Public health: flunking the test

We complain when there isn't enough swine flu vaccine and we complain when our health departments don't count all the cases. It's probably good so many people are out of work and can't eat in restaurants, because they aren't getting inspected because all available staff are trying to deal with the flu pandemic:

The current swine-flu wave may have peaked, but thousands of public health workers are trying to vaccinate millions of people against the new disease, fearing that another wave could emerge in the new year. Yet recession-driven budget cuts have thinned their ranks so far that they are being forced to cut back on childhood immunization clinics, restaurant inspections and planning anti-obesity programs to get the H1N1 job done.

Swine flu provides the first big test of the U.S. public health system in the economic downturn. Of the roughly 205,000 job positions in the public health sector, more than 12,800 jobs were eliminated from July 2008 to June 2009, according to the Association of State and Territorial Health Officials, a nonprofit organization that advocates for more public health funding.

An additional 12,000 local health department staff had hours cut or were put on furlough in the first half of 2009, according to the National Association of County and City Health Officials. About 55% of local health departments and 74% of state health departments cut programs from July 2008 to June 2009, according to two surveys by these organizations. (Betsy McKay, Wall Street Journal)

When Republican wingnut Grover Norquist said his goal was to cut government to the size where he could drag it into the bathroom and drown it in the bathtub, he didn't say he do it by getting into bed with Jack Abramoff. Instead of screwing each other they proceeded to screw the rest of us, with the help of all the Republicans and too many Democrats. Public health is now in worse shape than at any time in my 40 years in the profession:

Last spring, dozens of Mr. Fulton's staff spent six weeks dealing with a tuberculosis outbreak that involved tracking down 145 exposed people. Were an outbreak like that to happen now, "We would call all our staff out and would be working day and night," he said.

In Maine, which is still experiencing a surge of swine-flu cases, state health officials are reserving home visits by public health nurses only for major threats such as tuberculosis or child-abuse cases, said Dora Anne Mills, director of the Maine Center for Disease Control and Prevention. About three-quarters of the department's staff has been diverted to H1N1. Some chronic-disease programs have "taken a back seat" for the time being, she said.

"We're learning how thinly staffed we really are and have had to choose which types of health threats can hopefully wait six months to be addressed," she said. Among them are home visits by public health nurses that aren't related to a major health threat.

I know some of you don't think this pandemic is so bad. And as pandemics go, it isn't. It could be far, far worse and it might get that way. So far it is following closely the pattern of 1957 which began in the spring, had a second wave that started late summer peaking about now, then subsided, only to come back with a big third wave in January to March. In 1957 we didn't have a vaccine for the new H2N2 that appeared suddenly in the spring. We still don't know if the current vaccination campaign will make this pandemic different from 1957, but no responsible public health official is going to call an all out effort on the chances there won't be a wave 3, which would lead to many thousands of additional deaths, including perhaps hundreds more children. If the people who say the vaccine is completely ineffective are right (and you know we don't think they are) the health departments and hospitals will still be fully occupied with the flu problem in the form of sick people.

If swine flu is a test of public health, we've already flunked. And we have only ourselves -- and the political leaders who have been disinvesting in public health since 1980 -- to blame.

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Sadly the lesson that much of the public is taking from this pandemic is that rather than facing an unpredictable disease which might have been far worse, the common wisdom is that scientists yet again don't know much about their area of expertise and can't really be trusted. The hacked emails released in "climategate" reinforce this meme.

Sometimes I feel that the movie "Idiocracy" is an accurate prediction of the future.

I would like to thank collective of the Reveres for keeping this blog as it is most useful and interesting, one of the better sources of information on epidemiology for the lay public. I wouldn't have know how interesting the field was but for this blog.

"but no responsible public health official is going to call [off] an all out effort" and I completely agree.

In fact, we're still wrestling with the inside baseball stuff... N95s? Fit testing in private offices? No way everyone can afford or get N95 masks and fit test everyone even though OSHA and the health department says we have to (and some studies suggest no difference between surgical masks and N95 for flu, and others suggest fit testing is a waste of time and money.) But whatever the right answer, that's the daily work that gets put aside in public health emergencies. It happens that doing it well for H1N1 does it well for seasonal flu so the investment in doing it right is rewarding. But everything else, as you point out, needs to be done as well.

I thought that pandemic preparedness belonged in the original stimulus bill (Susan Collins insisted on removing it). Your post is why.

I have worked in 2 big city health departments. Several problems seem to have contributed to this:
1. Funding priorities are out of whack, and do not match the burden of disease/ risk profile in communities. E.g. Too much money goes to bioterrorism, and health departments strain to apply this money to areas where it can do dual-purpose benefit.
2. Health depts are unaccustomed to running short-term mass vaccination campaign of the type being employed in H1N1.
3. Inadequate staffing- the nationwide nursing shortage plus the fact that most public health nurses do not routinely give vaccine, makes for a very small pool of potential vaccinators. There is also not enough staff to administer and conduct the activities being funded by federal grants. The departments are literally buried with money, and end up giving much of it to contractors and technology purchases, because there's literally no meaningful programmatic way to spend this grant money (you often can't buy vaccine or medicines with it, or refrigerators, or hire new full-time staff, etc. due to grant restrictions).
4. Poor ability to generate or anticipate demand. It seems like public health has lost some major battles on the message war - people are being swayed by stories of unsafe vaccine, and don't understand why they should get H1N1 vax. It has also been very difficult to get the priority groups in particular to understand why they need to get vaccinated, which seems largely due to a failure of public messaging. To be quite honest, the health depts are not trying hard enough on this front - their logic is "we'll put vaccine out there, we'll run some billboards, and we'll call it a day." Greater effort is called for.

By Anonymous (not verified) on 12 Dec 2009 #permalink

Depending on where you are located, the numbers being vaccinated are failing for different reasons. In some cases, it is because of reductions in production of the vaccine based on funding. However, in other locations, it is because of public apathy after people saw no hint of a disaster from this flu virus spreading.

The health organizations have a hard road to walk in such situations in order to ensure enough people are convinced to get the vaccine and having enough dollars to get all those who come out vaccinated.

And of course, it's hardly the fault of the public health departments they're flunking, if they've been given 6-12% less time to take the test, and no number 2 pencil.

Speaking of the vaccine, is it now being offered to the general public in the U.S.? (i.e., adults who are not HCWs, caregivers of infants, or with certain chronic health problems?) Because if it is, I'd like to better my chances of escaping the third wave.

Although it may be too late for me anyway. A member of my household is visiting a household with small children where everyone has a bad flu. I'd guess 95% chance they'll get it, and at least a 50% chance I'll get it when they get home. *sigh*

I work in a small city health dept and this post is completely on the mark. We have had many staff shifted from their program areas to help with vaccination efforts and to manage the new funds that CDC provided for H1N1 and which must be used for vaccinations, when what we need is better overall infrastructure, community involvement and protection of vulnerable people across the board, NOT JUST FOR FLU. We are shifting from other programs to address H1N1, while at the same time some of our core programs are being completely cut from state budgets. What about those other programs, which are also about life and premature death? This pandemic is important to combat--but so are other diseases that cause morbidity and mortality and diminish lives across our communities.

By anonymous in Calif (not verified) on 12 Dec 2009 #permalink

I just got my H1N1 vaccination a little over an hour ago. I live in Santa Cruz, Ca., and today is the first day that the County Health Center had a flu shot clinic for anyone who wished to get vaccinated. They had a total of 1750 shots available, and were vaccinating from 10:00am until 5:00pm. I don't know what the lines may have looked like at 10:00 this morning, but when I arrived, at around 3:30, I had no more than a five minute wait. There are roughly 250,000 people in Santa Cruz County, and somewhere around 35,000 of them had been vaccinated, before today. Impossible to say just how many people have already been infected with the virus, of course. But my sense is that the overall numbers are not that high, and a third wave, should one begin to materialize after the first of the year, is going to find that a very significant portion of the population still has a completely naive immune system. The county has seen only 40 people hospitalized, with two deaths resulting from the virus, so there is little sense of urgency, here, with respect to the H1N1 virus. We'll see just how things shake out, over the next several months, of course.

Yes, public health -- the community's immune system -- is deficient. But that is not the only dynamic at play. History shows that epidemics, although rarely if ever accountable for the majority or disease and death, get society's attention. Human belief systems just don't get it. If the plague can't shock us, we don't respond. In fact the higher the incidence of endemic disease, the less contract is visible. That's why public health systems have always waxed and waned. Given the decades-long absence of a flu pandemic society is like an immune system that didn't get its booster shot, it forgets. This trend is worsened by the other societal trends right now -- distrust, rather hate, of government, appetites accostomed to sensational images, and attention spans only nanoseconds long. Regardless, as a director of a local public health department, I am not turning away any H1N1 vaccine unless the fridge threatens to overflow. Any noticable uptick in H1N1 incidence, and that same fickle public will be at the door and we'll vax them then, gladly, and without comment.

Correction of one typo that matters: contrast (not contract)

It's not just Public Health; recent APIC surveys paint a grim picture for hospital-based infection preventionists. It's as if no one sees infection prevention as a strategic imperative. It's foundational it's...

But now I'm just preaching to the choir.

I do not know about how things are now, but in my county, one of the most populous in Northern California, initially all the vaccinations got sucked up by the Kaiser system and public health didn't even have enough to cover health-care workers.

Tell me *that* wasn't the result of some crooked politics somewhere...

By Lisa the GP (not verified) on 12 Dec 2009 #permalink

Off topic but your restaurant reference reminded me of this:
My daughter sold frozen cookie dough for basketball. The school got the shipment on Thursday a.m. and said it would be put in the cafeteria freezer but when I picked it up on Friday a.m., it was in the locker room (no phys ed). Max time would be 24 hours unrefrigerated. It's in sealed plastic containers and I just put them in my freezer. Should I throw it out? I'll be minus $240 but it's worth it to not make anyone sick.

Sue: I'd throw it out (sorry). Freezing doesn't kill pathogens (except for certain parasites), it merely preserves them. So if there are some pathogens in the raw dough and you leave the dough at incubation temp. (roughly between 40 deg F and 120 deg F for more than four hours (the time it takes to enter the log phase and real start population growth revved up) you are in danger of having a lot of pathogen in the raw dough (if there was some in there to begin with; since many are ubiquitous in the environment and on hands, etc., you can't be sure there were none). What happens next depends on the pahogen. If it were heat stable (like the toxin produced by staph, baking the cookie wouldn't do anything to it and people would still get sick (nausea, vomiting 3 - 6 hours after). If it were something that depended on massive ingestion of pathogen (like many Salmonella species), it's possible the baking would kill them all if they were baked long enough. But if lightly baked, they could remain viable in the center of a cookie and after baking while sitting around for hours on the cookie dish you'd have a problem. So while it is more than likely you wouldn't have a problem, if you wanted to be safe I'd throw it out. The general rule: keep it hot or keep it cold or don't keep it.

RE: the cookie dough. I'd start with a couple of questions. First, do you know the dough sat in the locker room for the whole time, or did it get put in the freezer and then pulled out and hauled to the locker room just in time for pickup? If you had opened one when you first got it, you could assess how cold it was (frozen, <40°, or room temperature) Second, how was it packaged? If it was sitting on the counter in individual containers, it would thaw and then warm up much faster than if packed in cases, especially if the cases were then packed in styrofoam shipping boxes.Me, I'd just bake 'em and eat 'em, but that's me. Cookie dough isn't a very hazardous food (even if it had eggs in it.)

That said, Revere has the general rule right, keep it hot or keep it cold or don't keep it. Maybe bake a plate of them and give them to someone you don't particularly like...

MoM: If it were me I'd just bake 'em and eat 'em, too. I eat everything in fridge no matter how long it's been there (that is if I can get it before Mrs. R. throws them out for no good reason I can see except they have been in there for a long time) and I regularly eat from street vendors (even though I've gotten sick 3 times over the years). But this isn't me, it's a group and a pretty big pile of cookie dough and I assumed it was well over 4 hours in the right temp zone. So your questions are highly pertinent and the right ones to ask. But assuming the answers are it was sitting for a prolonged time at room temp and not knowing who was baking it and how and for how long and knowing people like to eat raw cookie dough, I think the heave-ho is the safest generic advice. Of course like everything else, the real answer is, "it depends."

Lisa the GP: It's my understanding that Kaiser insures about 30% of the population in northern California (and maybe 20% statewide) so it makes sense to me that they were provided H1N1 vaccine to distribute. That said, I hope they were initially vaccinating only people in priority groups if other people in priority groups were not receiving vaccine.

Thanks Revere, Thanks MOM.
I have to assume it sat there for 24 hours.
Thanks for the advice.

I was happy to find this fairly well written characterization of this pandemic so far as (at least) a "wake up call". Most news articles I find about the pandemic don't approach the quality of this one.