Last updated: 23 April 2020
Fighting Covid-19: What India can learn from its 60 year old Smallpox Eradication Programme
Vantage Point by Jaison Jacob
Few weeks ago, On a fine morning, I woke up to this news :
Covid-19 virus pandemic: India has tremendous capacity in eradicating Covid-19, says WHO
My first reaction was 'says who?' - do people still believe in fairy tales? Being a populous country, a pandemic is every Indian's nightmare but the executive director of World Health Organisation had a point here. Diseases like Smallpox and Polio once ravaged this land and at its prime, in 1963 - over 80% of all known Smallpox cases in the world and about 75% of all reported deaths occurred in this single country. 'Targeted public intervention' was India's secret weapon against these two killers and as a result India attained Smallpox free status in 1977.
So here we are, 60 years later at the onset of another pandemic which is on a rampage across Europe and American states. Can India stop it this time? there are no easy answers to this question but it is worth an investigation.
John Burn-Murdoch is someone who prepares a Covid-19 Virus trajectory tracker for Financial times and I first came across one of his charts on April 5th, roughly 60-70 days since the outbreak. Not just the tracking part but also the kind of insights one could derive from his charts are impressive.
At this point most of the countries had enforced lockdowns, Italy and Spain's death tolls are almost plateauing but going by the chart it looked like US and UK were not going to slow down any time soon.
A typical uncontrolled outbreak
A Pandemic can broadly be divided into 3 phases: Inter Pandemic Period, Pandemic Alert Period and finally the Pandemic Period. During the Inter Pandemic Period, No Virus Subtypes are detected in humans but their presence is found in animals. The Pandemic Alert period starts with the human infections with subtypes and small clusters with limited human to human 'local' transmission starts to form. Eventually this cluster gets larger and the virus starts increasingly adapted to humans which leads us to the Pandemic period where increased and sustained transmissions happens in the general population. Eventually the number of cases reaches a peak and then starts to decline. Taking example of US, the number of cases rose from 1X to 2X to 4X to 20X to 140X just over a period of 28 days. At this point we could only pray that the peak is attained sooner or it might take a toll on human life.
In any typical outbreak scenario, the first response is vaccine. By vaccinating enough people the chance of virus infection can be reduced. In absence of a vaccine, the best thing we could do is delay the outbreak peak by isolation - enforcing lockdowns and social distancing. This way, the rate at which people are getting daily infected can be reduced so that the healthcare will have lesser burden to take care and so the curve starts to flatten eventually leading to overall diminishing of the cases.
What is the status of interventions today?
Looking at Murdoch's charts - its evident that countries like China, Japan, Singapore, Hong Kong, Iraq and South Korea has managed to delay the outbreak. In Japan the strong social norms around obedience and mask wearing has helped flattened the curve while strict quarantine rules and contact tracing has helped Singapore. Hong Kong announced early school closures, quarantined possible cases and the community response to such rules were positive. South Korea started early test and trace programme with large scale testing. Overall Contact trace programme, mask wearing, and social obedience could control the outbreak.
Most countries who declared lockdown early on could also control the outbreak to an extend. Take example of Belgium (lockdown after 18 deaths), China (lockdown after 30 deaths), India (lockdown after 20 deaths), Iraq (lockdown after 10 deaths) could flatten the curve while countries like Spain (lockdown after 200 deaths), Italy (lockdown after 800 deaths) and US(lock down after 110 deaths) seems unsuccessful at controlling the pace.
For the comparison purposes in later part of this story, I'm creating a group of countries with distinctive Covid-19 situations as a response to the type of intervention strategies enforced by the respective countries today. These countries are Belgium, China, India,Iraq, Italy, Spain and United States
How fast can Covid-19 virus spread?
Basic Reproduction number or otherwise known as R0 ("arr not") tells us how many people on an average, an infected person will in turn effect but it doesn't tell you how deadly the epidemic is. R0 is a measure of how infectious a new disease is, and it helps guide epidemic control strategy implements by governments and health organisations.
If R0 < 1, disease will die faster. If R0 > 1, every sick person effects atleast one person on average, who would then infect 6 others. When compared to Smallpox, Covid-19 is comparatively less infectious !
How fatal is Covid-19 virus? What is my chance of survival?
Assume 8 deaths among 100 people in a community all diagnosed with the same disease. This means that amongst the 100 people formally diagonised with the disease, 8 died and 92 got recovered. The CFR therefore be 8%. If we can draw a line from High CFR to Low CFR, Untreated Rabies is 99% while the Common Cold is 0. Seasonal flu also has a relatively low CFR but it has killed 24000 to 62000 during the period from October 2019 to February 2020.
However there are some challenges with regards to calculating CFR for Covid-19 virus.
Globally 3.4% of reported Covid-19 cases have died but the Case Fatality Rate of Covid-19 is still debatable as there are biases involved in reporting crude CFR early in an epidemic. Initially it was thought to be 1.6% to 2%, then it was reported as 5.8% in Wuhan. So it can vary from place to place (I haven't seen a varying CFR in case of other viruses).
We still don't know how many people are actually infected as the number of tests done to find one Covid19 case varies from country to country - When Vietnam did 750 Covid-19 tests to confirm one positive case, India did only 24.5 and US did 5.3 tests. This raises another question - Are we doing enough tests?
The only number known is how many people have died out of those who have been reported to the WHO and overall its too early to make a conclusive statement about the mortality rate. From the data about early-stage Case Fatality Rates by underlying health conditions in China, the individuals with underlying health conditions are more vulnerable than those without.
For example, 10.5% of the people with Cardio Vascular Diseases who were diagnosed with Covid-19 died while only 7.3% of the diabetes patients died.
The cost of a Pandemic
Its very hard to calculate and Forecast the impact of Covid-19 since this disease is new to medicine. Compared to other Pandemics in history Covid-19 has done very less damage to the mankind. Black Death or Bubonic Plague from 1347 to 1351 has wiped out 30-50% of the European population whereas Smallpox (since 1520) is accounted for wiping out 90% of the American Aborigines and Plague of Justinian from 541 - 542 is accounted for the Fall of Roman Empire. So far Covid-19 has locked me up in a house for a month n half and thats why this crusade is personal for me. Apart from the human loss Covid-19 might also bring down economies and superpowers. Or who knows? we might as well be in the middle of another World War - We just don't know that yet!
From this vantage point, All Pandemics have a lot in common - right from the virus spread from animals to humans, detection of human subtypes - A long incubation period, symptoms which include high fever, Human to Human spread through contamination of environment etc. So far Smallpox is the only human disease to be eradicated and this is the reason why I believe we could benefit a lot from learning the historical accounts of the Smallpox response systems from back in the day.
Smallpox of 20th century
Heres the affect of Smallpox on the Group  countries defined in the above section. Here's what one can infer from the above chart: Overall the pandemic doesn't look like one single peak as mentioned in Wikipedia. India can be seen at the uglier side with huge peaks in a Zig Zag manner spreading over a period from 1925 to 1977. US had its difficult times but towards the end of World war 2, the numbers completely disappeared. Looks like People's republic of China's first task was to get rid of the the Virus. However in midst of this chaos, European countries like Belgium, Spain and Italy seems very silent - How did they manage to be in super-control of the situation?
The answer to this question lies in the 18th and 19th Centuries. In 18th century Europe, Smallpox killed on average, a staggering number of 400,000 people every year. Most people got infected in their lifetime and out of which 30% died. However towards the end of the end of the century an English Physician named Edward Jenner introduced the practice of vaccination with his Smallpox vaccine (1796) and most European countries started the vaccination early on by the beginning of 19th century.
The above chart shows the decline of deaths from smallpox and by the end of 19th century its clear that the Europeans had Smallpox under control.
Smallpox in British ruled India
Like Europe, the first dose of Smallpox vaccine Lymph in India arrived in 1802 and until 1850, the vaccine was imported from Great Britain. Under the Company rule in India, there were issues related to vaccination programme, Primarily, post vaccination deaths and unsuccessful vaccine take. Since the vaccine came from cow - the majority population of Hindus resisted the vaccination programme. Low rural coverage and other outbreaks like Cholera weakened the further efforts. By now it's almost 100 years since the first vaccine has arrived in India and Europe has managed to control the epidemic.
By comparing the size of population of the Group countries, the huge population could be another reason that might have slowed the vaccination efforts in British India.
This brings us to this burning question: Why didn't 100 years of vaccination reach 243.7 million people by 1900? Over the course of next 30 years, 979,738 cases of smallpox with a mortality of 42.3% is going to be reported! Surely the vaccination should have had some results! My further investigation into this topic led me to San Antonio's "Pale Horse" Bioterrorism Response exercise of 2002.
The % of vaccination also plays a critical role in controlling a Pandemic
This bio terrorism exercise was conducted to test the command infrastructure within a large table top exercise. The primary scenario was a terrorist attack involving aerosolised smallpox virus sprayed over attendees at the city's Alamo Dome during a sports event. No announcement or threat was relayed, and all attendees dispersed to their regular routines. The initial victims of smallpox then began seeking medical attention after the normal incubation period for the virus.
The above epidemic curves show the impact of mass vaccination of varying % of the population in the absence of any other public-health measures. From the charts it's clear that a 40% vaccination was inadequate to prevent an epidemic. Maybe all those years of 'delayed' efforts in the vaccination programme didn't do much good as they couldn't reach the 40%, Jan's figures talks about.
So from this vantage point, looking towards the future - If India ever come up with a mass vaccination programme, simply the target should be getting 80% vaccinated.
How was Smallpox eradicated from India?
After Independence, preventive smallpox immunisation continued as single most important activity of the public health agencies and 14 institutes within the country were producing vaccine. Despite all the efforts, incomplete coverage of the population and relative ineffectiveness of liquid lymph vaccine in warm climate, the disease retained its high epidemicity and its tendency to recur periodically in an epidemic fashion. The year is 1958, the 11th Assembly of WHO focusses on mass eradication programme of Smallpox. The world is preparing itself to get rid of Smallpox once for all.
If we look at the Pandemic behaviour, the cases occurred predominantly between the months of November and June and the curve of incidence rising sharply to a peak in March or April, falling equally rapidly to a low level by the time of Monsoon rains in July. This is very similar to the Covid-19 situation today - the first cases were reported on early December and most of the countries have reached the peak by April. Maybe the Virus is here to stay, keep coming back and hit us in waves until we have an immunisation programme in place.
NSEP or National Smallpox Eradication Programme
Back to the story, the pandemic returned every year claiming ~80% of all the known cases in the world. With 250 million doses of freeze dried vaccine by Soviet Union, 2 million doses from WHO and a grant of $2 million dollars from US ( $148,518,273.16 today's equivalent, inflation adjusted) India kickstarted its Pilot project in selected districts of each state. UNICEF also provided the equipments to make freeze dried vaccine.
Phase 1: Pilot Test / 1960 - 61
The government spend an year in preparation which includes administration, recruitment, training, procurement and storing thee vaccine. The official plan was to complete the Vaccination Programme in 2 years. For documentation, Registers were prepared to permit the individual registration of each person in every family, in every village or city in the entire country. The following details were noted in the register: sex, date of birth, previous vaccination, history of smallpox and for later recording of vaccinations to be given during the NSEP programme for subsequent 20 years and their results. Enumerators (Census people) were to precede the vaccination teams by several days so that during the registration process, the enumerators could reinforce the education and Propaganda to the people. The Vaccinators just followed them going door to door.
At the end of the Pilot programme, the evaluation committee noted disappointments: The health education and propaganda had not yielded the results that was expected out of them, The vaccinators lacked proper training, had to carry their own kits collection, delivery of vaccine and handle cooking their own food, Normal supply sources of vaccine failed and the marked variation in the number of vaccinations performed ranged from 27 to 109: while 100 targeted, 73 was the average achieved.
Phase 2: First Attempt / 1962 - 64
Learning from the previous attempt, the Government had a better planning in place. A vaccination unit was defined: which includes 1 supervising officer (supervising officers were also doctors/ paramedical assistants ), 1 paramedical assistant, 60 vaccinators, 12 inspectors, 12 enumerators, 2 health educators, 3 vehicles, 1 light truck with public announcement equipment, Each unit carried freeze dried vaccine in 20 dose ampules and rotory lancets were used to carry out the vaccination (1 or 2 insertions per person). There were 152 such units organised for a total population of 437.5 million and expected coverage for each unit was 3 million people in 2 years. Imagine, the population density of India in 1960 was 137.06 person/km^2, This look like a gargantuan task!!
The plan was to get 80% of all the sections of the people vaccinated. Remember the section where we talked about the '%' of people the vaccinations should target? - The reason why vaccinating 80% of the people could stop an outbreak is because of an idea called Herd Immunity. If enough people get immunised against a disease, they will create a protection for even those who are not vaccinated. This is important to protect those who can't get vaccinated, like the immunocompromised children.
By December 31, 1964, 68% people got successfully vaccinated. But there was an issue - "all the sections" of population were not defined. Only the necessity of vaccinating the newborns were repeatedly emphasised and the targeted 80% was without regards to primary vaccination (PV) or Re vaccination (RE). Primary vaccine failure happens when the person's immune system doesn't produce antibodies when first vaccinated. Apart from defining sections, there were some serious threats from the field: too many revaccinations, failures of impotent vaccines, absentees from the unit - now on an average of one vaccinator per 50,000 - 70,000 persons and poorly designed family cards and worn out health records added more difficulty in carrying out the campaign.
While the vaccinations progressed, on the other hand, the government struggled with deaths that couldn't be controlled, reason being the insufficient investigations to trace the origin of all the cases since it was frequently determined that the first case or cases was imported - returning pilgrims, visitors, tradesmen, labourers, travelling musicians etc. The floating population or the seasonal migrators are usually poorly vaccinated as they are not permanent responsibility of any local health body.
Phase 3: "Mopping up" / 1965 - 1966
In March 1966, the target was changed from 80% to 100%. With additional 200 million doses of vaccine, the improved Vaccination programme was kicked off. Finally 'all the sections' were defined, More assessments were made to evaluate the goals which included a Do it yourself kit for self evaluation to find out if smallpox was occurring even after the vaccination was conducted. Addition of a 'Local Sanitary Inspector' who is well versed with the local language from the local district added more value to the team as a local guide and later on more local vaccinators were recruited. Hardcore Mopping up continued to find out who all missed the first attempt and were given re-vaccination. With additional effort, the new round of vaccinations reached 20% of the population per year. Revaccination was made mandatory as a way to make sure it's effective. One big change was with the Rotary Lancet itself which was used to deliver the vaccine. Using the Rotary lancet was time consuming and wasteful of vaccine. After each vaccination, the vaccinator had to heat the lancet to sterilise it and the skin should be washed with soap and water before applying the vaccine. Now that the Rotary Lancet got replaced by a scratch method, the Mopping speeded up.
Post NSEP India and the anticlimax
"However, by 1967, it was clear to everyone that the campaign was unsuccessful; the number of smallpox cases in India was increasing"
On the basis of recommendations of an assessment team and a plan of operation signed by the Government of India and WHO in 1970, the following year, four WHO medical officers arrived in India to spearhead the revised eradication campaign. The 1974 smallpox epidemic of India was one of the worst smallpox epidemics of the 20th century as between January and May 1974, 15000 people died from smallpox. An operation by name "Target Zero" was started aiming at containing the last cases of smallpox, with the identification of the last smallpox patient in India occurring on May 24, 1975.
Lessons from the Smallpox Eradication Programme
The NSEP story warns us that the public health policies in India cannot be imposed from a central body - it reveals the importance of mobilising the local bureaucratic, political and civilian support for public health programmes reliant on large scale immunisation and isolation. The significance of the locally adapted public health activity messages is also notable as adapting them to the mass cultural customs and addressing the local concerns sounded very expensive but it worked. The vaccination work in the field required necessary negotiation skills with those being targeted to get a favourable result because explanations had to be provided to why someone needs to be isolated and his or her contacts be traced and immunised. People's refusal to cooperate with the investigative tours can go bad to an extend of people fleeing their places of stay and even hiding others from the units. these kind of tactics weakened the effectiveness of the emergency measures and even caused problems for the national and international agencies working with limited resources. [Reference]
Conclusion: What if we have to conduct a similar vaccination programme today?
It will be much easier than 60 years ago, the government can easily locate 67.40 to 89.2% of the population geographically. Compared to population density from 1960, 131 people/km^2, it is now 419 people/km^2. more than triple but these people are well connected by transportation, media and healthcare.
As of 2018, the % of total population of the rural India is 65.97%, at its lowest compared to its all time highest value of 82.08% in 1960. As we have seen before, at the time of NSEP, bringing the vaccination units to the rural India and then conducting vaccination from door to door was the most difficult task, but recently due to the heavy investments made in National Rural Health Mission, Immunisation has increased in rural areas.
This has been proved effective in recent Pulse Polio Immunisation Campaign. In some states, the gap is stark. In West Bengal, immunisation increased from 62.8% to 87.1% in rural parts, while the improvement is much lower in urban areas (from 70.3% to 77.7%). The gap between urban and rural areas stand at 10% today. This gap is because, the preventive care is mostly handled by the Public Medical Sector and compared to Urban sector, their presence is more established in the rural India.
When it comes to Covid-19, the underlying health conditions can affect the CFR of the infected and we don't have a method in place to locate such cases. This would be something the Government should focus on in the coming years.
In recent decades, India has made enormous progress lifting hundreds of millions of people out of poverty, improving literacy and life span, and turning its economy into a global powerhouse. But much of its economic might is based purely on the size of its population — 1.3 billion. The average Indian makes around $5 a day, on par with developing countries in sub-Saharan Africa. With 200 million Indians entering the work force in next 30 years the increasing pressure on an economy that is already facing record unemployment - which brings us to the our next problem.
Roughly 1/6th of India's households has a member who has stepped out of their home in order to be a work related migrant. As India's economy expands, their numbers are slowly yet unmistakably increasing. As we have seen in NSEP, the source of the virus was always imported by a returning pilgrim, tradesman, visitors, labourers. This floating population is always a threat in an outbreak scenario and towards the country's immunisation efforts. With the recent Covid-19 outbreak, the state of Kerala have managed to flattened the curve by contact tracing and setting up walk-in kiosks for sample collection. Since the cases reported in Kerala mostly came from abroad, it was easy for the local police, health ministry and media to identify, isolate people with symptoms and create a route map and track down the plausible positive cases meanwhile, there is an alarming number of migratory workers in the state who work in urban construction sites, brick kilns, or for the rural harvesting. This kind of seasonal migrators can also be found in other states like Maharashtra, Uttar Pradesh, Delhi, Odisha etc. With countrywide lockdown declared on March 25th, there were cases of 'reverse migration' where migrant workers, in the absence of jobs, homes and food, set on foot to walk back to their traditional areas without access to testing facilities to detect the virus. These migratory workers, possibly carrying the virus can have devastating impact on the places they are headed to. Another major challenge to the Government will be to stabilise these migratory groups and keep track of their immunisation records. It was widely discussed that the trigger for the reverse migration was fake news circulating in social media. Talking of Social media and fake news, the recent CAA protests has triggered the Supreme court of India to push the need for Government to publicise aims, objectives and benefits of a matters that affects the Indian Citizens to weed out fake news that was being circulated on such issues. We will have to see how the Government tackles this fake news issue going forward.
The Covid-19 situation has shown India the value for the media. On the one hand, social distancing has led to a spike in at-home media consumption, and growing numbers are turning to news providers for timely and trusted information on the crisis. From NSEP times, another factor that challenged the process was the lack of locally channelized content which people could get informed from, but today the country is armed with 902 local language television channels (apart from the national channels) ready to take the latest Covid-19 updates to the 1.3 billion people.
Here's what I think about this :