Vaccine
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Review Historical Article
Smallpox and its eradication in the Democratic Republic of Congo: lessons learned.
Smallpox eradication is considered to be one of the most remarkable accomplishments of the 20th century. Lessons learned from the campaign during the 1960s and 1970s in the Democratic Republic of Congo (DRC) can provide important information for the development of other eradication programs including polio. The DRC is the third largest country in Africa; the population suffers from extreme poverty, deteriorating infrastructure and health systems, and long periods of civil strife. ⋯ A number of important themes emerged during the campaign that could be beneficial to eradicating polio and future eradication programs that may follow. During the smallpox campaign, a standard vaccination program was implemented, surveillance was intensified, and there were strong collaborative programs with community involvement. These successful elements of the smallpox campaign should be adapted and applied in DRC in polio eradication programs.
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Interest and support for malaria control, eradication, and research has increased greatly over the past decade. This has resulted from appreciation of the huge medical, social, and economic burden that malaria exacts from endemic populations. Recent breakthroughs in drug development (artemisinin-based combination treatments), preventive interventions (long-lasting, insecticide-treated bed nets), improved diagnosis (rapid diagnostic tests), and community mobilization have resulted in deployment of new antimalarial tools. ⋯ President's Malaria Initiative, and other donors have resulted in substantial reductions in malaria morbidity and mortality. Bill and Melinda Gates have given great impetus to eradication with support for the development of key research strategies and direct funding of innovative research projects, including malaria vaccine and drug discovery, that could decrease disease and transmission. Linking research to field operations is a strategy that succeeded for smallpox eradication and will be required for the demise of malaria.
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Rigorous, independent, confirmation of disease eradication is necessary to assure credibility of the claimed accomplishment. The criteria and procedures for formal certification of global disease freedom are based on the biological and epidemiological features of the pathogen and its manifestations. Certification activities by previously endemic and at-risk countries include comprehensive documentation focusing on surveillance, reports of national independent review groups, and special field surveys. ⋯ Dracunculiasis (guinea worm) freedom has been certified in 187 countries. Regional commissions have certified the Americas, Asia, and Europe polio-free; however, re-establishment of endemic foci in countries previously declared disease-free has created special challenges for completing this program. Post-eradication activities require attention to surveillance, maximum security of the microbial agent, and essential research to assure maintenance of disease freedom.
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The smallpox eradication campaign operated in Ethiopia from 1970 until 1977. During this time Ethiopia had only 84 hospitals, 64 health centres and fewer than 400 physicians in a country of 25 million people. In 1970 smallpox vaccination was relatively unknown in the country, and the government actually contested the fact that smallpox was present in the country. ⋯ Over the course of the campaign approximately 14.3 million US dollars was spent. Working conditions were extremely challenging and a variety of chiefs, guerrillas, landowners and governments had to be appeased. The programme was successful due to the dedicated national and international staff on the ground and by having the full support of the WHO HQ in Geneva.
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The challenge for regions embarking on measles elimination will be to maintain high population immunity with excellent vaccination coverage and high-quality surveillance. Meeting this challenge will be especially critical for dealing with importations of measles virus that will occur as long as the virus is circulating anywhere in the world. Implementation of measles elimination strategies will uncover the "hidden" disease burden of rubella and congenital rubella syndrome. ⋯ Countries of LAC prioritized the routine national immunization program over short-term successes. While doing so, they have also encountered new opportunities to expand the benefits of disease control and elimination activities to other aspects of public health, most importantly towards improving health care for women and newborns and reducing inequities in health in the region's poorest communities. Implementation of similar strategies could lead to the global eradication of measles, rubella, and congenital rubella syndrome early this century, while strengthening routine immunization programs, and developing the capacity to introduce new and underutilized vaccines.