#209
Thirty years ago this week, I, along with thousands of other health care workers was involved in the Swine Flu inoculation program of 1976. It was an ambitious undertaking, attempting to vaccinate 220 million Americans, and there are lessons to be learned from that experience.
Invariably, whenever the H5N1 Avian flu is brought up, someone shakes their head and points to the Swine Flu debacle of 30 years ago. The Pandemic that didn’t happen. They seem to believe, because we avoided a disaster then, another will not happen. This is the sort of logic that the folks in New Orleans used, when year after year; major Hurricanes missed that port city. But of course, we know what happened in 2005.
Many readers of this blog may be too young to remember this little exercise in public health, or only vaguely recall the details. As I was there, and in a unique position to observe the process, I thought a walk down memory lane on this 30th anniversary would be appropriate.
In some ways, it was both Public Healths’ finest, and worst, hour. They created, and distributed a massive amount of vaccine in record time. Sure, there were problems; things didn’t always run smoothly. Instead of beginning the inoculations in August, as planned, we didn’t get delivery of the vaccine until late September, which was frightfully close to the beginning of flu season.
I was a young paramedic at the time, working in Florida, and was loaned out to the County Health Department to assist in their inoculation program and public awareness program. This was my introduction to panflu, and to the world of emerging infectious diseases. Basically, I was put on the `rubber chicken circuit’ over the summer (on my days off) and gave lectures at the Rotary, Kiwanis, Elks, etc. on Pandemic Flu. I was part of the Civil Defense planning commission, in-service training instructor for our County EMS, and that fall, gave thousands flu shots for the health department.
Our planning sessions, with the Health Department, Civil Defense, and EMS discussed many `what ifs’, but we came up with few answers. We simply decided, after numerous meetings, that we’d cope as best we could with whatever came our way. Not terribly sophisticated, I know.
I can tell you that, while there was deep concern over a pandemic back then, it didn’t rise to the level we are seeing today. Of course, this was before CNN, and 24-hour cable news, and the Internet. Almost no comparisons were made to the Spanish Flu, probably to avoid panic.
Interestingly enough, many of my routine patients had been teenagers, or young adults in 1918, and I had an opportunity to talk to some of them about the experience. Their vivid recollections did little to comfort me that summer. That generation is all but gone today, and so are the memories.
It was an election year. Richard Nixon had appointed Gerald Ford after he stepped down from office, and Ford badly needed a public mandate. He was an un-elected President, and his administration got off to a bumpy start. Today, some critics believe that Ford used the Swine Flu threat for political reasons. Possible, I suppose, but I honestly believe that the administration’s fears of a pandemic were legitimate.
The emergence of Swine flu at Fort Dix was a bit of a shock. The feeling was, we’d dodged a bullet in 1968 with the Hong Kong Flu. Compared to 1957, or worse, 1918, the 1968 outbreak barely passed muster as a pandemic. Roughly 750,000 people died from the Hong Kong Flu worldwide. For most Americans, it was a non-event.
But in February of 1976, a young recruit fell ill and died within 24 hours. Tests revealed he had a strain of influenza, previously unseen, dubbed Swine Flu. The alarm went out, and while no other deaths occurred at Fort Dix, many of the other soldiers tested positive for the virus. Most were without symptoms, but a few fell ill and recovered.
While the death rate was very low, this virus appeared to have the ability to be rapidly transmitted between people. And the fear was, it might develop a higher mortality rate as it mutated. Two weeks later, after consultation at the highest levels, the public was informed of the threat. While the decision to try to inoculate the nation before additional cases broke out turned out to be ill fated, I believe it was well intentioned. It was debated, and decided, that waiting until an outbreak occurred would be too risky. Once an outbreak began, a vaccine would be too little, too late.
So the decision was to inoculate the country as a prophylactic measure. More than 200 million doses of vaccine were hastily produced and a plan to inoculate the nation was announced.
Throughout the summer, we all waited for the vaccine to arrive. Waited, and worried. While summer is rarely a time of seasonal flu, we all knew that a pandemic strain respected no season. But we were lucky. No new cases were reported. And by Late September, the vaccine was delivered nationwide.
Discussions were held again, at the highest level. The vaccine was ready, but no new cases had been reported. Was it the right thing to do, to inoculate the country? Some health officials argued against it. But most agreed, it was the best solution.
So in early October, we got the go ahead. We set up vaccination stations in schools, shopping malls, and community centers. Back then; we used the pneumo-jet system, instead of needles. Today, that has fallen out of favor. Too much chance, in this age of AIDS and Hepatitis, of spreading other diseases. And mishandled, the high pressure injection could rip the skin.
The first few days, we were inundated with people wanting the shot. Mostly elderly, many of who had been alive in 1918. They remembered the horror of the Spanish Flu, and so they lined up early. Lines extended around the block. The first few days, people were turned away once the lines were too long. One day, our pneumo-jet system failed, and we had to quit early in the morning. Sorry folks, come back tomorrow.
It quickly turned into a logistical nightmare, and this was before people were really panicked. We did land office business the first week or two.
Then the first reports of suspicious deaths, and a strange form of paralysis made the paper. Three people dropped dead in Philadelphia after receiving the injection. The newspapers had a field day. Gerald Ford, in an attempt to reassure the nation, rolled up his sleeve on national TV to get the shot. But the seeds of mistrust had been sown. Fewer and fewer people showed up to get their shot.
The vaccine was blamed for a lot of deaths, and cases of Guillian-Berre syndrome (a form of paralysis). The fear of the vaccine was exacerbated by newspaper speculation. But the truth is, we were vaccinating a lot of elderly people, and many of their deaths, while attributed to the vaccine in the press, may have been from other causes. Overall, the incidence of Guillian-Barre Syndrome was somewhere around 10 out of a million vaccinations. Or five times higher than the background level of this disease.
By early December, we’d managed to vaccinate 40 million people nationwide, far short of our goal. And this was a monumental effort, and considered a national priority. And as no cases of Swine Flu had been reported anywhere in the world, the decision was made to halt the vaccination program. It was doing more harm than good.
To this day, some political observers blame the Swine Flu fiasco for Gerald Ford’s loss that November. Hindsight being 20/20, it’s easy to second-guess the decision to go ahead with the vaccinations. But the choice was to take a chance on a new vaccine, or risk millions of deaths from the flu. A bitter choice, indeed.
Of course, had the Swine Flu pandemic hit, the incidence of side effects would have been considered acceptable losses.
We learned a lot about mass inoculations, and the difficulties of pulling off that sort of thing. Lessons that to this day worry me. The glib response that we `could have a vaccine within 6 months’ of the virus going pandemic is laughingly optimistic.
Sure, we might have it in the lab. Maybe even in quantity, but right now that appears doubtful. Getting it out to the people will be a logistical nightmare, particularly if a pandemic is already underway. Right now, it appears that it will take two shots, a month apart, to confer immunity. That presents real problems. A person could come out from isolation for their first shot, and stand in line for hours with potentially infected individuals. They could well contract, and spread the disease, before the immunity kicked in.
How many people would risk coming out for a shot? Perhaps, between waves, it might work. I would imagine vaccination stations would be chaotic, and security of paramount importance. And if the infrastructure takes a hit, and supply lines are down, can we even distributed the vaccine effectively?
Difficult questions, with no real answers right now.
I can tell you that my level of concern this time is much higher. Mostly due to the high CFR (case fatality rate) of H5N1. This is a different critter, altogether. And frankly, my perception is we were better equipped back then to handle an outbreak. Less reliance on just-in-time inventory deliveries. Our surge capacity in hospitals was greater 30 years ago than it is today.
And, sad to say, the dedication of health care workers was greater back then. Today, the system has been taken over by MBA’s whose primary concern is the bottom line, and employees are oft times treated badly. This has eroded their allegiance and will ultimately have a deleterious effect on their willingness to work, and risk infection, during a crisis.
And lastly, the H5N1 virus has been detected in 55 countries. It is not an isolated outbreak. There are similarities between 1976 and today, but there are a great many differences, too.
As to why the Swine flu never took off, there are only theories. Probably a mutation rendered it non-infectious, and it simply died off. Or at least went into hibernation somewhere, someday to return. The outbreak was on an army base, and containment was possible. Avian flu is widespread, and it will do whatever it’s going to do.
While we did not see a swine flu outbreak in 1976, the following year we did see the A VICTORIA outbreak, and back then, it killed 36,000 people in the US, and overwhelmed the hospitals. We were seeing, and transporting, flu patients every day. Hospitals were often closed due to having no beds. ER’s would shut down due to overload. And this was far short of a pandemic. It was just a nasty flu season.
A lot of nurses and docs were out with the flu, as were some medics. I guess I was lucky, as I didn’t catch it.
So all of this for me, you see, is a case of Deja-Flu.
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