The politics of Swine Flu
In 1918-19 Swine Flu killed 21 million people. In a few months it may be back— but this time we’re ready for it
The human sneeze has a muzzle velocity of 152 feet per second. It can send a spray of 4,600 particles into the air for a distance of 12 feet. The particles can suspend in the air for as long as half an hour. Each particle can contain 19,000 bacteria colonies and together more than 85 million bacteria. The human sneeze is the most common form of the transmission of infectious influenza from one person to another.
Fort Dix, New Jersey, is a rambling collection of army buildings about a 40-minute drive from downtown Philadelphia. It provides a seven-week basic combat training course for raw recruits from the eastern seaboard of the United States. At any one time it contains a base population of about 21,000 army and civilian personnel. By early February, this year, David Lewis was
in his third week of the training course. He was from Ashley Falls, Massachusetts, and 19 years old. On February 3, Private Lewis, Echo Company, First Batallion, 3rd Basic Combat Training Brigade, presented himself to the base dispensary during the daily sick call. He complained of a general soreness, some nausea and a temperature of 100.4. He was ordered confined to quarters for 48 hours, but the next day, February 4, he left his barracks and joined his platoon for M-16 rifle drill on the post range. On the march back to barracks, he collapsed and was taken to the base hospital where he died between 7.30 p.m. and 7.45 p.m. Because there had been a high incidence of flu at Fort Dix and because of the manner of Lewis’ death, an autopsy was performed by the chief of the hospital’s pathology department, Dr. John Zabkar. He reported
his findings to Colonel Joseph Bartley, the assistant director of health and environment activities at Fort Dix, the next day.
The autopsy showed that Private Lewis had died of pure viral pneumonia caused by influenza. Traces of the strain were found in his trachea and were isolated in lung tissue. While some 300 recruits had come down with the flu on their return from Christmas leave, Lewis was the only fatality. Fort Dix medical teams took throat washings from all recruits suffering from flu and sent them to the New Jersey State Public Health Laboratory for identification. Dr. Martin Goldfield, a state immunologist. began testing the strains from Fort Dix against the reagents he had on hand at his laboratory. A virus known as A/Victoria/75, named because it had been first isolated in Australia, had been the most common flu strain infecting Canadians and Americans over the winter. Dr. Goldfield isolated four new strains from Fort Dix through a procedure called a complement fixation test. He was able to determine that it was the type of virus called influenza A. But it was not A/Victoria. This A virus was something completely new to him. He immediately called Dr. Walter Dowdle of the Centre for Disease Control in Atlanta, Georgia. Later the Fort Dix strains were hand-carried to the CDC for identification by Dr. Dowdle.
On Friday February 13, Colonel Phillip Russell was looking forward to a weekend of skiing in the Maryland mountains. He had bought a new pair of ski boots and some expensive Kneissel skis. His wife was to pick him up at his office at Washington’s Walter Reed Institute of Research where he is director of the division of communicable diseases and immunology. A tall spare man, Russell is an internist with a specialty in tropical diseases. He went to Johns Hopkins medical school and the University of Rochester and has spent much of his career in the tropics. Before he could leave his office for the ski hills he got a call from Dr. Dowdle in Atlanta. After a few pleasantries, Dowdle asked: “What the heck is going on up at Fort Dix?”
“I don’t know, Walt, apparently they’ve had a bump in their ARD [acute respiratory disease] rates.”
“Well, we’ve got something here,” Dowdle said.
Russell called his wife, told her to start for the mountains without him, and grabbed the next plane for Atlanta. The next morning, February 14, he met with Dr. Dowdle at the CDC. At the meeting were Dr. David Sensor, the director of the CDC, Dr. Goldfield, CDC staff immunologists and officials of the federal Bureau of Biologies, the department responsible for overseeing the production of various vaccines. Dr. Dowdle presented his data and the strain was identified for the first time as A/Swine/FU Dix-76. Swine influenza. Hog flu. The same strain of influenza blamed for the pandemic of 1918-1919 which tore through every country of the world killing more than 21 million people. Russell immediately flew back to Washington. His job was to field a number of medical teams at Fort Dix to track down the recruits from whom the original throat washings had been taken. He wanted to get antibodies from them to see if they reacted with the A/Swine. He activated a special operation called in militaryjargon EPICON: the epidemiologic consultation service, including a team of trained epidemiologists backed up by the infectious disease laboratory, the department of virus diseases and the health and environment branches of the surgeon general’s office. They had to find out how far the infection had spread. Each man had his job: Russell was responsible for determining the spread of the disease on the post; Goldfield was concerned about the state of New Jersey; and Dowdle was worried about the rest of the country.
For the next few weeks. Russell’s people worked seven days a week, existing on three or four hours sleep a night. Teams of officers and enlisted medics at Fort Dix monitored incoming patients at the base hospital. They took blood samples from whole platoons, between 40 and 50 men. They carried out a full sera:epidemiological study of the base, taking a 10% sample of the entire population, including the armv band. There was a feeling of urgency
but no panic. The last thing the doctors wanted was any hint of “wildfire,” the instantaneous spread of deadly disease throughout the United States. They were simply well-trained professionals doing their job.
The first man in Canada to learn of A/Swine was Dr. J. D. Abbatt of the laboratory centre for disease control at the Ministry of National Health and Welfare in Ottawa. Dr. Abbatt talks to Dr. Sensor once or twice a week about the prevalence of communicable diseases. In November the two had talked about the virulence of A/Victoria which was coming into Canada. After Dr. Sensor told Dr. Abbatt about the A/Swine isolates from Fort Dix, Abbatt called his chief. Dr. Alex Morrison. The two decided to call an emergency meeting of a group called the National Advisory Committee on Immunizing Agents. This 12-member committee meets from time to time to study the incidence of communicable diseases in Canada and make recommendations to government health authorities. Its chairman is Dr. J. M. S. Dixon of the University of Alberta and director of the provincial laboratory of public health. Dixon and the others were contacted and arrangements were made for the emergency meeting in the boardroom of the Laboratory for Disease Control at Tunney’s Pasture in Ottawa. They knew the Americans were thinking of mass inoculation against A/Swine.
The decision for mass inoculation had to be a political one based on the advice of experts in preventive medicine in both countries. On March 23, the national advisory committee met all day in Ottawa. At the same time, in Washington, the Immu-
nization Practices Advisory Committee was hearing reports from the people at the CDC and renowned immunologists from across the country. On Wednesday, March 24, President Gerald Ford announced a universal vaccination program for all Americans. It was the largest such program ever undertaken. It would cost $135 million. Because it is an election year. Ford was immediately accused of playing politics with scare tactics about an epidemic come November. Privately, U.S. medical officials were sorry the announcement had not come from the secretary of health, education and welfare instead of the Oval Office. Officials at the World Health Organization in Geneva expressed surprise at the suddenness of Ford’s decision, particularly when there was no evidence of any spread of the virus from Fort Dix to the general population. Less than a month later, a special meeting of WHO experts in Geneva would advise every country in the world to prepare for the possibility of an epidemic of swine flu next autumn. In Canada, Health Minister Marc Lalonde studied the recommendation of his advisory committee. In each province, medical officers of health had been alerted to the possibility of a new strain of flu and were told to report any new strains in their areas. Six days after the Ford announcement. Health Minister Lalonde rose in the Commons to announce a program of inoculation for 11.6 million Canadians, at a probable cost of $70 million. What vaccine we couldn't make ourselves, Lalonde said, we could buy from the Americans.
An injectable vaccine is the only known preventive measure against infectious influenza. Once you have it, you have to wait
it out. You can treat only the symptoms. The vaccine is made up of a tiny amount of the killed virus, just enough to kick into action the body’s self-defense mechanism for producing antibodies. These antibodies then fend off the onslaught of the fullstrength virus when it arrives. The virus itself has been around for centuries, in every country of the world. The name influenza
was coined by two Italian historians, Domenico and Pietro Buoninsegni, in 1580. They were convinced that the fevers, sore throats, nausea and soreness were directly attributable to the “influence” of star patterns. There are records of a flu-like epidemic in 412 B.C. which swept through the Athenian army. Between 1174 and the American Revolution there were an estimated 44 epidemic appearances of what seemed to be influenza. In the last century there were two pandemics of flu, in 184748 and in 1889. But it was not until 1933 that the first swine virus was isolated in human beings by a team of British scientists. For the first time, they got a look at a flu virus and saw how it worked. The flu virus itself, under magnification, looks like a soft cotton ball with two protrusions on the surface. These two proteins, the haemaglutinin and the neuraminidace, help the virus to do its damage. The haemaglutinin is a peg like structure which allows the virus cell to attach itself to the host cell. The neuraminidace resembles a spike and it allows the virus to unhook itself after infecting the healthy cell. The danger from flu comes from secondary infections such as bacterial pneumonia.
What puzzles scientists about the flu virus is its ability to change characteristics in what is called an antigenic shift. When a major shift occurs, a totally new strain is produced and to combat it an entirely new vaccine is needed. This happened in 1957 with the Asian Flu and in 1968 with the Hong Kong strain. Both caused widespread epidemics in Canada and the United States. It has happened again with the isolates discovered at Fort Dix. To find
out if the Fort Dix A/Swine is the same as the virus in the great pandemic of 1918, antibodies were taken from people who were exposed to the 1918 strain and tested against the Fort Dix virus; results were positive. This does not mean that the flu of 1976 is the same as the flu of 1918. No one has ever seen the 1918 virus. All it means is that the antibodies created by the 1918 strain react with the Fort Dix variety. It is on this assumption that the United States and Canada decided to go ahead with mass inoculations. It is a gamble against the slightest possibility that what happened in 1918 could happen again.
By September, 1918. the world was tired and depleted after four years of the most awesome butchery in history. The mass troop movements across oceans provided an excellent carrier for the disease which was called Spanish Flu or, more romantically, the Spanish Lady. Nobody knew precisely where it spawned. Some virologists say that all influenzas begin in South China where large masses of humans live near and mingle with large populations of animals. Swine influenza is so called because in the past 60 years or so it has caused flu-like diseases in pigs. Oddly enough the disease produces the same symptoms in pigs as in humans—sneezing, coughing, even spitting. Pig breeders had for quite some time noticed the spread of a crouplike disease among their herds. On Monday, September 30, 1918, the National Swine Breeders’ Show was ending its first day of competition. About 8 p.m. one of the chief adjudicators of the show—held in the William Holland Building of the fairgrounds in Cedar Rapids, Iowa—noticed the alarming spread of a coughing sickness among the pigs. The animals all had fevers, were coughing and exhibited signs of mild distemper. The judge ordered the show closed the next day. He wired his findings to Washington, to the Department of Agriculture, and in his telegram he used the words “hog flu.” Since that time there have been cases of flu epidemics within the hog population and even incidents of flu transmission between hog and human, usually among farm workers. The Fort Dix case was the first human to human transmission on record in years.
In the United States, it’s thought that the 1918 pandemic began in early March in an army base at Fort Riley, Kansas. All influenza strains are in the population at low or subclinical levels throughout the summer. They take hold in the general population in the autumn and through the winter. No one knows why. It could be that people move indoors during the winter, tend to group together and are generally less resistant to germs. By September, 1918, the incidence of Spanish influenza was making itself felt in North America. Public health authorities began to take measures that seemed worthwhile at the time but ultimately proved useless. Quarantines were instituted. Public buildings
such as theatres and concert halls were closed. People stayed away from barbershops and racetracks. Huge signs were erected in New York City: IT IS UNLAWFUL TO COUGH AND SNEEZE: $500 FINE OR A YEAR IN JAIL. Chicago’s health commissioner, Dr. John Dill Robertson, told his police department: “Arrest thousands if necessary to stop sneezing in public.” Policemen, mailmen, tram conductors, firemen and newsboys wore gauze face masks. It was all useless. Health authorities tried to promote public recognition of the danger with crude public relations gestures such as “spitless Sundays.” By December the hospitals were beginning to fill up and
new patients were put in the corridors. The deaths mounted. Baltimore ran out of coffins, Chicago ran out of hearses and switched to trolley cars. Nothing seemed capable of stopping it.
In Canada the flu. it seems, was transmitted by a well-meaning CPR conductor named David Reid Kennedy. He was assigned to escort a trainload of repatriated soldiers from Quebec City to Vancouver. The military base at Quebec was under quarantine with orders that no one be moved, but Kennedy climbed into the commanding officer’s office to get the travel vouchers he needed to move the troops. As the train moved to Vancouver,
THE DISEASE DOES THE SAME THING TO PIGS AS IT DOES TO HUMANS, THUS THE SWINE FLU’
Kennedy was getting more and more annoyed as car after car was hit by a strange disease. He was forced to cut the cars from the train at junction points along the way. Everywhere he cut loose a carload of sick soldiers, the flu spread. As winter came on. the epidemic grew worse. In Montreal, stores were ordered shut by 4 p.m. and motorcycle policemen patrolled the downtown streets to make sure the law was obeyed. In Hamilton, a department store announced there would be no Santa Claus that year. The Ottawa city council chamber was turned into an emergency aid station with 200 women working around the clock to make hospital sheets, diapers, towels. A staff nurse described the Drumheller Hospital in Alberta as “an inferno of sick and suffering.’' In Edmonton, the local chapter of the Victorian Order of Nurses discovered that their charter prohibited the nursing of epidemic cases. They voted to disregard their charter. Home remedies became the most popular conversation topic in the country. People hung cooked onions around their neck to fight the flu or washed their throats with lime water. They tried inhaling hot water and turpentine fumes and drinking glasses of hot milk mixed with ginger, soda and sugar. Everywhere people stopped shaking hands. The death toll rose. Montreal, with a 1918 population of 640.000. recorded 3.128 deaths. Toronto had 1,600 deaths in a population of 490.000. Ottawa, with a population of 104.000, had 570 deaths. Between September. 1918 and March, 1919. the Spanish flu killed 65.000 Canadians. In the United States, almost one in every four persons was hit by the flu and 500.000 died. By spring the virus had disappeared and the epidemic was over.
While no one is predicting what will happen next fall, most virologists and public health doctors say the intensive mortality rates of 1918-19 will not be repeated. For one thing, the development of antibiotics has lessened the danger of secondary bacterial pneumonia, a major cause of death 58 years ago. The production of swine vaccine should cut down the number of cases of virulent flu. To produce the vaccine, fertilized eggs are injected with the strain. The virus grows in the egg and then is separated from the egg protein in a zonal centrifuge. The virus is then killed with formalin and made ready for injection. In the United States four companies are capable of producing the vaccine. Because of the urgency, the companies have asked for relief from the antitrust laws so that the entire drug industry can be involved in vac-
A CPR CONDUCTOR, BY BREAKING QUARANTINE, CAUSED THE FLU TO SPREAD IN CANADA
cine production. In Canada, two companies—Connaught Laboratories of Toronto and the Armand Frappier Institute in Montreal—will produce the vaccine. Not everyone in the country will be inoculated. Children under the age of 16 are excluded because of the possibility of an adverse reaction to the vaccine (clinical tests have revealed that it can cause convulsions in children under the age of five years). Priority will be given to people over the age of 65 with respiratory conditions and those between the ages of 20 and 50. The major problem facing health officials is the production of the vaccine itself. Connaught hopes to have four million doses ready by September 1. To do this, the company will have to put its people on double or triple shifts. Connaught hopes to buy bulk concentrate of the vaccine from sources in the United States. The betting is that American authorities will sell to Canada whatever vaccine is left over from its inoculation program. Canadian health officials are also looking for supplies in West Germany and Switzerland, the two European countries capable of producing the vaccine on a mass scale. At the same time, federal authorities are running a flu surveillance program covering the whole country. Every two weeks 40 samples of blood from each province are being sent to Ottawa for examination. By studying the 400 blood samples, health officials can chart the course and intensity of the influenza. The vaccinations will be carried out by each province with starting date of September 1.
The entire program for mass vaccination here and in the United States is based on a matrix of carefully arrived at assumptions. Scientists are assuming the coming virus is similar to the swine strain of 191819. It may not be. They are assuming that the vaccine now being developed will be effective against the new strain. But because of the strain’s ability to recombine with other strains and change its characteristics, the vaccine could be rendered ineffective (although if A/Swine is in the population at a subclinical level, the vaccine should work). Finally they are assuming that the strain was transmitted from the grounds of Fort Dix. It is possible, however, that the virus made itself known and lost its ability to transmit in a few weeks. But if the mass vaccinations are a gamble, the risk is financial. To do nothing would risk lives, because the best evidence suggests that somewhere in the North American population A/Swine/Fort Dix-76 is breeding quietly and that by the fall it will be here.0