provide adequate m a t e r l a l support f o r t h e r e a l z a t l ~ nr f t h e programmetr.

Slnce t h e 1966 Assembly, subs-tantlal a d d ~ t i q n a ls u p p r t has b e a provlded by the

US23 m the form'of a v a c u n e donztlen t o kHO of 75 m l l l l o n doses p l u s considerable

h s l a t e r a l a s s i s t a n c e m t h e form of vacclne provlded t o countries m A s l a and Af*ica;

t h e USA has offered b i l a t e r a l eld m t h e form of t e c h r u c a l ~ r d m a t e r l a l assistance t o

U west Afrlcan countrles, a number of other countrles have offered to WHO vaccme and t r a n s p e r t t o be employed xn t h e programme.

2. The Smallpox P r o h l m Today Once a g l o b a l problelr~causmg m l l l o n s of cases annually, t h e reservoir of s d l p 0 ~ has progressively receded t o t h e polnt t h a t l e s s than 60 000 cases have been reccrded a m a l l y f o r t h e p a s t t h r e e years, Endemxc a r e a s a r e confmed t o a few c o u n t r l e s i n

South Amerlca, s u b S a h a r a n A f r l c a and s n w u n t r l e s m s s l a. Although^ each^ of^ t h e

endemlc countrles T S now cnnductlng v a c ~ m t l e nprogrammes of a g r e a t e r *r lesser degree

of intensity, t h e n e f f o r t s t o d ~ t ehave not been adequate to achleve a s m l l p a x - f r e e

status end t o mamtain t h ~ ss t a t u s.

The problem of su~allpcx,charever, 1s one shared by a l l countrles of the world.

me r e m t r o d u c k o n of t h e d l s e a s e m t o t h e non-endemic c o u n t r l e s 1s f e a r e d and mth goad cause. The mortality r a t e 1s hlgh among non-vaccinated persons who c o n t r a c t v a r i o l a major. I n t h e UK zrd Sweden durlng cutbreaks m 1962 and 1363, death occurred i n 4@ of unvacclnated persons d e s p i t e gocd medrcal care. Costs of vaccmation, quarantine

a d c o n t r o l programmes m t h e non-endemc c o u n t r i e s a r e high. Czechoslovakia h a s

e s t m a t e d t h a t lt e x p e d s annually over US4 1 m l l l l o n (US$ 0.073 per p r s o n ) m maintenance vsccmztlon, a d t h e United S t a t e s of America, US'% 20 n u l l l c n annually

(US$ 0.112 per person). The Uluted Kzngdom has e s t l m t e d t h a t the average c o s t of a

normal y e a r 1s US& 0.65 r m l L o n (US$ 0.01 per person), b u t when smallpox outbreaks occurred m 1301 and 1952, a d d l t l o n a l expenditures ~ n c u r r e ddurlng the outbreaks were estimated t o be US* 3.8 million.

From l i r m t e d evldence ~twould seem prrbahle t h a t l n t e n s l v e vaccination programma

u? c i t l e s , towns and villages throughout a country wrth the e s t a b l l s h m m t of a c t l v e

maintenance vacclnatlon programmes, particularly f o r t h e new bcrn md rmgrznts m the

lowest soclo-economc s t r a t a could effectively t e r m m a t e transrmsslon. The l n f l n i t e l y g r e a t e r s t a h l l l t y of freeze-dried ma l l p o x vac c u e unquallf i e d l y

recommends t h l s preperatlon over t h e glycerlnated fonr m f i e l d v a c c m a t l o n programmes,

e s p e c l a w m t r o p i c z l areas, Although u d e r some circumstances t h e glycerlnated

v a c a n e 1s p r e f e r r e d because of lower c o s t atxi ~ t sa v ~ i l a b l h wm slngle-dose contamers,

it 1s w e l l recognized t h a t even I n the b e s t mzmged medlcal f a c l l l t l e s , storage pra- cedures a r e frequently madequzte.

It 1s necessary f o r t h e e r a d i c c t l o n Frogrenums t o develep a systematic plan f o r

t h e detection of p o s s ~ b l ecases ard the concurrent m v e s t l g? t ~ o nregarding the source

and s z t e of a c q u l s l t l o n of t h e d l s e a s e , t h e l r v z c a m t l c m s t a t u s and the prompt m s t i g a -

t l o n of containment measures. Detalled epldemlologlcal l n v e s t l g a t ~ o nof a l l cases as t o

t h e reasons f o r t h e i r occurrence and t h e means by w h c h they a r e be- spread can be one of t h e most effective instruments t o provlde contmulng guldance and d l r e c t l ~ ni n the

vacclnatlon programne. I n the s m p l e s t terms, each case whlch occurs suggests the

p o s s l b l l l w of f l a w s I.I-I t h e programme, An outtreak, hcwever, small, demands a f u l l

c r l t l c a l revlew n t h appropriate r e v l s l o n s of t b flogramme.

Even m countries w l t h a llrmted 1oc;l h e a l t h s t r u c t u r e , a gystematlc s u r v e l n a n c e

p l a n can and must be developed a s En e s s e n t l c l component of t h e eradication wagramme. U n t l l a l l endemic countrlesohave canpleted v z l l d e r s d z c z t l o n p r o g r a m s and u n t l l

a t l e a s t a three-year perlod has elapsed m t h o u t documented cases anywhere i n ti-a world,

ma~ntenanceprogrammes of vacclnatlon w l l l be r e c p l r e d m each of t h e countries.

Pktnods f o r t h e conduct of malntenatce progremmes a r e expected t o v a r y m d e l y from country t o c m n t r y. Certaln spe c i f l c groups, however, m 11 r e q u r e particular emphasis. (1) Urban^ populations,^ e s p e c f i l l y^ those^ I n^ densely crowded lower^ soclo- econcmc areas. (2) F i a n t s^ who^ might be expected t o^ trznsmlt^ t h e^ d l s e a s e^ n d e 7 y^ and

those r e c e n t l y e n t e c m g urban are2s from less w e l l vaccmated rural

d l ~ ~ r ~ c t s.

(3) S c h o o l c h l d r e n^ emong whom^ d l s e a s e^ psy^ pass^ cplckly^ and thence t o t h e comriunlty n t lerge.

( 5 ) Dispensary end h o s p l t a l s t a f f s m ~ l u d m glaundry personr,al. The h ~ g h r l s k of d l s e e s e spreading t o t h e s e g r m p s has r e p e a t e a been ciemonstreted. Some countries may e l e c t t o carry out l n t e n s l f l e d prclgrammes augmented by ccontlnuing vacclnatlon programmes I n h e a l t h c e n t r e s and elsewhere, o t h e r s ITEJ l n c o r p c r a t e vaccma- t i o n I n t o o t h e r types of ~ m r m m z a t l o n 2nd d l s e a s e c o n t r o l progrzmtiles. Mhatever the

approach, ~t 1s most unpcrtnnt t o reach s p e c x f l c a l l y t h e groups noted a b w e a d t o

achleve a s near t o t a l coverage of t h e p c p u b t l o n a s p o s s ~ b l e. Fmzlly, ~t should be noted t h s t t h e developrilent@oft h e general h e a l t h s e r v l c e s 1s of t h e utmcst mportance t o carry out t h e effective m:~ntenance prrogrn~me.~~

4. Sumrnary

I n October 1965, D r Fred Soper, fmmerly D l r e c t c r of the Pan A m r l c a n Hezlth

Orgamzatlon, m r speech regarding t h e l m p l i c c t l c n s of s w l l p @ x e r a h c r t l c n , summarlzed

t h e present situation i ~ l t ht h e s e com~nents^ 3t : ltOur g e n e r a t ~ o nhes no excuse t o o f f e r f u t u r e generations Lf we contlnue t o p e r m t half cf t h e human r a c e t o s u f f e r from s m l l p o x whlle we attempt

t o defend ourselves m t h c o s t l y 2nd l n e f f l c ~ e n tq u a r a n t m e ad v a c c l n a t m n

c e r t l f l c a t e s I '. !'The s e l l u g has been done, t h e t o c l s e r e available, support h s heen

assured, t h e programme ~s:heady well-advznced. The only g u e s k o n 1s

whether our r ~ z t l o n a la d m t e r n z t l o n z l a d m m l s t r a t l v e agencles can nleasure up t o the challenge ."

(^3) American J. (^) Publlc Health, 56: 1652-1056, 1966

4.8 Supennsion 4.9 Team training b.9.1 O n e n t a t ~ o n

4.9.2 Practical field tralning

4.9.3 Duratron of t r a i n i x 5. Composition of Vacclnation Gmups and Requlslte Equipment 1 Programmes^ employing^ vaccina^ tion^ teams 5.1.1 General supervision

5.1.2 Personnel f o r vaccination t e r n

5.1.3 Local volunteer personnel 5.1.4 Advance publicity an4 arrangements pe mnne 1 5.1.5 Equipment 5.2 Programm s con?ucte? on house-to-house basis 5.2.1 Supervision of vaccmat~cmgroups 5.2.2 Other personnel 5.2.3 Equipwnt

6 , Development of the^ Vaccmation^ Programe^ m^ an^ Area

6.1 I n ~ t ia 1 contacts 6.2 Local l o g i s t i c s 6.3 Vacclnation schedules 6.b Selection o f vaccinat~onposts ( f o r vacclnatlon teams) 6.5 Deslgn and operation of vacclnatlon post 6.5.1 Post deslgn 6.5.2 Recor?il7g

6. Cleansing^ of arm before^ vacc~natlon 6.5.4 finger mrkw 6.5.5 T?acc:ne residue on tb arm

7. Accounkabllity f o r equipment

DRAFT

OPERATIOKS - PLATWING AND DEVELOPI~IZK'T

The oojective of Cie siallpo;, erac'ication ppoJect 1s to uterl-upt coiitpletely L.? transAilsslor!of srlallpo;:. Slnce -ckils illvolves c a r e f r l ST-stenatlcv a c c ~ t l o ~ i

o, a l l %-es an? sements of the gopulcrtioi~, operatlo~?alIx-ocedures an2 iedmques

ivcus 02 d11s activit.7. Snallgo-. erac'icatroa w l l l be i-ealzzed b-- i * e d u c ~ - ~ ,

L.~OU& vaccmatlon, the 1-~urbe~or" s ~ s c e p t r b l e sa-the gopulatlon t o dle point

t-:.~~-eit 1s ir~possiblefor Cie crsease t o sustain l t s e i f LT a c o n t ~ l u u l ;chain or

tcc.nsnisslon.

Ihe exteilt t o rihich the level of susce?tibilit.- taust -xreduced i n area

0:- population p o u p 1s Gepe~ldel~t0,: a iiu1313er of ractors, k l c l u h ~ qpopulatlou ccnslt--, size of the e x l s t i : ~S ~ s e a s ei-esevolr, b l i t l ~ra-ce, uigi-atio~lrate, ant? irequenc:~ an& cl=acter of &sease ~rtroC.uctio~~s.Success will be realizee

i lrough EL c o n t m u u ~appraisal of tAe e:ristlic situn tlon ail& adapt- tile attack

LO these factors.

It is ilLiposslble to desl,rc a s e t of speclfic operational directives wlilch w i l l

i r t a l l commies or even a l l areas of a s i A x l ecorn-~tm. The purpose of thls s3ctlon 1s t o iclentif:r soile general priiiclples ol" operatloo rrhlcll kave been s!lo~;il

zo be effective m acconplisliir~%,e objective of mterrupbux Ciscase t r a n s ~ u s s i o ~ l.

In att^clring Blsease m its natui-a1 habitat, principles must be translated

li--,o spec1r"ic a c t i m s r~i'chuithe coatext of the characteristics of the population ~ c the' 'behaviour of dlsease i n the area. Fret-uen-cl-7, these con~iztionsw i l l

;se ,marly Ir~cur~~enteSo r unlnown anC juQer.lei?ts w i l l lave t o bc lade on the basls

of madequate mfori~lation. It 1s :loped t h a t the prliicipies outlined w l l l be of

us: ~i t l a l : ~ ~such Jueements. F1e::lblllL-- a sense of opportunls~lr v i l l 'be

ii.=cessar:- t o adneve a1 expedltlous and successful e:cecution of tltlle programme.

The strateg:- and t a c t l c s of a successr^ul si~allpoxcar.1pa-n 111 Bolivla have bceil

tll described by hederllcsen. 1 Zlis c&lpaLq resulted 111 coriplete cessation of

s lallpox transmission. In dlscussiic reasoirs f o r the effectiveness of the campasn,

14. Routlne kispcctlon of saqgle householck f o r evlc'e~ce. d quit-it~t:-

m C q u a l i c - of vaccinatlo:1 about nine ea7.s a f t e r vaccuailon.

15. B e a l t l ~ecucation^ an?^ ,3uuollc^ m f^ orr,iation^ desxzned^ t o^ reacl?^ even^ t i e rllite--ate.

=ie factors til-ilcil bear direc'il-- on canpai=;n o p ~ a t i o n s fim-r ue ~rou,peS.Into

:our ~ e i i e ~ a lcategories :

1. Organization and ,)lard:i;.;; (part 3. )
2. S t n f f l r ~ a:? ~ e r s o ~ ~ ~ e! .~lam.ger~ie~t(Parts 4. 5. )
3. Fielc' activities (Parts 5. (. )
4. Herltil education (Sectloll IV). . 01:ar-lpatlon m Z Plauli;., Sysiermtic organlzaiio~l anc' pla,~n11; are v ~ t a lt o t;?e success of the progrwle ,..c' :lust pecec'e a,.Tr flelc' a c t l v l t y. To be consl6ered 1s the nature of the .- ~ l l p o , -problem itself, the cc:?aacteersttcs of the :zeopulztlo;l a a l the C O U ~ ~ : ~ ,

l e resources available IT. a2pi'oaclilk L-ie :robiem, and Kle objectives co 'be

2 ciL-qved.

Before elilbarlring on a srriallpo,; ezacLcatioii pi*ogramie m a given cou-ity7, it 1s

1 l-)ortant t o &efme a l e uature of tLla srlnllpox proulem as vie11 a s the extent and .-ture of recent vaccinataon a c t i v l t l e s ; t o determine the population Srlstributiori L 16 cilan.cterls"ccs &.C attitudes torzrarc: vaccination; t o assess the =;eo&raphic

c..-L-acterlstlcs of' the countr:?; t o aA?)ralse the resources available, a:? to match

t LC se i-esouilces lil Kle oest posssble i,w.mer t o the proble~~l. Inforr~?atlon^ should^ bc

collecteS. regardip& Liese several factors. So~leof this m f o m t l o n w l l l be

ieaiatelx- a t :lanP; sorle maT7requlre 1~1oi-eeetailed s e a r c h i r ~o r reconnaissance

s ~ J - - v ~ ~ s .Althougi? recogrilzlq ~ L m tzhe zore adequate Uie xciom~~ationa v a i l a ~ l e ,Lhe 2et;er the planning, 1%rrmst^ a l s o be^ note?^ -cilat^ a^ reasonable^ balance^ rlust^ always

'2e s t m c k betrreen the "ecucated ~ ; u e s s " anC the or"ten more laboriousl2- deternmee

?cL-lented f a c t.

&ta i-egarlii~zsnallL3o;. wo;'sli_c-- over tAe preceellil; C Lo 10 --eeis should >e a s s e i ~ b l e d. iiu1'3eis 01 czses b-. p o l l t l c a l susdlvlslo,l s- monk ( o r ST tiee!:) a s are11 as L ~ u f s e r sof cases b.- a;e a~c'sex 1~ll.l DC of assist3ilce LZ d e t e r ~inln;;11-1 i,hai a r e a s ;i,?Li ir,:i?t L30~~1a1;10;;10u", i ~ z i ' t l ~ ~ l a ~ er~i$zsis s:loulc be 2lacec :rlC:-- ~ c ~ , ~ z c T ;t o ~ a ~ ~ l i i a t l ~ ~ iactiv:t-~. B-- :z~ovfln, t l e u s u a l seaso-:a1 , x - c - t e ~ l ~o i ~ _ :eAsease, apJro,>~-laie -*oa2j u s t ,en-cs c;-: oe .xaCe E i Lie iis~os1~:0:1 of tern, s e;l~;a.;ecl ill o~rtd-aalicontcol. Slnce slnllpo,.

has ' x e ~ ii^ou,-d COEV~O~IL--t o i'01101r ;o;'~-~ei*rt(? i O 5 '-eaL-) c-'cllcal tz-eil?~, a

,,ore r e a l i s z i c a ~ p c l s a lof t h e ,:ro;;ress o i Cis ToSrarJile can ae o ~ t a m e di f long-tern l1ic:dence 6 ~ t a2.1-e available. >ere l m ~ t e dd a t a oil s i L ~ ~ I 1 p o zare c v a l l a o l e , a surve-r o; seleccec' a r e a s

a_ld p o ~ u l a i l o nzroups. i l ~ ~ue ~ zco;is~c;e~-edLO Geetenillfie tile f r e q u e a c ~ of pock-

rlarke?. m d r v i? u a l s o-- q e an< s z.^3 -

Po,xxlatloll data I n orc'er t o escaohs.: k e i1~1.1~he:of v a c c l n a t l o ~ i sri::ick, iinlst be ,lveii

durmw tile a t n c l : phase, &e s17z :d& d:stl-ibutlon of ille A 3 0 L? ~ ~ l n t i o ~ ~and

izs laate ~iLilcrease 1s of ol3vlous ~r-porte,lcc. E s t l l i ~ a t l o ~ l sf o r p ~ ~ t i c u l a r se,-r:ents of h e c o ~ b i _ t r - ~c a i be u7dertalren la collaboratioii m d consul?;atlo~zwith t h e n a t i o n a l s t a t l s t l c s o i f l c e , Cle I FIO represenrntlves and other ,NO s'af f s ~ ~ c ha s t h o s e conce~l~cc:111th -C:xe i , ~ a l a r l aeradlcat;oLl pj?osi*aliile and t k e develop,~entof t h e o a s l c l:ealC,. s e r v i c e s. llos c cou-Itrles ~1111l x v e some nforlimtlon regard1112 t h e a-I~luali u w e r s of l l v e i ) i ~ ~ h ~ ,as well as t h e r a t e s of lieonstal a d i d a n t nortalit7- v~L.:llchpentlit t i e e s z i r i ~ t l o r iof t h e r a t e of p o p u l a t i o ~ lIncrease. i2-1ere 1-10 c'ata a ~ - ea v a i l a b l e , one :lay, for p l a ~ m m

purposes, assdale a ?: per cea-i. s ~ l n u a lp o p u l a ~ i o ~ ~111ci9ease, , I ~ o - ~. D ~ T 'somewhat

l11211 f o r t,~osta r e a b u t a s a f e e s t l i e t e.

school eclvcation, e x h i a l t s , rL%i,i ,lessa;res, ~ l l l ~ z es t o y - t e l l e r s , e t c. ma:- a l l 'be used 1ziti1 vcr--l,G success I n c ' l f f e r e ~ l tareas.

%le 11atul-e &if cllsxri'sutio;. of d l 1 h o s p t a l s , i l e a l 3 cencres, a l d e POSZS, e LC. rrzlcn coL:ceivabl-- i l,iit s e ~ ve nr ' d e t e c x l o ~ ia d ~ e ~ > o r t l ~ - <sitss' f o r s r ~ l l d o : : cases s i - o ~ l ds e &etei-iil~iled m? plottec' o-- ap,x-opriz-~enE,s. I d o & - ~ a t l o nsllonlc' oe :at:?ere? % i ~ t l : ~ " e s p e c tzo e:,istent refr1,eration i a c l l i t i e s ~. , l c n, i r z A ~ tbe vse? f o r v a c c i ~ l cdegots. E;e zivailabllit-- anc' ;atui3e of e:.lste;lt ti-ensport cor.~,iunlca-clo~-~l a c l i l t l e s f o r teal,] ;se and f o r case no clf i c a t i o n shoulf se a ~ p r a l s e d. Legal s t a t ~ l x e sp e r t a m l r g t o v a c c l i l n t ~ o ~ io r sr.ialli~o;. c o n m ~ m ~ ~ e n t ~ r o c e d ~ = e s u: an out x-ed: sliould be 0'2taliled mc' i13elr ,oi-esenx aild po-centirl a p p l l c a b i l l t - - e:aJ1med. E ~ eg o s s l ~ l ec o n t r l b ~ t l o ~ :18::lch I ,ly;nt be ~ ~ i a d e Is- o f f l c ~ a lo r v o l m t a r

ziqoups should be explored a d evaluaixd. Ih,or c o n t 1 - l ~ u t ~ o n sl n t h e Ixst

have oeen 11aCe b-- Red CL-oss o r iied Crescelit S o c l e t l e s , (^) i z l s s l o ~ lgroups and churches, Peccc Corps, t h e i,tilltar-, De>ar'cri~nzs of Ldvcatlo~im u Pu'olic L S ~ ~ r n t l o i l ,variovs s o c ~ e lc l ~ ~ s ,i i ~ c i u s t r ~ e s ,schools, e t c. It has been t h e c o i m o ~ ~e:.perience ~ l i a x ,w1ch ~ i , x m a t l o nax3 Lxrsuasloli, a l a r s e n w b e r of can be ;rouC;ilx -co sear t o ~ c c o n p l l s ht J e task. Horrever, unless f i r ~ nc'irectloAi is a v a l l a o l e i s applied t o mte=;i3at1n=; t h e varlous ~ ~ i l ~ ~ l b ~ t o i * : 'f o r c e s , t h e ;j~*o~~-atu;lec a r 'seco~ieh o , ~ e l e s s l ~ rc'isorgallzed wid1 coi~segueiitl o s s o i this valuddle s n ~ j o r t.

3. 2 Baslc a->,i-oaciies t o 111 ;cnslv-. COLIA~tr--1-rc'e v a c c l ~ l a h o ~ :pzKs-ai cries

Tile a ~ p r o a c i rvsed in t-le s - r s t e i l a t ~ c~ a c c i ~ i a t l o ne i f o r t w l l l Aiavea

considerable o e a r l r c 01 : t h e logrs-ilcs a12 s ~ ~ s s e q u e ~ ~ tdevelopi,ie.it of t h e prozralme. Several ~ppi.oaches t o illtelislve -?acclimtior ji*oe;r&mes have been c iplolied. Tnelr r e l a t l v e I ierits n u s t be corefuil-r ~rel=-:e?..

1 Vaccination conducted m estabhshea l o c a l health s e m m qlspensanes, e t c.

2 Vacclnatlon on a s y s t e m t l c house-to-house basls

Vacclnatlon of large groups collected a t a ser'les of different locations 3.2.1 Vacclnatlon---- conducted ---- - (^) - m e s t a b l l s h e l (^) --local health s e m c e lispensarses e t c.

Although l o c a l health s e m c e rllspensanes can provlfie vaccmatlon to those

-:llllng o r able t o a v a l l themselves of these f a c l l ~ t l e s ,experience has shown t h a t cnly limiter! coverage I n a population can normally bo acheved by t h s approach,

even I n countries n t h a comparative plethora of a v a l a b l e l o c a l h e a l t h s e m c e s.

"he l e a s t w e l l educated I n the most densew crowded areas normally respond

~ o o r l y , although, ~t 1s In this grmp speclfkcally t h a t the h l g h s t l e v e l s of

1l.mnmity are require?. Nevertheless, these services should be u t l h z e d t o the manmum extent posslble a s a n adjunct to t h e pmgramm and m order t o " m i l i t a t e long-term rleveloprnent of l o c a l h e a l t h service units. 2.2 Vacclnatlon-- - on a^ s-ystematlc^ house-to-house-^ basis EJTany campaigns have k e n and are bemg c a r n e d out on a s y s t e m t l c ,

c I re fully-nappea house -to-house basis. If done cowe tent*, the overall

cqverage which can be achleved 1 s excellent by t h s methd. A^ substantla

of vaccinators and supervisory personnel 1s reqcnre4, however, since cxpcnence shows t h a t t h e ~ n. ) l v i d u a lvaccrnator normally can vaccinate an

a7r-rage of only 50 t o 70 persons per day by t h s approach. Fallures vlth

wspect t o t h l s system have been attmbuted, i n large part, t o undependable

vacc-~natorsand shortages of competent supe nncory personnel.

I n some p r o g m s so conducted, e f f o r t s have been made t o record xracc-~nationsand t h e i r r e s u l t s on ln-liv-~dualdetalled household r o s t e r s f o r retention a t th? l o f a l health units. Although superficially, this m u M

-ppear t o rep-resent an e f f l c i e n t system t o guarantee &equate c oyerage, t h l s

a ~ p r o a c hhas falls.) I n most clrcwnstances. The construction of such r o s t e r s 1 s inordinately time -consuming ; their maxntenance 1s d ~ f f i c u l t, m q r a n t ^amihes and groups have proved impossible to handle by t h i s system, i n some -~rstances, vaccinators have prepared r o s t a r s from available h s t s o f persons r - v i l e d f o r other purposes an4 have slmply l l s t e d these persons a s having