Better a vaccine without an epidemic than an epidemic without a vaccine

From Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It by Gina Kolata.  Page 137. I found this whole chapter terrific.  In 1976 the CDC et al were forced to make a decision great uncertainty and with poor comprehension of future estimates and especially future trade-off risks.  Their position was virtually identical to that of the CDC in 2020 with Covid-19.  They could imagine how bad it might be but they could not know.  They were far better (though not especially good) at estimating the first order costs and benefits but terrible at estimating the second order risks and consequences.  Decisions were made on the hoped for up-side benefits while ignoring the easily anticipated downside risk costs.  

It was clear that we could not say the virus would spread. But it was clear that there had been human-to-human spread at Fort Dix. It was also clear that there was not any immunity in the population to this virus, not if you were under 50 (or maybe 62).” That meant, he said, that “most people were at risk, especially young adults. An epidemic spreading into a pandemic had to be considered as a possibility.”

And even though the virus seemed to have disappeared from Fort Dix, after infecting only a few men there, no one could guarantee that it was really gone, Dowdle said. “Flu could do strange things. Six weeks was a short time. We had to report our fundamental belief that a pandemic was indeed a possibility.”

The difficulty, Kilbourne said, was in assessing the risk. As an advisor to the proposed vaccine program and an advocate of it, he noted, “I found it difficult to convey accurately and understandably a scientifically informed perception of the relation of the new virus to the putative 1918 agent and of the hazard it presented.” The Fort Dix virus came from swine, but that was a slim reed for the scientists. They did not have any way of deciding how dangerous a flu virus was without seeing it in action in a population. They could not compare the Fort Dix virus to the flu virus of 1918 because no one had any samples of the 1918 virus for comparison.

Kilbourne described the dilemma: “Therefore, one could only say that the Fort Dix virus might be more virulent, as virulent, or less virulent,” in comparison to the 1918 flu virus. “The limited clinical information from authenticated Fort Dix cases was inadequate to judge the virus’ potential, but its association with pneumonia and death in young recruits certainly provided no comfort.”

If the government decided to go ahead with a national swine flu immunization campaign, there literally was no time to waste. It would take months to make the vaccine and eight to ten weeks to distribute it nationally, the first time ever that so many people would be receiving a vaccine. It takes two weeks for a vaccinated person to become immune to the flu. And so the time from the manufacture of a swine flu vaccine to the successful immunization of most of the nation was going to be at least three months.

One option was to make the vaccine and store it, waiting to see if a deadly swine flu pandemic really did occur. That, however, could prove disastrous, the scientists at the meeting decided, since the flu could spread throughout the world overnight. “Better to store the vaccine in people than in warehouses,” one meeting participant said.

But Dowdle and others were hardly enthusiastic about taking immediate action to immunize the nation against swine flu. Neustadt and Fineberg interviewed a staff member at the Centers for Disease Control at that March 9 meeting who requested anonymity and who explained:

“There was nothing in this for the CDC except trouble. Here we were at the end of one flu season with time to try to do something before the next flu season. The obvious thing to do was to immunize everybody. But if we tried to do that, guide it, help it along, we might have to interrupt a hell of a lot of work on other diseases.”

Suppose there was an influenza pandemic, the meeting participant said. An immunization program was an almost certain invitation to disaster. Those who had been unable to get the flu shots in time would be angry because they would be vulnerable. Those who were immunized but who caught another virus that they thought was the flu would be annoyed because they would assume that the vaccine did not work. All in all, millions of people would be upset. Yes, a repeat of 1918 was unlikely. But, the participant said. “who could be sure?” And if it happened, “it would wreck us.”

Then take the other side of the argument, supposing there was no pandemic. Then, the staff member said, the Centers for Disease Control could be accused of wasting money, of “crying wolf,” he said. Everyone, from the people who got the shots to those who administered them, would criticize the agency. “It was a no-win situation,” the participant concluded.

The final decision on March 9 was predictable, however. These, after all, were people whose mission it was to protect public health and prevent disease. “Better a vaccine without an epidemic than an epidemic without a vaccine,” Kilbourne said.”

"Better a vaccine without an epidemic than an epidemic without a vaccine" is true only if you know the effectiveness of the vaccine, the lethality of the virus, and the potential negative side-effects of a new vaccine on a whole population.  They did not know any of these things and therefore Kilbourne's dictum was inoperable.