Analysis of H1N1 flu response shows progress, problems

Robert Roos

Jun 4, 2009 (CIDRAP News) – A coalition of health policy groups today offered a "good news, bad news" evaluation of the US response to the novel H1N1 influenza epidemic so far.

The good news: The experience has shown that years of pandemic preparation have paid dividends, particularly with regard to coordination, communication, antiviral drugs, and vaccine development.

The bad news: The outbreak has pointed up the serious limitations of the financially strapped public health sector, suggesting that it would be overwhelmed in a more severe and widespread epidemic.

The report was produced by Trust for America's Health (TFAH), a nonprofit, nonpartisan advocacy group in Washington, DC, in collaboration with the Center for Biosecurity at the University of Pittsburgh Medical Center and the Robert Wood Johnson Foundation.

"It was clear in our report that all the pandemic planning and preparedness efforts over the past several years have improved our ability to respond to an outbreak, but it was also clear that the situation didn't test the limits of our response," said Jeff Levi, PhD, executive director of TFAH, at a press briefing this morning.

Positives and negatives are sprinkled through the 10 lessons presented in the report, titled "Pandemic Flu Preparedness: Lessons from the Frontlines." Many of them repeat familiar TFAH messages about the need to restore and strengthen the nation's public health infrastructure.

Investments prove wise
The first finding was that federal, state, and local planning efforts of recent years "enabled public health officials to react to the outbreak effectively and keep the public informed. Investments in antiviral stockpiles and enhanced vaccine manufacturing capacity also proved to be prudent."

At the press briefing, David Fleming, MD, director of Seattle and King County Public Health, strongly endorsed that conclusion. He said Seattle officials had thought through many of the issues and stockpiled medications.

In particular, "Telling citizens we had sufficient supplies of Tamiflu [oseltamivir] went a long way" to help the situation, said Fleming, a peer reviewer for the report.

He said that by the time the outbreak began, private antiviral supplies were "essentially zero," because it was the end of the regular flu season. "We dipped into our local reserve [of antivirals] and made those available to people through our public health clinics," which resulted in moderate but not overwhelming use, he added.

Nationally, only modest amounts of stockpiled antivirals have been used, since relatively few people have been infected, said Thomas V. Inglesby, MD, deputy director of the Center for Biosecurity and a co-author of the report. But he said the stockpiles gave people confidence in their ability to help the sickest patients, adding, "I think the investment is widely seen to have been wise."

Lack of resources exposed
The second lesson cited in the report is that public health departments didn't have enough resources to carry out their carefully made plans.

"Capacity to track, investigate and contain cases of H1N1 has been hampered due to lack of resources," the document states. "For instance, CDC [Centers for Disease Control and Prevention] and state laboratory testing was days to more than a week behind the on-the-ground reality."

Fleming said the national surveillance picture was 1 to 2 weeks behind what was happening on the ground. In Seattle, some schools that had possible cases were closed and then reopened before the CDC confirmed and reported a single local case of the novel flu, he said.

Largely because of the economic recession, Fleming said, "It's getting really tough on the front lines of public health in this country now." For example, he said Seattle has had to reduce its public sector immunization efforts by 80%.

He also said a key part of Seattle's response to the novel flu was using public health nurses to educate school and daycare authorities about the outbreak. Ironically, many of the nurses were due to receive layoff notices 2 weeks after the start of the flu outbreak.

A third finding was that, though the outbreak was mild, healthcare systems in some areas were "overwhelmed." In many hospitals, emergency departments were flooded by the "worried well," and some outpatient clinics had inadequate personal protective equipment and "a limited understanding of infection control measures."

The report, however, doesn't offer an estimate of how widespread these problems were.

Need for flexibility, good communication
Another lesson was that the outbreak underlined that pandemic plans must be adaptable, according to the report. It notes that pandemic planning has focused on the threat of the virulent H5N1 avian influenza and often has assumed that the United States would have 6 weeks of lead time before an emerging pandemic strain overseas reached US shores. Instead, the novel H1N1 outbreak featured a generally mild virus emerging in North America.

On the public communication front, the report gives US leaders good grades, saying the president and other authorities conveyed consistent, accurate information about hand hygiene, respiratory etiquette, and the need to stay home when sick. Leaders also helped dispel rumors, such as concerns about the safety of imported Mexican foodstuffs.

Other lessons
Other early lessons from the epidemic, the report says, include the following:

Where schools were closed because of the outbreak, parents had to scramble to find alternative child care arrangements.
The lack of sick leave caused problems. There were reports of people with flu-like symptoms going to work because they had no sick leave, which is true for 48% of American workers, said Levi. Also, some parents sent sick children to school because they couldn't stay home to care for them.
Communication between the public health system and medical providers fell short, as many private practitioners complained that they did not receive CDC guidance documents in a timely fashion.
The World Health Organization's (WHO's) pandemic alert system was not well-matched with the realities of the H1N1 outbreak. (The WHO's alert phases are based strictly on the geographic spread of the virus, not the severity of disease. The agency said this week it would come up with a severity scale in an effort to reduce confusion.)
International coordination posed some problems: Against WHO advice, some countries closed their borders to Mexican citizens or banned pork from the United States and Mexico.

'Biggest single vaccination program'
Several questions at the press briefing had to do with how the novel virus might behave when the next flu season hits in the fall and the prospect of a nationwide vaccination campaign.

Inglesby predicted that the vaccination drive will be "the biggest single vaccination program for influenza and probably for any virus in a short period of time that's been performed in the United States." Five or six years ago, there would have been no possibility of starting mass vaccinations in the fall, because the necessary infrastructure investments had not been made, he added.

He and the other officials asserted that vaccination planning should forge ahead despite the unpredictability of public demand for the vaccine.

"If it turns out that for whatever reason there's not an interest in taking the vaccine, there'd be the ability to slow down or turn off production," he said. "But my sense is there'll be an unusual level of interest in the vaccine."

Fleming said school children will be a critical target group for vaccination against the new virus. Asserting that the virus is capable of causing "explosive" school outbreaks, he said, "We absolutely need to prioritize our kids and especially kids who are susceptible to complications from influenza."

It's not possible to predict whether the new virus will elbow out seasonal viruses and become the predominant strain next fall and winter, said Inglesby. That's why the government is proceeding with plans to offer vaccination against seasonal flu and the new virus.

"I'm agnostic, and health authorities seem to be agnostic in general about which one will out-compete the other," he said.

Full text of report
http://healthyamericans.org/assets/files/pandemic-flu-lesson.pdf