H1N1: A Lesson for Healthcare Preparedness

Since the early part of this decade U.S. healthcare agencies have been wondering not if but when the next major pandemic will hit.  The concerns raised by the 2002-03 SARS (Severe Acute Respiratory Syndrome) virus, and by several avian flu outbreaks, resulted in billions of dollars being spent, in the United States alone, to improve the nation’s preparedness to cope with infectious diseases.  Although several models to cope with such pandemics have been proposed, the reality of how hospitals, patients, and society at large will react – when such outbreaks occur – has been, to date, mostly educated guesses.

Related discussions – of how today’s hospital staff would react, for example, to the possibility of bringing such viruses home with them, and/or how healthcare institutions would be able to supply services if a high percentage of the medical staff is ill – cannot truly be known until those events actually occur.  Among the many other pandemic unknowns are how hospitals will be able to remain operational if their supply chains are disrupted for an extended period of time, or if essential resources (ventilators, for example) are in such great demand that they must be rationed out to viable patients.

Emergency healthcare planners at the local, state, and federal levels of government have engaged in countless hours of debate on such pandemic-related topics over the past few years. Nonetheless, there are few if any certain answers to any of these or other “unknown” issues.  Most of the contingency plans that have been developed to date are still based, therefore, on how citizens in Canada, China, and/or other nations reacted to the previously mentioned SARS and/or avian flu outbreaks.  Many assumptions in the U.S. pandemic planning literature, in fact, are little better than educated guesses – based in large part, moreover, from the so-called Spanish Flu global pandemic in 1918, which lasted two years and killed anywhere from 50 million to 100 million people throughout the world. (Its exact origins and the number of victims worldwide, and other relevant information, are still unknown.)

H1N1: An “Educational Moment” in Preparedness? The long-running uncertainties about the latest global pandemic could change very rapidly, though – starting now. By closely studying the current H1N1 (“Swine Flu”) outbreak the United States could use it as a more recent, and much more precise, example of how the nation’s healthcare institutions are likely to be affected by another pandemic more virulent in its intensity than the H1N1 outbreak – which, although officially declared by the World Heath Organization (WHO) to be a global pandemic, did not kill nearly as many people as the Spanish Flu did. The H1N1 virus did, though, involve a number of ancillary issues that other recent flu outbreaks had not fully addressed – but that are definitely worth studying.

To begin with, the H1N1 virus was, from the beginning, a news event that resulted in many major U.S. cities closely monitoring local flu outbreaks on an almost hourly basis.  It also: (a) produced surges of hundreds of patients – many of whom were somewhat dismissively categorized as “the worried well” – who presented themselves to emergency rooms throughout the country in unprecedented numbers; and (b) tested the ability of the nation’s pharmaceutical industry to isolate the H1N1 virus, develop a viable vaccine to counter it, and produce and distribute millions of doses of that vaccine – all within a very tight time frame. 

Most important of all, perhaps, particularly in the United States, is that the H1N1 outbreak also revealed weaknesses in the plans that had been developed to distribute the limited quantities of vaccine initially available to specially targeted groups – e.g., children, pregnant women, healthcare workers themselves, and other first responders. The problems inherent in the national U.S. system of distribution and tracking of vaccines resulted in turn – largely because of the limited supply – in creation of a new plan that differed, sometimes significantly, from one state to another. The evidence is not yet complete, of course, but at present it seems likely that the system’s inconsistencies were at least partly the result of the federal government’s reliance on state health departments to distribute and track the potentially harmful side effects (of the outbreak, and of the vaccine).

Mistakes, Misunderstandings & Miscalculations By the WHO’s definition, the United States is still struggling its way through the two-year 2009-2010 flu season. After the H1N1 outbreak is “officially” over, though, and a more complete, as well as more accurate, assessment of the national and global response efforts has been developed, many valuable lessons will undoubtedly come to light. The most important of those lessons, it seems likely, will be how well (or how poorly) the national healthcare system, and the system’s regulators, handled the pandemic. If decision makers at all levels of government learn those lessons, and revise – i.e., improve – the nation’s healthcare system accordingly, the mistakes, misunderstandings, and/or miscalculations evident during the 2009-2010 outbreak will not be repeated before and during the next pandemic.

In other words, the mistakes, large and small, made in dealing with the H1N1 virus could and should be clearly understood by healthcare planners – and by political decision makers – as warnings that, if heeded, could save countless lives during future pandemics.

One obvious example of such warnings involved the allocation of limited tools – e.g., anti-viral medications and vaccines – to fight the pandemic.  If the pandemic had been deadlier – and/or if it had spread in a different way – the political and public pressures for the vaccine would have been much more intense.  Some states – New York, for example – required their healthcare workers to be vaccinated, but other states did not (partly, it seems evident, because of the political pressure exerted by labor unions). If nothing else, this inconsistency showed what could and probably would happen in the United States, during future pandemics, if the federal government tries to require its healthcare workers to be vaccinated.

Isolation Problems and Contingency Plans Another issue that must be resolved ahead of time is that the patient surge into some hospital emergency rooms, generated by H1N1 fears, created significant “isolation” problems. There was a unique challenge to hospitals experiencing such surges on how to segregate the “real” flu patients from the “worried well” and other patients presenting themselves with non-flu symptoms. Most of the hospitals confronted with flu surges were not fully ready to cope with such a sudden influx of additional patients; even those hospitals with a well planned flu-response policy were overwhelmed at times. 

Fortunately, a few creative ways were developed to address all aspects of the pandemic – from the screening and rapid triage of patients to the use of non-emergency spaces – but concerns about EMTALA (Emergency Medical Treatment And Labor Act) issues, as well as the demands for flu testing, were nonetheless intense at these facilities.  The lessons these hospitals and other healthcare facilities lived through should be closely studied, therefore, and workable systems developed to cope with similar “surge” events in the future.

The H1N1 virus may return as early as the next flu season, perhaps – or a more virulent and deadly pandemic may take its place. Again, the question is not “if” but “when.” Most public health emergency planners believe that the United States is long overdue for a truly major outbreak of some type of infectious disease. Until that happens, though, U.S. hospitals and other healthcare facilities would be well advised to take very seriously the warnings issued and lessons learned from the past/current flu season – starting, perhaps, with ventilators, vaccine supplies, and staff shortages – and apply them to their future planning initiatives as soon as possible so that they will not only serve as an effective model for the United States but an example to the rest of the world as well.   

Theodore Tully
Theodore Tully

Theodore (Ted) Tully, AEMT-P, is President of STAT Healthcare, an Emergency Management consulting group. He previously served as Administrative Director for Emergency Preparedness at the Mount Sinai Medical Center in New York City, as Vice President for Emergency Services at the Westchester Medical Center (WMC), as Westchester County EMS (emergency medical services) Coordinator, and as a police paramedic/detective in Greenburgh, N.Y. He also helped create the WMC Center for Emergency Services, which is responsible for coordinating the emergency plans of 32 hospitals in the lower part of New York State.



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