Lessons Learned From California’s H1N1 Experience

Dealing with H1N1 flu this year has shed light on national and state defenses against health emergencies. As the threat appears to wane, California’s H1N1 flu experience raises questions about the state’s readiness to deal with a range of issues from education to dissemination. 

Delays in acquiring vaccine and then the logistics of distributing it focused attention on the status of government efforts on several fronts:

• Educational efforts about the disease itself and the values of inoculation;
• Difficulties in procuring vaccinations; and
• Logistics of administering vaccine in a state where as many as seven million residents have no regular health care provider or coverage.

In addition to issues raised about a specific and identified threat, the H1N1 experiences raise questions about California’s ability to deal with other emergencies ranging from bioterrorism to earthquakes.

We asked state and county health officials what lessons could be learned from the H1N1 experience and how those lessons could be put into practice.

We got responses from:

• Mark Horton, director of the California Department of Public Health
• Vanessa Cordova, spokesperson for the Alameda County Public Health Department

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Plans Crucial, but They Must Be Flexible

Mark Horton Director, California Department of Public Health

Although the H1N1 flu has not matched our worst fears about an influenza pandemic, it has tested our public health system like no other threat in recent years.

One of the most obvious but important lessons is the need for preparation. During the past five years, California has been preparing for a pandemic. This planning and training, as well as improvements in disease surveillance, laboratory capacity and communications, has been critically important in our efforts to slow the spread of the H1N1 flu.

In April, we discovered the first cases of H1N1 in the nation. The process of identifying and confirming H1N1 within a matter of hours illustrated that those investments were well spent. In close cooperation with local public health laboratories, we were able to process over 14,000 lab specimens during the early weeks of the pandemic. 

In 2006, California purchased a stockpile of medical supplies and equipment, antiviral medications and respirators in case a pandemic arose. It was a wise investment that has saved lives. As the H1N1 flu pandemic evolved, we were able to pre-position antivirals and respirators for distribution to counties, hospitals and clinics statewide in order to avoid shortages of those critical supplies.

Plans are absolutely critical for developing strategies for success, but sometimes plans need to quickly change.

The plan for mass vaccination against H1N1 here in California assumed an abundance of vaccine. Instead, production of vaccine lagged early on, while demand for the vaccine accelerated.

The results were significant shortages and regional variations in the amount of vaccine delivered. Working closely with local health departments, we modified the distribution plan to better ensure equitable distribution of vaccine across the counties. 

Every influenza pandemic is different. Planning and investing in key resources ahead of time, and being able to nimbly adjust to changing circumstances are two key lessons learned so far from this H1N1 pandemic. They are also lessons learned that will help us continue responding to this event as well as the next one.

 

Crossroads of Readiness and Reality

Vanessa Cordova Public Affairs Officer, Alameda County Public Health Department

Patient, physician or bureaucrat — it’s easy for any Californian to examine the current systemic public health response to the 2009 H1N1 pandemic and conclude the outmoded process of vaccine procurement and distribution is circling the drain.

So when the novel H1N1 virus presented in the San Francisco Bay Area in April of this year, and news of an imminent vaccine was announced shortly thereafter, local public health departments were quickly presented with a looming challenge: to mass vaccinate, based upon current epidemiology, individuals at highest risk for complications from exposure to the H1N1 virus.  In Alameda County, this includes roughly 650,000 residents, 25% of whom are uninsured.

The Alameda County Public Health Department is not unlike many of California’s 61 public health jurisdictions.  Charged with serving more than 1.5 million residents, resources are squeezed to provide essential services amid a persistent hiring freeze that shows no signs of softening.

Despite these hurdles, the public health department, with resolute support from the Alameda County Board of Supervisors, developed a comprehensive, community-based emergency readiness plan designed to enable an immediate local response to natural disasters and acts of terrorism, including the most seemingly implausible: weaponized anthrax. 

In the reality of the current pandemic, it’s easy to recognize the economy of such planning.

But the county’s preparedness has not been tested until recently, when the public health department adapted its bioterrorism response model to support H1N1 mass vaccination efforts.  In three days of clinics, the department vaccinated nearly 30,000 individuals countywide.

Although successful, the process has not been easy.  Assessing the demand for the H1N1 vaccine has been an empirical exercise further complicated by an elusive vaccine supply.  Furthermore, the need for medical and non-medical volunteer resources has demanded interagency solutions.

This year, Alameda County became the first in the state to successfully secure consent from the California Emergency Medical Services Authority to temporarily permit emergency medical services personnel to administer the H1N1 vaccine at the county’s mass vaccination clinics.  While modest, resource management models like this have become important readiness assets for other California counties, and additional best practices continue to be gleaned by public health departments statewide.

While much has been accomplished to curb the current public health crisis, the H1N1 pandemic is far from over. Despite increased vaccine availability, and fewer reports of severe illness and death, many more Californians will be infected by the virus, and the government response to this and other emergencies will continue to be debated. 

However, with the Golden State’s geographic vulnerability to natural disaster, and its pivotal station within a global economy, the time is now for local government and communities to initiate an active role in preparing for even the most improbable of catastrophic events.  And while bioterrorism response models may not always be a perfect fit for other large-scale emergencies, they may be a good place to start.