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Illustrations by Joe Cepeda

WorldWarWON (continued)

The Eradication-Escalation Strategy

One of our first field operatives in Nigeria was the very tall, irrepressible Dr. William Foege, whom I had recruited from his Lutheran mission post in Eastern Nigeria. Foege had previously worked with me at the CDC, most recently in the smallpox unit, and he welcomed the challenge of the new eradication program. (He was eventually to become director of the CDC and later of the Carter Presidential Center.)

In November 1966, before most personnel and equipment had reached the field, Foege and two CDC staff members arrived in Eastern Nigeria. They soon received reports of smallpox cases from missionaries and quickly worked to control them. Using borrowed motorbikes and a limited supply of vaccine, they successfully contained three outbreaks simply by vaccinating household and village contacts. They discovered that the first cases had come into the area from Northern Nigeria. In an effort to discover other outbreaks, they recruited a missionary-based radio network to help report cases; subsequently, other health units were included in the network.The smallpox cases were occurring primarily along the northern tier of the region, and so, as more vehicles and vaccine became available, they focused on this area.

By the end of May 1967, they had detected and contained 754 cases and vaccinated about 750,000 of the 12 million Eastern Nigeria inhabitants. Cases had rapidly diminished in number, and finally some weeks went by with no new cases being discovered. On May 30, Eastern Nigeria proclaimed itself the independent nation of Biafra. Active fighting broke out, and the CDC team was forced to flee the country. Later, Red Cross workers and others working in Biafra reported that they had encountered no smallpox cases. Smallpox transmission appeared to have been stopped by a vaccination program that had reached less than 10 percent of the population.

Foege concluded that the surveillance-containment component of the eradication strategy could prove to be more effective than we had anticipated that it might be possible to stop transmission even before a mass vaccination campaign could be completed.

A year later, in May 1968, he proposed this to the CDC staff for implementation throughout West Africa. The effort was to be labeled Eradication-Escalation. The one country where implementation of the strategy was delayed was, ironically, Nigeria. There had been serious concern that the Biafran civil war might spread more widely throughout that country and stop activities altogether. Thus, it was decided to put all possible effort into vaccinating as many people as possible as quickly as possible, in order to limit the size of potential subsequent outbreaks should the program be interrupted by war.

Meanwhile, the mass-vaccination programs using the jet injectors had proved to be remarkably effective. Special teams checking on vaccination coverage found that vaccinators were reaching more than 80 percent of the villagers. By September 1968, when the Eradication-Escalation strategy got under way, almost 60 million of the targeted 110 million vaccinations had already been given; fifteen of the twenty countries were free of smallpox. In Nigeria, with nearly half of the West Africa population, smallpox incidence had fallen dramatically. The special strategy did play a significant role, however, in Guinea and Sierra Leone, where operations began a year after the other programs.

The last cases in the whole of West Africa were thought to have occurred in October 1969, less than three years after the program had begun. Until March 1970 surveillance and search operations failed to detect other cases. An evening to celebrate the success of the program was in progress when a report was received of a suspect smallpox case admitted to a hospital in Northern Nigeria. Foster himself drove some two hundred miles to the hospital, confirmed the diagnosis, and undertook a nighttime emergency vaccination program.

Some thirty active and recovering patients came through the line. In all, seventy-five cases were eventually discovered before the outbreak was stopped. The final case occurred in May 1970—the last in West Africa.

A Smallpox Surveillance Team—Courage and Dedication

Under the direction of [Dr. Abdul Mohammed] Darmanger and [Dr. Arcot] Rangaraj, the Afghani field teams became a remarkably dedicated and courageous group. The investigation of a rumored outbreak in a northern mountainous area is illustrative. The team was sent on horseback to investigate but encountered three-foot-deep snow and had to turn back. They tried again by another route but again encountered snow. The horses were abandoned and the team continued on foot for four days to get to the outbreak area. They moved from village to village vaccinating and checking for cases as they went. In all, they spent six weeks in the middle of winter containing the outbreaks. When it was possible to carry out a thorough search of the area in the spring, no subsequent cases of smallpox were found.

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  • Joan Levin

    Chicago 03/27/2010 01:17:14 PM

    Sadly the important pioneering role of Dr. Karel Raska was overlooked in this article. You may read Dr. Alex Langmuir's appreciation of Dr. Raska and Dr. Henderson's addendum originally printed in 17 Intl. J. Epid. 491 (1988) at

  • Joan Levin

    Chicago 03/27/2010 01:25:33 PM

    Sadly the pioneering role of Dr. Karel Raska was overlooked in this article. Interested readers may learn more about this in Dr. Alex Langmuir's Appreciation and the Addendum by Dr. D. A. Henderson published in 17 Int. J. Epid. 491 (1988) and found online at .

  • JustinBeersons

    USA 04/13/2011 06:07:08 AM

    Hi - I am definitely glad to discover this. cool job!

  • zeroxtrpo

    england 05/04/2011 10:50:23 PM

    Wow this information is great! Thanks this has helped me a lot! I'm sure your posts are one of the best out there! Always so accurate!

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