1976 The US Swine Influenza Immunization Program: A NYC Perspective

[mixin]

18 page paper on all many aspects of the immunization program.
Just a few points of interest:

Because the amounts in the federal grant were originally calculated onthe basis of 10 million vaccinations, administering only six million immunizations meant that the federal monies per dose for administration were increased to about 23 cents per dose.

Direct cost of the swine influenza immunization program to the NYC Department of Health, 1976: $1,003,000

The New York City program began on October 12, 1976.

March 1976: Officials at CDC announce that U. S. faces possible swine flu epidemic in the fall. Virus is likened to the influenza virus of 1918.

December 14, 1976: Guillain-Barr6 paralysis reported linked to swine flu inoculations.

December 16, 1976: National swine flu program suspended because of concern that shots were linked to 94 cases of Guillain-Barr6 syndrome in 14 states.

January 15, 1977: Advisory Committee on Immunization Practices of Public Health Service recommends resumption of swine-flu program. The New York City Department of Health opts not to resume program fully but to make vaccine available to hospitals and private physicians. Five clinics opened in each of five city boroughs. Attendance at each runs about four persons per day.

http://ukpmc.ac.uk/picrender.cgi?artid=1507443&blobtype=pdf

[gsgs]

Re: 1976 The US Swine Influenza Immunization Program: A NYC Perspective

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291401/

Dowdle , 2006
.
Suggested citation for this article: Dowdle WR. Influenza pandemic
periodicity, virus recycling, and the art of risk assessment. Emerg Infect
Dis [serial on the Internet]. 2006 Jan [date cited].

http://dx.doi.org/10.3201/eid1201.051013

In 1976, speculation was rife that a new pandemic strain was due
in a few years. The concept of 10- to 11-year influenza A virus
pandemic patterns, with disappearance of the predecessor virus,
seemed entrenched in the influenza literature. Previous influenza
pandemics had occurred in 1968, before that in 1957, and before
that in 1947; carrying the logic further, pandemics also occurred
in 1929, 1918, 1900, and 1890 (12). The concept was supported
by the World Health Organization (WHO) classification scheme,
which implied that 4 influenza A subtypes had occurred in humans
since 1933. In addition, seroarcheologic findings had been interpreted
as evidence that the swine virus had last appeared in 1918, the Hong
Kong virus (now designated H3) in 1900, and the Asian (H2) virus in
1890, not exactly 10–11 years apart, but in the same order (13,14).
To some, the next pandemic virus in the sequence was the swine
virus of 1918 (13).

On February 13, 1976, the New York Times published a guest editorial
to remind the public and policy makers that influenza pandemics
had marked the end of every decade—every 11 years—since the
1940s. The editorial urged accelerated pandemic planning and
coordinated vaccine research (15).

Risk Assessment in 1976.
Coincidentally, on February 14, 1976, the day after the Times editorial
was published, the Center for Disease Control (CDC) hosted an
emergency meeting with the US Army, Food and Drug Administration,
National Institutes of Health, and New Jersey State Health Department
to assess the isolation of swine influenza virus from the late January
outbreak at Fort Dix, New Jersey (16). Information was insufficient at
the time to assess whether the swine influenza virus outbreak was a
unique event in susceptible young recruits or the beginning of a
pandemic, but the isolation of a predicted potential pandemic strain
almost on schedule did not go unnoticed.

On March 10, the Army provided data to the US Advisory Committee
on Immunization Practices that confirmed person-to-person transmission
of swine influenza virus (17). The single swine influenza death loomed
large, although most cases were mild. No one at the advisory committee
meeting equated the disease potential of this virus with 1918, but the
association of swine influenza virus with the most devastating pandemic in
memory was widely speculated in the news media. Slightly more than a
month after the outbreak, no evidence suggested that a pandemic would
or would not occur; a situation such as the Fort Dix outbreak had never
been encountered. On March 18, the action memo from the Assistant
Secretary of Health to the Secretary, Department of Health, Education,
and Welfare stated that "severe epidemics, or pandemics, of influenza
occur at approximately 10-year intervals" and publicly linked swine flu
with the pandemic of 1918 (18).

When WHO convened a meeting of consultants in Geneva on April 7 (19),
3 months had passed without evidence of further swine virus transmission
anywhere in the world. The swine A/New Jersey strain had not replaced
the current A/Victoria strain, which continued to circulate at Fort Dix well
into February, and no evidence of swine/Victoria virus reassortants had
been seen. Theories of what might happen were being overtaken by the
realities of what was happening. The Fort Dix outbreak was beginning to
look like an isolated event.

A report from the United Kingdom on the behavior of swine influenza virus
in infected human volunteers would not appear in Nature for some weeks
(20), but in April early rumors circulated that swine A/New Jersey virus
was more infectious than classic swine virus but that the symptoms were
mild to moderate. The report added little to risk assessment; the findings
were consistent with events seen in the outbreak. But an accompanying
editorial in Nature summarized the UK and likely European view, which
urged caution in vaccine stockpiling and immunization programs and
continuing assessment, "until the shape of things to come can be seen
more clearly" (21).

Beginning in April and continuing into May, a group of US investigators
used the Delphi technique to obtain an expert risk assessment with
minimal bias (22). The 15 participating scientists and epidemiologists
concluded that if swine influenza virus were to circulate in the United
States, the epidemic would more likely resemble those of 1957 and 1968
than that of 1918. The probability of further swine influenza virus
outbreaks was estimated at 0.10.

On August 1, a series of news reports began to appear on a fatal
respiratory illness among American Legionnaires attending a convention
in Philadelphia (18,23). Wide but inappropriate speculation that the cause
of these unprecedented deaths might be swine influenza, accompanied by
equally unprecedented national publicity, precluded further opportunity for
rational risk assessment.

Theory of Predictable Pandemics.
Unknowingly, at the same time as the Fort Dix outbreak, the Working
Group on Pandemic Influenza met in Rougemont, Switzerland, on January
26–28. Issues addressed included the growing body of evidence linking
the origin of antigenic shift to animal reservoirs of influenza viruses (24),
the questionable validity of predictable patterns of pandemic periodicity,
and the appropriate classification of the 1947 strain (25).



----------------------------------------
15. Kilbourne ED Flu to the starboard! Man the harpoons! Fill 'em with
vaccine! Get the Captain! Hurry! The New York Times. 1976. Feb 13. p. 32.
16. Sencer DJ, Millar JD Reflections on the 1976 swine flu immunization
program. influenza in 1976. Emerg Infect Dis. 2006;12. doi:
10.3201/eid1201.051007. [PMC free article] [PubMed] [Cross Ref]
17. Gaydos JC, Top FH Jr, Hodder RA, Russell PK Swine influenza A
outbreak, Fort Dix, New Jersey, 1976. Emerg Infect Dis. 2006;12. doi:
10.3201/eid1201.050965. [PMC free article] [PubMed] [Cross Ref]
18. Neustadt RE, Fineberg HV The swine flu affair. Decision-making on a
slippery disease. Washington: US Department of Health Education and
Welfare; 1978.
19. World Health Organization Influenza. Wkly Epidemiol Rec.
1976;51:123.
20. Beare AS, Craig JW Virulence for man of a human influenza-A virus
antigenically similar to "classical" swine viruses. Lancet. 1976;2:4–5. doi:
10.1016/S0140-6736(76)92964-0. [PubMed] [Cross Ref]
21. Stuart-Harris C Swine influenza virus in man. Zoonosis or human
pandemic. Lancet. 1976;2:31–2. doi: 10.1016/S0140-6736(76)92980-9.
[PubMed] [Cross Ref]
22. Schoenbaum SC, McNeil BJ, Kavet J The swine-influenza decision. N
Engl J Med. 1976;295:759–65. doi: 10.1056/NEJM197609302951405.
[PubMed] [Cross Ref]
23. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar
RG, et al. Legionnaires' disease: description of an epidemic of pneumonia.
N Engl J Med. 1977;297:1189–97. doi: 10.1056/NEJM197712012972201.
[PubMed] [Cross Ref]
24. Webster RG Strain surveillance in animals and birds. In: Selby P,
editor. Influenza: virus, vaccines, strategy. Proceedings of a working
group on pandemic influenza. Rougemont (Switzerland): Academic Press;
1976. p. 33–43.
25. Dowdle WR Influenza: epidemic patterns and antigenic variation. In:
Selby P, editor. Influenza: virus, vaccines, strategy. Proceedings of a
working group on pandemic influenza. Rougemont (Switzerland):
Academic Press; 1976. p. 17–21.

---------------------------------------------
for the serology review see also Dowdle's article from 1999
with more links:

http://www.who.int/bulletin/archives/77(10)820.pdf

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see also the thread at panflu-stats

http://www.setbb.com/fluwiki2/viewtopic.php?p=2742&mforum=fluwiki2#2742

[gsgs]

Re: 1976 The US Swine Influenza Immunization Program: A NYC Perspective

the question why the elderly were spared in the 1918 pandemic remains unresolved.
One theory is, that they had immunity from a H1-strain that circulated before 1889
and was then replaced by the 1889-strain, presumably H3.
But then immunity would have slowly built up, year by year, and increased
the earlier the people was born before 1889.
But there was almost no flu before 1889 in some countries, e.g. England.
And serology gave no hints to this, see the dowdle-chart for swine-H1.

Then the 1889 pandemic itself could have provided immunity,
but then it must have been stronger, the older they were in 1889.
I didn't see this connection elsewhere.

Now they found serological evidence that 1889 was H3, people born before ~1900
had antibodies to H3 before the 1968 pandemic started.

And Dowdle, quoting Housworth,Spoon, 1971 claims there was evidence from
the deathrates in the 1968 pandemic in USA that the elderly >75y were spared.

But that relies on their definition of "excess mortality", I cannot clearly verify it by
just looking at deaths from all causes, as they suggest.
see picture

I do see something, by looking at respiratory deaths
see picture

unfortunately monthly deathrates by agegroups are only available since 1959,
so I cannot easily compare with the 1957 pandemic

https://www.epimodels.org/midas/catdoc.do?methodToCall=download&catalogDocId=1074

we could have 2 types of immunity : against flu and pneumonia

-------------------------------------

one other question is, why the vax doesn't protect longer than one year and why infection
provides only immunity for some months.
And then there should have been that almost perfect protection in 1918 ??
But it didn't hold long, once H1 became seasonal, the elderly died as well.
E.g. in Liverpool 1951, no protection although the same virus had been around
since long

------------------------------------------
Kilbourne,2006:
With the exception of persons >70 years of age, the public was confronted (in 1957) by
a virus with which it had had no experience, and it was shown that the virus alone,
without bacterial coinvaders, was lethal (6).

6. Rogers DE, Louria DB, Kilbourne ED. The syndrome of fatal
influenza virus pneumonia. Trans Assoc Am Physicians. 1958;71:260–73.

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http://www.biomedcentral.com/1741-7015/10/162

> Conclusions: In all influenza pandemics of the 20th century, emergent viruses resembled
> those that had circulated previously within the lifespan of then-living people.

This was doubted by Dowdle above for the 1957 pandemic

> Such individuals were relatively immune to the emergent strain, but this immunity waned with
> mutation of the emergent virus.

you have to wonder, why the immunity did not wane during the ~70 years of separate
evolution in birds, where HA does also mutate antigenically.
But then it did wane within a few years after evolutions in humans ?
Another explanation could be, that rather younger people get immune faster and easier
to the new strain than the elderly.

> An immune subpopulation complicates and may invalidate vaccine trials. Pandemic influenza
> does not ‘shift’ mortality to younger age groups; rather, the mortality level is reset by the
> virulence of the emerging virus and is moderated by immunity of past experience.

so peak mortality is shifted to younger age groups

> In this study, we found that after immune escape, older age groups showed no further
> mortality reduction, despite their being the principal target of conventional influenza vaccines.

real infection provides a different sort of immunity than vaccines

> Vaccines incorporating variants of pandemic viruses seem to provide little benefit to those
> previously immune. If attack rates truly are similar across pandemics, it must be the case
> that immunity to the pandemic virus does not prevent infection, but only mitigates the
> consequences.

or both, well, it does not prevent infection always but maybe reduces the likelyhood
of infection significantly.