Another advancement in technology that favored mass vaccination was the invention of a jet injector method to vaccinate people in mass. The jet injector was developed in 1960 by Aaron Ismach during his time in the U.S. Army which he called it the Ped-O-Jet. The Ped-O-Jet was implemented in West Africa in 1966 and allowed for one thousand people to get vaccinated in an hour.[xxviii] This invention caused the vaccine to be delivered intradermally and became a reliable way to uniformly provide take rates close to one hundred percent immunity. While this innovation was economical and efficient, it had its own drawbacks.
The difficulties of the jet injectors were that the maintenance of the equipment became difficult, and it only served to vaccinate at a collection site. It had no advantage going from house to house in remote areas. The jet injector was replaced in 1969 by the bifurcated needle developed by Wyeth Laboratories, United States. The bifurcated needle was a two-tong steel rod that held the right amount for one vaccination. The needle was simple, and the vaccinator held the needle at a right angle to the skin, administering the exact dosage for the vaccine. In the field, the technique was easy to teach to vaccinators and provided immunization success up to ninety-eight percent. The needles were also inexpensive costing a half-cent each and could be reused after sterilization. Thus, the bifurcated needle’s real advantage is that it was more economical and much easier to deploy with vaccinators reaching remote areas and going house to house.[xxix] As the injector jet became obsolete, so did the mass vaccination plan.
The failures of mass vaccination became apparent during the implementation of the program in West Africa. The WHO reported, “Eradication campaigns based entirely or primarily on mass vaccination succeeded in some countries but failed in most.”[xxx] Mass vaccinations were only successful in well-developed countries with health services, reporting systems, and communications. Although, in countries in West Africa and India where particularly large groups in lower socioeconomic classes still suffered from smallpox transmissions, the WHO and the collaborating countries did not have enough resources to logistically fund and coordinate mass vaccinations in these regional areas susceptible to smallpox.
In these regions, if a critical mass of unprotected people accumulated, it led to explosive outbreaks when smallpox was introduced into the community. The solution came fortuitously in West Africa when Dr. William Foege responded to a smallpox outbreak in 1966 in Ogoja, Nigeria. Since the program was new, it meant vaccines remained in limited quantity, and villages were remote and miles away from any roads. Thus, Dr. Foege and his colleague, Dave Thompson, jumped on motorbikes to reach the village Ovirpua where five people suffered from the disease. Dr. Foege and his colleague acted fast and vaccinated the patients’ family members and other villagers in immediate contact with them.[xxxi] The next challenge Dr. Foege face was to implement the standard mass vaccination process, but he lacked the resources to complete this task. Dr. Foege pondered one solution to dilute the vaccine to spread it out amongst the villagers.
However, history has proven that this method reduces the potency of the vaccine and reduces immunization from one hundred percent to between sixty to seventy percent. Therefore, Dr. Foege’s plan was to gather intelligence about which villages in the Ogoja region had cases of smallpox. which locals reported only four villages suffered from the disease. Once Dr. Foege located the villages, he sent a smallpox eradication team to vaccinate the infected villages. Even though people at these villages were already infected, vaccination reduces the impact of the disease.[xxxii] And if the smallpox team missed anyone for vaccinations, Dr. Foege’s goal was to have enough vaccinated people to surround those who were infected which limited the spread of the disease.
Dr. Foege’s second plan was to used local knowledge from the missionaries to build a pattern where patients and their families routinely traveled.[xxxiii] This allowed Dr. Foege to find an additional three villages with smallpox incubating in hosts where he would use the remaining vaccines. Consequentially, Dr. Foege’s plan ceased the outbreak of smallpox. The plan developed by Dr. Foege became known as the surveillance and containment plan. Dr. Foege concluded that the Ogoja province outbreak proved that containment was more economical and efficient than the mass vaccination plan.
For example, Dr. Foege found out once the chain of the transmission broke, smallpox never returned to Ogoja; thus, he claimed, “then every additional vaccination was essentially wasted effort—a theft of time and vaccine.”[xxxiv] Afterwards, the CDC and USAID adopted surveillance and containment as the primary strategy. The strategy proved to be effective because in three years from 1967 to 1970 the CDC reduced 11,069 cases to zero in West Africa.[xxxv] Although the WHO expected West and Central Africa to be the most challenging regions, they ended up being the first geographical area in the WHO program to eradicate smallpox. The real test for the WHO smallpox program and the new primary strategy waited in India.
India proved to be a formidable challenge because of India’s estimated 600 million population and a history of a severe endemic of smallpox. Dr. Foege was called upon again to eradicate smallpox as a consultant to the WHO in New Delhi, India at the behest of Dr. Henderson.[xxxvi] For the surveillance and containment strategy to work in India the WHO needed an army of people. India’s government provided three hundred eighty-six districts with a total of thirty-five thousand people as primary health workers with a mobile squad of five vaccinators per district. Additionally, the WHO provided four long-term special epidemiologists and three short-term consultants rotating in deployments every two months, going to regions where the WHO assigned them the highest incidences of smallpox.
As a result, this enormous network of health care personnel helped streamline the reporting system necessary to respond to outbreaks in India. By 1973, the puzzle pieces started to fit where India saw an increase of “government commitment, increased national and international resources, increased vaccination staff, sufficient vaccine of good quality, an easy system for vaccinating using bifurcated needles, a timely reporting system, and cross-notification of cases between districts to provide a national approach.”[xxxvii] On the same note, the Soviet Union donated one billion doses of freeze-dried vaccines. Later, the WHO and United Nations Children’s Fund (UNICEF) provided supplies and equipment for India to produce its own freeze-dried vaccine.[xxxviii] Due to the improvements in the reporting system, India saw an increase of reported cases up to fifty percent instead of a decrease.
The WHO attributed the success of the reporting system by India’s government to its information gathering from all public sectors such as markets, schools, and other places of gatherings. Smallpox eradication teams used recognition cards of smallpox, chickenpox, and fevers with a rash as tools for villagers to help identify cases of smallpox. Also, the government created a system to reward people who reported cases of smallpox.[xxxix] The government provided a monetary reward system that initially paid the equivalent of $1.50 US to reporters and increased to $1,000 US at the end.[xl]