As reported by the New Haven Register, May 7, 2006.

Experts Caution Against Repeating Swine Flu Mistakes

By Abram Katz

Should avian influenza ever threaten in the United States, remember the swine flu of 1976. Not because the national response to the 30-year-old threat was a model of efficiency — far from it.

In fact, swine flu probably encompassed most of the pitfalls that could complicate public health responses to future public health crises, said Dr. Harvey V. Fineberg, president of the national Institute of Medicine and an expert on what went right and what went wrong in 1976.

Fineberg co-wrote an analysis of the swine flu and has written many professional articles. Fineberg said the federal response to the swine flu was molded in part by lingering fear of the catastrophic Spanish flu pandemic of 1918, a series of misconceptions, conflicting agendas and the perceived urgency to act even before the dimensions of the problem were not clear.

Even so, the country’s response was not as ineffectual as it now may seem, said Dr. John Shanley, director of infectious diseases at the University of Connecticut Health Center. "Given the state of the art in 1976, there were only a couple of strategies that they could have followed," he said. "They were in a no-win situation."

Public health officials around the world are now concerned about the type A (H5 N1) or avian flu, which has claimed millions of birds and about 109 out of 194 people infected since 1997.

The virus does not currently spread readily between people, but epidemiologists fear that the ever-changing influenza could mutate and become a contagious human killer. A pandemic would rapidly result because people have no residual immunity to (H5 N1).

To put influenza in perspective, the virus kills about 30,000 Americans in a "normal" year, Fineberg said. Influenza has evolved into a quick-change organism, requiring new vaccines every season. The virus has genes on eight separate strands of RNA.

Consequently, flu viruses can exchange, re-assort and recombine genes, leading to new strains every year. Occasionally, the "new" virus is especially virulent. The most recent pandemic was the Hong Kong flu, which killed an estimated 1.3 million people around the world in 1968. The 1968 pandemic was weak compared to the disaster of 1918-19, Fineberg said.

During three global waves, the 1918 flu killed about 500,000 people in the United States, 85 percent of whom were younger than age 55. About 1 in 200 Americans were killed. Worldwide, the Spanish flu is believed to have caused between 20 million to 50 million deaths, Fineberg said. The U.S. Centers for Disease Control and Prevention and other branches of the administration of President Gerald Ford responded quickly when an influenza virus believed to be similar to the 1918 pathogen appeared in soldiers at Fort Dix in 1976, he said.

At the time, most virologists accepted the theory that epidemics occur every 11 years and that the worst flu viruses naturally recycled about every 50 years. These apparent cycles suggested that a pandemic was due sometime between 1970 and 1979. The 1976 case seemed increasingly ominous. The Fort Dix flu turned out to be dissimilar to the 1918 virus, but by the time this was determined, the U.S. Centers for Disease Control and Prevention predicted a swine flu epidemic, and Health Education and Welfare Secretary David Matthews publicly cautioned that the new flu could kill 1 million Americans in 1976.

Ford convened a White House panel and decided to authorize a $135 million immunization program. Insurers refused to insure the vaccine manufacturers, leaving the federal government to accept liability for the vaccine, Fineberg said. About 40 million Americans were vaccinated. A case of Guillain-Barre syndrome, which leads to weakness and paralysis, was mistakenly blamed on the vaccine. The program was immediately halted. No swine flu epidemic ever developed.

"You always see an adverse effect spike" after vaccination of any kind starts, Shanley said. "People attribute adverse effects to the vaccine when there is no reason to." Federal and state planning was about as good as could be expected, he said.

However, Fineberg said policy assumptions and errors characterized the swine flu episode and should be kept in mind for the future: Overconfidence in theory.

  • Epidemiologists were sure that flu pandemics occurred every 11 years and flu strains recycled every 68 years.
  • Pre-existing agendas. Scientists, federal agencies, epidemiologists and other agencies jockeyed for preeminence.
  • Premature commitment and failure to address uncertainty. The government decided to simultaneously make a vaccine and immunize the population, allowing no chance to test the vaccine.
  • Insufficient questioning of implementation. Experts did not consider the liability issue, opposition, delays and the experience of past immunizations.

Officials planning for an avian flu outbreak should keep in mind that likelihood and severity can both change independently, Fineberg said. Assumptions must be scrutinized to avoid overconfidence in predictions, he said. "It’s easy to overestimate readiness to implement. How can 280 million people be immunized in three weeks? They can’t," Fineberg said. "If there is a pandemic the key will be community and state plans."