What Failed
Six things. Two failed before the disease was beaten, one failed while it was being beaten, and three have failed since. The three most recent ones are all failures of what happens after a problem is declared solved, which is the part nobody writes up.
Before And During
The failures inside the eradication effort itself.
Resolving to eradicate without funding it, 1959 to 1966
The World Health Assembly adopted a smallpox eradication resolution in 1959. For the next eight years little progress was made, because few staff and few funds reached WHO for smallpox work. [3] WHO allocated limited funds and voluntary contributions by countries were sparse. [24] The goal was agreed for eight years before anything happened.
Mass vaccination as the primary strategy
The programme was built around vaccinating whole populations. It was the shift away from that, towards finding cases and containing them, that accelerated the programme. [3] Eastern Nigeria stopped transmission by vaccinating contacts during a vaccine shortage, not by achieving coverage. [3]
Relying on reported case numbers
In 1967 an estimated 10 to 15 million people were infected per year while 132,000 cases were reported. [19] In 1973 a WHO search team found roughly 10,000 cases in an Indian state that had been reporting about 500 a week. [19] Passive reporting was not slightly incomplete. It was wrong by more than an order of magnitude, and any plan built on it was planning against the wrong number.
After The Declaration
These three are failures of the post-eradication regime, and all three are live.
Laboratory containment, 1978
An escape from the pox laboratory at Birmingham University Medical School infected a photographer working one floor above, in a different department. Two people were infected and one died. [13] These were the last recorded human smallpox infections, ten months after the last natural case, and they came from a laboratory with inadequate biosafety facilities. [14] The official investigation concluded the virus travelled through ventilation ducting, a conclusion that was disputed afterwards by observers who thought she had entered the laboratory itself. [13] Research on dangerous pathogens in the UK was moved to biosecure facilities as a result. [13]
Knowing where the virus is
At eradication, six laboratories were known to retain variola virus. [2] Stocks were consolidated to two authorised repositories. [8] Then on 1 July 2014 vials labelled variola, appearing to date from the 1950s, were found in an unused portion of a storage room in an FDA laboratory on the NIH campus in Bethesda. PCR testing confirmed variola virus DNA. [12] The phrase in the 1980 record is "known to retain". [2] Thirty-four years later that qualifier turned out to be carrying the weight.
Standing up emergency vaccination, 2003
The United States planned to offer vaccine to an estimated 500,000 public health and health care workers in the first 30 days of a programme that began on 24 January 2003. By 4 April, week ten, about 6% of that target had been vaccinated, 31,297 people. [18] The reasons recorded were that most of the 62 jurisdictions were not prepared on the start date, that implementers were worried about insufficient resources and liability protection, that workers were worried about risk to themselves and their families with no compensation provisions, and that jurisdictions had under three weeks to write their plans. [18]
Years the 1959 resolution went unfunded [3]
8 yr
Ratio of estimated to reported cases, 1967 [19]
~100x
Share of the 2003 US first-stage target reached by week 10 [18]
6%
The 2003 entry is a United States figure because that is where a public audit of a smallpox surge-vaccination attempt exists. [18] It is the only such record cited here. Whether other countries would do better or worse is not documented on this slate, and a sourced comparison would be a strong contribution.
Three of these six are not closed. Laboratory containment, the inventory of where the virus is, and the ability to vaccinate quickly in an emergency all appear again on the still open page, because a failure nobody has fixed is also an open item.