History Reminds Us That Vaccines Alone Don't End Pandemics

Encouraging news about several vaccines offers the possibility of bringing the coronavirus pandemic under control even as case numbers skyrocket. We can learn from history, however, that the country has a lot of work to do if we hope to beat covid-19 - even with a vaccine.

A century ago, during the 1918 influenza epidemic, accelerated efforts of medical researchers to discover, test and deploy an influenza vaccine did not produce an effective treatment or therapeutic. Medical authorities regularly reviewed experimental results and confirmed that although some serums did prevent the development of pneumonia in certain cases, none of the vaccines were useful in either preventing or treating influenza.

And yet, the process of researching, testing and recommending a vaccine in 1918 offers important insights, especially surrounding the importance of receiving clear, consistent and accessible guidance from public health organizations on the process for testing, evaluating and distributing vaccines. Perhaps most significantly, it confirms what the nation's top infectious-disease expert, Anthony Fauci, recently emphasized: Even with a vaccine, we must keep up mask-wearing and social-distancing guidelines.

A century ago, as medical researchers sought a therapy for influenza, public health agencies and government officials offered divergent and often contradictory statements about the potential value of serums and vaccines. On Oct. 2, 1918, a photograph of Boston Mayor Andrew Peters receiving an "anti-influenza serum" administered by Timothy J. Leary of Tufts University was published in The Boston Globe. The paper reported that the mayor was "feeling fine" with "absolutely no after effects" after his second dose of the vaccine. Following a conference of local, state and federal health officials, Massachusetts Health Commissioner Eugene Kelley declared, "We were all much interested and sympathetically so." He also conceded that more research was needed. The Boston Globe, however, concluded that the serum "is believed to be preventative as well as curative," suggesting that this measure could decrease the number of cases and deaths, thus bringing the epidemic under control.

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In late 2020, a major surge in cases, hospitalizations and deaths has intensified public attention on the potential for a coronavirus vaccine that promises to end the epidemic.

Yet this enthusiasm was more tempered in subsequent reports. One week later, a seemingly positive report from scientists convened by the Massachusetts Board of Health appeared as "a bright beacon of hope on a darkened horizon of epidemic" at a time when Boston had already recorded more than 3,000 deaths from influenza and pneumonia in one month. But the full report confirmed that no statistical or experimental evidence indicated that the vaccine worked either prophylactically or as a treatment.

Despite these cautions, Kelley recommended distribution of the influenza vaccine across Massachusetts as a preventive measure while offering ambivalent guidance on the actual efficacy of this measure: "The public is urged to remember that the use of the vaccine is still to be regarded as experimental. With reference to its therapeutic use, the State Health Department is without prejudice. This question is one that must be left to the judgment of the individual physician."

These contradictory reports on the value of vaccines were replicated across the United States as the epidemic spread to every city and most rural communities. Arizona Superintendent of Health Orville Brown declared that "the preventive treatment should, by all means, be used. It can do no harm and will either prevent the influenza or diminish the severity of the attack." The Utah Board of Health recommended that "the vaccine should be used by everybody as a preventive measure" because it "renders the subject absolutely immune from influenza." The Illinois Influenza Commission called the serum curative "only in desperate cases," and the Wisconsin Board of Health refused to distribute any vaccines or serums because they "have met with only partial success and the entire proposition is largely in the experimental stage."

In response to these contradictory and inconsistent positions, the U.S. surgeon general and leading medical journals declared at the end of October that serums and vaccines were still in experimental stages; they cautioned health officials, physicians and newspaper editors against making misleading promises about their value.

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The search for an effective flu vaccine would continue for nearly a century, and in fact, only in the past decade have U.S. public health officials recommended universal vaccination for all healthy adults and children. The fact that only one-half of American adults get a seasonal flu vaccine should be a cautionary tale for those expecting universal compliance with recommendations to get covid-19 vaccines, when they become available. As the influenza epidemic subsided across the country in early 1919, so too did the intense public interest in a vaccine. In late 2020, a major surge in cases, hospitalizations and deaths has intensified public attention on the potential for a coronavirus vaccine that promises to end the epidemic.

Reviewing conflicting recommendations about vaccines during the 1918 flu epidemic provides several important lessons in 2020. First, epidemics push scientists, health officials and research laboratories to accelerate efforts to develop effective vaccines. While this acceleration can produce results more quickly, it also raises serious concerns about products that may be rushed into use without sufficient evidence of their safety, effectiveness and reliability.

Second, pressure from the public to deliver a vaccine must be countered with an effort to educate the public about the steps needed for safe and effective development, testing and distribution. We need to follow the examples set by newspapers, medical journals and public health officials in 1918 who openly acknowledged the experimental nature of research efforts and disclosed the steps needed to determine the effectiveness and safety of vaccines.

Third, the effectiveness of vaccines must be proved, and publicized, in ways that inspire trust in the tools while also meeting rigorous standards. Effective public health messaging is essential to building confidence in the efficacy and safety of vaccines. A photograph of a smiling politician being vaccinated may send the message that the vaccine has limited side effects, but such messages must be accompanied by factual evidence of how testing and distribution will ensure healthy results for the entire community.

Finally, vaccines are not a magic bullet that will single-handedly end an epidemic. In 1918, as in 2020, a broad spectrum of public health measures was necessary to reduce infection and death rates. In early October 1918, the Massachusetts Board of Statistical Investigation warned that "the use of a vaccine should not be taken as an excuse for omitting such safeguards" as wearing masks and maintaining good ventilation. This warning from more than a century ago clearly resonates with the likely course of events in the months ahead, as vaccines slowly become available, but it takes many months for even most Americans who want a vaccine to get it. For many months, vaccines will be but one more public health measure essential to living with an epidemic.

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