H1N1 Influenza and the U.S. Response: Looking Back at 2009

January 12, 2010

The arrival of the new year has inspired a number of newspapers, magazines, and journals to look back at 2009’s experience with the ongoing swine flu pandemic. Their recent assessments and others can help answer four central questions about H1N1 and the U.S. response.

What is the current situation?

Flu pandemics come in waves. This outbreak’s first wave started in late April and peaked over the summer of 2009. The second wave, which began in August, may now be coming to a close. According to data from Quest Diagnostics, the world’s largest diagnostic testing company, requests for H1N1 tests have fallen 75% since they peaked the week ending October 28. Testing rates are now equivalent to those at the start of the second wave.

Although the CDC transitioned from tracking individual cases of H1N1 on July 24, it continues to estimate H1N1 hospitalizations and deaths. These approximate data indicate that 34 million to 67 million cases of H1N1 occurred between April and mid-November, with 154,000 to 303,000 influenza-related hospitalizations and 7,070 to 13,930 influenza-related deaths. Awful as they are, these numbers are thankfully far below the President’s Council of Advisors on Science and Technology’s August prediction of 30,000 to 90,000 deaths.

The 1918 to 1920 flu pandemic—the archetypal outbreak that killed 50 to 100 million people worldwide—was most dangerous in its later waves, which creates some worry about a third wave of 2009 H1N1. Luckily, however, former Centers for Disease Control and Prevention (CDC) Deputy Director Walter Dowdle and his colleagues, writing in the January 2010 issue of the Mayo Clinic Proceedings, report “no evidence of the evolution of the 2009 H1N1 virus toward a more transmissible or pathogenic phenotype.”

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In what ways did the U.S. response succeed?

This relatively good news resulted not only from luck regarding the spread and virulence of the virus but also from sustained government efforts against it. A comprehensive review of the 2009 swine flu response in last Saturday’s New York Times concludes that “a series of rapid but conservative decisions by federal officials worked out better than many had dared hope.”

Despite fear and pressure, these officials avoided their more extreme options. They did not use the national Tamiflu stockpile as a preventive mechanism. They did not mandate vaccination or issue federal orders to close schools. They did not heed Congressman Eric Massa’s call to close the border with Mexico, the source of the epidemic.

They did, however, provide clear news and advice on cdc.gov and flu.gov. Both websites worked to debunk potential causes of panic and the evolving arguments of the anti-vaccine lobby: that vaccination would be mandatory; that vaccines would be untested; that vaccines cause autism or Guillain-Barré Syndrome; that H1N1 is transmitted via pork consumption; and others.  According to several experts in the New York Times, the government largely defeated misinformation.

In what ways did the U.S. response fall short?

Criticism of the government’s response has largely focused on three areas—vaccine development, surveillance systems, and treatment infrastructure.

Federal officials predicted that 160 million doses of H1N1 vaccine would be available by October. In reality, there were fewer than 30 million by that time. Former U.S. Senators Bob Graham (D-Florida) and Jim Talent (R-Missouri) wrote a scathing January 4 editorial blaming the shortage on U.S. failure to “nurture the technologies and systems needed,” relying instead on “a 60-year-old production method based on chicken eggs.”

Like many critics, Graham and Talent also claim that the U.S. has an outdated diagnostic and disease surveillance system that “doesn’t give useful information … such as severity of illness [or] transmission rates.” The U.S. government also participates in international systems for early warning, but that those do not extend to Mexico. “This time,” CDC Director Thomas Frieden told the New York Times, “one [new virus] happened to emerge in a place where we don’t have a surveillance system.”

The experience with H1N1 in Mexico demonstrates a broader point about U.S. investment in global health—that enhancing surveillance and preparedness in other countries pays dividends here. The sooner other countries can identify a disease and the better they can contain it, the more warning the U.S. has and the fewer the risks it faces.

As for other infrastructure, the latest “Ready or Not?” report by the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation finds that swine flu “has exposed serious underlying gaps in the nation’s ability to respond to public health emergencies.” In the report, 20 states had six or fewer of the 10 key indicators of prepared infrastructure. Almost two-thirds of states had seven or fewer.

“The necessary investment of public funds is relatively modest,” Graham and Talent conclude. “What has been in short supply is leadership.”

Why are these lessons significant?

2009 H1N1 has been the least lethal of modern flu pandemics, with the death rate among infected persons likely between 0.026% and 0.048%. It could have been much worse.

Perhaps, as H1N1 is the first such pandemic in decades, many will not find this an immediate concern. When the next flu pandemic breaks out, however, they too will hope that the U.S. has built upon its successes in 2009—and learned from its failures.

That process must start well in advance of the next outbreak. “As the second wave of H1N1 starts to dissipate,” says TFAH Deputy Director Richard Hamburg, “it’s time to double down and provide a sustained investment in the underlying infrastructure, so we will be prepared for the next emergency and the one after that.”

Authored by Seth Gannon, CSIS Global Health Policy Center