Local health officials hope to learn from H1N1 scramble
Last fall's distribution of swine-flu (H1N1) vaccine in and around King County provoked broad public outrage and strained both public and private health-care capabilities. Public- health officials are analyzing lessons learned as they prepare for a future — and possibly more lethal — pandemic.
Seattle Times health reporter
Who should get scarce medical resources? For a report on the opinions of King County residents, go to www.kingcounty.gov/healthservices/health/preparedness/pandemicflu.aspx, see the "Public Engagement Project" under "Additional Pandemic Flu Resources."
Public commentsSurvey: Public Health — Seattle & King County wants to know about your experience with swine flu last fall. A survey is being mailed this week to 2,500 county residents asking how they got information, their opinions about vaccine distribution and other questions.
Public meetings: In April, Public Health will explore similar questions at a series of meetings with county residents, health providers, pharmacies, schools, businesses, community advocates and others. Details are still to be arranged. For more information: Meredith Li-Vollmer at email@example.com.
Vaccine timelineSignificant points in last fall's H1N1 vaccine distribution in King County:
Week of Oct. 5: Initial doses of "flu mist" arrive in King County; not suitable for high-risk patients, they are sent out for health workers.
Week of Oct. 12: Small amounts of injectable vaccine begin trickling in; they are sent primarily to hospitals and clinics for health workers and high-priority patients.
Oct. 21-23: Public Health — Seattle & King County holds four clinics for uninsured high-risk patients.
Oct. 24- Nov. 1: Hospitalizations for influenza (likely H1N1 but not necessarily lab-confirmed) and emergency-room visits for flu-like illnesses peak.
Nov. 6: Distribution of vaccine widens to include some pharmacies.
Dec. 5: Public Health opens ongoing clinics for uninsured and low-income.
Dec. 12: Vaccine supply increases and Public Health widens eligibility to anyone age 6 months and older.
Sources: King County H1N1 Healthcare Impacts Report (Nov. 17, 2009) and other reports
Swine flu turned out to be less deadly than first believed. But what if it had been a fast-moving, highly lethal pandemic, a modern Spanish flu or plague?
Or a disease likely to kill people with particular health conditions?
Such questions spurred a recent meeting of health workers convened by Public Health — Seattle & King County to assess local response to H1N1 flu.
Some health officials insisted that distribution of the vaccine went as well as possible, considering an unexpected early shortage.
Many Puget Sound residents strongly disagree.
In King County, which relied mainly on the private entities that typically dispense seasonal-flu vaccine slowly over several months, frantic callers besieged clinics and pharmacies in October.
They jammed phone lines, only to hear: no vaccine, no information, no plan. Again and again, people described how they felt: "abandoned."
In Snohomish County, mass-vaccination clinics in late October left thousands of high-risk vaccine-seekers lined up outside hospitals and schools for hours, many braving cold, wind or rain.
While patients with asthma and diabetes struggled in vain to get vaccinated, health workers endured shortages of protective masks, and many hospitals and clinics were overwhelmed by sick or anxious patients.
"Something obviously failed here," said Jim Reddin, a 62-year-old community-college teacher whose serious lung condition put him at high risk of complications.
For weeks in October, Reddin tried frantically to get a swine-flu shot. He was told there was no vaccine, only to find out later there was — just not for him.
He eventually got his shot — but too late to prevent swine flu and pneumonia. He was sick for more than two weeks.
Not surprisingly, Reddin is among many who wonder: Is this really the best we can do?
Early vaccine shortage
Public-health officials, who must try to stem outbreaks while working within a fragmented health-care system of independent players, acknowledge there were challenges.
Dr. David Fleming, director of Public Health, says it's a balancing act: Local providers need flexibility, but too much can be chaotic.
Fleming says the real problem last fall was the sudden shortage of vaccine. "The primary driver was not that the system was failing but that the vaccine wasn't here."
During October, the county had enough vaccine for only about 17 percent of those in priority groups identified by the Centers for Disease Control and Prevention, including those with chronic conditions or weakened immune systems, pregnant women, and those who care for babies younger than 6 months of age.
Fleming and others point to many successes, not the least of which was that Public Health fashioned a new distribution plan almost overnight. Orders for vaccine were dispatched quickly, and arriving doses immediately were pushed out to reach people's arms and noses.
And when supplies did increase, public-health departments across the state coordinated the release of vaccines to all comers.
Even so, Seattle-King County public-health officials are sending out surveys to county residents to ask what they could do better.
"We need to be much more prepared," said Dr. Jeff Duchin, chief of communicable-disease control for the agency. "This should be a wake-up call."
It should be, but the difficulties experienced with H1N1 nationally have been more like a "snooze alarm," said Dr. Irwin Redlener, director of The National Center for Disaster Preparedness at Columbia University.
It's how we react to most emergencies, he said: At first aroused and activated, we quickly "slip back into a state of complacency."
The H1N1 outbreak, according to a report in December on public-health preparedness by the nonprofit Trust for America's Health and the Robert Wood Johnson Foundation, "vividly demonstrated the existing gaps" in states' readiness.
According to the state-by-state report, "Ready or Not?" Washington state meets only five of 10 criteria for an adequate response to public-health emergencies. Only Montana scored lower.
Like any good stress test, H1N1 quickly found the point of greatest weakness: our fragmented collection of separate entities called a health-care "system."
That became clear to Dr. Mary King, medical director of the pediatric intensive-care unit at Harborview Medical Center, when she brought her premature baby home at the end of August. At risk because of lung problems, he was too young for the vaccine. Even King — as connected as they come — couldn't score vaccine for the baby's caregivers. Meanwhile, she said, friends' children with mild asthma were getting vaccinated.
"It doesn't mean those pediatric offices were wrong to vaccinate their patients," she said. "But there was no way to distribute the vaccine based on priority and need. ... I do think the system needs reconfiguration."
Even as supplies improved, there wasn't enough vaccine for everyone in priority groups, so each hospital, pharmacy and clinic created a list.
"Systems weren't accountable to each other," King said. "So access to the vaccine is different depending on what kind of group you're hooked into, let alone whether you're hooked into a system at all."
Early on, some King County pharmacies had vaccine before health-care providers. Fleming says that simply was "a glitch, a clerical error."
But when King County decided to hold free vaccine clinics for those without insurance on Oct. 21, while thousands of well-insured, high-risk patients were still searching for a shot, some considered faking poverty.
Inside clinics, doctors struggled to match the most vulnerable patients with various types of vaccine.
"It wasn't as simple as 'I have a dose of vaccine and you're high risk and I can give it to you,' " said Dr. Neil Kaneshiro, a Woodinville pediatrician. "It was a nightmare."
At Harborview, pharmacy officials struggled to decide which high-risk groups trumped others. "One of the things that's hard in health care is to even talk about rationing," said Cindi Brennan, director of clinical excellence for UW Medicine Pharmacy Services. "Rationing is a tough concept when you're used to having everything for everyone."
Harborview ultimately focused extra effort on pregnant women. "We actually called our patients who were pregnant — 'C'mon in!' " Brennan said. Nearly all did.
But many providers, particularly those without electronic patient records, couldn't cull a list quickly or muster staff to contact patients. "We were so overwhelmed with phone calls, it was impossible for us to reach out," Kaneshiro said.
Gap in adult care
Public and private health providers in King County have good relationships, Duchin said. But the health culture in general encourages independence. "Here, it's every man for himself, basically."
In countries where health care is more centralized, it's easier to set standards and inform providers.
"One of the huge issues in this society is we don't have an adult-vaccination program," Duchin said. Adults typically get vaccines from the private sector, where links with public health are weak. The H1N1 vaccine-ordering process was cumbersome, and many doctors simply didn't participate.
Still, there's good news: This emergency, like others, is generating creative ideas.
King shared hers at the recent assessment of the area's swine-flu response: Create a single database where patients could be sorted by risk factors. "You could actually have a real-time prioritization of people who need the vaccine," changed as new information came in.
Public-health officials say they welcome suggestions, even as they assess their decisions during the outbreak; for example, the pros and cons of mass vaccination versus dispersing to providers.
Dr. Gary Goldbaum, health officer for the Snohomish Health District, says its community partners — including schools, tribes, pharmacies and health providers — pushed for mass "clinics," arguing they would be most efficient. The clinics vaccinated some 28,000 people on two days in late October.
In more densely doctored King County, Duchin reasoned, providers could most reliably reach high-risk patients.
One item on the shortlist of most public-health officials: Improve communication with providers and the public. The messages during H1N1 were complicated, changing and often misunderstood, officials say.
The list of improvements they say they need to make is long. But money is tight, and many changes seem beyond their control.
There will be another pandemic, maybe a much more severe virus, King said — and no one disagrees. "The scary thing is: So what do we do next time?"
Carol M. Ostrom: 206-464-2249 or firstname.lastname@example.org
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