Okay. Mhm. Uh, today we are deviating

from oncology just a bit, and we're going to

have a discussion on influenza. The title is influenza

. This year and next, the program will be

moderated by Dr Vincent gonna head of the Department of

Epidemiology, M. D Anderson Hospital. Dr.

Gonna Thank you. Today's topic influenza is appropriate for

two reasons. First, as we meet today,

we're in the middle of a nationwide influenza outbreak caused

by the A Victoria strain. And second, there

are some disquieting reports about the scattered appearance of swine

influenza around the United States. In humans, this

is the same strain which caused the great influenza pandemic

of 1918. The question is being raised. Can

this strain enter the human population again with the same

disastrous results? Me to put this situation in perspective

for you, we've gathered a panel of professionals who

are both knowledgeable about and interested in influenza in order

of their seating. We have Dr William Paul Gleason

, who is the epidemiologist for the Research Influenza Research

Center at Baylor College of Medicine and an associate professor

in the Department of Microbiology. Dr. John Bea

Arthur, assistant professor of pathology at the University of

Texas Medical School and also a member of the Department

of Epidemiology. Here it Anderson Dr Robert MacLean is

chief of the department of Communicable Disease division at the

Houston City Health Department. And Dr James Steele is

professor of environmental science at the University of Texas School

of Public Health, is formally the chief of veterinary

affairs of the Department of Health, Education and Welfare

, and also, very specifically in relation of our

topic. Today is a consultant to the World Health

Organization on animal influenza. Our format today will be

short presentations by each panel member and then a general

discussion in which we hope the audience will join us

by way of introduction. I might say that flu

is characterized by a sudden onset in a population and

in an individual to the point of being diagnostic for

epidemics, for the population and diagnostic for an individual

patient. When the doctor hears about it looking into

the past for the best description of the onset of

flu, I came across one from the epidemic of

1905 Sir William Broadbent of England told of one of

his patients, who drove in at one gate of

the park in perfect health and out of the other

prostrate with influenza. Just about everyone can get influenza

. There is no socioeconomic boundaries. The epidemic of

17 89 and 17 90. It was 17 90

when it hit America. We get the quote in

the spring of 17 90 at which time George Washington

was rendered severely ill by it. I have one

slide that gives us an idea of how the communicable

disease center in Atlanta follows the course of influenza outbreaks

. Influenza continues to be the only infectious disease in

the nation, which causes epidemic excess mortality. Since

1957 there are something in the neighborhood of 300,000 excess

deaths that have been associate ID with influenza a mhm

on this slide. The solid line is the expected

number of deaths that we should see in the United

States Over time. Significant deviations are represented by the

dotted line, and when pneumonia and influenza deaths go

be uh beyond this dotted line here they are said

to have gone above the epidemic threshold. Looking at

the cases occurring this year, mhm for the Morbidity

and Mortality Weekly Report of January 17th We found that

the first cases of the winter were reported at that

time in January, the middle of January. In

less than two months, cases have been recorded from

all states in the continental United States. As of

this morning, influenza is characterized as being widespread in

the United States. The incidents has peaked in the

Northeast and it is increasing in the Western states.

Deaths due to pneumonia and influenza, as we saw

in that chart have increased and are above the so

called epidemic threshold in all areas of the country at

the present time. So that's where we are this

morning. First panel member that I'd like to call

upon to discuss some of the elements of influenza is

Dr Arthur. Thank you. Okay. The disease

that occurs uncomplicated by any other infection in human being

is usually turned to primary atypical pneumonia. The influence

of virus preferentially invades the respiratory passages, both those

of the nasal pharynx, the hyper pharynx as well

as the trachea and bronchi I, and may eventually

involve the lungs. In the most severe cases,

sporadic cases of the influenza pneumonia may have something of

the range of 1% mortality rate. And during the

great pandemics, the mortality rate may go. Asshole

. Aya's 3% of the people it's estimated that various

figures are could be found, but somewhere in the

range of 10 to 15 million people throughout the world

died in the 1918 to 1919 Pandemic persons of all

ages, maybe seriously involved in death occurs in all

all peoples. But preferentially mortality occurs in infants and

cardiac patients and in pregnant women, although certainly healthy

young adults can be seriously involved and oftentimes die with

this disease. Death, when it occurs, is

usually due to a type of al Volare capillary block

and failure of diffusion of oxygen. Sue the capital

. Remembering If persons die with this disease and obviously

Onley, those most severely affected, uh, go

on to have their lungs reputed autopsy for actual examination

of them. The lungs are markedly heavy, and

there's extensive oedema and hemorrhage microscopically. One confined some

inflammation within the Broncos, but this may often represent

a superimposed infection, and one of the problems of

trying to make a diagnosis histological e of any of

the viral pneumonias or the influential pneumonia, specifically is

the complication of a superimposed bacterial infection. One of

the features that does go along with a viral infection

, though, is the change of the alvito lining

cells into a cute boy. It'll type epithelium.

Normally, these cells would be indistinguishable. Such is

in this area. One cannot make out the lining

al Baylor cells, and then down in this region

, they're very enlarged. There's a controversy over whether

these are metal, plastic or hyper plastic. But

for whatever technical reason exists, there is the marked

thickening of the epithelial cells lining the al Volare spaces

. And where the Al Baylor capitally wall should be

a relatively thin membrane like this. There's the mark

thickening, with some fibrous tissue deposited in here and

a chronic inflammatory infiltrate. So this is why a

person has difficulty exchanging oxygen and carbon dioxide. Is

this mark thickening of the wall and the thickening of

the individual cells? Mhm. And here, a

slightly higher magnification shows the mark thickening these walls again

. If one would accept that this should be about

the normal thickness of these Alvalade walls, you see

the very marked thickening that would go on. The

histological picture is totally non specific for most of the

viral infections. This one actually comes from a case

of measles and hear their giant cells that would show

up. But the other changes are non specific and

represent that a viral infection. It's interesting that the

studies during the 1918 epidemic we're done in part by

a man named Goodpasture, Goodpasture wrote to papers that

were published in 1919. One of them had to

do with 30 autopsies from young men who were at

the naval station at Chelsea, just outside Boston.

And in these men. He described the interstitial pneumonia

and also secondary pneumonias, and his paper is very

well illustrated in one condensed English. Even now,

looking at the paper, those patients that had a

typical viral pneumonia and those that had secondary bacterial infections

. His second paper has brought him or enduring fame

as a medical person. And in this paper he

described only two individuals. But he had two men

that he wanted described more fully those cases where he

said they were bacteria logically sterile. He could not

find bacteria, either in cultures or in tissue sections

, and he described the very typical viral pattern in

both of these men. One of whom died seven

days after the onset of the illness. But the

other, he commented on, did have an atypical

appearance to his lungs, or rather, his clinical

course by running so long. And he also had

very atypical changes in the gloom Mary Ally with a

proliferated grammarian on Fridays and extra dates in the going

Merry Ally. This pattern we now recognize as what

we turn Goodpasture syndrome and probably this man had a

different disease, or at least a very atypical reaction

to the viral influenza. And we now associate the

deposition of Highland membranes in both lungs and kidneys with

the entity called Goodpasture syndrome. But the original paper

that Goodpasture describe this entity and was a person who

we thought was a victim of the flu. It's

also, um, I think should be interesting to

recall that the influence of virus was first identified and

isolated in 1933. Yet in the same paper,

Goodpasture wrote, I am convinced that this is a

that this is true and that the ideological factor is

not any of the numerous pathogenic micro organisms which have

been cultured from the lungs, often in pure culture

, but then an unknown virus which produces the general

intoxication is the cause of the disease. So I

think Goodpasture has a hallmark in the 1918 epidemic by

separating out a separate disease unknowingly and also truly predicting

that a viral ideology would be found for this disease

. Thanks. Dr. Gleeson, You have been

watching influenza in Houston. What do you find?

And how do you find it? Um, Vince

, The influence of research center was established here it

Baylor College of Medicine about two years ago, and

in the short period of its existence, Houston community

has had to endure to influence epidemics. And as

you all are aware, we're concerned about the possibility

of a third successive epidemic. Uh, I want

to say parenthetically, though, that the Influence research

center has other charges and the clinical epidemiologic observations that

I want to talk about for a few minutes today

, Uh, one of the direction Dr. Robert

Couch. Uh, studies are taking place and looking

at the host response. The immune response, a

protective response, thio natural and experimental infections with influenza

and also looking at the response to and the effectiveness

off various new vaccine preparations which hold some promise for

some improvement in our immunization programs against influenza. Well

, way. Look here. At the first slide

, you can see on this map of the greater

Houston metropolitan area some of the sights of surveillance for

influenza like illnesses, which have been established under the

the program of the Influence Research Center. Now these

centers include all of the neighborhood health clinics. Um

, they're part of the Harris County Hospital District on

and cooperating with us in studies. Here are the

physicians manning these clinics under the A community medicine department

at Baylor. Uh, it also includes Sentinel family

physicians in the Houston community who also culture the patients

that they see in their practice that might have a

federal respiratory illnesses. Um, there's extensive surveillance also

at Ben Taub in the pediatric, both outpatient and

inpatient areas, thes cultures, air all brought to

our laboratories at Baylor and processed for respiratory viruses.

Now, last year, just as the surveillance program

was initiated in the middle of December of 74 influenza

, a virus was prevalent in the community and this

virus was found. Thio have the energetic characteristics off

the influence of a Port Chalmers virus, which had

first been isolated in Australia in 1973. And you

can see that following a lull during the Christmas holidays

, this virus set did uhh establish a foothold and

produced a moderate outbreak here in the Houston community.

The next slide, we'll look at some of the

parameters of evidence that influences present in the community.

And in these endeavors we have the collaboration off the

epidemiology group at the Houston City Health Department under Dr

Maclaine in providing us information about public school absenteeism,

industrial absenteeism, emergency room visits and such things.

And I think you can see that there was nothing

very impressive about the impact of the Port Chalmers epidemic

in some of these parameters. In Houston last year

, there was just a slight suggestion of increased absenteeism

in public schools during the peak of the epidemic.

Industrial absenteeism here is evidence by absenteeism, and five

of the large department stores here in Houston didn't really

show us too much. Emergency room visits to Bend

Tab, uh, did not reflect any increase in

visits. There were probably some increase in pneumonia admissions

at the Medical Center hospitals. The only real evidence

that influence was present I think count from this elevation

of deaths attributed to influenza and pneumonia. During that

period, you could see that there were four successive

weeks when they were 12 or more deaths reported.

And this is definitely an unusual occurrence since if you

go back, I look at the weekly occurrence of

mortality for the previous two years. You'll see that

there were only two weeks in that entire period when

there were as many as 10 deaths reported in a

single week and those were single scattered weeks. So

they have four successive weeks off 12 deaths or more

. I think, uh, and it does reflect

the presence of influence and that this was a significant

though moderate outbreak. Um, during the fall,

we screened a pool of syrah. These were actually

collected from court bloods, taken a JD hospital,

and we found, as we might expected, that

80% of the cord blood showed that thes young females

that had experience with Port Chalmers like virus, and

you'll see that almost 80% had antibodies support Chalmers.

But we also screened these same sirrah against the A

Victoria. An urgent this virus had just then recently

been reported again from Australia and was reported to show

significant any energetic variation from the strain that we had

the previous year. And you could see that that

only 40% had any detectable, uh, antibody to

the A Victoria String. And we would then feel

that the population wa susceptible to possible spread of this

virus. But we were hoping that it has with

Port Chalmers, which was first isolated 73. It

might take another year to get here, and we've

had some time to yeah, dispense, um,

vaccine specifically for this. But a Z we'll see

in the next side this time was not available to

us because about the middle of January again, we

began to see some evidence in these parameters that I've

talked about of influenza activity in the community. And

sure enough, virus isolation started showing up. This

was a very early and preliminary look at this on

actually, in Week five, the number of proven

cases off influenza a Victoria roast about 232 and in

week six and seven and eight were already, uh

, approximately over 250 virus proven cases of influenza on

, If you can remember the history, Graham,

that I showed a minute ago. This is already

more than double the number of isolates that we had

last year so that we think that this probably is

a very significant epidemic. Well, just Thio refresh

your memory about the some of those parameters I talked

about. I'd like to just use this thing as

an outline in which discuss what's happened this year.

Already on weeks five and six, public school absenteeism

has been a 12% but then dropped in weeks seven

and eight down Thio 10 and 9%. Uh,

really, For the first time in three years that

we've maintained surveillance of industrial absenteeism, there has been

a peak, uh, in well, not really

a peak. There has been a significant increase in

absenteeism and in absenteeism, uh, reported to be

due to respond to our illness. Uh, in

these department stores, the reports are a little late

, but that appears to still be rising in week

seven. Um, emergency room visits. I had

been TOB again, if not reflected, really the

amount of influence activity in the community. But I

think this is because of the special role of anti

emergency Room in this community and that it sees a

great deal of trauma and other types of problems.

So there isn't much room for acute respiratory disease to

squeeze in. But way have then added to this

surveillance emergency room visits to the memorial hospital system and

in memorial Hospital system. We've seen an increase of

visits. Thio, the emergency room of the four

hospitals combined, um, which was running on average

about 172 visits per day for the five or six

weeks preceding the epidemic, and only 12% of the

people seeking care then reported in acute respiratory illness.

Uh, by week seven, this had increased to

217 visits per day, with 25% off people seeking

care reporting respiratory illnesses. So I think that this

, uh, setting then gives us a better indication

of what's going on. We've also seen a similar

increase in the number of visits to the General Pediatric

Clinic Van Top, and in fact, they had

a peak record number of Children seeking medical care there

on two Mondays ago, when there were a total

of 432 Children scenes in a 24 hour period,

This is a great greatly in excess of any previous

numbers seen there. We've also seen a pretty significant

increase in the money admissions to medical center hospitals.

In fact, the numbers our people are being admitted

for lower respiratory disease has doubled in the past two

weeks and up to about 80 per week, four

weeks, seven and eight of this year. No

reporting of mortality understandably lags so that way have not

yet seen a really increase in reported mortality. It

takes some time for death certificates to filter into the

health department. But in Week eight, for the

first time, there was an increase and there were

12 deaths reported that week. And I think we

would have to expect that the numbers will continue to

grow in that category. As the reports come in

, I'd like to just briefly talk a minute about

the age distribution off viral logically proven cases that we've

seen. And this sort of picture has been seeing

both in last year's epidemic in this year that in

the early weeks of the epidemic, the majority of

cases are proven in Children and that during the peak

of the epidemic in the later weeks. The age

distribution shifts so that the majority of cases are in

adults. And this represents our original isolates during the

first five weeks. And are these that we identified

, 61% were in Children under 15 years of age

. We made a quick tabulation of the eye slits

for weeks seven, and we found that that this

had reversed that. Now, uh, 60% of

the eye slits are in individuals over 60. We

saw the same thing last year when in the early

weeks of the epidemic, uh, during the time

that it was smoldering along, 70% of the isolates

were in Children under 15, and in the mid

part of the epidemic, approximately 50% were in people

over and above 15. I think this is important

because, uh, a sui look it not only

these figures on proven cases, but school absenteeism and

visit pediatric clinic. We sense that there is a

rapid horizontal spread of the virus through the community among

school age Children, and now we're probably experiencing the

effects of then vertical spread to both older and younger

younger individuals in the community. And actually, I

think in the last few years. A few weeks

, Um, following the peak in school age Children

, we've seen more complicated cases, and it's probable

that there is more mortality during that time. Well

, just this untraditional Thio. In anticipating some of

the comments that Dr Steele might make, I would

like to say that we recently screened another 100 current

records Sarah from JD Hospital and we included in the

energy and the energy for the swine influenza virus on

. We found that exactly zero of young adult females

in the community have antibodies to swine, uh,

influenza virus right now in the Houston community. So

this, I think, underlines some of our concern

about the possibility of the spread of swine like viruses

. Thank you. Dr. Maclaine is responsible for

the health of the city of Houston when it comes

to communicable disease. Dr. Maclaine, what's the

situation and what are you going to do about it

? Well, Vince, in my experience there two

times in the year when the state and local health

authorities get involved in the influenza problem one when they

have thio when they should the time when they have

to be involved, is when they get that first

call from a local news media station in the community

, usually sometime in December or January. I wanted

to know why the managing editor is out with what

he says is the flu and is there a virus

going around the community? I remember sitting down with

Dr Couch two years ago when they influenza center was

initiated, discussing what types of surveillance activities we could

strengthen and what types of activities could be added to

our local activities as a result of their funding mechanisms

. And I made the not so facetious remark that

you could probably abandon all these activities and sit back

and wait for that first phone call to come in

from a radio or television station. And I think

Dr Couch now is a little bit on my side

, since this, uh, again predictably occurred at

about the time these other parameters were beginning to show

that flew was president. The community, now the

other time with existing resource, is that we have

available to control influenza. That the health department should

be involved is at a time when you might conceivably

make an impact on the illness, particularly from controlling

serious morbidity and mortality, and that, naturally,

is in the fall. Each year, the U

. S Public Health Service Committee Advisory Committee on Immunization

immunization Practices produces with almost monotonous regularity and similar similarity

, uh, their annual flu prediction and recommendation for

vaccine administration. And outside of changing the components of

the A or B, strains in by violent or

Polly violent vaccines, they have consistently recommended that these

vaccines be administered to high risk individuals. And I

won't bore you with who these individuals are from a

medical standpoint. Yet when you look at it from

a realistic point of view, Uh, in 1974

it was estimated that they were between 50 and 60

million high risk individuals in the United States. And

yet only about 30 million doses of influenza vaccine were

produced and distributed. Uh, obviously then from time

zero, you only have enough vaccine to protect half

of your high risk population. Now, from a

practical point of view, uh, we also know

that probably, uh, a significant if not a

major proportion of influenza vaccine. Each year gets administered

to low risk individuals. Healthy factory workers, uh

, in various employee health programs. Uh uh,

closed populations such as the military and UH, perhaps

athletic teams where it would be a disaster if the

basketball team it couldn't make it on to the national

championship because of a now outbreak of influenza. So

we're faced with the problem that we have a vaccine

available. It is probably about 70% effective in reducing

morbidity and mortality if administered at the proper time of

year. But in this country today, only a

small fraction of the people that really ought to be

getting it are getting it. And therefore, I

doubt whether vaccine distribution has had any significant impact on

controlling the disease and those for whom it is intended

just as a, uh, for our own interest

to look at a relatively easily accessible, high risk

population in the fall. Late fall November of 1974

we looked at nursing homes in the city of Houston

. Uh, we surveyed 44 nursing homes to determine

the total number of influenza vaccine administrations and, more

specifically, the number administered Thio nursing home patients 65

years of age and older 43 nursing homes cooperated with

the study with reasonably reliable data. There were a

total of 5287 patients that were surveyed, 2846 had

received vaccine, which is 53.8%. And there were

4800 and 34 patients, 65 years of age and

older as a part of this survey, and only

56.2% of these had received influenza vaccine in time.

Thio protect them for the what was a Port Chalmers

outbreak that winter? Uh, as I said,

only 56.2% of a high risk group in nursing homes

have been vaccinated for nursing homes. Only reported 100%

vaccinated, and there were six homes in which no

vaccine at all had been administered. Now, from

a practical point of view, is a public health

physician. If I had thousands of doses of flu

vaccine available to me, I'm not sure I'd go

galloping through nursing homes and dispensing it to bed ridden

patients. That is a perhaps on a cost benefit

basis that would not be realistic. What we have

done in the health department, with the few doses

of vaccine we have had available for the last two

years have gone out to ambulatory senior citizens feeding centers

, which are far part of a federal program in

this area involving mostly, uh, poverty level of

senior citizens. We have administered vaccine Thio 800 to

1000 of these each fall as our resource is permitted

, Uh, we have not as yet gathered any

data on impact are zero conversion rates or so forth

. But at least we feel we're putting our vaccine

smaller amount that it is in an area where it

might be doing some good. Our only other health

department programs that have been consistent has been an annual

vaccination program for ambulance attendants, uh, in in

the Houston City Fire Department. And of course,

we provide the vaccine to our chest clinics, which

treat COPD and tuberculosis patients. But outside of that

, uh uh, what we do is but a

drop in the bucket in this community where there are

close to 200,000 people. Uh, that might be

considered high risk individuals at the present time. And

as you are well aware, federal programs such as

Medicaid and Medicare generally do not provide for preventive medicine

. I've had this complaint brought to my attention so

many times, Doctor, I can't afford the$30

it will take for me and my husband to go

to a private doctor to get our influenza vaccine on

. The Medicare will not pay for it. What

am I supposed to do? And I suppose the

federal answer is Wait till you get influenza and then

you can send the bills through Medicare and this government

program will pay for it. If you happen to

survive, so much the better. But I think

this is a deficiency in our current program. I

think the Center for Disease Control, to my knowledge

, is spending an extraordinary amount of money on surveillance

activities. But I see it the federal level no

push towards a practical, shall we say, intervention

type program where funds air actually being made available through

one resource or another to reach the population that the

federal government says and has said needs to be reached

every year and isn't being reached so that I'll turn

it over to Dr Steele, who is now at

the School of Public Health. On board is also

a zai mentioned of working with the World Health Organization

as a consultant for animal influenza. Um, to

my mind has to be one of the people who

keeps his finger on the pulse of veterinary affairs like

no one else. Probably in the world. Uh

, it's particularly interesting here because, uh, we're

talking about a virus that may go back and forth

between animals and humans and, uh, right now

of in late winter and early spring, we have

to decide whether or not swine influenza virus is going

to go back in the vaccine or whether we can

ignore it and say, This is just a sporadic

Dr Steele. Well, that's a very difficult one

to answer. But one of the leading influenza research

men of our times, Tommy Francis, who was

in Michigan, was head of the Army immunization activities

for influenza throughout World War two of many years thereafter

. And it was his recommendation that swine a virus

should be incorporated in vaccine and discussing it with Dr

Glaser realized I was recently in 1959. It was

still a part of the human vaccine given to the

civilian population. If when the military dropped it,

I do not know for certain. Now, talk

about the 1918 situation, and I'll tell you that

I'm old enough to remember it. Not that I

did any autopsies, but I read a lot about

it. And in an article I published in 1959

I researched the literature to find out when swine influenza

first appeared, and the best date that I can

put on it is September 1918 appeared in I'll was

called Hog flu. It was reported at the United

States Animal Uh Health Conference in December in Chicago that

year. It appears that the disease then became epizootic

and continued to explode late in the summer early fall

for the next 10 12 years, until it took

on a more, uh established character of being a

latent type of disease that could be provoked by meteorological

changes. Also, by coming in contact with Demopoulos

organisms or pastorello s, which are very common in

animals and also by physical provocations such as show opened

, Lewis demonstrated when they use calcium chloride in there

is a very interesting epidemic, a logical cycle to

the disease that Shope worked out many years ago involving

the lung, worm, lung, worm, eggs

, earthworms and swine. Doing just a fair number

of earthworms, and this is one part of the

cycle of the virus remaining in nature. But also

it can be latent within the animal and persist and

have re occurring epidemics or epizootic, Uh, during

the chilly months, uh, thinking from September until

March, the disease apparently disappears soon as the warm

weather occurs, Uh, Aziz to its importance at

the moment today, it's hard for me to evaluate

. I think studies that's going on in Baylor gonna

be more important or also c. D. C

. But it is of interest. A study was

made by Francis and Davenport, his group at Ann

Arbor, some years ago on the prevalence of swine

, a antibodies in the human population in the United

States and even in the report is very definitive that

practically anyone born before 1918 was carrying a swine influenza

a tighter after 1918. This starts to decline,

although it remains relatively high in rural populations that have

constant exposure to swine, and I think this is

probably still going on in our rural populations. But

today you have to realize that only 5% of our

people are defined as living in rural areas, uhh

! Just to acquaint you with the numbers that are

going on. We produce something between 191 100 million

pigs annually in the United States on guard. These

are the ones that are at risk. The disease

is mild in swine. So the vaccine that was

developed in the late 19 thirties early 19 forties,

which is a very effective vaccine, is seldom used

because the farmer will take the risk of saying,

Well, they get sick for a few days.

I just keep in the barn, protect him from

chilling factors. Prevent pneumonia from occurring, and pneumonia

does occur. Well, then they get the usual

penicillin struck tomatoes in combination treatment, which is a

fantasy of practically all respiratory diseases of animals. Today

, uh, the uh, problem is largely confined

to the United States. This is one thing that

has always disturbed me, another epidemic ologists that have

discussed this problem as they work from a world point

of view. Why has this disease remained constant in

the United States, southern Canada? It's seldom appears

outside. There's a few reports of isolates from England

, a few from Scandinavia. There's an unusual report

from Czechoslovakia and rats the Chinese look forward in they're

swine has not now as to susceptibility of swine.

They are susceptible to all of the human strains of

influenza, the Asian of 1956 and I have here

before me the review that was published in 1959.

Discussing that and it's relation, I had an article

in their relation to animals in the 1956 epidemic,

which originated, as we define it today someplace in

Eastern Asia, namely China. A study or survey

was made by two British investigators to determine if this

disease that is the Hong Kong strain may have originated

in swine. They were not able to come to

any conclusion. We at CDC at that time used

the Hong Kong and were able to produce a an

acute disease in swine and could recover virus for some

weeks after their artificial exposure. Looking to the future

of the possible reservoir of animals as of influenza,

we have a very large study going that is funded

by N. I H and, uh, in

cooperation with the World Health Organization. There is a

center at the University of Tennessee under uh, Webster

, that is studying the interrelation of all animal influenza

viruses, namely those found in birds. There is

an article and W H o chronicles for December 1975

a beverage in which he summarizes all the work that

has gone on and throughout the world. Uh,

influenza a various, uh, stereotypes have been recovered

from some 147 different species of birds. Uh,

this includes citizen birds canaries. Probably the most serious

has been in Turkey's, where some of the turkey

EP in our ticks as they refer to epidemics and

birds have actually wiped out flocks. And what we're

speculating on here is there is a constant re combination

because you cannot attribute it thio mutant and change.

The generations change so rapidly. That is the neuron

today's, uh, component of the virus that there

must be re combinations air going on. And actually

what we're looking at is nature's laboratory of developing new

strains of influenza. And we're looking at it from

a point of view, that is, a group

of physicians and veterinarians and Ecologists of when these re

combinations can occur that the organism the virus will take

on what is referred to as a business and attach

itself to a mammalian host and eventually this maybe man

. So, uh, we'll be at this for

a long time to come. And, uh,

it is my feeling that, uh, the immunization

committees should restore the swine influenza virus, uh,

to the vaccine that is used in man. Thank

you. Turning to a more informal panel type discussion

, ID like thio entertain questions from the floors as

well as from our other Panelists. We do have

microphones that can be used if you would like to

ask questions and just raise your hand and we can

bring them to you of to start off. Though

, uh, I'd like to ask the panel,

Uh, is it generally agreed that this is now

a re combination factor for viruses affecting man? Or

, uh, can we still, uh, say

that maybe a mutation for, um Well, there's

a great deal of interest in this in this possibility

. And at the meeting in NH recently, it

was pointed out that if re combination does occur in

nature, that the situation recently reported Fort Dix probably

represented an ideal circumstance because to get viruses, influence

, viruses, thio share and intermix there important and

urgent, particularly the hemagglutinin in their men today.

Sanderson's You usually mix them in culture and suppressed the

growth of one of the donors with antibody and then

allow them both to grow within the same tissue culture

. Uh, system. Uh, as you're aware

, in the military, all recruits receive vaccine when

they report for duty. So these recruits had received

three currently available vaccine which waas the Port Chalmers Imagine

. But of course, which has some cross ranking

antibody to Victoria, and so this made them partially

immune. Thio the a victorious strain on this,

by the way, is a unique situation, since

this is the first proven instance where to energetically distinct

influenza. A viruses have been found to be prevalent

in the same population at the same time because they

have identified both human cases off a Victoria infection and

the A swine like virus infection in the Fort Dix

military people in the same period. And as far

as we know, this is the first instance of

really well, at least since we've been able thio

isolate the flu virus. The first instance off Swine

virus is spreading by human to human contact. There's

certainly a lot of itself swine to human infection.

But there's no real evidence off human to human spread

of swine like viruses prior to this this recent Fort

Dix outbreak. So this situation then does represent a

situation where recombination may have occurred in nature, I

have to say, though, this is just one

of the hypotheses now current about the emergence of new

strains off our energetically distinct strains of influence. A

Fires ID take issue with any re combination of the

swine virus because from what I understand, the original

isolate in 1932 and comparing it with the annual isolates

that they come up on Easter Day at University Wisconsin

is more or less the center for all this for

the Americas. And the anti genic shift has been

of such a slight nature that you can actually say

it's probably the way the technicians handled the material.

That's true for swine virus. The swine virus has

been energetically stable, the swine hemagglutinin that the isolate

now is very similar to the swine hemagglutinin of the

original. I slipped back in 1931 but one thing

I didn't add to my, uh, there has

been four different isolations now. I just checked with

C D. C before I came over here and

also with Beaumont Hospital. That's the first appearance in

Texas. There's three soldiers have been diagnosed as having

swine like influenza or, uh, Beaumont Hospital.

El Paso. There's one at, uh, University

of Tennessee in a man working in an abattoir who

has Hodgkin's disease. There's two at the University of

Virginia Hospital at Charlottesville, and the 12th one has

appeared at Fort Dix from that what do you think

? Uh, Dr Steele, what do you think

, uh, could cause a virus to come from

an animal reservoir back into a, uh, human

population. When you consider that this has been the

same virus, it's been in the swine population the

whole time. Why are we worrying about it now

? Why do you think that there's a, um

, certainly, if, uh, if you have

30% of the population susceptible, you should be able

to get it to catch. Do we need to

wait for 80% for it to transfer over? Well

, I think it's the kind of thing that Francis

and his colleagues postulated that as the herd immunity talking

about human population as a whole declines that there is

an increasing number of susceptible, and within that susceptible

population there, there are individuals that are more susceptible

site. These two Hodgkins cases, or I didn't

cite there was one Hodgkin's case that died last year

at Mayo's, which was the first death that I

know is attributed to the swine influenza virus. During

my professional career, we've talked a lot about being

exposed to it, but that was the first death

. And, uh, I don't believe there is

their death at Fort Dix or not because I've heard

it both ways. Yes, there was one veil

case of Fort Dix, right? And when I

talk about recombination, though, what we're really hypothesizing

is that a and influenza virus strain with human violence

factors, whatever that ISS acquires, the hemagglutinin neuraminidase

of the swine virus. That's that's what the hypothesis

says that happened that that the human violence factor may

have been provided by the A Victoria strain prevalent at

Fort Dix and it acquired than the swine, including

Norman. Today's, of course, which is completely

different from the hemagglutinin. And there are many days

indigents, which are currently on influenza strains. The

Victoria strain another strange. So this and this is

, of course, the first time that we've We've

seen a a reversal of prevalence of a of return

of a previously prevalent imagine because this the Norman today's

engine, which is present on this swine like virus

, is very similar, if not identical to the

neuraminidase managing that was seen on all influences. Straight

strains isolated in this country prior to 1957 1957 Asian

epidemic then represented a complete shift in the Norman today

. Sanity, uh, human gluttons. Of course

, there have been three or four others in the

interim. I can't resist one last facetious question directed

at Dr Steele when I was in ST Louis at

the immunization conference this week, Dr Michael Greg agreed

with you that future influenza vaccine should contain an a

swine component. And he went on to say that

it was his personal gut reaction that the majority,

if not uh, all of the American population should

be immunized with a swine containing vaccine components. And

with 220 million people in the United States today,

would it be more practical to try to immunize 220

million people with a swine. Or would it be

of any benefit to go after 150,000 hogs? Yeah

. Uhh! Not the hog issue. I can

sell. Sell you right now that the swine vaccine

never sold in Peoria. E think that might be

a good note, but there's another one. Or

tow a close. There's another about a minute more

time. I just want to cite one other example

of where we thought we were going to get into

some deep trouble. When equine influenza first appeared in

1966 with the Prague strain, this was an influenza

A and naturally, there were reports that people were

crime currently ill with that and then in the Miami

strain, which appeared in 1963. And if it

hadn't been for the Euro Amadeus difference with the equine

to strain or the Miami strain, we would have

thought that was Hong Kong that have gotten into the

horses. And this is a very serious problem when

the states can't collect their taxes from the horse races

. Well, we've seen a number of reasons why

influenza can be important. Thio uh, man and

society I'd like to bring the session to a close

. I'd like to express our thanks to our panel

members for being with us today. And I'd like

to thank you for listening. You're gonna celebrate in

New York?