WHO knows best? National and international responses to pandemic threats and the "lessons" of 1976

Journal of the History of Medicine and Allied Sciences

Volumn 65, Issue 4, 2010, Pages 478-513

  Dehner, George ^a  

^a WICHITA STATE UNIVERSITY   (United States)

Author keywords

influenza; influenza vaccines; pandemic planning; Swine Flu; World Health Organization (WHO)

Indexed keywords

ARTICLE; HEALTH; HEALTH CARE POLICY; HISTORY; HUMAN; INFLUENZA; INFLUENZA VIRUS A H1N1; INTERNATIONAL COOPERATION; PANDEMIC; PUBLIC HEALTH; PUBLIC HEALTH SERVICE; STATISTICS; UNITED STATES; WORLD HEALTH ORGANIZATION;

HEALTH POLICY; HISTORY, 20TH CENTURY; HUMANS; INFLUENZA A VIRUS, H1N1 SUBTYPE; INFLUENZA, HUMAN; INTERNATIONAL COOPERATION; PANDEMICS; PUBLIC HEALTH; PUBLIC HEALTH PRACTICE; UNITED STATES; WORLD HEALTH; WORLD HEALTH ORGANIZATION;

EID: 77958574118     PISSN: 00225045     EISSN: 14684373     Source Type: Journal    
DOI: 10.1093/jhmas/jrq002     Document Type: Article

References (113)

1. See, for example, Richard E. Neustadt and Harvey V. Fineberg, The Swine Flu Affair: Decision Making on a Slippery Disease (Washington, DC: U. S. Department of Health, Education, and Welfare, 1978);
2. Arthur Silverstein, Pure Politics and Impure Science (Baltimore and London: Johns Hopkins University Press, 1981);
3. Sharon L. Begley, "Failure of the 1976 Swine Flu Drive", Yale J. Biol. Med., 1977, 50, 645-57;
4. and Walter R. Dowdle, "The 1976 Experience", J. Infect. Dis., 1997, 176, Suppl. 1, S69-S72.
5. Harry Schwartz, "Swine Flu Fiasco", New York Times, 21 December 1976, A33.
6. Neustadt and Fineberg's The Swine Flu Affair is the most influential investigation of the program. Silverstein's Pure Politics and Impure Science seeks to refute some aspects of Neustadt and Fineberg's criticism.
7. Here I model this discussion from Walter Dowdle who argues that risk assessment is a scientific process, while risk management is a political process. Although difficult in practice, Dowdle suggests that there is value in separating the process of scientific recommendations from political discussions. Dowdle, "The 1976 Experience", S69-S72.
8. From the "Constitution of the World Health Organization", article 2 (g). From the World Health Organization web site, http://www.who.int/ en/ (accessed 11 October 2007).
9. From the "Constitution of the World Health Organization", from the World Health Organization web site, http://www.who.int/en/ (accessed 11 October 2007).
10. Founding of the World Influenza Centre from M. M. Kaplan, "The Role of the World Health Organization in the Study of Influenza", Philos. Trans. R. Soc., London. Ser. B, 1980, 288, 417-21, 417-18, and current figures from: http://www.who.int/csr/disease/influenza/influenzanetwork/en/index.html (accessed 25 October 2009).
11. K. Stohr, "The WHO Global Influenza Program and Its Animal Influenza Network", Avian Dis., 2003, 47, 934-38, 935.
12. These meetings were subsequently published in J. Infect. Dis.
13. See "Influenza Virus Polypeptides and Antigens-Summary of Influenza Workshop I", J. Infect. Dis., 1972, 125, 447-56;
14. "Immunologic Methodology in Influenza Diagnosis and Research-Summary of Influenza Workshop II", J. Infect. Dis., 1972, 126, 219-30;
15. "Specific Immunity in Influenza-Summary of Influenza Workshop III", J. Infect. Dis., 1973, 127, 220-36;
16. "Epidemiology of Influenza-Summary of Influenza Workshop IV", J. Infect. Dis., 1973, 128, 361-86;
17. "Influenza Vaccines-Summary of Influenza Workshop V", J. Infect. Dis., 1974, 129, 750-71;
18. "Animal Influenza: Its Significance in Human Infection-Summary of Influenza Workshop VI", J. Infect. Dis., 1975, 131, 602-12;
19. "Genetics, Replication, and Inhibition of Replication of Influenza Viruses-Summary of Influenza Workshop VII", J. Infect. Dis., 1975, 132, 713-23;
20. and "Antiviral Agents in Influenza-Summary of Influenza Workshop VIII", J. Infect. Dis., 1976, 134, 516-27.
21. This technology, pioneered by Edwin Kilbourne, wedded the new viral type with a fast-growing laboratory strain. Technically a reassortment of the two viruses, the fastest growing, highest yielding strain that produced effective preventative immunity to the new virus was selected for vaccine production. See Edwin Kilbourne, "Future Influenza Vaccines and the Use of Genetic Recombinants", Bull. WHO, 1969, 41, 643-45
22. and Harold M. Schmeck Jr., "Race for a Swine Flu Vaccine Began in a Manhattan Lab", New York Times, 21 May 1976, B1.
23. Philip Selby, ed., Influenza: Virus, Vaccines, and Strategy, Proceedings of a Working Group on Pandemic Influenza, Rougemount, January 1976 (London: Academic Press, 1976).
24. Summary of discussion, Chairman W. R. Dowdle, rapporteur, accompanying J. W. G. Smith, "Surveillance and Early Warning", in Influenza: Virus, Vaccines, and Strategy, ed. Selby, 89-92, 91. The general discussion followed the eight papers that comprised the first session, "Surveillance and Early Warning", and presumably included all twenty-eight meeting participants.
25. See Influenza: Virus, Vaccines, and Strategy, ed. Selby, 23-92.
26. J. W. G. Smith, "Vaccination Strategy", in Influenza: Virus, Vaccines, and Strategy, ed. Selby, 271-94, 271 and 291.
27. Ibid., 279.
28. The eleven-year-cycle held that a new virus sparked a pandemic about every eleven years. The last pandemic influenza year was 1968. The recycling theory held that a limited number of viral types infected the human population and that as the population aged, those with immunity to a strain type formed a lesser percentage of the population making the conditions ripe for a reemergence of a viral type. See Edwin Kilbourne, "Epidemiology of Influenza", in Influenza Viruses and Influenza, ed. Edwin Kilbourne (New York: Academic Press, 1975), 483-538
29. and "Specific Immunity in Influenza-Summary of Influenza Workshop III", J. Infect. Dis., 1973, 127, 220-23
30. see especially chart on 221 for a comprehensive description of the eleven-year-cycle theory. The recycling theory and how it was understood following the 1968 Hong Kong Flu is drawn from Fred M. Davenport, "Prospects for the Control of Influenza", Am. J. Nurs., 1969, 69, 1908-11
31. and F. M. Davenport, E. Minuse, A. V. Hennessy, and T. Francis, Jr., "Interpretations of Influenza Antibody Patterns of Man", Bull. WHO, 1969, 41, 453-60.
32. The eleven-year-cycle theory has been abandoned and the recycling theory has come under sharp criticism. See W. R. Dowdle", Influenza A Virus Recycling Revisited", Bull. WHO, 1999, 77, 820-28.
33. Dowdle argues that the evidence does not substantiate the predictive pattern of influenza recycling.
34. See chart in "Influenza-A/Swine Serologic Survey-Fort Dix, 17-27 Feb. 76", Box 21, folder titled "Swine Flu-Ft. Dix, etc.", RG 442, National Archives and Records Administration, South East Region (hereafter cited as NARA's SE Region). The military survey information was reported to the CDC on 1 March 1976 and Walter Dowdle informed Charles Cockburn, WHO Director, Division of Communicable Diseases, on 2 March 1976. See Dowdle's handwritten notebook titled "Ft. Dix Log Book, Feb. ' 76", Box 32, RG 442, NARA's SE Region. Top reported the five hundred infection estimate at the influenza workshop held 25 March 1976.
35. See transcript from "Center for Disease Control, Bureau of Biologics, National Institute of Allergy and Infectious Disease Influenza Workshop March 25, 1976", 15, Box 32, unlabeled folder T-1 (2), RG 442, NARA's SE Region.
36. See G. C. Schild, Vaccine Studies in the U. K. [underlined in original], Box 32, unlabeled folder, loose papers, RG 442, NARA's SE Region. It is unclear when Schild presented this list of experiments to Walter Dowdle, but it was likely to have been when Schild came to the United States for the 10 March 1976 Advisory Committee on Immunization Practices meeting.
37. For a discussion of the meeting, see Neustadt and Fineberg, Swine Flu Affair, 10-16
38. and George Dehner, "Comparing National and International Responses to the Threat of Pandemic Disease: Examining National and International Responses to the 'Swine Flu' of 1976" (PhD diss., Northeastern University, December 2004), 109-15.
39. WHO observer Paul Bres from J. Lyle Conrad's handwritten notes from the 10 March ACIP meeting, Box 37, file titled "Files ACIP Flu Meeting-March 1976", R G 442, NARA's SE Region.
40. "Report for the Meeting of the Advisory Committee on Immunization Practices, Center for Disease Control, Atlanta, Georgia, U. S. A., 10 March 1976, Prepared by Dr. P. Bres, Chief Medical Officer, Virus Diseases, WHO, Geneva, and Dr. G. Schild, N. I. B. S. C., London", Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region.
41. Ibid. The Bureau of Biologics was the branch of the USPHS that was concerned with purity and potency of vaccines. In 1972, the bureau was moved to the Food and Drug Administration from the National Institutes of Health.
42. President Ford, "The President's Remarks Announcing Actions to Combat the Influenza", Weekly Compilation of Presidential Documents, 24 March 1976, 12, 483-84.
43. See "To: H. F. [Harvey Fineberg] and R. E. N. [Richard E. Neustadt] from T. K. [?], Re: Evening News Coverage of Swine Flu as Abstracted in Vanderbilt Television News Archive Index and Abstracts (March 25, 1976)", Box 44, file titled "Press Briefing 10/12/76-1977", RG 442, NARA's SE Region for television coverage and Harold M. Schmeck Jr., "Test of Flu Vaccine Expected in April", New York Times, 26 March 1976, A14, for print coverage.
44. See, for example, "H. Bruce Dull's Press Conference Influenza-Thursday February 19, 1976" announcing the Swine Flu strain discovery, Box 44, binder titled "Flu 1", tab "Feb. 19 Press Conference", RG 442, NARA's SE Region.
45. Anonymous ACIP advisor from Lawrence Wright, "Sweating out the Swine Flu Scare", New Times, 11 June 1976, 28-38, 38. Wright's article was considered an accurate account of behind the scenes activity at the CDC.
46. The United States contributed almost forty million dollars in fiscal year 1977, which was over 25 percent of the entire WHO budget. United Nations, Yearbook of the United Nations, 1976, Volume 30 (New York: Office of Public Information, United Nations, 1979), 975.
47. See "Memo To: H. F. [Harvey Fineberg] and R. E. N. [Richard E. Neustadt] from T. K. [?], Re: Evening News Coverage of Swine Flu as Abstracted in Vanderbilt Television News Archive Index and Abstracts (March 27, 1976)", Box 44, file titled "Press Briefing 10/12/76-1977", R G 442, NARA's SE Region.
48. See, for example, Theodore Cooper's (Assistant Secretary for Health, HEW) testimony to the Senate Subcommittee of the Committee on Appropriations, Preventative Health Services and Employment Programs Emergency Supplemental Appropriations, Hearing on H. J. Res. 890, 94th Cong., 2nd Sess., testimony of Theodore Cooper, 6 April 1976, 30. Sir John Skehel, one of the three representatives for WHO, at the March 10 ACIP meeting suggests that the support comment came from Paul Bres and that the "surprised" comment came from Fakhry Assaad. Assaad was part of the Division of Virology at WHO headquarters in Geneva, but unlike Bres was not directly involved in the Swine Flu investigation. There are a surprisingly small number of WHO expert staff at Geneva and they are pulled in many different directions because the WHO has to respond to emergencies of all sorts. Sir John Skehel, personal interview, 6 September 2007.
49. "Press Release WHO/16, 26 March 1976, Close Watch on New Flu Strain [underlined in original]", on file at the World Health Organization Library and Information Networks for Knowledge, Geneva. Press releases are unsigned but are designed to represent the view of the Director of the Division associated with the topic and ultimately he or she is responsible for it even if not directly the author. Occasionally, a press release is issued that causes some embarrassment for the Division Chief.
50. See, for example, A. M. M. Payne's (Section of Endemo-Epidemic Diseases, Division of Communicable Disease Services) letter to Dr. Dorland Davis (National Microbiological Unit, National Institutes of Health) dated 11 February 1953, apologizing for an over-optimistic press release. Since this was the only case I encountered of a WHO official apologizing for an official press release in WHO correspondence on influenza between the years 1949 and 1977, I have concluded that press releases, in general, accurately reflect the opinion of the WHO Division Director. Letter from Payne to Davis, 11 February 1953, World Health Organization Archives, WHO 2, DCINFL, 6 R. I. C. 3, (microfiche) Geneva, Switzerland (hereafter WHO Archives).
51. Press Release WHO/16, 26 March 1976, Close Watch on New Flu Strain [underlined in original].
52. J. Donald Millar's Draft-23 March 1976, "OPS Objective on Influenza", Box 32, unlabeled folder "T-1 (2)", and "March 24, 1976, The White House Fact Sheet Swine Influenza Immunization Program", Box 44, binder "Flu-1", tab "March 14-20", RG 442, NARA's SE Region.
53. The relationship to Spanish Flu played no official role in the decision by the USPHS and most influenza scientists rejected the notion that A/New Jersey was neo-Spanish Flu. It is undeniable that the Spanish Flu connection greatly facilitated passage and funding of the USPHS's vaccination plan. See Neustadt and Fineberg, Swine Flu Affair. Updated estimates on Spanish Flu's toll suggest that the global mortality was about fifty million. However, the authors acknowledge that this total may underestimated by up to 100 percent, meaning the total could be as high as one hundred million.
54. Niall P. A. S. Johnson and Juergen Mueller, "Updating the Accounts: Global Mortality of the 1918-1920 'Spanish' Influenza Pandemic", Bull. Hist. Med., 2002, 76, 105-15, 115.
55. Emphasis mine. Press Release WHO/16, 26 March 1976, Close Watch on New Flu Strain [underlined in original].
56. See "Memorandum for Honorable Spencer Johnson, Subject: Swine Flu Immunization of Non-Official Americans Overseas, from W. Delano Meriwether (Special Assistant to Assistant Secretary for Health; Director, National Influenza Immunization Program, Health, Education, and Welfare)", from Box 32, unlabeled folder, T-1 (4), RG 442, NARA's SE Region.
57. J. Lyle Conrad's handwritten notes from the 5/26 Conference of State and Territorial Health Epidemiologists meeting dated "5/26", from Box 37, file titled "ACIP Flu Meeting March 1976", RG 442, NARA's SE Region.
58. Walter R. Dowdle and J. Donald Millar, "Swine Influenza: Lessons Learned", Symposium on Infectious Disease, Med. Clin. of North Am., 1978, 62:5, 1048. This material was collected from papers stored at the Centers for Disease Control, internally labeled "Box 4 of 6", accession number 442-00-0058.
59. Summary of discussion, Chairman W. R. Dowdle, rapporteur, accompanying J. W. G. Smith, "Surveillance and Early Warning", in Influenza: Virus, Vaccines, and Strategy, ed. Selby, 89-92, 89.
60. A point sometimes not clear to members of expert committees as Dr. F. Assaad (Director, Division of Communicable Diseases) explained to Dr. George Galasso (National Institutes of Health) in a later discussion related to influenza in 1983. See letter from Dr. Assaad to Dr. Galasso, dated 15 December 1983, WHO Archives, 12/181/3, "WHO Informal Consultation on the Clinical Use of Amantadine/Rimantadine in Influenza, Vienna, Austria, 26-28/8/1983", Box. A.2138.
61. David Perlman, "The Flu Shot Program Poses a Dilemma", San Francisco Chronicle, collected from Box 44, unlabeled binder, blank tab, RG 442, NARA's SE Region. Penciled notation "S. F. Chronicle, 4/5/[76]."
62. Ibid. See also anon., "Swine Flu Scare", New York Times, 3 July 1976, A20;
63. and anon., "Light on Swine Flu", New York Times, 20 July 1976, A30.
64. Claude Hannoun, interview with the author, 21 August 2007.
65. See "List of Participants", attached to "Draft Agenda", Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region.
66. "Opening of the Consultation on Influenza, Geneva, 7-8 April 1976, by Dr. L. Bernard Assistant Director General", Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region.
67. Walter Dowdle, email to author, 25 March 2007. For another description of the format of expert meetings at the WHO, see David Tyrrell and Michael Fielder, Cold Wars: The Fight against the Common Cold (New York: Oxford University Press, 2002), 170-76.
68. The following account of this meeting is drawn from Walter Dowdle's handwritten notes unless otherwise noted. "World Health Organization Consultation on Influenza Geneva, 7 and 8 April 1976, Report to the Director-General (Vir/76.4)", Box 32, unlabeled folder, T-1 (3), RG 442, NARA's SE Region for report and Walter Dowdle's handwritten notes from Box 32, unlabeled folder, T-1 (3), RG 442, NARA's SE Region. The author has conducted an interview with Walter Dowdle to confirm and clarify the account of the meeting, 26 May 2005.
69. CDC report for the Special Meeting 7 February 1977, called by Joseph Califano, Secretary of Health, Education, and Welfare, "Center for Disease Control Handout 1, February 7, 1977, Distribution of Influenza 'A' Vaccines", [Report cover page not included], received from the Centers for Disease Control in response to Freedom of Information Request (06-0781) dated 4 January 2007, in possession of the author.
70. "Global Distribution of Influenza Vaccines, 2000-2003", Weekly Epid. Rec., 2004, 79, 366-67.
71. Although the quantity of vaccine produced in 2000 was more than twice that produced a decade before (David Fedson, unpublished observation), there is no evidence to suggest that there has been a significant change in the nations producing vaccine. Estimate of previous vaccine production from David S. Fedson, "Preparing for Pandemic Vaccination: An International Policy Agenda for Vaccine Development", J. Public Health Pol., 2005, 26, 4-29, 8.
72. Walter Dowdle, personal interview, 26 May 2005; letter from Hideo Fukumi to Dr. W. Chas. Cockburn, Chief Medical Officer, Virus Diseases, World Health Organization, dated 20 July 1973 enclosing a report "Recent Influenza Epidemic of the New Type B in Japan", WHO Archives 12/442/2 (72-73)
73. "Information on Influenza Incidence 1/7/1972-30/6/1973, Jacket 2", A.0525;
74. Claude Hannoun, personal interview, 23 August 2007;
75. and J. Lyle Conrad's letter to "Director, Immunization Division Bureau of State Services, dated April 23, 1976", Box 37, file titled "Swine Influenza National Influenza Immunization Program (NIIP) 1976-Correspondence", RG 442, NARA's SE Region.
76. David Sencer, personal interview, 9 May 2007.
77. Ian Furminger, personal interview, 30 October 2007.
78. J. Donald Millar, personal interview, 22 May 2007.
79. Millar, personal interview, 22 May 2007. In addition, see F. Fenner, D. A. Henderson, I. Arita, Z. Jezek, and I. D. Ladnyi, Smallpox and Its Eradication (Geneva: World Health Organization, 1988), for an overview of CDC involvement in the smallpox eradication campaign.
80. Millar, personal interview, 22 May 2007.
81. Sencer, personal interview, 9 May 2007.
82. Henderson does not recall whether the meeting was part of the April 7-8 Consultation on Influenza Meeting (which he also attended) or a meeting held just prior to the influenza experts meeting. But he is certain that the meeting was to discuss European vaccine manufacturing production capabilities in response to Swine Flu in 1976. D. A. Henderson, personal interview, 26 July 2007.
83. Dowdle's notes from the Geneva meeting refer to "Peggy." He has subsequently identified "Peggy" as Dr. M. Pereira. Walter Dowdle, personal interview, 26 May 2005.
84. Walter Dowdle's handwritten notes on the Geneva meeting, 7-8 April 1976, from Box 32, unlabeled folder, T-1 (3), RG 442, NARA's SE Region.
85. This experiment was subsequently reported in Lancet. See A. S. Beare and J. W. Craig, "Virulence for Man of a Human Influenza-A Virus Antigenically Similar to 'Classical' Swine Virus", Lancet, 3 July 1976, 2, 4-5.
86. This description of the results is slightly different from the results reported in the Lancet article. See Beare and Craig, "Virulence for Man of a Human Influenza-A Virus Antigenically Similar to 'Classical' Swine Virus", 4-5.
87. Dowdle, personal interview, 26 May 2005
88. and Edwin Kilbourne, personal interview, 20 January 2004.
89. Kilbourne, personal interview, 20 January 2004.
90. Dowdle, personal interview, 26 May 2005.
91. Dowdle ascribe these quotes to Dr. Cho [sic]. It is most likely Dr. Chang Yi-Hao, from the Vaccine Department of the Peking Institute of Biological Products, Peking China. However, it could be Dr. Kuo Yuan-Chi from the Institute of Epidemiology of the Chinese Academy of Medical Sciences, Peking China. Unless otherwise noted, the following quotes are from Walter Dowdle's handwritten notes on the WHO Consultation on Influenza Meeting from Box 32, unlabeled folder, T-1 (3), RG 442, NARA's SE Region.
92. Letter from V. Zhdanov, Director U. S. S. R. Influenza Centre to Dr. A. M. M. Payne, Chief, Section of E. E. Diseases, World Health Organization, dated November 1957 [received 12 December 1957], WHO Archives, 12/418/12, 23 (microfiche). Quote is from "Memorandum From: Professor Zhdanov, Deputy Minister of Health, To: Dr. Payne, Chief Section of E. E. Diseases, World Health Organization, dated 11 March 1958." WHO Archives, 12/418/12, 25 (microfiche). The author thanks Helen Hundley for translating the second document.
93. Report by Dr. A. S. Beare on his "Visit to the Department of Epidemiology, School of Public Health, University of Michigan under the auspices of the World Health Organization", attached to letter from A. S. Beare, Medical Research Council and Department of Health and Social Security, MRC Common Cold Unit to Dr. W. C. Cockburn, Virus Diseases Unit, dated 5 July 1972, WHO archives 12/445/6, "Collaborative Study on Live Influenza Vaccine Strains", A.526.
94. "Report to the Director-General on an Informal Consultation on International Collaboration in Research on Live Influenza Virus Vaccines, Geneva, 4 and 5 October 1971", WHO Archives, 12/445/6, "Collaborative Study on Live Influenza Vaccine Strains", Box A.526. There is no way to tell from this source, what, if any, importance was attached to this observation at this time.
95. Letter from G. C. Schild to Dr. Z. Nikolova, National Influenza Centre, Bulgaria, dated 16 September 1971, WHO Archives, 12/442/2 (71-72) 1 (microfiche).
96. Letter from Schild to Cockburn, dated 19 July 1974, WHO Archives, 12/442/2 (73-74), "Information on Influenza Incidence 1/7/73-30/6/74 Jacket 2", Box A.0525.
97. The unstable nature of live-virus vaccines still concerns some influenza experts today. There are several sets of dangers with live-virus vaccines. First, the introduction of the vaccine produces a real, albeit mild, infection by the influenza virus. This presents the opportunity for secondary bacterial infections because the virus is replicating in the respiratory tract. Second, the inoculated person sheds real live virus and poses a threat to others, especially immunosuppressed people. In tests up to 50 percent of these shed viruses represent reassortments of the original vaccine strains. This is dangerous both because two avirulent viruses can combine to form a virulent virus and because the virus could reassort with an emerging pandemic strain providing it with a heightened capacity for infection or replication. Information from Edwin Kilbourne, personal interview, 20 January 2004.
98. See letter dated 4 February 1976 from Maurice R. Hilleman, Director, Virus and Cell Biology Research, Merck Institute for Therapeutic Research to John R. Seal, Acting Deputy Director National Institute of Allergy and Infectious Diseases, National Institutes of Health, regarding the 20 January summary of the live-virus vaccine meeting. Obtained via Freedom of Information Act request (case no. 28820) to National Institute of Allergy and Infectious Diseases for information related to the "Swine Flu Program of 1976", material titled "Box 6, Book 42 containing workshops/meetings and fact sheets" in possession of the author.
99. Walter Dowdle's handwritten notes on the Geneva meeting, 7-8 April 1976 from Box 32, unlabeled folder, T-1 (3), RG 442, NARA's SE Region.
100. This, and the following quotes come from the "Consultation on Influenza, Report-First Draft, Recommendations", with Dowdle's penciled editing notes, Box 32 unlabeled folder T-1 (3), RG 442, NARA's SE Region unless otherwise noted.
101. As Dowdle later explained, this concern of live virus use was not a theoretical issue. He reports that this "extreme caution" on using live-virus vaccines was inserted because of reports that several investigators outside Western Europe intended to develop and test such vaccines. Walter R. Dowdle, "Influenza Pandemic Periodicity, Virus Recycling, and the Art of Risk Assessment", Emerg. Infect. Dis., 2006, 12, 34-39, 38, available from www.cdc. gov/eid.
102. Unfortunately, the first draft of the Consultation Report only included the "Conclusions and Recommendations." Presumably, the additional information existed at one time as the "Conclusion and Recommendations" section was paginated 11 and 12. Therefore, I cannot compare what changes may have been made in the characterization of the information. Unless otherwise noted, the following quotes are taken from this later draft, "Consultation on Influenza Geneva 7 and 8 April 1976, Draft Final Report", Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region.
103. A perception validated by Walter Dowdle. Walter Dowdle, personal interview, 26 May 2005.
104. The original sentence read [with the excised words in bold] "The appearance of a new strain of influenza A at Fort Dix, New Jersey, in the USA in February this year caused some concern about its spread from man-to-man because of its antigenic relationship to the swine influenza-like virus which caused the 1918 pandemic." "Opening of the Consultation on Influenza, Geneva, 7-8 April 1976, by Dr. L. Bernard, Assistant Director General", Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region. It is worth noting that the Common Cold Unit experiment could be construed as easing concerns that A/New Jersey might have the same mortality as Spanish Flu.
105. "Consultation on Influenza Geneva 7 and 8 April 1976, Draft Final Report", Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region.
106. Walter Dowdle, personal interview, 26 May 2005.
107. Emphasis mine. This and the following quotes are taken from "World Health Organization Consultation on Influenza Geneva, 7 and 8 April 1976, Vir/76.4" from Box 32, unlabeled folder T-1 (3), RG 442, NARA's SE Region.
108. Dowdle, personal interview, 26 May 2005.
109. Millar, personal interview, 22 May 2007
110. and D. A. Henderson, personal interview, 26 July 2007.
111. J. Donald Millar, Copy of notes faxed to author, 24 May 2007. Emphasis in original. In possession of the author.
112. Copy of letter from D. A. Henderson to Professor Richard E. Neustadt, dated 12 March 1979. Copy sent via email from David Sencer, 9 May 2007, in possession of the author.
113. The following quotes and summary are drawn from World Health Organization, "Consultation on Influenza, Geneva, 7 and 8 April 1976", Report to the Director-General, Vir/76.4, obtained from the WHO Library, Geneva.