The Washington Post - USA (2020-11-22)

SUNDAY, NOVEMBER 22 , 2020. THE WASHINGTON POST EZ RE A

the coronavirus pandemic

BY FRANCES STEAD SELLERS

News that a vaccine would be
available in record time brought
relief to Kelly Moore, director of
the Tennessee Immunization Pro-
gram, and a whole new set of
worries: how to build a network
of pandemic vaccine providers
from scratch and guarantee equi-
table access to communities of
color and rural spots across the
state’s 95 counties.
It was just over a decade ago,
and the H1N1 influenza virus was
rampaging across the country.
“We invested huge amounts in
2009,” said Moore, now associate
director of the vaccine education
organization Immunization Ac-
tion Coalition, describing a whirl-
wind of spreadsheets and brain-
storming sessions that ultimately
brought 1,500 pharmacies, hospi-
tals and clinics in her state to-
gether in a coordinated opera-
tion.
“Then, everybody went back to
business as usual, knowing the
next pandemic was coming,”
Moore said. “We knew we would
have to rebuild everything all
over again.”
Now, as the United States
ramps up for a vaccination drive
against the novel coronavirus,
boosted by reports of promising
results from two major clinical
trials, Moore and other experts
are frustrated that many of the
lessons of the 2009 H1N1 pan-
demic have not been addressed,
from ongoing investments in
public health infrastructure to
the use of transparent, fact-based
communication strategies. Some
of those insights have been ne-
glected, some blatantly ignored,
while other conundrums loom,
unsolved, over the upcoming dis-
tribution of the coronavirus vac-
cines.
Federal officials have been urg-
ing state and local health depart-
ments to heed lessons from 2009
even as they warn that the immu-
nization program ahead will be
far more complex.
Instead of tweaking an influen-
za vaccine to attack a new strain
as they did in 2009, the two
companies that reported this
month that their vaccines show
above 90 percent efficacy — phar-
maceutical giant P fizer and bio-
tech firm Moderna — are invent-
ing new technologies to counter a
new disease. While H1N1 dispro-
portionately affected people un-
der age 65, those at greatest risk
from covid-19, the illness caused
by the coronavirus, include the
elderly and people with preexist-
ing conditions, whose weakened
immune systems typically render
vaccines less effective. And next
year, people will probably need
two doses — spaced three or four
weeks apart — of a vaccine that
may be delivered in large batches
and have to be stored at ultralow
temperatures.
The most frequently cited les-
son from the H1N1 response is
common to the current pandemic
and may already be hampering
the upcoming distribution of the
coronavirus vaccines: the danger
of overly ambitious government
messaging.
During fall 2009, production
problems delayed delivery of the
federal pandemic vaccine just as

deaths were mounting, notably

among children. People stood in

line for lifesaving inoculations,

but by mid-October, only about a

quarter of the quantity that offi-

cials had been promising for

months was available.

Uncertain when further sup-

plies would arrive, public health

departments canceled immuni-

zation clinics. People were con-

fused and lost confidence in the

government’s strategy. By the

time enough vaccine was avail-

able, the threat from H1N1 had

diminished, and many people lost

interest in being immunized.

In 2010, at a meeting of vaccine

experts, Kathleen Sebelius, then

secretary of Health and Human

Services, referred to that over-

promising as one of the pandem-

ic’s “teachable moments.”

In a recent interview, Sebelius

acknowledged the dangers of

raising expectations too high,

even as she drew a sharp distinc-

tion between the messaging un-

der President Barack Obama,

whom she described as “absolute-

ly committed to following the

science and leading with the sci-

ence,” and the “garbled and con-

tradictory” messaging that has

pitted science against politics un-

der President Trump.

The current administration,

public health experts say, has

referred to a coronavirus vaccine

as if it will end the pandemic

quickly instead of taking to heart

the lessons of a decade ago and

the more complex hurdles ahead.

Administration officials such as

Health and Human Services Sec-

retary Alex Azar continue to

strike a far more upbeat note

about the swift impact of a vac-

cine than infectious-disease ex-

perts who have been closely in-

volved with previous efforts.

“It’s a cautionary note about

how much hope to pin on a

vaccine,” said Thomas Frieden,

referring to 2009, when he be-

came director of the Centers for

Disease Control and Prevention.

“Lots can go wrong,” said Frie-

den, now president of Resolve to

Save Lives, a global initiative tar-

geted at epidemics. “Lots.”

The politicization of public

health and explosion of conspira-

cy theories have exacerbated the

threat of misinformation and dis-

information that Gigi Gronvall,

an immunologist and senior

scholar at the Johns Hopkins

Center for Health Security,

helped counter in 2009, in both

her professional life and personal

interactions.

Gronvall remembers her inbox

filling with messages from ac-

quaintances concerned about the

safety of the H1N1 vaccine.

“I keep reading about it, and

nothing is really proving [to] me

that it is safe,” wrote one mother

about the H1N1 vaccine, wonder-

ing whether to take her child for a

shot or nasal spray. “But I also

realize that it is not safe to not get

it.”

Gronvall wrote back providing

a newspaper article and CDC ma-

terials on safety data.

“I would be very cautious about

a lot of the stuff on the Internet

about vaccines as a lot of it is total

garbage,” Gronvall explained to

the mother.

Those old concerns — about an

H1N1 vaccine with the same man-

ufacturing process as the season-

al flu vaccine — now strike Gron-

vall as minimal compared with

the combination of inflated opti-

mism and outright skepticism

whipped up around the coronavi-

rus vaccines. The need for frank,

fact-based communication was

clear in 2009, she said, but now

she is concerned that the adverse

events that inevitably accompany

any innovation “will be manipu-

lated to cause discord.”

A key takeaway from the H1N

vaccine was the role experienced

health-care workers play in con-

veying safety information to pa-

tients.

“The most important people

are the ones holding the syringe,”

said Bruce Gellin, president of

global immunization at the Sabin

Vaccine Institute and a former

HHS official. “They are going to

be asked, ‘What do you think?’ ”

With flu and measles vaccines,

years of compelling safety data

exist. But health-care workers do

not yet have the information to

answer questions authoritatively

about the coronavirus vaccines,

which are not being tested in

children, for example.

Those issues of building trust

could prove particularly impor-

tant when it comes to persuading

people in communities of color to

receive a new vaccine.

In 2009, African Americans

and Latinos were vaccinated at

lower rates than other groups,

according to a 2012 HHS evalua-

tion of the response that was

intended to enhance prepared-

ness. Just as they have historically

been at greater risk of flu, includ-

ing H1N1, people of color have

been disproportionately affected

by the coronavirus. But studies

show that a combination of barri-

ers to access, distrust of the medi-

cal system and the perceived risk

of side effects means they are less

likely to get vaccinated.

To counter those trends, mi-

norities have been listed among

high-priority groups for the coro-

navirus vaccine. But even that

designation is a complicating fac-

tor when it comes to a mass

vaccination program, experts say.

“Prioritization is important,

but in a huge population, how do

you carry that out in a way that is

efficient?” Gellin said. “If you

have a vial, and some [of the

vaccine] is going to go bad, do you

wait for the right people to show

up?”

In 2009, vaccine was held in

reserve for priority groups, in-

cluding pregnant women and

children, until it became clear

that limited supplies were being

wasted. Some states began relax-

ing their rules about targeting

priority groups. In Maryland,

Gronvall, who was pregnant and

therefore at high risk for H1N1,

found herself in line with others

who weren’t high-priority recipi-

ents.

In the case of a two-dose vac-

cine that may arrive in large

batches and have to be kept at

extremely low temperatures,

meeting prioritization goals is

harder still. If a person receives

one dose and then fails to show up

for a second shot, they will have

wasted a dose that could have

been used for another recipient.

And with numerous vaccines un-

der development, some people in

targeted groups may decide to

wait in the hope there’s a better

option in the pipeline.

But perhaps the most resound-

ing lesson that emerged from

2009 — and promises to compli-

cate the upcoming distribution —

is the lack of ongoing investment

in public health.

“We need a plan. We’ve needed

a plan for quite a long time,” said

Jason Terk, a pediatrician and

chair of the Texas Public Health

Coalition, who recalled running

short of syringes and other sup-

plies when administering the

H1N1 vaccine.

Some of the logistical challeng-

es in 2009 were met by temporari-

ly expanding a 25-year-old federal

program, Vaccines for Children,

that provides immunizations free

to minors who don’t have insur-

ance coverage. The initiative

formed the backbone of nation-

wide H1N1 distribution plans,

and many states adapted its infra-

structure to register new provid-

ers and create hotlines for health-

care workers who ran into prob-

lems ordering, receiving or ad-

ministering vaccines.

Launched in 1994, Vaccines for

Children provides more than

50 percent of childhood vaccines,

which are given to states that

then distribute them to more

than 40,000 private physicians’

offices and public clinics across

the country. The program has

been credited with preventing

hospitalizations, saving lives,

closing the immunization gap be-

tween White children and chil-

dren of color, and saving billions

in health-care costs.

“A system like [Vaccines for

Children] expanded to cover the

adults could yield enormous ben-

efits,” Terk said, providing greater

agility in the event of another

outbreak while also shoring up

public health. Increasing num-

bers of vaccines are available for

adults that protect against shin-

gles, pneumonia, hepatitis and

other illnesses, many of which are

underused.

Moore said the biggest stum-

bling block of 2009 still hasn’t

been resolved: There is no broad

adult immunization network en-

gaged with federal and state im-

munization programs, meaning

there is no database ready to

recruit the thousands of clini-

cians who will be needed to ad-

minister coronavirus vaccines.

But she is choosing to look

ahead, hoping the lessons that

will be learned from the coronavi-

rus vaccine program won’t be

squandered.

“My hope is we will leverage

this opportunity in a way we

didn’t leverage 2009,” Moore said.

“Episodic investment is no way to

do public health.”

[email protected]

Experts fear lessons f rom 2009

H1N1 vaccine are being ignored

JEFF ROBERSON/ASSOCIATED PRESS

Rep. William Lacy Clay (D-Mo.) and then-Health and Human Services Secretary

Kathleen Sebelius talk with H1N1 clinical trial subjects i n St. Louis in 2009.

KATHERINE FREY/THE WASHINGTON POST

A nurse gives a flu shot to 3-year-old Sofia Bueso l ast month in Baltimore. Experts worry

that a lack of investment in public health will hurt coronavirus vaccination efforts.

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