H1N1: Public health looks for lessons from pandemic's first year
■ Government agencies and others are examining their response to the virus and looking at how to handle future public health challenges.
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The Dept. of Health and Human Services in 2009 expected that about 189 million doses of influenza A(H1N1) vaccine would be needed to protect Americans against the virus.
But near the end of October of that year -- when H1N1 was peaking across the nation -- only about 22.4 million doses were available for shipping to states. People waited in line for hours at community clinics, many of which reported running out of vaccine before satisfying the demand. Many doctors didn't know when -- or if -- their offices would get vaccine.
HHS fell millions of doses behind its projections due to what officials said was antiquated vaccine technology. The shortage prompted HHS Secretary Kathleen Sebelius to call for a review of the federal government's system for handling public health emergencies, noting that gaps existed at each stage of the vaccine development process.
Now, a year after the first wave of H1N1 hit the U.S. in April 2009, HHS and other government agencies are evaluating their response to the pandemic. Critics have said that dire warnings about H1N1 were overblown, and that the distribution of vaccines could have been more efficient.
Public health officials say they have learned from the pandemic and hope to use those lessons to respond better next time.
"This flu season has made us even more committed to ensuring that vaccine production -- and all of our medical countermeasures -- are state of the art. Our experience with the ups and downs of the vaccine manufacturing process has made clear the need to enhance our country's influenza vaccine manufacturing capability," Sebelius said in a statement for the 44th National Immunization Conference in Atlanta on April 19.
Sebelius told the vaccine experts at the conference that the government "raised expectations too high" when it projected the quick production of vaccines. She said President Obama has allocated nearly $500 million in the 2011 budget to upgrade manufacturing of vaccine and other countermeasures.
Also in 2011, Novartis is scheduled to begin operating America's first cell-based vaccine plant in North Carolina. The facility will be able to produce a significant amount of vaccine within six months of the onset of a pandemic. This will help end the nation's reliance on egg-based technology, HHS said.
The HHS review, launched in December 2009, is focusing on the nation's vaccine development, including stockpiling and distributing doses. A report is expected later this spring, said HHS spokeswoman Gretchen Michael.
The Centers for Disease Control and Prevention launched an intense media campaign when it first identified H1N1 a year ago. The goal was to educate the public on the importance of getting vaccinated and preventing the spread of the virus.
As of March 29, H1N1 had infected about 60 million Americans. Nearly 12,000 died, and about 265,000 were hospitalized. About 36,000 people die from seasonal flu each year. However, H1N1 disproportionately affected young people, who are not typically casualties of seasonal flu.
"We're grateful this virus was not the terrible 1918 strain," said Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases. She added, "This is not what we were expecting. It could have been much worse."
A recent increase in H1N1-related hospitalizations in Georgia raised concerns that a third episode might be starting in the southeast.
As of April 10, Alabama and Georgia were reporting regional activity, which is one step below widespread activity. The CDC considers influenza to be widespread when at least half the regions in a state report outbreaks or increases in influenza-like illness and laboratory-confirmed influenza. No states reported widespread activity during the 13-week period ending April 10.
Who got the shot
More than 90 million doses of vaccine had been administered by mid-February, according to the CDC. An estimated 80 million Americans were vaccinated, including children 6 months to 9 years, who require two doses. With 126 million doses shipped to states, many physicians and health departments have vaccine going unused.
Despite such efforts, vaccination rates among some groups, such as minorities and health professionals, were low, officials said. For example, 37.1% of health care professionals were vaccinated, far below what health officials want.
The CDC is examining ways to better reach these groups with hopes of replicating successful school vaccination programs, Dr. Schuchat said. One in three children vaccinated against the virus was immunized in a school-related clinic.
The CDC also is exploring ways to strengthen global epidemiology capacity to help identify unusual strains of influenza, Dr. Schuchat said. "If [Mexico] had been able to do lab recognition of the new [influenza] strain even just a few weeks earlier than was done, we could have had the [H1N1] vaccination quite a bit earlier for the global community."
The World Health Organization has been criticized over how it handled the pandemic. An expert committee was convened in April to assess the WHO's response. The organization has said it could take a year or two after the pandemic ends to establish the true number of total deaths. As of April 11 its estimates stood at 17,798 reported deaths globally. The WHO's expert committee said that it is still too early to declare the pandemic over.
In this country, the CDC is encouraging physicians to keep H1N1 vaccine doses that have not expired until they receive the 2010-11 seasonal influenza vaccine, which will protect against H1N1. The agency plans to release guidelines on how to discard unused immunizations.
In discussing the response of health agencies, some doctors say the government has handled the pandemic appropriately.
"H1N1 was a very tricky situation to deal with," said Arnold Monto, MD, a professor of epidemiology at the University of Michigan School of Public Health. "It broke a lot of the rules. And it was dealt with as well as you can in a fluid situation."