Novel Swine Flu and Remembrance

 

Yes, that’s me 50 years ago today (1976),
giving Swine Flu Shots.

#19,355

Fifty years ago today - Oct 1st 1976 - the United States began a bold, and ultimately ill-fated, emergency vaccination drive against the anticipated arrival of a novel H1N1 `swine flu' virus that had been detected nine months earlier on an army base in New Jersey.  

As an impossibly young, freshly-minted paramedic, who dealt primarily with heart attacks, strokes, and car wrecks, I unexpectedly found myself playing a minor part in the preparations for, and implementation of, our county's  vaccination campaign.

As the county's first, and at that time only, paramedic I'd been on the `rubber chicken circuit' for nearly a year, promoting our new telemetry systems and advanced life support capabilities to every trailer park, condominium, and civic organization who would have us (mostly on my days off). 

So, in the early summer, when the Health Department was ready to start promoting the emergency flu vaccination program, I got the call. Once or twice a week I'd present the case for getting the vaccine when it became available in the fall to anywhere from a few dozen to a few hundred people.

Since much of my audience were elderly, many had been teenagers or young adults during the 1918 pandemic, and so I heard a lot about their experiences at these community meetings. It was sobering, to say the least.

While all of this undoubtedly led to my becoming an infectious disease blogger, the rest of the story - thankfully - is not about me. 

To put things in context, 1976 was an election year, and Gerald Ford was an unelected incumbent, having ascended to the office after Richard Nixon resigned in August of 1974.  

He'd gotten off to a rough start, and badly needed a mandate. 

In February of 1976, a young recruit at Ft. Dix fell ill and died within 24 hours. Tests revealed he had a strain of influenza, previously unseen, dubbed `Swine Flu’. It was an H1N1, a strain that had disappeared `from the wild’ after the 1957 Asian Flu pandemic.

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.

But CDC director David J. Sencer and others feared this virus could return in the fall - much like it did in 1918 - and spark another global pandemic. After considerable debate, President Ford held a televised press conference in March unveiling the National Swine Flu Immunization Program.

After a long, nervous, bicentennial summer - and no signs of the H1N1 virus - the decision was made to begin vaccination on October 1st. 

Things, famously, did not go as planned. Many of the early vaccine recipients were elderly, and several died within days of getting the shot.  While these appeared to be natural deaths, the media had a field day. 

Two weeks into the campaign, in an attempt to reassure the public of its safety, Gerald Ford got the shot live on TV. 

But the seeds of mistrust had been sown. Fewer and fewer people showed up for the shots. 

That was followed by reports of GBS (Guillain-Barré syndrome) among a small number of vaccine recipients. Whether, or how much, the shots contributed to these cases wasn't known then, but it further tarnished the vaccination campaign. 

In the end, the virus didn't reappear that fall. By December, > forty-million people had received the vaccine, and several hundred adverse events had been reported. The decision to pull the plug came on December 16th.  

You'll find a pretty complete narrative by Dr. Sencer et al., published 20 years ago in the EID Journal. I've only posted some extended excerpts, so follow the link to read it in its entirety.

Reflections on the 1976 Swine Flu Vaccination Program

David J. Sencer* and J. Donald Millar†
Author affiliations: *Atlanta, Georgia, USA;

Abstract

In 1976, 2 recruits at Fort Dix, New Jersey, had an influenza like illness. Isolates of virus taken from them included A/New Jersey/76 (Hsw1n1), a strain similar to the virus believed at the time to be the cause of the 1918 pandemic, commonly known as swine flu. Serologic studies at Fort Dix suggested that >200 soldiers had been infected and that person-to-person transmission had occurred. We review the process by which these events led to the public health decision to mass-vaccinate the American public against the virus and the subsequent events that led to the program's cancellation. Observations of policy and implementation success and failures are presented that could help guide decisions regarding avian influenza.       

(SNIP)

The National Influenza Immunization Program

On March 10, 1976, the Advisory Committee on Immunization Practices of the United States Public Health Service (ACIP) reviewed the findings. The committee concluded that with a new strain (the H1N1 New Jersey strain) that could be transmitted from person to person, a pandemic was a possibility.

Specifically, the following facts were of concern:

1. persons <50 years of age had no antibodies to this new strain;
2. a current interpandemic strain (A/Victoria) of influenza was widely circulating;
3.  this early detection of an outbreak caused by A/New Jersey/76/Hsw1N1 (H1N1) provided an opportunity to produce a vaccine since there was sufficient time between the initial isolates and the advent of an expected influenza season to produce vaccine. In the past when a new pandemic strain had been identified, there had not been enough time to manufacture vaccine on any large scale;
4. influenza vaccines had been used for years with demonstrated safety and efficacy when the currently circulating vaccine strain was incorporated;
5.  the military vaccine formulation for years had included H1N1, an indication that production was possible, and no documented adverse effects had been described.

ACIP recommended that an immunization program be launched to prevent the effects of a possible pandemic. One ACIP member summarized the consensus by stating "If we believe in prevention, we have no alternative but to offer and urge the immunization of the population." One ACIP member expressed the view that the vaccine should be stockpiled, not given.

(SNIP)

Shortly after the national campaign began, 3 elderly persons died after receiving the vaccine in the same clinic. Although investigations found no evidence that the vaccine and deaths were causally related, press frenzy was so intense it drew a televised rebuke from Walter Cronkite for sensationalizing coincidental happenings.

Guillain-Barré Syndrome

What NIIP did not and could not survive, however, was the second blow, finding cases of Guillain-Barré syndrome (GBS) among persons receiving swine flu immunizations. As of 1976, >50 "antecedent events" had been identified in temporal relationship to GBS, events that were considered as possible factors in its cause. The list included viral infections, injections, and "being struck by lightning." Whether or not any of the antecedents had a causal relationship to GBS was, and remains, unclear. When cases of GBS were identified among recipients of the swine flu vaccines, they were, of course, well covered by the press. Because GBS cases are always present in the population, the necessary public health questions concerning the cases among vaccine recipients were "Is the number of cases of GBS among vaccine recipients higher than would be expected? And if so, are the increased cases the result of increased surveillance or a true increase?" Leading epidemiologists debated these points, but the consensus, based on the intensified surveillance for GBS (and other conditions) in recipients of the vaccines, was that the number of cases of GBS appeared to be an excess.

Had H1N1 influenza been transmitted at that time, the small apparent risk of GBS from immunization would have been eclipsed by the obvious immediate benefit of vaccine-induced protection against swine flu. However, in December 1976, with >40 million persons immunized and no evidence of H1N1 transmission, federal health officials decided that the possibility of an association of GBS with the vaccine, however small, necessitated stopping immunization, at least until the issue could be explored. 

A moratorium on the use of the influenza vaccines was announced on December 16; it effectively ended NIIP of 1976. Four days later the New York Times published an op-ed article that began by asserting, "Misunderstandings and misconceptions... have marked Government ... during the last eight years," attributing NIIP and its consequences to "political expediency" and "the self interest of government health bureaucracy" (7). These simple and sinister innuendos had traction, as did 2 epithets used in the article to describe the program, "debacle" in the text and "Swine Flu Fiasco" in the title.

On February 7, the new secretary of DHEW, Joseph A. Califano, announced the resumption of immunization of high-risk populations with monovalent A/Victoria vaccine that had been prepared as part of the federal contracts, and he dismissed the director of CDC.

        (Continue . . . )

To this day, some political observers believe the decision to vaccinate the nation was politically motivated, and 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 now.

But the choice back then was to take a chance on rolling out a new and untried vaccine, or risk hundreds of thousands of deaths from a flu pandemic.

Of course, had the Swine Flu pandemic hit in the winter 1976, the incidence of side effects would likely have been considered acceptable.

 
Looking back, I have a hard time faulting the government for going ahead with the vaccination program. I know, it is very popular now to paint them as incompetent, or worse, but I believe that they believed the threat was genuine.

Unfortunately, good intentions don’t always guarantee good outcomes.

Ironically, H1N1 would reappear a year later as the `Russian Flu', which mainly affected those under the age of 20.  Many believe it escaped from a Russian or Chinese lab, as it was nearly identical to a strain that had last been seen in the 1950s (see Microorganisms: The Growing Phenomenon of ‘Frozen’ Virus Genome Sequences and Their Likely Origin in Research Facility Escapes).

Thankfully, the flu vaccines of today are far different from the crude whole-virus or early split-virus preparations common in 1976.  It should also be noted we used the old pneumo-jet system, instead of syringes with needles. 

Today, that delivery system 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.

Modern vaccines now use highly purified split-virus, subunit, recombinant, or cell-culture technologies that isolate key surface antigens - are generally administered using sterile, single-use disposable syringes - and have an enviable safety profile.

While the debacle of 1976 undoubtedly damaged the public's faith in flu vaccines, the successful rollout of an H1N1 pandemic vaccine in 2009 - and the COVID vaccine six years ago - hopefully gives the public more confidence going forward that a safe and effective vaccine can be developed and deployed in an emergency. 

Because like it or not, another pandemic is all but inevitable.