In early 2009, a new H1N1 influenza virus — also known as the “swine flu” — emerged in Mexico, with the World Health Organization declaring the outbreak a pandemic in mid-June.
By late April of that year, the Centers for Disease Control and Prevention (CDC) had already started working on a vaccine. The government promised that 120 to 160 million doses of H1N1 vaccine would be available by October to head off an expected second wave of infections.
But when October arrived, only about 23 million doses were available to states, with fewer than 17 million doses shipped that month, according to a report to Congress on the government’s pandemic response.
Dr. Rebecca Wurtz, an infectious disease physician and population health informaticist in the School of Public Health at the University of Minnesota in Minneapolis, said the government also did a poor job of communicating where the vaccine would be available and who should be first in line to get it.
“The vaccine wasn’t always available when people needed it or where they needed it,” she said.
These problems led to a drop in public confidence.
A Gallup survey from early November 2009 found that 54 percent of adults said the federal government was doing a poor or very poor job of providing the country with an adequate supply of the H1N1 vaccine.
The reason for the shortfall of the H1N1 vaccine was that the government was relying on 70-year-old egg-based vaccine manufacturing, the same method that’s commonly used to produce the seasonal flu vaccine.
The vaccine yields from that process, though, turned out to be much lower than even the government’s conservative estimates, reported the New York Times.
So by the time the vaccine was widely available in late December, the second wave of H1N1 in the United States had passed and many people were no longer interested in being vaccinated.
Wurtz said there was a similar waning of concern among parents about the virus. H1N1 was a serious illness in children, so when the virus first appeared, parents flooded pediatrician’s offices, worried that their kids had it.
However, “by the fall when the vaccine was available, parents didn’t rush to their kids’ doctor,” said Wurtz, “because their level of concern had changed and they didn’t want to subject their child to another shot.”
The vaccine shortages also led to a global battle for the limited supplies. Developed countries placed large advance orders for the H1N1 vaccine, leaving low-income countries, including Mexico, without enough doses.
Some aspects of the H1N1 vaccine rollout worked well.
Unlike the seasonal flu vaccine, which is purchased by doctors’ offices, public health agencies, and pharmacies, the federal government purchased all the H1N1 vaccine that would be used in the United States.
These doses were distributed to the states based on population size, and the states decided which providers should receive the vaccine to give out.
The CDC used a central distributor to get the vaccine to the states and built off the existing Vaccines for Children (VFC) program. This program, which is still around, allows state public health agencies to order vaccines to be distributed to private physicians’ offices and public health clinics.
Dr. Kathryn M. Edwards, a professor of pediatrics and scientific director of the Vanderbilt Vaccine Research Program in Nashville, Tennessee, said the VFC infrastructure works well in terms of getting vaccines to the states.
However, “it would be nice if we had an adult distribution system like the Vaccines for Children program,” said Edwards. “[With H1N1], it was harder to get the vaccines to adults [than] it was to children.”
In spite of the hurdles, the CDC estimated that from October 2009 through May 2010, 27 percent of Americans over the age of 6 months were vaccinated against H1N1, including 34 percent of the high-priority groups.
The groups initially targeted with the vaccine were pregnant women, people who lived with or cared for infants younger than 6 months, healthcare workers, people 6 months to 24 years old, and people ages 25 to 64 with underlying health conditions that increased their risk of complications.
It’s difficult to directly compare the H1N1 pandemic with what’s happening now.
We’ve already seen how much more severe COVID-19 is — after just 5 months, the United States has confirmed over 5 million cases of COVID-19, with more than 160,000 deaths.
In comparison, 12,469 Americans died from H1N1 in 2009 and 2010.
H1N1, though, still has lessons to teach us about how to roll out a vaccine.
Wurtz said the science of vaccine development has advanced since H1N1, so we should be able to create and test a vaccine for the coronavirus more quickly and more accurately.
“But human nature hasn’t changed, and our systems haven’t changed in those 11 years,” she said. “So some of the same problems that were encountered then will be encountered now.”
A lot of these lessons involve communication — including that the government should underpromise what it can do and then overdeliver.
“That’s a difficult line to walk,” said Wurtz. “To be clear and explicit, but not exaggerate about what we can deliver, and then do a better job than what we said we were going to do.”
Distribution will also need to be carefully managed by the federal government. However, the chaotic way in which the antiviral remdesivir was distributed earlier this year doesn’t bode well for what will happen with a coronavirus vaccine.
“It is going to be crucial to have [the coronavirus vaccine] distributed in an orderly way that is communicated in advance to governmental health agencies, state health departments, and healthcare organizations — in contrast to what happened with remdesivir,” said Wurtz.
Edwards said what’s also important is having clear and consistent messages about why we need a coronavirus vaccine, how carefully it’s being tested for safety and efficacy, and its role in helping the country reopen fully.
“We can distribute the vials of vaccine. That will be a challenge and that needs to be worked on,” said Edwards. “But if people do not want to get vaccinated, then no matter what we distribute, it is not going to be effective.”
As with H1N1, there likely won’t be enough doses of the vaccine to vaccinate everyone right away, so the government will need to decide who is first in line.
Wurtz said the priority groups will be people at greatest risk from COVID-19 — healthcare workers, older adults, people with underlying medical conditions, and essential workers.
The coronavirus has also had a disproportionate impact on racial and ethnic groups in the United States — including Black American, Native American, and LatinX communities.
“It’s clear that racial and ethnic minority populations in the United States are at higher risk for both illness and death from COVID-19,” said Wurtz. “So in rolling out the vaccine, we need to consider race and ethnicity as risk factors in ways that we haven’t before.”