WASHINGTON -- The sudden outbreak of swine flu in Mexico- rather than the feared onslaught of a deadly bird flu from Asia - taught the world's microbe hunters that if anything is as important as having a solid pandemic plan, it's knowing how to improvise.
"We have to be nimble," says World Health Organization flu expert Keiji Fukuda. "You have to have room to make decisions that are different from what the plans call for."
The emergence of the 2009 H1N1 swine flu that was recognized a year ago this week tested the ability of politicians and health experts to adapt to complex situations that demand practical solutions, sometimes beyond the scope of science, Fukuda says.
The SARS and H5N1 avian flu scares helped, he says, because they forced public health planners to implement new disease-reporting requirements, strengthen flu surveillance networks and establish global lines of communication. "It is just crystal clear to every one of us dealing with global health emergencies that things went better than they have in the past," Fukuda says.
But the planners hadn't anticipated, for instance, that flu would pop up in the spring, when the world's vaccine producers were already busy preparing seasonal flu vaccine for the fall. They also didn't plan on a government in transition - the pandemic erupted at precisely the moment that the Obama administration was racing to fill key positions, among them the secretary of Health and Human Services.
Secretary Kathleen Sebelius says that she went from her swearing-in ceremony on April 28 to the situation room, where she was briefed on swine flu by John Brennan, President Obama's assistant on Homeland Security and Counterterrorism, chief of staff Rahm Emanuel and other key officials. "Two hours earlier, I had been the governor of Kansas," she says.
Richard Besser, then acting director of the Centers for Disease Control and Prevention, now a medical correspondent for ABC News, says the lack of high-level political appointees made it easier to develop and implement plans, but harder to get agencies working together.
The challenges seemed almost overwhelming: identify the virus; grow out a strain that could be used to make a vaccine; determine who needs protection most; get the seed-strain to drug firms capable of making vaccine; test it for safety, effectiveness and dosing; churn out millions of doses; create, from scratch, mass vaccination programs; ramp up hospital surge capacity; get antiviral drugs to the people who need them most; and inform the public without sowing misinformation and panic.
University of Michigan flu expert Arnold Monto gives the federal government high marks for its actions. "I think the U.S. response was totally appropriate," he says. "We did get a little panicked at first, but when you're apprehensive about what's coming your way and getting reports of deaths flooding in from Mexico, that's understandable."
Both the CDC and the WHO have begun detailed reviews of their actions. An independent investigation was launched last week to determine whether the WHO hyped the pandemic. Here are observations from Fukuda, Sebelius and Besser on lessons learned from H1N1 flu:
- Education policymakers, schools and colleges must be full partners during a pandemic, both in deciding how to deal with school closures and in setting up mass vaccination clinics.
- Despite vaccine manufacturers' record speed in formulating H1N1 vaccine, egg-based production methods are too slow when a flu crisis strikes. And the USA must establish more domestic production.
The vaccine shortage left states grappling with complex decisions about which high-risk groups to vaccinate first. Hospitals doled out scarce doses to health workers and vulnerable patients, while government officials urged people to get vaccine and tried to manage expectations when supplies were slow in arriving.
- Many state health departments earned high marks for launching mass vaccine clinics when budgets were being cut and health workers laid off. Maryland worked with the developer of Walt Disney World's Fast Pass system to manage crowds; Arizona used a Web-based application called Survey Monkey to identify doctors capable of delivering vaccine.
- An aggressive communications plan was critical for building confidence in the government's actions, especially among parents wary of the new vaccine.
Despite the government's urgings, however, the vaccination effort fell short. Health officials administered about 90 million doses of vaccine, leaving about 71 million unused with their expiration dates approaching. "We're still trying to push people to get vaccinated," Sebelius says, because swine flu is still smoldering, especially in the Southeast. Things should go more smoothly this fall: H1N1 will be part of this year's seasonal flu vaccine.