H1N1: A Pandemic in Review

Some folks say the recent pandemic of H1N1 (“Swine Flu”) influenza was no big deal; just a product of media hype and overzealous public health officials. Others think we dodged a bullet because the H1N1 pandemic was not as bad as it could have been. And others say the H1N1 pandemic was an unmitigated disaster due to pointless school closings, poor governmental communication, overstressed medical care facilities, inexplicable delays in vaccine production and delivery, and many lives lost.

Actually, everybody’s right.

H1N1 arrived in the US in April amidst considerable alarm and panic. A new influenza virus prompted swift action by public health and governmental officials. Schools were closed, travel warnings were issued and flu-fighting medicines were shipped from the federal stockpile to the nation’s public health departments. In Mexico, initial mortality rates from this new flu looked high. Worldwide media went into overdrive covering every flu-related topic they could find.

The pork industry lost hundreds of millions of dollars because the new flu was thoughtlessly called the “Swine Flu.” Personal and business travel to Mexico was eliminated or put on hold. Surgical masks were sold out. Calls were made for quarantines and fever scanners at airports. After a month or so, coinciding with the public school summer recess, the first wave of H1N1 flu ended.

But H1N1 did not go away. It continued along during the summer months at a slow rate, giving CDC epidemiologists time to produce a vaccine and refine H1N1 prevention and treatment guidelines. Review of the first several thousand cases of H1N1 showed it to be no more life-threatening than regular seasonal flu. This was good news. H1N1 was not the “killer” pandemic many scientists had been expecting. But in contrast to seasonal flu, which causes the highest mortality in people over 65, H1N1 was disproportionately affecting children, pregnant women, and adults under 60 with chronic diseases.

Knowing H1N1 flu activity would increase again later in the fall, officials from public health, public schools and hospitals got busy making preparations for flu prevention and treatment, as well as planning for an H1N1 vaccine arriving by mid-October.

What we overlooked is pathogens like H1N1 are on their own time schedule and don’t wait for a vaccine. Universities with late August starts found that school convened with an unwelcome visitor.

Washington State University was one of the hardest hit by H1N1 with the first case identified three days before classes started. By the end of the second week of classes, more than 2000 students had flu-like symptoms.

Thankfully, most people infected with H1N1 had a fairly mild disease. Nevertheless, health care providers were inundated with flu sufferers. Hospitals resorted to triaging patients with mild illness and no risk factors away from their Emergency Rooms so staff could cope, resources could be reserved for those who really needed them, and the spread of infection reduced. Many clinics and urgent care facilities were seriously stressed for several weeks. One wonders what would have happened had H1N1 been a more severe illness.

The speed at which H1N1 spread was truly impressive. WSU's experience demonstrated how explosive a new flu could be in a population where 100 percent were susceptible. Many public schools were caught off guard as H1N1 caused absenteeism rates up to 40 percent, canceling classes as well as athletic contests. In Whitman County, Washington, even rural school districts were impacted following a “Teen Mixer” dance at the County Fair.

By the end of September and into early October, the H1N1 epidemic was on the wane locally. The rest of the state was at least a month behind as H1N1 reached a peak toward the end of October, gradually subsiding to rates similar to what was seen over the summer by the end of November. Since September, 1357 hospitalizations and 71 deaths attributed to H1N1 have been reported in Washington. The hospitalization rate was highest among children 0-4 years of age while the death rate was highest among adults 50-64 years old.

By the time vaccine arrived in any useful quantity, the second wave of H1N1 was nearly over. The delay caused extreme frustration to providers and patients alike. Despite this fact, nearly a million doses of vaccine were distributed statewide. In Whitman County, about 1,000 doses were given at the Public Health Department while an additional 6,000 doses were distributed to hospitals, clinics and pharmacies. Further public interest in receiving the vaccine has essentially evaporated even though we are unsure if H1N1 has a third act waiting for us later this winter.

In retrospect, we were very fortunate. Believe it or not, H1N1 spread much faster and with greater fury than the 1918 influenza pandemic. But H1N1 influenza was a much milder disease than the flu in 1918, at least to those of us who survived it. As such, it served well as a sort of “training pandemic” for public health and other governmental officials. We now know what parts of our influenza pandemic plan work well, which don’t, and what needs improvement. We found out that, even under ideal circumstances (instant recognition, immediate vaccine production, and ideal distribution), we lack the technology to crank out vaccine soon enough and in sufficient quantities to avert a disaster if we truly face a deadly flu.

Beefing up our response plans for the next influenza pandemic is reasonable. However, it is foolish to assume we can prepare for a flu pandemic like the historic 1918 outbreak. Our health care system was taken to the breaking point with H1N1; a relatively mild flu . We don’t have enough beds, enough ventilators, enough anti-viral medicines, or enough doctors and nurses to handle anything like the Great Influenza of 1918. More importantly our society can’t afford to have massive surpluses of highly trained people and materiel on hand “just in case.”

The only way to rationally respond to the next “killer” flu pandemic is to prevent it entirely. Current flu vaccines are produced with the new flu virus strain after it has been identified. We then grow the virus in chicken eggs for vaccine production. As H1N1 showed us, the 1950s era technology is ineffective. Our strain specific vaccines also become less effective if the virus mutates much. Constant genetic changes are the reason we need to get a seasonal flu shot annually to maintain effective immunity.

What if we could develop an effective vaccine that acted on the parts of the flu virus that don’t change or mutate? This could result in a “universal” flu vaccine that prevents illness from strains of influenza circulating now, and new ones that may emerge in the future; even “killer” strains.

The idea of a universal flu vaccine is doable. Some researchers are already testing candidate vaccines and other diseases are being eliminated using the same strategies. Influenza vaccine researchers should be supported, encouraged, and most of all funded with the lion’s share of influenza pandemic planning resources. We can prepare for managing and surviving the next flu pandemic all we want. But a much better strategy is to prevent it from happening so that, in the future, we will ask, what was the flu like back when you were young and we still got it?