Background
On April 26, 2009, the United States Government declared a public health emergency in response to the threat posed by the 2009 H1N1 influenza virus, A(H1N1)pdm09. This declaration triggered the Centers for Disease Control and Prevention (CDC) to ship large quantities of medical provisions from the Strategic National Stockpile (SNS) to state health departments around the nation in an effort to mitigate and control outbreaks of the novel virus. Included in this shipment were 11 million regimens of antiviral drugs (two neuraminidase inhibitors, oseltamivir and zanamivir), which were later accompanied by new federal guidance on the recommended clinical use of these drugs during the pandemic. These events prompted state and local health departments to make decisions regarding how and where publicly purchased antivirals would be used in their communities to treat ill persons and slow the spread of disease.
The large-scale deployment of antivirals during the H1N1 influenza response presented a unique opportunity to study the local public health implementation of plans and protocols to support medical countermeasure dispensing. As one of the CDC public health emergency capabilities, Medical Countermeasure Dispensing is defined as, "the ability to provide medical countermeasures (including vaccines, antiviral drugs, antibiotics, antitoxin, etc.) in support of treatment or prophylaxis…to the identified population in accordance with public health guidelines and/or recommendations". The H1N1 influenza pandemic offered a highly unusual situation in which state and local health departments across the country simultaneously carried out this function during a prolonged event of national significance.
The need for the public health management of antiviral drugs during an influenza pandemic did not take public health officials by surprise. Prior to 2009, public health agencies and community partners had been actively engaged in preparedness activities in anticipation of antiviral utilization during an influenza pandemic. Among those efforts were large-scale purchase of antiviral drugs and the development of plans to appropriately use these medications to treat influenza illness and to reduce the impact of a pandemic. However, given few opportunities to observe real-world response to an influenza pandemic, the preparedness community's understanding of state and local readiness for implementing a large-scale antiviral program has been limited. As a result, pre-pandemic assessments have reached wide-ranging conclusions regarding this preparedness capacity. In 2008, a federal assessment of pandemic influenza State Operating Plans found that "there are very few gaps in State readiness for antiviral drug distribution". Just one year later, the U.S. Department of Health and Human Services (HHS) Office of Inspector General reported notable gaps in antiviral plans at the local level, despite high scores in antiviral preparedness at the state level. While these reports may, at first, seem contradictory, the findings illuminate the differences in the roles, responsibilities, and capacities of health departments at the state and local levels. For many states, including California, the primary responsibility for managing local antiviral drug activities resides with Local Health Departments (LHDs) in order to enable local control, planning, and implementation.
The 2009 H1N1 influenza response provided a valuable opportunity to learn from the experiences of LHDs during a real public health emergency. While the demand for antiviral drugs during the 2009 H1N1 influenza response was not as dramatic as had been predicted in many pre-pandemic planning scenarios, this paper seeks to illuminate how LHDs nevertheless drew on their previous work to meet the needs for antiviral drugs within their community. The H1N1 pandemic also tested antiviral planning assumptions and forced LHDs to creatively respond to new and unexpected challenges. The purpose of this study, then, is to describe the range of methods used by LHDs in California to manage antiviral activities and to gain a better understanding of the related challenges experienced by health departments and their community partners, with the goal of informing future planning for local public health preparedness and response efforts.