Lessons from Swine Influenza.

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Lessons from Swine Influenza Harvey V. Fineberg, M.D. Ph.D. Regular and Pandemic Flu 2006 1 February 2006 US Future US Future 1918 Influenza Scourge The Incomparable Pandemic of 1918-19 >20 million passings overall >500,000 passings in the United States
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Lessons from Swine Flu Harvey V. Fineberg, M.D. Ph.D. Regular & Pandemic Influenza 2006 1 February 2006

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US Life Expectancy

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US Life Expectancy 1918 Flu Epidemic

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The Great Pandemic of 1918-19 >20 million passings overall >500,000 passings in the United States >200,000 passings in Great Britain >5 million passings in India High mortality among youthful grown-ups

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1976 American Bicentennial Year The most aspiring flu vaccination battle ever mounted in the U.S. in light of a flare-up of swine influenza in Fort Dix, New Jersey No flu pandemic showed up

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Sequence of Events in the Swine Flu Affair of 1976 New influenza flare-up – Jan CDC chooses – Feb-Mar HEW embraces, President reports – Mar Organization and field trials – Apr-Jun Vaccine obligation and enactment – Jun-Aug Starting and ceasing – Oct-Dec

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New Flu Outbreak <January> Respiratory sickness episode among armed force initiates at Fort Dix, New Jersey Majority are A Victoria flu Swine flu discovered One demise 13 clinical cases up to 500 with serologic confirmation of contamination with A Swine flu No proof of disease with A Swine flu at other armed force camps or somewhere else in New Jersey

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US Public Health Mindset about Influenza in 1976 Relatively serious plagues have a tendency to happen about once like clockwork Antigenic movements in sort A produce extreme pestilences Predominant H antigens have a tendency to reuse at 60-70 year interims Lesson of 1957 and 1968: too little vaccination, past the point of no return Specter of 1918-1919

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Hsw (H1) - ? a long time “Spanish” H3 – 68 years “Hong Kong” H2 - 68 years “Asian” 1880 1900 1920 1940 1960 1980 Theory of Antigenic Recycling

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CDC Decides <February-March> Consultations and question and answer session Feb 19 ACIP Meetings CDC’s Sencer composes “action memorandum” … “a solid plausibility [of] widespread…swine flu in 1976-77… populace under 50 is all around susceptible… elements for a pandemic.” “The circumstance is one of ‘go or no go’… A choice must be made now.”

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HEW supports, President declares <March> Secretary Mathews to Director of Budget “There is confirmation there will be a noteworthy influenza pestilence this coming fall… The projections are that this infection will kill one million Americans in 1976.” President Ford gathers a board of specialists at the White House (counting Drs. Salk and Sabin) and reports a national inoculation project, looks for $135 million assignment

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Organization and Field Trials <April-June> Asst Secy for Health Cooper announces objective of 95% vaccination in affirmation to Congress Public resistance surfaces to a pre-submitted inoculation program Chief Epidemiologist Goldfield of New Jersey Editorials in New York Times Sabin advocates “active stockpiling” Field trial shows poor results in youngsters

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Where to keep immunization? “It would be ideal to have an inoculation program without a scourge than a pestilence without a vaccination program.” (CDC, 1976)

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Vaccine Liability and Legislation <June-August> Casualty safety net providers decrease to offer obligation scope to immunization producers past 30 June 1976 Legionnaire’s infection flare-up in Philadelphia, 1 August 1976 Legislation embraced making the government the litigant in any suit emerging from the swine influenza program, PL 94-380, 12 August 1976

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Starting and Stopping <October-December> 1 million persons inoculated Oct 1-10 Three correspondent passings in Pittsburgh Oct 11; President Ford inoculated Oct 14 40 million immunized Oct 1 – Dec 16 Twice the same number of vaccinated as in any former year Highly variable scope by city and state Guillain-Barr㩠disorder reported late Nov Program suspended on December 16

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Seven Critical Features – section 1 Overconfidence in principle spun from small proof Conviction powered by prior motivation Zeal by wellbeing experts to make lay bosses “do the privilege thing” Premature responsibility

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Seven Critical Features – section 2 Failure to address instabilities Insufficient addressing of usage prospects Insensitivity to media relations and to long haul validity

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Overconfidence in principle spun from pitiful confirmation Epidemic seems at regular intervals Equating extreme pandemics with the presence of new strains Recycling antigens like clockwork

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Careful chronicled appraisal in the mid-1970’s found… The 20 noteworthy plagues somewhere around 1729 and 1968 happened at unpredictable interims of somewhere around 3 and 28 years (W.I.B. Beveridge, 1977) Of the six top years of overabundance mortality from Influenza An in the US (1936, 1943, 1953, 1957, 1960, 1963) one and only (1957) concurred with an antigenic movement in the infection (W. Dowdle, 1976)

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Pre-existing Agendas Close the insusceptibility crevice (Salk) So much to learn (Kilbourne) Value of the study of disease transmission (Stallones) Importance of anticipation (Sencer, Cooper) Vital part of the CDC (Sencer) Desire to make open private association (Cooper)

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Zeal by wellbeing experts Concern about political inspiration, absence of comprehension among lay bosses Heroic reaction to emotional danger Chance to get ready, to compensate for the absence of readiness in Asian Flu pestilence of 1957

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Premature Commitment Concatenating the choice to start producing the antibody with the choice to foundation an all inclusive inoculation crusade General Accounting Office report to Congress, June 1977: “ …when choices must be founded on exceptionally restricted exploratory information, HEW ought to set up key focuses at which the project ought to be formally reevaluated.”

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Failure to deliver instabilities Failure to gauge hazard Scientists hesitant to evaluate subjective danger Lay pioneers don\'t evoke quantitative assessments of danger Failure to consider limit conditions amid the months of arrangement for an adjustment in approach from a vaccination system to stockpiling

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Insufficient addressing of usage prospects Overstated points Dealing with back up plans and makers (risk, benefit, buy sureties) Coping with likely resistance Expected deferrals (obligation, dose, assent) Experience in distinctive purviews with past inoculation endeavors

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Insensitivity to media relations and long haul validity Media measures and qualities Controversy Coincident occasions Side impacts Institutional believability Professional consultative parts and political choice making Short-run and long-run contemplations

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Five Lessons from Swine Flu Building a base for system survey Thinking about doing Thinking of the media Maintaining validity Thinking twice about therapeutic learning

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Pitfalls to Avoid in Preparation for Avian Flu Confound probability and seriousness Fail to examine presumptions Overstate objectives and goals Fail to convey and disclose Over-appraisal status to execute

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Reflections Decisions in time and under vulnerability Low-probability, high outcome occasions Sequencing, new information, due dates Science and strategy i

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