Swine flu's lesson: We're not ready for anything virulent
The H1N1 pandemic should have come with an announcement: this is a test of the public health emergency system.
If this had been a virulent virus, there's a decent chance you might have been dead before you got the vaccine.
The H1N1 flu virus, also known as swine flu, turned out to be mild in most cases. But some experts say we dodged a bullet.
An estimated 50 million people got the flu - one out of six Americans. If the virus had been as deadly as first feared, the lack of vaccine would have created a national uproar.
The fact remains that an estimated 10,000 people in this country - including 79 in Illinois - died in part from flu complications because they did not get a vaccine.
And while health officials say supplies will increase rapidly in the next few weeks, it's still hard to get.
Last week in Skokie, Long Grove resident Lynn Cohn waited more than an hour, much of it outside in freezing temperatures, to get her 12-year-old daughter the shot. She couldn't get it through her pediatrician. To Cohn, the vaccine distribution has been a "debacle."
"Something is wrong with our system," she worried. "It's disturbing."
Those who study emergency preparedness say that the trickle of vaccine, and the failure to get it to those who needed it most, show that we remain unprepared for widespread health emergencies - and slow to address the problem.
"This should be a wake-up call, but it's more like a snooze alarm," said Dr. Irwin Redlener, director of The National Center for Disaster Preparedness at Columbia University in New York. He teamed up with the non-profit group Trust for America's Health on a report to be released Tuesday detailing deficiencies in the response to H1N1 and recommending changes in how future health emergencies are handled.
The response to the flu, he said, mirrors government failures to fix glaring deficiencies in responding to the 9-11 terrorist attacks and Hurricane Katrina.
"This," Redlener said, "was a warning sign."
Ailing children at end of line
The main problem, critics say, was failing to get the vaccine quickly to those who needed it most, particularly children with chronic medical conditions who were most at risk of dying from flu complications.
DuPage and Kane counties eventually had special one-day outreach programs, but local parents were generally mystified why there were few provisions for children with special health problems, while there was often no enforcement of who should get the shot. Health officials asked that health care and emergency workers, people age 6 months to 24 years, pregnant women, caregivers of children under age 6 months, and those 25 to 64 with chronic medical conditions be given priority for the shots, but made compliance voluntary.
Faced with a vaccine shortage, the U.S. Centers for Disease Control and Prevention issued more strict guidelines to concentrate on sick children. Public health officials in the Chicago area never implemented those stricter recommendations, despite a plea from the Illinois chapter of the American Academy of Pediatrics to do so.
Lake County Health Department Executive Director Irene Pierce said she repeatedly brought up the guidelines with other health officials, but was told not to diminish public interest in getting the vaccine by restricting it.
One group that could have helped was left largely out of the equation until now.
Doctors said they were in the best position to get the vaccine to those who needed it most. But most doctors were not given any vaccines until this month, two months after distribution began.
The Elmhurst Clinic, which ordered its vaccine directly from the CDC rather than through the state, was an exception that showed what a medical practice could do.
After inoculating 7,000 patients against seasonal flu, the clinic immunized another 8,000 or so patients against H1N1, Chief Operating Officer Marty Stull said.
The clinic used its electronic medical records and automated calling system to prioritize and call in pregnant women, children, and infant caregivers.
"After the pandemonium we saw with the health departments," she said, "this was a very orderly and precise way of administering the vaccine."
Yet she conceded that doctors could never handle all the demand in case of widespread urgent immunizations. Ideally, they would work in coordination with health departments and pharmacies, who are also just now getting vaccines.
Instead of doctors, the Illinois Department of Public Health gave the vaccine initially to hospital medical workers and to county health departments, with the idea they could decide how to meet local needs and could take care of people who don't have doctors or insurance.
But the amount given to each county varied greatly. Chicago, which got its own allocation from the CDC separate from and before the rest of the state, got 150,000 doses early on, while suburban Cook County, with almost as many residents, initially got only 20,000.
Once suburban children started dying from the flu, the demand suddenly far outstripped the supply. At least 13 children statewide have died of H1N1 flu since it was identified in April. Many had health conditions that put them at especially high risk for complications.
Thousands of concerned parents brought children to jammed vaccination clinics. In Lake County, some people waited for hours, only to be turned away as vaccine ran out.
In Cook County, the Department of Public Health committed first to vaccinate schoolchildren one town at a time, while everyone else had no access to the vaccine.
Eventually, as supplies increased, Cook County held both appointments and limited walk-in clinics. Officials sent vaccine to pediatric specialists and obstetricians, but said some were not set up to give out vaccinations.
DuPage County went with appointments. People complained about long waits on the phone and getting scheduled a month away - but they didn't have to stand outside and get turned away.
Kane County held mass immunizations, but had to temporarily suspend them when they ran out of vaccine, then offered appointments.
Fortunately, the number of deaths, hospitalizations, and patients with flu symptoms has decreased steadily for the past month.
Nationally, the CDC estimates 10,000 people died from the flu through Nov. 14. That's much less than the estimated 36,000 annual deaths from the common seasonal flu, but includes many young people that seasonal flu doesn't normally affect, and it isn't over yet.
Cause for concern
In general, the slow and only partially effective response to the swine flu is cause for concern about how the government will respond to a more urgent and deadly disaster, expert Redlener said.
A sudden biological attack - which terrorism experts see as likely - won't offer the luxury of months to make or distribute a vaccine or treatment. While some supplies like antibiotics are stockpiled and federal officials are working on speeding up vaccine production, more masks, ventilators, hospital beds and staff will be badly needed in a public health emergency.
"This was a warning sign," Redlener said. "If we invest in research and development and manufacturing, we'd bolster the public health system in general, make us more resilient to any biological disaster, and we'd create good jobs."
Dr. Irwin Benuck, president of the Illinois chapter of the American Academy of Pediatrics, said public health agencies must adapt to changing circumstances in an emergency.
He advocated getting more people into a medical practice, or medical "home," where a doctor or nurse can track their needs, notify and treat them.
"This was a dress rehearsal," Benuck said. "The lessons to learn are we need a medical home, and treatment needs to go to the people who are most in need."
Public health officials in Illinois admitted the situation was frustrating, but did not say they would have done anything differently.
"We're doing the best we can with what we have," Illinois Department of Public Health spokeswoman Kelly Jakubek said.
They say it's too early now, but they will review their response in future meetings and ongoing drills.
In a letter to the U.S. Department of Health and Human Services, senators Joe Lieberman of Connecticut, an Independent, and Republican Susan Collins of Maine, top members of a homeland security committee, complained that because health officials admitted no mistakes, the same problems will arise again.
"This approach raises doubts about our capacity to respond effectively to the ongoing epidemic," the senators wrote, "but also to prepare effectively for what could be even more serious epidemics in the future."