INTRODUCTION

In 1967, smallpox was endemic in 5 Asiancountries, whose total population amountedto 769 million . Four of these countries-Afghanistan, India, Nepal and Pakistan-were contiguous, sharing long borders, whichtravellers (including people infected withsmallpox) crossed with relative freedom.However, the fifth country, Indonesia (popu-lation, 112 million), lay some 2000 kilometressouth-east of the nearest endemic area on thecontinent-East Pakistan (after 1970, Bangla-desh). Comparatively few people travelledbetween Indonesia and the other 4 countries .Thus, it seemed logical and opportune toconcentrate resources and energies initially inIndonesia in the expectation that on becom-ing free of smallpox, the country would not beseriously threatened by importations (Wklyepidem . rec., 1969a). WHO resources commit-ted to Indonesia could then be shifted to otherprogrammes in Asia. The fact that smallpox

CHAPTER 13

INDONESIA

627

transmission had once been interrupted inIndonesia, immediately before the SecondWorld War, added strength to the belief thatthe objective could be attained .

As had been hoped, Indonesia was the firstof the 5 Asian countries to become free ofsmallpox. The programme began there inJune 1968 ; the last known case occurred littlemore than 32 years later, on 23 January 1972.The achievement of eradication so quickly insuch a large and populous country was both asurprise and a stimulus (and to some degree anembarrassment) to health staff in Bangladesh,India and Pakistan, whose programmes hadby then been in progress for a decade . Thatthis feat had been accomplished with littlemore than US$1 million in internationalassistance made it even more notable .

Success was not easily achieved in theIndonesian programme. Smallpox was ten-acious and spread readily even among popu-lations with exceptionally high levels of vac-cinial immunity-a marked contrast to the

ContentsPage

Introduction 627The decision to begin the programme 628Demography and geography

smallpox controlof Indonesia and its history of

631Smallpox incidence, 1963-1967 634Organization of the programme, January-June 1968 635The early stages of the programme, June 1968 July 1969 638The strategy changes, July 1969 643

Tjirebon regency 645Bandung regency 646Bogor regency 646Factors affecting transmission 646

The surveillance-containmentestablished

strategy becomes fully649

Strengthening of programmes in the outer islands, 1970 651Indonesia's last outbreak, 1971 654Morbidity and mortality patterns 655Conclusions 656

628

behaviour of the disease in most endemiccountries of Africa and the Americas . Fullcredit for the achievement is due to animaginative group of Indonesian and WHOstaff, who conceived and evolved effectivestrategies that were later adapted for use inother parts of the world and proved vital tothe interruption of smallpox transmission inthe Indian subcontinent . Among Indonesia'scontributions to global eradication were theconcept of a special programme involving avillage-by-village search for cases, the intro-duction of a reward system for anyone report-ing a case of smallpox and the development ofthe widely used WHO smallpox recognitioncard (see Chapter 10, Plates 10 .29, 10.30) .

A number of papers were prepared describ-ing selected aspects of the Indonesian pro-gramme, although a book would have beenwarranted to recount the whole gamut ofactivities . There was little time available toattempt a detailed narration, however . Wheneradication was certified in 1973, experiencedstaff were urgently needed in other countries ;key Indonesian staff and the WHO adviserswho had been assigned there respondedpromptly and, in so doing, contributed to therecord of achievement compiled in India,Bangladesh and Ethiopia .

THE DECISION TO BEGIN THEPROGRAMME

Originally it had been hoped that thecampaign in Indonesia might begin duringthe first year of the Intensified SmallpoxEradication Programme but its start wasdelayed until June 1968 . In part, this stemmedfrom doubt and inertia in the WHO RegionalOffice for South-East Asia in New Delhi,India. The then Regional Director believedthat the health resources in the countries ofthe region were too inadequate to permiteradication to be realized. He frankly andpublicly stated his view that the WorldHealth Assembly's decision to undertakeglobal eradication was ill-advised, and conse-quently offered little support to the pro-gramme. Likewise, the Regional Adviser forCommunicable Diseases, the senior technicalofficer, took little interest . A memorandum of10 October 1967 from Henderson to hissuperior in WHO Headquarters, Dr KarelRaska, the Director of the Division of Com-municable Diseases, summarized the situationprevailing during much of that year :

SMALLPOX AND ITS ERADICATION

"In December [1966] and April [1967], theconsiderable importance of an early visit toIndonesia to assess Government interest andcapability to undertake [smallpox eradication] hadbeen agreed by [the Regional Adviser for Commu-nicable Diseases] and myself. No visit has yet beenundertaken and none is contemplated until possi-bly November . In fact, I gather there was nocorrespondence with Indonesia on the question of[eradication] until July . . . No solutions are pro-posed ; no possible courses of action are outlined ."

Subordinate to the regional adviser andostensibly responsible for providing assist-ance to countries in developing smallpoxeradication programmes was a 2-man inter-country advisory team for epidemiologywhose duties then encompassed a range ofdifferent activities . During his visit to NewDelhi, Henderson had met the team, whichhad exhibited both an interest and a desire toproceed rapidly in the development of WHOsmallpox eradication programmes . Sub-sequent communication with them by mailproved difficult. All correspondence relatingto smallpox eradication between WHO Head-quarters and the regional office, as well asbetween the countries and the regionaloffice, was routed first to the regionaladviser. Seldom was it passed to the inter-country team. By the end of November 1967,the intercountry team had been permitted tomake only two brief visits, to Afghanistan andNepal, the only countries in the region inwhich WHO-supported smallpox eradicationprogrammes were then in progress . In theautumn of 1967, one of the team's members,Dr Jacobus Keja, prepared a draft plan ofoperations for Indonesia but was deniedpermission to visit the country to discuss theplan .

The lack of activity in the South-East AsiaRegion and its failure to obligate smallpoxeradication funds allotted for the calendaryear led to important financial ramificationsin the global programme as a whole. When thebudget for smallpox eradication for 1967 hadbeen approved by the Nineteenth WorldHealth Assembly, several countries had ex-pressed the view that an allotment ofUS$2.4 million for the first year was too largeand proposed instead that a sum ofUS$1 million should be provided (see Chapter9). The larger allocation was eventuallyagreed on, but only after assurances had beengiven by the Director-General that the fullamount was needed and could be spent. In theAmerican and Eastern Mediterranean Re-

gions, activities were progressing suffi-ciently well to ensure that the funds allottedto them would be obligated . However,US$806 000 had been assigned to the South-East Asia Region and little of it had beenspent. If these funds were not obligated by theend of the year, not only would they be lost tothe programme, but the possibility of ques-tions arising at the next World Health Assem-bly could be foreseen, conceivably resulting inreductions in subsequent budgets for small-pox eradication. Because of this problem, theRegional Director finally agreed, in Novem-ber 1967, that the intercountry team shoulddiscontinue its other activities and assumeprimary responsibility for smallpox eradica-tion under a higher-level regional officeofficial, the Assistant Director for HealthServices. With this administrative change, thedevelopment of a programme in the regionbecame feasible .

Three other events occurred during theautumn of 1967 which were to alter signifi-cantly the possibilities for eradication in theSouth-East Asia Region and in Indonesia inparticular . A new WHO Regional Director,Dr Herat Gunaratne, was nominated inSeptember 1967 and took office in February1968. As President of the Twentieth WorldHealth Assembly, in May 1967, Dr Gunaratne(a former Director-General of Health Ser-vices in the smallpox-free country of SriLanka) had stated categorically that the

13. INDONESIA

eradication of smallpox was wholly achiev-able, that it was simply a matter of will anddetermination . As testimony to this belief, heoffered his own considerable enthusiasm andsupport for the programme .

The second event was the appointment inNovember 1967 of Dr Julie Sulianti Saroso tothe post of Director-General for the Controland Prevention of Communicable Diseases inthe Indonesian Ministry of Health . Thisdecisive and energetic woman was deter-mined to revivify a discouraged and listlesshealth staff who had received little pay formore than 4 years because of a decision by theprevious government that health care costsshould be borne primarily by private individ-uals. Although the health staff were expectedto supplement meagre salaries throughcharges for their services, few were successfulin obtaining even subsistence wages . DrSulianti promptly asked for help from WHO .The regional office decided that Dr Kejashould visit Indonesia en route to an inter-country seminar on smallpox, due to begin inBangkok on 11 December . He arrived inJakarta on 7 December 1967 .

The third event was the development ofepidemic smallpox, beginning in August1967 with an outbreak in the capital city,Jakarta. By November, more than 50 cases aweek were being reported (Fig . 13 .1).

With Dr Sulianti, Dr Keja at once decidedto carry out a sample survey of the city to

Fig. 13 .1 . Jakarta Municipality : number of reported cases of smallpox, by 4-week intervals, 1963 -1967 .

629

630

Plate 13 .1 . Several national and intercountry seminars on smallpox eradication were held in Indonesia . At theconcluding seminar, in September 1972, Julie Sulianti Saroso, Director-General for the Control and Preventionof Communicable Diseases, presented an award to Nyoman Kumara Rai, who had directed the IndonesianProgramme since April . Standing behind the Director-General are 2 WHO advisers, G .G .O . Cuboni (for left)and W . L . R . Emmet .

assess vaccinial immunity-the first of manysuch surveys to be conducted during theglobal programme. For this survey, 20 fieldstaff from the smallpox and malaria pro-grammes were selected and trained. Eachexamined 200 children for vaccination scarsand the facial pockmarks of smallpox in ahouse-to-house survey beginning from ran-domly selected points in the city . In only 4days, the survey had been completed and theresults analysed. From the survey and a reviewof other available data, it was apparent thatthere were major problems :

(1) Reporting was incomplete . In all, 1265cases and 413 deaths had been recordedduring 1967, but because so many cases werefound during the survey the actual number ofcases was thought to be at least twice thisfigure .

(2) The number of vaccinations given wasinsufficient to sustain immunity. JakartaMunicipality's 49 vaccinators had performed384 000 vaccinations in 1967, but only 35 295(9.2%) had been primary vaccinations. In a

SMALLPOX AND ITS ERADICATION

population of 1 .4 million, with a birth rate of40 per 1000, it was calculated that 56 000primary vaccinations would be requiredannually simply to protect newborn infants.

(3) The proportion of successful primaryvaccinations was unsatisfactory . Take rates ofonly 60-80% were observed, a phenomenonattributed to the use of vaccine of lower thanacceptable titre as well as unsatisfactoryvaccination technique.

However, vaccinial immunity, though stillnot adequate, was found to be far higher thanexpected. Vaccination scars were seen in 90%of children aged 5-14 years, in 75% of thoseaged 1-4 years, and in 45% of infants agedless than 1 year . Nevertheless, the situationwas clearly disturbing . Smallpox was spread-ing rapidly throughout a reasonably wellvaccinated urban population ; the vaccinationcampaign was lagging and was further com-promised by the use of substandard vaccine ;extension of the epidemic into less wellvaccinated rural areas was only a matter oftime. A programme for smallpox eradication

13. INDONESIA

Table 13 .1 . Indonesia: population and number and category of administrative units, by island, 1968

was urgently needed and indeed its develop-ment proceeded rapidly .

The above-mentioned WHO intercountrysmallpox seminar in Bangkok, which, bylucky timing, took place immediately afterthe Jakarta survey, provided the opportunityfor a draft plan of operations to be finalized .Indonesia's representative, Dr IgnatioSetiady, Director of Communicable DiseaseControl, met Henderson and Dr Keja, andusing the latter's earlier prepared draft,worked out a plan for the programme andestimated the cost involved and the assistancerequired .

A critical problem, and one that was neverreally solved, was that of providing Indones-

Plate 13 .2 . Ignatio F . Setiady (b . 1929), Directorof Communicable Disease Control, at the 1967WHO seminar in Bangkok, Thailand, where plansfor the Indonesian programme were worked out .

631

a Population estimates as recorded in 1968 . United Nations (1985) data show a total population of 114 798 000 for Indonesia in 1968 .

ian staff with high enough salaries to permitthem to work virtually full time . Vaccinators,for example, were then receiving the equiv-alent of US$2 a month, which was insufficientto buy food for themselves, let alone for theirfamilies. WHO's resources could not dealwith the situation in its entirety . Despite thisproblem, it was apparent from the survey thatsomehow a large proportion of the popu-lation was being vaccinated. With hope ratherthan confidence that the vaccinators wouldcontinue to function, it was agreed thatsupplementary WHO funds would be pro-vided to a small number of senior Indonesianstaff to permit them to carry out full-timesupervisory functions ; other personnel wouldnecessarily work only part time, and fieldoperations would have to take this intoaccount. WHO also agreed to provide amedical officer and to purchase various items,including 15 vehicles, 135 motor cycles, 1550bicycles, 23 refrigerators and vaccine pro-duction equipment . By the end of December,funds for equipment and supplies had beenobligated. Less than a month later, on 24January 1968, Indonesia's Minister of Healthsigned a formal agreement with WHO autho-rizing the programme. Field operations werescheduled to begin in June 1968 .

DEMOGRAPHY AND GEOGRAPHYOF INDONESIA AND ITS HISTORY

OF SMALLPOX CONTROL

The country's demographic and geographi-° cal features, as well as its remarkable history of

smallpox control, were determining factors inthe development and progress of theprogramme .

The Indonesian archipelago, extendingover more than 4800 kilometres, consists of

IslandEstimated Administrative unitspopulationa(thousands) Provinces Regencies Municipalities Subdistricts Villages

Bali 2097 1 8 0 50 560Java 73 224 5 82 24 1 514 21 910Kalimantan 4 844 4 28 6 376 6 120Maluku 932 I 4 I 51 1 605Nusa Tenggara 4 450 2 18 0 154 2 267Sulawesi 8 358 4 33 4 354 3 838Sumatra 18 579 8 52 19 669 9204West Irian 896 1 9 0 35 892

Total 1 13 380 26 234 54 3 203 46 396

632

Fig . 13 .2 . Indonesia : population density, 1968 .

some 13 000 islands, of which 3000 areinhabited. In 1968, 66% of the country's 115million people lived on the densely populatedislands of Java and adjacent Bali (Fig. 13 .2 ;Table 13.1). Most of them (83%) lived inlocalities with 5000 or fewer inhabitants or inrural areas . However, it was estimated thatfully 60% of the population could be reachedby motorized vehicle, 20% by boat and 20%on foot or by bicycle .

For administrative purposes, Indonesia in1968 was divided into 26 provinces, whichwere subdivided into 288 regencies andmunicipalities (Table 13 .2), consisting of3203 subdistricts . The smallest administrativeunit was the village . The size of the popu-lation in these administrative divisions variedconsiderably from one area to another .

Although organized vaccination cam-paigns in Java dated back to 1856, an extraor-dinarily effective campaign was begun in the1920s which was successful in interruptingsmallpox transmission as early as 1936 (Table13.3) .

Of the 21 cases recorded between 1937 and1940, 7 were found to be importations and theothers were suspected to be either import-ations or mistaken diagnoses (Polak, 1968) .The Second World War intervened andmorbidity reporting ceased. After the war, no

Table 13.2. Indonesia: number and populationrange of administrative units

SMALLPOX AND ITS ERADICATION

cases are known to have occurred in Indonesiauntil May 1947. The first cases were reportedfrom the Riau Islands, adjacent to Malaysia, inwhich smallpox was then endemic. Over thenext few years, the disease swept eastwardsacross the western and central islands of thearchipelago, 99 016 cases being reported in1950. However, smallpox did not spreadbeyond Sulawesi and West Nusa Tenggara tothe numerous but more sparsely populatedislands to the east-East Nusa Tenggara,Maluku and West Irian (Fig . 13.3) .

The methodology employed in the vacci-nation campaign of the 1920s and 1930s is ofinterest, since the structure and many of theoperational components of the campaign stillexisted in 1968 (Polak, 1968), although thenumber of staff had diminished and the

Table 13 .3 . Indonesia: number of reported cases ofsmallpox, 1924-1940

Number of casesYear

Total for Indonesia

Java

Other islands

Administrative unit Number Population range

Province 26 500 000-28 000 000Regency/municipality 288 50 000-1 000 000Subdistrict 3203 5 000-100 000Village 46 396 < 1000-10 000

1924 6 717 5 941 7761925 4 681 4 658 231926 855 843 121927 766 297 4691928 298 46 2521929 614 271 3431930 419 408 II1931 176 69 1071932 562 349 2131933 57 7 501934 9 4 51935 43 10 331936 80 1 79

1937 I I 01938 12 9 31939 2 2 01940 6 0 6

quality of performance was poorer . A trainedvaccinator was assigned a vaccination districtof about 100 000 persons . Under the super-vision of a medical officer who was respon-sible for several regencies, he travelled bybicycle and on foot through his assigned dis-trict on a strictly prescribed schedule. Duringeach 3-month period, he devoted 8 weeks toprimary vaccination and 5 weeks to revac-cination . Infants were brought to designatedcollecting points not more than 6 kilometresfrom their homes and up to 150 were vacci-nated daily. In the case of revaccination, up to500 persons were dealt with each day. Whenoutbreaks occurred, intensive programmesof vaccination were conducted in the areasinfected . Most vaccinators used liquidvaccine, produced by the government-ownedquasi -independent Lymph Institute inBandung (Biofarma), which had opened in1891 . In the more remote districts, a remark-ably stable, room-dried and vacuum-sealedvaccine was used which had been first pro-duced in 1926 (Otten, 1932) .

In the systematic vaccination campaign,resumed after the Second World War, bothliquid and room-dried vaccines and eventuallysome freeze-dried vaccine were used . High

13. INDONESIA

Lvw'J

tr

i

1

\

MALAYSIA

(.-A9\

SumatraKalima tan

Java

Q

1`

0

Sulawesi

Bali Nusa Tenggaraboa

OMaluku

DEASTTIMOR

PAPUA 0pg

NEW GUINEA

633

Fig . 13 .3 . Indonesia and adjacent countries . The heavy line shows the limit of the spread of smallpox after itsreintroduction in 1947 .

inflation rates and the drastic reduction ofsalaries of government health staff forcedvaccinators and other personnel to take ad-ditional jobs. Periodic ad hoc mass vaccinationcampaigns were also conducted, financed bylocal merchants and village organizations .The numbers of vaccinations reported byvaccinators in Java from 1963 to 1967 indi-cate the extent of activity (Table 13.4) .

In all, 15-25% of the population in thedifferent provinces were reported to havebeen vaccinated annually by the special vac-cinators. Of the total number of vaccinations,10-15% were recorded as primary vacci-nations. In addition, vaccinations were per-formed in local clinics and maternal and childhealth units ; these were not included in thetotals but their number was thought to belarge. On the basis of this information, it wasdifficult to guess the probable extent ofvaccinial immunity . Not only were the re-ports of vaccinations performed considered tobe suspect, but primary take rates werereported to range from 33% to 88% . Bothhigh and low rates were recorded during theuse of each of the 3 forms of vaccine thenbeing produced : liquid, room-dried, and asmall quantity of freeze-dried vaccine . Be-

634 SMALLPOX AND ITS ERADICATION

Table 13.4 . Java : Estimated population, 1965, and number of reported vaccinations in selected provinces,1963-1967

cause refrigeration facilities were limited, lowprimary take rates with the thermolabileliquid vaccine were understandable. The lowtake rates with the more stable freeze-driedand room-dried vaccines reflected, in part, thelow potency of some batches ; moreover, noneof the dried vaccine was kept under refrigera-tion, since the manufacturer claimed that itretained its potency at room temperature for18 months. Although a few batches attainedthis degree of stability, most did not.

Special mass vaccination campaigns hadbeen conducted in Jakarta in 1962-1963, inEast Java in 1964, in West Java in 1965 and inCentral Java beginning in the autumn of1966. The campaigns were not well super-vised or well coordinated and were chron-ically short of funds to pay vaccinators andto purchase vaccines from the Biofarmalaboratory .

Despite the apparently questionable effi-cacy of the campaign, vaccinial immunity inJava proved to be surprisingly high, althoughthe level of immunity varied widely from onelocality to another. Sample cluster surveys,similar to the one conducted by Dr Keja inJakarta in December 1967, were carried out inJanuary and February 1968 throughout Java .In all, 56 619 children under 15 years of agewere surveyed . All the children were exam-ined to determine whether facial pockmarkswere present and whether or not they had avaccination scar . From these studies, an esti-mate of the level of vaccinial immunity was

Table 13 .5 . Java : proportion of children susceptible to smallpox,a by age group ; surveys of December 1967-January 1968

a I.e ., children who had neither facial pockmarks characteristic of smallpox nor a vaccination scar .

obtained (Table 13.5), as well as an approxi-mation of the completeness of smallpoxnotifications.

Less than one-quarter of all the childrenwere considered to be fully susceptible to thedisease. Only 807 (1 %) had facial pockmarkscharacteristic of smallpox . Since persons lessthan 15 years of age constituted approximatelyhalf the population and since only a smallproportion of those older than 15 were fullysusceptible, it was assumed that not more thanperhaps 10-15 % of the total population werethen susceptible to smallpox . Not surpris-ingly, at that time more than 75% of small-pox cases were reported to be occurringamong children under 15 years of age (Table13.6) and upwards of 80% of cases occurredamong those without a vaccination scar .

SMALLPOX INCIDENCE, 1963-1967

National data for smallpox prior to 1963provide little indication as to the incidence or

Table 13 .6. Jakarta and East Java: age distribution ofcases of smallpox, 1965-1966

Age group (years) Jakarta West Java Central Java East Java

< 1 55% 51 % 46% 72%

1-4 25% 27% 7% 23%

5-14 10% 12% 3% 7%

0-14 22% 25% 12% 20%

Number of childrenexamined 4 148 19 069 19 041 18 509

ProvinceEstimated Number of vaccinations (thousands)

population, 1965(thousands) 1963 1964 1965 1966 1967

Central Java 20 225 3 601 3 866 6 188 4 648 7 386

West Java 19 122 2 542 2 106 2 986 3 294 3 545

Jakarta 3 500 634 1844 103 1344 469

JoSjakarta 2 462 370 318 637 381 1059

Age group

(years)Jakarta East Java

<I 13% 11%1-4 55% 37%

5-14 16% 28%I S 16% 24%

Number of cases 308 4442

Table 13 .7 . Indonesia: number of reported cases of smallpox, by province, 1963-1972a

a No cases were reported from Maluku, East Nusa Tenggara or West Irlan during this period.

geographical distribution of the disease . Notonly did villages and regencies fail to report toprovincial authorities, but many provincialadministrations submitted no reports to thenational authorities . The number of casesofficially recorded at the national level variedfrom 1000 to 10 000 during the period 1952-1962. Better data are available for the years1963-1967, because smallpox control staffvisited each of the provinces during 1968 tocompile provincial data from previous yearsin order to obtain baseline information . In1963, 17 431 cases were recorded, of which allbut 3658 were from West Java (Table 13 .7).The most complete data available pertain tothe years 1965-1967, and these show a widerdispersion of smallpox throughout the centraland western islands of Indonesia .

Major epidemics were reported in 2 areasduring the period 1965-1967 (Fig. 13 .4). In1965, East Java reported 36 120 of the 56 359cases recorded in Indonesia and this epidemicwas followed in 1966 by one in neighbouringWest Nusa Tenggara . Central and SouthKalimantan experienced epidemics in 1965,which gradually subsided over the next 2years without a planned vaccination cam-paign. Other provinces of Indonesia alsoreported significant numbers of cases, butbecause of inadequate reporting few conclu-

13. INDONESIA 635

sions can be drawn about the comparativemagnitude of the smallpox problem in theseareas. That reporting was seriously deficientwas shown in the January 1968 survey in Java.In this survey, estimates of recent smallpoxincidence were derived from the prevalenceof facial pockmarks. The survey revealed that,at most, 10% of all cases were actually beingreported . Thus, it was calculated that morethan 100 000 cases had occurred in 1967 inJava alone. Reporting from the other islands,in which the health resources were fewer, wasmuch less complete than in Java .

ORGANIZATION OF THEPROGRAMME, JANUARY JUNE 1968

Dr Sulianti lost no time in setting theeradication programme in motion . As a firststep she changed a meeting on tuberculosisvaccination scheduled for February 1968 intoa planning seminar for smallpox eradication .It was to be the first of a series of annualnational meetings which reviewed the pro-gramme's progress and established specificplans and targets for the succeeding year .Those attending included Dr Sulianti's staff ;senior health officials from the provinces,regencies and municipalities ; directors of

Province 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Ball 0 0 6 2 652 43 0 0 0 0 0Java:

West Java 13 773 2 994 809 1 419 4 518 9 548 11 966 4 490 186 34Jakarta 1155 174 99 223 1 504 1 231 392 130 9 0Jogjakarta 0 0 6 40 34 3 2 0 0 0Central Java 1 196 1509 3 289 2 727 2 563 4 608 1 689 28 0 0East Java 178 8 896 36 120 2 284 1448 264 20 0 0 0

Kalimantan :West Kalimantan 0 0 603 133 I 72 41 0 0 0Central Kalimantan 0 0 2 106 162 4 0 0 0 0 0South Kalimantan 0 0 5 621 1 863 314 9 0 0 0 0East Kalimantan 0 2 0 0 218 0 0 0 0 0West Nusa Tenggara 0 0 123 19 632 1 199 0 0 0 0 0

Sulawesi:North Sulawesi 0 0 0 0 0 0 I 0 0 0Central Sulawesi 0 0 2 0 0 0 0 0 0 0South-east Sulawesi 0 0 0 9 6 0 0 0 0 0South Sulawesi 0 386 149 71 664 101 832 1 721 1 451 0

Sumatra :Aceh 0 35 694 1 000 143 5 0 122 0 0North Sumatra 0 1 373 2 843 297 378 508 873 1 217 285 0West Sumatra ISO 1 262 2 695 1 244 0 0 350 23 0 0Riau 0 162 140 138 16 22 775 526 22 0Jambi 0 0 0 12 0 0 201 1 504 147 0South Sumatra 833 359 1 054 1 048 328 901 748 220 0 0Bengkulu 0 0 0 0 0 0 0 0 0 0Lampung 146 61 0 329 97 78 82 100 0 0

Indonesia, total 17 431 17 213 56 359 35 283 13 478 17 350 17 972 10 081 2 100 34

636

Estimates of the Completeness of Case Notification

It was common knowledge that many cases of smallpox were not reported to the healthauthorities but the general belief was that the true figure was not more than perhaps 2-3times the number of recorded cases . The fact that 10 067 cases were known in 1967 to haveoccurred that year was of concern to health officials but it was not cause for real alarm . DrKeja suspected that underreporting was a much more serious problem and performed anumber of simple calculations to estimate its magnitude . The 1968 survey teams had foundthat 39 out of 8636 children under 1 year of age had the characteristic facial pockmarks andthus had contracted smallpox during the preceding year, 1967 . Extrapolating from thisrate of .4.5 cases per 1000 to the entire population of children under 1 year (2 457 000), DrKeja arrived at a figure of 11 056 cases. However, since Indonesian data showed that 40%in this age group died of smallpox, he reasoned that the actual number who had hadsmallpox was 1 .67 times larger . Making further corrections to allow for the fact that at least10% survived without recognizable pockmarks, and calculating that those under 1 year ofage accounted for not more than one-fifth of all smallpox cases, he estimated that at least100 000 cases of smallpox had occurred during 1967 in Java alone, or 10 times more thanthe number recorded . The numbers in the survey were small and the method of estimation,although unsophisticated in statistical terms, was understandable to non-technical people .The Minister of Health was incredulous and asked other statisticians to examine the data .All of Dr Keja's assumptions served to understate the magnitude of the problem . Case-fatality rates among infants under 1 year were nearer 50% than 40% ; the proportion ofthose surviving without recognizable pockmarks was closer to 35% than 10% ; and theproportion of cases in Indonesia among those under 1 year was actually 14% rather than20%. Finally, Dr Keja had made no effort to correct the estimate to reflect the fact that thechildren who were examined were all less than 1 year of age and thus, on average, hadactually been exposed to smallpox only over a 6-month period. His decision to develop aconservative but understandable estimate had been deliberate . The figure of 100 000 caseswas impressive in itself. When Indonesian statisticians independently made their ownestimates, they calculated that the number of cases had more likely been in the range of200 000-500 000 . The Minister was persuaded that smallpox was indeed a problem of highpriority in Indonesia .

maternal and child health, school health andmalaria control programmes ; and representa-tives from the armed forces, the Ministry ofHome Affairs and the Central Bureau ofStatistics . The seminar represented a laudableeffort to involve a wide range of civil andmilitary authorities in the programmealthough, in fact, few of those present wereto make significant contributions until late inits course .

It was decided to launch the programme inJune 1968 in Java and Bali, in which 66% ofthe population lived, and to extend it to theouter islands a year later. Additional vacci-nators would be appointed for each subdis-trict (40 000-50 000 population), whichwould more than double the number thenin the field. However, they would work onlypart time, as did the others, because their payremained low . A supervisor would be ap-

SMALLPOX AND ITS ERADICATION

pointed for each regency (500 000-1 000 000inhabitants) and additional supervisory staffwould be provided at provincial and nationallevels. In each of the 90 regencies and the 6provinces, a "fire-fighting" team of 3 or 4persons would be formed from existing staffspecifically to contain outbreaks .

Because the vast majority of cases wereoccurring among the unvaccinated, vacci-nators were instructed to concentrate on pri-mary vaccination. The maternal and childhealth centres were directed to vaccinate allinfants attending clinics (estimated to repre-sent about 40% of the total number ofinfants) and the school health services tovaccinate all schoolchildren (correspondingto about 50% of all children of school age) .The newly developed bifurcated needles andthe multiple puncture technique of vacci-nation would be employed by all vaccinators

Smallpox cases per100 000 inhabitants

0

1-9

10-99

100

13. INDONESIA

SouthSumatra

Central

SouthKalimantan

Kalimantan

Central JavaEast Java South

Sulawesi

Fig . 13 .4 . Indonesia : number of reported cases of smallpox per 100 000 inhabitants, 1965 -1967 .

except the members of national surveillance- cold-storage depots would be established atcontainment teams, who would use jet injec- national, provincial and regency levels, andtors supplied by WHO . It was agreed that only that each batch of vaccine produced by thefreeze-dried vaccine would be employed, that

Biofarma laboratory would be tested by WHO

South-eastSulawesi

637

"PWP

638

SMALLPOX AND ITS ERADICATION

Table 13 .8 . WHO support for the Indonesia programme, 1967-1974 (US$)a

a Excluding the cost of supplies of vaccine .

Table 13 .9 . Indonesia : principal items of equipment provided by WHO, 1968-1971

laboratories and released for use only aftercertification that it met WHO standards ofpotency, stability and bacterial content .In support of the programme, WHO

eventually provided a total of US$1 300 363to cover the purchase of supplies and equip-ment, local costs and staff costs (Tables 13 .8and 13 .9) ; it also provided for the acquisitionof 4.1 million doses of vaccine . Indonesia'sexpenditure amounted to US$3 600 000 . Thetotal outlay was equivalent to just overUS$0.04 per head of population .

The central staff initially consisted of 4medical officers (later increased to 8), 7 healthinspectors (later 10) and 12 administrativestaff. A WHO medical officer was assignedthroughout the programme (Dr M . F . Polak,July 1968 January 1969 ; Dr ReinhardLindner, January 1969 July 1971 ; Dr G. G.O. Cuboni, May 1971-1973), and an opera-tions officer, Mr William Emmet, was ap-pointed in August 1970. WHO short-termconsultants assisted for a period of approxi-mately 24 man-months .The programme was conducted by a

specially created Smallpox Eradication Unitin the Directorate of Epidemic Control underthe direction of a motivated and committedphysician, Dr P. A. Koswara . This unit, inturn, reported to Dr Sulianti. At the provin-cial level, there was a smallpox eradicationprogramme section, also headed by a full-timemedical officer . At the regency/municipality

level, the responsibility for the programmerested with a medical officer assisted by anexperienced senior sanitarian and one or moreassistant supervisory sanitarians .

THE EARLY STAGES OF THEPROGRAMME, JUNE 1968 JULY 1969

At the beginning of the programme, pre-occupation with the vaccination componentwas perhaps inevitable. This approach hadproved effective in the late 1930s, despitereliance on the use of thermolabile glycero-lated vaccine in the main islands and avariably potent but stable room-dried vaccinein more distant areas . National and WHOprogramme staff believed that with an alreadyhigh level of immunity, the increased numberof vaccinators, using a freeze-dried vaccine ofassured potency, should be able to find andvaccinate the comparatively small proportionof susceptible people and so interrupt trans-mission rapidly. As would prove true in othercountries of Asia, this strategy did not work.

Throughout Indonesia, 3130 vaccinators-approximately 1 for each subdistrict-and324 regency supervisors conducted the pro-gramme. On average, this amounted to 1vaccinator for every 39 000 persons, the ratioranging from 1 to 9000 in sparsely inhabitedareas to 1 to 50 000 or more in denselypopulated regions . The pre-war procedure,according to which vaccinators visited each

Year WHO personnel Local costs Supplies andequipment Total

1967 - 164 121 081 121 2451968 15 544 19 674 204 562 239 7801969 40 499 48 000 70 947 1594461970 70 269 63 618 18 156 152 0431971 70 117 66 186 36 548 172 8511972 56 624 68 157 45 595 170 3761973 53 785 58 344 52 674 164 8031974 47 299 53 971 18S49 119819Total 354 137 378 114 568 112

1 300 363

Equipment 1968 1969 1970 1971 Total

Vehicles 15 4 2 3 24Motor cycles 135 135 160 0 430Bicycles 1 550 1 550 0 0 3100Outboard motors 0 9 10 0 19Refrigerators 23 16 34 0 73Jet Injectors 25 0 0 0 25

13. INDONESIA 639

village 4 times a year to give primary vaccina-tions and one-third of all villages to performrevaccinations, was modified to emphasizeprimary vaccination . During 8 weeks of eachquarter, vaccinators were instructed to visitall villages to give primary vaccination to allpreschool children (up to 4 years of age),including newborn infants . During the re-maining 5 weeks, they were instructed to visitone-quarter of all villages to vaccinate orrevaccinate all children aged 5-14 years . Theprogramme was modified in Bali, in whichvaccination was entrusted to malaria surveil-lance workers. If well executed, this intensi-fied campaign would have ensured, within 1year, vaccinial immunity in nearly all childrenfrom birth to 14 years of age, the age group inwhich most cases were occurring.

The problems of vaccine supply and qualitywere gradually resolved over a period of 18months. Biofarma ceased production of theliquid and room-dried vaccines and began toproduce freeze-dried vaccine only . UNICEFprovided additional vaccine productionequipment and WHO recruited consultantassistance for the laboratory . Better methodsof quality control, as well as improved pro-

Plate 13.3 . Petrus Aswin Koswara (1931 - 1974), directed the national programme until April 1972 . Standingat centre, he is speaking with Dr Hasan Anoez, Provincial Medical Officer in South Sulawesi, and D .A. Hendersonin 1971 .

duction methods, were instituted . By the endof 1968, the quality of the freeze-driedvaccine began to meet accepted WHO stan-dards and, during 1969, the laboratory beganto produce sufficient vaccine to meet Indo-nesia's needs . In the meantime, vaccine do-nated to WHO by New Zealand, Thailand,the USSR and the USA augmented the supply .National and provincial cold-storage depotswere already available ; WHO providedadditional refrigerators for use at theregency level . To simplify procurement anddistribution, the national health authoritiesdecided to purchase all vaccine from Biofarmawith national funds and to distribute itwithout charge to provincial health depart-ments, which, in turn, were to distribute thevaccine to regencies.

Not surprisingly, a host of problems arosein a programme which was to be so greatlystrengthened and executed in such a largepopulation with only 6 months of prelimi-nary planning and organization . One by one,these difficulties were resolved . To cite a fewof the more important : deliveries of vehicles,bicycles and other items transported by seawere delayed by months because of customs

640

SMALLPOX AND ITS ERADICATION

Plate 13.4 . Biofarma laboratory, Bandung, (A) which produced smallpox vaccine for the programme . Aslate as 1968, room-dried vaccine was still being prepared by the procedure introduced by Otten in 1926 . Thevaccine pulp was dried in desiccators (B), after which it was put in vials which were sealed under vacuum (C) .The vaccine was remarkably heat-stable but difficult to produce and was often contaminated with bacteria .

clearance formalities ; government fiscal pro-cedures were cumbersome and payments forvaccine to Biofarma were held up, resulting inthe periodic cessation of production in late1968 and 1969 ; payments to staff weresimilarly interrupted from time to time, witha consequent suspension of work ; the record-ing of cases and transmission of data wereseriously deficient ; and effective supervisionat the beginning of the programme wasminimal. All these problems had to be dealtwith more or less simultaneously and allpersisted to some degree or recurred through-out most of the programme .

For the vaccination campaign, it was decid-ed to establish an annual target for primaryvaccinations equivalent to 6% of the popula-tion and one for revaccinations equiv-alent to 30% of the population . It was anunrealistic expectation, given that the vacci-nators worked only part time and that thesupervision and planning of vaccinator tourschedules were marred by lack of experience .Vaccinators on average performed only 20-80 vaccinations per day, of which between 2and 20 were primary vaccinations. The pro-gramme never met its targets, although itbegan to approach them in 1970 (Table13.10). A repeat stratified cluster samplesurvey in June 1969, similar to that performedin January 1968, showed no significantchange in the proportion of susceptible per-sons (Wkly epidem . rec., 1969c) .

The plan had called for "fire-fightingteams" at regency level to contain outbreaks,but few of the regency teams functionedwell-and most of them not at all-because oflack of interest and motivation . Vaccinationto control outbreaks was neither thoroughnor systematic ; the sources of cases were nottraced, and few of the locales of outbreakswere revisited to ensure that transmission hadbeen stopped .

Indonesia, so densely populated, hadseemed to be an ideal place to use jet injectors

Table 13.10 . Indonesia : number of primary vaccinations and revaccinations, 1968-1973

13. INDONESIA

641

in outbreak containment . The injectors wereprovided by WHO and, in August 1968, aconsultant was recruited to train specialvaccination teams in their use and main-tenance. As was true in many other areas, theconcept was attractive in theory but disap-pointing in practice. Except in urban areas,the population was not accustomed to gather-ing in large numbers at collecting points, andunless they did so the considerable capacity ofthe injectors could not be realized . Main-tenance and repair of the injectors and thelogistics of providing a flow of spare partsproved to be formidable obstacles. Within ayear, the jet injectors had been abandoned infavour of bifurcated needles . Not only did thelatter yield far better results in comparisonwith the old vaccinostyle (as was revealed in ashort trial in Ciloto, West Java) but they alsoproved to be considerably more economical inthe use of vaccine . Beginning in March 1969,the bifurcated needle was accepted as thestandard equipment for vaccination in theprogramme .

Improvement in the supervision and exe-cution of the programme was needed at alllevels and, to effect this, 13 "advance teams"(1 each in Jakarta, Jogjakarta and Bali, 2 inEast Java and 4 each in West and Central Java)were established in January 1969 . These teamsprovided a critical link in supervisionbetween the national programme directorateand the regencies and were ultimately instru-mental in instituting an effective surveil-lance-containment programme . They weregiven a month of special training and sent tothe field . Each team was provided with aWHO vehicle and was headed by a physicianwho was able to work full time in theprogramme, thanks to a salary subsidy paidby WHO. The initial plan called for theteams to spend two-thirds of their time insurveillance and containment activities andone-third in improving the supervision ofvaccinators .

Number of vaccinations Percentage of population coveredYear Primary

vaccinations Revaccinations Total Primaryvaccination Revaccination

1968 3 565 995 13 372 121 16938 116 3 .1 11 .61969 4 088 302 22 764 044 26 852 346 3 .5 19 .41970 5 755 770 27 058 671 32 814441 4 .8 22 .51971 4 957 651 19 668 733 24 626 384 4 .0 16 .01972 3 849 808 8 843 681 12 693 489 3 .1 7 .01973 3 874 766 6 329 022 10 203 788 3 .0 4.9

642

SMALLPOX AND ITS ERADICATION

Table 13 .11 . Indonesia: number of reported cases of smallpox by province and month, 1969a

a No cases were reported in Maluku, Ball, Nusa Tenggara or West Irian during this period .

Despite the chaotic beginning and thenumerous problems, remarkable progress wasrecorded in some provinces (Table 13 .11).East Java had experienced major epidemics in1964 and 1965 and, in consequence, hadconducted mass campaigns. However, thevaccination survey of December 1967-January 1968 (see Table 13 .5) showed thatvaccinial immunity was no better than inWest Java and far lower than in Central Javadespite the mass campaigns . In July 1968 adynamic Provincial Director of Communi-cable Disease Control, Dr Bahrawi Wongso-kusomo, and his assistant, Dr WitjaksonoHardjotanojo, took charge of the programmein East Java and vowed that they wouldinterrupt transmission before January 1969 .Vaccination activities were intensified,but-more important-any outbreaks foundwere energetically contained . During the last6 months of 1968, only 133 cases were detectedin the entire province . Between January andJune 1969, only 3 outbreaks occurred, each ofwhich could be traced to importations fromCentral Java ; all were well contained afterdiscovery. It was a remarkable achievement,accomplished almost wholly with provincialresources .

In Jakarta, under the leadership of DrGuno Wiseso, special teams equipped with jetinjectors demonstrated the efficacy of the

outbreak-containment strategy . During a 3-month period, they investigated and con-tained 73 outbreaks, in which 217 cases hadbeen reported (Wkly epidem. rec., 1970a). Theteams searched for additional cases, endeav-oured to find the origins of the outbreaksand vaccinated the inhabitants of the affectedadministrative units (about 200 persons ineach unit), as well as the people living in the 4surrounding units. During these activitiesthey discovered an additional 215 cases andvaccinated some 73 000 persons. A subse-quent assessment revealed that smallpoxtransmission had ceased within 2 weeks ofcontainment in two-thirds of the outbreaks(Table 13.12). Although these results wouldbe considered poor by later standards, it wasclear that outbreaks could, in fact, be quicklystopped .

No smallpox cases were reported in Bali orin the islands to the east after the programmebegan, and in February 1969 Jogjakarta re-corded its last cases. By June 1969, smallpoxin Central Java was being reported from only4 of 35 regencies but West Java continued toreport nearly 1000 cases per month . Mean-while, the complement of vaccinators andsupervisors in Java steadily increased and byJune had more or less reached the numbersplanned (Table 13.13) . In Kalimantan,Sulawesi and Sumatra, the programmes did

Province Jan. Feb . March April May June July Aug . Sept. Oct. Nov . Dec. Total

Java:West Java 1 691 1011 889 1 199 836 837 826 620 914

1 316 793 1 034 II 966Jakarta 66 35 45 60 43 28 11 37 34 21 9 3 392Jogjakarta I 1 0 0 0 0 0 0 0 0 0 0 2Central Java 467 162 141 160 136 137 231 119 66 19 20 31 1 689East Java 16 I 0 0 0 0 0 0 0 2 I 0 20

Kalimantan :West Kalimantan 2 3 14 5 2 2 3 I I 7 I 0 41Central Kalimantan 0 0 0 0 0 0 0 0 0 0 0 0 0South Kalimantan 0 0 0 0 0 0 0 0 0 0 0 0 0East Kallmantan 0 0 0 0 0 0 0 0 0 0 0 0 0

Sulawesl :North Sulawesi 0 0 1 0 0 0 0 0 0 0 0 0 1Central Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0South-east Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0South Sulawesi 2 2 0 0 39 62 92 259 110 107 76 83 832

Sumatra :Aceh 0 0 0 0 0 0 0 0 0 0 0 0 0North Sumatra 61 15 34 18 2 23 189 101 107 160 55 108 873West Sumatra 15 4 0 0 85 68 55 46 30 6 21 20 350Riau 0 0 0 0 0 73 82 570 16 20 2 12 775Jambi 14 0 4 0 0 4 II 14 0 42 93 19 201South Sumatra 64 25 8 86 24 5 3 153 163 102 75 40 748Bengkulu 0 0 0 0 0 0 0 0 0 0 0 0 0Lampung 22 12 23 2 2 0 0 0 0 21 0 0 82

Total 2 421 1 271 1 159 1 530

1 169

1 239 1 503 1920 1 441

1 823 1 146

1 350 17 972

Table 13 .12. Jakarta : number of weeks after containment in which new cases were detected, 1968

not officially begin until July 1969, and thusall reports were considered to be suspect .

The number of cases reported in Indonesiabetween January and June 1969 amounted to8789, a total not significantly different fromthe 8847 cases recorded during the sameperiod in 1968. Although the staff believedthat there was more complete reporting ofcases, it was impossible to measure the extentof improvement . What was certain, however,was that reporting was still incomplete . Thereporting of cases to the regency medicalofficer was the responsibility of village chiefs,but many chiefs completely neglected thistask, even though they were aware that caseswere occurring. Moreover, some regenciesfailed to report to the provinces, or, if theydid, the reports were greatly delayed . In June,reports from almost one-quarter of all prov-inces in Java and Bali were overdue by amonth or more. Reporting from other prov-inces was even more delayed and incomplete .

When the programme began, plans hadbeen made for its assessment by a WHO-Indonesia team one year later. In June 1969,this was undertaken and recommendationswere developed. The team was sharply polar-ized on the issue of mass vaccination . Onegroup maintained that, with vaccinialimmunity so high, the mass vaccinationcampaign could be said to have been com-pleted already and that all efforts should bedirected to surveillance and containment . Asecond group argued for a special campaign tomove rapidly and systematically throughoutthe country to vaccinate the now very smallproportion of people who had no vaccinationscars .

13. INDONESIA

Table 13 .13 . Java: population and number of vaccination staff and supervisors, June 1969

643

A compromise was reached and the teamsrecommended that : (1) special programmesshould be mounted to deal with the backlog ofunvaccinated children under 15 years of agein Jakarta and West and Central Java (thenumber was estimated to be 3 .3 million, or16.6% of a population of 19 .9 million chil-dren) ; and (2) surveillance should bestrengthened through improved reporting byvillage chiefs and other health staff, and moreactive outbreak containment by the special"fire-fighting" and advance teams . It wasrecognized that the backlog vaccination-cam-paigns would tax, and perhaps overstrain,available government resources, but the cam-paign was accepted as a component of thestrategy .

THE STRATEGY CHANGES,JULY 1969

The resources available did not permit theimplementation of backlog vaccination cam-paigns throughout the whole of Java, and sopriorities were defined . In East Java and theislands to the east, in which transmission hadbeen interrupted, efforts were to be directedsolely to the early detection and containmentof imported cases . In Central Java, lyingimmediately to the west, smallpox incidencewas declining and prospects for the earlyinterruption of transmission appeared good .Thus, the decision was made for vaccinationteams (called "backlog-fighting teams") tobegin work in the eastern regencies of CentralJava and to move westward in the expectationthat smallpox would progressively disappearin an east-to-west direction . Given the prob-

Province Population(thousands)

Number ofregencies/

municipalities

Staff category Ratio ofvaccinators

to populationPart-timemedical officers Supervisors Vaccinators

West Java 20 997 24 30 24 392 1 :54 000Central Java 22 268 35 35 33 498 1 :45 000East Java 26400 37 37 60 555 1 :48 000Jakarta 3 910 5 5 10 78 1 :50 000Jog)akarta 2714 5 5 5 74 1 :37 000Total 76 286 106 112 132 1 597 -

0 1 2 3 4 5 6 >_7

Outbreaks contained (62) 39 5 5 4 4 0 1 4Outbreaks still continuing (I I) 2 3 I 4 0 I 0 0

644

700

600

200

100

01968

1969

SMALLPOX AND ITS ERADICATION

1970

Fig . 13 .5 . Central Java : number of reported casesof smallpox, by month, 1968 -1970 .

ability that the situation in West Java wouldsoon follow the same course, backlog-fightingteams were scheduled to commence opera-tions in the province's 7 easternmost re-gencies .

As the backlog-fighting teams began vacci-nation in Central Java, the 4 provincialsurveillance teams started work in the north-west, where smallpox incidence was thehighest. Directed by a capable epidemiologist,Dr P. R. Arbani, these teams concentratedentirely on case detection and outbreak con-tainment. Gradually they extended the scopeof their operations to include the wholeprovince. The number of cases in Central Javadeclined dramatically (Fig . 13 .5). In Decem-ber only 31 cases were detected, and by May1970 the last case had occurred . The advanceteams had performed only 54 000 contain-ment vaccinations, a small fraction of the 5million vaccinations which were being givenannually in the province .

West Java presented a more formidableproblem. Provincial supervision had beeninadequate for many years and this wasreflected in the low levels of vaccinialimmunity throughout the province. Duringthe first half of 1969, an average of almost 250cases had been reported weekly-in a prov-ince whose notification system was the poor-

est in Java . In July, 4 special teams, eachconsisting of 5 vaccinators and a team leader,were recruited for each of the 7 regenciesbordering on Central Java (Koswara inWHO/SE/71.30). As in Central Java, theteams proceeded house by house and villageby village, performing primary vaccinationsand containing any outbreaks that werefound .

By October 1969, it became apparent thatsmallpox transmission was continuing inWest Java, even in regencies in which backlogfighting had been completed . Although theteams were instructed to intensify surveil-lance-containment activities, few did so. Inone regency, Tjirebon, in which no suchactivities had been conducted (Wkly epidem .rec., 1970a), a WHO adviser was assigned toundertake surveillance-containment activi-ties only . National staff supervised combinedsurveillance-containment and vaccinationprogrammes in 3 other regencies, includingBandung, in which smallpox incidence re-mained high. Two months later, in December,a main focus of smallpox in the province wasfound to be yet another regency, Bogor, inwhich so far no work was in progress .Resources were all but exhausted and only asingle team could be assigned there to conducta surveillance-containment programme .

Three different types of programme hadtherefore developed in an unplanned oper-ational experiment : (1) in Tjirebon, backlogvaccination was followed by an intensive

Plate 13 .5 . Reinhard R . Lindner (b . 1926) was theWHO smallpox adviser to the Indonesian programmefrom 1969 to 1971 .

Z0

0

00m

500x00

E400

0 Surveillance - containment

d

~„ 300

started

01 1

0C

surveillance-containment programme ; (2) inBandung, a combined backlog vaccinationand containment programme was directed bynational supervisors ; (3) in Bogor, a surveil-lance-containment programme only was con-ducted. The results of this experiment were todecide the subsequent strategy of the pro-gramme in Indonesia .

Tjirebon Regency

The backlog vaccination operation hadbegun in July 1969 and ended 18 weeks later .During 2025 man-days, the teams visited188 287 households in 267 villages . In all, 208smallpox cases were discovered in 24 villages .On completion of the work, a sample surveyshowed that the proportion of unprotectedchildren below 1 year of age had decreaseddramatically, from 83% to 26% ; of thoseaged 1-4 years, from 36% to 11% ; and ofthose aged 5-14 years, from 3% to 2% . Theillusion of a highly successful programme wasshattered when just 2 days after the pro-gramme had been completed, 12 mobile teamsfrom other provinces undertook a 2-daytraining exercise in Tjirebon . They discovered Ethat in 7 infected villages transmission wasstill continuing . By tracing the sources ofinfection, an additional 118 cases and 3undetected outbreaks were discovered .

Greater efforts were obviously needed, anda WHO consultant, Mr Michael O'Regan, wasassigned in mid-November. On arrival, hefound a frustrated but hard-working staffwith a disorganized record system and no day-to-day operational programme . In the yawsand leprosy programmes in which MrO'Regan had worked, methods had beendeveloped for the systematic search for casesthroughout extensive areas . Applying similarprinciples in Tjirebon, he obtained reliablemaps and lists of villages from the army and,with regency staff, planned a programmeconsisting of a systematic village-by-villagesearch for cases and house-to-house searcheswhen outbreaks were found . The basic workwas performed by 7 search teams each com-posed of 2 men on bicycles, their work beingsupervised by 2 search teams with vehicles . Inevery village, the programme was explainedto the village leader and assurances were giventhat, should he report a case, a team wouldcome to the village within 24 hours. Out-breaks, when discovered, were contained andthe locality concerned was revisited weekly

13. INDONESIA

645

until 4 weeks after the last case had occurred .Identification of the source of each outbreakpermitted the discovery of other, unreportedoutbreaks. Each night the staff met, reportedtheir findings and planned the followingday's work . The initial search revealed that, asat 1 December 1970, there were 31 villageswith active cases, but within 2 monthstransmission had been interrupted (Fig. 13 .6).

Intensivesurveillance-containment

Fig . 13 .6 . Tjirebon Regency : number of reportedcases of smallpox, by 4-week intervals, 1969-1970 .The last interval in 1970 includes 6 importations andII delayed reports of inactive cases.

646

SMALLPOX AND ITS ERADICATION

Cases continued to occur as a result ofimportations from other regencies but thesewere quickly contained . The Tjirebon pro-gramme was the first in the IntensifiedProgramme in which teams undertook asystematic area-wide search for cases withoutsimultaneously performing vaccinations . Thetechnique was later to be widely appliedthroughout Indonesia and was to prove vitalin interrupting transmission in the Indiansubcontinent.

Bandung Regency

In Bandung, the combined surveillance-containment and backlog-fighting operationunder the supervision of national staff hadbegun early in November 1968 and ended 26weeks later . The teams visited 401 490 house-holds in 242 villages and performed 163 194primary vaccinations ; 74 outbreaks with 565cases were detected and contained . Altogether4020 man-days were required. The resourcesneeded to interrupt transmission were evengreater than those expended in the Tjirebonprogramme .

Bogor Regency

A single surveillance team with a vehiclehad been assigned to Bogor in December1969, after a national team investigating areported outbreak discovered that not 1 but18 out of 24 subdistricts were infected .Because no additional resources could bespared, the team continued to work alone .During 42 weeks, active search and contain-ment detected 2101 cases in 101 villages, buttransmission was completely interrupted ;only 15 175 containment vaccinations wereperformed. Time was required to interrupt

Table 13.14. Tjirebon, Bandung and Bogor Regencies : percentage of children unprotected by vaccination, byage group, October 19703

aBased on Koswara (in WHO/SE/71 .30).

Plate 13 .6 . Vaccinators in Indonesia moved fromhouse to house, concentrating their efforts on youngchildren and infants who had not been vaccinatedpreviously . For this work, the bifurcated needle wasespecially valuable .

transmission in this densely populated area,but it was achieved at a cost of only 1802 man-days.

Factors Affecting Transmission

In October 1970, after transmission hadbeen interrupted in the 3 regencies, surveyswere conducted to determine comparativelevels of vaccinial immunity (Table 13.14) .

Smallpox transmission had been rapidlyinterrupted in Tjirebon once surveillance-containment measures had been effectivelyapplied, but vaccinial immunity was already

Less endemic area Highly endemic area

< I 28 44 86 661-4 11 12 46 325-14 6 7 23 18

0-15 12 14 39 30

Number of childrenexamined 8 342 8 480 768S 9S66

Percentage of children unprotected

Age groupBogor

(years)Tlirebon Bandung

high there. Success had also been achieved inBandung with improved supervision but at aconsiderable cost in resources . Bogor pre-sented a contrast . There, transmission had alsobeen successfully interrupted with surveil-lance-containment only, although 2-3 timesas many unprotected children remained . Theproportion that was unprotected was almostas high in the infected areas-in whichcontainment vaccination had been exten-sive-as it was in the less endemic areas .

Everyone involved in the programme wassurprised by the tenacity of smallpox in theseand other regencies of Java despite compara-tively high levels of vaccinial immunityand intensive surveillance-containmentmeasures. It was a contrast to the situationin Brazil and western Africa, in which surveil-lance and containment had quickly stoppedtransmission, even in less well vaccinatedpopulations (see Chapters 12 and 17). Indo-nesia, demographically and socially, was dif-ferent in several respects (Wkly epidem. rec.,1970a) . Population density in Java was one ofthe highest in the world and, traditionally,families carried children who were sick fromhouse to house to visit relatives . The traditionof isolating cases, so often observed in othercountries, was uncommon . Thus, many moresusceptible persons, on average, were exposedto smallpox cases than in most other areas .Because of high levels of vaccinial immunityand the greater frequency of exposure ofsusceptible persons, the age distribution of

13. INDONESIA

Table 13 . I5 . Comparative percentage distributionof smallpox cases, by age group, 1969a

Age group (years)

Jakarta

West Java

Brazil Pakistan

0-4

58

56

36

295-14

37

33

37

3915

5

11

28

31

aBased on Hartohusodo (in WHO/SE/71 .30) .

cases was different in Java from the corre-sponding distributions in Brazil and Pakistan,for example (Table 13.15) .

In Java, more than half of all cases werefound in children under 5 years of age ; fewcases occurred in adults . In Africa, SouthAmerica and Asia, cases were more evenlydistributed among all age groups .

Another factor of importance in smallpoxtransmission in Indonesia was climatic : small-pox was readily transmitted throughout theyear (Fig. 13.7). Indonesia, located between5°N and 5 °S of the equator, did not have thewide seasonal fluctuations in transmissionwhich were characteristic of countries such asBrazil, India and Pakistan (Wkly epidem. rec.,1969a) (see Chapter 4) . In these countries, inwhich transmission rates declined sharplyduring the summer and early autumn months,many chains of transmission terminatedspontaneously and the containment of out-breaks during these periods was comparative-ly simple . In Indonesia no such circumstancesobtained .

Fig . 13 .7 . Indonesia : number of reported cases of smallpox, by month, 1967-1972 .

647

648 SMALLPOX AND ITS ERADICATION

Smallpox Transmission in a Well-Vaccinated Area

An outbreak in Passar Minggu (population, 14 376), a densely populated section ofJakarta City, vividly illustrated the ability of smallpox to continue to be transmitted evenin well-vaccinated areas . In August 1970, the investigation of a death due to smallpox ledto the discovery of a chain of infection involving 20 cases extending over a period of 21weeks (see the figure below). A scar survey in the area revealed that only 2% of childrenbetween 5 and 14 years of age were unvaccinated (see table) . Overall, the proportion ofsusceptible persons in the area was only about 6%, almost none of whom were adults .

Passar Minggu : Vaccination Status of Children and Cases of Smallpox

The cases spread from one house to the next, usually over a distance of no more than 300metres (see illustration) . Nine of the cases resulted from intrafamilial transmission ; theremainder occurred through the visits of susceptible children to infected households .

0

300

300

I

1r

300

e11

01

1°1

3002000

O Denotes the presence of a case in a household and the case numberassigned to it .

200 Indicates the distance, in metres, between households .

Similar occurrences of slowly spreading endemic smallpox in well-vaccinated popula-tions were observed throughout the rural areas of West Java and, to some extent, of CentralJava. In the other endemic areas of Indonesia, none of those which experienced smallpoxafter 1968 was so densely populated and smallpox there was far more easily contained .

Age group(years)

(Emmet in WHO/SE/71 .30)

Percentageunvaccinated

Number Ofcases

<1 61% 21-4 20% 11

5-14 2 % 5>15 2

649

Fig . 13 .8 . Java : number of reported cases of smallpox, by regency, January - February 1969 and January -February 1970 .

THE SURVEILLANCE-CONTAIN-MENT STRATEGY BECOMES FULLY

ESTABLISHED

Despite the problems of the backlog vacci-nation campaign and the diversion of re-sources from surveillance-containment ac-tivities, progress was made in the "east-to-west" strategy in Java (Fig. 13.8). By February1970, endemic smallpox remained solely inWest Java. In Central Java, during 1970,only 28 cases were detected, all of which rep-resented outbreaks due to importations . Mean-while, programme activities were extendedto the outer islands .

Reporting, which had been so incompleteand greatly delayed, improved markedly in1970 following the assignment of a full-timemedical officer, Dr A. Karyadi, to assumeresponsibility for surveillance and data collec-tion. Simplified standardized reporting formswere adopted for the weekly reports and agoal was set for the receipt of reports with adelay of no more than 2 weeks from provincesin Java and of no more than 3 weeks from theouter islands (Karyadi in WHO/SE/71 .30) .

13. INDONESIA

Defaulting provinces were repeatedly contact-ed by letter, telegram, messenger and personalvisits to promote compliance . Cooperationwas sought from civil authorities as well . Inthe absence of an adequate postal service,many methods were utilized for the transmis-sion of provincial reports, including courierssuch as bus drivers, businessmen, specialmessengers and military personnel . Provincialauthorities, with assistance from the smallpoxeradication staff, sought to obtain promptlythe weekly reports from regency medicalofficers and health units . To simplify report-ing, the data requested were limited to thenames of infected villages and subdistricts,the numbers of cases and deaths, the ages ofcases, and the source of infection of eachoutbreak. Beginning in May 1970, a nationalweekly surveillance report was preparedwhich documented smallpox incidence andprogress in the campaign . This was distribut-ed to health authorities throughout Indone-sia. In September 1970, Dr Karyadi was ableto report that 95% of weekly reports werebeing received from provinces in Sumatra andSulawesi within 3 weeks. Just one year pre-

650

SMALLPOX AND ITS ERADICATION

Table 13 .16 . Indonesia : number of reported cases of smallpox, by province and month, 1970a

viously, only about half as many reports werebeing received, and then with delays of up to21 weeks. An increasing number of cases beganto be reported from Sumatra, reflecting betternotification (Table 13 .16). Despite improvedreporting, the number of provinces reportingcases began to fall drastically as from thebeginning of December 1970 (Fig. 13.9) .

a No cases were reported in Maluku, Kalimantan, Ball, Nusa Tenggara, West Irian or Jogjakarta during this period.

Fig . 13 .9 . Indonesia : number of provinces reporting cases of smallpox, by month, 1969 -1972 .

In West Java, 8 mobile surveillance-con-tainment teams worked with regency teams incarrying out active search operations andoutbreak containment . As the year pro-gressed, area vaccinators devoted less time toroutine vaccination and more to systematicsearches to detect cases and to contain out-breaks, as was done in Tjirebon. Initially,

Province Jan . Feb. March April May June July Aug. Sept. Oct . Nov. Dec . Total

Java:West Java

1 153

1 123 679 701 242 210 169 88 20 63 36 6 4 490Jakarta 2 2 1 14 1 0 23 4 39 0 1 43 130Central Java 5 8 11 4 0 0 0 0 0 0 0 0 28East Java 0 0 0 0 0 0 0 0 0 0 0 0 0

Sulawesi :North Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0Central Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0South-east Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0South Sulawesi 232 340 102 65 42 161 175 34 103 130 101 236 1 721

Sumatra :Aceh 0 0 56 55 I 0 0 0 0 6 0 4 122North Sumatra 34 26 61 220 108 171 214 132 54 60 99 38 1 217West Sumatra 3 0 6 12 0 0 0 0 0 0 0 2 23Riau 40 0 0 0 34 324 35 0 0 76 0 17 526Jambl 283 248 318 229 11 7 102 0 24 19 17 246 1 504South Sumatra is 20 10 78 27 15 13 6 0 36 0 0 220Bengkulu 0 0 0 0 0 0 0 0 0 0 0 0 0Lampung 0 I 0 58 2 10 12 5 12 0 0 0 100

Total

1 767 1 768 1 244 1 436 468 898 743 269 252 390 254 592 10 081

The Development and Use of the WHO Smallpox Recognition Card

Events which led to the development of the WHO smallpox recognition card and theuse of schools in the search for cases in Indonesia occurred in Bandung . Among the manyvaccinators engaged in search activities, there was one who recorded exceptional success indetecting outbreaks . Supervisors noted that, paradoxically, this vaccinator was consideredto be one of the laziest workers-the last to leave for the field and the first to return home .When asked how he was so successful, he admitted that instead of visiting all the houses in avillage, as instructed, he was visiting only the schools . There he showed children andteachers pictures of smallpox cases which appeared in a WHO teaching folder on smallpoxdiagnosis that had been prepared for Africa. Numerous case notifications were obtainedwith the minimum effort .

The teaching folder contained many different pictures of smallpox in African children .The photographs were small and the smallpox rash on a black skin appeared to differsomewhat from the rash on the skin of Indonesians, which was much lighter in colour .Nevertheless, most children had recognized the disease. Programme staff suggested thepreparation of a single large picture of an Asian child with smallpox for use as a recognitioncard. Thus, the WHO smallpox recognition card was first prepared, encased in plastic fordurability, and widely distributed around the world .

vaccinators were requested to search house byhouse, but because of the small numbers ofvaccinators available, they were subsequentlyasked to contact specific persons and the staffof various facilities who would be the mostknowledgeable regarding the existence ofsmallpox cases : (1) health units such as clinics,hospitals and aid posts ; (2) civil officials,notably village chiefs, who in Indonesia hadconsiderable authority in their designatedareas ; and (3) schoolchildren and teachers .Maps were prepared for each area, showingthe principal sites and persons to be visited . Atour schedule was established to ensure thateach was visited at least once a month . It wasduring these operations in West Java that theconcept arose of printing smallpox recogni-tion cards, depicting in colour a case ofsmallpox, which could be shown to thosebeing contacted . This idea, which was pro-posed by Indonesian field staff to WHOregional office and Headquarters staff, wasadopted and eventually tens of thousands ofsuch cards were printed and distributedwidely in Indonesia and other endemic coun-tries throughout the world (see Chapter 10) .

Containment activities were ever morerigorously defined and performed. In eachoutbreak, the "fire-fighting" or advanceteams ensured that patients were isolated intheir houses ; the names of all villagers wererecorded and everybody was vaccinated ; thesource of infection was identified and investi-

13. INDONESIA 651

gated ; and the teams remained in the villageat least overnight to ensure more completevaccination of those working in the fields orabsent during the day at the market or inschool .

STRENGTHENING OFPROGRAMMES IN THE OUTER

ISLANDS, 1970

Until 1970, resources and energies wereprincipally directed to the containment ofsmallpox in the heavily populated island ofJava. With the number of cases decliningrapidly in Java during 1970 (from 1160 inJanuary to 210 in June and to 49 in December)additional resources could be diverted to thetwo outer islands still harbouring smallpox-Sumatra and Sulawesi.

Sumatra had the higher priority because ofthe extensive inter-island boat traffic withJava. The programme in Sumatra had begunin July 1969 with an intensified vaccinationcampaign conducted by 567 vaccinators and73 supervisors. As in Java, this had little effecton smallpox incidence . During 1970, moreresources were made available to the pro-gramme (Wkly epidem. rec., 1970d), notablytransport and assistance from national cam-paign staff, and the strategy shifted fromintensive vaccination to surveillance-con-tainment. Smallpox spread less rapidly in the

652

more sparsely populated Sumatra and success-ful containment was easier, but this advantagewas counterbalanced by a less-developedhealth structure and poorer supervision . InSumatra, priority was given to the southernprovinces, those nearest Java, to minimize therisk of importations. In October 1970, SouthSumatra recorded its last cases, but thenorthern provinces (North Sumatra, Jambiand Riau) did not become smallpox-free untilAugust 1971 .

Sulawesi also began its programme in July1969, with 355 area vaccinators and 38supervisors. Endemic smallpox, however, wasfound only in South Sulawesi (population,5 million). Progress was slow : the ruggedmountainous terrain made travel difficult ;communication with villagers was a problembecause 15 different dialects were spokenthere ; and the civil and health infrastructure,after prolonged and devastating civil distur-bances, was less developed than in Sumatra orJava. The interruption of transmission inSulawesi was to require the best skills ofexperienced national and WHO staff and themost effective application of now well-

SMALLPOX AND ITS ERADICATION

defined techniques for case search and out-break containment.

Only 59 vaccination staff worked in SouthSulawesi-less than half the number planned .Throughout 1970 comparatively little pro-gress was made . However, early in 1971, withsmallpox transmission all but interrupted inJava and with incidence rapidly diminishingthroughout Sumatra, senior national staff andWHO advisers transferred to Sulawesi, andadditional automobiles, motor cycles andbicycles were assigned to the programme .The WHO smallpox recognition card beganto be used in contacts with schools and civilauthorities. In March 1971, a planned pro-gramme of meetings with village chiefs andother civil administrators was instituted inorder to acquaint them fully with the pro-gramme and to solicit their help in theprompt reporting of suspected cases . Manyconscientiously fulfilled this responsibilitythrough special search programmes whichthey independently organized . Isolation ofpatients in their houses, containment vacci-nation, both by day and by night, search forthe sources of outbreaks and identification of

Plate 13 .7 . Schoolchildren parade in support of the national smallpox eradication programme in SouthSulawesi, Indonesia .

Table 13 .17 . Indonesia : number of reported cases of smallpox, by province and month, 1971 a

exposed individuals who had left infectedvillages were more rigorously executed . Withimproved surveillance and containmentmeasures and heroic efforts by national andWHO staff, smallpox transmission came to anend in South Sulawesi in November 1971(Table 13.17) .

Immediately after the apparent detectionof the last case, the 1208 vaccinators inSulawesi, Sumatra and Kalimantan searchedvillage by village during a 4-month period,reaching 18 205 (73.5%) of the 24 781 vil-lages in the process. Although 920 suspectedcases were examined and 76 specimens weretaken, none revealed the presence of smallpox(WHO/SE/74.63, Cuboni et al .).

In the island of Kalimantan (population,5 million) and in the other provinces ofSulawesi, provincial and local health staff,without significant additional support fromnational or WHO staff, had unexpectedlysucceeded in interrupting transmission asearly as November 1969. How this wasachieved is not fully documented . Kaliman-tan had experienced a major epidemic ofsmallpox, with large numbers of reportedcases, during 1965-1967 . The epidemic mayhave begun before 1965, although no earlierdata are available . Because reporting was soincomplete, it is probable that the actualnumber of cases may have been 100 times or sogreater than the number recorded .

Programme staff at the time speculatedthat natural immunity induced by the epi-demic, combined with extensive vaccination,

13. INDONESIA

653

a No cases were reported in Kalimantan, Bali, Nusa Tenggara, West Irian or Jo8jakarta during this period .

had so reduced the number of susceptiblepersons that transmission was interruptedeven though the surveillance-containmentprogramme was much less effective than inother areas. However, a high level of immun-ity was not the primary explanation for theinterruption of transmission in Kalimantanand in Central, South-east and NorthSulawesi, as was shown in a February 1974survey . At that time, Indonesian staff con-ducted random cluster sample surveys amongchildren throughout these provinces (Table13.18) (WHO/SE/74.66, Cuboni et al .) . Inmost provinces, more than one-third of allchildren remained susceptible . Immunity lev-els were substantially below those in most ofJava, in which health services were far moreextensive.

Important to the interruption of trans-mission was the fact that the populations ofKalimantan and Sulawesi were concentratedin discrete areas, primarily along the coast .Communication between these populationcentres was much more difficult than in Javaor Sumatra. In effect, they were more like aseries of comparatively small island popu-lations than a land mass over which travelwas easily accomplished. Many outbreaksundoubtedly terminated spontaneously andothers responded to comparatively perfunc-tory containment and vaccination activities,as was the case in much of Africa, forexample . After transmission had been inter-rupted in an area, smallpox was reintro-duced only infrequently .

Province Jan. Feb. March April May June July Aug. Sept. Oct. Nov . Dec. Total

Java:West Java 9 24 17 12 0 0 0 0 0 0 0 129 186Jakarta 4 0 0 0 0 0 0 0 0 0 0 0 9Central Java 0 0 0 0 0 0 0 0 0 0 0 0 0East Java 0 0 0 0 0 0 0 0 0 0 0 0 0

Sulawesi:North Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0Central Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0South-east Sulawesi 0 0 0 0 0 0 0 0 0 0 0 0 0South Sulawesi 149 155 403 220 130 98 142 73 37 25 19 0 1 451

Sumatra:Aceh 0 0 0 0 0 0 0 0 0 0 0 0 0North Sumatra 40 90 20 30 I 56 34 14 0 0 0 0 285West Sumatra 0 0 0 0 0 0 0 0 0 0 0 0 0Riau 12 10 0 0 0 0 0 0 0 0 0 0 22Jambi 62 35 44 5 1 0 0 0 0 0 0 0 147South Sumatra 0 0 0 0 0 0 0 0 0 0 0 0 0Bengkulu 0 0 0 0 0 0 0 0 0 0 0 0 0Lampung 0 0 0 0 0 0 0 0 0 0 0 0 0

Total 276 314 484 267 132 154 176 87 37 25 19 129 2 100

654

SMALLPOX AND ITS ERADICATION

Table 13 .18. Kalimantan and Sulawesia : percentage of children unprotected by vaccination, by age group,February 1974

a South Sulawesi excepted .

INDONESIA'S LAST OUTBREAK, 1971

After the last cases occurred in Sulawesi inNovember 1971, 4 weeks elapsed duringwhich no smallpox cases were reported inIndonesia. It appeared that transmission hadbeen interrupted, but on 14 December 1971,the Director of the Smallpox EradicationProgramme received a report from Tanger-ang Regency (one of the 24 regencies/munici-palities in West Java) of 45 cases and 6 deathsin Sepatan Subdistrict, only 28 kilometresfrom Jakarta. Tangerang (population, Imillion) had recorded its last cases inFebruary 1971, fully 10 months earlier . Avillage-by-village search had been conductedin West Java between June and August 1971in the subdistricts which had reported casesduring 1970-1971 ; lack of personnel hadprecluded a search in all subdistricts . SepatanSubdistrict had not reported cases during thisperiod and thus had not been searched .

On investigation, it was found that as earlyas December 1970, a whole year earlier, manycases in Sepatan had begun to be reported tothe health centre by the subdistrict's vacci-nator. The medical officer of the healthcentre periodically organized ineffectual massvaccination campaigns to control the out-breaks but deliberately suppressed thereports of smallpox, fearing that he might be

punished for incompetence . In mid-December1971, a provincial mobile surveillance andsupervisory team visited the area on routinetour and was informed of the outbreaks by thelocal staff (Cuboni et al . in WHO/SE/76 .85).

Search and containment activities wereimmediately instituted . In the realization thatthe suppression of reports might be widelyprevalent, the decision was made to offer atransistor radio to any person who reportedan active case of smallpox. This, so far as isknown, was the first occasion in the Intensi-fied Programme when a reward was offeredfor case reporting. It proved to be highlyeffective. Numerous suspected cases withillnesses of all types were reported by peoplethroughout the area. Eventually, 160 small-pox cases with 15 deaths were confirmed in 3villages (total population, 7982) of SepatanSubdistrict ; nearly one-third were unprotect-ed when containment vaccination had begun(Table 13.19) .

The outbreak had started in Sarakan villagein December 1970 (Fig. 13.10), 1 year pre-viously, as a result of an importation fromWest Jakarta. Smallpox spread slowly, only 14cases occurring between December 1970 andMay 1971 . Eventually, the outbreak wascontained by a local vaccinator. Meanwhile thedisease had spread to Sangiang village in May1971 and, in September, numerous cases began

Table 13 .19. Sangiang, Sarakan and Gaga villages, Sepatan Subdistrict : number of vaccinations performedduring containment operations, 1972

a I .e ., those receiving primary vaccination as a percentage of the total vaccinated during the containment phase .

Province Population(thousands)

Number Percentage unprotected in age group (years):surveyed 0-1 1-4 5-14 0-14

West Kalimantan 2084 3403 87 60 20 42Central Kalimantan 643 3 173 81 44 18 35South Kalimantan 1 907 3 154 84 57 26 45East Kalimantan 714 3 321 79 43 22 35Central Sulawesi 885 3 989 73 39 12 30North Sulawesi 1 710 6 880 72 36 16 34South-east Sulawesi 716 3 618 68 30 8 26

VillageNumber of vaccinations

Percentageunprotecteda

Number ofcasesPopulation Primary

vaccination Revaccination Total

Sanglang 3 106 1 142 2013 3 155 36 131Sarakan 1904 307 1 371 1678 18 17Gaga 2 972 917 1 627 2 544 36 12

VILLAGES

Kupahandap

Gaga

Sangiang

Sarakan

O2 Indicates numbers of casesin each village each month

Fig . 13 .10 . Indonesia : last chain of smallpox transmission, 1970-1972 .

to occur. In all, 131 persons eventuallydeveloped smallpox in this village of 3106persons . At the end of November the diseasewas reintroduced into Sarakan village and, inDecember, it spread to nearby Gaga village .Finally, late in December, an outbreak of casesdeveloped in a village 80 kilometres distant .The last 2 known cases in Indonesia occurredon 23 January 1972, one of them in Gagavillage, and the other in Kupahandap village .

Concerned that other hidden foci might bepresent elsewhere in Indonesia, the pro-gramme staff decided in May 1972 to offer areward of 5000 rupiah (US$12) to anyonereporting a case. This was widely publicized .The following month, teams from through-out Indonesia began an active search pro-gramme. Numerous rumours were investi-gated and many specimens were examined,but no further cases were found. A summaryof the numbers of specimens examined inlaboratories during 1969-1973 (Table 13.20)indicates the extent of this activity.

MORBIDITY AND MORTALITYPATTERNS

Smallpox in Indonesia exhibited two un-usual features : (1) an exceptionally large pro-portion of cases among younger children ;and (2) case-fatality rates which were oftenlower than those observed elsewhere in Asia .

In June 1969 the joint WHO-IndonesiaAssessment Team analysed the age distribu-tion of 3823 cases in selected areas and duringperiods when reporting was considered to bereasonably complete (Table 13 .21). The agedistributions were similar in West andCentral Java and Jakarta, in which smallpox

13. INDONESIA

Discovery of epidemic

655

was then endemic. Cases in East Java occurredprimarily in outbreaks following importa-tions and the patients were generally older, aswas the case in other non-endemic areas.Excluding the data for East Java, 68 % of casesoccurred in children aged 0-4 years, a groupwhich comprised only 18 % of the populationof the country . A surprisingly high inci-denceabout 12%-was found in infantsunder 1 year of age, twice the proportionrecorded in India .

Smallpox spread in Indonesia more readilythan in most parts of the world and trans-mission occurred throughout the year withno apparent seasonal pattern . The facility ofspread can be attributed to the high popula-tion density and the custom in Indonesia ofcarrying sick children to visit relatives, thusexposing many more susceptible individuals .

The reported case-fatality rates in manyyears and during most outbreaks appeared tobe lower than those in the Indian subconti-nent. This is the converse of what might havebeen expected, because cases in Indonesiawere proportionately more numerous in thevery young, among whom case-fatality ratesare customarily higher . The question whethercase-fatality rates in Indonesia were substan-tially and uniformly lower than those in theIndian subcontinent was never resolved . Thereporting of both cases and deaths was grosslyincomplete throughout Indonesia before1968. The degree of underreporting of casescompared to that of deaths undoubtedlydiffered from year to year . This probablyaccounted for such discrepancies as a case-fatality rate of 10% in 1950 and one of 44%only a year later . With the commencement ofthe national programme, the reporting ofcases gradually improved, more rapid pro-

O

O © © m m

(D (D

D 1 1 11970 1971 1972

656

SMALLPOX AND ITS ERADICATION

Table 13.20 . Indonesia : laboratory examination of specimens, 1969-1973

gress being achieved in some areas than inothers. However, as in other countries, fewefforts were made to improve the complete-ness of the notification of deaths. Since theprogramme's goal was to interrupt the trans-mission of smallpox, it was more importantto know where and how many cases wereoccurring than to be aware of how manydeaths had taken place .

In containing outbreaks, especially in1970-1971, the smallpox eradication staffcarefully enumerated cases, and because teamsremained in the infected areas, the numbers ofdeaths (which usually occurred 1-2 weeksafter the onset of illness) were also knownfairly accurately . In those outbreaks, case-fatality rates of 5-10% were often observed,about half as high as the rates in the Indiansubcontinent. Data from Jakarta, however(Fig. 13.11), consistently showed muchhigher case-fatality rates . Jakarta had had areasonably complete system for the notifi-cation of deaths since 1965 and for the re-porting of cases since 1968 . The case-fatalityrates were twice as high as those of West Java,a province which surrounds it and acrosswhose borders residents moved freely . In otherrespects, the populations were essentiallysimilar with regard to nutrition and generalhealth. If it is assumed that the virus strain inJakarta was the same as that in West Java,the obvious explanation for the lower ratesin West Java would be incomplete notificationof deaths. And yet the case-fatality rates in

Table 13 .21 . Java: age distribution of 3823 cases of smallpox, 1968-I969a

West Java were similar to those observedlater in some well-studied outbreaks elsewherein Indonesia . The observations were neverreconciled .

CONCLUSIONS

Smallpox transmission in Indonesia wasinterrupted just 3 years and 7 months after theprogramme began in July 1968 . This was aremarkable achievement considering thecountry's size, population and the limitedinternational resources provided . The experi-ence in Indonesia had a profound effect onother programmes during the succeedingyears. Among the innovations were the WHOsmallpox recognition card, the offer of areward for reporting a case, a procedure forthe systematic search for cases throughout awide area, and the demonstration of theefficacy of a search based on contact withteachers and schoolchildren . More important,the success of the surveillance-containmentstrategy was forcefully communicated byIndonesian programme staff to their counter-parts in the Indian subcontinent throughpapers and seminars. Of particular signifi-cance was a specially convened WHO inter-regional seminar in New Delhi in December1970. One of the papers, contributed by DrKoswara, the Indonesian programme's direc-tor (Koswara in WHO/SE/71 .30), was

a Includes only cases, from parts of regencies and for limited periods, whose precise age was known .

YearNumber of regenciessubmitting specimens

Number ofspecimens

Number positive forvariola virus

Number positive forvaccinia virus

1969 19 235 74 01970 37 250 55 01971 38 150 IS 01972 113 1 009 12 I1973 109 599 0 6

ProvinceAge group(years) West Java

Number

%Central Java

Number

%Jakarta

Number %East Java

Number

%

< I 184 13 103 II IS 7 166 131-4 575 40 455 49 84 38 599 485-14 496 35 278 30 62 28 263 21

I5 173 12 98 10 59 27 213 17

Total 1 428 100 934 100 220 100 1 241 100

Fig . 13 .11 . Jakarta, Sumatra and West Java : smallpoxcase-fatality rates, 1964-1969 .

13. INDONESIA

657

entitled : "Is Routine Vaccination a Necessityin a Smallpox Eradication Programme?" Theauthor concluded that proper surveillance-containment action had brought smallpoxunder control in a short period, whileroutine vaccination and mass vaccinationcampaigns had had little effect in interrupt-ing transmission . Many participants at theconference severely criticized this view,which they considered tantamount to heresy .At that time, Indonesia had not yet stoppedtransmission in Java, let alone in Sumatra orSulawesi . Because of this, few of the partici-pants were persuaded by Dr Koswara's argu-ments. However, with the occurrence ofIndonesia's last case in January 1972, it wasapparent that the 11 -year-old programmes inIndia and Pakistan had much to learn fromthe Indonesian experience. A strong stimulusfor change was provided .

Plate 13 .8. Misah Bin Inang (A), one of the last two smallpox patients in Indonesia, became ill on 23 January1972. Facial pockmarks are apparent in this picture taken in 1979, but many persons (B) were more severelyafflicted .

wZ0Z