Pandemic Influenza A(H1N1): Lessons Learned So Far

BY BRUCE JANCIN
Elsevier Global Medical News

KEYSTONE, COLO. — Two large waves of pandemic influenza A(H1N1) have swept across the country, and now viral respiratory disease experts are assessing what the health care community did right—and wrong—to improve response should a third wave hit.

Topping the list of mistakes was the poor distribution of vaccine. The H1N1 vaccine was quickly developed, successfully tested, and manufactured in impressive fashion. It created an excellent antibody response in normal hosts. But there was a major breakdown in distribution, Dr. Gwen A. Huitt said at a meeting on allergy and respiratory diseases.

Another big problem was “woefully inadequate” viral testing methodology. So many people had a negative rapid test— even though they had classic symptoms of H1N1 infection—that the testing was basically abandoned. Rapid, reliable, and relatively inexpensive polymerase chain reaction (PCR) tests are being developed and will soon be available. But the new PCR tests are unlikely to find their way into most physicians‘ offices or smaller clinic facilities, said Dr. Huitt, director of the adult infectious disease care unit at National Jewish Health and professor of medicine at the University of Colorado, both in Denver.

Other areas in need of improvement include the following:

Poor education. Only about one-third of the general population has been vaccinated to date. Most of the public was not persuaded by the case for immunization made in the vaccination campaign.

More effective pandemic H1N1 education needs to be aimed not only at the public but also at health care workers, said Dr. Huitt at the meeting, which was sponsored by the National Jewish Medical and Research Center. Despite data showing that in most health care settings, surgical masks are just as protective as the more expensive N-95 masks (N. Engl. J. Med. 2009;361:1823-5), there was considerable resistance to the surgical masks on the part of unionized health care workers.

Treatment issues. Physicians learned too slowly that the antiviral agents are less effective in special populations. For example, it was discovered that higher doses of oseltamivir (Tamiflu) are required in obese patients—which was one of the groups at high risk of hospitalization and severe complications of H1N1.

Legal issues regarding mandatory vaccination. “We’re still dealing with this. Many institutions have mandated that health care workers, including docs, get vaccinated against influenza or lose their job. I can tell you there‘s ongoing litigation on this issue,” she said.

What did the medical community get right in the pandemic? Pandemic preparedness algorithms were already in place before case counts started rising. Antiviral agents were available in adequate quantities. Physicians and public health officials were quick to recognize that testing methods were inadequate and couldn’t be relied on. And the vaccine was protective.

Dr. Huitt indicated she has no relevant financial relationships.

Dr. Mark L. Metersky, FCCP, comments: Other aspects that the medical community got right were the immediate dissemination of information by Mexican public health authorities when the novel strain was detected, and the performance of several high-quality prospective clinical and epidemiologic studies that were made possible by the advance knowledge of a likely pandemic.