H1N1 (Public Health)

Continuing in the same line as the last two days, I want to talk about a few specific areas of the public health response. As I see it, there were three things that the public health community was primarily responsible for in this event. They are:

1. Crisis communication
2. Distribution of SNS and other medical assets
3. Surveillance (in this case I mean it very broadly to cover everything from initial detection to case confirmation

I will take each one in a little more depth below, especially the last.

1) Crisis communications: I’ve already said some of my thoughts on this topic, and Jimmy Jazz has an excellent post on it. In short, public health (at all levels, but especially the Feds from HHS and CDC) should have been the go-to people for messages about the outbreak, how serious it really was, and what actions people should take. Our media being what it is, things didn’t always work out that way. The Feds tried to stay in front of the story, with daily CDC calls, daily DHS, HHS press conferences, and other similar activities, but a lot of that was knocked down by a Vice President with a chronic case of leap-before-you-look.

2) Distribution of SNS: One of the biggest actions that HHS took was a deployment of 25% of the 66% of the flu items in the SNS to impacted states. Let me try and make that a little more clear – of the pandemic supplies in the SNS 66% was purchased by the federal government, and 33% was purchased by the states; as the H1N1 outbreak was ramping up, HHS made the decision to deploy 25% of the Federal portion (the 66%) to states without their having to request it. This is the medical equivalent of pre-positioning food/water stockpiles before a hurricane hits the Gulf Coast. It’s too early to get a good read on how much of that deployment was necessary, but even so it proved an invaluable test of the system itself. Now, instead of looking at the main SNS deployment numbers, which are “within 48 hours from the time a request is approved” and which are based on a single community or area needing assets, HHS can look at the time it actually took to activate a nationwide deployment. Additionally, states and locals have a chance to evaluate their Receipt, Staging, and Storage (RSS) plans and the rest of their distribution system.

3) Surveillance: As I said, I’m using this far more broadly that is probably legitimate, but there are a couple of related issues that I’d rather talk about together. On the one hand, we have what seems to be a failure of the US surveillance system to pick up the worrying cases in Mexico until after Canadian authorities. On the other, we have the time delay in getting specimens processed and confirmed as H1N1 by the CDC labs. (NOTE – this is based primarily on a daily brief I was receiving at work that included information on the attempts to get more testing kits out into the wild and the fact that there were jumps in cases whenever the labs got new kits – I don’t have a link to verify with.) Both of these point to problems with the lab system, and I am in no position to identify the best solution. One suggestion that is sure to surface is to pump more resources (read: money) into the CDC, NIH, or other arm of HHS to allow them to increase their capability. The flip side of that coin is to pump those same resources (read: even more money) out to the states to increase their capabilities. At least one private company is suggesting that, at least for early detection, their data-crawling program is the way to go.

Like I said, I don’t have the answer, but I’m willing to make some predictions: Over the next year there will be a lot of Federal money allocated to laboratory programs (either state, Federal, or both) to increase capacity; this increase will allow labs to add personnel, purchase fancy new equipment, and increase the use of programs like BioWatch, BioSense, etc (which have a fantastic track record); NONE of this funding will be added to the budget of the agency (HHS) but will all be emergency funding or some other kind of appropriation; in a year or two, when some new monster of the week rolls around the funding will go away and the labs will be left underfunded and will have to cut back to the levels of personnel, equipment, and systems they have now leaving us no better protected from the next outbreak.

My take-away from all of this? We really need to develop a sustainable model for improving our public health lab capabilities. This includes getting more funding to allow states and locals to hire more personnel and it also means getting those personnel to identify a data-sharing system that works and focus efforts on expanding it to where every public health lab in the country is using it. As for the other areas (communications, SNS), I think we need a full and thorough after action review (as I’ve pushed in other posts this week) to drill down to the core good/bad performances and identify the ways to make necessary improvements before this happens again.

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