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Smallpox eradication

December 15, 2010

Lessons from the Indonesian archipelago 1947–74 – by Vivek Neelakantan

While smallpox eradication in post-colonial South Asia has been well documented in contemporary historiography, a parallel body of work assessing the smallpox eradication campaign as it unfolded in post-independence Indonesia is lacking. A part of this problem relates to the compartmentalisation of Indonesian history into distinct periods such as the Dutch period, the Japanese occupation, the Indonesian Revolution, the Sukarno era, the Suharto era and the Reformasi era. Smallpox was largely overcome in the Indies archipelago at the start of World War II (1939) but made a comeback during the Revolutionary period (1947) – a period of political transition that fits untidily into the colonial–post-colonial division, which is problematic. In this article, I argue that the Indonesian smallpox eradication campaign (1947–74) serves as a crucible to examine the shift in strategy – from mass vaccination to surveillance and containment – within the policy circles of the WHO that ultimately contributed to the worldwide eradication of smallpox in 1980.

Since the introduction of vaccination on the island of Java in 1804, the colonial state in the Dutch East Indies (today known as Indonesia) successfully tackled smallpox through a series of mass vaccination campaigns consisting of the ‘dual system’: primary vaccination (which immunised as many infants as possible) and revaccination of the entire population once every seven years. Consequently, smallpox transmission was reduced to near-zero levels by 1939–40. However, during World War II, owing to the slackening of primary vaccination and revaccination, the Indonesian population’s immunity to smallpox weakened.

The geography of the Indonesian archipelago affected the spread of smallpox and shaped eradication efforts. Jean Assell/iStockphoto

The geography of the Indonesian archipelago affected the spread of smallpox and shaped eradication efforts. Jean Assell/iStockphoto

Waves of smallpox outbreaks began to affect Sumatra, beginning in October 1947. The Dutch Medical Resident in the Riau archipelago, Van Waardenburg, had reported that the first case of smallpox in postwar Indonesia was an unvaccinated Chinese child in the Riau island of Kundur, whose father would sail frequently across the Straits of Malacca to the island of Batu Pahat in Malacca, which was smallpox-endemic. In October and November 1947, smallpox outbreaks were reported amid the Orang Mantang community (sea nomads native to the Straits of Malacca), who would evade vaccination owing to their antagonism to Western medicine. Of the 89 reported smallpox cases from Kundur in 1947, 81 were from the Orang Mantang community. In 1948, the inter-island coastal traffic from Sumatra to Java – which had been smallpox-free – acted as a conduit for smallpox. In December 1948, the disease was imported into Batavia (now known as Jakarta). By June 1949, Batavia recorded an epidemic with 4841 reported cases. During this epidemic, the separation of smallpox patients from their families and subsequent transportation to the quarantine station on the island of Kramat Djati proved too radical, leading to unrest.

In the 1950s, Indonesia did not have a national smallpox eradication programme. Mass vaccination campaigns involving the earlier colonial dual system of separating infant vaccination from adult revaccination continued. The Pasteur Institute at Bandung manufactured Otten’s vaccine (dried vaccine sourced from buffalo lymph), which was used in mass vaccinations. The Institute and the Department of Health at the national level rarely achieved a consensus on questions such as the potency of the vaccine or standardisation of the vaccination technique.

In 1958, the Soviet Union proposed the global eradication of smallpox at the Eleventh World Health Assembly. The Global Strategy for the Eradication of Smallpox aimed to eradicate the disease from endemic areas of the world through a programme of mass vaccination involving at least 80 per cent of the population of the affected countries. In 1963, Indonesia launched a Five Year Programme to Combat Smallpox, under the overall control of the malaria eradication programme (implemented first as a pilot project in West Java, then in the provinces of South Sumatra, West Sumatra and East Java). Implementing the Five Year Programme proved to be a thorny issue, as the central government was in charge of epidemic control whereas the provincial governments were in charge of administering routine vaccinations. Coordinating epidemic control and the administration of routine vaccinations proved to be almost impossible in the 1950s. The WHO’s Regional Office for Southeast Asia (SEARO) criticised Indonesia’s policy of diverting malaria eradication personnel and infrastructure to smallpox eradication as being “premature”, as the nation had not yet eradicated malaria.

The Nineteenth World Health Assembly formulated the basic strategy of the Intensified Smallpox Eradication Programme (INSEP) in 1966. The two components were mass vaccination, covering at least 80 per cent of the population and surveillance, detecting smallpox cases and containment of outbreaks as they occurred. Indonesia initially introduced the INSEP on the islands of Java and Bali in 1968, expanding to Sumatra, Sulawesi and Kalimantan in 1969.

In West Java, backlog fighting (mass vaccination of infants and migrants) had covered 25 per cent of the population in 1969 but had failed to interrupt smallpox transmission. Nurses and vaccinators would not report outbreaks to the regency health officials as they were not given specific instructions on how to do so. It was customary in West Java to carry sick children to visit relatives. Isolation of the patient at home and vaccinating the immediate contacts in order to contain an outbreak proved unworkable.

North Sumatra was smallpox-endemic when the INSEP was launched in the province in 1969. Plantations employed up to 40 per cent of the workforce, but there was little coordination between plantation hospitals and the regency health services in the implementation of the INSEP. Smallpox surveillance was not effective in detecting cases as surveillance activities were carried on during the day, when the majority of villagers were at work on the plantation. As a result there was a huge backlog of unvaccinated individuals. In the plantation hospital at Simelungun, it was observed that children with symptoms of chickenpox were misdiagnosed with smallpox and isolated in a smallpox ward – where they were infected with the smallpox virus. They began to initiate new smallpox outbreaks soon after their discharge. Case notifications from village heads to the regency health services were incomplete as the disease was not suspected.

When Indonesia began the INSEP in 1968, 17 380 cases of smallpox were officially recorded. In 1970, there were 10 081 – 33 per cent of the world’s total cases of smallpox. In 1972, Indonesia recorded its last case. The WHO-sponsored Smallpox and its Eradication report states that smallpox transmission in Indonesia was interrupted in 1972, owing to the shift in strategy from mass vaccination to surveillance and containment. However, the reported success of the surveillance-based component of the INSEP in Indonesia was more apparent than real. Surveillance in the initial stages of the campaign was weak, as chickenpox cases were misreported as smallpox. But an unnamed vaccinator in Bandung successfully used colour photographs of smallpox cases published in a WHO teaching folder to obtain numerous case notifications, with remarkable success. The WHO staff adapted this field experience by printing ‘smallpox recognition cards’, which were used successfully for case detection in smallpox-endemic South Asia.

With smaller numbers of outbreaks since 1971, the vaccinators discontinued routine vaccination to look for cases. The health authorities considered every case to be a national emergency. The Department of Health announced a reward of 5000 rupiahs to anyone who reported a suspected case that was confirmed in the laboratory for smallpox. Despite this vigilance, no cases have been discovered in Indonesia since 1972. Indonesia was declared free of the pox, thus providing hope for the SEARO that smallpox eradication was attainable.

After two decades in which Indonesia did not have a coordinated plan to eradicate smallpox, the country’s chapter of the INSEP proved to be the crucible in which ideas related to mass vaccination and surveillance formulated at the WHO headquarters in Geneva were evaluated and adapted based on their applicability to local geographic and cultural factors. The success of the INSEP in Indonesia was based on a strategic shift from mass vaccination involving the total population to using smallpox recognition cards for case detection.

Vivek Neelakantan is a doctoral candidate at the Unit for the History and Philosophy of Science, University of Sydney, Australia.

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