Oct 262017
 

WHO (World Health Organization) chose this date, approximately 2 years after the last known case of naturally occurring smallpox, to announce that the disease has been completely eradicated from the world – a rare and stunning event. Smallpox is a special human disease in that it is one of the few that cannot migrate to other species. It can infect humans only, so the WHO set the goal of eliminating smallpox from human hosts because once there were no infected humans, the disease would be effectively extinct. There’s the extinction of one endangered species that no one laments. Smallpox exists now only in carefully guarded lab specimens (available for ongoing testing), which once in a while are mishandled and cause someone to be infected. But for all intents and purposes smallpox has been wiped out.

Not so very long ago, smallpox was a worldwide scourge with infants (and adults) dying regularly on all continents. Then Edward Jenner came along and vaccination was born. https://www.bookofdaystales.com/edward-jenner-and-smallpox/ Vaccination was very effective in Europe, but the rest of the world lagged behind – especially Africa. A concerted effort by the WHO got the job done, though, in the end. Into my teens (1960s) I was required to prove I was vaccinated against smallpox when traveling abroad, but by my twenties it all came to an end. Hooray.

Smallpox is caused by two strains of virus, Variola major and V. minor. V. minor is the rarer of the two strains, and causes a much less severe disease (sometimes called alastrim), with a fatality rate of around 1%. No treatment is available, and the only protection is vaccination. The virus is usually transmitted by prolonged face-to-face contact with a person showing symptoms. The incubation period averages 12–14 days. Smallpox was still causing an estimated 2 million deaths every year as late as 1967.

The global effort to eradicate smallpox from endemic areas, particularly in Africa, began in 1959 with a mass vaccination campaign. This approach met with little success, and a more-effective targeted approach was developed in the late 1960s. This involved active surveillance by case hunting, combined with rapid containment, by intensive vaccination, of infection in areas reporting outbreaks. The majority of African countries were free from smallpox by 1972. By the end of 1975, the virus had been eradicated worldwide except in Ethiopia, Somalia, and Kenya. The nomadic people of the Ogaden Desert retained endemic smallpox with an unusually mild form of the disease, which facilitated persistence in the population. From 1975, WHO efforts were concentrated on this region. Ethiopia saw its last case in August 1976 and Kenya in February 1977.

Somalia proved particularly challenging because much of its population of 3.5 million was nomadic. A mass vaccination campaign in the country in 1969 had failed because many nomadic people in the region had cultural objections to vaccination, and either refused or avoided it. Elimination efforts relied on an intensive reporting system. A severe drought in 1975 exacerbated the difficulties by increasing movement across the border with Ethiopia, and frequent outbreaks continued. In March 1977, surveillance efforts found over 3000 cases in the south of the country.The Somali government declared a state of emergency and successfully appealed to the United Nations for assistance. By June of that year, when the outbreak peaked, 3000 Somali health workers supervised by 23 international advisers were involved in the eradication efforts. Eradication work was hampered in July when the Ogaden War broke out, limiting access to the desert.

The last known natural occurring case of smallpox (V. minor) was contracted by Ali Maow Maalin around this date in 1977. Maalin worked as a cook at the hospital in the port-town of Merca in southern Somalia, as well as an occasional vaccinator for a WHO smallpox eradication team. He had not been successfully vaccinated, even though smallpox vaccination was obligatory for hospital employees. According to CDC epidemiologist Jason Weisfeld, one of the people who led the later containment effort in Merca, Maalin had received the smallpox vaccine but it had failed to take, and he had not been protected. Other sources, however, state that he had not been vaccinated. In an interview in 2007, Maalin said that he had not been vaccinated, explaining: “I was scared of being vaccinated then. It looked like the shot hurt.” Some ironies are staggering. The guy was helping eradicate the disease by encouraging vaccination, but didn’t get vaccinated himself and caught smallpox.

In August 1977, an outbreak developed in a Somalian nomadic group of twenty families; eight children developed symptoms in August to October. On 12 October 1977, two children with smallpox symptoms were discovered at an encampment near the small inland settlement of Kurtunawarey, around 90 km from Merca. Local officials drove the children to Merca, where there was a nearby isolation camp. Maalin, then aged 23, served as a guide to the party taking them in a closed Land Cruiser from the hospital where he worked either in the home of a surveillance supervisor or directly at the isolation camp. He is believed to have been infected during the journey, which lasted no more than 5–15 minutes. One of the children, a six-year-old girl named Habiba Nur Ali, died two days later. She was the last person to die from naturally acquired smallpox. The outbreak among the nomadic group was successfully contained by WHO workers by 18 October, but – critically – investigators failed to identify Maalin as a contact.

On 22 October, Maalin fell ill with fever and headache, and received malaria treatment in hospital. After four days a rash appeared. Perhaps working on the assumption that he had been successfully vaccinated against smallpox, Maalin was then believed to have chickenpox and was discharged from hospital. Over the next few days, his symptoms developed to indicate smallpox as the cause. Not wishing to be put into isolation, Maalin failed to report himself. On 30 October, a male nurse colleague reported him, possibly for the reward of 200 Somali shillings (around $35), and Maalin was transferred to the isolation camp. He was diagnosed with an infection of the Variola minor strain of smallpox, based on his symptoms and later confirmed by laboratory tests. The date of diagnosis is sometimes stated as 26 October 1977. Maalin did not experience complications, and subsequently recovered fully and was discharged in late November.

Donald Henderson, who directed the WHO eradication program from 1967 until 1976, describes Maalin’s case as “a classic one in depicting omissions and mistakes in program operations.” Maalin, described by Henderson as “a popular man,” had been visited by many relations and friends during his illness before he entered isolation. While hospitalized with fever, he had walked freely around the hospital, interacting with multiple patients.

Multiple measures were used to contain the potential outbreak in the town of Merca. The response was coordinated by Weisfeld and Karl Markvart. Maalin’s contacts were all traced by the WHO eradication team. A total of 161 contacts were identified, 41 of whom had not been vaccinated. There were 91 people who had been in face-to-face contact with Maalin, 12 of whom were unvaccinated. Some of his contacts lived up to 120 km outside the town. All contacts were kept under surveillance for six weeks. His face-to-face contacts and their families were vaccinated, but none showed any sign of having been infected. Merca Hospital was closed to new patients, all its medical staff were vaccinated and existing patients were quarantined in situ. The residents of the fifty houses neighboring Maalin’s lodgings were vaccinated, and vaccinations were later extended to the ward of the town in which Maalin lived. House-to-house searches throughout the entire town looked for cases. Police checkpoints on all exits to the town, including footpaths, were established to vaccinate anyone passing who had not been recently immunized. A total of 54,777 people were vaccinated in the two weeks following Maalin’s isolation. The response later broadened, with monthly house-to-house searches across the region widening to a search throughout Somalia, completed in December 1977.

The containment efforts proved effective and, on 17 April 1978, WHO’s Nairobi office sent a telegram stating: “Search complete. No cases discovered. Ali Maow Maalin is the world’s last known smallpox case.” Although there have been subsequent cases of smallpox from laboratory contamination, Maalin remains the last case of naturally acquired smallpox in the world. On 26 October 1979, two years after the day when Maalin’s rash appeared, WHO declared that smallpox had been eradicated globally.

Unfortunately the story does not end so well for Maalin. Maalin remained in the Merca area, where he was employed in a range of roles. In the mid-1990s, he was selling medicines in a nearby small town. Maalin was among the 10,000 volunteers who participated in the effort to eradicate poliomyelitis from Somalia, which succeeded in 2008. He explained his motivation for volunteering: “Somalia was the last country with smallpox. I wanted to help ensure that we would not be the last place with polio too.” Maalin worked for WHO as a local coordinator with responsibility for social mobilisation, and spent several years travelling across Somalia, vaccinating children and educating communities. The Boston Globe described him as one of the “most valuable” local coordinators for WHO. He encouraged people to be vaccinated by sharing his experiences with smallpox: “Now when I meet parents who refuse to give their children the polio vaccine, I tell them my story. I tell them how important these vaccines are. I tell them not to do something foolish like me.” He continued to work as a regional coordinator for the vaccination drive, and was hailed as one of the “true heroes” of the campaign. After the 2013 reintroduction of poliovirus into Somalia, Maalin was again carrying out vaccinations in the Merca district when he developed a fever, and died days later, on 22 July 2013, of malaria. He was survived by his wife and three children.

I’ve not been to Somalia nor the general region of the Horn of Africa, so I’m flying blind here when it comes to recipes. Until Somalia settles down politically I’m not going there either. But the cuisine looks familiar enough. There are different regional Somali culinary traditions of course, with some East African, Arab, Ethiopian, Yemeni, Turkish, Indian, and Italian influences. It is the product of Somalia’s tradition of trade and commerce. Some notable Somali delicacies include sabayad, lahoh/injera, halva, sambuusa, basbousa, and ful medames. Play with the names and you’ll understand. For example, sambuusa is a variant of the Indian samosa.  Here’s a video for you:

May 142015
 

NPG 62; Edward Jenner by James Northcote

On this date in 1796 Edward Jenner administered his first smallpox vaccination. I love the fact that he was also the first person to describe the brood parasitism of the cuckoo. Jenner was born in Berkeley, Gloucestershire, as the eighth of nine children. His father, the Reverend Stephen Jenner, was the vicar of Berkeley, so Jenner received a strong basic education. He went to school in Wotton-under-Edge and Cirencester. During this time, he was inoculated (NOT vaccinated) for smallpox, which had a lifelong effect upon his general health.

Let’s take time out to talk about inoculation versus vaccination – terms which are now confused. Inoculation, also called variolation, is the act of introducing the SAME pathogen into an individual as the one you want to immunize against. So, for example, some parents deliberately have their children play with ones with chicken pox so that they will catch the disease and in future be immune. This is inoculation. Vaccination is introducing a DIFFERENT pathogen to create immunity. Jenner was inoculated, that is, he was given a mild case of smallpox to immunize him. This can be effective but it is dangerous, and can be lethal.

At the age of 14, he was apprenticed for seven years to Daniel Ludlow, a surgeon of Chipping Sodbury, South Gloucestershire, where he gained most of the experience needed to become a surgeon himself. In 1770, Jenner became apprenticed in surgery and anatomy under surgeon John Hunter and others at St George’s Hospital. William Osler records that Hunter gave Jenner William Harvey’s advice, very famous in medical circles (and characteristic of the Age of Enlightenment), “Don’t think; try.” Hunter remained in correspondence with Jenner concerning natural history and proposed him for the Royal Society. Returning to his native countryside by 1773, Jenner became a successful family doctor and surgeon, practicing on dedicated premises at Berkeley.

Jenner and others formed the Fleece Medical Society or Gloucestershire Medical Society, so called because it met in the parlour of the Fleece Inn, Rodborough (in Gloucestershire), meeting to dine together and read papers on medical subjects. Jenner contributed papers on angina pectoris, ophthalmia, and cardiac valvular disease and commented on cowpox. He also belonged to a similar society that met in Alveston, near Bristol.

Jenner was elected Fellow of the Royal Society in 1788, following his publication of a careful study of the previously misunderstood life of the nested cuckoo, a study that combined observation, experiment, and dissection.

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His description of the newly hatched cuckoo, pushing its host’s eggs and fledgling chicks out of the nest (contrary to existing belief that the adult cuckoo did it) was only confirmed in the 20th century, when photography became available. Having observed this behavior, Jenner demonstrated an anatomical adaptation for it—the baby cuckoo has a depression in its back, not present after 12 days of life, that enables it to cup eggs and other chicks and toss them out of the nest. The adult does not remain long enough in the area to perform this task. Jenner’s findings were published in Philosophical Transactions of the Royal Society in 1788.

“The singularity of its shape is well adapted to these purposes; for, different from other newly hatched birds, its back from the scapula downwards is very broad, with a considerable depression in the middle. This depression seems formed by nature for the design of giving a more secure lodgement to the egg of the Hedge-sparrow, or its young one, when the young Cuckoo is employed in removing either of them from the nest. When it is about twelve days old, this cavity is quite filled up, and then the back assumes the shape of nestling birds in general.”

Jenner married Catharine Kingscote (died 1815 from tuberculosis) in March 1788. He might have met her while he and other Fellows were experimenting with balloons. Jenner’s trial balloon descended into Kingscote Park, Gloucestershire, owned by Anthony Kingscote, one of whose daughters was Catharine.

Inoculation was already a standard practice, but involved serious risks. In 1721, Lady Mary Wortley Montagu had imported variolation to Britain after having observed it in Istanbul, where her husband was the British ambassador. Voltaire, writing of this, estimates that at this time 60% of the population caught smallpox and 20% of the population died of it. Voltaire also states that the Circassians used the inoculation from times immemorial, and the custom may have been borrowed by the Turks from the Circassians.

In 1765, John Fewster published a paper in the London Medical Society entitled “Cow pox and its ability to prevent smallpox”, but did not pursue the subject further. In the years following 1770, at least five investigators in England and Germany (Sevel, Jensen, Jesty 1774, Rendell, Plett 1791) successfully tested a cowpox vaccine in humans against smallpox. For example, Dorset farmer Benjamin Jesty successfully vaccinated and presumably induced immunity with cowpox in his wife and two children during a smallpox epidemic in 1774, but it was not until Jenner’s work some 20 years later that the procedure became widely understood. Indeed, Jenner may have been aware of Jesty’s procedures and success.

The initial source of infection was a disease of horses, called “the grease”, which was transferred to cattle by farm workers, transformed, and then manifested as cowpox. Noting the common observation that milkmaids were generally immune to smallpox, Jenner postulated that the pus in the blisters that milkmaids received from cowpox (a disease similar to smallpox, but much less virulent) protected them from smallpox.

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On 14 May 1796, Jenner tested his hypothesis by vaccinating James Phipps, an eight-year-old boy who was the son of Jenner’s gardener. He scraped pus from cowpox blisters on the hands of Sarah Nelmes, a milkmaid who had caught cowpox from a cow called Blossom, whose hide now hangs on the wall of the St George’s medical school library (now in Tooting). Phipps was the 17th case described in Jenner’s first paper on vaccination.

Jenner vaccinated Phipps in both arms that day, subsequently producing in Phipps a fever and some uneasiness, but no full-blown infection. Later, he injected Phipps with variolous material, the routine method of immunization at that time. No disease followed. The boy was later challenged with variolous material and again showed no sign of infection.

Donald Hopkins has written, “Jenner’s unique contribution was not that he inoculated a few persons with cowpox, but that he then proved [by subsequent challenges] that they were immune to smallpox. Moreover, he demonstrated that the protective cowpox pus could be effectively used for vaccination from person to person, not just directly from cattle. Jenner successfully tested his hypothesis on 23 additional subjects. Jenner’s fame, thus, lies in the rigor of his analysis and not in being the first to vaccinate. Ahhh !! How many “facts” did I learn in school that are wrong.

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Jenner continued his research and reported it to the Royal Society, which did not publish the initial paper. After revisions and further investigations, he published his findings on the 23 cases. Some of his conclusions were correct, some erroneous. The medical establishment, cautious then as now, deliberated at length over his findings before accepting them. Eventually, vaccination was accepted, and in 1840, the British government banned variolation and provided vaccination using cowpox free of charge. The success of his discovery soon spread around Europe and, for example, was used en masse in the Spanish Balmis Expedition, a three-year-long mission to the Americas, the Philippines, Macao, China, and Saint Helena Island led by Dr. Francisco Javier de Balmis with the aim of giving thousands the smallpox vaccine. The expedition was successful, and Jenner wrote, “I don’t imagine the annals of history furnish an example of philanthropy so noble, so extensive as this.”

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Jenner’s continuing work on vaccination prevented him from continuing his ordinary medical practice. He was supported by his colleagues and the King in petitioning Parliament, and was granted £10,000 in 1802 for his work on vaccination. In 1807, he was granted another £20,000 after the Royal College of Physicians had confirmed the widespread efficacy of vaccination.

In 1811, Jenner observed a significant number of cases of smallpox after vaccination. He found that in these cases the severity of the illness was notably diminished by previous vaccination. In 1821, he was appointed Physician Extraordinary to King George IV, a great national honor, and was also made Mayor of Berkeley and Justice of the Peace. He continued to investigate natural history, and in 1823, the last year of his life, he presented his “Observations on the Migration of Birds” to the Royal Society.

Jenner was found in a state of apoplexy on 25 January 1823, with his right side paralyzed. He never fully recovered and eventually died of an apparent stroke, his second, on 26 January 1823, aged 73. He was survived by one son and one daughter, his elder son having died of tuberculosis at the age of 21.

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In 1979, the World Health Organization declared smallpox an eradicated disease. This was the result of coordinated public health efforts by many people and organizations, but vaccination was an essential component. And although the disease was declared eradicated, some pus samples still remain in laboratories in Centers for Disease Control and Prevention in Atlanta, Georgia, in the United States, and in State Research Center of Virology and Biotechnology VECTOR in Koltsovo, Novosibirsk Oblast, Russia.

The eradication of smallpox was made possible by the fact that it must have a human vector to survive. No human carriers, no smallpox. I well remember getting vaccinated in 1965, then a requirement for all international travelers. I’ve still got the little telltale scar on my upper left arm – the stigmata of a generation. Then you needed a new vaccination every 5 years because cowpox vaccination is not 100% effective for life. I dutifully had mine but none ever took after the first.

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Jenner lived and worked in the dairy lands of Gloucester famous for cheeses. Before refrigeration, Gloucester milk spoiled before it could make it to London so it was converted to cheese. There are two types of Gloucester cheese – Single Gloucester and Double Gloucester – both made since the 16th century. Prior to that Gloucester cheeses were made from sheep’s milk. Gloucester is a traditional, semi-hard cheese, at one time made only with the milk of the once nearly extinct Gloucester breed cows (and now on the verge of disappearing again).

Double Gloucester, like Cheddar, is made all over the world and, as such, varies in quality and does not have protected status. Single Gloucester is made only in Gloucestershire and is protected. Both types have a natural rind (outer layer) and a hard texture, but Single Gloucester is more crumbly, lighter in texture and lower in fat. Double Gloucester is allowed to age for longer periods than Single, and it has a stronger and more savory flavor. It is also slightly firmer. The flower known as Lady’s Bedstraw (Galium verum), was responsible for the distinctively yellow color of Double Gloucester. In the United Kingdom today, of these two types of cheese, it is the Double Gloucester which is more likely to be sold in supermarkets. Both types are produced in round shapes, but Double Gloucester rounds are larger. Traditionally, whereas the Double Gloucester was a prized cheese comparable in quality to the best Cheddar or Cheshire, and was exported out of the county, Single Gloucester tended to be consumed within Gloucestershire.

Most Double Gloucester sold in UK supermarkets is slab cheese, made in large creameries operated by major dairy companies such as Dairy Crest. It is normally sold as a supermarket own brand. This version of the cheese is pasteurized but not processed.

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Gloucester cheeses are endangered again because of EU regulations (see http://www.dailymail.co.uk/news/article-2730022/Double-Gloucester-cheese-disappear-supermarket-shelves-cows-produce-dying-EU-regulations.html ). The EU forbids TB vaccination of dairy cattle because immunized cows test positive for TB and so cannot be distinguished from infected animals. A strange ironic twist given that this breed is the source of Jenner’s first smallpox vaccination. Breeders had built up herds in the 1970s but are reluctant to fight the regulations, so herds are again in decline. It is estimated that only 450 purebred cows exist today.

Good traditional Gloucester cheese is hard to beat eaten as is. But you can use it as you would cheddar in recipes. For me, give me some water biscuits, a nice pot of creamery butter, and a good wedge of Gloucester and I am a happy man.