Tuesday, June 1, 2010

H1N1- The Great Pandemic?

Yes, it appears that news coverage of the H1N1 pandemic is not quite over yet. On May 25th, 2010, Toronto Public Health released a report (covered by the Globe and Mail) that showed that only 28.2% of Toronto residents received an H1N1 vaccination compared to a rather pathetic national average of 50%. This has caused great concern to public health officials. While I won't comment on reasons for the low Toronto vaccination rate, I'd like to make a few comments on the low national rate of adherence to the recommendations of Canada's national public health officials. I'd just like to post one comment out of the report that pretty much sums up Canada's experience with H1N1:

"The peak of infection in the second wave occurred at the end of October, just as vaccine was made available to priority populations; most of the serious illness occurred before significant immunity from vaccination was achieved." (my bold)

Despite massive expenditures on communication with the public through frequent (and often daily) press conferences with both Health Minister Leona Aglukkaq and Canada's Chief Public Health Officer Dr. David Butler-Jones as well as television and radio advertising, Canadians never really seemed to buy into the whole idea of getting vaccinated for what our health officials termed a pandemic. At first, there were massive line-ups that stretched for city blocks where frightened (and rightly so) Canadians waited in line for the precious nectar. When it became readily apparent that supplies of the vaccine were limited by production issues, the wheel started to come off the cart. First, some provincial authorities triaged those who were deemed most needy to stretch the limited supply of the vaccine to children and pregnant women and in some cases, to those who were immune compromised. Different provinces had different rules and, in this day and age of Canadians being easily able to access news stories from other provinces, the waters rapidly became muddied. It became unclear to most Canadians which group of people were to be prioritized in each jurisdiction and when clinics would be open to the general public.

Canadians were bombarded with media coverage of the unfortunate deaths that did result from contracting the H1N1 virus. We were continuously reminded to practice good hygiene by washing our hands properly, coughing or sneezing into our sleeves rather than our hands and to stay at home if we became symptomatic unless we required a visit to specially designated influenza clinics that had been set up. Basically, we were told to keep our distance from other people. Paranoia reached the point where physicians even removed their tattered 2006 vintage magazines from their waiting rooms lest they be a breeding ground for the dreaded virus. What was so ironic about this approach was that, at the same time, people were lining up by the thousands with other people, who may well have been asymptomatically carrying and spreading the H1N1 virus, to get their vaccinations. If this virus had been more virulent, the very act of lining up en masse could have led to far greater penetration into the population than would otherwise have been experienced. Common sense should have dictated that it really wasn't prudent to stand for hours in large crowds during a pandemic.

Another side effect of limited supply issues was the intermittent opening and closing of clinics. When supplies ran low, clinics would close for a day or for several days until their supplies were replenished. This made it nearly impossible to plan to get vaccinated once the vaccinations were available to all members of the public. There were many media reports showing video footage of frustrated vaccination "wannabes" arriving at a clinic, only to find a "Closed for the Day" sign on the door. As well, by the time vaccinations to all members of the public were widely available, it had become apparent that H1N1 was a much lessened threat.

Two types of Pandemic H1H1 2009 vaccine available were apparent, leading to even further confusion. The adjuvanted version was recommended for the general public while the unadjuvanted version was preferentially used for pregnant women because more safety information was available on the use of unadjuvanted vaccine in pregnant women. This led to additional public concern since none of the currently licensed flu vaccines in Canada contained an adjuvant.

Canadians also became somewhat jaundiced about the whole procedure of waiting for hours in line for a vaccination when it was revealed in early November that the players of the Calgary Flames and their families, coaches and office staff had jumped the queue and been vaccinated ahead of supposedly prioritized Albertans despite the fact that the province was running short of vaccine.

Even when it became apparent that the second wave of the H1N1 influenza was not as deadly as had been anticipated by public health officials, they kept sounding the alarm bells about a potential third wave well into December, urging people to get vaccinated with their, by now, huge oversupply of vaccine. The peak number infections took place in early November, in some jurisdictions, the vaccine wasn't available to the general public until early December.

A May 28, 2010 update by the World Health Organization stated that the H1N1 virus had resulted in at least 18,114 deaths and that it had been found in 214 countries. By comparison, the 1918 Spanish Flu Pandemic resulted in between 50 to 100 million deaths (3% of the world's population) and over 500 million (30%) of the world's population contracted the illness. In Canada, there were 428 deaths and 8678 hospitalizations (numbers depend on the source). The Public Health Agency of Canada didn't keep records on the number of Canadians who contracted mild cases of H1N1 but it appears that roughly 30 percent of the population was infected from antibodies discovered in blood tests performed on a sample group of 1600 Ontarians.

Believe it or not (and there's apparently nothing like flogging a dead horse) the Public Health Agency of Canada still has an active website for H1N1 here. They just don't seem to be able to let this one go. The website is a historical snapshot of things gone wrong and a few things gone right. For your information, it's estimated that Canada's response cost more than $2 billion.

Here are a few ideas that I think would be worth considering for the next pandemic:

1.) Health Canada should control all distribution and all provinces should have to adhere to the same triage listing (i.e. if pregnant women and children (or other people groups) are to be prioritized, they must be prioritized in all provinces and territories at the same time and for the same duration).

2.) Vaccinations for a potential pandemic should be administered through the practices of family physicians for the most part. These physicians should be the front line in any pandemic, especially in the case of a rather mild influenza as was experienced in 2009 - 2010. Family physicians are also aware of underlying conditions in their patients that will affect who should receive the vaccination early.

3.) Enforce a "no queue jumping" rule. Any official found guilty of allowing the vaccinations of low priority patients is immediately fired with cause. That should put an end to professional hockey players getting priority over those with underlying conditions such as cancer that make them vulnerable to any kind of illness.

In conclusion, some things were done right and some things definitely need to be fine-tuned the next time there is the threat of a pandemic. For some reason, although the World Health Organization bureaucrats classified this as a Phase 6 Pandemic (its highest level), it never really seemed to meet that criteria in the eyes of the Canadian public.

Let's hope that Health Canada and the WHO have not "cried wolf" this time and that Canadians will take the next truly serious pandemic seriously.

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