H1N1 pandemic tests our ability to prevent, respond

As medical experts warned last spring, the H1N1influenza virus has moved with alarming speed this fall and taken an exceptionally high toll at a time of year when we don’t normally encounter significant cases of flu. The Centers for Disease Control and Prevention now reports that H1N1 has spread to all parts of the U.S., with almost all states reporting widespread or regional outbreaks. While this new flu strain seems to be affecting most people mildly, it is clearly affecting a small percentage quite seriously, which raises the question of whether the virus is getting ahead of the public health system’s capacity at this moment to prevent it and respond to it.

This particular national health emergency has already taken the lives of thousands and thousands of people across the globe. Here in the U.S., The CDC has confirmed 411 deaths from H1N1, but at least another 2,400 people may have died from what appeared to be unconfirmed H1N1 illness or secondary infections of weakened patients, absent lab confirmation. That is well below the 36,000 that, on average, die every year from seasonal flu. But the season has at least five more months left to it.

Unlike traditional seasonal flu that disproportionately affects the elderly, the H1N1 virus is impacting young people, with over 50 percent of hospitalizations and a quarter of all deaths occurring in people under the age of 25. Alarmingly, young children are at very serious risk, with 95 pediatric deaths tallied so far. These pediatric mortality statistics for H1N1 flu are already equal to what we usually see over the entire course of a normal flu season for children. Regrettably, these numbers will climb higher as the outbreak shows no signs of waning. Pregnant women are also being hit hard. Of the over 100 pregnant women in intensive care with the virus through late August, 29 died.

The federal government in general, and the secretaries of the departments of Homeland Security, Health and Human Services, and Education in particular, have responded aggressively to the threat of the H1N1 virus. They have skillfully tracked the spread of the disease and who it is afflicting, worked with private-sector partners to develop a vaccine in record time, and provided important information to guide state and local officials through perils they may face as the virus escalates. The three department secretaries — Janet Napolitano, Kathleen Sebelius and Arne Duncan, and other officials — have been publicly accessible and visible, communicating critical developments in this public health emergency to the American public. Presidential directives and national strategies for infectious diseases and influenza pandemics that were issued over the last several years have informed and facilitated the federal government’s decisions, which proves, once again, the immense value of planning.

But, given the rapid spread of the virus and the intensity with which it has struck some people, I am concerned about three specific aspects of the federal government’s response.

First, the schedule for H1N1 vaccine production and availability originally set by the government has slipped. Less than three months ago, we were told that the CDC expected 120-160 million doses, based on reports from vaccine manufacturers. Two months ago, that estimate dropped to 85 million doses.

And last week it dropped again. Currently, 28-30 million doses are expected to be available by the end of October. We have heard unsettling reports of growing vaccine shortages that are leading a lot of people to ask if enough vaccine will be produced in time for all who will need it as the H1N1 escalates.

The CDC developed two vaccine distribution plans — one optimistic, one more conservative — based on the vaccine’s availability. I have asked the secretary of HHS whether the department switched from the optimistic plan to the more conservative one when it learned that vaccine availability would not meet the estimates.

Second, I am concerned that hospitals and public health departments do not have the capacity to care for the surge of people who may need hospitalization as a result of H1N1. This is not a new concern. For example, we’ve long worried about the capacity of our public health system to deal with the consequences of a bioterrorist attack on the U.S.

Congress has appropriated some $3 billion to help state and local officials address this problem and President Barack Obama’s declaration of H1N1 as a national emergency will help. Even so, a report this month by the Trust for America’s Health found that 27 states, including my own state of Connecticut, could exceed or come close to exceeding available hospital bed capacity during the peak of an outbreak, if 35 percent of the American people become infected with the flu, which the Trust says is a plausible number. Based on the 35 percent model, more than a million people in Connecticut could develop the H1N1 virus, which would result in more than 17,300 hospitalizations at the peak of such an outbreak, which is about 150 percent of the total hospital bed capacity in Connecticut.  I’m sure that situation repeats itself in other states and throughout the country.

My third concern is about the availability of intravenous anti-viral medications to treat the most critically ill with the H1N1 virus.  A recent report by the President’s Council of Advisors on Science and Technology posed a plausible scenario in which 30 to 50 percent of the population would be infected with the H1N1 virus, resulting in almost two million hospitalizations. The report estimated that between 150,000 and 300,000 of those hospitalizations could be so serious that they would require intensive care treatment.

A lot of those people, according to medical experts, may not be able to swallow or respond to oral anti-viral medications, such as Tamiflu and Relenza.

The Department of Health and Human Services has invested in some breakthrough scientific research to develop intravenous anti-virals for those too ill to take the existing pill form. These new drugs have not yet been approved by the Food and Drug Administration, although FDA is permitting their use on an emergency basis. However, I ask whether this intravenous medication will be available in time and in sufficient quantity for critically ill patients who may need it in order to survive. 
          
Lieberman is chairman of the Senate Committee on Homeland Security and Governmental Affairs.