Geoff FordenPandemics: When do you sound the alarm?

red=confirmed swine flu infections as of 26 April 2009
orange=suspected infections

To put this into SAT format: Public health surveillance is to pandemics (and bio-weapons) as ballistic early warning radars are to nuclear war. In addition to sharing an early warning role, there are also a number of important policy issues they have in common with nuclear war warning systems: How do you know its real? What constitutes the trip wire for full scale response? What is the proper level of response?

As we watch the start of this disease cycle, and wait for hard epidemiological numbers to crystallize, I want to explore the various policy choices that are available and the types of information that go into them. We should, however, keep two important historical examples in mind; the first shows the dangers of reacting too quickly while the second, the dangers of reacting too late or not at all.

In January 1976, a respiratory disease later determined to be swine flu passed person-to-person broke out at Fort Dix with one solider dying the day after first reporting symptoms. By the beginning of April, the CDC had decided to start a nation wide vaccination program with President Ford urging every American to get a shot. (Stockpiling vaccines was not considered because the dangers of vaccinations were not fully realized. It was considered better to “store the vaccine in people than in warehouses.”) Ten months after the first case was reported, 45 million people had been immunized. This short time line caused considerable logistical difficulties with one manufacturer using the wrong virus to derive their stock of vaccines. By the time the immunization program was shut down, after an increase in the number of deaths associated with the vaccine from Guillain-Barre syndrome reaching around 25 and only a handful of additional cases suspected, the program cost around $700 million in 2009 dollars. (Its hard for me to imagine a crash vaccine production program costing less or working more smoothly if we were faced with a need now.)

The other cautionary tail involves the outbreak of SARS (Severe Acute Respiratory Syndrome) in China in January 2003. At that time, eight health care workers and relatives of patients in a hospital in Guangdong Province came down with what they termed “atypical pneumonia.” (When SARS spread, first to Vietnam and later other countries, health care workers were particularly susceptible.) Provincial officials eventually traced the outbreak back to a single family in the province in November 2002. National authorities in Beijing handled this outbreak in what was then it traditional response to epidemics: they silently tried to control it “without upsetting social stability.” (Ruotao Wang, “China’s Response to SARS”, Temple Law Review, 2004, 77 p. 149 ) The world did not learn about SARS until March 2003 when Dr. Carlo Urbani , a doctor working in Vietnam and who soon died of the disease, reported it to the World Health Organization (WHO). WHO set up a secure internet site for doctors and researchers to communicate and exchange chest X-rays in the (unfulfilled) hope of finding a diagnostic tool. SARS spread to over 30 countries in a few weeks. In June 2003, WHO held a conference on SARS with nearly 1400 attendees. Meanwhile, infected patients were quarantined and while no specific cure was found, this was enough to break the back of the epidemic.

Quarantine is obviously an effect public health care measure. But will it be sufficient in the future? In my next post, I hope to examine various models for reacting to pandemics.


  1. Azr@el (History)

    H1N1 rears it’s head again. Just shy of a hundred years ago we had to teach little kids rhymes such as:
    Obey the laws
    And wear the gauze.
    Protect your jaws
    From septic paws.

    I wonder if this one will be virulent enough to warrant such measures again.

  2. MikeB (History)

    If an immunization program doesn’t cost too much and doesn’t kill too many people it is applauded as effective. Shouldn’t there be some proof required that flu control measures actually have some effect besides employment?

    Flu seasons seem to come and go with some regularity. They always come, they always go. How do we really know if a vaccine had any effect on a flu season?

  3. mp (History)

    If I may shamelessly link to my own blog, you might find this list of epidemic and biological threat monitoring programs and systems of relevance:

    (Mostly culled from a report from the Stimson Center last year.)

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