Delaware health: Officials warn of swine flu resurgence
Asian flu of 1957 serves as a cautionary tale
By HIRAN RATNAYAKE • The News Journal • January 17, 2010
A new, highly contagious flu virus emerges in the spring and quickly spreads.
The number of cases subsides over the summer, then returns in the fall with renewed ferocity.
Dire, yet vague, warnings are issued. Hospital pediatric departments fill with sniffling children and panicky parents. Sporting events and large gatherings are canceled. Some schools close for days.
And each week, the number of flu cases grows exponentially.
Drug companies sprint to make enough vaccine. Higher-risk people are given priority.
Then, just as winter hits, the number of cases ebbs. Parents stop clamoring for flu shots. Patients stop flooding doctors' offices.
The year is 1957.
It could just as easily be 2009.
"It was remarkably similar to the one we're seeing today," said Dr. D.A. Henderson, a young epidemiologist when the Asian flu, one of three pandemics last century, hit. "What we're looking at now and what we looked at back then is almost parallel. It's almost like you're running the same film a second time."
What has Henderson and others worried is if that parallel continues. In the early days of 1958, after flu vaccines went unused and people let their guard down, the death rate skyrocketed.
Like the swine flu, the Asian flu was a never-before-seen virus. Like the Asian strain (H2N2) did, the spread of the swine flu virus (H1N1) seems to have come to a halt. Delaware's Division of Public Health reported zero lab-confirmed swine flu cases last week. That was the first week since swine flu first emerged in April in which there were no new cases.
In December 1957, as Asian flu cases dried up, so did demand for vaccine. Thousands of doses went unused.
Today, as demand for swine flu vaccine subsides, the federal Centers for Disease Control and Prevention is pointing to the Asian flu as a cautionary tale as why people must continue to get vaccinated.
"We don't know what's going to happen over the next several weeks or months, but in 1957, [the low flu activity] essentially gave the all-clear whistle in that December-January time period," said Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases. "They had vaccines, but they didn't encourage its use and yet they did go on to see that increase in mortality. ... As long as this virus is circulating, it has the potential to cause illness."
There have been six confirmed swine flu-related deaths in Delaware since the spring. Karyl Rattay, director of Delaware's Division of Public Health, worries that if people do not get the vaccine, that total could substantially increase.
"Looking back at history, we must at least consider the possibility that a number of these pandemics in the past have had several waves, and with each wave, the morbidity and mortality had intensified," she said.
She fears complacency is already taking hold.
More than 100 doses are still available at the office of Dr. Stephen Wetherill, an internist in Wilmington. But many people who learn they can get the shot opt to "take their chances without it."
"I do try the hard sell," he said, "reminding them of the 1957 wave and that just because it's not here now doesn't mean it may not come back with a vengeance soon. But a lot of them still won't get it."
Adults in Delaware can receive the swine flu vaccine free from national pharmacy chains. The Delaware Division of Public Health is subsidizing the cost with a federal grant, and pharmacies have agreed to waive additional charges.
Susan Davis saw a sign advertising swine flu shots outside a pharmacy recently. But she has no plans to get vaccinated. She doesn't know anyone who caught swine flu.
"I was wondering why people would still be getting the shot if no one is getting the flu anymore," said Davis, who lives in Newark. "It doesn't seem as serious right now because it seems to have died down for good. I think it's gone."
It's a scenario Henderson has seen before.
In spring 1957, when Asian flu surfaced in the United States, he was a 28-year-old epidemiologist for the CDC (then called the Communicable Disease Center) and only a few months away from entering medical residency. At the time, health officials had not seen a new virus strain since the deadly Spanish flu of 1918.
Charting the number of cases for that year in a line graph would produce two humps. There was a peak in cases in the spring, a big dip in the summer, another peak in autumn, another dip at year's end.
Vaccine deemed key
Like today, health officials back then convened for special meetings on how to best protect their citizens. The production of a vaccine was deemed key to survival.
"It was recognized, however, at the time of the meeting that vaccine production was just getting under way and that little vaccine would be available for at least two to three months," Henderson wrote in a recent article published in a bioterrorism journal.
About 30 million doses were produced between August and October 1957. Like today, cases of the virus peaked in late October and steadily declined through November and December. About the same time, demand for the vaccine began to wane.
"The virus had appeared to just about have died out and the thinking at that time was that enough people had been infected so it was not likely to pick up again," Henderson said.
Health officials were correct in predicting that the flu activity would not rise again at the turn of the new year.
What they failed to forecast was that the death rate would take a dramatic turn upward.
An estimated 19,000 more Americans were killed during the Asian flu pandemic than with a normal flu season, and there were as many as 2 million deaths worldwide. By the time the Asian flu season ended in spring 1958, it had become one of the deadliest viruses of the century.
"What happened between that January and that March was very puzzling," said Henderson, who in November 1957 left his job with the CDC and began his residency in internal medicine at the Mary Imogene Bassett Hospital in Cooperstown, N.Y. "By that time, I was following it only from a distance, but the big surprise was that there were a lot of excess deaths."
Henderson is a distinguished scholar at the Center for Biosecurity at the University of Pittsburgh Medical Center in Baltimore. At 81, he is considered one of the foremost experts on infectious disease. He is credited with helping to eradicate smallpox and in 2002 was awarded the Presidential Medal of Freedom for his work.
A half-century later, he remains convinced that many Asian flu deaths would have been prevented had health officials continued to press people to get vaccinated.
"There was a lot of unused vaccine back then," he recalled. "There was just no more interest in getting it. It's sort of like where we are at right now."
Vaccine still available
Today, Delaware's public health division collects information from a number of sources to gauge how rapidly the flu is spreading.
Health officials recently downgraded flu activity level in Delaware to "sporadic" from "widespread." The demand for the swine flu vaccine has also faded, Rattay said.
Pharmacist Christopher Lowry said the Rite Aid in Newark where he works received 200 doses of swine flu vaccine on New Year's Day and still has most of those doses. In early October, customers came by in droves to get the seasonal flu shot.
"In our busiest time, all our seats were taken and people would be rotating in to be seen one after another," Lowry said. "People are still coming in now to get the [swine flu] shot, just not as many."
Health officials will be rolling out a second wave of heavy advertising alerting people that vaccine is still available and warning about complacency.
Another 9,100 doses of swine flu vaccine are expected this week, bringing the state's total to about 333,600.
"I do recall hearing that [in 1957] the media was used in the fall to get the word out about prevention efforts and, from my understanding, they did not really promote vaccination after the second wave," said Rattay, the public health division director. "If this one mimics other pandemics, there could very easily be a third wave soon. That's been one of our greatest concerns."
Warnings about complacency spurred David Arnold to seek out the vaccine. Last week, he got vaccinated even though he doesn't know anyone who's caught the virus.
"I'm trying to nip it in the bud because I just think that it could peak again later," said Arnold, 52, of Newark. "I want to protect myself in case that happens."